E1 Flashcards
Type 2 DM oral hypoglycemic preferd drug?
1-Metformin
2-GLP-1 agonist
2-SGT2 inhibitors
GLP-1 agonist Drugs?
Exenitide
Liraglutide
mechanism?
Slow gastric empiting
Inhibit glucagon secretion
Increase glucose-dependent Insulin secretion
Benefit?
Low hypoglycemia risk
Reduce appetite
Significant weight loss
Reduce mortality in CVD patients
S/E?
nausea
vomiting
A.Pain
Pancreatitis (Low risk)
What about SGT2 inhibitors (Glifozine)?
minimal weight loss
decrease B/P
decrease HF and CVE risk
Metabolic syndrome diagnosis algorithm?
3 of 5 criterion
what are these five criteria?
- A.Obesity( M: WC>40 and F: WC>35
- B/P > 130/80
- FBS> 100-110
- TGC>150 mg/dl
- HDL(M:<40mg/dl and F:<50)
What is the central pathogenesis?
Insulin resistance
IV fluid managment in DKA?
Rapid infusion with 0.9% NS
5% dextrose if RBS <200mg/dl(but cont.Insulie)
Insulin managment in DKA?
Give untile ketone free Continuous IV insulin(Stop in K<3.3) Change to SQ insulin when indication Overlap IV and SC insulin 1-2 hr NPH and glargine when DKA resolve
When will be SQ insulin indicated?
abele to eat
If RBS<200
Anion Gap<12
serum BC>=15meq/l
K managment In DKA?
IV K if K<5.3
assumed DKA patients are K depleted even if hyperkalemic
When to give BC?
if serum PH < 6.9
When to give phosphate?
Serum P < 1mg/dl
cardiac dysfunction
Respiratory depresion
Monitor serum CA frequentley
Hyponatremia and DKA?
DKA-pseudo hyponatremia due to Hyperglycemia
There is a 2 meQ decrease in serum Na for every 100mg glucose increment after 100 mg
Treat if severe hyponatremia or corrected calculated hyponatremia
corrected calculated hyponatremia?
Thru NA=Measured NA + 2x((mesured Serum G–100)/100)
MEN2 B triads?
Medullary tyroid CA
Pheochromocytoma
Marfanoid habitus
Mucosal neuroma
Marfanoid habitus and Mucosal neuroma presentation?
MH: Longhand to the trunk and long extremity
MN: Painless, Rubery tongue nodule
Managment?
Prophylactic thyroidectomy in Infancy
Regular serum fractionated metanephrine level
the first thing to do in patient with Hypocalcemia?
Repeat
Correct for hypoalbuminemia
Rule out hypomagnesemia(Cause PTH resistance)
Check for transfusion(Citrate bind serum ca)
Correct for hypoalbuminemia?
Low albumin deplete total, not free ca
Corrected Ca=measured ca + 0.8(4-S.Albumin level)
what to do next after checking the above?
PTH level-Should be High(normal: 14 to 65 pg/mL)
If low: Primary HPT
If high do VIT D level
Hormonal regulation of CA?
PTH: short term
VitD: Long term
FBGF 23 and Phosphate level?
Increase in high P level
Increase intestinal and renal loss P
High in hypocalcemia due to RF(Hyperphosphatemia)
Testes must be done in HTN patients?
Renal:(Elect.,Cr,urinalysis)
Endocrine:(FBG/H1C,Lipid P and TSH)
cardiac:ECG
other CBC
Optional tests?
Urine Cr/Ab ratio
Echo
Uric acide
acromegaly local symptoms?
Pituitary enlargement(headache, BHA, and focal neurologic D.)
MSK/Skine symptom?
Giantism Malocluded jaw Arthritis/arthralgia Proximal myopathy Hyperhidrosis Skin TAG Carpal tunnel syndrome Coarse facial features
CVS manifestation?
MCC of death CMP(Concentric HTP---DHF) VHD(AR, MR) LV dilation--Global hypokinesis HF arrhythmia
Pulmonary/GI?
OSA
Narcolepsy
Colonic polyp/ca
Diverticulosis
end-organ?
enlargement of tongue thyroid salivary gland liver kidney prostate
endocrine?
Galactothea DM Decrease libido Hyperparathyroidism Hypertriglyceridemia
pathophysiology?
Increase ILGF-1 production
clinical manifestation of glucagonoma?
Wight loss--due to catabolism Necrolytic migratory erythema Diarrhea--Inc Glucagon/secretin DM/Hyperglycemia Venous thromboembolism Neuropsychiatric Sx(depression and psychosis) Maybe MEN 1 component
Laboratory?
merked elevated glucagon(>500)
CTMRI–tumor and metastasis
N.N anemia(ACD,glucagon hematopoiesis inhibition)
Necrolytic migratory erythema feature?
painful pruritic papule
coalesce and form plaque with central scaling
commonly involve the face, groin, and extremity
A common cause of testicular atrophy?
Primary(testicular)
Secondary(Pituitary and hypothalamus)
combined(P and Sec)
Primary(testicular)?
Congenital(KS,cryptorchidism)
Drug(Alkylating agent and ketoconazole)
Orchitis(mumps),trauma and torsion
Chronic kidney disease
Secondary?
Gonadothroph damage(tumour,trauma,infiitrative disease9hemochromatosis) and apoplexy Gonadothroph suppression: Exogenous androgen, hyperprolactinemia,DM and morbid obesity)
Combined?
Hyperchorticolism
Cirhosis
Gonadothrope adenoma?
Usually secret alpha subunit(Non-functional)
Present pan pitutarism
Prolactine may be mildly elevated due to dopaminergic neural compression(unlike in prolactinoma, which has significant PL elevation >200)
Milk alkali syndrome pathphysiology?
Exessive intake of Ca and absorbed alki
Renal vasoconstriction & decreased GFR
Renal loss of Na and h2O
Reabsorbition of bicarbonate
Symptome?
Nausea,vomiting and constipation
Polyuria and polydypsia–Due to Na/K/Cl transporter and ADh receptor inhibition
Nuropsychiatric symptome
lab finding?
hypercalcemia
metabolic alkalosis
AKI
Surpressed PTH
Treatment?
D/C causetiv agent
Isotonic saline
Furosamide
TSH normal values are?
0.5 to 5.0 mIU/L
Ethnology of primary adrenal insufficiency?
Autoimmune
Infection
Malignancy
Hormonal finding?
Low cortisol
Low aldosterone
Low adrenal androgen
High ACTH
Clinical manifestation?
fatigu,loss of apitite and abdominal pain Hypovolumia Hyponatrimia Hyperkalemia Hyperpigmentation metabolic acidosis eosinophilia
When is common?
postpartum period(autoimune)
How to d/t from secondary(pituitary and hypothalamic defect)?
In secondary aldosterone is normal as a result of minimal symptoms, normovolemic, no electrolyte disturbance, and no hyperpigmentation
Special indication of statine in DM?
Age >40
LDL>160
10-year risk ASCVD > 7.5
Characteristics of glucocorticoid-induced myopathy?
Progressive proximal muscle weakness
Atrophy w/o pain and tenderness
Normal ESR and CRP
Distal LE more involved
mechanism?
catabolism/inhibition of Akt-1 signaling/ILGF inhibition—Muscle atrophy
Characteristics of primary hyperparathyroidism?
LOW TSH
High T3 and T4
approach?
If the sign of grave(ophthalmopathy)–Diagnose Graves
If have no–Do radioisotope uptake scan
Based on radioisotope scan?
High–asese focal or diffuse
if low–measure serum thyroglobulin
high uptake and nodal?
Toxic adenoma/(autonomous mean independent of TSH thyroid hormone production
High uptake and diffuse?
Graves disease
Low uptake and low TG?
Exogenous hormone
Low uptake and high TG?
Thyroiditis
iodine exposure
effect of cirrhosis on TFT?
Low total T3 and T4
Low free T3 and T4–euthyroid state
Normal TSH
Due to decreased TBG protine
Cirrhosis and testicular atrophy?
Due to direct injury
Due to affecting HPA
The first test to do inpatient with hypercalcemia?
Measure PTH level
Precipitating factor for thyroid storm inpatient with hyperthyroidism?
Surgery
Acute illness(infection and trauma)
Childbirth
Acute iodine load(contrast)
Clinical presentation?
High fever
CVS–HTN, Tachycardia, CHF, and Arhthemia
CNS-Agitation, delirium, seizure, and comma
Goiter, lid lag treamour
Nausea, vomiting, diarrhea, and jaundice
Indication of ACE/ARB in Diabetic nephropathy?
Albuminuria irespective of B/P level
Mechanism?
Since Hyperglycemia–pro-inflammation–RAAS activation–EA constriction–Elevated GHP–Proinurin–Irreversible BMD and Glomerulosclerosis
This drug halt this
Most sensetive test for protinuria?
Urine A/CR ratio
Normal Urine A/CR ratio?
less than 30 is
Faucher of central(secondary Hyperthyroidism)?
mostly macroadenoma(headache and visual disturbance)
Normal or high TSH
Other hypo pituitary symptoms
Factor increase TBG?
estrogen increment(Px,OCP,HRT) Aute hepatitis
Factor decrease TBG?
Cirrhosis
Nephrotic syndrome
Hyperandrogenism
Hypercortisolism
Lab characters and CM in both?
Euthyroid(may have minimal symptom but absent physical E finding)
May have normal THS
Affected total T4 and T3(normal free T4 and T3)
Painless thyroiditis feaucter?
Chronic autoimmune thyroiditis variant Mild brief hyperthyroid phase Small non-tender goiter Spontaneous recovery Low isotope uptake Positive TPO If occur within a year of postpartum--We call PPT
How to d/t from Hashimoto and subacute(Quervain thyroiditis)?
HT–predominant hypothyroidism/Variable RIU
QT–Painful goiter and elevated ESR/CRP
Gave disease managment option?
Antithyroid drug(mainly for mild and old pt)
Radioactive iodine
Thyroidectomy
Radioactive iodine S/E in graves?
Hypothyroidism in 99 patients after months/ years(unlike in the case of NG(autonomous nodule only affected)
need 6-18 week
We may use minimal radiation
Benefits of OCP in PCOS?
Treat menstrual irregularity Tx hirsutism (by decreasing androgen secretion and elevation of TBG)
Does HHS occur in?
T2DM
Older age
Clinical symptoms?
Hyperglycemia sx
AMS
Lab studies?
RBS>600 Normal PH and BC Normal anion gap Normal/mild ketonuria serum osmolarity>320
Managment?
Normal saline
IV insulin
Plasma K suplement if <5.3 Meq/L
which type of renal disease causes hypocalcemia due to Low Vit D activation?
CKD
The first test to do inpatient with HTN and Hypokalemia?
Plasma renin activity
morning Plasma aldosterone consentration
HigPRA and PAC?
Secondary cause
High PAC and low PRA(ratio >20)?
Primary hyperaldostronism
Do adrenal CT
Both low?
CAH(21HD) Exogenous GC GC resistance Cushing AMS
Radiation ablation S/E in graves?
Persistent hypothyroidism
Exacerbation of ophthalmopathy
Possible radiation exposure
Temporary hyperthyroidism(old pt not tolerate)
Exacerbation of ophthalmopathy prevention and mechanism?
start GC before Radiation Tx
due to R induced increment of TB Ab
Treatment of primary adrenal I?
GC(prednisolone..)
MC(fludrocortisone..)
Skin color in PAI?
Hyperpigmentasion(MSH In.)–MC
Vitiligo(AI destruction)–Rare
Prevension of DN progresion?
ACE/ARB
Agresive Htn Tx
Good glucose control(HA1C <7)
What next to see if the patient has HA1C 8-10?
Fasting and RBS
Both high?
consider insulin neutralizing Ab(But rare in human recombinant form)
Also, consider basal insulin deficiency(increase LA I dose)
Normal FBS and High RBS?
Consider post praedial hyperglycemia Add RAI(Aspart...)
Normal RBS and High FBS
Down phenomena (Due to morning increment of Gh &cortizole)
If HA1C>10
Indicate hyperglycemia throughout the day
oral hypoglycemic should not be used in RF?
metformin
SGCT2 inhibitors
