DR.

EDBERTO GENERAL FEB 19, 2021

TOPIC OUTLINE
I. Introduction
II. Diabetes Mellitus
III. Thyroid Abnormalities
A. Thyroid Function Test
B. Radioiodine Uptake & Scan
IV. Parathyroid Abnormalities
A. Hyperparathyroidism
B. Hypoparathyroidism
V. Acromegaly
VI. Cushing’s Syndrome
VII. Short Stature
VIII. Cases

LEGEND - should be measured on 2 different occassions

Must Know Book Doctor’s Lecturio - HbA1C cannot be used to gauge the 3-month
Lec average sugar in any form of anemia
- HbA1C cannot be used to detect if a patient
has a controlled blood sugar
III. Thyroid Abnormalities
I. Introduction A. Thyroid Function Test
Disorders of the Endocrine System: TSH FT4 FT3
- Hypofunction: hormone deficiency
Hyperthyroidism ↓ ↑ ↑
- Hyperfunction: hormone excess
- Hormone resistance: defect in sensitivity to Hypothyroidism ↑ ↓ ↓
hormones Subclinical Hypo ↑
Normal Normal
Dictum in Endocrinology: BIOCHEMICAL Subclinical Hyper ↓
TESTING FIRST THEN IMAGING - ↓ FT3 and FT4 → stimulate the pituitary,
- History → PE → biochemical tests → imaging resulting to ↑ TSH
1. Hormone measurements - ↑ FT3 and FT4 → inhibit the pituitary,
- Plasma/Serum and urine samples resulting to ↓ TSH
a. Basal hormone testing – for hormones with - Subclinical → only the TSH is abnormal
long half-life (e.g. thyroid hormones)
b. Paired hormone testing – cannot be B. Radioiodine Uptake & Scan
interpreted without the other test (e.g. Intact - Normal – equal
PTH and serum calcium, renin and uptake of iodine
aldosterone)
c. 24-hour urine samples – for hormones with
pulsatile secretion (e.g. cortisol,
metanephrines, vanillyl mandelic acid)
- assessment of hormone and metabolite
function
II. Diabetes Mellitus
- best screening test: FBS

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Chito, Marco, Mausisa, Najito, Picones, Villones, Carillo, Galvez, Tan, Utod
 DR. EDBERTO GENERAL FEB 19, 2021

- There is increased Phosphate ↓ ↑/N ↑

uptake of iodine
- Thyroid is enlarged Imaging: Technetium 99 – Sestamibi Scan

- Heterogenous uptake
- “hot nodules” (darker)
– causes the
hyperthyroid
symptoms
- “cold nodules” - lighter

- Only one area has

increased uptake

B. Hypoparathyroidism
- Classified based on the organ involved
o Primary – gland itself is involved
- Subacute thyroiditis – (removal of parathyroid glands)
inflammation of o Secondary – kidney is involved (
thyroid gland o Tertiary – in CKD
- Same thyroid function
test w/ *When you request of calcium, request for serum
hyperthyroidism but ionized calcium NOT serum total calcium
there is normal iodine
uptake on thyroid Low serum calcium:
scan
IV. Parathyroid Abnormalities - Trousseau sign: carpopedal spasm caused
A. Hyperparathyroidism by inflating the blood-pressure cuff to a level
- Classified based on the organ involved above systolic pressure for 3 minutes.
o Primary – gland itself is involved
o Secondary – kidney is involved - Chvostek sign: twitching of the facial
o Tertiary – in CKD muscles in response to tapping over the area
- PTH – increases the serum calcium level of the facial nerve
- Calcium and phosphate level is inversely
proportional to each other (except in tertiary
hyperparathyroidism) Serum Serum intact
calcium PTH
Primary Secondary Tertiary Primary
Calcium ↑ ↓/N ↑ ↓ ↓
Hypoparathyroidism
PTH ↑ ↑ ↑↑

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Chito, Marco, Mausisa, Najito, Picones, Villones, Carillo, Galvez, Tan, Utod
 DR. EDBERTO GENERAL FEB 19, 2021

- 1 mg overnight Dexamethasone suppression

V. Acromegaly
- Increase in extremities, shoe-size, ring finger
tightens, facies, bigger nose, wide space
teeth, macroglossia
- Excess secretion of growth hormone
- Screening tests: Serum IGF-1 level
- Confirmatory test: 75 OGTT
- Failure of GH suppression <0.4 ug/L
- Even if given glucose, there will be no
suppression of GH
DON’T GET SERUM GH LEVEL
- Imaging: Pituitary MRI
test
o Result: Serum cortisol >50 mol/L
- 24h urine cortisol
o Result: Increased 3x above normal
- Midnight plasma or salivary cortisol
o Midnight: expected cortisol is at nadir
o Result: Plasma >130 nmol/L /
Salivary 5 nmol/L
Possible locations of Cushing’s
1. Adrenal glands
2. Pituitary
3. Ectopic: chest or abdominal tumor

High dose dexa supp test: 2 mg q6 for the next 48h

ADRENAL ADENOMA

VI. Cushing’s Syndrome PITUITARY ADENOMA

- ACTH-secreting
Screening test:

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Chito, Marco, Mausisa, Najito, Picones, Villones, Carillo, Galvez, Tan, Utod
 DR. EDBERTO GENERAL FEB 19, 2021

- Bone aging (esp if w/o lucrative tests)

o is it hormonal or anatomical?
SECRETING TUMOR o Attained thru xray of the wrist
- Ectopic ACTH ▪ Hormonal/systemic: If >/<
2 yrs of the actual age
- Karyotyping
o Checking for chromosomal
abnormality

Causes of Short Stature

1. Congenital hypothyroidism
o Serum TSH >10
VII. Short Stature 2. Growth hormone deficiency
o Low Serum IGF-1
Document through a growth chart o Best test: Insulin-induced
- Height below 3rd percentile or >2 SD hypoglycemia
below the median height for age and sex ▪ Serum GH <3 ug/L during
- To know if genetic: hypoglycemia
o Midparental height ▪ Dangerous
o Height of siblings
VIII. Cases
Case 1
• J.L., 35/M
• Dizziness, easy fatigability
• Bilateral extremity weakness and cramps
• BP 200/110 mmHg, CR 98 bpm, RR 25
cpm, T 36.7C
• Serum K-2.1 mmol/L

Dx: Primary Aldosteronism

• Early onset HPN or CVA @ <40yo
• Drug-resistant HPN
• Hypokalemia
➔ Aldosterone: Renin = >750pmol/L &
Aldosterone >450 pmol/L
➔ Confirmatory test: Saline Infusion
test (2L of PNSS for 4 hrs)
➔ Unsuppressed aldosterone level
• Unenhanced Adrenal CT Scan
Workup: ➔ First-line imaging for adrenal glands
- Look for secondary sex characteristics
o If lacking, request karyotyping

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Chito, Marco, Mausisa, Najito, Picones, Villones, Carillo, Galvez, Tan, Utod
 DR. EDBERTO GENERAL FEB 19, 2021

Red arrow pointing to adrenal tumor secreting aldosterone

Adrenal MRI showing pheochromocytoma
causing primary aldosteronism
Case 2
• G.D., 32 y/o, M
• Palpitation, excessive sweating, flushing
• Loss of consciousness
• BP at home 180-220/100-120 on Amlodipine,
Metoprolol, Losartan
Dx: Pheochromocytoma
• Tumor in adrenal medulla secreting
catecholamines
• Screening
➔ 24-hour urinary fractionated metanephrine
(most sensitive) or;
MIBG Scintigraphy showing pheochromocytoma
➔ 24-hour urinary total metanephrine (most
specific)
➔ >3x elevated from normal suggests
pheochromocytoma
➔ Adrenal MRI/CT scan / MIBG Scintigraphy
/ FDG PET Scan

FDG PET Scan showing pheochromocytoma

Case 3:

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Chito, Marco, Mausisa, Najito, Picones, Villones, Carillo, Galvez, Tan, Utod
 DR. EDBERTO GENERAL FEB 19, 2021

• J.A., 26 y/o, M
• Loss of libido
• (-) headache, blurring of vision
• Confrontation test- (-) bitemporal hemianopsia

Dx: Primary adrenal insufficiency

• Screening:
➔ Short cosyntropin test / ACTH stimulation
Dx: Prolactinoma test
• Screening ➔ Serum cortisol <450 nmol/L, 30-60 min
➔ Serum prolactin >200 µg/L: after administration of 250 µg ACTH IV/IM
Hyperprolactinemia ➔ Elevated plasma ACTH
➔ Pituitary MRI: imaging of choice for ➔ Adrenal antibodies
pituitary gland ▪ (+) – Autoimmune adrenalitis
▪ (-) Request for chest x-ray, CT scan,
Serum 17-OHP, plasma VLCFA
REFERENCES
• Fauci, A., Jameson, J., Kasper, D.,
Hauser, S., Longo, D. and Loscalzo, J.,
2018. Harrison's Principles of Internal
Medicine. 20th ed. McGraw-Hill
Education.
END OF TRANSCRIPTION

Pituitary MRI showing prolactinoma REVIEW QUESTIONS

Case 4: 1. Imaging of choice for adrenal glands
• R.D., 24 y/o, M 2. Screening for primary aldosteronism
• Fatigue, lack of energy 3. Screening for Cushing’s syndrome
4. Twitching of the facial muscles in response to
• Weight loss
tapping over the area of the facial nerve
• Nausea, vomiting, abdominal pain
5. Which organ is involved in secondary
• BP 110/80 mmHg CR 80 bpm – lying down hyperparathyroidism?
• BP 90/60 mmHg CR 110 bpm – standing Answers: 1. CT scan, 2. Saline Infusion test, 3. Dexamethasone suppression test, 4. Chvostek sign., 5.
Kidney
• Postural hypotension
• Hyponatremia, hypokalemia

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Chito, Marco, Mausisa, Najito, Picones, Villones, Carillo, Galvez, Tan, Utod
 DR. EDBERTO GENERAL FEB 19, 2021

TRANSERS’ SPACE

SEND MONEY TO OUR GCASH:

09654811357
09212917807
09385208980

Arevalo, Jaranilla, Loreno, Jazareno, Luciano, Raro, Cuajao, Madera, Malaiba,

Chito, Marco, Mausisa, Najito, Picones, Villones, Carillo, Galvez, Tan, Utod