Endo Flashcards
Things that make A1c unreliable
A1c Epo Liver disease Hemoglobinopathies (Sickle cell disease) Iron-deficiency anemia (falsely elevated due to an increase in older erythrocytes)
How to test for symptomatic hypoglycemia
72-hour fast with hypoglycemic studies at the time of symptomatic hypoglycemia
Goal A1c in diabetes
Less than 7% (unless older)
Initial management of new onset diabetes
Metformin + lifestyle modification for 3 months
Management of diabetes after lifestyle modification
- Start metformin if A1c not at goal after 3 months (even if patient making progress. you want to aggressively reduce risk of micro and macrovascular complications)
- IF A1c remains at 9% or above after 3 months –> add orals
SE’s to know with GLP-1 agonists
- Pancreatitis
- Medullary thyroid carcinoma
Physiology of osmotic diuresis following AKI
High urea output in urine leads to osmotic diuresis, leading to hypernatremia
Indications for kidney biopsy
- Glomerular hematuria
- Severely increased albuminuria
- **Acute or chronic kidney disease of unclear cause
- kidney transplant dysfunction or monitoring
Clinical features of cisplatin-induced kidney injury
Polyuria and urinary excretion of sodium leading to volume depletion + tubular injury + hypomagnesemia (urinary magnesium loss) + proximal renal tubular acidosis with fanconi syndrome
- 7 days after starting
Lung pathology caused by paclitaxel
Diffuse interstitial lung disease
How is kidney failure risk determined + variables included
- kidney failure risk equation
- age + sex + eGFR + albuminuria
diseases associated with AA amyloidosis
Chronic inflammatory states (RA) – it’s an acute phase reactant so deposits in numerous tissues, including kidneys
Amyloidosis labs to know
SPEP with polyclonal gammopathy
Patients at high risk for RCC
ESRD patients
Bilateral cysts and masses in patient with ESRD think
Acquired cystic kidney disease
Management of acquired cystic kidney disease in patients with CKD
IF severe or higher stage –> bilateral nephrectomy (little use in partial nephrectomy given very little residual kidney function)
When patients are initiated on dialysis
GFR below 7.0 OR conventional indications for dialysis (uremic symptoms, metabolic abnormalities)
first step in workup of primary adrenal insufficiency + why
21-hydroxylase antibodies (looking for autoimmune adrenalitis)
primary adrenal insufficiency means
localizes to adrenal gland
primary adrenal insufficiency lab profile
low serum cortisol + elevated ACTH
most common cause of primary adrenal insufficiency in US
autoimmune adrenalitis
diagnosis of primary adrenal insufficiency
just low serum cortisol + elevated ACTh (don’t need cosyntropin stimulation test)
management of amenorrhea + hyperprolactinemia in psych patient on risperidone
- pituitary MRI (rule out pituitary adenoma)
- talk to psych before discontinuing risperidone
treatment of primary adrenal insufficiency
- BOTH glucocorticoid and mineralocorticoid replacement (affects all layers of the adrenal cortex)
- hydrocortisone BID (has shorter duration and BID dosing mimics circadian rhythm of endogenous cortisol secretion)
- fludrocortisone daily
Next step after radiographic diagnosis of Paget disease of the bone
Serum alkaline phosphatase (need a baseline. it is a marker of treatment efficacy in Paget’s)
How bisphosphonates cause severe hypocalcemia
- people who are vitamin d deficient can’t correct for calcium deficiency through increased osteoclast activity because antiresorptive drugs suppress osteoclastic bone resorption
what to always remember before starting zometa
Check vitamin D and correct before starting
Hungry bone syndrome pathophys
After parathyroidectomy for primary hyperPTH, rapid influx of calcium from blood into the skeleton causes hypocalcemia
Presentation of androgen-producing adrenal tumor
signs of androgen excess over short period of time (hirsutism, virilization – deep voice, facial hair)
Workup of suspected androgen secreting adrenal tumor
CT abdomen
New term for euthyroid sick syndrome
Nonthyroidal illness syndrome
lab features of nonthyroidal illness syndrome
- low serum T3
- low or low-normal serum T4
- low or normal TSH
- looks like subclinical hypothyroidism but T4 and T3 or low or low normal
Management of Cushing patient post adrenalectomy
Daily glucocorticoid replacement (hypercortisol secretion suppresses hypothalamic axis, when this axis is recovered following removal of the source/adrenalectomy, endogenous cortisol production is impaired. You don’t need fludrocortisone because mineralocorticoid secretion is not under ACTH control. Aldosterone secretion from the contralateral adrenal gland isn’t impacted.
Definition of cushing’s syndrome
presentation of cortisol excess (due to a variety of causes)
definition of cushing’s disease
cortisol excess due to pituitary adenoma secreting ACTH
Use of phenoxybenzamine
Preoperative alpha-receptor blockade for 10-14 days before surgery for pheochromocytomas and paragangliomas to prevent hypertensive crises during surgery
How to test for hypogonadism
- Measure 8AM testosterone
- IF low repeat, second 8AM testosternoe
Hypogonadism diagnosis
2 low AM testosterone levels
Monitoring of chronic hypoparathyroidism
- monitor urine calcium excretion (without PTH, urinary calcium excretion is higher than normal for any given serum calcium level, which can lead to complications like kidney stones and impaired GFR) -
- if calcium levels are high, calcium and/or vitamin d replacement needs to be decreased
Management of hypothyroidism in pregnancy
- increase synthroid dose by 30% (pregnant women with hypothyroidism are unable to augment thyroidal production of T4 and T3)
First step after gender incongruence diagnosed in managing transgender patient
Refer for discussion of reproductive options
steps in transgender medicine before surgery
- engage in at least 1 year of satisfactory social role change + consistent and compliant hormone treatment
Preconception counseling for diabetic women
- dilated eye exam (at increased risk of developing diabetic retinopathy because rapid increases in glycemic levels during pregnancy can worsen preexisting retinopathy)
Management of steroid-induced osteoporosis
- need osteoporosis screening within 6 months of initiation of long-term steroids
- Oral bisphosphonates (alendronate) for anyone with Z score less than -3 and steroid treatment of >7.5 mg/day for 6 or more months
Lab features of thyroid adenoma
- Elevated free T4
- Inappropriately normal or elevated TSH level
“Honey moon” phase of type 1 DM
- Drastic reduction in endogenous insulin production creates glucose toxicity that impairs remaining beta cells –> as exogenous insulin improves glycemic control, remaining beta cells experience less tress and start secreting more endogenous insulin –> thus people have rapid glycemic control and low A1c’s and need very little endogenous insulin
Management of honey moon phase of DM1
Decrease both prandial and long acting insulin
Denosumab trade name
xgeva
Management of denosumab
Continue indefinitely! and don’t get DEXAs, which won’t change management (it circulates in the blood for up to 9 months after subcutaneous injection, but once cleared, resorption transiently but dramatically increases, which can cause abrupt decline in bone mineral density and vertebral fractures
Management of patient with type 1 DM who is NPO
- decrease basal insulin (require basal insulin or will go into DKA)
- DC mealtime
- add SSI
Workup of adrenal incidentaloma
Screen for adrenal hyperfunction in all incidental adrenalomas
- test for pheo (even in absence if HTN because may exist in the absence of HTN and typical signs. they are now commonly discovered)
- test for Cushing
IF HTN –> screen for primary hyperaldo
How to test for pheos
24 hr urine total metanephrine measurement
Preferred screening for Cushing
1-mg overnight dexa suppression test
Testing required before parathyroidectomy for primary hyperparathyroidism
25-hydroxyvitamin d (avoid postoperative hypocalcemia)
What is subclinical cushing syndrome
- ACTH resulting in metabolic (hyperglycemia and HTN) and bone abnormalities but no Cushing syndrome (obesity, facial plethora, fat deposition, striae)
Primary hyperaldo aldosterone-renin ratio cutoff for diagnosis
Aldosterone-renin ratio of less than 20
How to screen for Cushing syndrome in a pt who works night shifts
24-hour urine free cortisol
Usual cause of hypothyroid patients requiring increasingly higher doses of synthroid
Malabsorption syndromes
Term for rash with celiacs
dermatitis herpetiformis
Celiac features
- abdominal pain
- weight loss
- rash
management of abnormal semen analysis
Repeat in 2 weeks, if abnormal, refer to reproductive endocrinologist
Endocrine effects of chronic opioid use
hypogonadism
Turner syndrome clinical features
- short
- neck webbing, hearing loss, aortic coarctation, bicuspid aortic valve
Evaluation of postprandial hypoglycemia
- mixed-meal test (consisting of types of food that normally induce hypoglycemia
Management of secondary adrenal insufficiency (eg after discontinuation of steroids)
hydrocortisone (no mineralocorticoid deficiency in secondary AI)
Treatment of primary adrenal insufficiency
hydrocortisone and fludrocortisone
Levothyroxine dosing
- weight-based
- except in older adults (over age 65) and patients with cardiovascular disease (due to effects of thyroid hormone on myocardial oxygen demand)
First step after diagnosis of Cushing syndrome (hypercortisolism diagnosed)
ACTH level (to determine if ACTH dependent or independent)
Management of postmenopausal osteoporosis
Bisphosphonates
medications to hold before screening for secondary HTN
Spironolactone
A1c goal for older adults with complex medical history
7.5-8.0%
Endocrine SE’s of checkpoint inhibitors
Hypophysitis (headache, pituitary enlargement, and hypopituitarism)
Indication for adrenalectomy with adrenal masses
- radiologic featrues suggestive of increased risk of malignancy:
size >4 cm
density >10 hounsfield units - contrast washout <50% at 10 minutes
Work up of hypocalcemia
1) exclude hypomagnesemia (hypomagnesemia causes functional reversible PTH hypofunction)
2) check PTH
Cutoff for using metformin in CKD
EGFR>45
most common causes of hyperthyroidism
Toxic adenoma
Multinodular goiter
Treatment of toxic adenoma
- Radioactive iodine or surgery
to do for initial diagnosis of DM2 visit
- dilated eye exam
- spot urine albumin-creatinine ratio
- foot exam
Management of diabetic patient with preprandial blood glucose levels at goal but A1c not at goal
Measure postprandial blood glucose level (may detect undetected hyperglycemia that could be treated with an increase in prandial insulin)
Preprandial/fasting glycemic goals
80-130
Management of primary hyperparathyroidism
IF asymptomatic –> monitor serum calcium and creatinine q6-12 months + DEXAs q2 years
IF calcium greater than 1 mg above upper limit OR EGFR less than 60 OR 24-hour urine calcium greater than 400 mg/day OR incrreased stone risk/renal stones OR T-score less than or equal to negative 2.5 –> parathyroidectomy
Indications for parathyroidectomy
- calcium greater than 1 mg above upper limit
- EGFR less than 60 OR 24-hour urine calcium greater than 400 mg/day
- increased stone risk or presence of renal stones
- T-score less than or equal to negative 2.5
Testing prior to parathyroidectomy
Parathyroid sestamibi scan
Management of hypercalcemia in patients with primary hyperparathyroidism
IF meeting indications –> parathyroidectomy
- Cinacalcet only used in adults in whom parathyroidectomy can’t be performed
Workup of patient with primary hyperPTH prior to endocrine referral
DEXA
Initial step following diagnosis of subclinical hypothyroidism
- Repeat TSH/T4 (rule out transient elevation of serum TSH)
Lab findings in Hashimoto thyroiditis
Positive thyroid peroxidase antibodies
When to measure T3
Never
Next 2 steps after diagnosis of primary hyperaldo
Abdominal CT –> Once adenoma confirmed, Adrenal vein sampling (confirm source of hyperaldosteronism – in some cases adenomas aren’t visualized so you need to confirm source of secretion and lateralization. Also need to confirm hyperfunctioning)
First step in evaluation of a thyroid nodule
Neck US (need to determine that biopsy is indicated + ensure no additional nonpalpable nodules that warrant fine needle biopsy)
Secondary vs. primary hypothyroidism
Primary = inadequate function of the gland itself Secondary = inadequate stimulation by TSH from pituitary gland
Monitoring of secondary hypothyroidism post adrenal gland surgery
- just check T4 not TSH (patient doesn’t have pituitary gland). Dose is titrated based on free T4.
How to tell patients to take synthroid
- On empty stomach, 1-3 hours after ingestion of food
- take separately from calcium or iron-containing supplements (4 hours apart)
Management of hypoglycemic unawareness
- reduce all insulin doses (need to provide body with an opportunity to restore the ability to detect hypoglycemia) (even if patient has elevated a1c)
Age cutoff for osteoporosis screening
65 or older
First 2 steps in myxedema coma management
FIRST STEP: Empiric treat for AI with Intravenous hydrocortisone (can discontinue if cortisol normal. if AI is present, giving thyroid hormone prior to steroids can precipitate adrenal crisis by augmenting cortisol metabolism)
Second step: IV synthroid
Management of papillary thyroid carcinoma
Thyroid lobectomy. If completely resected, no adjuvant therapy.
Management of metastatic papillary thyroid carcinoma
Lobectomy with adjuvant radioactive iodine therapy
Diagnoses of diabetes insipidus
Urine and serum osmolality (low urine osmolality + high serum osmolality + hypernatremia in a patient with polyuria is diagnostic of DI)
- don’t need to do water deprivation test or desmopressin challenge
Management of thyroid storm
- beta blockers
- antithyroid drug therapy
- IV steroids
- potassium iodide
Management of amiodarone-induced thyrotoxicosis
If type 1 (vascularity on US) –> stop amio
If type 2 (no increased vascularity + no nodules or goiter) –> give steroids, continue amio, then decide on whether to continue amio (long half life so no immediate benefit to stopping + need to weigh risks/benefits of cardiac disease)
Workup of rapid-onset hirsutism
- Pelvic ultrasound (looking for androgen-secreting ovarian tumors)
IF negative –> adrenal CT ( exclude adrenal cortisol-secreting neoplasm)
Lab profile of osteomalacia
- low 25-hydroxyvitamin D
- low calcium
- low phos
- high PTH
Osteogenesis imperfecta clinical features
Genetic syndrome leading to collagen abnormalities and…
- short stature
- body deformity
- hearing loss
- dental deformities
- blue sclera
Osteitis fibrosa cystica pathophys + classic patient
- high bone turnover after prolonged exposure of bone to high levels of PTH in hyperparathyroidsm
- CKD patients
