Endo Questions Flashcards
. What is an excellent marker of the insulin-resistant condition in metabolic syndrome?
Hypertriglyceridemia
Hypertriglyceridemia is an excellent marker of the insulin-resistant condition.
Hyperuricemia reflects defects in insulin action on the renal tubular reabsorption of uric acid and may contribute to hypertension through its effect on the endothelium.
In the setting of insulin resistance, the vasodilatory effect of insulin is lost but the renal effect on sodium reabsorption is preserved. Insulin also increases the activity of the sympathetic nervous system, an effect that is preserved in the setting of insulin resistance.
42-year-old female came into the Endocrinology outpatient clinic for consultation. She also expressed the desire to be screened for obesity and its associated conditions. On physical examination, her BMI was 26 kg/m2, her waist circumference was 85cm, and her waist-hip ratio was 0.90. Which of the following is NOT an appropriate recommendation for this patient?
a.
Recommend screening for depression using Patient Health Questionnaire-9 every 6 months
b.
Recommend screening for dyslipidemia using fasting lipid profile
c.
Recommend screening for osteoarthritis using x-ray yearly
d.
Recommend screening for polycystic ovarian syndrome using Rotterdam criteria
Recommendations for work up for obesity
MODY type?
hepatocyte nuclear transcription factor 4-alpha
MODY 1: hepatocyte nuclear transcription factor 4-alpha
MODY 3: HNF 1-alpha
Progressive decline in glycemic control but may respond to sulfonylureas
MODY 5: HNF 1-beta
Progressive impairment of insulin secretion and hepatic insulin resistance, require insulin treatment with minimal response to SU
Other abnormalities: renal cysts, mild pancreatic exocrine insufficiency, abnormal LFTs
MODY 2: glucokinase gene mutations
Mild to moderate but stable hyperglycemia that does not respond to OHAs
Higher glucose levels needed to elicit insulin secretory responses (higher insulin setpoint)
MODY4: pancreatic and duodenal homeobox 1
Homozygous mutations: pancreatic agenesis
Heterozygous mutations: DM
MODY type?
HNF1 ALPHA
MODY 3: HNF 1-alpha
Progressive decline in glycemic control but may respond to sulfonylureas
MODY type?
HNF 1-beta
MODY 5: HNF 1-beta
Progressive impairment of insulin secretion and hepatic insulin resistance, require insulin treatment with minimal response to SU
MODY type?
glucokinase gene mutations
MODY 2: glucokinase gene mutations
Mild to moderate but stable hyperglycemia that does not respond to OHAs
Higher glucose levels needed to elicit insulin secretory responses (higher insulin setpoint)
MODY type _ ?
pancreatic and duodenal homeobox 1
MODY4: pancreatic and duodenal homeobox 1
Homozygous mutations: pancreatic agenesis
Heterozygous mutations: DM
insulin resistance syndrome affects young women and is characterized by severe hyperinsulinemia, obesity, and features of hyperandrogenism. This is usually due to an undefined defect in insulin-signaling pathway?
Type A insulin resistance syndrome affects young women and is characterized by severe hyperinsulinemia, obesity, and features of hyperandrogenism. This is usually due to an undefined defect in insulin-signaling pathway
Type Binsulin resistance syndrome affects middle-aged women and is characterized by severe hyperinsulinemia, features of hyperandrogenism, and autoimmune disorders. These patients have autoantibodies directed at the insulin receptor.
Polycystic ovary syndrome affects premenopausal women and is characterized by chronic anovulation and hyperandrogenism.
Lipodystrophies are characterized by selective loss of adipose tissue, leading to severe insulin resistance, and hypertriglyceridemia.
insulin resistance syndrome affects middle-aged women and is characterized by severe hyperinsulinemia, features of hyperandrogenism, and autoimmune disorders. These patients have autoantibodies directed at the insulin receptor.
Type B INsulin resistance
syndrome characterized by chronic anovulation and hyperandrogenism
PCOS
Polycystic ovary syndrome affects premenopausal women and is characterized by chronic anovulation and hyperandrogenism.
Lipodystrophies are characterized by selective loss of adipose tissue, leading to severe insulin resistance, and hypertriglyceridemia.
characterized by selective loss of adipose tissue, leading to severe insulin resistance, and hypertriglyceridemia?
Lipodystrophies are characterized by selective loss of adipose tissue, leading to severe insulin resistance, and hypertriglyceridemia.
What is the most common pattern of dyslipidemia in patients with diabetes mellitus?
Elevated triglycerides, low HDL
exercise-induced hypoglycemia mechanism?
a.
Defect in fatty acid oxidation including defects in the carnitine cycle, fatty acid beta-oxidation disorders, electron transfer disturbances, and ketogenesis disorders
b.
Defect in gluconeogenesis, particularly in fructose-1,6-bisphosphatase
c.
Increased activity of monocarboxylate transporter 1 in beta-cells leading to hyperinsulinemia
d.
Mutations in glucokinase, SUR1, or Kir6.2 potassium channel
C.Increased activity of monocarboxylate transporter 1 in beta-cells leading to hyperinsulinemia
Non-diabetic hypoglycemia also results from inborn errors of metabolism, where cases in adults can be classified into fasting hypoglycemia, postprandial hypoglycemia, and exercise-induced hypoglycemia.
A and B are enumerated mechanisms of fasting hypoglycemia.
D is a mechanism of inborn error of metabolism leading to postprandial hypoglycemia. Other errors include congenital disorders of glycosylation and inherited fructose intolerance.
1 unit of insulin for every __mg/dL
1 unit of insulin for every 30-60mg/dL
47-year-old male with Type 2 diabetes mellitus visited your clinic due to painful pins and needles sensation on his hands and feet. He has been experiencing this for 7 months now and has been taking paracetamol + tramadol which affords no relief. What is the best treatment option?
a.
Duloxetine
b.
Folic acid
c.
Tapentadol
d.
Vitamin B complex
TCAs
Diabetic neuropathy may respond to tricyclic antidepressants, venlafaxine, carbamazepine, tramadol, or topical capsaicin products. An 8% capsaicin patch requires application by a healthcare provider.
a centrally acting opioid, is also approved by the FDA, but has only modest efficacy and poses addiction risk, making it and other opioids less desirable and not a first-line therapy.
Tapentadol
Two oral agents approved by the U.S. Food and Drug Administration (FDA) initially used for pain associated with diabetic neuropathy.
duloxetine and pregabalin, or gabapentin
can be used to suppress insulin in sulfonylurea-induced hypoglycemia.
Octreotide
evaluation of gynecomastia
a condition that occurs when there are high levels of calcium and alkali in the body, leading to metabolic alkalosis and kidney damage
milk alkali syndrome
a rare genetic disorder that causes tumors in the endocrine glands. These tumors are usually benign, but can sometimes become cancerous.
Wermer syndrome’a rare genetic disorder that causes tumors in the endocrine glands. These tumors are usually benign, but can sometimes become cancerous.
the mechanism of Familial hypocalciuric hypercalcemia (FHH) for hypERcalcemia
**he mechanism of FHH is from an inactivating mutation in a single allele of the CaSR. The primary defect is abnormal sensing of blood calcium by the parathyroid gland and renal tubule, causing inappropriate PTH secretion and excessive calcium reabsorption in the distal renal tubules.
mechanism for hypercalcemia for lithium therapy?
lithium therapy:** stimulation of parathyroid cell replication and shifting of parathyroid hormone (PTH) secretion curve **to the right in response to calcium
Mechanism behind Malignancy-related hypercalcemia:
Malignancy-related hypercalcemia: p**roduction and secretion of PTHrP, **or through direct bone marrow invasion
mechanism behind Vitamin D-related hypercalcemia
Vitamin D-related hypercalcemia: increased intestinal calcium absorption and increased release from bone
Osteoporosis bone density that falls ____ SD or more below mean for young healthy adults of same sex and race, i.e. T-score < -2.5 in the lumbar spine, femoral neck, or total hip
bone density that falls 2.5 SD or more below mean for young healthy adults of same sex and race, i.e. T-score < -2.5 in the lumbar spine, femoral neck, or total hip
Low bone density: T score <____ at increased risk for osteoporosis
Low bone density: T score <-1.0 , at increased risk for osteoporosis
instructions for oral administration of alendronate apply to all three oral bisphosphonates (alendronate, risedronate, ibandronate):?
Taken with a full glass of water before breakfast after an overnight fast
Alendronate is contraindicated in patients with stricture/inadequate emptying of the esophagus
Patients must remain upright for at least 30 minutes after taking the medication
Guidelines for surgery in asymptomatic Primary hyperparathyroidism
- Serum calcium >1mg/dl
- Renal : Creatinine CLearance <60ml/min
-24 H urine for calcium >400mg/day and increased sotne risk by biochemical
Presence of nephrolithiasis, nephrocalcinosis by x-ray utz or CT - Skeletal: BMD by DXA Tscore <-2.5 lumbar spine, total hip, femoral neck, distal one third radius
- vertebral fracture
Age <50
indications for bone mineral density testing
AGE
NORMAL: women aged >=65 and men aged >=70
POSTMENOPAUSAL: 50-69yomen
with Fracture after age of 50
Adults with RA and glucocorticoids daily > 3 months
indications for vertebral testing?
Women aged 70 and above
men aged 80 and above with Tscore of spine, total hip and fenoral neck <1.0
women aged 65-59 with tscore <1.5
Post menopausal women and men aged .50 years:
- low trauma fracture >50 years
- historical height loss >1.5
- Prospective height loss 0.9 in
- Recent or ongoing long term glucorticoid
causes of thyrotoxicosis without hyperthyroidism
- subacute thyroiditis
- silent thyroiditis
- other causes: amiodarone, radiation, infarction of adenoma
- ingestion of excess thyroid hormone or thyroid tissue
causes of secondary of hyperthyroidism
TSH -secreting pituitary adenoma
Thyroid hormone resistance syndrome
Chorionic gonadotropin secreting tumors
Gestational thyrotoxicosis
A 26-year-old female came to your clinic for difficulty concentrating, weight gain despite poor appetite, weakness and hair loss. Neck examination revealed a diffusely enlarged anterior neck mass without bruits. On physical examination, the skin was dry and cool to touch and there was significant alopecia. Laboratory exams revealed a TSH of 20 uIU/mL (NV 0.35-4.9), and an FT4 of 1.0 pmOL/L (NV 9-19). What is the next best laboratory examination to determine the etiology of your patient’s hypothyroidism?
a.
Cranial MRI
b.
TSH-receptor antibody
c.
Thyroid peroxidase antibody
d.
Thyroglobulin antibody
TPO Antibody
- Dx: Subclinical hypothyroidism
Levothyroxine therapy is indicated for patients with thyroid cancer since most tumors are still TSH-responsive. What range of TSH should be targeted in patients at intermediate risk of recurrence
Levothyroxine therapy is indicated for patients with thyroid cancer since most tumors are still TSH-responsive. What range of TSH should be targeted in patients at LOW risk of recurrence
**Low risk of recurrence: 0.5-2.0 mIU/L
Intermediate risk of recurrence: 0.1-0.5 mIU/L
High risk of recurrence: <0.1 mIU/L
Known metastatic disease: <0.1 mIU/L
Levothyroxine therapy is indicated for patients with thyroid cancer since most tumors are still TSH-responsive. What range of TSH should be targeted in patients at KNOWN METASTATIC risk of recurrence
Low risk of recurrence: 0.5-2.0 mIU/L
Intermediate risk of recurrence: 0.1-0.5 mIU/L
High risk of recurrence: <0.1 mIU/L**
Known metastatic disease: <0.1 mIU/L**
Levothyroxine therapy is indicated for patients with thyroid cancer since most tumors are still TSH-responsive. What range of TSH should be targeted in patients at HIGH risk of recurrence
High risk of recurrence: <0.1 mIU/L
Known metastatic disease: <0.1 mIU/L
A 38 year-old patient without comorbidities arrived at the clinic with a complaint of adrenal mass detected on whole abdominal ultrasound. A CT done showed a 4.8 x 3.5cm mass at the right adrenal gland. He otherwise is asymptomatic with physical examination and the rest of laboratories (CBC, serum electrolytes) normal. Which of the following is NOT an indicated screening test for hormone excess
a.
Serum androstenedione
b.
Plasma aldosterone
c.
Plasma metanephrines
d.
Midnight salivary cortisol x 2
Answer: B. PLASMA ALDOSTERONE X
Screening tests for hormone excess:
- Plasma metanephrines / 24 hour urine for metanephrine excretion
- Dexamethasone 1mg overnight test; if Postive -> ACTH, midnight salivary cortisol 2x, 24h urine cortisol
- Plasma aldosterone and plasma renin in patients with hypertension and or hypokalemia
- if tumor >4 cm serum 17 hydroxyprogesterone, ANDROSTENDIONE, and DHEAS
What is the most important prognostic** histopathologic parameter in adrenocortical carcinoma?**
Ki67 proliferation index
There is no established grading system for ACC, and the Weiss score carries no prognostic value.
The most important prognostic histopathologic parameter is the Ki67 proliferation index,** with Ki67 <10% indicative of slow to moderate growth velocity, whereas a Ki67 ≥10% is associated with poor prognosis** including high risk of recurrence and rapid progression.
within how many weeks of initial therapy for prolactinoma should cranial MRI be repeated to assess adenoma size?
within 16 weeks
Mass effect symptoms, including headaches and visual disorders, usually improve dramatically within days after cabergoline initiation. Improvement of sexual function requires several weeks of treatment but may occur before complete normalization of PRL levels.
MRI should be repeated within 16 weeks after initial therapy of macroadenomas as shrinkage of invasive adenomas may be striking.
After initial control of prolactin levels has been achieved, cabergoline should be reduced to the lowest effective maintenance dose.
The most important major side effect of antithyroid drugs is?
The most important major side effect of antithyroid drugs is agranulocytosis (<1%). It is essential that antithyroid drugs are stopped and not restarted if a patient develops major side effects.
A pituitary adenoma is suspected based on MRI, initial hormonal evaluation usually includes:
(1) basal prolactin (PRL)
(2) insulin-like growth factor (IGF)-1
(3) 24-h urinary free cortisol (UFC) and/or overnight oral dexamethasone (1 mg) suppression test
(4) alpha-subunit follicle-stimulating hormone (FSH), and luteinizing hormone (LH)
(5) thyroid function tests
true or false
Patients who miss a dose can be advised to take two doses of skipped tablets at once due to the long half-life of T4.
TRUE
Criteria for screening for type 2 DM in adults
BMI >25, 23, with RF:
Fam hx of diabetes (parent or sibling)
RAce
Hypertension >140/90
HDL chol < 35 or TG greater than 250
PCOS or acanthosis nigricans
history of cardiovascular ds
physical inactivity
-GDM - should be screen q3 yeasrs
45 yo q3 years
individuals with HIV
FPG normal? IFG? and DM?
Normal <5.6mmol/L (100)
Pre Diabetic 5.6-6.9mmol/L
DM >7.0mml/L (126)
HbA1c normal? impaired? and DM?
normal <5.6%
Impaired 5.7 - 6.4%
DM >=6.5%
2H PG normal? Impaired? and DM?
Normal 7.8
Impaired 7.8 -11.0
DM > 11.1
High level of physical activity recommended?
