ENDO Flashcards

Question

A 42/F with T2DM with a BMI of 30 was admitted in the hospital due to acute pyelonephritis. She is currently afebrile with BP of 120/80. She is currently on insulin glargine 6 units SC injected at night and regular insulin 6 units pre-meals. Her current pre-lunch CBG is 280 mg/dL. Based on ADA recommendations, which of the following regimens will best address her hyperglycemia immediately? (HPIM C397 p2873) a. Increase insulin glargine to 8 units pre-bedtime b. Give regular insulin 8 units SC pre-lunch c. Add insulin glargine 10 units pre-breakfast d. Give regular insulin 10 units SC pre-lunch

Answer 1

The correct answer is: Give regular insulin 10 units SC pre-lunch

Answer 2

The correct answer is: Regular insulin via multiple SC boluses

Answer 3

The correct answer is: 24 and 28 weeks

Answer 4

The correct answer is: There is a positive impact of a period of improved glycemic control on later disease.

Answer 5

The correct answer is: Repeat albuminuria test after 3 months.

Answer 6

The correct answer is: There is loss of ankle deep-tendon reflexes and foot drop.

Answer 7

The correct answer is: High triglyceride, low HDL, normal LDL

Answer 8

The correct answer is: Pseudomonas aeruginosa

Answer 9

The correct answer is: Failure of insulin secretion to fall during hypoglycemia

Answer 10

The correct answer is: Familial Chylomicronemia

Answer 11

The correct answer is: Acute pancreatitis

Answer 12

The correct answer is: Omega-3 FA

Answer 13

In DECREASING ORDER of frequency Hyperprolactinemia is the most common pituitary hormone hypersecretion syndrome in both men and women The correct answer is: Lactotrope

Answer 14

Patient has classic signs of ACROMEGALY Somatostatin analogues are used as adjuvant treatment for: • preoperative shrinkage of large invasive macroadenomas • immediate relief of debilitating symptoms and reduction of GH hypersecretion • in frail patients experiencing morbidity • in patients who decline surgery • when surgery fails The correct answer is: Octreotide

Answer 15

24 hr urine free cortisol is elevated in both High dose Dexa suppression test will be able to inhibit cortisol production in ACTH-dependent pituitary tumors via the feedback mechanism but has NO EFFECT on ECTOPIC ACTH sources Rapid onset of symptoms and pigmentation are associated with ECTOPIC ACTH secretion Basal inferior petrosal : peripheral vein ACTH ratio of <2 is consistent with ECTOPIC ACTH secretion The correct answer is: Cortisol is <5 ug/dL after high-dose dexamethasone suppression

Answer 16

NELSON’S SYNDROME A disorder characterized by rapid pituitary tumor enlargement and increased pigmentation secondary to high ACTH levels. Prophylactic radiation therapy may be indicated to prevent the development of Nelson’s syndrome after adrenalectomy. The correct answer is: Nelson syndrome

Answer 17

NON-FUNCTIONING PITUITARY ADENOMAS They are the most common type of pituitary adenomas They are usually MACROADENOMAS at the time of diagnosis because clinical features are not apparent until mass effect occurs Based on immunohistochemistry, most clinically nonfunctioning adenomas can be shown to originate from gonadotrope cells. It is important to distinguish this circumstance from true prolactinomas, as nonfunctioning tumors do not shrink in response to treatment with dopamine agonists The correct answer is: They are the most common type of pituitary adenoma.

Answer 18

``` VASOPRESSIN SECRETION Can be stimulated by the ff: • Hyperosmolarity (280 mosm/L) • Hypotension (10-20% decrease in BP) • Nausea (very potent – can cause 50-100 fold rise in AVP) • Acute hypoglycemia • Glucocorticoid deficiency • Smoking ``` There is no evidence that pain or other noxious stresses have any effect on AVP unless they elicit a vasovagal reaction with its associated nausea and hypotension The correct answer is: Pain

Answer 19

Acute hypernatremia and increased volume of urine in the setting of post-cranial surgery is highly suggestive of post-op pituitary diabetes insipidus Urine osmolarity of <300 mosm/L is present in pituitary DI, primary polydipsia and nephrogenic DI Plasma AVP <1 pg/mL is present in both primary polydipsia and pituitary DI The pituitary bright spot is almost always absent or abnormally small in patients with pituitary DI Plasma osmolarity of >300 can be present in both DI and non-DI etiologies The correct answer is: No pituitary bright spot on MRI

Answer 20

HYPONATREMIA TREATMENT Patient most likely has Chronic Hyponatremia secondary to SIADH from lung CA Patient is euvolemic and asymptomatic Hyponatremia in this case should be corrected more gradually to avoid osmotic demyelination syndrome This can be achieved by restricting total fluid intake to less than the sum of urinary and insensible losses. This regimen is often hard to adhere to. It is often necessary to add a treatment that increases urinary water excretion. The oral AVP2 antagonist, tolvaptan, is best suited for this purpose. The correct answer is: Give tolvaptan 15 mg/tab 1x a day

Answer 21

A diagnosis of Cushing’s should be considered when several clinical features are found in the same patient, in particular when more specific features are found. These include * fragility of the skin, with easy bruising * broad (>1 cm), purplish striae * signs of proximal myopathy, which becomes most obvious when trying to stand up from a chair without the use of hands or when climbing stairs The correct answer is: Proximal myopathy

Answer 22

DIAGNOSTIC SCREENING FOR MINERALOCORTICOID EXCESS The accepted screening test is concurrent measurement of plasma renin and aldosterone with subsequent calculation of the aldosterone-renin ratio (ARR) Serum potassium should be normalized prior to testing Stopping antihypertensive medication can be cumbersome, particularly in patients with severe hypertension. For practical purposes, in the first instance the patient can remain on the usual antihypertensive medications, with the exception that MR antagonists need to be ceased at least 4 weeks prior to ARR measurement. Carvedilol can falsely increase ARR The correct answer is: Continue telmisartan and correct hypokalemia prior to ARR measurement

Answer 23

DIAGNOSIS OF INCIDENTALOMAS Unenhanced CT is the procedure of choice for imaging the adrenal glands Size alone is of poor predictive value, with only 80% sensitivity and 60% specificity for the differentiation of benign from malignant masses when using a 4-cm cut-off Tumor density on CT is of additional diagnostic value as many adrenocortical adenomas have low attenuation values. However, many of them also present with higher HU FNA or CT-guided biopsy of an adrenal mass is rarely indicated • FNA of pheochromocytoma can cause hypertensive crisis • FNA of adrenocortical carcinoma can cause needle track metastasis • Should only be considered in a patient with nonadrenal malignancy and a newly detected adrenal mass, after ruling out pheochromocytoma and if the outcome will influence therapeutic management The correct answer is: FNA or CT-guided biopsy of an adrenal mass is rarely indicated.

Answer 24

PRIMARY ADRENAL INSUFFICIENCY Primary adrenal insufficiency is most commonly caused by autoimmune adrenalitis. Isolated autoimmune adrenalitis accounts for 30–40%, whereas 60–70% develop adrenal insufficiency as part of autoimmune polyglandular syndromes (APSs) Rarer causes of adrenal insufficiency involve destruction of the adrenal glands as a consequence of infection, hemorrhage, or infiltration. Tuberculous adrenalitis is still a frequent cause of disease in developing countries. The correct answer is: Autoimmune adrenalitis

Answer 25

PRIMARY ADRENAL INSUFFICIENCY Characterized by the loss of both glucocorticoid and mineralocorticoid secretion A distinguishing feature of primary adrenal insufficiency is hyperpigmentation, which is caused by excess ACTH stimulation of melanocytes. Hyponatremia can be present in both mineralocorticoid deficiency and in secondary adrenal insufficiency due to diminished inhibition of ADH release by cortisol. Increased plasma renin will confirm presence of mineralocorticoid deficiency Low BP and postural hypotension can be present in both The correct answer is: Hyperreninemia

Answer 26

The correct answer is: 46,XY/47,XXY

Answer 27

CONGENITAL ADRENAL HYPERPLASIA The classic form of 21-hydroxylase deficiency (21-OHD) is the most common cause of CAH The salt-wasting form of 21-OHD results from severe combined glucocorticoid and mineralocorticoid deficiency. Females with classic simple virilizing form of 21-OHD present with genital ambiguity. They have impaired cortisol biosynthesis but do not have salt loss. Patients with non-classic 21-OHD produce normal amounts of cortisol and aldosterone but at the expense of producing excess androgens. The correct answer is: 21-hydroxylase

Answer 28

The conversion of testosterone to DHT is necessary for the masculinization of the urogenital sinus and genital tubercle. The correct answer is: 5α dihydrotestosterone

Answer 29

The correct answer is: Primary ovarian insufficiency

Answer 30

The correct answer is: Pulmonary embolism

Answer 31

The correct answer is: Systemic Lupus Erythematosus

Answer 32

VERY LOW-CALORIE DIETS (VLCDs) The primary purpose of a VLCD is to promote a rapid and significant (13- to 23-kg) short-term weight loss over a 3- to 6-month period. The proprietary formulas designed for this purpose typically supply ≤800 kcal, 50–80 g of protein, and 100% of the recommended daily intake for vitamins and minerals indications include the involvement of well-motivated individuals who are • moderately to severely obese (BMI, >30 kg/m2) • have failed at more conservative approaches to weight loss • have a medical condition that would be immediately improved with rapid weight loss The risk of gallstone formation increases exponentially at rates of weight loss >1.5 kg/week Prophylaxis against gallstone formation with UDCA 600 mg/d is effective in reducing this risk. The correct answer is: It typically supplies ≤800 kcal per day with 50-80 g of protein

Answer 33

Bariatric surgery can be considered for patients with • severe obesity (BMI, ≥40 kg/m2) OR • for those with moderate obesity (BMI, ≥35 kg/m2) associated with a serious medical condition The correct answer is: Refer for bariatric surgery

Answer 34

The current criteria for the diagnosis of DM emphasize the HbA1c or the FPG as the most reliable and convenient tests for identifying DM in asymptomatic individuals. An OGTT, although a valid means for diagnosing DM, is not often used in routine clinical care with the exception of pregnancy care and screening for gestational diabetes. Abnormalities on screening tests for diabetes should be repeated before making a definitive diagnosis of DM, unless acute metabolic derangements or a markedly elevated plasma glucose are present These criteria also allow for the diagnosis of DM to be withdrawn in situations when the glucose intolerance reverts to normal It is important to note that race and ethnicity may impact the reliability of HbA1c levels. For example, African Americans have a higher HbA1c value compared to non-Hispanic whites with a similar level of glycemia. The correct answer is: The current criteria allow for the diagnosis of DM to be withdrawn when glucose tolerance becomes normal.

Answer 35

ADA RECOMMENDATIONS FOR SCREENING The ADA recommends screening all individuals aged >45 years every 3 years and screening individuals at an earlier age if they are overweight (BMI >25 kg/m2 or ethnically relevant definition for overweight) and have one additional risk factor for diabetes The correct answer is: 45

Answer 36

ADA RECOMMENDATIONS FOR SCREENING The ADA recommends screening all individuals aged >45 years every 3 years and screening individuals at an earlier age if they are overweight (BMI >25 kg/m2 or ethnically relevant definition for overweight) and have one additional risk factor for diabetes The correct answer is: Blood pressure of 140/90

Answer 37

GENETIC CONSIDERATIONS OF DM Although the risk of developing type 1 DM is increased tenfold in relatives of individuals with the disease, the risk is relatively low: 3–4% if the parent has type 1 DM and 5–15% in a sibling . Hence, most individuals with type 1 DM (75%) do not have a first-degree relative with this disorder Type 2 DM has a strong genetic component. The concordance of type 2 DM in identical twins is between 70 and 90% Individuals with a parent with type 2 DM have an increased risk of diabetes; if both parents have type 2 DM, the risk approaches 40% Type 2 DM is polygenic and multifactorial, because in addition to genetic susceptibility, environmental factors (such as obesity, poor nutrition, and physical inactivity) modulate the phenotype The correct answer is: Most individuals with Type 1 DM do not have a first-degree relative with this disorder.

Answer 38

DM PREVENTION A number of agents, including a-glucosidase inhibitors, metformin, thiazolidinediones, GLP-1 receptor pathway modifiers, and orlistat, prevent or delay type 2 DM but are not approved by the Food and Drug Administration for this purpose. Pharmacologic therapy for individuals with prediabetes is currently controversial because its cost-effectiveness and safety profile are not known. The ADA suggests that metformin be considered in individuals with both IFG and IGT who are at very high risk for progression to diabetes (age <60 years, BMI ≥35 kg/m2, and women with a history of GDM) The correct answer is: Metformin

Answer 39

MONOGENIC FORMS OF DM MODY 1, MODY 3, and MODY 5 are caused by mutations in hepatocyte nuclear transcription factor (HNF) 4a, HNF-1a, and HNF-1B, respectively. Individuals with an HNF-1a mutation (MODY 3) have a progressive decline in glycemic control but may respond to sulfonylureas. Individuals with MODY 2, the result of mutations in the glucokinase gene, have mild-to-moderate, but stable hyperglycemia that does not respond to oral hypoglycemic agents MODY 4 is a rare variant caused by mutations in pancreatic and duodenal homeobox 1, a transcription factor that regulates pancreatic development and insulin gene transcription The correct answer is: MODY 3

Answer 40

The correct answer is: Elevated blood pressure

Answer 41

Lipids annually Diabetes-related kidney disease testing annually Blood pressure assessment quarterly Foot examination • 1-2 times/year by provider • Daily by patient The correct answer is: Blood pressure assessment every 3 months

Answer 42

AVOIDANCE OF EXERCISE-RELATED HYPO/HYPERGLYCEMIA • monitor blood glucose before, during, and after exercise • delay exercise if blood glucose is >14 mmol/L (250 mg/dL) and ketones are present • If the blood glucose is <5.6 mmol/L (100 mg/dL), ingest carbohydrate before exercising • Monitor glucose during exercise and ingest carbohydrate to prevent hypoglycemia • Decrease insulin doses (based on previous experience) before and after exercise and inject insulin into a non-exercising area • Learn individual glucose responses to different types of exercise The correct answer is: Inject insulin into a non-exercising area.

Answer 43

ASSESSMENT OF LONG TERM GLYCEMIC CONTROL Measurement of glycated hemoglobin (HbA1c) is the standard method for assessing long-term glycemic control. Glycemic level in the preceding month contributes about 50% to the HbA1c value As the primary predictor of long-term complications of DM, the HbA1c should mirror, to a certain extent, the short-term measurements of SMBG These two measurements are complementary in that recent intercurrent illnesses may impact the SMBG measurements but not the HbA1c Likewise, postprandial and nocturnal hyperglycemia may not be detected by the SMBG of fasting and preprandial capillary plasma glucose but will be reflected in the HbA1c The HbA1c is an “average” and thus does not detect glycemic variability in the way SMBG and CGM can. The correct answer is: Nocturnal hyperglycemia will be reflected in the HbA1c.

Answer 44

TYPE 1 DM INSULIN REGIMENS In general, individuals with type 1 DM require 0.4–1 units/kg per day of insulin divided into multiple doses, with ~50% of the insulin given as basal insulin To determine the meal component of the preprandial insulin dose, the patient uses an insulin-to carbohydrate ratio • a common ratio for type 1 DM is 1 unit/10–15 g of carbohydrate, but this must be determined for each individual To this insulin, dose is added the supplemental or correcting insulin based on the preprandial blood glucose (one formula uses 1 unit of insulin for every 2.7 mmol/L [50 mg/dL] over the preprandial glucose target An alternative multiple-component insulin regimen consists of bedtime NPH insulin, a small dose of NPH insulin at breakfast (20–30% of bedtime dose), and preprandial short-acting insulin The correct answer is: A common insulin-to-carbohydrate ratio is 1 unit per 15 g of carbohydrate.

Answer 45

Patient has rise in HbA1c on metformin monotherapy as well as reduction in eGFR Next step is to add a second agent, usually an oral antihyperglycemic in combination with metformin Patient can still use metformin but in reduced dose (eGFR <35) Empagliflozin cannot be initiated at eGFR <45 Glargine can be added only if dual OHAs cannot control HbA1c after next reassessment Pioglitazone is contraindicated in this patient due to her CHF Vildagliptin is the best choice because it can be given without renal dose adjustment The correct answer is: Vildagliptin

Answer 46

Patient cannot tolerate Metformin (nausea and vomiting) and has hypoglycemic episodes Miglitol and repaglinide are nonsulfonylurea secretagogues, while glimepiride is a sulfonylurea. All of them can cause hypoglycemia which the patient is already having due to poor appetite SGLT2 inhibitors like dapagliflozin do not cause hypoglycemia and is best suited for our patient among the choices The correct answer is: Dapagliflozin

Answer 47

Patient has uncontrolled DM on Metformin therapy and is steadily gaining weight (increase in BMI) Pioglitazone, gliclazide and glargine all cause weight gain due to effects of insulin GLP-1 receptor agonists like dulaglutide cause weight loss that can benefit obese patients The correct answer is: Dulaglutide

Answer 48

SGLT2 INHIBITOR INDUCED EUGLYCEMIC DKA Inhibition of SGLT2 on the alpha cell may lead to increased glucagon and consequently liver production of glucose and ketones Euglycemic DKA presents with metabolic acidosis and ketone formation in the background of only a slightly elevated glucose levels (<250 mg/dL) Euglycemic DKA may occur during illness or when ongoing glucosuria masks stress-induced requirements for insulin. These agents should not be prescribed for patients with type 1 DM or pancreatogenic forms of DM associated with insulin deficiency The correct answer is: Canagliflozin

Answer 49

INSULIN THERAPY IN TYPE 2 DM Insulin should be considered as part of the initial therapy in type 2 DM, particularly in: • lean individuals • those with severe weight loss • in individuals with underlying renal or hepatic disease that precludes oral glucose-lowering agents • In individuals who are hospitalized or acutely ill. The correct answer is: 55/F with tuberculosis-related cachexia

Answer 50

CHOICE OF INITIAL GLUCOSE-LOWERING AGENT Insulin secretagogues, biguanides, GLP-1 receptor agonists, and thiazolidinediones improve glycemic control to a similar degree (1–2% reduction in HbA 1c) and are more effective than a-glucosidase inhibitors, DPP-IV inhibitors, and SGLT2 inhibitors Assuming a similar degree of glycemic improvement, the clinical advantage of one class of drugs is not clear; any therapy that improves glycemic control is likely beneficial. Insulin secretagogues, GLP-1 receptor agonists, DPP-IV inhibitors, a-glucosidase inhibitors, and SGLT2 inhibitors begin to lower the plasma glucose immediately, whereas the glucose-lowering effects of the biguanides and thiazolidinediones are delayed by weeks . Not all agents are effective in all individuals with type 2 DM. Biguanides, a-glucosidase inhibitors, GLP-1 receptor agonists, DPP-IV inhibitors, thiazolidinediones, and SGLT2 inhibitors do not directly cause hypoglycemia Most individuals will eventually require treatment with more than one class of oral glucose-lowering agents or insulin, reflecting the progressive nature of type 2 DM Durability of glycemic control is slightly less for sulfonylureas compared to metformin or thiazolidinediones The correct answer is: DPP-IV inhibitors begin to lower the plasma glucose immediately

Answer 51

You cannot give insulin immediately for this patient because his POTASSIUM is only 3 mEq/L; correct potassium first Despite a bicarbonate deficit, bicarbonate replacement is not usually necessary. However, in the presence of severe acidosis (arterial pH <7.0), the ADA advises bicarbonate (50 mmol [meq/L] of sodium bicarbonate in 200 mL of sterile water with 10 meq/L KCl per hour for 2 h until the pH is >7.0) Use 0.9 Saline as the initial fluid for resuscitation, shift to 0.45 saline after volume status has been restored. The correct answer is: Measure electrolytes and anion gap every 4 hours for first 24 hours.

Answer 52

DKA RESOLUTION As ketoacidosis improves, b-hydroxybutyrate is converted to acetoacetate. Ketone body levels may appear to increase if measured by laboratory assays that use the nitroprusside reaction, which only detects acetoacetate and acetone The acidosis and ketosis resolve more slowly than hyperglycemia. The improvement in acidosis and anion gap, a result of bicarbonate regeneration and decline in ketone bodies, is reflected by a rise in the serum bicarbonate level and the arterial pH Depending on the rise of serum chloride, the anion gap (but not bicarbonate) will normalize. A hyperchloremic acidosis (serum bicarbonate of 15–18 mmol/L [15–18 meq/L]) often follows successful treatment and gradually resolves as the kidneys regenerate bicarbonate and excrete chloride The correct answer is: Normal anion gap metabolic acidosis

Answer 53

HHS vs. DKA In HHS, fluid losses and dehydration are usually more pronounced than in DKA due to the longer duration of the illness. The patient with HHS is usually older, more likely to have mental status changes, and more likely to have a life-threatening precipitating event with accompanying comorbidities Even with proper treatment, HHS has a substantially higher mortality rate than DKA. The correct answer is: HHS has a higher mortality rate than DKA Question 42

Answer 54

MANAGEMENT OF DM IN A HOSPITALIZED PATIENT Insulin infusions are preferred in the ICU or in a clinically unstable setting because the half-life of the infused insulin is quite short (minutes) The absorption of SC insulin may be variable in such situations. Regular insulin is used rather than insulin analogues for IV insulin infusion because it is less expensive and equally effective. Insulin-infusion algorithms should integrate the insulin sensitivity of the patient, frequent blood glucose monitoring, and the trend of changes in the blood glucose to determine the insulin-infusion rate. Because of the short half-life of IV regular insulin, it is necessary to administer long-acting insulin prior to discontinuation of the insulin infusion (2–4 h before the infusion is stopped) to avoid a period of insulin deficiency. The correct answer is: Regular insulin as intravenous infusion

Answer 55

MANAGEMENT OF DM IN A HOSPITALIZED PATIENT In patients who are not critically ill or not in the ICU, basal or “scheduled” insulin is provided by SC, long-acting insulin supplemented by prandial and/or “corrective” insulin using a short-acting insulin (insulin analogues preferred) The use of “sliding scale,” short-acting insulin alone, where no insulin is given unless the blood glucose is elevated, is inadequate for inpatient glucose management and should not be used. The short-acting, preprandial insulin dose should include coverage for food consumption (based on anticipated carbohydrate intake) plus a corrective or supplemental insulin based on the patient’s insulin sensitivity and the blood glucose A corrective insulin supplement might be 1 unit for each 2.7 mmol/L (50 mg/dL) over the glucose target. If the patient is obese and insulin-resistant, then the insulin supplement might be 2 units for each 2.7 mmol/L (50 mg/dL) over the glucose target (140-180 mg/dL). For the patient in the case: • Pre-lunch CBG of 280 mg/dL (100 mg/dL over glucose target of 180 mg/dL) • For obese patients, we use 2 units for each 50 mg/dL over target • Since patient is 100 mg/dL over the target (50 x 2) = we add 4 (2 x 2) units to current prelunch regular insulin dose = 6 + 4 = 10 units The correct answer is: Give regular insulin 10 units SC pre-lunch Question 44

Answer 56

MANAGEMENT OF DM IN A HOSPITALIZED PATIENT Individuals with type 1 DM who are undergoing general anesthesia and surgery or who are seriously ill should receive continuous insulin, either through an IV insulin infusion, their insulin infusion device, or by SC administration of a reduced dose of long-acting insulin. Short-acting insulin alone is insufficient. Prolongation of a surgical procedure or delay in the recovery room is not uncommon and may result in periods of insulin deficiency leading to DKA. Insulin infusion is the preferred method for managing patients with type 1 DM over a prolonged (several hours) perioperative period or when serious concurrent illness is present (0.5–1.0 units/h of regular insulin). If the diagnostic or surgical procedure is brief (<2 h), a reduced dose of SC insulin may suffice (20–50% basal reduction, with shortacting bolus insulin withheld or reduced). The correct answer is: Regular insulin via multiple SC boluses

Answer 57

GESTATIONAL DM Current recommendations advise screening for glucose intolerance between weeks 24 and 28 of pregnancy in women not known to have diabetes. Therapy for GDM is similar to that for individuals with pregnancy-associated diabetes and involves MNT and insulin, if hyperglycemia persists. Oral glucose-lowering agents are not approved for use during pregnancy, but studies using metformin or glyburide have shown efficacy and have not found toxicity The correct answer is: 24 and 28 weeks

Answer 58

GLYCEMIC CONTROL AND COMPLICATIONS The microvascular complications of both type 1 and type 2 DM result from chronic hyperglycemia Evidence implicating a causative role for chronic hyperglycemia in the development of macrovascular complications is less conclusive. The DCCT phase demonstrated that improvement of glycemic control reduced nonproliferative and proliferative retinopathy (47% reduction), albuminuria (39% reduction), clinical nephropathy (54% reduction), and neuropathy (60% reduction) The benefits of an improvement in glycemic control occurred over the entire range of HbA1c values, indicating that at any HbA1c level, an improvement in glycemic control is beneficial. One of the major findings of the UKPDS was that strict blood pressure control significantly reduced both macro- and microvascular complications. In fact, the beneficial effects of blood pressure control were greater than the beneficial effects of glycemic control. In both the DCCT and the UKPDS, cardiovascular events were reduced at follow-up of >10 years, even though the improved glycemic control was not maintained The positive impact of a period of improved glycemic control on later disease has been termed a legacy effect or metabolic memory. The correct answer is: There is a positive impact of a period of improved glycemic control on later disease.

Answer 59

DM RETINOPATHY Duration of DM and degree of glycemic control are the BEST PREDICTORS of the development of retinopathy. Nonproliferative retinopathy is found in many individuals who have had DM for >20 years. Hypertension, nephropathy and dyslipidemia are also risk factors. Although there is genetic susceptibility for retinopathy, it confers less influence than either duration of DM or degree of glycemic control. The correct answer is: Diagnosed DM since 50 years of age

Answer 60

DM RETINOPATHY Individuals with known retinopathy may be candidates for prophylactic laser photocoagulation when initiating intensive therapy. Once advanced retinopathy is present, improved glycemic control imparts less benefit, although adequate ophthalmologic care can prevent most blindness. Fenofibrate, while not reducing cardiovascular events in individuals with diabetes and dyslipidemia, does reduce the progression of retinopathy. Routine, nondilated eye examinations by the primary care provider or diabetes specialist are inadequate to detect diabetic eye disease, which requires a dilated eye exam performed by an optometrist or ophthalmologist, and subsequent management by a retinal specialist for optimal care of these disorders. Treatment of proliferative retinopathy or macular edema with laser photocoagulation and/or anti-VEGF therapy (ocular injection) usually is successful in preserving vision. Aspirin therapy (650 mg/d) does not appear to influence the natural history of diabetic retinopathy. The correct answer is: Fenofibrate

Answer 61

Since patient has only his 1st positive urine albumin test, next step is to repeat test within 3-6 month period He needs 2 out of 3 positive urine albumin tests to be diagnosed with albuminuria Begin treatment only after confirmation of the albuminuria The correct answer is: Repeat albuminuria test after 3 months.

Answer 62

DM NEPHROPATHY Patient has CKD G3bA3 (Stage 3A with Albuminuria of >300 mg/g) and is at risk for CKD progression. Improved glycemic control reduces the rate at which albuminuria appears and progresses in type 1 and type 2 DM. However, once there is a large amount of albuminuria, it is unclear whether improved glycemic control will slow progression of renal disease. Numerous studies in both type 1 and type 2 DM demonstrate the effectiveness of strict blood pressure control in reducing albumin excretion and slowing the decline in renal function. Blood pressure should be maintained at <140/90 mmHg in individuals with diabetes and possibly <130/80 in individuals at increased risk for CVD and CKD progression The correct answer is: Maintaining BP <130/80 mmHg

Answer 63

DM NEPHROPATHY Either ACE inhibitors or ARBs should be used to reduce the albuminuria and the associated decline in GFR that accompanies it in individuals with type 1 or type 2 DM. Most experts believe that the two classes of drugs are equivalent in patient with diabetes. ARBs can be used as an alternative in patients who develop ACE inhibitor–associated cough or angioedema. After initiation of therapy, some increase the dose and monitor the urinary albumin. There is no benefit of intervention prior to onset of albuminuria or using a combination of an ACE inhibitor and an ARB. If use of either ACE inhibitors or ARBs is not possible or the blood pressure is not controlled, then, diuretics, calcium channel blockers (nondihydropyridine class), or beta blockers should be used. The correct answer is: There is no benefit in starting ACE-inhibitors prior to onset of albuminuria.

Answer 64

DM NEUROPATHY Distal Symmetric Polyneuropathy • is the most common of diabetic neuropathy • most frequently presents with distal sensory loss and pain • Symptoms may include a sensation of numbness, tingling, sharpness, or burning that begins in the feet and spreads proximally • Pain typically involves the lower extremities, is usually present at rest, and worsens at night. • As diabetic neuropathy progresses, the pain subsides and eventually disappears, but a sensory deficit persists and motor defects may develop. • Physical examination often reveals sensory loss (to 10-g monofilament and/or vibration), loss of ankle deep-tendon reflexes, abnormal position sense, and muscular atrophy or foot drop. Autonomic Neuropathy • Cardiovascular autonomic neuropathy, reflected by decreased heart rate variability, resting tachycardia and orthostatic hypotension is associated with an increase in CVD • Gastroparesis and bladder-emptying abnormalities are often caused by the autonomic neuropathy • Hyperhidrosis of the upper extremities and anhidrosis of the lower extremities Mononeuropathy • less common than polyneuropathy in DM and presents with pain and motor weakness in the distribution of a single nerve • Involvement of the third cranial nerve is most common and is heralded by diplopia. The correct answer is: There is loss of ankle deep-tendon reflexes and foot drop.

Answer 65

DM NEUROPATHY Chronic, painful diabetic neuropathy is difficultto treat with only symptomatic treatment being available; evidence of the effectiveness of improved glycemic control in painful diabetic neuropathy is lacking. Two agents, duloxetine and pregabalin, have been approved by the U.S. Food and Drug Administration (FDA) for pain associated with diabetic neuropathy. Tapentadol, a centrally acting opioid, is also FDA-approved, but has only modest efficacy and poses addiction risk, making it and other opioids less desirable and not a first-line therapy. Diabetic neuropathy may respond to tricyclic antidepressants, gabapentin, venlafaxine, carbamazepine, tramadol, and topical capsaicin, although none of these are FDA-approved for this indication. The correct answer is: Duloxetine

Answer 66

DYSLIPIDEMIA IN DM The most common pattern of dyslipidemia is hypertriglyceridemia and reduced high density lipoprotein (HDL) cholesterol levels. DM itself does not increase levels of low-density lipoprotein (LDL), but the small dense LDL particles found in type 2 DM are more atherogenic because they are more easily glycated and susceptible to oxidation The correct answer is: High triglyceride, low HDL, normal LDL

Answer 67

``` LOWER EXTREMITY COMPLICATIONS Interventions with demonstrated efficacy in diabetic foot ulcers or wounds: • Off-loading • Debridement • Wound dressings • Appropriate use of antibiotics • Revascularization • Limited amputation ``` Antiseptic agents should be avoided. Topical antibiotics are of limited value. The correct answer is: Antiseptic agents

Answer 68

INFECTIONS IN DM Patient has signs and symptoms of invasive otitis externa Invasive otitis externa is usually secondary to Pseudomonas aeruginosa infection in the soft tissue surrounding the external auditory canal, usually begins with pain and discharge, and may rapidly progress to osteomyelitis and meningitis. The correct answer is: Pseudomonas aeruginosa

Answer 69

The correct answer is: Increase glucagon

Answer 70

The correct answer is: Increased epinephrine

Answer 71

HYPOGLYCEMIA WITHOUT DIABETES Patient most likely has an INSULINOMA. An insulinoma—an insulin-secreting pancreatic islet b-cell tumor—is the prototypical cause of endogenous hyperinsulinism. More than 99% of insulinomas are within the substance of the pancreas, and the tumors are usually small (<2.0 cm in diameter in 90% of cases). The fundamental pathophysiologic feature of endogenous hyperinsulinism caused by a primary b-cell disorder or an insulin secretagogue is the failure of insulin secretion to fall to very low levels during hypoglycemia. Non-B-cell Tumors: hypoglycemia is due to overproduction of an incompletely processed form of insulin-like growth factor II (“big IGF-II”) that does not complex normally with circulating binding proteins and thus more readily gains access to target tissues. Iatrogenic hypoglycemia: Combined deficiencies of glucagon and epinephrine in people with insulin-deficient diabetes Cortisol deficiency: associated with impaired gluconeogenesis and low levels of gluconeogenic precursors The correct answer is: Failure of insulin secretion to fall during hypoglycemia

Answer 72

LIPOPROTEIN COMPOSITION Because lipid is less dense than water, the density of a lipoprotein particle is primarily determined by the amount of lipid per particle. Chylomicrons are the most lipid-rich and therefore least dense lipoprotein particles, whereas HDLs have the least lipid and are therefore the most dense lipoproteins. In addition to their density, lipoprotein particles can be classified according to their size, determined either by nondenaturing gel electrophoresis or by nuclear magnetic resonance profiling. There is a strong inverse relationship between density and size, with the largest particles being the most buoyant (chylomicrons) and the smallest particles being the most dense (HDL). The correct answer is: Chylomicrons

Answer 73

PRIMARY HYPERLIPOPROTEINEMIAS The correct answer is: Familial Chylomicronemia

Answer 74

MANAGEMENT OF SEVERE HYPERTRIGLYCERIDEMIA It is generally considered appropriate medical practice to intervene in patients with TGs >500 mg/dL in order to reduce the risk of pancreatitis It remains controversial whether individuals with severe hypertriglyceridemia are at increased risk for ASCVD Modifying the lifestyle of the patient with severe hypertriglyceridemia often is associated with a significant reduction in plasma TG level. Despite lifestyle interventions, many patients with severe hypertriglyceridemia require pharmacologic therapy Patients who persist in having fasting TG >500 mg/dL despite active lifestyle management are candidates for pharmacologic therapy. The two major classes of drugs used for management of these patients are fibrates and omega-3 fatty acids (fish oils). The correct answer is: Acute pancreatitis

Answer 75

MANAGEMENT OF SEVERE HYPERTRIGLYCERIDEMIA It is generally considered appropriate medical practice to intervene in patients with TGs >500 mg/dL in order to reduce the risk of pancreatitis It remains controversial whether individuals with severe hypertriglyceridemia are at increased risk for ASCVD Modifying the lifestyle of the patient with severe hypertriglyceridemia often is associated with a significant reduction in plasma TG level. Despite lifestyle interventions, many patients with severe hypertriglyceridemia require pharmacologic therapy Patients who persist in having fasting TG >500 mg/dL despite active lifestyle management are candidates for pharmacologic therapy. The two major classes of drugs used for management of these patients are fibrates and omega-3 fatty acids (fish oils). The correct answer is: Omega-3 FA

Answer 76

STATINS The magnitude of LDL lowering associated with statin treatment varies widely among individuals, but once a patient is on a statin, the doubling of the statin dose produces an ~6% further reduction in the level of plasma LDL-C Statins also reduce plasma TGs in a dose-dependent fashion, which is roughly proportional to their LDL-C–lowering effects Statins have a modest HDL-raising effect (5–10%) that is not generally dose-dependent. Serum CK levels need not be monitored on a routine basis in patients taking statins, because an elevated CK in the absence of symptoms does not predict the development of myopathy and does not necessarily suggest the need for discontinuing the drug . Substantial (greater than three times the upper limit of normal) elevation in transaminases is relatively rare, and mild-to-moderate (one to three times normal) elevation in transaminases in the absence of symptoms need not mandate discontinuing the medication The correct answer is: Transaminase elevation of 3x the normal levels in the absence of symptoms does not warrant discontinuation of the drug.

Answer 77

PCSK9 INHIBITORS PCSK9 inhibitors are antibodies that bind to circulating PCSK9 and prevent its interaction with the LDL receptor. They are highly effective in lowering LDL-C, with a mean 50–60% reduction in LDL-C. These antibodies are administered subcutaneously every 2–4 weeks. They are generally well-tolerated, with the major side effect being injection site reactions. They are indicated as second line (after statin) or third line (after statin + ezetimibe) therapy in patients with FH or CHD in whom LDL-C is not reduced to acceptable levels with statin (+/- ezetimibe) alone. The correct answer is: Evolocumab

Answer 78

The correct answer is: Blood pressure <130 mm systolic

Answer 79

TREATMENT OF METABOLIC SYNDROME In general, recommendations for weight loss include a combination of caloric restriction, increased physical activity, and behavior modification. Caloric restriction is the most important component, whereas increases in physical activity are important for maintenance of weight loss. The correct answer is: Caloric restriction

Answer 80

TREATMENT OF METABOLIC SYNDROME Diets restricted in carbohydrate typically provide a more rapid initial weight loss. However, after 1 year, the amount of weight reduction is minimally more reduced or no different from that with caloric restriction alone. Although increases in physical activity can lead to modest weight reduction, 60–90 min of daily activity is required to achieve this goal. Even if an overweight or obese adult is unable to undertake this level of activity, a significant health benefit will follow from at least 30 min of moderate-intensity activity daily. Of note, a variety of routine activities, such as gardening, walking, and housecleaning, require moderate caloric expenditure The correct answer is: Gardening and housecleaning count as physical activities with moderate caloric expenditure.

Answer 81

TREATMENT OF METABOLIC SYNDROME Because insulin resistance is the primary pathophysiologic mechanism for the metabolic syndrome, representative drugs in these classes reduce its prevalence. In a meta-analysis of nine trials involving 12,026 participants, the TZD pioglitazone versus placebo was associated with reduction in ASCVD events in patients with insulin resistance (metabolic syndrome), prediabetes and type 2 diabetes. Benefit of TZDs has been seen in patients with NAFLD, and with metformin in women with polycystic ovary syndrome, and both drug classes have been shown to reduce markers of inflammation The correct answer is: 41/F with NAFLD

Answer 82

VITAMIN D SYNTHESIS In response to ultraviolet radiation of the skin, a photochemical cleavage results in the formation of vitamin D from 7-dehydrocholesterol Vitamin D enters the circulation whether absorbed from the intestine or synthesized cutaneously, bound to vitamin D–binding protein, an a-globulin synthesized in the liver Vitamin D is subsequently 25-hydroxylated in the liver by a cytochrome P450 oxidase in the mitochondria and microsomes. The second hydroxylation, required for the formation of the mature hormone, occurs in the kidney The 25-hydroxyvitamin D-1a-hydroxylase is a tightly regulated cytochrome P450–like mixed function oxidase expressed in the proximal convoluted tubule cells of the kidney. PTH and hypophosphatemia are the major inducers of this microsomal enzyme in the kidney. Calcium, FGF23, and the enzyme’s product, 1,25(OH)2D, repress it. The correct answer is: PTH

Answer 83

DIAGNOSIS OF VITAMIN D DEFICIENCY The most specific screening test for vitamin D deficiency in otherwise healthy individuals is a serum 25(OH)D level. The National Academy of Medicine has defined vitamin D sufficiency as a vitamin D level >50 nmol/L (>20 ng/mL) Vitamin D deficiency leads to impaired intestinal absorption of calcium, resulting in decreased serum total and ionized calcium values. This hypocalcemia results in secondary hyperparathyroidism . In addition to increasing bone resorption, PTH decreases urinary calcium excretion while promoting phosphaturia. This results in hypophosphatemia . Since PTH is a major stimulus for the renal 25(OH)D 1a-hydroxylase, there is increased synthesis of the active hormone, 1,25(OH)2D. Paradoxically, levels of this hormone are often normal in severe vitamin D deficiency. Therefore, measurements of 1,25(OH)2D are not accurate reflections of vitamin D stores and should not be used to diagnose vitamin D deficiency in patients with normal renal function The correct answer is: Normal levels of 1,25(OH)2D

Answer 84

The correct answer is: Nephrocalcinosis

Answer 85

The correct answer is: Serum creatinine every 12 months

Answer 86

Patient has Hypercalcemia of Malignancy (from Lung CA). His PE indicates that he has pulmonary congestion Although hydration is the initial choice of treatment for hypercalcemia, it is contraindicated for this patient. Hydration + forced diuresis is likewise contraindicated Zolendronate cannot be used due to elevated creatinine. Calcitonin is the best strategy for rapid correction of hypercalcemia, followed by hemodialysis for this patient. The correct answer is: Start Calcitonin 200 IU nasal spray, 1 spray per nostril

Answer 87

Hypocalcemia associated with hypomagnesemia is associated with both deficient PTH release and impaired responsiveness to the hormone. Patients with hypocalcemia secondary to hypomagnesemia have absent or low levels of circulating PTH, indicative of diminished hormone release despite a maximum physiologic stimulus by hypocalcemia. Plasma PTH levels return to normal with correction of the hypomagnesemia. Thus hypoparathyroidism with low levels of PTH in blood can be due to hereditary gland failure, acquired gland failure, or acute but reversible gland dysfunction (hypomagnesemia). The correct answer is: Hypomagnesemia

Answer 88

The correct answer is: Higher serum total hormone concentration

Answer 89

The correct answer is: Graves disease

Answer 90

The correct answer is: LT4 replacement

Answer 91

The correct answer is: 3-6 months after starting meds

Answer 92

The correct answer is: Observe and follow-up after 6-12 weeks

Answer 93

Management of Thyroid Storm * PTU 500-1000 mg LD, then 250 mg q6 * SSKI 5 drops q6 started 1 hour after PTU is loaded (Wolff-Chaikoff effect) * Propranolol 60-80 mg PO q4 or 2 mg IV q4 * Hydrocortisone 300 mg IV bolus, then 100 mg IV q8 * Antibiotics if indicated * Miscellaneous: cooling, oxygen, IV fluids The correct answer is: Propylthiouracil

Answer 94

The correct answer is: de Quervain’s thyroiditis

Answer 95

The correct answer is: 55 years old

Answer 96

The correct answer is: Papillary

Answer 97

The correct answer is: Repeat UTZ-guided FNAB

Answer 98

Hypercalcemia of Malignancy PTHrP • most common substance involved in solid tumors (humoral hypercalcemia of malignancy) • Usually associated with squamous cell CA and renal tumors • Causes bone resorption through systemic action Direct bone marrow invasion • Usually in hematologic malignancies • Bone resorption through local destruction Increased 1,25(OH)2D • Usually seen in lymphoma The correct answer is: PTHrP

Answer 99

The correct answer is: IV hydration

Answer 100

``` Risk factors include: • Prior fracture • Family history of hip fracture • Low body weight • Cigarette smoking • Excessive alcohol use • Steroid use • Rheumatoid arthritis ``` The correct answer is: A 60/F who came in for an executive check up

Answer 101

The correct answer is: 1000 mg/day

Answer 102

The correct answer is: Pituitary adenoma

Answer 103

The correct answer is: Higher metabolic potency

Answer 104

The correct answer is: LT4 replacement

Answer 105

The correct answer is: 55 years old

Answer 106

The correct answer is: Bisphosphonates

Answer 107

The correct answer is: Thyroid hormones act via negative feedback through thyroid hormone receptor β2 (TRβ2).

Answer 108

The correct answer is: Increased thyroid hormone metabolism by the placenta.

Answer 109

The correct answer is: Levels are undetectable after radioablation.

Answer 110

The correct answer is: Absence of colloid.

Answer 111

The correct answer is: 25 – 50μg per day – subclinical hypothyroidism requiring treatment

Answer 112

The correct answer is: Discontinue her methimazole and monitor her thyroid function.

Answer 113

The correct answer is: 5 drops of SSKI together with loading dose of antithyroid drug then every 6 hours.

Answer 114

``` Risk factors include: • Prior fracture • Family history of hip fracture • Low body weight • Cigarette smoking • Excessive alcohol use • Steroid use • Rheumatoid arthritis ``` The correct answer is: A 60/F who came in for an executive check up

Answer 115

The correct answer is: Small slim people tend to have lower than average BMD measurements.

Answer 116

The correct answer is: Bariatric surgery in an option in patients with metabolic syndrome and a BMI of > 40 kg/m2, or 35 kg/m2 with comorbidities.

Answer 117

The correct answer is: Now then every year thereafter

Answer 118

The correct answer is: Family history of type 1 diabetes mellitus

Answer 119

The correct answer is: Latent autoimmune diabetes of the adult

Answer 120

The correct answer is: BP < 140/90

Answer 121

The correct answer is: Degludec

Answer 122

The correct answer is: Canagliflozin

Answer 123

The correct answer is: Continue insulin drip titration

Answer 124

The correct answer is: BP should be maintained to less than 130/80 if the patient is at risk for CKD progression

Answer 125

The correct answer is: Revascularization

Answer 126

The correct answer is: Decrease insulin

Answer 127

The correct answer is: Higher metabolic potency

Answer 128

The correct answer is: Graves disease

Answer 129

The correct answer is: LT4 replacement

Answer 130

The correct answer is: 3-6 months after normalization of TSH

Answer 131

The correct answer is: Observe and follow-up after 6-12 weeks

Answer 132

The correct answer is: Propylthiouracil

Answer 133

The correct answer is: de Quervain’s thyroiditis

Answer 134

The correct answer is: 55 years old

Answer 135

The correct answer is: Papillary

Answer 136

The correct answer is: Repeat UTZ-guided FNAB

Answer 137

The correct answer is: PTHrP

Answer 138

The correct answer is: Bisphosphonates

Answer 139

The correct answer is: A 60/M who has a heavy smoking and alcohol history

Answer 140

The correct answer is: 1000 mg/day

Answer 141

The correct answer is: Adrenal adenoma

Answer 142

The correct answer is: Hyperglycemia

Answer 143

The correct answer is: Pituitary apoplexy

Answer 144

The correct answer is: Bromocriptine

Answer 145

The correct answer is: Basal plasma AVP

Answer 146

The correct answer is: A 45/F with HDL of 40 mg/dL, BP of 120/90 and waist circumference of 90cm

Answer 147

The correct answer is: Start Calcitonin 200 IU nasal spray, 1 spray per nostril

Answer 148

The correct answer is: Serum creatinine every 12 months

Answer 149

The correct answer is: Low calorie diet

Answer 150

The correct answer is: Acute pancreatitis

Answer 151

The correct answer is: Loss of ankle deep-tendon reflexes and foot drop.

Answer 152

The correct answer is: Maintaining BP <130/80 mmHg

ENDO Flashcards

(176 cards)