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STEP 2 ENDOCRINOLOGY > Additional Flashcards > Flashcards

Additional Flashcards

1
Q

Increased PTH drives ____ (? increase, decrease) in sr. Ca2+ and ____ (? increase, decrease) in sr. PO4 levels in ______.

A

↑ PTH –> ↑ sr. Ca2+ & ↓ sr. PO4 in primary HyperPTH

*primary HyperPTH seen in
-single hyper-functioning adenoma (80%)
-Parathyroid hyperplasia (15%)
-PTH carcinoma (~5%)

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2
Q

Secondary hyperPTH is driven by ___.

A

hypocalcemia that may be caused by

-Dietary calcium deficiency
-dietary/pathological Vit D deficiency
-*renal insufficiency (sr. PO4 levels are ↑)

*renal insufficiency–> ↓ Vit D production–> ↓ dietary ca2+ absorption

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3
Q

Tertiary Hyper PTH due to ______ seen in _____, and is marked by __ in sr. levels of ca2+, PO4, and PTH.

A

d/t hyperplasia and autonomous hyperactivity of PTH gland seen in pts. with long standing secondary hyperPTH on dialysis;

marked by ↑ serum levels of all three (PTH, calcium and phosphate); phosphate is high because kidneys are unable to execute increased excretion of phosphate under PTH influence.

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4
Q

In ectopic PTHrP secretion (lung or breast malignancy), serum PTH levels are ____ in setting of very high sr. ca2+ and normal/low sr. PO4.

A

serum PTH levels are ↓ in setting of ↑↑ sr. Ca2+ and normal/↓ sr. PO4.

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5
Q

What are the s/s a/w hypercalcemia?

A

stones, bones, moans, groans, and psychiatric overtones.

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6
Q

What is the initial m/m of acute hypercalcemia?

A

IV fluids (first-line t/t),

and IV calcitonin

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7
Q

____ is used for long term t/t of hypercalcemia.

A

IV bisphosphonates.

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8
Q

Hypercalcemia d/t malignancy is usually t/t with _____.

A

bisphosphonates.

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9
Q

What is the first-line t/t of symptomatic/moderate-severe Paget’s disease of the bone?

A

Bisphosphonates

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10
Q

Pts. with Paget’s disease of the bone who are intolerant to first-line bisphosphonates, can be t/t with ____.

A

Calcitonin.

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11
Q

In addition to osteoarthritis and pathologic fractures, what are some other serious complications of Paget’s disease of the bone?

A

-High-output cardiac failure (d/t AV connections),
-Osteosarcoma (1% cases).

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12
Q

Increased sr. Alkaline phosphatase with increased sr. Gamma-glutamyl transpeptidase (GGT) are suggestive of _____ (? liver, bone) pathology.

A

Bone pathology e.g. Paget’s disease of the bone.

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13
Q

In Paget’s disease of the bone, Sr. Ca2+ and Sr. phosphate levels are ___ (? increased, normal, decreased).

A

normal;

Abnormal in Paget’s disease
-Sr. Alkaline phosphatase
-Sr. GGT levels

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14
Q

What are some medications other than the best initial t/t agents bisphosphonates that can be used in t/t of osteoporosis?

A

-PTH analogues (Teriparatide) act as PTH proxy, and reduce bone resorption.

-Denosumab: monoclonal Ab to RANK-L

-Raloxifene: selective estrogen R modulator.

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15
Q

Osteoporosis is the most common cause of pathological fractures in women with _____, and men over age ____ yrs.

A

-in women with low-body weight, and
-in men over age 60 yrs.

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16
Q

What are the s/s of Paget disease of the bone?

A

Mostly asymptomatic and require no t/t;

for s/s remember MNEMONIC: Paget’s PANICS!

-Pain: bone pains
-Arthralgia
-Nerve compression (e.g. deafness)
-Increased bone density
-Cardiac failure (high-output)
-Skull involvement/Sclerotic vertebra/e

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17
Q

Osteoporosis is confirmed with a DEXA T-score of _____.

A

2.5 SDs less than normal.

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18
Q

DEXA T-score of 1-2.5 below normal is indicative of ____.

A

Osteopenia.

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19
Q

DEXA screening scan is recommended for _____.

A

-women > 65 yrs age,
-men > 70 yrs. of age
-pts. with other risk factors for osteoporosis.

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20
Q

Distal radius fracture (Colles fracture) following minimal trauma in an elderly pt. is suggestive of ___.

A

Osteoporosis.

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21
Q

Defect in bone mineralization often caused by severe Vit D deficiency leads to ____, manifested by bone pains, _____ serum Ca2+ and PO4, and ____ PTH levels.

A

Osteomalacia; manifested by bone pains, low serum Ca2+ and PO4, and elevated PTH (Secondary HyperPTH).

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22
Q

How do TRH and or TSH affect PRL hormone secretion?

A

TRH directly stimulates PRL, whereas
TSH *indirectly stimulates PRL via dopamine pathway.

*TSH –> inhibits dopamine —> relieves dopamine’s inhibitory effect on PRL.

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23
Q

GnRH is inhibited by which anterior pituitary hormone?

A

PRL (thus causing lactational amenorrhea).

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24
Q

What is the effect of somatostatin (SS) on GH and TSH?

A

Both are inhibited by SS.

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25
Q

A pt. with familial hypocalciuric hypercalcemia (FHH) will have ___ lab profile.

A

-Elevated sr. Ca2+, elevated Sr. Mg2+
-Low ur. Ca2+ (unlike other abnormal hypercalcemic states in which the kidneys filter out ↑↑ Ca2+ –> hypercalciuria).
-Normal/mildly ↑ PTH

*FHH is a rare AD disorder d/t LOF mutation of calcium sensing receptors (CaSR) in PTH gland, kidneys etc, reducing their sensitivity and thus increasing their set point for Ca2+ sensing. So increase in PTH occurs at higher levels of sr. calcium; kidneys keep on reabsorbing Ca2+ and Mg2+ until their higher levels in serum –> maintaining hyperCa2+ and HyperMg2+.

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26
Q

In _____, an inherited disorder, both the PTH gland and kidneys are insensitive to increase in sr. Ca2+ levels d/t decreased sensitivity of the Ca2+ sensing R’s in the same.

A

FHH.

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27
Q

Severe hemorrhage (anywhere in the body) leading to pituitary infarction causing panhypopituitarism is known as _____, and is commonly seen after _____ hemorrhage.

A

Sheehan syndrome; postpartum hemorrhage.

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28
Q

Pituitary apoplexy results d/t ___.

A

Pituitary hemorrhage.

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29
Q

Which pituitary hormones are usually affected first in hypopituitary pathology?

A

Gonadotropins and GH.

*p/w hypogonadism in adults/adolescents, and growth retardation in children.

MN: GnRH and GH are Gone first in hypopituitarism!

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30
Q

What is the normal A.M. serum cortisol range?

A

3-25 mcg/dL.

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31
Q

Adrenal insufficiency is likely at serum cortisol levels of less than ____.

A

3 mcg/dL–> confirm etiology with ACTH levels.

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32
Q

lack of hyperpigmentation is characteristic of _______ adrenal insufficiency as ACTH levels are low.

A

Secondary adrenal insufficiency.

*unlike in primary adrenal insufficiency, ACTH levels are high leading to hyperpigmentation as ACTH is co-stimulatory of MSH.

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33
Q

ACTH stimulation test (aka Cosyntropin test) is indicated when AM cortisol levels are between ____ mcg/dL.

A

3-18 mcg/dL.

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34
Q

____ is the test of choice to diagnose hypothyroidism d/t hypopituitarism (aka secondary hypothyroidism).

A

Free T4;
TSH must be checked concurrently but TSH is not diagnostic as its levels may be normal or even high in sec. hypothyroidism.

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35
Q

Before starting levothyroxine for secondary hypothyroidism d/t TSH deficiency, ____ must be tested to rule out ______ to prevent adrenal crisis.

A

sr. ACTH levels must be tested to rule out ACTH deficiency because levothyroxine increases cortisol clearance, and can precipitate adrenal crisis in pts. who are already ACTH deficient.

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36
Q

___ should be suspected in a new onset HTN pt. with hypokalemia.

A

Primary hyperaldosteronism.

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37
Q

A pt. with new onset HTN develops hypokalemia upon initiation of t/t with diuretics. What is the most likely cause of his HTN.

A

Primary hyperaldosteronism.

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38
Q

The best screening test for primary hyperaldosteronism is _____. Positive tests must be confirmed with _____.

A

Early morning *PAC: PRA > 20 (& PAC > 15 mg/dL) is suggestive of primary hyperaldosteronism.

Confirm positive tests with aldosterone suppression (salt loading) test. In absence of local adrenal pathology, salt should suppress aldosterone secretion. If Sr. PAC still high–> confirm adrenal pathology with imaging (CT).

*plasma aldosterone conc. to plasma renin activity

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39
Q

In a pt. with PAC/PRA > 20, and an abnormal aldosterone suppression test, what is the next step in confirming the diagnosis of primary hyperaldosteronism.

A

adrenal CT scan.

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40
Q

In a pt. with suspected of primary hyperaldosteronism in whom CT scan does not reveal a discrete unilateral mass (adenoma)_____ must be done to differentiate between an adenoma and hyperplasia.

A

Adrenal venous sampling.

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41
Q

In a pt. with hyperosmolar hyperglycemic state (HHS), pH, sr. HCO3 and anion gap are ______ (? elevated, decreased, normal).

A

normal pH,
normal sr. HCO3, and
normal anion gap.

-normal/slightly ↑ serum ketones.

ABNORMAL:
-RBS > 600 mg/dL (frequently > 1000 mg/dL)
-Sr. osmolality > 320 mOsm/kg

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42
Q

What is the initial/immediate step in m/m of a pt. in HHS?

A

-Rehydration with IV *NS, and
-start Insulin infusion if **sr. K+ > 3.3 mEq/L
-add K+ to IVF if sr. K+ < 5.3 mEq/L

*use 0.45% NS if corrected sr. Na+ levels are normal/high after the second/third hour, or the pt. is eunatremic/hypernatremic at presentation.
Corrected Sr. Na+ =
Measured Sr. Na+ (mEq/L) + 2 mEq/L for every 100 mg/dL of glucose level at sr. glucose levels of > 100 mg/dL.

** If sr. K+ < 3.3 mEq/L, then withhold Insulin until Sr. K+ levels are raised to > 3.3 mEq/L through IV K+ replacement.
K+ replacement must continue so that levels are > 5.3 mEq/L. Insulin can be started at sr. K+ levels > 3.3 mEq/L.

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43
Q

In addition to the initial m/m with IV NS, what is the mainstay t/t of HHS?

A

IV Regular Insulin.

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44
Q

Serum K+ must be replaced during m/m of HHS with insulin, if levels are below ____. Why?

A

If sr. K+ levels are < 5.3 mEq/L;
because Insulin will rapidly drive K+ into the cells inducing hypokalemia in an already total K+ deficit state seen in HHS.

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45
Q

____ modality of t/t leads to a transient worsening of Graves opthlamopathy d/t increase in the titers of ____ after t/t initiation.

A

RAI;
d/t increase in titers of Thyrotropin receptor antibodies (TRAb) on TSH receptors on retro-orbital fibroblasts and adipocytes, during initial t/t phase.

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46
Q

____ can be used to prevent RAI-induced worsening of opthalmopathy in graves disease.

A

Glucocorticoids

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47
Q

In m/m of DKA, serum pH, electrolytes, and anion gap must be monitored every _____ hourly, and serum glucose must be monitored every ___ hours.

A

serum pH, electrolytes, and anion gap must be monitored every 2-4 hours, and

serum glucose must be monitored hourly.

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48
Q

_____ is the best index to monitor the response to t/t in DKA.

A

serum anion gap.

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49
Q

After initial infusion of IV NS in DKA, half NS (0.45%) can be started when sr. Na+ levels are _____.

A

≥ 135 mEq/L.

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50
Q

Dextrose can be added to infusion when sr. glucose levels reach ____ in t/t of DKA with IV insulin.

A

Add Dextrose when Sr. glucose < 200 mg/dL.

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51
Q

In m/m of DKA, Insulin infusion must be put on hold if sr. ____ levels are ______.

A

Withhold Insulin infusion, if Sr. K < 3.3 mEq/L.

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52
Q

Sr. K+ must be replaced if serum levels are below ___ in DKA.

A

< 5.3 mEq/L.

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53
Q

Insulin infusion must be reduced when sr. glucose levels reach ___.

A

below 200 mg/dL.

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54
Q

In DKA m/m, IV Insulin can be switched to subcutaneous Insulin when _____.

A

resolution of DKA achieved evident by normal AG, and pt. is able to eat.

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55
Q

When is sodium-bicarbonate administration indicated in t/t of DKA?

A

in severe DKA with blood pH ≤ 6.9.

*normal pH is 7.35-7.45.

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56
Q

Trans-sphenoidal resection of a prolactinoma is considered in pts. with _____.

A

very large tumors (size > 3 cm) or in symptomatic pts. who responded poorly to medical t/t with dopamine agonist such as cabergoline or bromocriptine.

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57
Q

A pituitary adenoma with sr. PRL levels > 200 ng/dL or repeat level > 200 ng/dL, suggest a ____.

A

Prolactinoma.

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58
Q

A pituitary microadenona is ___ in size, and macroadenoma is ___ in size.

A

pituitary microadenona: < 10 mm;
pituitary macroadenoma ≥ 10 mm (1 cm).

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59
Q

Initial t/t with dopamine agonists such as cabergoline or bromocriptine is considered in pts. with a ___ prolactinoma.

A

macro-prolactinoma, or symptomatic pts.

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60
Q

Which CNS tumor that p/w headache, visual disturbances along with s/o hypopituitarism d/t anatomic compression has a bimodal age distribution?

A

Craniopharyngiomas

*present between 5-14 yrs, and 50-75 years.

*Adamantinomous type in pediatric populations, and papillary type in adults.

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61
Q

What is the difference between Somogyi effect vs Dawn phenomena?

A

Somogyi effect is
-A.M. rebound hyperglycemia d/t midnight hypoglycemia in diabetics.
-t/t by reducing evening insulin dose.
-3 am blood glucose levels will be low.

Dawn phenomena is
-A.M. hyperglycemia d/t normal diurnal ↑ in counter regulatory hormone secretion (GH, cortisol) after midnight.
-3 am blood glucose is normal/↑.

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62
Q

Bradycardia, irregular respirations, and a widened pulse pressure in a pt. with neurological s/s are indicative of ___, and termed _____.

A

High ICP (intracranial pressure);

termed Cushing’s triad.

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63
Q

____ is the leading cause of death in children with DKA, and occurs in about ___ % of presenting cases.

A

Cerebral edema; 0.2-1 %

*AVOID/PREVENT by SLOW administration of IVF and insulin so as to correct effective osmolarity over a 36-48 hr period.

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64
Q

Cerebral edema in DKA results from ?

A

-rapid reversal of hyperglycemia induced osmolar shifts with IVF + Insulin

-cerebral vasoconstriction d/t acidosis and hypercapnia

-cytotoxic edema

-reperfusion injury with vasogenic edema during rehydration phase of DKA t/t.

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65
Q

What factors increase the r/o cerebral edema in DKA pts.?

A

pts. with

-High initial BUN
-Low initial PCO2
-t/t with *bicarbonate
-refractory hyponatremia even as blood glucose levels are improving.

*some experts recommend administering bicarbonate only if pH is < 7.0

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66
Q

In absence of oral or IV access, ___ can be given to t/t severe hypoglycemia in a pt.

A

IM Glucagon.

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67
Q

What are the 2 main categories and their progress of hypoglycemia symptoms?

A

Neuroglycopenia —> adrenergic (autonomic) activation.

Neuroglucopenic s/s include
-headache,
-blurred vision,
-confusion,
-lightheadedness.

Autonomic s/s include
-sweating
-anxiety
-pounding heart (↑HR)

68
Q

A pt. on beta-blocker therapy may present without typical s/s of hypoglycemia or only _____ symptom when hypoglycemic.

A

diaphoresis as sweat glands have adrenergic activation but cholinergic innervation.

69
Q

Sr. prolactin levels of > 200 ng/dL in a male or a non-pregnant female is most likely d/t _____.

A

Prolactinoma (Pituitary adenoma)

70
Q

Methimazole use during early pregnancy is associated with which congenital defects?

A

-Choanal atresia

-Aplasia cutis congenita

-Duodenal atresia

-Goiter

71
Q

Pregnant women under t/t for hyperthyroidism may be switched back to Methimazole after ____ weeks of gestation.

A

after 16 weeks

*Methimazole must be stopped and PTU started as soon as pregnancy is confirmed and given at least until 16 weeks or beyond.

72
Q

Fruity odor of the breath, abdominal pain, nausea, vomiting and rapid deep breathing (Kussmaul respiration) are more common in _____ than _____ complication of diabetes.

A

more common in DKA than HHS.

73
Q

For pts. motivated to change modifiable risk factors, _____ (? month/year) trial of lifestyle modifications before starting anti-diabetic medications is reasonable.

A

a 3-month trial,

or 6 month trial (in those with HbA1c closer to 7%)

74
Q

_____ is the best initial therapy for adults newly diagnosed with T2DM under what specific conditions?

A

Metformin, under specific conditions that newly diagnosed diabetic pts.
-DO NOT HAVE marked hyperglycemia (eg. sr. glucose > 300 mg/dL or HbA1C > 9.0%), and

-Renal function is normal.

75
Q

First-line anti-diabetic agent Metformin is CI in pts. with?

A

CKD with GFR < 30 mL/min.

76
Q

In newly diagnosed T2Ds with HbA1C > 9.0% or BSL > 300 mg/dL, _______ must be used as initial therapies.

A

Insulin, or

GLP-1 agonist (liraglutide, semaglutide)

77
Q

What is the MOA of metformin?

A

-decreases hepatic gluconeogenesis (most prominent MOA)

-Increases Insulin sensitivity

-increases peripheral glucose uptake

-increases glycolysis (? in enterocytes)

78
Q

Adverse effects of metformin include?

A

-Nausea,

-Diarrhea

-Vit B12 deficiency

-Lactic acidosis (high risk in CKD).

79
Q

____ is an example of insulin secretagogue.

A

Sulfonylureas (eg. Glimepiride, Glyburide, )

80
Q

Non-thyroidal illness syndrome formerly known as _____ marked by low T3, low free T4, and low TSH is seen in ______ pts.

A

Euthyroid sick syndrome (ESS) is seen in pts. with critical illness (eg. ICU pts) with no prior history of thyroid/endocrine disorder.

81
Q

ESS can be seen in ___ percent of critically ill pts.

A

> 75%

82
Q

TFT should be rechecked/reassessed after ____ in pts. with ESS.

A

About 6 weeks after discharge from the hospital.

83
Q

_____ is the most common genetic alteration in thyroid cancer.

A

BRAF mutation: in ~ 45% of sporadic papillary thyroid ca (PTC), esp. aggressive types.

PTC with BRAF mutations may progress to anaplastic thyroid ca.

PTCs:
-account for 70-80% of all thyroid ca’s
-a/w RAS, BRAF, or TRK gene mutations
-a/w RET
-lymphatic spread;
-psammoma bodies
-females (30-50 yrs)
-orphan anne nuclei
-excellent prognosis

84
Q

RET mutations are a/w ___ thyroid cancers.

A

medullary thyroid cancers (1-2%)

*usually part of MEN2A/2B disease spectrum
*calcitonin producing

85
Q

Other than activating mutations of BRAF proto-oncogene, what other gene mutations may be a/w with the “most common” papillary thyroid cancer?

A

Activating mutations of
-RAS proto-oncogene
-TRK genes

Overexpression of
-RET proto-oncogene.

86
Q

Large volume watery and brownish diarrhea (>1-3 liter/24hr) without blood/mucus, about >10/day, that persist even with fasting along with dehydration, muscle weakness, muscle cramps and fatigue are suggestive of ______.

A

VIPoma; a/w

dehydration,
hypokalemia, and
hypochlorhydria

+ hyperglycemia (~ 25-50% cases)
+ hypercalcemia (~ 25-50% cases)

87
Q

Hyperglycemia may be present in cases of VIPoma d/t _____.

A

-stimulatory effect of VIP on hepatic glycogenolysis, and

-inhibitory effect of hypokalemia on insulin release in the pancreas.

88
Q

Resolution criteria during m/m of HHS include?

A

-Plasma glucose levels < 200 mg/dL
-Plasma eff. osmolality < 315 mOsm/kg
-Anion gap < 10
-Sr. bicarbonate > 18 mEq/L
-Venous pH > 7.3
-Improvement of mental and hemodynamic status.

89
Q

Anytime before or during t/t of HHS, insulin should be withheld or stopped when _______.

A

serum K+ levels is below 3.3 mEq/L.

*Stop/withhold insulin, add K+ to IVFs;
Restart Insulin when sr. K+ levels are > 3.3 mEq/L.

90
Q

List the anti-diabetic drugs/classes that are either weight neutral or induce weight loss in patients.

A

weight neutral:
-alpha-glucosidase inhibitors such as acarbose, miglitol
-DPP IV inhibitors: “gliptins”

Weight loss inducing:
GLP-1 agonists: “tides” ~ 2.2 kg wt. loss

91
Q

Other than dehydration, hypokalemia, and achlor-/hypochlorhydria, what other metabolic derangements may be seen in VIPoma?

A

Hyperglycemia and hypercalcemia in about 25-50 % cases.

92
Q

Normally, ADH secretion is suppressed when plasma osmolality is _____.

A

when plasma osmolality is < 280mOsm/kg of H2O.

*normal plasma osmolality= 275-295 mOsm/kg of H2O.

93
Q

Hyponatremia in setting of low-normal serum osmolality, high urine osmolality, and high ur. Na+ (>40 mEq/L) is suggestive of ___.

A

SIADH; p/w

Plasma osm is < 275 mOsm/kg.

Ur osm is > 100 mOsm/kg (n. is 50-1200)

Ur. Na+ > 40mEq/L.

94
Q

What are some most common causes of SIADH?

A

CNS: stroke, hemorrhage, infection, trauma, surgery, mental illness, psychosis.

Malignancies (ectopic ADH secretion): SCLC (most common), extra-pulmonary small cell ca, Head/Neck ca, olfactory neuroblastoma.

Medications: carbamazepine/oxcarbazepine, Chlorpropamide, cyclophosphamide, SSRI

Surgery

Pulmonary: Pneumonia (mc), asthma, atelectasis, ARF, pneumothorax, mechanical ventilation.

HIV

95
Q

The role of lithium is t/t of SIADH is very limited, and is used in t/t of ____ and/or ___ cases of SIADH.

A

severely symptomatic and refractory cases.

*Lithium inhibits the effects of ADH at collecting tubules.

96
Q

The first line best t/t of SIADH includes?

A

Restriction of water intake to < 800ml/day.

97
Q

What is the next best step in m/m of SIADH if a pt. does not respond to fluid restriction?

A

IV hypertonic saline

*slow infusion at ≤ 0.5 mEq/L/hr to avoid osmotic demyelination syndrome.

98
Q

What are the two most important secretory products of a pheochromocytoma?

A

NE and Ach.

99
Q

Preoperative medical m/m of pheochromocytoma include ____ to stabilize the BP.

A

α-blockade —> β-blockade

e.g. phenoxybenzamine x 7-14 d –> propranolol

100
Q

Systemic glucocorticoids used in m/m of thyroid storm act by ______.

A

reducing the peripheral conversion of T4–> T3, and may also affect the underlying autoimmune process.

101
Q

Worldwide, ____ is the MCC of hypothyroidism, whereas in industrialized world, ____, ___, and ___ are the MCCs of hypothyroidism.

A

Worldwide, Iodine deficiency is the MCC;

In industrialized world, the mcc are
-Hashimoto thyroiditis
-iatrogenic hypothyroidism
-secondary: to pituitary dysfunction.

102
Q

Enlist and describe the classification criteria for DKA.

A

Mild DKA
pH: 7.30 - 7.25 (n= 7.35 -7.45)
sr. HCO3: 18-15 mEq/L (n= 22-28)

Moderate DKA
pH: 7.24 -7.0
sr. HCO3: 15-10 mEq/L

Severe DKA
pH < 7.0
sr. HCO3: < 10 mEq/L

103
Q

T1D has onset typically around which age?

A

5-15 yrs

104
Q

For hyperglycemia to develop, ___ percent of beta cells must have destroyed in T1D.

A

80-90%

105
Q

The autoantibodies in *classic T1D (aka autoimmune T1D) are directed against _____.

*T1D may be idiopathic (uncommon).

A

Any one or more of the following:

-Insulin
-Glutamic acid decarboxylase (GAD)
-Islet antigens (IA2 & IA2-beta)
-Zinc transporter (ZnT8).

106
Q

HLA ____ alleles affect an individuals susceptibility to T1D in presence of specific environmental triggers.

A

HLA-DR/DQ

Remember: D for diabetes and D for D alleles.

107
Q

Viruses strongly a/w T1D are ____ and ____.

A

rubella viruses (congenital rubella syndrome), and human enteroviruses.

108
Q

T1D shares the HLA-DQ2 genotype with ____, and may occur together.

A

Celiac disease.

109
Q

Starvation ketosis results from _____ resulting in lipolysis and ketone body formation.

A

inadequate carbohydrate intake

Remember: body first uses fat for energy during starvation.

110
Q

Blood glucose levels are ____ (? low, high, normal) in starvation ketosis.

A

normal

Remember: ketosis is being induced during starvation to maintain blood glucose levels.

111
Q

Basal-bolus insulin is the next best step in m/m of T2Ds with ______ on metformin mono-therapy, or T2Ds with ______ on at least 2 oral agents.

A

marked hyperglycemia (BSL > 300 mg/dL or HbA1c > 9%),

or

in pts. on at least 2 oral agents with high HbA1c.

112
Q

Sulfonylureas can be added to the t/t regimen in pts. on metformin mono-therapy under what specific conditions?

A

in pts. on metformin mono-therapy who do not have “marked hyperglycemia” i.e. BSL is not more than 300 mg/dL or HbA1c is not more than 9%.

113
Q

______ insulin is usually recommended when initiating insulin therapy in a T2D pt. with poor glycemic control on 2 or more oral anti-diabetic agents.

A

Long-acting insulin e.g. insulin glargine 10 units at BEDTIME.

114
Q

List some causes of nephrogenic DI.

A

-chr. lithium therapy

-hypercalcemia

-hereditary gene mutations

-sickle cell disease

-severe persistent hypokalemia

115
Q

In pts. suspected of having nephrogenic DI d/t lithium toxicity, ____ is the best test to confrm the diagnosis.

A

Desmopressin test;

*administering Desmopressin will not increase low ur. osm. in nephrogenic DI.

116
Q

In a T1D p/w DKA, ____ is/are the best initial t/t, whereas a T1D pt. p/without DKA, ______ is the best initial t/t option.

A

Best initial t/t in T1D

-p/w DKA: IVF + continuous IV Insulin infusion.

p/without DKA: *Basal-Bolus insulin provided by MDI or continuous infusion with insulin pump.

*Basal-Bolus insulin will prevent DKA if not already present.

117
Q

Severe hypocalcemia with sr. Ca2+ levels less than _____ mEq/L in a symptomatic pt. is t/t with _____ or ____.

A

Severe hypocalcemia is albumin-corrected sr. Ca2+ levels < 7.5 mEq/L;

T/t: SLOW ADMINISTRATION of IV Calcium gluconate or CaCl2.

118
Q

Mild -moderate hypocalcemia defined by albumin-corrected sr. Ca2+ levels of ____ can be t/t with ___.

A

Mild -moderate hypocalcemia is albumin-corrected total sr. Ca2+ level 7.5-8.5 mEq/L

oral calcium carbonate /calcium citrate
+ Vit D.

119
Q

Diabetic neuropathy can be of the following types.

A

-generalized

-Focal

-multifocal

-autonomic

120
Q

____ is the most common type of diabetic neuropathy.

A

chronic sensorimotor distal symmetric polyneuropathy

*initially asymptomatic for long time –> foot ulcers;
t/t with TCA, SSRIs

121
Q

Which major systems are involved in diabetes associated autonomic neuropathy? What are the s/s?

A

CVS:
-resting tachycardia,
-orthostatic hypotension,
-High mortality d/t complications such as silent MI.

GIT:
-Gastroperesis
-enteropathy p/w constipation or diarrhea

GUS:
-Erectile dysfunction
-retrograde ejaculation
-bladder dysfunction.

122
Q

Describe the different types of peripheral neuropathies a/w diabetes?

A
  1. Distal symmetric sensorimotor poly-neuropathy:
    -most common type of neuropathy in diabetes
    -involves small fiber neuropathy (SFN) affecting the A-delta (thinly myelinated) & C fibers (non-myelinated).
    -progressive loss of distal sensation; “stocking & glove” fashion.
    -s/s: numbness, burning, tingling, prickling pain, electric-shock like sensation, ache, tightness, touch hypersensitivity.
  2. Bilateral peripheral mono-neuropathy:
    -most commonly affects the median nerve at the wrist, or
    -CPN (foot drop) in diabetics.
  3. Diabetic Amyotrophy:
    -aka Lumbosacral radiculoplexus neuropathy is the most common type of diabetic polyradiculopathy
    -d/t ischemic injury d/t non-systemic microvasculitis
    -causes focal pain–> proximal leg weakness
    -a/w autonomic features and weight loss.
123
Q

Small fiber neuropathy (SFN) affecting the ___ and ___ fibers is seen in which disease states?

A

thinly myelinated A-delta fibers and non-myelinated C fibers;

Seen in
-Diabetes (chr. sensorimotor polyneuropathy)

-Alcoholic neuropathy

-HIV/AIDS

-Amyloidosis

-leprosy.

124
Q

____ is an asymmetric vasculitic neuropathy causing ischemic nerve damage is often seen in _____ and ____.

A

Mono-neuropathy multiplex;

seen in polyarteritis nodosa, and ANCA-associated vasculitides.

125
Q

Metabolic syndrome is aka ____ or ____.

A

Insulin resistance syndrome or syndrome X.

126
Q

Based on *NCEP-ATP III, what are the criteria for diagnosis of Metabolic syndrome?

*National Cholesterol Education Program-Adult Treatment Panel III.

A

Diagnosis of Metabolic syndrome is made when any 3 of the following conditions are met:

  • BP ≥ 130/85 OR under drug t/t for HTN.
  • HDL < 40 mg/dL (men) /< 50mg/dL (women), OR
    drug t/t for low HDL.

*WC ≥ 40 in (102 cm) in men/≥ 35 in (88 cm) in women.

*sr. TG > 150mg/dL OR drug t/t for high TGs.

*FBS > 100 mg/dL OR drug t/t for high blood glucose.

MN: PHATS (pressure, HDL, Abd. girth, TG, Sugar)

127
Q

Initial t/t for metabolic syndrome involves _____.

A

6 month period of diet and exercise

128
Q

A newborn baby with cleft palate, abnormal facies, cardiac abnormalities p/w seizures and tetany d/t hypocalcemia, most likely has _____ syndrome d/t ____ chromosomal abnormality.

A

*DiGeorge syndrome d/t 22q11 deletion.

*aka CATCH-22 (aka Velocardiofacial synd.) involves
-Cardiac abnormalities:TOF, Truncus arteriosus, CoA
-Abnormal facies: low-set ears, micrognathia, hypertelorism.
-Thymic aplasia –> T-cell deficiency
-Cleft Palate
-HypoPTH–> hypocalcemia–> tetany, seizures.

129
Q

Other than antithyroid drugs, which medications can cause hypothyroidism?

A

-Amiodarone: ↓ TH synthesis & secretion; ↓ T4–> T3

-Lithium: ↓ TH synthesis and secretion.

-Ethionamide (MDR-TB)

*Anti-cancer: IFN-α, TKI, Immune-checkpoint Inhibitors.
-cause destructive thyroiditis.

*Suni-tinib (TKI); Ipi-li-mumab (ICP-inhibitor)

130
Q

Which drugs can cause decreased absorption of T4 in pts. taking levothyroxine for hypothyroidism?

A

-calcium carbonate (OTC antacid)

-Omeprazole (PPI)

-cholestyramine

-Colestipol

131
Q

Which drugs can cause abnormal TFTs by increasing T4 clearance but do not cause hypothyroidism?

A

Anti-epileptics:
-Phenytoin
-carbamazepine
-Phenobarbital

Anti-retroviral:
-Ritonavir

132
Q

Which drugs affect the TBG levels?

A

-Estrogenic: tamoxifen
-androgens
-glucocorticoids

133
Q

In women on t/t for hypothyroidism, target TSH during pregnancy must be maintained between ____, by increasing the levothyroxine dosage.

A

1.0-2.5 mU/L.

134
Q

If increase in levothyroxine is declined by the patient as pregnancy is diagnosed, then TSH levels must be checked every ______ (? days or weeks).

A

Immediately and every 4 weeks to assess TSH maintenance between 1.0-2.5 mU/L;
any dose adjustment must be followed by TSH check every 4 weeks as well as once every trimester for TSH maintenance.

135
Q

What are some risk factors for adrenal hemorrhage leading to adrenal insufficiency?

A

-Post-operatively

-sepsis

-N. meningitis: waterhouse Friedrichson syndrome

-Pathological or iatrogenic bleeding d/t
*Anticoagulation t/t (even within therapeutic range)
*HIT
*Anti-phospholipid syndrome

136
Q

_____ can be used as initial t/t in suspected but unconfirmed cases of adrenal insufficiency, whereas ____ is given in confirmed cases of adrenal insufficiency.

A

Dexamethasone (predominant GC) in unconfirmed cases of AI;

Hydrocortisone (GC and MC activity) in confirmed cases of AI.

137
Q

IV calcium gluconate is indicated in t/t of which conditions?

A

-Acute severe hypocalcemia

-Hyperkalemia a/w ECG changes (Sr. K+ > 7 mEq/L)

-CCB overdose

138
Q

The next best step in assessment of a hyper-functioning thyroid nodule (clinically+ low TSH) is ____, whereas for a hypo-functioning nodule (c/p + high/normal TSH) is ______.

A

radionuclide thyroid nodule scan (Scintigraphy) for hyper-functioning thyroid nodule (to characterize hot and cold nodules and thus guide further steps).

Thyroid ultrasound for hypo-functioning thyroid nodule (to assess size and nodule features to guide further steps).

139
Q

Ultrasonographic patterns of a thyroid nodule a/w intermediate or high risk of malignancy include?

A

HIGH RISK (70-90% risk): Solid hypo-echoic nodule, or solid hypo-echoic component in a partially cystic nodule with any of the following:
* irregular margins
* micro-calcifications
* taller than wide shape
* rim calcifications
* e/o extra-thyroidal extension

INTERMEDIATE RISK (10-20% risk): Solid hypo-echoic nodule with smooth margins
* without micro-calcifications,
* without extra-thyroidal extension, or
* without taller-than-wide shape

140
Q

SIADH is seen in about ___ percent of cases of SCLC, and is a/w worse outcome for the pt.

A

7-16%

141
Q

Which infections are a/w SIADH?

A

pulmonary infectious states such as pneumonia or TB.

142
Q

SIADH may be a/w use of ____ anti-depressants.

A

SSRIs

143
Q

Best initial diagnostic test for adrenal insufficiency is ____.

A

morning serum cortisol (8 am-9 am)

Results interpretation:
Level < 3 μg/dL —> suggest AI
Level > 18 μg/dL —> rule out AI
Level 3-18 μg/dL –> require High Dose ACTH stimulation test.

144
Q

High-dose ACTH stimulation test involves ____.

A

IV/IM administration of 250 μg of ACTH f/by measurement of sr. cortisol 30-60 minutes later.

145
Q

Sr. cortisol < 18 μg/dL after high-dose ACTH stimulation test confirms ____, whereas sr. cortisol > 18 μg/dL after high-dose ACTH stimulation test may suggest _____ or ____.

A

Sr. cortisol < 18 μg/dL after high-dose ACTH stimulation test confirms PRIMARY AI;

sr. cortisol > 18 μg/dL after high-dose ACTH stimulation test suggest any of the following two:
-recent-onset secondary AI, or
-partial ACTH deficiency

*test with low-dose ACTH stimulation test or HPA axis test with Insulin tolerance test or metyrapone test.

146
Q

Measurement of serum 11-deoxycortisol is indicated in hypertensive forms of CAH such as d/t _____ or ______.

A

CAH d/t 11 beta-hydroxylase deficiency (a/w virilization) or 17 alpha-hydroxylase deficiency (a/w feminization) .

147
Q

A pregnant women may be diagnosed with “Overt diabetes” if her HbA1c is found to be ____ during routine tests in early pregnancy.

On the other hand, gestational diabetes mellitus (GDM) is diagnosed when standard screening done between _____ weeks of gestation are abnormal with early pregnancy HbA1c < 6.5%.

A

≥ 6.5%;

GDM first tested with oral GTT during 24-28 weeks of gestation; resulted positive if any of the following are present during a 75g oral GTT:

FBS: 92 mg/dL
1-hr: 180 mg/dL
2-hr: 153 mg/dL

148
Q

What are the risk factors for GDM?

A

-Obesity
-personal h/o macrosomia of previous child
-past h/o GDM
-PCOS
-F/H/O T2D.

149
Q

Maternal hyperglycemia in pregnancy is a/w?

A

-fetal macrosomia (BW > 4000 g)
-neonatal hypoglycemia
-polycythemia
-jaundice
-hypocalcemia

150
Q

Insulin must be initiated in pregnant women with diabetes under what conditions?

A

in diabetic pts. with any of the following:

-not responding to lifestyle interventions
-in cases with symptomatic hyperglycemia
-FBS > 125 mg/dL
-RBS > 200 mg/dL

151
Q

Which factors are a/w a worse prognosis in pts. with papillary thyroid cancer, which otherwise has a good overall prognosis in absence of distant metastasis.

A

-age > 45 yrs
-male sex (F/M ratio is 2.5:1)
-bone/brain/lung or other distant metastasis
-size > 1 cm

152
Q

The follicular variant of papillary thyroid cancer is a/w ____ prognosis.

A

best prognosis

153
Q

Hurthle cell (aka oncocytic) is a variant of ____ thyroid cancer, and is a/w a ___ prognosis d/t _____.

A

follicular thyroid cancer;
a/w a poor prognosis d/t high r/o metastasis and recurrence.

154
Q

Hashimoto’s thyroiditis is aka ___.

A

chronic lymphocytic thyroiditis or chronic auto-immune thyroiditis.

155
Q

Chronic lymphocytic (Hashimoto’s) thyroiditis is commonly associated with which pathologic conditions?

A

-T1D
-Sjogren syndrome

-Turner syndrome
-chronic HCV infection

156
Q

The risk of thyroid lymphoma, a rare thyroid malignancy is greatly increased by approx. ____ percent in pts. with ____ thyroiditis.

A

~60% in pts. with chronic lymphocytic (Hashimoto’s) thyroiditis.

157
Q

What are different name designations of Riedel’s thyroiditis?

A

Riedel’s thyroiditis is aka

-Fibrous thyroiditis, or

-Invasive thyroiditis, or

-IgG4-related disease

158
Q

Other than the thyroid gland (Riedel’s thyroiditis), what other organs may get affected in IgG4 related disease ?

A

Multiple organ involvement causing

-autoimmune pancreatitis

-Sclerosing cholangitis

-Sialadenitis

-retroperitoneal fibrosis

159
Q

The initial dose of levothyroxine is roughly ____ mcg/kg/day in young healthy individuals; however, lower dose of ____ per day must be started in older individuals and those with CAD.

A

1.6 mcg/kg/day in young healthy individuals;

25-50 mcg/day in older individuals and those with CAD.

160
Q

Thyroxine replacement in older individuals must be less aggressive. A higher target TSH levels of ____ mIU/L must be maintained in older individuals > 65 yrs as compared to younger adults in whom a target TSH of ___ mIU/L must be maintained.

A

TSH levels of 4-6 mIU/L must be maintained in older individuals > 65 yrs;

target TSH of 1-3 mIU/L must be maintained in younger individuals.

161
Q

Riedel’s thyroiditis (IgG4-RD) can be differentiated from anaplastic carcinoma based on HPE which shows ___ in Riedel’s thyroiditis .

A

HPE in Riedel’s thyroiditis (IgG4-RD) shows a characteristic “cartwheel” appearance of fibroblasts and inflammatory cells and Eosinophils.

162
Q

IgG4-related disease (IgG4-RD) is more common in ___ (?gender).

A

M > F
but thyroid involvement in the form of riedel’s thyroditis is 4 times more common in women (F > > > > M)

163
Q

Hyperthyroidism causes increase in BP d/t ___ in spite of low SVR; hypothyroidism causes increased BP ____.

A

d/t increased myocardial inotropy (& chronotropy) ;

hypothyroidism causes increased BP d/t increase in SVR.

164
Q

____ pts. with a __-prolactinoma may be observed over time.

A

asymptomatic pts. with a micro-prolactinoma

165
Q

Pts. with a macro-prolactinoma or symptomatic tumors must initially be t/t with ___, f/by ____ if initial t/t is ineffective.

A

Initial t/t with dopamine agonists such as carbegoline or bromocriptine (normalize PRL levels and tumor may regress in size);

If pt. is unresponsive to initial t/t or have very large tumor (> 3cm) at presentation, then trans-sphenoidal resection must be undertaken.

STEP 2 ENDOCRINOLOGY (2 decks)

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