Thyroid
What labs (TSH, Free T4) would you expect in a primary hypothyroid patient?
TSH: high.
Free T4: low
what is the treatment for this?
Explain the most common symptoms associated with diabetes and why patients experience them?
Polyuria -> body tries to excrete excess glucose via urine, osmotic gradient pulls water into urine -> pee a lot.
Polydipsia -> large water loss increases thirst and so patients drink a lot
Polyphagia -> intracellular starvation increases appetite
name at least 3 complications of hyperparathyroidism
What are the layers of the adrenal cortex and what to they secrete?
Zona Glomerulosa - Aldosterone
Zona Fasciulata - Cortisol
Zona Reticularis - DHEA
A patient with galactorrhea and erectile dysfunction is likely to have an elevation in which laboratory value?
Prolactin
Growth Hormone
Vasopressin
DHEA
Prolactin
which beta blocker is preferred in treatment of a thyroid storm? Why?
Propranolol - improves symptoms as well as decreases conversion of T4->T3
Which type of insulin is used for use in pumps? What about management of DKA?
Rapid insulins only for use in pumps, regular insulin for IV admin during DKA.
What is the preferred laboratory method of diagnosing serotonin neuroendocrine tumors?
What is treatment?
Urine 5-HIAA (end product of 5HT metabolism, preferred to serum serotonin (dont ask me why))
Treatment is somatostatin analogs (eg. Octreotide) or surgical resection/debulking.
Differentiate presentations of Cushings Disease vs. Addisons disease
Cushings: Moonface, buffalo hump, central obesity, muscle atrophy in arms/legs, HTN, Abd striae, hypogonadism, Headache, fatigue, weakness, thirst/polydipsia.
Addison's: weight loss, abd pain, n/v/d, arthralgia, confusion/psychosis, hypoglycemia, hyponatremia, hyperpigmentation, syncope.
what are some diagnostics we can do to diagnose gigantism/acromegaly?
Serum IGF-1 (usually >5x normal in acromegaly)
Serum GH
Glucose suppression test (should suppress GH, but doesn't in gigantism/acromegaly)
MRI brain w/ and w/out contrast to rule out pituitary adenoma.
A patient presents with several months of insomnia, heat intolerance, weight loss and intermittent diarrhea. Upon exam you notice a slightly enlarged thyroid, and labs show decreased TSH, with elevated free T4 and positive TRAb antibodies. What is the preferred initial treatment?
Methimazole or propylthiouracil (decrease thyroid hormone synthesis), Beta blockers for symptoms.
Can also do radioactive iodine to destroy thyroid, or thyroidectomy, but these are more invasive and not first-line.
what electrolyte do we need to monitor when managing diabetic ketoacidosis? Why?
Administration of insulin will push potassium into cells, potentially causing hypokalemia
A patient has a thyroidectomy, and the next day starts to have palpitations, muscle cramps and distal numbness/tingling. Labs show low serum calcium, low PTH, low Free T4 and high TSH. EKG shows QT prolongation. What likely has occured, and how do we treat it?
Likely parathyroid injury/resection with thyroidectomy causing hypocalcemia. Treat with either PO calcium & calcitriol, or if severe IV calcium gluconate.
A 7 year old boy comes in to his PCPs office for recent severe headaches, and sweating. He has not been interested in playing with friends recently and has felt very restless. He is hypertensive and tachycardic, and appears diaphoretic on exam. What lab must be collected to rule out this rare tumor?
Urine/serum catecholamines to r/o pheochromocytoma.
Differentiate microadenoma and macroadenoma and when they are usually diagnosed
Microadenoma = <1cm, typically diagnosed earlier as they often secrete hormones, leading to symptoms. Symptoms depend on hormone secreted.
Macroadenoma = >1cm, typically diagnosed later as they don't secrete hormones, symptoms due to mass effect (eg. compression -> headache, vision changes, syncope, etc).
explain management of decompensated hypothyroidism (myxedema coma)
1) ventilate if needed
2) Correct hypovolemia, circulatory shock - give isotonic fluids
3) give thyroid hormone, vasopressors)
4) passive rewarming to correct hypothermia
5) Water restriction to correct hyponatremia
6) possible stress steroid dose if refractory hypoglycemia.
What is NOT indicated for chronic management of Type II DM?
Foot exam annually
BP at every visit
A1c Q3-6 months
Eye exam annually
Foot exam annually - this should be done at every visit
What is NOT associated with Werner Syndrome (MEN I)?
Parathyroid hyperplasia
Pancreatic islet cell tumors
Pheochromocytoma
Pituitary tumors
Pheochromocytoma
in primary hyperaldosteronism, differentiate treatment for adrenal adenoma vs. adrenal hyperplasia
Adrenal adenoma = surgical resection often curative
Adrenal hyperplasia = cant do surgery (involves whole gland). Treat with low salt diet, spironolactone (inhibits action of aldosterone)
Differentiate central/nephrogenic diabetes insipidus and their treatments.
Central DI: Lack of ADH release from posterior pituitary. Treat with synthetic ADH (Desmopressin)
Nephrogenic DI: ADH release normal, kidneys can't respond. Treat with thiazide diuretics, low salt diet
a patient presents with anterior neck pain, and reports she had symptoms consistent with a viral URI a week ago. her thyroid is diffusely tender, and labs are as follows: Elevated free T4, decreased TSH, negative antibodies. What treatment would you recommend?
This sounds like subacute viral thyroiditis (post viral illness, painful tender thyroid, initial hyperthyroid then self-limiting hypothyroid phase)
NSAIDs/Steroids for treatment.
What is the pathophysiology of hyperosmolar hyperglycemic state? What is the common presenting complaint? How do we treat?
Stress state (eg. infection, surgery) in the background of type II DM, causes increased glucose release due to sympathetic mediators. Enough insulin present to prevent lipolysis -> ketones.
Common presentation is neuro symptoms (eg. AMS, Seizures)
Treatment:
-correct hypovolemia -> IV fluids
-Correct hyperosmolarity -> insulin (check potassium first!)
-admission to ICU
- +/- head CT to r/o other causes of AMS.
Gastrinomas are mostly _______ (Malignant/benign), and 90% are located within _______. Treatment includes ______ and some complications include _______ (4)
Malignant
Gastrinoma triangle (cystic duct, Duodenum, neck of pancreas)
High dose PPI/Surg resection.
Complications: GI bleed, perforation, Stricture/obstruction, Metastatic liver disease
What are some causes of cushing syndrome? How do we treat each type?
Iatrogenic (eg. prescribed steroid use) - Taper steroids.
Adrenal adenoma = Surgical resection/Adrenalectomy
Pituitary adenoma = surgical resection
*If surgery contraindicated, can use PO Ketoconazole (inhibits cortisol synthesis)
Which set of labs would be indicative of possible SIADH?
A: Serum Na >135, Urine Na >40, Plasma Osmol <280, Urine Osmol >300
B: Serum Na <135, Urine Na >40, Plasma Osmol >280, Urine Osmol <300
C: Serum Na <135, Urine Na, >40, Plasma Osmol <280, Urine Osmol >300
D: Serum Na >135, Urine Na, >40, Plasma Osmol <280, Urine Osmol >300
C: Serum Na <135, Urine Na, >40, Plasma Osmol <280, Urine Osmol >300.
Too much ADH => retention of water -> dilutes plasma = hyponatremia, decreased plasma osmolarity (hypotonic hyponatremia). Makes very concentrated urine with high sodium. Body responds to increased volume with some Na, H2O diuresis -> less urine, euvolemia, hypotonic hyponatremia.