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Elderly Patients Have Higher TSH Concentration
Elderly patients have higher TSH concentration
- Keywords:: Step 3, Endocrine, Thyroid Dysfunction
The distribution of TSH values in the population differs by age. In an analysis of 16,533 individuals in the National Health and Nutrition Examination Survey III (NHANES III), there was an age-related shift toward higher TSH concentrations in older patients. For example, the 97.5 centile for TSH in adults aged 20 to 29 years, or over age 80, was 3.56 and
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Medicine
Medicine
Todos
- tolearn
- MKSAP todos
- heart murmurs
Organ Systems
- Allergy and Immunology
- Rheumatology
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- Dermatology
- Endocrine
- ENT
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- Hemeonc
- ID
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- Nephrology
- Urology
- Neurology
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Subject Areas
- General
- Biostats
- Psychiatry
- [[Geriatric
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Paget Disease
Paget disease
- related: Endocrine
Symptoms and Diagnosis
Symptoms
- most commonly present as asymptomatic elderly pt with high alk phos or incidental finding on imaging
- Sx: focal area of bone pain, deformity, fracture
- Atypical: spinal cord, cranial nerve compression from expansion of bone
Diagnosis
- thickening of cortical
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Thyroid in Pregnancy
Thyroid in pregnancy
Pregnancy and thyroid medications
However, methimazole is a potential teratogen and should not be used during the first trimester. These teratogenic effects consist of scalp defects, tracheoesophageal fistula, and choanal atresia. During the first trimester, pregnant patients should be switched to propylthiouracil, which carries less risk of birth defects.
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Diabetes Management
diabetes management
- related: Endocrine
- tags: #note
Types of insulin
- short acting: regular; onset 30 min - 1 hour
- rapid acting: NPH, lispro; onset 15 - 30 min
- Lantus (glargine): given sometimes once and sometimes twice a day.
- Levemir (detemir): does not last 24 hours, only lasts 12
- NPH: 12 hours, give 2x/day
- Humulin-R: 6 hours, give with meals, only use if can't afford others
- U-500: 500 units of concentrated insulin, use when using more than
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Hypercalcemia
Hypercalcemia
- related: Endocrine, hypocalcemia
- tags: #note
Symptoms
- confusion
- delirium
- short QT
This patient has newly discovered hypercalcemia. Patients with mild hypercalcemia are often
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Hyperparathyroidism
hyperparathyroidism
- related: Endocrine, Parathyroid
- tags: #endocrine
Hyperparathyroidism
- primary hyperparathyroidism: inappropriate high PTH
- high PTH, high Ca
- secondary: chronically low Ca in renal failure
- high PTH, low Ca
- tertiary: renal failure, unresponsive.
- high PTH, high Ca
- familial hypocalciuria hypercalcemia: abnormal Ca sensor
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Hyperthyroidism
Hyperthyroidism
- related: Endocrine
- tags: #note
Sx
- tachycardia
- AMS, psychosis, agitation, anxiety
- lid lag, stare, itchy eyes
- hyperreflexia
Dx
- high output cardiac failure
- all types of tachyarrhythmias
- hypercalcemia
- elevated LFTs
- thrombocytopenia
- TSH, free T4, total T3
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Hypoparathyroidism
hypoparathyroidism
- Keywords: Step 3, Medicine, Endocrine, Parathyroid
Hypoparathyroidism
- primary: low PTH, surgery, radiation, autoimmune, congenital (Digeorge, APS-1)
- pseudohypoparathyroidism: abnormal sensor to PTH in kidney and bone
- lab looks like secondary hyperparathyroidism
- high PTH, low Ca, high phos
- Albright's Hereditary Osteodys
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Pheochromocytoma
pheochromocytoma
- related: Endocrine
Abdominal imaging is the next step for localizing a pheochromocytoma after biochemical confirmation of the tumor. Both CT and MRI are highly sensitive for localizing pheochromocytomas, which are usually located in the adrenal glands. Clinically active pheochromocytomas are typically >4-4.5 cm in diameter and have a high tissue density on CT scan (generally
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Pituitary Adenoma
pituitary adenoma
- Keywords:: Step 3, Medicine, Endocrine
- Related: 07 Pituitary Secretions
Gonadotrophs adnenoma
This patient has amenorrhea and hypogonadism with suppressed luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels but increased α-subunits. This is strongly suggestive of a nonfunctioning pituitary adenoma, which usually arises from the gonadotropin-secreting cells (gonadotrophs) in the pituitary gland. Normal
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Prolactinoma
prolactinoma
- related: Endocrine
- tags: #endocrine
Prolactin levels naturally increase during pregnancy due to stimulation from high estrogen levels, peak at delivery, and then normalize within 1-2 months after delivery, even with continued breastfeeding. Although prolactin levels increase transiently above basal levels with response to suckling, this response significantly diminishes a few weeks after delivery. This patient is no longer breastfeeding and is
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Subclinical Hypothyroidism
Subclinical hypothyroidism
- related: Endocrine, Elderly patients have higher TSH concentration, hypothyroidism
- tags: #note
Subclinical hypothyroidism (SCH) is defined as an elevated serum TSH level with a normal free thyroxine. The most common cause is chronic lymphocytic Hashimoto thyroiditis. T
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Thyroid Nodules
Thyroid nodules
- related: Endocrine
Patients with thyroid nodules >1 cm should be evaluated based on their cancer risk factors (eg, family history, past radiation exposure, cervical lymphadenopathy), compressive symptoms (eg, hoarseness, difficulty swallowing), and thyroid functional
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Diabetes A1C Goal
diabetes A1C goal
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related: Endocrine
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A1C ± 0.3 on check
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ADA recommendation: patients with long life expectancy: < 7%
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ACP recommendation: A1C between 7% and 8% for most people
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Dr. Aloi: older people <8.5%
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Diabetes Second Line
diabetes second line
- related: Endocrine
- advance to dual therapy when A1C > 9% after 3 months of metformin
Liraglutide, a glucagon-like peptide-1 (GLP-1) receptor agonist, is an appropriate adjunctive agent with metformin in this patient as it will improve glycemic control and contribute to desired weight loss. There are potential concerns for development of pancreatitis and medullary thyroid carcinoma with GLP-1 re
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Primary Adrenal Insufficiency
Primary Adrenal Insufficiency
- related: Endocrine, adrenal crisis
- tags: #note
Causes
- autoimmune
- cancer mets/lymphoma
- infection
- bleeding, infarct
- adrenoleukodystrophy
- CAH
Workup
- low cortisol, high ACTH, can use Cosyntropin stimulation test
- most common cause: autoimmune adrenalitis
- destruction of all layers of adrenal cortex
- positive 21-hydroxylase antibodies in 90% of case
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Thyroid Cancer
thyroid cancer
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Hyperprolactinemia
hyperprolactinemia
- related: Endocrine, prolactinoma and pregnancy, prolactinoma
- tags: #endocrine
Causes of high prolactin:
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most common cause:
- physiologic (pregnancy and lactation)
- physiologic stress, coitus, sleep, nipple stimulation
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pathologic:
- primary hypothyroidism
- pituitary stalk compression
- medications: antipsychoti
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Hypocalcemia
hypocalcemia
- related: Endocrine, Parathyroid, hypocalcemia after osteoporosis treatment, hypercalcemia
- tags: #note
Causes
- hyperphosphatemia: check ionized Ca.
- IV bicarb can cause hypocalcemia and deposition of calcium phosphate in renal tubules
- hypocalcemia is common abnormality after massive transfusion
Symptoms
- mild: muscle cramps, tingling sensations
- severe: seizure
- long QT
Treatment
- Usually do not need reple
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Subacute Thyroiditis
subacute thyroiditis
- related: Endocrine
- cause: thyrotoxicosis following viral URI
- sx: tender thyroid
- pathogenesis: leakage of stored thyroid hormone from damaged thyroid follicles
- dx: low <10% radioactive iodine intake
- management: symptomatic with NSAIDS, beta blocker
- monitor hypothyroid after initial period
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Grave's Disease
- related: hyperthyroidism, Endocrine
- tags: #endocrine
The majority of patients receiving radioactive iodine therapy show improvement in 4-8 weeks, and up to 80% of patients develop hypothyroidism between 2-6 months following treatment. However, post-treatment hypothyroidism can sometimes be transient and self-limited.
TSH may remain suppressed for months after the resolution of hyperthyroidism and does not always indicate ongoing hyperthyroidism
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Diabetes Inpatient Management
diabetes inpatient management
- related: Endocrine
- tag: #note
- Discontinue oral hypoglycemics, especially metformin & sulfonylureas
- Basal Bolus insulin regimen is the preferred guideline driven inpatient regimen
- Inpatient BG goal: 140-180 mg/dL pre-prandially, without severe or recurrent hypoglycemia. ebm NICE-SUGAR trial
- If a patient is having hypoglycemia, they have no BG targets, other than resolving the hypoglycemia.
- Total daily dose (TDD) = ba
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Myxedema Coma
myxedema coma
- related: Endocrine, hypothyroidism
- tags: #note
History
- personal or family hx of autoimmune disease
- Grave's disease hx
- recent pregnancy
- medications: amiodarone, lithium
- Hx of brain surgery, pituitary surgery, head trauma
- trigger: any stress, infection/MI
Sx
- AMS: slow or psychosis
- hypothermia
- slowed organ function
- non pitting edema everywhere
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Steroids and Cortisol
steroids and cortisol
- related: Endocrine
- tags: #note
Steroids and cortisol level
- dexamethasone: will suppress cortisol level
- hydrocortisone: will contribute to cortisol
- prednisone: some contribution to cortisol level
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Cushing Syndrome
Cushing syndrome
- related: Endocrine
- Cushing syndrome: suppressed ACTH production due to excess cortisol secretion from adrenal gland
- following surgery: impaired endogenous cortisol production. Chronic atrophy from lack of ACTH stimulation
- Give hydrocortisol following surgery and then taper
- fludrocortisone not required
- aldosterone secretion from contralateral adrenal gland not impacted
- fludroco
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Euthyroid Sick Syndrome
euthyroid sick syndrome
- related: Endocrine
- aka nonthyroidal illness syndrome (NTIS)
- demographics: hospitalized and critically ill patients
- pathogenesis: illness suppress thyrotropin releasing hormone
- labs
- suppressed but detectable TSH
- undetectable TSH is not NTIS
- Can sometimes have elevated TSH but not > 20 mU/L
- T4 usually normal
- T3 lower than normal due to decreased deiodinase acti
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Male Hypogonadism
male hypogonadism
- related: Endocrine
This patient has symptoms (ie, decreased libido, possible early testicular atrophy) that warrant testing for hypogonadism. His loss of early-morning (nonsexual) erections suggests an organic (rather than psychogenic) cause of erectile dysfunction. Hypogonadism is common in men with obesity and/or diabetes/prediabetes, likely due to dysfunction of th
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Thyroidectomy and Calcium
thyroidectomy and calcium
- related: Endocrine
- post thyroidectomy, pts can have chronic hypoparathyroidism with hypocalcemia
- at follow up 6 months, obtain 24 hour urine calcium
- without PTH, urinary calcium excretion increased, leading to nephrolithiasis and renal insufficiency
- goal serum Ca level: low-normal
- goal mag: > 2
- goal urine calcium: normal
- If urinary Ca > 300mg/25hrs, decrease Ca and/or vitami
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Diabetes Insipidus
diabetes insipidus
- related: Endocrine
Diagnosis
- If urine output < 300cc/hr x3 hours, then get DI labs
- one dose dex won't interfere cortisol level
- random cortisol: 3-18 normal range
- use prednisone for secondary DI as no aldosterone needed. Does not need hydrocortisone
Causes
In addition to increasing the prednisone, the antidiuretic hormone (ADH) analogue desmopressin acetate is the most appropriate treatment. This patient most likely has central nervo
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Methimazole
methimazole
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related: Endocrine
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daily CBC with diff and LFT
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repeat free T4 q48h while inpatient
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Ebm NICE-SUGAR Trial
NICE-SUGAR trial
- related: diabetes inpatient management, Endocrine, ebm
- tag: #ebm
- clinical question: in icu patients, does intensive glycemic control reduce mortality compared to conventional control
- primary: 90 day mortality, hypoglycemic events
- bottom line: intensive control (81-108) leads to higher mortality compared to conventional control (<180)
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Adrenal Crisis
adrenal crisis
- related: Endocrine
- tags: #note
Symptoms
- tachycardic, hypotensive, may need pressors
Diagnosis
- Low Na, high K
- Na 130s, K > 5
- primary adrenal insufficiency
- secondary adrenal insufficiency:
- exogenous steroids
- pituitary surgery, radiation, trauma
- pituitary mass
- hypophysitis: checkpoint inhibitors
Treatment
- stress dose hydrocortisone: stress dose steroid
- taper off as soon as possible based on clini
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Hypothyroidism
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Pituitary Apoplexy
pituitary apoplexy
- related: Endocrine
- tags: #note
Symptoms
- nausea, vomiting
- sudden onset, worst headache in life
- eye symptoms: diplopia
- tachycardia, hypotensive
Diagnosis
- normal vs apoplexy
- CT does not diagnose 50% of the time, order MRI head if suspecting apoplexy
Treatment
- neurosurgical and
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Stress Dose Steroid
stress dose steroid
- related: Endocrine
- tags: #note
- hydrocortisone 200 mg/day
- 50 mg q6h
- 100 mg q8h
perioperative
- give stress dose steroids for chronic prednisone patients
https://www.uptodate.com/contents/the-management-of-the-surgical-patient-taking-glucocorticoids
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Inpatient Diabetes Management Presentation 1 2022
inpatient diabetes management presentation 1 2022
- related: Endocrine, diabetes blue book
Why management Why DM glycemic target nice-sugar trials amcc diet tf + lantus lantus - nph
starting dose lantus, meal time npo TDD insulin resistance: SSI
AM or PM Lantus
Hypoglycemia
Case
SSI
Lantus and meal time
holding insulin
The dietary
NPH Lantus conversion
questions
- Should long acting basal insulin bring down fasting glucose to 180
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Diabetes Blue Book
diabetes blue book
- related: Endocrine, diabetes care in the hospital
- tags: #note
Hyperglycemia inpatient
Any acute illness results in a state of stress with release of hormones (e.g. glucocorticoids) and cytokines, which in turn cause insulin resistance. This increased insulin resistance will exacerbate any underlying defect in carbohydrate metabolism leading to either overt diabetes mellitus or so called “stress hyperglycemia.” Patients a
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Diabetes Care in the Hospital
diabetes care in the hospital
- related: Endocrine, diabetes blue book
- tags: #note
HOSPITAL CARE DELIVERY STANDARDS
- 15.1 Perform an A1C test on all patients with diabetes or hyperglycemia (blood glucose >140 mg/dL [7.8 mmol/L]) admitted to the hospital if not performed in the prior 3 months.
- 15.2 Insulin should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin dosage based
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A1C Affected By
A1C affected by
- related: Endocrine
- tags: #note
Hemoglobin A1c (HbA1c) is a widely used laboratory assay for glycated hemoglobin and is reported as a percentage of glycated hemoglobin in the sample. The rate of glycation is proportional to the ambient glucose concentration. Because hemoglobin levels are usually stable, HbA1c can be used as a marker for glycemic control in pati
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Perioperative Management of Chronic Glucocorticoid
perioperative management of chronic glucocorticoid
- related: Endocrine, Perioperative
- tags: #endocrine
Suppression of adrenal function is likely to develop in patients receiving corticosteroids for a prolonged period. This is especially true for those who receive high doses and those who are
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Calcium and Bone Disorders
Calcium and Bone Disorders
- related: Endocrine
- tags: #endocrine
Calcium Homeostasis and Bone Physiology
Regulation of serum calcium level is complex and dependent on the actions of vitamin D and parathyroid hormone (PTH). The primary effect of vitamin D is to enhance the absorption of calcium within the intestinal tract, whereas the effects of PTH are primarily mediated through regulation of calcium retention and excretion in the kidney (**[Figure 15](http
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Disorders of Glucose Metabolism
Disorders of Glucose Metabolism
- related: Endocrine
- tags: #endocrine
Hyperglycemia results from abnormal carbohydrate metabolism secondary to insulin deficiency, peripheral resistance to insulin action, or a combination of both. Hyperglycemia that exceeds the normal glucose range but does not meet the diagnostic criteria for diabetes mellitus is defined as prediabetes, which increases the risk for the development of diabetes.
Diabetes Mellitus
Screeni
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Disorders of the Adrenal Glands
Disorders of the Adrenal Glands
- related: Endocrine
- tags: #endocrine
Adrenal Anatomy and Physiology
Although considered one organ, the adrenal glands have two functionally distinct regions: an outer cortex and an inner medulla. The cortex secretes hormones that are classified as mineralocorticoid (aldosterone), glucocorticoid (cortisol), and androgen (dehydroepiandrosterone [DHEA]). The medulla secretes catecholamines.
The adrenal cortex is composed of th
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Disorders of the Pituitary Gland
Disorders of the Pituitary Gland
- related: Endocrine
- tags: #endocrine
Hypothalamic and Pituitary Anatomy and Physiology
The pituitary gland is located in the sella turcica posterior to the sphenoid sinus. The optic chiasm is located superior to the pituitary gland, and the carotid arteries are lateral (Figure 2). The gland is composed of the anterior pituitary (adenohypophysis), which
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Disorders of the Thyroid Gland
Disorders of the Thyroid Gland
- related: Endocrine
- tags: #endocrine
Thyroid Anatomy and Physiology
The thyroid gland is the largest dedicated endocrine organ. The usual anatomic location of the isthmus is just anterior to the second to fourth tracheal rings. The parathyroid glands are often located posterior to the superior and middle portions of each thyroid lobe. The recurrent laryngeal nerves, which innervate most of the intrinsic muscles of the
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Reproductive Disorders
Reproductive Disorders
- related: Endocrine
- tags: #endocrine
Physiology of Female Reproduction
Coordinated actions of the hypothalamus, pituitary gland, and ovaries (known as the hypothalamic-pituitary-ovarian axis) give rise to ovulatory cycles in women. The pulsatile release of gonadotropin-releasing hormone (GnRH) drives the anterior pituitary cells to secrete follicle-stimulating hormone (FSH) and luteinizing hormone (LH) (**[Figure 11](
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Transgender Hormone Therapy Management
Transgender Hormone Therapy Management
- related: Endocrine
- tags: #endocrine
Transgender medicine involves the care of persons whose gender identity differs from their sexual assignment at birth. Gender incongruence is persistent incongruence between gender identity and external sexual anatomy at birth not arising from a confounding mental disorder; gender dysphoria is discomfort arising from incongruence between a person's gender identity and their external se
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Testosterone Replacement Therapy
testosterone replacement therapy
- related: Endocrine
- tags: #endocrine
Testosterone replacement therapy (TRT) should be considered only in men with clinically significant **androgen deficiency** (eg, low libido, erectile dysfunction, loss of body hair, gynecomastia, decreased bone density, testicular atrophy) and an ==unequivocally low morning serum testosterone level== (eg, <200-300 ng/dL, depending on the reference). Nonspecific symptoms
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Metformin Reduces B12 Absorption
metformin reduces b12 absorption
Metformin reduces intestinal absorption of vitamin B12 by up to 30%. The mechanism is thought to involve impaired calcium-dependent binding of the intrinsic factor-B12 complex to its receptor, thus decreasing ileal absorption. The risk of developing vitamin B12 deficiency increases with older patients, higher metformin doses, and longer durations of treatment. Neurologic symptoms m
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Carcinoid Syndrome
carcinoid syndrome
- related: Endocrine, Valvular Diseases
- tags: #endocrine
Carcinoids are generally slow-growing neuroendocrine tumors found most commonly in the distal small intestine, proximal colon, and lung. Tumors can secrete up to 40 products (eg, serotonin, histamine, vasoactive intestinal peptide) that are usually metabolized by the liver and cause minimal symptoms in many patients. Gastrointestinal carcinoid tumors most commonly ==metastasize to
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Inappropriately Normal TSH Could Be Sign of Central Hypothyroidism
inappropriately normal TSH could be sign of central hypothyroidism
- related: Endocrine, hypothyroidism
- tags: #endocrine
This patient's clinical findings (eg, fatigue, weight gain, dry skin, hyponatremia, normocytic anemia) are suggestive of hypothyroidism, but his TSH is not elevated. In light of his history of ==pi
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Obesity Management
obesity management
- related: Endocrine
- tags: #endocrine
This patient has failed to improve with an adequate trial of dietary modification. In addition, she has continued to gain weight and now meets the definition of obesity (BMI >30 kg/m2). In light of the risk of obesity-related complications, pharmacologic therapy is indicated.
Initial med
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Charcot Arthropathy as Result of Diabetic Neuropathy
charcot arthropathy as result of diabetic neuropathy
- related: Endocrine
- tags: #endocrine
This patient with diabetic peripheral neuropathy has developed foot erythema, warmth, and edema following minor trauma (eg, bumping the foot), suggesting acute neuropathic (Charcot) arthropathy. Acute neuropathic arthropathy is characterized by an ==exaggerated, local inflammatory response tha
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Follow up for Papillary Thyroid Cancer
follow up for papillary thyroid cancer
- related: Endocrine
- tags: #endocrine
This patient has a low risk for recurrent thyroid cancer due to young age (< 45 years) and small (< 4 cm) nonmetastatic tumor. Papillary thyroid cancer is the most common type of thyroid cancer and usually recurs in the neck. The prognosis is usually very good in small tumors without high-risk features (eg, vascul
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Hypoglycemia Ddx
hypoglycemia ddx
- related: Endocrine
- tags: #endocrine
This patient has symptomatic hypoglycemia and fulfills Whipple's triad (blood glucose <55 mg/dL, hypoglycemic symptoms, relief of symptoms with glucose administration). In addition, his contemporaneous insulin and C-peptide levels are at the upper limit of normal, suggesting that his hypoglycemia is due to excess release of endo
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Hypogonadotrophic Hypogonadism
hypogonadotrophic hypogonadism
- related: Endocrine
- tags: #endocrine
In Diabetes
This patient has hypogonadal symptoms with a low serum testosterone level and low/inappropriately normal FSH and LH levels. This is consistent with hypogonadotropic (central) hypogonadism. Hypogonadism is common in men with type 2 diabetes, especially those age >65 or with concurrent obesity. For this
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Erectile Dysfunction Causes
erectile dysfunction causes
- related: Endocrine
- tags: #endocrine
Most men with end-stage renal disease (ESRD) experience sexual dysfunction. Manifestations can include low libido, erectile dysfunction, decreased frequency of intercourse, and infertility. Sexual dysfunction in ESRD is usually multifactorial. Common contributing factors include vascular/vasoactive impairment, p
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Copper Deficiency
copper deficiency
This patient’s presentation of myeloneuropathy, normocytic anemia, leukopenia, and history of gastric bypass is consistent with likely copper deficiency precipitated by recent zinc supplementation. Acquired copper deficiency is most commonly due to gastric surgery; other causes include prolonged total parenteral nutrition, excessive zinc ingestion, and malabsorptive enteropathies (eg,
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