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UWORLD ABIM > Endo > Flashcards

Endo Flashcards

1
Q

Which CN affected in pituitary apoplexy?

A

acute pituitary hemorrhage. will cause severe HA, bitemporal visual defects, likely adrenal insuff and CN3 paresis.

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2
Q

initial tests for suspecting Cushing

A

Pick any:

  • overnight dexamethasone suppression test
  • 24 hour urinary free cortisol assay
  • late-night salivary cortisol measurement
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3
Q

tx for hyperecalcemia from granulomatous dz

A
  • decrease calcium/oxalate intake
  • avoid sun exposure
  • volume expansion
  • low dose steroids
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4
Q

T/F: Bisphophonates are safe in CKD

A

FAlse! Don’t use if CrCl <30

Can use denosumab in renal insuff (monitor for hypocalcemia)

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5
Q

acromegaly testing

A

Step 1: Measure IGF-1 levels (note: GH fluctuates diurnal so not used)
Step 2: confirmatory testing with oral glucose suppression test (75g glucose). + = GH >2
Step 3: brain MRI (pituitary mass found in 70%)

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6
Q

T/F: statins can worsen hypothyroid myopathy

A

true and vice versa

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7
Q

Mgmt of pituitary incidentaloma

A

<10mm: prolactin levels or targeted hormone testing if any sxs
>10mm: check pituitary hormonal functions, consider surgery (can also follow,and prolactinomas respond well to medical therapy)

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8
Q

T/F: Hyperprolactinemia is common in CKD

A

true. does not respond to HD, can normalize with dopamine agonists however sexual dysfunction often persists due to multifactorial

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9
Q

Difference in presentation of hyperparathyroidism and hypercalcemia of malignancy

A

HyperPTH: Insidious onset, often asx/mild, Ca elevated mild (<11)

Malignancy: acute onset, significant sxs and severe hyperCa (>13)

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10
Q

Osteoporosis in men should prompt screening for:

A

Screen for hypogonadism with an early-morning serum testosterone assay

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11
Q

initial eval in hyperthyroid patient without features of Graves

A

Radioactive iodine uptake (RAIU)

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12
Q

High RAIU scan

A

Diffuse uptake pattern: Graves

Nodular uptake: Toxic adenoma, Multinodular goiter

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13
Q

Low RAIU

A

Measure Tg

  • decreased: exogenous hormone
  • elevated: thyroiditis, iodide exposure, extraglandular production
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14
Q

why is cosyntropin test needed prior to levothyroxine in central hypothyroidism?

A

This is an ACTH stimulation test. Levothyroxine can precipitate adrenal crisis in patients with concurrent adrenal insufficiency.

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15
Q

Anti-tpo (thyroperoxidase)

A

chronic lymphocytic thyroiditis aka Hashimoto (PRIMARY HYPOTHYROIDISM WITH ELEVATED TSH)

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16
Q

T/F: Risk of malignancy of thyroid nodule is independent of TSH

A

False.

Elevated TSH = higher risk malignancy.

Suppressed TSH suggests hyperfunctioning nodule, which is typically benign.

Other descriptors which increase risk of malignancy = >1cm, hypoechoic, vascular, microcalcifications

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17
Q

Hormonal testing after adrenal incidentaloma

A

All incidental tumors need at least hormone testing.

Must eval for:

  • excess cortisol (i.e. overnight dexamethasone suppression test)
  • pheo: urinary fractionated catecholamines and metanephrines

If hypertension: plasma aldosterone and aldosterone:renin activity ratio

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18
Q

T/F: Patients with type 2 diabetes and obesity commonly have hypogonadotropic hypogonadism

A

True. If it is borderline low (200-300), do not routinely need pituitary imaging.

If markedly low (<200) or signs of other pituitary hormone abnormalities, pituitary MRI to eval for mass

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19
Q

Testing in all patients with medullary thyroid cancer

A

RET mutation genetic testing.

  • also eval for co-existing tumors (i.e. metanephrines for pheo) and for mets
  • calcium for hyperparathyroidism
  • MTC is seen in MEN 2A and 2B
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20
Q

T/F: Hereditary hemochromatosis causes secondary hypogonadism

A

True. Look for a patient with sick sinus syndrome. Iron deposits in the pituitary gonadotrophs.

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21
Q

Next step when RAIU shows toxic adenoma (mildly elevated, high-normal RAIU) or multinodular goiter with over hyperthyroidism (low TSH, high T4)

A

Radioactive iodine ablation (definitive tx)….or surgical thyroidectomy

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22
Q

side effects of SGLT2 inhibitors

A

UTI, hypotension, vaginal candidiasis

**use cautiously if hx of PVD/diabetic ulcer/neuropathy b/c increased risk of LE amputation

**inc in DKA (euglycemic)

**they decrease glucose reab in kidney - osmotic diuresis = hypotension. reduce doses of diuretics

(note, they don’t cause wt loss)

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23
Q

Which DM med causes wt loss

A

GLP-1 (liraglutide, exenatide, dulaglutide), low risk of hypoglycemia, good add on to metformin . AE = pancreatitis, GI side effects (n/v/d), wt loss

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24
Q

T/F: Hypogonadism is common in men with obesity and diabetes

A

True, HPA axis dysfunction. If other features are present (loss of body hair, gynecomastia, hot flashes, osteoporosis), should prompt workup for androgen def

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25
Q

initial step in eval of male hypogonadism

A

morning serum total testosterone level. Next step after testosterone is FSH and LH

(measuring free testosterone is not recommended initially, is expensive and inaccurate)

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26
Q

When would you do MRI of pituitary in workup of hypogonadism?

A

First check serum total testosterone. If low, check FSH and LH. If low (secondary hypogonadism), it should be considered if severe hypogonadism (testosterone <150), other pituitary deficiencies (TSH, GH), high prolactin or mass effect sxs

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27
Q

Which patients definitely need stress dose steroids perioperatively?

A
  • daily pred for >3 weeks

- any patient who has developed Cushingoid features (including wt gain)

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28
Q

T/F: Subclinical hypothyroidism does not require treatment

A

False.

Indications for tx: TSH >10

if TSH 7-9.9 and <70, tx

if sxs, enlarging goiter or anti-TPO titer detected, tx

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29
Q

T/F: All patients with central hypothyroidism should undergo neuroimaging and chemical testing

A

True

especially adrenal, i.e. ACTH stimulation test known as cosyntropin stim test…since giving levo to central patients can precipitate adrenal crisis

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30
Q

workup in a patient with Cushing appearance

A
  1. Confirm the dx: abnormal results on 2 screening tests (low dose dex suppression test, 24 hour urine free cortisol, late night salivary cortisol)
  2. Establish etiology: ACTH independent (low) vs ACTH-dependent (normal/high). Measure ACTH level
  3. F/u imaging:
    ACTH independent usually have a cortisol-secreting adrenal mass or adrenal hyperplasia (CT adrenal glands); ACTH-dependent usually have ACTH-secreting pituitary adenoma (Cushing dz), or ectopic
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31
Q

How do you evaluate a patient with ACTH-dependent Cushings?

A

-can include high dose dexamethasone suppression tests, corticotropin-releasing hormone stim testing, MRI pituitary, desmopressin stim test, inferior petrosal sinus sampling

Suppression of cortisol following high-dose dex = corticotroph pituitary adenoma

ectopic ACTH secreting tumors will have no suppression of cortisol fellowing high dose dex (resistant to feedback inhibition)

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32
Q

High dose dexamethasone suppresses pituitary ACTH and adrenal cortisol means

A

source is pituitary. If MRI negative, do intrapetrosal sinus sampling for ACTH to confirm source is pituitary

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33
Q

ACTH is high but high dose dexamethasone does not suppress cortisol production

A

ectopic tumor is release ACTH. Most common tumors = SCLC, pheochromocytoma, medullary thyroid carcinoma and bronchial carcinoid.

Get chest/abdomen CT

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34
Q

Tx for Cushing syndrome

A

Surgical resection of the adrenal gland (ACTH independent), pituitary gland (ACTH dependent) or ectopic tumor (ACTH dependent)

Bisphosphonate if low bone density

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35
Q

T/F: Patient found to have an incidental adrenal mass >1 cm but no sxs can be reassured and observed

A

False. This defines an incidentaloma, all patients require biochemical workup for:

  1. Cushings: 1-mg overnight dexamethasone suppression test
  2. Pheo: 24-hour urine metanephrines and catecholamines

**If htn or hypokalemia, measure plasma aldosterone-renin ratio

if no surgical resection, repeat imaging in 6-12 months

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36
Q

Next steps if secondary hypogonadism is confirmed (i.e. low/inappropriately normal LH and FSH)

A
  • check prolactin
  • check iron studies to rule out hemochromatosis
  • MRI to eval for hypothalamic/pituitary lesions
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37
Q

fever or sore throat in a patient take methimazole or PTU

A

agranulocytosis until proven otherwise

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38
Q

how do you manage hyperthyroidism in pregnant patient?

A

No radioactive iodine (in pregnancy or breastfeeding)

PTU in first trimester, then methimazole

39
Q

side effects of Methimazole and PTU

A

agranulocytosis
hepatotoxicity (more PTU)
rash

40
Q

tx of multi-nodular goiter

A

Radioactive iodine (i-131)…hyperactive nodules take up iodine preferentially, normal tissue gets minimal radiation. freq achieve euthyroidism

41
Q

common things that decrease levothyroxine absorption

A

celiac disease
calcium and iron supplements
PPI

42
Q

managing levothyroxine in pregnancy

A

increase the dose by 30%

check thyroid function frequently in pregnancy

43
Q

why are steroids useful in thyroid storm?

A

Decrease peripheral T4–>T3 conversion and improve vasomotor stability

44
Q

how does urinary chloride help determine cause of metabolic alkalosis

A

Vomiting: will be hypochloremic afterwards, so you will reabsorb chloride from urine and thus low urinary chloride

Diuretics/Gittelman/Barter: unable to reabsorb chloride and lose it in urine

45
Q

When TSH is low, how can you differentiate thyroxtoxicosis from euthyroid sick syndrome

A

Measure T3 levels. in ESS, hospitalized patients commonly have low T3 due to illness supressing T4–>T3 conversion…treating these patients thyroid is not beneficial, will return to normal w/in a few weeks

46
Q

T/F: Thyroid nodule with low TSH suggests hyperfunctioning nodule, increasing risk of malignant

A

False. It does suggest a hyperfunctional (hot) nodule, but these are usually BENIGN aka hyperthyroidism. Do thyroid scan and uptake

47
Q

How does TSH help guide management of a new thyroid nodule?

A

Low TSH: Iodine 123 scintigraphy. Hot nodules = tx hyperthyroid. Cold nodules = FNA

Normal/High TSH: FNA

48
Q

T/F: Thyroid nodules >1cm with normal/elevated TSH typically can be observed

A

False. These should get FNA. A low tsh is more reassuring than normal/high TSH

49
Q

laryngospasm after thyroid surgery

A
  • immediate post extubation: bilateral recurrent laryngeal nerve injury
  • w/in few hours: wound hematoma
  • 24 hours after, with paresthesias/cramps: hypocalcemia
50
Q

how to manage TG-induced pancreatitis?

A

Glucose >500: Insulin infusion

Glucose <500/severe pancreatitis: consider plasma exchange (apheresis)

51
Q

DKA mgmt

A
  • NS (if low Na) or 1/2NS (normal or high Na)
  • add D5W @ BG <200
  • hold IV insulin if k <3.3; switch to SQ when abel to eat, BG <200, AG <12, HCO3>15 (overlap IV and SQ 1-2 hours)
  • add IV K if K+<5.3
52
Q

long term effects of hyperthyroidism

A 
osteoporosis 
systolic HTN 
Atrial fib 
depression 
heart failure
53
Q

Thyroid nodule with suppressed TSH next step

A

Thyroid scintigraphy

54
Q

Thyroid nodule with normal/elevated TSH next step

A

FNA

55
Q

These drugs are sulfonylureas, which can cause weight gain, hypoglycemia and reduced drug clearance in kidney failure

A

Glyburide
Glipizide
Glimepiride

GLOW GLucose (hypoglycemia)

56
Q

T/F: Levothyroxine dose adjustments should be based on TSH

A

TRUE, not based of a higher or lower T4

57
Q

mgmt of post-prandial hypoglycemia in patient on BB insulin

A

reduce bolus insulin (not basal)

58
Q

why does size of pituitary mass matter?

A

Micro (<10mm) unlikely to grow large enough for compressive effects (i.e. visual loss)…only tx if specific indications.

Macro (>10mm) requires tx

59
Q

Effects of hyperprolactinemia (i.e. pituitary tumor)

A

-supresses gonadotropin secrtion and causes hypogonadism in premenoupausal women = infertility, amenorrhea, hot flashes, osteoporosis

–>tx with dopamine agonist (i.e. cabergoline, bromocriptine)

60
Q

what time do total serum testosterone levels need to be drawn?

A

between 7am - 10am (this is when testosterone is highest)

61
Q

how does hyperthyroidism affect calcium/pth axis

A

Thyroid increases bone turnover (osteoporosis/fracture risk), expect hypercalciuira. PTH is suppressed, leading to less conversion of 25-vit D to 1,25 - vit d

tx of thyroid corrects emtabolic abnormalities but not lost bone density

62
Q

How to manage T2DM with suboptimal control on oral therapy

A

HbA1c:

<10%: Basal insulin therapy (without bolus), target <7% if fail then add prandial

> 10%: Basal plus prandial insulin therapy

63
Q

how can you tell if thyrotoxicosis is secondary to exogenous/factititous use?

A

Low thyroglobulin (supressing it with exogenous)

64
Q

T/F: RAIU (I-131) is good tx for Graves opthalmopathy

A

False, it can worsen it and thus should be avoided when there are ocular sxs

65
Q

T/F: PTU has a blackbox warning

A

True, for fulminant hepatitis/acute liver failure. usually only used in first trimester of pregnancy and in thyroid storm (decreases conversion T4 to T3)

66
Q

T/F: RAIU for Graves can be used in pregnancy

A

False, delay pregnancy 6-12 months

67
Q

T/F: Goal in hypo and hyper is based off of TSH

A

Usually true.

One caveat is for hyperthyroidism in pregnancy, in this case you aim for free t4 in goal

68
Q

T/F: Thyroidectomy > RAIU in certain cases

A

True:

  • large goiter
  • obstructive sxs
  • suspected thyroid cancer
  • pregnant patients
  • severe opthalmopathy
69
Q

T/F: Tx women with subclinical hypothyroidism who are pregnant or want to become pregnant

A

TRUE

70
Q

What are some labs that can be abnormal when hypothyroid?

A

Hyponatremia
Hyperprolactinemia
Increased CK, AST
Hypercholesterolemia

71
Q

What is destructive thyroiditis and why do classic thryotoxicosis drugs (M, PTU) not really work? How would you tx?

A

Subacute (de Quervain)
Silent (painless)
Postpartum

Causes release of preformed thyroid hormones. Can have pain of thyroid gland. ESR/CRP elevated. Usually a cycle of hyperthyroid, euthyroid, hypothyroid then resolution. Permanent hypothyroidism can follow these syndromes.

Tx: Pain mgmt (NSAIDS or STEROIDS); Sx control (BETA BLOCKER); Tx hypoT (LEVOTHYROXINE). repeat studies in 4-6 months

72
Q

ACTH Stim test

A

used to diagnose primary adrenal insufficiency (Addison’s disease).

You can accurately perform it after dexamethasone but NOT after hydrocortisone. it can be done any time of day. Positive test = cortisol <18 after ACTH stimulation.

73
Q

Primary adrenal insufficiency

A

Addisons disease. It is a high ACTH state. Disease of adrenal cortex, so will also have low aldosterone (low Na, high K, high Renin. this is why you give fludricortisone as well)

74
Q

T/F: beta blocker for pheo

A

false, alpha blocker. beta blocker can cause severe adrenal crisis (HTN)

75
Q

t/f: random glucose >200 + hyperglycemia is diagnostic

A

true. otherwise fasting glucose >126, 2 hour glucose test >200, HbA1c >6.5. Need 2 of these tests or the random glucose with sxs

76
Q

TZDs (pioglitazone) can cause (AE):

A

fluid retention/heart failure

weight gain

77
Q

contraindication to GLP-1

A

personal/fhx of medullary thyroid cancer/MEN2

hx of pancreatitis

severe renal insufficiency

78
Q

orals for DM if weight loss is desired

A

GLP-1
Pramlintide
SGLT2 inhibitors

GPS

79
Q

which oral DM cause hypoglycemia

A
  • sulfonylureas (glipizide, glimepiride)
  • Meglitinides (repaglinide, nateglinide)
  • pramlintide
  • SGLT2 inhibitors (empagliflozin, dapagliflozin)
80
Q

DKA tx

A
  • insulin (delay if K <3.3)
  • potassium when K <5.5
  • do 1/2NS + D5 when BG <250
  • continue insulin infusion until gap closed
81
Q

when/how screen gestational DM?

A

week 24-28 with 75g 2-hour OGTT

82
Q

T/F: Women with hx of GDM at high risk for developing T2DM and require annual screening following delivery

A

true

83
Q

surreptious hypoglycemia

A
  • oral hypoglcyemic agents: C peptide inappropriately high @ time of hypoglycemia, screen for sulfonylurea and meglitinide metabolites
  • insulin: c-peptide low

72 hour fast: for insulinoma will have elevated C-peptide and glucose <45

84
Q

T/F: obtain TSH in all patients with hyperprolactinemia

A

true. and pregnancy test in women

85
Q

Urine osmolalithy <200 and inability to increase urine concentration during water deprivation test

A

Diabetes Insipidus. Desmopressin test: if positive, central and get pituitary MRI. If negative, renal US

86
Q

tx of nephrogenic DI

A

lithium induced: stop lithium or add amiloride

otherwise: thiazide diuretic + salt restriction

87
Q

forms of destructive thyroiditis (release of preformed hormone)

A
  • de quervain (subacute). firm and painful
  • silent (painless)
  • postpartum

permanent hypotT can follow any of these. ESR elevated often

88
Q

decreased/no uptake on RAIU scan

A

Thyroiditis
Iodine load
Surreptious ingestion

vs graves has diffuse homogenous increased uptake

89
Q

T/F: Avoid radioactive iodone in severe graves opthalmopathy and pregnancy

A

true

90
Q

T/F: treat subclinical hypothyroidism when TSH >10 and also women who are pregnant/want to become pregnant

A

true

91
Q

goal for TSH when treating hypoT

A

1-2.5

92
Q

thyroid nodule imaging

A

TSH low: RAIU

TSH normal/high: Thyroid US

93
Q

T/F: FNAB for thyroid nodules >1cm

A

true, or <1cm and risk for cancer/suspicious US

UWORLD ABIM (10 decks)

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