PHISIOLOGY Flashcards
Negative feedback: The increase of a hormone generates … of its regulatory hormone
inhibition
Positive feedback: The increase of a hormone generates … of its regulatory hormone
stimulation
Circadian rhythm:
Variation every 24 hours
First messenger: The …
Second messenger: Molecule located at the … that is derived from the hormone-receptor interaction
hormone
intracellular level
The transmission of messages can be carried out by…
endocrine, paracrines, neuroendocrine mechanisms or as a neurotransmitter.
In addition to the classical endocrine glands, the … have emerged as essential endocrine organs in controlling homeostasis.
adipose tissue, the gastrointestinal system, and the nervous system
Transport proteins modulate the concentration of… hormone, which is biologically….
Free, active
The secretion rates of each hormone should be known for application to pathophysiology, diagnosis, and treatment. …. rhythms are especially important.
Circadian and monthly
There are different types of membrane receptors, whose activation generates different signaling pathways that allow hormonal action to be carried out. This mechanism of interaction with the target cell is typical of… hormones.
peptide
Thyroid and steroid hormones interact with… receptors and their effects are primarily mediated by genomic mechanisms.
intracellular
Knowing the …, whether positive or negative, is essential for the control of hormonal homeostasis and has transcendental applications in the diagnosis and adjustment of hormonal treatments.
feedback mechanisms
Which hormones signal through transmembrane receptors?
Peptides and glycoproteins
Which hormones are synthesised as prehormones or preprohormones?
Peptides and glycoproteins
Which hormones are hydrophilic and are stored in vesicles?
Peptides and glycoproteins
Which type of hormones circulate unbound in blood?
Peptides and glycoproteins
Which hormones are administered by injection?
Peptides and glycoproteins (like in insulin)
Which hormones have a fast effect?
Peptides
Which hormones have a short half-life?
Peptides
What kind of hormone is GH?
Peptides
Which kind of hormone is ACTH (adrenocorticotropin)?
Peptide
Which kind of hormone is PRL (prolactin)?
Peptide
Which kind of hormone is vasopressin (ADH)?
Peptide
Which kind of hormones are insulin and glucagon?
Peptides
Which kind of hormone is leptin?
Peptide
Which kind of hormone is PTH (parathyroid hormone)?
Peptide
What kind of hormones are gastrointestinal hormones?
Peptides
Which type of hormones have a common alpha subunit and a unique beta subunit?
Glycoproteins
What type of hormone is TSH (thyrotropin)?
Glycoprotein
What type of hormone is FSH (follicle stimulating hormone)?
Glycoprotein
What type of hormone is LH?
Glycoprotein
What type of hormone is HCG (chorionic gonadotropin)?
Glycoprotein
What type of hormone is estradiol?
Steroid
What type of hormone is progesterone?
Steroid
What type of hormone testosterone?
Steroid
What type of hormone is cortisol?
Steroid
What type of hormone is aldosterone?
Steroid
What type of hormone are thyroid hormones?
Amines
What type of hormones are catecholamines?
Amines
What type of hormones are derived from cholesterol?
Steroids
What type of hormones are lipophilic?
Steroids and amines
What type of hormones are transported by binding globulins?
Steroids and amines
What type of hormones have intracellular receptors?
Steroids and amines
What type of hormones are administered orally?
Steroids and amines
What type of hormones are derived from tyrosines?
Amines
Cortisol follows … rythms
CIRCADIAN
FSH and LH follow… rythms
ULTRADIAN
Cortisol is transported by…
CBG
Thyroxine is transported by…
TBG
Testosterone is transported by…
SHBG
…regulate renal elimination of the hormone and modulate the free fraction of the hormone.
Binding proteins
Peptide, glycoprotein and catecholamine hormones bind to … receptors, like GPCR
Membrane
Thyroid hormone receptors are…
Intracellular: nuclear
Steroid hormone receptors are …
Intracellular: in cytoplams
POSITIVE HORMONAL FEEDBACK
Most hormonal feedbacks are…
NEGATIVE
Hashimoto’s disease /hyperthyroidism. It’s a … disease, affecting the thyroid gland itself.
primary
(Primary disease=target organ)
If a tumor in the brain prevents the release of TSH (thyroid stimulating hormone), it’s a… hypothyroidism.
secondary
(Secondary disease=anterior pituitary)
A … hypothyroidism would be a defect or deficiency in TRH (thyrotropin-releasing hormone), which is supposed to act on the pituitary gland to induce TSH release, which in turn induces T3 and T4 secretion.
tertiary
(Tertiary disease=hypothalamus)
The pituitary gland comes from the invagination of the roof of the …, which forms the Rathke’s pouch, which meets a diencephalic prolongation called the…. Together they constitute the ….
The region of epithelial origin will give rise to the…, while the one constituted by nervous tissue is the… or posterior pituitary.
The total gland is housed in the …, below the optic chiasm.
oral cavity, infundibulum, pars tuberalis
adenohypophysis, neurohypophysis
turkish sella of the sphenoid
…. imaging is the most accurate imaging test to investigate the causes of pituitary dysfunctions.
… is an alternative in patients with pacemakers or claustrophobia.
… is useful in the assessment of pituitary macroadenomas, thus it may compromise the optic chiasm.
Magnetic resonance
CT Scan
Campimetry or eye fundoscopy
HYPOPITUITARISM
Lack of GH causes…
Size delay, reduced quality of life
HYPOPITUITARISM
Lack of PRL causes…
Postpartum agalactia
HYPOPITUITARISM
Lack of ACTH causes…
Secondary (cortical) adrenal insufficiency
HYPOPITUITARISM
Lack of TSH causes…
Secondary hypothyroidism
HYPOPITUITARISM
Lack of FSH/LH causes…
Secondary hypogonadism
HYPOPITUITARISM
Lack of ADH causes…
Cranial diabetes insipidus
HYPERFUNCTIONING SYNDROMES
Excess GH causes…
Acromegaly/gigantism
HYPERFUNCTIONING SYNDROMES
Excess of PRL causes…
Hyperprolactinemia
HYPERFUNCTIONING SYNDROMES
Excess of ACTH causes…
Cushing’s diseases, hypercortisolism
HYPERFUNCTIONING SYNDROMES
Excess of TSH causes…
Secondary hyperthyroidism
HYPERFUNCTIONING SYNDROMES
Excess of FSH/LH causes…
Gonadotropinomas
HYPERFUNCTIONING SYNDROMES
Excess of ADH is caused by…
Inadequate secretion of ADH
ACTH means
Adrenal cortex stimulating hormone (adrenocorticotropin)
TSH means
Thyroid stimulating hormone (thyrotropin)
AVP/VP/ADH mean
Arginine vasopressin (antidiuretic hormone)
GHRH means
Hormone that stimulates the synthesis and release of GH
SS/Somatostatin:
Hormone that inhibits the synthesis and release of GH
TRH
Hormone that stimulates the synthesis and release of TSH
CRH
Hormone that stimulates the synthesis and release of ACTH
LHRH/GnRH:
Hormone stimulating the synthesis and release of FSH and LH
GnIH means
Gonadotropin-inhibitory hormone
IGF-1 means
Insulin-like growth factor
IGFBP means
IGF-1 binding protein
T4 means
Thyroxine
T3 means
Triiodothyronine
The adenohypophysis and neurohypophysis have different embryological origins. The neurohypophysis consists of axons and neurovascular junctions of neurons of the … nuclei. The adenohypophysis has … origin.
supraoptic and ventricular, epithelial
The hypothalamic-pituitary portal system ensures the functional connection between the central nervous system and the hormonal secretion of the adenohypophysis, this is an example of….
neuroendocrine integration
The regulation of pituitary function is carried out by hypothalamic hormones and feedback mechanisms of peripheral hormones, except for …, which lacks peripheral hormone to receive feedback modulation.
… interacts with the hypothalamic dopaminergic system which self-regulates its secretion thanks to its inhibitory effect.
prolactin
The activity of the hypothalamic-pituitary-effector axes recognize circadian variations and numerous additional factors that modulate their function, such as …
sleep, stress, diet and iatrogenesis among others.
Stress has stimulatory effects on … and inhibitory effects on …
GH, ACTH and Prolactin, TSH and gonadotropins.
There are some functional connections between the neurohypophysis and the adenohypophysis, such as the regulation of …
ACTH secretion by vasopressin.
If a person has an adenoma (pituitary tumour), optic function will be compromised. Why?
Optic chiasm is just above the pituitary.
What will happen to prolactin with a trauma in the infundibulum?
Its levels will increase: as there is no dopamine (produced in substantia nigra), prolactin cannot be downregulated. The rest of pituitary hormones, however, will be found at low levels.
Disease in which there is excessive growth hormone
ACROMEGALY
GH and IGF1 actions
Cell growth induction and anabolic effects
Protein which most frequently binds IFG1
IGFBP3
Hormone which has a negative effect on growth plates of chondrocytes
Glucocorticoids
Why can we have amenorrhea when suffering too much stress?
Stress stimulates prolactin, and prolactin can inhibit gonadotropins.
The most frequent cause of hyperprolactinemia is…
Pharmaceutical. A patient taking antipsychotics can block the infundibulum system responsible for producing dopamine.
Thyroid hormones general function
Stimulate metabolism
Hormones produced by the ADENOHYPOPHISIS
TSH, ACTH, PRL, GH, FSH, LH
Hormones produced by the neurohypophisis
ADH, OXYTOCIN
GH is stimulated by…
GHRH
GH is inhibited by …
Somatostatin
TSH is stimulated by…
TRH
TSH is inhibited by…
Somatostatin
PRL is stimulated by…
VIP, SER, TRH
PRL is inhibited by…
Dopamine
ACTH is stimulated by…
CRH, VP
FSH and LH are stimulated by…
LHRH
FSH and LH are inhibited by…
Gonadotropin inhibitory hormone
GH leads to … production
IGF-I
TSH leads to … production
T3, T4
ACTH leads to … production
cortisol
FSH leads to … production
estrogens, progesterone and testosterone
LH leads to … production
inhibin
HYPOTHALAMIC-PITUITARY SOMATOTROPIC AXIS (GH AND IGF1)
HYPOTHALAMIC-PITUITARY-ADRENAL AXIS REGULATION
REGULATION OF PROLACTIN SECRETION
TSH SECRETION REGULATION
HYPOTHALAMUS-PITUITARY-GONADOTROPE AXIS
VASOPRESSIN (ADH) MECHANISM
If a patient suffers damage (during thyroid surgery) in the non-recurrent laryngeal nerve, they might …
lose their voice (DYSPHONIA)
TSH levels produced by the pituitary can be reduced by…
Negative feedback of T4, T3 and either by dopamine, somatostatin and glucocorticoids.
C cells in the thyroid follicle secrete…
CALCITONIN
Daily need of iodine
Adults: 150mcg/d
Children: 90-120 mcg/d
Pregnant women: 200 mcg/d
Iodine is measured indirectly in…
24-hour urine collection (the amount excreted reliably reflects the intake)
Endemic iodine deficiency is associated with…
CRETINISM and severe HYPOTHYROIDISM with impairment of statural development and the central nervous system.
When TSH reaches the thyrocytes, it interacts with a … receptor triggering signaling pathways involving second messengers such as … related to mitogenesis and cell proliferation.
G-protein-coupled,
cAMP, diacylglycerol, phospholipase C and kinases
There are TSH receptor stimulating antibodies, which bind to the same receptor as TSH and triggers long-lasting hyperactivity generating a type of hyperthyroidism that is known as …
Graves-Basedow disease.
Iodination (=organification) and coupling reactions in the colloid of the thyroid are catalysed by the…
PEROXIDASE
A lack of peroxidase would cause…
HYPOTHYROIDISM (no thyroid hormone would be produced, as it is responsible for iodination and coupling)
If the intake of iodide exceeds 2 mg / day, the intraglandular concentration of iodide reaches a level that paradoxically suppresses the activity of…, blocking the biosynthesis of the hormone. This phenomenon is known as the….
Thyroid peroxidase, Wolff-Chaikoff effect
1 MIT + 1 DIT=
T3
2 DITS=
T4
…% of thyroid hormones are found free, in the active form
1
In plasma, thyroid hormones are captured in their highest proportion especially by TBG (thyroid hormone binding globulin), albumin and transthyretin.
Free T4 … in pregnant women
Decreases.
This is because estrogens stimulate the rake of TBG
TBG increases with…
Estrogens and TSH
TBG decreases with …. So it causes T4 free levels to…
Liver disease and malnutrition
increase
…serves in its highest proportion of prohormone to generate…, which has greater metabolic activity, although it has a shorter half-life.
T4, T3
When a patient presents hypothyroidism, we usually give them … as it has a longer half-life (even though it is weaker).
T4
The largest proportion of circulating… comes from circulating… rather than from direct synthesis by thyroocytes.
T3, T4
T4 is converted into T3 in peripheral tissues by…
D1 (deiodinase 1)
T4 is converted into T3 in the brain and in the pituitary by…
D2
In stress situations or systemic diseases, T4 is converted to inactive T3 by…
This is known as the syndrome of …
D3
SICK EUTHYROID
T3 and T4 are hormones which just have receptors in the…
Nucleus
The metabolism of thyroid hormones takes place through the action of deiodinases that eventually give rise to compounds without biological activity. Conjugation with sulfate or glucuronic acid enhances elimination by…
bile, urine, and feces.
Hypothalamus pituitary thyroid axis
Synthesis and secretion of thyroid hormones
Conversion of T4, into T3 or rT3
Thyroid hormones actions
Pathological thyroid hormone
The basic functional unit of the thyroid gland is the…. in which the incorporation of iodide and the synthesis of thyroid hormones take place.
The thyroglobulin located preferentially in the… is the matrix that stores the thyroid hormone molecules and their precursors.
thyroid follicle, colloid
Iodide is trapped from the circulation by the… and incorporated into the thyrocyte against an electrical gradient.
sodium-iodide symporter (NIS)
… plays a crucial role in the synthesis of thyroid hormones. Thyroid autoimmunity phenomena are very frequently directed through antiperoxidase tests that are associated with autoimmune hypothyroidism.
Thyroid peroxidase
T4 and T3 are synthesized from …
The secretion of T4 and T3 requires the recovery of…. from the lumen of the follicle by endocytosis.
…. is then broken down in lysosomes to release T4 and T3.
tyrosine and iodide.
thyroglobulin
The interaction of … with the membrane receptor in the thyrocyte potentiates all steps of the synthesis and secretion of thyroid hormones. These steps include iodide uptake, iodination, coupling and thyroglobulin recovery. … stimulates growth of thyrocytes.
TSH
Pharmacological iodine overload can paralyze thyroid hormone biosynthesis due to the ….
Wolff-Chaikoff effect.
Less than 1% of T3 and T4 circulates freely. Only the free fractions of T4 and T3 are biologically active. Free T4 and free T3 enter the target cell.
90% of … undergoes deiodination to become …, which interacts with its nuclear receptor.
T4, T3
…inhibits TSH secretion, while … stimulates it.
Stress, cold.
Thyroid hormones stimulate energy expenditure and have various metabolic effects, as well as synergistic effects with the activation of …
beta-adrenergic receptors.
T3 plays a key role in growth and in normal development of the… , simultaneously with other hormones such as GH, IGF-1, insulin, and sex hormones. It is also involved in multiple functions of the endocrine system such as …
central nervous system
gonadal function and GH secretion.
Thyroid hormones act on … receptors, but TSH acts on … receptors.
Nuclear, membrane
The treatment of hyperthyroidism, paradoxically, is to give more iodine, due to the …. effect. It blocks thyroid function.
WOLFF-CHAIKOFF
Normal plasma calcium concentration
10 mg/dl
A …% of calcium remains as a ionized form
45-50
In metabolic or respiratory alkalosis, ionised calcium levels…
Decrease=HYPOCALCEMIA
In acidosis, ionised calcium levels…
Increase=HYPERCALCEMIA
Protons bind to albumin and displace Ca2+.
…. are the key elements of calcium and phosphorus homeostasis.
Intestinal absorption, renal elimination and bone exchange
Hormone which increases bone resorption and plasma calcium
PTH
Hormone which increases intestinal calcium absorption, bone resorption and plasma calcium
Vitamin D
Hormone which decreases bone resorption and plasma calcium
Calcitonin
Hormones which have anabolic effects at the bone level
Sex steroids and the somatotropic axis
Hormones which have a catabolic profile in bone.
thyroid hormones, cortisol and cytokines
PARATHYROID GLAND
We have 4 even though some people can have 5
Half-life of PTH
2 minutes
That is why during thyroid surgery, we measure PTH at the moment
A damage in the recurrent laryngeal nerve might cause…
DISPHONIA
PTH release is increased by…
HYPOCALCEMIA, hyperphosphatemia, catecholamines
PTH release is suppressed by…
HYPERCALCEMIA, vitamin D, severe hypomagnesemia
Activation of the beta2-adrenergic receptor… PTH secretion.
stimulates
Sometimes we give calcium to the patient but it is suppressed due to low magnesium levels. This phenomenon is known as…
REFRACTORY HYPOCALCEMIA
PTH ACTIONS
It increases calcium and phosphorus resorption in bones. It increases calcium resorption in kidneys, where it also carries out PHOSPHATE EXCRETION.
… is produced in kidneys thanks to PTH action and participates in vitamin D activation
1-alpha hydroxylase
… is the main modulator of calcium absorption in the small intestine
Vitamin D
When PTH is secreted in excess there is an increase in resorption that translates into ….
osteoporosis
PTH activates osteoblasts… and osteoclasts…
Directly, indirectly
The balance between … expression by osteoblasts determines how much osteoclast differentiation and bone resorption will occur.
RANKL (activated by PTH) and OPG
In osteoporosis, an Ab against RANK is given so that osteoclastogenesis is not induced. This Ab is called…
DENOSUMAB
…. promotes bone resorption and osteoclastogenesis
PTH
… inhibits bone resorption and osteoclastogenesis
OSTEOPROGESTERIN (produced by osteoblasts)
… inhibits osteoblasts differentiation from progenitor cells and increases bone resorption and osteoclastogenesis.
SCLEROSTIN
… is an Ab against SCLEROSTIN
Romosozumab
With …. PTH doses we have a normal- anabolic axis with osteoblasts growth and survival, as well as an increase in bone density
Low-intermittent
With … PTH doses we have a disease-catabolic axis which displaces the balance of osteoclast activity: bone resorption increases too much and bone density decreases considerably.
high
PTH in the distal convoluted tubule…
Stimulates calcium absorption
PTH in the proximal tubule…
Has a phosphaturic effect (excretion of phosphate) and activates 1-alpha hydroxilase for vit D synthesis.
… exerts an inhibitory effect on the PTH gene and stimulates the synthesis of the calcium-sensing receptor
Vitamin D
If we have low vitamin D levels, we would have … PTH levels
High
Vitamin D comes from the synthesis of … from 7-dehydrocholesterol in the skin by the action of UV rays
CHOLECALCIFEROL
Measurement of … levels is used to assess vitamin D status.
25-hydroxyvitamin D (inactive form), as it has a long half-life in the circulation (2-3 weeks)
Calcitriol is the … form of vitamin D
Active
INTESTINAL CALCIUM REABSORPTION
Calcium enters in the enterocyte in favor of gradient thanks to the… transporter
TRPV6
INTESTINAL CALCIUM REABSORPTION
Calcium is captured inside the enterocyte by…
CALBINDIN PROTEIN
INTESTINAL CALCIUM REABSORPTION
… transporter conducts calcium against gradient so that it eventually reaches the bloodstream.
PMCA
The activation of vitamin D in the kidneys entails the stimulating effect of … on the 1 alpha hydroxylation
PTH
1-alpha hydroxylase is inhibited by …, which at the same time promotes phosphaturia in the proximal tubule
FGF23 (fibroblast growth factor 23)
The … has multiple effects, but the most relevant is its role in hypercalcemia associated with malignant tumors, which is mediated by increased renal calcium reabsorption and bone resorption generated by PTHrp
PTH-related protein (PTHrp), produced by tumor cells
…. secreted by parafollicular cells has an antiresorptive effect at the bone level, so it has been used in the treatment of osteoporosis, however, its physiological role does not seem significant.
Calcitonin
PTH increases calcium levels in …, calcitonin increases calcium levels in …
Blood, bone
… also play a role favoring phosphorus renal excretion and inhibiting the synthesis of vitamin D and PTH.
FGF 23 and its Klotho receptor
… are essential in many biological processes including cell secretion, coagulation, enzyme activation, muscle contraction, bone mineralization, among others.
Calcium and phosphorus
…% of calcium is in ionic form, which is the active fraction for muscle excitability. Ionic calcium is modulated by pH;… reduces calcium and, therefore, is a potential cause of symptoms.
50, alkalosis
Vitamin D is synthesized from 7-dehydrocholesterol in the skin in the presence of UVB light or is acquired in the diet. It is hydroxylated to 25-hydroxycholecalciferol in the liver and activated by renal 1α-hydroxylase to …
1,25-dihydroxyvitamin D.
…are the two most important hormones in the control of calcium and phosphorus metabolism. … also has modulatory effects. … increases the 1 alpha hydroxylation of vitamin D.
PTH and vitamin D
FGF 23
PTH
… have both hypercalcemic effects. … is phosphaturic, … is not. The role of … is the stimulation of the intestinal absorption of calcium and phosphorus.
PTH and VIT D
PTH, VitD
Vit D
Bone tissue shows great remodeling activity, thanks to the interaction of …
osteoblasts and osteoclasts.
… enhance the production of osteoblasts and osteoclasts.
PTH and vitamin D
The PTH receptor is expressed on …, not …. PTH has both anabolic and catabolic actions on bone depending on the dose and timing of administration.
PTH promotes bone resorption by upregulating … in osteoblasts.
osteoblasts, osteoclasts
M-CSF and RANKL
… binds to osteoblasts to support osteoclast differentiation through RANKL and promotes bone mineralization by maintaining adequate serum calcium and phosphorus levels.
1,25-dihydroxyvitamin D
The regulation of PTH is carried out by interaction with the … on parathyroid chief cells.
calcium-sensitive receptor (CASR)
Osteocytes secrete … that increases bone resorption by inhibiting osteoblast differentiation and favoring osteoclast production and action.
sclerostin
… have regulatory effects on phosphocalcic metabolism, the latter in relation to its phosphaturic effect thanks to the interaction with its Klotho receptor in the kidney. … inhibits the synthesis of PTH and vitamin D.
PTHrp and FGF23
FGFG23
Both hyper and hypoparathyroidism have clinical manifestations predominantly dominated by …, respectively.
hypocalcemia and hypercalcemia
Physiological knowledge has given rise to various therapeutic opportunities for the treatment of parathyroid dysfunctions and osteoporosis. Anti-RANK ligand and anti- sclerostin antibodies represent advances in …
Cinacalcet is a calcimimetic used for the treatment of ….
anti-resorptive treatment.
hyperparathyroidism
If you suspect hypopituitarism, which pituitary-peripheral hormonal axes do you consider may be involved?
Free TSH-T4, ACTH-CORTISOL, Gonadotropins-TESTOSTERONE
Which hormonal profile is compatible with a diagnosis of hipotuitarism?
Low cortisol and normal ACTH (explicación en hojas TBL)
IF THE DIAGNOSIS OF HYPOPITUITARISM IS CONFIRMED AND TREATMENT WITH THYROXINE IS PRESCRIBED, WHICH PARAMETER OF THOSE MENTIONED BELOW IS THE MOST RELEVANT FOR ADJUSTING THE DOSE:
Free T4
For hypopituitarism diagnosis, when doing a screening we measure…
TSH
Once diagnosed, for treatment in a patient with hypothyroidism, we measure…
Free T4
ACCORDING TO THE PHYSIOLOGICAL EFFECTS OF GROWTH HORMONE, WHICH OF THE FOLLOWING SYMPTOMS IS MOST RELEVANT IN GENERATING A CLINICAL SUSPICION OF ACROMEGALY?
Increased hand and foot size.
WHAT WOULD BE THE BIOCHEMICAL PATTERN THAT WOULD CONFIRM THE DIAGNOSIS OF ACROMEGALY IN THIS PATIENT?
Inability to suppress GH after oral glucose
THE PATIENT WAS FINALLY TREATED AFTER EVIDENCING A PITUITARY ADENOMA OF
2 CM IN THE PITUITARY RESONANCE IMAGING. WHICH OF THE FOLLOWING OPTIONS IS THE BEST TO KNOW IF THE TREATMENT HAS BEEN SUCCESSFUL 3 MONTHS AFTER SURGERY?
Measure baseline IGF-1
WHICH OF THE FOLLOWING SYMPTOMS SHOULD MAKE US SUSPECT THE POSSIBLE EXISTENCE OF HYPERPROLACTINEMIA?
Amenorrhea, galactorrhea, hirsutism
HOW CAN WE CONFIRM THE EXISTENCE OF HYPERPROLACTINEMIA?
Measuring basal morning prolactin (donde debería estar baja)
A FRANK ELEVATION OF PROLACTIN (164 NG/ML; RR <25 NG/ML) WAS CONFIRMED, A PITUITARY IMAGING STUDY EVIDENCED A POSSIBLE MACROPROLACTINOMA OF 1.8 CM INTRASELLAR LOCALIZATION.
PHARMACOLOGICAL TREATMENT WAS INDICATED.
HOW WILL YOU ASSESS WHETHER THE INDICATED DOSE OF TREATMENT IS CORRECT?
MEASURING BASAL PROLACTIN AND SYMPTOM PROGRESSION, ASSESSING MENSTRUAL PERIODICITY and CONDUCTING A NEW IMAGING STUDY
In GRAVES DISEASE, we have immunoglobulins against…
TSH receptors
What imaging test would be most appropriate for hyperthyroidism?
Scintigraphy: it is fast
How do we do de follow up of a patient with hyperthyroidism?
We measure TSH, Free T4, Free T3
Treatment for hyperthyroidism:
- THIONAMIDES. They inhibit iodination and coupling
- I131: Na Iodide
- Surgery
Blood analysis appropriate when suspecting hypothyroidism?
Free T4 and T3, TSH, TPO antibodies
If it was only for screening: TSH
REMEMBER: TPO is responsible for organification, iodinidation and coupling
How are we following a patient with HASHIMOTO’S disease?
We measure TSH and free T4
In the secondary hypothyroidism, TSH levels can be…
LOW OR NORMAL
THIS IS IMPORTANT!!!
In a thyroid surgery, we can have…
HYPOPARATHYROIDISM: parathyroid glands are damaged (hypocalcemia which does not permit muscle relaxation: trousseau sign and chvostek sign) and recurrent laryngeal nerve also (patient has shortness of breath)
In a patient with hypoparathyroidism we give…
Intravenous calcium
Phosphate levels are already high
ADRENAL GLANDS
Cortex is of … origin
Mesodermal
Marrow is of … origin
Ectodermal
The right suprarrenal vein drains into…
Vena cava (acceso directo)
The left suprarrenal vein drains into…
Left renal vein (para acceder, primero renal vein)
The right adrenal gland has a … shape
Triangular, more piramidal
The left adrenal gland has a … shape
Semilunar
Zona glomerulosa in the cortex produces…
ALDOSTERONE
Zona fasciculata in the cortex produces…
CORTISOL
Zona reticularis in the cortex produces…
ANDROGENS
The medulla (chromaffin cells), produce…
EPINEPHRINE AND NOREPINEPHRINE (CATECHOLAMINES)
Aldosterone, cortisol and androgens are … hormones and are produced in the …
Steroid, cortex
Epinephrine and norepinephrine are … and are produced in the …
Catecholamines, medulla
50% of Androgens in women come from …
Adrenal gland
If you consider hypercortisolism as a possible diagnosis, which of the following symptoms seems most interesting to reinforce the clinical suspicion?
A. Poor blood pressure control despite anthypertensive treatment
B. Low back pain
C. Signs of proximal myopathy
D. High body mass index
C. Signs of proximal myopathy
CORTISOL IS CATABOLIC AND IT ENHANCES VASCULAR REACTIVITY
Those patients have purple striae, easy bruising, obesity, hypertension, infertility…
Which of the following hormonal determination do you think is most useful to biochemically suspect endogenous hypercortisolism?
A. Plasma cortisol at 8 a.m.
B. Plasma cortisol at midnight
C. Basal ACTH
D. All of the above
B. Plasma cortisol at midnight (if it is higher than 1.8, we diagnose hypercortisolism)
If we suspected adrenal insufficiency, we do it in the morning
If you confirm hypercortisolism. Which would be the classical hormonal pattern of a pituitary origin?
A. Elevated urinary cortisol and suppressed ACTH
B. Normal urinary cortisol and normal ACTH
C. Elevated morning cortisol and normal ACTH
D. Elevated urinary cortisol and elevated ACTH
D. Elevated urinary cortisol and elevated ACTH
Pituitary tumour (ACTH ELEVATED) is called…
Cushing’s disease
If you suspected a diagnosis of adrenal insufficiency, which of the following signs would you explore to reinforce your suspicion?
A. Hand tremor
B. Abdominal obesity
C. Ankle edema
D. Orthostatic hypotension
D. Orthostatic hypotension
(Problems in aldosterone production)
No cortisol production causes…
ADDISON’S DISEASE: hypoglycemia, pigmentation of skin, postural hypotension, weakness…
POMC is the precursor of…
ACTH and MSH (melanin).
When we have low cortisol, ACTH goes up and MSH also.
That is why with adrenal insufficiency there is hyperpigmentation.
Which biochemical pattern of plasma determinations is classic for untreated primary adrenal insufficiency?
A. Low ACTH and morning cortisol
B. Elevated ACTH and low morning cortisol
C. Normal ACTH and low nocturnal cortisol
D. Low ACTH and normal morning cortisol
B. Elevated ACTH and low morning cortisol
Types of adrenal insufficiency
- Primary: problems in adrenal gland, NO CORTISOL AND NO ALDOSTERONE.
- Secondary: low ACTH production maybe be because of a pituitary tumour, here we have NORMAL ALDOSTERONE
- Tertiary: no CRH, ACTH, CORTISOL, but ALDOSTERONE IS INTACT.
Once the diagnosis has been confirmed and treatment with hydrocortisone has been started. Which of the following parameters do you consider to be of greatest interest to monitor whether the hydrocortisone dose is adequate?
A. Cortisol and ACTH at different times of the day
B. Morning cortisol and ACTH
C. Urinary free cortisol
D. All of the above
A. Cortisol and ACTH at different times of the day
Por la mañana estaría bajo (por eso toma la medicación).
No es C, porque los niveles de ACTH deberían cambiar tmb y verse rebajados ante la presencia de cortisol
Which of the following symptom/sign can make you suspect the diagnosis of pheochromocytoma?
A. Weight loss
B. Arterial hypertension
C. Drowsiness
D. Cold intolerance
A. Weight loss (IT IS CATABOLIC)
Other symptoms include: palpitation, blurry vision, heart failure…
If you need to achieve diagnostic certainty, which of the following measurements seems most accurate?
A. Metanephrines in blood
B. Blood catecholamines
C. Urine catecholamines
D. Vanilmandelic acid in urine
A. METANEPHRINES IN BLOOD
Epinephrine and norepinephrine have a short half-life.
PHEOCHROMOCYTOMA
Once the diagnosis is confirmed, surgical treatment is indicated. Which preoperative pharmacological preparation would you consider important to minimize the effect of tumor manipulation and the consequent rel catecholamines?
A. Alpha adrenergic blocker
B. Beta adrenergic blocker
C. Diuretic
D. It will not be necessary
A. Alpha adrenergic blocker
2ndly, we could block BETA2
(We do not want a heart attack, we want to reduce vasoconstriction)
Weight loss (Pérdida de peso), polyuria, polydipsia (excessive thirst), polyfagia (extreme hunger)… causes: (LAS CUATRO P DE DIABETES)
DIABETES MELLITUS
It is not DIABETES INSIPIDUS because weight loss or polyfagia is not common in that type of diabetes.
With a diabetes mellitus, which blood test analysis would you ask for?
GLUCOSE IN BLOOD
Type 2 diabetes, metabolic syndrome which shows…
Obesity, insulin resistance, hyperglycemia, dyslipidemia, hypertension
(GLUT-4 IS NOT WORKING, but we have beta cells)
In type 1 diabetes…
Problems in beta cells
Normal glucose levels
Between 70 and 100
Diagnosis of diabetes
- HIGHER THAN 126 (FASTING STATE)
- HIGHER THAN 200 ( AT ANY TIME)
ORAL GLUCOSE (75G): IF IT IS HIGHER THAN 200
SABER ESTOS VALORES
YOU START ANTIDIABETIC MEDICATION
HOW ARE YOU GOING TO DO THE FOLLOW-UP OF THIS PATIENT?
A. Cholesterol measurement
B. Glycated hemoglobin
C. Fasting glucose
D. Insulin measurement
B. GLYCATED HEMOGLOBIN (nos sirve a largo plazo)
A patient with type 1 diabetes has loss of consciousness and begins sweating, she might have…
A. Hyperglucemia
B. Hypoglucemia
C. Seizure
HYPOGLUCEMIA (our sympathetic nervous system activates, glucagon increases)
We treat her with intramuscular glucagon or intravenous glucose (as she is unconscious).
If she were conscious she would be treated with food with sugar
Tumour in adrenal medulla which produces adrenaline
PHEOCHROMOCYTOMA
