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Step3 Uw Selfmade > Advanced Endo 1 > Flashcards

Advanced Endo 1 Flashcards

1
Q

Congenital hypothyroidism?

A

CF: normal at birth, age<1month (jaundice, poor feeding, hypothermia), age 1-4months ( FTT, constipation)
Dx: newborn screening, inc. TSH & dec T4

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2
Q

Congenital hypothyroidism?

A

Mxn: confirm TSH/T4, start levothyroxine immediately, order usg thyroid, refer to endocrinologist
Prognosis: excellent e rxn, at risk for permanent neurological defects wout rxn

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3
Q

Primary hyperparathyroidism?

A

Etiology: parathyroid adenoma/hyperplasia/carcinoma, inc risk in MEN 1 & 2A
CF: asymptomatic( most common), mild/nonspeciific symptoms( fatigue, constipation), abdominal pain, bone pain, renal stones, neuropsychiatric symptoms

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4
Q

Primary hyperparathyroidism?

A

Dx findings: hypercalcemia, elevated or inappropriately normal PTH, elevated 24 hr urinary ca excretion

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5
Q

Indications for parathyroidectomy?

A

Age <50, symptomatic hypercalcemia, complications; osteoporosis (T score <-2.5, fragility fracture), nephrolothiasis/ calcinosis, CKD (GFR <60mL/min), elevated risk of complications; ca >_ 1 mg/dl above normal, urinary ca excretion > 400mg/day

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6
Q

Familial hypercalciuric hypercalcemia?

A

Positive family history

Urinary ca excretion < 200mg/day

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7
Q

Primary hypothyroidism: ?

A

A/w pernicious anemia( autoimmune)
Pernicious: due to intrinsic factor deficiency due autoimmune destruction of parietal cells
CF: involvement of post & lateral column; ataxia/ loss of proprioception/ vibration, peripheral neuropathy, weakness, spasticity
Symptoms more prominent in lower than upper extremities

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8
Q

Treating e vit b12; what to notice?

A

Vit b12 treatment in moderate- sever megaloblastic anemia may lead to severe/life threatening hypokalemia due to uptake of K by newly formed RBCs
Serum K monitored during first 48 hrs and replacement done depending on measured levels.
Some transfuse PRBCs in severe megaloblastic anemia before vit b12 supplementation to prevent hypokalemia

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9
Q

Effects of combined estrogen/progesterone menopausal hormone therapy?

A

Beneficial: menopausal symptoms( hot flashes/vaginal atrophy), bone mass/fractures, colon ca, type 2 DM, all cause mortality( age<60)
Detrimental: VTE, breast ca, CHD(age>60), stroke, gall bladder disease
Neutral: cognition/dementia, endometrial ca( inc e unopposed estrogen), ovarian ca, all cause mortality age> 60)

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10
Q

Osteoporosis & osteopenia?

A

Normal: Tscore -1 or greater
Low bone mass(osteopenia): Tscore -1 to -2.5
Osteoporosis: Tscore -2.5 or less or history of fragility fracture

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11
Q

Screening for osteoporosis?

A

Women age>_ 65 or postmenopausal women <65 e additional risk factors for osteoporosis; low body weight, current smoking, FHO hip fracture, use of glucocorticoids
Postmenopausal counselled on preventive measures such as weight bearing exercises, intake of calcium & vitamin D

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12
Q

Osteoporosis: bisphosphonates indications?

A

Low bone mass e h/o fragility fracture
Bone density criteria for osteoporosis( Tscore <-2.5 on DXA)
Osteopenia (Tscore betn -1 & -2.5) e 10 yr probability for major osteoporotic fracture >_ 20% or hip fracture >_ 3% based on FRAX risk calculator

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13
Q

Pubertal gynecomastia?

A

Etiology: imbalance betn estrogen & androgens during mid puberty(tanner stage 3-4)
CF: small(<4cm), firm, unilateral or bilateral subareolar mass/ no pathologic features( nipple discharge, axillary lympadenopathy, systemic illness)
Mxn: reassurance & observation, resolves ein 1 yr

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14
Q

Pseudogynecomastia?

A

Deposition of fat in overweight or obese boys

Difference betn pseudo & physiologic gynecomastia: no palpable mass in pseudo gynecomastia

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15
Q

Metformin side effects?

A 
GI upset( nauseas, abdominal pain, diarrhea), dec intestinal vit b12 absorption & lactic acidosis( rare but fatal); lactic acidosis incidence higher in abnormal renal function(cr>1.5 mg/dl in men, >1.4mg/dl in women or cr clearance <60mL/min) or hepatic dysfunction
Other CIs for metformin: alcohol abuse, sepsis, CHF
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16
Q

Metformin & cardiac catheterization ?

A

Metformin when given e large dose iodine contrast( cardiac catheterization) inc risk of lactic acidosis so metformin is stopped on day of IV iodine contrast exposure and restart atleast 48 hrs after procedure

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17
Q

Impaired fasting blood glucose?

A

Range betn: 100-126 mg/dl, above 126mg/dl is diabetes

People e impaired blood glucose levels has inc risk of coronary artery disease and progression to overt diabetes

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18
Q

Choice of rxn in graves hyperthyroidism?

A
  1. Antithyroid drugs: mild hyperthyroidism, older age e limited life expectancy, preparation for RAIU or surgery, pregnant ( PTU in 1st trimester)
  2. RAIU: moderate to severe hyperthyroidism e or eout mild opthalmopathy, pt preference in mild hyperthyroidism
  3. Thyroidectomy: very large goiter, suspected thyroid cancer, coexisting primary hyperparathyroidism, pg pts who cannot tolerate thionamides, severe opthalmopathy, retrosternal goitre e obstructive symptoms
    # should be started e beta blockers & antithyroid to achieve euthyroid state
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19
Q

Choice of rxn in graves hyperthyroidism?

A

Antithyoid drugs: methazole preferred due to risk of hepatotoxicity e propylthiouracil
RAI: contraindicated in pregnant and lactation

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20
Q

Evaluation of antithyroid drug efficacy?

A

Lab evaluation done 4-6 wks later after starting antithyroid drugs and then every 2-3 months.
TSH may remain suppressed for many months after initiation of therapy & does not accurately reflect thyroid function status. So total T3 & free T4 should be used to assess efficacy of ATD therapy especially early in treatment
If total T3 & free T4 normailze can move to definitive therapy

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21
Q

Levothyroxine rxn for differentiated epithelial( papillary & follicular) thyroid ca?

A 
Small, low risk tumors: target tsh 0.1-0.5 for 6-12 months, then low normal range
Intermediate risk tumors: target tsh 0.1-0.5
Large, aggressive tumors: target tsh<0.1; continue for several years
# suppresive doses of levo a/w inc risk of bone loss & AF so degree of tsh suppression depends on initial tumor stage & risk of recurrence
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22
Q

Acromegaly: mortality cause?

A

Untreated acromegaly, CVD is leading cause. Disorders include: htn, LV dysfunction, assymmetrical septal hypertrophy, conduction defects, coronary atherosclerosis and myocardial fibrosis
Early CVD is reversible e successful rxn of acromegaly
Other cause of mortality in acromegaly: diabetes, resoiratory problems & malignancy
Also has risk of colon cancer

23
Q

Primary hyperaldosteronism( conn syndrome)?

A

Hypertension, hypokalemia can lead to impaired urinary concentrating ability causing polyuria.
Screening test: plasma aldosterone to plasma renin activity ratio (>30 indicates excessive aldosterone secretion from adrenal)
Pts e essential htn have suppressed renin, aldosterone above 15ng/dl is required to intrepret test correctly

24
Q

Thyroid effects of amiodarone?

A
  1. Dec T4-T3 conversion: inc T4,dec T3,normal/inc TSH Rxn:none needed
  2. Inhibition of thyroid hormone synthesis: inc TSH, dec T4. Rxn: levothyroxine
  3. AIT type 1(iodine induced inc in thyroid hormone synthesis): dec tsh, inc T4/T3, dec RAIU, inc vascularity in USG. Rxn: antithyroid drugs
  4. AIT type 2(destructive thyroiditis): dec tsh, inc T3/T4, undetectable RAIU, dec vascularity on USG. Rxn: glucocorticoids
25
Q

Primary ovarian insufficiency:CF/cause/mxn?

A

Cf: amenorrhea<40 yrs, hypoestrogenic symptoms(hot flashes), inc fsh, dec estrogen
Major causes: turner syndrome, fragile x syndrome, autoimmune oophoritis, anticancer drugs, pelvic radiation, galactosemia
Mxn: estrogen therapy( e progestin if intact uterus)

26
Q

POI?

A

Risk of bone mass loss -> inc risk of fragility fractures
In absence of specific risk factors(breast cancer) pts e POI should receive oral or transdermal estrogen plus progesterone until the average age of normal menopause, around 50.
Risk less in young women and benefits outweigh risks

27
Q

Hypoglycemia risk during exercise in diabetic pts taking insulin or insulin secretagogues(sufinylureas)?

A

Physical activity promotes noninsulin mediated glucose uptake into skeletal muscle inc risk of hypoglycemia in diabetics taking insulin.
Prevention: reduce dose of short acting insulin 1-3 hrs prior exercise, reduction proportionate to intensity of exercise. If exercise prolonged (>60mins) or done before breakfast then basal insulin should be reduced. Taking CHO containing snaks after exercise or is BG< 100 before, during or after exercise. Additionally, maintaining oral hydration and avoiding inj insulin inj in exercising limbs

28
Q

Hereditary haemochromatosis: manifestations?

A

Skin: hyperpigmentation( bronze diabetes)
Musculoskeletal: arthalgia, arthopathy, chodrocalcinosis
GI: elevated hepatic enzymes e hepatomegaly(early), cirrhosis(late) & inc risk of HCC
Endocrine: DM, secondary hypogonadism, hypothyroidism
Cardiac: restrictive or dilated cardiomyopathy & conduction abnormalities
Infections: inc susceptibility to listeria, vibrio vulnificus & yersinia enterocolitica

29
Q

HH: dx?

A

Initial evaluation: iron studies (inc iron, ferritin & transferrin saturation)
Dx confirmed e genetic testing for HFE
Rx: therapeutic phlebotomy e removal of 1 unit of blood each wk until iron stores normalize

30
Q

Secondary hypogonadism: common causes?

A

Anabolic steroids, chronic glucocorticoid or opioid use, hyperprolactinemia, cKD cLD, diabetes, pituitary tumors

31
Q

Screening test for DM?

A

1.HbA1c: preferred in nonfasting state, >6.5 = diabetes, 5.7-6.4= inc risk for diabetes, <5.7= normal
2. Fasting blood glucose: no caloric intake for >8hr, >126= diabetes, 100-125= inc risk for diabetes, <100= normal
3. Random glucose level: > 200 e symptoms of hyperglycemia= diabetes, 140-199= inc risk of diabetes, <140= normal
4. Oral glucose tolerance test: most sensitive test, 75g glucose load e glucose testing for 2hr, > 200= diabetes, 140-199= inc risk for diabetes, <140= normal
# testing maybe repeated in cases of discordant or equivocal reaults
# if a pt is asymptomatic, a positive test should be reconfirmed e the same test on a diff day

32
Q

Screening for DM?

A

Asymptomatic e abnormal screening test require repeat measurement e same trst to confirm dx. If 2 diff testa are available & are concordant, no repeat testing is necessary. If 2 tests are disconcordant, then additional diagnostic testing is required to confirm the dx. Pt e symptomatic hyperglycemia and RBG >_ 200 can be diagnosed e diabetes without confirmatory testing.

33
Q

Physiologic changes in throid axis during pg?

A

Resemble mild thyrotoxicosis: inc total T4, high normal or mildly elevated free T4, suppressed TSH

34
Q

Physiologic changes in thyroid axis during pg?

A

Mild thyrotoxicosis: no rxn required
Moderate- severe due to graves or nodular thyroid disease: thionamide antithyroid drugs( methimazole, propylthiouracil). Propyl preferred during 1st trimester due to teratogenicity of methimazole, & methimazole given in 2nd, 3rd trimester due to hepatotoxicity of propyl. Overtreatment of hyperthyroidism during pg lead to fetal hypothyroidism & goitre, so rxn should be titrated to maintain mild hyperthytoid state.

35
Q

Metformin side effects?

A

Metformin related lactic acidosis: risk factors include impaired renal function, hypovolemia, severe liver disease & heart failure
Mxn: aggressive IV fluid support, clarification of acid base status e ABG analysis & measurement of lactate & ketone levels.

36
Q

Familial hypocalciuric hypercalcemia vs Primary hyperparathyroidism?

A

FHH. PHPT
S. Ca. N/ mildly inc. high
PTH. N/ high. N/high
HyperCa sym. None. Maybe present
Bone density. N. Often low
UrinaryCa exc.low. High
(Cccr<0.01). (Cccr>0.02)
Rx. Reassurance. Parathyroidectomy
or serial monitoring

37
Q

Thyroid nodule:dx?

A

Thyroid nodule-> clinical evaluation, TSH level & USG; => cancer risk factors or suspicious US findings: FNA. => no cancer risk factors or suspicious US findings; => normal/ elevated TSH: FNA: rx based on findings => low TSH: iodine 123scintigraphy; => hyperfunctional(hot) nodule: rx hyperthyroidism, => hypofunctional(cold) or indeterminate: FNA

38
Q

Mxn of differentiated thyroid cancer( papillary or follicular)?

A

Mxn depend on patient age, comorbid condn, extent of disease. Surgery recommended for diff thyroid cancer in good surgical candidates but specific surgery and adjuvant therapy depend on stage of disease at diagnosis. USG of neck & cervical lymph nodes primary modality for initial staging of thyroid cancer. Total thyroidectomy: large papillary thyroid cancers, extra thyroid tumor extension, distant metastases, in pts e h/o head or neck radiation exposure. More extensive neck dissection: pts e involvement of adjacent neck structures or regional lymph nodes. Simple thyroid lobectomy: papillary cancer<1cm e no lymph node involvement

39
Q

MEN syndrome?types?

A

MEN 1: primary hyperparathyroidism, enteropancreatic tumors, pituitary tumors
MEN 2A: MTC, phaechromocytoma, hyperparathyroidism
MEN 2B: MTC, phaechromocytoma, other; mucosal or intestinal neuromas or marfanoid habitus

40
Q

MEN 2?

A

Autosomal dominant e germline mutations involving RET proto oncogene in chromosome 10.

41
Q

Investigations in MTC pts?

A

Serum calcitonin/CEA, neck USG( regional metastases), genetic testing for germline RET mutations, evaluation for coexisting tumors( hyperparathyroidism, phaechromocytoma)

42
Q

MTC & PCC

A

PCC present in 40% pts of MTC & undiagnosed PCC cause life threatening hemodynamic complications during & after thyroid surgery. Plasma free metanephrines elevated in PCC & confirmed e 24 hr urinary fractionated metanephrines, catecholamines & abdominal imaging. Once PCC ruled out, MTC pts may proceed to thyroidectomy.

43
Q

Congenital adrenal hyperplasia?

A

21 hydroxylase def: dec cortisol & aldosterone, inc testosterone, inc 17 hydroxypg. Symptoms; ambigous genitalia in girls, salt wasting( vomiting, hypotension, dec Na, inc K)

44
Q

CAH?

A

11beta hydroxylase: dec cortisol & aldosterone, inc testosterone, inc 11 deoxycorticosterone & 11 deoxycortisol.
Symptoms: ambigous genitalia in girls, fluid & salt retention, hypertension
17 alpha hydrxylase def: dec cortisol & testosterone, inc mineralocorticoids, inc corticosterone. Symptoms; all pts phenotypically girls, fluid & salt retention, hypertension

45
Q

Euthyroid sick syndrome?

A

Early/mild. Prolonged/severe
T3. Dec. Dec
T4. N. Dec
TSH. N. Dec
Reverse T3. Inc. Inc

46
Q

Euthyroid sick syndrome?

A

Most common low T3 syndrome due to dec conversion of T4 to T3. Conversion occur due to deiodination. Factors that inhibit deiodination include high endogenous cortisol levels, cytokines (TNF), starvation & certain medications (glucocorticoids, amiodarone) or adaptive response to stress. Rx: deferred unless abnormal thyroid function persists after pt has returned to baseline health

47
Q

Cushing syndrome: dx?

A

Inc urinary cortisol, non suppresible high dose dexamethasone test & undetectable ACTH levels suggest chsuing due to adrenal etiology. NBS imaging of adrenal euther CT or MRI, however MRI sometimes more useful for further characterization of adrenal tumors.

48
Q

Autoimmune polyglandular failure?

A

Includes autoimmune disease like type 1 dm, hypothyroidism, addison’s disease, pernicious anemia, celiac disease, atrophic gastritis, primary hypogonadism
For detection of adrenal failure: cosyntropin stimulation test is done

49
Q

HHS? First step in mxn?

A

Aggressive fluid correction as such pts have fluid loss of 8-10L
Neurologic symptoms occur due to markedly inc serum osmolality, Na inc/dec, K inc due to relative insulin def but actually have total body K deficit due to inc urinary excretion.

50
Q

FTT?

A

Defined by wt below 5th percentile or down trending wt percentiles crossing 2 or major percentiles(50th, 25th, 10th). Causes: inadequate calorie intake, inadequate calorie absorption( cystic fibrosis, celiac disease) & inc calorie requirements( hyperthyroidism, congenital heart disease)

51
Q

FTT?

A

Most common etiology: inadequate calorie intake sec to psychosocial stressors includes poverty, lack of knowledge of appropriate feeding techniques( excessive water to formula powder ratio), and poor parental/child relationship( neglect, abuse).
First step: thorough history & physical examination to find clues about the cause.

52
Q

Lithium & thyroid?

A

Lithium interfere e thyroid hormone synthesis & release causing range of thyroid abnormailities typically during first 2yrs of rxn. Goiter & hypothyroidism common , hyperthyroidism & autoimmune thyroiditis infrequent. Physician should obtain clinical exam for goiter & thyroid function tests prior to initiating lithium rxn & every 6-12 months thereafter.
Development of lithium induced hypothyroidis not an indication to stop lithium. Pt can continue lithium if necessary & add rx e levothyroxine.

53
Q

Nonfunctional pituitary adenoma?

A

Arising from gonadotrophs sometimes. Normal gonadotrophs secrete LH & FSH( which are dimeric hormones consisting a common alpha subunit & diff beta subunit) but dysfuctional cells in most gonadotroph adenomas secrete just common alpha subunit.

54
Q

Nonfunctioning pituitary adenoma: preferred rxn?

A

Trans sphenoidal surgery, whcih provide rapid relief of associated neurologic symptoms. Pt may also regain normal gonadal function after resection. Radiation: adjunct therapy for incompletely resected adenomas.

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