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PANCE > Endocrinology - 7% > Flashcards

Endocrinology - 7% Flashcards

1
Q

Acromegaly/Gigantism

Pituitary Disorders

dx, tx

A

Dx

  • serum IGF-1 elevation - 3-10x ULN
    • can also monitor response to tx
  • Plasma GH via radioimmunoassay
    • blood taken before breakfast, normal is < 5ng/mL
    • then measure, GH suppression after glucose load
  • CT or MRI for pituitary tumor

Tx

  • Transsphenoidal surgical resection
  • Octreotide or Lanreotide to suppress GH secretion
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2
Q

Acromegaly/Gigantism

Pituitary Disorders

A

MCC pituitary adenoma - excessive Growth Hormone

Gigantism - if GH hypersecretion begins in childhood, before epiphyses closure

Acromegaly - GH hypersecretion begins in adulthood, after epiphyses closure [A for Adults]

Sxs

  • Headaches, visual spot defects
  • Gnathism, weight gain
  • enlarged/spade hands and feet
  • congestive cardiac failure
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3
Q

Addison’s Disease

(Adrenal Insufficiency)

dx, tx

A

Dx:

  • 8AM Serum cortisol < 3mcg/dL and ele ACTH > 200 pg/mL
  • ACTH Stimulation Test
    • Primary/Addison’s - high ACTH, low cortisol
    • Secondary/pituitary - low ACTH, low cortisol
  • Cosyntropin Stimulation Test**
    • Cortisol serum should rise > 20 ug/dL
    • Primary/Addison’s: high ACTH, low cortisol
    • Secondary/pituitary: low ACTH, low cortisol
  • Serum Dehydroepiandrosterone (DHEA) < 1000 mg/dL
  • HypoNa
  • HyperKalemia
  • CT of Adrenal gland
  • Adrenal Autoantibodies

Tx:

  • Addison’s - Glucocorticoid + mineralcorticoid replacement therapy
    • Hydrocortisone 1st line
    • Fludrocortisone - if no renin or aldosterone
  • DHEA for women who want to start a family
  • Secondary/pituitary - fix pituitary
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4
Q

Addison’s Disease

(Adrenal Insufficiency)

eti, sxs

A

LOW cortisol d/t autoimmune destruction of adrenal cortex

can be precipitated by stress, illness, trauma, infection, met cancer

Sxs:

  • hyperpigmentation - bronze - increased ACTH
  • weakness
  • anorexia, wt loss
  • Pain - athralgias, myalgias
  • Anxiety, irritability, depression
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5
Q

Cushing’s Disease

dx, tx

A

Dx:

  1. 24 hr urine free cortisol collection
    • if ele cortisol => ACTH level
      • ​high plasma or serum ACTH = ACTH dependent cause
        • MRI of brain => pituitary adenoma (Cushing Disease)
      • low plasma or serum ACTH = ACTH independent cause
        • ​CT of adrenals => adrenal mass/adenoma
  2. Low dose Dexamethasone Suppression Test
    • failure of steroid to decrease cortisol = diagnostic
  3. High dose Dexamethasone Suppression test
    • no suppression (cortisol still high) = Cushing’s syndrome

Tx for Cushing’s Disease - Transsphenoidal resection

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6
Q

Cushing’s Disease

eti, sxs

A

HIGH cortisol

Eti:

  1. Cushing Syndrome
    • sxs from prolonged exposure to excess cortisol
  2. Cushing’s Disease
    1. ACTH secreting pituitary microadenoma, usu on v small anterior pituitary
    2. F 3x > M

Sxs:

  • Obesity - buffalo hump, moon facies, supraclavicular pads
  • HTN
  • Thirst
  • Pigmented striae
  • oligomenorrhea/amenorrhea
  • polyuria
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7
Q

Diabetes Inspidus

eti, Sxs

A

Deficiency of or resistance to Vasopressin (ADH) - decr kidney’s ability to reabsorb water = massive polyuria

Eti: MC dx in children

Central DI

  • deficiency of ADH from posterior pituitary/hypothalamus
    • no ADH production MCC idiopathic
    • autoimmune destruction of posterior pituitary from trauma, infx, sarcoidosis

Nephrogenic DI

  • lack of reaction to ADH
    • partial or complete Insensitivity to ADH
    • Drugs (Lithium, Amphoterrible)
    • HyperCa and hypoK - can’t concentrate urine
    • Acute tubular necrosis

Sxs:

  • polyuria
  • polydipsia
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8
Q

Diabetes Inspidus

dx, tx

A

Dx:

  • Serum osmolality (blood) is high - blood gets thicker bc water is not getting reabsorbed
  • Urine osmolality is low - too much water:solute ratio
  • Water Deprivation Test
    • ​establish diagnosis of DI - urine continues to be dilute
    • r/o psychogenic - ADH working so urine osmolality would increase
  • Desmopressin DDAVP Stimulation Test -differentiates btwn Central or Nephrogenic
    • ​Central - urine concentration increase = response to ADH
    • Nephrogenic - continue production of dilute urine bc kidneys do not respond

Tx:

  • Central - desmopressin/DDAVP
  • Nephrogenic - Na and protein restriction, HCTZ, indomethacin
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9
Q

Diabetic Ketoacidosis

A

Medical emergency - complications of Diabetes

Increased insulin req’s = shortage. Body starts to use excess fat => ketone accumulations

Insulin deficiency => hyperglycemia => deH2O => ketonemia (anion gap Met Acidosis) => potassium def

Younger pts w/ Type 1 DM

Sxs:

  • thirst, polyuria, polydipsia, nocturia
  • weakness, fatigue, confusion
  • N/V
  • Chest pain/ abd pain
  • Signs - tachypnea/tachycardia, hypotension, decreased skin turgor, fruity breath/Kussmaul’s respiration

Dx:

  • Blood sugars > 250 mg/dL
  • anion gap Met acidosis pH < 7.3 and HCO3 < 18
  • Plasma ketones

Tx: IV fluids & insulin!

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10
Q

Diabetic Mellitus Type 1

eti, sxs, dx, tx

A

Type 1 - MC in young people

  • Immune mediated - pancreatic islet B cells destruction via autoimmune (type 1A) and idiopathic (type 1B, MC in Asian and African)

Sxs:

  • Polyuria
  • Polydipsia
  • wt loss despite normal or increased appetite (polyphagia)
  • Blurred vision
  • Glucosuria

Dx

  • Random glucose > 200mg/dL
  • fasting glucose > 126 on > 1 occassion
  • HbA1c > 6.5%

Tx

  • Mediterranean diet
  • Insulin - regular insulin - in abd
  • Daily asp to decr DVT risk
  • Opthal exam
  • Mod exercise
  • prompt tx of infx
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11
Q

Diabetes Mellitus Type 2

eti, sxs, tx (no meds)

A

Type 2 - younger persons who are overwt/obese; central obesity

Sxs:

  • Polydipsia
  • Polyuria
  • Fatigue
  • Candida vaginitis
  • Skin infx
  • blurred vision
  • poor wound healing

Dx

  • Random glucose > 200
  • Fasting > 126
    • If btwn 100-125, PO glucose tolerance test - 3 hr plasma glucose > 200
  • A1c > 6.5%
    • A1c 5.7-6.4 = Prediabetes
    • Fasting glucose - 100-125
    • 2 hr PO glucose tolerance test 140-199

Tx:

  • Weight loss - diet, exercise
  • monitor eyes/feet
  • control BP <140/90
  • Urine Albumin/Cr screening
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12
Q

Diabetes Mellitus T2

Meds

A

Biguanid - Metformin

  • decr hepatic glucose production & intestinal absorption
  • C/I if eGFR < 30ml/min; not rec’d with 30 to 45 ml/min
    • dc 24 hrs before contrast and resume 48 hrs after
    • monitor Cr, stop if Cr > 1.5

Sulfonylureas -“Glyburide, Glipizide, Glimepiride”

  • stimulates pancreatic B-cell Insulin release
  • oldest DM drugs - risk of hypoglycemia
  • Glipizide, Glyburide, Glimepiride

Thiazolidinediones - “Pioglitazone, Rosigilitazone”

  • Increase Insulin sensitivity in peripheral receptor site adipose and muscle tiissues; has no effect on pancreatic beta cells
  • C/I - CHF, liver disease, fluid retnetion, wt gain, bladder cancer (pioglitazone), increase in MI/HF (rosigilitazone)

Alpha glucosidase Inhibitors

  • Delays Intestinal glucose absorption
  • GI side effects - TID dosing
  • Acarbose, miglitol

GLP-1 Agonists -“tide” - injectable

  • lower blood sugar by mimicking incretin -causes insulin secretion and decreased glucagon, delays gastric emptying, works on pancreas (can cause pancreatitis)
  • SE - req’s injection, freq GI SE,
  • benefits of weight loss, reduced CV mortality (semaglutide)
  • Dulaglutide (trulicity), Exenatide (bydureon)

DPP-4 Inhibitors

  • inhibits degradation of GLP1 so more circulating GLP1
  • expensivie, incr risk of HF (sxagliptin)
  • Sitagliptin (januvia)

SGLT2 Inhibitors -“flozin” urinate like crazy

  • lowers renal glucose threshold, Increases urinary glucose excretion
  • SE - vulvovaginitis, UTI, lower limb amps, AKI, DKA, ortho hypotension
  • Benefits - wt loss, reduction in systolic BP, reduce CV risk

Insulin

  • add in blood sugar A1C > 9
  • Basal supplement (NPH, lispro, glargine, detemir)
    • rest and digest
  • Prandial bolus (lispro, aspart, glulisine vs regular [short acting]
    • before meals
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13
Q

Dwarfism

Pituitary Disorders

dx, tx

A

Dx

  • serial measurement > 2.5 dev below normal mean = GH eval
  • low IGF-1 and IGF-binding protein 3
  • Bone age - Xray of child’s hand for chronological age comparison
    • if >2yrs behind chronological age = positive
    • somatomedin C + GF with blood tests
  • MRI or CT of brain for cause

Tx

  • subcut injections of recombinant Human GH
  • Surgery for pituitary adenoma
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14
Q

Dwarfism

Pituitary Disorders

eti, sxs

A

GH deficiency = slow growth pattern

primary or with hypothalamus and pitutiary disorders

Achondroplasia - FGFR3 mutation

Sxs

  • in adults - lower bone density and decreased muscle mass (no affects on bone growth)
  • GH deficiency in infancy = hypoglycemia and micropenis
  • in children = bone growth delays relative to chronological age
    • understimulation of osteoblasts => short stature
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15
Q

Hyperparathyroidism

A

Overactive parathyroid gland - secrete too much PTH = incr level of Ca

increase PTH => bone breakdown => Ca rise

  • Primary - d/t parathyroid adenoma
  • Secondary - physiologic resposnse to hypoCa or Vit D deficiency (MCC kidney disease)

Sxs: same as hypercalcemia

  • bone loss (incr PTH and Ca abs from bones) = pain in bones
  • renal loss of Ca = kidney stones
  • incr GI abs of Ca = abd groans
  • irritability, psychosis, depression = moans

Dx:

  • Incr Ca, PTH, decr phosphorus
  • urine - hyperphosphaturia, hypercalciuria

Tx:

  • Primary = surgical resection, if all 4, remove 3.5 glands
  • Secondary = replace cause (vit D/Ca supp)
  • if Ca very high = IV fluids, Lasix, calcitonin
    • tx osteoporosis with bisphosphonates
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16
Q

Hyperthyroidism

A

Production of too much thyroxin hormone - increase metabolism

Eti - MCC Grave’s disease (autoimmune), toxic adenoma, thyroiditis, pregnancy, amiodarone

Sxs:

  • weight loss, anxiety
  • warm, moist skin
  • insomnia
  • fine tremor, muscle cramp, hyperreflexia
  • amenorrhea
  • tachycardia/palpitations
  • Graves - diffuse goiter w/ bruit, exopthalmos, pretibial myxedema
  • heat Intolerance

Dx:

  • TSH low and T4 high - primary disease
  • TSH high and T4 high - secondary dz
  • Anti-thyrotropin antibodies
  • RA Iodine uptake = increased uptake in
    • Graves = diffusely high uptake
    • Toxic Multinodular goiter = Discrete areas of high uptake

Tx:

  • BB symptomatic - propanolol
  • Methimazole
  • Propylthiouracil (PTU) - safe for pregnancies in the first trimester, then switch to Methimazole
  • Radioactive iodine I-131
  • Thyroidectomy - complication recurrent laryngeal
17
Q

Hypoparathyroidism

A

body secrets low PTH => decr serum Ca

MCC - thyroidectomy

Same Sxs as hypoCa:

  • Tetany, tingling, cataracts
  • Chvostek’s sign - facial n illicit twitch
  • Trousseau’s sign - carpal spasms after BP cuff inflation

Dx

  • HypoCa, low PTH
  • hyperphosphatemia
  • low urinary Ca

Tx

  • Vit D and Calcium gluconate
18
Q

Hypothyroidism

A

95% Autoimmune - MC Hashimoto’s or prev thyroidectomy/iodine ablation, congenital

Sxs: - everything LOW OR SLOW

  • Weakness, lethargy, slow speech
  • dry/coarse hair, weight gain
  • cold intolerance
  • depression
  • anemia, bradycardia, hyporeflexia

Dx

  • TSH high
  • T4 and T3 low
  • Antithyroid peroxidase
  • Antithyroglobulin ABs

Tx

  • Levothyroxine/Synthroid
19
Q

Multiple Endocrine Neoplasia

Neoplasms

A

Autosomal Dominant - inherited condition that develops multiple endocrine tumors

Three types

  • MEN Type 1 (Wermer Syndrome) - 3Ps
    • Parathyroid hyperplasia
    • Pancreatic islet cell tumors (2/3 of pts with MEN1, ZES or insulinoma
    • Pituitary tumors
  • MEN Type IIa (Sipple Syndrome) - MPP - 2Ps
    • Medullary thyroid carcinoma (100% of pts)
    • Pheochromocytoma - >1/3 of pts
    • Parathyroidism - primary
  • MEN Type IIB - MMMP
    • ​Medulary Thyroid carcinoma - more aggressive than in IIa
    • Mucosal neuromas - nasopharynx, oropharynx, larynx, conjunctiva
    • Marfanoid body habitus
    • Pheochromocytoma

Tx

  • Surgical resection
  • treat symptoms for MEN I
  • MEN II - MTC - tyrosine kinase inhibitors, chemotherapy
20
Q

Neoplastic Syndrome

Neoplasm

A

Consequence of cancer in body - mediated by humoral factors (cytokines and hormones) secreted by tumor cells or immune response against the tumor

SCLC

  • Tumor product - ACTH, ADH, ab against presynaptic Ca2+ channels
  • Cushing syndrome, SIADH, Lambert Eaton

Squamous Cell LC

  • PTH related peptide, TGF-B, TNF< IL-1

Renal Cell Carcinoma

  • Erythropoietin
  • Polycythemia, HyperCa

Thymoma

  • Antibodies against nicotinic Ach receptor at postsynatic neuromuscular junction
  • Myasthenia gravis

Intracranial Neoplasm

  • ADH
  • SIADH

Leukemias and lymphomas

  • Excess nucleic acide turnover, TLS
  • Gout , urate nephropathy
21
Q

NonKetotic Hyperglycemia

A

MC in DM T2 during physiological stress

high blood sugar = high osmolarity w/o significant ketoacidosis

Eti

  • acute infx/med conditions
  • drugs that impair glucose tolerance - glucocorticoid, or increase fluid loss (diuretics)

Sxs:

  • days to weeks
  • Altered LOC
  • signs of deH2O, weakness
  • leg cramps
  • vision problems

Dx:

  • Blood sugar > 600 mg/dL or 30 mmol/L
  • Osmolarity > 320 mOsm/kg
  • pH > 7.3

Tx

  • IV NS 0.9%
  • IV insulin (if K > 3.3 mEq/L)
  • LMWH - risk of clots
  • decrease slowly - risk of cerebral edema if not
  • K replacement as needed
  • target plasma glucose in acute tx is 250-300 mg/dL
22
Q

Pheochromocytoma

A

Catecholamin secreting adrenal tumor - secretes NorEpi and Epi

a/w Neurofibromatosis Type 1, MEN 2A/2B

Sxs - 5Ps

  • Pressure - HTN
  • Pain - HA
  • Perspiration - excessive sweating
  • Palpitations
  • Pallor

Dx

  • 24 hr catecholamines w/ metabolites - metanephrine and vanillylmandelic acid
  • MRI or CT of abd

Tx

  • complete adrenalectomy
  • a blockade - phenoxybenzamine or phentolamine x 7-14d followed by BB for HTN control
    • do NOT give BB first = life threatening HTN
23
Q

Pituitary Adenoma

Pituitary Disorders

A

Microadenomas < 1cm in diameter; adenomas are > 1cm = macroadenomas

35-60yo; benign

Sxs

  • Most to least common types
    • Prolactinoma - Galactorrhea, amenorrhea, infertility, decreased libido
      • incr prolactin >200ng/mL
      • MRI dx
      • tx with Bromocriptine
    • Non-secreting adenoma
      • ​secrets a-subunit
    • Somatotroph adenoma - Acromegaly
      • incr GH or prolactin
    • Corticotroph Adenoma - Cushing’s disease
      • incr ACTH
    • Thyrotroph Adenoma - Hyperthyroidism
      • incr TSH

Dx

  • MRI - sellar lesions or tumors
  • Endocrine studies - TSH, FSH, prolactin, ACTH, LH

Tx

  • Transsphenoidal surgery - active or compressive tumors
  • medical mgmt - Dopamine inhibits prolactin Cabergoline or Bromocriptine
  • Acromegaly - TSS + Bromocriptine (dopamine dec GH production)
24
Q

Adrenal Tumor/Neoplastic Disease

Primary Endocrine Malignancy

A

see pheochromocytoma

25
Q

Thyroid Neoplastic Disease

Primary Endocrine Malignancy

A

Hoarse voice, solitary cold nodule on uptake sacan

MC - papillary carcinoma, medullary is most deadly

Dx

  • US - initial
  • Thyroid uptake scan
  • Microcalc, hypoechogenicity, solid cold nodule, irregular margins
  • FNB - ***gold - all lesions >1cm

Tx

  • Surgical resection
  • Chemo/ext beam radiation
26
Q

SIADH

eti, sxs

Neoplasms

A

Inappropriate release of ADH = impaired water excretion = water retention and dilutional hypoNa

Etis

  • Malignancy - small cell (oat cell) of lung
  • Medications - carbamazepine, cyclophosphamide, NSAID, sulfonylureas, SSRIs
  • CNS disturbnances - infection, malignancy, stroke
  • TBI
  • Pulmonary Disturbances - PNA, Tb
  • Mechanically ventilated pts

Sxs

  • N/V, headache, confusion, weakness, fatigue
27
Q

SIADH

dx, tx

A

Dx

  • low serum Na <135 mmol/L
  • low plasma osmolality < 275 mOsm/kg
  • low serume uric acid < 4mg/dl
  • Nl adrenal and thyroid function

Urine studies

  • high urine Na (>40 mmol)
  • high urine osmolality (>100 mOsm/kg)

Tx

  • fluid restriction
  • Na management
    • mild to mod => isotonic 0.9% saline with furosemid
    • Severe = hypertonic 3% saline
  • Meds
    • Vaptans (ADH receptor antagonist) = Tolvaptan, Conivaptan
    • Demeclocycline (ADH recept antagonist)
    • Lithium - decr responsiveness to ADH
28
Q

Subacute thyroiditis

(de Quervain’s Thyroiditis)

A

MCC of thyroid pain, mc in F>M

Eti - post viral and muscle aches - following symptoms of fever, myalgias, & pharyngitis

Sxs:

  • Inflamed, painful thyroid - localized neck pain
  • fever and muscle aches
  • Early hyperthyroid course, then hypothyroidism

Tx

  • NSAID
  • Methimazole, PTU

Increased ESR 60-100

29
Q

Thyroid Carcinoma

A

MCC = radiation exposure; nodules must be >1cm to be palpated

Types

  1. Papillary carcinoma is MC, thyroid adenoma MC benign nodule; young F 40-60
  2. Follicular - hematologic spread, CNA or CNB to confirm
  3. Medullary - MEN syndrome - calcitonin level, tx w/ ext beam radiation
  4. Anaplastic - SOB, hoarseness, CNB, sx bx, tx w/ sx or palliative, poor prog

Dx

  • US - malignant if
    • microcalcifications, hypoechogenicity, Irregular nodule margins,
  • lesions > 1 cm biopsied
  • Thyroid uptake scan
    • ​cancerous lesion do NOT take up iodine “cold”
    • non-cancerous lesion will take up iodine “hot”
  • FNA to culture
30
Q

Thyroid Nodules

Evaluation

A
  1. Palpable nodule > 1cm
  2. Confirm with US
  3. if TSH low =>
    • Thyroid Radioiodine Uptake or Scintigraphy scan
      • malignant wont take up iodine = nonfunctional “cold”
      • Confirm with FNA
  4. if TSH normal or high => FNA if
    • microcalc, irreg margins
    • next to recurrent laryngeal n. or LNs

Tx

  • malignant- thyroidectomy
  • benign - f/u in 6 mos
  • unsatisfactory specimen - FNA repeat 1-4 wks to mirror structure
31
Q

Thyroiditis - Drug induced and Infectious

A

Drug Induced

  • antithyroid meds - methimazole and PTU
  • lithium - bipolar
  • amiodarone - antiarrhythmic
  • Interferon alpha
  • Tyrosine kinase inhibitors - anticancer
  • TSH recheched q 6-12 mos

Infectious

  • Hematogenous spread of staph or strep
  • Inflammation - fever, heat, pain, redness, swelling
  • Incr WBC
32
Q

Thyroiditis - Hashimoto’s

A

Inflammation of the thyroid gland - multiple etiologies

Hashimoto’s thyroiditis

autoimmune form - thyroid tissue is destroyed by antibodies over time = chronic hypothyroidism

Sxs:

  • goiter on PE
  • high levels of anti-TPO antibodies

Tx

euthyroid - no treatment

Chronic hypothyroidism - lifelong sub w/ T4 aka levothyroxine

33
Q

Thyroiditis - Postpartum thyroiditis

A

2-12 months after giving birth

Immune system diminished after pregnancy => after birth immune system becomes more active and attacks thyroid

Hyperthyroid phase 5-7 mos after birth followed by normal thyroid function

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