+ bone disease

screening
Endocrinopathies Diabetes
-pituitary:
1ry 2ry
*prolactine HTN HTN
*GH mellitus insipedus
-thyroid + Th. mass polyuria
emergency
acute chronic D/C chronic
-parathyroid
(hypercalcemia)
-adrenal
*cortex > aldosteron or
cortisol
*medulla > epinephrine
*adrenal mass
(incidentiloma)
-neuroendocrine
tumors
 Screening test:
#Colon cancer
screening =
colonoscopy AGE Follow up
⑧

1- General population ≥50 yo 10 years

2- IBD (UC-crohns) 10 years of diagnosis annual

3- Colon polyps-
10 yo annual
familial adenamtous
-at 20 yo > upper GI endoscopy
polyposis

4-Hereditary Non- 20 yo annual

polyps colon cancer -at 40 yo > upper GI endoscopy

5- 1st degree relative 40 yo 5 years

with colon cancer

others:
-flexed sigmoidoscopy 3-5 years
-CT enterography

#Lung cancer
x CXR/HRCT/MRI/US
✓ Low dose CT to
55 -80 yo that 30 pack/year
or
Ex-smoker (up to 15 years)
**all patient (smoker)>65 yo > abdominal US to rule out Aortic aneurysm
 #osteoparosis = x skleletal survay/bone scan ✓DEXA scan
at > 65 yo
< 65 + 10 year fracture risk 9%
chronic use of steroid (6.5 mg PO x3months)

#HTN = sphygmomanometer
-All adult > 18 yo
-HTN <40 yo proceed with 2ry HTN work up

#Lipid profile (fasting)

≥ 35 yo male
≥ 45 yo female

#DM
-All adult BP >130/80 > DM metabolic syndrome
polycystic ovarian syndrome
-Normal BP >45 yo

#Breast
40-50 yo (45yo) mammogram 1-2 years
 **Radiation increase risk for sarcoma Bone diseases

÷
Paget’s disease Osteomalacia
Osteoporosis (silent)
NL ca/po4/Vitamin D low Ca/vitamin D
NL CA/Po4/VItamin D
Hormone Problem/smoking TTT? supplement
↑Alkaline phosphatase
—————
#leg pain + ↓hearing,↑head size
Screen or Risk factors:
risk of fracture, osteosarcoma
DEXA:
TTT? Bisphosphonate
Osteopenia:
- 1.0 to -2.4 > FRAX test 10 years

- osteoporosis: ↑ ↓

< -2.5
x vitamin d/calcium
✓ bisphosphenate PO “alendronate”
IV Zoledronic acid

*if pt have osteopenia + fracture +

osteoporotic (high risk) > treat
 1ry hyperpara:
Hypercalcemia approach:
-↑PTH
Dizzness, polyuria, constipations, renal stones, nausea/vomiting, -↑Ca

=
pancreatitis, PUD -↓Po4
what to order? 2ry hyperpara:
-↑PTH
Free Ca (ionized)
-↓Ca
≥ 1 high -↑Po4
Next? PTH
#High/normal= #Low
order urine Ca level: if order PTHrP if:
High = 1ry hyperparathyroidism > order neck US High = malignancy (lung cancer
Low = familial hypocalcuric hypercalcemia (FHH) -squamous)
(FE Ca <0.01) Normal: order Vitamin D metabolism:

,
1,25OH↑= 25OH↑ NL
sarcoidosis or Vitamin D MM
lymphoma toxicity
(granuloma)
Treatment of hypercalcemia:
Aggressive hydration = IV Normal saline up to 2500/hour - 4-6 liter/day > to increase renal ca
excretion
option:
# IV Zalodoric acid (malignancy) but it’s CI in renal failure
#Denosumab takss months to begin action + expensive (malignancy)
#Cacitonin works within hours but short half life
#Steroids excellent in granuloma
#Hemodialysis
primary hyperparathyroidism Sx
<50 yo
Ca > 1mg/dL>ULN
Cr clearance <60
DEXA scan < -2.5
Endocrinopathies: 1st to order serum hormones then > imaging
-Pituitary: 2 Diseases:
Prolactinoma:
1- Galactorrhea, amenorrhea, ↓lipido < 10 mm = microadenoma MRI FU
1st thing you do ? pregnancy test [ >10 mm or symptomatic = caberogolin
Next if -ve pregnancy? Fasting prolactin if: ↑= order pituitary MRI
(dopamin agonist)
IF failed or neurological sx
> surgical trans-sphenoidal
**high risk of recurrence 20%
still no improvement > Radiation
Acromegaly
2- change voice/shoe size, ↑length, carpal tunnel syndrome, headache, sleep apnea,
↓lipido, ↑sweating, acanthosis
at risk of :
HTN/DM/cardiomyopathy/
Order:
serum test: insulin like GH factor if: ↑= order OGTT (confirmatory) then GH: ↑GH
(Normally it will suppress GH) > Order pituitary MRI
-
eye sx no > somatostatin analoge (octeritide)
compression or GH receptor antagonist (pegvisomant)
> surgery
# pt had surgery in brain(post trauma / ischemic encephalopathy (sheehan

]
syndrome)/anything in brain …) >> polyuria >3 L urine output/day + ↑Na >145
or
# pt took DRUG > kidney problem:
-Bipolar (lithium)
-fungal infection (amphotercin) Diabetes insipidus
-sickle cell
-sever hypercalcemia
-sever hypokalemia
>>> polyuria > 3L UOP/day + ↑Na >145

How to Approach Polyuria?

1- Urine osmolarity

=
>1000 <800
osmotic: water diaeresis
-Glucose serum Na
-Urea
Water
-Mannitole >145 deprivation
<136
test
Urine osmo (same) ↑Urine osmo
>> Diabetes >> polydipsia
insipidus
> Give
Vasopressin
dDAVP
-
U. osmo ↑ U. osmo (same)
CENTRAL Nephrogenic
ADH defiency ADH resistance
TTT? TTT? stop lithium and give ameloride if
desmopressin+ Lithium induced
hydrochlorothia
zide
 Adrenal

CORTEX MEDULLA

Cortisole Epinephrin
Aldosterone ↑
weakness (↓K) -paraoxysmal palpitation
-episodic ↑BP
↑BP, metabolic alkalosis
-diaphoresis
<40 yo -pallor
-headache
gland outside gland = pheochromocytoma
primary secondary Work up? 1- screening?

↑aldosteron ↑renin Urinary metanephrine or VMA = ↑↑↑

↓renin ↑aldosteron Confirm? serum free metanephrine if:

Screen? Causes? ↑↑↑Pheochromocytoma

1- aldosterone:renin ratio -CHF > Do CT adrenal (size/location)

>20:1 > saline suppression test if: -CLD (asciti) > 1/ give IV hydration

surpassed = 1ry hyperaldosteronism -Diuretics 2/ alpha blocker (phenoxubenzamine)

> do CT adrenal if: -Renin secretin tumors 3/ BB

**Unilateral adenoma TTT the cause to down regulat receptor > Surgery

>5cm = surgery
< 5cm and functioning = medical
TTT Medical TTT by K sparing
(spirolacton) + KCL

**Bilatral hyperacid. > Conn’s

syndrome > Medical TTT by K
sparing (spirolacton) + KCL
 Cortisol

=
↑CORTISOL ↓CORTISOL
Suspected cushing (clinically) acne/moon face/truncal Adrenal insufficiency
obesity/straea
Fatigue, abdominal pain, N/V, dizziness,
Labs:↓K, ↑BP, Metabolic alkalosis, hyperglycemian↑NA
hyperpigmentation (buccal, palmar crease),
1st screening?
orthostatic hypotension
-24 hour urine free cortisol
Labs: ↑k, metabolic acidosis,↓glucose,↓Na
or
↑eosinophils, ↑Ca,l ymphocystosis
- low dose overnight dexamethasone = CI in liver problem
suspect hypocorticolism
or
↓
- 11 pm salivary cortisol = in pregnancy Serum cortisol AM
> ↑↑↑cortisol (hypercorticolism)> ↓
Order ACTH: hypocorticolism
↓
stimulation test ( give ACTH)
cosyntropin
↑pituitary ↓1ry hypercorticolism
cortisol
“2ry hypercorticolism” “cushing syndrome” not stimulated ↑↑
ACTH dependent CT adrenal > surgery “1ry adrenal pituitary cause
HD-dexamethasone after surgery: insuffency” = addison “2ry adrenal
suppression test oral hydrocortisone + fludrocortisone disease hyperpigmentation insuffency”
“mineralocorticoids" ↑ACTH↓Cortisol ↓ACTH↓cortisol
↑↑ACTH not ↓ ↓
↓↓ACTH
surpassed CT adrenal etiology: MRI pituitary
Pituitary > Pituitary MRI > Cushing Disease
Ectopic -autoimmune TTT?
TTT?
> CT chest/abdomen -infection (TB) hydrocortisone alone
Cabergoline
to rule out tumor Mitotane -hemorrhage
—— Metyrapone -metastasis
surgery for ACTH if no improvement > Transsphenoidal surgery -deposition
ectopic (sarcoidosis,hemochro
matosis)
-drugs ( rifampin )

acute insufficient chronic

Volume resuscitation hydrocortisone +
with normal saline fludrocortisone
+hydrocortisone
 Neuroendocrine tumors

#abdominal pain, wheezes, diarrhea, facial flush, tricuspid regurgitation > Carcinoid tumor (serotonin)
increase 5HIAA in urine
TTT? octreotide (somatostatin analogue) drug of choice in hyper secreting tumor

#abdominal pain, new onset diabetes ( ) rash in lower limbs > pancreatic neuroendocrine tumor
(glucogonoma) high glucagon
surgery

#palpitation, dizziness, non diabetes, Blood glucose 35 >

>> do 72 hours fasting test >in normal people Blood Glucose still > 50 bcz of cortisol and GH
but if < 35 (too much insulin) = insulinoma (high c-peptide+insulin level) >> surgery

#35 yo man, parathyroid hyperplasia, diarrhea + abdominal pain + infertility? multiple gastric
deudnal ulcer

It
MEN 1 MEN 2A MEN 2B

Pituitary adenoma Parathyroid hyperplasia Pheochromocytoma

Medullary thyroid cancer
Parathyroid hyperplasia Pheochromocytoma
Masrfanoid feature
Pancreatic (gastrinoma) Medullary thyroid cancer
 Adrenal incidentiloma = nodule -mass found incidentally bt
CT abdomen >1cm
functioning or not?

HTN Non HTN

screen for:
cushing: Low dose dexamethasone cushing pheo
hyperaldesteron: same before
pheochromocytoma: same before

CT adrenal (venous contrast)

-
malignant feature being feature
>> surgery

Thyroid mass
US thyroid

=
benign feature >20 mm
hypoechoic
check TSH solid
microcalcification

I
low NL/high lymph node involvement
' Taller than wide
radioactive FNA
t
FNA
Hot>thyrotoxicosis Cold>>FNA
FNA indications?
-US feature
-NL/high TSH
-Low TSH but cold in RAI