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2012-08-10 18:07:13

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  1. M/c cause of hyperthyroidism
    Grave's Disease (90%)
  2. Grave's Disease
    Auto-immune disorder in which autoantibodies attach to TSH receptors and stimulate thyroid hyperfunctioning
  3. epidemiology of Graves
    Women who are 20-40 yo
  4. Graves HLA markers
    HLA B8 and HLA DR3
  5. Other diseases Graves is associated with
    Pernicious anemia, myasthenia gravis, DM
  6. People with Graves are at risk for developing what other conditions?
    • Addisons
    • Alopecia areata
    • celiac disease
    • cardiomyopathy
    • hypokalemic periodic paralysis
  7. Other causes of hyperthyroidism
    • Toxic adenomas
    • De Quervains
    • postpartum thyroiditis
    • pregnancy
    • exogenous thyroid hormone ingestion
    • trophoblastic tumors
    • amiodarone
  8. Eye sx of hyperthyroidism
    • mild: chemosis, conjunctivitis, proptosis
    • severe: exophthalmos, diplopia, corneal dring
  9. Thyroid storm usually follows what?
    stressful illness, thyroid surgery, or radioactive iodine administration
  10. Thyroid storm sx
    • high fever
    • tachycardia
    • vomiting
    • diarrhea
    • dehydration
    • marked weakness
    • muscle wasting
    • extreme restlessness, confusion, delirium, emotional lability
  11. Expected lab values in hyperthyroidism
    • Low TSH
    • Elevated T4, T3, free T4, free T3 index, and thyroid resin uptake
    • High ABs in graves
    • High ESR in Subacute thyroiditis
    • High iodine uptake in Graves and toxic multinodular goiter
  12. How do you evaluate eye s/sx caused by thyroid issues?
  13. Thyroid storm tx
    • Beta blockers (propanolol) and hydrocortisone
    • supportive therapy
    • attempts to control ^T with a thiourea drug, followed by iodide
  14. Hyperthyroid tx
    Methimazole or PTU x 12-24 months
  15. Tx of hyperthyroid in pregnancy
  16. complication of PTU/methimazole
  17. When is surgery done for hyperthyroid?
    • pregnant pts
    • large goiters
    • malignancies
  18. When is radioactive iodine done?
    • permanent  control (esp in elderly)
    • preferred over surgery
    • CI in pregnancy
  19. How do you tx ophthalmopathy in hyperthyroid pts?
    IV methylprednisolone
  20. How do you tx afib in hyperthyroid?
    • large doses of digoxin,
    • anticoag with warfarin
  21. Causes of hypothyroiditis
    autoimmune thyroiditis, previous thyroid surgery, or radiation therapy
  22. thyroiditis sx
    fatigue, lethargy, anoxrexia, constipation, depression, menstrual abnormalities, muscle stiffness, memory impairment, cold intolerance, dry skin
  23. Lab studies in vT
    • Elevated TSH
    • Low total T4 and free T4, T3 may be nl
    • presence of antithyroid peroxidase and antithyroglobulin Abs
  24. m/c thyroid disorder in the US
  25. Epidemiology of Hashimotos
    • familial
    • 5% in population >65 yo
    • more common in women, pts with Hep C
  26. What drugs are associated with thyroiditis?
    Amiodarone, interleukins, and interferon
  27. Subacute thyroidits
    • May present with acute sx or silenetly
    • m/c in young or middle-aged women
    • usually caused by viruses, peaks in summer
  28. Diffusely enlarged, firm, and finely nodular thyroid
  29. Other medical conditions that hashimoto's is associated with
    • autoimmune xerostomia
    • keratoconjunctivitis
    • mild myasthenia gravis
    • IBD/celiac
  30. Presentation of subacute thyroiditis
    • acute, painful glandular enlargement with dysphagia, low-grade fever, fatigue, and malaise
    • radiation of pain to ears
  31. prognosis of postpartum thyroiditis
    manifests 1-6 months after delivery, lasts for less than 1-2 months
  32. Presentation of suppurative thyroiditis
    fever, pain, redness, fluctuant neck mass; associated with bacterial, fungal, or parasitic causes
  33. how do you distinguish thyroidits from Graves?
    Doppler U/S
  34. Hashimoto's tx
     lifelong replacement with thyroid hormone for hypothyroidism or large goiter; watchful waiting with others
  35. Subacute thyroidits tx
  36. Postpartum thyroiditis
    watchful waiting, propanolol for cardiac sx
  37. m/c type of thyroid cancer
  38. Most aggressive type of thyroid cancer
  39. high serum calcitonin and CEA
    medullary tumors
  40. m/c cause of hypoparathyroidism
  41. Causes of hypoparathyroidism
    • heavy metal toxicity
    • granulomas
    • Ridel's thyroiditis
    • tumors
    • infection
    • Autoimmune problems
    • magnesium deficiency
  42. DiGeorge's Syndrome
    hypoparathyroidism, congenital facial and cardiac anomalies
  43. Sx of hypoparathyroidism
    • tetant, carpopedal spasm, cramping, convulsions, circumoral and distal extremity tingling and irritability
    • positive Chvostek's Sign and Trousseau's phenomenon
    • cataracts
    • teeth and nail defects
  44. Chvostek's Sign
    facial muscle contraction after tapping the facial nerve
  45. Trousseau's sign
    Carpal spasm with blood pressure cuff inflation
  46. Lab studies in hypoparathyroidism
    • serum calcium, urinary calcium, parathyroid hormone levels are low
    • serum mag is low
    • serum phosphate is high, alk phos is normal
  47. EKG changes in hypoparathyroidism
    prolonged QT and T wave abnormalities
  48. Tetany management
    airway maintenance, slow administration of IV calcium
  49. Hypoparathyroid tx
    • po Ca and Vit D prep to keep serum calcium between 8 and 8.6
    • mag supplementation
    • measure serum and urine calcium levels
  50. What meds should be avoided in hypoparathyroidism?
    phenothiazines and furosemide
  51. Causes of hyperparathyroidism
    • parathyroid adenoma (m/c)
    • hyperplasia
    • carcinoma
  52. Sx of hyperparathyroidism
    • asx m/c
    • polydipsia, polyuria caused by hypercalcemia
    • renal stones, nephrocalcinosis, and renal failure
    • bone pain, arthralgias, pathologic fx,
    • bones stones abdominal groans psychic moans fatigue overtones
  53. Causes of secondary hypercalcemia
    • malignant tumors
    • multiple myeloma
    • granulomatous disorders
    • hyperthyroidism
    • medications
    • prolonged bed rest
    • acute renal failure
  54. What is the def of hypercalcemia (lab)?
    Ca > 10.5
  55. Labs expected in hyperparathyroidism
    • Increased Ca
    • decreased phos
    • Elevated PTH
  56. Hypercalcemia EKG changes
    prolonged PR interval, shortened QT, bradyarrhythmias, haert block, and asystole
  57. Hyperparathyroidism tx
    • surgical tx
    • hdration
    • bisphosphonates
  58. Leading cause of blindness in the US in people > 60 o
    diabetic retinopathy
  59. m/c complication of DM
  60. Diabetic ketoacidosis sx
    anorexia, nausea, vomiting, dehydration, stupor, coma
  61. recommended diet for T1DM
    • Carbs: 45-65% of diet
    • protein 10-35%
    • fat 25-35% (<7% saturated)
  62. rapid acting insulins
    • lispor
    • aspart
    • glulisine
  63. long acting insulins
    • glargine
    • detemir
  64. Time durations for rapid acting insulin
    • peak in 1 hour
    • 4 hour duration of action
    • take 20 mins before meal
  65. Time durations for regular insulin
    • take an hour before meals
    • effect in 30 mins
    • peaks in 60 mins
    • lasts 5-7 hours
  66. Time durations for NPH
    • onset in 2-4 hours
    • peak in 8-10 hours
    • duration 18-24 hours
  67. detemir duration
    17 hours
  68. glargine duration
    24 hours
  69. sulfonylureas
    • glyburide
    • glipizide
    • glimeperide
  70. ADRs of sulfonylureas
    • weight gain
    • hypoglycemia
  71. MOA of thiazolidinediones
    sensitize peripheral tissues to insulin
  72. CI for thiazolidinediones
    heart failure, liver disease
  73. a-glucosidase inhibitors, and their MOA
    • acarbose
    • miglitol
    • delay absorption of carbs from the intestine
  74. Exenatide MOA
    lowers blood glucose via slowing of gastric emptying, stimulatin pancreatic insulin response to glucose, and prevents glucagon release after meals
  75. goal BP for diabetics
  76. whipple's triad
    hx of hypoglycemic sx, fasting blood glucose of 40 mg or less, immediate recovery on administration of glucose
  77. Chronic adrenocortical insufficiency
    Addison's Disease
  78. m/c cause of addison's disease
    autoimmune destruction
  79. Addion's sx
    • fatigue
    • weakness
    • anorexia/weight loss
    • irritability
    • myalgias, arthralgias
    • amenorrhea
    • hyperpigmentation
  80. Lab findings in Addisons
    • Increased K and Ca, decreased Na and glucose
    • decreased cortisol
    • increased ACTH
  81. Dx of Addisons
  82. Tx of Addisons
    • Oral hydrocortisone or prednisone
    • DHEA to women
  83. Tx of addisonian crises
    Aggressive IV saline, glucose, and glucocorticoids
  84. Hypercortisolism
    Cushing's Disease
  85. Cushing's Syndrome causes
    • m/c exogenous corticosteroids
    • Adrenocortical tumors
    • nonpituitar ACTH producing tumors (ie, SCLC)
  86. Cushing's Disease causes
    • excess secretion of ACTH by the pituitary, often resuling from a small, benign pituitary adenoma
    • m/c cause is Cushing's syndrome
  87. Hypercortisolism presentation
    • obesity, HTN, thirst, polyuria with or without glycosuria
    • most specific: proximal muscle weakness, pigmented striae
  88. buffalo hump
  89. supraclavicular pads
  90. Dx of cushings
    • 24 free cortisol > 125
    • overnight dexamethasone suppresion test = plasma cortisol > 10 mcg
  91. Tx of Cushings
    • resection of pituitary adenoma and hydrocortisol replacement
    • removal of tumors
  92. Tx of acromegaly or gigantism
    • remove tumor
    • dopamine agonists if fail surgery
    • somatostain analogs for persistent disease
    • Pegvisomant
  93. m/c nonlethal type of dwarfism
  94. Cause of dwarfism
    mutation in FGFR3 gene
  95. Cause of DI
    deficiency of or resistance to vasopressin (ADH)
  96. Secondary causes of DI
    hypothalamic or pituitary pathology caused by tumor, anoxic encephalopathy, surgery, accidental trauma, infection, sarcoidosis, multifocal langerhaans cell granulmatosis, or metastic disease
  97. clinical features of DI
    intense thirst, craving ice water, large volume polyuria, hypernatremia and dehydration
  98. DI workup
    • glucose, BUN, Ca, uric acid, K, and Na
    • 24 hour urine collection
    • Confirm central DI with  vasopressin challenge test
  99. Tx of DI
    • Desmopressin acetate for central DI and pregnancy
    • Mild cases: adequate hydration
  100. Tx of nephrogenic DI
    • indomethacin, alone or in combo with HCTZ
    • desmopressin
    • ameloride
  101. Drugs that can cause osteomalacia
    phenytoin, carbamezapine, valproate, barbituates
  102. Milkman lines
  103. Looser zoners
  104. Tx of osteomalacia
    • Ergocalciferol (50,000 PO BIW x 6-12 mo, followed by 1-2000U QD)
    • phosphate supplementation and Vit D
    • PO calcium
  105. Paget's Disease
    localized dysplastic bone formation
  106. Clinical features of Paget's
    • 3/4 are sxmatic
    • bone and joint pain is often the first sx
    • common sites of involvement are: spine, pelvis, femur, humerus, tibia, and skull
  107. m/c neurologic finding in Pagets
    Mixed sensorineural/conductive deafness
  108. How does paget's affect the heart?
    increases Q, can lead to heart failure
  109. Lab findings in Pagets
    • Serum calcium and phosphate are nl, alk phos is high
    • Hypercalciuria is common, urinary hydroxyproline is elevated in active disease
    • Hypercalcemia occurs in pts on bed rest
  110. Tx of Pagets
    • cyclic administration of bisphosphonates is tx of choice
    • alternative is nasal calcitonin-salmon (miacalcin)
  111. fibric acid derivatives, and their MOA
    • gemfibrozil and fenofibrate
    • reduce synthesis and breakdown of VLDL
  112. fibric acid derivatives side effects
    cholelithiasis, hepatitis, myositis
  113. Ezetimibe MOA
    blocks intestinal absorption  of dietary andbiliary choleesterol, used as monotherapy or with a statin