Fatigue (Raff) Flashcards

1
Q

A 48 year old woman comes to your office complaining of fatigue and tiredness. • Physical Examination: No obvious abnormalities. – BP - normal – Height/weight – BMI not increased – Menstrual History – menopause at 45 y.o. – Normal fasting blood glucose

List Top 3 Possible Diagnosis (endocrine obviously) in the order you would evaluate them

A

Adrenal insufficiency: order ACTH or co-syntropin test

Hypothyroidism

Hypercalcemia

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2
Q

You suspect your patient has Adrenal insufficiency. What labs would you order

A

ACTH stimulation test: baseline cortisol, and aldosterone levels

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3
Q

What imaging would you want to get if you suspect adrenal insufficiency?

A

If it looks like primary adrenal insuffiecinecy get a CT of the abdomen

if you suspect 2nd adrenal insufficiency get CT of the pituitiary

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4
Q

What is a very common cause of adrenal insuffiency?

A

Addisons

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5
Q

Explain secondary adrenal insuffiency

A

Pituitary is not putting enough ACTH out thus adrenal gland atrophies; ACTH will ALWAYS be elevated in primary adrenal insufficiency

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6
Q

What symptoms do you expect to see with hypercalcemia? What about hypocalcemia?

A

Hypercalcemia: weakness: bones/stone/groans

Hypocalcemia: tetany

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7
Q

What labs and test would you order for a pt you suspect has Hashimotos?

A

Get TSH levels

Primary hypthyroidism you would see elevated TSH

In secondary hypothyroidis you would see low or inappropriately not elevated TSH so levels may look normal

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8
Q

What tests would you order for a pt you suspect has Hypercalciuria?

A

Look at serum Ca+ levels: if elevated, order PTH levels

If Ca+ is elevated and PTH is elevated or inappropriately NOT low; likely primary hypercalcinemia–> a tumor is secreating PTH causing increase in Ca+ levels called primary hyperparathyroidism

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9
Q

What could cause Secondary Hypercalciuria?

A

A rPTH secreating tumor may do this

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10
Q

Where is Ca+ aborbed in the GI system?

A

GI Calcium Absorption

  • 20-70% (highest in children) is Abosrbed and
  • 90% in duodenum and jejunum
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11
Q

By what process is Ca+ absorbed in the GI tract?

A
  • Energy-dependent, cell-mediated process regulated by 1,25(OH)2D
  • Passive diffusional paracellular pathway
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12
Q

What promotes Ca+ absorption

what inhibits it?

A

Promotes: PTH which is released when there is low plasma Ca++

Inhibited by High plasma calcium thus no PTH is realsease

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13
Q

What affect does PTH have on the kideys?

The Intestine?

The bones?

A

Kidneys: Causes conversion of 25-hydroxyvitamine D–> 1,25-dihydroxyvitamin D

cause Ca abosrpiton in gut

Causes Ca++ bone Reabsorption

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14
Q

What are the mechanisms by which Ca+ is reaborbed?

A
  • Energy-dependent, cell-mediated process regulated by 1,25(OH)2D
  • Passive diffusional paracellular pathway
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15
Q

Calcium Receptor on Parathyroid Hormone Secreting Cells

A

see image

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16
Q

PTH controls calcium balance directly and indirectly through

A

1,25(OH)2D

17
Q

Signs and symptoms of hypercalcemia

A

Bones, Stones, groans, moans and pyschiatric overtones

Fatigue and weakness, Constipation, Nausea and vomiting, Abdominal pain (ulcers)

Osteoporosis, Polyuria and polydipsia, Renal stones, Impaired memory, confusion, and depression, Drowsiness, Coma

18
Q

Key diagnostic eval for pt with hypercalcemia

A

Patient history and review of old labs, Serum calcium, Albumin, Phosphorus

PTH: if LOW–> get PTHrP

Do a 24 hr urine calcium and creatinine, abdominal xray adn bone mineral density

19
Q

DDx for Hypercalcemia:

_____• PTH is high or inappropriately not suppressed

_____• PTH is low

A

PTH dependent

PTH Independent

20
Q

Causes of PTH independent hypercalcemia

A

Sarcoid granulomas, lytic lessions, Vit D intox, malignancy

21
Q

PTH Dependent Causes of Hypercalcemia

A
  • Primary hyperparathyroidism
  • Familial hypocalciuric hypercalcemia
  • Parathyroid Carcinoma
  • Extremely rare
22
Q

What group is it more common to see primary hyperparathyroidism in?

A

postmenopausal women

23
Q

Stats on causes of primary hyerparathyroidism

A

85% adenomas

5-12% are 2 or more adenomas

8-15% hyperplasia

24
Q

What do the following have in common?

  • MEN 1
  • MEN 2
  • Familial Hyperparathyroidism

• Familial Hyperparathyroidism and jaw tumors

A

Primary Hyperparathyroidism Familial Syndromes

25
Q

Primary Hyperparathyroidism Indications for Surgery

A

Symptomatic hypercalcemia

Calcium 1 mg/dl above upper limit of nl

Nephrolithiasis

Osteoporosis/Fragility fractures

Renal Insufficiency

Age less than 50 yrs.

Patient preference

26
Q

Why can patients with primary hyperparathyroidism have hypercalciuria if PTH increases calcium reabsorption?

A

Tm is saturated thus Ca will spill over into the urine: it reaches its reabsorption limits

27
Q

Why can pts with primary hyperparathyroidism have hypophosphatemia?

A

PTH inhibits Phosphate reabsorption in the proximal tubules resulting in hypophosphatemia

28
Q

How is a Parathhyroidectomy perfromed?

A

• Small incision with Local anesthesia

Must have preoperative localization • Ultrasound

  • 99m-technetium sestamibi • CTscan
  • Intraoperative parathyroid hormone monitoring
  • Need to see 50% decrease in PTH after removal of suspected adenoma
29
Q

Medical Management of Hyperparathyroidism

A
  • Optimize hydration
  • Avoid calcium sparing diuretics
  • Normal calcium intake
  • Optimize vitamin D status
  • Potential use of a calcimimetic
  • Calcium sensing receptor agonist • Cinacalcet (Sensipar)
30
Q

Mechanisms of Hypercalcemia of Malignancy

A

PTH related protein (PTHrP)

Osteolytic bone mets

Unregulated 1,25 dihrydoxy Vit D

Osteoclast activating factors

Ectopic PTH

31
Q

What is PTH releated protein or PTHrP

A
  • N-terminal homology with PTH
  • Not measured by PTH assays
  • Found in normal tissue
  • May be important in fetal development

Chromosome 12 ( PTH on 11 )