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TiKi TaKa CK ENDOCRINOLOGY
TiKi TaKa CK ENDOCRINOLOGY
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. THYROID DISEASES:
___________________
___________________
. HYPOTHYROIDISM:
_________________
* PRIMARY Hypothyroidism * * Secondary Hypothyroidism * * TERTIARY
Hypothyroidism *
________________________ _________________________
_________________________
. -- T3 & T4. . -- T3 & T4. . -- T3 & T4.
. ++ TSH. . -- or normal TSH. . -- or normal TSH.
. Ex: Auto-immune Hashimoto's.
. HASHIMOTO's THYROIDITIS:
__________________________
. Hypothyroidism symptoms: Slow, tired, fatigued pt with weight gain.
. Anti-TPO Abs (Anti-thyroid peroxidase antibodies).
. -- T4 & ++ TSH.
. Tx -> T4 or thyroxine replacement.
. High risk of developing THYROID LYMPHOMA.
A . 1st step -> Cilinical evaluation - TSH level & thyroid ULTRA$OUND.
______________________________________________________________________
C . TSH LEVEL ??
________________
. Normal or ++ -> FNAB.
. -- Low -------> D. (I 123 scintigraphy).
D . I - 123 scintigraphy:
_________________________
. HYPER-functional (HOT) nodule -> Treat hyperthyroidism.
. HYPO-functional (COLD) nodule -> FNAB.
. FACTITIOUS THYROTOXICOSIS:
____________________________
. Due to exogenous thyroid hormone.
. H/O of psychiatric illness or attempted weight loss (Herbal remedy!).
. Thyrotoxicosis syms (Palpitations - sweating - weight loss - hyperactivity &
diarrhea).
. Lid lag may be present but NO exophthalmos (Excluding Grave's dis.).
. The ingested thyroid hormone disturbs the native thyroid axis !
. RAIU is decreased (-- Radio Active Iodine Uptake).
. Dx -> "LOW SERUM THYROGLOBULIN" is the main stay of diagnosis.
. Dx -> -- TSH & ++ T3 &/or T4.
. TOXIC ADENOMA:
________________
. ++ T4 & -- TSH levels.
. Symptoms suggestive of thyrotoxicosis.
. Radioactive uptake in the nodule & suppression of uptake ith rest of the thyroid
gland.
. No infiltrative ophthalmopathy.
# THYROID MALIGNANCIES:
_______________________
1 * PAPILLARY CARCINOMA:
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-> MOST COMMON TYPE & BEST PROGNOSIS.
-> Slow infiltrative local spread.
-> Presence of PSAMMOMA bodies.
2 * MEDULLARY CARCINOMA:
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-> CALCITONIN secretion.
3 * FOLLICULAR CARCINOMA:
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-> Invasion of the tumor capsule & blood vessels.
-> Early metastasis to distant organs.
* MEN TYPE 1:
______________
. Parathyroid adenoma.
. Pituitary tumor.
. Pancreatic tumor.
. {Mutation in the MEN 1 tumor suppressor gene}.
. DM SCREENING TESTS:
_____________________
. DKA MANAGEMENT:
_________________
.1. RAPID INTRAVENOUS NORMAL SALINE (0.9% SALINE).
.2. RAPID INTRAVENOUS REGULAR INSULIN.
.3. K correction.
.4. TTT of infections e.g. Abs.
_______________________________ ....................
________________________________
. DIABETIC KETOACIDOSIS (DKA) .................... HYPEROSMOLAR HYPERGLYCEMIC
STATE
________________________________ ....................
________________________________
. Type (1) DM usually. ____________________ . Type (2) DM.
. YOUNGER age. ____________________ . Older.
. LESS confusion. ____________________ . MORE confusion.
. Hyperventillation MORE common ____________________ . Less common.
. Abdominal pain MORE common. ____________________ . LESS common.
___________________________________________________________________________________
___
. Glucose 250 - 500 mg/dl. ____________________ . > 600
. HCO3 < 18 meq/L. ____________________ . > 18
. +++++ ANION GAP. ____________________ . NORMAL.
. POSITIVE serum ketones. ____________________ . NEGATIVE.
. Serum osmolality < 320 ____________________ . > 320.
. DIABETIC NEPHROPATHY:
_______________________
. Begins with HYPERFILTRATION (++GFR) & MICROALBUMINURIA.
. If not ttt well .. Micro becomes Macroalbumiuria > 300 mg/dl.
. INTENSIVE BLOOD PRESSURE CONTROL to prevent worsenening of the condition.
. Use ACE Is with blood pressure goal 130/80 mmHg.
. Most sensitive screening test is -> RANDOM URINE MICRO-ALBUMIN/CREATININE RATIO.
. DIABETIC NEUROPATHY:
______________________
. DISTAL SYMMETRIC SENSORIMOTOR PLOYNEUROPATHY.
. STOCKING GLOVE pattern.
. It is the most common risk factor of foot ulcerations in diabetics.
. Tx -> TCAs (Amitriptyline - Gabapentin).
. DIABETIC GASTROPATHY:
_______________________
. Autonomic neuropathy of the GIT.
. Symptoms of delayed gastric emptying & gastroparesis.
. -- Esophageal dysmotility -> Dysphagia.
. -- Gastric emptying -------> Gastroparesis.
. Gastroparesis (Nausea - vomiting - early satiety - postprandial fullness).
. -- intestinal function ----> diarrhea - constipation - incontinence.
. Tx -> DN control - SMALL FREQUENT MEALS - METOCLOPROMIDE (prokinetic &
Antiemitic).
. SEs of Metoclopromide -> Extrapyramidal syms -> Tardive dyskinesia (Give
Erythromycin).
. INSULINOMA:
_____________
. BETA CELL TUMOR.
. Normally, blood glucose < 60 mg/dl result in complete suppression of insulin
secretion.
. Hypoglycemia in the presence of inappropriately ++ serum insulin levels =
insulinoma.
. ++ C-peptide level.
. ++ Pro-insulin.
. DIABETES INSIPIDUS:
_____________________
. Due to ADH defeciency or resistance.
. Urine osmolality is < serum osmolality.
. Polyurea & polydipsia.
. H/O of tendency to COLD BEVERAGES to QUENCH THIRST.
. Exclude psychogenic polydipsia using water deprivation test.
. Differentiate bet. central & nephrogenic DI using ARGININE VASOPRESSIN.
. Tx -> NORMAL SALINE.
. Tx -> CENTRAL -> INTRANASAL SPRAY DDAVP.
. Tx -> NEPHROGENIC -> NSAIDs & HCZ.
. BOTTOM LINE:
______________
* Diabetes insipidus:
______________________
. Polyurea - polydipsia - excretion of diluted urine with ++ serum osmolality.
. HYPER-VITAMINOSIS "D":
________________________
. H/O of trials of weight loss with vitamin supplementations.
. Vit. D ++ Ca absorption -> Hypercalcemia.
. Constipation - Abd. pain - Polyurea - Polydipsia.
. METABOLIC $YNDROME:
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1- ABDOMINAL OBESITY -> Waist circumference (Men > 40 & Women > 35 inches).
2- DIABETIS MELLITIS -> Fasting glucose > 100 - 110 mg/dl.
3- HYPERTENSION ------> Blood pressure > 130/80 mmHg.
4- HYPERLIPIDEMIA ----> Triglycerides > 150 mg/dl & HDL (Men < 40 & Women < 50
mg/dl).
. ACROMEGALY:
_____________
. ++ GROWTH hormone by SOMATOtroph PITUITARY ADENOMA.
. GH -> ++ IGF-1.
. IGF-1 ++ growth of bones & soft tissues.
. Coarse facial features - arthralgia - uncontrolled HTN - skin tags.
. Carpal tunnel $.
. Dx -> The MOST SENSITIVE TEST is -> IGF-1 level (GH level fluctuations is
deceiving).
. Suppression of GH by giving glucose excludes acromegaly.
. MRI -> Pituitary lesion.
. Tx -> Surgical resection with trans-sphenoidal removal.
. Tx -> Somatostatin - Cabergoline or bromocriptine.
. MOST COMMON CAUSE OF DEATH is CONGESTVE HEART FAILURE.
. Non cardiac causes of death: stroke - cancer colon - renal failure.
. PROLACTINOMA:
_______________
. Prolactin secreting micro-adenoma.
. Pituitary tumor < 10 mm in diameter is called micro-adenoma.
. Amenorrhea & galactorrhea in females.
. Hypogonadism in males.
. Its small size can't lead to mass effects of ++ ICT.
. Tx -> 1st line is medical ttt with Dopamine agonists (CABERGOLINE or
BROMOCRIPTINE).
. Cabergoline normalizes the prolactin level & shrinks the tumor's size.
# CALCIUM HOMEOSTASIS:
______________________
. 3 forms of calcium (ionized Ca 45% - Albumin bound Ca 40% - Inorganic anions
bound Ca).
. Albumin plays an imp. role !
. Pts with hypo-albuminemia can have a low level of total plasma ca,
. However ,, They may NOT present with clinical hypocalcemia,
. Because their level of ionized calcium (physilologically active form) remained
normal.
. So .. it is imp. to calculate the CORRECTED SERUM CALCIUM LEVEL.
. CORRECTED SERUM CALCIUM LEVEL = TOTAL Ca + 0.8 (4 - Serum Albumin).
. Another rough method,
. With every 1 g/dl change in serum albumin level from 4 g/dl,
. there is a change in total plasma Ca level by 0.8 mg/dl.
. PRIMARY HYPO-THYROIDISM:
__________________________
. Causes -> post-surgical- congenital absence - autoimmune.
. Post surgical may occur after thyroidectomy & removal of 3.5 out of 4
parathyroids.
. -- Ca -> perioral tingling - numbness - ms cramps - carpopedal spasms -
seizures.
. EKG -> prolongation of the QT interval.
. PRIMARY HYPER-PARA-THYROIDISM:
________________________________
. Causes -> Parathyroid adenoma (90%) - hyperplasia (6%) & carcinoma (2%).
. Associated with MEN 1 & 2A.
. 80 % of pts are asymptomatic.
. Abdominal groans, renal stones, bones #s & psychic moans.
. ++ Ca & -- PO4 & ++ or normal PTH.
. 24 hours urinary calcium > 250 mg.
. Urinary calcium/creatinine > 0.02 (To rule out familial hypo-calciuric hyper-
calcemia).
. Dx -> 3Ds SESTAMIBI scan + U/$ to locate the hyperactive parathyroid tissue
presurgery.
. Tx -> Parathyroidectomy for symptomatic pts.
. Surgery indications:
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-> Serum Ca level > 1 mg/dl above the upper limit of normal (11mg/dl).
-> Young age < 50 ys.
-> Bone mineral density < T-2.5 at any stage.
-> -- Renal function (GFR < 60ml/min.).
. HYPERCALCEMIA of MALIGNANCY:
______________________________
. ++ Ca -> confusion - lethargy - fatigue - anorexia - polyuria & constipation.
. Associated with SQUAMOUS cell lung cancer.
. CXR finding of lung cancer (lobar mass & perihilar lymphadenopathy).
. Malignancy produces PTH related peptide PTHrP -> ++ Ca & -- PO4.
.| .| .| .| .|
.Immobilization
. PAN-HYPO-PITUITARISM:
_______________________
* Pituitary tumors are the most common cause by exerting pressure on pituitary
cells.
* HYPOTHYROIDISM (Central):
___________________________
-> Fatigue, cold intolerance, -- appetite, constipation & dry skin.
-> Bradycardia, delayed relaxation phase of DTRs & anemia.
* -- GONADOTROPINS:
___________________
-> Women -> Amenorrhea, infertility & hot flashes.
-> Men -> -- energy & libido.
. OSTEOPOROSIS:
_______________
. Postmenopausal woman.
. presenting with multiple bony #s.
. NORMAL serum Ca - PO4 & PTH.
. OSTEOMALACIA:
_______________
. Vit. D defeciency in ADULTS.
. Bony pain & tendrness.
. -- serum Ca & PO4.
. -- urinary Ca.
. ++ ALP & ++ PTH.
. -- 25 OH-D.
. X-ray -> BILATERAL SYMMETRIC PSEUDO-FRACTURES (LOOSER ZONES).
. PAGET's DISEASE:
__________________
. NORMAL serum Ca - PO4 & PTH.
. INCREASED ++ ALKALINE PHOSPHATASE.
. Tx -> BIPHOSPHONATES -> inhibit OsteoCLASTs asctivity.
.. CAUSES of HYPOKALEMIA & ++ BOTH ALDOSTERONE & RENIN -> (Check Cl):
_____________________________________________________________________
. SURREPTITIOUS VOMITING:
_________________________
. Scars & calluses on the dorsum of the hands & dental erosions.
. Result from chemical & mechanical injury as the pt uses his hands to induce
vomiting.
. Dental erosions result due to ++ exposure to gastric acid..
. May lead to hypovolemia & hypochloremia -> Low urine Cl level.
# ADRENAL DISORDERS:
____________________
____________________
________________________________________________________________________________
. Sources of Cushing $ ------> Pituitary tumor - Ectopic - ACTH Adrenal adenoma:
________________________________________________________________________________
. ACTH ----------------------> HIGH - HIGH - LOW.
. High dose dexamethazone ---> Suppression - No - No.
. Specific tests ------------> MRI - CT - CT adrenals.
. Tx ------------------------> Removal - Removal - Removal.
. Dx -> Measure (PA:PRA) -> Plasma Aldosterone : Plasma Renin Activity ratio.
. Result -> ++ Plasma Aldosterone & -- Plasma Renin Activity i.e. Ratio > 30 !
. (PA:PRA) -> is the most specific test.
.4. PHEOCHROMOCYTOMA:
_____________________
. Headache, palpitations, tremors, anxiety & flushing.
. Episodic elevations of blood pressue.
. Dx -> BEST INITIAL -> ++ catecholamines level in plasma & urine.
. Dx -> BEST INITIAL -> ++ metanephrines & VMA levels.
. Dx -> MOST ACCURATE -> CT or MRI or MIBG of the adrenal glands.
. Tx -> PHENOXYBENZAMINE (Alpha blocker) "FIRST" to control blood pressure.
. e'out Alpha blockage, BB may lead to CATASTROPHIC ++ in BP due to unopposed
Alpha stim.
. Tx -> Propranolol is used "AFTER" an alpha blocker .
. Tx -> Surgical resection.
. N.B. It is a part of MEN type 2 A & B (DNA testing is imp. RET PROTO-ONCOGENE).
. ERECTILE DYSFUNCTION:
_______________________
. Failure to achieve a spontaneous erection.
. Causes:
. * NEUROGENIC -> injury of the parasympathetic nerve fibers (# pelvis or urethral
tear).
. * VENOGENIC -> Disruption of tunica albuginea (# penis).
. * ENDOCRINOLOGIC -> ++ prolactin & -- Testosterone.
. * SITUATIONAL -> Anxiety (Nighttime & morning erctions are preserved).