increased free T4/T3 (markedly increased)

&

decreased TSH (TSH may be so low its undetectable)

EKG +- sinus tachy, A. fib, A. flutter

anti-thyroid meds: methimazole, PTU

beta blockers for symptoms

supportive: IV fluids

glucocorticoids (prevents conversion of T4 into T3 & impairs hormone production)

oral/IV sodium iodide (decreases thyroid hormone release)

antipyretics (avoid ASA - increases T4)

1. accidental damage/removal of parathyroid during neck/thyroid sx
2. autoimmune destruction of parathyroid gland
3. not very common - XRT, hypomagnesemia (Mg required for secretion of PTH)

• signs of hypocalcemia: carpopedal spasm, Trousseau & Chvostek sign, perioral parasthesias, increased DTR

triad: hypocalcemia + decreased intact PTH + increased phosphate

Mg may be low/normal/high

1. HTN: most consistent finding (secondary HTN) may be temp or sustained
2. PHE: Palpitations, HA's (paroxysmal), excessive sweating.  Chest or abd pain, weakness, fatigue, weight loss (despite increased appetite)

1. increased 24h urinary catecholamines including metabolites (metanephrine & vanillylmandelic acid)
2. MRI or CT of abd. to visualize adrenal tumor

1. complete adrenalectomy 
2. preop non-selective alpha blockade: phenoxybenzamine or phentolamine x 7-14 d --> followed by BB or CCB to control HTN.  DO NOT initiate therapy with BB (to prevent unopposed alpha-constriction during catecholamine release triggered by sx or spontaneously, which could lead to life threatening HTN)

• decreased basic metabolic rate
• cold inteolerance (decreased heat production)
• weight gain (despite decreased appetite)

• dry, thickened rough skin, loss of outer 1/3 of eyebrow
• goiter
• non-pitting edema (myedema)

• hypoactivity: fatigue, sluggishness, memory loss, depression, decreased DTR
• hoarseness of voice

• contpiation
• anorexia

• bradycardia, decreased CO
• pericardial effusion

• iodine deficiency (diet)
• hashimoto's thyroiditis
• postpartum thyroiditis
• pituitary hypothyroidism
• hypothalamic hypothyroidism
• cretinism 
• riedel's thyroiditis

cretinism

(macroglossia, hoarse cry, coarse facial features, umbilical hernia, weight gain, mental retardation if not corrected)

riedel's throiditis

• painless fixed nodular may grow rapidly (resembles malignancy)
• RARE (assoc w/ other fibrotic d/o)
• Treatment: steroids, tamoxifen & levothyroixine

• increased basic metabolic rate
• heat intolerance (increased heat production)
• weight loss (despite increased appetite)

• skin warm, moist, soft, fine hair, alopecia, easy bruising 
• goiter

• hyperactivity: anxiety, tremors, nervousness, fatigue, weakness, tremors, increased sympathetic

• diarrhea
• hyper defecation

• grave's disease
• Toxic multinodular goiter
• TSH secreting tumor
• excess intake of T3, T4
• iatrogenic thyrotoxicosis
• lithium thyrotoxicosis (lithium can cause hyperthyroid or hypothyroid state)

• autoimmune, MC in women 20-40
• circulating TSH receptor antibodies cause increased thyroid hormone synthesis, release, and thyroid gland  gland growth. Worse w stress (ie pregnancy, ill)
• MCC of hyperthyroidism

• clinical hyperthyroidism
• diffuse enlarged thyroid
• thyroid bruits
• opthalmopathy: lid lag, exophthalmos/proptosis (exclusive to Graves)  hyaluronic acid deposition tx w/ steroids. smoking & iodine may make worse. 
• pretibial myxedema: nonpitting, edematous, pink to brown plaques/nodules on shins

not all tests need to be done

• + thyroid-stimulating IG Ab (most spp)
• +- thyroid peroxidase & anti-TG Ab
• hyperthyroid TFT's: increased FT4/T3, & low TSH 
• RAIU: increased diffuse uptake 

1. radioactive iodine; MC. destroys thyroid gland, will need hormone replacement
2. methimazole/propylthiouracil : PTU safe in pregnant
3. BB (propranolol) for sx relief 
4. Thyroidectomy: if compressive sx, no response to meds, if RAI is CI (ie. pregnancy)

toxic multinodular goiter (plummer dz) TMG

• painless, enlarged thyroid
• may present in euthyroid state (rarely in hyperthyroid state)

• hypothyroidism usually permanent
• levothyroxine tx : thyroid replacement 

• + thyroid Ab present (same as hashimoto's)
• TFT's (hyper/hypo) depend on when they present
• decreased radioactive iodine uptake 

• return to euthyroid state c/n 12-18 months w/o treatment ASA
• no anti-thyroid meds
• 20% possible permanent hypothyroidism

• amiodarone (containes iodine)
• lithium 
• alpha interferon

• often returns to euthyroid states when medication is stopped, steroids 

• increased ESR (hallmark)
• NO thyroid Ab
• TFT's (us hyperthyroid)
• decreased radioactive iodine uptake

levothyroxine

monitor TSH @ 6 wk interval when initiating/changing dose

iodine deficiency 

(US is hashimoto's)

• excessive increased PTH production
• MC type
• Parathyroid adenoma MCC (80%)
• parathyroid hyperplasia/enlargement (20%)
• 20% of pts taking lithium.MEN I & II; malignant rare

hyperparathyroidism

pituitary tumors

pancreatic tumors

hyperparathyroidism

pheochromocytoma

medullary thyroid carcinoma

• increased PTH in response to hypocalcemia or vit. D deficiency (parathyroid tries to compensate by increasing PTH to increase Ca levels)
• chronic kidney failure (MCC of secondary). kidney normally convert vit. D to usable form

• prolonged PTH stimulation after prolonged 2ry hyperparathyroidism --> autonomous PTH production
• may be seen in post transplant pts as well

• signs of hypercalcemia : stones, bones, abdominal groans, psychic moans
• decreased DTR

• Triad: hypercalcemia + increased intact PTH + decreased phosphate 
• increased 24h urine calcium excretion
• increased vit. D
• osteopenia on bone scan

1. surgery: parathyroidectomy (subtotal = 3 1/2 removal of gland).  total parathyroidectomy (removal of all 4 glands w/ auto transplantation of parathyroid tissue in forearm)
2. vit. D/Ca supplementation if 2ry
3. tx hypercalcemia if sxatic (IV fluids, furosemide, calcitonin)

1. ADH (vasopressin) deficiency (central DI)
2. insensitivity to ADH (nephrogenic) --> inability of kidney to concentrate urine --> production of large amounts of dilute urine

• no ADH production
• MC type
• idiopathic MC
• autoimmune destruction of posterior pituitary
• head trauma
• tumor (brain or pituitary)
• infection
• sarcoid granuloma 

• partial or complete insensitivity to ADH
• Drugs: lithium, amphotericin B, demeclocycline
• Hypercalcemia & hypokalemia (disrupts kidneys concentrating ability)
• acute tubular necrosis
• hyperparathyroidism

1. fluid deprivation test: establishes the dx of DI, normal response --> progressive urine concentration (to conserve H2O --> increasing urine osmolality)  DI: continued production of dilute urine (decreased Uosm < 200 & low specific gravity < 1.005)
2. desmopressin (ADH) stimulation test: differentiates nephrogenic from central DI. Give ADH : central DI --> reduction in urine output (increased Uosm) indicating response to ADH.  Nephrogenic DI --> continue production of dilute urine (no response to ADH)

• patients usually only become clnically symptomatic w/ decreased oral free water intake

1. polyuria (up to 20 L/day) + polydipsia (to maintain H2O) Nocturia (eneuresis in children) 
2. HYPERNATREMIA if severe or decreased PO H2O intake. Dehydration, hypotension, CV collapse

desmopressin DDAVP (synthetic ADH)

carbamazepine (decreases ADH)

Na/protein restriction --> HCTZ, indomethacin

hypotonic fluid

(pure water orally is preferred, D5W, 1/2 normal saline)

IA : autoimmune destruction triggered by 1 or more environmental factors

IB: non autoimmune beta cell destruction

CHAOS

Chronic HTN, Atherosclerosis, Obesity(central), strokes

1. sensori-motor - paresthesias, abnl gait, decreased proprioception in a "stocking glove" pattern, pain, decreased DTR
2. autonomic: orthostatic hTN, gastroparesis:N/V/D, constipation, impotence
3. retinopathy: painless deterioration of small retinal vessels
4. nephropathy : progressive kidney function deterioration leading to microalbuminuria
5. macrovasulcar: atherosclosis --> CAD, PVD, stroke
6. increased risk of infections: d/t vascular insufficiency & immunosuppresion from hyperglycemi
7. hypoglycemia 

• nonproliferative (background): microaneurysms earliest change 
•  exudative changes leakage of lipoproteins (hard exudates - deep yellow w/ sharp margins, circinate) or
•  blood (dot or flame-shaped hemorrhages) --> 
• cotton wool spots (aka soft exudates - fluffy gray-white infarction of n. fiber layer ischemia)
•  closure of retinal capillaries, retinal venous beading (tortuous/dilated veins)

• neovascularization : new abnl bv growth, hemorrhage

• macular edema
• blurred vision
• central vision loss
• can occur @ any stage 

• nodular glomeruloscleosis described as pink hyaline material around glomerular capillaries (d/t protein leakage)
• Diabetes mellitus

• ACEI (reduces protein leakage & slows progression)
• low Na diet

too much insulin use

too little food

excess exercise

• autonomic: sweating, tremors, palpitations, nervousness, tachycardia
• CNS: HA, lightness, confusion, slurred speech, dizziness

• random blood sugar 50-60mg/dL
• sx occur @ 60
• brain dysfunction begins @ 50

• mild < 60: 10-15 fast acting CHO, fruit juice, hard candies & recheck in 15 min
• if severe/unconscious, < 40 --> IV bolus of D50 or inject glucagon SQ

1. fasting plasma glucose >= 126 : fasting @ least 8 hrs 2 occasions GOLD STANDARD
2. HgA1c >= 6.5% : indicates average blood sugar 10-12 wks prior 
3. 2 hr plasma glucose >= 200 : oral glucose tolerance test 3 hr GTT gold standard in gestational
4. plasma glucose >= 220 : in pts w. classical sx of hyperglycemia

1. pts >= 45
2. BP > 135/80
3. younger adults w/ BMI > 25
4. if >= 1 RF 
5. fam hx of type II DM
6. low HDL
7. polycystic ovarian syndrome
8. non-caucasians

1. diet, exercise, lifestyle changes: tried FIRST in Type II
2. oral antihyperglycemic agents
3. +- insulin in aunable to control
4. Diet - carbs 50-60%, protein 15-20%, unsat fats 25-30%
5. insulin if type 1, insulin preferred for gestational

1. HgbA1c < 7.0 (check q3 mo if not controlled, twice a year if controlled)
2. Pre-prandial blood glucose goal - 80-110 (60-90 if prego)
3. post prandial BH < 140

LDL < 100

HDL > 40

TG < 150

• gabapentin 
• +- TCA
• foot care (wide loose fitting shoes, nail trimming, podiatrist monitoring)

DM control

laser photocoagulation tx

Bevacizumab (proliferative)

vitrectomy

DM control

ACEI if microalbuminuria

low Na+ diet

1. HgbA1c: 5.7-6.4
2. fasting glucose 100-125
3. oral glucose tolerance test: 140-199

insulin resistance

predisposed to developing DM, CAD, CVA

HDL < 40 in men, < 50 in women

increased BP 135/85

triglycerides > 180

fasting blood sugar 100-135

waist circumference > 35 inches in women

wast circumference > 40 inches in men

lispro (Humalog) & Aspart (Novolog)

given @ same time of meal 

5-15 min onset, peak 1 hr, duration 3 hr

regular (Humalin -R)

given 30-60 min prior to meal

onset 30m-1h, peak 2-3h, duration 4-6 hr

NPH (Humulin N & Novolin N)

Lente (Humulin L & Novolin L)

covers insulin for about half day (or overnight)

onset 2-4h, peak 4-12h, duration 16-20h

ultralente (U), insulin glargine (lantus), detemir (levemir)

covers insulin for 1 full day (basal insulin) 

onset 6-8h, peak 12-16h, duration 20-30h

lantus

(do not mix with other types of insulin!)