Term
| When the anterior pituitary is compromised, which hormone is affected first? why is this important? |
|
Definition
d
GH - induces protein synthesis and nitrogen retention and impairs glucose tolerance by antagonizing insulin action
GH |
|
|
Term
Endocrine hormone maintenance of homeostasis:
1. ___ controls about 25% of basal metabolism in most tissues
2. ____ exerts a permissive action for many hormones in addition to its own direct effects
3. ____ regulates Ca and P levels
4. ___ control vascular volume and serum electrolytes (Na and K) concentration
5. ____ maintains euglycemia in the fed and fasting states |
|
Definition
1. thyroid hormone controls about 25% of basal metabolism in most tissues
2. cortisol exerts a permissive action for many hormones in addition to its own direct effects
3. PTH regulates Ca and P levels
4. Mineralcorticoids control vascular volume and serum electrolytes (Na and K) concentration
5. insulin maintains euglycemia in the fed and fasting states |
|
|
Term
a 43 t/o female presents w/ a concern of hot flashes and flushing intermittently during the day and soaking sweats and night x6 mosw/o changes in frequency of severity. FH: T2DM, insulin dependent.
BP: 90/60
P:72
R:15
BMI: 40
PE: central obesity, skin tags around neck.
Labs: A1C 4.3, BG 90, Random BG 110 |
|
Definition
|
|
Term
Hypothyroidism:
1. The most common form is ?
2. If TSH is high and FT4 is low, the problem is where?
3. If TSH is high and FT4 is normal, the problem is what?
Hyperthyroidism:
4. The most common form is?
5. In this case, what will TSH and FT4 be? |
|
Definition
1. Hoshimoto's (autoimmune)
2. primary (thyroid itself)
3. subclinical
4. Grave's (autoimmune)
5. Low TSH (maybe unmeasurable) and high FT4 |
|
|
Term
Hypothalamic horomones:
1. stimulates TSH and prolactin
2. simulations LH and FSH if pulsatile, inhibitory if chronic
3. stimulates ACTH
4. stimulates GH if pulsatile, inhibitory if chronic
5. inhibits GH, also found throughout gut and pancreas
6. inhibits prolactin
7. stimulates prolactin |
|
Definition
1. stimulates TSH and prolactin: TRH
2. simulations LH and FSH if pulsatile, inhibitory if chronic: GnRH
3. stimulates ACTH: CRH
4. stimulates GH if pulsatile, inhibitory if chronic: GHRH
5. inhibits GH, also found throughout gut and pancreas: Somatostatin
6. inhibits prolactin: Dopamine
7. stimulates prolactin: PRF's |
|
|
Term
Anterior pituitary hormones:
1. stimulates thyroid hormone production
2. gonadotropins -- stimulate sex steroid production by gonad and germ cell development
3. stimulates cortisone reproduction
Posterior pituitary hormones:
1. increases BP , causes water retention
2. stimulates uterine contraction and milk let down |
|
Definition
Anterior pituitary hormones:
1. stimulates thyroid hormone production: TSH
2. gonadotropins -- stimulate sex steroid production by gonad and germ cell development: LH/FSH
3. stimulates cortisone reproduction: ACTH
Posterior pituitary hormones:
1. increases BP , causes water retention: ADH/Vasopressin
2. stimulates uterine contraction and milk let down: Oxytocin |
|
|
Term
| what is the most importnat function of ADH? |
|
Definition
|
|
Term
sx of ?
HA,
visual field loss - bitemporal hemianopsia (loss of upper outer field first)
3rd nerve palsy
sx related to pituitary dysfunction
Sx related to hypothalamic dysfunction
pituitary apolplexy |
|
Definition
|
|
Term
|
Definition
dx: MRI w/ or w/o contrast
- CT w/ or w/o contrast
- hormone assessment
tx: observation
- resection by TSS or craniotomy
- radiation
- medication if prolactinoma or acromegaly |
|
|
Term
Most common type of pituitary tumor? high rate of recurrence
sx: amenorrhea, galactorrhea, hypogonadism, HA
dx?
tx?
what drug do you NOT want to give to pts w/ this tumor? |
|
Definition
prolactinoma (prolactin-producing tumor)
dx: prolactin level, TSH, MRI of pituitary
tx: observation, dopaminergic meds (bromocriptine, permax, dostinex), surgery, radiation
don't give psych meds - decrease dopamine
|
|
|
Term
Acromegaly and gigantism:
1. onset before fusion of growth plates = ?
2. onset after fusion of growth plates = ?
dx and tx? |
|
Definition
1. gigantism
2. acromegaly
dx:
Increased serum IGF --> GOLD STANDARD
+/- serum GH level
BMP
MRI
tx: surgery
somatostatin injection |
|
|
Term
what dz?
distortion of facial features, growth of hands andf eet
thickening of skin
severe arthritis and spinal stenosis
polyps, nodular goiter
Frankenstein look
Parts of bones that can respond but do not - ends of bones enlarge |
|
Definition
|
|
Term
sx: slow linear grwoth, not necessarily short stature
cherubic features "Baby fat"
dx?
tx? |
|
Definition
growth hormone deficiency
dx: grwoth charts - measure kid at every visit
serum IGF --> GOLD STANDARD
NOT just single GH level
FT4 & TSH
MRI pituitary
Criteria: projected adult height is more than two SD below mean
tx: GH injection daily |
|
|
Term
Sx: Decrease in lean body mass in adulthood, increase in body fat
fatigue, dyslipidemia
dx and Tx? |
|
Definition
adult onset GH deficiency
dx: IGF-1 level
Stimulation testing: insulin-induced hypoglycemia
tx: GH injection |
|
|
Term
DX?
- Pituitary problem Caused by decreased ADH
- Characterized by excess thirst and urination
water deprivation test: Cause pt to become dehydrated - ADH should go up, but won't in these pts
tx? |
|
Definition
Diabetes insipidus
tx:
Central: DDAVP
Nephrogenic: no Rx or hydrochlorothiazide |
|
|
Term
What dx?
Hallmark is low osmolality (hypOnatremia)
- pt will be hyper or euvolemic = dilute blood + concentrated urine
causes: blood in CNS or tumor
sx: lethargy, confusion, coma, seizure
dx of exclusion, must verify normal liver, kideny, heart, thyroid, and adrenal function
tx? |
|
Definition
Syndrome of inappropriate ADH secretion (SIADH)
tx: fluid restricion (<1500 cc/day)
may need diuretic if severe |
|
|
Term
| the science of dealing w/ chemical communications from one cell to another |
|
Definition
|
|
Term
ex of ____: testosterone. made in the testis and works in the testis
ex of ____: GI hormones. Made in a cell and work in the same cell. |
|
Definition
|
|
Term
| the ___ is the largest endocrine organ |
|
Definition
|
|
Term
2 main classes of hormones:
1. include PTH, glucose, and insulin. free floating in the blood. rapidly secreted and rapidly cleared. half life is minutes. work on cell membrane receptors.
2. testosterone, cortisol, estrogen, and Vit D. protein bound. do not exist free in blood. last for hours to days. intracellular receptors. activates cellular metabolic processes |
|
Definition
|
|
Term
| Why does hypothyroidism have high TSH and low T3/T4? |
|
Definition
| Negative feedback: thyroid isn't producing enough T3/T4 so the pituitary tries to keep stimulating it by producing TSH |
|
|
Term
Parts of the adrenal crotex:
1. outside layer - secretes aldosterone
2. central - secretes cortisol
3. inner layer - secretes DHEA, androstiendione, androgens
4. secretes epi, NE, and cortisol |
|
Definition
1. zone glomerulosa
2. zona fasciulata
3. zona reticularis
4. adrenal medulla |
|
|
Term
Adrenal medulla tumor composed of chromaffin cells capable of secreting E, NE, and dopamine
rare, but often sought after
1/1M
0.3% of population
90% in adrenal
Right > left
sx: HTN + triad (palpitations, HA, sweating spells)
Spells last 10-60 min
HTn may be sustained or episodic
Dyspnea, anxiety, tumor
Dirrhea
dx? tx? |
|
Definition
pheochromocytoma
dx: 24 hr urine: VMA, free catecholamines, metanephrine, normetanephrine
if Pos, do CT, then MIBG
tx: surgical resection -- tx of choice
alpha adrenergic blockade required two weeks prior to surgery to counter vasoconstriction
|
|
|
Term
| Rule of 10's regarding pheochromocytoma |
|
Definition
10% malignant
10% bilateral
10% extra adrenal (paragangliomas)
10% familial |
|
|
Term
Adrenal insufficiency:
1. Loss of adrenocortical hormones due to destruction or impairemtn of adrenal cortex
2. reduced secretion by pituitary gland of ACTH
3. failure of hypothalamus to produce CRH |
|
Definition
primary
secondary
tertiary |
|
|
Term
| If someone has hypopituitaryism (adrenal insufficiency) what is the first hormone you need to treat? |
|
Definition
| cortisol - vascular system will collapse w/o it |
|
|
Term
| #1 cause of adrenal insufficiency? |
|
Definition
|
|
Term
| Secondary causes of adrenal insufficiency |
|
Definition
empty sella syndrome
sarcoidosis
tumors
histocytosis
sheehan's sydnrome
head trauma |
|
|
Term
| ischemic pituitary necrosis due to severe blood loss during pregnancy |
|
Definition
|
|
Term
| What causes tertiary adrenal insufficiency |
|
Definition
| long term glucocorticoid use --> suppresses cortisol production |
|
|
Term
sx: abdominal pain, D/N/V
orthostatic hypotension
dizziness
hyperpigmentation -- looks like they've been tanning
weakness, depression, fatigue, psychosis
weight loss
salt craving
Labs: increased BUN/Cr, hyperkalemia, hyponatremia, hypoglycemia, normocytic anemia, elevated TSH
dx?
tx? |
|
Definition
adrenal insufficiency
dx: Cosyntropin/cortisol (ACTH) stimulation test: <20 ug/dl
serum ACTH elevated
random cortisol level <5ug/dl
tx:
prednisone 2.5-7.5 mg/day
Hydrocortisone 15-20 mg am, 5-10 mg pm
Fludrocortisone (Florinef) 0.05-0.2 mg/day
triple steroids in times of stress
|
|
|
Term
Adrenal insuffiency:
if Low cortisol and low ACTH, think?
If low cortisol and high ACTH, think? |
|
Definition
low cortisol, low ACTH = secondary or tertiary
low cortisol, high ACTH - primary |
|
|
Term
|
Definition
Five S's: salt, sugar, steroids, support, search for illness
give IV saline, D5, and steroids |
|
|
Term
____ is increased level of cortisol production
___ is decreased level of cortisol |
|
Definition
|
|
Term
|
Definition
exogenous glucocorticoids
for example: pt w/ giant cell arteritis on high dose steroids for extended period of time |
|
|
Term
sx: dramatic red striae --- pathognomonic
- hypokalemia
- easy bruising
- osteoporosis
- proximal weakness - have pt bend down to touch toes. these pts will have to walk hands back up legs
- diastolic HTN >105
- central obesity
- Moon face
- Acne
- hirsutism
- increased supraclavicular fat pad = "buffalo hump"
- oligomenorrhea
- abnormal glucose tolerance
- hyperpigmentation
- CHF, edema
dx?
tx? |
|
Definition
Cushing's
dx: 24 hr urine - free cortisol and creatinine
dexamethasone suppression tests: 1 mg at 11pm, measure cortisol at 8 am. >5 ug/dl is pos
serum ACTH
tx: transsphenoidal adrenal surgery
- radiation
- ketoconazole - for pts who are not surgical candidates |
|
|
Term
Females > males, presents in 3rd-5th decade
sx: HTN + Hypokalemia (muscle cramps and weakness) --> pathognomonic
- metabolic alkalosis
- hypomagnesemia
dx: elevated serum aldosterone, suppressed renin (20:1 aldosterone:renin)
- 24 hr urine aldosterone >20 mg/day
tx? |
|
Definition
Hyperaldosteronism
tx: adrenalectomy
spironolactone |
|
|
Term
Causes of hyperaldosteronism:
1. 65% of primary hyperaldosteronism, small <2cm. L>R, produce greater amounts of aldosterone. HTN more severe (200/100)
2. aldosterone less elevated, HTN less severe |
|
Definition
Aldosterone-producing adenoma (Conn's syndrome)
Bilateral adrenal hyperplasia (idiopathic hyperaldosteronism) |
|
|
Term
| What should you do with an incidental adrenal mass? |
|
Definition
evaluate for hormone secretion and malignancy:
-plasma renin, aldosterone --> hyperaldosterone
- DHEA, 24 hr urine for cortisol --> cushing's
- VMA, metanephrine, catecholamines --> pheo
If all are normal, than mass is non-functioning |
|
|
Term
Adrenal mass... what do you do?
1. nonfunctioning mass >4.5 cm or horomone-secreting
2. If <4.5 cm and nonfucntiong?
3. if mass increases in size? |
|
Definition
1. surgical removal
2. CT scans at 6 mos for 3-4 years
3. surgery |
|
|
Term
___ is not secreted continuously but in pulses. it is required by too much causes receptor down regulation, causing FSH and LH secretion to cease.
functions: causes gonadotrophs to secrete gonadotropin hormones |
|
Definition
|
|
Term
Gonadotropins:
1. facilitate sperm production, cause sperm to undergo miosis
2. stimulate androgen steroid secretion
3. secreted by placental cells |
|
Definition
|
|
Term
Male endocrine negative feedback:
1. FSH neg feedback -- ___ secreted by sertoli cells and __ created from testosterone.
2. LH neg feedback by hypothalamic and pitutiary ___ levels. |
|
Definition
1. inhibin and estradiol
2. testosterone |
|
|
Term
| What happens if testes are unable to produce adequate testosterone? |
|
Definition
| LH & FSH levels will be high |
|
|
Term
___ cells are the androgen producers
___ cells are the "support cells" for sperm. they secrete adrogen binding protein and mullerian inhbiting hormone |
|
Definition
|
|
Term
| What effects do androgens control? |
|
Definition
Hair pigmentation
muscle growth and maintenance
vocal cord chances
metabolic, behavioral, and reporductive effects |
|
|
Term
| disease in which germ cells fail to migrate from yolk sac to gonadal bridge -- results in no sperm production |
|
Definition
| sertoli cell only syndrome |
|
|
Term
Sx of _____:
- maybe none
- no or reduced testicular function - loss of muscle strength, decrased libido, decreased facial hair (don't need to shave as often), gynecomastia, low sperm count, overall loss of sense of well being, lack of energy, ED |
|
Definition
|
|
Term
| Classifying testicular failure... primary vs. secondary? |
|
Definition
primary: problem w/ testes
secondary: problem w/ FSH and LH |
|
|
Term
| Low sperm count + low/normal FSH & LH = ? |
|
Definition
secondary testicular failure
LH and FSH should rise when sperm count drops |
|
|
Term
type of secondary testicular failure characterized by lack of gonadotropins
type of primary testicular failure - defective development of testes or ovaries characterized by increased levels of gonadotropins |
|
Definition
hypogonadotropic hypogonadism
hypergonadotropic hypogonadism |
|
|
Term
Gonadal dysfunction
- pubertal delay
- low androgens
- poor/absent spermatogenesis
altered testosterone/estradiol (T/E) ratio
- gynecomastia
increased risk of breast cancer |
|
Definition
|
|
Term
| tx for hypogonadism (secondary and primary) |
|
Definition
general: androgen replacement/supplementation
secondary: gonadotropins or GnRH |
|
|
Term
| 55 y/o male with nightsweats. what is one thing that should be in your ddx? |
|
Definition
|
|
Term
| when is a man a candidate for testosterone replacement? |
|
Definition
serum <200 ng/dl
older w/ sx of hypogonadism |
|
|
Term
azoospermia
oligospermia
asthenospermia
sperm problems are __% of causes of infertility |
|
Definition
azoospermia - no sperm
oligospermia - low sperm count
asthenospermia - normal #, reduced motility
35% |
|
|
Term
Semen analysis:
1. concentration
2. volume
3. motility
TMC? |
|
Definition
1. concentration:
normal >20 mil/ml
mild/mod 10-19 mil/ml
severe 5-9 mil
very severe <5 mil
2. volume:
only a problem if <1ml or >10ml
3. motility:
Normal: >40%
mild/mod: 20-39%
Severe: 10-19%
very severe: <10%
Total motile count: (vol x conc x motility). Normal is >35 mil |
|
|
Term
What to tell pts?
1. mild-mod problem
2. severe or very severe |
|
Definition
1. fertility w/o tx is possible
sperm count <15 mil, motility 35%
2. fertility w/o tx very unlikely
IV w/ ICSI is only chance
<5 mil no matter what motility or <5% motility with <15 million sperm
with azoospermia/oligospermia there is a very high chance of chromosomal anomaly - need to do genetic analysis |
|
|
Term
| Major risk factors for atherosclerosis/cardiovascular disease are? 7 |
|
Definition
high LDL
low HDL
smoking
HTN
DM
age
fm hx of premature CHD |
|
|
Term
| states that increased plamsa cholesterol increases the risk of CHD -- diets high in fat and cholesterol increase plasma cholesterol |
|
Definition
| cholesterol-diet-CHD hypothesis |
|
|
Term
|
Definition
oxidized LDL --> macrophages --> foam cells --> fatty streak --> lesion becomes fibrous and extends
All this is an INFLAMMATORY process |
|
|
Term
Healthy levels:
1. total cholesterol
2. LDL
3. HDL
4. Trigs |
|
Definition
1. total: <200 mg/dL ideal, >240 is high
2. LDL: <100 ideal, >190 very high
3. HDL: >60 is good, <40 is bad
4. <150 is good, >500 is very high |
|
|
Term
dyslipidemia
most common kind? |
|
Definition
Good LDL but low HDL and high Trigs
most common - secondary - due to DM or hypothyroidism |
|
|
Term
relatively common disorder caused by mutations in LDL receptor gene that results in LDL malfuction or absence in cells -- leads to elevated plasma LDL and total cholesterol
Plasma trigs not elevated
PE: xanthalasma, tendon xanthomas |
|
Definition
familial hypercholesterolemia
if LDL >200, think this |
|
|
Term
autosomal dominant trait of unknown cause causing elevated plasma cholesterol, trigs, and increased susceptibility to CHD
Features:
- mod elevation of plasma cholesterol and trigs or both
- affected family members
- NO XANTHOMAS!
- premature CHD |
|
Definition
| familial combined hyperlipidemia |
|
|
Term
** Diagnostic criteria for metabolic syndrome **
waist circumference
Trigs
HDL
BP
fasting glucose |
|
Definition
waist: Men > 102cm, women >88 cm
Trigs: >150 or on drugs for high trigs
HDL: Men <40, women <50 or on drugs for HDL
BP: >130systolic or >85 diastolic or drugs for HTN
Fasting glucose: >100 or drugs for DM |
|
|
Term
mutation in apo-E gene resulting in defecting binding to receptors.
pt will say everybody in their fam has high trigs
pathognomonic: palmar xanthomas |
|
Definition
| type III hyperlipoproteinemia (Familial dysbetalipoproteinemia) |
|
|
Term
| Correcting ___ will often cure hypertriglyceridemia in type I DM |
|
Definition
|
|
Term
| Trigs > 2000 mg/dl, lipema retinalis, eruptive xanthomas, fatty liver, pancreatitis |
|
Definition
| diabetic lipema (caused by insulin deficiency) |
|
|
Term
| A1C is 14, trigs are 500. what's the next step? |
|
Definition
| start with insulin regimen |
|
|
Term
increased LDL
increased trigs
increased chylomicrons remnants
decreased HDL
NO xanthomas? |
|
Definition
| type 2 dm w/ insulin resistance |
|
|
Term
all pts with significant hyperlipidemia should be screened for ____
these pts often have:
increased LDL (250-600)
increased trigs
unchanged or slightly low HDL |
|
Definition
|
|
Term
___ therapy in postmenopausal women in known to increase CHD even risk in older women with a hx of MI
this increases trigs and LDL |
|
Definition
|
|
Term
| alcohol consumption and choleesterol |
|
Definition
|
|
Term
| ____ and cholesterol: incrased TC, lDL, trigs, plasma apo-B, TC:HDL ratio, and plasma LPa |
|
Definition
|
|
Term
| drugs that influence cholesterol |
|
Definition
glucocorticoids
thiazidees and B-blockers
exogenous androgens (reduce HDL) |
|
|
Term
Factors increasing LDL (5)
Factors increasing trigs (11)
Decreasing HDL |
|
Definition
LDL: hypothyroidism
obesity
pregnancy
cirrhosis
nephrotic syndrome
Trigs: DM, hypthyroid, obesity, CKD, pregnancy, alcohol, estrogen, diuretics, B-blockers, isoretinoids, corticosteroids
HDL: androgens, cigarettes, anabolic steroids, B blockers, obesity, progestogens |
|
|
Term
|
Definition
|
|
Term
| a major goal in the tx of severe hypertriglyceridemia is to avoid ____ |
|
Definition
|
|
Term
hypercholesterol tx:
1. pt w/ CHD or CHD equivalent
2. Pt w/o CHD or CHD equivalent |
|
Definition
1. lipid-lowering agent + lifestyles changes
2. lifestyle changes for 3-6 mos before starting therapy |
|
|
Term
| dietary changes for hyperlipidemia pts |
|
Definition
5-% of calories as carbs
30% as fats
20% as protein |
|
|
Term
|
Definition
1. statins (HMG-CoA reductase inhibitors)
2. bile acid sequestrants
3. ezetimibe
4. niacin, fibrates, omega-3 fatty acids |
|
|
Term
| everyone w/ DM >40 y/o needs to be on a ____, regardless of LDL |
|
Definition
|
|
Term
A 66 y/o WW presents for second opinion. During a recent visit to her gynecologist, her TC was 300mg/dl. The gynecologist prescribed a statin, but she is reluctant to take a medication. She has no other risk factors, has a healthy life style, and does not have CAD.
what is appropraite for this pt?
Initiation of statin therapy
Initiation of therapy with bile acid sequestrant
Measurement of fasting lipid profile
Initiation of therapy with ezetemibe |
|
Definition
| measurement of fasting lipid profile |
|
|
Term
30 y/o WM was recently discharged after being treated for acute pancreatitis, fasting lipids showed TGs of 1670 mg/dl.
Which of the following agents is appropriate for this the therapy of his hypertriglyceridemia?
Niacin
A statin
A bile acid sequestrant
Ezetemibe |
|
Definition
| niacin - best for lowering trigs |
|
|
Term
45 y/o WW with history of type 2 Diabetes that is well controlled on metformin 500 mg BID. She has no hx of HTN, no smoking, no presonal or family history of CAD. She excercises daily and follows low fat diet. Lab evaluations reveals a serum TC:220 mg/dl, HDL:42 mg/dl, LDL:141 mg/dl, TGs:185 mg/dl.
What is the next step in management.
Continue current diet and exercise program
Start low-carbohydrate diet
Start therapy with an HMG-CoA reductase inhibitor (a statin)
Start therapy with nicotinic acid
Start therapy with a bile acid sequestrant. |
|
Definition
statin - she has DM so she needs to be on a statin no matter what
|
|
|
Term
45 y/o WM with hx of CAD, has been taking simvastatin 40 mg daily, he exercises regularly and is following the therapeutic life style change diet. Lipids profile results: TC:200 mg/dl, LDL: 125 mg/dl, TGs:150 mg/dl, HDL: 41 mg/dl. Thyroid function and liver function are normal.
What is the most appropriate therapy for this patient.
Increase simvastatin dose to 80 mg daily
No further lipid lowering therpay
Add a bile acid sequestrant or ezetimibe
Add gemofibrozil, 150 mg BID |
|
Definition
| add bile acid sequestrant or ezetimibe -- had CHD so LDL needs to be below 100. |
|
|
Term
A 57 y/o Man with established coronary heart disease is being treated with atorvastatin, 40 mg daily. His current lipid profile is as follows:
TC:202,LDL:69,HDL:41,Triglycerides:315.
The next step in management should focus on which one of the following target values:
Serum total cholesterol <200mg/dl
Serum triglycerides <200 mg/dl
Serum HDL >45 mg/dl
Serum non-HDL <130 mg/dl
High sensitivity C-reactive protein <0.5mg/L |
|
Definition
serum non-HDL <130
tx: bile acid seq or ezetimibe to raise HDL |
|
|
Term
A 65 y/o Man is referred for an elevated blood pressure. BP was 165/95 mmHG. Fasting lipids: TC:284,LDL:190,HDL:34,Triglycerides 300. He smokes a pack of cigarettes per day, has sedentary life style and consumes fast food almost daily. He has no symptoms of coronoary artery disease. The patient’s Framigham risk is >30% for coronary artery disease within the next 10 years.
Most appropriate management?
Begin a theraputic life style changes (diet and exercise) with a f/u appointment in 6 months.
Begin therapy with a statin with the goal of lowering LDL to 130 mg/dl
Begin therapy with a statin with the goal of lowering LDL to <100 mg/dl and his non-HDL to <130 mg/dl
Begin therapy with a bile acid sequestrant
Begin therapy with an insulin sensitizer. |
|
Definition
begin statin w/ goal of lowering LDL to <100 mg/dl and non-HDL to <130 mg/dl
framingham score is >30%... need lower scores |
|
|
Term
Framingham study:
low, intermed, and high risk? |
|
Definition
Low <10% risk of CHD at 10 years
Intermediate: 10-20%
High: >20% |
|
|
Term
1. largest ca store in body?
2. regulates Ca excretion/absorption in presence of activated Vit D and PTH |
|
Definition
|
|
Term
what disease?
bones, stones, groans, psych undertones:
nephrolithiasis (stones - renal involvement)
bowel hypomotility/constipation (groans) & pancreatitis (moans) - GI involvement
osteopenia/osteoporosis (bones)
decreased concentraiton and confusion (psych)
also cardiovascular: bradycardia, HTN, shortened QT |
|
Definition
|
|
Term
2 main causes: hyperparathyroidism and cancer
sx: Bones, stones, groans, moans, psych undertones
studies: PTH, CXR, serum phosphate, 24 hr urine ca and cr, Vit D-25-OH, SPEP/UPEP
must repeat labs again to make dx |
|
Definition
hypercalcemia
(>10.5, >14 is deadly)
tx:
mild: hydration
mod-severe: hydration, forced diuresis, bisphosphonates
Ca restrictions |
|
|
Term
| 73 y/o WM presents from the hills with mental status changes, failure to thrive, no medication, no PCP, no supplements, (drinks a swig of Listerine daily which he swallows), Cr of 1.8, and Calcium (Ca) of 12.6. |
|
Definition
|
|
Term
What cause for hypercalcemia?
1. big fluctuations in PTH and no change in Ca
2. big fluctuations in Ca with no change in PTH |
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Definition
1. hyperparathyroidism
2. cancer |
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Term
PTH secreted almost instantly w/ decrease in ionized Ca
- PTH increases Ca by : increased bone reabsorption, incrased intestinal ca through calcitriol, decreased urinary ca
Indications for surgery – preop localization can be difficult…
Ca >1.0 mg/dL above the upper limit of normal
Creatinine clearance <60 mL/min
Osteoporosis of hip, lumbar spine, or distal radius
Age <50 years |
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Definition
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Term
Inactivation of CaSR (calcium sensing receptor)
Autosomal Dominant
24 hour urine calcium excretion
Ca/Cr clearance ratio less than 0.01 in 80% of cases
99% filtered Ca resorbed
Ca/Cr clearance ratio = [24-h Urine Ca x serum Cr] ÷ [Serum Ca x 24-h Urine Cr]
what drug can mimic this? |
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Definition
Familial hypcalciuric hypercalcemia (FHH)
HCTZ (thiazides) |
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Term
53 y/o WF, feeling well, just got back from wintering in Phoenix, routine physical
Ca of 10.8, Alb 3.9, PTH of <2
Additional questions? Lab?
No hx nephrolithiasis, no FH calcium problems, cancer |
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Definition
| cancer (high Ca, low PTH) |
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Term
68 y/o WF with fatigue, abdominal pain, decreased urinary output
Calcium 9.8 three months ago, now 15.8 with normal alb
On HCTZ for HTN
One month ago started taking vitamin D
cause of hypercalcemia? |
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Definition
| Vit D + HCTZ can both increase ca |
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Term
Signs/Symptoms
Often asymptomatic or lab abnormality (albumin correction)
Neuromuscular
Perioral numbness
Cvostek’s - contraction of the ipsilateral facial muscles elicited by tapping the facial nerve just anterior to the ear
Trousseau's - carpal spasm by inflation of a sphygmomanometer above systolic blood pressure for three minutes
Seizures
Myopathy
Prolonged QT
Intellectual impairment
Dry puffy skin, cataracts, dental hypoplasia, steatorrhea, skeletal abnormalities
most common causes?
tx? |
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Definition
hypocalcemia
most common cause: Vit D deficiency
also, pancreatitis, Mg def (alcoholism), hypoparathyroid, hypoalbuminemia
tx: ca and vit d supplements,
treat other causes |
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Term
83 y/o WF, bed bound nursing home resident with Alzheimer’s, slightly low calcium of 8.1 mg/dL (8.2-10.4), albumin of 4.0 (normal), PTH of 90 pg/mL, is on 1,200mg elemental calcium a day.
What lab do you check to make the diagnosis? |
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Definition
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Term
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Definition
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Term
55 y/o WM admitted for ETOH detoxification, chronic alcoholic without abdominal pain, has lived on the streets for months, has received multiple IV boluses of calcium for the past two days with a calcium level that just won’t normalize.
What lab do you check? |
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Definition
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Term
54 y/o WF with an undetectable calcium (<5.0) over the past 2 weeks, with an albumin of 2.0, a normal magnesium & potassium, and an elevated phosphorus.
What lab do you check to make the diagnosis? |
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Definition
| PTH - undetectable = hypoparathyroidism |
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Term
Causes of hypocalcemia:
1. decrased PTH and Ca
2. Decreased PTH and Ca, increased Phos
3. Decreaesed PTH, Ca, and Mg
4. Decreased Ca, increased PTH and Phosp
5. Decreased Ca, Phosp, and 25-oh-D, increased PTH
6. Decreased 25-OH-D and Ca, increased PTH, phos, Mg, Cr |
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Definition
1. hypoparathyroid
2. FHH
3. Hypomagnesmemia
3. Pseudohypoparathyroid
5. Vit D def
6. CKD |
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Term
45 y/o WF with goiter, and fatigue.
TSH = 46 high
Free T4 = 0.06 low |
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Definition
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Term
| complications of untreated hypothroidism |
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Definition
| hypercholesterolemia, diastolic dysfunction on echo, CAD |
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Term
| when to treat hypothyroid |
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Definition
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Term
Twin sister of Case #1, 45 y/o WF with goiter, fatigue, and feels her thyroid is messed up as well.
TSH = <0.001 low
FT4 = >6.0 high |
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Definition
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Term
| low TSH, elevated T4, pain, previous viral URI |
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Definition
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Term
| how do you make dx of hyperthyroid? |
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Definition
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Term
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Definition
beta blockers
refer to endocrine
graves - thyroid ablation, PTU
hot nodule - ablation
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Term
| complications of hyperthyroid |
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Definition
| a fib, CHF, osteoporosis, liver dz |
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Term
You are at the state fair in Colorado, checking people’s thyroid function studies for fun.
27 y/o WM, feels fine, with…
TSH = 0.02 - low
Free T4 = 1.2
What’s the diagnosis? |
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Definition
subclinical hyperthyroid
treat if high risk for bone/cardio complications or if uptake scan is high or bone scan is lwo |
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Term
Pt is on their way home from their Endocrinologists appointment, where they had a complete panel of thyroid function studies performed that were normal, including a TSH of 2.21 and they wreck their car.
You are consulted on them later that day for their hyperthyroidism, checked in the ICU, with the patient on a ventilator and a TSH of 0.02
What’s the diagnosis? |
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Definition
sick euthyroid syndrome
reverse T3 (rT3) increases, T4 low |
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Term
26 y/o WF presents in her 3rd trimester without prenatal care, with goiter but is feeling OK.
TSH is low
Free T4 is low
Total T3 is elevated
What’s the diagnosis? |
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Definition
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Term
62 y/o WM presents with SOB & facial flushing every time he has to lift his hands above his head at work.
What’s the name of this sign? |
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Definition
Pemberton's sign
can be caused by a really big goiter blocking artery |
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Term
| evaluation of thyroid nodule |
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Definition
–Is it functioning?
•Check a TSH FIRST
–If low proceed to uptake scan
–If normal proceed to fine needle aspiration (FNA)
–If elevated, how big is the nodule, may likely need hormone replacement if less than 1.5 cm.
–Is it cancer?
If TSH is normal --> FNA,
NOT ultrasound
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Term
| What does an insulin molecule actually do? |
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Definition
| Opens GLUT4 glucose transporters |
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Term
| GLucose transporter that will function regardless of DM status to take glucose to the brain - responsible for basal glucose uptake |
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Definition
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Term
1. Fasting blood glucose of 100-125
2. 2hr blood glucose of 140-199
3. fasting blood glucose of 126 or higher or 2 hr value 200 or high
what distinguishes between the two tests? |
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Definition
1. impaired fasting glucose (IFG)
2. impaired glucose tolerance (IGT)
3. Diabetes
1&2 are both "pre-DM"
glucose toelrance test (OGTT) is postprandial |
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Term
Classic onset of ____:
polyuria, polydipsia, weight loss, lethargy |
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Definition
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Term
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Definition
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Term
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Definition
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Term
| 4 characteristics of T2DM |
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Definition
| hyperglycemia, insulin resistance, relative insulin deficiency, associated w/ obesity |
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Term
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Definition
glycemic control
management of CV risks
prevention of microvascular complications
management of weight |
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Term
% of glycated hemoglobin
corresponds to BG avg for last 2-3 mos
modifies CV risk |
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Definition
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Term
DM Retinopathy:
1. characterized by?
2. risk reduced by ___ & ____ |
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Definition
1. neovasculization of blood vessels that burst and cause retinal hemorrhage and blindness
2. lowering A1C and seeing eye dr yearly |
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Term
Diabetic nephropathy is most common cause of ___ in developed countries
Hallmark: ____
Leads to renal failure and eventual dialysis
Reduce risk by? |
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Definition
renal failure
proteinuria marked by microalbuminuria and frank proteinuria
keeping A1C down and ACE/ARBs |
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Term
Therapeutic goals for CV disease and DM:
1. LDL if just DM
2. LDL if DM + CAD
3. BP
4 ? |
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Definition
LDL: <100
LDL <70 if CAD and DM
BP <130/80
Quit smoking! |
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Term
most common complication in DM-1
sx: tremor, pallor, palps, diaphoresis, fatigue, lethargy, HA, behavior changes, drowsy, unconcious, seizure, coma |
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Definition
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Term
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Definition
1. TDD:
Type 1: 0.5 units/kg/day
Type 2: 0.7 units/kg/day
2. Basal insulin:
Glargine/detemir: 1/2 (TDD)
NPH: AM dose 0.4xTDD, PM dose 0.2xTDD
3. Pre-meal insulin
lispro/aspart/glulisine - with glargine/detemir: 1/2 TDD divided equally between meals
regular - with NPH: 0.2xTDD in Am and PM
Correction dosing:
sensitivity factor = 2000/TDD
Correction dose = (current BG-target BG)/sensitivity factor
- target BG = 140 or 150
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Term
25 year old male
Polyuria, polydipsia
25 Lb Wt loss x 3 months
Glucose 418
A1c 13.2%
CO2 22, anion gap 10
Wt 68 kg
what tx? |
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Definition
Type 1 DM -- insulin only
68x0.5 = 34 units/day
glargine 17 units PM
aspart 17 units/3 = 6 units with each meal
correction factor (2000/34) = 59, (418-140)/59 = |
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Term
pt has hyperglycemia in AM and hypoglycemia over night.
dx and tx? |
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Definition
dawn phenomenon
- insulin pump |
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