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82 Cards in this Set
- Front
- Back
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Pheochromocytoma -
What is it |
MC primary tumor of
adrenal gland in adults from chromaffin cells secretes epi & NE associated with - von Hippel Lindau syn MEN II & III neurofibromatosis |
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Pheochromocytoma -
What is Rule of 10 |
10% bilateral
10% malignant 10% extra-adrenal 10% calcify 10% kids 10% familial |
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Pheochromocytoma -
Hx/PE |
The 5 P's -
Pressure (inc. BP) Pain (HA) Perspiration/Diaphoresis Palpitations Pallor intermittent tachycardia chest pain anxiety |
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Pheochromocytoma -
Dx |
CT or MRI
24-hr urinary catecholamine metabolites - HVA, VMA |
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Pheochromocytoma -
Tx |
Before surgery -
■ A-antag - phentolamine phenoxybenzamine use first ■ then B blockers - propanolol metyrosine ■ or labetalol - A & B blocker Def. Tx - surgery |
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Adrenal Insufficiency -
What is it What is it due to |
Primary - Addison's disease
secondary - from dec. ACTH prod. by pit. usu from abrupt cessation of chronic glucocorticoid Tx Addison's - ■ from destruction of adrenal cortex ■ => def. of mineralocorticoid and glucocorticoids ■ MC etiology (US) - autoimmune destruction ■ may occur as part of polyglandular def syndrome - hypothyroidism hyperparathyroidism DM1 pernicious anemia gonad failure vitiligo chronic mucocut candidiasis ■ can be due to - congen enzyme def adrenal hemorrhage - Waterhouse-Friderichson syn TB tertiary - low ACTH low cortisol from chronic supraphysiological doses of glucocorticoids => suppresses CRH release |
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Adrenal Insufficiency -
Hx/PE |
Hx -
weakness n/v Addisonian crisis - n/v hypoglycemia dehydration CV collapse PE - hypotension anorexia skin hyperpigmentation-Addison no pigmentation changes - secondary |
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Adrenal Insufficiency -
Dx |
Dx for primary -
rapid ACTH admin measure cortisol Hyponatremia hyperkalemia eosinophilia ■ ACTH - high in Addison's low in secondary ■cortisol after ACTH challenge low in Addison's high in secondary |
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Adrenal Insufficiency -
Tx |
Replace glucocorticoids &
mineralocorticoids inc. steroids in stress taper off glucocorticoids |
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Hyperaldosteronism -
What is it |
Primary -
MCC: unilat adrenocort adenoma (Conn's syndrome) most remaining cases - b/l adrenocortical hyperplasia Secondary - dec. renal blood flow => stim. renin-angiotensin sys causes - obstructive renal artery disease renal vasoconstriction edematous d/o |
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Hyperaldosteronism -
Hx/PE |
HTN
headache polyuria muscle weakness tetany paresthesias periph edema - if severe |
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Hyperaldosteronism -
Dx |
Hypernatremia
hypokalemia metabolic alkalosis low plasma renin (in primary) inc. 24-hr urine aldosterone CT or MRI |
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Hyperaldosteronism -
Tx |
Correct BP & K+,
then lap or open adrenalectomy spironolactone - if b/l hyperplasia |
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Congenital Adrenal Hyperplasia (CAH) -
What is it |
MC adrenal d/o of infancy & childhood
group of genetic d/o AR defect in 1 of adrenal enzymes involved in adrenal steroid hormone syn from cholesterol MCC - 21-hydroxylase def. other causes - 11b-hydroxylase def. 17a-hydroxylase def. 21-hydroxylase def. - inc. 17-hydroxyprogest & DHEA dec. aldosterone dec. cortisol complete def. - salt-wasting form most severe form |
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Congenital Adrenal Hyperplasia (CAH) -
Hx/PE |
■ Female infants -
ambig genitalia (clitoral enlargement, fusion of labia majora, urogenital sinus) ■ male infants - macrogenitosomia ■ older - virilization precocious puberty |
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Congenital Adrenal Hyperplasia (CAH) -
Dx |
High levels
in blood and urine of - cortisol precursors androgens |
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Congenital Adrenal Hyperplasia (CAH) -
Tx |
■ Cortisol -
dec. ACTH & adrenal androgens ■ surgery - female infants with ambig genitalia |
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Cushing's Syndrome -
What is it What causes it |
Hypercortisolism
MCC- iatrogenic (excess admin) other causes - ■ cushing's dis - central primary pituitary adenoma inc. ACTH ■ ectopic ACTH production - carcinoid tumor small cell lung cancer (inc. ACTH) ■ excess adrenal secretion of cortisol - b/l adrenal hyperplasia adrenal carcinoma dec. ACTH |
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Cushing's Syndrome -
HX/PE |
Hx -
depression excessive hair growth Sxs of diabetes oligomenorrhea growth retardation weakness acne PE - HTN central obesity muscle wasting thin skin easy bruisability purple striae hirsutism moon facies "buffalo hump" |
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Cushing's Syndrome -
Dx |
Low-dose dexamethasone test -
screening 0.5 mg q6h x 4 ■ suppress - (morning plasma cortisol) normal ■ doesn't suppress - abnormal obese (false pos.) depression (false pos.) alcoholic (false pos.) Do 24-hr urine free cortisol - ■ suppress - normal ■ doesn't suppress - cushing syndrome high-dose dexamethasone test - 1 mg q6h x 4 ■ suppress - pituitary tumor- cushing's dis ■ doesn't suppress - adrenal adenoma or cancer small cell lung cancer confirm - CT - adrenal MRI - sphenoid hyperglycemia, glycosuria, hypokalemia |
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Cushing's Syndrome -
Tx |
Surgical resection
irradiation - pituitary only mitotane ketoconazole metyrapone aminoglutethimide |
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Cushing's Syndrome -
Complications |
Inc. susceptibility to
infections vertebral compression Fx avascular necrosis of femoral head |
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DM Type 1 -
What is it |
Autoimmune destruction
of B cells hyperglycemia secondary to insulin def. => need exog insulin usu Dx in kids or adolescents usu < 30 y/o assoc. with HLA-DR3 & 4 Ab against glutamic acid decarboxylase |
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DM Type 1 -
Hx/PE |
Polyuria
nocturia polydipsia polyphagia rapid or unexplained weight loss |
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DM Type 1 -
Dx |
At least 1 of following -
random plasma glucose >200 mg/dL fasting >126 on 2 sep. x's 2-hr postprandial glucose >200 after 75g oral GTT on 2 sep. times urine glucose & ketones HbA1c - reflects glucose levels of prior 3 mos. < 7 is goal, slows dev & prog of: microvascular disease retinopathy nephropathy neuropathy |
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DM Type 1 -
Tx |
Insulin injections
monitor glucose levels annual eye exams annual testing of microalbumin foot exams |
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DM Type 2 -
What is it |
Hyperglycemia secondary to
end-organ insulin resistance MC diagnosed in obese > 40 y/o no known HLA assoc. often has fam Hx |
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DM Type 2 -
Hx/PE |
Insidious onset
may init present with Sxs of diabetic complications also, polyuria polydipsia polyphagia HONK |
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DM Type 2
Dx |
Urine glucose & ketones
HbA1c - reflects glucose levels of prior 3 mos. < 7 is goal, slows dev & prog of: microvascular disease retinopathy nephropathy neuropathy |
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DM Type 2 -
Tx |
Diet, wt. loss & exercise
LDL goal = < 100 strict BP control BP goal = < 130/80 oral agents - monotherapy or combination if uncontrolled metformin thiazolidinediones- glitazones sulfonylureas a-glucosidase inhib insulin - alone or in comb statins |
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Metformin -
Method of Action Side Effects |
Inhibs liver gluconeogenesis
inc. periph sensitivity to insulin may dec. intest. absorption of CHO side effects - GI Sxs lactic acidosis - rare |
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Thiazolidinediones
(the "glitazones") - Method of Action Side Effects |
Inc. periph sensitivity
to insulin side effect - edema |
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Sulfonylureas
(Tolbutamide, Glyburide, Glipizide) - Method of Action Side Effects |
Inc. pancreatic secretion
of insulin side effects - hypoglycemia wt. gain |
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Alpha-glucosidase inhibs -
Method of Action Side Effects |
Dec. intest. absorption of CHO
side effects - upset GI |
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Somogyi Effect -
What is it Tx |
Rebound a.m. hyperglycemia
secondary to early morning hypoglycemia bedtime - glucose in range 3-4 am - hypoglycemia 6 am - rebound hyperglycemia due to release of: epi, glucagon & cortisol Tx - dec. p.m. insulin |
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Dawn Phenomenon -
What is it Tx |
A.M. hyperglycemia
secondary to GH Tx - inc. p.m. NPH insulin |
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DKA -
What is it |
DM 1
• from inadeq insulin levels - noncompliance new onset of DM stress (MI stroke alcohol pancreatitis trauma) • acute infection, esp: pneumonia UTI • drugs, esp: corticosteroids thiazides sympathomimetics |
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DKA -
Hx/PE |
N/V
abdom pain Kussmaul respiration fruity breath severe dehydration mental status changes • electrolyte abnorm - hypokalemia hypophosphatemia inc. anion gap metab acidosis |
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DKA -
Dx |
Serum electrolytes
glucose ketones BUN/Cr osmolarity ABG UA - ketones B-hydroxybutyrate not detected |
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DKA -
Tx |
NS
IV regular insulin correct K+ Tx initiating event NS changed to D5 when - blood glucose 200-250 NPH when tolerate oral feeds |
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Nonketotic Hyperosmolar Syn -
What is it |
DM2
hyperglycemia => osmotic diuresis inadeq fluid intake => extreme dehydration insulin suppresses ketogenesis => no Sxs of acidosis => inc. period of dehydration => high glucose levels precip factors - acute infection stress glucocorticoids inc. fluid loss noncompliance |
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Nonketotic Hyperosmolar Syn -
Hx/PE |
Profound dehydration
altered mental status high osmolarity high plasma glucose - > 600 mg/dL no acidosis |
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Nonketotic Hyperosmolar Syn -
Tx |
Tx initiating event
aggressive fluid and electrolyte replacement insulin |
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Diabetic Retinopathy -
What is it How to prevent Tx |
Had DM at least 3-5 years
to prevent - control hyperglycemia control HTN annual eye exams laser photocoagulation therapy if retinal neovascularization |
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Diabetic Nephropathy -
What is it How to prevent |
Glomerular sclerosis
mesangial expansion => glomerular HTN, dec. in GFR, nephrotic syndrome, microalbuminuria, RF to prevent - ACE inhib control BP control glucose |
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Diabetic Neuropathy -
What is it Tx |
Symmetric polyneuropathy
distal ft and hands paresthesias dysesthesias painless loss of sense of - touch vibration proprioception temp => foot trauma, Charcot's joint, infections, diabetic ulcers autonomic neuropathy - esoph dysmotility impotence orthostatic hypotension delayed gastric emptying (gastroparesis) from vagal neuropathy early satiety => n/v Dx - gastric emptying study Tx - TCAs gabapentin metoclopramide |
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Diabetic Macrovascular
Complications - What are they Tx |
Lg vessel atherosclerosis -
angina MI TIA stroke periph vascular disease MCC of death in diabetic pts - CV disease Tx - BP goal - <130/80 LDL goal - < 100 mg/dL trigly goal - < 150 mg/dL evidence of complications - start on low-dose ASA |
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Acromegaly -
What is it |
Adult condition
from benign pituitary adenoma secretes (excessive) GH kids - gigantism |
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Acromegaly -
Hx/PE |
Enlarged jaw, hands, feet
facial features coarsen => carpal tunnel syn diastolic HTN arthritis glucose intolerance DM bitemporal hemianopsia - due to compression of optic chiasm by pit. adenoma internal organs increase MCC of death - cardiac failure |
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Acromegaly -
Dx |
■ screen - GTT
normal - GH levels suppressed acromegaly - levels higher ■ CT or MRI after document biochemistry ■ serum GH levels - pulsatile, thus unreliable |
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Acromegaly -
Tx |
Transsphenoidal resection
or irradiative ablation octreotide - dec. tumor size bromocriptine |
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Hyperparathyroidism -
What is it |
MCC - 1 gland hyperplasia
can have 4 gland hyperplasia carcinoma is rare |
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Hyperparathyroidism -
Hx/PE |
70% asymp
"stones, bones, groans, psych overtones" nephrolithiasis nephrocalcinosis bone pain fractures osteitis fibrosa cystica n/v constipation PUD pancreatitis fatigue depression anxiety disturbed sleep/concentration muscle aches arthralgias |
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Hyperparathyroidism -
Dx |
Hypercalcemia
hypercalciuria hypophosphatemia inc. PTH "brown tumors" |
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Hyperparathyroidism -
Tx |
If symptomatic -
pre-op bisphosphonates parathyroidectomy "hungry bone syndrome" - hypocalcemia after surgery removal acute hypercalcemia - IV fluids loop diuretics |
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Hypothyroidism -
What is it |
MCC - Hashimoto's thyroiditis
autoimmune women > men other causes - ■ subacute thyroiditis ■ postpartum thyroiditis ■ drugs - iodide amiodarone sulfonamides lithium ■ iatrogenic - radioactive thyroid ablation excision & inadeq supplement ■ myxedema ■ cretinism - untreated congen hypothyroid severely stunted physical & mental growth |
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Hypothyroidism -
Hx/PE |
Weakness, fatigue
cold intolerance constipation weight gain depression hoarseness menstrual irreg dry, cold, puffy skin edema bradycardia thin eyebrows delayed relaxation of DTRs |
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Hypothyroidism -
Dx |
Elevated TSH
dec. T4, free T4 & free T3 antimicrosomal Ab antithyroglobulin Ab |
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Hypothyroidism -
Tx |
Levothyroxine
gradually if elderly or have CAD monitor TSH & T3 |
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Subacute Thyroiditis -
What is it |
de Quervain's
granulomatous thyroiditis probably caused by virus |
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Subacute Thyroiditis -
Hx/PE |
Follows viral URI
fever hyperthyroidism => hypothyroidism => euthyroid thyroid - asymm enlarged firm tender |
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Subacute Thyroiditis -
Dx |
Early -
high T3 & T4 high ESR low TSH low radioactive iodine uptake |
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Subacute Thyroiditis -
Tx |
Self-limited
can treat Sxs - ASA propanolol prednisone |
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Myxedema -
What is it |
Abnorm deposits of
mucopolysaccharides (hyaluronic acid, chondroitin sulfate) due to severe hypothyroidism puffy face periorbital swelling expressionless face |
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Myxedema Coma -
What is it Precip by Tx |
Life-threatening complication
of hypothyroidism long h/o untreated hypothyroidism extreme hypothermia resp depression seizures coma precip by - infection trauma exposure to cold drugs that suppress CNS Tx - IV levothyroxine add IV hydrocortisone if abnorm adrenal function |
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Pretibial myxedema -
What is it |
Partial form of myxedema
in lower legs in Graves' disease |
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Hyperthyroidism -
What is it |
MCC - Graves
toxic diffuse goiter usu women 20-40 y/o other causes - toxic multinodular goiter toxic adenoma subacute thyroiditis lymphocytic thyroiditis pit. TSH hypersecretion Jod-Basedow phenomenon struma ovarii |
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Hyperthyroidism -
Hx/PE |
Hx -
wt. loss heat intolerance nervousness inc. bowel freq. weakness menstrual abnorm PE - warm, moist skin goiter tachy atrial fib thyroid bruit tremor hyperactive reflexes exopthalmos pretibial myxedema |
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Hyperthyroidism -
Dx |
Dec. TSH
inc. total T4, free T4, free T4 index TSH receptor Ab |
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Hyperthyroidism -
Tx |
■ Propranolol
■ mild, goiter - methimazole carbimazole PTU ■ severe - 131I thyroid ablation ■ large goiter, pregnant - thyroidectomy ■ if ablation or surgery - levothyroxine |
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Hyperthyroidism -
Complications |
Thyroid storm
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Thyroid Storm -
What is it |
Acute
from untreated or inadeq. treated severe hyperthyroidism 25% mortality precip by - surgery infection DKA toxemia of pregnancy embolism |
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Thyroid Storm -
Sxs |
Hi fever
dehydration tachycardia high-output CHF coma |
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Thyroid Storm -
Tx |
saline
glucose hydration glucocorticoids O2 cooling blanket Tx hyperthyroidism - 1st PTU then iodine then B-blocker (propranolol) then dexamethasone |
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Thyroid Nodule -
What is it |
Common
inc. with age majority benign higher risk of malignancy - h/o neck irradiation cold nodules firm, fixed solitary nodules rapidly growing nodules with hoarseness or dysphagia |
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Thyroid Nodule -
Hx/PE |
Hx -
■ Usually init asymp ■ to distinguish benign from malignant - note any systemic Sxs: hypo- or hyperthyroidism dysphagia dyspnea odynophagia hoarseness fam h/o medullary thyroid ca h/o neck irradiation ant. cervical lymphadenopathy PE - if carcinoma: firm fixed NT |
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Thyroid Nodule -
Dx |
■ 1st step - check TSH
■ if TSH inc. - check for Hashimoto's check Ab check T4 ■ if TSH dec. - radioiodine scan if cold = malignant ■ if TSH normal - FNAB (1st procedure) ■ thyroid function tests ■ US - det. if cystic ■ radioactive scan - det. if hot or cold check for metastases ■ FNA - best method to assess malig |
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Thyroid Nodule -
Tx |
■ if FNAB benign -
thyroid hormone (suppresses TSH & shrinks nodule) then US ■ malignant - resection ■ not clear - lobectomy await final path report |
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Osteoporosis -
What is it Risk factors |
Common metabolic bone disease
severe dec. in bone density => bone fractures easily rate of bone resorption > rate of formation bone produced is normal, but too little of it bone mass peaks 30-35 y/o rate of formation then dec. MCC of pathological Fx in elderly, thin women usu thin, white, postmenopause inc. risk - smoking long-term admin of heparin long-term admin of glucocorticoid |
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Osteoporosis -
Hx/PE |
Hip fractures
distal radius fractures vert. compression fractures => dec. height => prog. thoracic kyphosis |
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Osteoporosis -
Dx |
■ Lab tests - normal
■ XR - global demineralization once > 30% bone density lost ■ DEXA scan - dual-energy XR absorptiometry bone mineral density < 2.5 SD (below normal) vert. bodies prox. femur distal radius |
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Osteoporosis -
Tx |
Prevention
Ca2+ supplements & vit D through adulthood smoking cessation wt-bearing exercises bisphosphonates raloxifene intranasal calcitonin |
