Endocrine

Question 1

Macular edema treatment

Answer 1

Anti VEGF intravitreal injections
Monthly for 12 months then followed by intermittent injections to prevent recurrence

Question 2

Asymptomatic patients with primary hyperparathyroid are surgical candidates if they have any of the following:

Answer 2

1. serum calcium level >1 mg/dL (0.25 mmol/L) above the upper limit of normal
2. creatinine clearance <60 mL/min
3. T-score <−2.5 or vertebral fracture
4. age <50 years

Question 3

The diagnosis of Familial hypocalciuric hypercalcemia, if ca / creat ratio

Answer 3

< 0.01

IF > 0.02, FHH is excluded

Question 4

Sclerosis inhibitors Romosozumab ( evenity) contraindication

Answer 4

It increases risk of CVA, MI, CV death

It’s should be followed by bisphosphonate or denosumab

Question 5

Bisphosphante contraindicated in

Answer 5

GFR < 35
Vit D or Hypocalcemia until corrected

Question 6

Denosumab side effects

Answer 6

Cellulitis
Bronchitis
Osteonecrosis of the jew and femur

Question 7

Paget disease assessment

Answer 7

1. Serum ca
2. Vit D
3. Whole body radionuclide bone scan

Question 8

Treatment of Paget disease

Answer 8

Single dose of 5 mg iv zoledronic acid

Question 9

Morning cortisol level suggests AI

Answer 9

< 82.8

Question 10

Morning cortisol level unlikely to be AI

Answer 10

> 414

Question 11

Synacthen test

Answer 11

=< 496.8 ; AI

> 496.8 ; unlikely

Question 12

Adrenal insufficiency diagnosis steps

Answer 12

1. Morning cortisol
2. If in green zone ; Synacthen
3. If confirmed AI ; do ACTH to see if it’s 1ry or 2 ry
4. If 1 ry AI ; do 21 hydroxylase antibody
5. If antibody-ve ; do CT adrenal

Question 13

To diagnose primary aldosteronism

PAC/PRA should be……?

Answer 13

A PAC/PRA > 20 with a PAC of at least 15 ng/dL (414 pmol/L) is considered a positive result

Question 14

How to diagnose primary aldosteronism In patients taking an ACEi or or ARBs?

Answer 14

renin should be elevated and testing may start with PRA measurement.

If the PRA is suppressed, the likelihood of primary aldosteronism is high

Question 15

How to diagnose primary aldosteronism in patients taking Mineralocorticoid receptor antagonists (spironolactone and eplerenone) and high doses of amiloride ?

Answer 15

These medications can significantly interfere with interpretation of PAC/PRA and

should be discontinued 4 to 6 weeks before evaluation if possible.

However, if testing while a patient is taking a mineralocorticoid receptor antagonist reveals suppressed PRA, further testing can be done without stopping the medication.

Question 16

The localization study of choice for primary aldosteronism

Answer 16

-CT adrenal

• Most patients with primary aldosteronism should undergo adrenal vein sampling to confirm the source.

Question 17

Treatment of primary aldosteronism

Answer 17

1. adrenalectomy ( Serum potassium levels should be monitored weekly for the first month postoperatively)
2. Spironolactone if not candidates or refuse surgery

Question 18

Initial tests in pheochromocytoma

Answer 18

Initial tests include measurement of

1. plasma free metanephrine collected in a supine position or
2. 24-hour urine fractionated metanephrine and catecholamine levels.

*medications should be discontinued at least 2 weeks before testing if possible.

mild elevations may require repeat testing.
Levels >4 times the upper limit of normal, in the absence of acute stress or illness, are consistent with a catecholamine-secreting tumor.

Plasma free-metanephrine is a more convenient test and is often chosen if the index of suspicion is high.

If suspicion is low, urine fractionated metanephrine and catecholamines may be a better option.

Question 19

tumor localization in pheochromocytoma ?

Answer 19

tumor localization should only occur after establishing the biochemical diagnosis of catecholamine excess to avoid misdiagnosing an incidental nonfunctioning adrenal mass as a pheochromocytoma.

-abdominal and pelvic contrast-enhanced CT
If the CT scan is negative, and suspicion of a catecholamine-secreting tumor is high,

-the next step is advanced
imaging, including the iodine 123-metaiodobenzylguanidine, octreotide, or gallium-68 DOTATATE scans.

Advanced imaging may also be indicated in patients with very large pheochromocytomas (>10 cm) to detect
metastatic disease or paragangliomas to detect several tumors.

Question 20

The definitive treatment for pheochromocytoma/paraganglioma ?

Answer 20

• surgical resection.
• Preoperative α-receptor blockade with phenoxybenzamine for 10 to 14 days before surgery is essential to prevent hypertensive crises during surgery.

The dose is progressively increased to achieve
1. BP 130/80 mm Hg or less and pulse of 60 to 70/min seated,

2. and SBP >/= 90 with pulse of 70 - 80/min standing.

Question 21

α-blockade & β-blocker in pheochromocytoma?

Answer 21

A β-blocker is added after α-blockade is achieved to manage reflex tachycardia, but it should never be started before adequate α-blockade, because unopposed α-adrenergic vasoconstriction can result in a hypertensive crisis.

Question 22

Pheochromocytomas may occur in familial syndromes including …?

Answer 22

1. MEN type 2,
2. von Hippel-Lindau syndrome, and
3. neurofibromatosis type 1.

Therefore, all patients with catecholamine-secreting tumors should be offered genetic counseling.

Question 23

All patients with an adrenal incidentaloma should undergo testing for

Answer 23

Cushing syndrome and pheochromocytoma if the unenhanced CT attenuation is > 10 HU

In selected patient:
- HTN + Hyper K ; PAC/PRC ration

• androgens , who suspected; DHEA, testosterone and androstenedione

Question 24

Target TSH in papillary thyroid cancer

Answer 24

To reduce cancer recurrence, a sufficient dose of levothyroxine is administered to suppress the serum TSH below normal

Question 25

Primary ovarian insufficiency

Answer 25

High FSH & LH in amenorrheic woman < 40 years of age

Question 26

Menopausal ovarian failure

Answer 26

High FSH & LH in amenorrheic woman > 40 years of age

Question 27

Drug holiday in Osteoporosis

Answer 27

Can be initiated in a patient who is not at high risk of # after 3 years (IV) to 5 years (oral) of bisphosphonate treatment

If patient remaining at high risk of # may be continue bisphosphonate or switch to alternative medication

Question 28

(Low ) 24-hour urine calcium excretion in

Answer 28

1.FHH

2. Malnutrition or malabsorption of vitamin D and/or calcium

Question 29

Osteomalacia
Mineral abnormalities?

Answer 29

High Alk.phos

Low ca
Low phos