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Endocrine > TEST 1 > Flashcards

TEST 1 Flashcards

1
Q

hypopituitarism

A

-partial/complete loss of anterior pituitary
-dx- MRI*, CT, pituitary hormone levels
-primary- tumor (MC), infarction (apoplexy, sheehan’s), inflammatory (meningitis, abscess, sarcoidosis), infiltrative (langerhan’s cell histiocytosis, hemochromatosis), iatrogenic, autoimmune
-secondary- hypothalamic
-insidious onset is MC but sudden is more deadly
-congenital is deadly (GH only affects kids)
-ACTH with adrenal crisis and TSH with myxedema -> deadly
-GH is lost first -> GnRH, TSH, ACTH
-ADH rarely lost unless secondary issue -> if pt has polydipsia or SIADH -> suspect hypothalamus

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2
Q

hypopituitarism tx: urgent cute adrenal insufficiency, visual field loss, prolactinoma, pituitary apoplexy

A

-urgent acute adrenal insufficiency -> ASAP glucocorticoids -> 100mg hydrocortisone IV, then 5-100 every 6 hrs and fluid replacement
-visual field loss/tumor -> ASAP referral -> transsphenoidal removal or irradiation
-hormone replacement
-dopamine agonist- prolactinoma
-pituitary apoplexy- ASAP surgery if visual issues or coma

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3
Q

ddx of generalized hypopituitarism

A

-anorexia nervosa- maintenance of secondary sexual characteristics! (this differentiates it) despite amenorrhea -> increased GH (low IGF) and high cortisol
-alcohol liver disease of hemochromatosis- evidence of liver disease -> lab testing
-myotonia dystrophica- progressive weakness, premature balding, cataracts, facial features of accelerated aging -> lab testing
-polyglandular autoimmune disease

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4
Q

hypopituitarism in children

A

-pituitary tumor- craniopahrngioma
-langerhan’s cell histiocytosis
-cleft palate
-idiopathic, hereditary (5%)
-ht below 3rd precentile
-skeletal maturation > 2yrs behind -> left hand x-ray
-late puberty
-CT or MRI
-mid to late childhood -> IGF-1 measured
-tx- surgery, GH therapy, other hormone therapy

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5
Q

ACTH deficiency

A

-fatigue, weak
-wt loss
-hypotension
-hypoglycemia
-intolerance to stress and infection
-decreased axillary and pubic hair
-NO hyperpigmentation
-plasma and urine steroid levels are low

-dx-ACTH stimulation test- synthetic ACTH (cosyntropin) -> cortisol should rise >21 and aldosterone >4 from baseline after 30-60 mins
-insulin tolerance test- hazardous in panhypopituitarism, DM, old -> CI in CAD and epilepsy

-tx- cortisol replacement

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6
Q

Kallmans syndrome

A

-lack of GnRH
-midline facial defect- cleft
-anosmia, sensorineural deafness
-color blind
-hypogonadism
-unilateral renal agenesis (missing 1 kidney)- 50%
-cryptochidism (testes dont descend), micropenis
-bimanual synkinesis (mirror)
-ataxia, cognitive problems
-menarache with secondary amenorrhea

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7
Q

panhypopituitarism

A

-simmond’s syndrome- involves all hormones -> embolic infarction, tumor, syphilis, tuberculosis, metastatic abscess
-sheehan’s syndrome- placenta not delivered right away -> no contraction -> blood loss -> pituitary necrosis from hypovolemia and SHOCK
-no lactation after birth, fatigue
-loss of secondary sexual characteristics (pubic and axillary hair)

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8
Q

pituitary apoplexy

A

-adrenal crisis
-sudden
-pituitary outgrows blood supply
-hemorrhagic infarction of normal or tumor pituitary
-headache, neck stiff, fever, visual field defects*, oculomotor palsies
-compression on hypothalamus -> coma
-hypopituitarism results suddenly -> vascular collapse due to low ATCH and cortisol
-CSF +/- blood
-MRI- hemorrhage

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9
Q

gigantism

A

-little bony deformity
-delayed puberty
-hypogonadotropic -> eunuchoid habitus

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10
Q

acromegaly

A

-1st symptoms- coarsening of face, soft tissue swelling of hands and feet
-naso-sinus abnormality -> snoring, sinusitis, sleep apnea
-diplopia
-arthralgias - TMJ- prognathism
-gums grow -> teeth gaps
-dorsal kyphosis
-deepening of voice
-increase soft tissue- macroglossia, heel thickness (>22mm), sausage fingers
-barrel chest
-insulin resistance, glucose intolerance -> hyperglycemia
-hypertriglyceridemia
-HTN, cardiovascular abnormal
-pulmonary issues from soft tissue growth
-colonic polyposis
-hyperprolactenemia- galactorrhea
-decrease libido and impotence

-tumor- headache, visual issues -> hypopituitarism due to compression
-mortality- stress on body, prone to malignancy
-oily, doughy moist handshake, sweaty
-carpal tunnel, weakness in arms and legs
-skin tags*
-frontal bossing

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11
Q

non-pituitary tumor secretion of GH

A

-RARE
-Pancreatic cancer
-Small cell lung cancer
-Tumors of the adrenal gland
-Carcinoid syndrome
-Carcinoma of the thyroid
-Hypothalamic tumors - extremely rare -> Hamartoma, glioma, or gangliocytoma

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12
Q

acromegaly/gigantism dx

A

-symptoms lead to suspicion
-IGF-1*
-GOLD STANDARD- OGGT - confirms dx
-if GH fails to decrease to <1 after ingestion of glucose -> +
-give glucose- GH and IGF should decrease BUT with acromegaly it will not decrease
-MRI- pituitary adenoma
-CT*
-whole body scan, SPECT, somatostatin receptor scintigraphy - ectopic tumor

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13
Q

gigantism/acromegaly tx

A

-surgery- 1st line
-microadenomas (<10mm), macro (>10mm) -> most are macro (50% curable with resection)
-usually do med or radiation therapy with resection

-Pharmacotherapy- 2nd line
-somatostatin analogs- octreotide -> can also be give before surgery to shrink the tumor down
-dopamine agonist- cabergoline or bromocriptine
-GH receptor antagonist- pegvisomant

-radiation- adjunct or 3rd line
-used for non-resectable, pharm therapy fail, or adjunct
-usually used on its own
-risk of hypopituitarism within 10 years
-stereotactic (gamma knife) radio surgery

-decline in sweating/oily skin -> hallmark of surgical success
-soft tissue symptoms resolve with tx
-bone changes do not resolve
-if colonic polyps were an issue -> continued to be high risk
-if tx before articular cartilage damage -> joint symptoms are reversible

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14
Q

hypothalamic pituitary lesions

A

-MC tumor- hypo (compression) or hypersecretion
-headache, visual field defects
-thirst, altered appetite
-MRI
-can cause enlarged sella

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15
Q

pituitary adenoma

A

-macroadenoma- >10mm -> mass effect
-macro -> look for signs of hypopituitarism!!!!!!!!! (big enough to compress) -> pallor, hypotension
-microadenoma- <10mm -> hormones effect
-secretory- prolactinoma, GH secreting, corticotroponin secreting, thyrotropin secretion
-non-secretory- MC gonadotropin -> usually present with visual defects bc no hormone symptoms

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16
Q

secretion pituitary adenomas

A

-GH-secreting tumors: Signs of acromegaly

-Thyrotropin-secreting pituitary adenoma:
-Thyrotoxicosis
-Goiter
-Visual impairment

-Corticotropin -secreting pituitary adenoma:
-Truncal obesity
-Round face
-Dorsocervical fat pad (buffalo hump)
-Hirsutism
-Acne
-Menstrual disorders
-Hypertension
-Striae
-Bruising
-Thin skin

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17
Q

MEN

A

-autosomal dominant
-genetic testing
-MEN1- pituitary, parathyroid, pancreas
-MC prolactinoma
-Carney syndrome- spotty skin, myxomas, endocrine tumors (testicular, adrenal, pituitary)
-McCune-Albright syndrome- polyostotic fibrous dysplasia, pigmented skin patches, endocrine disorders (GH pituitary tumors, adrenal adenomas, autonomous ovarian function
-familial acromegaly

-MEN2- medullary thyroid cancers, pheochromocytoma, hirschspring disease

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18
Q

pituitary metastases

A

-rare
-POSTERIOR PUTIATRY (almost exclusively)
-diabetes insipidus!
-lung, GI, BREAST*
-MRI- hard to distinguish from pituitary adenoma
-primary or metastatic lymphoma, leukemias, plasmacytomas can occur within sella

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19
Q

prolactinoma S&S

A

-MC tumor
-usually microadenoma in women
-women - galactorrhea, amenorrhea, infertility, low libido, osteoporosis, painful sex, increase body hair, atrophic vaginitis, loss of labial fat pads, decrease breast size

-men- visual disturbances!
-usually macroadenoma- hypopituitarism
-hypogonadism, low libido, ED, infertility, decrease body hair, gynecomastia, galactorrhea (1/3), osteoporosis, decrease body hair

-apathy in women and men- ddx depression
-pharmacologic causes- amphetamines, nicotine, TCA, verapamil, estrogens*
-other causes: chronic renal failure, liver disease, ectopic production of prolactin- bronchogenic carcinoma (mostly small cell undifferentiated)*, hypernephroma

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20
Q

prolactinoma dx and tx

A

-are medications causing it?
-TSH*
-serum prolactin levels
-prolactin is episodic- stress can increase
-repeat sample should be taken if borderline
-NORMAL- <20
-if single draw is > 200 -> dx prolactinoma
-MRI*!

-tx- INDICATION- infertility or macroadenoma
-dopamine agonist- 1st line -> cabergoline, bromocriptine
-if visual issues -> transsphenoidal surgery
-radiotherapy- prior to surgery or after
-reoccurance is high after tx stops

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21
Q

macroadenoma

A

-seizures if extends into temporal lobe- rare
-lateral extension into cavernous sinus- impaired oculomotor function - CN 3, 4, 6, 5
-ophthalmoplegia- squint
-double vision
-bitemporal hemianopsia -MC
-hemifield slide- drift apart

22
Q

empty sella

A

-appear empty due to CSF compressing pituitary
-congenital, primary, secondary to injury (childbirth, surgery, trauma, radiation)
-MC- obese female with HTN
-idiopathic intracranial HTN
-spinal fluid rhinorrhea
-usually normal functioning -> hypopituitarism can occur
-can occur with tumors
-CT or MRI dx
-no tx if asymptomatic

23
Q

ADH

A

-increases permeability of distal tubular epithelium -> increase reabsorption of water
-can cause vasoconstriction at high levels
-MAIN STIMULUS- high osmotic pressure
-other stimulus- volume depletion (baroreceptors in LA, PV, carotid sinus, aortic arch via vagus and glossopharyngeal), pain, stress, emesis, hypoxia, exercise, hypoglycemia, B-blockers, angiotensin, prostaglandins
-inhibitory- alcohol, alpha-blockers, glucocorticoids
-removal of pituitary does NOT result in DI -> remaining hypothalamic neurons produce ADH

-a lack of is caused by primary (hypothalamic/stalk) or secondary (hypophysectomy, injury, tumor, infection, granulomas, vascular)

24
Q

DI sx

A

-CDI
-acute or insidious, any age
-primary- polydipsia, polyuria
-secondary- can also have secondary sx depending on cause
-3-30 L/day urine
-Sp.gr < 1.005
-urine osmolality <200
-nocturia
-ADH < 1

-NDI
-inherited or secondary to renal impairment
-ADH >1

25
DI dx
-water deprivation test* -weight pt before, draw electrolytes and urine osmolality -urine collected hourly for- osmolality OR Sp.gr measurement -administer 5u ADH -> urine collected 60 mins after -D/C if: orthostatic hypotension, >5% wt loss, postural tachycardia, urine concentration doesnt increase by > .001 sp gr OR >30 osmolality -NORMAL- increase > 1.02 sp gr OR > 700 (exceeding plasma) -CDI- urine osmolality increase > 50% (not higher than plasma) -NDI- no response -partial CDI- osmolality increases above plasma -ADH measurement- not necessary -if you do it, you measure after water deprivation and before ADH administration OR after infusion o hypertonic saline
26
psychogenic polydipsia
-ingest up to 6L fluid/day -nocturia is ABSENT -acute- can concentration urine during water deprivation -chronic- unable to concentrate urine during water deprivation -NO response to ADH after water deprivation -after prolonged restriction to < 2 L/day -> normal concentration ability is restored within several weeks
27
DI tx
-desomopressin- synthetic ADH, many routes -S/E- fluid retention, headache, increase BP, URI or allergic rhinitis -diuretics- thiazides -ADH releasing drugs: -chloropropamide (hypoglycemia) -carbamazepine -clofibrate -prostaglandin inhibitors: -reduce GFR and renal blood flow -NDI- thiazide, low salt, low protein
28
SIADH criteria, causes
-max dilute urine with hyponatremia/osmolality WITHOUT: -volume depletion or overload -stress -pain -diuretics or other meds that stim ADH -no cardiac, hepatic, renal, adrenal*, thyroid* impairment -dx of exclusion -CAUSES: -drugs -post op stress, mechanical ventilator, anesthetics -hormones- ADH, desmopressin, oxytocin -CNS infection, trauma, neurosurgery* -pulmonary!- pneumonia, TB, emphysema, SCLC* -head trauma
29
SIADH signs and symptoms
-asymptomatic -confusion -lethargy -vomiting -seizures -hypoosmolality plasma- <275 -euvolemic- normal volume -hyperosmolality urine- >100 often >300 -serum uric acid < 4 -normal K, Cr, acid base -normal adrenal and thyroid
30
SIADH diff dx
-hypervolemic hypotonic hyponatremia: -edema -CHF, liver cirrhosis with ascites, nephrotic syndrome, protein losing enteropathy -hypovolemic hypotonic hyponatremia: -diuretics, burns, diarrhea, vomiting -interstitial nephritis, obstructive nephropathy -mineralocorticoid deficiency
31
SIADH tx
-fluid restriction- 1st line -achieve safe plasma Na - > 120 -determine and treat underlying cause -d/c meds causing -for refractory cases -> demeclocycline or normal saline infusion -tetracycline antibiotic- antagonizes effect of ADH
32
diabetic retinopathy
-within 20 years all type 1 has it and 60% of type 2 -type 2 presents at dx -macular edema and PDR are MC cause of vision loss -type 2- dilated and comprehensive exam @ dx -cataracts -glaucoma
33
stages of DR
-mild NPDR- increase vascular permeability, microaneurysms, intraretinal hemorrhage, ANNUAL FU -moderate NPDR- venous caliber changes, IRMAs, 6-12 MO FU, color fundus photography -severe/very severe NPDR- ischemia, IRMAs, extensive hemorrhage and microaneurysms, 3-4 MO FU, color fundus photography, panretinal photocoagulation -PDR- ischemia with neovascularization at optic disk and retina, vitreous hemorrhage, retinal traction, tears, and detachment, 2-4 MO FU -If CSME present: color fundus photography, fluorescein angiography, and photocoagulation
34
neuropathy + dx
-caused by high glucose, glycation end products, sorbitol, blood fat levels, ischemia -type 2- @ dx -type 1- 5 years after dx -nerve conduction studies -electromyographic exam -US -foot exam at every visit or more: -temperature/pinprick -vibration with 128Hz -quantitative sensory testing -monofilament (4/10) -gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressents, sodium channel blockers -anticonvulsants, topical cream, moisturizer -infected ulcer -> antibiotics -fil calluses with pumice
35
symmetric polyneuropathy
-MC -stocking glove -vibratory, thermal pain, paresthesia -ulcers, charcot arthropathy -PVD
36
autonomic neuropathy
-internal organs- GI, GU, cardio, peripheral -charcot foot -edema, pruritus, pulsation, tight, aching, sweating -GU- bladder, retrograde ejaculation, ED, dyspareunia -GI- gastroparesis, enteropathy -cardio- exercise intolerance, hypotension -dx- direct microelectrode recording of postganglionic C fibers -galvanic skin responses -measurement of vascular responses -tx- midodrine, diuretics, d/c aggravating drugs, elevate feet, stockings, screen for CVD -tx GI- metoclopramide (motility), erythromycin, R/O atherosclerosis/tumor, loperamide (anti-diarrhea), antibiotic, stool softeners, dietary fiber -aldose reductase inhibitors -ACE inhibitors- doesnt need to be HTN
37
polyradiculopathy
-amyotrophy- thigh pain with muscle weakness and atrophy -dx- electromyographic studies
38
mononeuropathy
-single nerve -compression / ischemia -carpal tunnel -elbow -foot- unilateral foot drop -numbness, edema, pain, prickling -cranial- CN 3, 4, 6 -> diplopia, abn visual fields, unilateral pain, paralysis
39
nephropathy
-first evidence - albuminuria (>300) -by the time Cr is high -> 50% renal lost -GOALS: -bp <140/90 and <130/80 in ASCVD -HmgA1c <7 and <8 for GDM -preprandial 90-130 -peak postprandial <140 -kidney transplant- blood type, human leukocyte antigens (HLAs), cross matching antigens -1. high GFR -2. microalbuminuria with some glomeruli damage -3. albuminuria (>200), Cr and urea rise, BP may rise -4. GFR < 75, HTN, proteinuria -5. GFR <10 -tx- bp, protein restriction, ACE -end stage- hemodialysis, transplant, peritoneal dialysis -dialysis- limit potassium and fluid, phosphorus
40
DKA
-ketones > 5 -glucose > 250 -pH < 7.2 and gap > 12 -bicarbonate < 15 -high amylase and lipase -low insulin and high glucagon -> glucagon converts FFA to ketones -> insulin would normally block this -> acetoacetic acid and β-hydroxybutyric acid -can be caused by infection, cocaine, inadequate insulin use, pregnancy, infarction -dry membranes, SOB, kussmaul respirations, fever if infection, acute cerebral edema in children (monitor fluids!) -children with highest BUN and lowest CO2 at presentation -> greatest risk
41
DKA tx
-potassium 5.5 and greater -> IV insulin -4.5- monitor while giving -<3.3- you cant give insulin -<5.5 supplement K 10 -<3.5 supplement K 40-80 or if bicarbonate if given -cont until acidosis and glucose is good -rapid 2-3L 0.9% saline in first 1-3hrs -once BP and urine flow stable -> 0.45% saline -5% glucose and 0.45% saline when glucose reaches 250 -IV insulin -increase 2-10 fold if no response by 2-4hrs -once 250 glucose you can reduce dose -cont insulin until anion gap is WNL and blood and urine are neg for ketones -pH <7 -> bicarbonate -once tx initiated may need to supplement phosphate and Mg -ICU- labs every hour -capillary glucose every 1-2 hrs -electrolytes and anion gap every 4 hrs -vitals every 1-4 hrs FU: -education (underlying cause) -if sick or oral intake is compromised: -check capillary blood glucose often -if glucose >300 check urinary ketones -drink water -continue or increase insulin -seek medical attention if dehydration, persistent vomiting or uncontrolled hyperglycemia
42
hypoglycemia tx
-Mild- carbohydrate 10-15 gram* -Moderate: -20-30 gram of carbohydrates* -Glucagon, 1 mg IM - if unconscious -Severe: -50% dextrose 25 g IV -Glucagon 1 mg IM or IV
43
HHNK
-causes- drugs, procedures, chronic illness, acute illness -K is not urgent bc insulin is present -hyperglycemia, dehydration, hyperosmolar -NO/slight ketosis, NO acidosis -complications- MI, stroke, PE, mesenteric vein thrombosis, disseminated intravascular coagulation -dehydration
44
-postprandial glucose targeted if A1c goals are not met despite reaching pre-prandial glucose
45
monitoring diabetes
-prediabetes- yearly -uncontrolled diabetes or transition- quarterly -diabetes stable - 6-12 months -microalbuminuria, lipids, LFTs, Cr, GFR, c-peptide level, TSH- at dx and annual -type 1- 3-4 times a day SMBG -type 2- ass needed SMBG
46
metabolic syndrome
-waist circumference -glucose levels (prediabetes/resistance) -BP -triglycerides, HDL
47
insulin types
-bedtime intermediate or bedtime/morning long acting -> if A1c is still high -> rapid acting before breakfast, or lunch, or dinner depending on when glucose starts to rise -basal- long acting, 1-2x a day, rarely cause hypoglycemia -rapid insulin- regular -bolus insulin -> rapid, given before food -NPH- intermediate acting -mixed- NPH and regular insulin
48
GDM risk factors
-Fasting plasma glucose concentration >85 mg/dL or -2-hour postprandial glucose concentration >140 mg/dL -> Indicates need to perform a 75-g oral glucose tolerance test
49
Graves disease
-toxic diffuse goiter -MC genetic autoimmune -can be brought on by environment (stress) -smoking -> ophthalmopathy -postpartum -high HLA -dermopathy - pretibial myxedema -ophthalmopathy- can happen before and or after event -> sympathetic overactivity -thyroid acropachy*** -hyperreflexia (brisk), muscle wasting, proximal myopathy -osteopenia -hypercalcemia / uria (mc) -children- high linear growth, eye symptoms -elderly- CHF, afib
50
other thyroid disease
-plummer disease - toxic multinodular goiter -jodbasedows disease- iodine induced, or amiodarone -subacute thyroiditis- viral, idiopathic -nodule >1-2mm -> bx -confusion- high bilirubin, LFTs, ferritin -microcytic anemia, thrombocytopenia -tx- antithyroid (thioureylene, propylthiouracil, methimazole), propanolol -radioactive iodine- CI in children <10, preg, active orbitopathy -thyroidectomy- children, preg who cant handle antithyroid, compression, cancer, rapid progression with comorbid -uni or multinodule goiter -> radiation after stable with antithyroid or surgery -fu- antithyroid- every 3 months -iodine radiation- 6 weeks, 3 months, 6 months, 1 year, annual -postpartum- 6 weeks

Endocrine (26 decks)

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