Endocrinology Flashcards
Diabetes mellitus type 1 (PE)
Autoimmune pancr beta-cell destruction; insulin def
Polyuria, polydipsia, polyphagia, rapid weight loss
Nonobese child; young adult
Ass w/ HLA-DR3 and -DR4
At onset: anti-islet cell Ab, anti-GAD Ab, anti-insulin Ab, anti-Zn transporter Ab
Diabetes mellitus type 1 (dg, ttt)
Dg: at least 1 of 3:
- Random glu ≥200 w/ symptoms
- Fasting(>8h) glu ≥126 then 2h-post glu toler test ≥200
- HbA1c >6.5%
ttt: ins injec to get preprand glu 80-130 and postprand glu <180; test HbA1c /3months (goal <7%; child <7.5%)
Ins pump for continuous short-act ins
Diabetes mellitus type 2 (PE)
Insulin resistance in periph tissues w/ insuff ins secretion
Polyuria, polydipsia, polyphagia, blurred vision, fatigue
Insidious onset; usually already w/ complic
Older adults w/ abdo obesity
Strong genet predispo
RF: obesity, rapid weight gain, fam Hx, sedentary, ↑age, metabolic sd
Diabetes mellitus type 2 (dg)
Dg: at least 1 of 3:
- Random glu ≥200 w/ symptoms
- Fasting(>8h) glu ≥126 then 2h-post glu toler test ≥200
- HbA1c >6.5%
Negative anti-islet cell Ab, anti-GAD Ab
Diabetes mellitus type 2 (screening, ttt)
Screening: all ptts w/ RF (HTN/ob/fam Hx/racial-ethn minorities); if no RF, HbA1c for all 45yo, if <5.7% repeat/3y; if fasting glu >100+<126 or impaired toler, fqt retest
ttt: goal HbA1c <7% (aver glu 154)
Health maintenant in DM2
DM = highest R for CVds
All DM ptts given statin if >40yo + ≥1 other CV RF
BP control <140/80; ACEIs/ARBs #1
Annual PE screen CVds (BP/lipid), nephropa (microalb), retinop (eye exam), neurop (foot care)
Pneumonia vaccine to all DM >19yo
Acute complication of DM1
DKA
Precip by stress (inf/MI/trauma/alcoh); ins noncompliance
Abdo pain/N/V/Kussmaul resp/mental stat ch/fruity breath
Glu>250; metab acid (bicar<18); ↑ketones (urine+serum); ↑anion gap; Nl serum osm
ttt: fluid, K+, contin ins, P, ttt cause
Acute complication of DM2
Nonketotic hyperosmolar hyperglycemia (HHS)
Precip by stress (inf/MI/trauma/alcoh); ins noncompliance; bad diet
Dehydration/mental stat ch
Glu>600; No acid (bic>18); No ketones; Nl anion gap; Serum osm >320
ttt: aggres fluids, e- repl, insulin, ttt cause
Chronic complications of DM (retinopathy, nephropathy, macrovascular)
Retinopathy (nonprolif/prolif): when DM ≥3-5y; prevent w/ gly+BP control, eye exam, laser photocoag for retinal neovasc
Nephropathy: glomer hyperfiltr then microalb; when DM >10y; prevent w/ ACEIs/ARBs, BP+gly control
Macrovasc complic: CV, cerebroV, PVD
CV complic #1 death in DM
Chronic complications of DM (neuropathy)
Neuropathy: periph N; symm sensorimotor; burn/pain/trauma/inf/ulcers; foot care + analgesics
GI: gastroparesis; ttt metoclopramide
GU: neurogenic bladder, overflow incont, erect dysf
CV: orthostatic hypoTN
Metabolic syndrome (PE, ttt)
MS = Insulin resistance sd = sd X
Ass w/ ↑R of CAD and CV mortality
Abdo obesity; high BP; impaired gly contr; dyslip
ttt: intensive weight loss; aggres chol manag; BP contr
Metformin + lifestyle modi ↓ DM onset in this sd
Metabolic syndrome (dg)
≥3 of 5 criteria:
- waist ≥102cm men/ ≥88cm women
- Tg ≥150
- HDL <40 men; <50 women
- BP ≥ 130/85 or requirement for anti-HTN
- Fasting glu ≥100
Thyroid function tests (TFTs)
- TSH: #1 for screening (unless Hx of brain injury, then free T4 also)
- Radioactive iodine uptake+scan: level+distrib of I uptake
- Total T4: Not for screening; 99% of circ T4 bound to TBG (total T4 dep on level of TBG)
- Free T4: preferred screening test
! ↑TBG in pgncy/estrog admin/inf: No ttt
Hyperthyroidism / Thyrotoxicosis (dg)
HyperTh: ↑ synthesis T3/T4
Thyrotox: ↑ levels T3/T4
Dg: TSH then T4, rarely T3
+/- RAI scan; thyroglobulin
Thyroid storm: acute life-threat thyrotox: AF/fever/delirium; ttt: urgent antithyr then iod/IV esmolol/CS and ICU adm; high-dose potassiun iodide
Hyperthyroidism / Thyrotoxicosis (etiologies)
- Graves ds: autoimm; TSH recept-stimulating Ab ↑ synthesis T3/T4; exopht/preteb myxedema/thyroid bruits
- Toxic adenoma/toxic multinodular goiter: hyperT by autonom hyperactive nodules
- Thyroiditis: transient infl of Th; release of previous Hes; tempor ↑T3/T4; hypoTh may follow hyperT
- Fetal thyrotoxicosis: infant to mother w/ Graves; TSH-stim Ab (IgG) cross placenta
Hyperthyroidism / Thyrotoxicosis (ttt)
Propranolol
Antithyroid drugs (methimazole, PTU)
Radioactive I131 ablation or total thyroidectomy (then levothyroxine)
Steroids for severe ophthalmopathy
If unttt: long-term bone loss
Hypothyroidism (etiologies)
- Hashimoto thyroiditis: autoimm; antithyroglobulin Ab + antithyroid peroxidase Ab
- Thyroiditis (postpartum/postviral/subacute): hypoTh then hyperTh
- Secondary hypoTh: pituitary tumor/surgery
- Congenital hypoTh: dysgenesis; failure to thrive, hypotonia, umbilical hernia, prolonged jaundice
- Generalized resistance to Hes: ↑T3/T4; Nl/↑ TSH
Hypothyroidism (dg, complic, ttt)
Dg: TSH#1 then free T4; ↑ LDL/Tg; ↑CK; hypothermia
Complic: ↑R of thyr lymphoma (in Hashimoto); myxedema coma (severe hypoTh w/ ↓ mental status, hypothermia, hypoTN, bradycardia, hypoventil; morta 30-60-%; ttt ICU and urgent IV levothyr + IV hydrocortisone)
ttt: levothyroxine: if uncomplic or in subclinical hypoTh if TSH>10
Thyroiditis
Infl
Subtypes: subacute granulomatous, radiation-induced, autoimmune, postpartum, drug-induced
Subacute: tender thyr, malaise, URI symptoms, painful
Other subtypes: painless
Dg: thyrotoxicosis then hypoTh; ↓ uptake RAI
ttt: B- (hyperTh) or levothyrox (hypoTh); subacute is self-limited but NSAIDs or oral CS if severe
Thyroid neoplasms (PE)
Th nodules: ↑ w/ age; 95% benign
Usually asympt, incident dg
If hyperfct nod: hyperTh sympt, not malignant
Large nod near trachea/esoph: dysph, dyspn, cough
↑R of malign: Hx of neck radiation; cold nod (min uptake); female; <20 or >70yo; fam Hx; firm/fixed nod; rapidly growing + hoarsness
Check ant cervical LN
Thyroid neoplasms (ttt)
Benign FNA: follow w/ PE/US to see develop of suspicious charact
Malignant FNA: surgical resec (hemi/total) #1; then adj radioiodine ablation for follicular
Intermediate FNA: watchful waiting vs hemithyroidectomy
Types of thyroid carcinoma
Papillary: 75-80%; F3:M1; slow grow; lymph spread; ⊕prognosis; (orph Annie nuclei + psammoma bodies)
Follicular: 17%; hemato spread; ⊕prognosis
Medullary: 6-8%; ass w/ MEN2; calcitonin-prod C cells; prognosis related to degree of vasc invasion
Anaplastic: <2%; rapid enlarg+metast; ⊖prognosis
Osteoporosis (RF, complication)
Low bone mass
Esp thin postmenop women; ↑R x2 after 65yo
After min trauma: fx of hip/verteb compress/distal radius
RF: smoking, age, excess caff/alcoh, estrog deplet, hypogonad men, unttt hyperTh, chron infl ds, CS
Complic: fx w/ 50% ↑ morta in 1y after hip fx
Osteoporosis (dg, ttt)
DEXA: screening all women >65yo, men >70yo + if RF
Dg: BMD <2.5 SDs than T-score
Osteopenia: BMD betw/ 1-2.5 SDs below T-score
Normal Ca/P/PTH
ttt: prevent+ttt w/ Ca + VitD supplem
Smok cess, weight-bearing exo
Bisphosphonates; antiresorptive (SERM, denosumab); anabolic (teriparatide=PTH)
Paget disease (PE, complication)
↑ rate of bone turnover; mosaic lamellar bone
Ass w/ hyperparath and ↑R osteosarcoma
Esp skull, verteb, pelvis, long bones
Asympt but may have aching bone/joint, headache, bony deform, fx, nerve entrap (hear loss)
Complic: fx, high-output cardiac failure, osteosarcoma
Paget disease (dg, ttt)
Dg: radiographic (lytic/sclerotic); ↑ALP but Nl GGT and Nl Ca/P
ttt: Ca + VitD supplem
Severe pain: NSAIDs, acetamino; Asympt not ttt
Fx: bisphosphonates, calcitonin slow resopt
Hyperparathyroidism (types)
1* hyper: 80% from hyperfct adenoma; 15% parath hyperplasia; 5% parath carcinoma
2* hyper: ↑PTH after renal insuff (↓vitD), Ca def, vitD def
3* hyper: in dialysis w/ long-stand 2* hyperpara then hyperplasia of parath; ≥1 gld autonomous
Pseudohypoparathyroidism: PTH resist, ↑PTH but ineff; ↓Ca, ↑P; ass w/ Albright osteodystrophy
Hyperparathyroidism (dg, ttt)
Most 1* asympt but may show PE hyperCa
1*: hyperCa, hypoP, hyperCaUria, ↑PTH
DEXA: may have low BMD or osteoporosis
99mTc scan + US: localize solit adenoma
Stones, bones, moans, groans, psychiatric overtones
ttt: parathyroidectomy if sympt or ↑↑Ca/↑crea/↓BMD/<50yo
Solit aden: 1 gld removed
Hyperplasia: 3.5 glds removed
Hyperparathyroidism 1* (ttt other than surgery, complication)
ttt of hyperCa: IV fluids then loop diuretics
Add bisphosphonates if malignancy or acute (IV)
+/- calcitonin
If renal insuff: oral phosphate binders + ↓P in diet
Cinacalcet: lowers PTH in 2* hyperpara or if surg CI
Complic: hypercalcemia; hungry bone sd (post-surg) w/ severe/prolong hypoCa + ↑bone uptake
Hypoparathyroidism (etiologies)
Iatrogenic (post-surg)
Autoimmune
Congenital (DiGeorge)
Infiltrative ds (hemochromatosis, Wilson)
Hypopituitarism
By mass, surgery, radiation, Sheehan (infarction), apoplexy (hge), infiltr ds (hemochrom), inf
FSH, LH, TSH affected #1
Suddenly or gradually
Dg: 8AM cortisol, free T4, testo/estrad, IGF-1
ttt: cause
Cushing syndrome (etiologies)
#1 exog cause: prolong ttt w/ CS #1 endog cause: Cushing ds (↑ACTH by pit adenoma)
Other: bilat adr hyperplasia/adr adenoma/adr cancer; ectop ACTH by cancer (carnicoid/medull thyr/small cell lung)
Cushing syndrome (dg, ttt)
Dg: susp → overnight 1mgDXM or 24h urin free cortisol → suppr=Nl; no suppr=confirm w/ ↑urin cort → Cushing sd
ACTH+cort → ↓ACTH=adr tumor; both↑=ACTH-dep Cush
MRI pit → aden(>4-5mm)=Cush ds; No/<4mm aden then CRH-stim test + ACTH gradient (⊖ectopic/⊕Cush ds)
ttt: surgical resect of source; permanent He replac
Acromegaly (PE, dg)
#1 cause: benign pit GH-secre adenoma ↑R: carpal tun sd, obstr sleep apn, DM2, heart ds, HTN, colon K, arthritis; bitemp hemianops (by pit adenoma)
Dg: ↑IGF-1, confirm w/ oral glu suppr test (GH remains ↑); MRI. Do not measure baseline GH
Acromegaly (ttt, complication)
1 cause of death: CHF (diastolic dysfct)
ttt: transsphenoidal surg resect or external beam radiation
Octreotide (somatost analogue)
Pegvisomant (GH recept antag)
Hyperprolactinemia
Etiologies: pituit adenoma (#1), pituit stalk compress, drugs (dopa antag), renal failure, cirrhosis Inhib GnRH (↓FSH/LH): infertil/galactorrh/amenorrh; bitemp hemianops; !always r/o pgncy
Dg: prolact >200; MRI
ttt: #1 dopamine agon (cabergoline/bromocriptine); surgery (if refract or compression)
Diabetes insipidus (etiologies, PE)
Central (ADH def): pituit tumor/ischemia/hge, brain trauma, inf, metast, autoimm
Nephrogenic (ADH resist): renal ds, drugs (lithium)
Polydipsia, polyuria, persistent thirst, dilute urine
Normonatremic; if limited water access (hosp/elderly) then hyperNa (alter ment stat/lethargy/seiz/coma)
Diabetes insipidus (dg, ttt)
Dg: water deprivation test → high volume of inapprop dilute urine (No concentr)
DDAVP (ADH analog) replac test: Central (↓urin outp, ↑urin osm by 50-100%); Nephrog (No effect on both)
MRI (mass in central DI)
ttt: DDAVP (central); salt restric+water intake (nephrog) +/- thiazide
SIADH
ADH releas indep of serum osm; euvolemic hypoNa
Ass w/ CNS ds, pulm ds, ectop tumor/paraneopl, drugs
Dg: Urin osm >50-100 + serum hypo-osm w/o reason for ↑ADH (CHF/cirrhosis/hypovolemia); urin Na ≥40
ttt: fluid restriction (#1); ttt cause
SLOWLY give hyperton saline if severe hypoNa or if sympt + monitor ICU to prevent central pontine myelinolysis
Demeclocyline (ADH recep antag) or Conivaptan (vasopressin recep antag): normalize natremia
Adrenal insufficiency (etiologies)
1: Addison ds (autoimm cortical destruct), congen enz def, Waterhouse-Friderichsen sd (adren hge), inf, TB
2/3*: ↓ACTH prod or ↓CRH prod; cessation of long-term GC ttt (>20g for >3wks)
1: hyperpigm, ↓GC, ↓mineraloC
2: ↓GC, No hyperpigm, Nl mineraloC (MC not ACTH dep)
Adrenal insufficiency (PE, dg)
Weak, fatigue, anorexia, ↓weight, hyperpigm in Addison
Dg: 8AM corti + ACTH measure; if non-dg, synthetic ACTH stimul test
Adr insuff = 8AM cort <3 w/o exog GC; failure of cort to ↑>20 after ACTH confirms dg
Adrenal insufficiency (ttt)
ttt: 1* replace GC+MC; 2/3 only replace GC
Adr crisis: IV steroids (100mg/8h hydrocort), e- replac, 50% dextrose, aggr fluids (0.9% saline)
↑steroids when stress (surg/inf/trauma)
If chronic steroid ttt, taper slowly to prevent 2/3 AI
Pheochromocytoma (etiologies, PE)
Tumor of chromaffin tissue; in adr medulla or extra-adr
Ass w/ MEN 2A and 2B; von-HipLin ds, neurofibromat
10%: extra-adr, bilat, malign, child, familial
Paroxysm tachycard, palpit, chest pain, diaphor, HTN, headache, tremor, anxiety
Pheochromocytoma (dg, ttt)
Dg: CT, MRI; nuclear MIBG scan for extra-adr/metast
↑metaneph (free in plasma or 24-h urine)
ttt: surg resec
! pre-op: alpha-block (phenoxybenz) to contr HTN then B- to contr tachycard
Hyperaldosteronism
Adrenocort hyperpl (70%); unilat adr adenoma (=Conn sd; 30%) HTN, headache, polyuria, muscle weakness Dg: HypoK, metab alkal, hypoMg, hyperaldo, ↑aldo/renin ratio; CT or MRI
ttt: surgic resec if tumor (after BP + K+ correction); epleronone (aldo recep antag) if bilat hyperpl
Congenital adrenal hyperplasia
Enz def → impaired cort synth
21-hydr def (95%); 11-hydr def; 17-hydr def
Dg: HypoNa, hyperK, metab acid; if severe, life-thr salt wasting; in 21-hydr def, ↑17-hydroxyprogest
ttt: immediate fluid resusc + salt replet; cortisol to ↓ACTH + androg; fludrocortisone if severe 21-hydr def
Possible surgical correction of ambig genit
Multiple Endocrine Neoplasias
AD inheritance
MEN1: pancr islet cell tumors, parathy hyperplasia, pituit adenomas
MEN2A (RET mut): medull thyr carcinoma, pheo/adr hyperpl, parathy hyperplasia
MEN2B (RET mut): medull thyr carcinoma, pheo, oral/intest ganglioneuroma, marfanoid habit
