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ENDOCRINE Group 10 Pituitary Disease Panhypopituitarism Which hormones are lost first? The least life threatening lost first: FSH, LH Which pituitary disorder affects the pituitary gland itself? Secondary disorders A patient comes to you complaining of loss of axillary, pubic and body hair. He also complains of losing his sense of smell. What is the most likely diagnosis? Kallman’s syndrome True or false: In adrenal deficiency there will be hyperpigmentation. • FALSE Most common tumor causing hypopituitarism in children Craniopharyngioma Common signs and symptoms of a basilar skull fracture: Bilateral ecchymosis “Battle sign”-ecchymosis of mastoid Clear otorrhea or rhinorrhea Patient comes in one week after delivering her baby complaining of no lactation and loss of pubic and axillary hair. What is the diagnosis? Sheehan’s syndrome What is the treatment of choice for a pituitary adenoma? Transphenoidal microsurgery Hyperprolactinemia What is prolactin inhibitory factor (PIF)? Dopamine Treatment of choice? Medical preferred over surgical • Bromocriptine Patient comes to your office complaining that recently he has had trouble fitting in his gloves, hat and shoes. Upon physical exam you notice protrusion of the jaw and enlargening of the tongue. What is your diagnosis? Acromegaly True or false: Desmopressin is used for the treatment of nephrogenic Diabetes insipidus • FALSE- it it used for central diabetes insipidus where the production of ADH is deficient • In nephrogenic DI, ADH levels are normal, but there is a defect in kidney tubules that interferes with water reabsorption Secondary causes of nephrogenic DI: Hypercalcemia Hypokalemia A euvolemic hyponatremia is common in which disease? SIADHSyndrome of Inappropriate Antidiuretic Hormone Secretion What is a complication of correcting SIADH too rapidly? Contraction of brain cells resulting in demyelination ADRENAL What hormone causes reabsorption of Na at the level of the kidney? Aldosterone Two major causes for aldosterone release? Hypovolemia or hypokalemia What hormone counters insulin’s effects, is increased with stress/trauma, with a diurnal pattern? Cortisol How does it counter insulin’s effects in the body? Hyperglycemia, increases hepatic gluconeogenesis. What hormone is responsible for the development of secondary sex characteristic? Androgens These hormones are also neurotransmitters in the CNS? Catecholamines: Epinephrine, Norepinephrine MCC of hyperaldosteronism? Conn’s syndrome. Etiology? Unilateral adrenal aldosterone producing adenoma Aldosterone to renin ratio in primary hyperaldosteronism? Increases plasma aldosterone to renin ratio How do you perform a aldosterone suppression test? Give Na and aldosterone is not suppressed. Central obesity with striae and thin extremities, HTN, DM, glucose intolerance, proximal muscle weakness? Hypercortisolism Two additional common signs? Moon face, buffalo hump. Prolonged use of exogenous steroids or ACTH causes? Cushing’s Syndrome What causes Cushing’s Disease? Increased pituitary secretion of ACTH Common etiology? Pituitary adenoma First diagnostic test for Cushing’s? 24 hr urine cortisol Second Test? Low dose dexamethasone for suppression Third diagnostic test? ACTH If decreased, then? It’s adrenal. Fourth diagnostic test? High dose dexamethasone. If it doesn’t suppress ACTH then what? Tumor is ectopic. Weight loss, salt cravings, hyperpigmentation, abdominal pain? Addison’s MCC Addison’s in US? Autoimmune Worldwide? TB What are the two stimulation diagnostic tests for Addison’s? Cosyntropin and Metyrapone Increased K, decreased Na, decreased cortisol, decreased aldosterone, decreased androgen, ACTH increased? Primary or secondary Addison’s? Primary Paroxysmal HTN, sweating, headache, palpitations, hyperglycemia, flushing, orthostatic hypotension? Pheochromocytoma Diagnostic TOC? Metanephrine and vanillylmandelic acid TOC pre-op a-blockers and b-blockers, w/venous ligation and removal of gland Parahyperthyroidism, pancreatic islet cell tumor, pituitary tumor MEN I- Wermer’s presentation Parahyperthyroidism, adrenal tumor, thyroid (medullary carcinoma) MEN IIA- Sipple syndrome Mucosal/GI, Marfanoid, adrenal (pheochromocytoma), thyroid (medullary carcinoma) MEN IIB- Mucosal and GI Increased blood Ca, increased PTH? Hyperparathyroidism Manifestation? Stones, bones, groans, psychic overtones, and short Q-T What substance do you take into account when measuring the Ca level? Albumin Decreased Ca, prolonged Q-T, paresthesias, muscles cramps, hyperactive DTRs? Hypoparathyroidism What special signs can you test for in PE? Chvostek’s and Trousseau’s Chovostek’s sign- is a carpal spasm with use of BP cuff. True/False? False Decreased Ca, increase PTH, short stature, round face, short 4th metacarpal, and mental retardation? Pseudo- hypoparathyroidism THYROID DISEASES Where The Hypothalmus Where is TSH released from? Anterior Pituitary Where is TRH released from? is T3 & T4 released from? Thyroid What is the major hormone secreted into circulation and converted in the cell? T4 Why is thyroid hormone critical in children? Brain and musculoskeletal development. What happen without it? Growth impairment and mental retardation What form of hypothyroidism is this? Congenital Tx: prompt T4 What substance is required to produce thyroid hormone? Iodide Where do we get it? Salt Iodine deficiency is the MCC of primary hypothyroidism in the US? True or False False It is, however, the MCC worldwide Patient presents with fatigue, SOB, hair loss and cold intolerance? DX? Hypothyroidism Other Slow movement/speech, weight gain PE will reveal… Delayed DTRs, non-pitting edema, cool pale skin, loss of lateral 1/3 of eyebrow Labs reveal: Low TSH MCC symptoms include? of primary hypothyroidism Hashimotos’s Etiology? Autoimmune What is the most severe form of Hypothyroidism? Myexedema Coma. Presentation? Hypothermia, respiratory depression, cardio collapse Patient presents with anxiousness, thinning hair, muscle weakness and heat intolerance. DX? Hyperthyroidism Additional Increased appetite and weight loss PE reveals? Warm and moist skin, tachycardia, hyperreflexia, and exophthalmus Initial lab indicator? Low TSH; Why? negative feedback Second symptoms include? lab: T4 high What will be seen on radioactive iodine uptake? Increased uptake. TOC radioiodine ablation MCC for hyperthyroidism? of hyperthyroidism? Grave’s disease Patient presents with exaggerated hyperthyroidism plus delirium, CHF, stupor and fever. Dx? Thyroid storm Tx: beta- blockers anti-thyroid agents Dexamethasone Supportive Tx: IV fluids and cooling blankets Can you name a rare cause hyperthyroidism…. Hint: it has nothing to do with the thyroid gland? Ovarian dermoid tumor containing thyroid tissue. What is the most common cause of diabetic hospital admissions? Problems with the feet- peripheral neuropathy Stocking and glove distribution refers to what? Loss of perception of vibrations, temperature, touch, position sense, and altered pain perception Where are the most common area for an ulcer in diabetic patients? Dorsal portion of toes, plantar of metatarsal heads and heel Your patient has just been diagnosed with diabetes- educate the patient on changes that may need to be made. Shoes Checking feet regularly for ulcers Moisturizers Glucose control Yearly podiatry assessments Gonadal Dysfunction Total Chromosomal number and sex chromosome in females • 46 and XX Total Chromosomal number and sex chromosome in males? • 46 and XY A tall person comes to your office with… decrease facial and axillary hair Gynecomastia High voice Decrease libido Small/firm testes What would you predict the person’s chromosome are? 46 and XXX What would you notice in the physical of a person with turner’s syndrome? Webbing of the neck Short stature Short 4th metacarpal Mutiple congenital abnormalites to heart and kidney. What you would be the treatment? Estrogen replacement High dose of recombinant growth hormone Cardiac and renal evaluation What is the karotype of the following? Female pseudohermaphroditism • 46XX karyotype Male pseudohermaphroditism • 46XY karyotype True hermaphoditism • Have both 46XX and 46XY Upon phsical examination you notice clitoral enlargement and excessive production of androgens. Your likely dx? • Female pseudohermaphroditism Is the patient able bear child? • Yes What is the likely Dx? Upon • • • • Test physical you note… Blind vagina Sparse axillary and pubic hair Testes are present in abdomen Breast development show.. • Testosterone level • Xy karotyping • LH high and FSH normal Testicular What feminization syndrome would be your therapy? • Estrogen Diabetes Mellitus Type 1 Hyperglycemia is caused from? Low insulin secretion or Insulin resistance and low secretion Most common etiology is? Autoimmune from beta islet cell destruction MC in Scandinavia and northern Europe Dependent on insulin for life (unlike idiopathic form of DM) What genetic markers predispose you to DM 1? Human Leukocyte Antigen- 95% have HLA DR3 or HLA DR4 Circulating Islet Cell Antibodies- 85% of patients test in 1st week of onset What are some common clinical presentations? *Polyphagia, polydypsia, polyuria *Weight loss/inability to gain weight Blurry vision Diabetic Neuropathy *Ketoacidosis Abdominal Pain What are some manifestations of ketoacidosis? Deficiency Lipolysis Free Fatty Acids Ketonemia Metabolic Acidosis Fruity Breath Odor (acetone) Dehydration (hypotension, tachycardia) Kussmaul’s Respiration (rapid deep breathing)- corrects acid base disorder Insulin How do you treat DKA? 0.9% NS for 1 hr Then 0.45% NS with dextrose (prevent hypoglycemia) for 3 hrs Insulin Replacement K+ replacement (as needed)- from fluid loss and intracellular shift of K+ into cells due to insulin replacement Tx Underlying Cause What is the best screening test for DM? Fasting Plasma Glucose How long do you fast for? Fast for 8 hours prior to the test What is the reference range of the fasting plasma glucose? FPG <100mg/dl = reference range What is the impaired fasting range? FPG ≥ 100 mg/dl = impaired fasting glucose What is the range that is diagnostic for DM? FPG ≥ 126 mg/dl = diagnostic of DM (must be done 2x) What is the best test to diagnose DM? Oral Glucose Tolerance Test Can you fill in this chart? Value after 1 hr of Fasting (fasting plasma glucose) Reference Range Impaired Glucose Tolerance Dx DM Value after 2 hrs of glucose (Glucose Load) Answers Value after 1 hr of Fasting (fasting plasma glucose) Value after 2 hrs of glucose (Glucose Load) Reference Range < 110 mg/dl < 140 mg/dl Impaired Glucose Tolerance 110-125 mg/dl ≥ 140 and <200 mg/dl Dx DM ≥ 126 mg/dl ≥ 200 mg/dl What is measured as a screening tool for DM to log glycemic control? Hemoglobin A1C (not diagnostic) What percent saturation should a diabetic patient strive for with Hgb A1C? Should be saturated < 6.5% What are some lab findings of DM 1? Microalbuminuria Ketonuria Glucose in Urine Anti-insulin Antibodies Hypoinsulinemia Insulin What are 2 names of a “rapid form” of insulin? Rapid- Lispro and Aspart What is a name of a “short acting” insulin? Short- Regular What is a name of an “intermediate acting” insulin? Intermediate- NPH and Lente What is a name of a “long acting” insulin? Long- Ultralente What is the most commonly used combination amounts of NPH and Regular? MC Combination- 70 NPH/30 Regular What is the pathophysiology of the Somogyi Effect? 1 patient takes insulin at night Patient becomes hypoglycemic Counter-Regulatory hormones cortisol and glucagon are released Glucagon releases glucose from liver Cortisol increases insulin resistance Patient awakens with hyperglycemia What is the treatment? Treatment- Reduce night insulin dose DM What is the Dawn Phenomenon? Increase in plasma glucose levels between 5 and 9 a.m., without preceding hypoglycemia Which type of DM does this affect? DM Type 1 and 2 Why is there hyperglycemia? Attributed to desensitization effects of growth hormone and insulin on tissues May cause mild hyperglycemia or may add to the Somgyi Effect What are some Microvascular Complications of DM 1? Retinopathy Nephropathy Neuropathy What are some Macrovascular Complications of DM 1? Cardiovascular Disease Cerebrovascular Disease Peripheral Vascular Disease Type II Diabetes What are some of the clinical features that are associated with DM 2? polydipsia polyuria Blurry vision Age: greater than 30 Race: African American, Native American, Hispanics, Asians Associated with HTN, Dyslipidemia A pregnant 28 y.o presents to your office with elevated glucose levels What is the DX? -Gestational Diabetes What are some of the Complications associated with this disease? -Birth defects, -Fatal macrosomnia -Birth trauma -Resp. distress What are some dermatological findings associated with DM 2? Acanthosis nicgricans Xanthomas Ulcerations Gangrene Necrobiosis Lipoidica What would you expect to see on a urine dip stick? Glycosuria Proteinuria Very little ketoneuria What are some complications that are associated with DM 2? Peripheral neuropathy Atherosclerosis Retinopathy PVD Nephropathy A patient presents with the following symptoms: Chronic watery diarrhea Weight loss Colickly abdominal pain *FLUSHING and Dehydration* What is the Dx? Vipoma