PPP ROSH- Endo Flashcards
What PE finding is seen w/ Primary Adrenal Insufficiency but no Secondary Insufficiency
How are Primary and Secondary different
What medication can falsely lower free T4
Skin pigmentation: inc ACTH releases MSH, inc pitgment
1: intact HP axis, dec cortison, inc ACTH
2: HPAxis not intact, dec ACTH
Anticonvulsants
Hyperthyroid
Sub-clinical hyperthyroid
Central hypothryoidism
Low TSH, High T4/3
Low TSH, Normal T4/3
Low TSH, T3/4
Subclinical hypothyroid
Primary hypothyroid
TSH producing adenoma
High TSH, Norm/Norm
High TSH, low/low
High High High
How is Hashimotos Dx confirmed
What layer of adrenal gland do Pheos arise from
How are Pheos Dx
Thyroid peroxidase or,
Thyroglobulin Abs
Medulla
Fractionated metanephrine, catecholamines in 24hr urine
Plasma fractionated metanephrine
Graves Dz is AKA ?
What causes this Dz
What is the classic triad
Toxic diffuse goiter- MCC of hyerthyroidism
Ab to thyroid hormone receptors
Pretibial myxedema
Exophthalmos
Diffuse goiter
What causes the exophthalmos and pretibial edema in Graves Dz
Only DM medicatin proven to reduce mortality
What test differs DMT1 from DMT2
Glycosaminoglycan accumulation
Metformin
C-peptide: absent in DMT1
Lab results for SIADH
Lab results for dehydration
Lab results for DI
Dec serum NA/Osmolality; Inc urine osmolality
All three inc’d
Inc serum Na/Osm, dec urinary osm
Biguanides
Sulfonylureas
Thiazolidinediones
Metformin- dec hepatic production, inc muscle/fat insulin sensitivity
- ide: inc insulin secretion (2nd Gen starts w/ G)
- litazone: inc insulin sensitivity at muscle/fat
Meglitinides
A-glucosidase inhibitors
DPP-4 inhibitor
-glinidine: inc insulin secretion (hypoglucose, weight gain)
Acarbose, Miglitol: dec intestinal absorption of carbs
-gliptin: inc insulin secretion (can induce pancreatitis)
Glucagon-like peptide 1 agonists
Insulin
Gliflozin
-tide: inc insulin secretion, dec glucagon secretion (c/i in Pts w/ MedHx of pancreatitis)
Inc glucose uptake
-flozin: dec absorption of filtered glucose in prox tubules to inc excretion/dec plasma levels
Criteria for Dx DMT2
Pathophys of Acromegaly
What is the initial and confirmatory Dx test
Sxs w/ random ≥200
≥200 2hrs after 75g glucose
Fasting ≥126
A1c ≥6.5%
Post-pituitary pituitary release of GF, causes IGF-1 release
IGF-1;
PO glucose then test GF
What labs are used to confirm Hypothyroid Dx
What is the name of the sign when lateral eye brows thin out
How is HyperCa d/t malignancy Tx when bisphosphonates are C/i
Inc anti-microsomal/thyroglobulin Ab titers
Queen Anne
Denosumab
Define Androgen Insensitivity Syndrome
How do Pts appear on PE
MOA of Metoclopramide
46XY: female phenotype, male genotype d/t x-link recessive androgen receptor dysfuntion
Male brain w/ female body: breast development, no body hair, blind pouch
Inhibits dopamine receptors, inc sympathetic activation
Primary adrenal Insufficiency lab results
How are Pts Tx during crisis
What is the best Dx test for adrenal insufficiency
HyperK, HypoNa, HypoGlu; Dec adlosterone/cortisol; Inc ACTH w/ intact HPA
Hydrocortisone
Serum cortisol
What DM meds can lead to Hypoglycemia
E+ abnormality seen w/ rhabdo
? is the most important lab for determining thyroid function
Sulfonylureas
Insulin
Neglitinides
Hyper K
Free T4- active form of thyroxine
? PE finding aids w/ Dx of hyperthyroidism
What diabetic meds work through the incretin system
What are the two naturally occurring incretins
Anterior neck bruit
DPP4 inhibitor- gliptins
Glucagon-like peptide, Glucoinsulinotropic peptide- enhance B-cell secretion after glucose ingestion
Define the Incretin Effect
How are the two naturally occurring incretins cleared from the body
Define Chronic Autoimmune Thyroiditis
inc’d insulin secretion after glucose absorption
Dipeptidyl peptidase- enzymatically inactivates incretins
Hashimotos- inc TRH/TSH, dec T3/4; Tx: Levo
DKA vs HHS levels
How does Tx differ by K levels
DKA: >150mg
HHS: >500mg
> 5.2: begin insulin
3.3-5.2: 20-30mEq K w/ each L of fluid
<3.3: hold insulin, supplemental K 2-30mEq/hr until >3.3
Peds formula for Hypoglycemia fluid replacement
How is anion gap calculated
(2 x Age-yrs) +8
> 8yrs; D50 1ml/kg
1-8yrs: D25 2ml/kg
<1yr: D10 2-5ml/kg
2yrs old= 24ml of D25
Na - (Cl + BiCarb);
Norm: 3-10, higher= acidosis
? lab needs to be checked in Pts w/ hyperlipidemia despire adherence to statin therapy
Correct medication sequence for thyroid storm
What meds are used to Tx residual acromegaly after surgery
TSH
BB/PTU/Methimazole
Iodine/steroid, bile acid sequestrate
(BB, PPU, Iodine, HydroCor)
Somatostatin: Octreotide
Dopamine analogue
GF antagonist
What causes Pts to develop jaundice during thyroid storms
When Tx Pts w/ DM and already on PO meds, what additional medication regiment is preferred
? is the MC pituitary adenoma and ? Tx has the most efficacy
Hepatic hypoxia d/t peripheral O2 consumption and congestion 2/2 high output HF
Continue PO meds, add long acting insulin
Prolactinoma- Carbergoline > Bromocriptine (dopamine agonists)
BB MOA during hyperthyroid
PTU MOA during hyperthyroid
Methimazole MOA during hyperthyroid
Dec sympathetic activity, dec T4-3 conversion
Blocks thyroid hormone synthesis, dec T4-3 conversion
Blocks thyroid hormone synthesis
Iodine MOA during hyperthyroidism
Steroid MOA during hyperthyroidism
What PE finding is more likely suggestive of hypothyroid
Inhibits thyroid hormone release
Dec peripheral T4-3 conversion and adrenal insufficiency
Dec DTR relaxation
Name of the procedure for transphenoid resection of pituitary tumors
3 types of vision loss and location of mass
Hardy
L eye blind: L optic nerve
Bitemporal hemianopia: chiasm compression
Homonymous hemianopia: L cerebrovascular
MC precipitating event to thyroid storms
? presenting factor is most predictive of mortality during myxedema coma
What are the four stages of TSH, T3, T4 during De Quervains thyroiditis
Infection
Severe hypothermia
1: Dec, Inc Inc
2: N N N
3: Inc Dec Dec
4: N N N
Why is cholestyramine given after thyroid storms
Addisons two AKAs
How is a Thyroid Storm 2/2 exogenous hormone abuse Tx
Dec enterohepatic recirculation of thyroid hromone
Primary adrenal insufficiency,
Hypocortisolism
BB, Dexamethasone
? DM meds are c/i in Pts w/ Hx of pancreatitis
MOA of Bisphosphonates for HyperCa
MOA of Calcitonin for HyperCa
GLP-1s: -tides
Inhibit Ca release from bone
Inhibit bone resorption
What needs to be avoided when Tx HyperCa
When is dialysis indicated
What are the 4 cells found in the Islets of Langerhans and what does each release
Thiazides
> 18mg
A: glucagon
B: insulin
D: somatostatin
Epsilon: ghrelin
Pentad for Dx of Hashimotos
Define Myxedema Coma
How do Pts present w/ this
Inc TSH, Low T4
+ anti-peroxidase Abs
+ anti-thyroglobulin Abs
Hypothyroidism decompensating metabolic/mental status
Bradycardic
AMS
Hypo-temp, tension
How are Myxedema Comas Tx
If TSH dose is increased during hypothyroid Tx, when are Pts f/u
What is the first/initial screening test for Pts w/ RFs for Pheos
Hydrocortison w/ Levo
q6wks until normal TSH range
Plasma fractionated metanephrines
What medication is recommended for Dm Tx when Metformin is C/i
Primary Hypogonadism lab results
Secondary Hypogonadism lab results
Sufonylurea: Glipizide
Inc FSH/LH, dec T
Low/Norm FSH/LH
Dec T
? are the two MC polyneuropathies
What are the two MCC of this MC
? Sx suggests a CNS d/o
Chronic, axonal injury
DM, Uremia
Spasticity d/t upper motor neuron involvement
Two major s/e of using Sulfonylureas for DM Tx
? DM emergency has a higher mortality rate
Pt presentation for Pituitary Apoplexy and initial Tx
Hypoglycemia, Weight gain
HHS
Sudden HA, N/V, 2* Adrenal insufficiency, HyperK, HypoGlu; Tx: Hydrocortisone
Pts w/ recurrent hypoglycemic episodes while taking Glimepiride need ? med
What can cause DM A1c levels to be artificially low
Initial and test of choice to for suspected Addisons
Octreotide: inhibits glucose stimulated insulin release to prevent hypoglycemia
Hemoglobinopathies: inc RBC turnover, dec life span
Initial: Morning serum cortisol
Toc: rapid ACTH stim test
ADA recommends screening DMT2 in ? populations
Primary Hyperaldosteronism Is AKA and presents as ?
What meds can be used for Tx
BMI <25 and Triglycerides >250
Conn Dz: aldosterone producing adenoma
HTN HypoK, Met alkalosis
Spironolactone/Eplerenon; Adrenalectomy
MC type of thyroid Ca
? type has a poor prognosis
How would Growth Hormone Deficiency post-head trauma present
Papillary
Anaplastic
Low GH, IGF-1, IGF binding protein
How is Growth Hormone Deficiency Dx
MCC of Cushing Syndrome
MC Endogenous cause is ?
Low IGF-1
Insulin tolerance test
GHRH-arginine test
Exogenous, Iatrogenic from long term CCS therapy
Cushing Dz: excessive ACTH secretion
Red flags for thyroid nodule
Size >4cm hard/fixed
Invasive Sx; dysphagia, hoarse
Rapid growth
FamHx
Age <20, >65
Radiation
Male
ACTH/Cortisol trends between Primary/Secondary/Tertiary d/os
What would biopsy results show in Hashimotos
Define Riedels Thyroiditis
Primary: opposite
2/3ry: same
Lymphocytic infiltration w/ germinal and Hurthle cells- enlarged epithelial cells w/ eosinophilic granular cytoplasm
Rock hard, rapidly growing thyroid nodule w/ poor movement during swallowing
How is Riedel’s Thyroiditis Dx
What are the only two thyroid nodules that present as “rock hard”?
MC presentation of Graves Dz
IgG4 serum levels
Anaplastic Ca, Riedels thyroiditis
Afib
Risk of PTU during Hyperthyroidism Tx
First/Second line Tx for Central DI
How is Nephrogenic DI Tx
Liver toxicity/failure
DDAVP, Carbamazepine, Chlorpropramide
Hydrochlorothiazide, Indomethacin, Amiloride
How does Cretinism present
These Pts are at inc risk for developing ? later in life
Then Tx w/ PO Thyroxine, pt may develop ? d/t meds
Birth hypothyroidism: hypotonia, coarse facial features, wide sutures, umbilical herniea
NHL
Papillary Ca
Role of Aldosterone
Function of Cortisol
Adrenal crisis are caused by ?
Na reabsorption, K excretion
Stims gluconeogenesis- inc protein break down and inc FA mobilization while dec ImmSystem
Insufficient cortisol
Primary Adrenal Insufficiency
Secondary Adrenal Insufficiency
Tertiary Adrenal Insufficiency
Addisons; autoimmune induced dec cortisol secretion causing inc ACTH
Dec ACTH from pituitary causing low low ACTH and cortisol levels (adenoma, d/c steroids)
Dec CRH induced low ACTH and cortisol
Initial Dx testing for Primary Adrenal Insufficiency include ?
What meds are used in sequence for Tx
Lab result triad for Cushing’s Syndrome
8am serum cotisol w/ plasma ACTH levels then,
High dose ACTH stim test
Hydrocortisone- 1st, Fludrocortisone- Addison’s only
Inc cortiosl/aldosterone (Na reabsorb- HTN), dec K (Cushing Dz- inc ACTH from pituitary adenoma)
How is Cushing’s Syndrome Dx
What are the three etiologies of Cushing’s Syndrome
24hr urine w/ low dose Dexameth suppression
High dose suppression:
Dec ACTH- adrenal tumor
Norm/Inc ACTH- ectopic ACTH tumor
Pituitary tumor: inc ACTH, Inc Cortisol
Adrenal tumor: Dec ACTH, Inc Cortisol
Ectopic ACTH: Inc ACTH, Inc Cortisol; (SCLCa) won’t respond to Dexameth suppression test
Cushing’s Syndrome high dose result interpretation
How is Cushing’s Syndrome Tx
How is Cushings Dz Tx
Pituitary: dec ACTH, dec cortisol
Adrenal: dec ACTH, inc cortisol (no change)
Ectopic: inc ACTH, inc cortisol
Ectopic/Adrenal: resection or Ketoconazole
Transphenoidal surgery
Gigantism/Acromegaly is caused by pituitary adenoma releasing GH or non-pituitary tumor releasing ?
How are non-operable Pts Tx
Secondary Adrenal Insufficency lab results
GHRH
Octreotide, Lanreotide
Dec ACTH, cortisol; Normal aldosterone
DEXA categories
MOA of Bisphosphonates
Dawn Phenomenon and Syomogyi Effect
Penia: -1 - -2.4
Porosis: ≤-2.5
Sev: ≤-2.5 w/ Fx
Dec bone resorption to preserve bone mass
D: Dec insulin sensitivity, surge of regulatory hormones; inc bed time insulin/avoid bedtime snack
S: hypo to hyper glycemia d/t GH, inc bedtime insulin/take snack
3AM dose; rises at 3AM= Dawn; Low= Somogyi
Rapid Acting insulin
Short Acting insulin
Intermediate Acting insulin
Long Acting insulin
Lispro, Aspart, Glulisine: 5-15, 45-75, 2-4hrs; same time as meal
Regular: 30min, 2-4hrs, 5-8hrs; <60min prior to meal
NPH, Lente; 2hr, 4-12hr, 8-18hr; covers half day/night, often used at bedtime
Detemir, Glargine:
2h, 3-9h, 6-24hrs; 2hr, none, >20hrs
Only insulin w/out peak effect
Which one can cover one full day
What types should not be mixed w/ other types of insulin
Glargine
Detemir
Long Acting
Hypoglycemia in non-DM can be screened for w/ ? test
How is severe hypoglycemia Tx
Paget’s MC affects ? part of the body
C-peptide: elevation w/ endogenous insulin production
Bolus D50 or Glucagon
Femur Lung Pelvis Skull
How is Paget’s identified on PE
What form of Ca are Pts prone to
How is this Dx
Warm extremities, Deafness
Osteosarcoma
Inc Alk Phos, X-ray lytic lesion/thick cortices
How is Paget’s Tx
Define Hyperparathyroid Dz
What are the three types by etiology
Bisphosphonates and Calcitonin
Excess PTH secretion increasing Ca levels (Sxs tart at 12)
Primary: parathyroid adenoma (Inc PTH/Ca, Dec Phos)
Secondary: MC d/t CKDz (N/Dec Ca, Inc Phos/PTH)
Tertiary: PTH produced regardless of Ca (all inc)
Triad of Hypoparathyroidism
What are the 3 PE signs
How are Pts x
Dec Ca/PTH, Inc phosphate
Chvostek’s, Trousseaus, Inc DTRs
Vit D, Ca, Synthetic PTH
Tetany= IV Ca gluconate
What two lab results may be seen w/ Dx of Hypothyroidism
What are the 3 P’s of MEN 1
Define MEN 2
Normo-Normo anemia, High cholesterol (primary)
Overactive exocrine glands:
Hyperparathyroidism- MC
Pancreatic tumors- 2nd MC
Prolactinomas
Overactive endocrine gland d/t RET proto-oncogene:
Medullary ca, Pheo, Neuroma, Marfanoid habitus
What presentation can hint at MEN 2 Dx
? is the MC tumor of the pituitary
What lab results would be seen w/ this MC
Medullary thyroid ca in infancy
Prolactinoma- adenoma of lactotroph cells
Inc prolactin, Dec FSH/LH
What are the etiologies of SIADH
What does this cause to occur
How are Pts Tx by severity
Excess ADH release d/t:
CNS: MC; d/t subarachnoid hemorrhage
Pulm: SCLCa
Dec serum osmolality, inc urine osmolality
Mild: water restriction
Mod-Sev: AHD receptor antagonist (Coni/Tol-vaptan)
Sev: IV hypertonic saline w/ Furosemide
How is Chronic SIADH Tx
MC type of thyroid Ca
Thyroid Ca w/ distant mets more common
Demeclocycline
Papillary after radiation exposure
Follicular- 2nd MC, incidence w/ iodine deficiency; Lung>Liver>Brain>Bone
Medullary thyroid Ca is d/t ? genetic mutation and will have ? lab result
What marker is used to track for recurrence after total thyroidectomy
MC type of thyroid nodule
RET mutation, Inc calcitonin
Calcitonin
Follicular/Colloid- rapid growth w/ no movement during swallowing
What med is avoided during Tx of thyroid storms
MCC of suppurative thyroiditis
How is this Dx for Tx planning
ASA- displaces thyroid hormones off of carrier proteins
Staph A- F/C/pain worse w/ extension, relieved w/ flexion
Leukocytosis, Inc ESR, FNA w/ Gram stain
What are the only two painful thyroid conditions
What types of tumors release ACTH to induce Cushings Syndrome
Subacute (Granulomatous, Dequervain)
Suppurative thyroiditis
Small Cell Lung Ca
Cushings Syndrome dexamethasone etiologies and suppression test results
Etiology:
Pituitary tumor: inc ACTH, inc Cortisol
Adrenal tumor: dec ACTH, inc Cortisol
Ectopic ACTH: inc ACTH, inc Cortisol
Low dose suppression:
Pituitary: inc ACTH, inc Cortisol
Adrenal: dec ACTH, inc Cortisol
Ectopic: inc ACTH, inc Cortisol
High dose suppression
Pituitary: dec ACTH, dec Cortisol
Adrenal: dec ACTH, inc Cortisol
Ectopic: inc ACTH, inc Cortisol
