Endocrinology

● Hypothyroidism
○ Thyroid Hormone release
○ Low T3, and T4 - Energy, metabolism, and thermogenesis
◆ High Cholesterol
◆ + anti thyroid hormone - “Hashimoto Disease”
◇ Absence of Thermogenesis
◇ Weight gain
◆ Classifications
. Primary = + TSH but thyroid cannot secrete T3 and T4
. Secondary = Pituitary gland *Adenohypophysis (cannot secrete TSH)
. Tertiary = Hypothalamus cannot secrete TRH (Thyrotropin Hormone)
. Congenital = Maternal iodine deficiency *Cretinism
◆ Diagnostics
◇ Low T3 and T4
1
◇ High Cholesterol
◇ At primary = Elevated TSH
◆ Managements:
◇ Levothyroxine (Synthroid) - T4 —> T3
■ Thyroid hormone replacement
■ Administer in the morning - to prevent insomnia
■ Monitor for BP and PR prior
□ Baseline
□ Thyrotoxicosis —> hyperthyroidism
▲ Up BP, PR, RR/ VS
■ Diet: Low Calories - for energy
■ Exercise - gradual
□ ROM -> Isometric -> Light Ex. -> Moderate Ex.

. Myxedoma Coma - rebound hypothyroidism

◆ Abrupt withdrawal from Medication, Surgery, Infection, Sedatives, Opioids
◆ Precipitating Cause (Opioids/ Steroids) —> Hyper Active Adrenal Cortex (Minero,Gluco,Andro) —> ACTH no longer needed (produced by adenohypophysis= will
4
go to sleep tatampo , no TSH, no one will stimulate Thyroid to produce T3,T4)
3
◆ Manifestations:
2
◇ Hypotension
1
◇ Hypothermia
◇ Bradycardia
◇ Bradypnea
◆ Managements:
◇ Levothyroxine - to replace T3 and T4
◇ Address precipitating factor
◇ Assess for airway
◇ Aspiration precaution
◇ Warming blanket
 ◇ H. Educ
■ Avoid infection by washing
■ Inc. Hygience

● Hyper Parathyroid gland

○ Increase PTH = Bone resorption —> Inc. Calcium —> Dexa: Low bone density—> Symptoms: Relaxed,
◆ bradypnea, brady cardiac low tendon reflex, seizure = coma
◆ Diagnostics
◇ DEXA = Dual energy X-ray = Low density, Inc. Calcium, Inc. Calcium, Calcium Crystals in urine/renal stones
◆ Treatment:
◇ Sodium wasting diuretics
■ Furosemide Lasix
◇ Oral phosphate - inversely
■ Inc. Phosphate = Dec. Ca = Inc. Na (use of sodium wasting)
■ Dec. Phos = Inc. Ca
◇ Biphosphanates
■ Low Ca by inhibiting PTH
■ Alendronate and Fosamax
◇ Calcimimetics = Dec. Calcium
■ Salmon Calcitonin
■ Cincalcet (Sensipar)
◇ Parathyroidectomy
■ Ask the pt to swallow and speak (Vagus Nerve CN X - PNS innervation)
◆ Management:
◇ Diet: Low Calcium, Inc. OFI (2L - 3L)
◇ Weight
◇ Weekly I and O
◇ Strain wee wee
◇ Prevent Injury
◇ Exercise: ROM —> Isometric —> Light —> moderate —> heavy
● Hypoparathyroidism
◆ Dec. PTH —> Dec. Ca, High Phosphorous
◆ Dec. Calcium
◆ Manifestation: Hypoca (Excit) Inc. Na, Dec. Calcium
◇ Carpopedal spasm - trousseau
◇ Facial twitching - chovstek
◇ Photophobia
■ Inc. active pupils (Miosis)
◇ Neuro:
■ Convulsion
■ Tremors
◇ Cardio
■ Tachycardia
■ Tachypnea
 ◆ Treatment Mod:
◇ Calcium Solution = Inc. Ca
■ Calcium Gluconate
■ Calcium Chloride
■ Calcium Citrate
◇ 125 di-hydroxycalcitriol = Activated D.
■ Vit D./Calciferol + 7-Cholesterol = Calcitriol *inc. the absorption of Ca in the GI
◇ Phosphate Binders - lowers phosphorous (*inversely proportionate with calcium)
■ Bind with phosphorous —>will increase Calcium
■ Al Hydroxide - Alang Tae —> Constipation + Mg Hydroxide - Mgtatae —> Diarrhea = Kremil-S
◆ Managements:
◇ High Calcium, Low Phosphorus
■ (C)anned Sardines
■ Dairy
■ Leafy greens
■ (P) Organ meats
■ Egg yolks
■ Avoid milk
◇ Bedside: IV Ca Gluconate
◇ Precaution: Seizure Precaution
■ anticonvulsant = administer Sodium ion channel blocker = phenytoin; avoid Ca ion channel blocker = ethosuxinide; Na + Ca = Carbamazepine
■ Side rails
■ Lower bed
■ Avoid stimulating environment
□ Tv
□ Dim
□ Perfumes
□ Stimulants
◇ GABA enhancers
■ Benzodiazepam
■ Barbiturates
◇ Prepare tracheostomy, suction and oxygen
● Pheochromocytoma
○ Tumor adrenal medulla (Epi and norepi -> SNSR
○ There is peripheral hyperplasia
◆ By product of N/E = Vanelylmandelic Acid
○ Diagnostic:
◇ Increase VMA - found in urine
◇ Total plasma catecholamine
■ N/E during rest
◇ Clonidine Test =
■ A2-agonist = SNS
○ Manifestation:
◆ High BP, RR, Temp
 ◆ Diaphoresis
◆ Tremors
◆ High Metabolism
○ Treatment
◆ Adrenalectomy -
◆ Non-selective Alpha Antagonist
◇ Low SNS
■ Regitine (Phentolamine)
■ Phenoxybenzamine ( Dibenzyline) -> Long term treatment
◇ Ca calcium blocker - NOT FOR NEURO *effect vasodilation
■ Dipine
■ Verapamil
■ Diltiazem
◆ Diet
◇ High Calcium
○ Management:
◆ Post: Watch out for No SNS! *everything goes down
◆ Rebound: Inc. Sodium, Dec. Calcium, Inc. Phosphate
◆ Adre C+M = Dec. Corticosteroids (M,G,A)
◆ Corticosteroid therapy
◇ Avoid fresh
◇ Private
◇ Avoid crowded
◆ Look out for SHOCK due to organ removal: To compensate
◇ HYPO
◇ TACHY
◇ TACHY
■ Decrease pressure —> Baroreceptor —> Tachycardia —> Tachypnea
. Fluid Replacement = Increase OFI
. Fluid Resuscitation = Isometric
. PLRS - fluid resuscitation
. PNSS - blood transfusion

Primary Adrenal Insufficiency

● Addison’s Disease
○ Adrenal Gland - Dec. ACTH stimulates—> Adrenal Cortex to release (Glucose, Mineral, Andro) but is low because ACTH is low
◆ Mineralocorticoids (Aldosterone) sodium retention
◇ Dec. Na
■ Hyponatremia - Inhibited
■ Hyperkalemia + Hypermagnesemia
◆ Glucocorticocoids
■ Hypoglycemia
■ Decrease Cortisol - temporary rebound increase cortisol
□ Loss water and sodium
 ■ Decrease ADH
◇ Hyperpigmented - compensatory mechanism
◆ Low Adrogen
◇ Low Body Hair
◇ Below Puberty: Ipit Voice/ Voice changes
◇ Above puberty: Impotence
○ Treatment:
◆ Corticosteroids
◇ Hydrocortisone (Solusef)
■ Mineralo/Gluco
◇ Prednisone
○ Management:
◆ Corticosteroid precaution
◆ Avoid stress —> Inc. cortisol
◆ Daily weight; I & O for aldosterone (sodium retention)
◆ Avoid infection
○ Addisonian Crisis = too much cortisol (2x cortisol levels)
◇ Exacerbation(worsening) of Adrenal insufficiency precipitated by stress, infection, and dehydration (concentrated cortisol)
◆ Manifestations: Worsening of Addisons
◇ VS: Shock
◇ NM: Weakness
◇ INF: Fever
◆ Management:
◇ IV resuscitation + Corticosteroids for shock
◇ Adjunct Therapy: Oral corticosteroids *if no IV infusion
◇ Increase Cortisol: Cushing Syndrome — overdosage of cortisol
◆ Treatment:
◇ DBVAP (retention) + EPI (SNS) = Inc. ADH + EPI: Sympathetic Nervous Response
● Cushing Disease
○ Presence of pathogenesis that results to increase secretion of cortisol
○ Mineralocorticoid (Sodium and water retention)
◆ Hypernatremia - hyper-excitability
◆ Increase water retention - Fluid overload
◇ High in BP
◇ Increase ICP & Increase IOP = PAIN!
◆ Diagnosis:
◇ Dexamethasone: worsening corticosteroid
◇ Administered at night
■ Cortisol remains high in the morning
◆ Manifestations: Cushing Triad
◇ Hypertension - fluid retention
◇ Bradycardia - Increase Sodium (Excitability)
◇ Cheyne-stokes - fluctuates between tachypnea, hyperpnea, apnea
◇ Glucocortisol
 ■ Skin: Hyperpigmented
■ Body: Hypermetabolism
□ Peripheral fat and muscle wasting
□ Weight gain
□ Moon face
□ Truncal obesity
□ Buffalo hump
◇ Mineralocorticoids
■ Hypernatremia
■ Hypokalemia
■ Hypovolemia
◇ Androgens
■ Females: Hirsutism, deepened voice, enlarged clitoris, breast atrophy
■ Male: Loss of libido
◆ Treatment
◇ Adrenal Enzyme (inhibitor-stops synthesis of steroids)
■ Metyrapone (Lysodren)
■ Mitotane (Metopirone)
■ Aminoglutothiamide (Cytadren)
◇ Antifungals - inhibits ergosterol —> Cortisol synthesis
■ Ketoconazole (Nizoral)
■ Fluconazole
● Diabetes
○ Type 1 - Insulin Dependent
◆ Destruction of the pancreatic Beta cells
○ Type 2 - Non-Insulin Dependent
◆ Increase Insulin resistance
Pathophysio
◆ Glucose to free within circulation —> Inc. Serum Osmolality (Hyperglycemia)—> Increase Viscosity —> Increase Osmotic Pressure in the Glomerulus and Renal
Tubule = Sluggish flow of blood —> Polyuria —> Deficient water in the ECS —> stimulate the brain to increase OFI (Polydipsia) —> Increase Food consumption
—> Polyphagia
◆ Diagnostic Test
◇ FBS - 70-110 mg/dl - >126mg/dl (DM) for 2x reading (baseline)
◇ Post - <120 mg/dl - >200 for 2hrs
◇ Oral glucose tolerance test
■ 1st hr. 140 mg dl
■ 2nd hr.
■ 3rd hr. Normal
□ ABN: No return to Normal
◇ HBA1C (3-4mo’s) - <6% - 6.5%
◆ Treatment Mod:
◇ Insulin
■ Rapid Acting - Onset would be 0-5 mins, will peak 1-2, duration 2-4 hrs
□ Lispro
 □ Aspart
□ Apidra
■ Short Acting - O = 30-60 min, P = 2-4 hrs, D = 4-6 hrs
□ AKA Cleared Insulin (Given 30 minutes before meals)
□ Humulin R - Regular Insulin*
■ Intermediate Acting - O = 2-4 hrs, P = 4-12 hrs, D = 6-20 hrs
□ Taken after meal
□ NPH - Neutral Protamine Hagedorn AKA Humulin N/ Novolin N*
■ Long Acting Insulin - O = 1 hr, P = 1-24 hrs, D = 24 hrs
□ Controls blood glucose all through out constantly
□ Humulin U (Ultralente)*
□ Glargine
▲ Determir
◇ OHA - Oral Hypoglycemic Agent
■ Sulfonylureas - regardless before and after meals
□ Generation 1
▲ Chlorpropamide (Diabinese)
▲ Tolbutamide (Orinase)
▲ Tolazamide (Tolinase)
□ Generation 2
▲ Glimepiride (Amaryl)
▲ Glyburide (Diabeta)
▲ Glibenclamide* AO 144 2004
▲ Glipizide (Glucotrol)
■ Non-Sulfonylureas - stimulate pancrease to secrete insulin after meals only!
□ Repaglinidine (Prandin)
□ Nateglinidine (Starlix)
◇ Biguanides - inhibits liver from producing glucose, and increases sensitivity to insulin, decreases the synthesis of cholesterol
■ Glucophage/ Fostamet = Metformin*