Endocrinology
what is the general treatment for hyperparathyroidism
- Remove the PARATHYROID adenoma, subtotal parathyroidectomy (3 1/2 of gland removed), or total parathyroidectomy - If it is secondary, then once you replace the cause (Vitamin D and Calcium supplementation) you will have fixed the problem. - If the calcium is very high - treat with IV fluids, furosemide, or calcitonin - May need to treat osteoporosis with Bisphosphonates.
what is the treatment for thyroid cancer
- Treatment depends on the type of cancer and prognosis depends on staging, with a 99% 5-year survival with locally confined, less than 1 cm papillary carcinoma - Always involves complete or partial removal of the thyroid with chemotherapy and external beam radiation reserved for anaplastic thyroid cancer - Recommended TSH level for pt: 1-2.0
Thyroiditis can also be seen in patients taking certain drugs. what drugs would you consider for this diagnosis
1. Antithyroid medications: methimazole and propylthiouracil 2. Lithium - bipolar disorder 3. Amiodarone - antiarrhythmic 4. Interferon alpha 5. Tyrosine Kinase Inhibitors (e.g., Sunitinib) - anti-cancer 6. Checkpoint inhibitors (e.g., Nivolumab, Pembrolizumab)
how does increased PTH (in hyperparathyroidism) raise the blood calcium levels
1. Breaking down the bone (where most of the body's calcium is stored) and causing calcium release 2. Increasing the body's ability to absorb calcium from food from the GI tract 3. Increasing the kidney's ability to hold on to calcium that would otherwise be lost in the urine This results in increased serum and urinary calcium, osteoporosis, and renal calculi.
what will be the results of radioactive iodine uptake in Graves disease and toxic multinodular thyroid
1. Graves: Diffusely high uptake 2. Toxic multinodular: Discrete areas of high uptake
in thyroiditis, if there is PAIN think of which diagnoses
1. Painful subacute - De Quervain's (granulomatous) usually post viral 2. Infectious - bacterial mainly - strep or staph most common 3. Radiation 4. Trauma
in thyroiditis, if there is NO PAIN think of which diagnoses
1. Postpartum - 1-2 months of hyperthyroidism after delivery 2. Drug-induced - the most common cause of drug-induced thyroiditis is Lithium or Amiodarone 3. Hashimoto thyroiditis
what are the levels of TSH and FT4 in hyperthyroidism
1. TSH: Decreased in primary disease (↓ TSH and ↑ Free T4), elevated in secondary disease (↑ TSH and ↑ Free T4) 2. FT4: Elevated although may be normal
what are the types of thyroid cancers
1. papillary 80% 2. follicular 10% 3. medullary 4% 4. anaplastic 1%
how can you diagnose DI
1. serum osmolality (high -- unable to stop the secretion of water into the kidneys so blood becomes more concentrated) 2. urine osmolality (low -- because it is so dilute) 3. *water deprivation test -- simplest/most reliable method* - continued production of *dilute* urine despite water deprivation 4. desmopressin stimulation test -- - Central: reduction in urine output indicating a response to ADH - Nephrogenic: continued production of dilute urine (no response to ADH) because kidneys can't respond
what is the treatment for hyperthyroidism / graves
1. the cardiac symptoms of Graves' disease can be treated with β-Blockers -- atenolol 25-50 mg po QD is most common and can be increased up to 200 mg po QD if needed 2. methimazole: starting dose for mild hyperthyroidism is 10 mg PO QD 3. Propylthiouracil (PTU) P for pregnant (first trimester) 4. radioactive iodine 5. surgery (thyroidectomy)
when will you see post partum thyroiditis
2-12 months after giving birth Immune system diminished during pregnancy ⇒ after childbirth immune system is more active and might attack the thyroid Hyperthyroid phase 5-7 months after birth followed by normal thyroid function
what is the most reliable index of cortisol secretion when testing for cushing disease
24 hour urinary free cortisol
in hyperparathyroidism, what is the treatment if if calcium is very high
: IV fluids, Lasix, calcitonin; treat osteoporosis with bisphosphonates
what level of plasma or serum ACTH suggests an adrenal tumor
< 20 pg/mL
Which of the following is accurate about the epidemiology of acromegaly? A. Gigantism is more common than acromegaly B. Acromegaly is typically associated with a delay in diagnosis C. The mean age for onset of acromegaly is the second decade of life D. Men develop acromegaly more frequently than women
B. Acromegaly is typically associated with a delay in diagnosis Gigantism is extremely rare, with approximately 100 reported cases to date. Acromegaly is more common than gigantism, with an incidence of 3-4 cases per million people per year and a prevalence of 40-70 cases per million population. The mean age for onset of acromegaly is in the third decade of life; the delay from the insidious onset of symptoms to diagnosis is 5-15 years, with a mean delay of 8.7 years. The mean age at diagnosis for acromegaly is 40 years in men and 45 years in women. Men and women are equally affected.
A 38-year-old woman comes to your office with a 3-month history of sweating, palpitations, weight loss, nervousness, irritability, insomnia, hand tremors, and diarrhea. She has no significant past illness. One of her sisters has rheumatoid arthritis. The patient, a stockbroker, is finding it increasingly difficult to perform her job because of profound fatigue and inability to concentrate. On examination, her blood pressure is 140/ 70 mm Hg. Her pulse is 120 beats/ minute and regular. She demonstrates mild proptosis. You feel a smooth, diffusely enlarged, and nontender thyroid gland. Cardiovascular examination reveals a loud S1 and a loud S2 with a systolic ejection murmur heard loudest along the left sternal border. The murmur does not radiate. No other abnormalities are noted. What is the most likely diagnosis in this patient? A. toxic multinodular goiter B. Graves disease C. Hashimoto thyroiditis D. pheochromocytoma E. panic disorder
B. Graves disease
Which of the following is generally accepted as the most sensitive screening tool for primary hypothyroidism? A. Free thyroxine (T4) assay B. Third-generation thyroid-stimulating hormone (TSH) assay C. Anti-thyroid peroxidase (anti-TPO) antibody assay D. Antithyroglobulin (anti-Tg) antibody assay
B. Third-generation thyroid-stimulating hormone (TSH) assay
What is the best treatment for a patient with prolactinoma? A. transsphenoidal resection B. bromocriptine C. clomiphene D. lithium E. thyroxine
B. bromocriptine Treatment is controversial, but because of a high rate of recurrence with surgery, initial therapy with cabergoline or bromocriptine is the best choice. Treatment with dopamine agonists is not curative; it does, however, reduce the prolactin level, reduce the tumor mass, and increase fertility. Side effects include nausea and vomiting, an increase in liver enzymes, and an increase in serum uric acid.
What is the acute treatment of choice for this patient (above vignette) A. prednisone orally B. hydrocortisone intravenously C. dexamethasone orally D. ACTH intravenously
B. hydrocortisone intravenously Because of the acutely ill state of this patient, dexamethasone sodium phosphate 4 mg every 12 hours or hydrocortisone 100 mg intravenously every 6 hours for 24 hours should be administered acutely. If the patient shows adequate clinical response, the dose may be tapered gradually and changed to oral prednisone.
In the previous scenario thyroid function testing confirms a current hypothyroid state. What is the most appropriate course of action? A. perform a radioactive iodine scan B. thyroid replacement therapy with close follow-up of thyroid function C. no treatment; this will resolve on its own D. assure the patient that her thyroid function will normalize in a few weeks E. perform a thyroid ultrasound
B. thyroid replacement therapy with close follow-up of thyroid function The patient should be started on thyroid replacement therapy to correct her current hypothyroidism. Her TSH level should be monitored because most patients will become euthyroid during a period of weeks to months and will no longer need replacement. A subset of patients will remain hypothyroid. Ultrasound and radioactive iodine scanning have little value in this setting.
A 38-year-old woman is seen in your office for a complete baseline health assessment. You have never seen this patient before. She feels well and tells you that she is "wonderfully healthy." She has had no weight loss or gain; no sweating, no tremors, no diarrhea or constipation; no anxiety or depression; no irritability; and no other symptoms. On examination, she is found to have a 2-cm nodule in the left lobe of the thyroid gland. Her blood pressure is 120/ 70 mm Hg. Her pulse is 90 beats/ minute and regular. What is the first test that should be ordered to evaluate the patient's physical examination abnormality? A. magnetic resonance imaging (MRI) scan of the thyroid B. thyroid ultrasound study C. radioactive iodine uptake scan D. FNA of the nodule E. computed tomography (CT) scan of the thyroid
B. thyroid ultrasound study
what will labs show in hyperparathyroidism
Blood = ↑ Ca, ↑ PTH, and ↓ phosphorus Urine = hyperphosphaturia, hypercalciuria (all Ca and phosphorus go out through kidneys to urine)
how do you administer the high dose cosyntropin stimulation test
Blood or urine cortisol is measured after an IM injection of cosyntropin (synthetic ACTH) The normal response is a rise in blood and urine cortisol levels after synthetic ACTH is given Primary adrenal insufficiency results in little or no increase in cortisol levels (< 20 mcg/dL) after ACTH is given
A 38-year-old man presents to the emergency department experiencing a severe headache and heart palpitations. He appears to be anxious and perspiring heavily. On examination, he is found to be tachycardic and his blood pressure is 158/102 mm Hg. His urine catecholamines are increased. If imaging were performed, what is the most likely location where a lesion would be found? A. Pituitary gland B. Liver C. Adrenal gland D. Testicle E. Kidney
C. Adrenal gland Pheochromocytomas produce, store, and secrete catecholamines. They are usually derived from the adrenal medulla, although they may be found in other locations.
Clinical findings associated with Cushing disease include all of the following, except A. Weight gain B. Menstrual irregularity C. Depression/ emotional lability D. Excessive thirst E. Glucose intolerance
C. Depression/ emotional lability
Two suspicious thyroid nodules are identified after the appropriate primary test is ordered. What is the next test in the evaluation of the patient's thyroid nodules? A. serum T4 B. radioactive iodine uptake thyroid scan C. FNA of the nodules D. thyroid ultrasound study E. CT scan of the thyroid
C. FNA of the nodules
Which of the following is accurate regarding treatment of acromegaly? A. Pharmacologic therapy is the first-line treatment for acromegaly B. Radiation therapy is routinely indicated for most patients with acromegaly C. For most patients with acromegaly, surgical removal of the pituitary gland tumor is the primary treatment D. Somatostatin and dopamine analogues and GH receptor antagonists should be routinely instituted if surgery for acromegaly is required
C. For most patients with acromegaly, surgical removal of the pituitary gland tumor is the primary treatment
A 25-year-old woman presents with the sudden onset of increased thirst and increased urination. This began abruptly 1 week ago and has not abated since. She states that since then, she has been thirsty all the time. The only significant illness in her life has been a diagnosis of bipolar affective illness that was made 5 years ago treated with lithium carbonate 1200 mg/ day. Her serum lithium levels have been normal since starting treatment. On examination, her blood pressure is 110/ 70 mm Hg. She has lost 5 pounds during the past week and looks somewhat dehydrated. When informed that her symptoms may be caused by medication taken for her mood disorder, she becomes distraught and refuses to discontinue or switch medications due to past difficulties with medication trials. What is the first step in pharmacological management? A. Discontinue her lithium B. Desmopressin C. Hydrochlorothiazide D. Amiloride
C. Hydrochlorothiazide Typically the first step is to discontinue the offending drug, however at this point discontinuing lithium is not acceptable to the patient based on her difficulty with managing her mood disorder. As a result, thiazide diuretics are the most appropriate next step because they are the first-line pharmacological therapy for nephrogenic diabetes insipidus
Which of the following is the most common cause of acromegaly? A. Increased growth hormone (GH)-releasing hormone (GHRH) from hypothalamic tumors B. Ectopic GHRH from nonendocrine tumors C. Pituitary adenomas or hyperplasia D. Ectopic GH secretion by nonendocrine tumors
C. Pituitary adenomas or hyperplasia Causes of excess IGF-I action can be divided into the following three categories: - Release of primary GH excess from the pituitary - Increased GHRH secretion or hypothalamic dysregulation - Hypothetically, the excessive production of IGF-binding protein, which prolongs the half-life of circulating IGF-I
This patient will need chronic treatment with which of the following (above vignette) A. hydrocortisone B. fludrocortisone acetate C. both
C. both The chronic treatment of Addison disease is a combination of hydrocortisone (15 to 25 mg/ day) and fludrocortisone (0.05 to 0.3 mg/ day). This combination is based on the need for a combination of glucocorticoid replacement and mineralocorticoid replacement. Dosage is increased for stressful events such as infection. Watch for activation of latent tuberculosis.
A 29 year old woman presents to the clinic for the second time. You previously diagnosed her with a viral URI. She states that she began to improve, but her sore throat moved to the front of her neck and she began having palpitations. She now feels tired all the time and is constipated. Physical examination is normal except for mild, diffuse tenderness of the thyroid. What is the most likely diagnosis for this patient? A. Grave's disease B. Hashimoto thyroiditis C. subacute thyroiditis D. papillary thyroid carcinoma
C. subacute thyroiditis
patients with hypervolemic hyponatremia likely have what other comorbidities
CHF, nephrotic syndrome, renal failure, cirrhosis
why do you need CNS imaging for acromegaly / gigantism
CNS imaging to detect a pituitary tumor; If a tumor is not visible, excessive secretion of pituitary GH may be due to a non-CNS tumor producing excessive amounts of ectopic GHRH
what is the clinical presentation of hypothyroidism
Cold intolerance, fatigue, constipation, depression, weight gain, bradycardia Congenital: round face, large tongue, hernia, delayed milestones, poor feeding
how can you diagnose cushing disease
Confirming high cortisol with a 24 hr urine free cortisol, late-night serum cortisol, and/or low-dose dexamethasone suppression test Once confirmed, the source of the high cortisol needs to be determined with an ACTH level
A 25-year-old man comes to your office with his wife. He is very concerned about some "bizarre symptoms" that he has been experiencing. He is the chief executive officer of a family-owned manufacturing company and is "really embarrassed to go out in public any longer." He tells you that approximately 6 months ago, he began to experience the following symptoms: headaches, visual spots or defects, weight gain, an appearance of his forehead growing, enlarging hands and feet (he could no longer get his gloves and shoes on), and increased sweating. On examination, mental status is normal, and the apical impulse is felt in the fifth intercostal space, midclavicular line. His blood pressure is 170/ 105 mm Hg. He does have a protruding brow, and three discrete visual field defects are noted (two in the left eye and one in the right eye). His tongue appears enlarged, and he is sweating profusely. What is the most likely diagnosis in this patient? A. ACTH excess B. Prolactinoma C. Primary hypopituitarism D. Acromegaly
D. Acromegaly
Which of the following is accurate regarding the workup of acromegaly? A. Routine imaging studies should be performed in all patients suspected of having acromegaly B. GH is the most reliable biochemical indicator of acromegaly C. Most patients investigated for acromegaly have a post glucose GH level that is intermediate (5-10 ng/mL) D. Elevated IGF-I values in a patient suspected of acromegaly almost always indicate GH excess
D. Elevated IGF-I values in a patient suspected of acromegaly almost always indicate GH excess IGF-I is the most reliable biochemical indicator of acromegaly. An excellent linear dose-response correlation between serum IGF-I levels and 24-hour integrated GH secretion has been demonstrated. Elevated IGF-I values in a patient whose symptoms prompt appropriate clinical suspicion almost always indicate GH excess. IGF-I is useful not only in diagnosis but also in monitoring the efficacy of therapy. Because of the relatively high incidence of nonfunctioning, incidentally discovered pituitary adenomas, imaging studies should be obtained only after a firm biochemical diagnosis of acromegaly has been made. Only a small percentage of patients investigated for acromegaly have a postglucose GH level that is intermediate (5-10 ng/mL). In these patients, other tests can be used to define their status.
A 65-year-old woman with a seizure disorder controlled with phenytoin presents to your office complaining of muscle cramps, dry skin, and depression. Examination shows carpal-pedal spasms after application of a blood pressure cuff. The most likely diagnosis is A. Hypothyroidism B. Hyperventilation with panic attacks C. Hyperkalemia D. Hypocalcemia E. Hyponatremia
D. Hypocalcemia
Myxedema coma is a severe form of hypothyroidism that most commonly occurs in which of the following? A. Male patients with hypothyroidism and excessive weight gain B. Female patients with galactorrhea and menstrual disturbances secondary to hypothyroidism C. Patients with hypothyroidism and decreased appetite, sleepiness, hair loss, and dry skin D. Patients with untreated hypothyroidism who are subjected to an external stress
D. Patients with untreated hypothyroidism who are subjected to an external stress
In which of the following groups is screening for hypothyroidism recommended? A. All adults older than 50 years on a routine basis B. Pregnant women, but not until the second trimester C. Asymptomatic adults older than 40 years D. Women older than 50 years who have one or more clinical features of the disease
D. Women older than 50 years who have one or more clinical features of the disease
What treatment will be most effective to acutely alleviate the patient's symptoms of hyperthyroidism? A. methimazole B. radioactive iodine C. propylthiouracil (PTU) D. atenolol
D. atenolol Patients with hyperthyroidism display symptoms of increased adrenergic tone causing tachycardia, palpitations, anxiety, and other symptoms. Beta-adrenergic blocking agents, such as atenolol, are effective in alleviating many of these symptoms in the acute setting. Use of methimazole or PTU will decrease excessive production of thyroid hormone, but they take time to work and have no effect on thyroid hormone already in circulation. Diltiazem is a calcium channel blocker that may help control tachycardia, but it is not effective at blocking increased adrenergic tone. Radioactive iodine ablation may be an appropriate definitive treatment for certain forms of hyperthyroidism, but it does not have a role in the acute setting.
Which of the following statements regarding "hot nodules" and "cold nodules," found on radioactive iodine scan, is true? A. cold nodules are more likely than hot nodules to be benign B. cold nodules need not be investigated any further C. cold nodules are more likely than hot nodules to be associated with signs and symptoms of hyperthyroidism D. cold nodules always require further investigation to differentiate benign from malignant status E. all nodules, whether hot or cold, require further investigation to differentiate benign from malignant status
D. cold nodules always require further investigation to differentiate benign from malignant status
A 22-year old female comes to your clinic complaining of breast secretions. Her periods have been absent and she complains of decreased sex drive. On examination there is definite galactorrhea. her blood pressure is 138/78 and there are no abnormalities on PE. What is the most likely diagnosis? A. anorexia nervosa B. stress C. pregnancy D. prolactinoma
D. prolactinoma
What is the best initial test to diagnose hyperthyroidism? A. radioactive iodine uptake test B. thyroid ultrasound study C. free serum thyroxine (T4) D. serum thyroid-stimulating hormone (TSH) E. thyroid antibodies
D. serum thyroid-stimulating hormone (TSH)
what is central diabetes insipidus
Deficiency of ADH from posterior pituitary/hypothalamus
What is the treatment for central DI
Desmopressin/DDAVP (synthetic ADH)
what is the MOA of addison's disease
Destruction of the adrenal cortex resulting in loss of cortisol production (↓ cortisol)
how can you diagnose acromegaly or gigantism
Diagnose by measuring IGF-1 and GH levels
what are some causes of hypernatremia
Diarrhea, burns, diuretics, hyperglycemia, diabetes insipidus, a deficit of thirst
what is the thyroid presentation of hashimoto's thyroiditis
Diffusely enlarged, painless, nodular goiter
A 45-year-old female undergoes a transsphenoidal approach for a pituitary prolactinoma. Surgery proceeded without complications and the entire mass was removed. The patient's urine output is 4 L on postoperative day 1, and labs are significant for serum Na of 145 mEq/L (normal: 135-145). Urine osmolality is 185 mOsm/kg, and urine specific gravity is 1.004 (normal: 1.012 to 1.030). Which of the following choices is the next best step? A. Water restriction B. Loop diuretic C. CT scan of the brain D. 0.45% NaCl administered intravenously E. Desmopressin
E. Desmopressin The patient's history and lab results are consistent with post-surgical central diabetes insipidus. The most reasonable next step is the administration of desmopressin or chlorpropamide.
A 64-year-old woman presents to the office with decreased hearing, and pain over her sternum, pelvis, and her right tibial tubercle. On x-ray, the involved bones are noted to be expanded and denser than normal. Which of the following would be the appropriate initial treatment for this patient? A. Ibuprofen 600 mg po every 6 hours B. Indomethacin 25 mg po tid C. Meclizine 25 mg po tid D. Methotrexate 7.5 mg po qd E. Tiludronate 400 mg po qd
E. Tiludronate 400 mg po qd This patient's signs and symptoms are consistent with Paget disease of bone. Bisphosphonates have become the treatment of choice for this disease. Tiludronate, taken orally for 3 months, is very effective in treatment of this disease.
Of all the possible causes of the condition in this patient, which of the following is the most common? (above vignette) A. adenoma of the adrenal gland B. hyperplasia of the adrenal gland C. carcinoma of the lung D. corticosteroid therapy for suppression of inflammation E. adenoma of the pituitary gland
E. adenoma of the pituitary gland The most common cause of Cushing syndrome is corticosteroid therapy. If steroids are excluded, the three major causes are as follows: (1) pituitary Cushing's disease (60% to 70%) as a result of an adenoma; (2) adrenal Cushing's disease (15%) from an adenoma, hyperplasia, or malignant neoplasm; and (3) ectopic Cushing's disease (15%) from a malignant neoplasm (small cell carcinoma of the lung). Thus, the most likely cause of Cushing syndrome in the patient described, who has not been taking any medication for more than 1 year, is a pituitary adenoma.
Of the following, what would be the best serum test to order for a prolactinoma? A. estrogen B. progesterone C. LH D. FSH E. prolactin
E. prolactin
what population is most commonly affected by thyroid cancer
F 40-60 yo
how does low dose dexamethasone suppression test work
Give a steroid (dexamethasone) ⇒ failure of steroid to decrease cortisol levels is diagnostic ⇒ proceed next to high dose dexamethasone suppression test ⇒ no suppression = Cushing's syndrome Suppression < 5 ugs/dL excludes Cushing with some certainty
what are some causes of hyperthyroidism
Grave's disease (autoimmune). Toxic adenoma, thyroiditis, pregnancy, amiodarone
what are some causes of hypothyroidism
Hashimoto's (chronic lymphocytic/autoimmune), previous thyroidectomy/iodine ablation, congenital
what is the clinical presentation of hyperthyroidism
Heat intolerance, palpitations, sweating, weight loss, tremor, anxiety, tachycardia - Graves: Diffuse goiter with a bruit, exophthalmos, pretibial myxedema - Thyroid storm: Fever, tachycardia, delirium
how can you diagnose addison's disease
High dose cosyntropin (synthetic ACTH) stimulation test
Differentiating test for causes of Cushing's syndrome
High-dose dexamethasone suppression test (done in response to a positive low dose test)
what are the physical features of cushing disease
Hypercortisolism (↑ Cortisol) ⇒ obesity (buffalo hump, moon facies, supraclavicular pads), HTN, thirst, polyuria, hypokalemia Proximal muscle weakness, pigmented striae; backache, headache, oligomenorrhea/amenorrhea / ED; emotional lability/psychosis
what will labs show for hypoparathyroidism
Hypocalcemia ↓ CA+, low ↓ PTH, hyperphosphatemia, low urinary calcium
what is the treatment for hypocalcemia
IV calcium gluconate or calcium chloride
what is the treatment for hypercalcemia
IV normal saline and furosemide
what is the treatment for moderate hyponatremia
IV normal saline, loops may be added
what is the clinical presentation of subacute thyroiditis
Inflamed, painful thyroid, fever and muscle aches
what is nephrogenic diabetes insipidus
Lack of reaction to ADH
what is the treatment for hypothyroidism
Levothyroxine. Oral T4 (L -thyroxine) (Levoxyl, Synthroid) is the preferred treatment and is given in the lowest dose that restores serum TSH levels to the mid-normal range Treatment should be continued through pregnancy Follow up with serial TSH monitoring
what genes is pheo associated with
MEN2A/B, Neurofibromatosis type 1
what is the diagnostic study of choice for pituitary tumors
MRI
if its an ACTH dependent cause, what is the next step in management
MRI of brain to look for pituitary adenoma (cushing disease)
pituitary adenomas: Microadenomas are less than 1 cm in diameter, whereas adenomas that are 1 cm or more are commonly referred to as macroadenomas
Microadenoma < 10 mm Macroadenoma > 10 mm
what is the clinical presentation of hyponatremia
Muscle cramps and seizures
what will labs show for thyroid cancer
Nonfunctional nodules - normal or high TSH and normal thyroid hormone level Solid and echogenic, irregular margins, microcalcifications, > 1 cm
what are the sxs of addison's disease
Nonspecific symptoms: Hyperpigmentation, hypotension, fatigue, myalgias, GI complaints, weight loss
what are the s/s of hyponatremia
Peripheral and presacral edema, pulmonary edema, JVD, hypertension, decreased hematocrit, decreased serum protein, decreased BUN/CR
what is the clinical presentation of hypernatremia
Poor skin turgor, dry mucous membranes, flat neck veins, hypotension, increased BUN/CR ratio > 20:1 Decrease circulating volume = decrease of flow to kidneys means more bound urea in the blood which means ↑ BUN
what are the some labs you can look at for endocrine studies
Prolactin, GH, ACTH, TSH, FSH, LH
what will EKG show for hypocalcemia
Prolonged QT
what is the presentation of hypocalcemia
QT prolongation, Trousseau's sign, Chvostek's sign
how can you trx acromegaly
Remove pituitary tumors surgically or using radiation therapy Sometimes pharmacologic suppression of GH secretion or activity: If tumors cannot be removed, give octreotide or lanreotide to suppress GH secretion
patients with euvolemic hyponatremia likely have what other comorbidities
SIADH, steroids, hypothyroid
what are the s/s of pituitary corticotroph adenoma
Secrete ACTH ⇒ present with Cushings syndrome
what are the s/s of pituitary thyrotroph adenoma
Secrete TSH ⇒ presents with hyperthyroidism
what is the treatment for nephrogenic DI
Sodium and protein restriction - hydrochlorothiazide, indomethacin
what is the treatment for drug induced thyroiditis
Stop offending drugs *lithium *Amiodarone - will usually return to euthyroid state once the meds are stopped
what is the best test to diagnose hyperthyroidism
TSH
in drug induced thyroiditis, how often should TSH be checked, and T4 therapy given
TSH should be checked every 6-12 months - T4 therapy given right away
what will labs show for hypothyroidism
TSH- elevated in primary disease. Low T4 (↑ TSH and ↓ Free T4) Hashimoto's: Antithyroid peroxidase, antithyroglobulin antibodies
what is tertiary hyperparathyroidism
Tertiary hyperparathyroidism is a situation where individuals who have had secondary hyperparathyroidism for many years develop primary hyperparathyroidism. In tertiary hyperparathyroidism parts of the parathyroid gland start making parathyroid hormone independently of blood calcium levels - resulting in hypercalcemia.
what is the cause of paget's disease of the bone
The exact cause is unknown but can be triggered by infections (e.g. measles) and linked to genetic mutations
what is the treatment for infectious bacterial thyroiditis
The treatment is that for any febrile disease, including specific antibiotic drugs if the invading organism has been identified and its sensitivity to the drug established. Surgical drainage if abscess present
what are the s/s of paget's disease
This condition can be symptomless for a long period of time. When symptoms do occur, they may include bone deformities, broken bones, and pain in the affected area. Over time, affected bones may become fragile and misshapen. May lead to osteosarcoma - Paget's Sarcoma
what is the treatment for pheo
Treat with complete adrenalectomy Preoperative nonselective α-blockade: phenoxybenzamine or phentolamine x 7-14 days followed by beta blockers to control HTN. *DO NOT initiate therapy with beta blockade to prevent unopposed alpha constriction during catecholamine release triggered by surgery, could lead to life threatening HTN*
what is trousseau's sign
Trousseau's sign is considered positive when a carpopedal spasm of the hand and wrist occurs after an individual wears a blood pressure cuff inflated over their systolic blood pressure for 2 to 3 minutes
what is the gold standard test for cushing disease
Twenty-four-hour urine test: A test in which urine is collected for 24 hours to measure the amounts of cortisol. A higher than normal amount in the urine may be a sign of disease in the adrenal cortex
what is the treatment for hypoparathyroidism
Vitamin D and Calcium Long term: recombinant human parathyroid hormone to make up for bodies underproduction
how can you diagnose paget's disease
XR, labs, bone biopsy to exclude malignancies
what is the cause of acromegaly and gigantism
a pituitary adenoma that secretes excessive amounts of Growth Hormone; rarely, they are caused by non-pituitary tumors that secrete GHRH
a 25-year-old man concerned about some "bizarre symptoms" that he has been. He tells you that approximately 6 months ago, he began to experience the following symptoms: headaches, visual defects, weight gain, an appearance of his forehead growing, enlarging hands and feet (he could no longer get his gloves and shoes on), and increased sweating. On examination, mental status is normal, and the apical impulse is felt in the fifth intercostal space, midclavicular line. His blood pressure is 170/ 105 mm Hg. He does have a protruding brow, and three discrete visual field defects are noted (two in the left eye and one in the right eye). His tongue appears enlarged, and he is sweating profusely. what is the diagnosis?
acromegaly
what diagnosis is typically autoimmune but may be due to TB in endemic areas?
addison's disease
a 25-year-old male presents complaining of fatigue, weight loss, and recurrent nausea and vomiting. On physical exam, he appears weak and has skin that appears abnormally tan. Her blood pressure is 90/70. A basic metabolic panel reveals hyponatremia and hyperkalemia. what is the diagnosis?
addison's disease (primary adrenal insufficiency)
what are the s/s of lactotroph adenomas (pituitary)
amenorrhea, galactorrhea, and headaches
this type of thyroid cancer has No effective therapy that exists, and the disease is generally fatal. About 80% of patients die within 1 year of diagnosis
anaplastic
what antibodies are present with Graves disease
anti-thyrotropin antibodies
what is the most common cause of secondary hyperparathyroidism
chronic kidney disease
a 32-year-old woman who comes to the clinic because of new skin markings on her abdomen. Physical exam shows a round face, large purple striae over the abdomen, and several ecchymoses over her trunk, arms, and legs. She describes easy bruising, as well as a significant weakness when she tries to stand up from sitting on the ground. Her 24-hour urine free cortisol is 3 x the upper limit, her late-night serum cortisol is elevated and her plasma ACTH level is < 5 pg/mL. what is the diagnosis?
cushing's syndrome
what is the following diagnosis a collection of signs and symptoms due to prolonged exposure to excess cortisol
cushing's syndrome symptoms from ↑ cortisol secretion. It doesn't specify the cause or source of excess
what does a high ACTH level indicate -- dependent or independent cause?
dependent
what diagnostic test can help differentiate central vs nephrogenic DI
desmopressin (ADH) stimulation test
a 25-year-old male complaining of an unabated thirst that began three weeks ago. He is constantly drinking and goes to the bathroom around five times a night. He has lost five pounds over the last few weeks. The patient is on lithium for bipolar disorder. His BP is 115/70. The patient's labs are significant for serum Na of 145 mEq/L (normal: 135-145). Urine osmolality is 185 mOsm/kg, and urine specific gravity is 1.004 (normal: 1.012 to 1.030).
diabetes insipidus
caused by a deficiency of or resistance to vasopressin (ADH), which decreases the kidneys' ability to reabsorb water, resulting in massive polyuria
diabetes insipidus
what are the s/s of pituitary adenoma
diminished temporal vision, or bitemporal hemianopsia = MC visual
what are some causes of nephrogenic DI
drugs (Lithium, Amphoterrible), hypercalcemia and hypokalemia affect the kidney's ability to concentrate urine, acute tubular necrosis
what will labs show with paget's disease
elevated levels of alkaline phosphatase
what is the trx for adrenal crisis
emergent IV saline, glucose, steroids
what is the treatment for hashimoto's with and without thyroiditis
euthyroid: no trx chronic hypothyroidism: lifelong substitution with T4
Once you see a cold nodule on thyroid physical exam findings, you must rule out cancer. To do this you will need a
fine needle aspiration
this type of thyroid cancer is more common among older patients and in regions of iodine deficiency. It is more malignant than papillary carcinoma, spreading hematogenously with distant metastases
follicular
what is the treatment for asymptomatic hyponatremia
free water restriction
what are the s/s of pituitary growth hormone tumor
gigantism, acromegaly
what is the most common cause of hypothyroidism in the US
hashimoto's thyroiditis
what will labs show for hashimoto's
high levels of anti-TPO antibodies
what are the s/s of thyroid cancer
hoarse voice, solitary cold nodule on thyroid uptake scan Firm and hard on palpation Fixed during swallowing Swollen lymph node in the neck region and only on one side
what is the trx for addison's disease
hydrocortisone / prednisone PO daily 1. *Synthetic glucocorticoids: hydrocortisone or prednisone, hydrocortisone is 1st line* 2. Synthetic mineralocorticoid: fludrocortisone for primary Addison's disease only 3. Increased dietary salt intake 4. Adjustments in dosage are made according to the clinical response. A proper dose usually results in a normal WBC count differential
a 33-year-old woman presents to the emergency department due to diffuse pain and fatigue. The woman states that she feels like her bones and muscles diffusely hurt. She also has experienced some abdominal pain as well and states that she has trouble focusing.
hyperparathyroidism
a condition in which one or more of the parathyroid glands become overactive and secrete too much parathyroid hormone (PTH). This causes the levels of calcium in the blood to rise
hyperparathyroidism
a 34-year-old female complaining of irritability and nervousness, heat intolerance with increased sweating, and weight loss despite an increase in appetite.
hyperthyroidism / thyroiditis
the production of too much thyroxine hormone. It can increase metabolism and accelerate the body's metabolism, causing unintentional weight loss and a rapid or irregular heartbeat
hyperthyroidism / thyroiditis
what is the treatment for severe hyponatremia
hypertonic (3%) saline
a 33-year-old woman whose vision has been steadily declining over the past two years. She further complains that her lips and feet feel numb. Her medical history is notable for medullary thyroid cancer status post total thyroidectomy.
hypoparathyroidism
an uncommon condition in which your body secretes abnormally low levels of parathyroid hormone (PTH)
hypoparathyroidism This causes calcium levels in the blood to decrease
what is the clinical presentation of adrenal crisis
hypotension, AMS
a 28-year-old woman with increased fatigue and a 10-lb weight gain over the last 2 months. She states that she "feels cold" all the time, has decreased energy, and is experiencing worsening constipation. Patient has a tender thyroid, increased TSH, elevated antimicrosomal antibodies, and increased antithyroglobulin antibodies.
hypothyroidism
what are some causes of central diabetes insipidus
idiopathic, autoimmune destruction of posterior pituitary from head trauma, brain tumor, infection, or sarcoidosis
what will labs show in subacute thyroiditis
increased ESR 60-100
what is the most common metabolic abnormality associated with hyperparathyroidism
increased calcium
what are the risk factors for paget's disease
increasing age and a family history of the condition
what does a low ACTH level indicate -- dependent or independent cause?
independent
what is the treatment for hypernatremia
intravenous (IV) 5% dextrose in water (D5W) Rapid overcorrection causes cerebral edema and pontine herniation
what are the characteristics of acromegaly
large hands, feet, nose, lips, ears, jaw, tongue Presents as gigantism (excessive height) if occurs before epiphyseal closure
what are the signs of hypoparathyroidism
low calcium Chvostek's sign - tap facial nerve illicit cheek twitch Trousseau's sign - BP cuff inflation illicit carpal spasm
what will XR show with paget's disease
lytic lesions and thickened bone cortices
hypercalcemia is associated with what other comorbidities
malignancy and hyperparathyroidism
this type of thyroid cancer may be sporadic (usually unilateral); often familial
medullary
what are the most common pituitary adenomas
microadenomas: that are functional (hypersecretion of pituitary hormones), nonfunctional or compressive
what are some ultrasound findings for thyroid cancer that put a nodule at high risk of malignancy
microcalcifications, hypoechogenicity, a solid nodule, irregular nodule margins, chaotic intranodular vasculature, and a nodule that is more tall than wide.
what is the treatment for pituitary adenomas
often surgical 1. Transsphenoidal surgery: management of choice for removal of ACTIVE or compressive tumors 2. Medical management is the first line for prolactinomas - Dopamine inhibits prolactin release - Cabergoline or Bromocrpitine (dopamine acgonists) 3. Acromegaly: TSS + Bromocriptine (dopamine decreases GH production)
what are the classic signs of infective thyroiditis
ones of inflammation: fever, heat, pain, redness, and swelling ↑ WBC
a bone remodeling disorder that results in the formation of an unorganized mosaic of woven and lamellar bone that is less compact and weaker than the normal bone
paget disease of the bone
what is the most common type of thyroid cancer
papillary carcinoma (PAPILLARY IS POPULAR)
what locations of the body does paget's disease most commonly affect
pelvis, skull, spine, and legs
Catecholamine secreting adrenal tumor - secretes norepinephrine and epinephrine autonomously and intermittently
pheochromocytoma
Noncancerous tumors in the pituitary gland that don't spread beyond the skull
pituitary adenoma
what is the cause of subacute thyroiditis
post-infectious and viral in origin Usually following symptoms such as fever, myalgia, and pharyngitis
what are the 5 P's with pheos?
pressure, pain (HA), perspiration, palpitations, pallor
lactotroph adenomas are pituitary masses that cause hypersecretion of
prolactin
what is the most common lactotroph adenoma (pituitary)
prolactinomas
what is the most common risk factor for thyroid cancer
radiation exposure
what is the treatment for secondary hyperparathryoidism
replace cause (vitamin D/Ca supplementation)
Low ACTH and low cortisol suggest ___
secondary or tertiary adrenal insufficiency
what is the treatment for hypoparathyroidism with tetany
secure airway, IV calcium gluconate
what is hyponatremia
serum sodium of < 135 mmol/L
what is considered hypernatremia
serum sodium of > 145 mmol/L
what is considered hypocalcemia
serum total calcium < 8.4 mg/dL ionized fraction of calcium < 4.4 mg/dL
what is considered hypercalcemia
serum total calcium > 10.5 mg/dL ionized fraction of calcium > 5.6 mg/dL
Elevated ACTH with low cortisol is diagnostic of primary adrenal insufficiency, particularly in patients who are ___
severely stressed or in shock
what will ECG show for hypercalcemia
shortened QT interval
patients with hypovolemic hyponatremia likely have what other comorbidities
sodium loss (renal, non-renal)
Infectious bacterial thyroiditis (rare) is often due to the hematogenous spread of ___ or ___
staph or strep
what is the most common cause of thyroid pain and has a greater incidence in women
subacute thyroiditis (quervain's thyroiditis)
what is the treatment for primary hyperparathyroidism
surgical correction to remove the overactive parathyroid gland ⇒ If all 4, remove 3.5 glands
how can you determine if a thyroid mass is benign or malignant
thyroid uptake scan A cancerous lesion does not make hormone and will not take up iodine from a radioactive thyroid scan. (COLD NODULE) A non-cancerous lesion does make hormone and will take up iodine at either a normal rate or a quicker rate. (HOT NODULE) COLD = CANCER
what are some causes of hypoparathyroidism
thyroidectomy; autoimmune destruction of thyroid gland
general term that refers to "inflammation of the thyroid gland".
thyroiditis
what is the clinical presentation of hypoparathyroidism
tingling, tetany, cataracts
what is the treatment for cushing's disease
transsphenoidal selective resection of pituitary tumor cures 75-90% 95% 5-year survival ketoconazole given to inoperable pts Iatrogenic steroid therapy - begin gradual steroid withdrawal to prevent Addisonian crisis
how can you diagnose thyroid cancer
ultrasound lesions > 1 cm should be biopsied
what is the treatment for subacute and postpartum thyroiditis
usually resolve on their own after 12-18 months, often only need pain management 1. Beta-blockers during hyperthyroid state 2. T4 for several months during hypothyroid phase until TSH normalizes then can be stopped 3. Occasionally permanent hypothyroidism 4. Aspirin for pain and inflammation
what is the clinical presentation of hyperparathyroidism
weakness, fatigue, constipation ⇒ Stones, bones, abdominal groans, psych moans, and fatigue overtones bone loss from increased PTH and Ca absorption from bones = pain in bones renal loss of Ca and phosphorus = kidney stone increase GI absorption of Ca and abdominal cramps = groans irritability, psychosis, depression = moans
what is the cause of secondary hyperparathyroidism
↑ PTH by a physiologic response to hypocalcemia or vitamin D deficiency
what is the cause of primary hyperparathyroidism
↑ PTH usually caused by a PTH secreting parathyroid ADENOMA
what will labs show with hypercalcemia
↑ PTH, ↑ Calcium, ↓ phosphorus
what will labs show for hypocalcemia
↓ Ca+ ↓ PTH ↑ phosphate
what is the diagnostic triad for hypoparathryoidism
↓ Ca+, ↓ PTH, and ↑ phosphate Why the low serum calcium? Calcium is low because the gland cannot secrete PTH (hence a low PTH) and PTH is responsible for the reabsorption of calcium from the bones, kidneys, and GI tract. Because you can't reabsorb calcium, your calcium will be low. Why the elevated phosphate? PTH normally inhibits the reabsorption of phosphate by the kidney. Therefore, without enough PTH there is more reabsorption of the phosphate leading to a high phosphate level in the blood.
what are some lab findings associated with addison's disease
↓ sodium, ↓ 8 AM cortisol, ↑ ACTH (primary), ↑ potassium (primary), low DHEA
what is the presentation of hypercalcemia
"Stones, Bones, abdominal groans, psychiatric moans", EKG: shortened QT interval.
how can you diagnose pheo?
- 24-hour catecholamines including metabolites (metanephrine and vanillylmandelic acid) - MRI or CT of the abdomen to visualize the tumor
what is the treatment for paget's disease
- Bisphosphonates (which reduce bone resorption and may improve pain and quality of life), and occasionally, calcitonin - Surgery can help correct bone deformities, decompress an impinged nerve, and reduce fractures
what are the risk factors for thyroid cancer
- Prior radiation (head or neck) - Family history of thyroid cancer - Being > 65 y/o or < 20 y/o
A 24-year-old man comes to your office with the following symptoms: an extreme feeling of weakness, a 20-pound weight loss, a change in the color of his skin (his skin has become hyperpigmented), and lightheadedness and dizziness. On examination, the patient has definite skin hyperpigmentation since you last saw him 9 months ago. His blood pressure is 90/ 70 mm Hg. He looks acutely ill. On laboratory examination, his serum sodium is low (115 mEq/ L), his serum potassium is high (6.2 mEq/ L), his serum urea is elevated at 9 mg/ dL, and his serum calcium is elevated (12 mg/ dL). A. Addison disease B. Cushing syndrome C. primary hyperparathyroidism D. primary renal failure
A. Addison disease This patient has Addison's disease or primary adrenocortical insufficiency. The prominent clinical features of Addison disease include weakness (100%), weight loss (100%), hyperpigmentation (95%), and hypotension. The pertinent laboratory findings include hyponatremia, hyperkalemia, increased blood urea nitrogen, hypercalcemia, increased plasma ACTH, and decreased serum cortisol level.
Which of the following is not a common physical sign of hypothyroidism? A. Ascites B. Bradycardia C. Slowed speech and movements D. Jaundice
A. Ascites
A 42-year-old woman comes to your office with the following signs and symptoms: obesity (she has gained 40 pounds in the past 6 months), elevated blood pressure at her last walk-in clinic visit, increased body hair, purple streaks on her abdomen, "a fat face" (her description), and pains in her bones and joints. She is taking no medication at present, nor has she been taking any medication for the past year. On examination, her body mass index is 35 kg/m2. Her blood pressure is 160/110 mm Hg; she has obvious hirsutism over her entire body, and her abdomen (which is obese) has purple striae. Her face not only is plethoric but also demonstrates a double chin. Her thoracic spine shows evidence of what is known as a buffalo hump. What is the most likely diagnosis? A. Cushing's syndrome B. Addison's syndrome C. prolactinoma D. hyperparathyroidism
A. Cushing's syndrome
Which of the following is the initial treatment indicated in most cases of mild to moderate hypothyroidism? A. Levothyroxine at a dose of 50-75 µg/day B. Levothyroxine at a dose of 4 µg per kilogram of lean body weight as an intravenous bolus, with 100 µg administered 24 hours later C. Desiccated thyroid at a dose of 15-30 mg orally per day D. Liothyronine at a dose of 25 µg orally per day
A. Levothyroxine at a dose of 50-75 µg/day
Which of the following symptoms is more common in individuals with acromegaly? A. Visual field defect B. Hyperprolactinemia C. Sex steroid deficiency D. Prognathism
A. Visual field defect Acromegaly can be an insidious disease. Symptoms, which may precede diagnosis by several years, can be divided into the following groups: Symptoms due to local mass effects of an intracranial tumor Symptoms due to excess of GH/IGF-I Symptoms due to excess of GH/IGF-I include: - Soft tissue swelling and enlargement of extremities - Increase in ring and/or shoe size - Hyperhidrosis - Coarsening of facial features - Prognathism - Macroglossia - Arthritis - Increased incidence of obstructive sleep apnea - Increased incidence of glucose intolerance or frank diabetes mellitus, hypertension, and cardiovascular disease - Hyperphosphatemia, hypercalcuria, and hypertriglyceridemia possible - Increased incidence of congestive heart failure, which may be due to uncontrolled hypertension or to an intrinsic form of cardiomyopathy attributable to excess GH/IGF-I - Increased incidence of colonic polyps
A 24-year-old man comes to your office with the following symptoms: an extreme feeling of weakness, a 20-pound weight loss, a change in the color of his skin (his skin has become hyperpigmented), and lightheadedness and dizziness. On examination, the patient has definite skin hyperpigmentation since you last saw him 9 months ago. His blood pressure is 90/ 70 mm Hg. He looks acutely ill. On laboratory examination, his serum sodium is low (115 mEq/ L), his serum potassium is high (6.2 mEq/ L), his serum urea is elevated at 9 mg/ dL, and his serum calcium is elevated (12 mg/ dL). What is the most likely cause of this patient's symptoms of addison's disease? A. autoimmune destruction of the adrenal gland B. overstimulation of the adrenal gland C. an adrenal adenoma D. a pituitary adenoma
A. autoimmune destruction of the adrenal gland Most commonly, Addison disease results from an autoimmune destruction of the adrenal gland. At least 50% of patients with Addison disease have anti-adrenal antibodies. Other potential causes of adrenocortical insufficiency include tuberculosis, disseminated meningococcemia, and metastatic cancer.
Which of the following medications provides effective long-term control of hyperthyroidism? A. methimazole B. propranolol C. levothyroxine D. prednisone
A. methimazole
Your diagnosis of hyperthyroidism is confirmed with TSH levels. Which test is the next most appropriate to determine the underlying etiology? A. radioactive iodine uptake B. fine-needle aspiration (FNA) of thyroid C. free T4 D. ultrasound study E. TSH receptor antibodies
A. radioactive iodine uptake
Which of the following laboratory results is most consistent with a diagnosis of primary hyperparathyroidism? A. serum calcium 11.5 mg/dL (normal 8.5 to 10.5 mg/dL) B. ionized calcium 3.2 mg/dL (normal 4.6 to 5.3 mg/dL) C. serum magnesium 1.1 mEq/L (normal 1.3 to 2.1 mEq/L) D. serum phosphate 3.0 mg/dL (normal 2.5 to 4.5 mg/dL)
A. serum calcium 11.5 mg/dL (normal 8.5 to 10.5 mg/dL) Hypercalcemia (greater than 10.5 mg/dL) is the hallmark of primary hyperparathyroidism.
what is cushing disease
ACTH secreting pituitary microadenoma usually very small on anterior pituitary; F 3x > M secondary - ↑ cortisol due to ACTH excess, typically caused by a pituitary adenoma - ACTH causes adrenals to secrete cortisol
if its an ACTH independent cause, what is the next step in management
CT of adrenal glands to look for adrenal mass such as an adenoma
