TIM Endo Module Part 2

What is the avg blood glucose that corresponds to this A1C%? 5%

97

Desirable LDL Cholesterol

<100 mg/dL

Desirable total cholesterol

<200 mg/dL

Undesirable HDL cholesterol

<35mg/dL

Hemoglobin A1c goal for most patients is

<7

Hemoglobin A1c goal for older patients and those at high risk of hypoglycemia

<8

desirable HDL cholesterol

>60 mg/dL

◦ Most sensitive and most commonly used test for primary hypothyroidism and hyperthyroidism ◦ Helpful in diagnosis and surveillance ◦ is also called ◦ thyrotropin ◦ thyrotrophin

TSH (thyroid stimulating hormone serum levels)

Lab tests to evaluate thyroid function

TSH and FT4

TRH deficiency (hypothalamus)=

Tertiary Hypothyroidism

-Usually detected on physical exam or incidentally during other rad. procedures -Thyroid function tests mandatory -Small nodules usually asymptomatic ◦ > 1 cm have higher chance of being malignant -Ultrasound good first choice, FNA is best to assess ◦ In MNG the 4 largest should be biopsied ◦ If solitary nodule FNA indicated when: ◦ Nodule > 5mm with suspicious findings on U/S ◦ Nodules associated with LN

Thyroid nodules

The following describes diagnosis of_______? Labs Ultrasound Scans - radioactive iodine Fine Needle Aspiration (FNA) Course needle biopsy

Thyroid Cancer

The following are effects of __________ -Increased metabolic rate -Mobilization of substrates for ATP generation by cells -Increased delivery of substrate to cells -Increased delivery of oxygen to cells and carbon dioxide removal from cells

Thyroid Hormone (T3 and T4)

Rare, life-threatening exacerbation of hyperthyroidism High mortality rate Often related to acute illness or radioactive iodine treatment TX: supportive, PTU, propanolol, steroids and Abx ◦ Adrenal insufficiency??

Thyroid Storm/Thyrotoxic Crisis

-Group of disorders characterized by thyroid inflammation -May be related to acute illness and present with severe thyroid pain -May present with no evidence of inflammation and illness manifests as thyroid dysfunction or goiter

Thyroiditis

Clinical syndrome resulting from tissues being exposed to high levels of circulating thyroid hormones

Thyrotoxicosis

Name the type of fat -found in hydrogenated oils (processed oils) like canola, corn, and vegetable oil (all fried foods!) -bad bc increase levels of LDL and decrease HDL

Trans fats

The following are management approaches for____? -Diet is the key here! (if not familial!) -some meds will help to reduce this: Fibrates, niacin, omega-3s

Triglycerides

The following are risk factors for _________ • Smoking • Overweight and Obesity • Physical Inactivity • A1C over 7 • BP > 140/90 • Non-HDL Cholesterol >130

diabetes-related complications

Blood glucose level after 8 hour fast

Fasting Blood glucose

Screening - Yearly • Monofilament exam • DP & PT pulses • Check for ulcers and infection Prevention - Foot care handout Treatment - Podiatry

Feet (Type 2 DM)

What type of thyroid cancer is described by the following? ◦ More aggressive ◦ Less common ◦ Can cause thyrotoxicosis ◦ Mets to neck, node, bone, lungs ◦ Can follow w/ radioactive iodine

Follicular

Painful thyroiditis ◦ Preceded by harmless virus ◦ F>M, 35-50 y/o, geographical, seasonal ◦ Presentation and DX ◦ Jaw pain, ESR high, thyroid tender, WBC hi or normal, RAIU depressed ◦ Treatment ◦ Aspirin, Beta blockers, NSAIDS, +/-steroids

Subacute thyroiditis (deQuervain's thyroiditis, granulomatous thyroiditis)

Stimulates thyroid hormone synthesis and secretion Target cell: thyroid gland

TSH (Thyroid stimulating hormone)

tx of pseudohypoparathyroidism

calcium and vitamin D

What is the avg blood glucose that corresponds to this A1C%? 7%

152

What is the avg blood glucose that corresponds to this A1C%? 6%

126

borderline LDL cholesterol

130-159

Borderline triglyceride level

150-199 mg/dL

What is the avg blood glucose that corresponds to this A1C%? 8%

183

Most patients with A1C > 9 will need how many meds to reach goal

2

Type _____ diabetes accounts for approximately 90% to 95% of all diagnosed cases of diabetes; type ____diabetes accounts for approximately 5-10%.

2, 1

Borderline total cholesterol

200-239 mg/dL

Undesirable triglyceride level

200-499 mg/dL

What is the avg blood glucose that corresponds to this A1C%? 9%

212

What is the avg blood glucose that corresponds to this A1C%? 10%

240

If HA1c is not at goal check every

3 months

Borderline HDL cholesterol

35-60

Everyone ages _____ who may be at risk of CVD

40-75

If HA1C is at goal at least twice, check every

6 months

Basic facts of ____? -_______ secreting cells constitute 20% of the pituitary cell population -CRH is the predominant stimulator of ______ synthesis and release -______ secretion is pulsatile and exhibits a circadian rhythm peaking at 6:00 am -______ levels are increased by stress, exercise, acute illness and insulin induced hypoglycemia -Major function of the ______ hypothalamic pituitary axis is to maintain metabolic homeostasis and mediate the neuroendocrine stress response -_______ stimulates lipoprotein uptake into cortical cells - ________ induces cortical steroidogenesis by maintaining adrenal cell proliferation -_______ increases the transport of cholesterol into the mitochondria and activates its hydrolysis

ACTH (adrenocorticotrophic hormone)

Stimulates production of corticosteroid hormones Target cells: adrenal cortex

ACTH (adrenocorticotropic hormone)

Stimulates reabsorption of water from urine in the kidneys Stimulates vasoconstriction in arterioles of the bode, thereby increasing blood pressure Target cells: kidney, smooth muscle in the arteriole walls

ADH (Antidiuretic hormone or vasopressin)

Basic Facts of? - Most important physiologic action is to influence the rate of water excretion by promoting the concentration of urine -________ effect is achieved by increasing the hydroosmotic permeability of cells that line the distal tubules and medullary collecting ducts of the nephron Low _____ concentration results in the production of large amounts of urine Secretion of ____ is regulated largely by the osmotic pressure of body fluids

AVP (Antidiuretic Hormone)

The following are the clinical features of ______ and ______ Frontal bossing Increased hand and foot size Mandibular enlargement Prognathism Widened space between the lower incisor teeth Sleep apnea Cardiomyopathy and arrhythmias Headache Amenorrhea Galactorrhea Paresthesias Deepening of the voice Colon polyps Hyperhidrosis Oily skin Muscle weakness and fatigue Macroglossia

Acromegaly and Gigantism

The following are the lab and diagnostic procedures for ? -IGF-1 levels -GH Suppression Test -Serum electrolytes -EKG -MRI

Acromegaly and Gigantism

The following is the treatment/management for? -Surgery -Dopamine agonist -Somatostatin Analogues -GH antagonist -Radiation

Acromegaly and Gigantism

Usually the result of somatotrope adenoma

Acromegaly and Gigantism

The following is the etiology of ____ and _____ Extrapituitary Tumor Pancreatic Islet Cell Tumor Central Hypothalmic hamartomas Peripheral Adrenal Adenoma Small Cell Lung Cancer Pheochromocytoma

Acromegaly, Gigantism

The following describes _________ and ________ Definition - hypersecretion of growth hormone Etiology Pituitary (98%) GH Cell Adenoma Mixed GH and PRL Adenoma Mammosomatrope Cell Adenoma Plurihormonal Adenoma GH Cell Carcinoma MEN I

Acromegaly, gigantism

◦ Most common thyroid disorder is the US ◦ Follicular cells destroyed - inability to produce T3 and T4 ◦ Thought to be autoimmune ◦ Labs ◦ TSH first: high ◦ Antithyroid peroxidase + - specific to Hashimoto's ◦ Antithyroglobulin + ◦ T4, T3: low

Autoimmune/Hashimoto's

Least common & most aggressive thyroid cancer

Anaplastic

What type of thyroid cancer is described by the following? ◦ Least common ◦ Most aggressive ◦ Does not concentrate iodine ◦ Presents with pain and hoarseness

Anaplastic

The following are hormones of the _______ pituitary -ACTH -FSH -LH -TSH -PRL (prolactin) -GH -MSH (Melanocyte stimulating hormone)

Anterior

-Unmineralized organic portion of bone matrix -Forms prior to maturation of bone tissue

Bone osteoid

⚬ Is this patient high risk for CAD? If so, maybe start tx ⚬ Is this patient not high risk for CAD Recommend lifestyle modifications Total cholesterol: 200-239 mg/dL LDL: 130-159 HDL: 35-60 TG: 150-199

Borderline

- insulin and C-peptide are linked when first made by the pancreas. C-peptide level reflects the level of insulin

C-Peptide

The following are modifiable risk factors of _______ -dyslipidemia (#1) -HTN -cigarette smoking -diabetes and insulin resistance -obesity/sedentary lifestyle

CAD

The following describes who is at risk of ____________ Men • Middle-age men with total cholesterol > 230 = greater risk of CHD • Every 10 mg/dL rise In LDL raises the risk of CHD by 10%!! • Every 5 mg/dL rise In HDL will lower the risk of CHD by 10%! Women • Similar to men • The higher the HDL, the less risk of CHD compared to men Family History • Familial hypercholesterolemia: genetic mutation in apolipoprotein B ⚬ High LDL with early CHD ⚬ If homozygous: very high levels In childhood • Familial hypertriglyceridemia: very high VLDL, recurrent pancreatitis and hepatosplenomegaly In childhood

CHD

Screening - Yearly Lipid Panel Prevention • Blood pressure control • Blood glucose control • Low dose Aspirin (81mg) per guidelines • Statin per guidelines

CVD Prevention (Type 2 DM)

_______ is needed for? ⚬ Plasma membranes (to create and repair) ⚬ Amino acid production ⚬ Steroid hormone production

Cholesterol

1. Type 1 diabetes (due to β-cell destruction, usually leading to absolute insulin deficiency) 2.Type 2 diabetes (due to a progressive insulin secretory defect on the background of insulin resistance) 3.Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes) 4.Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young [MODY]), diseases of the exocrine pancreas (such as cystic fibrosis), and drug- or chemical-induced diabetes (such as in the treatment of HIV/AIDS or after organ transplantation)

Classification of Diabetes Mellitus

Definition- hypersecretion of adrenocorticotrophic hormone Etiology Adrenal hyperplasia -Secondary to pituitary ACTH overproduction -Pituitary hypothalamic dysfunction -Pituitary ACTH producing micro or macroadenomas Adrenal macronodular hyperplasia

Cushing's Disease

The following describes the clinical features of ? -obesity (80%) -thin skin (80%) -moon facies (75%) -Hypertension (75%) -Purple skin striae (65%) -Hirsutism (65%) -Amenorrhea (60%) -Plethora (60%) -Proximal muscle weakness (60%) -Truncal obesity (50%)

Cushing's Disease

The following describes the epi of? -3 times greater in women than in men -Most frequent age of onset is 3rd to 4th decades

Cushing's Disease

The following describes the etiology of _________ Adrenal micronodular hyperplasia Sporadic Familial (Carney's syndrome) Adrenal neoplasia Adenoma Carcinoma Exogenous, iatrogenic Prolonged use of glucocorticoids Prolonged use of ACTH

Cushing's Disease

The following describes the pathophysiology of ________ -All cases of endogenous Cushing's syndrome are due to increased production of cortisol by the adrenal gland -In most cases the cause is bilateral adrenal hyperplasia secondary to hypersecretion of pituitary ACTH or ectopic production of ACTH by a non-pituitary source Most evidence indicates that the primary defect is a pituitary adenoma, as tumors are found in >90% of patient's with pituitary dependent adrenal hyperplasia

Cushing's Disease

The following are the labs/diagnostic procedures of? -CBC -Serum electrolytes -Basal ACTH level -24 hour urinary free cortisol -Dexamethasone suppression test -MRI

Cushing's Syndrome

The following is the treatment/management of? -Selective transsphenoidal resection (treatment of choice) -Low dose cortisol replacement -Medication Ketoconazole

Cushing's Syndrome

⚬ When we screen, this Is what we want to see ⚬ If they are on treatment, we know we made progress Total cholesterol: <200mg/dL LDL: <100mg/dL HDL: > 60mg/dL TG: <150mg/dL

Desirable

7th leading cause of death in the United States (and may be underreported).

Diabetes

Definition - decreased secretion or action of AVP which results in a large volume of dilute urine. The disorder is associated with polyuria with symptoms of urinary frequency and enuresis and excessive thirst. 24 hour urine volume is > 50 ml/kg of body weight Osmolarity is < 300 mosmol/L

Diabetes Insipidus

The following are the clinical features of? -polydipsia -polyuria -shock

Diabetes Insipidus

The following are the labs/diagnostic procedures of? -24 hour urine collection -Electrolytes -Fluid Deprivation Test -AVP challenge test

Diabetes Insipidus

The following is the pathphys of? Net decrease in AVP by < 80-85%, the amount of hormone produced under basal conditions is insufficient to concentrate the urine and the rate of output increases exponentially to symptomatic levels

Diabetes Insipidus

The following is the treatment/management of? -DDVAP -Chlorpropamide for Pituitary DI

Diabetes Insipidus

a chronic condition in which the pancreas no longer produces enough insulin or the cells stop responding to the insulin that is produced, so that glucose in the blood cannot be absorbed in the cells of the body

Diabetes Mellitus

Screening - Yearly • Urine Microalbumin • Creatinine Prevention - Blood pressure control Blood sugar control Treatment - Angiotensin-converting-enzyme inhibitors (ACE) or Angiotensin II receptor blockers (ARB)

Diabetic Nephropathy

Female Stimulates growth of ovarian follicle Male Stimulates sperm production Target cells: female ovaries and male testes

FSH (Follicle stimulating hormone)

The following are the clinical effects of? Atherosclerosis/Arteriosclerosis Build-up of "plaque" in the walls of blood vessels or In the lumen of vessels. - Can cause Peripheral Artery Disease (PAD) Why Is this bad? Coronary Artery Disease (CAD)/ASCVD Build-up of plaques In the small arteries of the heart (coronaries) causing blockage Ex: angina, myocardial Infarction Hypertension Increased pressure In the arteries due to narrowing from plaque/atherosclerosis The more plaque build-up, the worse the HTN

Dyslipidemia

The following describes _________ Epidemiology • 50% of the US population has some form of dyslipidemia! • Caused by genetic, diet or a combination • Familial dyslipoproteinemias: abnormal lipid- metabolizing enzymes or lipid receptors Etiology: ⚬ Diabetes ⚬ Pancreatitis ⚬ Hypothyroidism ⚬ Renal disease ⚬ Medications: ￭ Beta-blockers ￭ Steroids (glucocorticoids) ￭ Antiretrovirals, Immunomodulators Risk factors -diet high in saturated or trans fats (they tell the liver to make more cholesterol) -genetic predisposition -remember: fat is not the enemy!

Dyslipidemia

Common in regions with low I diets ◦ Increased rates congenital hypothyroidism ◦ Goiters can get BIG!!!! Usually caused by Iodine def, but can be caused by certain foods, mineral deficiencies, water pollutants Presentation - big goiter ◦ May have substernal goiter Labs ◦ TSH and T4 normal ◦ RAIU usually hi Treatment ◦ Iodized salt (prevention) ◦ T4 - helps shrink goiter ◦ thyroidectomy

Endemic Goiter

Screening - Yearly Dilated Retinal screening exam Prevention - Blood sugar control Blood pressure control Treatment - Ophthalmology

Eyes Check (Type 2 DM)

◦ Direct measure of unbound thyroxine ◦ Not affected by variations in protein binding

FT4 (free thyroxine immunoassay)

Increase growth and metabolism in target cells; synthesis of somatomedin in the liver to stimulate growth at the epiphyseal plate Target cells: almost every cell in the body

GH (Growth hormone)

stimulates the breakdown of glycogen to glucose in the liver

Glucagon

metabolic pathway that results in the generation of glucose from certain non-carbohydrate carbon substrates. Liver - 80% Kidney - 20%

Gluconeogenesis

The following is the presentation of _______ "exophthalmos" ◦ Edema and inflammation of extraocular muscles ◦ Increase in orbital CT and fat ◦ Increase in retrobulbar tissue ◦ Early or late stages _______ dermopathy

Graves (Hyperthyroidism)

60-80% cause of hyperthyroidism ◦ Excessive production and growth of the gland ◦ Females > Males 8:1 ◦ Genetic component/environmental stimulus ◦ Autoimmune process causing antibodies to develop against TSH receptor

Graves Disease

Basic Facts of _______? -Most abundant anterior pituitary hormone _____ secreting somatotrope cells constitute 50 % of the total anterior pituitary cell population _____ secretion is pulsatile with greater levels at night ______ induces protein synthesis and nitrogen retention and impairs glucose tolerance by antagonizing insulin action _______stimulates lipolysis _______ effects are mediated through IGF-1 ______induces linear bone growth 67

Growth Hormone

The most abundant AP hormone

Growth Hormone

Name the type of lipoprotein -phospholipids and protein -recycles excess bad cholesterol from the blood to the liver to be excreted as bile or converted to steroids!! aka reverse cholesterol transport -the good cholesterol: we want this one to be HIGH because it's protective

HDL

Reasons why _____ is so good It can remove cholesterol from arterial walls (preventing or helping to treat atherosclerosis) • Protects LDL from oxidation • Helps maintain endothelial function (vessel walls = strong!) • Anti-inflammatory • Anti-thrombotic • If someone has Inflammatory disease = HDL dysfunction ⚬ Ex: Obesity, DM

HDL

The following are management approaches for____? -increase exercise! -we don't have many meds that help with this specifically: Niacin

HDL

(Chronic Lymphocytic Thyroiditis) ◦ Most common thyroid disorder in the US and most common cause of hypothyroidism ◦ Up to 95% in women, usually b/t 30 and 50 yo ◦ Autoimmune condition ◦ Linked to SLE, RA, DM, Sjogren's ◦ Sx of goiter instead of hypothyroidism ◦ Tx with levothyroxine if hypothyroid

Hashimoto's Thyroiditis

Most common thyroid disorder in the US

Hashimoto's thyroiditis (AUTOIMMUNE)

reflects the average blood glucose level over past 8 - 12 week (life of a red blood cell is 120 day) - Falsely high - Iron deficiency anemia -Falsely low - hemolytic anemia, end stage renal disease, acute and chronic blood loss

Hemoglobin A1C

Patterns specific to the type of tissue distribution leading to hyperthyroidism on RAIU

Hot nodules

The following is the Dx for _________? • HALLMARK: HYPERCALCEMIA • Ionized calcium levels - hi • PTH - hi (IRMA assay) - confirmatory • Phosphate levels - low to normal • Alkaline Phosphatase - hi if bone disease present • 25-OH -vitamin D - low Screen for deficiency (can make bone sx's worse) • Urine calcium - hi or normal • Renal Ultrasound vs noncontrast CT-stones, parathyroidectomy • Bone density studies (DEXA Scan)

Hyperparathyroidism

Definition - hypersecretion of the pituitary hormone prolactin Etiology Physiologic pregnancy lactation chest wall stimulation sleep Stress Pathologic Hypothalamic-Pituitary Stalk Damage Tumors Empty Sella Lymphocytic hypophysitis Rathke's cyst Irradiation Trauma Pituitary Hypersecretion Prolactinoma (most common) Acromegaly

Hyperprolactinemia

The following are clinical features (endocrine) of _______ Hallmark symptoms/ signs in females -Galactorrhea -Hypogonadism -Infertility and Amenorrhea Hallmark symptoms/signs in males -Impotence -Loss of libido

Hyperprolactinemia

The following are the lab/diagnositc procedures for __________ -Basal fasting morning PRL levels -TSH and T4 -MRI -Pregnancy test -Electrolytes -Renal Function Test

Hyperprolactinemia

The following are treatment/management goals of _____ -Normalize PRL levels to alleviate suppressive effect on gonadal function -Stop the galactorrhea -Preserve bone mineral density -Treat underlying cause -Dopamine agonist

Hyperprolactinemia

The following are causes of ______? -Graves Disease (60-80%) • Toxic multinodular goiter/toxic adenomas • Subacute thyroiditis • Excessive exogenous thyroid (factitia) • Toxic adenoma - Plummer's disease ◦ Common cause of __________ in the elderly, long standing simple goiter or adenoma secreting T3 and T4 - subtle clinical features • Exposure to Iodine (Amiodarone) ◦ Jod-Basedow Phenomenon

Hyperthyroidism

The following are labs for _______ TSH - low and... T4 high RAIU ◦ Low - thyroiditis, factitious ◦ High - Graves, adenoma TSH antibody receptor - Graves disease Elevated ESR - thyroiditis

Hyperthyroidism

The following are treatments for? Depends on cause Beta blockers to reduce symptoms Graves Disease ◦ Antithyroid drugs - methimazole, propylthiouracil ◦ Radioactive ablation ◦ surgery Toxic Adenoma or MNG ◦ Surgery ◦ Radioactive ablation

Hyperthyroidism

The following describes _______? Excessive thyroid function Thyrotoxicosis - clinical syndrome resulting from tissues being exposed to high levels of circulating thyroid hormones 19/1000 women in US and 1.6/1000 men

Hyperthyroidism

The following is the presentation of _____________ -nervousness -weakness -heat intolerance -diaphoresis -fatigue -menstrual irreg -frequent BM -weight change -palpitations -stare -lid lag -tachycardia or A-fib -fine resting tremors -moist, warm skin -hyperreflexia -fine hair -heart failure-rare -Exopthalmos-Graves

Hyperthyroidism

The following are the signs and symptoms of? • +/- sx's • Muscle cramps, tetany • Perioral, hand, feet numbness & tingling • Increased (hyperreflexive) DTRs • Chvostek's Sign, facial muscle contraction • Trousseau's phenomenon, carpopedal spasms • Defective teeth, dry & scaly skin, thin brittle nails • Loss of eyebrows • Candidiasis, Cataracts • Irritability, AMS • Convulsions • Stridor

Hypoparathyroidism

The following describes the Dx of? -Serum calcium is LOW • PTH is LOW • Serum phosphate is HIGH • Urine calcium low • Alk phos normal • +/- CT (dense bones) • +/- slit-lamp

Hypoparathyroidism

The following is the tx of ? • IMMEDIATELY if acute attack aka TETANY Airway, IV calcium gluconate • Underlying cause • Calcium supplementation (calcitriol) po • Vitamin D 2 (ergocalciferol)- long & short acting • Magnesium supplementation • Teriparatide (recombinant PTH) sc-for severe cases • Watch for other autoimmune diseases...

Hypoparathyroidism

A Dz characterized by low PTH, low total & ionized calcium & an increase in serum phosphate

Hypoparathyroidism (Parathyroid Tetany)

The following is the etiology of? • Surgical - thyroidectomy* • Transient postsurgical* • Autoimmune (Idiopathic) • Mutations of the calcium-sensing receptor (CaSR) • Developmental abnormalities • Transient neonatal hypocalcemia • Infiltrative damage • Radiation • Magnesium deficiency

Hypoparathyroidism (Parathyroid Tetany)

Definition - insufficiency or impaired production of one or more of the anterior pituitary trophic hormones

Hypopituitarism

The following are laboratory/diagnostic procedures for _____________ -Insulin Tolerance Test -CRH -ACTH Stimulation Test -Thyroid Function Test -LH/FSH -Combined Anterior Pituitary Test -Serum Electrolytes -MRI

Hypopituitarism

The following are the clinical features of ? -Manifestations of it varies depending on which specific hormone or hormones are lacking and whether their deficiency is partial or complete -Patients with it may have single or multiple hormonal deficiencies. -When one deficiency is discovered others must be sought FSH/LH -Hyposmia -Delayed puberty -Micropenis -Loss of axillary, pubic and body hair -Decreased libido -Amenorrhea TSH -Fatigue -Weakness -Weight change ACTH -Fatigue -Weakness -Weight loss -Hypotension -Hypoglycemia -Nausea and/or vomiting GH -Asthenia -Obesity -Reduced Cardiac Output

Hypopituitarism

The following is the etiology of ________ - reduced pituitary function can result from inherited disorders, but more commonly, it is acquired and reflects the mass effects of tumors or the consequences of inflammation or vascular damage.

Hypopituitarism

The following is treatment for _________ -replacement hormones -remove offending agent

Hypopituitarism

The following are functions of the ________ Vegetative Functions - Involuntary or unconscious functions (internal conditions of the body) -Body temperature -Osmolality of body fluids -Hunger -Thirst -Body weight Endocrine -Controls pituitary hormone release or inhibition by a group of chemical mediators appropriately designated releasing or release-inhibiting hormones -TRH - Thyrotropin-releasing hormones -CRH - Corticotropin- releasing hormone -AVP - Vasopressin -LHRH - Lutenizing hormone releasing hormone -GHRH - Growth hormone-releasing hormone -GIH - Growth hormone-release-inhibiting hormone (somatostatin) -PIF - Prolactin-release inhibiting factor -PRF - Prolactin-releasing factor

Hypothalamus

Beta cells release Insulin & Alpha cells release Glucagon

Pancreas

The ventral part of the diencephalon that forms the floor and part of the lateral wall of the third ventricle. Anatomically it includes the preoptic area, the optic tract, optic chiasm, mammillary bodies, tuber cinereum, infundibulum, and neurohypophysis, (but for physiological purposes the neurohypophysis is considered a distinct structure).

Hypothalamus

Decreased thyroid activity due to primary disease of the thyroid gland or lack of pituitary TSH ◦ Iodine deficiency most common cause worldwide (but NOT here in the US) ◦ In areas of iodine sufficiency (like LA) ◦ Autoimmune disease (Hashimoto's thyroiditis) ◦ Iatrogenic causes - tx of hyperthyroidism

Hypothyroidism

The following are early signs and symptoms of? -Fatigue -Lethargy -Muscle cramps -Cold intolerance -Dry skin -Headaches -Constipation -Thin, brittle nails -Thinning Hair -Pallor -Delayed Relaxation of DTRs

Hypothyroidism

The following are late signs and symptoms of? -slow speech -absence of sweating -peripheral edema -hoarseness -decreased senses -weight changes -goiter -puffiness face/eyelids -thick tongue -hard, pitting edema -hypotension and bradycardia

Hypothyroidism

The following is tx for ________ Synthroid (Levothyroxine, T4) Cytomel (T3) ◦ Start LOW and GO SLOW! ◦ Follow TSH and free T4 and clinical status Once treatment has been stabilized and pt sx relieved and TSH levels normalized, patient should be monitored with yearly TSH level.

Hypothyroidism

_________ in Pregnancy Patient should be euthyroid prior to conception. Thyroid function needs to be monitored. ◦ Upon confirmation of conception ◦ Beginning of 2 nd and 3rd trimesters. • 30% increase of dose upon confirmation of pregnancy ◦ Dose of levothyroxine may need to be increased during pregnancy.

Hypothyroidism

facilitates transport of glucose into cells and other effects

Insulin

Most common cause of hypothyroidism worldwise

Iodine deficiency

Name the type of lipoprotein -cholesterol and protein -cholesterol is essential for steroid hormones and bile acids (so we need some) -This is the most abundant of lipoprotein in the serum and the one most likely to cause plaques in arteries

LDL

The following are management approaches for____? -diet -exercise -medications (statins are first line!)

LDL

The following describes ______ • Delivers cholesterol to the tissues • Receptors on the liver bind to LDL (LDLr) to control how much lipoprotein Is synthesized ⚬ Remember: we need some but not too much! • ___oxidation + migration to blood vessel walls + phagocytosis by macrophages = Atherosclerosis some genetic predispositions will affect the function of the receptors---> easier to develop ____ excess

LDL

Female Stimulates ovulation, estrogen and progesterone synthesis in ovary Male Stimulates androgen synthesis in the testes Target cells: female ovaries and male testes

LH (Luteinizing Hormone)

Originally the term was used to describe the border structures around the basal region of the cerebrum The term now has been expanded to include the entire neuronal circuitry that controls emotional behavior and motivational drives Major Parts: HYPOTHALAMUS Subcortical limbic structures Limbic cortex

Limbic System

LDL: Low-density lipoprotein HDL: High-density lipoprotein TG: Triglycerides TC: Total cholesterol "Non-HDL cholesterol": LDL + VLDL • Best predictor of cardiovascular risk

Lipid Panel

The following describes where _______ come from? ⚬ Dietary fat --> chylomicrons --> liver ⚬ Liver --> lipoproteins ￭ Lipoproteins: lipids, phospholipids, cholesterol, triglycerides

Lipids

Stimulates synthesis of melanin and dispersion of melanin granules in epidermal cells Target cells: melanocytes

MSH (Melanocyte Stimulating Hormone)

Most common and least aggressive thyroid cancer

Papillary

What type of thyroid cancer is described by the following? ◦ Only 4 % ◦ 1/3 sporadic, 1/3 familial, 1/3 MEN type 2 ◦ Arises from perifollicular cells ◦ Secretes ACRH (Adrenocortical releasing hormone) -causing Cushing's ◦ Mets

Medullary

Conditions producing diffusely decreased bone density (osteopenia) & diminished bone strength. Categorized by histologic appearance -osteoporosis -osteomalacia -Paget Disease of bone (Osteitis Deformans)

Metabolic Bone Diseases

1st line med for Type 2 DM (usually)

Metformin

- Test for loss of protective sensation using a Semmes-Weinstein 5.07 (10 g) monofilament at specific sites to detect loss of sensation in the foot

Monofilament Test

Long standing hypothyroidism markedly worsens ◦ Complication of hypothyroidism ◦ Generally elderly with another illness ◦ S/SX: stupor, respiratory depression, cardiac dysfunction, hypothermia ◦ Vigorous treatment

Myxedema coma

The condition maintaining a constant output of a system by exertion of an inhibitory control on a key step in the system by a product of the system

Negative feedback

The following is the etiology of which kind of diabetes insipidus? Acquired -Drugs -Metabolic -Obstruction -Vascular -Neoplasm Primary polydipsia Acquired Psychogenic Dipsogenic

Nephrogenic

Female Stimulates smooth muscle contraction in uterine wall, stimulates milk ejection Male Stimulates contraction of smooth muscle of male reproductive tract Target cells: female =uterus male=smooth muscle of male reproductive system

OT (Oxytocin)

• Responsible for Bone formation • Produce a matrix of osteoid

Osteoblasts

• Responsible for Bone breakdown • Remove bone tissue by removing its mineralized matrix & breaking down the organic bone aka RESORPTION

Osteoclasts

Def: Defective skeletal bone mineralization. Caused by any condition that results in inadequate calcium or phosphate mineralization of bone osteoid. AKA Rickets in children

Osteomalacia

Metabolic bone disease where bone matrix intact, mineralization decreased

Osteomalacia

The following are the s/sx's of? Depend on age @ onset & severity Usually asx'ic @ 1st Bone pain & tenderness Painful proximal muscle weakness (esp. pelvic girdle) Fx's w/little or no associated trauma Infants & children: heart failure, laryngospasm, bone deformities, dental problems.

Osteomalacia

The following is how to Dx ______? Alk phos - elevated Calcium & phosphorus - WNL or low 25-hydroxy-vitamin D - low DEXA, XR Radiologic features: -Thinning of cortical bone -Stress & pathologic fractures - Pseudofractures (Looser's zones or Milkman fx's) -Bone softening -Rickets in children-widened, expanded growth plate

Osteomalacia

The following is the etiology of? Vitamin D deficiency (MCC) Results in impaired Ca++ absorption Liver Dz, CKD, meds (anticonvulsant) Deficient calcium intake (1000mg/day) Bisphosphonates (non-nitrogen) Phosphate deficiency Aluminum toxicity (antacids) Hypophosphatasia - genetic Disorders of Vitamin D metabolism

Osteomalacia

The following is the tx and prevention of _________? Prevention: Adequate Vit D intake & adequate sun exposure 15 minutes, without sunscreen, twice/wk Salmon, cod liver oil, milk Supplement pts taking anticonvulsants/antiepileptic drugs Deficiency treated w/: Ergocalciferol (Vitamin D2 supplementation) Then Vitamin D3 (cholecalciferol)

Osteomalacia

-Def: a reduction in the strength of bone that leads to an increased risk of fractures. -MC metab. bone d/o -Rate of Bone resorption> rate of Bone formation -High morbidity & indirect mortality White women: 40% lifetime risk of related fx's Fragility fractures...2 million fx's annually Crush fractures of vertebrae Femoral neck fractures Distal radius fractures

Osteoporosis

Metabolic bone disease where both bone matrix & mineralization decreased

Osteoporosis

The following are s/sxs of? Often asx'ic +/- backache Spontaneous fx Collapse of vertebrae Loss of height

Osteoporosis

The following are the MCC of? -aging -high-dose corticosteroids -ETOH'ism, smoking -sex hormone deficiency

Osteoporosis

The following are used to diagnose ____________? -Alk phos usually WNL, or elevated if + fx -Serum calcium - WNL -Phosphate - WNL -PTH- WNL -Vit D deficiency common *** (check 25-hydroxyvitamin D) -<30 ng/mL: vit D deficiency DXA Scan: Determines hip and L-spine bone density -predicts fx risk -low radiation -T score-postmenopausal white women >/= -1: WNL -1.0 to -2.5: Osteopenia <-2.5: Osteoporosis Zscore: other groups of people Quantitative CT-more accurate but....

Osteoporosis

The following are ways to prevent _____? Adequate diet (protein, Ca++, Vit D) High impact/WB exercise*** Weight training Avoid smoking Avoid alcohol

Osteoporosis

The following describes? Modeling During growth: Allows long bones to adapt in shape to the stresses placed on them Stimulation of osteoblast formation Suppression of osteoclast activity Increased bone formation Remodeling In adults: Repair microdamage and supply Calcium from skeleton to maintain serum Calcium

Osteoporosis

The following is prevention/tx of? Vitamin D 800-2000 IU daily -Along w/sun exposure, prevents & treat Osteomalacia not osteoporosis Bisphosphonates- inhibit osteoclast-induced bone resorption - Increase bone density and reduce incidence of fx's - Alendronate, risedronate qwk (reduce both fxs) -Ibandronate sodium monthly (reduces vertebral fx) -Osteonecrosis of jaw, esophagitis, esophageal cancer, femur fx Hormone replacement therapy- low dose can prevent but not treat Selective estrogen receptor modulators (SERMs)- -Raloxifene - prevention and treatment Increases bone density, Reduces risk of vertebral fx's (40%) Teriparatide - PTH analog (2 year max) Stimulates production of new collagenous bone matrix Must be co-administered with sufficient Vit D and Calcium Beware of hypercalcemia Calcitonin - nasal spray QD Reduces incidence of vertebral fx's, suppresses osteoclast activity Last resort. +/- cancer risk

Osteoporosis

The following is the etiology of? -aging -high-dose corticosteroids -ETOH'ism, smoking -sex hormone deficiency Hormone excess Immobilization Tobacco use Malignancy Medications (SSRI, heparin, rosiglitazone) Genetic Disorders (osteogenesis imperfecta) Misc. (anorexia nervosa, liver dz, RA)

Osteoporosis

Female Stimulates milk production Male May play a role in the sensitivity of the testes interstitial cells to LH Target Cells: Female (mammary glands) male (not known)

PRL (Prolactin)

The following is the function of which hormone? Function: • On Bones: ____ & 1,25-dihydroxyvitamin D (OH)2D act synergistically to increase the net release of skeletal calcium • On the Kidneys: increases renal phosphate excretion & stimulates calcium reabsorption & synthesis of Vit D which-->Stimulates gastrointestinal calcium absorption

PTH

The following describes ______? Starts with overactive osteoclastic bone resorption followed by increased compensatory osteoblastic bone formation - results in disorganized bone - bone is more expanded, less compact, and more vascular = more likely to fx and/or deform

Paget Disease

The following describes s/sx's of? Often asx'ic...3/4 asx'ic @ time of Dx Bone pain usually 1st Sx Can involve one bone or many Skull, femur, tibia, pelvis, humerus Bones become soft... Kyphosis, bowed tibias Frequent fx's "chalkstick fx's" If skull involved: HAs Increased hat size Deafness CN palsies Dense expanded bones on XR Initial lesions: typically osteolytic w/"osteoporosis circumscripta" in skull advancing flame-shaped lytic lesions on long bones Then: Mixed lytic & sclerotic appearance Eventually: thickened & deformed

Paget Disease

The following is the Dx of? Alk phos - very high Serum phosphate - WNL Serum Ca++ - WNL or elevated Serum procollagen type I N- terminal propeptide Urine N-telopeptide of type 1I collagen cross-links (NTx) Screen for Vit D deficiency Bone scan Delineates activity of bone lesions before any radiographic changes apparent.

Paget Disease

The following is the tx of _______? +/- Monitor asymptomatic minimal involvement pts. Bisphosphonates Monitor Alk Phos Prognosis is good - unless sarcomas develop (1-3%) from bone lesions. Worsens the earlier in life the Dz starts

Paget Disease

MC in the UK

Paget Disease of Bone

Metabolic bone disease w/ elevated alk phos

Paget Disease of Bone

The following describes ______? Def/Epi/Eti: Dz of bone manifested by one or more bony lesions which have high rate of bone turnover & disorganized osteoid formation. Involved bones are: vascular, weak, & deformed MC in the UK M>F Pts > 40 yrs old Cause unknown...likely genetic Usually discovered incidentally on XR or by increased alk phos on labs

Paget Disease of Bone (Osteitis Deformans)

______ Types of thyroiditis Specific variations of Hashimoto's thyroiditis ◦ Postpartum thyroiditis - like Graves, but usually less severe ◦ Sporadic painless thyroiditis Both have same clinical course ◦ Initial hyperthyroid phase ◦ Followed by hypothyroidism ◦ If hypothyroid >6 months, most likely permanent ◦ Return to euthyroid state

Painless

What type of thyroid cancer is described by the following? ◦ Most common and least aggressive ◦ Usually single nodule, can become mulitfocal ◦ Hx of radiation to head or neck ◦ Familial ◦ Spreads to regional nodes and lungs ◦ Cold nodules

Papillary

The following describes the anatomy and physiology of ________? -Number & location varies in normal individual -Variability in location > in the lower parathyroid glands -Superior parathyroids may be found close to the thyroid capsule or actually w/in the thyroid capsule • Can be located behind the pharynx or the esophagus, lateral to the larynx or behind any part of the thyroid

Parathyroid Gland

The following describes the histology of? -Each parathyroid gland is invested by a thin connective tissue capsule that extends into the parenchyma as fibrous septa dividing the gland into lobes -Clusters of cells are interspersed with fat • Ratio of 50:50 (cells:fat) -Cells of the Parathyroid Gland • Chief Cells • Oxyphils • Clear Cells

Parathyroid Gland

Daily exercise, or at least not allowing more than 2 days to elapse between exercise sessions, is recommended to enhance insulin action. Include at least 150 min/week of physical activity Adults with type 2 diabetes should ideally perform both aerobic and resistance exercise training for optimal glycemic and health outcomes. Children and adolescents with type 2 diabetes should be encouraged to meet the same physical activity goals set for youth in general.

Physical activity and Type 2 DM

The following is the etiology of which kind of diabetes insipidus? Acquired Granulomas Infections Inflammatory Chemical toxins Vascular Pregnancy Congenital malformations Genetic

Pituitary

The following is the pathophysiology of _________ -Most are clonal in origin. A single cell with altered growth control and feedback regulation gives rise to the it. In a number of cases, a point mutation has occurred in the alpha subunit of cytosolic GTP-binding protein that normally regulates growth stimulatory transduction. (as a result the "G" protein is on much longer)

Pituitary Adenomas

Most common cause of pituitary hormone hyposecretion and hypersecretion in adults

Pituitary adenomas

-An epithelial body located at the base of the brain in the sella turcica attached by a stalk to the hypothalamus, from which it receives an important neural and vascular outflow. -The "master gland" of the endocrine system that produces six major hormones and two additional hormones.

Pituitary gland (hypophysis)

The following describes the embryological structure of the ________ -Anterior Pituitary is derived from Rathke's Pouch (which is an embryonic invagination of the pharyngeal epithelium) -Posterior Pituitary is derived from a neural tissue outgrowth from the hypothalamus

Pituitary gland (hypophysis)

A condition causing the output of a system to increase continually by exertion of a key stimulatory effect on a key step in the system by a product of the system

Positive feedback

The following describes the ___________ pituitary -Hormones are transported to it in the axoplasm of the neurons, nerve fibers passing from the hypothalamus to it -the cells bodies of the cells that secrete the hormones are not located in this gland, but are large neurons called madnocellular neurons, located in the supraoptic and paraventricular nuclei of the hypothalamus -Composed mainly of glial cells called pituicytes, which act largely as a supporting structure for large numbers of terminal nerve fibers and terminal nerve endings -These tracts pass to the neurohypophysis through the pituitary stalk -The nerve endings are bulbous knobs that contain many secretory granules -These endings lie on the surfaces of capillaries into which they secrete: -ADH Antidiuretic Hormone or Vasopresin (supraoptic nuclei) -Oxytocin (paraventricular nuclei)

Posterior

The following hormones are stored in the _________ pituitary -Antidiuretic hormone or vasopressin (ADH) -Oxytocin (OT)

Posterior

Pneumovax 23 Hepatitis B

Preventative vaccines type 2 DM

Pneumonic for? -Painful bones -Renal stones -Abdominal groans -Psychic moans -Fatigue overtones

Primary Hyperparathyroidism

The following are the clinical features of_____? Clinical Features: • Loss of appetite (extremely high calcium • Thirst (polydipsia) • Frequent urination (polyuria) • Diminished DTRs • Parasthesias • Muscle weakness • Bone & Joint pain • Constipation • Fatigue • HTN Severe Sx's (extremely high calcium levels) -N/V -Memory loss -Depression -Fractured bones, cystic bone lesions -Nephrolithiasis, Nephrocalcinosis

Primary Hyperparathyroidism

The following is Tx for _______? -Indications for medical monitoring: Mild serum calcium elevation Mild, asymptomatic No previous episodes of life threatening hypercalcemia Normal renal & bone scans -During medical monitoring: Keep active Avoid immobilization Drink adequate fluids Avoid thiazide diuretics, large doses of Vit A, and calcium-containing antacids -Indications for surgical treatment: -Markedly elevated serum calcium levels -Sx'ic -A life threatening hypercalcemic episode -Kidney stones, bone dz, pregnancy -Markedly elevated 24 hour urinary calcium level -Indications for surgical treatment: -Substantially reduced bone mass as determined by direct measurement -Relative youth (< age 50-60) -Pts. whom medical surveillance is not desirable or suitable

Primary Hyperparathyroidism

The following is the epidemiology of _____? • MCC of hypercalcemia • Women (74%) affected more than men, >45 yrs of age • MC'ly occurs in seventh decade • Prevalence 0.1-0.4% of persons • If present prior to age 30, higher incidence of multiglandular Dz

Primary Hyperparathyroidism

The following is the etiology of _____? • Exposure to head, facial or neck irradiation • Medications (thiazides & lithium) • Inherited (10%) • Malignancy, multiple myeloma • Parathyroid cancer (rare) • Solitary adenoma • MEN I (Wermer's Syndrome) • Occurs in MEN 2A also, but less frequently

Primary Hyperparathyroidism

◦ Congenital defect - cretinism ◦ Autoimmune process - Hashimoto's ◦ Iodine deficiency ◦ Non toxic multinodular goiter ◦ Radiation induced ◦ Drug induced

Primary Hypothyroidism

• Chronic, poorly regulated excessive secretion of PTH by one or more parathyroid glands that results in hypercalcemia. • 80% of the time 2/2 single parathyroid adenoma

Primary hyperparathyroidism

MCC hyperprolactinemia

Prolactinoma

The following are the Dx of? Dx: -serum calcium is LOW -PTH is HIGH!!! -Elevated Phosphate

Pseudohypoparathyroidism

The following are the clinical features of _______? Clinical Features: • Cataracts • Intracranial calcifications • Parasthesias • Seizures • Developmental anomalies, MR • Short stature • Round Face • Short 4th metacarpal - brachydactyly

Pseudohypoparathyroidism

The following describes? Etiology: • Genetic Epidemiology: • Children Pathophysiology: • Abnormality in the renal PTH receptor adenylyl cyclase complex that produces cAMP

Pseudohypoparathyroidism

• An uncommon hereditary metabolic disorder characterized by a biochemical hypoparathyroidism (hypocalcemia & hyperphosphatemia), increased secretion of PTH & target tissue unresponsiveness to the biologic actions of PTH • Renal resistance to effects of PTH • Typically associated w/distinctive skeletal & developmental defects

Pseudohypoparathyroidism

Name the type of fat -found in meat and dairy -bad bc promote production of LDL by the liver

Saturated Fats

Seen in Chronic Kidney Disease (CKD) when: • Hyperphosphatemia & reduced 1,25- dihydroxycholecalciferol produce an initial decrease in ionized calcium • leading to parathyroid gland stimulation (SECONDARY HYPERPARATHYROIDISM) thus an increase in PTH secretion • can lead to tertiary hyperparathyroidism = hyperplasia resulting in autonomous PTH secretion

Secondary Hyperparathyroidism

TSH deficiency (pituitary)=

Secondary Hypothyroidism

Looser's zones & Milkman's fx's are considered

pseudofractures

Risk Factors - previous radiation to head and neck, iodine exposure during nuclear fallout Presentation ◦ Thyroid asymmetric, fixed to skin ◦ Lymphadenopthy ◦ Hoarseness ◦ Cold nodule on scan

Thyroid Cancer

The following are treatment options for? Based on test results ◦ Cyst ◦ Hot nodule ◦ Cold nodule ◦ Papillary and follicular ◦ +/- Chemotherapy ◦ Medullary ◦ +/- tyrosine kinase inhibitors (vandetanib or cabozantinib) if patient has Metastatic disease ◦ Anaplastic ◦ Platin based chemo Almost always surgery in ALL before chemo.

Thyroid Cancer

Physical exam findings for ______ BMI Blood pressure ' Skin - acanthosis nigricans, monilial infections Eyes - fundoscopic exam - retinal hemorrhage and exudate Heart - arrythmias, valve disease Foot exam - DP & PT pulses, check for ulcers, tinea pedis, Monofilament exam

Type 2 Diabetes

The following are meds for? Insulin Sulfonylureas - Glipizide and Glimepiride Biguanides - Metformin Alpha-glucosidase Inhibitors -Acarbose, Miglitol Thiazolidinediones - Pioglitazone, Rosiglitazone Meglitinides - Repaglinide, Nateglinide Amylin analogs - Pramlintide GLP-1 RA - Liraglutide, Dulaglutide DPP-4 Inhibitors - Sitagliptin, Saxagliptin SGLT-2 Inhibitors - Empagliflozin, Canagliflozin, Dapagliflozin

Type 2 Diabetes

The following are risk factors for? •45 years or older •Have a parent, brother, or sister with type 2 diabetes •Have ever had gestational diabetes (diabetes during pregnancy) or given birth to a baby who weighed more than 9 pounds •Are African American, Hispanic/Latino American, American Indian, or Alaska Native (some Pacific Islanders and Asian Americans are also at higher risk) •Are overweight - BMI ≥25 (Asian - ≥ 23) •Are physically active less than 3 times a week •Hypertension (BP ≥ 140/90 or on therapy) •HDL <35 ±Triglycerides > 250 •Cardiovascular disease •Condition associated with insulin resistance (severe obesity, acanthosis nigricans, polycystic ovary syndrome)

Type 2 Diabetes

The following are the key lab tests for? Fasting Blood glucose - Blood glucose level after 8 hour fast Hemoglobin A1C - reflects the average blood glucose level over past 8 - 12 week (life of a red blood cell is 120 day) - Falsely high - Iron deficiency anemia -Falsely low - hemolytic anemia, end stage renal disease, acute and chronic blood loss Urine Microalbumin - test to detect very small levels of a blood protein (albumin) in the urine. < 30 mg/day - normal, 30-300 mg/day - microalbuminuria, > 300 mg/day - macroalbuminuria. Elevation is early sign of diabetic renal disease C-peptide - insulin and C-peptide are linked when first made by the pancreas. C-peptide level reflects the level of insulin Monofilament Test - Test for loss of protective sensation using a Semmes-Weinstein 5.07 (10 g) monofilament at specific sites to detect loss of sensation in the foot

Type 2 Diabetes

The following are used for the initial eval and screening of ________ Weight/BMI Blood pressure Eye exam - Retinal screening Foot exam - Monofilament exam Hemoglobin A1C Lipid Panel Urine Microalbumin CMP - kidney function and liver enzymes TSH - consider in women < 50 Hepatitis B immunity

Type 2 Diabetes

The following explains how ______ impairs the immune system High blood sugar can impair the ability of white blood cells to come to the site of an infection, stay in the infected area, and kill microorganisms. • more severely affected by common infections, such as influenza and pneumonia caused by Streptococcus pneumoniae. • Yeast infections on the skin and in the urinary tract. • Severe infection of the outer ear with the bacteria Pseudomonas aeruginosa. This infection is called malignant external otitis. It causes severe ear pain and drainage from the infected ear.

Type 2 Diabetes

The following is a screening recommendation for _________ American Diabetic Association (ADA) 1) Everyone over 45 years every 3 years 2) Any age with BMI ≥ 25 AND one or more risk factors: ● Physical Inactivity ● First Degree Relative with diabetes ● High Risk Ethnic groups - African American, Hispanic/Latino American, American Indian ● History of gestational diabetes or baby > 9 pounds ● Hypertension (≥ 140/90 or on therapy) ● HDL <35 ±Triglyceride >250 ● Cardiovascular disease history ● Prediabetes (A1C ≥ 5.7%) ● Condition with insulin resistance (severe obesity, acanthosis nigricans, polycystic ovary syndrome)

Type 2 Diabetes

The following is a screening recommendation for _________ by USPSTF - Everyone age 40-70 with BMI ≥ 25

Type 2 Diabetes

The following is the clinical presentation of? • The majority of patients are asymptomatic at presentation • The classic symptoms of hyperglycemia including polyuria, polydipsia, nocturia, blurred vision, and weight loss • Polyuria occurs when the serum glucose concentration rises significantly above 180 mg/dL (10 mmol/L), exceeding the renal threshold for glucose reabsorption, which leads to increased urinary glucose excretion. Glycosuria causes osmotic diuresis (ie, polyuria) and hypovolemia, which in turn can lead to polydipsia. • Rarely adults with type 2 diabetes can present with a hyperosmolar hyperglycemic state, characterized by marked hyperglycemia, severe dehydration, and obtundation, but without ketoacidosis. • Diabetic ketoacidosis (DKA) as the presenting symptom of type 2 diabetes is also uncommon in adults but may occur under certain circumstances (usually severe infection or other acute illness) and in non-Caucasian ethnic groups.

Type 2 Diabetes

The following is the pathophys for? Insulin is a hormone made by the pancreas that facilitates the movement of glucose from the blood into the cells for use as energy. cells don't respond normally to insulin; this is called insulin resistance. The pancreas makes more insulin to try to get cells to respond. Eventually the pancreas can't keep up, and the blood sugar rises, setting the stage for prediabetes and _______. Pathophysiology involves at least 7 organs and tissues including the pancreas, liver, skeletal muscle, adipose tissue, brain, gastrointestinal tract and kidney.

Type 2 Diabetes

Ways to diagnose? Hemoglobin A1C ≥ 6.5 % OR Fasting Blood sugar ≥126 OR Random blood sugar ≥ 200 with classic symptoms of hyperglycemia OR 2-hr PG ≥ 200 during Oral Glucose Tolerance Test (75 g)

Type 2 Diabetes

• a variable disorder of carbohydrate metabolism • caused by a combination of hereditary and environmental factors • develops especially in adults and most often in obese individuals • characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production

Type 2 Diabetes

⚬ Start treatment now! ⚬ At extremely high risk for complications Total cholesterol: greater than or equal to 240 LDL: greater than or equal to 160 HDL: less than 35 TG: 100-499

Undesireable

Name the type of fat -found in nuts, seeds, plants, fish, avocado oils -not bad--> help the liver break down the bad LDLs and excrete via bile

Unsaturated fats

- test to detect very small levels of a blood protein (albumin) in the urine. < 30 mg/day - normal, 30-300 mg/day - microalbuminuria, > 300 mg/day - macroalbuminuria. Elevation is early sign of diabetic renal disease

Urine Microalbumin

Name the type of lipoprotein -triglycerides and protein -triglycerides transfer energy from food into cells -they are the least dense but most closely associated with food intake

VLDL

MCC of osteomalacia

Vit D deficiency

________Can be a result of: Deficient production of Vitamin D in the skin Lack of dietary intake Accelerated losses of Vitamin D Impaired Vitamin D activation Resistance to the biologic effects of 1,25(OH)2D The elderly, nursing home residents Clinical manifestations: consequence of impaired intestinal calcium absorption +/- asymptomatic, if mild-moderate Hypocalcemia, secondary hyperparathyroidism, osteopenia, proximal myopathy if chronic Check Serum 25(OH)D level (<30 deficient vs <20 ng/mL severely deficient) Serum total and ionized calcium levels low

Vitamin D deficiency

Just need to fill in the word once :)->It's the same word Glucose damages the inner linings of both big and small _______. The _______ respond by layering on plaque, a substance that fills in the ______ so that oxygen-rich blood has a hard time getting through to the eyes, kidneys, legs and feet.

arteries

midbrain (mesencephalon)=

brainstem

thalamus + hypothalamus (diencephalon) cerebrum (telencephalon)

forebrain (prosencephalon)

Undesirable LDL cholesterol

greater than or equal to 160

undesirable total cholesterol

greater than or equal to 240

W/hypothyroidism expect to see ______ TSH and ____T4

high, normal or depressed

cerebellum + pons (metencephalon) medulla oblongata (myelencephalon)

hindbrain (rhombencephalon)

There are no sx of _______...so don't wait until they have CAD/HTN/CVD to intervene

hyperlipidemia

The following is the epi and pathophys of ________ Epi: -uncommon in all ages -in childhood dominated by growth failure -in adults hypogonadism caused by lack of FSH and LH Pathophys (dependent upon eti): -pituitary dysplasia -septo-optic dysplasia -tissue specific factor mutations -developmental hypothalamic dysfunction -acquired ___________

hypopituitarism

__________ can give a falsely high level and increased red cell turn over can give a falsely low level

iron deficiency anemia

Desirable Triglyceride level

less than 150 mg/dL

first line treatment for all patient with diabetes type 2

lifestyle modification with diet and exercise

MC metabolic bone disorder

osteoporosis

The following are the two classifications of _________ -microadenoma <10mm in diameter -macroadenoma > 10mm in diameter

pituitary adenoma

benign neoplasms that arise from one of the five pituitary cell types a benign epithelial tumor in which the cells form recognizable glandular structures or in which the cells are clearly derived from glandular epithelium

pituitary adenoma

The following is the epi of ? -Most common cause of pituitary hormone hyposecretion and hypersecretion in adults -Account for 10% of all intracranial neoplasms -At autopsy up to 1/4th of all pituitary glands harbor an unsuspected microadenoma -Pituitary imaging detects a small pituitary lesion in at least 10% of normal individuals

pituitary adenomas

The following describes the anatomical structure of _______________ -Small gland appx 1 cm in diameter and 0.5 to 1 gram in weight -Lies in the sella turcica, a bony cavity at the base of the brain -Connected to the hypothalamus by the pituitary stalk or hypophyseal stalk

pituitary gland (hypophysis)

MCC of hypercalcemia

primary hyperparathyroidism

The following describes what kind of hypothyroidism? Normal serum free T4 Slightly elevated TSH Vague, non-specific symptoms of hypothyroidism May be result of undertreated overt hypothyroidism TX? - might really help!!

subclinical

Dexamethasone suppression Test--> if release of cortisol does not stop what does this mean?

tumor causing release of ACTH