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STEP 2CK Review > 10 Endocrinology > Flashcards

10 Endocrinology Flashcards

1
Q

Female pt presents with galactorrhea and amenorrhea.

How to workup?

A

DDx:

  1. prolactinoma
  2. hypoT (leads to high TRH, stimulating prolactin)
  3. DA blockers (antipsychotics)
  • taking antipsychotics?
  • get TSH, Prolactin

If prolactin elevated, get MRI

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2
Q

prolactinoma

-tx med

A

bromocriptine, cabergoline (DA agonist)

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3
Q

Acromegaly

-how to workup

A

workup:

  1. high IFG-1 (GH varies too much during day, even though tumor secretes this)
  2. glucose supproession test (does giving glucose lower GH?)
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4
Q

Acromegaly

  • what kills them
  • tx, medical
A
  • cardiomegaly and diastolic HF

- somatostatin (octreotide) before surgery

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5
Q

Hormones of ant pit (5) vs post pit (2)

A

post pit has 2: oxytocin, ADH

ant has the rest:
GH, TSH, ACTH, LH/FSH, Prolactin

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6
Q

chronic hypopituitarism

  • how does it present?
  • how to dx
  • tx
A

Less important hormones lost first: LH/FSH and GH, then TSH, then ACTH (BP)

So, first is reduced libido and menstruation, fatigue, vague sxs

  • insulin stim test (induce hypoglycemia, does GH increase?)
  • MRI to confirm, replace hormones
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7
Q

Acute hypopituitarism

  • what 2 dx to know, how present?
  • tx?
A
  1. sheehans–ischemic pituitary post-partum
    - reduced lactation post-partum is 1st sign
  2. apoplexy–pit tumor outgrows blood supply, bleeds
    - rapid decompensation–Think sudden HA with vision change and N/V, followed by adrenal insuff, lethargy, coma. Catastrophic.

Tx: replace hormones! (esp cortisol, T4)

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8
Q

MRI shows no pituitary. what is going on

A

Empty Sella syndrome.

pituitary is located somehwere else.

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9
Q

Male pt presenting with low libido and vision change. think what

A

Prolactinoma

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10
Q

Diabetes insipidus tx:
central
nephrogenic

A
  • desmopressin

- gentle diuretics (HCTZ +/- amiloride)

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11
Q

SIADH causes

-think what 3 categories

A
  1. brain–tumor, infxn, trauma
  2. lung–small cell CA, COPD, TB
  3. hypothyroid (high TSH can stim ADH)
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12
Q

SIADH tx

A

tx underlying cause (eg head trauma, etc)

-Demeclocyline to induce nephrogenic DI to get rid of free water

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13
Q

Sick euthyroid syndrome

A

TSH normal, but T4 wacky.

Pt in ICU can get this. Disregard the T4 if TSH is normal!

This is only time to get a rT3 level. (in sick euthyroid rT3 is elevated, confirming sick euthyroid)

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14
Q

When to get free T3 level

A

Only get if you suspect hyperthyroid (low TSH), but T4 is normal/low

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15
Q

What things affect total T4 level? (2 to remember)

A
  1. estrogen (pregnancy) increases proteins (thyroid binding globulin). So, increased total T4
  2. Cirrhosis is low protein. So, low total T4
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16
Q

Female pt with hyperthyroidism sxs. TSH low, T4 high, cold RAIU.

-DDx, and what is next step

A

Suspicious for:

  1. factitious hyperT
  2. struma ovarii
  3. thyroiditis (acute stage)

Get thyroglobulin levels. Elevated with T4 production, so struma ovarri and thyroiditis have elevated thyroglobulin.

If low, then factitious!b Can also do Sestamibi scan of ovaries.

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17
Q

Pt with hyperthyroid sxs. You confirm labs–low TSH, high T4.

What is next step, and what results possible?

A

Do RAIU test

  • diffuse–Graves
  • diffuse nodules–nodular goiter
  • hot adenoma

If thyroid NOT hot, then:

  • Thyroiditis (wait for thyroid to calm down, might be temp hypothyroid)
  • factitious
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18
Q

Hashimoto’s

-how to dx

A
  1. anti-TPO (thyroid peroxidase),
  2. anti-TG (thyroglobulin).
    (these 2 are 90% spec) Definitive is Bx.

Can present with transient hyper and hypothyroidism

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19
Q

Grave’s unique sxs (2) among all hyperT

-how to tx

A
  1. exophthalmos–tx with steroids

2. pretibial edema

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20
Q

Thyroid storm tx in what order, mechs

A

First, IVF and cooling blankets. Then 3 P’s

  1. Propranolol–reduce HR to increase BP
  2. PTU/methimazole–reduce T4 production
  3. Prednisone (more likely IV methyprednisolone)–reduce T4-T3 conversion

Iodide can also be used (Wolff-Chaikoff). Thyroid preferential picks up iodide instead of making T4, so temporizing measure. However, if thyroid storm not fixed, that iodide will be used to make more T4! (Wolff-Chaikoff escape)

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21
Q

Thyroid storm, what alarm sxs?

A

Alarm sxs:
Fever
Delirium
Hypotension

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22
Q

Pt with hyperthyroidism. TSH low, T4 high.

How to know if this is Graves or early Hashi’s?

A

ESR/CRP is elevated in Hashi’s only

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23
Q

Thyroid nodule

-how to workup

A

Get TSH first, even if asx. If euthyroid, then get FNA.

If obvious dx is CA (hx of neck CA), then go straight to excision.

24
Q

Papillary cancers:

what to remember about each

A

PFA-M

Papillary–MCC. orphan annie, psammoma, resection with good prognosis

Follicular–“sneaky.” FNA cannot dx, spreads hemotogenously. However, full resection and iodine ablation will find and kill all mets.

Anaplasic–bad, chokes esophagus and trachea. Death 1 yr

Medullary–MEN 2a/b, Calcitonin producing (so HypoCa)

25
Q

MEN syndromes

A

diamond, square, triangle with tip

MEN 1–pit, parathyroid, panc
MEN 2a–parathyroid, thyroid medullary, pheo
MEN 2b (lincoln–tall)–mucosal, thyroid medullary, pheo

26
Q

rT3 level

A

Only get if suspect sick euthyroid. will be increased, confirming sick euthyroid

27
Q

thyroglobulin level

-how does this correlate with other thyroid labs

A

Thyroglobulin is increased when T4 production is increased. So, you can use to see factitious hyperT

28
Q

Thyroiditis

-name types and differences

A

All can present with transient hyperT (can be months), then transient hypoT.

  1. Hashi’s–stays hypothyroid
  2. de Quervain (tender thyroid)
  3. silent lymphocytic–eventually recovers.(in hypothyroid state, distinguish from Hashi’s with Ab tests)
29
Q

New Grave’s dx

-what meds

A

Propranolol first, PTU/methimazole takes time for effect

Prednisone for exophtalmos

30
Q

Hyperthyroidism meds in pregnancy

A

‘PTU in Pregnancy’ but more complicated:

PTU in 1st trimester and women who might become pregnant

Methimazole in 2nd/3rd trimester to reduce liver complication risks that PTU has

31
Q

Nuclear emergency, what med

A

Potassium Iodide. Blocks uptake of radioactive iodide in nuclear emergency

32
Q

Pt with thryoid nodule, asx, euthyroid. FNA is equivocal. Do what next?

A

RAIU when FNA equivocal.

If cold area, tx as CA
If hot area, tx as toxic adenoma

33
Q

Follicular thyroid Ca, CT does not show mets

-how to tx

A

General rule–total thyroidectomy, then radioactive iodine (kills all possible mets)

34
Q

you suspect hypercortisolism

-DDX and full workup algorithm?

A

“Low THen High”
4 DDx: Adrenal adenoma, extra-adrenal tumor, pituitary tumor, exogenous steroids

  1. low-dose DST overnight, or 24h urine cortisol.

If not suppressed, Cushing’s syndrome confirmed. Do:
2. ACTH

If low, then primary-hypercort–adrenal tumor or exogenous steroids. MRI/CT.

If high, then:
3. High dose DST
If cortisol suppresses, then Pit tumor. MRI/inferior petrosal sinus sampling.
If cortisol not suppressed, then Ectopic ACTH (small cell/panc CA)

35
Q

You suspect hyperaldosteronism

  • DDx
  • Workup algorithm
A

DDx: primary (Conn’s) vs secondary (renovascular, CHF, cirrhosis, nephrotic)

  1. 8am Aldo, Renin, Aldo:Renin. D/C HTN meds beforehand.

Aldo high, Renin high, Aldo:Renin<10: Likely 2ndary. Do Angiogram of renal arteries.

Aldo high, Renin low, Aldo:Renin >20: Likely Primary. Next step:
2. Salt Suppression Test. If Aldo not lowered, then confirm primary. CT/MRI to find tumor.

36
Q

Hyperaldosteronism. You confirmed primary with Salt suppression test. Now you do CT/MRI looking for adrenal tumor.

What to be careful about

A

50% of hyperaldo pts have incidentaloma. Don’t cut out GOOD ADRENAL

Use Adrenal Vein sampling to confirm mass is indeed the adenoma.

37
Q

Pheo

5 P’s, +2 more

A 
Pressure--BP high
Pain--HA or chest
Palpitations
Pallor--vasoconstriction
Perspiration

Add 2 more P’s:
phentolamine
phenoxybenzamine

38
Q

Pheo

  • what dx tests (2)
  • what if tumor does not appear on CT/MRI
A 
24h urine metanephrines (better test), or 
Urine VMA (cheaper)

If CT/MRI doesn’t show, use a MIBG scintillography scan. Can also do Adrenal vein sampling.

39
Q

You see an adrenal incidentaloma

  • Do what tests
  • what size importance
A

R/o the 3 main tumors:

Conn’s–Aldo, Renin
Pheo–24h urine metanephrines/urine VMA
Cushing’s–low dose DST

If <4cm, can observe. >4cm or increase in size over time, intervene.

40
Q

You suspect Adrenal insuff:

how to workup?

A

Main ddx: Addison’s vs Pit issue

  1. 3am cortisol. If low, then:
  2. ACTH (cosyntropin) stim test, measure cort in 60min

If cort still low, then primary. CT/MRI abd, replace hormones

If cort high, then secondary. MRI head

41
Q

Adrenal insuff:

-tx of primary vs secondary

A

Primary (Addison’s, TB):

  1. prednisone
  2. fludrocortisone

Secondary (Pit issue)
1. prednisone only

42
Q

Migratory necrolytic dermatitis

-what’s going on

A

If pt also has DM, then this is Glucagonoma! CT to find it, resect.

Can also get glucagon level

43
Q

You suspect insulinoma

  • how to dx and confirm
  • how to know not factitious?
A

72h fast, with monitoring for sxs (including sz). Confirm with somatostatin receptor scintigraphy (SRS) test +/- CT scan.

Factitious can be exogenous insulin and sulfonylurea.

  • C peptide level (low in exogenous)
  • sulfonylurea level
44
Q

Diabetes dx tests (3)

A
  1. Random BGx1, with sxs
    200+
  2. Fasting BGx2
    125+ both times= DM
    100-125: do 2h OGTTx1:
200+ = DM
140-200 = pre
<140 = normal
  1. A1C
  2. 5+ = DM
  3. 7 - 6.5 = pre
45
Q

T2DM pts:

  • goal A1C?
  • Oral meds max A1C reduction
  • insulins max A1c reduction
  • What A1C to start insulin?
A

goal <7%

oral: -3
insulin: -7

start insulin at A1C of 9

46
Q

T2DM treatment approach

A
  1. lifestyle + Metformin
  2. if 3 mo not at goal, add 2nd agent, based on comorbidities
  3. if 3 mo again, not at goal, start insulin.
47
Q

metformin

-contraindications (3 to know)

A

CKD (Cr >1.5 males, 1.4 females)
CHF
Liver dz

48
Q

side effects and contraindications:

metformin
sulfonylureas
TZDs

A
  • diarrhea (goes away)
  • CKD (lactic acidosis), CHF
  • hypoglyc
  • reduced dose in CKD (b/c hypoglyc risk)
  • weight gain, CHF risk
  • CHF
49
Q

T2DM uncommon med classes

  • class names
  • ex brand names
  • side effects
A
  1. DPP4-i (sitagliptin)
  2. GLP-i (exenatide)
  3. acarbose
  4. SGLT2-i (canagloflozin)
  5. weight neutral
  6. weight loss
  7. diarrhea, flatulence
  8. DKA risk
50
Q

Outpt insulin regimens

-what are the 2

A
  • basal-bolus

- mixed (‘idiot insulin’): 2x/daily 70/30 humulin or novolin

51
Q

Inpatient diabetes

-how to do it the right way

A

Basal bolus (+Sliding scale). Remove oral meds.

  1. Calculate TDI (total daily insulin) = 0.5U/kg unless Cr high. If TDI
52
Q
  1. Somogyi effect, vs
  2. Dawn phenomena
    - how to diff
A
  1. (rebound hyperglyc) too much insulin at night, high AM glucose. Body responded by making more glucose, then insulin wore off by AM.
  2. to little insulin at night, high AM glucose.

Check 3AM glucose to diff!
If high, then Dawn
If low, then Somogyi

53
Q

DKA management:

-describe main steps to discharge

A
  1. start NS, check e-lytes
  2. If K <4.0, give KCl and don’t give insulin yet
  3. K good, Give insulin.
  4. keep giving insulin until AG closes. If hypoglyc, switch to D5 1/2NS
  5. once AG closed, stop insulin drip and bridge with long-acting SQ insulin. Have pt eat. If AG still closed, go home.
54
Q

Young adult, no hx diabetes, comes to ED for polydipsia, polyuria, fatigue.

Suspect what, check what labs

A

Could be DKA vs HHS

Glu: 300-500
BMP: AG
ABG: acidosis
ketones (serum, urine): +

Glu: 800-1000
BMP: no AG, but possible contraction alkalosis! Also pseudohypoNa.
ABG: no acidosis
ketones: -

HHS: could see metabolic alkalosis (contraction) causing slow breathing, leading to hypoxia and hypercapnia (intubate!). Coma, unresponsive.

55
Q

Diabetes pts

-what things to check routine, how (3)

A
  1. eyes. q1yr eye exam
  2. peripheral neuro. monofilament exam
  3. renal: microalb/Cr ratio

STEP 2CK Review (20 decks)

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