Endocrine lecture +spring+2012+student+copy
- 1. Endocrine Problems When the Pituitary and thyroid function goes awry
- 3. Growth Hormone Excess • Overproduction of growth hormone (GH) • Effects middle age adults • Enlargement of hands & feet with joint pain • Changes in physical appearance, with thickening and enlargement of bony and soft tissue of the face and head • Enlargement of tongue may cause speech difficulty, sleep apnea may occur due to upper airway narrowing. • Skin becomes thick, leathery, and oily. • Clients with acromegaly may experience peripheral neuropathy and proximal muscle weakness. Women may develop menstrual disturbances.
- 6. Treatment
- 7. Post Op Care
- 8. Post Op Complication • Transient Diabetes Insipidus –can loose ADH (which helps them hold on to water) putting out more and more fluid (letting go over all of it – cerebral edema could cause this too • May occur due to the loss of antidiuretic hormone or due to cerebral edema • Assessed by monitoring urine output and serum and urine osmolarity
- 9. Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
- 10. SIADH
- 11. Goal of Treatment • Restore normal fluid volume and osmolality • Restrict fluids • 3% saline IVF
- 12. Diabetes Insipidus (DI) • Associated with a deficiency of production of or secretion of ADH or renal response to ADH • Results in fluid and electrolyte imbalances • Depending on the cause DI may be transient or a chronic lifelong condition • Can be classified as Central DI or neurogenic DI or nephrogenic DI
- 13. Case Studies • John, 20 is in the ICU after suffering a head injury in a motor vehicle crash. His urine output, which averaged 30 to 50 ml/hour, has suddenly increased to more than 300 ml/hour over the past 2 hours, and the urine specific gravity has dropped to less than 1.005. • Mary, 42, arrives in the ED complaining of weakness, dizziness, fatigue, and urinary frequency. Her urine specific gravity is less than 1.006. She has a long- standing history of bipolar disorder, which has been treated with lithium.
- 14. Upsetting the Balance Causes of central/neurogenic DI • Idiopathic • Head: neurotrauma, neurosurgery, tumors, anoxic encephalopathy, cerebral aneurysm, cavernous sinus thrombosis • Infections affecting the central nervous system: tuberculosis, syphilis, mycoses, toxoplasmosis, encephalitis, meningitis • Infiltrative disorders: sarcoidosis, histiocytosis X (multifocal Langerhans cell granulomatosis) • Pregnancy-related: vasopressinase- induced, acute fatty liver of pregnancy • Congenital and familial: Wolfram syndrome • Other: post-supraventricular tachycardia, anorexia nervosa Causes of nephrogenic DI • Medications: lithium, amphotericin B, phenytoin, corticosteroids, anticholinergics, rifampin, aminoglycosides • Alcohol • Electrolyte imbalances: hypercalcemia, hypokalemia • Chronic tubulointerstitial diseases: analgesic nephropathy, sickle-cell disease, multiple myeloma, amyloidosis, sarcoidosis, Sjogren syndrome, systemic lupus erythematosus, polycystic kidney disease, pyelonephritis, medullary cystic disease, acute tubular necrosis • Congenital: vasopressin V2 receptor defect, aquaporin-2 water channel defect
- 15. Diabetes Insipidus • Can be neurogenic, nephrogenic, or psychogenic • Symptoms include: Are the same – Polydipsia – Polyuria (5-20L/day) – Weakness and fatigue – SX of hypernatremia-due to too much water drank – Will drink out of toilet must be monitored Diabetes insipidus = no release of fluid – like theyre dehydrated even tho they are drinking
- 16. Diagnosis
- 17. Goal of care • Maintenance of fluid and electrolyte balance; what is underlying cause • Treatment: – hypotonic saline or D5W IVF;
- 18. Back to John and Mary • John, who has a head injury, is in the ICU, and on the ventilator, he has a PA catheter to monitor hemodynamic status. • Mary, who has nephrogenic DI is admitted to the ICU for close monitoring. During her history we learn she doubled her dose of lithium without telling her psychiatrist and without having her levels checked.
- 19. Structures and Hormones • Thyroid gland produces: – Thyroxine (T4) and tri-iodo-thyronine (T3) – Calcitonin • Parathyroid glands produce: – Parathyroid hormone
- 20. Goiter • Hypertrophy of the thyroid gland due to excess TSH stimulation • Treatment with thyroid hormone prevents further enlargement • surgical if too large can cause issue w/breathing
- 21. Goitrogens thyroid inhibitors Thyroid Inhibitors Other Drugs Select Foods Propylthiouracil (PTU) Sulfonamides Broccoli Methimazole (Tapazole) Salicylates Brussel sprouts Iodine in large doses P-Aminosalicylic acid Cabbage Used to block thyroid Lithium Cauliflower Amiodarone (Cordarone) Kale All thyroid inhibitors These block thyroid hypothyroid Mustard Peanuts Strawberries These foods in very large excessive amts Turnips
- 22. Malignant Nodules • Palpable • More than 30,000 new cases of thyroid cancer each year • Painless nodule is the presenting SX • Removed if malignant or compressing trachea
- 23. Thyroiditis
- 24. Hyperthyroidism • Most common form is Grave’s disease • Hyperactivity of the thyroid gland with resulting hypermetabolism • Diffuse thyroid enlargement and excessive thyroid hormone secretion • Auscultation may reveal a bruit/hear over gland • Opthalmopathy eyeballs out - is common finding • Client may exhibit weight loss, tremors, increased nervousness, excessive perspiration sweaty palms all time • HTN, insomnia, hot all time, lower room temp needed quieter rooms • High cals – vitamins – sunglasses protect corneas – prob eyes closing (saline gtt),
- 25. Thyroid Storm (Acute thyrotoxicosis) • Hyperthyroidism can cause symptoms such as sweating, feeling hot, palpitations and weight loss. Symptoms of thyroid storm are more severe: can be life threatening – fever (up to 105.3) – rapid heart rate – nausea/vomiting – diarrhea – irregular heart beat – weakness – heart failure – heart racing – confusion/disorientation / pulmonary edema – heart not profusing low B/P MAT in 50’s -
- 26. Hyperthyroidism • Treatment – Drug therapy • Antithyroid drugs Propylthiouracil (PTU), methimazole(Tapazole) – Inhibit synthesis of thyroid hormones • Iodine (SSKI) – In large doses rapidly inhibits synthesis of T₃ and T₄ and blocks their release into circulation • β-Adrenergic blockers (Inderal) – Utilized for symptomatic relief of thyrotoxicosis – Radioactive iodine therapy • Damages or destroys thyroid tissue, thus limiting thyroid hormone secretions. Maximum effect may not be seen for 2 to 3 months = takes time teach they will have to work. • Watch Fluid intake: aware at home contact w/ppl (caregiver) – Surgical removal
- 27. Thyroidectomy • Prior to surgery the patient may receive iodine treatment or PTU to alleviate thyrotoxicosis • Monitor for iodine toxicity – swelling of buccal mucosa and other mucous membranes, excessive salivation, nausea/vomiting, and skin reactions • Preop teach the client – cough and deep breath, leg exercises • Teach the client to support the head manually while turning in bed to minimize stress on the suture lines • The client may have difficulty talking after surgery for a short time • Assess every 2 hours for the first 24 hours for signs of hemorrhage or tracheal compression • Semi-fowler’s position, avoid flexion • Monitor vital signs, check for signs of tetany
- 28. Hypothyroidism • Results from insufficient circulating thyroid hormone – Result of a variety of abnormalities – Iodine deficiency most common cause worldwide – In the US atrophy of the thyroid gland most common cause – All newborns are screened for thyroid deficiency – Drugs such as amiodarone (Cordarone) (contains iodine) and lithium (blocks hormone production) are known to produce hypothyroidism
- 29. Hypothyroidism • Symptoms vary depending on severity, duration, & age of onset • Systemic effects characterized by slowing of body processes • Long-term effects may involve any body system bur are more pronounced in the neurologic, cardiovascular, GI, reproductive, and hematologic
- 30. • Neurologic – Fatigued, lethargic, personality and mental changes. (impaired memory, slowed speech, decreased initiative, somnolence) • Cardiovascular – Decreased cardiovascular contractility, decreased cardiac output • GI – Decreased motility, achlorhydria (absence or decrease of hydrochloric acid), constipation which may lead to obstipation • Reproductive – Menorrhagia, anovulatory cycles, subsequent infertility • Hematologic – Anemia, low hematocrit, cobalamin, iron and folate deficiencies
- 31. Myxedema Coma • Serious complication, medical emergency • Can be precipitated by infection, drugs, exposure to cold, and trauma • Characterized by: subnormal temperature, hypotension, and hypoventilation
- 32. Treatment of hypothyroidism • Levothyroxine (Synthroid) – Monitor heart rate and report if >100 – Report chest pain – Carefully monitor patients with cardiovascular disease
- 33. Hyperparathyroidism • Primary hyperparathyroidism – Increased secretion of PTH leading to disorders (helps to regulate these ) of calcium, phosphate (when one is up the other is lower), and bone metabolism – Most common cause is benign tumor (adenoma) • Secondary hyperparathyroidism – Compensatory response to conditions that induce or cause hypocalcemia (vit D deficiencies, malabsorption, CKD) • Tertiary hyperparathyroidism – Occurs when there is hyperplasia of the parathyroid glands and a loss of negative feedback. Seen in patients who had a kidney transplant after long period of dialysis for CKD • Treatment of choice is surgical removal – Most effective
- 34. Hypoparathyroidism • Associated with hypocalcemia • Treatment is IV calcium in the emergent phase – May give calcium chloride, calcium gluconate or calcium gluceptate – ECG monitoring during administration • Patients with hypoparathyroidism need instruction on long-term drug therapy and nutrition • Oral calcium supplements, Vitamin D (Rocaltrol), high-calcium meal plan
- 35. The Adrenal Cortex • The adrenal cortex is a factory for steroid hormones. • Two to three dozen different steroids are synthesized and secreted from this tissue. • Two classes are of particular importance: Class of Steroid Major Representative Physiologic Effects Mineralocorticoids Aldosterone Na+, K+ and water homeostasis Glucocorticoids Cortisol Glucose homeostasis and others Additionally, the adrenal cortex produces some sex steroids, particularly androgens.
- 36. Cushing Syndrome • Caused by an excess of steroids, particularly glucocorticoids • Most common cause – Administration of exogenous corticosteroids – 85% of endogenous cases due to ACTH- secreting pituitary tumors • Manifestations seen: weight gain in trunk, face and cervical spine • Loss of collagen so hard to heal • Delayed wound healing • Hyperglycemia r/t steroids • Protein wasting • Insomnia • hypertension
- 37. Cushing Syndrome • Caused by excess of steroids, particularly glucocorticoids • Most common cause – administration of exogenous corticosteroids • prednisone – 85% of endogenous cases due to ACTH-secreting pituitary tumor
- 38. Treatment • Primary goal is to normalize hormone secretion via: --Medications --Surgery Do 24hr urine for free cortisole if low dexamethasone suppression test If pituitary adenoma surgery Adrenal tumor surgery
- 40. Postoperative Care (Adrenalectomy) – Risk of hemorrhage – Manipulation of glandular tissue may release hormones into circulation – BP, fluid balance, and electrolyte levels tend to be unstable because of hormone fluctuations
- 41. Addison’s Disease • All three classes of adrenal corticosteroids are ↓ in Addison’s disease (glucocorticoids, mineralocorticoids, androgens)
- 42. CAUSES --Autoimmune response to adrenal tissue --Tuberculosis – second most common cause –Infarction –Fungal infections –AIDS –Metastatic cancer
- 43. Addison’s Disease• Primary features: – progressive weakness – fatigue – weight loss, anorexia – nausea/vomiting, diarrhea – skin hyperpigmentation – orthostatic hypotension – Low Na, High K • Diagnosis done by clinical features and when cortisol levels are subnormal or fail to rise over basal levels with an adrenocorticotropic hormone stimulating test
- 44. Addisonian Crisis • Risk for life-threatening Addisonian Crisis caused by –Insufficient adrenocortical hormones –Sudden, sharp decrease in these hormones
- 45. Treatment • Hydrocortisone • Lots of IV fluids Glucocorticoid dosage must be ↑ during times of stress to prevent Addisonian Crisis
- 46. Nursing Implementation • Acute intervention – Frequent assessment necessary – Assess vital signs and signs of fluid and electrolyte imbalances frequently for first 24 hours – Take daily weights – Administer corticosteroid therapy diligently • Protect against infection – Assist with daily hygiene – Protect from extremes • Light • Noise • Temperature – Patient cannot cope with these stresses due to the inability to produce corticosteroids
- 47. Education for patient • Situations requiring corticosteroid dose adjustment include • Fever • Influenza • Tooth extraction • Physical exertion • Death in family • Any type of extreme
- 48. Pheochromocytoma
Editor's Notes
- #3: Master Gland= regulates everything = regulates glandular activity if go wrong effects hormones throughout your body Posterior pituitary – secretes oxytocin – cervical dilatation – uterus to contract during delivery – let down of milk in breast feeding ADH= vasopressin = regulates water is retained in vascular space – Anterior pituritary = growth hormone = ACTH (stimulates adrenal)= TSH Thyroid stimulating hormone = gonadotrpic hormones = FSH follical stimulating hormone Luitinizing hormone prolactin – necessary after childbirth – breast feeding
- #4: Overproduction of growth hormone = acromegaly Middle age c/o change shoe size change significantly over a period of time, trouble sleeping, toung thicker, changes in facial features = always middle age, after epipheaseal plate closes – boney and soft tissue enlarges esp. in face and head speech diff. sleep apnea bc of it, upper airway narrowing, can have peripheral neuropathies, bc benign tumor = overgrowth of bone and soft tissue (both genders equal get HA and migrains due to tumor giving pressure and visual disturbances Look at: at risk for = growth hormone mobilizes the fat stored for energy so it increases the fat in the blood (freeing up fat sotres) GH antagonizes the action of insuling, over secretion of GH and it antagonizes insulin will have high blood sugars (hyperglycemia) can end up w/glucose intolerance life expectancy can reduce from 5-10 yrs if not txed, cardiac resp dz diabetes and higher risk to colorectal cA also
- #5: Xray look tumor Physical exam look at features and what they tell you Glucose challenge test Tumor taking up space in brain, increase ICP
- #6: 2 GH attained then oral glucose given then check 30 60 and 2 hr, if normal you will have a drop in BS w/acromegaly no drop sometimes it will increase
- #7: Preop lifelong replacement of hormones can be perm loss. Risks HOB elevated 30 deg no coughing no sneezing blow nose any stimulation that could cause closure area to break open, that is open to the brain --- risk infection (meningitis) - cannot brush teeth for 14days no brushing teeth for 14 days Radiation shrink tumor (ppl too high risk for surgery) can use in combination shrink first then so surgery radiation w/drug therapy Actreotid (sandostatin) also used w/ GI bleeding given SQ for a week, receptor binding drug to try to reduce tumor Over all goal return hormones to normal
- #8: Put on ABX Kept on bed rest Leak will seal again If not will go in and reseal
- #9: Concentration of osmotically active particals in solution If see a lot of fluid loss as compared to what is going in send for serum osmolarity – if very low then you are dealing w/diabetes insipatus) give ADH to tx
- #10: Here we have Soggy Sid, and he has SIADH, a condition that continually releases the antidiuretic hormone (ADH). With increased ADH, the body retains water and gets so soggy that water intoxication may occur. Sid’s cap is hiding his bandaged head from a head injury, which is a major risk factor for SIADH. Due to his cerebral edema, he is prone to seizures. Notice his limbs are small. There is no obvious edema, yet he has gained weight in his body. The intake and output record will document low urinary output because he’s keeping it all on board. The urine specific gravity will be high. The serum sodium will be decreased (dilutional). Limit Soggy Sid’s fluid intake. He may be given diuretics to assist with fluid excretion, especially if he has respiratory or cardiac problems. Keep Soggy Sid’s bed flat or only slightly elevated. This position of his head will decrease the secretion of ADH. Keep the neuro checks going. Soggy Sid is in serious condition. Very low sodium and low chloride Urine is very concentrated Renal function is completely normal *** Skinny legs and arms Edema is in the middle Def wt gain Seen a lot in malignancy (small cell lung CA) many times how they are Dx – Lmit fluid intake Check sodium ??? Raise HOB helps release ADH
- #11: Diagnosis is made by simultaneous measurement of urine and serum osmolality. Dilutional hyponatremia is indicated by a serum sodium less than 134, serum osmolality less than 280mmol/kg, and a urine specific gravity greater than 1.025 Will measure the serum osmolality 280 mm/kg listen to recording Urine specific gravity 0.125
- #12: Treatment is directed at the underlying cause. Avoid medications that stimulate the release of ADH. The immediate goal is to restore normal fluid volume and osmolality. If symptoms are mild and the serum sodium is greater than 125 the only treatment may be to restrict fluids to 800 to 1000 ml per day. In severe cases those less than 120, and with neurological symptoms,** intravenous hypertonic saline solution 3% may be administered. This requires a slow infusion rate on a pump to avoid increasing the serum sodium level too rapidly. 120-125 ml hr if to fast can go opposite cause seizures coma death – then draw another level see where they are A loop diuretic such as furosemide may be useful to promote diuresis but only if the sodium level is at least 125. fluid restrictions are also indicated in severe hyponatremia. Find underlying cause : metabolic / tumor/ or medication / don’t give anything that will stimulate ADH
- #13: Neurologic prob = don’t have the production of deficiency Nephrologic – lack of response to ADH Depending on cause can be transient or life long condition Can be central or neurogenic DI same thing Nephrogenic renal kidneys
- #14: Increase in urine output USG specific gravity dropped Lithium Thinking DI (diabetes insipidus )
- #15: Central Neurogenic DI : Nephrogenic DI Steroids : hold on to fluid then come off will pee it all out later Alcohol Nephrogenic
- #16: Psychogenic – primary less common = assoc w/excessive water intake = due to leasion or other psychological prob. Continued need to drink water will go into a state of DI and become hypernatremic RARE
- #17: Water deprivation test to diagnose DI – Clarification: page 1161 – Patients who have central DI or neurogenic DI will have an increase in urine osmolality and a significant decrease in urine volume after being given the desmopressin acetate (DDAVP) this is what is meant by the 9% rise. Nephrogenic DI will not be able to increase urine osmolality due to inability to respond appropriately. Refer to table 49-3 page 1161 Osmolality refers to the number of dissolved particles per unit of water in urine. It is a more accurate measure of urine concentration than specific gravity, especially when diagnosing renal disorders. Normal value 500 to 800 mOsm/L
- #18: Blance do not want to go into fluid overload Hypernatremia cannot correct too fast : can cause all the issues as the hyponatremia I&O hr / wts daily v/s at least q hr Central DI fluid and hormone replacement are Tx orally of IV depending on condition Hypotonic saline dextrose d5 Titrated to replace fluid ML to ML Desmopresin DDAvP analog of ADH replacement of choice (hormone) nasal IV Orally central DI Vasopressin can be used also Nephrogenic GI – diatary – low sodium , thiazide diuretics, hydrodiuril, or diuril can be used If not work Utilize Indocin helps induce renal responsiveness to ADH Nursing care: v/s I&O Urine specific gravity Lung sounds Labs ordered and done and looking for results Notify Dr. as coming in
- #19: How will we treat each of these patients?. Fluids and DDAVP (hormone replace) Check lithium levels (stop giving ) get psych may need Indocin to get some response going (lithium is blocking response to ADH Low sodium Hypotonic fluids Close monitoring
- #23: Not getting into the 4 main types of CA painless palp. Nodules Do US as first test can do thyroid scan Show hot or cold (nodules) hot benign (cold nodules have higher chance of being malignant has to do w/the uptake on the scan) If malig take out surgically poss unilateral lobal or bil / total lobectomy Assess Airway obstruction Bleeding And manifestations of hypocalcemia: if nicked Hypocalcemia (parathyroid is close to thyroid)
- #24: Acute inflammation of thyroid gland Recovery in few weeks to months NSAIDS then cortico steroids s If symp will use Tenormin or Inderal If hypothyroid will get
- #25: Everything revved up / hypo everything slowed down
- #26: Thyroid storm what do : if not due to meds BB lower heart rate Fluids No stimulation calm cool If due to meds: Don’t give med and tx like storm then calculate new medication dose Could give thyroid inhibitors if not allergic Tapazol / PTU temporary
- #27: Newly Dx : Tx: Surgical: Parathyroid nick Hypothyroid Airway CA levels Injur Laryngeal nerve Can go into thyroid toxic crisis Infection
- #28: Leakage bleeding in area Bedside: Suction Trach tray (emergency) O2 if need Check tetany = due to CA –due to manipulation or hit parathyroid Want them to speak to you, tell me you name (need to verbalize) if can’t speak = damage to laryngeal nerve (be concerned) Look for drooping also
- #29: Not enough thyroid hormone Destruction of thyroid tissue And secondary issues exist
- #30: Myxedema / Hypothyroid More in older adults / 5x more in women than men Exopthalamus Gains wt Sleep all day Cold all the time (severe cold intolerance
- #31: Puffyness Periobital edema Mask like effect Hair loss Cold intolerance Brittle nails Course sckin Muscle weakness Swelling Wt gain
- #32: Medical emergency = extreme of symptoms of hypothyroid Lead to unconscious ness and coma Tx w thyroid replacement If untx Go into Cardo collapse = hypoventilation , hyponatremia, hypoglycemia and lactic acisosis – die
- #33: Older adults or cardiac issue – started on lower doses initially = can increase myocardial O2 demand If experience chest pain report EKG done and Cardiac enzymes done immediately If pt comes in and on Synthroid get Thyroid level
- #34: Primary Over secretion is increased CA level Secondary Chronic kidney pts Vitamin deficiency due to impaired absorption Tertiary – no negative feedback – transpland or long dialysis Loss of appetite Fatigeed Loss of bone Kidney stones Fractures Parathyroid elevated Ca level can exceed greater 10 Phosphorus levels less than 3 Tx on how severe If take out parathyroid – rapid reduction of CA level – Criteria for surgery Ca level > 12 Markedly reduced bone density Take out part or all May try autotransplantation of a normal part of parathyroid put in the forearm or the sterno where still produce PTH to help normalize hormones If fails will CA supp for ever Calcamimetic (sensipar) agents : increase the sensitivity of Ca receptors that decrease PTH secretion and CA drug levels Used often If have surgery Monitor Hemorrhage f/E disturbance Tetany : mild – if becomes more severe ca gluconate
- #35: Hypo Calcemia not enough PTH not common Tetany tingling of lips Extreme stiffness of ext. Painful tonic spasms Dysphasia Constriction of throat (feels like ) Tx iv CA in emergent phase Monitor EKG Long term therapy Oral Ca supp and Vit D High Ca meal plan Accidentally had parathyroid removed w/thyroid removed
- #36: Factory for steroid hormones many synthesized and secreted here Mineral and Glucocorticoid
- #37: Excess of glucocorticoid most common cause : long term corticosteroids High sodium level (feature) Low potassium Have to watch heart – (arrhythmias) And infection – very diff to heal
- #39: Soemtimes just drug mizorol or sidodren Usually from a tumor and end up surgery if it is a primary If long term corticosterioid use : can do gradual d/c use to qod to improve condition
- #41: Very ill if surgery HTN or Hyperglycemia need optimal control w/ insuling meds before surgery Hypocalcemia need to be electrolyte balance before surgery Iv therapy (central line ) monitor central venus pressure DVT prophylaxis Adrenal very vascular high risk hemorrhage Manipulation can make them leak hormone out risk hypertension or hypotension have to watch High doses iv corticosteroids – to have adequate response to stressors monitor B/P hypertensive (risk for bleeding Risk for infection due to steroids Delayed wound healing
- #42: Primary adrenal glands themselves Secondary is function hypothalamus
- #43: Infection Vascular prob Surgical removal of adrenal glands Reaction to medication Can trigger this Vascular causes thromobosis – condition trigger hemorrhage sepsis Antifungals rifampin phenotonin phenobarbital Corticosteroids too fast coming off can put you into addisons dz
- #44: Craves salt = low sodium hyponatremia = low b/p K higher can be hyperkalemic Hypoglycemic Tired and weak Under stress worse May stay in bed all day If not eating N/V diarrhea become dehydrated lose wt much more severe bronze color to skin – r/t increase melanocytes stimulating hormone so increased levels To preven crisis : must replace hormones for him (corticosteroids) if go into adisonian crisis it is fatal With that then will be extremely Hypotensive tachycardic hyponatremic hyperkalemic sever (listen to before 56 fever confused and weak If not tx immed w/fluid will lead to shock Circ collapse w/further renal insufficiency can be unresponsive lead to death Tx w/ cortico steroids
- #45: Taught how to increase steroids (change depending on what stress is going on) there is a kit
- #47: Like w/ hyperthyroid cannot respond to extremes Quiet mannor im going to turn on light
- #48: Glucocorticoids dived 2/3 in am 1/3 in afternoon Mineral corticoids 1xday in am (preferred reflects the circadian rhythm of your own hormones and decreases s/e) Teach how to deal w/stress
- #49: Article is in d2l