Endocrinology Flashcards
1
Q
DM type I
A
- onset: slow in adults, rapid in children, autoimmune, Finland/Sardinia (by Italy)
- Type 1A: immune mediated, HLA associated, white, no FHx, autoantibody (+)
- Type 1B: idiopathic, AA/Asian, autoantibody (-), FHx
- sxs: 3Ps (polyuria, polydipsia, polyphagia), wt loss, infxn, nocturia, blurry vision
- dx: autoimmune markers, GAD65 autoAbs, islet cell autoAbs, insulin autoAbs, C-peptide low (no active insulin in body)
- tx: insulin pen, vial and basal bolus with carb counting, check gluc at least 4x daily
2
Q
DM type II
A
- insulin resistance: hyperinsulin at first, then hypoinsulinemic
- insulin resistance doesnt change - insulin secretion changes, B-cell decline gradual, def of amylin, def of GLP-1: stops glucagon, satiety, inc insulin release, postprandial gluc increases over time
- RF: first deg relative, age, obesity
- sxs: blurred vision, 3Ps, WIN, Acanthosis nigricans, ketonuria and wt loss (rare), fatigue, pruritus, recurrent candidal vaginitis, blurred vision, poor wound healing
- dx: randome glucose >200 (w/ sxs), fasting >126 (2+ occasions), HbA1C >6.5%, OGTT if fasting 100-125, diabetic dyslipidemia (high TGs, low HDL, altered LDL)
- tx: diet, exercise, wt loss, metformin
- goal of HbA1C = 6-6.5, FBS goal = 100-124, 1-2 PP (<180), screen annually
3
Q
dawn phenomenon and somogyi phenomenon
A
- dawn phenomenon: increased resistance to insulin in the early morning d/t counter-reg hormones
- tx: increase overnight basal insulin, exercise, metformin, TZD
- somogyi phenomenon: rebound fasting hyperglyc following undetected hypoglyc overnight, excess hunger, wt gain, worsening hyperglyc
- tx: dec overnight basal insulin or eat a snack at bedtime
4
Q
hyperthyroidism
A
- associated: afib
- subclinical hyperthyroidsim = low TSH, normal T3/T4
- sxs: anxiety, insomnia, irritability, palps, wt loss, heat intolerance, sweating, D, increased freq, oligomen, tremor, hyperactivity, tremulousness
- signs: moist skin, tachycardia, hyperreflexia, flushed, diaphoretic, wide pulse pressure
- dx: Primary hyperthyroid - TFTs (TSH low, total T3 high, free T4 high)
- autoantibody tests (antithyroid peroxidase Ab, TS-immunoglob
- scintigraphy (thyroid scan) - if etiology unclear after initial labs
- tx: propranolol, methimazole, propylthiouracil (can . use in preg and thyroid storm), RAI tx, thyroidectomy
5
Q
hypothyroid
A
- primary: failure of thyroid to produce sufficient T3 (iatrogenic - prior tx of hyper thyroid, hashimotos)
- secondary: hypothyroid dt pituitary dz, low TSH/free T4
- tertiary: dt hypothal dz (TRH def), low TSH/free T4
- associated: carpal tunnel syndrome
- sxs: constipation, fatigue, lethargy, weakness, wt gain, depression, menorrhagia, cold intolerance, cramps, slow mentation, inability to concentrate, dull expresion, m weakness, arthralgias, hoarseness
- signs: dry, rough skin, coarse hair, palpable enlarged thyroid, brittle nails, puffy face and eyelids, yellowing of skin (carotenemia), decreased DTRs
- dx: thyroid fn tests
- primary: high TSH (most sensitive)
- secondary: low TSH
- tertiary: low TSH
- free T4 low in clinically overt
- Ab testing, CBC (normocytic anemia MC)
- tx: levothyroxine (T4) → effects in 2-4wk →monitor TSH and clinical state periodically
6
Q
Grave’s dz (diffuse toxic goiter)
A
- 80%, metabolically active gland, MCC of hyperthyroidism, mostly younger women with other autoimmune conditions, Autoimmune (thyroid stimulating IgG Ab binds TSH receptors on surface o f thyroid cells triggering synthesis of excess thyroid hormone)
- sxs: pretibial myxedema, exophthalmos (periorbital edema, diplopia, or proptosis), thyroid bruit, diffusely enlarged, symmetric, nontender gland
- dx: measurement of thyroid Abs (anti-TPO high, TSI high), scintigraphy (diffuse uptake)
- tx: antithyroid meds, radioactive iodine preferred, saline eye drops and tight fitting sunglasses, high dose steroids with orbital decompresison surgery and ocular radiation tx for severe exophthalmos
7
Q
thyroid storm
A
- rare, life-threatening complication of thyrotoxicosis, acute exacerbation of hyperthyroidism
- precipitating factors: infxn, DKA, stress (trauma, surgery, illness, labor)
- sxs: marked fever, agitation, psychosis, confusion, nausea, vomiting, diarrhea, signs: tachycardia
- tx: supportive tx, antithyroid agents (PTU q2h, iodine), BB, dexameth (generates peripheral T3 from T4, adrenal support
- high mortality (20%)
8
Q
hashimoto’s thyroiditis
A
- MCC: autoimmune thyroid disorder and MCC hypothyroidism
- MC in F, genetics + FH common, slow decline in thyroid fn
- sxs: puffiness of face and . eyelides: periorbital myxedema, thinning of outer halves of eyebrows, goiter (MC feature) - hard, nonpainful, nontender, multinodular, irregular, asymmetric
- dx: antiperoxidase Abs (90% +), anti thyroglobulin . Ab, antimicrosomal Ab high, irregular I-131 on thyroid scan (not required to DX)
- tx: levothyroxine (T4)
9
Q
primary adrenal insufficiency (addison dz)
A
- chronic adrenocortical insufficiency
- adrenal gland does not produce cort, aldosterone, or sex hormones (retain no sodium), primary adrenal failure from autoimmune adrenalitis
- sxs: hyperpig dt increased ACTH, MSH (POMC), anorexia, abdominal pain, N, V, wt loss, lethargy, confusion, psychosis, weakness, malaise, postural HoTN, dizziness, salt craving
- signs: hypotension (orthostasis)
- dx: electrolytes (hyponat, hyperkalemia, hypoglycemia, hypercalcemia, elevated SCr), low serum cort, high ACTH, low aldo and high renin
- cosyntropin test = definitive (cort will not elevate sufficiently → test also known as astandard ACTH test
- tx: daily oral steroids (hydrocort, prednisone), daily fludrocort (mineralocort)
10
Q
secondary adrenal insufficiency
A
- long-term steroid therapy - most common cause overall, dysfunciton of hypothalamic pituitary . component of HPA axis: only steroid and androgen deficiency present
- sxs: hx of prior use of oral steorids shuts down adrenal axis and causes acute adrenal crisis when stopped (weakness, malaise, postural HoTN, lethargy, confusion, psychosis)
- sings: alabaster pale skin
- dx: electrolytes (hyponat, hyperkalemia, hypoglyc, serum cort low, serum ACTH low, nl aldosterone and renin, ACTH test → cort will not respond at all)
- tx: only daily steroid required
11
Q
addisonian (adrenal) crisis
A
- HoTN refractory to IV fluids or acutely ill pts with chronic steroid use (moon facies, buffalo hump), any stress can precipitate adrenal crisis
- sxs: fatigue, anorexia, generalized aches, weakness, lethargy, abd pain, N, V
- signs: severe HoTN (orthostasis)
- dx: hyponatremia, hyperK, hypoglyc, elevated SCr, metabolic acidosis, acute renal failure, cortisol low, ACTH stim test or cosyntropin test (cort will not elevate sufficiently)
- tx: IV hydrocortisone, fludrocortisone, IV fluids, monitor fluid intake and output, and serum K levels frequently
12
Q
cushing syndrome
A
- excessive exogenous cort, MCC = iatrogenic dt prescribed prenisone, androgen excess absent (exog steroids suppress production by adrenals), second MCC = ACTH secreting adenoma (AKA cushing dz) →bilateral adrenal hyperplasia (androgen excess common)
- sxs: striae, buffalo hump, central obesity, moon facies, lanugo, acne, easy bruising, proximal muscle weakness and wasting, osteoporosis, AVN of fem head, HA, depression, mani
- signs: HTN, DM, menstrual irreg, infertility, Cushing dz only = masculinization
- dx: HD dexamethasome suppression test, midnight serum cortisol, late night salivary cort, urinary free cort, CT or MRI, sustained elevated cort, hypoK, hyperglyc, glucosuria
- tx: if iatrogenic → taper steroids, if ACTH secreting adenoma, transphenoidal resection of tumor, adrenal adenoma → pit radiation, med adrenalectomy, bilateral adrenalectomy, ectopic ACTH production (2/3 SCC from lungs)
13
Q
hyperthyroidism in infants
A
- F>M, MCC in children is graves dz
- sxs: jittery, loose stool, worsening school performance, poor concentration, hyperactivity, fatigue, emotionally labile, nervous, personality disturb, insomnia, weight loss, palps, heat intol, sweating
- signs: tachycardia, tremor, proximal mm weakness, warm skin
- dx: TFTs, TSH low, total T3 high, free T4 high, autoantibody tests (antithyroid peroxidase Ab, TS immunoglobulin)
- tx: sxatic relief (propranolol relieves tachycardia, tremor, sweating, anxiety), anti-thyroid meds (methimazole, PTU)
14
Q
hypothyroidism in infants
A
- severe cretinism (congenital hypothyroid), mental impairment, AAP recommends screening between 2-4d of birth
- sxs: round face, hirsute forehead, large ant/post fontanelle, wide suture, protruding tongue, hoarse cry, distended abd, prolonged jaundice, lethargy, poor weight gain, constipation
- signs: dry skin, hypoactivity, poor feeding, mottling, hypothermia, poor muscle tone, macroglossia, hypertelorism
- dx: TFTs, serum TSH high (most sensitive), free T4 low, Ab testing, CBC (normocytic anemia MC)
- tx: levothyroxine
15
Q
heat and cold intolerance
A
- heat intolerance ddx: hyperthyroidism
- cold intolerance ddx: myxedema (hypothyroidism
- myxedema coma: rare condition, precipitating factors (cold exposure, infxn, trauma, narcotics)
- sxs: depressed state of consciousness, profound hypothermia, resp depression
- tx: supportive tx for BP and breathing, IV thyroxine, IV hydrocortisone
- high mortality rate (50-75%)
- myxedema coma: rare condition, precipitating factors (cold exposure, infxn, trauma, narcotics)
16
Q
palpitations
A
- ddx: hyperthyroid, pheochromocytoma
17
Q
tremors
A
- ddx: hyperthyroidism, thyrotoxicosis
- mcc thyrotoxicosis = grave’s dz
- 80%, metabolically active gland, MCC of hyperthyroidism, mostly younger women with other autoimmune conditions, Autoimmune (thyroid stimulating IgG Ab binds TSH receptors on surface o f thyroid cells triggering synthesis of excess thyroid hormone)
- sxs: pretibial myxedema, exophthalmos (periorbital edema, diplopia, or proptosis), thyroid bruit, diffusely enlarged, symmetric, nontender gland
- dx: measurement of thyroid Abs (anti-TPO high, TSI high), scintigraphy (diffuse uptake)
- tx: antithyroid meds, radioactive iodine preferred, saline eye drops and tight fitting sunglasses, high dose steroids with orbital decompresison surgery and ocular radiation tx for severe exophthalmos
- mcc thyrotoxicosis = grave’s dz
18
Q
hyperparathyroidism etiology and sxs
A
- Primary: one or more glands produce inappropriate PTH relative to Ca2+
- MCC: parathyroid adenoma
- secondary: high PTH and low or nl Ca2+
- MCC: chronic renal failure, vitD def, renal hypercalciuria, most found incidentally by hypercalcemia on routine labs, most F>50
- sxs: most asxatic; stones, bones, groans, psychiatric overtones
- stones: nephrolithiasis, frequent urination
- bones: body aches and pains, osteitis fibrosa cystica (brown tumors - predisposes to fx), weakness
- groans: abdominal pain, constipation, N/V/A
- psychiatric overtones: depression, fatigue, anorexia, sleep disturbance, anxiety, lethargy
- signs: HTN, dec DTRs
19
Q
hyperparathyroidism dx and tx
A
- dx: serum Ca2+ HIGH, serum phosphate LOW, serum PTH HIGH (first line)
- total and ionized Ca2+ high, alb low, urine caAMP high
- XR: subperiosteal bone resorption, osteopenia
- tx: if serum Ca2+ >12 - IV fluid resuscitation; otherwise follow up
- primary: BB, k-phos supplement, dietary calcium restriction, bisphosphonates, calcimimetic agents (calcinet), parathyroidectomy
- secondary: 400IU vitD (calcitriol) daily for vitD deficiency (annual Ca and Cr measurements, annual KUB for stones, DEXA q2-3y), PO Ca, dietary phos restriction for renail failure
20
Q
Diabetes insipidus
A
- Diabetes insipidus - excretion of large volume of dilute urine
- sxs: polyuria, nocturia, polydipsia
- dx: hypernatremia, 24h urine collection, urine osmolality LOW, water restriction test = confirmatory (differentiates central DI from primary polydipsia)
21
Q
central diabetes insipidus
A
- neurohypophyseal - deficient secretion of ADH resulting in variable degree of polyuria
- SODIUM IS HIGH IN CENTRAL DI
- idiopathic, possibloy autoimmune injury to ADH producing cells, MC type
- sxs: polyuria, abrupt, excretion of dilute colorless urine, polydipsia, nocturia
- dx: hypernat, urine osmolality LOW, water restriction and desmopressin test inc urine osmolality by 300, ADH LOW
- tx: desmopressin PO, nasal spray, or injection, chlorpropamide increases ADH secretion and enhances effect of ADH
22
Q
Nephrogenic Diabetes insipidus
A
- normal ADH secretion, but varying renal resistance to water-retaining effect
- children: x-linked; acquired from drug exposure (chronic lithium use, amphotericin B, metabolic conditions - hypercalcemia, hypokalemia), or renal damage
- sxs: polyuria (gradual), nocturia
- dx: hypernatremia, urine osmolality low, water restriction and desmopressin test: will not increase urine osmolality, ADH nl to high
23
Q
DKA etiology and sxs
A
- MC acute life-threatening complication of diabetes
- MC: type 1, but may occur with type 2
- precipitating factor: omission/inadequate insulin, infxn (MC), new onset T1 DM, pancreatitis, AMI, CVA, drugs, acidosis drives K out of cells -> hyperK
- sxs: fatigue and weakness (hrs to days), abd pain, vom, polyuria, polydipsia
- signs: rapid deep resp (kussmaul resp), tachycardia, hoTN, dec turgor, fruity or acetone breath, if severe - AMS (can lead to stupor or coma)
24
Q
DKA dx and tx
A
- dx studies: ABG (pH <7.3), gluc >250, serum HCO3 <15, serum ketones +
- check: serum K, anion gap (assess severity of acidosis and follow progress of tx, beta hydroxybutyrate (primary ketone body), serum osm >250
- tx: restore circulation (IV saline), tx insulin def (IV insulin infusion until urinary ketones resolve - SQ insulin), tx lyte disturb (Na initially low, inc with IVF; K/PO4 initially high, dec with IVF/IVI; mg low), search for underlying causes of met decomp.
25
Q
hyperosmolar hyperglycemic state etiology and sxs
A
- precipitating factors: infxn, AMI, CVA, trauma, dec access to water, med effects or interactions
- RF: >65y, nursing home, change in DM meds, infxn, dmentia, sufficient insulin activity to prevent lipolysis and ketogenesis, results from gradual diuresis -> severe dehydration and lyte depletion
- sxs: polyuria/dipsia/phagia, gen weakness, N/V (no abd pain, develops over days-weeks), mental staus changes (MC), stupor/coma
- signs: severe dehydration (dry mucous membranes, poor skin turgor, delayed cap refill), tachycardia, ortho hoTN
26
Q
hyperosmolar hyperglycemic state dx and tx
A
- dx: ABG (arterial ph >7.3 - no acidosis), glucose >600, serum hCO3 >15, serum ketones or ketonuria - small, glucosuria
- check serum osm - >320-380, anion gap <10, hyponatremia, K+ low/nl, BUN elevated
- tx: restore circulation - IV saline, tx insulin circ with IV regular insulin, treat electrolyte disturb (recheck hourly)
