FNP III Endocrine
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What is carpopedal spasm indicative of?
Name two tests on physical examination that demonstrate hypocalcemia?
Is one of the neuromuscular signs indicating hypocalcemia and is a significant sign of tetany.
Trousseau's sign -- carpal spasm demonstrated by a flexed elbow, wrist adduct thumb over the palm, flexed metacarpal pharyngeal joints, adduction of hyper extended fingers extended interphalangeal joints in response to a blood pressure cuff 20 mmHg above the systolic blood pressure for 3 minutes.
Chvostek's sign - abnormal unilateral spasm of the facial muscle when the facial nerve is that the low zygomatic arch anterior to the earlobe.
What are some physical signs and symptoms of chronic hypocalcemia?
Cardiovascular symptoms include hypotension, bradycardia, CHF and dysrhythmias. Prolonged QT intervals may be seen on an EKG.
The skin may be course dry and scaly. Alopecia may be present with thinning of the eyebrows and eyelashes.
What is gynecomastia?
What special considerations are there gynecomastia in adolescents?
Gynecomastia is enlargement of glandular breast tissue in men, resulting in increased breast size. Gynecomastia that presents before or after puberty and cannot be associated with physiological aging, a drug, or chronic disease requires further investigation by an endocrinologist.
Gynecomastia associated with puberty has an age onset at 12 to 14 years. The duration is approximately 6 months and then regression is expected.
Differentiate between true gynecomastia and pseudo-gynecomastia?
Affirm or rubbery, mobile, disklike mound of tissue at least 2 to 4 cm in diameter arising concentrically from beneath the nipple and aerial our region confirms gynecomastia.
Distinguish between vellus hair and terminal hair?
Hirsutism is an increase in terminal hair growth on the face, chest, back, lower abdomen, pubic area, axilla, and inner thighs of females.
Velles hair is found over most of the body and is fine, soft, and I'm pigmented. Terminal hairs are found on the scalp, eyebrows, and the axillary and pubic areas after puberty.
Testosterone levels greater than 200 ng per deciliter in women suggests what?
The Need for an Ovarian Tumor Workup.
What is the most common cause of increased neck size?
The most common cause of increase in neck size is an enlarged thyroid gland. Other potential causes include, masses, neoplasms, cysts and lymph node enlargements.
What 2 conditions are associated with polydipsia polyphagia and polyurea?
Diabetes mellitus and renal disease
What conditions are associated with polydipsia and polyurea?
dehydration, diabetes and sit this, hypokalemia, hyperparathyroidism, psychogenic, Sheehanis syndrome, sickle cell anemia, Cushing's disease, and diuretics.
What conditions are associated with polydipsia in polyphagia?
What are the major differential diagnoses for weight gain?
Hypothyroidism, Cushing syndrome, renal or hepatic disease, CHF, premenstrual syndrome, medication use, depression, and excessive caloric intake.
Describe unintentional weight loss?
Unintentional weight loss of more than 5% of usual body weight within 6 to 12 months may reflect a physical or psychological illness.
A 10% loss of body weight in one to 2 months is predictive of a poor clinical outcome.
What are the clinical manifestations of long-term hyperthyroidism?
The long-term effects of inadequate treated hypothyroidism are heart disease, osteoporosis, mental illness, and infertility.
What is the most common cause of hyperthyroidism in the United States?
Graves' disease is by far the most common cause of hyperthyroidism.
Graves' disease is an autoimmune disorder characterized by autoreactive agonistic antibodies to the TSH receptor, Graves' disease accounts for 80 to 90% of hyperthyroidism cases peaking and young adults 20 to 40 years old.
Define the difference between thyrotoxicosis and hyperthyroidism?
Thyrotoxicosis encompasses hyperthyroidism and is defined as an acute inflammation of the thyroid gland resulting in rapid excretion parentheses (rather than overproduction) of stored thyroid hormones.
What is the most common cause of thyrotoxicosis?
The most common cause of thyrotoxicosis is subacute thyroiditis.
What is Plummer disease?
A type of goiter is more common in older adults and is a complication of chronic, and active nodular goiter. This condition is more common in other parts of the world were dietary iodine deficiency is prevalent.
Describe the bio activity of T3 and T4 hormones?
T3 is normally 20 to 100 times more biologically active than T4, which is converted to T3 in peripheral tissues.
What clinical presentation would you expect from a person with hyperthyroidism?
Most patients with hyperthyroidism will complain of some combination of anxiety, nervousness, diaphoresis, fatigue, heat intolerance, palpitations, weight loss, and insomnia.
What drug is given to block thyroid hormone synthesis?
What drug is given to block conversion of T4 to T3?
Propylithiouracil (PTU) is given daily and to to for divided doses to block thyroid hormone synthesis.
Hydrocortisone is given IV to block conversion of T4 to T3.
What is thyroid acropachy?
Thyroid acropachy clubbing of the digits and signs of new bone growth and hands secondary to long-standing hyperthyroidism.
What is thyroid storm?
Thyroid storm is a severe sometimes fatal form of hyperthyroidism that requires immediate emergency medical care.
Described the initial testing for hyperthyroidism?
The initial screening test for hyperthyroidism or measurement of this serum TSH assay and the free thyroxine (FT4) immunoassay.
In most cases of hypothyroidism a TSH level less than 0.35 mcIU/mL usually accompanies an elevated free thyroxine (FT4).
If the FT4 for is normal a T3 level should be obtained because about 5% of hyperthyroid patients have normal T4 levels, but elevated T3 levels.
When is the diagnosis of thyrotoxicosis considered?
The diagnosis of thyrotoxicosis is considered in cases of hyperthyroidism with TSH levels are depressed and measurements of T4 are normal.
What type of nodules on the nuclear scintigraphy test are suspicious of malignancy?
Cold nodules are highly suspicious for time commitment malignancy and must be further evaluated.
What are the treatment options for Graves' disease?
Antithyroid drugs, radioactive iodine, and surgery.
The most successful treatment in achieving permanent euthyroid state is surgery, however it is rarely the preferred method of treatment unless the thyroid gland is extremely enlarged and pressing on other structures in the neck.
What is the treatment of choice for hyperthyroidism in the United States in middle-aged and older adults?
Radioactive iodine -- 131 is the treatment of choice for hyperthyroidism in the United States.
A radioiodine dose of 75 to 200 mcCi per gram of estimated thyroid tissue is administered orally and concentrates an overactive thyroid cells where it admits radiation causing inflammation and the ultimate distraction of the pathological cells.
How is subacute thyroiditis treated?
Subacute thyroiditis is a self-limiting condition treated with anti-inflammatory agents and prednisone.
It often follows a viral illness or it
What is congenital hypothyroidism known as?
Thyroid hormone deficiency at birth was historically called cretinism is now known by the less pejorative term congenital hypothyroidism.
What the most common worldwide cause of thyroid disorders?
Was the most common type of autoimmune thyroid disease?
Heidegger efficiency with worldwide prevalence of 2 to 5%.
Hashimoto's thyroiditis is a type of primary hypothyroidism.
What is the cause of secondary hypothyroidism?
The cause of secondary hypothyroidism refers to the failure of the pituitary gland to secrete adequate amounts of TSH.
What are the early classical symptoms of hypothyroidism?
The early classic symptoms include fatigue, dry skin, slight weight gain, cold intolerance, constipation, and heavy menses.
What is the initial lab screening for hypothyroidism
The diagnosis of hypothyroidism is made by measuring serum TSH and FT4.
If the TSH is low, inappropriately normal, or insufficiently elevated in the presence of low T4 values, central hypothyroidism caused by hypothalamic or pituitary disease should be excluded before starting thyroid replacement therapy.
What is the most specific test for diagnosing primary hypothyroidism?
The sensitive thyrotropin assay is the most specific test for diagnosing primary hypothyroidism.
A rise in the TSH will precede any other abnormality of thyroid function is the 1st evidence of primary hypothyroidism.
What is the goal in central hypothyroidism?
To noramalize FT4 because the TSH is not reliable.
Treatment for hypothyroidism is the daily admin of thyroid hormone to restore the patient to a euthyroid state.
The usual medication is a synthetic preparation of T4. (Synthroid / levothyroid)
What is the common dose for thyroid hormone replacement?
1.6 mcg/kg per day for full replacement.
The TSH should be measured every 6 to 8 weeks after initial therapy and before each dosage increase. The most common dosage is 75 to 100 mcg/day.
What type of CA is most thyroid CA?
- 60% = papillary
- 20% = follicular
- 20% = medullary or anaplastic
When observing a fast growing goiter, consider?
Non- Hodgkin's lymphoma a rare type of thyroid CA
What is the major risk factor for development of thyroid cancer?
The major risk factor for development of thyroid cancer is exposure to ionizing radiation. Several historical incidents have resulted in high-dose radiation exposure and have been linked to an increased in incidence of thyroid papillary malignancies and children.
What are the symptoms of thyroid cancer?
The major symptom of thyroid cancer is one or nodule and then back usually painless.
Tight or fulfilling the neck, difficulty breathing or swallowing, hoarseness, hemoptysis and swollen lymph nodes.
New onset of hoarseness with hemoptysis is strongly suggestive of malignant growth. Progressive dysphagia and shortness of breath may indicate invasiveness.
When should you be suspicious of a malignant thyroid growth?
Nodules that develop in men, and persons younger than 20 or older than 60 with a history of exposure to radiation are suggestive of malignancy.
Malignant growths are more likely to be irregular in shape, fixed, firm, and nontender.
Elevated serum calcitonin is a strong tumor marker of medullary thyroid cancer.
What is the treatment of choice for thyroid cancer?
Thyroidectomy or near total thyroidectomy is the treatment of choice, and patients are often treated with radioactive iodine therapy to ablate any remnant thyroid tissue.
What is Cushing's syndrome?
Cushing's syndrome is a moderate of symptoms and physical features produced by persistent in appropriate hypercortisolemia.
Cushing's syndrome may be caused by cortisol hyper secretion of the adrenal cortex to the cortical hypertrophy or tumor of the adrenal gland. The prolonged administration of large doses of exogenous glucocorticoid hormones will also cause Cushing's.
In patients with Cushing's disease, what secretes excesses of amounts of ACTH?
Pituitary adenomas secrete excessive amounts of ACTH. ACTH acts directly on the adrenal cortex to stimulate the production of cortisol.
Described on physical exam what might be seen in the patient with Cushing's disease?
Common complaints include weight gain, back pain, headaches, skin changes, and muscle weakness.
Excessive accumulation of fat in the face these typical moonface appearance.
The "Buffalo hump" appearance is caused by excessive accumulation of fat in the supra-clavicular and dorsocervical area.
Skin changes include hirsutism, acne, and stiae. Skin wounds heal slowly in the presence of excessive cortisol.
What tests are used to diagnose Cushing syndrome?
- Use one of four to diagnose
- 1. urine free cortisol
- 2. lignite salivary cortisol
- 3. Overnight dexamethasone suppression test
- 4. Longer low dose dexamethasone suppression test
What is the treatment of choice or pituitary adenoma causing Cushing's disease?
Transsphenoidal pituitary microsurgery.
If surgery is unsuccessful irradiation of the pituitary may be considered.
In DM what is considered impaired fasting glucose or impaired glucose tolerance?
A fasting glucose between 110 and 126 mg/dL.
Or a 2 hour postglucose load blood glucose of 140 to 200 mg/dL.
What does DM type 1 result from?
Destruction of beta-cells.
90% is immune mediated destruction of beta cells.
10% is idiopathic.
Diagnosis is often made when the patient presents in ketoacidosis.
What are some of the initial presenting SX of DM type 1?
The classic symptoms are polyuria, polyphagia, anorexia, and weightloss.
Nocturnal enuresis is often a disturbing symptom reported by many patients.
When does the American Diabetic association recommend tx?
Treatment should be aimed at maintaining an A1C of less than 7%.
True or False: Type 1 Diabetics are usually lean?
What percentage of diabetics are type 2?
90% of diabetics in America are type 2.
Type 2 is characterized by sufficient circulating endogenous insulin, resistance to insulin action, and an inadequate compensatory insulin secretion response.
What is the first line medication recommended for type 2 diabetics?
What do you have to ensure to prescribe metformin?
Adequate renal function, serum creatinine less than 1.4 or creatinine clearance greater than 50mL/min.
What is gout?
Metabolic disease that produces inflamatory arthritis. Urate crystal form in lower temps, knee, toe, etc.
After repeated attacks, crystalline deposits form a tophus, or nodular deposit.
Test serum uric acid.
Treatment is colchicine for acute attacks and may be used for long term prevention.
Probenecid is the first line of drug used for prevention but not within 30 days of an acute attack.
Allopurinol is used for those that cannot tollerate probencid.
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