Exam #4 Flashcards
1
Q
Anterior Pituitary
A
- adenohypophysis
- vascular
- produces hormones:
- ACHT: increases cortisol
- TSH: increase T4/T3
- FSH: gonads
- LH: gonads
- GH
- excessive GH is almost always due to a tumor
- overproduction of GH = acromegaly
2
Q
Posterior Pituitary
A
- neurohypophysis
- neural
- collects, stores and releases hormones based on signals received
- vasopressin (ADH): reabsorbs water
- oxytocin: lactation
3
Q
Acromegaly
A
- anterior pituitary issue with GH
- excess of growth hormone after the epiphyseal plate closure: no growth in height but hands, feet and face. Big tongue, deep voice, thickened vocal chords
- generally affects middle-aged adults
- starts gradually: 7-9 yrs between onset and final dx
- causes: pituitary adenoma (tumor on ant pit)
- life expectancy reduced 5-10 years: excess circulating glucose, triglycerides
- if untreated these patients are likely to have cardiac (atherosclerosis), respiratory (tightening of throat), diabetes (increased circulating glucose, GH inhibits insulin) and cancers (increased tissue growth from GH)
4
Q
S/S of Acromegaly
A
- thickening of hands, feet, nose, and mouth
- usualyl what leads to dx with CT scan and they visualize tumor
- speech issues: thickening of tongue, deepening voice, hypertrophy of vocal chords
- slepe apnea: upper airway narrowing
- peripheral neuropathy: result of nerve damage, pain generally to hands and feet, excess tissue increases pressure on nerves
- muscle weakness
- visual changes/headache (tumor)
- Labs: increased GH, increased IGF1, increased glucose
5
Q
IGF1
A
look up
6
Q
DX of acromegaly
A
- MRI, CT to assess pituitary tumor
- ophthalmic exam: tumor may put pressure on optic nerve
- diagnosis often promted by headaches and/or visual changes
7
Q
TX of acromegaly
A
- hypophysectomy: removal of pituitary tumor
~ done transphenoid
~ incision is made just unde the inner, upper lip
~ immediate reduction in GH levels followed by a drop in IGF1 levels, will be seen in just a few weeks post removal - radiation: if surgery fails
~ goal is complete remission
~ done in combination with drugs - medications: octreotide reduces GH, SQ 3 x week
- sandostatin and lareotide: longer acting, IM every 2-4 weeks, GH inhibitor
8
Q
Trans-sphenoidal Hypophysectomy
A
- HOB 30 degrees
- decrease pressure on the sell turnica (where pituitary is located) and decreases headaches
- assess neuro changes
- instruct pt to avoid: vigorous coughing, sneezing, straining, blowing nose
- prevent CSF leakage: relax, bedrest,
- glucose level > 30 = CSF leak
- pt at risk for meninngitis if CSF leak
- if pt complains of consistent supraorbital headache, may indicated CSF leak: bedrest, tyelinol for headache
- CSF leak usually resolves within 72 hours and if it doesnt may need surgery
- mouth care q 4 hours
- avoid brushing teeth for 10 days
9
Q
SIADH
A
- overproduction of ADH from posterior pituitary with low sodium in ECF which causes intracellular swelling
- due to a tumor in the post pit
- S/S SIADH
~ hyponatremia (norm 135-145)
~ hypo-osmolality (285-295)
~ headache: sodium issues, neuro issues
~ muscle cramps, muscle twitching
~ weakness, vomiting, abdominal cramps
~ fluid retention and concentrated urine with normal kidney function - increaesd urine osmolarity, decreased ECF osmolarity
10
Q
how does SIADH happen?
A
- ADH causes sodium retention, thereby holds in water
- inappropriate ADH causes too much water to be retained
- bronchogenic small cell cancer (oat cell ca): synthesizes and releases ADH, secretes its own synthetic ADH
11
Q
TX of SIADH
A
- serum sodium
12
Q
Diabetes Insipidus
A
- vast quantities of dilute urine
- deficiency of production or secretion of ADH
(1) central DI: pituitary issue, lack of ADH production or release - brain injury, CNS infarction, brain tumor or head surgery (all increase ICP)
- leasts for 10-14 days
- dilantin can give you DI
(2) nephrogenic DI: adequate amounts of ADH but kidneys dont respond - renal damage or lithium (blocks ADH at kidney level)
(3) psychogenic DI: from excessive water intake - lesios in the thirst center or by psychiatric problem
13
Q
S/S of DI
A
- massive diuresis, urine output of 4-30L a day
- low urine specific gravity
- low urine osmolarity and high serum osmolatity
- increased thirst
- generalized weakness
- weight loss
- constipation
- poor skin turgor
- hypotensions
- tachycardia
- shock
- increased sodium in serum
- cells shrink, neuro issues, agitation, muscle issue
- decreased ADH, high na, high serum osmo, increased urine output
- urine specific gravity
14
Q
DI TX
A
(1) central DI
- DDAVP - IV, SQ, nasal: synthetic for of ADH taht causes reabsoprtion of water decreases the amount of urine, pt not to drink more than 3 L a day, weights daily
- DSW IVF titrate to replace urine output: hypotonic solution to decrease serum osmo
(2) nephrogenic DI
- low sodium diet
- thiazide diuretics
- serial labs: sodium, osmolality
- strict I&Os
- daily weights
15
Q
Thyroid Gland
A
- thyroxine (T4) and Tri-iodothyronine (T3) regulate energy metabolism , growth, and development
- Goiter: hypertrophy and enlargment of thyroid gland
- hyper/hypothyroidism or normal thyroid funtion (too mch T3/T4)
- goiter can be found in graves disease
- most often a goiter is found with lack of iodine in diet
- malignant nodules needs to be removed: radiation can be used, palpable deformity of the thyroid gland
- thyroiditis: inflammation of thyroid, pain around ear down to thyroi. palpate and listen to bruit near thyroid
- viral or bacterial or autoimmune in nature
- TX: bacterial abx, hypothyroid needs thyroid replacement
16
Q
hyperthyroidism
A
- excess circulating levels of T3/T4
- increased cellular metabolism
- effects women more than men
- primary ages effects 20-40yrs
- Grave’s Disease: autoimmune disease unknown etiology marked by thyroid enlargement and excess TSH
17
Q
Grave’s Disease
A
- autoimmune disease
- thyroid enlargement and excess TSH
- initially: increased T3/T4 which causes no TSH in ant pit
- later: decreased T3/T4 and increased TSH in ant pit
- patient develops antibodies to TSH receptors: antibodies bind to receptors causing stimulation of the thyroid gland and releasing T3 and T4
18
Q
S/S hyperthyroidism
A
- HTN
- increased HR and bounding pulse
systolic murmor: r/t hypervolemia ad hypertension - dysrhythmias: increased myocardial oxygen consumption
- palpitations
- exophthalmos: protrusion of eyeballs (fluid buildup behing eyes, eyelid forced open)
- increased cell metabolism all otgether
- increased appetite
- weight loss
- diarrhea
- hair loss
- thinning nails
19
Q
thyroid storm, thyroid crisis
A
- don’t know you have it then exposed to a stressor and it happens all of a suddent
- hyperthyroidism untreated may lead to a thyroid storm
- all hyperthyroid manifestations are heightened
- critical illness lasts 7-10 days, potentially lethal
- thought to be caused by several stressors: infection, trauma, surgery, heart and nerve tissue become more sensitive
- S/S = r/t increased tissue sensitivity to thyroid horomones: severe tachy, heart failure, high temp, shock, restlessness, agitaiton, seizures, abdominal pain, nauseam, vomiting, diarrhea, delirium, coma
- labs: low TSH and increased thyroxine
- TX: antithyroid drugs, iodine, beta adrenergic blockers, prophylthiouracil (PTU) and methimzole (tapazole) inhibit synthesis of thyroid hormones
- iodine inhibits synthesis of T3 and T4 (only when given in very large doses it inhibits production), beta blockers treat symotims of slow heart rate
20
Q
Hyperthyroidism, diagnostic testing
A
- hyperthyroidism: Low TSH level, elevated free T4
- normal TSH levels: 0.3-5.4
- normal T4 levels: 5-12
- these tests along with s/s and history will confirm diagnostics
- how to differentiate grave’s disease from other hyperthyroidisms: RAIU (radioactive iodine uptake test) – graves = 35-95%, thyroiditis =
21
Q
treatment for hyperthyroidism
A
- antithyroid drugs: propylthiouracil (PTU) and methimazole (tapazole): antithyroid drugs blocks the synthesis of thyroid hormones. PTU also blocks conversion of T4 to T3
- PTU only orally absorbed
- can take 1-2 weeks to work
- may be used long term 6-15 months
- iodine: used with other antithyroid drugs to prepare patient for thyroidectomy or for treatment of thyrotoxic crisis
- not used long term
- large doses of iodine inhibit synthesis of T3 and T4
- beta adrenergic blockers utilized to treat symptoms caused by tissue responses to catecholamine
- RAI destroys thyroid tissue thus limiting the secretion of thyroid horomone: maximal effet is seen in 2-3 months, pt remain on therapy until maximal effects seen from RAL
- surgical therapy utilized when patient is unresponsive to other forms of therapy, also used with removal of a large goiter that is presing on the throat or thyroid
- subtotal thyroidectomy: surgery of choice, significant portion of thyroid removal
- total thyroidectomy: 90% of thyroid removed
22
Q
concerns with hyprethyroid treatment
A
- can make pt hypothyroid due to removal of too much thyroid tissue
- post operatively: N/v, oxygen levels, comfort
- watch site for swelling of the net and tissues, hemorrhage, hematoma laryngeal stridor
- trachestomy tray in the room always in case of emergency
- take frequent vitals, frequent oxygen checks HOB up to decrease swelling
- watch for signs of tetany d/t hypoparathyroidism
- trousseaus sign: sign of Tetnay, bp cuff inflated and wrist flexes
- chevostek’s sign: cheek flinches, sign of tetany
- tetany = a condition marked by intermittent muscular spasms, caused by malfunction of the parathyroid glands and a consequent deficiency of calcium.
23
Q
dangers after thyroid surgery
A
- airway swelling
- n/v
- HOB elevated
- watch for s/s of tetany (can be caused by nicking the parathyroid during surgery)
- tetany: proximity to parathyroid, chvosetek’s sign and trousseau’s sign
24
Q
hypothyroidism
A
- insufficient cirrculating thyroid hormone r/t destruction of thyroid tissue, defective hormone synthesis (lithium, amiodarone), iodine deficiency
- may be transient: from thyroiditis, discontinuation of thyroid therapy (if you stop synthroid and your body isnt used to making its own thyroid hormone then it will be slow at making it at first)
- iatrogenic: can be the result of a thyroid removal of tissue removal
25
Q
patho of hypothyroidism
A
- decreased protein synthesis: may lead to absent RBC and amino acid production
- Incomplete fat & carbohydrate metabolism: inadequate gluconeogenesis
- ineffective lipolysis: high cholesterol levels, cant break down fat so leads to high cholesterol
- hyaluronic acid: gel like substance, in interstitial tissues - puffy face and eyes, accumulates in muscles, esp heart, tongue, pharynx, esophagus
26
Q
s/s hypothyroidism
A
- fatigue, lethargy
- personality changes: depression, somnelence
- impaired memory, slowed speech
- depressed appearance about them
- disruptive sleep patterns
- SOB, exercise intolerance
- constipation
- hair loss, brittle nails, weight gain
- myexedema: gel like distribution in face, mask-like
- symptoms depend on severity: some may have no symptoms, periorbital edema, puffy skin, prominant tongue
- decreased cardiac output and contractility
- anemia is a common problem due to decreased protein levels and increased o2 consumption (high cellular metabolism)
- Gi motility slowed
- intolerant of cold, cant shiver to keep themselves warm
- respiratory: muscles weak, increased PaCO2, decreased PaO2, decreased RR
- kidneys: decreased GFR, increased ADH secretion, inabikity to maintain body heat
27
Q
myxedema coma
A
- mental slugglishness can lead to coma
- this is a medical emergency
- subnormal temperature
- hypotension, decreased CO
- hypoventilation, decreased RR
- patient needs: IV thyroid replacement thearpy, vital organ support (in ICU)
- ICU with warming blanket, IV warming fluids, ventilator, meds to help with BP
28
Q
hypothyroidism diagnostic tests
A
- serum level TSH can be indicative of cause of hypothyroidism
- TSH high = defect originated in the thyroid
- TSH low = defect originates in pituitary or hypothalamus
- low T4
- elevated cholesterol, triglycerides, creatinine kinase
- pt may be anemic, poor RBC synthesis
- decreased erythropoietin and RBC production
