Endocrine Flashcards
1
Q
How can you differentiate Type 1 DM from steroid-induced DM in a patient started on steroids 6 months ago for suspected primary adrenal insufficiency?
A
Steroid-induced DM will not show ketoacidosis (T1DM will show ketoacidosis); Addison’s disease is usually treated with physiologic doses of steroids (not enough to cause steroid-induced DM)
2
Q
MOA of Pioglitazone?
A
PPARg agonist
3
Q
Pioglitazone belongs to class of …
A
Thiazolidinediones
4
Q
Major AE of Pioglitazone?
A
Pulmonary edema
5
Q
Which type of patient is at greatest risk of developing pulmonary edema during Pioglitazone use?
A
CHF
6
Q
HbA1c at which patients should be started on insulin (especially if they have symptoms of hyperglycemia)?
A
A1c > 9.0
7
Q
Benefit of basal insulin vs. NPH insulin?
A
Basal insulin has lower risk of hypoglycemia
8
Q
4 aspects of clinical presentation for MELAS?
A
Seizures, Hearing loss, Lactic acidosis, Stroke-like episodes
9
Q
Myasthenia gravis represents a disease of …
A
Neuromuscular junction
10
Q
Characteristic of muscle weakness seen in Myasthenia gravis?
A
Muscle weakness worsens as the day progresses
11
Q
2 most common aspects of clinical presentation for Myasthenia gravis?
A
Double vision, Ptosis
12
Q
What accounts for Double vision, Ptosis seen in setting of Myasthenia gravis?
A
Weakness of extraocular muscles
13
Q
2nd most common aspect of clinical presentation for Myasthenia gravis?
A
Dysphagia
14
Q
What accounts for Dysphagia seen in setting of Myasthenia gravis?
A
Weakness of bulbar muscles
15
Q
Etiology of Myasthenia gravis?
A
Ig against ACH-R
16
Q
Strong association exists between Myasthenia gravis and …
A
Thymoma
17
Q
2 DOCs for Raynaud syndrome?
A
Nifedipine, Amlodipine
18
Q
Nifedipine, Amlodipine belong to which class of medication?
A
DHP CCBs
19
Q
Best management of retrosternal, multinodular goiter in patient presenting with dysphagia?
A
Surgical excision
20
Q
29 yo female presents with asymptomatic hypercalcemia (due to primary hyper-parathyroidism); HX of stomach ulcers; FHX of pituitary tumors – diagnosis?
A
MEN1 syndrome
21
Q
3 hallmarks of MEN1 syndrome?
A
3 P’s … Pituitary, Parathyroid, Pancreas
22
Q
Best management of MEN1 syndrome in patient < 50 yo?
A
Parathyroidectomy
23
Q
Most common extracranial tumor of childhood?
A
Neuroblastoma
24
Q
Most common sites of origin for Neuroblastoma?
A
Adrenal medulla, Sympathetic chain ganglia
25
Clinical presentation for Neuroblastoma?
Painless abdominal mass, flushing, sweating
26
What accounts for HTN in setting of Neuroblastoma?
Mass compression of renal artery … activation of RAS … HTN
27
What accounts for flushing, sweating in setting of Neuroblastoma?
Catecholamine surge
28
Levels of PTH seen in familial hypocalciuric hypercalcemia?
Increased
29
How can you distinguish familial hypocalciuric hypercalcemia from primary hyperparathyroidism?
Check urinary Ca2+ … low in familial hypocalciuric hypercalcemia, high in primary hyperparathyroidism
30
First step of evaluation for familial hypocalciuric hypercalcemia?
Serum PTH
31
Clinical presentation of familial hypocalciuric hypercalcemia?
Asymptomatic hypercalcemia
32
Inheritance pattern of familial hypocalciuric hypercalcemia?
AD
33
Etiology of familial hypocalciuric hypercalcemia?
Mutation in calcium-sensing receptor
34
Clinical presentation of hyperglycemic hyperosmotic nonketotic state (HHS)?
Very high BG, AMS, No ketoacidosis
35
Initial management of hyperglycemic hyperosmotic nonketotic state (HHS)?
IV fluids, IV insulin, K+ replacement
36
Best treatment for patients with hyperglycemic hyperosmotic nonketotic state (HHS) once BG has been corrected to < 200?
Subcutaneous insulin (basal-bolus regimen)
37
Change to mineralcorticoids in setting of 21-hydroxylase CAH?
Decreased
38
Change to glucocorticoids in setting of 21-hydroxylase CAH?
Decreased
39
Change to androgens in setting of 21-hydroxylase CAH?
Increased
40
Symptoms seen in setting of 21-hydroxylase CAH?
Ambiguous genitalia in girls, Precocious puberty in males
41
Change to K+ in setting of 21-hydroxylase CAH?
Increased
42
Change to Na+ in setting of 21-hydroxylase CAH?
Decreased
43
Change to BP in setting of 21-hydroxylase CAH?
Decreased
44
Change to mineralcorticoids in setting of 11-hydroxylase CAH?
Increased
45
Change to glucocorticoids in setting of 11-hydroxylase CAH?
Decreased
46
Change to androgens in setting of 11-hydroxylase CAH?
Increased
47
Symptoms seen in setting of 11-hydroxylase CAH?
Ambiguous genitalia in girls
48
Change to K+ in setting of 11-hydroxylase CAH?
Decreased
49
Change to BP in setting of 11-hydroxylase CAH?
Increased
50
Change to mineralcorticoids in setting of 17-hydroxylase CAH?
Increased
51
Change to glucocorticoids in setting of 17-hydroxylase CAH?
Increased
52
Change to androgens in setting of 17-hydroxylase CAH?
Decreased
53
Symptoms seen in setting of 17-hydroxylase CAH?
Ambiguous genitalia in males; Absent puberty
54
Change to K+ in setting of 17-hydroxylase CAH?
Decreased
55
Change to BP in setting of 17-hydroxylase CAH?
Increased
56
Inheritance pattern of 21-hydroxylase CAH?
AR
57
Diagnostic test for 21-hydroxylase CAH?
Elevated levels of 17-hydroxyprogesterone
58
Best management of 21-hydroxylase CAH?
Chronic replacement of glucocorticoids + mineralocorticoids; Genital reconstruction for females
59
4 aspects of clinical presentation for pheochromocytoma?
Episodic HA, palpitations, sweating; Resistant HTN
60
Genetic syndrome associated with pheochromocytoma?
MEN2
61
Best screening test for pheochromocytoma?
24-hour fractionated urinary metanephrine + catecholamine excretion
62
After biologic confirmation, what is the next step of workup for pheochromocytoma?
Abdominal imaging with CT, MRI
63
Most common location of pheochromocytoma?
Adrenal glands
64
Patient with high clinical suspicion for pheochromocytoma, but (-) MRI/CT – what is next step?
MIBG scan
65
Preoperative management of pheochromocytoma?
10-14 days of alpha blocker for BP control, then b blocker
66
Common intraoperative complication of pheochromocytoma?
Hypotension
67
What accounts for hypotension as intraoperative complication of pheochromocytoma?
Decreased catecholamine levels in circulation after tumor removal
68
Best management of intraoperative hypotension during removal of pheochromocytoma?
NML saline bolus
69
Best management of intraoperative HTN during removal of pheochromocytoma?
Phentolamine
70
Typical change to thyroid hormone seen in the setting of amiodarone use?
Decreased peripheral conversion of T4 T3 … (high T4, low T3)
71
How can amiodarone also lead to hypothyroidism?
High iodine content in amiodarone inhibits synthesis of thyroid hormone
72
Which b blocker is used in thyrotoxic emergencies, due to its ability to decrease peripheral conversion of T4 T3?
Propranolol
73
Of all the b blockers, why does Propranolol have the ability to decrease peripheral conversion of T4 T3?
Propranolol is a non-cardioselective b blocker
74
Prognosis for amiodarone-associated changes in thyroid hormone?
Will see changes to thyroid hormones during first 3 months … then thyroid hormone abnormalities will resolve after 3 months
75
3 aspects of clinical presentation for alcoholic ketoacidosis?
AMS, ketonuria, mild hyperglycemia
76
Change to anion gap in alcoholic ketoacidosis?
Increased
77
Typical BG in DKA?
BG > 250
78
Best management of alcoholic ketoacidosis?
IV dextrose, NML saline, thiamine … (insulin not necessary)
79
Most common cause of obesity?
Imbalance of caloric intake / energy expenditure … overeating
80
60 yo female presents after MVA; States that she did not see other car approaching from side; Reports HX of bilateral adrenalectomy for treatment of Cushing’s disease; PE shows bitemporal hemianopsial – diagnosis?
Nelson syndrome
81
What is Nelson’s Syndrome?
Tumor of pituitary gland
82
Etiology of Nelson’s Syndrome?
Loss of negative feedback of adrenal glucocorticoids following bilateral adrenalectomy
83
Clinical presentation of Nelson’s Syndrome?
Bitemporal hemianopsia, hyperpigmentation
84
Diagnostic tests for Nelson’s Syndrome?
MRI showing pituitary enlargement, elevated ACTH levels
85
Best management of Nelson’s Syndrome?
Pituitary tumor is aggressive … so treat with surgery + radiation of pituitary gland
86
Possible strategy for prevention of Nelson’s Syndrome after bilateral adrenalectomy?
Pituitary radiation
87
Disadvantage of Pituitary radiation for prevention of Nelson’s Syndrome after bilateral adrenalectomy?
Increased risk of hypopituitarism
88
What is now the preferred treatment for Cushing Syndrome (no longer bilateral adrenalectomy)?
Transsphenoidal pituitary surgery
89
How does amiodarone cause hyperthyroidism?
Increases thyroid hormone synthesis
90
How does amiodarone cause hypothyroidism?
Large iodine load in amiodarone suppresses synthesis of thyroid hormone; Directly inhibits peripheral conversion of T4 T3
91
Electrolyte abnormality associated with hypothyroidism?
Hyponatremia
92
Additional testing that all patients placed on amiodarone should undergo?
TSH every 3-4 months
93
35 yo female presents with uncontrolled HTN; Reports mood swings, recent DX of DM; PE shows no abdominal bruit, full peripheral pulse; CXR shows vertebral osteopenia – diagnosis?
Cushing syndrome
94
2 lab values associated with Cushing syndrome?
Hypokalemia, metabolic alkalosis
95
2 screening test options for Cushing syndrome?
24-hour urinary free cortisol, Dexamethasone suppression test
96
Normal response to Dexamethasone suppression test?
Serum cortisol is suppressed after administration of dexamethasone
97
2 greatest risks of mortality in patients with acromegaly?
Cardiovascular disease, Colon CA
98
How does acromegaly lead to Cardiovascular disease?
Asymmetric septal hypertrophy, conduction defects, myocardial fibrosis
99
Clinical presentation of Cystic Fibrosis?
Chronic productive cough, fatigue, weight loss, recurrent respiratory infection
100
Inheritance pattern of Cystic Fibrosis?
AR
101
2 most common pathogens responsible for recurrent respiratory infection in cystic fibrosis?
Staph aureus, Pseudomonas
102
CXR finding that suggests Cystic Fibrosis?
Bronchiectasis … (several parallel linear opacities in lung parenchyma)
103
Gold standard diagnostic test for Cystic Fibrosis?
Sweat chloride test
104
22 yo female presents to initial OCP use; Reports HX of hypothyroidism, currently taking levothyroxine – relationship between starting OCP and patient’s hypothyroidism?
Levothyroxine will likely need to be increased due to effects of OCP
105
In addition to starting OCP, what are 2 other circumstances that may warrant increase in levothyroxine dose for patient?
Pregnancy, Acute hepatis
106
Why do pregnancy, acute hepatitis, and OCP use warrant increased dose of levothyroxine?
Increased estrogen level increases the amount of Thyroxine-Binding Globulin (TBG) in circulation … decreases levels of free circulating thyroid hormone (T3,T4)
107
In addition to increasing levothyroxine dose in patients who are pregnant OR using OCPs, what other screening should be performed on regular basis?
TSH measurements
108
42 yo female presents with GI symptoms consistent with IBS; CT abdomen shows 2cm adrenal mass – next step of workup?
Workup for hormone hypersecretion/malignancy
109
5 essential lab studies for patient with incidental adrenal mass?
Serum electrolytes, Dexamethasone suppression test, 24-hour urine catecholamines, metanephrine + VMA, 17-ketosteroid
110
3 characteristics of adrenal incidentalomas that require surgical excision?
Malignant tumors, Size > 4cm, Functional tumor
111
Best management of adrenal incidental tumors that do not have suspicious characteristics?
Observation with serial abdominal imaging; Removal if increasing in size
112
Initial step of workup for patient with high clinical suspicion for diabetic neuropathy?
Tuning fork screening test
113
3 first-line DOCs for management of diabetic neuropathy?
SNRIs, Pregabalin, TCAs
114
Example of SNRIs used in treatment of diabetic neuropathy?
Duloxetine
115
35 yo male presents with excessive daytime sleepiness; BMI = 36; HX of HTN – diagnosis?
Obstructive Sleep Apnea
116
Next step of workup for patient with high-clinical suspicion for Obstructive Sleep Apnea?
Polysomnography
117
41 yo female presents with amenorrhea, dyspareunia, blurred vision; Labs show prolactin = 50, undetectable LH and FSH; a subunit is increased – diagnosis?
Pituitary adenoma
118
Primary treatment for Pituitary adenoma?
Trans-sphenoidal surgery
119
3 test results that are DIAGNOSTIC for T2DM?
HbA1c > 6.5%, Fasting BG > 126, Random BG > 200, Oral glucose tolerance BG > 200
120
A1c that corresponds to pre-DM?
5.7-6.4%
121
Fasting BG that corresponds to pre-DM?
100-125
122
Random BG that corresponds to pre-DM?
140-199
123
Oral glucose tolerance BG that corresponds to pre-DM?
140-199
124
What is the most sensitive test for diagnosis of T2DM?
Oral glucose tolerance test
125
Effect of intensive BG control in T2DM on macrovascular complications (MI, CVA)?
No change
126
Effect of intensive BG control in T2DM on microvascular complications (neuropathy, nephropathy, retinopathy)?
Improvement
127
Effect of intensive BG control in T2DM on mortality?
No change / Increased
128
2 classes of oral DM medications that carry risk of hypoglycemia?
Sulfonylureas, Meglitinides
129
2 examples of Sulfonylureas?
Glyburide, Glipizide
130
Suffix of Meglitinides?
“-glinides”
131
Suffix of GLP-1 mimetics?
“-tide”
132
Suffix of DPP-4 inhibitors?
“-gliptin”
133
Clinical presentation of subclinical hypothyroidism?
Elevation in TSH, with normal free T4 levels
134
Next step of work-up for patient with subclinical hypothyroidism?
Order Anti-TPO Ig
135
4 situations in which subclinical hypothyroidism warrants treatment?
Symptoms of hypothyroidism, Anti-TPO Ig, Abnormal lipid profile, Ovulatory + menstrual dysfunction
136
Best management of DKA?
IV normal saline, Continuous IV insulin
137
Additional treatment for DKA?
K+
138
At what point should K+ be administered to a patient with DKA?
If K+ levels are < 5.2
139
Equation for calculating anion gap?
Na – (Cl + HCO3)
140
While managing a patient with DKA – at what point should IV insulin infusion be replaced by subcutaneous insulin treatment?
Subcutaneous insulin when … Anion Gap has returned to NML; HCO3- is < 15; pH > 7.30
141
Patient is admitted for DKA; BG has improved from 320 to 154; Anion gap remains elevated, HCO3- remains > 15 – what is best step of management?
IV insulin should be continued … but rate of IV insulin infusion should be halved, and dextrose should be added to IV fluids (to prevent hypoglycemia)
142
When replacing IV insulin infusion with subcutaneous insulin in a patient with DKA – how should that replacement be done?
Subcutaneous long-acting insulin takes a while to go into effect … IV insulin should be continued for 1-2 hour after subcutaneous insulin is started … (prevents rebound ketoacidosis)
143
Normal fasting BG?
70-100
144
BG that constitutes hypoglycemia?
BG < 60
145
3 aspects of Whipple’s Triad (suggestive of true hypoglycemia)?
Low BG, Symptoms of hypo-BG, Symptoms resolve when patient is given glucose
146
2 methods of basal insulin administration in patients with T1D?
Glargine (lantus) QD; NPH BID
147
If a patient becomes hypoglycemic before dinnertime, how should insulin regimen be adjusted?
Decrease dose of AM long-acting insulin (or NPH)
148
Change to C-peptide in patient with exogenous insulin use?
Low
149
Change to C-peptide in patient with oral hypoglycemic agents?
High
150
Change to C-peptide in patient with insulinoma?
High
151
40 yo male presents with symptoms of hypoglycemia; Labs show elevated serum insulin, elevated C-peptide, elevated proinsulin – next step of diagnosis?
Screen for oral hypoglycemic agents … need to distinguish between insulinoma vs. oral hypoglycemic agent use
152
Appearance of Graves Disease on thyroid scan?
Diffuse uptake
153
Best management of symptomatic Graves Disease?
b blocker + anti-thyroid drug
154
2 examples of anti-thyroid drugs?
PTU, MMZ
155
When is PTU preferred to MMZ?
1st trimester pregnancy
156
2 alternatives to anti-thyroid drugs?
Radioactive iodine, Thyroidectomy
157
Which lab test should be performed 4-6 weeks after initiating anti-thyroid drugs in a patient with Graves Disease?
Total T3 + free T4
158
Definition of Euthyroid Sick Syndrome?
Low T3, NML T4, NML TSH … in an asymptomatic patient
159
Etiology of Euthyroid Sick Syndrome?
Decreased peripheral conversion of T4 T3
160
Best management of Euthyroid Sick Syndrome?
Observation in acute patient … reassess T3/T4/TSH levels when back to baseline health
161
1st step of workup for patient with newly discovered hypercalcemia?
Serum PTH levels
162
Effect of severe hypercalcemia due to malignancy on PTH levels?
Suppressed
163
What causes suppression of PTH in the setting of hypercalcemia of malignancy?
Secretion of PTH-related protein
164
Approach to urgent surgery in a patient with hypothyroidism (newly-diagnosed via labs)?
Surgery may proceed if no symptoms of myxedema coma
165
AE of starting levothyroxine in a patient about to undergo surgery?
Risk of MI in patients with existing CAD
166
___ refers to an atypical presentation of hyperthyroidism in elderly patients that is characterized by lethargy, confusion, depression
Apathetic thyrotoxicosis
167
Apathetic thyrotoxicosis is often misdiagnosed as …
Dementia
168
MOA of SGLT-2 inhibitors?
Promotes glucose excretion at level of proximal renal tubule
169
3 AEs of SGLT-2 inhibitors?
Vulvovaginal candidiasis, UTI, polyuria
170
Most common cause of subclinical hypothyroidism?
Chronic lymphocytic thyroiditis (Hashimoto’s)
171
Lab value that suggests increased likelihood of subclinical hypothyroidism progressing to Chronic lymphocytic thyroiditis (Hashimoto’s)?
High levels of anti-TPO antibodies
172
Change to TSH in subclinical hypothyroidism?
Elevated
173
Change to T4 in subclinical hypothyroidism?
NML
174
Complication of subclinical hypothyroidism?
Recurrent miscarriage
175
Clinical presentation of subacute thyroiditis?
Hyperthyroidism, fever, neck PAIN
176
2 alternate names for subacute thyroiditis?
De Quervain thyroiditis, Subacute granulomatous thyroiditis
177
Subacute thyroiditis is typically preceded by …
URI
178
What accounts for hyperthyroidism symptoms in subacute thyroiditis?
Release of stored thyroid hormone due to follicular injury
179
Appearance of thyroid scan in subacute thyroiditis?
Very low radioactive iodine uptake
180
2 additional conditions in which low radioactive iodine uptake is seen on thyroid scan?
Post-partum thyroiditis, Surreptitious thyroid hormone use
181
Clinical prognosis for subacute thyroiditis?
Spontaneous resolution
182
Best management of subacute thyroiditis?
Supportive care
183
2 medications that can be used in supportive care of subacute thyroiditis?
NSAIDs, b blockers
184
Role of b blockers in management of subacute thyroiditis?
Minimize hyperadrenergic symptoms (sweating, palpitations)
185
Does subacute thyroiditis cause a hyper- or hypothyroid state?
Hyperthyroid phase, then followed by hypothyroid phase
186
Epidemiology of tertiary hyperparathyroidism?
CKD patients
187
Change to Ca2+ levels in tertiary hyperparathyroidism?
High
188
Change to PO3- levels in tertiary hyperparathyroidism?
High
189
Change to PTH levels in tertiary hyperparathyroidism?
High
190
Best management of tertiary hyperparathyroidism?
Parathyroidectomy
191
Clinical presentation of tertiary hyperparathyroidism?
Bone pain
192
Additional lab value seen in setting of tertiary hyperparathyroidism?
Elevated alkaline phosphatase
193
What accounts for elevated levels of alkaline phosphatase in tertiary hyperparathyroidism?
High bone turnover
194
45 yo male is on escalating doses of levothyroxine; Despite therapy, he continues to have elevated TSH levels – diagnosis?
Levothyroxine malabsorption
195
2 conditions that might require escalating doses of levothyroxine?
Malabsorption (celiac disease), Pregnancy
196
2 drugs that might require escalating doses of levothyroxine?
Iron, Calcium
197
3 drugs that might interfere with thyroxine metabolism, requiring escalating doses of levothyroxine?
Carbamazepine, rifampin, phenytoin
198
70 yo female presents with symptoms of hyperthyroidism; She was recently diagnosed with CAD via coronary angiogram, with stent placement – diagnosis?
Iodine-induced hyperthyroidism (from iodine contrast)
199
Additional etiology of Iodine-induced hyperthyroidism?
Amiodarone
200
Clinical prognosis of Iodine-induced hyperthyroidism?
Self-limited
201
Best initial treatment of Iodine-induced hyperthyroidism?
b blockers
202
Additional treatment of Iodine-induced hyperthyroidism?
MMZ
203
68 yo female presents with hypoglycemia in setting of suspected sulfonylurea overdose; In addition to dextrose-50, which medication should be administered?
Octreotide
204
Rationale for administering octreotide to patients with hypoglycemia in setting of suspected sulfonylurea overdose?
Dextrose administration can cause transient hyperglycemia, which may elicit an even higher level of insulin secretion + subsequent rebound hypoglycemia … Octreotide is a somatostatin analogue that decreases insulin secretion to prevent rebound hypoglycemia
205
2 lab values seen in congenital hypothyroidism?
High TSH, Low T4
206
Best management of congenital hypothyroidism?
Start levothyroxine immediately, Thyroid US
207
Clinical prognosis for congenital hypothyroidism?
Excellent prognosis with treatment; Risk for permanent neurological defects without treatment
208
Most common etiology of congenital hypothyroidism?
Thyroid dysgenesis
209
36 yo female presents with palpitations, irregular menstrual cycle; PE shows HTN, lid lag, warm skin, hand tremor; Labs show elevated TSH, T3, T4, a subunit – diagnosis?
TSH-secreting pituitary adenoma
210
Change to TSH, T3, T4, a subunit in thyroid hormone resistance?
TSH, T3, T4 = elevated; a subunit = NML
211
Change to TSH, T3, T4, a subunit in pregnancy?
TBG = elevated; TSH = NML; T3, T4 = elevated
212
Change to TSH, T3, T4, a subunit in surreptitious thyroid hormone use?
T3, T4 = elevated; TSH = low
213
28 yo male presents with polyuria, polydipsia; BP 160/94; Labs show hypokalemia – diagnosis?
Primary hyperaldosteronism (Conn Syndrome)
214
Best screening test for Primary hyperaldosteronism?
Plasma Aldosterone/Renin ratio
215
What accounts for polyuria in the setting of Primary hyperaldosteronism?
Hypokalemia … causes an impaired urinary concentrating state
216
Normal fasting BG level?
< 126
217
Patients with impaired fasting BG (109-126) are at increased risk for …
CAD
218
Duration of glucocorticoids that necessitates a tapering dose to prevent suppression of the HPA axis (causing adrenal insufficiency)?
Duration > 3 weeks requires a taper; Duration < 3 weeks can be stopped abruptly
219
Effect of intensive BG control in patients with T2DM on macrovascular complications (MI, CVA)?
No change
220
Effect of intensive BG control in patients with T2DM on microvascular complications (neuropathy, nephropathy, retinopathy)?
Improved
221
Effect of intensive BG control in patients with T2DM on overall mortality?
No change
222
Clinical presentation of anabolic steroid abuse?
Changes in mood, worsened acne, hirsutism
223
Change to lipid levels in anabolic steroid abuse?
Decreased HDL
224
Change to CBC in anabolic steroid abuse?
Increased hemoglobin and hematocrit
225
Change to testes in anabolic steroid abuse?
Decreased testicular size + sperm count; Gynecomastia
226
3 aspects of clinical presentation for Hereditary Hemochromatosis?
Secondary hypogonadism, skin hyperpigmentation, DM
227
8 yo male presents after 3 days of NV, fever; T103, HR 176, BP 70/30, RR 34; Labs show Na 128, BG 290; UA shows (+) ketones, glucose - what is explanation for patient’s hyperglycemia?
Stress hyperglycemia
228
Typical clinical presentation of Stress hyperglycemia?
Sepsis
229
Etiology of Stress hyperglycemia?
Increased circulating levels of stress hormones (catecholamines, cortisol)
230
20 yo female presents for follow-up of idiopathic hypoparathyroidism; Takes 50,000u Vitamin D, 1.5g calcium daily; Labs show Ca 7.8, Phos 5.2, urinary calcium 680 - best step in management?
Begin thiazide diuretic
231
What is best treatment for patients with hypoparathyroidism?
Vitamin D
232
Role of thiazide diuretic in treatment of hypoparathyroidism?
Increases serum Ca2+, decreases urinary Ca2+
233
40 yo male presents for follow-up of T1DM; Current A1c 6.6; Labs shows TC 170, LDL and TG are WNL - what is best management?
Start statin
234
3 indications for starting statin as primary prevention?
Age > 40 with DM, LDL > 190, ASCVD risk > 7.5%
235
Best management of patients with hyperthyroidism and cardiovascular manifestations (SVT, A-Fib)?
B blocker to control symptoms and HR
236
67 yo male presents with CAD, warranting drug-eluting stent placement; TSH noted to be low in hospital; Today TSH is even lower (0.08); RAI scan shows increased homogenous uptake of RAI; Vitals are stable; Free T3 and T4 are both WNL - diagnosis?
Subclinical hyperparathyroidism
237
Clinical presentation of Subclinical hyperparathyroidism?
NML T3/T4, Low TSH
238
Best management of Subclinical hyperparathyroidism for patients with TSH < 0.1?
Anti-thyroid medications, radioactive iodine
239
Best management of Subclinical hyperparathyroidism for patients with TSH 0.1-0.5?
Will likely experience spontaneous remission, should be monitored with periodic thyroid function tests
240
10 yo male presents after tonic-clonic seizure; Recent muscle cramping (exacerbated by exercise), declining school performance; PE shows BL cataracts, 3+ reflexes; Labs show Ca2+ 6, Phos 8.3 (high), PTH 150 (high); Non-contrast head CT shows calcification of basal ganglia - diagnosis?
Pseudohypoparathyroidism
241
Clinical presentation of Pseudohypoparathyroidism?
Seizures, muscle cramping, hyperreflexia (hypoCa2+), basal ganaglia calcification, cataracts
242
Etiology of Pseudohypoparathyroidism?
End-organ resistance to PTH
243
Lab findings associated with Pseudohypoparathyroidism?
High Phos, High PTH, Low Ca2+
244
36 yo female presents with lower back pain HX of Roux-en-Y GBP surgery 2 years ago; Labs show PTH 955 (high); DEXA shows osteopenia - diagnosis?
Osteomalacia
245
36 yo female presents with lower back pain HX of Roux-en-Y GBP surgery 2 years ago; Labs show PTH 955 (high); DEXA shows osteopenia - what is next best step?
Vitamin D measurements
246
Risk of lactic acidosis associated with metformin increases with … (4)
Hypovolemia, liver disease, renal dysfunction, CHF
247
36 yo female presents after multiple episodes of hypoglycemia, none of which were associated with symptoms; Current A1c 7.8 - which intervention is most likely to restore hypoglycemic awareness?
Carefully avoiding low BG levels
248
60 yo female presents for diffuse abdominal pain, NV; Symptoms began a few hours ago after routine colonoscopy; HX of T2DM, managed with sitagliptin, canagliflozin, detemir; Reports significant weight loss after discontinuing metformin; Other meds include HCTZ, statin, ARB; Labs show AGMA, Cr 1.2, Ca2+ 8.8, BG 160; UA shows glucose, ketones; ABG shows 7.28, O2 99, CO2 28 - diagnosis?
Euglycemic DKA
249
Which medication is associated with Euglycemic DKA?
SGLT2 inhibtors (-flozins)
250
Typical BG levels seen in Euglycemic DKA?
BG < 250
251
10 yo female presents with declining school performance, irritable mood, distraction, weight loss; PE shows anxiety, 3+ DTRs - diagnosis?
Hyperthyroidism
252
Complication of Hyperthyroidism?
Osteoporosis
253
32 yo female presents 6 months after total thyroidectomy and central neck dissection for medullary thyroid CA; Serum calcitonin before surgery 250, now is 120; What is next best step of workup?
CT scan neck + chest
254
32 yo female presents 6 months after total thyroidectomy and central neck dissection for medullary thyroid CA; Serum calcitonin before surgery 250, now is 120 - diagnosis?
Metastatic thyroid CA
255
26 yo female with hypothyroidism is on a stable dose of levothyroxine; Recently started on combination OCP; Thryoid function tests today show worsening hypothyroidism - how do OCPs alter thyroid hormone function?
OCPs alter thyroid hormone transport and tissue delivery … Estrogen/OCPs stimulates synthesis of TBG, so less free thyroid hormone available
256
Best insulin regimen for T1DM patients who cannot intake PO due to NV?
Decrease glargine, continue short-acting SSI based on BG levels
257
Patients with thyroid nodules should be evaluated with …
TSH, thyroid US
258
Patients with thyroid nodules + suspicious findings on US should undergo …
Fine-needle aspiration, cytology
259
Patients with thyroid nodules + low TSH …
Radionuclide scan
260
What is the primary means of staging thyroid cancer?
US of neck + cervical LNs
261
Best management for papillary thyroid cancer <1 cm?
Lobectomy
262
Best management for papillary thyroid cancer <1 cm?
Thyroidectomy
263
68 yo male presents with confusion, fatigue; BP 99/59, HR 132, RR 22; PE shows disorientation; Labs show Na 151, K 6.1, HCO3 18, Cr 1.6, BG 810; EKG shows A-Fib with RVR, non-specific T wave changes - diagnosis?
HHS (hyperosmolar hyperglycemic state)
264
First step in management of HHS (hyperosmolar hyperglycemic state)?
Aggressive fluid resuscitation
265
Typical K supply in patients with HHS (hyperosmolar hyperglycemic state)?
Total body deficit of K
266
23 yo male presents with blurry vision in both eyes; Reports increased urination, polydypsia, weight loss; States that he has not been compliant with insulin regimen - what is best step in management?
Improve glycemic control
267
54 yo female presents after recently-diagnosed DM; Reports new skin rash; PE shows 4x5cm lesion with central clearing; Patient also reports fatigue, weight loss, diarrhea, abdominal pain, facial flushing - diagnosis?
Glucagonoma
268
Classic rash seen in cases of Glucagonoma?
Necrolytic Migratory Erythema
269
Description of Necrolytic Migratory Erythema?
Erythematous scaly rash with central clearing and elevated border with crusting
270
Description of rash seen in pellagra?
Symmetric, distributed in sun-exposed areas, forms vesicles and blisters
271
34 yo female with Addison’s Disease was discharged from recent hospitalization with hydrocortisone; Reports episodes of LH, salt-craving; Labs show Na 130, K 5.5 - which medications should be added to her regimen?
Fludrocortisone
272
Alternate name for Addison’s Disease?
Primary adrenal insufficiency
273
Best management of Addison’s Disease?
Glucocorticoid (hydrocortisol) + Mineralocorticoid (fludrocortisone)
274
31 yo female presents 5 weeks after vaginal delivery; Reports significant weight loss, fatigue, sweating, heat intolerance; States that her breast milk “dried up quickly”; TSH < 0.01, T4 18, (+) anti-TPO; Radioactive uptake in thyroid is 1.5% - diagnosis?
Post-partum thyroiditis
275
Appearance of Post-partum thyroiditis on thyroid uptake scan?
Decreased
276
Lab finding associated with Post-partum thyroiditis?
(+) TPO Ig
277
Pattern of thyroid disease seen in Post-partum thyroiditis?
Hyper, then hypo
278
Etiology of Sheehan Syndrome?
Obstetric hemorrhage
279
Post-partum thyroiditis is a variant of …
Chronic lymphocytic thyroiditis
280
17 yo male presents for breast mass; PE shows palpable, tender, well-circumscribed 5cm mass deep to the R nipple; Labs shows elevated b-HCG, elevated estrogen – diagnosis?
b-HCG secreting testicular tumor
281
17 yo male presents for breast mass; PE shows palpable, tender, well-circumscribed 5cm mass deep to the R nipple; Labs shows elevated b-HCG, elevated estrogen – next step of workup?
Testicular US
282
Physiologic cause of gynecomastia?
Imbalance between ratio of estrogens/androgens
283
Gynecomastia with b-HCG elevation – diagnosis?
Testicular tumor
284
Gynecomastia with decreased LH, decreased testosterone – diagnosis?
Central hypogonadism (pituitary tumor)
285
Gynecomastia with increased LH, decreased testosterone – diagnosis?
Primary hypogonadism
286
Gynecomastia with increased LH, increased testosterone – diagnosis?
Thyrotoxicosis
287
Gynecomastia with estrogen elevation – diagnosis?
Testicular, adrenal tumor
288
Change to serum thyroglobulin in the setting of exogenous thyroid hormone use?
Decreased … due to suppressed thyroid follicular activity
289
Change to 24-hour radioiodine uptake in the setting of exogenous thyroid hormone use?
Decreased … suppression of thyroid follicular activity
290
26 yo female presents 5 months after delivery for fatigue, weight gain, leg swelling; Labs show TSH 244, Na+ 128, low serum osmolarity – diagnosis?
Postpartum thyroiditis
291
Postpartum thyroiditis is a variant of …
Lymphocytic (Hashimoto) thyroiditis
292
What is the definitive management of hyponatremia in Postpartum thyroiditis?
Levothyroxine
293
78 yo male presents with palpitations, dizziness, SOB; Thyroid exam and US reveals a 3cm nodule that should increase uptake of radioactive iodine; Labs show TSH < 0.01, T4 3.3; Patient started on metoprolol for palpitations; What is best next step for management?
MMZ
294
What is the definitive therapy for toxic thyroid adenoma?
Radioactive iodine ablation … or … Thyroidectomy
295
What must occur before radioactive iodine ablation or thyroidectomy for toxic thyroid adenoma?
Pretreatment with anti-thyroid drugs (MMZ)
296
What are ideal instructions for patients with hypothyroidism taking levothyroxine?
On an empty stomach, with water 30-60 minutes before breakfast
297
6 medications that decrease levothyroxine absorption?
Cholestyramine, iron, calcium, aluminum hydroxide, PPI, sulcrafate
298
3 treatments that increase TBG concentration?
Estrogen replacement, OCP, tamoxifen
299
3 treatments that decrease TBG concentration?
Androgens, glucocorticoids, anabolic steroids
300
3 medications that increase thyroid hormone metabolism?
Rifampin, phenytoin, carbamazepine
301
4 aspects of hyperthyroidism in older adults?
Apathy, weight loss, decreased appetite, lethargy
302
7 yo male presents with NV, abdominal pain, fatigue; HR 134; PE shows dry MM; Labs show K 5.8, BG 500; VBG shows pH 7, HCO3 4; US shows ketonuria, glucosuria; Patient treated with NS bolus, insulin drip – what is addition step of necessary management?
Admission to ICU
303
5 lab findings associated with DKA?
BG > 200, HCO3 < 15, pH < 7.3, AG > 14, Serum/urine ketones
304
Best management of DKA in children?
10 mL/kg isotonic fluids, Insulin insulin
305
Complications of DKA in children?
Cerebral edema
306
What should be added to fluids in patients with DKA?
K+ … but not HCO3-
307
24 yo female presents for 2.1cm nodule in R thyroid lobe; Lab studies show NML T3, T4, TSH; Thyroid US shows 2.6x1.7x1.3cm solid nodule – what is next best step?
Perform fine-needle biopsy
308
Best management of thyroid nodule >1cm with low TSH?
Radionucleotide thyroid scan
309
Best management of thyroid nodule >1cm with normal TSH?
FNA with nodule cytology
310
First step of management for patients with 1cm thyroid nodule?
Thyroid US, TSH levels
311
24 yo female presents for 2.1cm nodule in R thyroid lobe; Lab studies show NML T3, T4, TSH; Thyroid US shows 2.6x1.7x1.3cm solid nodule; Further workup reveals diagnosis of medullary thyroid cancer; Serum calcitonin 300, genetic studies show mutation in RET – what is next best step?
Get plasma-free metanephrine levels
312
Clinical presentation of MEN1 syndrome?
3 Ps – parathyroid, pituitary, pancreatic
313
Clinical presentation of MEN2A syndrome?
Medullary thyroid cancer, pheochromocytoma, parathyroid hyperplasia
314
Clinical presentation of MEN2B syndrome?
Medullary thyroid cancer, pheochromocytoma, marfanoid habitus, mucosal hamartomas
315
All patients with new Medullary thyroid cancer should get …
Serum calcitonin, CEA, neck US (for regional metastasis), genetic studies for RET mutations
316
56 yo female presents with lethargy, weight loss, NV, constipation; PE shows pallor, prolonged relaxation time of ankle reflexes; Labs show HGB 11.2, Na 129, BG 64, TSH 0.35, T4 0.5, cortisol 7 – diagnosis?
Central hypothyroidism, possible adrenal insufficiency
317
Central hypothyroidism originates from …
Hypothalamus, pituitary
318
2 lab values that suggest Central hypothyroidism?
Low T4, Low TSH
319
Best test for patient with suspected adrenal insufficiency?
ACTH levels, ACTH stimulation test
320
Response of adrenals to ACTH stimulation in patient with primary adrenal insufficiency?
Subnormal increase in cortisol to ACTH administration
321
28 yo female with HX of T1DM presents to clinical for advice about insulin management; Reports that she takes 16u glargine at bedtime, and 4-6u lispro before meals; She plans to run a 5K this weekend – wondering how she should adjust her insulin regimen before the run?
Decrease breakfast dose of lispro
322
What is best management for reducing risk of hypoglycemia during exercise in patients with T1DM?
Decrease dose of short-acting insulin within 1-3 hours prior to exercise
323
Best management of familial hypocalciuric hypercalcemia?
Reassurance
324
Inheritance pattern of familial hypocalciuric hypercalcemia?
AD
325
Etiology of familial hypocalciuric hypercalcemia?
Mutation in CaSR that leads to decreased calcium sensitivity
326
Equation for calculation of calcium/creatinine clearance ratio (UCCR)?
UCCR = (Ca-urine/Ca-serum) / (Creat-urine/Creat-serum)
327
UCCR for familial hypocalciuric hypercalcemia is …
<0.01
328
UCCR for primary hyperparathyroidism is …
>0.02
329
Electrolyte abnormalities associated with primary adrenal insufficiency?
Hyponatremia, hyperkalemia, hyperchloremia, metabolic acidosis
330
First step of workup for patients with suspected primary adrenal insufficiency?
AM cortisol, ACTH
331
AM cortisol and ACTH that are diagnostic for primary adrenal insufficiency?
Low cortisol, High ACTH
332
If Am cortisol and ACTH are non-diagnostic for primary adrenal insufficiency, what is the next appropriate step of workup?
ACTH stimulation test
333
What accounts for loss of axillary and pubic hair in primary adrenal insufficiency?
Decreased androgen production
334
What accounts for increased pigmentation in primary adrenal insufficiency?
Increased ACTH and MSH
335
54 yo female presents after recently-diagnosed DM; Reports new skin rash; PE shows 4x5cm lesion with central clearing; Patient also reprots fatigue, weight loss, diarrhea, abdominal pain, facial flushing - diagnosis?
Glucogonoma
336
Classic rash seen in cases of Glucogonoma?
Necrolytic Migratory Erythema
337
Description of Necrolytic Migratory Erythema?
Erythematous scaly rash with central clearing and elevated border with crusting
338
Description of rash seen in pellagra?
Symmetric, distributed in sun-exposed areas, forms vesicles and blisters
339
32 yo female presents for follow-up visit after head CT showed abnormal sella; Patient reports normal menstrual cycles; Labs show no abnormalities in prolactin, IGF-1, LH, FSH, TSH, free T4; Plasma cortisol is normally suppressed after administration of dexamethasone; MRI shows a 5mm hypointense lesion in the pituitary space - next step of workup?
Repeat MRI of pituitary in 6-12 months
340
Nerve damage associated with diabetes mellitus?
Distal symmetric polyneuropathy in “stocking glove pattern”, erectile dysfunction, loss of cremasteric reflex, diminshed testicular sensation, bladder dysfunction, inability to masturbate
341
26 yo female with PMHX of papillary CA treated with thyroidectomy and radioactive ablation presents for checkup; Currently on levothyroxine 125 mcg; TSH 4.8, free T4 1.3 (NML 0.8-1.8); Recent US shows no recurrence of thyroid disease - what is best management of her levothyroxine?
Increase levothyroxine to bring TSH to low-NML range
342
Goal TSH for patient with HX of thyroid CA with distant metastasis?
< 0.1
343
63-year-old male presents for wellness visit; BG 255; reports frequent urination, polydipsia, 23 pound weight loss in past 6 months; history of obesity, hypertension, chronic pancreatitis, OSA, CKD, HF with EF 35%; which medication is most appropriate for treatment of DM in this patient?
Insulin
344
63-year-old male presents for wellness visit; BG 255; reports frequent urination, polydipsia, 23 pound weight loss in past 6 months; history of obesity, hypertension, chronic pancreatitis, OSA, CKD, HF with EF 35%; diagnosis?
Pancreatogenic DM, in the setting of chronic pancreatitis
