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Pheochromocytoma Workup Flow: Biochem confirmation (plasma metanephrines) > Localize (CT/MRI adrenal) > Genetic counseling (consider in all) > Pre-op blockade (α-blockers) > Surgery (adrenalectomy)
#NEET @DrAishaSk @vibhus007 #clinicalpearl #endotip #endotumor
📌 The #thiazide challenge test to differentiate between primary #hyperparathyroidism and secondary hyperparathyroidism due to idiopathic #hypercalciuria.
Ref. J Endourol. 2009 Feb;23(2):191-2.
#EndoTwitter #MedEd #EndoTip #PTH
A quick #endotip
2 commons reasons for a high TSH in patients taking levothyroxine (LT4):
- Inadequate intake: not fasting, not taking, taking with other medications.
- Inadequate assessment: TSH takes 4-6 weeks to normalize after LT4.
A quick #endotip
The dawn phenomenon refers to morning hyperglycemia.
Why? Hormones that increase serum glucose, like cortisol, glucagon, and mainly GH, peak in the early morning.
Who? Mainly pts with diabetes - directly related to low insulin levels/function.
A quick #endotip
"-releasing hormone" (RH) are hypothalamic hormones that release a pituitary hormone.
Hypothalamus --> Pituitary
GnRH --> FSH/LH
GHRH --> GH
TRH --> TSH
CRH --> ACTH
Prolactin is an exception. Hypothalamic dopamine inhibits its secretion.
A quick #endotip
TSHoma is a rare pituitary tumor (adenoma) that produces TSH, causing hyperthyroidism.
How to treat? Pituitary surgery, but...
❗️Do not forget that euthyroidism is necessary before surgery.
🤔How? Somatostatin analogs (octreotide, lanreotide) or methimazole!
🤔 Does metformin cause vitB12 deficiency?
❗️Metformin is the most prescribed drug for type 2 diabetes. Should you monitor vit B12 in pts taking it?
Follow the🧵
#MedTwitter #tweetorial #Endotip
A quick #endotip reminder
❗️Gestational diabetes (GD) screening should be done btw 24 and 28 weeks of pregnancy!
✅Insulin resistance ⬆️ steadily over pregnancy and peaks around 34 weeks - placental lactogen effect.
🛑Don't screen for GD at 20 weeks of pregnancy!
A quick #endotip reflection
Progress in medicine can also cause new medical conditions.
SGLT2i ("flozin") benefits :
- ⬇️ glycemia, no hypoglycemia
- ⬇️ weight
- Prevents CKD progress
- Prevents HF hospitalization and progress
❗️New condition: euglycemic DKA
A quick #endotip
✅Expect retinopathy for pts with type 1 diabetes and diabetic nephropathy.
❗️For type 2 diabetes, several pts with nephropathy don't have retinopathy.
🎯 Nephropathy with no retinopathy is a flag to renal biopsy in T1D, but not in T2D!
A quick #endotip
Thyroglobulin = most abundant thyroid protein
🧐Thyroglobulin⬆️ in the serum:
1) Thyroid destruction: subacute/acute thyroiditis
2) Differentiated thyroid cancer recurrence after total thyroidectomy
✅ Thyroglobulin for thyroid as AST/ALT for the liver!
A quick #endotip
🚫As a general rule, do not order free T3!
🧐Why? Currently available assays have high variability, and results are not so reliable.
✅Total T3 is preferred for assessing "T3 status"!
A quick #endotip
Although thyrotoxicosis typically presents very symptomatic, more subtle presentations are expected in 2 settings:
1) elderly;
2) pts taking some drugs such as beta-blockers and amiodarone!
A quick #endotip
✅If you suspect someone has acromegaly or gigantism, order IGF-1 and IGFBP-3.
✅Both should be ⬆️
🧐IGF-1 is produced by the liver, stimulated by GH, and has a more steady serum value than GH.
🧐IGFBP-3 is a binding globulin and the main carrier of IGF-1.
A quick #endotip
🧐Graves' disease is often chronic with periods of remission and activity.
✅Many pts treated with methimazole have a remission period after drug withdrawal followed by activity weeks, months, or years after!
A quick #endotip
🤔As a general rule, hormones' levels fluctuate a lot.
📢 Repeat hormone measurements, especially if it doesn't make sense or is mildly abnormal!
Quick #endotip
🤔Consistently low TSH in pts receiving LT4 almost always indicates that you should decrease LT4...almost always!
❗️Secondary hypothyroidism is rare, but it is there. Be sure your pt has no history of pituitary problems! Free T4 is the target in this case.
A quick #endotip
❗️Random cortisol measurement has no clinical value for diagnosing adrenal insufficiency!
📢 Despite many labs providing reference ranges, it doesn't make sense. Cortisol falls throughout the day in healthy individuals.
A quick #endotip
Adrenal insufficiency:
🤔How does primary differ from secondary?
Primary = adrenal not working = ⬇️aldosterone
Primary = ⬆️ACTH
Difference:
⬇️ aldosterone = ⬆️K possible (30-50%) and severer hypotension
⬆️ ACTH = hyperpigmentation (> 90%, but often subtle)
Quick #Endotip
💡LH, FSH, HCG, TSH are glycoprotein hormones with identical alpha subunits - differ in the beta subunit!
--> Pregnancy: ⬆️ HCG -> ⬇️ TSH
--> Twin pregnancy: ⬆️⬆️ HCG -> ⬇️⬇️TSH
❗️Gestational transient thyrotoxicosis (~2%): 1st trimester, mild symptoms!
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