Intralesional glucocorticoid

 Intralesional glucocorticoid :

Used in Conditions like as follows : 

-Dupuytren Contracture

-Gout in Renal Failure

-Keloids

-Alopecia areata

Endocrine (USMLE) high yield Cases

Case: Primary psychogenic polydipsia

Case: Pheochromocytoma

Case: DKA (Diabetic ketoacidosis)

Case: Familial hypocalciuric hypercalcemia

American Diabetes Association (ADA) guidelines for Diabetes mellitus

According to the American Diabetes Association (ADA) guidelines , Diabetes Mellitus (DM) screening should start at age 45 in patients with no DM risk factors. However, patients with risk factors require screening at an earlier age.

The risk factor for developing future DM include excess body weight, family history of type 2 diabetes, and hypertension.



ADA guidelines recommend one of the following DM screening tests.

Plasma HbA1c is a screening modality for diabetes mellitus. Fasting plasma glucose, oral glucose tolerance test, and hyperglycemia in the presence of symptoms can also be used. However the results should be confirmed by repeat testing in the absence of unequivocal hyperglycemia.

Dawn Phenomenon and the Somogyi Effect-USMLE CK

For Dawn phenomenon HYPER -INCREASE INSULIN 
For Somogyi phenomenon HYPO -DECREASE INSULIN

In other way which we are giving insulin :---
Somogyi = so much insulin. 
Dawn = down insulin.

Thyrotoxicosis with low radioactive iodine

The most important cause of thyrotoxicosis with low radioactive iodine uptake include:

1.Subacute painless thyroiditis
2.subacute granulomatous thyroiditis
3.iodine induced thyroid toxicosis
4.levothyroxine overdose
5.Struma ovarii

Multinodular Goiter

Multinodular Goiter - Euthyroid Patient : 

Non-Tender-thyroid nodule.

USG: 

Difference between Primary aldosteronism and Secondary aldosteronism

Primary Aldosteronism

• Increase intravascular Volume
• Decrease RENIN Level
• Do not have pedal edema
• Hypertension

Secondary Aldosteronism

• Decrease intravascular Volume
• Increase RENIN level 
• Somtimes have Edematous state
• Hypotension

Insulin therapy and its types

Insulin types depicted on the graph below : Regular insulin is preferred in the initial treatment of Diabetic ketoacidosis(DKA). Recognize the different types insulins and their durations of action.

Line A- rapid-acting (e.g., lispro)

Line B-regular

Line C-NPH

Line D-Lente

Line E-Ultralente

Line F-Glargine

Diabetic patients need two types of insulin: both a basal long-acting insulin and a short acting insulin. 
The latter covers post-meal hyperglycemia. The best basal, long-acting insulin is glargine insulin(Lantus), which is supplemented by at least 3 shots of short-acting insulin at mealtimes. Before the advent of glargine, NPH was the best long-acting basal insulin.
Since NPH is only good for 12-18 hours, patients need two shots per day, plus the short-acting mealtime shots. Glargine allows only four shots per day, while the use of NPH requires five shots.

The best short-acting insulins are aspart and lispro. Before the advent of these two drugs, regular insulin was the best option for postmeal hyperglycemia. Insulin aspart and insulin lispro have a very rapid onset of action.

Endocrine diseases list

Pituitary Hypofunction

Disorders of the thyroid gland

Thyroid neoplasms

Disorder of calcium and phosphate regulation

Endocrine pancreas

Disorders of the endocrine pancreas

Adrenal cortical hypofunction

Adrenal Medulla

Cystic disease of the kidney

Glomerular diseases

Salivary gland diseases.

Sialolithiasis (Salivary duct stones)

Sialadenitis (Inflammation of Salivary glands)

Viral e.g. mumps parotitis

Bacterial especially in postep. or dehydrated patient, and associated with sialolithiasis

Autoimmune chronic sialadenitis

e.g. Sjogren syndrome in RA causing xerostomia and keratoconjunctivitis sicca with lacrimal gland involvement Together called Miculiz syndrome

Chronic granulomatous sialadenitis,

e.g. TB, sarcoidosis

Salivary gland tumor

Pleomorphic adenoma

Warthin tumor, aka papillary cystadenoma lymphomatosum

Adenocarcinoma, squamous cell carcinoma and mucoepidermoid carcinom are rare.

Grave disease.(hyperthyroidisim)...c

In Graves ophthalmopathy the volume of the retro-orbital connective tissues and extra-ocular muscles is increased as a result of several causes

(1) marked infiltration of the retro-orbital space by mononuclear cells, predominantly T cells

(2) inflammatory edema and swelling of extra-ocular muscles;

(3) accumulation of extracellular matrix components, specifically hydrophilic glycosaminoglycans such as hyaluronic acid and chondroitin sulfate;

(4) increased numbers of adipocytes (fatty infiltration).

Grave disease.(hyperthyroidisim)...b

ages of 20 and 40, women, HLA-B8 and -DR3

concordance rate in monozygotic twins is as high as 60%

antibodies to the TSH receptor, thyroid peroxisomes, and thyroglobulin

Thyroid-stimulating immunoglobulin(TSI)

Thyroid growth-stimulating immunoglobulins (TGI)

TSH-binding inhibitor immunoglobulins (TBII)

Grave disease.(hyperthyroidisim)...a

characterized by a triad of

Thyrotoxicosis, caused by a diffusely enlarged, hyperfunctional thyroid

Infiltrative ophthalmopathy with resultant exophthalmos

A localized, infiltrative dermopathy (pretibial myxedema)

Myxedema

apathy and mental sluggishness that may mimic depression

cold intolerant, and often obese.

Mucopolysaccharide-rich edema accumulates in skin and tissues, causing broadening and coarsening of facial features, enlargement of the tongue, and deepening of the voice.

Bowel motility is decreased, resulting in constipation.

Pericardial effusions are common;

heart is enlarged, and heart failure may supervene.

Cretinism

hypothyroidism developing in infancy or early childhood

may also result from inborn errors in metabolism (e.g., enzyme deficiencies)

If there is maternal thyroid deficiency before the development of the fetal thyroid gland, mental retardation is severe.

impaired development of the skeletal system and central nervous system, with severe mental retardation, short stature, coarse facial features, a protruding tongue, and umbilical hernia

Major features of Cushing syndrome

Central obesity (about trunk and upper back)

Moon facies

Weakness and fatigability

Hirsutism

Hypertension

Plethora

Glucose intolerance/diabetes

Osteoporosis

Neuropsychiatric abnormalities

Menstrual abnormalities

Skin striae (sides of lower abdomen)

Female reproductive system

The female reproductive system is illustrated to the right. “Eggs” are produced in the ovaries, but remember from our discussion of meiosis, that these are not true eggs, yet, and will never complete meiosis and become such unless/until first fertilized by a sperm. Within the ovary, a follicle consists of one precursor egg cell surrounded by special cells to nourish and protect it. A human female typically has about 400,000 follicles/potential eggs, all formed before birth. Only several hundred of these “eggs” will actually ever be released during her reproductive years. Normally, in humans, after the onset of puberty, due to the stimulation of follicle-stimulating hormone (FSH)one “egg” per cycle matures and is released from its ovary. Ovulation is the release of a mature “egg” due to the stimulation of leutenizing hormone (LH), which then stimulates the remaining follicle cells to turn into a Corpus luteum which then secretesprogesterone to prepare the uterus for possible implantation. If an egg is not fertilized and does not implant, the corpus luteum disintegrates and when it stops producing progesterone, the lining of the uterus breaks down and is shed.
Each “egg” is released into the abdominal cavity near the opening of one of the oviducts or Fallopian tubes. Cilia in the oviduct set up currents that draw the egg in. If sperm are present in the oviduct (if the couple has recently had intercourse), the egg will be fertilized near the far end of the Fallopian tube, will quickly finish meiosis, and the embryo will start to divide and grow as it travels to the uterus. The trip down the Fallopian tube takes about a week as the cilia in the tube propel the unfertilized “egg” or the embryo down to the uterus. At this point, if she had intercourse near the time of ovulation, the woman has no idea whether an unfertilized “egg” or a new baby is travelling down that tube. During this time, progesterone secreted by the corpus luteum has been stimulating the endometrium, the lining of the uterus, to thicken in preparation for possible implantation, and when a growing embryo finally reaches the uterus, it will implant in this nutritious environment and begin to secrete its own hormones to maintain the endometrium. If the “egg” was not fertilized, it dies and disintegrates, and as the corpus luteum also disintegrates, its progesterone production falls, and the unneeded, built-up endometrium is shed.
The uterus has thick, muscular walls and is very small. In a Nulliparous woman, the uterus is only about 7 cm long by 4 to 5 cm wide, but it can expand to hold a 4 kg baby. The lining of the uterus is called the Endometrium and has a rich capillary supply to bring food to any embryo that might implant there.
The bottom end of the uterus is called the Cervix The cervix secretes mucus, the consistency of which varies with the stages in her menstrual cycle. At ovulation, this cervical mucus is clear, runny, and conducive to sperm. Post-ovulation, the mucus gets thick and pasty to block sperm. Enough of this mucus is produced that it is possible for a woman to touch a finger to the opening of her vagina and obtain some of it. If she does this on a daily basis, she can use the information thus gained, along with daily temperature records, to tell where in her cycle she is. If a woman becomes pregnant, the cervical mucus forms a plug to seal off the uterus and protect the developing baby, and any medical procedure which involves removal of that plug carries the risk of introducing pathogens into the nearly-sterile uterine environment.
The vagina is a relatively-thin-walled chamber. It servs as a repository for sperm (it is where the penis is inserted), and also serves as the birth canal. Note that, unlike the male, the female has separate opening for the urinary tract and reproductive system. These openings are covered externally by two sets of skin folds. The thinner, inner folds are the Labia Minora and the thicker, outer ones are the labia majora. The labia minora contain erectile tissue like that in the penis, thus change shape when the woman is sexually aroused. The opening around the genital area is called the vestibule. There is a membrane called the Hymen that partially covers the opening of the vagina. This is torn by the woman’s first sexual intercourse (or sometimes other causes like injury or some kinds of vigorous physical activity). In women, the openings of the vagina and urethra are susceptible to bacterial infections if fecal bacteria are wiped towards them. Thus, while parents who are toilet-training a toddler usually wipe her from back to front, thus “imprinting” that sensation as feeling “right” to her, it is important, rather, that that little girls be taught to wipe themselves from the front to the back to help prevent vaginal and bladder infections. Older girls and women who were taught the wrong way need to make a conscious effort to change their habits.
At the anterior end of the labia, under the pubic bone, is the Clitoris the female equivalent of the penis. This small structure contains erectile tissue and many nerve endings in a sensitive glans within aprepuce which totally encloses the glans. This is the most sensitive point for female sexual stimulation, so senstiive that vigorous, direct stimulation does not feel good. It is better for the man to gently stimulate near the clitoris rather than right on it. Some cultures do a procedure, similar to circumcision, as a puberty rite in teenage girls in which the prepuce is cut, exposing the extremely-sensitive clitoris. There are some interesting speculations on the cultural significance of this because the sensitivity of the exposed clitoris would probably make having sexual intercourse a much less pleasant experience for these women.

Male Reproductive System

The male reproductive system is illustrated to the right. Sperm are produced in the testes located in the scrotum. Normal body temperature is too hot thus is lethal to sperm so the testes are outside of the abdominal cavity where the temperature is about 2° C (3.6° F) lower. Note also that a woman’s body temperature is lowest around the time of ovulation to help insure sperm live longer to reach the egg. If a man takes too many long, very hot baths, this can reduce his sperm count. Undescended testes (testes are supposed to descend before birth) will cause sterility because their environment is too warm for sperm viability unless the problem can be surgically corrected.
From there, sperm are transferred to the Epididymis coiled tubules also found within the scrotum, that store sperm and are the site of their final maturation (Coiled tubules in the scrotum that store sperm) coiled tubules also found within the scrotum, that store sperm and are the site of their final maturation.
In Ejaculation: expulsion of semen vas deferens (plural = vasa deferentia). From the epididymis, the vas deferens goes up, around the front of, over the top of, and behind the bladder. A vasectomy is a fairly simple, outpatient operation that involves making a small slit in each scrotum, cutting the vasa deferentia near where they begin, and tying off the cut ends to prevent sperm from leaving the scrotum. Because this is a relatively non-invasive procedure (as compared to doing the same to a woman’s oviducts), this is a popular method of permanent birth control once a couple has had all the children they desire. Couples should carefully weigh their options, because this (and the corresponding female procedure) is not designed to be a reversible operation.
The ends of the vasa deferentia, behind and slightly under the bladder, are called the ejaculatory ducts. The seminal vesicles are also located behind the bladder. Their secretions are about 60% of the total volume of the semen (= sperm and associated fluid) and contain mucus, amino acids, fructose as the main energy source for the sperm, and prostaglandins to stimulate female uterine contractions to move the semen up into the uterus. The seminal vesicles empty into the ejaculatory ducts. The ejaculatory ducts then empty into the urethra (which, in males, also empties the urinary bladder).
The initial segment of the urethra is surrounded by the Prostate Gland: the largest of the accessory glands which puts its secretions directly into the urethra prostate gland(note spelling!). The prostate is the largest of the accessory glands and puts its secretions directly into the urethra. These secretions are alkaline to buffer any residual urine, which tends to be acidic, and the acidity of the woman’s vagina. The prostate needs a lot of zinc to function properly, and insufficient dietary zinc (as well as other causes) can lead to enlargement which potentially can constrict the urethra to the point of interferring with urination. Mild cases of prostate hypertrophy can often be treated by adding supplemental zinc to the man’s diet, but severe cases require surgical removal of portions of the prostate. This surgery, if not done very carefully can lead to problems with urination or sexual performance.
The bulbourethral glands or Cowper’s glands are the third of the accessory structures. These are a small pair of glands along the urethra below the prostate. Their fluid is secreted just before emission of the semen, thus it is thought that this fluid may serve as a lubricant for inserting the penis into the vagina, but because the volume of these secretions is very small, people are not totally sure of this function.
The urethra goes through the penis. In humans, the penis contains three cylinders of spongy, erectile tissue. During arousal, these become filled with blood from the arteries that supply them and the pressure seals off the veins that drain these areas causing an erection, which is necessary for insertion of the penis into the woman’s vagina. In a number of other animals, the penis also has a bone, the baculum, which helps to stiffen it. The head of the penis, the glans penis, is very sensitive to stimulation. In humans, as in other mammals, the glans is covered by the foreskin or prepuce, which may have been removed bycircumcision. Medically, circumcision is not a necessity, but rather a cultural “tradition”. Males who have not been circumcised need to keep the area between the glans and the prepuce clean so bacteria and/or yeasts don’t start to grow on accumulated secretions, etc. there. There is some evidence that uncircumcised males who do not keep the glans/prepuce area clean are slightly more prone to penile cancer.

Hypothyroidism

is a condition in which the thyroid gland does not make enough thyroid hormone.
See also:
Chronic thryoiditis (Hashimoto's disease)
Subacute thyroiditis
Silent thyroiditis
Neonatal hypothyroidism
Symptoms
Early symptoms:
Being more sensitive to cold
Constipation
Depression
Fatigue or feeling slowed down
Heavier menstrual periods
Joint or muscle pain
Paleness or dry skin
Thin, brittle hair or fingernails
Weakness
Weight gain (unintentional)
Late symptoms, if left untreated:
Decreased taste and smell
Hoarseness
Puffy face, hands, and feet
Slow speech
Thickening of the skin
Thinning of eyebrows
Treatment
The purpose of treatment is to replace the thyroid hormone that is lacking. Levothyroxine is the most commonly used medication. Doctors will prescribe the lowest dose that effectively relieves symptoms and brings the TSH level to a normal range. If you have heart disease or you are older, your doctor may start with a very small dose.
Lifelong therapy is required unless you have a condition called transient viral thyroiditis.
You must continue taking your medication even when your symptoms go away. When starting your medication, your doctor may check your hormone levels every 2 - 3 months. After that, your thyroid hormone levels should be monitored at least every year.
Important things to remember when you are taking thyroid hormone are:
Do NOT stop taking the medication when you feel better. Continue taking the medication exactly as directed by your doctor.
If you change brands of thyroid medicine, let your doctor know. Your levels may need to be checked.
Some dietary changes can change the way your body absorbs the thryoid medicine. Talk with your doctor if you are eating a lot of soy products or a high-fiber diet.
Thryoid medicine works best on an empty stomach and when taken 1 hour before any other medications. Do NOT take thyroid hormone with calcium, iron, multivitamins, alumin hydroxide antacids, colestipol, or other medicines that bind bile acids, or fiber supplements.
After you start taking replacement therapy, tell your doctor if you have any symptoms of increased thyroid activity (hyperthyroidism) such as:
Rapid weight loss
Restlessness or shakiness
Sweating
Myxedema coma is a medical emergency that occurs when the body's level of thyroid hormones becomes extremely low. It is treated with intravenous thyroid hormone replacement and steroid medications. Some patients may need supportive therapy (oxygen, breathing assistance, fluid replacement) and intensive-care nursing.
Causes
The thyroid gland is located in the front of the neck just below the voice box (larynx). It releases hormones that control metabolism.
The most common cause of hypothyroidism is inflammation of the thyroid gland, which damages the gland's cells. Autoimmune or Hashimoto's thyroiditis, in which the immune system attacks the thyroid gland, is the most common example of this. Some women develop hypothyroidism after pregancy (often referred to as "postpartum throiditis").
Other common causes of hypothyroidism include:
Congenital (birth) defects
Radiation treatments to the neck to treat different cancers, which may also damage the thyroid gland
Radioactive iodine used to treat an overactive thyroid (hyperthyroidism)
Surgical removal of part or all of the thyroid gland, done to treat other thyroid problems
Viral thyroiditis, which may case hyperthyroidism and is often followed by temporary or permanent hypothyroidism
Certain drugs can cause hyperthyroidism, including:
Amiodarone
Drugs used for hyperthyroidism (overactive thyroid), such as propylthiouracil (PTU) and methimazole
Lithium
Radiation to the brain
Sheehan syndrome, a condition that may occur in a woman who bleeds severely during pregnancy or childbirth and causes destruction of the pituitary gland
Risk factors include:
Age over 50 years
Being female
Tests & diagnosis
A physical examination may reveal a smaller-than-normal thyroid gland, although sometimes the gland is normal size or even enlarged (goiter). The examination may also reveal:
Brittle nails
Coarse facial features
Pale or dry skin, which may be cool to the touch
Swelling of the arms and legs
Thin and brittle hair
A chest x-ray may show an enlarged heart.
Laboratory tests to determine thyroid function include:
Serum TSH
T4 test
Lab tests may also reveal:
Anemia on a complete blood count (CBC)
Increased cholesterol levels
Increased liver enzymes
Increased prolactin
Low sodium
Prognosis
In most cases, thyroid levels return to with proper treatment. However, thyroid hormone replacement must be taken for the rest of your life.
Myxedema coma can result in death.
Prevention
There is no prevention for hypothyroidism.
Screening tests in newborns can detect hypothyroidism that is present from birth (congenital hypothyroidism).
Complications
Myxedema coma, the most severe form of hypothyroidism, is rare. It may be caused by an infection, illness, exposure to cold, or certain medications in people with untreated hypothyroidism.
Symptoms and signs of myxedema coma include:
Below normal temperature
Decreased breathing
Low blood pressure
Low blood sugar
Unresponsiveness
Other complications are:
Heart disease
Increased risk of infection
Infertility
Miscarriage
People with untreated hypothyroidism are at increased risk for:
Giving birth to a baby with birth defects
Heart disease because of higher levels of LDL ("bad") cholesterol
Heart failure
People treated with too much thyroid hormone are at risk for angina or heart attack, as well as osteoporosis (thinning of the bones).
When to contact a doctor
Call your health care provider if you have symptoms of hypothyroidism (or myxedema).
If you are being treated for hypothyroidism, call your doctor if:
You develop chest pain or rapid heartbeat
You have an infection
Your symptoms get worse or do not improve with treatment
You develop new symptoms



regards by
Dr.M M ADNAN
contact id:adnan_dani12@yahoo.com

Diseases of the Thyroid

Hyperthyroidism

Most effects of hyperthyroidism are obvious from the preceding discussion of the various physiologic effects of thyroid hormone. However, some specific effects should be mentioned in connection especially with the development, diagnosis, and treatment of hyperthyroidism.Causes of Hyperthyroidism (Toxic Goiter, Thyrotoxicosis, Graves’Disease).

In most patients with hyperthyroidism, the thyroid gland is increased to two to three times normal size, with tremendous hyperplasia and infolding of the follicular cell lining into the follicles, so that the number of cells is increased greatly. Also, each cell increases its rate of secretion severalfold; radioactive iodine uptake studies indicate that some of these hyperplastic glands secrete thyroid hormone at rates 5 to 15 times normal.The changes in the thyroid gland in most instances are similar to those caused by excessive TSH. However,plasma TSH concentrations are less than normal rather than enhanced in almost all patients and often are essentially zero. However, other substances that have actions similar to those of TSH are found inthe blood of almost all these patients. These substancesare immunoglobulin antibodies that bind with the same membrane receptors that bind TSH. They induce continual activation of the cAMP system of the cells,with resultant development of hyperthyroidism.
These antibodies are called thyroid-stimulating immunoglobulin and are designated TSI.They have a prolonged stimulating effect on the thyroid gland, lasting for as long as 12 hours, in contrast to a little over 1 hour for TSH.
The high level of thyroid hormone secretion caused by TSI in turn suppresses anterior pituitary formation of TSH.
The antibodies that cause hyperthyroidism almost certainly occur as the result of autoimmunity that has developed against thyroid tissue. Presumably, at some time in the history of the person, an excess of thyroid cell antigens was released from the thyroid cells, and this has resulted in the formation of antibodies against the thyroid gland itself.
Thyroid Adenoma. Hyperthyroidism occasionally results from a localized adenoma (a tumor) that develops in the thyroid tissue and secretes large quantities of thyroid hormone. This is different from the more usual type of hyperthyroidism, in that it usually is not associated with evidence of any autoimmune disease. An interesting effect of the adenoma is that as long as it continues to secrete large quantities of thyroid hormone, secretory function in the remainder of the thyroid gland is almost totally inhibited because the thyroid hormone from the adenoma depresses the production of TSH by the pituitary gland.

Symptoms of Hyperthyroidism

The symptoms of hyperthyroidism are obvious from thepreceding discussion of the physiology of the thyroidhormones:
(1)a high state of excitability,
(2)intolerance to heat,
(3)increased sweating,
(4)mild to extreme weight loss (sometimes as much as 100 pounds),
(5)varying degrees of diarrhea,
(6)muscle weakness,
(7)nervousness or other psychic disorders,
(8)extreme fatigue but inability to sleep, and
(9)tremor of the hands.

Exophthalmos.

Most people with hyperthyroidism develop some degree of protrusion of the eyeballs. This condition is called exophthalmos.A major degree of exophthalmos occurs in about one third of hyperthyroid patients, and the condition sometimes becomes so severe that the eyeball protrusion stretches the optic nerve enough to damage vision. Much more often, the eyes are damaged because the eyelids do not close completely when the person blinks or is asleep. As a result, the epithelial surfaces of the eyes become dry and irritated and often infected, resulting in ulceration of the cornea. The cause of the protruding eyes is edematous swelling of the retro-orbital tissues and degenerative changes in the extraocular muscles.

In most patients,immunoglobulins can be found in the blood that react with the eye muscles. Furthermore, the concentration of these immunoglobulins is usually highest in patients who have high concentrations of TSIs.

Therefore, there is much reason to believe that exophthalmos, like hyperthyroidism itself, is an autoimmune process.The exophthalmos usually is greatly ameliorated with treatment of the hyperthyroidism.



regards by
Dr.M M ADNAN
contact id:adnan_dani12@yahoo.com