Endocrine Flashcards
1
Q
What antibodies do we check for type 1 diabetes?
A
GAD65 and IA-2
2
Q
How treat hypoglycemia unawareness?
A
lowering insulin dose and allowing average plasma glucose to rise for several weeks
3
Q
How diagnose Type 2 diabetes?
A
Elevated fasting glucose >126 x 2
Random glucose > 200 with symptoms (no need for repeat)
A1c > 6.5 x2
2 hour glucose after OGTT > 200 x2
4
Q
When start screening for type 2 diabetes?
A
USPSTF - age 40 and up if overweight, earlier if risk factors
ADA - overweight adults with one add’l risk factor and all patients 45 or older
5
Q
What is the most effective way to minimize a patient’s risk of developing diabetes?
A
Intensive weight loss and dietary / lifestyle modification (not metformin!)
6
Q
If a patient is non adherent with multiple insulin injections is there adherence likely to increase by using an insulin pump?
A
no
7
Q
In what situations will the A1c be falsely low?
A
hemolytic anemia, patients taking Epo, patients with AKI
8
Q
What is the GFR threshold for Metformin (At least according to boards guides)
A
GFR 30
9
Q
when should screening for complications begin in patients with type 1 diabetes and type 2 diabetes?
A
type 1 - five years after diagnosis
type 2 - immediately
10
Q
What intensity statin is recommended for:
Diabetes and avg cardiovascular risk?
A
Age 40 and up, ASCVD < 7.5 -> mod intensity statin
11
Q
What intensity statin is recommended for:
Diabetes and CAD, peripheral vascular dz and ASCVD > 7.5?
A
High intensity statin
12
Q
How treat diabetic mononeuropathy? ex. 3rd nerve palsy
A
trick question, do not treat, resolves spontaneously
13
Q
How dx HHS
A
isms > 320, glucose > 600, low or no serum ketones and a relatively normal arterial pH and bicarb
14
Q
How treat HHS?
A
Volume resuscitate with NS
IV insulin AFTER expanding intravascular volume
SubQ insulin when patient is eating and glucose is < 200
15
Q
How diagnose DKA?
A
hyperglycemia, ketosis and hypovolemia, pH < 7.3, bicarb < 15, Anion gap
16
Q
How treat DKA?
A
Normal saline, (1/2 normal if serum sodium is high or normal), then insulin, K repletion, glucose when plasma glucose < 250. Continue insulin and glucose until anion gap is normal
17
Q
Should you stop insulin infusion in DKA before complete clearing of ketones?
A
No, not according to Board Basics, ‘will cause relapse of DKA”
18
Q
What are the inpatient glucose goals for critically ill patients
A
140 to 180
19
Q
When should pregnant women be screened for gestational diabetes?
A
24 to 28 weeks gestation with 75gm 2 hour OGTT
20
Q
How often should women with gestational diabetes be screened for diabetes after delivery?
A
annually
21
Q
How are pregnant women with gestational diabetes treated differently than non pregnant adults?
A
- insulin is preferred after dietary changes
- ACE, ARBs and cholesterol lowering drugs should be stopped
- eye exam once per trimester
- aggressive BP control with methyldopa, b-blockers (except atenolol), CCBs and hydral
22
Q
Patient without diabetes, fasting glucose <60, asymptomatic, should they be evaluated?
A
NO! (see page 83 board basics)
23
Q
How can C peptide testing be used to evaluate non diabetic fasting hypoglycemia?
A
marker of endogenous insulin production, cleavage product of insulin production.
Elevated iso: surreptitious use of oral hypoglycemic agents, insulinoma
Low iso surreptitious use of exogenous insulin
24
Q
Workup of suspected insulinoma?
A
72 hour fast: measure glucose, insulin and peptide. If glucose <45, insulin > 5-6 and c peptide elevated then proceed with abdominal imaging
25
When suspect hypopituitarism?
primary target organ hypo function PLUS headache or loss of peripheral vision
26
If concerned about pituitary apoplexy, how should you treat?
glucocorticoids until AI has been ruled out
27
How classify pituitary adenomas?
microadenoma <10mm
macroadenoma >= 10mm
28
If you see:
galactorrhea and amenorrhea
Next steps?
serum prolactin level to assess for prolactinoma
29
If you see:
enlargement of hands, feet, nose, lips or tongue and increased spacing of teeth
Next steps?
Serum IGF-1 and OGTT to assess for acromegaly
30
If you see:
Prox muscle weakness, facial rounding, centripetal obesity, striae, diabetes and HTN
Next steps?
24hr urine cortisol excretion, Dex suppression test or late night salivary cortisol, elevated serum ACTH level to assess for Cushing's
31
Goiter and hyperthyroidism
Next steps?
Check TSH and T4 for TSH secreting pituitary adenoma (rare)
32
How manage prolactinoma if:
| - microprolactinoma, normal menses
observation
33
How manage a prolactinoma if:
| symptomatic
medication such as a dopamine agonist like cabergoline (preferred to bromocriptine), can stop if prolactinoma no longer seen on imaging but need to repeat testing because recurrence rates are up to 50%
34
How manage a pituitary adenoma secreting GH, ACTH or TSH or if have mass effect or unresponsive to meds
surgery
35
How to confirm the diagnosis of diabetes insipidus?
urine osms less than 200 and inability to increase urine concentration during a water deprivation test
36
How you differentiate between Central and nephrogenic DI?
Desmopressin challenge. If the urine concentrates and that indicates central. Next order an MRI the pituitary gland. If The test is negative then order a kidney ultrasound.
37
How does subacute thyroiditis typically present?
Firm and painful thyroid gland
38
What can happen as a result of all forms of destructive thyroiditis
Permanent hypothyroidism
39
What does the term hyperthyroidism refer to?
Increased thyroid hormone production and release
40
What are some signs of hyperthyroidism in older adults
Atrial fibrillation, heart failure, depression
41
How does one diagnose thyroid storm?
Clinical diagnosis. Life threatening hyperthyroidism associate cardiac decompensation, fever, delirium and psychosis
42
How does one diagnose hyperthyroidism?
TSH and free T4. If TSH is suppressed and T4 is normal, order free T3
43
How does exogenous thyroid hormone impact thyroglobulin levels?
decreases thyroglobulin levels. can use this to diagnose surreptitious use of thyroid hormone
44
What is the diagnosis: elevated TSH, elevated T3, elevated free T4?
Secondary hyperthyroidism from a pituitary tumor
45
Diagnosis from RAIU scan: diffuse homogeneous increased uptake
Graves disease
46
Diagnosis from RAIU scan: patchy areas of increased uptake
Toxic multi nodular goiter
47
Diagnosis from RAIU scan: focal increased uptake with decreased uptake uptake in the rest of the gland
Solitary adenoma
48
Diagnosis from RAIU scan: decreased or no uptake
Iodine load, thyroiditis, surreptitious ingestion of thyroid hormone
49
Radioactive iodine therapy is first-line for what diagnoses?
Toxic multinodular goiter
Toxic adenoma
* do not use in pregnancy or breast-feeding
Typically restores euthyroidism
50
What medication is first-line for Graves disease?
Methimazole
SE: agranulocytosis, drug rash, hepatotoxicity
51
What medication is first line for Graves disease in the first trimester and preferred in thyroid storm?
PTU (Propylthiouracil)
SE: Agranulocytosis, drug rash, hepatotoxicity (more common than with Methimazole)
52
What is the preferred treatment and definitive therapy for severe Graves opthalmopathy?
Thyroidectomy (also first line if local symptoms from bulk effect)
53
Management of thyrotoxicosis: treatment for sympathetic nervous system symptoms
Atenolol or propranolol
54
Management of thyrotoxicosis: preparation for thyroidectomy
Methimazole
55
Management of thyrotoxicosis: severe Graves ophthalmopathy
Methimazole or thyroidectomy
avoid radioactive iodine because can cause worsening ophthalmopathy
56
Management of thyrotoxicosis: pregnancy
PTU the first trimester
Methimazole in 2nd and 3rd
NO radioactive iodine
57
Management of thyrotoxicosis: subclinical hyperthyroidism
Methimazole if TSH <0.1
58
Management of thyrotoxicosis: subacute thyroiditis
NSAIDs or glucocorticoids for pain
Beta blockers for symptoms
levothyroxine for symptomatic hypothyroidism
Repeat thyroid studies in 4-6 months
50% of patients thyroid studies will normalize without intervention
59
Management of thyrotoxicosis: suspicious nodule
Fine needle aspiration followed by thyroidectomy if Malignant
60
Management of thyrotoxicosis: thyroid storm
PTU
Iodine potassium solutions
glucocorticoids
beta blockers
61
If you see a patient with a fever or sore throat on PTU or Methimazole what should you presume?
agranulocytosis
62
What labs does a patient with central hypothyroidism have?
low TSH and low T4 (both suppressed)
63
Is an antithyroid peroxidase antibody assay needed to make the diagnosis of Hashimoto's thyroiditis?
no, but high levels are associated with higher risk of permanent hypothyroidism
64
What other lab findings can be seen in hypothyroidism?
- elevated prolactin
- low sodium
- increased CK, AST, cholesterol
65
hypothyroidism labs in an inpatient -- what should you do?
repeat labs in 4-8 weeks, usually recover
66
Do you need a thyroid scan and radioactive iodine uptake test to diagnose hypothyroidism?
NO
67
What's the diagnosis? elevated TSH and normal T4
subclinical hypothyroidism - only treat if TSH > 10 (per Board Basics book), if pregnant or want to become pregnant
68
What can decrease levothyroxine absorption?
celiac disease
ca and iron supplements
PPIs
69
Treatment for myxedema coma?
levothyroxine and hydrocortisone (continue hydrocortisone until adrenal insufficiency has been ruled out)
70
By what % should you increase Levothyroxine dose during pregnancy?
30% (2 extra pills a week)
| check TFTs regularly during pregnancy
71
First next steps when find a thyroid nodule?
ultrasound and TSH
72
Thyroid nodule - TSH is low, what is the next step?
low TSH suggests a benign and autonomously functioning thyroid adenoma.
- order RAIU scan to confirm dx and rule out additional nonfunctioning nodules within a multi nodular goiter
73
When should you get a fine needle aspiration biopsy for a thyroid nodule?
all nodules > 1cm with suspicious sonographic features and a normal TSH
nodules <1cm in patients with risk factors for thyroid cancer or suspicious sonographic characteristics
74
when should you check a calcitonin level in a patient with a thyroid nodule?
only if they have hyperCa or a family history of thyroid cancer or MEN2
75
How are benign thyroid nodules managed?
1. serial US - rule out malignancy if they grow or develop concerning ultrasound characteristics
76
How should hyper functioning solitary thyroid nodules be treated?
radioactive iodine ablation or hemithyroidectomy
77
When should patients with a thyroid nodule have surgery?
- continued nodule growth despite normal initial FNAB results
- non diagnostic results on repeat FNAB
- patients with malignant cytology
- large multinodular goiters associated with compressive symptoms
78
What tests are first line for Cushing syndrome?
- 1mg overnight dexamethasone suppression test (positive if fails to suppress cortisol to <3)
- 24 hour urine cortisol
- elevated late night salivary cortisol
79
If a patient who is being worked up for Cushing's has an elevated cortisol level, what is the next step?
ACTH level to distinguish between ACTH dependent and independent hypercortisolism
80
If a patient who is being worked up for Cushing's has a high ACTH level (>20pg/mL) what is the next step?
pituitary MRI or CT
81
If a patient who is being worked up for Cushing's has a low ACTH level (<5pg/mL) what is the next step?
Adrenal CT
82
If a patient who is being worked up for Cushing's has a high ACTH level and no tumor on cranial imaging, what is the next step?
8mg dex suppression test to differentiate between pituitary tumor and ectopic tumor ACTH production.
- no suppression of cortisol -> ectopic tumor
- > next step is CT chest + AP
- if suppression is achieved -> pituitary source -> intrapetrosal sinus sampling for ACTH
83
What is the treatment for Cushing syndrome?
surgical resection of adrenal, pituitary or ectopic tumor
| bisphosphonates for treatment of hypercortisolism
84
what is the definition of an adrenal incidentaloma?
>1cm adrenal mass discovered incidentally
85
What is workup of adrenal incidentalomas?
- 1mg overnight dex suppression test
- 24 hour urine metanephrines and catecholamines
- plasma Aldo and renin if HTN or hypoK
86
Treatment of an adrenal incidentaloma?
surgery if >4cm or functioning
| monitoring if <4cm (6-12 month f/u) + repeat hormone testing
87
How do we diagnose hypoadrenalism?
8:00am serum cortisol <3
| values >18 exclude the diagnosis
88
How do we differentiate between primary and secondary adrenal insufficiency?
elevated morning ACTH (>20pg/mL) -> adrenal CT
| suppressed or 'normal' ACTH (<5pg/mL) -> pituitary MRI
89
What do we do if someone has a non diagnostic AM cortisol to evaluate for hypoadrenalism?
stimulation testing with ACTH
90
If a patient is diagnosed with autoimmune adrenal insufficiency, what else should they be tested for?
thyroid disease, type 1 diabetes, other autoimmune endocrine diseases
91
what is the treatment for hypoadrenalism?
4mg Dex and IV fluids if suspect an acute processes (do NOT wait for labs to come back, dex will NOT interfere with serum cortisol assay)
Hydrocort 10-30mg/dL. Oral fludricort only if primary adrenal insufficiency. Increase up to 10x for stress like surgery. Do not need fludricort if the patient is on >40 of hydrocortisone
92
Can you prescribe dexamethasone for chronic replacement therapy for hypoadrenalism?
NO!
93
What diseases are pheos associated with?
VHL
NF type 1
MEN 2
94
How do we diagnose a pheochromocytoma?
- 24 hour urine metanephrines and catecholamines if LOW pretest probability
- plasma metanephrines when clinical suspicion is high (known hereditary syndrome or compatible symptoms)
95
If someone has positive biochemical tests for a Pheo, what are the next steps?
MRI or CT of abdomen and pelvis
| If those are equivocal, then a radioactive MIBG scan can aid in localization
96
What is the treatment for a Pheo?
Surgery
phenoxybenzamine to control BP prep
Give IV saline to maintain intravascular volume
can use nitroprusside or phentolamine intra-op to control BP
97
What can happen if you give beta blockade before alpha blockade in a patient with a pheo with HTN?
severe paroxysmal hypertension
98
How prevalent is hyperaldo in patients with HTN?
up to 14%!
99
What are the diagnostic criteria for hyperaldo?
plasma Aldo to renin ratio >20
plasma aldo level >15
give a high salt load -> will not suppress aldosterone in patients with an aldosterone adenoma
100
When should you think about hyperaldo?
HTN, hypoK, FH of primary hyperaldo
101
What BP meds can interfere with hyperaldo testing?
spironolactone and eplerenone because they antagonize the aldosterone receptor
102
If a patient has hyperaldo confirmed on lab tests, what are the next steps?
CT or MRI of adrenals
| adrenal vein sampling prior to surgery to determine source of aldosterone secretion if imaging is unrevealing
103
what is the treatment for hyperaldosteronism?
spironolactone or eplerenone for adrenal hyperplasia
laparoscopic adrenalectomy for an Aldo producing adenoma
can also add on a thiazide
104
Do all patients with hyperaldo have hypoK?
NO, only 50%
105
Most common cause of primary ammenorrhea
50% due to chromosomal disorders, most common is Turner syndrome (XO)
106
Diagnosis: lack of secondary sex characteristics, growth retardation, webbed neck, skeletal abnormalities
Turner syndrome
107
What is the diagnostic workup for primary amenorrhea?
pregnancy test
karyotype
FSH, LH, TSH, prolactin
pelvic US
108
What is the definition of secondary amenorrhea
absence of menstruation for 3 cycle intervals OR 6 consecutive months in women with previous menstrual flow
109
Common med offenders for secondary amenorrhea?
newly initiated OCPs
antipsychotics
reglan
110
What is the diagnostic workup for secondary amenorrhea?
pregnancy (most common cause!)
pelvic US to dx Asherman syndrome (fibrous uterine scarring)
if above workup is negative:
- estradiol, FSH, LH, TSH, prolactin
111
Diagnosis for cause of secondary amenorrhea:
low estradiol
low or inappropriately normal FSH and LH
hypogonadotrophic hypogonadism
ddx:
- hypothyroid
- hyperprolactin
- hypothalamic (stress, weight loss, exercise)
- pituitary (tumor, Sheehan syndrome)
112
Patient with hypogonadotrophic hypogonadism what is the next step in their workup?
progesterone challenge test
- > no bleeding indicates low estrogen, measure estrogen level
- > bleeding indicates normal estrogen and suggests possible hyperandrogenism (ex. PCOS)
113
Diagnosis for cause of secondary amenorrhea:
- low estradiol
- elevated FSH and LH
hypergonadotrophic hypogonadism
ddx:
- premature ovarian insufficiency
- chemo
- pelvic radiation
114
What is the treatment for secondary amenorrhea?
treat underlying disorder
estrogen and progesterone replacement until menstruation returns OR age 50 years to prevent osteoporosis
For hypothalamic amenorrhea: reduce exercise, improve nutrition and attend to emotional needs
115
Patient comes in with hirsutism and oligomenorrhea, what is the most likely diagnosis?
PCOS
116
What are the diagnostic criteria for PCOS?
2 of the following:
- ovulatory dysfunction
- lab or clinical evidence of hyperandrogenism (hirsutism, acne)
- US evidence of polycystic ovaries
117
Lab evidence suggestive of PCOS?
mildly elevated testosterone and DHEAS levels
LH/FSH ratio greater than 2:1
*only need to order when ruling out androgen producing neoplasm, otherwise PCOS is a clinical diagnosis
118
What diagnosis should you suspect in a woman with rapidly progressive hirsutism or virilization?
androgen secreting ovarian or adrenal tumor
119
Treatment for PCOS?
- intensive lifestyle modification
- if want to get pregnant: OCP and spironolactone for hirsutism
- if want to get pregnant: clomid or letrozole
120
What is the definition of infertility
inability to conceive after 1 year of intercourse without contraception in women <35, or 6 months if => 35
121
How diagnose testosterone deficiency?
two 8am total testosterone levels below reference range
if equivocal, measure free testosterone by equilibrium dialysis or mass spec
if low -> measure LH, FSH and prolactin
122
If a patient is having regular morning erections, no gynecomastia and normal genitalia exam should you measure serum testosterone?
no!
123
What should you monitor while giving testosterone treatment?
PSA and hematocrit
124
What can result from testosterone therapy?
small testicles and male infertility
125
What is the most common cause of hypercalcemia in outpatients?
primary hyperparathyroidism
126
Lab findings in primary hyperparathyroidism?
elevated PTH, low phos
127
Lab findings in hypercalcemia of malignancy?
low PTH, pos is normal or low
128
Lab findings in multiple myeloma?
```
low PTH
elevated Pos
AKI
Anemia
hyperCa
```
Dx: serum and urine protein electropheresis
129
Labs in sarcoid and other granulomatous diseases?
low PTH
phos elevated
calcitriol elevated (especially in sarcoid)
130
Workup for hyperCa?
iCal to exclude pseudohypercalcemia caused by an increase in plasma proteins that can bind calcium
PTH
Phos
Cr
25-OH D
131
Next step in patients with hyperCa and normal PTH?
Measure urine Ca to exclude familial hypocalciuric hypercalcemia
132
Next step if hyperparathyroid is confirmed and surgery is indicated?
sestamibi scan to look for an adenoma
133
What is the most common manifestation of MEN1?
primary hyperparathyroid
134
Treatment for hyperCa?
volume resuscitation with normal saline (LR contains Ca)
IV bisphosphonates and serum calcitonin
Oral steroids if HyperCa is from multiple myeloma or sarcoid
135
Should you use loop diuretics to treat Ca?
Boards Basics says NO, unless the patient has kidney or heart failure, in which case you should first volume expand and then use loop diuretics (see page 102 in board basics...I know this is not what we do in reality)
136
What is the most common manifestation of MEN2?
medullary thyroid cancer
137
What lab should you check in all patients with primary hyperparathyroid?
serum vit d!
| 50% of patients have coexisting vit D deficiency
138
When should patients with primary hyperpara go to surgery?
1. symptomatic with hypercalcemic complications: stones, bones, etc.
2. asymptomatic patients with
- elevated serum Ca level >1mg/dL above ULN
- GFR <60
- DEXA with T score < 2.5
- age <50
**need to carefully trend Ca post op
139
How should you treat patients with primary hyperpara who are not surgical candidates?
cinacalcet or bisphosphonates
140
When should women undergo DEXA screening?
65yo
Sooner if increased risk using FRAX tool with 10yr risk > 8.4%
141
how often should you repeat DEXAs?
q10-15 years if normal or slightly low BMD and no risk factors
142
is primary osteoporosis associated with any abnormalities on lab testing in the absence of fractures?
NO
143
DEXA range for osteopenia
T score -1 to -2.4
144
DEXA range for osteoporosis
T score less than 2.5
also diagnosed by fragility fracture (fracture from a fall at standing height or lower)
145
MCC osteoporosis in women and men?
women: estrogen deficiency
men: testosterone deficiency
146
Tx for osteoporosis?
- smoking cessation
- decrease EtOH
- resistance exercises
- sunlight
- Vit D and Ca supplementation
147
What are indications to treat someone with anti resorptive therapy for low bone density?
- osteoporosis
- osteopenia with high-risk factors
- prior fragility fracture
cost effective with FRAX >20% for major osteoporotic fracture and or risk of hip fracture >3%
148
What bisphosphonates are first line?
alendronate or risedronate
149
what bone density meds are recommended in patients with stage 4 CKD?
denosumab - monoclonal antibody that inhibits osteoclast activation
150
what can you use to treat pain from osteoporotic fractures?
calcitonin
151
Are the effects from denosumab sustained after the treatment is stopped?
NO!
152
How long should you treat with bisphosphonates for?
At least 5 years can then consider a drug holiday
153
What are risks with osteoporosis drugs?
oral bisphosphonates: erosive esophagitis and atypical hip fracture
IV bisphosphonates and denosumab: osteonecrosis of the jaw
teriperidate: assoc with osteosarcoma
154
how long can you treat with teriperidate for?
max 2 years (risk of osteosarcoma)
155
Should you use estrogen replacement therapy for postmenopausal women with osteoporosis?
NO
156
Can you combine teriperidate with a bisphosphonate?
NO
157
Which patients should not receive IV bisphosphonates?
severe hypocalcemia and CKD
158
When should you get a follow up DEXA after starting therapy for osteoporosis?
24 months
159
how treat osteomalacia related to vit d deficiency?
oral ergocalciferol 1000 to 2000 U/d and Ca 1g/d
160
When should you look for osteomalacia?
patients with fractures, nursing home residents (says the book)
161
What is the best test for Vit D levels?
25-OH D
162
What counts as a vit d replete level?
>= 20 says national academy of medicine
163
What patients have lower level of Vit D from meds or medical conditions?
obesity
glucocorticoids
orlistat
malabsorptive disorders
164
what is the recommended treatment dose for vit d deficiency?
50,000 IU of ergo or cholecalciferol then maintenance therapy 1500 to 2000 u /daily
165
Paget's disease: workup?
isolated alk phos elevation -> bone scan -> follow up xrays
treat with bisphosphonates
166
Should you routinely screen for Vit D deficiency?
No, not in healthy populations
high value care
