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41 Cards in this Set
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- Back
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pt with thyroid cancer in remission. What is your TSH goal? how? increased risk for
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suppress TSH bellow normal range <0.35.
- incrased levo - increased risk for a fib and bone loss |
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tx for hyperglycemia after acute phase resolves
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long acting and short acting insulin
- avoid oral hypoglycemics in the hospital |
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young to midadult with episodic hypertensive crisis, paroxysmal symptoms unresponsive to conventional treatment. think? how dx? tx? imaging? pt becomes hypotensive in OR - how tx?
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pheo
- measure plasma metanephrines or 24 hour urine for metanephrines, vanillylmandelic acid, and catecholamines - Note that drugs like alpha blockers can interfere with the test. - alpha blockaid (phenoxybenzamine) for 10-14 days prior to operation. Only give beta blockers to patients that are adequately blocked. - IV bolus of normal saline. pressors are not as useful because they are alpha blocked. phentolamine is used for acute hypertension intraoperatively |
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ocp AFFECT on thyroid
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increased serum thyroid binding globulin.
may need to increase levo |
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dysphagia, face turns red and neck veins become engourged with arms raised over head. source
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thyroid - Pemberton's test.
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elevated TSH, low T4, and positive antithyroid peroxidase antibodies. Dx? Later develops rapidily enlarging thyroid and dysphagia Dx? Path
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hashimotos thyroiditis
- thyroid lymphoma - hashimotos causes chronic lymphocytic infiltrate increasing lymphoma risk |
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non enlarged thyroid with elevated T4 and low TSH. suspect? test? What should be the iodine uptake? Thyroglobulin level
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- excessive exogenous thyroid medication
- Low 24 hour radioactive iodine uptake (RAIU) as exogenous thyroid is decreasing thyroid production - low. if high, it would mean stroma ovarii of thyroiditis |
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dm patient with puritic raised rash, that develops central clearing with crusting on the edges, unresponsive to steroids, with angular cheilosis. think? Dx how? How tx
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glucagonoma
- measure glucagon which will be high - surgery |
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thyroid nodules palpated: algorhythm
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TSH->
if normal: fine needle aspiration if nodule >1cm If decreased (suggests thyrotoxicosis 2/2 excessive production of thyroid from nodule(s)): radioisotope scan -> if hot nodule (increased iodine uptake in a nodule and decreased elsewhere)-> then observation as the chances of malignancy are low IF elevated -> think hashimotos thyroditis with enlargement due to accumulatin of lymphocytes. Tx with levo |
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what is better at evaluating thyroid nodules, CT or US
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US
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pt dx with papillary thyroid cancer. next step? How do you know if you got i all? staging?
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1. near total thyroidectomy (NTT)
2. high dose radioactive iodine 3. total body radioiodine scan is used to look for residual tissue/metastisis 4. suppressive doses of levothyroxine are given to suppress TSH below normal (creating subclinical thyrotoxicosis). TSH is a growth factor for papillary and follicular thyroid cancer - Then look for serum thyroglobulin level. It should be undetectable. If not, residual disease - Staging unnecessary as slow growing and will find with RAIU scan. |
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three most common causes of hypercalcemia?
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1. primary hyperparathyroidism - calcium levels about >12 are rare. if so, think malignancy
2. malignancy - very high calcium levels 3. vitamin d induced hypercalcemia |
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medulary thyroid cancer with elevated calcitonin, and RET protooncogene. Think? Next step
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- MEN 2 syndrome
- test for pheocytochromatoma with plasma metanepherines |
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healthcare worker with hypoglycemia after recent social stressor with elevated C peptide and elevated insulin. differential? Next test?
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- exogenous insulin use vs. sulfonylureas use vs. insulinoma
- c peptide and proinsulin are low with exogenous insulin use but high with oral hypoglycemics e.g. sulfonylureas and meglitinides - screen for sulfonylurea (e.g. glyburide, glypizide) - |
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mother with type 1 DM. Risk of offspring developing type 1 dm? If the father only has type 1 DM/
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3% which is higher than the general population
- 6% |
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tight glucose control affect on: macrovascular complications? microvascular complications?
- increases risk for |
- unclear (e.g. MI)
- decreases (e.g. retinopathy, nephropathy, neuropathy) - hypoglycemia |
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***3 months of fatigue, cold intolerance, amenorrhea, constipation, dry skin, headaches, and muscle cramps with Physical exam showing: symmetric thyromegaly , delayed relaxation of knee and ankle jerks, and positive tinnels sign, and periorbital puffiness. TSH >> elevated, free T4 low. Think?
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primary hypoparathyroidism 2/2 Hashimoto's thyroiditis
- antimicrosomal antibody level (anti TPO) - HLD |
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thyrotoxicosis path? tx
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release of preformed thyroid
- NSAID and beta blocker. |
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indications for parathyroidectomy in secondary hypoparathyroidism
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1. calcium >10.5 not responding to conservative management
2. moderate to sever hyperphosphatemia not responding to medical management 3. PTH>1000 4. intractable bone pain 5. intracable puritis 6 episoide of calciphylaxis 7 soft tissue calcification |
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sarcoid mechanism of hypercalcemia
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increased prodcution of 1 alpha hydroxylase, which converts 25-hydroxyvitamin D to 1,25 hydroxyvitamin D, leading to increased absorption of gastrointestinal calcium. Hypercalcemia suppresses PTH and increases urinary calcium excretion
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suspect gastroparesis. next step?
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rule out obstruction with EGD
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treatment of hyperthyroidism in pregancy
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propylthirouricil during 1st trimester. stop later due to liver failure concern
methimazole during 2nd and 3rd. don't use early b/c of birth defects. |
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patient does not respond to osteoporosis therapy or has rapid bone loss. Think?
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multiple myeloma
- serum and protein electroporesis |
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first lline treatment for prolactinoma
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dopamine receptor agonist -> decrease tumor size.
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pt on sulfonylurea (glyburide) and as persistant hypoglycemia refractory to glucose challenge. Tx?
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- Octreotide - decreases insulin secretion
- NOTE: glyburide increases insulin secretion. |
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young pt with htn, hyperglycemia, mood swings, hypokalemia, osteoporosis, and metabolic alkalosis. think? test?
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Cushing's Syndrome
- overnight dexamethasone supression or 24 hour urinary free cortisol. Normal would be suppresed below 3 in the serum |
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When do you need to worry about steroid withdrawl? dose? What happens?
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>7.5mg/day
> 3 weeks - if less then ok to stop cold. - suppresses hypothalamic pituitary axis -> tertiary adrenal insuficiency. |
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when is Metformin contraindicated
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CHF, alcoholism, renal failure
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how does type II DM differ from pancreatic DM?
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pancreatic DM damages alpha islet cells that produce glucagon and are therefore more likely to be hypoglycemic
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what dm drugs are contraindicated with renal failure
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metformin, glyburide
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tx of thyroid storm? what should not be given?
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steroids because they inhibit T4-> T3 conversion
- don't give iodine b/c it can be used as substrate to make more thyroid hormone |
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cheap test for dx dm neuropathy
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tuning fork
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small solitary non tender neck mass <2months, with elevated T3 and T4 and decreased radioactive iodine. dx? tx? Associated with? confused with
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subacute lymphocytic thyroiditis (painless thyroiditis). release of preformed thyroid from inflamed gland. Course is transient and no curative tx needed.
- bb - interferon alfa (hep c), interlukin 2, amiodarone |
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how should levo be taken
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empty stomach and not with other meds, especially calcium and iron which impair absorption
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t score for osteoporosis
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>2.5
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tx of low serum calcium, and high urine calcium
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thiazide
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- PTH at upper limit of normal and hypercalcemia and urinary calcium>200. think?
if urinary calcium<100. Think? tx? |
pathalogic. primary hyperparathyroidismPTH should be low due to feedback
- familial hypocalciuric hypercalcemia. reassurance |
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dka. how long does the insulin drip continue?
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until the gap closes.
- if glucose<200 w/ gap-> half iv insulin and switch to D5 1/2 NS to prevent hypoglycemia |
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what defines the resolution of DKA? how do you transition from insulin drip to subcut?
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eat, glucose<200, bicarb>18, and gap<12.
- keep drip running for two hours after subcutaneous is given. |
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pt with addison's disease on steroids developes diabetes. Why?
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Schmidt's syndrome: addison's, type 1 dm, and thyroid disease
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indications for parathyroidectomy in primary hyperparathyroidism
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1. symptomatic pt
2. asymptomatic w/ -Serum Cal> 1.0 above upper normal - GFR<60 - T score<2.5 or fragility fracture - age<50 |
