Endocrine

Question 1

Pt with recent h/o trauma/surgery now has tachycardia, hypertension, cardiac arrhythmias, high fever, tremor, altered mentation, and lid lag.
Diagnosis & Management

Answer 1

Thyroid storm (thyrotoxicosis) 
Propanolol, PTU, Prednisone, Potassium 

*triggered by surgery, trauma, infection, iodine contrast, or childbirth.

Question 2

Thyroid nodules first step in assessment:
_______

After that, what else should be done?
____ & _____

Answer 2

Physical examination*
TSH & Thyroid U/S

*Evaluate the size, mobility, and firmness of the thyroid nodule & check for enlarged cervical lymph nodes.

Question 3

Pt with thyroid nodule on physical exam with no concerning u/s features and a low TSH
Next best step management?

Answer 3

Radionuclide thyroid scan using iodine

RAIU

Question 4

A hypofunctioning (“cold”) nodule (decreased isotope uptake compared to surrounding tissue on RAIU) is associated with a ___ cancer risk f/u with ___.

A hyperfunctioning (“hot”) nodule (increased isotope uptake in the nodule on RAIU) is associated with a ___ cancer risk f/u with ___.

Answer 4

High (f/u with FNA)

Low (f/u with Hyperthyroid tx)

Question 5

Thyroid Nodule >1 cm with certain features u/s: microcalcifications
irregular margins
vascular
are at risk for cancer.
Next best step management?

Answer 5

Fine-needle aspiration (FNA)

Question 6

Noncystic thyroid nodules >2 cm on u/s.

Next best step management?

Answer 6

Fine-needle aspiration (FNA)

Question 7

____ is an important tumor marker in medullary thyroid carcinoma (MTC).
Get in patients with a thyroid nodule + FMH MTC
or
FNA of the nodule is consistent with MTC.

Answer 7

Calcitonin

Question 8

Pt with painless ulcer

(typically at weight-bearing pressure sites on the sole of the foot like bony prominences of metatarsal bones)

+/- “Punched out” irregular borders w/ necrosis
+/- adjacent callus

Answer 8

Neuropathic ulcers

(MCC: Diabetes)

2/2 repeated pressure, friction, or trauma due to lack of sensation in the local tissues

Question 9

Thyroid function tests are often abnormal in patients with severe, acute illness. The most common pattern is:
__ TSH
__ T4
__ T3
which may represent an adaptive response to severe illness.

Answer 9

Normal T4 and TSH with low T3

euthyroid sick syndrome

Question 10

Management of Euthyroid sick syndrome in recently critically ill patient (2)

Answer 10

Observe without treatment

F/U thyroid test done once pt is at baseline health

Question 11

Risk Factors:
Severe acute illness, ICU stay, given glucocorticoids
s/t Decreased peripheral conversion of T4 to T3

Answer 11

Euthyroid Sick Syndrome

High circulating levels of glucocorticoids and inflammatory cytokines (TNF)

Question 12

Euthyroid Sick Syndrome

Early levels: __T3, __T4, __TSH
Late levels : __T3, __T4, __TSH

Answer 12

↓ T3, – T4, –TSH

↓T3, ↓T4, ↓TSH

Question 13

Pt with recent blood transfusion now has:
Numbness/Paresthesias in the fingertips & around lips
Muscle cramps (intact strength)
Chvostek (wrist spasm) & Trousseau signs (face spasm)
Paresthesias
Hyperreflexia/tetany
Seizures
Prolonged QT

Diagnosis:

Answer 13

Hypocalcemia

High-volume blood transfusion → pt w/ impaired hepatic fxn (liver lac, cirrhosis, shock) → chelation (binding) of ionized Ca by citrate from transfused blood → Hypocalcemia

*Other potential features of severe hypocalcemia include laryngospasm, encephalopathy, & HF

Question 14

Causes of Acute hypocalcemia:
\_\_\_\_\_\_\_
Pancreatitis
Sepsis (impairs hepatic fxn)
\_\_\_\_\_\_\_
Tumor lysis syndrome
Acute alkalosis (↑ albumin binding Ca)

Answer 14

Parathyroidectomy (Neck surgery)
Blood transfusion (Chelating citrate)

Question 15

Treatment of Acute hypocalcemia:

Answer 15

IV calcium gluconate/chloride

Question 16

Hyperprolactinemia, likely s/t a prolactin-secreting pituitary adenoma (prolactinoma) causessuppressionof __manifesting as ____.

Initial treatment usually includes ____.
If non-responsive treat with _____.

Answer 16

GnRH (thus FSH/LH)

central hypogonadism

Dopamine Agonists (cabergoline, bromocriptine)

Transsphenoidal surgery

Question 17

Indications for treatment of hyperprolactinoma include pts with:
(3)

Answer 17

central hypogonadism (low E = osteoporosis/fractures)
galactorrhea
mass effect symptoms (HA, visual defects)

Question 18

The most common complication seen post Thyroidectomy or Para-thyroidectomy (Neck surgeries)

Answer 18

Hypocalcemia/Hypoparathyroidism

*other causes of Hypoparathyroidism include:
post surgical/autoimmune parathyroid destruction
defective calcium-sensing receptor

Question 19

Classic triad: episodic headache, sweating & tachycardia

Medication resistant HTN or HTN accompanied by unexplained ↑ glucose

Answer 19

Pheochromocytoma

↑ urine or plasma metanephrines

Question 20

Family history or familial syndromes associated with pheochromocytoma (3-4)

Answer 20

MEN2 (A&B)
NF1
VHL

Question 21

Management of pheochromocytoma

3

Answer 21

FIRST preoperative alpha blockers
THEN beta blockers
Lastly, surgical resection

Question 22

The primary treatment for papillary thyroid cancer.

Answer 22

Surgical resection

Question 23

Postoperative adjuvant therapies for patients at increased risk of recurrence of papillary thyroid cancer include (2)

Answer 23

Radioiodine ablation
&
suppressive doses of thyroid hormone

Question 24

Parathyroidectomy is recommended for patients <50 or all pts with ____ or _____ .

Answer 24

symptomatic hypercalcemia (polyuria, constipation, depression)
complications (Kidney stones, osteoporosis, AMS)

Question 25

Pt presents with Fever as high as (104-106ºF)
Tachycardia, HTN, CHF, arrhythmias (atrial fibrillation)
Agitation, delirium, seizure, coma
Goiter, lid lag, tremor, warm/moist skin,
Nausea, vomiting, diarrhea or jaundice
Dx and Tx:

Answer 25

Thyroid Storm

β blocker (propranolol)
PTU → potassium iodine (SSKI)
Glucocorticoids (hydrocortisone)

Identify trigger & treat, supportive care

Question 26

Patient with recent h/o surgery/trauma has hypotension (despite being given IVFs) with tachycardia, abdominal pain, vomiting, and weakness.
Dx & Tx?

Answer 26

Adrenal insufficiency

Fluid resuscitation & IV dexamethasone

Question 27

Patient with recent h/o surgery/trauma has hypotension/shock (despite being given IVFs) with tachycardia, Fever, abdominal pain, vomiting, weakness, and +/- AKI.
Dx & Tx?

Answer 27

Adrenal insufficiency

Fluid resuscitation & IV dexamethasone
Monitor ‘lytes

Question 28

Diagnostics for suspected Acute Adrenal insufficiency (4)

Seen in acute illness, injury, or surgery in pts with:
Chronic adrenal insufficiency/glucocorticoid use
Congenital adrenal hyperplasia
Adrenal hemorrhage/infarction

Answer 28

↓ Cortisol
↓ Aldosterone
↑ ACTH
↑/– Renin

CMP ( Na, K, ↑/–BUN/Cr)
*ACTH stimulation test when stable

Question 29

___ can occur in prolonged immobilization (quadriparesis) due to increased osteoclastic activity.

Treatment:

Answer 29

Hypercalcemia

Tx: Bisphosphonates (prevent bone loss)

Question 30

Paroxysms of severe hypertension in patients with pheochromocytoma can be precipitated by ___, induction of ___, and medications.

Answer 30

Surgery
anesthesia

(catecholamine-producing tumors from chromaffin cells in adrenal medulla)