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39 Cards in this Set

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microadenoma vs. macroadenoma
(microadenoma and macroadenoma refer to tumors in pituitary)

-use size of 1 cm to distinguish b/w micro and macroadenomas
*PRL>200==>macroadenoma

women: microadenoma
men: macroadenoma
complications of pituitary tumor
bitemporal hemianopsia
(tumor compresses medial optic fibers==>lose peripheral/temporal vision)
Et of prolactinoma

-which causes highest PRL levels and which causes least?
"4 P's":
Prolactinoma
Pregnancy
Primary hypothyroidism
Prescription drugs

Serum PRL levels:
lactotroph (PRL-secreting) macroadenoma>pregnancy>the others
Sx of prolactinomas
Women:
(microadenoma)
amenorrhea
galactorrhea

Men:
(macroadenomas)
visual disturbances, H/A
hypogonadal
what is PRL level in macroadenoma
PRL>200
PRL>200 indicates what?
macroadenoma
Tx Hyperprolactinemia
MEDICAL!

bromocriptine or cabergoline
(DA analogs)
how confirm hyperprolactinemia
MRI
how localize acromegaly?
MRI
how Dx acromegaly?
GH, IGF-1, +/- OGTT
Tx acromegaly?
1. Trans-sphenoidal surgery=BEST initial Tx

2. Medicine
*GH receptor antagonist: pegvisomant
*somatostatin analogs:
-ocTREOTIDE
-lanTREOTIDE

3. Radiation
Sx of DI
-polyuria, polydipsia
-serum: high [Na]
-serum: high osmolality
-urine: low osmolality < 200
-Tx: DDAVP (VP=VasoPressin=ADH)
urine osmolality <200 indicates?
DI
hypothyroidism:
-Sx
-Lab values
-Dx
-Tx
Sx:
weight gain
constipation
depression
cold intolerance
menstrual irreg
dry skin, hair falls out

Lab values:
Primary hypothy: lo T4, hi TSH
Scondary hypothy:lo T4, lo TSH

Dx:
TFT's + exam
(don't need imaging)

Tx: levothyroxine
hyperthyroidism
-et
-Sx
-DDx
-Tx
Et:
*Graves
-Toxic MNG (Multinodular GoiteR)
-Solitary toxic nodule
-Subacute Thyroiditis
-Iodine-induced
-Iatrogenic/factitious

Sx:
*Lid retraction/lag
*Proptosis
*Thyroid bruit
tachycardia (60%)
weight loss
diarrhea
heat intolerance
diaphoresis
menstrual abnl
palpitations

DDx:
A. High RAIU (RadioActive Iodine Uptake):
1. Graves
2. Toxic MNG
3. Solitary toxic nodule

Low RAIU:
1. Subacute thyroiditis
2. iodine-induced
3. Iatrogenic/factitious

Tx for High RAIU:
-thyroidectomy
-anti-thyroid drugs
-Radioiodine

Tx for low RAIU:
*Tx Sx!
==>B blockers
==>NSAID's for SAT (SubAcute Thyroditis)
"Euthyroid Sick Syndrome"
*low T4
*low T3
*low (but deteactable) TSH

No Tx, just let person recover from non-thyroid illness
*low T4
*low T3
*low (but deteactable) TSH

suggest?
Euthyroid Sick Syndrome

No Tx, just let person recover from non-thyroid illness
thyroid nodules
-benign/malig?
-Dx?
>95% euthyroid
(<10% malignant)

Dx: FNA thyroid biopsy

Incidentalomas:
U/S guided bx. if > 10 mm
Hypercalcemia:
-pathophys
-et
-Dx
Pathophys:
-incr bone resorp of Ca++
-incr gut abs of Ca++
-incr renal abs of Ca++

Et:
Common-
*Hyper-PTH
*Malignancy

Rare-
vit A/D toxicosis
hypothy
FHH

Dx: PTH level!

High PTH==>
*Primary Hyper-PTH
-rarely: FHH (Familial Hypocalciuric Hypercalcemia
==>check 24-hr urine Ca++

Low PTH
*Malignancy
*everything else
hypocalcemia
-et?
Vit D def
Vit D Def
-Sx
low Vit D
low Ca++
low phosphorus
low urine Ca++ (why?)
high PTH
Osteoporosis
-et?
-Dx?
-Tx
Primary osteoporosis:
Women:
*Post-menopausal
*Senile

Men:
*Senile

Secondary Osteoporosis
-Women (30%)
-Men (60%)
*Glucorticoid excess
*Testicular
*EtOH failure

Et of Secondary Osteoporosis:
a. Hyper-PTH
b. low Vit D
c. Hypercalciuria
d. Female & MALE hypogonadism
e. Glucocorticoid xs
f. Hyperthy
g. Mult myeloma

Dx: BMD
R/O secondary causes

Tx for Primary Osteoporosis:
-Vit D & Ca++ supp
-Anti-bone resorption:
*Bisphosphanates
-MOA: directly decr osteoclast activity & incr osteoclast apoptosis
-decr hip fractures

*Raloxifene (SERM)
-decr vertebral fractures

*Calcitonin
-MOA: directly decreases osteoclastic resorption
-decr vertebral fractures
-Bone formation:
*Teriparitide (PTH)
(PTH directly causes bone resorption & formation..
If given intermittently,
formation>resorption.
If given continuously,
resorption>formation)

-exercise (Goljan: women should exercise w/weights to prevent osteoporosis)
-fall precautions
Pathogen of DM1 vs 2
DM1:
total insulin def

DM2:
partial insulin def
insulin resistance
incr hepatic gluc production
anabolic vs. catabolic
Anabolic:
*insulin

Catabolic ("Counter-regulatory"):
==>gluconeogen):
*Glucagon
*GH
*cort
*catecholamines
DKA
Decr anabolics:
decr insulin

Incr catabolics:
-incr glucagon
-incr GH
-inc cort
-inc catecholamines
DKA Tx
-replace fluids
-replace K
-IV insulin (til anion gap resolves)
-Tx precipitating cause (infxn)
what usu causes DKA?
infxn
Dx DM?
-fasting BG>=126 x2

OR

-random BG>=200 + classic Sx of hyperglycemia
DM complications
Microvascular:
-retinopathy
-nephropathy
-neuropathy

Macrovascular:
-MI
-Stroke
-PVD
Tx DM
DM 1:
-diet
-insulin:
*24 hr insulin coverage:
NPH x 2 OR glargine x 1


DM 2:
-diet/exercise
-(insulin):
*24 hr coverage not always needed
*add nighttime NPH to oral agents
-oral Rx:
a. partial insulin def==>sulfonylureas
b. insulin res==>glitazones
c. incr hep gluc prod==>metformin
d. exenatide (injxn)
-SC injxn BID (5-10 mcg/day)
-glucagon-like peptide 1 analog
==>decr hep gluc prod
-incr B cell mass
==>incr glucose-dep insulin secretion
-FDA approved for use w/metformin +/- sulfonylureas
-delays gastric emptying/promotes weight loss
-low risk of hypoglycemia
lipid profile in DM2
-tx?
-high TG
-high LDL
-low LDL

Tx high TG:
*gemfibrozil, fenofibrate
-niacin

Tx: high chol
*statins
-ezetimibe
-bile acid resins

*risk of myositis when used in combination
Metabolic Syndrome
AKA "Insulin Resistance Syndrome"

*obesity
*insulin resistance, high insulin levels
*hyper-TG, diabetes

*HTN
*lipid abnl
*Coronary Artery Dz
Hypoglycemia D/O
*do 24 hr-fast:

1. Insulinoma
*low gluc
*high insulin
*high C peptide

2. Sulfonylurea
*low glucose
*high insulin
*high C peptide
*positive sulfonylurea screen

3. Surreptitious insulin injxn
*low glucose
*high insulin
*low C peptide
MCC secondary Adrenal insufficiency?
MCC=exogenous steroid Tx
(2nd MC is pit dz)
"incidentalomas"
-def?
-where found?
-do endocrine imaging?
=endocrine gland tumors found incenidentally on imaging studies:
-ultrsound
-CT
-MRI
-PET scan

*small
*non-fxn'al
*rarely malignant

Prevalance:
1. MC=thyroid (up to 50% on Ultrasound)
2. Pituitary (15%)
3. Adrenal

Do endocrine imaging?
*don't do endocrine imaging for Dx
*only do endocrine imaging for localization after a biochemical Dx is secure
Best Tx for pit tumors?
Best initial Tx for all pit tumors except prolactinomas=
Transphenoidal Surgery

Tx prolactinoma with DA analogs:
-bromocriptine
-cabergoline
Adrenal Insufficiency
Primay:
-high ACTH==>hyperpigmented
-ALDO deficiency
-d/t destruction of adrenal cortex (Addison's Dz)=autoimmune

Secondary:
-low ACTH==>not hyperpigmented
-normal ALDO
-d/t prob w/pit:
*MCC=corticosteroid Tx
2nd MC=pit dz
Tx AI
(HC=HydroCortisone=glucocorticoide replacement)

Primary AI & Secondary AI:
**Must replace glucocorticoids:

Stress (Acute): HC 100 mg q8
Maint(Chronic): HC 20/10

--For Primary AI, must also replace mineralocorticoid (b/c they are ALDO deficient, vs Secondary AI):

fludrocortisone (mineralocorticoid replacement)
Primary Aldosteronism:
-et?
-how distuinguish b/w causes?
Et:
1. *MCC=hyperplasia of both adrenal gladns (70%)
2. Conn's syndrome-ALDO-secreting tumor (usu just one side)--(30%)

*Distinguish b/w the 2 causes by:
-gold std=adrenal venous sampling for ALDO and Renin
-abdomen CT: see whether both gland are enlarged (adrenal hyperplasia) or just one is enlarged (ALDO-secreting tumor on one adrenal=Conn's syndrome)