pituitary

thyroid

parathyroid

adrenal glands

pancreas 

TSH

Free T4

Free T3

TSH receptor antibody

anti-thyroid peroxidase

anti-thyroglobulin antibody

TRH stimulation test 

anti-thyroid peroxidase antibody

and

anti-thyroglobulin antibody

(these are always ordered together) 

hypothyroidism

and

hyperthyroidism 

< 0.1 mU/L

and

> 20 mU/L

the lab will call you if you get these 

Potassium Iodine

lithium 

anti-thyroid medications 

Amiodarone

Heparin

NSAIDS

steroids 

90%

 99% 

1. to diagnose hyper- or hypothyroidism

2. to monitor response to replacement or suppressive therapies 

exogenous T4

heparin

propranolol 

Hyperthyroid hormone levels

high or low TSH?

high or low T4?

low TSH

high T4 

Hypothyroid hormone levels

high or low TSH?

high or low T4?

high TSH

low T4 

to support a diagnosis of Grave's disease if it is in doubt

normal levels <130% of basal activity 

1. get a baseline TSH level

2. give an IV bolus of TRH

3. in 30 minutes get another TSH level 

hypermetabolism: weight loss, inc appetite, heat intolerance

epinephrine effect: strong rapid pulse, tremors and anxiety, atrial fibrillation

Thyroid storm: which can be life threatening if the pt has a serious illness of trauma 

hyperactive multinodular goiter or thyroid tumor

factitious: pt took synthroid to get smarter or lose weight

secondary hyperthyroidism: TSH producing tumors

tertiary hyperthyroidism: TRH producing tumors 

unexplained weight loss,

anxiety, tremor,

new onset of atrial fibrillation

or a mental status change 

TSH will be very low

Free T4 will be high

antibody to TSH receptor will be + 

mental slowness, fatigue, loss of interest

weight gain, constipation, hair falling out, cold intolerance

delayed deep tendon reflexes 

hashimoto's

iatrogenic: surgery or radiation

iodine deficiency

meds: valproic acid

secondary or tertiary hypothyroidism (rare) 

Primary hypothyroidism hormone levels

(like hashimoto's) 

high or low TSH?

high or low free T4?

+ or - anti-thyroid peroxidase?

+ or - anti-thyroglobulin?

TSH will be high

free T4 will be low

anti-thyroid peroxidase and/or anti-thyroglobulin will be + 

1. mobilizing Ca++ from the bone

2. increasing kidney reabsorption of Ca++, decreasing phosphate reabsorption

3. stimulates kidney to convert Vit D

4. increases GI absorption of Ca++

(step 3 is used to allow step 4) 

total Calcium

ionized Calcium

PTH

PTH-related protein

phosphorus (if its increased Ca++ is lowered) 

< 6.0 mg/dL

or

> 13.0 mg/dL

What are the normal levels for total Ca++?

Ionized Ca++?

total Ca++ : 9.0-10.5 mg/dL

ionized Ca++ : 4.5-5.6 mg/dL

N/V

somnolence: drowsiness

coma 

hyperparathyroidism - most common

malignancy - 2nd most common

drugs: thiazide diuretics, antacids, vit D  

evaluation of hypercalcemia

monitoring in chronic renal failure 

hypercalcemia likely due to a malignancy like lung cancer

(order a PTHrP and work up for occult tumor) 

secondary hyperparathyroidism seen in Chronic renal failure

high BUN

high Creatinine

low Ca++

high phosphorus (this binds up the Ca++) 

If the adrenals produce too much cortisol, what sxs do you see?

What is this condition called?

hyperglycemia

hypernatremia

HTN

hypokalemia

CUSHING SYNDROME 

moon-face, round

acne

buffalo hump

facial hair

striae

weight gain

thin extremities with mm atrophy

thinning of hair

red cheeks 

hypoglycemia

hyponatremia

hypotension

hyperkalemia

ADRENAL INSUFFICIENCY

addison's disease if the problem is the adrenal itself and not any precursors 

5-23 mcg/dL

tends to peak around 8 am and drops to about 1/2 this level by 4 pm

diurnal variation 

stress and obesity

drugs: estrogen, BCPs, amphetamines 

dexamethasone suppression test

helps distinguish pathologic causes from those related to stress or obesity 

a low dose (1 mg) is given at 11 pm

cortisol is then drawn at 8 am

this should have suppressed the ACTH with > 50% reduction in the 8 am cortisol (if its a stress or obesity issue)

if it doesn't consider a referral

pt will need an extensive work up for adrenal/pituitary pathology 

a tumor of the adrenal medulla that makes NorEpi and Epi

it increases BP/HR

increases glycogenolysis, gluconeogenesis and lipolysis

very uncomfortable for the pt, puts them at risk for a stroke 

a 24 hour urine checking for:

epi and norepi

metanephrine and normetanephrine

VMA (the product catabolism of both metanephrine and normetanephrine)

hard test to do 

If AM cortisol is high and

ACTH is low,

what should you suspect? 

insulin resistance of tissues, therefore concentration ranges from high (early) to low (late)

glucagon concentration often elevated

Fasting glucose levels

normal?

impaired glucose tolerance?

diabetes?

normal: <100 mg/dL

impaired glucose tolerance: 100-125 mg/dL

diabetes: >125 mg/dL 

Glucose Tolerance Test: In order to be considered normal, glucose levels should be <____ after a 1 hr,

AND they should be <____ after 2 hrs.

1 hr: <200 mg/dL

2 hr: < 140 mg/dL (both are normal)

if at 2 hr its 140-200 you have IGT

if its > 200 you have DM 

stress and exercise

drugs: anti-HTNs, beta-blockers, lasix, nicotine and BCPs 

there is insulin resistance

use of hypoglycemic drugs

or an insulinoma 

there is suppression of secretion by exogenous insulin adminstration

or Beta-cell failure 

cortisol

ACTH

24 hour urine for catecholamines, metanephrines and VMA 

fasting glucose

oral glucose tolerance test

HgA1c

insulin

C-peptide

insulin and C-peptide tests should always go hand in hand 

1. defends against infection and foreign antigens of other origin

2. also attacks: tissues by autoimmunity, transplants by rejection, some antigens causing allergy

multiple myeloma

or a benign problem that in 10-15% of people will turn into multiple myeloma in the next 15 years

protein

ie liver disease, GI loss and bloody urine

acute phase reaction, mostly with inflammatory disease

(ie liver or kidney disease)

general increase in plasma cells

suppressor T cells overcome helper T cells

or there is a helper T cell deficiency

defense against invaders

often almost solely antibody

other times, like with TB, its all cellular

also can be mixed

IgG

used to diagnose most common immunodeficiencies

secretions: tears, GI tract, genital areas

testing is used to define IgA levels/deficiency

RAST test

(panel of antigens)

an unusual group of diagnoses

viral infections

various malignancies

THC 150-250 units/ml

C4 16-40 mg/dl

C3 100-180 mg/dl

THC -- 250

C4 -- 40

C3 -- 200

THC -- 100

C4 -- 10

C3 -- 80

THC -- 100

C4 -- 30

C3 -- 50

THC -- <10 or 0

C4 --30

C3 -- 140

THC -- 50

C4 -- <8

C3 -- 100

occult blood testing

Helicobacter pylori testing

eating red meat within 72 hours of the test

 taking oral iron

a urease-producing Gram-negative bacterium

(it destroys the mucous lining)

100% of duodenal

80% of gastric ulcers

1. serum antibody testing

2. urease breath test

3. upper endoscopy w/ CLO test

4. upper endoscopy w/ biopsy

melena > 48 hrs in duration

severe abd pain

immunocompromised

If diarrhea persists >14 days,

is bloody,

and is negative for fecal leukocytes

what should you test for?

Crohn's disease

ulcerative colitis

malabsorption

IBS - diagnosis of exclusion

amylase

lipase

bc as lipase breaks down fats it produces fatty acids with strong negative charges

Ca++ has a strong positive charge and binds to these exposed fatty acids which lowers serum Ca++ levels

low Ca++ in pancreatitis is a bad sign, esp if it stays persistently low

amylase and lipase are not elevated

DM -- elevated glucose

malabsorption and malnutrition -- decreased serum protein

1. synthesis of many plasma proteins

2. detoxification and excretion into bile of waste products

3. processing dietary elements... aas, fats, proteins and vits

4. clearing blood of any microbes or toxins that have been absorbed in the GI tract

how well the liver cells are doing their job

Heptaocyte function

how well the liver is excreting bile

biliary excretion function

if the liver cells themselves have been damaged

hepatocyte integrity

serum albumin

prothrombin time

serum ammonia

total bilirubin

conjugated and unconjugated bilirubin

alkaline phosphate

gamma-glutamyl transpeptidase (GGT)

aspartate aminotransferase (AST)

alanine aminotransferase (ALT)

lactate dehydrogenase (LDH)

hepatocyte disorders such as chronic liver disease

malnutrition

malabsorption

or if the kidneys are damaged

biliary tract blockage

coumadin therapy

liver failure

get a GI consultation

a degradation product of heme

and is water insoluble (unconjugated bilirubin)

if total bilirubin is elevated and >50% is conjugated

(blockage of the biliary tract)

anything that blocks bile getting from the liver to the duodenum

gallstones

pancreatic tumors

excessive RBC hemolysis that overwhelms the livers ability to conjugate the incoming bilirubin

the liver itself is damaged and cannot conjugate the normal amount of incoming bilirubin

blockage to the biliary tree

or bone disease

about 8 hrs

peaks in 24-36 hours

returns to normal in 3-7 days