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Endocrinology
Internal Med
100
Science
Graduate
10/02/2015

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Term
rare potentially fatal complication of untreated (or partially treated) thyrotoxicosis usually after a precipitating event (sx, trauma, infection)
Definition
thyroid storm
Term
Clinical manifestations of thyroid storm
Definition
hypermetabolic state: palpitations, A. fib, tachycardia, high fevers, N/V, psychosis, delirium, tremors, dehydration, shock
Term
How do you diagnose thyroid storm?
Definition

increased free T4/T3 (markedly increased)

&

decreased TSH (TSH may be so low its undetectable)

EKG +- sinus tachy, A. fib, A. flutter

Term
treatment of thyroid storm
Definition

anti-thyroid meds: methimazole, PTU

beta blockers for symptoms

supportive: IV fluids

glucocorticoids (prevents conversion of T4 into T3 & impairs hormone production)

oral/IV sodium iodide (decreases thyroid hormone release)

antipyretics (avoid ASA - increases T4)

Term
RARE! either low PTH or insensitivity to its actions
Definition
hypoparathyroidism
Term
etiologies of hypoparathyroidism
Definition
  1. accidental damage/removal of parathyroid during neck/thyroid sx
  2. autoimmune destruction of parathyroid gland
  3. not very common - XRT, hypomagnesemia (Mg required for secretion of PTH)
Term
Clinical manifestations of hypoparathyroidism
Definition
  • signs of hypocalcemia: carpopedal spasm, Trousseau & Chvostek sign, perioral parasthesias, increased DTR
Term
How do you diagnose hypoparathyroidism?
Definition

triad: hypocalcemia + decreased intact PTH + increased phosphate

 

Mg may be low/normal/high

Term
How do you treat hypoparathyroidism?
Definition
Ca supplementation + vit D : ergocalciferol or calcitriol
Term
catecholamine-secreting adrenal tumor (enterochromaffin cells) secretes NE & EPI autonomously & intermittently (triggers include sx, exercise, pregnancy, meds: ex TCA, opiates, metoclopramide)

RARE (only accounts for 0.1-0.5% of its w/ HTN)
Definition
pheochromocytoma
Term
90% benign; 10% malignant. May be assoc w/ MEN syndrome II
Definition
pheochromocytoma
Term
Clinical manifestations of pheochromocytoma
Definition
  1. HTN: most consistent finding (secondary HTN) may be temp or sustained
  2. PHE: Palpitations, HA's (paroxysmal), excessive sweating.  Chest or abd pain, weakness, fatigue, weight loss (despite increased appetite)
Term
How do you diagnose pheochromocytoma?
Definition
  1. increased 24h urinary catecholamines including metabolites (metanephrine & vanillylmandelic acid)
  2. MRI or CT of abd. to visualize adrenal tumor
Term
Treatment of pheochromocytoma
Definition
  1. complete adrenalectomy 
  2. preop non-selective alpha blockade: phenoxybenzamine or phentolamine x 7-14 d --> followed by BB or CCB to control HTN.  DO NOT initiate therapy with BB (to prevent unopposed alpha-constriction during catecholamine release triggered by sx or spontaneously, which could lead to life threatening HTN)
Term
calorigenic symptoms of hypothyroidism
Definition
  • decreased basic metabolic rate
  • cold inteolerance (decreased heat production)
  • weight gain (despite decreased appetite)
Term
skin changes with hypothyroidism
Definition
  • dry, thickened rough skin, loss of outer 1/3 of eyebrow
  • goiter
  • non-pitting edema (myedema)
Term
CNS effects of hypothyroidism
Definition
  • hypoactivity: fatigue, sluggishness, memory loss, depression, decreased DTR
  • hoarseness of voice
Term
GI effects of hypothyroidism
Definition
  • contpiation
  • anorexia
Term
CVS effects of hypothyroidism
Definition
  • bradycardia, decreased CO
  • pericardial effusion
Term
reproductive effects of hypothyroidism
Definition
menorrhagia
Term
glucose effects of hypothyroidism
Definition
hypoglycemia
Term
Causes of hypothyroidism
Definition
  • iodine deficiency (diet)
  • hashimoto's thyroiditis
  • postpartum thyroiditis
  • pituitary hypothyroidism
  • hypothalamic hypothyroidism
  • cretinism 
  • riedel's thyroiditis
Term
congenital hypothyroidism d/t maternal hypothyroidism or infant hypopituitarism
Definition

cretinism

(macroglossia, hoarse cry, coarse facial features, umbilical hernia, weight gain, mental retardation if not corrected)

Term
normal thyroid storm replaced by fibrotic tissues
Definition

riedel's throiditis

 

Term
Riedel's thyroiditis
Definition
  • painless fixed nodular may grow rapidly (resembles malignancy)
  • RARE (assoc w/ other fibrotic d/o)
  • Treatment: steroids, tamoxifen & levothyroixine
Term
abnormal thyroid hormone levels w/ normal thyroid gland function seen w/ illness (ex sx, malignancies, sepsis, cardiac dz)
Definition
euthyroid sick syndrome
Term
Euthyroid sick syndrome
Definition
  • decreased T4 & T3, decreased TSH
  • resembles 2ndary hypothyroidism lab wise
  • T3 abnormally low
  • TSH may be low, normal, or slightly high
Term
calorigenic symptoms of hyperthyroidism (thyrotoxicosis)
Definition
  • increased basic metabolic rate
  • heat intolerance (increased heat production)
  • weight loss (despite increased appetite)
Term
skin changes with hyperthyroidism (thyrotoxicosis)
Definition
  • skin warm, moist, soft, fine hair, alopecia, easy bruising 
  • goiter
Term
CNS changes with hyperthyroidism (thyrotoxicosis)
Definition
  • hyperactivity: anxiety, tremors, nervousness, fatigue, weakness, tremors, increased sympathetic
Term
GI effects of hyperthyroidism (thyrotoxicosis)
Definition
  • diarrhea
  • hyper defecation
Term
reproductive effects of hyperthyroidism (thyrotoxicosis)
Definition
scant periods, gynecomastia
Term
glucose effects with hyperthyroidism (thyrotoxicosis)
Definition
hyperglycemia
Term
Etiologies of hyperthyroidism (thyrotoxicosis)
Definition
  • grave's disease
  • Toxic multinodular goiter
  • TSH secreting tumor
  • excess intake of T3, T4
  • iatrogenic thyrotoxicosis
  • lithium thyrotoxicosis (lithium can cause hyperthyroid or hypothyroid state)
Term
What do thyroid d/o's affect all organ systems?
Definition
because thyroid hormone is used by all cells of the body for normal cell metabolism
Term
Cause of graves
Definition
  • autoimmune, MC in women 20-40
  • circulating TSH receptor antibodies cause increased thyroid hormone synthesis, release, and thyroid gland  gland growth. Worse w stress (ie pregnancy, ill)
  • MCC of hyperthyroidism
Term
Clinical manifestations of graves disase
Definition
  • clinical hyperthyroidism
  • diffuse enlarged thyroid
  • thyroid bruits
  • opthalmopathy: lid lag, exophthalmos/proptosis (exclusive to Graves)  hyaluronic acid deposition tx w/ steroids. smoking & iodine may make worse. 
  • pretibial myxedema: nonpitting, edematous, pink to brown plaques/nodules on shins
Term
Diagnosing graves disease
Definition

not all tests need to be done

  • + thyroid-stimulating IG Ab (most spp)
  • +- thyroid peroxidase & anti-TG Ab
  • hyperthyroid TFT's: increased FT4/T3, & low TSH 
  • RAIU: increased diffuse uptake 
Term
Treatment of graves disease
Definition
  1. radioactive iodine; MC. destroys thyroid gland, will need hormone replacement
  2. methimazole/propylthiouracil : PTU safe in pregnant
  3. BB (propranolol) for sx relief 
  4. Thyroidectomy: if compressive sx, no response to meds, if RAI is CI (ie. pregnancy)
Term
Clinical hyperthyroidism, diffuse enlarged thyroid, bitemporal hemianopsia, mental disturbances
Definition
TSH secreting pituitary adenoma
Term
Increased FT4/T3 + increased TSH
Definition
TSH secreting pituitary adenoma
Term
treatment of TSH secreting pituitary adenoma
Definition
transsphenoidal sx to remove pituitary tumor
Term
clinical hyperthyroidism : but NO skin changes, palpable nodules
Definition

toxic multinodular goiter (plummer dz) TMG

 

Term
Compressive sx: dyspnea, dysphagia, stridor, hoarseness
Definition
toxic aenoma (TA)
Term
MCC of hypothyroidism in US
Definition
Hashimoto's (chronic lymphocytic)
Term
Clinical manifestations of hashimoto's
Definition
  • painless, enlarged thyroid
  • may present in euthyroid state (rarely in hyperthyroid state)
Term
How do you diagnose hashimoto's
Definition
  • + thyroid Ab present: thyroglobulin Ab, antimicrosomial & thyroid peroxidase Ab
  • TFT's (us Hypothyroid)
  • decreased radioative uptake (usually not needed)
  • Bx: lymphocytes, germinal follicles, Hurthle
Term
Duration of hashimoto's
Definition
  • hypothyroidism usually permanent
  • levothyroxine tx : thyroid replacement 
Term
painless, enlarged thyroid
thyrotoxicosis --> hypothyroid (depend on when they present)
Definition
post-partum hypothyroid
Term
How do you diagnose postpartum hypothyroid d/o
Definition
  • + thyroid Ab present (same as hashimoto's)
  • TFT's (hyper/hypo) depend on when they present
  • decreased radioactive iodine uptake 
Term
duration and treatment for post-partum hypothyroid d/o
Definition
  • return to euthyroid state c/n 12-18 months w/o treatment ASA
  • no anti-thyroid meds
  • 20% possible permanent hypothyroidism
Term
Medication induced hypothyroid d/o cause
Definition
  • amiodarone (containes iodine)
  • lithium 
  • alpha interferon
Term
Medication induced hypothyroid treatment
Definition
  • often returns to euthyroid states when medication is stopped, steroids 
Term
De Quervain's (granulomatous) - painful subacute - diagnosis
Definition
  • increased ESR (hallmark)
  • NO thyroid Ab
  • TFT's (us hyperthyroid)
  • decreased radioactive iodine uptake
Term
synthetic T4
Definition

levothyroxine

monitor TSH @ 6 wk interval when initiating/changing dose

Term
MCC of hypothyroidism worldwide is..
Definition

iodine deficiency 

(US is hashimoto's)

Term
Primary hyperparathyroidism
Definition
  • excessive increased PTH production
  • MC type
  • Parathyroid adenoma MCC (80%)
  • parathyroid hyperplasia/enlargement (20%)
  • 20% of pts taking lithium.MEN I & II; malignant rare
Term
Men I
Definition

hyperparathyroidism

pituitary tumors

pancreatic tumors

Term
MEN IIa
Definition

hyperparathyroidism

pheochromocytoma

medullary thyroid carcinoma

Term
secondary hyperparathyroidism
Definition
  • increased PTH in response to hypocalcemia or vit. D deficiency (parathyroid tries to compensate by increasing PTH to increase Ca levels)
  • chronic kidney failure (MCC of secondary). kidney normally convert vit. D to usable form
Term
Tertiary hyperparathyroidism
Definition
  • prolonged PTH stimulation after prolonged 2ry hyperparathyroidism --> autonomous PTH production
  • may be seen in post transplant pts as well
Term
clinical manifestations of primary hyperparathyroidism
Definition
  • signs of hypercalcemia : stones, bones, abdominal groans, psychic moans
  • decreased DTR
Term
Diagnosis of primary hyperparathyroidism
Definition
  • Triad: hypercalcemia + increased intact PTH + decreased phosphate 
  • increased 24h urine calcium excretion
  • increased vit. D
  • osteopenia on bone scan
Term
treatment of hyperparathyroidism
Definition
  1. surgery: parathyroidectomy (subtotal = 3 1/2 removal of gland).  total parathyroidectomy (removal of all 4 glands w/ auto transplantation of parathyroid tissue in forearm)
  2. vit. D/Ca supplementation if 2ry
  3. tx hypercalcemia if sxatic (IV fluids, furosemide, calcitonin)
Term
Diabetes insipidus
Definition
  1. ADH (vasopressin) deficiency (central DI)
  2. insensitivity to ADH (nephrogenic) --> inability of kidney to concentrate urine --> production of large amounts of dilute urine
Term
Etiologies of Central DI
Definition
  • no ADH production
  • MC type
  • idiopathic MC
  • autoimmune destruction of posterior pituitary
  • head trauma
  • tumor (brain or pituitary)
  • infection
  • sarcoid granuloma 
Term
etiologies of nephrogenic DI
Definition
  • partial or complete insensitivity to ADH
  • Drugs: lithium, amphotericin B, demeclocycline
  • Hypercalcemia & hypokalemia (disrupts kidneys concentrating ability)
  • acute tubular necrosis
  • hyperparathyroidism
Term
How do you diagnose diabetes insipidus
Definition
  1. fluid deprivation test: establishes the dx of DI, normal response --> progressive urine concentration (to conserve H2O --> increasing urine osmolality)  DI: continued production of dilute urine (decreased Uosm < 200 & low specific gravity < 1.005)
  2. desmopressin (ADH) stimulation test: differentiates nephrogenic from central DI. Give ADH : central DI --> reduction in urine output (increased Uosm) indicating response to ADH.  Nephrogenic DI --> continue production of dilute urine (no response to ADH)
Term
Clinical manifestations of diabetes insipidus
Definition
  • patients usually only become clnically symptomatic w/ decreased oral free water intake
  1. polyuria (up to 20 L/day) + polydipsia (to maintain H2O) Nocturia (eneuresis in children) 
  2. HYPERNATREMIA if severe or decreased PO H2O intake. Dehydration, hypotension, CV collapse
Term
Treatment of central DI
Definition

desmopressin DDAVP (synthetic ADH)

carbamazepine (decreases ADH)

Term
Treatment of nephrogenic DI
Definition

Na/protein restriction --> HCTZ, indomethacin

 

Term
If patient is symptomatic with central or nephrogenic DI -->
Definition

hypotonic fluid

(pure water orally is preferred, D5W, 1/2 normal saline)

Term
type 1 diabetes : types
Definition

IA : autoimmune destruction triggered by 1 or more environmental factors

IB: non autoimmune beta cell destruction

Term
risk factors for type II diabetes
Definition

CHAOS

Chronic HTN, Atherosclerosis, Obesity(central), strokes

Term
Complications of diabetes mellitus
Definition
  1. sensori-motor - paresthesias, abnl gait, decreased proprioception in a "stocking glove" pattern, pain, decreased DTR
  2. autonomic: orthostatic hTN, gastroparesis:N/V/D, constipation, impotence
  3. retinopathy: painless deterioration of small retinal vessels
  4. nephropathy : progressive kidney function deterioration leading to microalbuminuria
  5. macrovasulcar: atherosclosis --> CAD, PVD, stroke
  6. increased risk of infections: d/t vascular insufficiency & immunosuppresion from hyperglycemi
  7. hypoglycemia 
Term
DM : Nonproliferative retinopathy (1st sign)
Definition
  • nonproliferative (background): microaneurysms earliest change 
  •  exudative changes leakage of lipoproteins (hard exudates - deep yellow w/ sharp margins, circinate) or
  •  blood (dot or flame-shaped hemorrhages) --> 
  • cotton wool spots (aka soft exudates - fluffy gray-white infarction of n. fiber layer ischemia)
  •  closure of retinal capillaries, retinal venous beading (tortuous/dilated veins)
Term
DM : proliferative retinopathy (2nd)
Definition
  • neovascularization : new abnl bv growth, hemorrhage
Term
DM : maculopathy retinopathy (3rd, last)
Definition
  • macular edema
  • blurred vision
  • central vision loss
  • can occur @ any stage 
Term
first sign of diabetic nephropathy
Definition
microalbuminuria
Term
Kidney bx: Kimmelstiel-Wilson
Definition
  • nodular glomeruloscleosis described as pink hyaline material around glomerular capillaries (d/t protein leakage)
  • Diabetes mellitus
Term
treatment of nephropathy (DM)
Definition
  • ACEI (reduces protein leakage & slows progression)
  • low Na diet
Term
Hypoglycemia is usually d/t
Definition

too much insulin use

too little food

excess exercise

Term
Clinical manifestations of hypoglycemia
Definition
  • autonomic: sweating, tremors, palpitations, nervousness, tachycardia
  • CNS: HA, lightness, confusion, slurred speech, dizziness
Term
How do you diagnose hypoglycemia?
Definition
  • random blood sugar 50-60mg/dL
  • sx occur @ 60
  • brain dysfunction begins @ 50
Term
Treatment for hypoglycemia
Definition
  • mild < 60: 10-15 fast acting CHO, fruit juice, hard candies & recheck in 15 min
  • if severe/unconscious, < 40 --> IV bolus of D50 or inject glucagon SQ
Term
How do you diagnose DM?
Definition
  1. fasting plasma glucose >= 126 : fasting @ least 8 hrs 2 occasions GOLD STANDARD
  2. HgA1c >= 6.5% : indicates average blood sugar 10-12 wks prior 
  3. 2 hr plasma glucose >= 200 : oral glucose tolerance test 3 hr GTT gold standard in gestational
  4. plasma glucose >= 220 : in pts w. classical sx of hyperglycemia
Term
Screening for DM
Definition
  1. pts >= 45
  2. BP > 135/80
  3. younger adults w/ BMI > 25
  4. if >= 1 RF 
  5. fam hx of type II DM
  6. low HDL
  7. polycystic ovarian syndrome
  8. non-caucasians
Term
Treatment of DM
Definition
  1. diet, exercise, lifestyle changes: tried FIRST in Type II
  2. oral antihyperglycemic agents
  3. +- insulin in aunable to control
  4. Diet - carbs 50-60%, protein 15-20%, unsat fats 25-30%
  5. insulin if type 1, insulin preferred for gestational
Term
glucose control goals
Definition
  1. HgbA1c < 7.0 (check q3 mo if not controlled, twice a year if controlled)
  2. Pre-prandial blood glucose goal - 80-110 (60-90 if prego)
  3. post prandial BH < 140
Term
Goals of DM for lipid control
Definition

LDL < 100

HDL > 40

TG < 150

Term
Treatment for neuropathy in DM
Definition
  • gabapentin 
  • +- TCA
  • foot care (wide loose fitting shoes, nail trimming, podiatrist monitoring)
Term
treatment for retinopathy with DM
Definition

DM control

laser photocoagulation tx

Bevacizumab (proliferative)

vitrectomy

Term
treatment for nephropathy for DM
Definition

DM control

ACEI if microalbuminuria

low Na+ diet

Term
What is considered pre-diabetic?
Definition
  1. HgbA1c: 5.7-6.4
  2. fasting glucose 100-125
  3. oral glucose tolerance test: 140-199
Term
Metabolic syndrome X
Definition

insulin resistance

predisposed to developing DM, CAD, CVA

HDL < 40 in men, < 50 in women

increased BP 135/85

triglycerides > 180

fasting blood sugar 100-135

waist circumference > 35 inches in women

wast circumference > 40 inches in men

Term
rapid acting insulin
Definition

lispro (Humalog) & Aspart (Novolog)

given @ same time of meal 

5-15 min onset, peak 1 hr, duration 3 hr

Term
Short acting insulin
Definition

regular (Humalin -R)

given 30-60 min prior to meal

onset 30m-1h, peak 2-3h, duration 4-6 hr

Term
intermediate insulin
Definition

NPH (Humulin N & Novolin N)

Lente (Humulin L & Novolin L)

covers insulin for about half day (or overnight)

onset 2-4h, peak 4-12h, duration 16-20h

Term
long actin insulin
Definition

ultralente (U), insulin glargine (lantus), detemir (levemir)

covers insulin for 1 full day (basal insulin) 

onset 6-8h, peak 12-16h, duration 20-30h

Term
____ causes fewer hypoglycemic episodes than NPH
Definition

lantus

(do not mix with other types of insulin!)

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