MTB 2 Flashcards
WU for thyroid nodule
- TFT’s = TSH and T4
2. If normal - Bx gland with FNA
What is a hot nodule
Non-cancerous
Produces excess thyroid hormone
Shows up on scan - takes up isotope
What is a cold nodule
Cancerous
Nonfunctioning
Defects/holes in scan
Solid
Follicular thyroid cancer
Spread
Hematogenous spread to Lung, Brain, Bone
Invasion of tumor capsule and BVs
Encapsulated
Papillary Thyroid cancer
Unencapsulated
Local LN involved
Psamomma bodies = ground glass cytoplasm, pale nuclei with inclusion bodies
MC thyroid cancer
Papillary Thyroid cancer
MCC of hypercalcemia
Other causes
Primary Hyperparathyroidism
Others: Vit D toxicity, Sarcoidosis, Thiazides, Lithium, Hyperthyroidism, Mets to bone, MM
Presentation of of hypercalcemia
Confusion Stupor, Lethargy Constipation, N/V, Pancreatitis Short QT syndrome, HTN Osteoporosis Nephrolithiasis, DI, Renal insufficiency
Tx for Hypercalcemia
- Saline hydration w Loops (furesomide) if crackles are heard
- Bisphosphonates - inhibit bone digestion by encouraging osteoclasts to undergo apoptosis
- Calcitonin to inhibit osteoclasts if above not working
Hyperparathyroidism Labs
EKG
High PTH, Calcium Low/N Phosphorus High Chloride High BUN/Cr High AP EKG short QT
What is osteitis fibrosa cystica?
Presentation?
Increased osteoclastic bone resorption
Bone pain, Fx, swelling, bone cysts, brown tumors
Hyperparathyroidism TX
Surgical removal of glands
Causes of Hypoparathyroidism
Neck surgery
Hypomagnesiumemia
Renal Failure
Role of Magnesium and PTH
Mg needed for PTH to be released from gland
Renal Failure and Calcium
RF causes hypocalcemia
kidney converts 25 OH to 1,25 OH Vit D
Albumin and Calcium relationship
Low albumin causes decrease in total Calcium
Free Calcium Normal
EKG for Hypocalcemia
Prolonged QT
Diff b/t Cushing Dz and Syndrome
Dz = Pituitary overproduction of ACTH Syndrome = Hypercortisolism
MCC of hypercortisolism
Pituitary ACTH = Cushing DZ
Best initial test Hypercortisolism
24-Hour Urine Cortisol
Or
1 mg overnight dexamethasone suppression test
Most specific test for Hypercortisolism
24 hour urine cortisol
- Elevation confirms Dx
Best initial test to determine source or location of hypercortisolism
ACTH testing:
High then source is:
- Pituitary
- Ectopic Production - Lung, carcinoid
If ACTH is elevated, next step?
MRI brain
- Pituitary lesion - this is the source
If MRI brain does not show a lesion, next step in hypercortisolism
Inferior Petrosal Sinus sample for ACTH
- High ACTH = pituitary is source
- if not - scan chest
Where does Inferior Petrosal sinus drain from
From Cavernous sinus
Joins sigmoid sinus to form internal Jugular Vein
Effects of hypercortisolism - Labs
Hyperglycemia Hyperlipidemia Hypokalemia Metabolic Alkalosis Luekocytosis
Cortisol relationship w insulin and aldosterone
Antiinsulin
Aldosteronelike effects -> Kidney’s distal tubule = excretes Potassium and Hydrogen ions
TX for hypercortisolism if pituitary source
Transphenoidal surgery
TX for hypercortisolism if Adrenal source
Laparoscopic surgery
Low ACTH
High-dose dexamethasone: No suppression
Adrenal source
High ACTH
High ACTH in petrosal sinus
High-dose dexamethasone: Suppresses
Pituitary source
High ACTH
Low ACTH in petrosal sinus
High-dose dexamethasone: No suppression
Ectopic source
Hypoadrenalism etiology
Addison Dz AI destruction of gland Infxn Adrenoleukodystrophy Mets
Hypoadrenalism Presentation
Weakness Fatigue AMS N/V/Anorexia HypoTN Hyponatremia Hyperkalemia Eosinophilia Hyperpigmentation
Dx Tests for Hypoadrenalism
Cosyntropin Stimulation test
- synthetic ACTH
- measure cortisol before and after
- Normal - rise in cortisol after cosyntropin admin
Labs in Hypoadrenalism
Hypoglycemia Hyperkalemia Metabolic Acidosis Hyponatremia High BUN
Tx for Hypoadrenalism
- Replace steroids with hydrocortisone
2. Fludrocortisone - high in mineralocorticoid/aldosterone like effect
MCC of Primary Hyperaldosteronism
Solitary Adenoma
Presentation of Primary Hyperaldosteronism
High BP + Low Potassium
Best initial test in Primary Hyperaldosteronism
Ratio of plasma Alosterone to Renin
PAC: PRA
Most accurate test in Primary Hyperaldosteronism to confirm unilateral adenoma
Sample of venous blood draining adrenal
- High Aldosterone
TX for Primary Hyperaldosteronism
Unilateral adenoma: Laparoscopy
Bilateral hyperplasia: Eplerenone or Spironolactone
Best initial test for Pheochromocytoma
Free metanephrines in plasma
Tx for Pheochromocytoma
Alpha blocker - non-selective - non-competitive Beta blocker CCB Surgical removal w pre op tx of alpha blocker
Diff b/t DM type I and II
Type I = insulin deficiency
Type II = insulin resistance
Dx of Diabetes
2 fasting glucose > 125 OR 1 glucose > 200 + Sx's OR Increased glucose on tolerance test
Metformin AEs and MOA
AEs: Metabolic Acidosis
MOA: blocks gluconeogenesis
Which hypoglycemic drug increases obesity
Sulfonylureas - increase insulin release from pancreas, driving glucose
Hypoglycemic drug that is CI in CHF
Thiazoladinediones (glitazones)
Hypoglycemic drug ass’d with increased risk of MI
Rosiglitazone
Hypoglycemic drug helps in weight loss
Incretins - Exenatide, Sitagliptin
Which insulin gives steady state for entire day
Glargine
Which insulin has shortest onset of action
Lispro
Aspart
Glulisine
Onset = 5-15 mins, peak at 1 hr, last 3-4 hours
DKA TX
- Large volume saline and insulin
Insulin - Continuous, rapid IV drip until AG corrected. Then bolus 5-10 units regular insulin - Replace K+
What electrolyte indicates elevated Anion Gap
HCO3-
If DKA pt is stabilized on IVF and insulin, but blood glucose is increasing, what is best next step?
Add D5 to IVF
When is HCO3- given in DKA?
Severe acidosis where pH < 7 Or losing in stool Or kidneys
Usually wrong answer
What is goal LDL and TGs be in DM pts
LDL -< 100 mg/dL
TG - <150
What is goal BP be in DM pts
< 130/80
If greater - start ACEi/ARB
Next step if urine microalbumuria
ACEi or ARB
ASA in DM?
Daily over 30 yoa
What is cause of Diabetic Osteomyelitis
Contiguous spread - poor tissue perfusion b/c of arterial insufficiency -> Immune system can’t combat infxn in area around ulcer - soft tissue entry to bone
Neuropathy - decreases sensation causing ulcers
ACEi or ARB effect on kidney
Decrease rate of progression of nephropathy by decreasing intraglomerular HTN
Increase Renal Blood Flow
Tx for Gastroparesis
Metoclopromide
Erythromycin
Diabetic Retinopathy-Nonproliferative
Presentation
TX
Cotton wool spots, exudates, less severe and more common
TX: Tight glucose control
Diabetic Retinopathy - Proliferative
Presentation
TX
Neovascularization
Vitreous Hemorrhages
Tx: Laser Photocoagulation
TX for Diabetic Neuropathy
Pregabalin
Gabapentin
TCAs - Amitryptiline
Persistent - Narcotics, Tramadol
What are Charcot’s Joints
Ass’d with?
Loss of sensation due to recurrent injury
Chronic, progressive arthropathy
Ass’d with Syphilis, Tabes Dorsalis, Syringomyelia,
Presentation of Charcot’s Joints
Decreased proprioception, pain and temp
Deformed joints, arthritis, mild pain, Fx, DJD
