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M/c cause of hyperthyroidism
Grave's Disease (90%)
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Grave's Disease
Auto-immune disorder in which autoantibodies attach to TSH receptors and stimulate thyroid hyperfunctioning
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epidemiology of Graves
Women who are 20-40 yo
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Graves HLA markers
HLA B8 and HLA DR3
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Other diseases Graves is associated with
Pernicious anemia, myasthenia gravis, DM
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People with Graves are at risk for developing what other conditions?
- Addisons
- Alopecia areata
- celiac disease
- cardiomyopathy
- hypokalemic periodic paralysis
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Other causes of hyperthyroidism
- Toxic adenomas
- De Quervains
- postpartum thyroiditis
- pregnancy
- exogenous thyroid hormone ingestion
- trophoblastic tumors
- amiodarone
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Eye sx of hyperthyroidism
- mild: chemosis, conjunctivitis, proptosis
- severe: exophthalmos, diplopia, corneal dring
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Thyroid storm usually follows what?
stressful illness, thyroid surgery, or radioactive iodine administration
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Thyroid storm sx
- high fever
- tachycardia
- vomiting
- diarrhea
- dehydration
- marked weakness
- muscle wasting
- extreme restlessness, confusion, delirium, emotional lability
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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
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How do you evaluate eye s/sx caused by thyroid issues?
MRI
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Thyroid storm tx
- Beta blockers (propanolol) and hydrocortisone
- supportive therapy
- attempts to control ^T with a thiourea drug, followed by iodide
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Hyperthyroid tx
Methimazole or PTU x 12-24 months
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Tx of hyperthyroid in pregnancy
PTU
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complication of PTU/methimazole
agranulocytosis
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When is surgery done for hyperthyroid?
- pregnant pts
- large goiters
- malignancies
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When is radioactive iodine done?
- permanent control (esp in elderly)
- preferred over surgery
- CI in pregnancy
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How do you tx ophthalmopathy in hyperthyroid pts?
IV methylprednisolone
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How do you tx afib in hyperthyroid?
- large doses of digoxin,
- anticoag with warfarin
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Causes of hypothyroiditis
autoimmune thyroiditis, previous thyroid surgery, or radiation therapy
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thyroiditis sx
fatigue, lethargy, anoxrexia, constipation, depression, menstrual abnormalities, muscle stiffness, memory impairment, cold intolerance, dry skin
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Lab studies in vT
- Elevated TSH
- Low total T4 and free T4, T3 may be nl
- presence of antithyroid peroxidase and antithyroglobulin Abs
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m/c thyroid disorder in the US
Hashimoto's
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Epidemiology of Hashimotos
- familial
- 5% in population >65 yo
- more common in women, pts with Hep C
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What drugs are associated with thyroiditis?
Amiodarone, interleukins, and interferon
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Subacute thyroidits
- May present with acute sx or silenetly
- m/c in young or middle-aged women
- usually caused by viruses, peaks in summer
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Diffusely enlarged, firm, and finely nodular thyroid
Hashimotos
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Other medical conditions that hashimoto's is associated with
- autoimmune xerostomia
- keratoconjunctivitis
- mild myasthenia gravis
- IBD/celiac
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Presentation of subacute thyroiditis
- acute, painful glandular enlargement with dysphagia, low-grade fever, fatigue, and malaise
- radiation of pain to ears
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prognosis of postpartum thyroiditis
manifests 1-6 months after delivery, lasts for less than 1-2 months
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Presentation of suppurative thyroiditis
fever, pain, redness, fluctuant neck mass; associated with bacterial, fungal, or parasitic causes
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how do you distinguish thyroidits from Graves?
Doppler U/S
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Hashimoto's tx
lifelong replacement with thyroid hormone for hypothyroidism or large goiter; watchful waiting with others
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Subacute thyroidits tx
ASA
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Postpartum thyroiditis
watchful waiting, propanolol for cardiac sx
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m/c type of thyroid cancer
papillary
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Most aggressive type of thyroid cancer
anaplastic
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high serum calcitonin and CEA
medullary tumors
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m/c cause of hypoparathyroidism
thyroidectomy
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Causes of hypoparathyroidism
- heavy metal toxicity
- granulomas
- Ridel's thyroiditis
- tumors
- infection
- Autoimmune problems
- magnesium deficiency
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DiGeorge's Syndrome
hypoparathyroidism, congenital facial and cardiac anomalies
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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
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Chvostek's Sign
facial muscle contraction after tapping the facial nerve
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Trousseau's sign
Carpal spasm with blood pressure cuff inflation
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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
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EKG changes in hypoparathyroidism
prolonged QT and T wave abnormalities
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Tetany management
airway maintenance, slow administration of IV calcium
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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
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What meds should be avoided in hypoparathyroidism?
phenothiazines and furosemide
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Causes of hyperparathyroidism
- parathyroid adenoma (m/c)
- hyperplasia
- carcinoma
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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
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Causes of secondary hypercalcemia
- malignant tumors
- multiple myeloma
- granulomatous disorders
- hyperthyroidism
- medications
- prolonged bed rest
- acute renal failure
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What is the def of hypercalcemia (lab)?
Ca > 10.5
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Labs expected in hyperparathyroidism
- Increased Ca
- decreased phos
- Elevated PTH
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Hypercalcemia EKG changes
prolonged PR interval, shortened QT, bradyarrhythmias, haert block, and asystole
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Hyperparathyroidism tx
- surgical tx
- hdration
- bisphosphonates
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Leading cause of blindness in the US in people > 60 o
diabetic retinopathy
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m/c complication of DM
neuropathy
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Diabetic ketoacidosis sx
anorexia, nausea, vomiting, dehydration, stupor, coma
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recommended diet for T1DM
- Carbs: 45-65% of diet
- protein 10-35%
- fat 25-35% (<7% saturated)
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Time durations for rapid acting insulin
- peak in 1 hour
- 4 hour duration of action
- take 20 mins before meal
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Time durations for regular insulin
- take an hour before meals
- effect in 30 mins
- peaks in 60 mins
- lasts 5-7 hours
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Time durations for NPH
- onset in 2-4 hours
- peak in 8-10 hours
- duration 18-24 hours
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detemir duration
17 hours
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glargine duration
24 hours
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sulfonylureas
- glyburide
- glipizide
- glimeperide
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MOA of thiazolidinediones
sensitize peripheral tissues to insulin
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CI for thiazolidinediones
heart failure, liver disease
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a-glucosidase inhibitors, and their MOA
- acarbose
- miglitol
- delay absorption of carbs from the intestine
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Exenatide MOA
lowers blood glucose via slowing of gastric emptying, stimulatin pancreatic insulin response to glucose, and prevents glucagon release after meals
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goal BP for diabetics
<130/80
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whipple's triad
hx of hypoglycemic sx, fasting blood glucose of 40 mg or less, immediate recovery on administration of glucose
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Chronic adrenocortical insufficiency
Addison's Disease
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m/c cause of addison's disease
autoimmune destruction
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Addion's sx
- fatigue
- weakness
- anorexia/weight loss
- irritability
- myalgias, arthralgias
- amenorrhea
- hyperpigmentation
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Lab findings in Addisons
- Increased K and Ca, decreased Na and glucose
- decreased cortisol
- increased ACTH
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Dx of Addisons
Cosntropin
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Tx of Addisons
- Oral hydrocortisone or prednisone
- DHEA to women
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Tx of addisonian crises
Aggressive IV saline, glucose, and glucocorticoids
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Hypercortisolism
Cushing's Disease
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Cushing's Syndrome causes
- m/c exogenous corticosteroids
- Adrenocortical tumors
- nonpituitar ACTH producing tumors (ie, SCLC)
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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
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Hypercortisolism presentation
- obesity, HTN, thirst, polyuria with or without glycosuria
- most specific: proximal muscle weakness, pigmented striae
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supraclavicular pads
cushings
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Dx of cushings
- 24 free cortisol > 125
- overnight dexamethasone suppresion test = plasma cortisol > 10 mcg
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Tx of Cushings
- resection of pituitary adenoma and hydrocortisol replacement
- removal of tumors
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Tx of acromegaly or gigantism
- remove tumor
- dopamine agonists if fail surgery
- somatostain analogs for persistent disease
- Pegvisomant
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m/c nonlethal type of dwarfism
achondroplasia
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Cause of dwarfism
mutation in FGFR3 gene
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Cause of DI
deficiency of or resistance to vasopressin (ADH)
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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
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clinical features of DI
intense thirst, craving ice water, large volume polyuria, hypernatremia and dehydration
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DI workup
- glucose, BUN, Ca, uric acid, K, and Na
- 24 hour urine collection
- Confirm central DI with vasopressin challenge test
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Tx of DI
- Desmopressin acetate for central DI and pregnancy
- Mild cases: adequate hydration
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Tx of nephrogenic DI
- indomethacin, alone or in combo with HCTZ
- desmopressin
- ameloride
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Drugs that can cause osteomalacia
phenytoin, carbamezapine, valproate, barbituates
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Milkman lines
osteomalacia
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Looser zoners
osteomalacia
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Tx of osteomalacia
- Ergocalciferol (50,000 PO BIW x 6-12 mo, followed by 1-2000U QD)
- phosphate supplementation and Vit D
- PO calcium
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Paget's Disease
localized dysplastic bone formation
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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
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m/c neurologic finding in Pagets
Mixed sensorineural/conductive deafness
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How does paget's affect the heart?
increases Q, can lead to heart failure
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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
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Tx of Pagets
- cyclic administration of bisphosphonates is tx of choice
- alternative is nasal calcitonin-salmon (miacalcin)
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fibric acid derivatives, and their MOA
- gemfibrozil and fenofibrate
- reduce synthesis and breakdown of VLDL
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fibric acid derivatives side effects
cholelithiasis, hepatitis, myositis
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Ezetimibe MOA
blocks intestinal absorption of dietary andbiliary choleesterol, used as monotherapy or with a statin
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