Sweaty skin (hyper or hypothyroidism)
Hyper
Cold skin (hyper or hypothyroidism)
Hypo
Myxedema (hyper or hypothyroidism)
Hypo
Adults or kid:
Thyroid hormone regulates metabolism and energy expenditure
Adults
In adults does thyroid hormone:
(Increase/decrease) O2 consumption
(Increase/decrease) thermogenesis
(Increase/decrease) protein catabolism
Increase,
Increase,
Increase
Thyroid hormone is important for normal _______ development in kids. It also promotes protein ________.
Neural, anabolism
T3 or T4 plays a larger role on target tissues, and why?
T3, it's active form
Is more T3 or T4 released in system, what happens once it is released?
T4 (80%), converted to T3 in target tissues with deiodinase
Is T3 or T4 more potent?
T3 (by 4x)
A goiters is from an increase of ______, the gland enlarges from increased stimulation, and lack of ______.
TSH, iodine
What additional findings are seen with a goiter?
Difficulty swallowing/breathing, swelling, tightness in throat, cough/hoarseness
Causes of goiter include:
__________ deficiency
H__________
G_____________
M__________
Solitary thyroid ________
P___________
I________
Iodine deficiency
Hashimoto's
Grave's
Multinodular
Solitary thyroid nodule
Pregnancy
Inflammation
If you gave a person with primary hypothyroidism an injection of TSH would T3/4 levels increase, why or why not?
No
They don't have iodine required to make thyroid hormones
Primary hypothyroidism site
Thyroid
Secondary hypothyroidism site
Anterior pituitary
Tertiary hypothyroidism site
Hypothalamus
Chronic deficiency of T3/4, develops slowly over years, and S/S depend on severity; dx?
Hypothyroidism
Decreased metabolism (cold/tired/fatigue/weight gain)
(hyper or hypothyroidism)
Hypo
Constipation
(hyper or hypothyroidism)
Hypo
Diminished hearing/arthralgia
(hyper or hypothyroidism)
Hypo
Decreased protein synthesis (brittle nails, thin hair, dry/thin skin)
(hyper or hypothyroidism)
Hypo
Bradycardia
(hyper or hypothyroidism)
Hypo
Decrease level of consciousness & weight gain
(hyper or hypothyroidism)
Hypo
Hypothermia, hypoventilation (look at partial pressure of CO? and O?)
(hyper or hypothyroidism)
Hypo
Hypoactive bowel sounds, slow reflexes, slow speech/thought process
(hyper or hypothyroidism)
Hypothyroidism
What lab findings would you see with hypothyroidism, in regards to increase?
TSH, CK-MB & CO?
What lab findings are decreased with hypothyroidism? (5)
T3/4, free T4, O?, pH, glucose
Autoimmune, congenital, pituitary adenoma, pregnancy are all causes of?
(hyper or hypothyroidism)
Hyp
Iodine deficiency, treatment for hyperthyroidism (surgery-radioiodine) and primary dysfunction are causes of?
(hyper or hypothyroidism)
Hypothyroidism
What heart problems can result from hypothyroidism? (2)
Impaired pumping, increased LDL/cholesterol
What mental health issues happen with hypothyroidism?
Depression, slowed mental function
If you have a long-term uncontrolled hypothyroidism case, what can result?
Peripheral neuropathy or myxedema (not necessarily long-term)
Hypothyroidism can cause infertility because it interferes with ___________. Birth defects are also increased if the disease is _________.
Ovulation, untreated
In suspected hypothyroidism, you must look at TSH & free T4; if normal/low TSH and low free T4 you'd want to rule out what?
Secondary hypothyroidism or hypopituitarism by MRI of pituitary
In suspected hypothyroidism, you must look at TSH & free T4; if TSH is elevated, normal/low free T4 you'd want to rule out what? (4)
Early hypothyroidism, Hashimoto's, subacute thyroiditis, AI lymphocytic thyroiditis
In suspected hypothyroidism, you must look at TSH & free T4; you see elevated TSH, low free T4; what is your dx?
Primary hypothyroidism
Warm/sweaty in
(hyper or hypothyroidism)
Hyper, increased metabolic rate
Increased protein catabolism (weight loss, weak muscles)
(hyper or hypothyroidism)
Hyper
Hyperexcitable reflexes
(hyper or hypothyroidism)
Hyper
Irritability or insomnia
(hyper or hypothyroidism)
Hyper
Increase force of heart contraction and appetite
(hyper or hypothyroidism)
Hyper
Patient is irritable, restless, diarrhea, insomnia and heat intolerance, dx?
Hyperthyroidism
Tachycardia, abnormal heart rhythms
(hyper or hypothyroidism)
Hyper
Dyspnea, palpations
(hyper or hypothyroidism)
Hyper
Weight loss, hyperthermia
(hyper or hypothyroidism)
Hyper
Labs for primary hyperthyroidism would be:
_________ T3/4
_________ TSH
(Present/absent) thyroid antibodies
(Increased/decreased) glucose
Increased T3/4
Decreased TSH (only increased if pituitary secreting tumor - secondary)
Present
Increased
Diaphoresis
(hyper or hypothyroidism)
Hyper
Causes of hyperthyroidism include
A_________
T____________
Overtreatment of _____________
Discontinue __________
S______
P________ Tumor
A_______-___________
Adenoma
Thyroiditis
Hypothyroidism
Medications
Stress
Pituitary tumor
Auto-immune
Complications include increased heart rate, brittle bones (osteoporosis)
(hyper or hypothyroidism)
Hyper
Complications include exopthalmus & red, swollen skin
(hyper or hypothyroidism)
Hyper
Primary hypothyroidism AKA iodine deficiency
______ thyroid hormones
______ TRH
______ TSH
Decreased
Increased
Increased
M/C cause of goiter that's autoimmune
Grave's
What produces thyrotropin receptor antibodies (TRAb) that mimic TSH action?
Graves ds
30% have eye disease/problems with this disease including pressure-pain, puffy eyelids, red/inflamed?
Graves (exopthalmus)
Graves' disease:
_____ T3/4
_____ TRH
_____ TSH
Up
Down
Down
Where is problem with Graves' disease?
Between pituitary and thyroid
What is autoimmune disorder where thyroid peroxidase antibodies attack (TOP) the enzyme?
Hashimoto's
What is result of TPO's attacking thyroid peroxidase with Hashimoto's?
Low/none T3/4
M/C cause of hypothyroidism, what age does it occur, males or females more common
Hashimoto's 45-65, women
Hashimoto's Disease
_____ thyroid hormones
_____ TRH
_____ TSH
where is problem?
Down
Up
Up
Thyroid
Severely advanced hypothyroidism causes skin changes, swelling/increased thickness of skin/face
Myxedema
Congenital disorder (genetic mutation) present at birth causing stunted mental/physical growth AKA congenital hypothyroidism
Cretinism
Hypothalamus secreting tumor
_____ TRH
_____ TSH
______ T3/4
Up
Up
Up
Hypothalamus suppressing tumor
_____ TRH
_____ TSH
______ T3/4
Down
Down
Down
If tumor is in hypothalamus look at what hormone?
TRH
If tumor is in pituitary look at what hormone?
TSH
Pituitary secreting tumor
_____ TRH
_____ TSH
______ T3/4
Down
Up
Up
Pituitary suppressing tumor
_____ TRH
_____ TSH
______ T3/4
Up
Down
Down
Tumor cells do not respond to ________ feedback signals.
Negative
With TSH levels very low in TSH/TRH suppressing tumor, would you expect goiter?
No
If you find tumor in anterior pituitary through MRI, what is next step?
biopsy (see if it is malignant)
Two diseases with antibodies/immunoglobulins present?
Graves, Hashimoto's
Two diseases there is no possibility of goiter?
TRH/TSH suppressing tumor
TRH secreting tumor
(Hyper or hypothyroidism)
Hyper
TSH secreting tumor
(Hyper or hypothyroidism)
Hyper
TRH suppressing tumor
(Hyper or hypothyroidism)
Hypo
TSH suppressing tumor
(Hyper or hypothyroidism)
Hypo
TSH either high or low
T3/T4 levels low
Possible antibodies
Goiter present possible
(Hyper or hypothyroidism)
Hypo
TSH either high or low
T3/4 levels high
Possible antibodies
Goiter present possible
(Hyper or hypothyroidism)
Hyper
4 types of thyroid cancer from least to most severe
Papillary, follicular, medullary, anaplastic
What accounts for 80/85% of thyroid cancers due to radiation exposure with peak onset age 45-50 females 3:1?
Papillary cancer
Papillary cancer presents with calcific bodies ______% of the time, and has prognosis related to tumor _______, age & gender.
35-45
Size
50% of those with papillary cancer can spread where? You can also see local ________.
Lymphnodes, invasion
Distant spread with papillary cancer is seen particularly in these 3 locations
Lung, liver, bone
Cure rate of papillary cancer
Nearly 100%
Patient has papillary cancer, how is this treated? (3)
Thyroidectomy, radioactive iodine ablation or TSH suppression (meds)
What accounts for 10% of thyroid cancer, increase incidence with age?
Follicular carcinoma
Follicular carcinoma tends to metastasize to _______, thus ________ _____ are common with condition.
Bone, path fx
If you wanted to take supplements for thyroid should you take with empty or full stomach, how long before/after eating?
Keep calories balanced, 1/2 hour before eating (empty)
What can impede absorption of thyroid hormones?
Dietary fiber
Avoid fiber in foods like walnuts, soy, ______ supplements when trying to treat thyroid
Iron
Diet high in _____ products may cause ________ in thyroid function.
Soy, decrease
If trying to help thyroid stay clear of _____ supplements/medications, but if you can't avoid take SEVERAL hours before/after taking thyroid medications.
Calcium
Antidepressants, Gluten?, sugary foods, coffee, high sodium foods, can all have affect on?
Thyroid regulation
Equilibrium of blood calcium are maintained by what 3 mechanisms?
Calcium absorbed by intestines, movement of calcium into/out of bones, and kidney reabsorption/secretion
What 3 hormones are involved in regulation of level of calcium in the blood?
PTH, calcitonin, calcitriol (active Vit D)
What hormone provides long term and day to day regulation of blood calcium levels?
PTH and calcitonin
The body also has minute to minute regulation of calcium, from what?
Osteocytes in bone
Calcium levels are important to proper functioning of what 2 systems?
MSK and nervous system
Where is calcitonin released from?
Thyroid
What does calcium do to bone resorption?
Decreases (decrease bone breakdown)
What decreases release of calcium from bone?
Calcitonin
Calcitonin receptors are on _________, which slows down removal of Ca++.
Osteoclasts
Does calcitonin increase or decrease excretion of calcium in the urine?
Increase
What is secreted in response to decreased blood calcium levels from parathyroid gland?
PTH
What signals osteoclasts to release Ca from bone?
PTH
What signals calcium to reclaim more Ca++?
PTH
What stimulates kidney to start synthesis of calcitriol?
PTH
When PTH stimulates kidney to synthesize calcitriol, what are the 2 net affects?
Increased intestinal absorption of Ca++
Increased absorption of P
PTH & calcitonin directly affects what 2 organ/systems?
Bone/kidney
Which of the following is not a risk factor for osteoporosis?
Race
Smoking
Post-menopausal age
Thin physique
Diabetes
Diabetes
Osteoporosis increases risk of what type of fractures
Vertebral compression & hip
What intervention is needed for those dx with OPorosis?
Intervention to reduce fall/fx risk
Address diet/lifestyle
What are some important health issues caused from resultant bone fractures associated with OP
Chronic pain, loss of independence, mortality
Which of following two are not risk factor for development of OP?
Age
Previous fracture
Glucocorticoid therapy
RA
Excess body weight
Low body weight
Loss of steroid hormone production
Current smoking
Excessive alcohol
Parental history of hip fracture
Past
excess body weight
Past smoking
What risk calculator is used to assess 10 year probability of fracture?
FRAX
The FRAX says _____% of white women, _____% of men, (increase/decrease) in AA, Asians?
14, 3-5, decrease AA, increase Asians
What is probably most common form of secondary osteoporosis?
Glucocorticoid excess
What inflammatory condition makes patient susceptible to accelerated bone loss with even low doses of glucocorticoids?
RA
Common causes of OP:
________ deficiency
________ women
Pathologically with __________
Hyper______________
Men with _______ failure
Gonadal
Menopausal
Amenorrhea
Hyperprolactinemia
Gonadal failure
What are some endocrinopathies that cause OP?
Hyperparathyroidism, long term hyperthyroidism
Other causes of OP:
_____nutrition and nutritional deficiency (malabsorption)
Drugs that accelerate _____ _____
Malnutrition
Bone loss
Cyclosporine, antiepileptics, heparin and GnRH inhibitors do what?
Accelerate bone loss (cause OP)
What lab is most useful for predicting fx risk?
T-scores
What are some serum level evaluations that should be considered routine for patients with OP (3)?
Calcium, phosphorus, Alk phos
If one has OP, what would we expect above values (Ca, P, AP) to look like?
Typically normal
If Ca, P, Alk Phos levels are abnormal with OP patient, what should we suspect?
AP increased in presence of healing fx
When is fx considered pathologic?
Minimal trauma or obvious x-ray finding
If one suffers path fx what other diagnoses must be excluded?
Osteomalacia, Paget's, malignancy
Patient has increase in alk phos, nor to decrease calcium, bone pain tenderness and proximal mm weakness, what do you suspect?
Osteomalacia
Patient has high alk phos with weakened enlarged bones and skeletal deformities?
Paget's disease
MM, metastatic ds, and vertebral osteomyelitis can be cause of
Path fx's
When do we reach peak bone mass? See huge jump between what ages?
Early 20/30's (under influence of sex steroid hormone production)
10-20
The ________ peak bone mass, the less likely to develop OP.
Higher
What other factors play a role in our peak bone density?
G________***80%
G______ S________
P_______ A______ (weight-bearing)
Nutrient Intake (_____)
Genetics
Gonadal steroids
Physical activity
Calcium
Type of bone growth involved with peak bone density with factors is referred to as
Modeling
After skeletal maturation is reached, new phase is called
Remodeling
When remodeling bone:
It repairs __________ bone
Existing bone __________
______ released to maintain serum levels
Damaged, strengthened, calcium
What age does bone breakdown exceed bone replacement, but increases MARKEDLY AFTER MENOPAUSE!!
Age 35
Osteoporosis is present when bone mineral density is less than ______ standard deviations less than normal.
2.5
How many people suffer from osteoporotic fx yearly?
2 million
Primary or secondary osteoporosis
Decrease bone mass, fractures in postmenopausal women, older men/women because age
Primary
Primary or secondary osteoporosis
Decrease bone loss from specific clinical disorder
Secondary
At any age _____ have twice as many fractures (osteoporosis related).
Women
Generalized bone loss is
Osteopenia
Osteoporosis, osteomalacia, rickets, hyperPTH, metastatic cancer are causes of
Osteopenia
What is most common malignancy of bone
Metastatic cancer
Difference between osteopenia and osteoporosis
Osteoporosis is more severe with more likely chance of path fracture
MC metabolic bone disease
OP
If you're from what background increases risk of OP?
Northern Europe or Asian
Creation of new bone does not keep up with removal of old bone is cause of ___________. (Imbalance)
OP
M/C location of spontaneous fx for OP
Mid/lower T/S
Decreased height and stooped posture can be symptom of what condition
OP
Hormone, diet, malabsorption, smoking, alcohol, Ca-wasting nephropathy, meds, radiation, disease, immobility can cause what?
Imbalance in bone breakdown and creation (etiology of OP)
Strongest hormonal risk factor for women and OP
Low/lack of estrogen
Men with decrease _________ levels as they age is a risk factor for OP
Testosterone
Treatment for what cancers accelerate bone loss?
Prostate & breast
Overactive or too much thyroid medications for underactive thyroid (thus too much thyroid hormone) can be cause of
OP
Overactive _______ and ________ glands also can cause OP.
Parathyroid, adrenal
Low intake of what vitamin decreases bone density, early bone loss and increase risk of fractures
Calcium
Having eating disorder or being underweight is a dietary factor for what disease
OP
If one has _____ surgery, there is decreased area of absorption of calcium, thus factor for what disease?
GI, OP
Long term use of injected corticosteroids interferes with bone ________ process.
Rebuilding
Heparin, seizure medications, gastric reflux, cancer, and transplant rejection are all other medications that can affect what?
OP
Celiac disease, IBD, Kidney/Liver ds, cancer, lupus, MM, RA are all disorders that interfere with
OP
What lifestyle choices have affect with OP?
Sedentary, excessive alcohol (more than 2 a day), tobacco use
How is OP best dx, most precise? Over what age must population be screened?
Bone density (DEXA)
Over 65
Blood serum
Radiographic films (bone/joint fracture or bony abnormalities)
UA
CT Scan (masses)
Bone scan
MRI (soft tissue, lig/disk)
Help to dx what?
OP
Complications of OP include fractures of?
Spine (non-traumatic)
Hip (fall)
Forearm
Recommendations for treatment of OP are based off risk of breaking bone in next _____ years AKA the _____ ________ test.
10, bone density
To treat OP, you can increase dietary intake of what 3 things?
Calcium, Vit D, protein
To treat OP, you can do estrogen replacement therapy, but what risks are posed?
More likely for blood clots, endometrial/breast cancer, and maybe heart disease
What medication that can be used to treat OP caused mid-femur cracks, osteonecrosis of jaw and is AKA for Fosomax, Boniva, recast, actonel?
Biphosphonate medications
What hormone can be given to treat OP besides estrogen?
Parathyroid hormone
What conservative treatments can be made for OP?
Exercise (weight bearing/training, balance), chiropractic, PT
Analgesics can be given to OP patients, why?
Muscle pain and muscle spasms (it is relaxant)
Prognosis of _______ is dependent on age, mobility, severity of bone loss, underlying causes and complications related to fx.
Osteoporosis
What is key to osteoporosis management?
Prevention
If you are excess weight instead of underweight with osteoporosis, what happens to arm & wrist fracture?
they are increase in prevalence
Alternative medicine for osteoporosis includes _______ protein, but avoid if history of ______ cancer.
soy, breast
If one is osteoporotic in nature they must, eat more vegetables, fruits and whole grains, choose healthy sources of protein & fat, get plenty of ________, limit sugar, salt and __________ additives and limit caffeine/alcohol.
calcium, phosphate
Not enough or too little vitamin D can lead to _______ because it is needed for calcium to be absorbed into GI tract.
osteoporosis
Too much Vitamin D can lead to _______ bone resorption.
increased
Sodium in excess causes (increase/decrease) calcium loss through urine.
increase, MOST COMMON CAUSE OF CALCIUM LOSS
Caffeine & alcohol causes (increase/decrease) calcium loss through urine.
increase
Bone loss noted in 25-50% of _______ abusers.
alcohol
Steroids cause (increase/decrease) amount of calcium absorbed by intestines, and (increase/decrease) calcium excretion through kidneys.
decrease, increase
Steroids trigger elevated secretions of _________ (increasing bone resorption/breakdown).
PTH
Steroids suppress (osteoblastic/osteoclastic) activity.
osteoblastic
Estrogen affect on calcium levels in bone:
*retards bone resorbing affects of _________
*results in a (increase/decrease) in bone loss
IN HIP AND SPINE!!!
PTH
decrease
Estrogen affect on calcium levels in bone:
*helps to deactivate ____________ activity
*helps to maintain normal rates of ________ formation/resorption
osteoclastic, bone
Lack of estrogen causes osteoclast population to (increase/decrease) and (increase/decrease) osteoclast lifespan.
increase (EXPLOSION), increase
Lack of estrogen causes (increase/decrease) in estrogen-receptor signaling on osteoblasts.
decrease
Within first 5-7 years of menopause, a woman loses up to _____% of her bone mass.
20
Smokers have lower levels of what hormone? They may also see (increase/decrease) levels of calcium absorption.
estrogen, decrease
HRT is used in menopausal women, if they have not had a __________. ____________ also used to decrease risk of endometrial cancer.
hysterectomy, progesterone
HRT with ______ injections can help with OP.
PTH
If HRT is started within the first 6 years of menopause, it reduces risk of bone loss by?
50%
Protected bone mass, delayed breakdown of collagen (skin), relief of hot flashes, reduce risk of fractures/heart disease; what is this?
pros of HRT treatment with OP
Gallstones, migraines, bloating, irritability, increase risk of breast cancer, what is this?
cons of HRT treatment with OP
2 M/C causes of hypercalcemia
hyperparathyroidism and bone cancer
Sarcoidosis, TB, Intoxication with A/D or Ca++ antacids, lithium or thiazides are other causes of
hypercalcemia
What is the most likely cause of hypercalcemia if discovered in an asymptomatic patient via routine lab screenings?
primary hyperthyroidism with solitary adenoma
Patient has 12 g/dL of calcium in blood or lower, but it is still out of normal range what would you suspect?
no symptoms, possibly polyuria/dehydration
Patient has 13 g/dL of calcium in blood or higher, what would you expect symptomatic?
GI (anorexia, nausea)
MSK (arthralgia, myalgia, weakness)
CNS (lethargy, stupor, coma, mental status change, psychosis)
MORE SEVERE
Main symptoms of hyperparathyroidism
stones (hypercalcemia)
moans (ab pain)
groans (myalgia)
bones (bone pain)
psychiatric over tones (mental status changes)
Hyperparathyroidism is diagnosed by:
(increase/decrease) calcium levels
(increase/decrease) phosphate levels
(increase/decrease) PTH
up
down
up
A patient with acute onset of symptomatic hypercalcemia is more likely to have a what? chronic?
acute: cancer
chronic: parathyroid gland
What are 3 types of hematologic cancers should one consider with hypercalcemia?
MM
Lymphoma
Leukemia
What are 3 types of solid tumor cancers that can present with hypercalcemia?
breast, kidney, lung
What is best way to differentiate between cancer-related hypercalcemia and primary hyperparathyroidism?
cancer-related: suppressed PTH
Primary hyperparathyroidism
is PTH high or low? acute or chronic hypercalcemia?
high
acute or chronic
MEN syndromes
is PTH high or low? acute or chronic hypercalcemia?
high
both
Malignancy
is PTH high or low? acute or chronic hypercalcemia?
low, acute
PTHrP assay
is PTH high or low? acute or chronic hypercalcemia?
low acute
Primary hyperparathyroidism (1, 2, and 3)
as well as MEN syndromes
is PTH high or low? acute or chronic hypercalcemia?
high
chronic (MENs can be acute)
what does MEN stand for?
multiple endocrine neoplasias
Primary or secondary hyperparathyroidism?
increase production of PTH resulting in hypercalcemia, increase risk over 40, 2:1 women to male
primary
glands work - secrete PTH in response to low Ca or Vit D
Primary or secondary hyperparathyroidism?
secondary
Primary or secondary hyperparathyroidism?
increase PTH & Ca
primary
Primary or secondary hyperparathyroidism?
Decrease Ca++, increase PTH
secondary
#1 cause of hyperparathyroidism, #2, #3
1: adenoma (80-85%)
2: hyperplasia
3: carcinomas
If between 10-12 g/dL of calcium-- patients are usually asymptomatic, with 85% with no _____ or ____ manifestations
renal or bone
medications
Vit A/D
renal failure
malignancy
causes of
hyperparathyroidism (primary)
prolonged immobility
dehydration
supplements
causes of
hyperparathyroidism (primary)
renal calcium loss
calcium deficiency
vit D deficiency
causes of
hyperparathyroidism (primary)
malabsorption and chronic kidney disease are causes for primary or secondary hyperparathyroidism
secondary
CV, CNS, GI, GU, Misc, MSK S/S all complications of what
hyperparathyroidism
if I was looking at labs for hyperparathyroidism you'd want to check?
Calcium, phosphorus, PTH, serum creatinine (24 hour urine Ca + creatinine), ECG
US, BMD, Renal US used for dx of?
hyperparathyroidism
Primary hyperparathyroid:
(increase/decrease) calcium
(increase/decrease) phosphorus
(increase/decrease) PTH
(increase/decrease) alk phos
up
down
up
up
Granulomatous disease, FHH, Milk-Alkali syndrome, medications, immobilization, Vit D/A intoxication, adrenal insufficency and hyperthyroidism are all (CHRONIC/ACUTE) causes of hypercalcemia, with (HIGH/LOW) PTH
chronic, low