Endocrinology PDF

Diagnostic Methods
Diagnostic Test
Measures
Indications
USPSTF
ADA
Screening for
Type 2
Diabetes
Recommendations when
adult patients should be
screened for type 2
diabetes
ADA Risk Factors
Result
Test Interpretation
Parameters
BP > 135/80
BMI 25 AND
1 other risk factors
Age 45
Overweight
Family history
Habitual physical
inactivity
High-risk ethnic or
racial group
History of LGA infant
or GDM
BP 140/90
Dyslipidemia
PCOS
Previous IGT or IFG
History of vascular
disease
One of these criteria must be confirmed with the

same / different criteria on another day
Diagnostic
Criteria for
Type 2
Diabetes
Necesssary laboratory
testing to diagnose
diabetes
C-Peptide
By-product of degradation of
proinsulin into active insulin
HbA1C
Glycated hemoglobin
that forms when
hemoglobin is exposed
to glucose
A1C 6.5%
FPG 100 - 125 mg/dL
FPG 126 mg/dL

Prediabetes
2 hour OGTT
200 mg/dL
RPG 200 mg/dL AND

symptoms (polyuria,
polydipsia, weight loss,
blurred vision)
OGTT 140 - 199 mg/dL
HgbA1C 5.7 - 6.4%
Type 1 Diabetes
LOW
Type 2 Diabetes
Normal or HIGH
Normal
3 - 6%
Goal for
Diabetics
< 7%
Newly diagnosed diabetes
Diabetes
Other
Suspected poor
long-term glucose
control
Can be used to identify gastrinoma

spread or malingering C-peptide
with hypoglycemia may reflect abuse
of insulin)
Normalized within 3 weeks of
normoglycemic levels
Does not require fasting
Good DM control = 1 - 2 times yearly
Suboptimal DM control =
every 3 months
Point-of-care HbA1C assays are not
sufficiently accurate to use for
diagnostic purposes.
Cannot be used in patients with RBC
formation and/or turnover
disorders.
Compiled by Drew Murphy, Duke Physician Assistant Class of 2015
Diagnostic Methods
Diagnostic Test
Measures
Indications
Medications
Activity level
Stress
Glucose
Testing
Blood glucose levels
Factors
Liver disease
Hormonal tumors
Pancreatic disorders
Pregnancy
Fructosamine
Glycated albumin or
serum protein
Hyperglycemia within
few weeks
Thyroid
Hormones
TSH
Hormones secreted by
the thyroid
Suspected poor shortterm glycemic control
Chronic hemolytic anemias

T3
T4
TRH
TBG
Test Interpretation
Parameters
Diuretics
Estrogens
HIGH
Blockers
Corticosteroids
Acetaminophen
Alcohol
LOW
Propanolol
Anabolic steroids
2 Hour GTT Fasting Specimen
Normal
70 - 99 mg / dL
Prediabetes
100 - 125 mg / dL
Diabetes
> 125 mg / dL
2 Hour GTT 2 Hour Specimen
Normal
< 140 mg / dL
Impaired Glucose
140 - 199 mg / dL
Tolerance
Diabetes
> 199 mg / dL
3 Hour GTT Interpretation
Fasting
< 95 mg / dL
1 Hour
< 180 mg / dL
2 Hour
< 155 mg / dL
3 Hour
< 140 mg / dL
2 values above
Abnormal
reference range
1 value above
Equivocal
reference range
Result
Triiodothryonine
Thyroxine
Thyroid stimulating
hormone (thyrotropin)
Thyroid releasing
hormone
Thyroxine binding
globulin
Other
Random Plasma Glucose
Any time of day without regard to the
last meal
Fasting Blood Glucose
No caloric intake for 8 hours
Oral Glucose Tolerance Testing
Timed blood draw after oral load of a
specific amount of glucose
1 hour OGTT - 50 g glucose then 1
hour blood draw
2 hour OGTT - 75 g glucose then 2
hour blood draw
3 hour OGTT - 100 g glucose then
blood draw at 1, 2,
and 3 hours
Limited use in patients with serum

Normal
1.5 - 2.4 mmol/L (when albumin (nephrotic state or hepatic
(varies with serum
serum albumin is 5 g/L) disease)
albumin)
When T3 and T4 levels are low, TRH
production is stimulated. TRH
stimulates the anterior pituitary to
release TSH which accelerates all
aspects of thryoidal iodine
metabolism and hormon production.
Thyroid antibodies
Diagnostic Methods
Diagnostic Test
Measures
Indications
Thyroxine Binding
Globulin
Amount of binding protein

affects that serum levels of
T3 and T4
Thyroid disease
T3 Resin Uptake
Indirect way to distinguish

TBG excess or deficiency
Thyroid
Stimulating
Hormone
T4
Hormone that stimulates

T3 and T4 production
Result
HIGH
LOW
HIGH
Hyperthyroidism
Hypothyroidism
LOW
Test Interpretation
Parameters
Euthyroid (pregnancy)
Estrogen
Euthyroid (nephrotic)
Androgens
Hyperthyroidism
Hypothyroidism
HIGH
Hypothyroidism
Variable
Thyroid disease
LOW
Other
Results dependent on amount of

TBG available
Inverse relationship to endogenous
T4
Hyperthyroidism
Euthyroid sick syndrome
Thyroxine
HIGH
Hyperthyroidism
Normal
Euthyroid
Thyroid disease
LOW
Thyroid
Antibodies
Antibodies against
thyroid cells
Serum Cortisol
Amount of cortisol in
the blood
Euthryoid sick syndrome
Hypothyroidism
Microsomal Ab >
IgG autoantibodies are directed at
Thyroiditis
Diffuse hyperthyroidism
1:32 Titer
thyroid cell receptors for TSH.
Autoimmune thyroiditis
Thyroglobulin Ab
Grave's disease
Hypothyroidism
> 1:100
High
Thyroglobulin and
Lymphocytic thyroiditis
Thyroid carcinoma
Microsomal
Antigens
Highest
Morning
Cushing syndrome
Cushing's disease
Lowest
Evening
Cushing syndrome
Cushing's disease
Ectopic ACTH-producing
Adrenal Tumor
HIGH
Adrenal Tumor
tumor
tumor
Hyperaldosteronism
Adrenal insufficiency
Normal
Hyperaldosteronism
Addison's disease
Pituitary disease
LOW
Adrenal crisis
Adrenal crisis
Pituitiary disease
2 Adrenal insufficiency
Diagnostic Methods
Diagnostic Test
Measures
Indications
24-Hour Urine
Cortisol
Cortisol level in a
24-hour collection of
urine
Cushing's Syndrome
(screening)
Circadian rhythm
Stress
Affecting Factors
Glucocorticoid
Salivary Cortisol
Result
HIGH
Cushing's
Normal
20 - 100 g/24 hr
Pituitary disorders
Cushing's disease
Ectopic
ACTH-producing tumor
Adrenal tumor
Hirsuitism
Virilization
ACTH
Stimulation
Test
Measures plasma cortisol

before and after injection
of synthetic ACTH
Dexamethasone
Suppression Test
Cortisol levels after

receiving the cortisolmimic dexamethasone
Adrenal insufficency
CRH is injected and

cortisol and ACTH levels
are measured
Adrenal tumors
Does Not Respond to
CRH
5 mL of the collection needs to be

frozen or refrigerated with
preservative (10 boric acid) < 4 hours
of collection completion
No reference range.
Often ordered with the ACTH
Interpret results in context of patient.
stimulation test
1 Adrenal insufficiency Diurnal variation
Cushing's disease
Addison's disease
HIGH
tumors
Hirsuitism
Virilization
Adrenal tumor
LOW
Steroid medication
Hypopituitarism
Rapid screening test may be ordered
along with a baseline ACTH test. IF
Rises
Normal adrenal glands
abnormal, it may be followed with a
1 - 3 day prolonged ACTH stimulation
test to help differentiate between 1
and 2 AI.
Minimal Change Damaged adrenal glands
LOW
Normal
Non-Adequate
Change
Cushing's syndrome
Cushing's syndrome
Cushing's syndrome
Other
Assay is highly subject to error
Measures the amount of serumHelpful in ambulatory patients who can collect and
free cortisol that diffuses freely
store multiple specimens over time
into the saliva
Hormone produced by
Adrenocorticotropic the anterior pituitary
gland often produced in
Hormone (ACTH)
response to biological
stress
CRH
Stimulation
Test
Test Interpretation
Parameters
Higher doses of dexamethasone can

be given over 48 hours to distinguish
between an ACTH-producing pituitary
tumor & other causes of Cushings
syndrome
Baseline measurements are taken,
and another sample is taken at 30
and 60 minutes.
Ectopic ACTH-secreting
tumors
Diagnostic Methods
Diagnostic Test
Measures
Aldosterone
Mineralocorticoid that
manages the salt and
potassium in the blood
Indications
Test Interpretation
Parameters
1 Hyperaldosteronism
HIGH
Cushing's syndrome
Normal
Pituitary disease
Addison's disease
LOW
Cushing's syndrome
Result
Hyperaldosteronism
Cushing's syndrome
Pituitary disease
Addison's disease
Other
Testosterone
Adrenal
Androgens
Androstenedione
Adrenal disorders
Dehydroepiandrosterone (DHEA)
Dehydroepiandrosterone Sulfate
(DHEAS)
17Hydroxycorticosteroids
Indirect measue of excessive

plasma glucocorticoids
17-Ketogenic
Steroids
Indirect measue of
excessive plasma
glucocorticoids
Renin
Plasma Free /
Fractionated
Metanephrines
Enzyme relased by the

kidneys when increased
potassium and decreased
sodium is in the blood
Biochemical testing for

pheocromocytoma
Cause of Cushing's
syndrome
Pituitiary disease
VERY HIGH
Adrenal adenoma
Adrenal carcinoma
HIGH
Cause of Cushing's syndrome
VERY HIGH
HIGH
Tested through urine samples

Ectopic ACTH secretion Limitations
Some medications
Pituitary disorders
Estrogens
Adrenal adenoma
Urine glucose
Adrenal carcinoma
Adrenal carcinoma
Principal 17-KS is DHEA
Pituitary disorders
Limitations
Ectopic ACTH secretion Pregnancy
Hirsuitism
Estrogens
Virilization
Penicillins
Eryhtromycins
Adrenal adenoma
Addison's disease
Adrenal tumor
Adrenal hyperplasia
Hirsuitism
Virilization
Addison's disease
HIGH
Hyperaldosteronism
Pituitary disease
Normal
Pituitary disease
Cushing's syndrome
LOW
Cushing's syndrome
Pheocromocytoma
HIGH
(with symptoms)
Pheocromocytoma
Normal
Diagnostic Methods
Diagnostic Test
Measures
Indications
Epinephrine
Urine
Catecholamines
Norepinephrine
Adrenal disorders
Dopamine
Test Interpretation
Parameters
Caffeine
Epinephrine
Ethanol
Isoproteranol
Levadopa
HIGH
Nicotinine
Nitrogylcerine
Reserpine
Bananas
Stress
Clonidine
Prazosin
LOW
Radiographic agents
Renal failure
Result
Adrenal disorders
Normetanephrine
Radiograph
Uses x-rays to view a nonuniformly composed object
Requires a 24-hour collection

Limitations
Aldomet
Isoproternol
Metoclopramide
Acetaminophen
Cimetidine
24-hour collection
Interfering Drugs
Aldomet
Codeine
Isoproteranol metabolites
Metoclopramide
Levels of acetaminophen
Compound in peppers
Endogenous 4-0-methyldopamine
Metanephrine
Urine
Metanephrines
Other
Calcification
(due to tuberculosis)
Infection
Enlarged Adrenals
CT / MRI
Advanced imaging
techniques
Evaluation of the size

and shape of the adrenal
and pituitary glands
Cancer
Pheocromocytoma
Small or Normal
Adrenal Glands
Autoimmune diseases
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms
Test
Laboratory
Result
Treatment
Insulin Resistance
180 mg/dL
126 mg/dL
Group of metabolic
diseases characterized by
hyperglycemia resulting
from defects in insulin
secretion, action, or both
Insulin Therapy
Hyperlipidemia, HTN,
obesity, IGT, and PCOS
Diabetes Progression
Impaired glucose
tolerance and
post-prandial glucose
Fasting
Plasma
Glucose
Impaired fasting glucose
Type 2 Diabetes Risk

Factors
Type 1 Diabetes
Absolute deficiency of insulin
secretion
Diabetes
Mellitus
Polyuria
Polydipsia
Weight loss
Fatigue
Blurred vision
Infections
100 - 125 mg/dL

(Pre-diabetes)
Weight loss
Exercise
Months 1 - 6
16 individual
sessions with a RD
Months 7 - 36
Minimum of 1
session every
other month with
RD
200 mg/dL
Insulin Therapy for Type 1

Oral Glucose
Tolerance
Testing
Use of multiple dose insulin injectors

or CSII therapy
140 - 199 mg/dL
Matching of prandial insulin to
(Pre-diabetes)
carbohydrate intake, pre-meal blood
glucose, and anticipated activity
Use of insulin analogs
Random
Glucose
200 mg/dL with

symptoms
Hyperglycemia
Type 2 Diabetes
Insulin resistance
Diabetic ketoacidosis
Nonketontic
hyperosmolar syndrome
Acanthosis nigricans
(type 2)
Skin tags
(type 2)
Hirsutism
(PCOS)
Gestational Diabetes
Diabetes that develops
during pregnancy and
resolves after pregnancy
140 - 180 mg/dL

glucose goal
Lifestyle Modification
Type 2 diabetes
Family history
Age > 45
High-risk ethnic
population
Habitual ethnic
population
Medications
Obesity
Medications
6.5%
(diagnostic)
HBA1C
Asymptomatic
(especially type 2)
Stroke
Retinopathy
End-stage
kidney disease
Complications
Heart disease
Fasting
Foot / leg amputations
Glucose
Neuropathy
Autonomic neuropathies
Neovascularization
Two Hour
Vitreous hemorrhages
Fundoscopic Findings in
OGTT Plasma
Macular edema
Diabetic Retinopathy
Glucose
Retinal thickening
Hard exudates
< 7.0%
(goal)
Factors That Affect Insulin

Absorption
Strenuous use of
Exercise
injected limb
< 1 hour
Do not rub site
Massage of Area
vigorously
with heat
Temperature
with cold
Abdomen > arms
Site of Injection
> thigh
Lipohypertrophy
Delays absorption
Large Dose
(>80 units)
Diet
(hospitalized)
Medications
(hospitalized)
Severity of Illness
(hospitalized)
Delays onset and

duration
Different and
unpredictable
Glucocorticoids
Pressors
126 mg/dL
Hypoglycemia
Protocal
200 mg/dL
Varies
Administration of
IV dextrose
Eat 15 g of
carbohydrate if
alert and able to
eat
Be wary of overtreating with an
excess of
carbohydrates
See
Pharmacology
study guide
Other
LADA
Latent autoimmune diabetes of
adulthood
MODY
Maturity onset diabetes of the young
Diseases Due to Adipocytes
Type 2 diabetes mellitus
Inflammation
Arthritis
Cancer
ASCVD
Hypertension
Atherogenic dyslipidemia
Thrombosis
Cardiovascular disease is the major
cause of mortaility for individuals
with diabetes. Type 2 diabetes is an
independent risk factor for
macrovascular disease.
Diabetic nephropathy occurs in
20 - 40% of diabetic patients and is
the single leading cause of end-stage
renal disease.
Diabetic neuropathy cannot be
reversed. Glucose control can slow
the progression.
ABCs of Coronary Prevention
A - aspirin, ACEI, A1C control
B - -blockers and BP control
C - cholesterol management
D - diet, don't smoke, risk
E - exercise
Glycemic control has been shown to
promote WBC function and facilitate
wound healing.
Relatively large doses of insulin
compared with those required to
treat type 1 may be necessary to
overcome insulin resistance of type 2
and lower A1C.
Type 2 DM patients who have done
well on oral agents at home may
often need insulin in the inpatient
setting.
Sliding scale insulin should not be
used as monotherapy.
Diabetes Management
Diabetes education
Nutrition consult
Remove offending medications
Educate patient on management of
lows
Achieve inpatient blood glucose
Clinical Medicine
Condition / Disease
Diabetic
Ketoacidosis
Pituitary
Hormones
Hypothyroidism
Cause
Life-threatening complication in
diabetic patients due to a
shortage of insulin that leads to
metabolism of fatty acids and
produces ketone bodies
Substances made in the

pituitary gland that acts
on another tissue or
organ to produce an
effect
Colder intolerance
Fatigue
Thyroid gland fails to make T4
Heavy menstrual
bleeding
Weight gain
Secondary
Dry skin
Constipation
Pituitary
Tumors
Deficiencies of pituitary
hormones
Neoplasms of the
pituitary gland
Test
Laboratory
Result
Patients will say that it is the worst they

Blood Glucose
have very felt
Nausea
Vomitting
Ketones
Weakness
Lethargy
Fruity breath
Abdominal pain
BMP
Hyperventilation
Anterior Pituitary Hormones
Estrogen in
FSH
Spermatogenesis in
Ovulation regulation
LH
Testosterone stimulation
in
Thyroid hormone
TSH
production
Prolactin
Induces lactation
Controls acral grouwth
Mediated by GH
GH
stimulating IGF-1 from
the liver
Stimulates cortisol
ACTH
production
Posterior Pituitary Hormones
Vasopressin
Prevents free water loss
Oxytocin
Induces labor
Primary
Pituitary gland fails to make TSH
Hypopituitarism
Signs and Symptoms
Myxedema coma
2 Hypothyroidism
2 Adrenal Insufficiency
Hypogonadotropic
Hypogonadism
Growth Hormone
Deficiency
HIGH
HIGH
Acidemia
Free T4
Panhypopituitarism
Majority of hormones
Headache
Bitemporal hemianopsia
Opthalmoplegia
Ptsosis
Hypopituitarism
CN III and VI palsies
FSH / LH
Prolactin
IGF-1
ACTH
Cortisol
Thyroid Profile
2 hypothyroidism is much rarer than

1 hypothryoidism. TSH cannot be
followed for TH replacement.
LOW
No GH
Diabetes Insipidus
Other
4.6 - 8 episodes per 1000 diabetics
Treatment of DKA represents 1 in 4
health care dollars spent on direct
care for patients with Type 1
LOW / Normal
(2)
No TSH
No ACTH
No FSH
No LH
No ADH
No AVP
Medications
The pituitary lies at the base of the

brain in an area called the sella
turcica.
Anterior Pituitary Anatomy
Pars tuberalis
Pars intermedia
Pars distalis
Posterior Pituitary Anatomy
Infundibular stalk
Pars nervosa
HIGH (1)
TSH
Treatment
Insulin drip
IV fluids
Potassium
Insulin drip
EKG
Insulin drip
Assessment
9 I's of Hypopituitarism
Invasive
Infarction
Infiltrative
Injury
Immunologic
Iatrogenic
Infectious
Idiopathic
Isolated
15% of all intracranial neoplasms
70 - 90% of patients with pituitary
macroadenomas have deficiencies in
1 or more pituitary hormones at the
time of presentations.
Clinical Medicine
Condition / Disease
Secondary
Adrenal
Insufficiency
Cause
Failure to secrete ACTH
Signs and Symptoms
See Adrenal Insufficiency for more information
Test
Morning
Cortisol
Laboratory
Result
<5
ACTH
LOW
Cortrosyn
Stimulation
Test
No response
Insulin
Tolerance Test
Unilateral renal agenesis
Hypogonadotropic
Hypogonadism
Growth
Hormone
Deficiency
Hypogonadism due to an
impaired secretion of
gonadotropins
Low levels of growth

hormone
Cleft lip
Congential adrenal
hypoplasia
DAX-1
Hypogonadism from
gonadotropins
Acquired Etiologies
Malnutrition
Severe illness
Hospitalization
Anorexia nervosa
Prolonged exercise
Exercise bulimia
Dose opioids /
Obesity / Type 2 DM
methadone
dose glucocorticoids
Mass lesions
Trauma
Surgery
Radiation
Encephalitis
Hemochromatosis
Low energy
Poor sense of well-being
Social isolation
Muscle mass
Change in body
composition
Poor exercise tolerance
Dysregulated body temperature
Medications
Cortisone acetate 25 - 37.5 mg per

day
Other
There is no need for
mineralocorticoid replacement.
Hyperkalemia and hypotension are
rarely seen.
Hyperpigmentation is not seen.
Hydrocortisone 15 - 25 mg per day in

2-3 divided doses
Prednisone 4 - 7.5 mg per day in

divided doses
See Treatments
section
Diagnostic
Stress doses for trauma or surgery
Metyrapone
Test
Amenorrhea
Infertility
Erectile dysfunction
Congential Etiologies
X-linked (Kal-1)
Autosomal dominant
(Kal-2)
Hypoplasia olfactory
Kallman's Syndrome
bulb
Treatment
LOW
Testosterone
FSH / LH
HIGH (1)
Estrogen
LOW
Hormone replacement (if indicated)

Androderm Patch
LOW
Testosterone
MRI
< 150 ng/dL

(more predictive
of central lesions)
Angrogel
Clomiphen
()
Assess for cause
Testim
Fertility
Treatment
Prolactin
Fortesta
Assessment
HCG injections
()
Iron / TIBC
Insulin
Tolerance
Test
IGF-1
GH
Axiron
Hemachromotosis
Infusion drops
blood glucose to
< 40 mg/dL
GH should rise
above 5 (adults) or
10 (children)
Normal
(50%)
LOW
Child
Hormone
Replacement
Criteria
Adult with
3 other pituitary
hormone
deficiencies with
symptoms
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms
Polyuria
Test
Laboratory
Result
Hypernatremia
Polydipsia
Treatment
Vasopressin
BMP
SQ DAVP
Normal glucose
Spray DAVP
5 - 10 liters of urine output
Diabetes
Insipidus
Easy to administer
Allows variable
dosing
Easy to administer
Oral DAVP
Alternative to
nasal route
Allow breakthrough polyuria
Urine osmolality
No water diets
Medic-Alert
< 600
and excessive
beverage
PRN Really
Pregnancy
Dose
URI
Requirements
Diagnostic
Allergic rhinitis
Dose medications during times of
stress
Rhinal Tube DAVP
Absence of anti-diuretic
hormone (vasopressin)
leads to the inability to
concentrate urine
Idiopathic
UA
Familial
Panhypopituitarism
Etiologies
Infiltrative diseases
Water
Deprivation
Test
Metastatic tumor
Trauma / surgery
Pituitary
Imaging
Wolfram syndrome
Pituitary MRI
Hypothyroidism
Hypocortisolism
GH
Amenorrhea
Panhypopituitarism
Medications
Immediate
bioavailability
Short duration of
action
Immediate
bioavailability
Menopause
Decreased hormone
production from the
pituitary gland
Infertility
Polyuria
Polydipsia
Morning
Cortisol
Low-Dose
ACTH
Stimulated
Cortisol
Hypogly.Induced
Cortisol
Free T4
LH
FSH
Free
Testosterone
( )
Estradiol ()
Specific gravity
< 1.0006
Other
Etiologies of Nephrogenic DI
Amyloidosis
Myeloma
Sjgren's syndrome
Sickle cell anemia
Hypercalcemia
Recovery from ATN
Lithium
Foscarnet
Methicillin
Demeclocycline
Colchicine
Asssess
< 9.5 g/L
Treat underlying cause
(Arginine-GHRH
stimulated GH)
< 11 g/L
(Acipomox-GHRH
stimulated GH)
Cortisol
< 5 g/dL
< 18 g/dL at
30 minutes
< 20 g/dL
LOW
Hormone
Replacement
Protocol
Thyroid hormone
Sex steroids
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms

Galactorrhea
Test
Laboratory
Result
Treatment
Infertility
Amenorrhea
Indications for
Therapy
Hyperprolactinemia
Headache
Elevated prolactin
blood levels
Mass effect
If prolactin > 200
If prolaction is between
20 - 150
Gigantism
Growth disorder due to a growth

hormone secreting tumor during
puberty and prior to epiphyseal plate
fusion
Cabergoline
Neurosurgery
Can grow up to 8' 11" tall.
Hyperhidrosis
Headaches
Visual deficit
Acromegaly
Hormone
Replacement
Bromocriptine
Other
Microadenoma
< 1 cm tumor
Macroadenoma
> 1 cm tumor
Hyperprolactinemia supresses LH and
FSH secretion. This suppresses
estradiol and testosterone
production and causes
hypogonadism in both and .
Rapid linear growth
Acral enlargement
Growth hormone
secreting pituitary tumor
in adulthood
Dopaminergic
Drugs
Pituitary ademona
Renal failure
Pregnancy
Prolactinoma
Pituitary adenoma
Renal failure
Pregnancy
Drugs
Other pituitary tumors
Hypothalamic tumors
Chest wall stimulation
Medications
Macroadenoma
Enlarging
microadenoma
Infertility
Bothersome
galactorrhea
Gynecomastia
Testosterone
deficiency
Oligomenorrhea
Amenorrhea
Acne
Hirsuitism
Macroadenoma
Mass effect
Visual field deficit
Fertility desired
No fertility desired
Microadenoma
Visual field full
No mass effect
Estrogen
Testosterone
Weight gain
Hypertension
Cardiomyopathy
Splaying teeth
Visceral Enlargement
HIGH
Not affected by
time, food intake,
exercise, or sleep
Arthralgia
> 2 ng/mL
Indicated when
Hypogondal symptoms
GH After 2
IGF-1 levels
Hour OGTT
equivocal
Most specific
Fatigue
dynamic test
Tumor can be
Galactorrhea
seen
Pituitary MRI
Abdominal and
LV hypertrophy
chest imaging
(if normal)
Prominent brow
If MRI (-) or
evidence of
Diabetes
pituitary /
GHRH
somatotroph
Thyroid
hyperplasia on
post-op pathology
Liver
Glucose
Other Lab
Phosphorus
Kidneys
Abnormalities
Prolactin
Maxillofacial changes
Prostate
IGF-1
MEN-1
POSITIVE
Incidence - 3 - 4 cases / 1 million

Prevalence - 50 - 60 / 1 million
Mean age - 40 - 45 years
Surgery
Somatostatin analog
Sandostatin
GH receptor antagonists
Dopamine agonists
X-ray radiation therapy
Treatment Goals
Lower IGF-1 to
normal range
GH < 1 ng / mL
on OGTT
Relieves
symptoms
Treat
comorbidities
Pegvisomant
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms

Supraclavicular and
dorsal fat pads
Proximal muscle
weakness
Plethora
Central obesity
Cutaneous wasting
Cushing's
Syndrome
Excessive cortisol
production
Purple striae
Spontaneous ecchymosis
Osteopenia
Hypertension
Early or delayed puberty
Growth retardation
(children)
Small cell lung cancer
Carcinoid tumors
Pheochromocytoma
Thymoma
Ectopic ACTH Etiologies
Pancreatic cell tumors
Medullary carcinoma of
the thyroid
Adrenal adenomas
Adrenal carcinoma
Micronodular
hyperplasia
Macronodular
hyperplasia
Adrenal
Hypercortisolism
Etiologies
Thyrotropin
(TSH) Secreting
Pituitary Tumor
Test
Laboratory
Result
Extremely rare tumors

that leads to excessive
TSH levels
Surgery (first line)

24 Hour Urine
for Free
Cortisol
HIGH
Nightly
Salivary
Cortisol
HIGH
Cortisol After
Suppressing
With Oral
Dexamethsaone
> 2.0 ng/mL
Incidental tumors
Radiologic
Studies
Hyperthyroidism
High thyroid hormone

levels
Frequent stools
Oily hair / skin
Exercise intolerance
Proximal muscle
weakness
Nervousness and
irritability
Sleep disturbances
Tremors
Mentstral flow
Palpitations /
tachycardia
History of thyroid
disease
Onycholysis
Exophthalmos
Lid lag
Thyroid enlargement
Bruit
SEM
Brisk DTR relxations

pahse
Pretibial myxedema
Metyrapone
Adrenal steroid
synthesis
inhibitors
Adrenalectomy
Ketaconazole
False (-) scan
Prolactin
Hyperphagia
Sweating
Somatostatin
analogs
Other
Pituitary Cushing's (Cushing's
Disease)
Excessive ACTH production due to
pituitary adenoma
Adrenal Cushing's (Cushing's
Syndrome)
Excessive cortisol from tumor of
adrenal gland (ACTH independent)
Ectopic Cushing's
Tumor produces additional ACTH
Frequent use of synthetic
glucocorticoids can cause Cushing's.
Do not do radiographyic studies

prior to lab studies.
Sub-Unit
Weight loss
Heat intolerance
Mitotane
Medical Therapy
Inapproriately
elevated or
normal
GH
Hyperthryoidism
Medications
Hallmark: Lack of diurnal

variation between lab studies
TSH
Goiter
Treatment
Surgery
X-ray radiation therapy
Medical therapy (octreotide)
Octreotide
HIGH
Ablation of thyroid tissue
Common Etiologies
Graves disease
Toxic multinodular goiter
Toxic nodule
Thyroiditis
Rare Etiologies
TSH production
Intake of iodine (Jod-Basedow)
Thyrotoxicosis factitia
Clinical Medicine
Condition / Disease
Graves Disease
Cause
Autoantibodies react
with TSH receptors
Signs and Symptoms

Symmetric non-tender
goiter (80%)
Ocular findings
Pretibial myxedema
Bruit
Multicellular autonomous
function due to an unknown
etiology
Enlarged, irregular, and nodular thyroid
Toxic Nodule
Constitutive activation of
the TSH receptor through
a somatic mutation of
the receptor gene
Subacute
Thyroiditis
Viral infection leads to

thyroid hormone leakage
form the destruction of
the thyroid gland
Silent
Thyroiditis
Transient autoimmune
dysfunction causes
thyroid destruction
Thyrotoxic
Crisis
(Thyroid
Storm)
Severe symptoms due to

pre-existing untreated or
inadequately treated
thyrotoxicosis
30 - 40 years old
History of non-toxic
mulitnodular goiter
Onycholysis
(ring finger)
Enlarged, very tender, and irregular thyoid gland
Pain in the thyroid
Laboratory
Result
Fever
Enlarged and nodular thyroid gland (50%)
Sudden onset of
hyperthyroidism
Post-partum (possibly)
Fever
Profuse sweating
Tachycardia
Tremulousness
Restlessness
Delirium
Psychosis
Nausea / vomitting
Thyroid
Uptake and
Scan
TSH
Free T4
Free T3
Thyroid
Uptake and
Scan
TSH
Free T4
Free T3
Thyroid
Uptake and
Scan
TSH
Free T4
Free T3
ESR
Thyroglobulin
Thyroid
Uptake and
Scan
TSH
Free T4
Free T3
Anti-Thyroid
Antibodies
Thyroid
Uptake and
Scan
Treatment
Medical therapy
Methimiazole
Subtotal thyroidectomy
Radioactive iodine treatment
Diffused
Blockers
Selenium administration
(Graves opthalmopathy)
Other
Favorable Prognosticators for
Remission
Small goiter
Free T3 predoinance
(-) TSI titer
Goiter size with thionomide
therapy
HIGH
Multiple masses
Patchy uptake
HIGH
Single mass
"Hot" nodule
( uptake)
"Cold" nodule
( uptake)
HIGH
Aspirin
Anti-inflammatory treatment
NSAIDs
Assessment
Steroid therapy
Prednisone
HIGH
30% of patients blocker therapy
Assessment
20% mortality
PTU 300 - 400 mg Q4 hours

Iodine
SSKI
Blockers
IV fluids
Stupor
Glucose
Supportive Care
Later Symptoms
Medications
HIGH
Free T3
Toxic
Multinodular
Goiter
Age > 50
Test
TSH
Free T4
Coma
Correct
hypernatremia
Hypotension
Treat hyperpyrexia
Propranolol
Clinical Medicine
Condition / Disease
Hypothyroidism
Cause
Insufficient amount of
thyroid hormone
Signs and Symptoms

Weight gain
Fatigue / lethargy
Cold intolerance
Hoarseness
Constipation
Coarse hair / hair loss
Dry skin and hair
Myalgias
Bradycardia
Depression
Menstral flow
History of thyroid
disease
Cognitive impairment
Concentration
Endemic Goiter
Impaired thyroid
hormone synthesis
Multinodular
Goiters
Unknown, possibly
multifactorial, etiology
Treatment
HIGH
Thyroid replacement therapy
(except central)
Lithium use
Delayed DTR relaxation

phases
Cytotoxic anti-thryoid antibodies
(particularly anti-thyroglobulin)
attack the thyroid gland
TSH
Laboratory
Result
Hearing
Periorbital edema
Hashimoto
Thyroiditis
Test
Medications
Other
Hypometabolic Hypothyroidism
cholesterol
2% , 0.2% , and 1 : 4000 newborns
in North America have
hypothyroidism
Primary Etiologies
Loss of functioning thryoid tissue
Goiterous Etiology
Impairment of hormone biosynthesis
with compensatory thyroid
enlargement, lithium therapy, and
iodine deficiency or excess
Central Etiology
Lack of TSH or pituitary or
hypothalamic failure
Goiter or no detectable
thyroid tissue

Age > 50
No detectable
thyroid tissue
Iodine deficiency
Goiter
TSH
LOW
Prevalent in Asia, Latin America,

central Africa, and some regions in
Europe
MNG1
Goiter
Thyroid replacement therapy
Free T4
MNG2
MNG3
Thyroxine suppression of TSH

Possible genetic
link
Surgical excision (for obstructive

symptoms)
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms
Test
Laboratory
Result
TSH
Treatment
Medications
Assess
Observation (categories I and II)
Firm nodule with

irregular shape
Fixation to underlying
tissues
Ultrasound
Detects 80% of
malignancies
8 - 15 mm
hypoechoic
nodules
Nodules 1 cm
Regional adenopathy
Fine Needle
Aspiration
Thyroid
Nodules and
Neoplasms
Nondiagnositic
Benign
Indeterminant
Uncontrolled cell growth

in the thyroid
History of head or
neck irradiation
Intranodular
microcalcifications
Sensitivity and
specificity > 90%
History of ionizing
radiation exposure at
age < 18
Irregular / blurred
margins
U/S-Fine Needle
Aspiration
Mixed
echogenicity
Suspicious
Malignant
Thyroid Scan
Previous history of
thyroid cancer
Intranodular
vascular spots
No value if TSH is
normal
Doppler flow
Voice, breathing, or
swallowing changes
Categories III
and IV
Near-total thyroidectomy (V and VI)
or surgical lobectomy (V)
GEC
Papillary
Thyroid
Carcinoma
Family history of thyroid

malignancy
MEN type 2 in
1 relative
30 - 50 years old
2 - 3 cm
Invasion of adjacent
tissue (15%)
Lymph node spread

(20 - 50%)
Benign
( 5% risk of
malignancy)
Suspicious
( 40% of
malignancy)
Repeat U/S if significant growth

(> 2 mm or 20% in 2 dimensions)
Thyroidectomy (by experienced

surgeon)
Thyroxine suppression
(< 1 cm without invasion)
Radioactive iodine therapy for several
months post-op
Distant metastases (< 7%)

Metastases
Most common type of

thyroid cancer
Q6 months
ret
Associated
Age
Outcome Factors
(MACIS)
Completeness of
tumor rescetion
Neck exam
Follow Up
FT4
Invasion
TSH
Size
Thyroglobulin
Other
Bethesda System for Nodules
I - Nondiagnostic or unsatisfactory
II - Benign
III - Atypia of undermined
significance or follicular lesion of
undetermined significance
IV - Follicular neoplasm (or
suspicious)
V - Suspicious for malignancy
VI - Malignant
pTMN Staging System
T0 - No evidence of tumor
T1 - < 2 cm in greatest dimension and
limited to thyroid
T2 - 4 cm > greatest dimension
> 2 cm
T3 - > 4 cm in greatest dimension and
limited to thyroid
T4 - Beyond thyroid capsule
N0 - No regional LN metastasis
N1 - Regional LN metastasis
N1a - Ipsilateral cervical LNs
N1b - Bilateral, midline, or
contralateral cervical or mediastinal
LNs
M0 - No distant metastasis
M1 - Distant metasis
AJCC Stage Groupings
< 45 Years Old
Stage I - Any T, any N, M0
Stage II - Any T, any N, M1
> 45 Years Old
Stage I - T1, N0, M0
Stage II - T2, N0, M0
Stage III
T3, N0, M0
T5, N0, M0
Any T, N1, M0
Stage IV
Any T, Any N, M1
4:1
Survival
98% at 5 years
96% at 10 years
95% at 20 years
Staging
I - Only in thryoid
II - Spread beyond thyroid (< 45 years
old) or > 1 cm but still in thyroid (> 45
years old)
III - > 45 years old and spread outside
of thyroid but not the neck or lymph
node spread
IV - > 45 years old and spread to
other parts of the body
Clinical Medicine
Condition / Disease
Follicular
Thyroid
Carcinoma
Medullary
Thyroid
Carcinoma
Cause
Uncontrolled cell growth

orginating from the thyroid cells
responsible for the production
and secretion of thyroid
hormones
Signs and Symptoms

> 50 years old
Treatment
Medications
Lymph node spread

(4 - 6%)
Lung
See Papillary Thyroid Carcinoma
Bone
Regional lymph node
involvement
Aggressive surgery
Lung
MEN Type 2
Metastases
Associated
Bone
Liver
T-Score
(BMD YN)
T Score =
SD
BMD -1.0 SD
Normal
Wall-occiput distance
below YN
> 0 cm
Rib-pelvis distance
-1.1 < BMD < -2.4
Osteopenia
2 fingerbreadths
SD below YN
Armspan-height
BMD -2.5 SD
Osteoporosis
difference > 5 cm
below YN
Central Bone Density Devices
Pain
PA spine
Permanent
Lateral spine
DXA
disfigurement
Hip
Forearm
Loss of height
Total body
Spine
Fracture Complications
Loss of self-esteem
(trabecular bone)
QCT
Radiation dose
Depression
Less precise for
follow-up
Risk of hip fracture
Peripheral Bone Density Devices
Forearm
Morbidity / mortality
p-DEXA
Finger
Calcaneus
Risk Factors
pQCT
Forearm
SXA
Calcaneus
Personal history of
History of fracture in
Calcaneus
fracture as adult
1 relative
QUS
Tibia
Finger
Smoker
Weight < 127 lbs
RA
Fingers
Diagnostic Laboratory Tests
Caucasian
Age
Calcium
Liver Function
Creatinine
CBC
Dementia
Bicarb
TSH
Especially if age
Poor health / frailty
Estrogen deficiency
25 OH D
> 60 or clinically
indicated
Calcium intake
Alcoholism
Radiographic Studies
Plain X-rays Bone dens. testing
Poor eyesight
Recurrent falls
MRI / CT
Scintigraphy
Tetracycline labed transiliac bone
Inadequate physical activity
biopsy
Fractures
Osteoporosis
Laboratory
Result
Metastases
> 40 years old
Cancer originating from

the parafollicular cells
that produce calcitonin
Test
Skeletal disorder
characterized by
compromised bone
strength predisposing
a person to an
increased risk of
fracture
BMD
Nutrition
Calcium
supplements
(1500 mg/day)
Vitamin D
(400 IU/day in
summer months
or 1000 IU/day in
winter or age >65)
Applications of a load to the skeleton

during physical therapy
Body mechanics to prevent vertebral
fractures
Back extensor muscle strengthening
Cardivascular fitness to reduce fall
potential
Education on prevention of falls
Medical Therapy
Risks of Hormone
Replacement
Therapy
Calcium /
vitamin D
Bisphosphonates
Estrogen
SERMs
Calcitonin
Denosumab
Forteo
15% Global
index
29% CHD
41% Stoke
111% VTE
22% Total CVD
26% Invasive
breast cancer
37% Colorectal
cancer
34% Hip and
clinical vertebral
factures
Other
2:1
Survival
80% at 20 years
70% at 30 years
Staging
1:1
Survival
60 - 70% at 10 years
Staging
I - < 1 cm
II - 4 cm > size > 1 cm
III - Spread to lymph nodes
IV - Spread to other body parts
4:1
Caucasians and Asians are the more
Alendronate
commonly affected, but it affects all
races.
24% mortality in the first year
25% require long-term nursing care
Risedronate
Indications for BMD Testing
65 and 70
50 < 65 with (+) risk profile
in meopausal transition with
Ibandronate
specific risk factor for fractures
Fracture in adults after age 50
Adults with a condition or taking
meds associated with bone mass
Zoledronic Acid
or bone loss
Anyone being concerned for
pharmacologic therapy for
osteoporosis
Raloxifene
Being treated for osteoporosis
Anyone not receiving therapy in
which evidence of bone loss would
lead to treatment.
Salmon Calcitonin
Type of calcium is unimportant
except in achlorhydria (calcium
citrate).
Secondary Causes of BMD
Denosumab
(first 2 in each category on PP slide)
Hypogonadism
Hypercalciuria
Malabsorption of nutrients
Forteo
Alcohol
Gastrectomy
Inflammatory bowel disease
Multiple myeloma
Hemolytic anemia
See
Excess glucocorticoids
Pharmacology Excess thyroid hormone
study guide for Cystic fibrosis
more information Rheumatoid arthritis
Typically, do not use combination
therapy to treat osteoporosis.
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms

Altered mentation
Elevated serum
calcium level
Polyuria
Polydipsia
Kidney stones
Abdominal Pain
Tetany
Paresthesias
Muscle twitching
Carpopedal spasm
(+) Trousseau's sign
(+) Chvostek's sign
Seizures
Laryngospasm
Cardiac changes
Hypotension
Hypocalcemia
Low serum calcium level
Papilledema
Heart failure
Ectopic calcification
Extrapyramidal signs
Parkinsonism
Chronic Symptoms
Serum
Calcium
Dementia
Subcapsular cataracts
Abnormal dentition
Dry skin
Treatment
PTH
1, 25
Dihydroxy
Vitamin D
Medications
Treat underlying cause
Furosemide
> 10.5 mg/dL
Enhance
Calciuresis
Urine Calcium
Etiologies
1 Hyperparathyroidism
Malignancy
Familial hypocalciuric
Skeletal Resorption
hypercalcemia
Endocrine disease
Immobilization
Lithium
GI Absoprtion
Milk-Alkali syndrome
Skeletal Resorption Granulamatous disease
and GI Absorption
Lymphoma
Thiazides
Aminophylline
Other Mechanisms
Estrogens
GH
Acute renal failure
Bronchospasm
Laboratory
Result
Nausea / vomiting
Renal failure
Hypercalcemia
Test
Fluids
(2 - 3 L/day PO for
mild and IV saline
for severe)
HIGH
HIGH
Loop diuretics
Pamidronate
Zoledronic Acid
Biphosphonates
Calcitonin
Calcitonin
Cinacalcet
Cinacalcet
Plicamycin
Inhibit
Osteoclastic
Resorption
Plicamycin or
gallium nitrate
(last line)
HIGH
Other
Pathogenesis
Bone resorption by osteoclasts
Enhanced GI absorption of calcium
may contribute
Hypercalcemia represents eclipsed
renal capacity to excrete calcium
load
Gallium Nitrate
Prednisone
EKG
Shortened QT
Serum
Calcium
< 8.7 mg/dL
EKG
Arrhythmia
Prolonged QT
Following etiologic scenarios

only list non-normal labs
(see PowerPoints for full list)
Glucocorticoid therapy
(inhibits osteoclastic resorption and
reduce intestinal absorption)
Solumedrol
Calcium supplement
(2000 - 4000 mg/day)
Assumes normal
hepatic 25
hydroxylase
activity
Hypoparthyroidism
Ergocalciferol (D2) 50k units PO D2
PTH
LOW
or Cholecalciferol
QWeek for 8
Phosphorus
HIGH
(D3) If 25 OH D
weeks for 25 OH
1,25 OH D
Normal or LOW
Activiating Mutation
Deficient
vitamin D
Calcium-Sensing Receptor
< 20 ng/mL
PTH
Normal or LOW
Phosphorus
HIGH
Hypomagnesemia
1000 IU/day for
PTH
Normal or LOW
maintenance
Magnesium
LOW
PTH Resistance
PTH
HIGH
Phosphorus
HIGH
0.5 - 1.5 g BID
Vitamin D Deficiency
PO
PTH
HIGH
Clacitriol
Corrected
LOW or Normal
(if 25 OH D
Serum
Sufficient)
Potential risk of
Phosphorus
LOW or Normal
hypercalciuria or
25 OH D
LOW
hypercalcemia
1,25 OH D
Normal or HIGH
Creatinine
HIGH
Ergocalciferol
Etiologies
Inadequate PTH production
Inadequate vitamin D production
PTH resistance
Vitamin D resistance
Miscellaneous causes
Cholecalciferol
Calcitriol
Clinical Medicine
Condition / Disease
Osteomalacia
Paget's
Disease
Cause
Softening of the bones

caused by defective bone
mineralization secondary to
inadequate amounts of
available phosphorus and
calcium
Excessive breakdown and

formation of bone
followed by disorganized
bone remodeling
Signs and Symptoms

Diffuse bone pain
Waddling gait
Muscular weakness
Factures
Pseudofractures
(Looser's zones)
Long Bones
Common Sites
Ribs
Pelvis
Asymptomatic
Localized pain
Bowing
Fracture
Headache
Hearing loss
Pelvis
Femur
Common Sites
Spine
Skull
Tibia
1 Adrenal Insufficiency Symptoms
Primary
Hyperpigmentation
Salt craving
Hyponatremia
Hyperkalemia
Vitiligo
Pallor
Auto-immune thyroid
disease
CNS symptoms
Test
Serum
Calcium
Ionized
Calcium
Laboratory
Result
PTH
Vitamin D
Bone Density
Alkaline
Phosphatase
Bone Turnover
Markers
Adrenal
Insufficiency
LOW
HIGH
Medications
Ergocalciferol
See Hypocalcemia for use of

ergocalciferol, cholecalciferol, and
calcitriol
LOW
Elemental phosphorus supplements
Indiscernible from
(250 - 1000 mg QID PO)
osteoporosis
HIGH
HIGH
(often)
Outpatient and Non-ICU Inpatient
Bisphosphonates and calcitonin to

inhibit osteoclast resorption and bone
formation
DO NOT WAIT FOR LAB RESULTS TO

TREAT ADRENAL CRISIS
3 g/dL
"Addison's Disease"
Dysfunction at the level of the
adrenal gland by a local lesion or
disease process
LOW
Treatment
Calcium supplement
(1500 - 2000 mg/day)
AM Cortisol
Adrenal hemorrhage,
necrosis, or thrombosis
Meningococcal sepsis
Abrupt Onset
Pseudomonas
Etiologies
Secondary
Coagulation disorders
Metastatic cancer with
ACTH
Inadequate ACTH secretion in the
bleed
Stimulation
pituitary gland
Test
Auto-immune adrenalitis
Infectious adrenalitis
Slow Onset
Metastatic cancer
Etiologies
Congenital adrenal
hyperplasia
Adrenomyeloneuropathy
Pituitary tumor /
Tertiary
surgery / radiation
Craniopharyngioma
Inference with CRH secretion in
Plasma ACTH
Slow Onset 2 and 3 AI Isolated ACTH deficiency
the hypothalamus
Etiologies
Megace
Long-term
glucocorticoid therapy
Hypothalamic tumor
Treat hypotension with volume

18 g/dL rules therapy
out AI
4 mg IV dexamethasone or
100 mg IV hydrocortisone
If 3 - 18, need
dynamic testing
Hydrocortisone
20 mg PO QAM
Glucocorticoid
10 mg PO QPM
Pre- and postMaintenance
Dexamethasone
cortisol dose
Therapy
0.5 mg PO Qday
< 17 g/dL
Prednisone
5 mg PO Qday
Fludrocortisone
Rules out 1 and
0.1 - 0.2 mg Qday
2 AI
Assess postural
hypotension,
orthostasis, serum
> 100 pg/mL
K, plasma renin
Mineralocorticoid
(1 AI)
Dose in
Replacement
summer PRN
Dose in
5 - 45 pg/mL rules
essential
out 1 AI (look for
cause of 2 and
Do not use K3 AI)
sparing diuretics
for anti-HTN
Cholecalciferol
Calcitriol
Neutra-Phos
K-Phos Neutral
Other
Also known as rickets (in childhood)
Etiologies
Vitamin D disorders
Hypophosphatemia
Mineralization disorders
Vitamin D supplementation
(calcitriol) is needed to prevent 2
hyperparathyroidism because
phosphorus binds and prevents
calcium absorption.
Pamidronate
Zoledronic Acid
Alendronate
Risedronate
Tiludronate
Etidronate
Calcitonin
Aldosterone
Major mineralocorticoid
Made in the zone glomerulosa (outer
layer) of the adrenal cortex
Stimulates renal tubule reabsorption
Dexamethasone of sodium and excretion of
potassium
Prevents hypovolemia and
hyperkalemia
Cortisol
Major glucocorticoid
Made in the zona fasciculata and
reticularis
Counters the effects of insulin
Diurnal secretoin (highest in AM)
in exercise and stress
Hydrocortisone
Anti-inflammatory
ACTH Stimulation Test
Give 250 g of cosyntropin
(synthetic ACTH)
Measure serum cortisol before, 30,
and 60 minutes after injection.
Can be given IM
AI Prophylaxis in Surgery
Pre-Op - 100 mg IV hydrocortisone x
1 and continue Q8h for first 24 hours
Fludrocortisone
Can cut dose by after 24 hours
Cut dose by each day until back at
maintenance
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms

Chin
Upper lip
Hirsutism
Increased hair growth
Common Sites
Abdomen
Chest
Menstrual irregularities
Laboratory
Test
Result
Serum
Testosterone
Diagnostic
(Total and
Free)
AndroStenedione
DHEA-S
Amenorrhea
CT
Virilization
Development of gender
differences
Defeminization
Breast size
Deep voice
Pseudohermaphroditism
Congenital
Adrenal
Hyperplasia
Rare tumors that secrete

androgens
Usually > 5 cm in diameter at diagnosis
Enzymatic defects in adrenal

steroid hormone synthesis
pathways leads to inadequate
cortisol and/or mineralocorticoid
secretion
Non-Classical Form
Salt-wasting form
Hirsutism
Menstrual irregularity
Mimics PCOS
Asymptomatic
Virilizing syndrome
Stop any offending medications

Aldactone
> 700 g/dL

implicates adrenal Laparoscopic bilateral oophorectomy
androgen excess
Determine if
hyperplasia or
carcinoma when
DHEA-S is HIGH
Other
Etiologies
Idiopathic
Polycystic ovarian syndrome
Androgen-secreting adrenal adnomas
Androgen-secreting adrenal
carcinomas
Ovarian tumors
Congenital adrenal hyperplasia
ACTH-dependent Cushing's syndrome
Glucocorticoid resistance
Finasteride
Oral
contraceptives
PCOS Treatment
Metformin
Flutamide
Assess
Abdominal CT
Serum
Androgen
With DexaMethasone
Suppression
Androgen-Secreting
Adrenal Adenoma
Androgen-Secreting
Adrenal Carcinoma
Pelvic Echo
Medications
> 1000 ng/dL

implies ovarian / Medical management
adrenal neoplasm
Pelvic
Examination
Frontal balding
Treatment
Anti-androgens
(only if not
pregnant)
Rare
HIGH
More common than adenomas
Serum
Androgen
With DexaMethasone
Suppression
HIGH
DHEA
DHEA-S
HIGH
HIGH
Classically with an associated
androgen excess
Clinical Medicine
Condition / Disease
Cause
Signs and Symptoms
Hypertension
Primary
Hyperaldosteronism
Muscle cramping
Overproduction of
aldosterone by the
adrenal glands
Muscle weakness
Periodic paralysis of
muscles
Pain
Pallor
Palpitations
Classic 5 P's
Laboratory
Result
Hypokalemia
BMP
Metabolic
alkalosis
Serum Renin
LOW
Serum
HIGH
Aldosterone
Aldosterone :
> 20
Renin Ratio
HIGH
24 Hour Urine
< 5 g/dL with
Aldosterone
LOW renin is
suspicious
Solitary adenoma
Abdominal CT
or carcinoma
18-OH
Indicative of APA
Corticosterone
Assess localization
by looking at
Adrenal Vein
lateralization of
Sampling
elevated
aldosterone level
Test
24 Hour Urine
Catecholamines
and Its
Metabolites
Serum MetaNephrines
Plasma CatePerspiration
cholamines
Imaging
MEN IIA and
Orthostatic hypotension
IIB
Von HippelLindau
Headaches
Hypertension
Von Recklinghausen
Medications
Anti-aldosterones
Remove
Offending
Medications
ACEIs
CCBs
150 mEq sodium intake daily
Other
Presenting Forms
Solitary / unilateral aldosteroneproducing adenoma (APA)
Bilateral hyperplasia of the zona
glomerulosa
1 Adrenal hyperplasia
Adrenal carcinoma
Amiloride is no longer recommended
due to cardiac effects
Surgery
(aldosterone producing adenoma)
MineraloC
receptor
antagonists
Medical Therapy
Spironolactone
Eplerenone
Adrenergic
blockade
(first)
Diagnostic
Medical
Management
Pressure
Neuroendocrine tumor of
the medulla of the
Pheochromocytoma
adrenal glands
Treatment
Blockade
(never before )
Rule of 10s
10% Extra-adrenal
10% Bilateral
10% Familial
10% Malignant
10% Not associated with HTN
Post-Operative Complications
Labile blood pressure
Post-resection hypotension / shock
Hypoglycemia
Needs adequate -blockade before
surgery
CCBs
Look for familial
syndromes
Surgical resection
Pharmacology
Drug
Sulfonylureas
Generic Examples /
Brand Name
chlorpropamide
tolazamide
tolbutamide
glipizide
glyburide
glimepiride
repaglinide
Meglitinides
natglinide
Mechanism of Action
Stimulates pancreatic
-cell insulin release
Indications
Pharmacokinetics
Type 2 Diabetes
metformin
Stimulates pancreatic
-cell insulin release
Hugs pancreas in one
squeeze to cover
ingested food
-Glucosidase
Inhibitors
Promotes glucose uptake by fat

and muscles
Decreases intestinal absorption
of glucose
pioglitazone
Promotes glucose
uptake by fat and
muscles
rosiglitazone
Stimulates PPAR- to
inhibit hepatic glucose
output
Glitazones
About to eat a meal
Type 1 Diabetes
miglitol
saxagliptin
linagliptin
Hypoglycemia
Weight gain
Should never prescribe 1st

generation sulfonylureas
GI effects
Weight loss
Vitamin B12 depletion
Lactic acidosis
Metformin needs to be
stopped 24 hours before IV
contrast and re-initiated
24 hours after.
Liver toxicity
Fluid retention
Weight gain
Headache / Fatigue
Hgb and Hct
Fractures
Cardiovascular disease
(rosiglitazone)
Bladder cancer
(pioglitazone)
Flatulence
Adding insulin to glitazones

results in increased weight
gain.
Inhibits -glucosidase to
slow carbohydrate
absorption
Failed sulfonylurea therapy
A: Oral
Kidney disease
Liver disease
Elderly
Alcohol abuse
Heart failure
IV contrast media
Liver disease
Heart disease
Type 2 Diabetes
Trunk obesity
A: Oral
Type 2 Diabetes
A: Oral
D: Altered with renal
function
Inhibits DPP-4
enzyme from rapidly
breaking down GLP-1
Type 2 Diabetes
Bowel disorders
Liver impairment
Kidney impairment
Pancreatitis
Pancreatitis
Headache
(saxagliptin)
UTI
(saxagliptin)
Hyperuricemia
(linagliptin)
Hyperlipidemia
(linagliptin)
Hepatotoxicity
(alogliptin)
Alogliptin is not recommended

for liver failure patients.
Pancreatitis
GI disorders
CrCl < 30 mL/min
Thyroid cancer
History of MTS
Multiple endocrine neoplasia
syndrome type 2
Nausea
Vomiting
Weight loss
Possible pancreatitis
After prescribing GLP-1

agonists, the patient's
sulfonylurea dose needs to be
cut in half.
Drug Interactions
Oral antibiotics
Contraceptives
Analgesics (theoretical)
Sulfonylureas
Insulin (hypoglycemia)
Drugs that interact with GLP-1
agonists should be
administered at least 1 hour
prior to GLP-1 agonists.
Need for weight loss
alogliptin
exenatide
Increases glucosedependent insulin

secretion
Decreases inappropriate
glucagon secretion
GLP-1 Agonists
Monitoring / Other
Type 2 Diabetes
sitagliptin
Dipeptidyl
Peptidase 4
Inhibitors
Adverse Effects
Renal dysfunction
Hepatic dysfunction
A: Oral
A: Oral
Type 2 Diabetes
acarbose
Contraindications
Hugs pancreas all day
Inhibits hepatic glucose output
Biguanides
A: Oral
t: 72 hours
(chlorpropamide)
Slows gastric emptying

liraglutide
Deceases appetite
Type 2 Diabetes
Need for weight loss
A: SQ
Sites: Thigh, abdomen,
and upper arm
Exenatide
D: 6 hours apart and
increase after 30 days if
needed
Liraglutide
D: Daily independently
of meals
Pharmacology
Generic Examples /
Brand Name
Mechanism of Action
Pramlintide
Symlin
Inhibits the -cell

hormone that
suppresses glucagon
secretion from
pancreatic cells
Colesevelam
Welchol
Bile acid sequestrant
Bromocriptine
Cycloset
Canagliflozin
Invokana
Sodium-glucose
co-transporter 2 (SGLT2)
inhibitor
Type 2 Diabetes
Need to adjunct diet

and exercise
Dapagliflozin
Farxiga
Sodium-glucose
co-transporter 2 (SGLT2)
inhibitor
Type 2 Diabetes
Need to adjunct diet

and exercise
Drug
Indications
Pharmacokinetics
A: SQ
Adjunct treatment for

type 2 diabetes
Statin intolerance
Dopamine agonist
Adjunct treatment for type 2 diabetes
May affect circadian rhythms
Novolin R
Humalog
Supplemental insulin
for meals
Diabetes
Meals
NovoLog
Apidra
Humulin N
Novolin N
Basal Insulin
Lantus
Long-term insulin
used to provide
coverage throughout
the day
Diabetes
Levemir
Humulin 70/30
Insulin Mixes
Novolin 70/30
HumaLog 75/25
Combination of NPH
and regular insulin
Type 2 Diabetes
NovoLog Mix 70/30

Initiate basal insulin first
Insulin Initiation
Protocol in Type 2
Diabetes
Adverse Effects
See GLP-1 Agonists
Type 2 Diabetes
Humulin R
Bolus Insulin
Contraindications
See GLP-1 Agonists
Monitor fasting blood glucose and adjust insulin

until fasting SMBG goals are reached.
A: Oral
D: BID or daily
Size: Huge tablets
D: Daily with a meal
within 2 hours of
wakening
Obstructive bowel disease

Triglyceride > 500 mg/dL
Cardiovascular disease
Peptic ulcer disease
Psychosis
Dementia
Renal insufficiency
(eGFR < 45 mL/min/1.73 m2)
Renal insufficiency
2
(eGFR < 30 mL/min/1.73 m )
GI effects
UTIs
(uncircumised and )
Hypotension
Hyperkalemia
UTIs
Hypotension
Hyperkalemia
Bladder cancer
D: Basal insulin 10 units

daily (average-sized
patient) or 0.2 units/kg
daily (obese)
Other medications need to be

taken 1 hour before or 4 hours
after administration.
0.4 - 0.5% A1C reduction
Moderately decreases A1c
Should be used with caution in

s that are prone to yeast
infections
Rapid-acting insulin is far more

expensive than the shortacting.
A: 15 minutes prior to
meal
Short-Acting
O: 0.5 - 1 hour
Peak: 2 - 3 hours
Duration: 3 - 6 hours
Rapid-Acting
O: < 0.25 hour
Peak: 0.5 - 1.5 hours
Humulin N / Novolin N
O: 2 - 4 hours
Peak: 6 - 10 hours
Duration: 10 -16 hours
Lantus
O: 5 hours
Levemir
O: 2 hours
D: Daily or BID
D: in AM and in PM
Humulin / Novolin
D: 30 minutes before
meal
HumaLog / NovoLog
D: 15 minutes before
meal
Monitoring / Other
Amylin agonist
Diabetics do not have any
amylin in their bodies.
Low A1C changes with
pramlintide
Acidic pH of Lantus gives a long

duration of action.
Levemir is bound to albumin to
give it a long duration of action.
Hyperglycemia
(Humulin and Novolin)
Not ideal for Type 1 DM
Change the insulin dose by 10 20% when tritating insulin.
If fasting SMBG goals are met but A1c > 7%, add
bolus insulin for meal-time coverage
Pharmacology
Drug
Generic Examples /
Brand Name
Mechanism of Action
Indications
Insulin Initiation
Protocol in Type
1 Diabetes
Contraindications
Adverse Effects
Adjustment
Algorithm
Method of dosing
correction insulin
U-500 Insulin
Extremely highly
concentrated regular
insulin
Synthroid
Levoxyl
Levothroid
Rule of 1800
Based on blood sugar level
1800
Correction Factor =
TDD
Insulin =
Unithroid
Regular-Type 1 Patient
1 unit of bolus typically
changes by 50 mg/dL
Insulin-Resistant Patient
changes by 25 - 30 mg/dL
Insulin-Sensitive Patient
changes by as much as
70 - 100 mg/dL
Prescription only
A U-100 syringe can be used to
inject U-500 insulin.
Current Blood Sugar Goal Blood Sugar

Correction Factor
Rule of 500
Based on carbohydrate intake
500
Grams of CHO covered per 1 unit =
TDD
> 200 units of insulin daily
Hypothyroidism
Thyroid hormone
replacement
Monitoring / Other
If using NPH as basal, you must
decrease the amount of bolus
used by 20% and titrate as
needed.
50% of TDD and divided

into meal time doses
Bolus
Thyroxine
Pharmacokinetics
Establish estimated insulin requirement

Adult
0.5 - 0.7 units/kg/day
Prepubertal
0.6 - 0.9 units/kg/day
Pubertal
< 1.5 units/kg/day
Adolescence
0.6 - 1 units/kg/day
Insulin Resistance
> 1 units/kg/day
Calculate basal and bolus doses
50% of total daily dose
Basal
(TDD)
Young patient with no

cardiac disease
Full replacement
Elderly or Angina
Patients
Begin with 12.5 - 25 g

by 12.5 - 25 g every
2 - 3 months
Osteoporosis
Cardiac contractility
Atrial fibrillation
Allergic reaction
A: Slowly but 80%

B: 40% converted to T3
E: 6 weeks
D: 1.4 - 1.6 g/kg IBW
t: 7 days
Monitoring
Assess response with TSH after
6 weeks
Re-assess at 6 months
Annual reassessments
Adjust dose by 12.5 g
increments
A: Rapid
Liothyronine
Cytomel
T3
Tums
Inhibits PTH
secretion
Caltrate
Calcium
Os-Cal
Viactiv
Citracal (citrate)
Vitamin D
Component of bone
mineralization
Increase calcium
absorption from the
small intestines
Phase patient into hypothryoidism

B: No more than 500 mg
can be absorbed at one
time
> 65
> 70
Required: 1200 mg
Younger (50 - 65) with History of fracture after (elemental) total daily
risk factors
age 50
Osteoporosis
Rheumatoid arthritis
Glucocorticoid use
Osteoporosis
Fall reduction
Required: 800 - 1000 IU

D3 daily
Limit: 4000 IU daily
Hypercalcemia
Kidney stones
Constipation
Nausea / vomitting
Metallic taste
Arrhythmia
Hypercalcemia
Hypercalcemia
Benefits
Bone mineral density
Possible fracture risk
Can be obtained through diet
Drug Interactions
Antibiotics
Thyroid medications
Fat-soluble vitamin
Often requires OTC
supplementation
Pharmacology
Drug
Generic Examples /
Brand Name
Mechanism of Action
alendronate
risedronate
Bisphosphonates
ibandronate
Inhibits osteoclasts
or osteoclast
precursors to
decrease the rate of
bone resorption
zoledronic acid
Denosumab
Raloxifene
Teriparatide
Calcitonin
Prolia
Evista
Forteo
Binds and blocks

nuclear factor-
ligand to prevent
osteoclast formation
Selective estrogen
receptor modulator to
prevent bone resorption
Recombinant PTH
that stimulates
osteoblasts and
increases calcium
absorption and
reabsoprtion
Antagonizes parathyroid
hormone
Indications
Pharmacokinetics
A: Oral (alendronate,
Osteoporosis
risedronate,
Oral Pros
Oral Cons
ibandronate) or IV
Cost
(ibrandronate,
Administration directions
Long-term efficacy
zoledronic acid)
Risk of atypical fracture B: 0.6% oral
Prevents hip fractures
Esophageal irritation E: Renal
Irregular administration t: > 10 years in bone
Ease of use (new ones)
Drug interactions
IV Cons
IV Pros
Reduced death after
Contraindicated with
fracture
ClCr
Prevents hip fractures
Infusion reactions
Good for poor adherence
Cost
Infrequent administration
Lab monitoring
A: SQ
Osteoporosis
Pros
Good for poor adherence
Prevents vertebral and
hip fractures
Can be used with
renal function
Osteoporosis
Hypocalcemia (18%)
Difficulty swallowing (1%)
Esophageal inflammation (2%)
Gastric ulcer (3%)
Visual disturbances (7%)
Acute IV phase reaction
Atypical femur fractures
A-fib
Osteonecrosis of the jaw (< 1%)
Hypocalcemia
Pregnancy
Dermatitis (11%)
Eczema (11%)
Rash (3 - 11%)
Limb pain (12%)
Edema (5%)
Hypercholesterolemia (7%)
Sciatica (5%)
Bone pain (4%)
URI (5%)
Hypocalcemia
DVT
Hot flashes (8 - 29%)
Edema (5%)
Arthralgia
Flu syndrome
Relatively new
History or high risk of
breast cancer
A: Oral
D: Daily
Osteoporosis
Painful vertebral
fractures
Osteoporosis
Recently
postmenopausal
Associated Risks
MI
Breast cancer
Stroke
Pulmonary embolus
DVT
History of VTE
Nursing
Pregnancy
A: SQ
D: Daily for 2 years
Orthstasis
Hypercalcemia
Leg cramps
Dizziness
Osteosarcoma
A: Intranasal
Rhinitis (12%)
Epistaxis
Fractures while on osteoporosis treatment
Estrogens
Adverse Effects
Hypersensitivity
Hypocalcemia
Esophageal stricture
Inability to sit or stand upright
for 30 minutes
Cons
Expensive
SQ injection
Dermatological adverse
effects
Only
Inhibits osteoclast bone

resorption
Contraindications
Monitoring / Other
Fracture Reduction
aldendronate - 50% all
risedronate - 49% spine
36% other
ibandronate - 50% spine
zoledronic acid - 70% spine
41% hip
25% other
EXPENSIVE
Fracture Reduction
68% Spine
40% Hip
20% other
Monitoring
Calcium
Magnesium
Phosphorus
Reduces spine fractures by 30 55%
Approved for the prevention of
breast cancer
EXPENSIVE
Fracture Reduction
65% Spine
53% Non-spine
Cons
Cost
Daily SQ injection
Hypotension
Nausea
Max of 2 years
No reported fracture data
Cons
Irritating nose spray
Alternate nostril use
No fracture data
Breast cancer risk

Stroke
VTE
Diabetes Medications
Class
Rapid-Acting Insulin
Generic Name
insulin aspart
insulin glulisine
insulin lispro
liraglutide
pramlintide
Brand Name
NovoLog
Apidra
HumaLog
Humulin R
Novolin R
Humulin N
Novolin N
Levemir
Lantus
Amaryl
Glucotrol
Diabeta
Starlix
Prandin
Glucophage
Actos
Avandia
Precose
Glyset
Nesina
Tradjenta
Onglyza
Januvia
Byetta
Bydureon
Victoza
Symlin
canagliflozin
Invokana
dapagliflozin
Farxiga
Short-Acting Insulin
regular insulin
Intermediate-Acting
Insulin
NPH insulin
Long-Acting Insulin
Sulfonylurea
Meglitinide
Biguanide
Thiazolidinedione
-Glucosidase Inhibitor
Dipeptidyl Peptidase-4
(DPP-4) Inhibitor
Glucagon-Like Peptide-1
(GLP-1) Agonist
Amylin Analog
Sodium-Glucose CoTransporter 2 (SGLT2)
Inhibitor
Osteoporosis Medications
insulin detemir
insulin glargine
glimepiride
glipizide
glyburide
nateglinide
repaglinide
metformin
pioglitazone
rosiglitazone
acarbose
miglitol
alogliptin
linagliptin
saxagliptin
sitagliptin
exenatide
Class
Bisphosphonate
Generic Name
alendronate
ibandronate
risedronate
zoledronic acid
Monclonal Antibody
Against Receptor
Activator of Nuclear
Factor - Ligand
Selective Estrogen
Receptor Modulator
Parathyroid Hormone
Analog
Brand Name
Fosamax
Boniva
Actonel
Reclast
Zometa
Prolia
denosumab
Xgeva
raloxifene
Evista
teriparatide
Forteo

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Diagnostic Methods

ADA Risk Factors

One of these criteria must be confirmed with the

FPG 100 - 125 mg/dL

FPG 126 mg/dL

RPG 200 mg/dL AND

OGTT 140 - 199 mg/dL

HgbA1C 5.7 - 6.4%

Newly diagnosed diabetes

Can be used to identify gastrinoma

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Blood glucose levels

Suspected poor shortterm glycemic control

Chronic hemolytic anemias

Limited use in patients with serum

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Amount of binding protein

Indirect way to distinguish

Hormone that stimulates

Results dependent on amount of

Euthryoid sick syndrome

Measures plasma cortisol

Cortisol levels after

CRH is injected and

5 mL of the collection needs to be

Assay is highly subject to error

Higher doses of dexamethasone can

Indirect measue of excessive

Enzyme relased by the

Biochemical testing for

Cause of Cushing's syndrome

Tested through urine samples

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Uses x-rays to view a nonuniformly composed object

Requires a 24-hour collection

Evaluation of the size

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Signs and Symptoms

Impaired fasting glucose

Type 2 Diabetes Risk

100 - 125 mg/dL

Insulin Therapy for Type 1

Use of multiple dose insulin injectors

200 mg/dL with

140 - 180 mg/dL

Factors That Affect Insulin

Delays onset and

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Substances made in the

Thyroid gland fails to make T4

Patients will say that it is the worst they

Pituitary gland fails to make TSH

Signs and Symptoms

CN III and VI palsies

2 hypothyroidism is much rarer than

The pituitary lies at the base of the

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

Failure to secrete ACTH

Signs and Symptoms

See Adrenal Insufficiency for more information

Unilateral renal agenesis

Low levels of growth

Poor sense of well-being