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35 Cards in this Set
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Cushing syndrome |
XS cortisol |
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Cushing causes |
Exogenous corticoS - decreased ACTH -> bilateral adrenal atrophy Adrenal - primary A adenoma, hyperplasia, Ca - decreased ACTH -> atrophy of uninvolved A gland - can PC as primary aldosteronism = Conn syndrome ACTH secretion - paraneoplastic (small cell lung ca, bronchial carcinoids), ACTH secreting pituitary adenoma = Cushing disease - increased ACTH -> bilateral adrenal hyperplasia |
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Cushings findings |
HT Weight gain Moon facies Truncal obesity Buffalo hump Hyperglycaemia - insulin resistance Skin changes - thinning, striae Osteoporosis Amenorrhea Immune suppression |
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Cushings dx |
Increased free cortisol on 24hr urine analysis Midnight salivary cortisol Overnight low-dose dexamethasone suppression test Low ACTH: Suspect adrenal tumor = ACTH independent Cushing syndrome - MRI to confirm High ACTH: Distinguish between Cushing disease and ectopic ACTH secretion = high-dose dexoM suppression test and CRH stimulation test - Ectopic secretion: No suppression after dexoM, no increase with CRH - Cushing disease: Suppression, increase in ACTH and cortisol |
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Primary hyperaldosteronism |
Adrenal hyperplasia Conn syndrome = aldosterone secreting adrenal adenoma => HT, hypoK, metabolic alkalosis, low plasma renin Normal Na and no edema due to aldosterone escape mechanism Uni or bilateral TX: Surgery to remove tumour +/- spironolactone = K sparing diuretic, aldosterone antagonist |
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Secondary hyperaldosteronism |
Renal perception of low intraV volume -> overactive renin-angiotensin system Renal A stenosis, CHF, cirrhosis, nephrotic syndrome High plasma renin TX: Spironolactone |
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Addison disease |
Chronic primary adrenal insufficiency Due to renal atrophy or destruction by disease - autoimmune, TB, metastasis Aldosterone and cortisol deficiency -> hyponatremic volume contraction -> hypotension HyperK, acidosis, skin and mucosal hyperpigmentation (MSH - by product of XS ACTH production from POMC) Adrenal atrophy Absence of hormone production All 3 cortical divisions - spares medulla Secondary adrenal insufficiency - decreased pituitary ACTH production - no skin/mucosal hyperpigmentation, no hyperK |
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Waterhouse-Friderichsen syndrome |
Acute primary adrenal insufficiency Due to adrenal haemorrhage A/W Neisseria meningitidis septicaemia, DIC, endotoxic shock |
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Neuroblastoma |
Tumour of adrenal medulla Children - under 4yo From neural crest cells Occurs somewhere along sympathetic chain PC - ab distention, firm irregular mass that can cross the midline Homovanillic acid HVA - bd product of dopamine - increased in urine Bombesin + Less likely to develop HT A/W overexpression of N-myc oncogene |
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Pheochromocytoma |
Tumour of adrenal medulla Adults Derived from chromaffin cells - neural crest 10s - 10% malignant, 10% bilateral, 10% extra-adrenal, 10% calcify, 10% kids |
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PheoC symptoms |
Most secrete epiN, NE, dopamine -> episodic HT A/W von Hippel-Lindau dx, MEN 2A/B Symptoms in spells - release and remit |
5 Ps Pressure - HT Pain - headache Perspiration Palpitations - tachyC Pallor |
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PheoC findings |
Urinary VMA = bd product of NE and epiN Plasma catecholamines increased |
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PheoC treatment |
Irreversible alpha-antagonists - phenoxybenzamine Beta-blockers Followed by tumour resection Alpha-blockade must be achieved before giving beta to avoid hypertensive crisis |
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Hypothyroidism |
Cold intolerance Weight gain Decreased appetite Hypoactivity Lethargy Fatigue Weakness Constipation Hyporeflexia Myxedema - facial, periorbital Dry cool skin Coarse brittle hair BradyC Dyspnea on exertion Increased TSH Decreased free T3/T4 Hypercholesterolemia - low LDL expression |
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Hyperthyroidism |
Heat intolerance Weight loss Increased appetite Hyperactivity Diarrhoea Hyperreflexia Pretibial myxedema - graves dx Periorbital edema Warm moist skin Fine hair Chest pain Palpitations Arrhythmias Increased no of and sensitivity of beta adrenergic receptors Decreased TSH Increased free or total T3/4 Hypocholesterolemia - increased LDL receptor expression |
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Hashimoto thyroiditis |
HypoT Autoimmune disorder Antithyroid peroxidase, antithyroglobulin Abs HLA-DR5 Increased risk of non-Hodgkin lymphoma Early hyperT - thyrotoxicosis during follicular rupture Hurthle cells Lymphoid aggregate + germinal centres Moderately enlarged nontender thyroid |
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Congenital hypoT = cretinism |
HypoT Severe, fatal Due to maternal hypoT, thyroid agenesis, T dysgenesis, iodine def, dyshormonogenic goiter Pot bellied Pale Puffy faced child Protruding umbilicus Protrubent tongue Poor brain development |
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De Quervain thyroiditis |
Subacute hypoT Self limited, often following flu-like illness Early hyperT Granulomatous inflammation Increased ESR Jaw pain Early inflammation Very tender thyroid PAIN |
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Riedel thyroiditis |
HypoT Thyroid replaced by fibrous tissue Fibrosis may extend - locally - airway - mimicks anaplastic carcinoma Manifestation of IgG4-related systemic disease Fixed hard rock like and painless goiter |
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Other causes of hypoT |
Iodine def Goitrogens Wolff-Chaikoff effect Painless thyroiditis |
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Toxic multinodular goiter |
HyperT Focal patching of hyperfxn follicular cells Work independently of TSH due to mutation in TSH receptor Increased release of T3/4 Jod-Basedow phenomenon: Thyrotoxicosis if pt with iodine def goiter is made iodine replete |
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Graves' disease |
HyperT AutoAb IgG stimulate TSH receptors on thyroid Diffuse goiter Retro-orbital fibroblasts - exophthalmos: proptosis, extraocular muscle swelling Dermal fibroblasts - pretibial myxedema Often presents during stress - childbirth |
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Thyroid storm |
HyperT Stress-induced catecholamine surge Complication of graves and other hyperT disorders PC: Agitation, delirium, fever, diarrhoea, coma, tachyA -> death Increased ALP due to increased bone turnover TX = 3Ps - propranolol, Propylthiouracil, prednisolone |
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Thyroid cancer |
Thyroidectomy Surgery - hoarseness, hypoCa, transection of inf thyroid A |
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Papillary ca |
Most common Excellent prognosis Empty appearing nuclei = Orphan Annie eyes Psammona bodies Nuclear grooves Increased risk with RET and BRAF mutations, childhood irradiation |
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Follicular ca |
Good prognosis Invades thyroid capsule Uniform follicles |
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Medullary ca |
From Parafollicular C cells Produces calcitonin Sheets of cells in amyloid stroma A/W MEN 2A/B - RET mutations |
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Anaplastic ca |
Undifferentiated Older pts Invades local structures Very poor prognosis |
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Lymphoma |
A/W Hashimoto thyroiditis |
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Primary hyperParaT |
Adenoma HyperCa HyperCalciuria HypoPhosphatemia Increased PTH Increased ALP Increased cAMP in urine Asymptomatic PC: Groans, stones, moans, bones Osteitis fibrosa cystica = cystic bone spaces filled with brown fibrous tissue - bone pain |
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Secondary hyperParaT |
Due to decreased gut Ca absorption and increased PO4 Chronic renal disease - hypoVitD -> deceased Ca absorption HypoCa HyperPhosphatemia - in chronic renal failure, hypo in other causes Increased ALP Increased PTH Renal osteodystrophy: Bone lesions due to renal dx |
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Tertiary hyperParaT |
Refractory hyperPT from chronic renal disease Increased PTH Increased Ca |
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HypoParaT |
Accidental surgical excision of paraT glands, autoimmune destruction, DiGeorge syndrome HypoCa Tetany Chvostek sign - tapping of facial nerve -> contraction of facial muscles Trousseau sign - occlusion of brachial A with BP cuff -> carpal spasm |
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PseudohypoParaT |
= Albright hereditary osteodystrophy AD Unresponsiveness of kidney to PTH HypoCa Shortened 4th/5th digits Short stature |
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Pituitary adenoma |
Prolactinoma - most common Functional - hormone producing - PC based on hormone produced Non functional - silent - PC with mass effect - bitemporal hemianopia, hypopituitarism, headache PL - amenorrhea, galactorrhea, low libido, infertility - TX: dopamine agonists - bromocriptine |
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