B Laboratory Findings in Objective-C

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B Laboratory Findings
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The diagnosis of diabetes insipidus as a cause of polyuria or hypernatremia requires clinical judgment There is no single diagnostic laboratory test Evaluation for diabetes insipidus should include an accurate 24-hour urine collection that is measured for volume and creatinine A urine volume of < 2 L/ 24 h (in the absence of hypernatremia) essentially rules out diabetes insipidus Serum is assayed for glucose, urea nitrogen, calcium, potassium, sodium, and uric acid Hyperuricemia occurs in many patients with diabetes insipidus, since reduced vasopressin stimulation of the renal V1 receptor causes a reduction in the renal tubular clearance of urate A supervised vasopressin challenge test may be given: Desmopressin acetate is given in an initial dose of 005 01 mL (5 10 mcg) intranasally (or 1 mcg subcutaneously or intravenously), with measurement of urine volume for 12 hours before and 12 hours after administration Serum sodium must be obtained immediately in the event of symptoms of hyponatremia The dosage of desmopressin is doubled if the response is marginal Patients with central diabetes insipidus notice a distinct reduction in thirst and polyuria; serum sodium stays normal except in some saltlosing conditions In nonfamilial central diabetes insipidus, MRI of the pituitary and hypothalamus and of the skull is done to look for mass lesions The pituitary stalk may be thickened, which may be a manifestation of Langerhans cell histiocytosis, sarcoidosis, or lymphocytic hypophysitis When nephrogenic diabetes insipidus is a diagnostic consideration, measurement of serum vasopressin is done during modest fluid restriction; typically, the vasopressin level is high
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Differential Diagnosis
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Central diabetes insipidus must be distinguished from polyuria caused by diabetes mellitus, Cushing s syndrome or corticosteroid treatment, lithium, hypercalcemia, hypokalemia, and the nocturnal polyuria of Parkinson s disease It must also be distinguished from nephrogenic diabetes insipidus (see above), the excessive fluid intake seen in psychogenic polydipsia, central nervous system sarcoidosis, and intravenous fluid administration
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B Oxytocin Deficiency
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Women lacking oxytocin are unable to nurse their infants Oxytocin induces the contraction of myoepithelial cells surrounding the mammary alveoli, which leads to the
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ejection of milk Both oxytocin and milk removal are required for postpartum alveolar proliferation and successful lactation Nasal oxytocin (Syntocinon) is not available in the United States It is used to promote milk let-down in normal postpartum women and with variable success in women with hypopituitarism The dosage is one puff into each nostril in the sitting position 2 3 minutes before nursing
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Clinical Findings
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A Symptoms and Signs
Excessive GH causes tall stature and gigantism if it occurs in youth, before closure of epiphyses Afterward, acromegaly develops The term acromegaly, meaning extremity enlargement, seriously understates the manifestations The hands enlarge and a doughy, moist handshake is characteristic The fingers widen, causing patients to enlarge their rings Carpal tunnel syndrome is common The feet also grow, particularly in shoe width Facial features coarsen since the bones and sinuses of the skull enlarge; hat size increases The mandible becomes more prominent, causing prognathism and malocclusion Tooth spacing widens Macroglossia occurs, as does hypertrophy of pharyngeal and laryngeal tissue; this causes a deep, coarse voice and sometimes makes intubation difficult Obstructive sleep apnea may occur A goiter may be noted Hypertension (50%) and cardiomegaly are common At diagnosis, about 10% of acromegalic patients have overt heart failure, with a dilated left ventricle and a reduced ejection fraction Weight gain is typical, particularly of muscle and bone Insulin resistance is usually present and frequently causes diabetes mellitus (30%) Arthralgias and degenerative arthritis occur Overgrowth of vertebral bone can cause spinal stenosis Colon polyps are common, especially in patients with skin papillomas The skin may also manifest hyperhidrosis, thickening, cystic acne, skin tags, and areas of acanthosis nigricans GH-secreting pituitary tumors usually cause some degree of hypogonadism, either by cosecretion of PRL or by direct pressure upon normal pituitary tissue Decreased libido and impotence are common, as are irregular menses or amenorrhea Secondary hypothyroidism sometimes occurs; hypoadrenalism is unusual Headaches are frequent Temporal hemianopia may occur as a result of the optic chiasm being impinged by a suprasellar growth of the tumor
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