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-Elicited by inflation of BP cuff 20 mm above systolic held for 3 minutes
-Carpal spasm of flexed elbow and wrist
-Adducted thumb over the palm
-Flexed metacarpophalangeal joints
-Adduction of hyperextended fingers
-Extended interphalangeal joints
-When accompanied by respiratory distress needs emergency care
-Idiopathic and pubertal gynecomastia:
•Should resolve spontaneously within 1 to 2 years
•Requires no medication
•Followed biannually and the size of the disk measured until it has resolved
-Tamoxifen 10 mg twice daily may be useful in painful gynecomastia
-Cold compresses and analgesics may also relieve discomfort
-Reassurance and attention to any impact on body image
-Instruction on breast and testicular self-examination
•All cases in which gynecomastia appears before puberty
•Does not resolve 2 years following puberty
•Occurs in the presence of:
-Abnormal serum levels of free testosterone and luteinizing hormone (LH)
-Accompanied by abnormal presence or absence of secondary sex characteristics, undermasculinization, or small, asymmetrical testes
•Pubertal male: referral is indicated at any time when physical findings are not consistent with normal growth and development
- caused by increased secretion of androgens by the ovary or adrenal glands or an increased sensitivity to androgens
- Testosterone levels greater than 200 ng/dL (in women) suggest adrenal or ovarian pathology
- DHEA-S is above 700 ng/dL, an adrenal tumor workup is indicated
- LH/FSH (follicle-stimulating hormone) level is increased in 75% of cases of polycystic ovarian disease
- should be managed in collaboration or referral with specialist in endocrinology
- euthyroid state is the goal of treatment
- minimizing the adverse effects of treatment
- decreasing the incidence of hypothyroidism
- possible medications: beta-blockers for faster symptom relief; antithyroid medications (PTU and MMI)
- radioactive iodine-131 is the treatment of choice for hyperthyroidism
Hyperthyroidism: Follow-up•Monitor thyroid function tests at least twice a year •Initial treatment should be evaluated at 1 month and at 3 months or more frequently if the patient is symptomatic •Therapy with antithyroid medications should continue for 3 to 12 months •After radioiodine therapy, thyroid function tests should be performed at 6 weeks, 12 weeks, 6 months, and annually thereafterGraves' Disease- most common cause of spontaneous hyperthyroidism - autoimmune disorder - may reflect a defect in suppressor T-cell function - presence of antibodies to the thyroid-stimulating hormone receptorHypothyroidism: Testing- elevated TSH and decreased free T4 - If the TSH is low, normal, or insufficiently elevated in the presence of low T4 values, central hypothyroidism caused by hypothalamic or pituitary disease should be excluded - CBC, chemistry panel, UA, lipid panel, ECG, CXRHypothyroidism: Management- Goal: normalize, not suppress, the TSH - daily administration of thyroid hormone: usual dose is 1.6 mcg/kg per dayHypothyroidism: Follow-up- after therapy is initiated, check patient's TSH in 4-6 weeks - target TSH level is 0.3-3.0 mclU/mL - once stable dose of levothyroxine established, TSH level can be checked bianually or anuallySubclinical Hypothyroidismthe presence of normal free T4 with an elevated TSHSubclinical Hypothyroidism managementThe American Thyroid Associated recommends treating subclinical disease when: - TSH level is greater than 10 mlU/mL - antithyroid antibodies are present - serum lipid levels are abnormal - patient smokes - patient is symptomatic at this TSH levelThyroid Cancer- Major risk factor: exposure to ionizing radiation - usually painless - new onset of hoarseness with hemoptysis is strongly suggestive of a malignant growth - initial testing is ultrasonography - FNA needed to diagnosisCushing's Syndrome- persistent inappropriate hypercortisolemia - ACTH excess caused by a pituitary tumor, which in turn causes over secretion of cortisol by the adrenal glandCushing's Syndrome: Subjective-Gradual, developing over months or years -Common complaints: weight gain, back pain, headaches, skin changes, and muscle weakness -Women report menstrual irregularities and hirsutism -Men report decreased libido and impotence -Emotional lability, increased appetite and weight gain, increased irritability, anxiety, poor concentration and memory, and sleep disturbancesCushing's Syndrome: Objective- generalized or central obesity: "moon face", or "buffalo hump" - Skin changes: atrophy of the epidermis and connective tissue - MS: muscle weakness and wasting; osteoporosisCushing's initial testing- urine-free cortisol - late-night salivary cortisol - 1-mg overnight dexamethasone suppression test - longer low-dose DST - additionally: CBC, CMPAddison's Disease- autoimmune destruction of the adrenal cortex - elevated ACTH levels - Adrenal insufficiencyAddison's Disease: Diagnostic Testing- morning plasma cortisol of < 3mcg/dl is diagnostic - ACTH > 200 mcg/dl - cortrosyn stimulation test: failure of cortisol to rise to > 10 or double from baseline at 60 minutes is positive for primary insufficiency - above 20 is a normal resultGout Clinical Presentation- pain, tenderness, erythema, and swelling - monoarticular - the joint most frequently affected is the first metatarsal joint - excruciating pain that awakens the patient at night - tophi deposits?Gout Testing- uric acid level often above 7.5 mg/dL - ESR and WBC count may be elevated during an acute attack - x-ray of affected joint - joint fluid aspirationPharmacological treatment for an acute Gout attack- NSAIDs: indomethacin is choice for gout - Colchicine - CorticosteroidsGout lifestyle management- limiting high-purine content foods (organ meats, high fat meat, gravy, etc) - limiting ETOH - increasing fluids - activity must be restricted during an acute attackGout Pharmacological prophylaxis- initiated following the second or third attack - consistent hyperuricemia greater than 8 mg/dL - Colchicine and NSAIDs may be continued in lower doses up to 12 months following an acute attackPharmacological management for obesity- Catecholaminergic - Phentermine - Diethylpropion (Tenuate) - Sibutramine HCL monohydrate (Meridia) - Orlistat - Saxenda - Contrave - Belviq - QsymiaThe clinician suspects that a client seen in the office has hyperthyroidism. Which of the following tests should the clinician order on the initial visit?High sensitivity thyroid-stimulating hormone (TSH) and free T4Joyce is seen in the clinic complaining of vague symptoms of nervousness and irritability. She says that her hair will not hold a permanent wave anymore. On physical examination, the clinician finds an irregular heartbeat and brisk reflexes. The differential diagnosis should include which of the following conditions?ThyrotoxicosisThe patient is prescribed radioactive iodine (RAI) and asks the clinician how this drug works. The clinician's response should include which of the following data?RAI destroys thyroid tissueA patient is diagnosed with hypothyroidism. Which of the following electrocardiogram changes should the clinician expect as a manifestation of the disease?sinus bradycardiaWhich of the following laboratory findings should the clinician expect in a patient with untreated Graves' disease?- elevated TSH receptor antibody - elevated antithyroglobulin antibody - elevated antimicrosomal antibodyA 25-year-old patient presents to the clinic with fatigue, cold intolerance, weight gain, and conspitation for the past 3 months. On physical examination, the clinician notices muscular stiffness; coarse, dry hair; and a delay in relaxation in deep tendon reflexes. Which test should be ordered next?Thyroid-stimulating hormoneAfter 6 months of Synthroid therapy, the clinician should expect which result in the repeat thyroid-stimulating hormone studies?NormalWhich of the following is essential for diagnosing thyroid cancer?fine-needle aspirationA woman presents with new-onset hoarseness with hymoptysis. For which condition should the clinician focus an examination?Thyroid cancerT/F: urine free cortisol is one of the four diagnostic tests recommended for Cushing's syndrometrue