Terms in this set (651)
what is paracrine action?
hormone action that acts on same tissue that is excreting hormone
what is autocrine action?
hormone acts on same cell that is releasing it
what type of hormones diffuse across cell membranes?
what type of hormones bind to cell membrane receptors and activate intracellular pathways to affect change?
amino acid derivatives
what types of hormones are water soluble?
proteins and some amino acid derivatives
what types of hormones are fat soluble and carry protein binding globulins to remain soluble in blood?
steroids and some amino acid derivatives
what types of hormones have cell membrane receptors?
what gland produces and secretes melatonin?
what are the 2 functions of melatonin?
regulate sleep-wake cycle and suppress sexual development
what connects the anterior pituitary and the hypothalamus?
portal venous system
what hormones are released from the posterior pituitary?
oxytocin and ADH
what anterior pituitary hormone is released by lactotrope cells?
what anterior pituitary hormone is released by somatotrope cells?
what anterior pituitary hormone is released by gonadotrope cells?
LH and FSH
what anterior pituitary hormone is released by corticotrope cells?
what anterior pituitary hormone is released by thyrotrope cells?
what do C-cells in the thyroid produce?
what does calcitonin do?
inhibits osteoclasts and forces calcium into bone in states of hypercalcemia
what are the 3 layers of the adrenal cortex? (superficial to deep)
where are glucocorticoids released from?
where are mineralcorticoids released from?
where are androgens released from?
what is aldosterone?
what is released by the adrenal medulla?
epinephrine and norepinephrine
what do A cells of the pancreas secrete?
what does glucagon do?
raises blood glucose by promoting gluconeogenesis and glycogenolysis
what do D cells of the pancreas secrete?
what ovarian cells secrete estrogen, progesterone, and testosterone?
what ovarian cells secrete progesterone and androstenedione?
what does inhibin do?
inhibit the release of LH and FSH
what cells secrete testosterone?
what cells of the testes perform spermatogenesis and release inhibin?
what pancreatic diseases can cause DM?
what other endocrine disorders can cause DM?
what drugs can cause DM?
what are the 3 'P's of DM symptoms?
polyuria, polydipsia, polyphagia
what are some additional symptoms of DM?
to be diagnosed with DM, what must the fasting glucose be?
to be diagnosed with DM, what must the 2-hour post 75g oral glucose tolerance test be?
to be diagnosed with DM, what must the HbgA1C be?
what cell membrane receptors transport glucose from the ECF to the ICF?
what does insulin do?
-suppresses hepatic gluconeogenesis
-stimulate glucose uptake
-suppresses lypolysis and ketogenesis in liver
-decreases amino acid release
-drives potassium intracellularly
-acts as growth factor
what are incretins (GLP-1 proteins)?
GI paramones that down regulate production of Glucagon during meals
what effect does epinephrine have on blood glucose?
increases blood glucose
what effect do cortisol and growth hormone have on glucose?
inhibit glucose utilization
what is the usual cause of Type I DM?
autoimmune - antibodies against beta cells
latent autoimmune diabetes of adults
what is LADA?
a latent form of Type I DM that usually presents like Type II (insidious), but insulin is deficiency
is DKA a complication most seen with DM 1 or 2?
Type I DM
what are ketones?
a product of fat breakdown to form glucose
what causes DKA?
lack of insulin causes the accumulation of ketones in the serum , lowering the pH
what must serum glucose be to be diagnosed as DKA?
what must arterial pH be to be diagnosed as DKA?
what must bicarb be to be diagnosed as DKA?
what must anion gap be to be diagnosed as DKA?
what are common S&S of DKA?
acetone smell to breath and urine
why could peaked T waves on ECG be present with DKA?
how is DKA treated?
-replace electrolytes (potassium)
-restore acid-base balance
why could altered mental status occur with DKA?
why is hypotension associated with DKA?
why is hypothermia associated with DKA?
rapid IV replacement of fluids is colder than body temperature
why can DVT be associated with DKA?
acidosis can cause hypercoagulability
what do we do after glucose falls to 200 to prevent hypoglycemia?
add a dextrose-containing solution
what types of things are diabetic patients screened for?
what fasting glucose levels are associated with pre-diabetes?
what HgbA1C levels are associated with pre-diabetes?
what fasting glucose levels are associated with gestational diabetes?
what HgbA1C levels are associated with gestational diabetes?
what does overt diabetes in pregnancy mean?
diabetes before pregnancy
what does gestational diabetes in pregnancy mean?
diabetes caused by pregnancy
how is diabetes screened for in pregnancy?
50g oral glucose tolerance test
with a 50g oral glucose tolerance test in pregnancy, what is a positive result?
>140 after 1 hour
with a 75g oral glucose tolerance test in pregnancy, what is a positive result after 1 hour?
with a 75g oral glucose tolerance test in pregnancy, what is a positive result after 2 hours?
maturity-onset diabetes of the young
is MODY type I or type II DM?
is insulin resistance associated with MODY?
metabolic syndrome involves 3 or more of the following:
high fasting glucose
how does insulin resistance occur in Type II DM?
weakening of intracellular messengers from insulin receptors
what hyperinsulinemia cause in early stages of Type II diabetes?
what is a normal BMI?
what is the effect of increased sorbitol?
deposits intra and extracellularly to cause cell dysfunction/death
what are some macrovascular complications of DM?
peripheral vascular dz
what are some microvascular complications of DM?
are men or women diabetic patients more likely to have cardiovascular dz?
what is the goal for BP in diabetics?
hyperosmolar nonketotic hyperglycemic states
is HONK a more common complication of Type I or Type II?
what is HONK?
high osmolality (from hyperglycemia) causes diuresis, resulting in severe dehydration and presence of insulin prevents generation of ketones
what must the plasma glucose be to be in HONK?
what must the plasma pH be to be in HONK?
what must serum HCO3 be in HONK?
what must urine/serum ketones be in HONK?
what must the serum osmolality be in HONK?
why is arterial thrombosis present in HONK?
due hyperviscosity of blood from hyperglycemia
how is HONK treated?
-slow infusion of insulin
what is the main risk of HONK that we are worried about?
how often are outpatient DM office visits?
every 3 months
what do outpatient DM office visits usually focus on?
-screen for diabetic complications
what complication of DM is associated with hepatomegaly?
how often must we look at HgbA1C?
every 6 mos
how often must we look at urine microalbumin?
how often must we look at lipid profile?
how often must we look at UA?
how often must diabetics have ophthalmology exam?
what is chronic insidious sensory neuropathy?
symmetic, "stocking glove" distribution of vibratory, pain, temp, proprioception sensory dysfunction
is chronic insidious sensory neuropathy associated with hyperglycemia?
what is acute painful neuropathy?
paresthesias associated with hyperglycemia
what is proximal motor myopathy?
self-limited weakness of proximal muscles of lower extremities, with or without pain
what are some examples of focal nerve palsies?
carpal/tarsal tunnel, thoracic outlet syndrome, palsies of extraocular nerves (III, IV, VI, VII)
can autonomic nerves experience palsies?
what are symptoms of vagal nerve palsies?
tachycardias, sinus arrhythmias, prolonged QT
what are symptoms of GI nerve palsies?
what pain medications can be used to treat neuropathies?
what promotility agents can be used to treat GI neuropathies?
what does Charcot's joint usually indicate?
how does Charcot's joint usually have to be treated?
what is acanthosis nigrans?
hyperpigmentaion of neck and axilla
what is necrobiosis lipidoidica diabeticorum?
autoimmune ulcer associated with Type I DM
what is granuloma annulare?
ring-worm like autoimmune lesion associated with Type I DM
what is Fornier's gangrene?
necrotizing fasciitis of scrotum/groin
how is fornier's gangrene treated?
debridement and broad-spectrum abx
what are common infections associated with DM?
what is mucormycosis
highly invasive fungus that looks like a sinus infection, but can be quite deadly
how is mucormycosis treated
surgery and amphotericin B
what is erythrasma?
corynibacterium infection of skin that looks like cellulitis
what complications of DM can cause erectile dysfunction?
treatments for erectile dysfunction
viagra, cialis, alprostadil, surgical pump, rod insertion, external pump
what percentage of DM patients suffer foot ulcers?
what DM complications cause diabetic foot ulcers?
peripheral neuropathy, peripheral arterial disease, or infection/ulceration
are pulses intact with foot neuropathy?
with DM foot neuropathy, what forms at pressure points because patient is not walking correctly?
what do toes look like on xray with DM foot neuropathy
misaligned/sublexed metatarsal heads
are pulses present with ischemic DM foot?
no - either absent or markedly diminished
where are ulcerations located with ischemic DM foot?
at watershed areas
what is shown on xray with ischemic foot?
calcified arteries on xray
what will show diminished flow to region or significant drop in arterial pressure in ischemic foot?
what is the difference in sensation between DM foot neuropathy and ischemic foot?
sensory deficit with neuropathy, but ischemic foot can still have sensation
what are the 3 most common pathogens of foot infections
strep pyogenes, staph aureus, pseudomonas
therapy options of foot infections
pressure point protection
what studies are more sensitive for osteomyelitis than plain film xray?
three-phase bone scan and MRI
is no osteomyelitis, how long should a foot infection be treated?
if gram pos pathogen, what abx should be used for foot infections?
what abx should be used to treat anaerobic gas gangrene?
metronidazole or clindamycin
what abx should be used to treat pseudomonas foot infections?
ceftazadine + aminoglycoside
if MRSA or pen-resistant strep is the cause of a foot infection, what is the abx of choice?
what broad spectrum abx is used for foot infections?
treatment of ischemia of foot
amputation - last resort
3 types of debridement
what is the most common cause of blindness in developed countries?
what are cotton wool spots?
edematous changes of retina from ischemia
what causes hard exudates?
retina cell lysis
what is rubeosis iridis?
bleeding into anterior chamber
clinical findings of background DM retinopathy
cotton wool spots
clinical findings of preproliferative retinopathy
intraretinal microvascular changes
cotton wool spots
clinical findings of proliferative retinopathy
hemorrhages into vitreous
clinical findings of advanced DM retinopathy
rubeosis iridis (bleeding into anterior chamber)
clinical findings of maculopathy
exudative/ischemic changes to fovea
changes in central vision
what causes cataracts in diabetes?
osmotic changes with episodes of hyperglycemia
what causes glaucoma in diabetes?
rubeosis iridis blocks outflow tracts of anterior chamber
can DM cause ocular nerve palsies?
what cause hard exudates away from main vessels?
what can we do to slow the progression of diabetic eye disease?
control blood glucose and BP and quit smoking
what is fluoroscein angiography?
IV contrast picture of retinae
what ethnicities are more prone to develop nephropathy?
african-americans and south asians
what is the functional change of diabetic nephropathy?
what are the structural changes of diabetic nephropathy?
-thickened glomerular basement membrane
-increased glomerular pressures
-damage to glomerular capillaries
-enlarged glomeruli begin to scar
what happens after structural changes of diabetic nephropathy?
basement membrane defects allow albumin to seep across, making it detectable in urine (microalbuminuria)
what stage happens with diabetic nephropathy after microalbuminuria?
what are manifestations of overt nephropathy?
-rise in plasma Cr
-fall in GFR
what stage of nephropathy occurs after overt nephropathy?
end stage renal disease
what is used to treat microalbuminuria?
ACE-inhibitors or ARB
how do we calculate microalbuminuria?
24 hour collection or spot value compared to urine Cr
at what Cr level must we stop oral agents?
do insulin requirements increase or decrease when GFR decreases?
what are the 1st options of HTN in diabetes?
when should pregnancy be discouraged in diabetics?
-ischemic heart disease
how do we screen for gestational diabetes?
50g oral glucose tolerance test
what is a positive 50g oral glucose tolerance test?
is gestational diabetes associated with increased risk of congenital malformations?
maternal risks of diabetes in pregnancy
-progression of microvascular complications
-high rate of C section
why is a higher rate of C section associated with diabetes in pregnancy?
increased sugar causes increased insulin, which is a growth factor, making the baby larger
fetal risks of of diabetes in pregnancy
-respiratory distress syndrome
how do we treat gestational diabetes?
does insulin cross the placenta?
do metformin and sulfonylureas cross the placenta?
what percentage of fetuses are killed by DKA?
is hypoglycemia in mother harmful to fetus?
why is arthrogryposis associated in infants of diabetic mother?
large baby isnt able to move properly in utero, causing joints to freeze
what is the most common complication of insulin therapy?
what levels of blood glucose define hypoglycemia?
what happens if glucose goes below 50?
impaired cognitive function
what happens if glucose goes below 40?
loss of consciousness
what happens if glucose goes below 30?
coma and/or seizure
can symptoms of hypoglycemia be elicited by normalizing a poorly-controlled diabetic?
what is the somogyi effect?
nocturnal hypoglycemia from too high a dose of insulin given at night, resulting in high morning glucose
what is the dawn phenomenon?
high fasting morning glucose from normal cortisol release in morning
how can we differentiate between the dawn phenomenon and the somogyi effect?
check glucose at 2am, if increased = somogyi effect
what causes the somogyi effect?
older, cheaper forms of insulin - NPH
how is hypoglycemia treated?
how should diabetics prepare for surgery if they cannot eat?
give half of usual insulin
what is the glycemic index?
how quickly and how highly a food item can make a person's blood sugar jump up compared to the same amount of pure glucose
what do we want the blood sugar 2 hours postprandial in DM patients to be?
what do we want the fasting blood sugar to be in DM patients?
what is the DOC for type II DM?
risks of metformin with renal or liver failure
can metformin promote weight loss?
can metformin cause hypoglycemia?
effects of metformin
-increases glucose uptake
-increase insulin sensitivity
effects of metformin with polycystic ovarian syndrome
side effects of metformin
what type of acid base disorder is lactic acidosis?
metabolic acidosis with anion gap
S&S of lactic acidosis
what is the oldest drug glass for diabetes treatment?
which type of DM do sulfonylureas treat?
what do sulfonylureas do?
increase insulin production
4 1st generation sulfonylureas
3 2nd generation sulfonylureas
can sulfonylureas cause hypoglycemia?
what drugs increase the bioavailability of sulfonylureas?
what drugs decrease effectiveness of sulfonylureas?
difference between meglitinides and sulfonylureas?
meglitinides have much shorter half life
can meglitinides prevent diabetic complications?
why are meglitinides not often used?
expensive and inconvenient (need to take with each meal)
repaglinide (prandin) and nateglinide (starlix)
brand name of repaglinide
generic of prandin
brand of nateglinide
generic of starlix
what do intestinal absorption blockers do?
decreases absorption of monosaccharides by blocking the enzyme responsible for breaking down sucrose into glucose and fructose
contraindications for intestinal absorption blockers
hepatic and renal impairment
side effects of intestinal absorption blockers
1 intestinal absorption blockers
what does orlistat do?
reduces fat absorption, promoting steatorrhea
rosiglitazone (avandia) and pioglitazone (actos)
brand of rosiglitazone
generic of avandia
brand of pioglitazone
generic of actos
what do thiazolidinediones do?
-enhance insulin receptor activity, increasing insulin sensitivity
-benefit lipid metabolism
-reduce macrovascular disease
side effects of thiazolidinediones
anemia, fluid retention, reduction in bone density
1 dopamine-2 receptor agonists
side effects of dopamine-2 receptor agonists
dizziness, psychosis, nausea
what tumors are dopamine-2 receptor agonists used to treat?
1 bile acid sequestrants
side effect of bile acid sequestrants
what do bile acid sequestrants do?
2 DPP-4 inhibitors
sitagliptin and saxagliptin
what does DPP-4 do?
an enzyme in gut that degrades GLP-1
what does GLP-1 do?
mediating release of insulin
do DPP-4 inhibitors work for type I or type II DM?
what do DPP-4 inhibitors do?
increase release of insulin
how are incretin mimetics administered?
2 incretin mimetic
exenatide (byetta) and liraglutide (victoza)
brand of liraglutide
generic of victoza
brand of exenatide
generica of byetta
what are incretin mimetics a synthetic analogue of?
what do incretin mimetics do?
-slow gastric emptying
-increases release of insulin
what type of DM are incretin mimetics used for?
what do sodium-glucose co-transporters do?
-block reabsorption of glucose in renal tubules, increasing glucose excretion
side effects of sodium-glucose co-transporters
yeast infections and UTIs (increased urination)
can sodium-glucose co-transporters cause hypoglycemia?
1 amylin analogue
brand of pramlinitide
brand of symlin
what secretes amylin?
pancreatic islet cells
what do amylin analogues do?
slows gastric emptying and decreases release of glucagon
do amylin analogues reduce HgbA1C?
so amylin analogues promote weight loss?
how must amylin analogues be given?
in conjunction with insulin therapy
how can insulin be administered?
IV, SQ, inhaled
3 rapid acting insulins
insulin lispro (humalog)
insulin aspart (novolog)
insulin glulisine (apidra)
1 intermediate-acting insulins
2 long acting analogues
insulin glargine (lantus)
insulin detemir (levemir)
would we rather use a reactive or retroactive insulin regimen?
1 inhaled insulin
when is inhaled insulin used and in what type of DM?
preprandial insulin in Type I or II
stipulations for inhaled insulin
-cannot have smoked in previous 6 months
-no history of asthma or COPD
how often does the catheter and needle need to be changes with an insulin pump?
every 3 days
what is the goal HbgA1C for DM therapy?
what is the goal fasting blood sugar level for DM therapy?
what is the goal 1-2 hr post-prandial blood sugar for DM therapy?
how often should DM patients have lipid screening?
every 5 years
what should BP be in DM patients?
how do we test GH?
-stimulate with insulin or check IGF-1 serum value
what does posterior pituitary deficiency cause?
3 stimuli for ADH secretion
-high serum osmolality
S&S of diabetes insipidus
etiologies of cranial diabetes insipidus
-post surgery/head trauma
etiologies of nephrogenic diabetes insipidus
-renal medullary diseases
how do we differentiate between cranial and nephrogenic diabetes insipidus?
water deprivation test or response to exogenous ADH
treatment of diabetes insipidus
-increase fluid intake
causes of SIADH
-small cell lung carcinoma
criteria to diagnose SIADH
-urine sodium >20
-normal adrenal, thyroid, renal function
-high urine osm
S&S of SIADH
long term damage from correction of sodium too quickly
-central pontine myelinolysis
volume status of SIADH
-treat primary cause
what happens if sodium is correct too fast with diabetes insipidus?
post partum infarction of pituitary
S&S of pituitary hypofunction
-decreased visual acuity
-loss of temporal visual fields
-loss of color vision
-loss of thirst sensation
-dysregulation of temperature
clinical manifestations of growth hormone deficiency in pediatrics
-failure to thrive
-low birth weigh
clinical manifestations of growth hormone deficiency in adults
-loss of bone density
S&S of gonadotropin deficiency in peds
S&S of gonadotropin deficiency in adults
-loss of libido
S&S of ACTH deficiency
S&S of prolactin deficiency
inability to lactate
most common type of pituitary adenoma
are prolactinomas usually functioning or nonfunctioning?
are somatotrophic adenomas usually functioning or nonfunctioning?
what do somatotrophic adenomas secrete?
are thyrotroph adenomas usually functioning or non-functioning?
are gonadotroph adenomas usually functioning or non-functioning?
are corticotroph adenomas usually functioning or non-functioning?
what do corticotroph adenomas cause?
S&S of prolactinomas
-evidence of hypopituitary symptoms
what stimulates prolactin secretion?
treatment of prolactinomas
-bromocriptine or cabergoline (increase dopamine)
long-term consequences of acromegaly
-prematrue vascular disease
-obstructive sleep apnea
treatment of acromegaly
-GH antagonist (pegvisomant)
-dopamine agonist (cabergoline)
what are craniopharyngiomas?
rathke pouch remnant tumors
are craniopharyngiomas usually benign or malignant?
what is a pituitary apoplexy?
spontaneous bleed into an adenoma
S&S of pituitary apoplexy
-severe acute headache
-acute visual symptoms
-hypofunction of pituitary
treatment of pituitary apoplexy
causes of empty sella
-pituitary tumor resection
-increased intracranial pressure
-multiparous women (5+ children)
-basilar skull fractures
S&S of sheehans
-inability to lactate
what thyroid cells secrete calcitonin?
what thyroid cells secrete T3 and T4?
drugs that increase secretion of TSH
physiological effects of thyroid hormone
-stimulation of metabolic pathways
-increase of tissue O2 consumption
what test differentiates autoimmune from infectious hyperthyroidism?
nuclear/technicium or iodine scan
what test is used to characterize a thyroid nodule as hot or cold?
nuclear/technicium or iodine scan
difference between cold and hot thyroid nodules
-cold: less uptake of radiomarkers and usually malignant
-hot: cause hyperthyroid state, no need to biopsy
physical exam of hyperthyroidism
causes of goiter?
iodine deficiency goiter
symptoms of goiter
-sudden enlargement and pain
-stridor, hoarse voice
when do we biopsy thyroid nodule?
treatment of goiter
-shrink with supplemental thyroxine
leading cause of thyroid cancer
follow up after 1 year of thyroid cancer
-neck US 6 mos after tx
follow up 2-10 years after thyroid cancer
-neck ultrasound every 1-2 years
follow up 11-20 yrs after thyroid cancer
-annual clinical exam
-TSH, free T4
-neck US every 1-3 yrs
follow up 21+ years after thyroid cancer
-neck US every 3-5 years
etiologies of hyperthyroidism
-toxic nodular goiter
-exogenous intake of thyroxine
S&S of hyperthyroidism
-high output cardiac failure
additional S&S of thyroid storm
sudden onset of:
treatment of thyroid storm
how do iodine agents treat thyroid storm?
supresses release of T3 and T4
how does methimazole treat thyroid storm
blocks thyroxine synthesis
anti-TSH abs stimulate TSH receptor
additional S&S of Grave's disease
-bruits over thyroid
-loss of color vision
treatment of Grave's disease\
toxic nodular goiter
adenoma with thyrotoxicosis
treatment for acute and subacute thyroiditis
-treat symptoms: corticosteroids and NSAIDs
does every hyperthyroid state warrant radioiodine uptake and scan?
subacute granulomatous thyroiditis
hyperthyroidism followed by hypothyroidism and recover
what causes subacute granulomatous thyroiditis?
destruction of thyroid follicular cells
high or low uptake on thyroid scan with subacute granulomatous thyroiditis?
2 categories of subacute granulomatous thyroiditis
painful and painless
S&S of subacute granulomatous thyroiditis
-tender diffuse goiter
-elevated T3 and T4
what usually causes subacute granulomatous thyroiditis?
how long does subacute granulomatous thyroiditis last?
treatment of subacute granulomatous thyroiditis
S&S of infectious thyroiditis
-unilateral neck mass
what is thyroid function like with infectious thyroiditis?
is a fistula from piriform sinus associated with bacterial or viral infectious thyroiditis?
main etiologies of infectious thyroiditis
how is infectious thyroiditis diagnosed?
treatment of infectious thyroiditis
how does thyroid function of classic painless thyroiditis present?
transiently hyperthyroid, then hypo, then absent
how is postpartum thyroiditis different from grave's?
who is at risk of drug induced thyroiditis from interferon-alpha?
Hep C patients
common drugs that cause drug-induced thyroiditis
how does amiodorone-induced thyroiditis present?
-hyperthyroidism from inflammation
-hypothyroidism from antithyroid effect of iodine
how does lithium-induced thyroiditis present?
what is fibrous thyroiditis called?
what is Reidel's thyroiditis?
scarring down of thyroid
treatment of fibrous thyroiditis
NSAIDs or prednisone
treatment of drug-induced thyroiditis
NSAIDs or prednisone
what thyroid disorder takes up a high level of radioactive iodine?
what is considered high radioactive iodine uptake?
what is normal radioactive iodine uptake?
what is low radioactive iodine uptake?
what thyroid disorders tale up low amounts of radioactive iodine?
-severe iodine excess
S&S of hypothyroidism
-swelling of eyelids, face, limbs
-slow-relaxing deep tendon reflexes
etiology of myxedema coma
S&S of myxedema coma
-altered mental status
treatment of myxedema coma
why do we give steroids in myxedema coma?
just incase adrenal insufficiency is happening
why do we give abx in myxedema coma?
to protect against infx
what does CBC show with myxedema coma?
normocytic anemia of chronic disease
what are liver enzymes like with myxedema coma?
S&S of cretinism
-failure to thrive
-coarse hair and skin
-decreased muscle tone
treatment of cretinism
with cretinism, what do we want to keep TSH for best long-term outcomes (weight gain, osteoporosis, lipid profile)?
how does hCG increase T3 and T4?
hCG stimulates TRH, which increases TSH, which increases T3 and T4
does sick euthyroid syndrome need to be treated?
what is sick euthyroid syndrome?
sick patient in ICU may have low T3 and T4
when do we treat subclinical hyperthyroidism?
if patient has CHF, pregnant, or has symptoms
3 layers of adrenal cortex from most superficial to deep
what does zona glomerulosa secrete?
what does zona fasiculata secrete?
what does zona reticularis secrete?
what does the adrenal medulla secrete?
what does CRH do?
stimulate release of ACTH
what does ACTH do?
stimulate cortisol release
what does cortisol do?
-increase glucose production
-mobilizes fatty acids
-demargination of neutrophils
what androgens are secreted from the adrenals?
DHEA and androstenedione
what effect does cortisol have on NE and E?
increases conversion of norepinephrine to epinephrine
what do alpha 1 receptors do?
what do alpha 2 receptors do?
-inhibits insulin secretion
what do beta 1 receptors do?
-increases renin production
what do beta 2 receptors do?
S&S of primary hypoadrenalism
-vague abdominal complaints
why is hyperpigmentation associated with hypoadrenalism?
overproduction of ACTH has melanin activity
what are sodium levels of primary hypoadrenalism like?
what are potassium levels of primary hypoadrenalism like?
what are calcium levels of primary hypoadrenalism like?
what are glucose levels of primary hypoadrenalism like?
what does CBC show with primary hypoadrenalism?
what are renin levels of primary hypoadrenalism like?
high plasma renin
what are aldosterone levels of primary hypoadrenalism like?
what causes an addisonian crisis?
stress - severe illness, surgery, etc
lack of ACTH
lack of CRH
how can we differentiate secondary from tertiary hypoadrenalism?
-glucagon stimulation test
what does the metirapone test do?
blocks synthesis of cortisol
immediate treatment of addisonian crisis?
hydrocortisone and IV fluids
what are postassium levels like with hypoaldosteronism?
what type of acid-base issue is associated with hypoaldosteronism?
normal ion gap metabolic acidosis
what is ammonia excretion like with hypoaldosteronism?
aldosterone synthesis impairment causes of hypoaldosteronism
-congenital adrenal hyperplasia
drugs that cause hypoaldosteronism
renin release impairment causes of hypoaldosteronism
what is pseudohypoaldosteronism?
receptor or channel defects
type 1 pseudohypoaldosteronism
looks like hypoaldosteronism, but with high serum aldo levels
which type of pseudohypoaldosteronism is associated with HTN?
causes of hyporeninemic hypoaldosteronism
treatment of primary adrenal insufficiency hypoaldosteronism
-mineralcorticoid and glucocorticoid replacement
treatment of hyporeninemic hypoaldosteronism
-low potassium diet
-loop or thiazide diuretic
causes of conn's syndrome
-benign cortical adenoma
-bilateral hyperplastic adrenals
classic presentation of conn's syndrome
screening test for conn's syndrome
what will aldo:renin ratio be like in conn's?
high aldo:low renin
what test is needed to ID cause of Conn's
CT or MRI
differentials of Conn's
-back liquorice intake
congenital adrenal hyperplasia
who do we test for Conn's?
-HTN + hypokalemia
-HTN + adrenal incedentaloma
-HTN + sleep apnea
-HTN + family history of cerebrovascular accident at young age
-HTN and family history of primary aldosteronism
management of Conn's
-surgical removal of adenoma
excessive glucocorticoid because of pituitary problem - too much ACTH
what happens to adrenal glands in cushing's disease
hyperplasia from overstimulation
why is hirsuitism associated with cushings disease?
because adrenal androgens are produced in excess as well
why is infection associated with cushing's?
why is CAD associated with cushings?
S&S of cushing's
-fragile, bruisable skin
-proximal muscle weakness
-poor wound healing
what does CBC show with cushings?
what are potassium levels like with cushings?
is acidosis or alkalosis associated with cushings?
what is HgbA1C like with cushings?
is hypo or hyperlipidemia associated with cushings/
what is the best test for cushings?
dexamethasone suppression test
treatment of cushings by cortisol blockade
what type of MEN are adrenal tumors more common?
diseases associated with adrenal adenomas
where does adrenal carcinoma usually metastasize to?
lung, bone, liver
adrenal masses under what size with benign features can just be watched?
neoplasm of adrenal medulla
what cells do pheochromocytomas originate from?
chromaffin cells (sympathetic ganglion)
what do pheochromocytomas secrete?
excessive epi and norepi
simular to pheochromocytoma, but less active, distrubated along other sympathetic ganglia
do pheochromocytoma or paraganglionomas have a more malignant potential?
S&S of pheochromocytoma
-altered bowel habits
how do we test for pheochromocytoma?
24 hour urine for free catecholamines
what scan is specific for pheochromocytoma or paraganglionomas?
MIBG radionuclide scan
treatment of pheochromocytoma
-alpha blockade FIRST
-then beta blockade
what is sodium like with CAH?
what is potassium like with CAH?
what is glucose like with CAH?
what is cortisol like with CAH?
what is aldo like with CAH?
what is renin like with CAH?
what is 17-hydroxyprogesterone like with CAH?
treatment of CAH
corticosteroids or mineralocorticoids
S&S of insulinomas
-symptom release with glucose
part of insulin cleaved off when being used
is C- peptide present with injected insulin?
episodic hypoglycemia and diarrhea bc of bariatric surgery
hemihypertrophy (on one side of body)
S&S of zollinger-ellison syndrome (gastrinoma)
-multiple peptic ulcers
are most gastrinomas malignant?
what type of MEN are gastrinomas associated with?
treatment of gastrinomas
high dose PPI
what scan can isolate location of gastrinoma?
what do VIPomas secrete?
vasoactive intestinal peptide
S&S of VIPomas
treatment of VIPomas
S&S of glucagonomas
-necrolytic migratory erythema
treatment of somatostatinomas
where are carcinoid tumors located
anywhere in GI tract, but most often in small bowel
S&S of carcinoid syndrome
-cardiac valvular lesions (myxoma)
2 ways to get an accurate serum calcium measurement
-adjust for serum albumin
-ionized calcium measurement
action of PTH
-stimulate osteoclast activity
-increase calcium reabsorption
-decrease phosphate reabsorption
-increase 25-OH vit D to active 1,25-OH vit D
-increase gut calcium and phosphate absorption
what cells make calcitonin?
actions of calcitonin
-inhibits osteoclast activity
-reduce bone resorption
is vit D fat or water soluble?
intestinal effects of vitamin D
-increases calcium and phosphate absorption
bone effects of vitamin D
increases osteocalcin and osteopontin
what is Paget disease?
disease of bone remodeling in which osteoclasts are overactive and bone is replaced in patchy areas with a vascular, fibrous tissue
symptoms of Paget disease
-dull, constant pain
where is Paget disease most common?
when is Paget dsease pain worse?
at night and when physical forces are applied to affected bone
which bones are more often effected by paget disease?
skull and axial skeleton
what does a plain film show with paget disease?
punched out areas and sclerosis in various phases
what are alkaline phosphatase levels like with paget disease?
what does an explosive rise in alk phos indicate with paget disease?
treatment of paget disease
bisphosphonates at higher doses than osteoporosis
what is milk-alkali syndrome?
what is william's syndrome?
urinary S&S of hypercalcemia
GI S&S of hypercalcemia
neurologic S&S of hypercalcemia
cardiac S&S of hypercalcemia
psychiatric S&S of hypercalcemia
if iPTH is high, what is indicated
low iPTH indications
treatment of hypercalcemia
-fluids and loop diuretic
-remove offending agent/tumor
is primary hyperparathyroidism usually associated with a single adenoma or multiple adenoma syndromes?
from hypocalcemia and hyperphosphatemia of renal insufficiency
long-standing secondary hyperparathyroidism leads to autonomous function of hyperplastic nodules
familial hypocalciuric hypercalcemia
inappropriately high iPTH despite high serum calcium, low urinary calcium
how does lithium cause hyperparathyroidism?
can cause parathyroid hyperplasia
S&S of hyperparathyroidism
why would a parathyroid radionucleotide scan be done?
if surgical resection is decided to ID ectopic tissue
indications for surgery in primary hyperparathyroidism
-serum calcium > 1
-history of life threatening hypercalcemia
-renal calcification or reduction in GFR
-400 mg of calcium in 24 urine collection
S&S of acute hypocalcemia
tremor in forearm with BP cuff
tap over jaw, masseter tremor
S&S of chronic hypocalcemia
-ectopic calcifications in cornea
treatment of acute hypocalcemia
treatment of chronic, nonsevere hypocalcemia
what is osteomalacia called in kids?
risks for vit D deficiency
-upper GI surgery
-small bowel dz
-chronic liver or kidney dz
S&S of vit D deficiency
-waddling gait, bowed legs
-craniotubes in neonates
-enlargement of costochondral junctions
-enlarged wrists and ankles
-delayed tooth eruption
treatment of vit D deficiency
replace vit D
difference between osteomalacia and osteoporosis
osteomalacia matrix is inadequately mineralized, but osteoporosis matrix is decreased but mineralized properly
risks of osteoporosis
-low calcium intake
-vit D deficiency
how is bone mass assessed?
S&S of osteoporosis
most common fracture sites with osteoporosis
#1 treatment of osteoporosis
#2 treatment of osteoporosis is bisphosphonates is failed
what does denosumab do?
decreases osteoclast activity
what prevents the development of uterus and cervical tissues?
Mullerian inhibiting factor
what produces Mullerian inhibiting factor?
what does LH do in male puberty?
stimulates testosterone production
what does FSH do in male puberty?
stimulates seminiferous tubules to allow for spermatogenesis
what causes secondary sexual characteristics in male puberty?
metabolism of testosterone by 5-alpha-reductase
what can cause gynecomastia in male puberty?
temporary imbalance in testosterone and estradiol levels
breakdown product of androgens
causes of hypogonadotropic hypogonadism
-raised intracranial pressure
causes of primary hypogonadism
S&S of male hypogonadism
long arms and legs
benefits of testosterone replacement
-increased bone density
-increased muscle mass
drawbacks of testosterone replacement
-increased heart dz
-increased risk of prostate cancer
how is testosterone given?
transdermal or injection
what needs to be monitored with testosterone replacement?
other name for proliferative phase
other name for secretory phase
what causes menstruation?
-withdrawal of estrogen and progesterone
-ischemia of stroma of endometrium
proliferative (follicular) phase
-endometrial growth and follicle maturation in ovary
-viscous mucus develops to close cervix
-release of follicle into fallopian tubes
-thinning of cervical mucus
-rise in basal body temp
stringy cervical mucus on exam
abdominal pain with ovulation
secretory (luteal) phase
-corpus luteum of unfertilized follicle remnant causes increase secretory gland growth from rise in progesterone
-develop blood vessels of uterine lining
is FSH or LH released in higher amounts in the proliferative phase?
effect of increased FSH during proliferative phase
maturation of follicle and gradual rise in estrogen
is estrogen higher before or after ovulation?
before (positive feedback loop)
effect of LH rise
causes corpus luteum to produce progesterone
what phase does progesterone rise?
effect of estrogen and progesterone during secretory phase
inhibits further LH and FSH secretion
adolescent girl by age 16 never experiencing a period, but still developing secondary sexual characteristics
absence of menses in a women with previous periods for either 3 cycles or 6 months
S&S of menopause
risks of systemic estrogen supplements
breast and uterine cancer
why do we sometimes give estrogen along with progesterone?
to decrease risk of breast cancer
uses of topical estrogen
partial estrogen agonist/antagonist
benefit of raloxifen
decreased risk of breast cancer than estrogen
benefit of progestrone alone
benefit of clonidine
benefits of testosterone in menopause
polycystic ovary syndrome
excessive androgen production (ovarian and/or adrenal)
effect of polycystic ovary syndrome with insulin
age of polycystic ovary syndrome onset
15-25 years old
S&S of polycystic ovary syndrome from androgen excess
capital hair loss
S&S of polycystic ovary syndrome from anovulatory cycles
additional symptoms of polycystic ovary syndrome
LH:FSH ratio in polycystic ovary syndrome
level of progesterone in polycystic ovary syndrome
level of androgen in polycystic ovary syndrome
treatment of polycystic ovary syndrome
what does finesteride do to treat polycystic ovary syndrome?
block androgen conversion from testosterone to more active dihydrotestosterone
what does metformin do to treat polycystic ovary syndrome?
decreases androgen production and insulin resistance
treatment of hirsuitism in polycystic ovary syndrome
-type I DM
type II polyglandular autoimmune syndome
what should be replaced first when treated type II polyglandular autoimmune syndome?
replace adrenal function 1st
why do we replace adrenal function before thyroid function with polyglandular autoimmune syndome?
if we replace thyroid function 1st, we can cause shock in the patient
-chronic active hepatitis
type I polyglandular autoimmune syndome
-type I DM
-autoimmune thyroid diseases
type III polyglandular autoimmune syndome
-phenotype similar to turner's syndrome
Werner syndrome (progeria)
what endocrine dysfunction is associated with Down syndrome?
is MEN I autosomal dominant or recessive?
neoplasms of what glands are associated with MEN I?
the 3 P's
manifestations of parathyroid neoplasms with MEN I
manifestations of pituitary neoplasms with MEN I
manifestations of pancreas neoplasms with MEN I
-pancreatic polypeptide secreting tumor
diagnosis of MEN I
2 of 3 (parathyroid, pituitary, pancreas) tumors are found
are MEN I tumors usually malignant or benign?
manifestations of MEN IIA
-medullary thyroid cancer
-cutaneous lichen amyloidosis
is MEN IIA autosomal dominant or recessive?
what cells are cancerous with medullary thyroid cancer?
manifestations of MEN IIB
-medullary thyroid cancer
endocrine manifestations of CHF
-increased atrial natriuretic peptide
endocrine manifestations of sleep apnea
endocrine manifestations of renal failure
-low 1,25OH vit D
-elevated plasma renin
-elevated prolactin (Decreased excretion)
endocrine manifestations of liver failure
-impaired clearance of androstenedione (gynecomastia)
-increased conversion to estrogen
what cancer is SIADH seen with?
small cell lung cancer
what cancers is ectopic ACTH production seen with?
-small cell lung cancer
what cancers is parathyroid hormone-related peptide seen with?
-squamous cell lung cancer
-renal cell cancer
what cancers if EPO seen with?