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laracrystalo's version from 2016-07-17 14:30

CALCIUM AND BONE

Question Answer
when to start DEXA? 65 yo in women; 70 yo in men
osteoporosis scoreT is < -2.5
osteopenia scoreT of -1 --> -2.5
osteoporosis labs?normal
prevent osteoporosisCalcium, vit D, weight bearing exercise, stop smoking
tx osteoporosisbisphosphonates
paget increase risk of what cancer?osteosarcoma
paget associated with which disease?primary hyperparathyroid
loss of hearingpaget
paget labs?normal except elevated Alk Phos
tx severe paget dz?bisphosphonates
heart complication of paget?high output cardiac failure form AV connections
primary hyper PTH labshigh PTH, high Ca+, low phos
secondary hyper PTH labshigh PTH, nl/low Ca+, high phos
tertiary hyper PTH labshigh PTH, high Ca++, high phase
squamous cell cancer labshigh PTHrP with low PTH, high Ca+, nl/low phos
causes of primary hyper PTHhyper functioning adenoma, parathyroid hyperplasia
causes of secondary hyper PTHrenal insufficiency from decreased 1, 25 OH D causing physiologic increase in PTH, Ca++ deficiency, vitamin D deficiency
causes of tertiary hyper PTHdialysis its with longstanding secondary leads to hyperplasia of glands and then one or more become autonomous
short 4th metatarsal or carpal?think alright hereditary osteodystrophy causing pseudohypoparathyroidism
tx hypercalcemia?IVF, loop diuretics, bisphosphonates if malignancy, calcitonin
sx of hypercalcemia?stones, bones, groans, moans, psych overtones
does primary hyper PTH have calciuria?yes! if low ca+
what has low calciuria?familial hypocalciuric hypercalcemia (no tx necessary. asymptomatic)
list of causes of hypercalcemiahyper parathyroidism, vitamin D intoxication, sarcoidosis, thiazide diuretics, hyperthyroidism, bone metastasis, multiple myeloma, squamous cell cancer, immobilization, familial hypocalciuric hypercalcemia
short QThypercalcemia
long QThypocalcemia
causes of hypocalcemiaprimary hypo PTH from prior neck surgery like thyroidectomy, hypomagnesemia, renal failure, vitamin D deficiency, fat malabsorption, low albumin like in liver failure
signs of hypocalcemiafacial nerve hyper excitability, carpopedal spasm, perioral numbness, mental irritability, seizures, tetany
easily induced hypokalemia after starting thiazide diuretic?think primary hyperaldosteronism (conns)
what's the major source of estrogen in menopause?peripheral conversion of adrenal androgens by aromatase in adipose tissue (increased in obese women)
what is DHEAS associated with?adrenals
levels of hormones in anabolic steroid use?low LH and FSH and T by negative feedback
memorize

CORTISOL and ALDOSTERONE

Question Answer
cushing disease?ACTH secreting pituitary adenoma
low ACTH and bilateral adrenal atrophy?exogenous corticosteroids
low ACTH and atrophy of an adrenal?primary adrenal adenoma/hyperplasia or carcinoma
high ACTH and bilateral adrenal hyperplasia?ACTH secreting pituitary adenoma or paraneoplastic secretion from small cell or bronchial carcinoid
first step in diagnosis of cushing syndrome?free 24 hour urine cortisol (best) or 1mg overnight dexamethasone suppression test
cushing syndrome?hypercortisolism
second step in diagnosis of cushing syndrome?after cortisol levels are determined to be high, then measure ACTH. If low, it means adrenal source, if high, it could be from pituitary or from ectopic cancer.
in short, low ACTH determines the source to be ...the adrenals
3rd step in diagnosis of cushing syndrome?after determining high cortisol and ACTH levels, either do abd MRI for low ACTH to find adrenal cancer, OR do dexamethasone suppression test to determine if pituitary ACTH adenoma (suppresses) vs ectopic ACTH from lung cancer or carcinoid (does not suppress)
high cortisol, low ACTH?cortisol releasing adrenal adenoma
high cortisol, high ACTH with adequate suppression with dex?ACTH secreting pituitary adenoma (cushing disease)
what should you do if you think you have a pituitary secreting adenoma?MRI of brain, but sometimes too small to see, so then petrosal vein sampling for ACTH, after CRH. If elevated, it is confirmed.
high cortisol, high ACTH, no suppression with dex?ectopic ACTH secretion by small cell or bronchial carcinoid cancer
CRH stimulation test shows high ACTH?pituitary adenoma
CRH stimulation test shows low ACTH?ectopic ACTH by small cell or carcinoid
effects of high cortisol on sugar, fat, potassium, blood gases, WBC?hyperglycemia, hyperlipidemia, hypokalemia, metabolic alkalosis, leukocytosis
what happens if you find adrenal incidentaloma?blood or urine metanephrines to exclude phew, renin/aldo to exclude hyperaldosterone, 1mg overnight dex suppression test
what causes adrenal insufficiency?infection (TB, MAC), adrenoleukodystrophy (autoimmune), metastatic adrenal cancer, exogenous steroid withdrawal
signs of adrenal insufficiency?weak, fatigue, AMS, N/V/, hypotension, low Na+, high K+, hyper pigmentation
adrenal function test?cosyntropin stimulation test. measure cortisol before and after administration. Normal people should have a rise in cortisol after admin.
primary adrenal insufficiencyhigh ACTH, low aldosterone
secondary adrenal insufficiencylow ACT, high aldosterone
tx of adrenal insufficiency?hydrocortisone to replace steroids and fludrocortisone
eosinophilia is sign of ...hypoadrenalism
what do you measure to confirm acromegaly?IGF1
primary hyperaldosteronism causes?solitary adrenal adenoma or form bilateral hyperplasia
high BP and low K+? primary hyperaldosteronism
test for hyperaldosteronism?plasma aldosterone to renin ratio
primary hyper aldosterone levels?high aldo, low renin, low K+
what do you do once you have found high aldo, low K+, and low renin?CT scan to find adrenal adenoma or hyperplasia, then may need adrenal venous sampling
tx of bilateral adrenal hyperplasia?spironolactone or epleronone
tx of unilateral adrenal adenoma?conn syndrome, resection by laparoscopy
what causes HTN and low K+ with low renin and low aldosterone?CAH, steroid resistance, exogenous mineralocorticoids, cushing syndrome, altered aldosterone metabolism
signs of pheo?HTN, headache, sweating, palpitations
test for pheo?free metanephrines in plasma or urine
tx pheo?give phenoxybenzamine, an alpha blocker, then beta blocker and removed surgically by laparoscopy
causes of secondary hyper aldosteronism?renal artery stenosis, diuretics, cirrhosis, CHF, renin secreting tumor, malignant HTN, coarctation of aorta
levels in secondary hyper aldosteronism?high aldosterone, high renin
MEN 1pituitary, parathyroid, pancreatic
MEN2Aparathyroid, pheochromocytoma, medullary
MEN2Bpheochromocytoma, medullary, neuromas
memorize

SODIUM and WATER

Question Answer
hypothyroid can cause...hyponatremia
what causes central DI?stroke, brain tumor, trauma, hypoxia, infiltration of gland from sarcoidosis, or infection
what causes nephrogenic DI?chronic pyelonephritis, amyloidosis, myeloma, sickle cell disease, lithium, demeclocycline, hyperclacemia, hypokalemia
how does DI present?high volume urine and excessive thirst, volume depletion, hypernatremia
how does acute DI present?signs of hypernatremia like confusion, disorientation, lethargy, seizure, coma
labs of DI serum vs urine?high serum sodium, high serum osmolality, low serum volume, high urine volume, low urine osmolality, low urine Na+
how do you distinguish between central and nephrogenic?vasopressin stimulation test
what does vasopressin stimulation test show in central DI?urine volume decrease and urine osmolality increase
what does vasopressin stimulation test show in nephrogenic DI?change, still high urine volume, low urine osmolality, low urine sodium
how to treat central DI?vasopressin
how to treat nephrogenic DI?HCTZ, amiloride, NSAIDS, correct hypokalemia or hypercaclemia
euvolemic hyponatremia with continued urinary sodium excretion?SIADH
urine osmolality > serum osmolality?SIADH
tx SIADH?fluid restriction, hypertonic saline, conivaptan, demeclocycline
high serum osmolality > 290 causes?hyperglycemia or advanced renal failure
low serum osmolality and low urine osmolality causesprimary polydipsia, alcoholic malnutrition
low serum osmolality and high urine osmolality causes and high urine sodium causesSIADH, adrenal insufficiency, hypothyroid
low serum osmolality, high urine osmolality, high urine sodium causes?volume depletion, CHF, cirrhosis
if urine osmolality is less than 100, think...primary polydipsia
urine osmolality increases with vasopressin in ...central DI
urine osmolality remains unchanged with vasopressin in ...nephrogenic DI
high urine osmolality after water deprivation test?primary polydipsia
memorize

TSH

Question Answer
associated with lymphomaHashimoto
most common complication of thyroidectomyhypocalcemia (anxiety, muscle cramps, poor sleep, long QT)
how does low magnesium affect PTH?decreased PTH causes low calcium in alcoholics
congenital hypothyroid most commonly due tothyroid dysgenesis in america. In developing world due to iodide deficiency
tx congenital hypothyroid withlevothyroxine
what is the most common cause of symptomatic hypercalcemia?cancer
what is the most common cause of asymptomatic hypercalcemia?primary hyper PTH
euthyroid sick syndromelow T3 syndrome that happens in acute, severe illness. normal T4 and TSH
hypothyroid associated with what other labsHLD, hyper TG, low Na+, elevated CK, elevated AST/ALT
tx hypothyroid in pregnancy?with PTU
what is myxedema coma and how do you treat?hypothyroid crisis tx: intubate, IVF, thyroxine
what is thyroid storm and how do you treat?tachycardia, HTN, arrhythmia, fever, tremor, AMS, lid lag triggered by surgery, trauma, infection, childbirth. Tx with propranolol, IVF, PTU, steroids, eventually surgery ablation
generalized resistance to thyroidhigh serum T4 and T3 with normal to mildly elevated TSH. Symptoms of hypothyroid despite high levels of everything
cretinismfetal hypothyroidism. small, MR, umbilical hernia, jaundice, big tongue
neonatal thyrotoxicosis due to ...transplacental passage of maternal anti-TSH receptor antibodies
tx neonatal thyrotoxicosis?methimazole and beta blocker
what is systolic HTN in thyrotoxicosis caused by?hyper dynamic circulation from increased myocardial contractility and HR
risks of untreated hyperthyroid?rapid bone loss (osteoporosis), cardiac tachyarrhythmia (fib), proximal muscle weakness and atrophy
what antibodies in graves aphthalmopathy?antithyrotropin R autoantibodies
how is thyroid related to prolactin?prolactin is stimulated by 5HT and TRH, inhibited by DA. Hypothyroid can stimulate amenorrhea and galactorrhea
memorize