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82 Cards in this Set

  • Front
  • Back
Pheochromocytoma -
What is it
MC primary tumor of
adrenal gland in adults
from chromaffin cells
secretes epi & NE
associated with -
von Hippel Lindau syn
MEN II & III
neurofibromatosis
Pheochromocytoma -
What is Rule of 10
10% bilateral
10% malignant
10% extra-adrenal
10% calcify
10% kids
10% familial
Pheochromocytoma -
Hx/PE
The 5 P's -
Pressure (inc. BP)
Pain (HA)
Perspiration/Diaphoresis
Palpitations
Pallor

intermittent tachycardia
chest pain
anxiety
Pheochromocytoma -
Dx
CT or MRI
24-hr urinary catecholamine
metabolites - HVA, VMA
Pheochromocytoma -
Tx
Before surgery -
■ A-antag -
phentolamine
phenoxybenzamine
use first
■ then B blockers -
propanolol
metyrosine
■ or labetalol - A & B blocker

Def. Tx - surgery
Adrenal Insufficiency -
What is it
What is it due to
Primary - Addison's disease

secondary -
from dec. ACTH prod. by pit.
usu from abrupt cessation of
chronic glucocorticoid Tx

Addison's -
■ from destruction of adrenal
cortex
■ => def. of mineralocorticoid
and glucocorticoids
■ MC etiology (US) -
autoimmune destruction
■ may occur as part of
polyglandular def syndrome -
hypothyroidism
hyperparathyroidism
DM1
pernicious anemia
gonad failure
vitiligo
chronic mucocut candidiasis
■ can be due to -
congen enzyme def
adrenal hemorrhage -
Waterhouse-Friderichson syn
TB

tertiary -
low ACTH
low cortisol
from chronic supraphysiological doses
of glucocorticoids
=> suppresses CRH release
Adrenal Insufficiency -
Hx/PE
Hx -
weakness
n/v

Addisonian crisis -
n/v
hypoglycemia
dehydration
CV collapse

PE -
hypotension
anorexia
skin hyperpigmentation-Addison
no pigmentation changes -
secondary
Adrenal Insufficiency -
Dx
Dx for primary -
rapid ACTH admin
measure cortisol

Hyponatremia
hyperkalemia
eosinophilia
■ ACTH -
high in Addison's
low in secondary
■cortisol after ACTH challenge
low in Addison's
high in secondary
Adrenal Insufficiency -
Tx
Replace glucocorticoids &
mineralocorticoids
inc. steroids in stress
taper off glucocorticoids
Hyperaldosteronism -
What is it
Primary -
MCC: unilat adrenocort adenoma
(Conn's syndrome)
most remaining cases -
b/l adrenocortical hyperplasia

Secondary -
dec. renal blood flow
=> stim. renin-angiotensin sys
causes -
obstructive renal artery disease
renal vasoconstriction
edematous d/o
Hyperaldosteronism -
Hx/PE
HTN
headache
polyuria
muscle weakness
tetany
paresthesias
periph edema - if severe
Hyperaldosteronism -
Dx
Hypernatremia
hypokalemia
metabolic alkalosis
low plasma renin (in primary)
inc. 24-hr urine aldosterone
CT or MRI
Hyperaldosteronism -
Tx
Correct BP & K+,
then lap or open adrenalectomy

spironolactone -
if b/l hyperplasia
Congenital Adrenal Hyperplasia (CAH) -
What is it
MC adrenal d/o of infancy & childhood
group of genetic d/o
AR
defect in 1 of adrenal enzymes
involved in
adrenal steroid hormone syn
from cholesterol
MCC - 21-hydroxylase def.
other causes -
11b-hydroxylase def.
17a-hydroxylase def.

21-hydroxylase def. -
inc. 17-hydroxyprogest & DHEA
dec. aldosterone
dec. cortisol

complete def. -
salt-wasting form
most severe form
Congenital Adrenal Hyperplasia (CAH) -
Hx/PE
■ Female infants -
ambig genitalia
(clitoral enlargement,
fusion of labia majora,
urogenital sinus)
■ male infants -
macrogenitosomia
■ older -
virilization
precocious puberty
Congenital Adrenal Hyperplasia (CAH) -
Dx
High levels
in blood and urine of -
cortisol precursors
androgens
Congenital Adrenal Hyperplasia (CAH) -
Tx
■ Cortisol -
dec. ACTH & adrenal androgens
■ surgery -
female infants with
ambig genitalia
Cushing's Syndrome -
What is it
What causes it
Hypercortisolism
MCC- iatrogenic (excess admin)

other causes -
■ cushing's dis -
central
primary pituitary adenoma
inc. ACTH
■ ectopic ACTH production -
carcinoid tumor
small cell lung cancer
(inc. ACTH)
■ excess adrenal secretion
of cortisol -
b/l adrenal hyperplasia
adrenal carcinoma
dec. ACTH
Cushing's Syndrome -
HX/PE
Hx -
depression
excessive hair growth
Sxs of diabetes
oligomenorrhea
growth retardation
weakness
acne

PE -
HTN
central obesity
muscle wasting
thin skin
easy bruisability
purple striae
hirsutism
moon facies
"buffalo hump"
Cushing's Syndrome -
Dx
Low-dose dexamethasone test -
screening
0.5 mg q6h x 4
■ suppress -
(morning plasma cortisol)
normal
■ doesn't suppress -
abnormal
obese (false pos.)
depression (false pos.)
alcoholic (false pos.)

Do 24-hr urine free cortisol -
■ suppress -
normal
■ doesn't suppress -
cushing syndrome

high-dose dexamethasone test -
1 mg q6h x 4
■ suppress -
pituitary tumor- cushing's dis
■ doesn't suppress -
adrenal adenoma or cancer
small cell lung cancer

confirm -
CT - adrenal
MRI - sphenoid
hyperglycemia, glycosuria,
hypokalemia
Cushing's Syndrome -
Tx
Surgical resection
irradiation - pituitary only
mitotane
ketoconazole
metyrapone
aminoglutethimide
Cushing's Syndrome -
Complications
Inc. susceptibility to
infections
vertebral compression Fx
avascular necrosis of
femoral head
DM Type 1 -
What is it
Autoimmune destruction
of B cells
hyperglycemia secondary to
insulin def.
=> need exog insulin
usu Dx in kids or adolescents
usu < 30 y/o
assoc. with HLA-DR3 & 4
Ab against glutamic acid
decarboxylase
DM Type 1 -
Hx/PE
Polyuria
nocturia
polydipsia
polyphagia
rapid or
unexplained weight loss
DM Type 1 -
Dx
At least 1 of following -
random plasma glucose >200 mg/dL
fasting >126 on 2 sep. x's
2-hr postprandial glucose >200
after 75g oral GTT
on 2 sep. times

urine glucose & ketones
HbA1c -
reflects glucose levels of
prior 3 mos.
< 7 is goal,
slows dev & prog of:
microvascular disease
retinopathy
nephropathy
neuropathy
DM Type 1 -
Tx
Insulin injections
monitor glucose levels
annual eye exams
annual testing of microalbumin
foot exams
DM Type 2 -
What is it
Hyperglycemia secondary to
end-organ insulin resistance
MC diagnosed in obese > 40 y/o
no known HLA assoc.
often has fam Hx
DM Type 2 -
Hx/PE
Insidious onset
may init present with Sxs
of diabetic complications
also, polyuria
polydipsia
polyphagia
HONK
DM Type 2
Dx
Urine glucose & ketones
HbA1c -
reflects glucose levels of
prior 3 mos.
< 7 is goal,
slows dev & prog of:
microvascular disease
retinopathy
nephropathy
neuropathy
DM Type 2 -
Tx
Diet, wt. loss & exercise
LDL goal = < 100
strict BP control
BP goal = < 130/80

oral agents -
monotherapy or
combination if uncontrolled
metformin
thiazolidinediones- glitazones
sulfonylureas
a-glucosidase inhib
insulin - alone or in comb
statins
Metformin -
Method of Action
Side Effects
Inhibs liver gluconeogenesis
inc. periph sensitivity
to insulin
may dec. intest. absorption
of CHO

side effects -
GI Sxs
lactic acidosis - rare
Thiazolidinediones
(the "glitazones") -
Method of Action
Side Effects
Inc. periph sensitivity
to insulin

side effect -
edema
Sulfonylureas
(Tolbutamide,
Glyburide,
Glipizide) -
Method of Action
Side Effects
Inc. pancreatic secretion
of insulin

side effects -
hypoglycemia
wt. gain
Alpha-glucosidase inhibs -
Method of Action
Side Effects
Dec. intest. absorption of CHO

side effects -
upset GI
Somogyi Effect -
What is it
Tx
Rebound a.m. hyperglycemia
secondary to early morning
hypoglycemia

bedtime - glucose in range
3-4 am - hypoglycemia
6 am - rebound hyperglycemia
due to release of:
epi, glucagon & cortisol

Tx - dec. p.m. insulin
Dawn Phenomenon -
What is it
Tx
A.M. hyperglycemia
secondary to GH
Tx - inc. p.m. NPH insulin
DKA -
What is it
DM 1
• from inadeq insulin levels -
noncompliance
new onset of DM
stress
(MI
stroke
alcohol
pancreatitis
trauma)
• acute infection, esp:
pneumonia
UTI
• drugs, esp:
corticosteroids
thiazides
sympathomimetics
DKA -
Hx/PE
N/V
abdom pain
Kussmaul respiration
fruity breath
severe dehydration
mental status changes
• electrolyte abnorm -
hypokalemia
hypophosphatemia
inc. anion gap metab acidosis
DKA -
Dx
Serum electrolytes
glucose
ketones
BUN/Cr
osmolarity
ABG
UA -
ketones
B-hydroxybutyrate not detected
DKA -
Tx
NS
IV regular insulin
correct K+
Tx initiating event

NS changed to D5 when -
blood glucose 200-250

NPH when tolerate oral feeds
Nonketotic Hyperosmolar Syn -
What is it
DM2
hyperglycemia
=> osmotic diuresis
inadeq fluid intake
=> extreme dehydration
insulin suppresses ketogenesis
=> no Sxs of acidosis
=> inc. period of dehydration
=> high glucose levels

precip factors -
acute infection
stress
glucocorticoids
inc. fluid loss
noncompliance
Nonketotic Hyperosmolar Syn -
Hx/PE
Profound dehydration
altered mental status
high osmolarity
high plasma glucose -
> 600 mg/dL
no acidosis
Nonketotic Hyperosmolar Syn -
Tx
Tx initiating event
aggressive fluid and
electrolyte replacement
insulin
Diabetic Retinopathy -
What is it
How to prevent
Tx
Had DM at least 3-5 years

to prevent -
control hyperglycemia
control HTN
annual eye exams

laser photocoagulation therapy
if retinal neovascularization
Diabetic Nephropathy -
What is it
How to prevent
Glomerular sclerosis
mesangial expansion
=> glomerular HTN,
dec. in GFR,
nephrotic syndrome,
microalbuminuria,
RF

to prevent -
ACE inhib
control BP
control glucose
Diabetic Neuropathy -
What is it
Tx
Symmetric polyneuropathy
distal ft and hands
paresthesias
dysesthesias
painless loss of sense of -
touch
vibration
proprioception
temp
=> foot trauma,
Charcot's joint,
infections,
diabetic ulcers

autonomic neuropathy -
esoph dysmotility
impotence
orthostatic hypotension
delayed gastric emptying
(gastroparesis)
from vagal neuropathy
early satiety
=> n/v
Dx - gastric emptying study

Tx -
TCAs
gabapentin
metoclopramide
Diabetic Macrovascular
Complications -
What are they
Tx
Lg vessel atherosclerosis -
angina
MI
TIA
stroke
periph vascular disease

MCC of death in diabetic pts -
CV disease

Tx -
BP goal - <130/80
LDL goal - < 100 mg/dL
trigly goal - < 150 mg/dL
evidence of complications -
start on low-dose ASA
Acromegaly -
What is it
Adult condition
from benign pituitary adenoma
secretes (excessive) GH
kids - gigantism
Acromegaly -
Hx/PE
Enlarged jaw, hands, feet
facial features coarsen
=> carpal tunnel syn
diastolic HTN
arthritis
glucose intolerance
DM

bitemporal hemianopsia -
due to compression of
optic chiasm by pit. adenoma

internal organs increase
MCC of death - cardiac failure
Acromegaly -
Dx
■ screen - GTT
normal - GH levels suppressed
acromegaly - levels higher
■ CT or MRI after
document biochemistry

■ serum GH levels -
pulsatile, thus unreliable
Acromegaly -
Tx
Transsphenoidal resection
or irradiative ablation
octreotide - dec. tumor size
bromocriptine
Hyperparathyroidism -
What is it
MCC - 1 gland hyperplasia
can have 4 gland hyperplasia
carcinoma is rare
Hyperparathyroidism -
Hx/PE
70% asymp
"stones, bones, groans,
psych overtones"
nephrolithiasis
nephrocalcinosis
bone pain
fractures
osteitis fibrosa cystica
n/v
constipation
PUD
pancreatitis
fatigue
depression
anxiety
disturbed sleep/concentration
muscle aches
arthralgias
Hyperparathyroidism -
Dx
Hypercalcemia
hypercalciuria
hypophosphatemia
inc. PTH
"brown tumors"
Hyperparathyroidism -
Tx
If symptomatic -
pre-op bisphosphonates
parathyroidectomy
"hungry bone syndrome" -
hypocalcemia after surgery removal

acute hypercalcemia -
IV fluids
loop diuretics
Hypothyroidism -
What is it
MCC - Hashimoto's thyroiditis
autoimmune
women > men
other causes -
■ subacute thyroiditis
■ postpartum thyroiditis
■ drugs -
iodide
amiodarone
sulfonamides
lithium
■ iatrogenic -
radioactive thyroid ablation
excision & inadeq supplement
■ myxedema
■ cretinism -
untreated congen hypothyroid
severely stunted physical
& mental growth
Hypothyroidism -
Hx/PE
Weakness, fatigue
cold intolerance
constipation
weight gain
depression
hoarseness
menstrual irreg

dry, cold, puffy skin
edema
bradycardia
thin eyebrows
delayed relaxation of DTRs
Hypothyroidism -
Dx
Elevated TSH
dec. T4, free T4 & free T3
antimicrosomal Ab
antithyroglobulin Ab
Hypothyroidism -
Tx
Levothyroxine

gradually if elderly or have CAD
monitor TSH & T3
Subacute Thyroiditis -
What is it
de Quervain's
granulomatous thyroiditis
probably caused by virus
Subacute Thyroiditis -
Hx/PE
Follows viral URI
fever
hyperthyroidism
=> hypothyroidism
=> euthyroid

thyroid -
asymm enlarged
firm
tender
Subacute Thyroiditis -
Dx
Early -
high T3 & T4
high ESR
low TSH
low radioactive iodine uptake
Subacute Thyroiditis -
Tx
Self-limited
can treat Sxs -
ASA
propanolol
prednisone
Myxedema -
What is it
Abnorm deposits of
mucopolysaccharides
(hyaluronic acid,
chondroitin sulfate)
due to severe hypothyroidism
puffy face
periorbital swelling
expressionless face
Myxedema Coma -
What is it
Precip by
Tx
Life-threatening complication
of hypothyroidism
long h/o untreated hypothyroidism
extreme hypothermia
resp depression
seizures
coma

precip by -
infection
trauma
exposure to cold
drugs that suppress CNS

Tx -
IV levothyroxine
add IV hydrocortisone if
abnorm adrenal function
Pretibial myxedema -
What is it
Partial form of myxedema
in lower legs
in Graves' disease
Hyperthyroidism -
What is it
MCC - Graves
toxic diffuse goiter
usu women 20-40 y/o

other causes -
toxic multinodular goiter
toxic adenoma
subacute thyroiditis
lymphocytic thyroiditis
pit. TSH hypersecretion
Jod-Basedow phenomenon
struma ovarii
Hyperthyroidism -
Hx/PE
Hx -
wt. loss
heat intolerance
nervousness
inc. bowel freq.
weakness
menstrual abnorm

PE -
warm, moist skin
goiter
tachy
atrial fib
thyroid bruit
tremor
hyperactive reflexes
exopthalmos
pretibial myxedema
Hyperthyroidism -
Dx
Dec. TSH
inc. total T4, free T4,
free T4 index
TSH receptor Ab
Hyperthyroidism -
Tx
■ Propranolol
■ mild, goiter -
methimazole
carbimazole
PTU
■ severe -
131I thyroid ablation
■ large goiter,
pregnant -
thyroidectomy
■ if ablation or surgery -
levothyroxine
Hyperthyroidism -
Complications
Thyroid storm
Thyroid Storm -
What is it
Acute
from untreated or inadeq.
treated severe hyperthyroidism
25% mortality
precip by -
surgery
infection
DKA
toxemia of pregnancy
embolism
Thyroid Storm -
Sxs
Hi fever
dehydration
tachycardia
high-output CHF
coma
Thyroid Storm -
Tx
saline
glucose
hydration
glucocorticoids
O2 cooling blanket

Tx hyperthyroidism -
1st PTU
then iodine
then B-blocker (propranolol)
then dexamethasone
Thyroid Nodule -
What is it
Common
inc. with age
majority benign

higher risk of malignancy -
h/o neck irradiation
cold nodules
firm, fixed solitary nodules
rapidly growing nodules
with hoarseness
or dysphagia
Thyroid Nodule -
Hx/PE
Hx -
■ Usually init asymp
■ to distinguish benign from malignant -
note any systemic Sxs:
hypo- or hyperthyroidism
dysphagia
dyspnea
odynophagia
hoarseness
fam h/o medullary thyroid ca
h/o neck irradiation
ant. cervical lymphadenopathy

PE -
if carcinoma:
firm
fixed
NT
Thyroid Nodule -
Dx
■ 1st step - check TSH
■ if TSH inc. -
check for Hashimoto's
check Ab
check T4
■ if TSH dec. -
radioiodine scan
if cold = malignant
■ if TSH normal -
FNAB (1st procedure)


■ thyroid function tests
■ US -
det. if cystic
■ radioactive scan -
det. if hot or cold
check for metastases
■ FNA -
best method to assess malig
Thyroid Nodule -
Tx
■ if FNAB benign -
thyroid hormone
(suppresses TSH & shrinks nodule)
then US

■ malignant -
resection

■ not clear -
lobectomy
await final path report
Osteoporosis -
What is it
Risk factors
Common metabolic bone disease
severe dec. in bone density
=> bone fractures easily

rate of bone resorption >
rate of formation
bone produced is normal,
but too little of it
bone mass peaks 30-35 y/o
rate of formation then dec.

MCC of pathological Fx in
elderly, thin women
usu thin, white, postmenopause

inc. risk -
smoking
long-term admin of heparin
long-term admin of glucocorticoid
Osteoporosis -
Hx/PE
Hip fractures
distal radius fractures
vert. compression fractures
=> dec. height
=> prog. thoracic kyphosis
Osteoporosis -
Dx
■ Lab tests - normal
■ XR -
global demineralization once
> 30% bone density lost
■ DEXA scan -
dual-energy XR absorptiometry
bone mineral density
< 2.5 SD (below normal)
vert. bodies
prox. femur
distal radius
Osteoporosis -
Tx
Prevention
Ca2+ supplements & vit D through adulthood
smoking cessation
wt-bearing exercises
bisphosphonates
raloxifene
intranasal calcitonin