Endo Block 2 Flashcards

1
Q

What is the most convenient population level measure of overweight and obesity currently available?

BMIs of what percentage are categorized as overweight, Class 1-3?

A

BMI- kg/m^2

Normal: 18.5-24.9
Over: 25-29.9
Class 1: 30-34.9
Class 2: 35-39.9
Class 3: Greater than 40
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2
Q

What are four cons of using BMI as a measurement tool?

Upper body obesity that is located ? and ? is more significant than lower body obesity of fat located ? or ?

A

Mis-classifies 25% of PTs
No account for fat location
Not accurate for sedentary/body builders
Not distinguished between fat/lean mass

Abdomen/flank
Thigh/buttocks

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3
Q

Fat that is located ? is more hazardous to health and is composed of ? fat

Females must have a minimum body fat of -% to have a regular menstruation?

A

Abdominal fat
Visceral

13-17%

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4
Q

Upper body obesity and abdominal fat is associated w/ abnormal adipose lipolysis leading to ? and higher incidences of ? complications

What is the number one cause of high output heart failure?

What is the number one public health concern linked to increasing levels of obesity?

A

Insulin resistance
Metabolic

Obesity

DM

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5
Q

Men must have _% body fat

What is the name of an environment that can increase the chance of a PT becoming obese?

A

3%

Obesigenic

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6
Q

What are the 5 parts of the motivational interview?

What is the most common genetic cause of obesity?

What is an independent predictor of metabolic abnormalities associated w/ obesity over and above the effects of exercise?

A
Nutrition intervention
Physical activity
Behavior therapy
Pharmacotherapy
Bariatric surgery

Prader-Willi Syndrome- demonstrates hyperphagia (compulsive overeating over long periods of time)

Sedentary activities

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7
Q

If an adopted PT is concerned about weight gain, how can this be predicted?

What are the typical features of Prader-Willi Syndrome?

A

Biological parents weight

Hypotonia
Almond shaped eyes
Narrow bifrontal diameter
Thin upper lip

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8
Q

What is done during PE for an obesity work up?

What diabetic drugs can cause weight gain?

A

BMI, degree/distribution of body fat, nutritional status, signs of secondary cause

Insulin
Sulfonyureas
Thizolidinediones

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9
Q

How much weight loss can be expected with conventional diet techniques?

What is the more important part of obesity management?

A

20% lose 20lbs and maintain for 2yrs
5% maintain a 40lbs loss
Avg= 7% loss from baseline

PT-Provider contact

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10
Q

Trimble’s obesity management plan and associated goals?

Define Very Low Calorie Diet

A

Diet/Exercise= greatest loss
Only diet= moderate loss
Only exercise= small loss
No Tx= no loss

800-1000cal/day x 4-6mon w/ average loss of 15%
Significant weight gain after 18mon

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11
Q

What are six classes of drugs that are known to cause weight gain?

What class of medication can be considered for these PTs that have underlying psych issues?

A
Psych/Neurological
Steroid hormones
Anti-diabetes (Insulin, Sulfonylureas, Thiazolidinediones)
Anti-histamines
Anti-HTN
Anti-retroviral therapy

SSRIs

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12
Q

How much exercise is recommended per week by the College of Sports Med?

How much moderate exercise is recommended per day?

A

150min moderate
75min vigorous
Equivalent mod/vigorous combo
Weights 2x/wk

1hr

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13
Q

When are meds added to obesity management?

What GI agent is used for management and how does it exert it’s effect in PTs?

A

BMI >30
BMI >27 w/ obesity related RFs: HTN, DM2, CVD

Orlistat- Inhibits intestinal lipase/fat absorption
S/e- oily stool/diarrhea, incontinence

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14
Q

What CNS stimulant/anorexants are used for obesity management and how does it do it?

A

Lorcaserin- SSRA, promotes satiety for moderate weight loss >5%
S/e= HA, breast tumors

Phentermine- inc NorEpi/dopamine uptake suppressing appetite x 3mon

Phen/Topiramte- migraine prophylaxis, weight loss effect. C/i- hypothyroid, glaucoma
D/c if no loss in 4wks

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15
Q

What antidepressant/opioid agonist is used for obesity management?

A

Bupropion/Naltrexone- regulates dopamine reward system, cravings and overeating behaviors
S/e- GI upset
Caution in Psych Hx
C/i- HTN, opioid use, seizure, eating d/o

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16
Q

What GLP-1 agonist can be used for obesity management

A

Liraglutide- DM management med, increases insulin secretion, decreases inappropriate glucagon and slows gastric emptying
S/e- tachy, HA, hypoglycemia, nausea
C/i- medullary thyroid CA, MEN2a

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17
Q

What are the general contraindications for using weight loss meds?

A
Uncontrolled CAD
Pregnancy/feeding
Hx of psych dz
<18y/o
Certain med use- MAOIs
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18
Q

When is bariatric surgery a consideration for obesity management?

What is the name of the gastric bypass procedure?

A

> 40% BMI or >35 w/ co-morbidities

Roux-en-Y gastric bypass
Restrictive/malabsorptive surgery, distal stomach resected. Remaining pouch is anastomosed to retro-colic segment of jejunum leaving gastric capacity at 30-50mL
Dec food intake/absorption of ingested food

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19
Q

What is the name of the Lap Band procedure?

Define Sleeve Gastronomy

A

Vertical banded gastroplasty
Prosthetic band dec size of gastric outlet
Multiple f/u visits for adjustment

Creation of sleeve over bougie, removing portion of greater curvature
Dec ghrelin levels x 1yr
Restricts food intake

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20
Q

Define Dumping Syndrome

What does Hirsutism mean?

A

Bariatric surgery complication when PT has to defecate nearly immediately after eating

Latin- shaggy, hairy
Excessive terminal hair growth that appears in women in a male pattern

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21
Q

Androgens act on sex-hormone responsive hair follicles causing a transition from ? to ?

Half of women with Hirsutism will have ?

A

Vellus into terminal

Hyperandrogenism

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22
Q

What will be seen in women with hirsutism that have increased follicle sensitivity to normal levels of androgens?

What is the Hirsutism is pathological?

How is Hirsutism scored?

A

Normal labs- genetics

Elevated circulating androgens, will have elevated labs

Ferriman-Gallwey score
Norm: <8
Max: 36

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23
Q

Where does DHEA S come from?

Where does Androstenedione released from?

Where is testosterone ( the most potent) secreted from?

A

Adrenal gland

Ovary and adrenal gland

Ovary/adrenal gland

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24
Q

What is the most potent androgen in females?

65% is bound to ? protein
33% is bound to ? protein

A

Testosterone

Sex hormone binding globulin
Albumin

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25
How and where is free testosterone converted into dihydrotestosterone? Why is this conversion important?
In the skin by 5a-reductase 5-DHT stimulates androgen dependent hair follicles
26
What are the 5 etiologies of hirsutism? Which etiology is most common in middle eastern and Mediterranean groups?
``` Idiopathic/familial PCOS Steroidogenic enzyme defect Neoplastic d/o Rare/pharmacologic ``` Idiopathic/Familial
27
What lab results would be seen in Med/Middle eastern females w/ Hirsutism? What is believed to be that cause of this?
Normal androgen levels Onset at puberty Regular menses, PE Higher 5a-reductase activity
28
What is beleived to be the most common cause of Hirsutism in females? How is this acquired?
PCOS- function d/o of ovaries Functional d/o of ovaries Familial passsage of autosomal dominant trait
29
50% of Hirsutism PTs have elevated levels of ? What criteria is used to Dx Hirsutism?
Testosterone Rotterdam Criteria 1- extra androgen (hirsutism, acne, androgenic alopecia) 2- ovarian dysfunction/polycystic morphology (oligo/amenorrhea, infertility) 3- Absence of other causes of excess testosterone (pregnancy, thyroid, neoplasm)
30
What are the S/Sxs associated with the 3 parts of Rotterdam criteria?
Androgen excess/Elevated testosterone- Hirsutism, Acne, Androgenic alopecia Ovarian dysfunction- Oligo/Amenorrhea w/ anovulation, infertility Absence of other causes of testosterone- pregnancy, thyroid dysfunction, neoplasm, Cushings, Hyperprolactinemia
31
What are two unique facts about a PCOS Dx? How is PCOS Tx?
30% of PCOS women doen't have cystic ovaries 30% of normal menstruating women do have cystic ovaries Restore cycles/fertility Reduce Sxs- hair, oil, weight
32
Congenital adrenal hyperplasia is a defected level of ? enzyme? What are the two types?
21-hydroxylase Classic- complete deficiency; ambiguous genitals, virilized when treated w/ CCS Non-classic: partial deficiency; PCOS and adrenal adenomas are more likely to develop Irregular menses, gradual onset of hirsutism
33
What neoplastic d/os can cause Hirsutism?
Ovarian tumors Adrenal carcinoma Pure androgen secreting adrenal tumor
34
What are the 4 features of neoplastic d/o hirsutism? What is the next step for this PT?
Onset out of peri-menarchal period Rapid/severe hair progression Recent menstrual irregularity Signs of virilization (deep voice, inc muscles) Measure androgen levels
35
What are the rare causes of hirsutism? What medications can cause hirsutism?
Acromegaly Cushings ``` Minoxidil- Tx of androgenic alopecia (frontal balding) Cyclosporine- imm suppressant Phenytoin- anti-seizure Anabolic steroids Progestins in OCPs (Norethindrone) ```
36
Key S/Sxs of Hirsutism
``` Inc hair Inc sebaceious activity Menstrual irregularities Anovulation Amenorrhea Defeminization Virilization ```
37
What lab is the most useful test for evaluating Hirsutism?
Serum androgen to find adreanl/ovarian neoplasm Free testosterone- most important Androstenedione DHEA-S
38
If female PT has testosterone levels >200ng/dl what is the next step? What if these tests are negative?
Pelvic exam and US Bilateral CT of adrenal glands
39
What are the second and third labs evaluated during hirsutism?
Serum androstenedione- >1000 suggests ovarian/adrenal neoplasm. Do pelvic US and bilateral CT adrenal scan Serum DHEA-S- >700mcg= adrenal source Order bilateral adrenal CT scan
40
What labs are ordered for a hirsutism work up? What images are ordered for hirsutism after PE and labs?
``` LH/FSH 17-hydroxyprogesterone Fasting insulin/glucose TSH/FT4/PRL UA- cortisol Lipids ``` Adrenal CT- elevated DHEAS, elevated testosterone after negative pelvic and US Pelvic US- elevated testosterone/androstenedione Pelvic MRI- visualized tumors of ovary
41
When are neoplastic origins of hirsutism treated?
Surgery
42
What are the non-surgical Tx options of hirsutism and are c/i in pregnancy?
Spirinolactone- K sparing w/ anti-androgenic action Flutamide- non-steroid, non-selective anti-androgen Finasteride- 5a-reductase inhibitor, only used in post-menopause females
43
What med can be added to spirinolactone to increase it's efficacy? What drug combo is more effective than spirinolactone?
OCPs Metformin OCPs and Flutamide
44
What are the new combined OCPs used to reduce hirsutism and acne? What are the s/e of using these combos
Desogestrel Drospirenone Norgestimate Inc DVT risk, use lower estrogen formulas
45
When/why is metformin used for hirsutism? What is it's use combined with?
PCOS to improve menses and promote weight loss W/ Sironolactone
46
When/why is Simvastatin used for hirsutism? When is Clomiphene used?
Reduces hirsutism and testosterone levels in PCOS, improved when sued w/ OCPs Fertility aid in PCOS and infertility
47
What cosmetic therapies can be used for hirsutism? What are the etiologies of gynecomastia?
Vaniqa cream- dec hair growth in 4-8wks ``` Physiologic Endocrine Dz Systemic Dz Neoplasms Meds- 59 total ```
48
What are the 4 physiological causes of gynecomastia?
Neonatal- transient and self resolving, due to high estrogen from pregnancy Puberty- very tall/overweight boys, 60% of normal boys affected and self resolves in 1yr Aging- seen w/ dec testosterone and weight gain, increased SHBG reduces free testosterone Obesity- inc fat increases aromatse activity converting testosterone into estradiol (usually pseudo-gynecomastia)
49
What's the difference between glandular and fatty gynecomastia? What are the 5 etiologies of gynecomastia?
Glandular- tender Fatty- non-tender ``` Physiologic Endocrine dz Neoplasm Systemic Dz Meds- 59 of them ```
50
What are the endocrine abnormalities that can cause gynecomastia? What are the 3 systemic diseases that can cause gynecomastia?
Androgen insensitivity Hypogonadism- Klinefelters Hyperprolactinemia Hyperthyroidism Liver, renal dz Spinal cord injury
51
What types of neoplasms can cause gynecomastia?
Steroid producing (estrogen) hCG producing in lung, teste, hepatocellular, gastric carcinoma Breast Ca- unilateral, irregular, painless, firm/fixed to underlying tissue
52
At a BioChem level, what causes gynecomastia? Male breast cancer has a higher incidence rate in ? PT population?
Testosterone converted by aromatase into estradiol in adipose/extra-gonadal tissues Klinefelters
53
What are 5 meds that can cause gynecomastia?
Spironolactone*- only common Cimetidine Ketoconazole 5a-reducatse inhibitors for BPH (Proscar, Avodart) Exogenous steroid/androgen HIV Tx w/ highly active antiretroviral therapy- especially Efacirenz or Didanosine
54
FSH stimulates ? process LH stimulates ? process? Gynecomastia presents as ? development while CA presents as ?
F- binds to Sertoli cells in seminiferous tubules to stimulate spermatogenesis L- Leydig cells in testes to produce testosterone G: concentric C: ecentric, off to side
55
Gynecomastia is usually located ? when compared to where female breast cancer usually shows How is gynecomastia Dx?
CA- supper lateral quad, gynecomastia- under nipple Clinically
56
DDx of gynecomastia
Unilateral, Painless, Eccentric= Breast Ca, Lipoma, Neurofibroma Bilateral, Painless= obesity, pseudogynecomasti
57
What labs are ordered for gynecomastia? How is Klinefeltors Dx'd?
PRL, hCG, LH, testosterone, estradiol, TSH Persistent gynecomastia w/out identifiable etiology
58
If a male has one of what 5 conditions, no work up is needed for gyneocmastia
``` Hypogonadism Liver Dz Testicular tumor Hyperthyroid Medication Hx ```
59
Lab results for gynecomastia
PRL and b-hCG High PRL= hyperprolactinemia, pituitary lesion High b-hCG= malignancy in liver, lung, testis Testosterone/LH Low T, High LH= primary hypogonadism Low T, low LH= secondary hypogonadism Estradiol Inc in testicular tumors, liver dz, obesity, inc levels of b=hCG TSH/FT4 Hyperthyroid inc SHBG, dec free testosterone
60
What imaging is needed for gynecomastia PTs?
Mammography, CXR US for suspicious mammogram findings Needle biopsy w/ cytology for suspicious unilateral/asymmetric enlargement to distinguish tumor from mastitis
61
How is pubertal gynecomastia Tx?
Observe, f/u Q6mon Self resolving in 1-2yrs ``` Painful/Persistant: SERM (Ramoxifen, Faloxifene) better for glandular type Aromatase inhib (Anast/Letrozole) ```
62
How is hypogonadism related gynecomastia Tx? This Tx can only occur after ?
Testosterone replacement, can worsen condition Lab confirmed Dx
63
When is radiation therapy used for gynecomastia? When is surgery used as a last resort?
Prostate CA + gynecomastia Persistent and severe cases
64
Testosterone + aromatase= ? Testosterone + 5a-reductase= ?
Estradiol- wolffian duct, brain, muscles, body hair, spermatogenesis, libido 5a-DHT- (masculine effects) External genitals, Male body hair pattern Temporal baldness
65
What are the three effects testosterone exerts? Most important androgen in men is testosterone due to its impact on what non-endocrine organs?
1: Direct impact on androgen receptors 2: converted to estradiol/5a-DHT 3: non-endocrine organ impact Muscle, adipose, bone, metabolism, brain function
66
# Define Hypogonadism What are the two types?
Deficient testosterone secretion from testes (low testosterone) P: failure of testes to produce (hypergonadotropic hypo- high LH/FSH) S: hypothalamus/pituitary failure to secrete gonadotropins (hypogonad- low LH/FSH)
67
S/Sxs of hypogonadism Hypogonadism can occur in what four time frames?
Low libido ED, Fatigue, depression Reduced endurance Early prenatal Late prenatal Pre-puberty/puberty deficient Post-puberty deficient
68
# Define Early Prenatal Hypogonadism Define Later Prenatal Hypogonadism
1st trimester T deficiency Ambiguous genitalia Pseudohermaphroditism- ovary or testi True hermaphrodite: both Deficiency of testosterone during 3rd trimester= micropenis, cryptochordism
69
# Define Puberty Hypogonadism Define Post-puberty hypogonadism
T deficiency at puberty Dec strength/endurance High voice/Dec hair No sexual maturity or differentiation Mid life lack of testosterone Dec libido/energy/hair Impotence/Wrinkles
70
# Define Eunochoidal Proportions What d/o is this normally seen in?
GH stims bones to grow out of proportion Testosterone=closed plates Arm span>height by +5cm Crown-pubis
71
What 4 labs need to be drawn in the morning due to diurnal release? What class drug is given to PTs w/ BPH?
GnRH, LH, FSH, Testosterone 5a-reductase inhibitor
72
How much of testosterone is bound and where is it bound to? What part of life has a lower portion of free testosterone?
54-75% to SHBG 44% to albumin Elderly, higher SHBG levels
73
What are the three main types of hypogonadism?
Primary- defect of testes (hypergonad hypogonad) Low T, Inc LH/FSH Secondary- defect of hypothalamus/pituitary (hypo, hypo) Low T, L or N LH/FSH (inappropriately normal) Androgen defect/resistance Inc T, Inc LH/FSH but effects of low T
74
What can cause Primary Hypogonadism?
Congenital: Klinefelter, Cryptochordism, Bilatearal anorchia Acquired: age trauma infection(mumps/gonorrhea, leprosy) chemo/radiation
75
What is the most common congenital/chromosomal abnormality among males causing primary hypogonadism? What are the comorbidities that come w/ this Dx?
Klinefelter 47XXY ``` Breast Ca DM CPDz Osteoporosis Varicose veins ```
76
What type of testicular development does Klinefelters cause and how is it Dx?
Firm, Fibrotic, Nontender, Small <2cm (N=>3.5) High LH/FSH, low T Keryotyping
77
How is Cryptorchidism Tx non-surgically? If surgical Tx must be done for cryptorchidism, what age is it done at? What are the associated risks w/ infertility?
hCG 1500mg x 3 days Orchipexy @12-24mon 75% if bilateral 50% if unilateral
78
Define Vanishing Testicle Syndrome
Primary Hypogonadism. Bilateral Anorchia Testes @ 14-16wks of gestation, empty scrotum Normal growth/development until secondary sexual development fails to show at puberty
79
How is Bilateral Anorchia Dx? How are all forms of Primary Hypognoadism Tx?
hCG stimulation test + test= no inc of testosterone Crypto= inc of testosterone ``` Testosterone IM Q2-3wks Testosterone patches Topical application= most stable levels, transfer risk Buccal- Q12hrs PO from not avail in US Pellets- SQ administration ```
80
When does monitoring needs to be done for PTs taking testosterone? What also needs to be checked every 6-12mon in these PTs?
Starting 14 days after initiation Lipids, LFTs, CBC, PSA, DRE Repeat Q6mon
81
What are the 5 s/e of testosterone replacement? What are the c/i of using this therapy?
``` Dec HDL Acne Gynecomastia Liver abnormalities Polycythemia ``` Prostate hyperplasia/CA Boys <13y/o
82
What are the four causes of Secondary Hypogonadism?
Congenital: Kallmann (most common cause of 2* Hypo) Acquired: Panhypopituitary, Hyperprolactinemia Other-meds age obesity illness ETOH drugs
83
# Define Kallmann Syndrome What odd Sx do they present with?
X-linked inheritance causing isolated gonadotropin deficiency GnRH cells near olfactory bulbs= anosmia
84
How do PTs w/ Kallmann Syndrome present? How are they Dx?
Prepubertal testes (small/rubber) Eunuchoidal build +/- gynecomastia 50% unilateral renal agenesis Low T, Low/N LH/FSH
85
What is the most common cause of hyperprolactinemia What are the two major causes of "other" etiologies of Secondary Hypogonadism
Pituitary adenoma Inhibits GnRh and T Dec LH efficacy Obesity Poor health
86
How is Secondary Hypogonadism Tx? Defective androgen action/resistance only happens in ? PTs?
Weight loss Underlying issue Testosterone + other hormone for fertility High T, FSH, LH in 46XY Phenotype female Genotype male
87
How/why are PTs w/ 46XY Dx? What PE finding is indicative of this Dx?
Amenorrhea | No uterus is palpable blind pouch w/out uterus, cervix, Fallopian tubes
88
How are PTs w/ CAIS Tx? Where is 5-AR Deficiency frequency increased?
Remove testes Estrogen Tx Dominican republic New Guinea Turkey
89
DHT is needed for neonatal target organ development during what point of development? How doe these PTs present to clinic and on lab results?
8-12wks Poorly developed prostate/external genitals Appears female Crytorchid tested Normal T/FSH/LH
90
# Define Guevedoce What other findings are seen with 5a-reductase deficiency?
Penis development at 12 from inc T due to alternate DHT production pathways Masculinity Adams apple Deep voice
91
A cells make ? B cells make ? D cells make ? F cells make ?
Glucagon Insulin Somatostatin Ghrelin
92
Glucagon acts on ? to convert ? Glucagon promotes ?
Hepatocytes- glycogen to glucose Gluconeogenesis- formation of glucose from lactic acid and amino acids
93
What is the most important regulator of glucagon and insulin levels? DM is a syndrome of disordered ? and inappropriate ?
Blood glucose Metabolism, Hyperglycemia
94
# Define DM Type 1 What is the greatest risk factor for DMT2 insulin resistance?
``` Usual PT= kids Autoimmune destruction of B-cells/Catabolic d/o REQUIRES insulin UnTx= Ketosis Not linked w/ FamHx ``` Visceral Obesity- adipocytes secrete adipokines, impair insulin signaling
95
# Define MODY How does this get passed through generations?
Maturity Onset Diabetes of Young Non insulin dependent DM <25, non-obese PTs due to impaired glucose-induced secretion of insulin Autosomal dominant
96
What are secondary causes of hyperglycemia? What does Diabetes, Insipidus, and Mellitus mean?
Insulin insensitivity: Tumors, Steroids, Liver dz Red insulin secretion Pheo, Pancreatitis, Drugs D: excessive urine/siphon I: tasteless M: honeyed, sweet
97
Metabolic Syndrome puts PTs at risk to develop ? What waist size is dangerous for this development? What organ system is first to start the decline towards metabolic syndrome?
DM2, CVD >40 / >35 Renal function: hyperuricemia
98
3 of what 5 criteria are needed to Dx metabolic syndrome? What Dx is given to these PTs?
``` Ab obesity: >102/88cm TG: >150 HDL: < 40/50 BP: +130/85 Fasting glucose: +110 ``` Pre-Diabetic
99
What are the characteristic S/Sxs of DM1
``` Polyuria- osmotic diuresis Polydipsia Polyphagia Blurry vision- hyperosmolar fluids Weight loss PHOTN Pareasthesia DKA ```
100
Since DM2 is ASx, what is a common initial complaint in women? What derm issue is seen in DM2 PTs?
Vaginitis Acanthosis Nigricans- hyperpigmented thickened skin on neck/groin/axilla
101
What is the equivalent to DKA of DM2? What is not a screening test for DM?
Hyperglycemic Hyperosmolar Coma UA
102
What are the two tests primarily used for DM? What diabetic like issue is seen on UA of pregnant PTs?
Plasma glucose HbA1c Nondiabetic glycosuria
103
What ketonuria levels require hospitalization? How long does glycated HgB circulate in blood?
>3.0mmol 120d Reflects glycemia for up to 12wks previously
104
How often is A1C measured in diabetics? What can this measurement be used for?
Q3-4mon Screening/Dx
105
What are the normal plasma glucose levels? What are normal, impaired and diabetic OGTT results? What are normal, impaired and diabetic A1C levels?
Fasting: +126= DM Fasting: 100-125= impaired Random: +200 w/ Sxs= DM N: <140 I: 140-199 D: >200 N: <5.7 I: 5.7-6.4 D: 6.5 or higher
106
What steps can be done to prevent/delay development of DM2? What is the next step for suspected DM but normal plasma glucose?
Dec weight 5-10% Diet, Exercise, Drugs OGTT
107
What can cause a false high OGTT result?
Low RBC turnover: Fe, B12, Folate deficient Kidney/liver failure ``` Rapid RBC turn over: Bleeding Anemia Transfusion Hemolysis Kidney/Liver Failure ```
108
What is the first and descending complications to occur with an average A1C of 6.5% or higher? What blood measurement is used for A1C scores if PT hs abnormal HgB or hemolytic states?
Retinopathy Nephropathy Neuroapthy/Microalbuminuria Skin/membrane Serum Fructosamine- nonenzymatic glycosylation of serum protein (albumin) from past 1-2wks
109
What two measurements can be taken to differentiate between Dm1 and DM2 An abnormal lab should be confirmed on a different day using ? test?
Insulin C-peptide: fragment of proinsulin, mirrors levels Fasting glucose
110
What are the levels of FPG, HbA1C, random and 2hr OGTT needed for Dx and won't be on test
FPG: +126mg HbA1c: +6.5% Random: >200mg w/ Sxs OGTT: >200mg
111
What is the first step in diabetic management? What Sxs are seen in DM w/ glucose levels >200 or <60
Self management, education and support +200: Thirst, dry, tired -60: Shaky, sweaty, weak Don't use UA for monitoring
112
Medical Nutritional Therapy can decrease HgA1C by how much? What is the most important part of DM Diet?
1. 0-1.9% for DMT1 0. 3-2% for DMT2 Healthy eating patterns, especially Mediterranean style pattern (high in/soluble fiber)
113
Low glycemic index foods are _ or less High glycemic index foods are _ or more
55 or less 70 or more
114
What is the "magical pill" for health and diet? This "magic pill" mimics what class of drug? These two things can reduce the effects of ? DM Sx?
Protection from polyphenols- inhibits glucose absorption, oxidative stress and inflammation A-glucosidase inhibitors Neuropathy
115
What is the first, last and anytime line of Tx of diabetes? What are the next two steps?
Therapeutic lifestyle change Weight loss Exercise
116
Since all DM PTs are ImmComp, what vaccines do they need? What meds are considered in all PTs w/ DM?
Influenza Penumococcal- at Dx and repeat at 65 if first dose was prior to 65y/o Glycemic agents ASA Lipid lowering ACE/ARB
117
What is the JNC 8 B goal for PTs w/ DM? GLP-1 RA meds are only used for ? type of DM? This is the 1st line medication for all new cases of DM2
<140/90 Only DMT2 Metformin
118
Glycemic control agents are used for DM, what are the classes and meds of each class?
``` Biguinide: metformin DPP4i: -gliptin GLP-1RA: tide SGLT2i: -gliflozing TZD: glitazone AGI: -acarbose ``` SU/GLN: -glipizide/-glyburide
119
What is the MOA of Metformin? What are the advantages, disadvantages and c/i of using metformin?
Dec gluconeogenesis, inc hepatic insulin sensitivity A: Lipids, no hypoglycemia, weight loss D: lactic acidosis C: CKD, alcoholics, CHF
120
What two classes are included under "Incretin Therapy"? Meds in this class end w/ ? What is the DPP4/Metformin combo pill?
DPP4 inhibitors GLP-1 agonists -gliptin Janumet
121
What is the MOA of DPP4s? What are the advantages, disadvantages and c/i of using DPP4 inhibitors?
Prevent degradation of incretins which stimulate insulin release, dec glucagon Low hypoglycemia risk Reactions, pancreatitis, URI Renal impairment,
122
What are GLP-1 agonists effect on hypoglycemia and weight? When are GLP-1 agonists used in DM therapy?
Hypo: neutral Weight: decrease No solo use, added to Metformin or Sulfonylureas
123
What is the MOA of GLP-1 agonists? What are the advantages, disadvantages and c/i of using this drug?
Stimulate insulin release, reduce glucagon and slow GI emptying Weight loss, addresses post-prandial glucose, weekly administration GI, pancreatitis, medullary thyroid CA, injection MEN2, medullary CA, gastroparesis
124
What DM Tx med is also a formulation for obesity Tx? What are SGLT-2 inhibitors effect on hypoglycemia and weight?
GLP1 agonist: Liraglutide Hypo: neutral W: loss
125
What is the MOA of SGLT-2 inhibitors? What is an FDA benefit of this med? What are the advantages disadvantages and c/i of using SGLT-2 inhibitors?
ONLY med to work at level of kidney Dec re-absorption, inc urinary excretion Approved for reducing CV risk Weight loss Inc urination, reduced BP, UTIs
126
What are TZDs effect on hypoglycemia and weight gain? What are their MOA?
Hypo: neutral Weight: GAIN Sensitizes peripheral tissue to insulin
127
What are the advantages, disadvantages and c/i of TZDs?
Improved lipids, slows DM progression Inc risk of MI, edema, Osteoporoses, weight inc NYHA 3,4 Liver Dz
128
What is the effect of sulfonylurea on hypoglycemia and weight? What is their MOA?
Severe hypo Weight gain Stims insulin release
129
What are the 1st and 2nd generation sulfonyureas? What are the advantages, disadvantages and c/i of using them?
1st: Tolbutamide 2nd: Glipizide- long acting Longevity, cheap Only PO med to cause Hypoglycemia (SFN>GLN) Liver/renal dz
130
What is the MOA of AGIs? What are the advantages, disadvantages, c/i of using these?
Delay carb absorption Weight neutral, address post-prandial glucose GI Intestine d/o, Cirrhosis
131
What PT populations have an A1C goal of <6.5, <7, <7.5, <8 ad <8.5
6. 5: pregnant adults if able w/out hypoglycemia/polypharm 7: non-pregnant healthy adult 7. 5: Older/healthy adult, children, adolescents 8: Hx of severe hypoglycemia 8. 5: Older adult, frail, limited life span
132
What is the DM2 oral agent algorithm? What DM med is started/used first for PTs w/ A1C >9 w/ Sxs?
``` If HbA1C <9 Nutrition/exercise Metformin x 3mon (D-Day) 3mon: D+3, Dual therapy 3mon D+6, Triple therapy 3mon: D+9, Insulin w/ PO agents (never more than 3 PO agents), except ``` Insulin + metformin
133
Major s/e of Metformin, Pioglitazone, GLP-1, DPP4, SGLT2 classes?
Met: lactic acidosis Pio: fluid retention, Fxs, bladder CA GLP: N/V/pancreatitis DPP4: pancreatitis (only moderate efficacy class) SGLT2: UTI, GU fungal infxn, dehydration
134
What are the two groups of insulin and what belongs in each?
Bolus- Rapid: Lispro, Aspart, Glulisine Short: Regular Basal- Intermediate: NPH Long: Glargline, Detemir
135
What type of insulin is used in the ER to Tx DKA? DMT2 Pts need to stop taking ? med if insulin is added to their Tx routine?
Short acting- Regular, can be given IV Sulfonylureas- only PO agent that causes hypoglycemia
136
When adding insulin to DMT2 PTs, what type is usually added first? Define Dawn Phenomenon and Somogyi Effect and how each one is Tx?
NPH/Long acting (Glargine, Detemir) at bed time Dawn: inc 02-0300 glucose levels, inc bed time dose Somogyi: low 02-0300 glucose levels, reduce bedtime insulin dose Both result in morning hyperglycemia, 02-0300 check to differentiate
137
Why do Dawn and Somogyi Phenomenons happen?
D: reduced tissue sensitivity to insulin that develops between 05-0600 due to GH S: surge of Epi produces high glucose by 0700
138
What DMT2 medication is used for DM and weight loss? Hypoglycemia is the most common complication inf DM PTs being Tx w/ and feel Sxs when levels are below ?
GLP1 receptor agonists - add on therapy on to Metformin or Sulfonylurea Insulin <54mg
139
What are the first 3 Sxs of hypoglycemia? What class med can blunt these Sxs? Neurological Sxs don't show until blood glucose is below ?
Tachy, Palpitation, Termulousness BBs <50mg
140
How can mild/mod hypoglycemia be Tx? How is severe cases Tx?
15g of carbs Glucagon kit- 1mg Given to every PTs receiving insulin
141
What is given in the ER for hypoglycemia? Who is most likely to have DKA?
IV glucose 50ml IM glucagon 1mg if glucose is unavailable DMT1 w/ pump DMT2 during trauma/sepsis
142
How can early DKA be detected quickly in PTs w/ pumps? What is the cut off indicator that PTs need to seek medical help while self-monitoring w/ DKA during sick day?
UA ketones Test urine ketone Q2-4hrs >250mg x >6hrs 4-6ox fluid Q30m
143
How does DKA present?
``` Polyuria/dipsia x 1-2 days N/V/Fatigue Hypothermia Tachy w/ HOTN pH <7.4 (6.9-7.2) Hyper-K on lab, actually depleted in body ```
144
How is DKA Tx? What is one of the most serious shortcoming of DKA Tx? What is the fluid of choice for Tx DKA? What fluid is used if PT presents w/ hypernatremia (Na>150)
IV fluid, Insulin, K, BiCarb Fluid deficit: 4-5L 0. 9% NS: 1L over 1-2hrs 0. 45% NS
145
What can be induced if Tx w/ DKA fluid resuscitation is too aggressive? During DKA Tx, when is fluid Tx switched?
>5L in 8hrs= ARDS, Cerebral edema <250mg= switch to 5% glucose solution
146
Insulin replacement falls where in the DKA Tx algorith? What is the f/u step to this sequence
After fluids IF K is >3/5meq If K is <3.5, delay insulin until K is normal
147
How much K is given to PTs during DKA Tx? How does hyper/hypo-K show on EKG?
KCl 10-30meq during 2 or 3rd hr of Tx Hyper= peaked T Hypo: flat T, U wave
148
When is NaBicarb used for DKA Tx? What is the last step of consideration when Tx DKA?
pH <7.0 1-2 ampules added to 1L of 0.45% of saline ABX- cholecystitis, polynephritis may be severe in these PTs
149
What is the second most common form of hyperglycemic coma? What PT population is it normally seen in?
HHS- hyperglycemia w/ no ketosis Middle age/elder w/ DM2
150
PTs suffering from HHS usually have what underlying systemic Dz or are taking ? meds? Why is HHS more deadly than DKA?
CHF, CKD Thiazides, Glucocorticoids Slow onset w/ 10x higher glucose levels
151
What will be seen on PE of PT w/ HHS? What will be seen on labs?
Profound dehydration w/ no Kussmaul respirations | Hyperglycemia Hyponatremia Prerenal azotemia NO ketosis or acidosis
152
How is HHS Tx?
IV fluid, insulin, K 4-6L over 8-10hrs Hypovolemia+oliguria= NS 0.9% No hypovolemia= 0.45% NS Once glucose is <250, start 5% dextrose, 0.45% or 0.9% NS Insulin- only if glucose >250 KCl- added earlier than DKA Tx, not if CKD/oliguria is present
153
What are the DMT1 complications? What are the DMT2 complications
Renal Dz Blindness Neuropathy Death from end stage renal dz Renal dz Blindness Neuropathy Macrovascular Dz= MI*/stroke
154
What is the difference of the anion gap between HHS and DKA? Chronic DM complications include what 5 systems?
HHS: Norm DKA: High (>10) ``` Ocular Nephropathy Neuropathy CV Skin/membrane ```
155
What are the two categories of diabetic retinopathy?
Nonrpoliferative "background": Microaneurysms Exudates Dot hemorrhage Proliferative "malignant" Cotton wool spots Leading cause of blindness in US
156
How is proliferative retinopathy Tx?
Photocoagulation Bevacizumab- injection to stop growth of new vessels HTN management Tobacco cessation
157
When do DMT1 or DMT2 get eye exams ? that coincide for testing for? What are seen as kidney function begins to decline?
1: 5yrs after Dx then annually 2: at Dx, then annually Microalbuminuria Albuminuria to urea/creatinine accumulation in blood
158
What is the TOC for diabetic nephropathy What levels/how many positive tests are needed for Dx?
Morning spot urine for albumin/creatinine ratio, can't be detected by urine dipstick 30-300mcg 2-3pos tests within 3-6mon before Dx
159
How id DM microalbuminuria Tx? How is progressive diabetic nephropathy Tx?
ACEI (even in T1 PT w/ normal BP) ARBs Low protein diet Dialysis due to macro proteins in urine
160
What is the most common form of diabetic peripheral neuropathy What is "rocker bottom" foot deformity
Distal symmetric polyneuropathy (glove/stocking or Charcot) starting w/ the longest axons Charcot arthropathy- joint subluxation, periarticular Fxs
161
What type of diabetic neuropathy is reversible? What nerves are most likely to be involved by this?
Isolated peripheral Femoral and CNs (CN3 palsy)
162
How is painful diabetic neuropathy Tx? Autonomic neuroapthy in DM can effect what 4 things?
Amitriptyline- TCA Duloxetine- SNRI Gabapentin Capsaicin cream BP/P, GI tract, Bladder, ED
163
What med can be used for DM w/ GI tract autonomic neuropathy induced gastroparesis What can be used for diarrhea
Metoclopromide 30min before meals/bed, only for 3mon Broad spectrum ABX Loperimide
164
What can be used for ED from DM? Half of PTs w/ DM will develop ? after 20yrs of the Dz
Sildenafil Papaverine- intracavernous injection ``` Peripheral vascular dz: Ischemia of LE ED Intestinal angina Gangrene of feet ```
165
What meds are given to DM w/ PVDz? What are the lipid goals for these PTs?
ACE/ARB ASA Statin LDL <100/<70 w/ CAD HDL >40 TG <150
166
DM get annual foot exams to check for ulcers IAW ? program What three factors lead to diabetic foot problems?
LEAP: lower extremity amputation prevention w/ monofilament test, 10g pressure, 10 spots Ischemia Peripheral neuropathy Secondary infection
167
DMT2 can have increased risk of developing ? fungal infection? What skin finding can be seen on shins/dorsal surface of foot? When are DM PTs referred to Endocrinology?
Thrush Necrobiosis Lipoidica Diabetricorum Type 1: at Dx Type 2: if difficulty w/ reaching goals
168
What hand issue can be seen in DM w/ long standing diabetes? What labs are drawn at each DM visit?
Dupuytrens contracture ``` Fasting CMP: 110-120 HbA1C: <7% Microalbumin for DMT2 (at Dx and annually) Lipid- annual Ophthalmology- dx and annual ```
169
What vaccines do DM PTs need? Leading cause of death for type 1/2 DM?
Pneumovax Influenza 1: Renal Dz 2: MI
170
What is normal Ca level? What organs are directly and indirectly responsible for Ca regulation?
Serum: 8.5-10.5mg Ionized/Free: 4.6-5.3mg Direct: parathyroid, kidney w/ Ca sensing receptors Indirect: intestine
171
What hormones regulate serum Ca? What stimulates for the major one to inc/dec?
PTH, Vit D, Calcitonin Stim: falling Ca/Mg level Inhib: rising free Ca/Mg level
172
What does PTH stimulate/inhibit Where is calcitonin made and what does it do?
Resorption of bone to inc systemic Ca/Phosph Opposite of PTH Parafollicular cells in thyroid gland in response to elevated serum Ca level to Inhibits osteoclasts Produced in
173
When are calcitonin levels monitored? What are the first and second most common causes of Hypercalcemia?
Thyroid Ca ``` High Ca, High PTH Primary hyperparathyroidism (adenoma, hyperplasia, CA) ``` Norm Ca, High PTH: (familial hypocalciuric hypercalcemia) High Ca, Low PTH: Secondary malignancy, non parathyroid CA (milk alkali syndrome) Can be from any type of CA
174
What is the first step in investigating hypercalcemia? What are the S/Sxs of hypercalcemia
What is the PTH doing? Mild: ASx Severe: >14mg, CA concern Groans Moans Overtones Bones Stones
175
What is the first part of Tx for parathyroid adenomas? What monitoring steps are done for ASx PTs?
Hydration F/u Q6mon: BP, SrCr Yearly: Urine Ca, Kidney function Bone density Q2yrs
176
What Ortho Dx is indicative of Hypercalcemia? What is a rare but serious cause of High Ca/High PTh? How is MEN induced parathyroid hyperplasia Tx?
Osteitis Fibrosa Cystica MEN 1, 2, 4 Subtotal parathyroidectomy, 3.5 glands removed
177
What are the three types of hyperparathyroidism? What lab results are seen in Parathyroid CA?
Benign parathyroid adenoma Parathyroid hyperplasia Parathyroid CA Sever hyperCa, Very high PTH corrected w/ surgery
178
What lab results are seen in Familial Hypocalciuric Hypercalcemia? How is it Tx?
Defective Ca receptors in parathyroid leading to: Normal PTH Permanent HyperCa, HypoCalciruia None avail, autosomal dominant d/o
179
How do you tell between parathyroid cancer and small lung cell cancer? What protein will increase in PTs w/ parathyroid malignancy? What will be seen on labs?
High PTH= parathyroid Low PTH= SCLCa PTHrP Severe HyperCa Low PTH High PTHrP
180
What types of CA can cause PTHrP increases? Define Milk Alkali Syndrome
Squamous CA of lung, esophagus, head/neck Renal, Bladder, Ovarian, Breast CA Triad of HyperCa, Metabolic alkalosis, Acute kidney injury
181
What vitamin increase can suppress PTH? Where can this increase be causes by if it wasn't ingested?
Vit D Lymphoma Granulomatous Dz: Sarcoidosis, TB, Histoplasmosis, Coccidiomycosis Thyrotoxicosis Immobilization- ICU PT, Dx of exclusion
182
How is hypercalcemia managed?
``` Hydration/Activity Furosemide- + calciuresis No thiazides, Vit A/D, Antacids Avoid Vit A/D Dialysis if renal failure ```
183
When are Bisphosphonates used for hypercalcemia? What is the MOA in Tx?
Hyperparathyroidism, Malignancy, Immobilization Surgery Pre-Op- Inhibits osteoclast reabsoprtion of Ca
184
What is the TOC in malignancy associated hypercalcemia What Tx is added for post-menopause PTs?
IV Bisphosphonates Estrogen
185
What is the most common cause of hypocalcemia? Elderly hospitalized PTs w/ hypocalcemia, variant PTH levels are likely to be deficient in ?
CKD Vit D
186
Hypoalbuminemia is a common cause of low ? If this is due to hypoalbuminemia, it's not clinically significant if ?
Total serum Ca Ionized Ca is normal
187
If albumin is low, check ? or calculate the correct one What can cause HypoCa w/ High PTH What causes HypoCa w/ low PTH
Ca Pseudohypoparathyroid (PTH resistance) Vit D deficient/resistance Hypoparathyroidism (PTH deficiency)
188
What are the S/Sxs of HypoCa
``` CATS go numb Convulsion Arrhythmia Tetany Seizure Numb/parasthesia in hands, feet, mouth ``` Chvetskys Trousseaus
189
What are the lab results in true HypoCa What all is checked?
Serum Ca <8.5 Ionized serum Ca <4.6 Mg, PTH, Vit D
190
What is happening in the body during HypoCa w/ inc PTH? What bone changes are seen due to inc PTH?
Defected renal PTH receptors Inc Ca excreted in urine Cystic lesions Pathologic Fxs Demineralization
191
# Define Albrights Hereditary Osteodystrophy What can cause Vit D induced HypoCa, Inc PTH
``` HypoCa, Inc PTH PTH resistance (pseudohypoparathyroid) Short, round face, short 4th/5th metacarpals ``` Defective supply Malabsorption: Sprue, Crohns Meds: Rifampin INH Phenytoin Rickets
192
# Define Osteomalacia How do PTs present and what X-ray finding is seen?
Adult Vit D deficiency Bone pain Radiolucent lines perpendicular to cortex- Loosers Lines Pseudo Fxs- pathognomonic for Rickets/Osteomalacia
193
How is ASx Hypocalcemia from any origin Tx? Define Hypoparathyroid Tetany
PO supplements, Vit D, Sunlight Acute Hypocalcemia Medical emergency- dec PTH circulating causes dec Ca level
194
How is Hypoparathyroid Tetany Tx on inpatient status? What maintenance Tx are they placed on after emergent Tx?
Airway Tx HypoMg first w/ Mg Sulfate Tx low Ca w/ Ca Gluconate 1-3g PO Ca/Vit D w/ meals per day
195
How often are post-Acute Hypocalcemia Tetany PTs monitored? What is given it PT presents w/ hypercalciuria
Q3mon for Ca levels w/ Spot urine Ca HCTZ- keeps Ca in blood
196
# Define Osteitis Deformans What happens in this Dz?
Paget's Dz Autosomal dominant Dz Bone lysis replaced by vascular fibrous CT tissue leading to bone formation that's more likely to Fx
197
What is the first Sx of Paget's Dz? Why do these PTs go deaf?
Pain, constant and worse at night, not relieved w/ rest Inc warmth over bones Leads to HOutput HF Middle/inner ear cavities lay w/in petrous portion of temporal bone
198
What is the name of Fx that occurs in Paget's PTs? What will be seen on labs?
Chalk stick Inc alkaline phosphatase (ALP) Normal Ca, Phosph, PTH Inc Ca if PT is immobile
199
What would a bone scan of Paget's show? What x-ray finding can be seen?
Inc uptake in skull, spine and long bones Pic frame vertebrae
200
How is ASx Paget's Tx? What is the DOC for Sx Tx?
Annual ALP checks/x-rays Bisphosphantes- IV Zoledronate
201
Vit D is controlled by ?
Intestines