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Session 2 CM endo1

CM- Endo -1- Hypothal & Pituit lect 1-4

Where is the hypothalmus found anterior part of the fllor of the third ventricle below and in front of the hypothalamic sulcus
What hormones are secreted by the hypothalmus TRH, GnRH, GRH, CRH
What is the function of the following hormones and where is it secreted from TRH TRH- Thyroid Releasing hormone from hypothalmus stimulates TSH and Prolactin in the Ant. Pituitary
What is the function of the following hormones and where is it secreted from GnRH Gnrh- Gonadotropin releasing hormone from hypothalmus stimulates secretion of FSH and LH
What is the function of the following hormones and where is it secreted from GRH GRH- Growth hormone releasing hormone from hypothalmus stimulatess secretion of GH
What is the function of the following hormones and where is it secreted from CRH CRH- Corticotropin releasing hormone from hypothalmus stimulates release of ACTH
Where is the pituitary found Found in the sella turcica surrounded by sphenoid bone covered by dura mater
Where is the optic chiasm in relation to the pituitary and why is this relevant optic chiasm is superior to the pituitary gland this is important because tumors in the pituitary can compress the optic chiasm causing visual field defecits
What is the connection between the hypothalmus and pituitary called called the hypophyseal stalk
how is the pituitary divided anterior and posterior divisions
Primary secretory division of the pituitary takes up around 80% of the gland anterior pituitary
What are the hormones secreted from anterior pituitary GH- growth hormone Prolactin ACTH TSH FSH LH
What type of cell in the anterior pituitary makes GH somatotrophs
What type of cell in the anterior pituitary makes Prolactin Lactotrophs
What type of cell in the anterior pituitary makes ACTH corticotrophs
What type of cell in the anterior pituitary makes TSH thyrotrophs
What type of cell in the anterior pituitary makes FSH and LH Gonadotrophs
part of the pituitary that is actually a down growth from the hypothalmus and secretes two peptides posterior pituitary
what are the two peptides secreted by the pos. pituitary Oxytocin and Vasopressin
What is the function of oxytocin and where is it secreted from acts on uterine smooth muscle to initiate contractions and stimulates lactation in the mammary ducts. Secreted from pos. pituitary
What is the function of vasopressin and where is it secreted from Also known as Anti Diuretic Hormone it increases water resorption at the distal tubule in the kidney and allows for concentration of urine. Secreted from the pos. pituitary
What are the functions of growth Hormone (GH) where is it secreted from promotes linear growth of bone inhibits the effect of insulin by impairing glucose uptake by cells -release stimulated by low blood sugar -release inhibited by high blood sugar -somatostatin inhibits its release secreted from ant. pituitary
What effects do low and high blood sugar have on Growth Hormone (GH) Low blood sugar stimulates GH high blood sugar lowers GH
What effect does somatostatin have on Growth hormone (GH) inhibits growth hormone
What is the function of Prolactin and where is it secreted from stimulates lactation in postpartum period promotes breast development during pregnancy to prepare for milk production -inhibits -inhibited by dopamine
What is the function of ACTH and where is it secreted from stimulates the adrenal gland to produce cortisol and androgens secreted from Ant. Pituitary
What is the function of TSH and where is it secreted from stimulates iodine uptake by thyroid gland stimulates release of T4 and T3 resembles hCG -Inhibited by somatostatin, dopamine, and excess cortisol -Secreted from Ant Pituitary
What is the function of FSH & LH and where is it secreted from FSH and Lh stimulates ovaries and testes to produce sex steroids -LH stimulates testosterone and estrogen in male leydig cells FSH and LH stimulate sperm maturation LH- in females stimulates corpus leteum to make progesteron and LH spike causes ovulat
What does LH and FSH do in men LH stimulates testosterone and estrogen in male leydig cells LH and FSH are both needed for sperm maturation
What do LH and FSH do in females LH stimulates the corpus luteum in females to produce progesterone for placental development LH also causes ovulation with mid cycle spike FSH- stimulates estrogen required in the development of ovarian follicles. Stimulates spermatogenesis
What are some common and not so common pathologies that can causes of hypopituitarism -Space occupying tumors that compress the hypothalmus or pituitary gland -Radiation or surger -Empty Sella -Vascular events such as sheehan's syndrome or pituitary apoplexy
What is empty sella structural defect where the pituitary is falttened on the floor of the sella
What is sheehan's syndrome severe hemorrhaging during delivery causes infarction of the pituitary
What is Pituitary apoplexy Hemorrhage/infarction of the pituitary due to trauma, tumor, anticoagulation, or sickle cell anemia
What are the clinical features of anterior pituitary destruction or deficiency in hypothalamic stimulators Hypogonadism, Hypothyroidism, andrenocortical deficiency, Growth hormone deficiency
What would hypopituitarism causing hypogonadism appear as clinically decrease in sex drive, impotence, amenorrhea
what would hypopituitary causing hypothyroidism appear as clinically mental slowness, constipation, cold intolerance, and weight gain (slugs)
What would hypopituitary causing adrenocortical deficiency appear as clinically weakness, nausea, fever, hypotension(that doesn't respond to IV fluids)
What would hypopituitary causing growth hormone deficiency appear as clinically epsiodic hypoglycemia with fasting, short stature
How would you diagnose hypopituitary test target gland hormones- T4/T3. testosterone, and cortisol, if they are low you need to measure pituitary hormones -Check TSH, FSH, LH, ACTH, and prolactin low levels suggest hypothalamic/pituitary deficiency high levels suggest target gland probl
How are tumors of the pituitary classified classified according to size and hormone production
What is a pituitary tumor less than 10mm called and what is one greater than 10mm called microadenoma vs macroadenoma
Are pituitary tumors often malignant no but they can cause local invasion and expansion tumors can cause visual field defects by compressing optic chiasm
What is a somatotroph adenoma tumor causes excess GH M=F usually seen in 30-40yr olds slow growing
what type of pituitary tumor causes acromegaly, gigantism w/ soft tissue growth, sleep apnea, thickening of skin, spade like blunt fingers, carpal tunnel syndrome and hyperinsulinism Somatotroph adenoma
How do you diagnose a somatotroph adenoma check blood glucose, elevated blood calcium and phosphorus levels, elevated somatomedins, elevated GH levels, GLUCOSE TOLERANCE TEST, finally MRI
What would you see on a normal glucose tolerance test vs someone with somatotroph adenoma Give 100gm glucose then measure GH levels normal- decrease in GH to less than 5ng/mL at 60 minutes Acromegaly- may decrease GH levels but not below 5ng/mL
what is the treatment for a somatotroph adenoma transphenoidal surger: gamma knife 80% success rate for small tumors Radiation 4500-5000 rads 60-80% success Bromocriptine: dopamine agonist given orally can decrease GH levels Octreotide: a somatostatin analogue decrease GH given sub Q
what is the most common form of pituitary tumor lactotroph
What is the pituitary tumor called that secretes excess prolactin lactotroph or prolactinoma
When are similiar signs and sypmtoms of a lactotroph seen side effects are similiar to those seen during pregnancy
What are the s/sx of a lactotroph adenoma galactorrhea, in women menstrual disorder, in men hypogonadism, weight gain, irritability, hirsutism
How to dx a lactotorph adenoma -first do a pregnancy check (hCG) because it is the most common cause of amenorrhea -check prolactin level micros secrete 30-100ng/ml macros over 200 ng/ml check visual field- a deficit would warrant an MRI because tumor could be compressing optic chia
how do you tx lactotroph adenomas -dopamine agonist bromocriptine when fertility is wanted oral birth contrl if fertility is unwanted -cabergoline like bromocriptine Transphenoidal surger generally 20% recurrence rate
Type of pituitary tumor that causes excess glucocorticoids ACTH secreting tumors
What is the difference between cushing's disease and cushing's syndrome cushing disease tumor is in the pituitary cushing syndrome tumor is in the adrenal gland or lung(bronchocarcinoma)
Who is more likely to have acth secreting tumor and when is it most often seen F:M 8:1 seen in 20-40 year olds 80-90% are microadenomas that often invade locally
what are the s/sx of cortisol excess (acth secreting tumor) weight gain hypertension hyperpigmentation easy bruising proximal muscle weakness osteopenia immune suppression anti-inflammatory action anti-allergic action
What should you think about when you see buffalo hump and/or centripital obesity and puprle stria on the trunk cushing's disease
why do you see osteopenia and immunesuprresion in cushing's disease the osteopenia results from increased renal excretion of calcium and immunesuprresion from decrease in antibody production
How would you diagnose an ACTH secreting tumor 1st document cortisol excess with a 24hr urine collection 2nd document elevated ACTH level by serum 3rd do a dexamethasone suppresion test
What would you see with a dexamethasone test if the tumor is an ACTH high dose of dexamethasone mimics cortisol so you should see a suppresion in pituitary ACTH by negative feedback which in turn suppresses endogenous cortisol if you have an ACTH secreting tumor the cortisol level should decrease 50%
if you have high cortisol and dexamethasone test didn't decrease cortisol by 50% whay type of tumor do you most likely have and how do you narrow down where it is located you most likely have a tumor in the adrenal gland or lung. to determine if it is an adrenal tumor you should see a decrease in cortisol if you decrease ACTH if it is in the lung cortisol will remain constant since ACTH has no effect on lung tissue
What imaging technique are you going to use to locate a -pituitary tumor secreting ACTH -adrenal tumor secreting cortisol -lung tumor secreting cortisol Pituitary tumor- MRI Adrenal tumor CT Scan Lung Tumor- CT scan
HOw does petrosal sinus sampling help a surgeon determine the location of a pituitary tumor each petrosal sinus receives venous drainage from the ipsilateral pituitary higher levels of ACTH will be seen in the sinus on the same side as the tumor
what are the TX for ACTH secreting tumor transphenodal resection conventional radiation ketoconazole -inhibits adrenal cortisol metyrapone- inhibits conversion of cholesterol to pregnenolone which reduces adrenal cortisol production
what type of tumor has the only cases occur in men usually macroadenomas may be due to lon standing kleinfelters syndrome Gonadotropin secreting tumor- most only secrete FSH
What are teh s/sx of gonadotropin secreting tumor impotence or infertility visual impairment due to compression of optic chiasm
how do you dx a gonadotropin secreting tumor elevated FSH, low testosterone, MRI reveals large adenoma
s/sx of this pituitary tumor are hyperthyroid, goiter, no exopthalmos, diarrhea, fatigue and muscle weakness and is usually a macroadenoma TSH secreting Tumor
how do you dx a TSH secreting tumor elevated TSH, T3/T4, MRI shows large tumor and injection of TRH produces no increase in TSH production
what are the tx options for a TSH secreting tumor transphenoidal surger ablative therapy- with radioactive iodine octreotide- long acting somatostatin decreases TSH shrinks tumor
this deficiency is found in children 6-12 months of age you have deceleration in growth velocity after normal birth weight short stature on physical exam slow linear growth Growth Hormone Deficiency
How to dx growth hormone deficiency low serum somatomedin (after ruling out malnutrition, liver disease, hypothyroidism, and congenital dwarfism) Confirm by giving GH
What is the protocol for testing Growth hormone deficiency by administering Growth hormone measure fasting GH levels Give IV insulin until glucose falls to below 50 this should stimulate GH to above 6ng/dl if it is present then inject exogenous GH should cause rise in somatomedin/GH level
how do you treat growth hormone deficiency GH injections, most effective before puberty, improves lean body mass, controversial in adults
This pituitary hormone deficiency is rare and always associated with another pituitary deficiency prolactin deficiency
how would you dx a prolactin deficiency TRH stimulation test obtain baseline levels inject protirelin prolactin levels should increase two fold if present
rare pituitary deficiency mimics adrenal insufficiency generally due to impaired secretion of CRH by hypothalmus or Exogenous steroid use that suppresses the pituitary ACTH deficiency
what are the s/sx of ACTH deficiency Nausea/vomiting weakness/fatigue Fever Hypotension-****that doesn't respond to IV fluids
how do you dx an ACTH deficiency CRH test -obtain baseline serum ACTH -Inject 1mcg/kg CRH as IV bolus -recheck ACTH/cortisol at 15,30,and 60 mins -ACTH should peak at 15mins -Cortisol should peak at 30-60 min
What is the TX for ACTH deficiency replace corticosteroids -GOLD STANDARD hydrocortisone given orally 20mg am and 10mg pm doses can be tapered down as clinical signs improve. -prednisone/decadron must be converted by the body to cortisol for action -DURING STRESS dose should be 100mg/8
Why do you need to increase the dose of hydrocortisone given to 100mg every 8hrs for an ACTH deficient patient during stress and illness because cortisol is the stress hormone it is needed during these times to ensure proper body function
What are the likely causes of a TRH deficiency insufficient production of TRH by the hypothalmus pituitary adenoma compressing thyrotropic cells previous pituitary surgery pituitary destruction by trauma or hemorrhage
what are the s/sx of TRH deficiency looks like hypothyroidism -fatigue -weight gain -constipation -menstrual irregularities -dry skin/hair loss SLUG EFFECT
How do you dx a TRH deficiency check TSH and T4 if both are low inject TRH should see an increase in TSH if the lesion is in the hypothalmus if no increase in TSH the lesion is in the pituitary
What is the TX for TRH deficiency replace thyroid hormone with synthroid or levoxyl
What are common causes of gonadotropin deficiencies hypothalamic/pituitary tumors compressing gonadotroph cells (most common is craniopharyngioma) -Prior pituitary surgery -Prolactinomas secreting excess prolactin inhibit fsh/lh -congenital defect (kallman's syndrome)
What is the most common tumor that causes gonadotropin deficiency by compressing gonadotrophs craniopharyngioma
autosomal dominant familial syndrome with deficiency in GnRH so NO FSH/LH associated with hypoplasia/atrophy of the olfactory bulb Kallman's syndrome
what are the s/sx of kallman's syndrome undescended testes gynecomastia delay in puberty and associated growth spurts anosmia-lack of smell
how would you dx kallman's syndrome -check GnRH, FSH, LH, testosterone ALL will be low
What is the TX for Kallman's syndrome pulsitile GnRH testosterone replacement given 100-300mg/month This fixes all problems except infertility
What is the synthetic version of oxytocin called pitocin
How does estrogen affect action of oxytocin estrogen lowers the threshold of smooth muscle membrane potential enhancing the effect of Oxytocin on causing uterine contraction
What effect will oxytocin have on uterine smooth muscle oxytocin may cause contraction in quiescent uterus or increase contraction strength and frequency in active uterus
What is the reflex release of oxytocin as baby leaves the uterus it causes dilation of uterus, cervix, and vagina this causes release of oxytocin creating stronger contractions to push the baby out. more dilation occurs more oxytocin is released
HOw is oxytocin involved in lactation oxytocin gets released after stimulation of nipple which then causes the mammary duct cells to contract and eject the milk -this is inhibited by stress
What is the other name for Vasopressin ADH (anti diuretic hormone)
What are the effects of vasopressin (ADH) at the kidney: increases water resorption in distall collecting duct concentrating urine Cardiovascular: causes vasoconstriction increasing B/P in hypovolemia, ADH maintains peripheral perfusion LIVER: increases GLUCOGENOLYSIS
What effect would increased plasma osmolality have on vasopressin (ADH) Vasopressin would be released to increase water resorption to counteract the increased osmolality
What effect would a decrease in total body water have on vasopressin (ADH) vasopressin would be released to increase water resorption to combat the dehydration and hypovolemia.
What is diabetes insipidus insufficient vasopressin(ADH)resulting in- inability to concentrate urine
What are the three types/causes of diabetes insipidus neurogenic diabetes insipidus nephrogenic diabetes insipidus psychogenic polydipsia
Deficiency in Vasopressin(ADH) caused by -surgery in hypothalmus or pituitary -head trauma -active pituitary or metastic tumor -infiltrative disease of pituitary (histiocytosis, granulomas) -CNS infection -idiopathic (decreased vasopressin fibers) Neurogenic causes of diabetes insipidus
Type of diabetes inspidues marked by -normal to elevated ADH w/poor renal response caused- -chronic renal disease -sickle cell -chronic K+ def -hypercalcemia -medication (lithium, fluoride, methoxyflurane anes, declomycin and colchicine) -cong defe nephrogenic diabetes insipidus
type of diabetes insipidus also known as potomania caused by excessive drinking increased water load leads to inhibition of vasopressin(ADH) leading to water diuresis Psychogenic diabetes insipidus
what are the s/sx of diabetes insipidus hypernatremia (serum sodium >140), excessive thirst(polydipsia), large volume diluted urine (polyuria)>4L/day
how do you dx diabetes insipidus inappropriately dilute urine w/ elevated serum osmolality leading to hypernatrimia elevated serum osmolality (>295mosm/kg) dilute urine osmolality (<200mosm/kg) low urine specific gravity (<1.005)
What is a test that aid in testing for diabetes insipidus that must be done under close supervision as patient can become rapidly dehydrated Water Deprevation test
What is the difference in baseline plasma and urine osmolality in nephrogenic/neurogenic vs psychogenic diabetes insipidus nephro/neuro DI urine is dilute while palsma is highly concentrated Psycho DI urine and plasma are both dilute due to excessive water intake
What is the protocol for carrying out a water deprevation test -first obtain baseline plasman and urine osmolality -deny patient fluids for 12-18hours -measure ADH level -to distinguish nephro from neuro inject aqeous vsopressin -measure urine osmolality 1 hour after injection
What should you see with a normal, nehpro/neuro DI, and psychogenic DI individual after withholding water for 12-18 hours normal person- will reduce urine output urine osmolality will increase Nephro/Neuro- will maintain diluted urine output psycho- will always increase urine osmolality
How do you distinguish nephrogenic vs neurogenic diabetes insipidus inject aqueous vasopressin then 1 hour after injection measure urine osmolality Nephr- no change in urine osm Neuro- urine osmolality would increase
What is the TX for neurogenic DI drug of choice is DDAVP or pitressin tannate
What is the TX for nephrogenic DI salt restriction thiazide diuretic cholrpropamide, carbamazepine, increase ADH release from the pituitary
Inappropriate secretion of ADH in the face of low plasma osmolality excess water resorption causing volume expansion syndrome of inappropriate secretion of ADH (SIADH)
What can cause syndrome of inappropriate secretrion of ADH HEAD TRAUMA malignant lung tumors tuberculosis Adrenal insufficiency medications(clofribrate, tegretol, thiazides all stimulate ADH release)
How would you dx Syndrome of inappropriate secretion of ADH hyponatremia hypo-serum osmolality normal renal function normal thyroid tests(rules out myxedema) urine is hypertonic no adrenal insufficiency
How would you tx SIADH fluid restriction for mild cases severe cases may need normal saline IV to decrease hypo-natremia Loop diuretics-decrease effect of ADH promote water loss demeclocycline-causes reversible nephrogenic DI
Acromegaly is caused by overproduction of GH
GH deficiency caused by underproduction of GH
SIADH caused by overproduction of vasopressin(ADH)
Diabetes insipidus caused by underproduction of vasporessin(ADH), Poor functioning kidney, psychologic increase in water uptake
What is Sheehan syndrome underproduction of any pituitary hormone
What does a pituitary adenoma cause overproduction of any pituitary hormone depending on cell type involved in tumor
What is hypopituitarism underproduction of any pituitary hormone
Created by: smaxsmith
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