Endocrine Comp - Sheet1 (1) Flashcards
What is Somogyi effect?
Somogyi is AM hyperglycemia triggered by insulin related hypoglycemia
Define Dawn effect.
AM hyperglycemia triggered by physiological release of cortisol growth hormone and catecholamines
Which lipid lowering medication should be avoided in a patient who has gout?
Niacin
Define metabolic syndrome.
Metabolic Syndrome: 3 or more of the following: Abdominal obesity - Increased triglycerides - Decreased HDL - HTN - Hyperglycemia
What endocrine disorder can Tolvaptan cause?
Nephrogenic diabetes insipidus
What are increased levels of beta-hydroxybutyrate diagnostic of?
Diabetic Ketoacidosis (DKA)
What is Sipple syndrome?
MEN 2a (Hyperparathyroid - Medullary thyroid cancer - Pheochromocytoma)
What is Wermer’s syndrome?
MEN 1 (Parathyroid tumors - Pituitary - Pancreatic)
Is central or nephrogenic diabetes insipidus more likely to respond to desmopressin?
Central (Nephrogenic is resistant to ADH and desmopressin is an ADH analog)
In a patient with secondary corticoadrenal insufficiency, what would happen to cortisol levels after a cosyntropin stimulation?
Cortisol levels would increase
What does no change in cortisol levels after initiation of a cosyntropin stimulation indicate?
Primary corticoadrenal insufficiency
What is cosyntropin?
ACTH
How does hyperpigmentation differentiate hypocortisol states?
Hyperpigmentation occurs with primary corticoadrenal insufficiency (Addison’s disease)
How does Trousseau’s sign differ from Trousseau sign of malignancy?
Trousseau’s sign: Carpopedal spasm with inflation of BP cuff > SBP for > 3 minutes - Trousseau sign of malignancy: Migratory thrombophlebitis + GI or lung CA
Nodular goiter with hyperthyroidism without exophthalmos?
Plummer’s disease
What specific type of thyroiditis is Hashimoto’s thyroiditis?
Chronic lymphocytic thyroiditis
Initial hyperthyroidism which may occur with Hashimoto’s thyroiditis?
Hashitoxicosis
What is the only lipid lowering medication which has been shown to cause angioedema?
Ezetimibe
Which lipid lowering medication may cause flushing pruritus and nausea?
Niacin
Which DM medication is contraindicated in NYHA class III or IV heart failure?
Pioglitazone
Pancreatitis is a side effect of what two classes of oral DM medications?
DPP-4 inhibitors - GLP-1 analogs
Fruity or “acetone” breath is consistent with which hyperglycemic state?
Diabetic ketoacidosis
Which cholesterol medication may cause constipation and metabolic acidosis?
Bile sequestration agents
Which cholesterol medication may cause increase in blood glucose levels?
Niacin
Which cholesterol medications are best for LDL control?
Statins
Which medications commonly cause hyperlipidemia?
Protease inhibitors - Thiazide diuretics
What common endocrine disorder is associated with hyperlipidemia?
Hypothyroidism
List two long acting insulins
Insulin glargine - Insulin detemir
List three rapid acting insulins.
Insulin glulisine - Insulin lispro - Insulin aspart
What class of oral diabetic medication should not be given to patients with G6PD?
Sulfonylureas
Nausea and diarrhea are common side effects of which oral diabetic medication?
Metformin
List the risk factors for gestational diabetes.
Obesity - Maternal age - Family HX DM - Prior macrosomal birth
What are the two recommended treatment options for gestational diabetes?
Lifestyle changes and insulin
What values during a 24-28 week gestation 75 gm 2 hour GTT are diagnostic of DM?
One hour > 180 mg/dl - Two hour > 153 mg/dl
What fasting blood glucose level is diagnostic of gestational diabetes at any time during pregnancy?
> 92 mg/dl
List the four ADA recommended agents to add to metformin if needed.
Insulins (Basal first) - Sulfonylureas - Pioglitazone - GLP-1 agonists
What is the initial treatment strategy for type 2 DM as per the ADA?
Metformin + lifestyle changes
What is the BP goal for diabetic patients?
< 130/80
Which vaccines are recommended for diabetic patients?
Influenza vaccine annually and pneumococcal vaccination every 5-7 years
List the recommended screening for diabetics.
HbA1C Q 6 months - Annual: Monofilament testing for neuropathy - Dilated retinal exam - UA microalbumin - Lipid screening - PVD screening
Polydipsia polyuria with a blood glucose of 842 mg/dl without metabolic acidosis suggests?
Hyperosmolar non-ketotic hyperglycemia
What are the relative contraindications to metformin use?
Heart failure - Liver disease - EtOH abuse - Hypo-perfusion states
What are the absolute contraindications to metformin?
Serum creatinine > 1.5 Men > 1.4 women
What is the primary treatment strategy for type 1 diabetes?
Insulin therapy
At least one of the four diagnostic criteria must be present to diagnose DM. List all four.
Fasting BG > 126 mg/dl - HbA1C > 6.5% - BG > 200 @ 2 hours on GTT - Random BG > 200 plus signs and symptoms
What do bitemporal hemianopsia and galactorrhea suggest?
Pituitary tumor
What disorder is most likely with Polydipsia, polyuria, increased serum osmolality and decreased Urine osmolality?
Diabetes insipidus
Which disorder causes osteoporosis, bone pain, renal calculi GI symptoms and psychosis?
Hyperparathyroidism
How does Ezetimibe work?
Blocks intestinal absorption of cholesterol
What laboratory test can be drawn to confirm myalgia is due to statin therapy?
Serum creatine phosphokinase
What is the most common cause of gynecomastia in adults?
Medication or drugs
Treatment of choice for central diabetes insipidus (DI) and DI associated with pregnancy?
Desmopressin
What is the treatment of choice for Cushing’s Disease?
Trans sphenoidal resection of the pituitary adenoma or surgical resection of ectopic cortisol producing tumor and cortisol (hydrocortisone or fludrocortisone) replacement if needed
What is the most likely cause of acromegaly?
Pituitary adenoma
What is the HDL level which is considered to be protective?
HDL over 60 mg/dL
What does a fasting glucose of 100-125 indicate?
Impaired glucose tolerance
What fetal effects does gestational diabetes produce?
Macrosomia
Which type of thyroiditis has fever pain redness and neck mass?
Suppurative Thyroiditis - Most common cause staph or strep
What is the preferred test to set initial dosing of thyroid replacement?
TSH
What is the treatment for Hashimoto’s thyroiditis?
Lifetime replacement of thyroxine (T4) (levothyroxine or liothyronine)
What is the drug of choice to treat a pregnant/breast feeding patient with hyperthyroidism?
PTU in the first trimester then methimazole for rest of pregnancy (both are OK for nursing)
Decreased growth hormone from infancy results in which condition?
Dwarfism
Frontal bossing, tall stature and macroglossia represent which disorder?
Acromegaly
What are the cardinal signs and symptoms of Cushing syndrome or disease?
Buffalo hump - Moon face - Blue abdominal striae - Truncal obesity - Hyperglycemia - Hypertension
List four drugs which cause thyroiditis.
Lithium - Amiodarone - Interferon alpha - Interleukin-2
Salt craving hyperpigmentation of skin and fatigue represent which disorder?
Addison’s
What does a cold nodule on thyroid uptake scan likely represent?
Malignancy
List two common presentations which are consistent with pituitary adenoma?
Temporal field loss of vision - Galactorrhea
What is the most common cause of acromegaly?
Pituitary adenoma
List three medications which may be used for Cushing patients who can not have surgical correction?
Mitotane - Metyrapone - Ketoconazole
What screening should long term Cushing syndrome or disease patients have?
DEXA (Osteoporosis common in long term hyper-cortisol states)
Decreased ACTH and high cortisol levels in a high dose dexamethasone suppression test is diagnostic for which disorder?
Cushing syndrome (primary) will result in decreased ACTH from the dexamethasone
Increased ACTH result from a high dose dexamethasone suppression test is diagnostic for which disorder?
Cushing disease (secondary) will continue with increased ACTH despite the dexamethasone
What result is expected with a low dose dexamethasone suppression test?
Decreased cortisol = Normal - Cushing disease or syndrome will result in persistent increased cortisol
List three causes of Cushing syndrome?
Adrenal adenoma - Adrenal hyperplasia - Adrenal cancer
Is Cushing’s disease or syndrome more common?
70% of patients have secondary (Cushing’s disease) from ACTH secreting tumors
What test other than the dexamethasone suppression test can be used for Cushing disease?
Serum ACTH will be increased in Cushing’s disease (secondary)
What test other than the dexamethasone suppression test can be used for Cushing syndrome or disease?
24 hour urine for cortisol will be increased in both
What is the difference between Cushing syndrome and Cushing’s disease?
Syndrome is primary - Disease is secondary
What happens to glucose blood pressure inflammation and metabolism in Cushing’s syndrome or disease?
Increased glucose - Increased blood pressure - Decreased inflammation - Increased metabolism
What is the treatment for corticoadrenal insufficiency?
Hydrocortisone or fludrocortisone
List four less common causes of primary corticoadrenal insufficiency?
Tuberculosis - Adrenal infection - Metastasis to adrenal gland - Adrenal trauma
What is the most common cause of primary corticoadrenal insufficiency?
Addison’s disease
What symptoms may result from abrupt withdrawal of long term high dose steroids?
Severe N/V/D - Significant hyponatremia - Hyperkalemia - Hypoglycemia
A patient has decreased ACTH and increased cortisol. Is this primary or secondary disease?
Primary
What basic metabolic panel finding might one find in a patient with Addison’s disease?
Hyponatremia
What CBC finding might one find in a patient with Addison’s disease?
Eosinophilia
List three osteoporosis treatments.
Bisphosphonates - Denosumab - Teriparatide
What screening should hyperparathyroid patients undergo?
DEXA for osteoporosis
What medication can be used for hyperparathyroidism?
What medication can be used for hyperparathyroidism?
What is the most common treatment for primary hyperparathyroidism?
Surgical removal
Are renal calculi are more common with hypo or hyperparathyroidism?
Hyperparathyroidism due to increased urinary excretion of calcium from the high serum calcium levels
List the five hallmark signs and symptoms of hyperparathyroid disease.
Osteoporosis - Renal calculi - Bone pain - GI symptoms - Depression/psychosis
What happens to serum and urinary calcium in hyperparathyroidism?
Increased PTH = increased Serum Ca++ and decreased Urine Ca++ initially but increased Urine Ca++ chronically
Prolonged hypoparathyroidism can produce symptoms which mimic which neurological disorder?
Parkinson’s
Prolonged hypoparathyroidism can result in what acute neurological event?
Seizure
What is the treatment for hypoparathyroidism?
Oral calcium and vitamin D to keep serum calcium > 8
What happens to serum and urinary calcium in hypoparathyroidism?
Decreased PTH = Decreased Serum Ca++ and increased Urine Ca++
What are the three systems which parathyroid hormone affects to change calcium levels?
Intestinal absorption - Bone resorption - Renal reabsorption
What is the sign? Ipsilateral facial contraction with tapping anterior to ear.
Chvostek’s sign
What is the sign? Carpopedal spasm with inflation of BP cuff > systolic pressure for > 3 minutes.
Trousseau’s sign
List two signs which can occur with hypoparathyroidism.
Trousseau’s sign - Chvostek’s sign
Hypoparathyroidism may be caused by chronic depletion of which electrolyte?
Magnesium
What is the most common cause of hypoparathyroidism?
Surgical removal
In a patient with a cold thyroid nodule what procedure should be performed for definitive diagnosis?
Fine needle aspiration (FNA) biopsy
List three genetic risk factors for thyroid cancer.
Familial medullary thyroid CA - MEN - Familial adenomatous polyposis
What is the most common risk factor for thyroid cancer?
Radiation exposure
List four etiologies for painless thyroiditis.
Postpartum - Drug induced - Chronic lymphocytic - Fibrous
List four etiologies for painful thyroiditis.
Subacute thyroiditis - Radiation induced - Traumatic - Infectious
What instructions regarding food should be given to a patient taking levothyroxine?
Take on an empty stomach many foods decrease absorption.
Which medications can cause hyper or hypothyroidism?
Amiodarone and lithium
List three medications which can cause hyperthyroidism.
Levothyroxine - Amiodarone - Lithium
A hypothyroid patient has an increased TSH and an decreased Free T4. Is this primary or secondary disease?
Primary
List three non-autoimmune causes of hyperthyroidism.
Toxic adenoma or multinodular goiter - Thyroiditis - Iatrogenic
A hypothyroid patient has an decreased TSH and an decreased Free T4. Is this primary or secondary disease?
Secondary
What is the most common cause of secondary hyperparathyroidism?
End stage renal failure
Which antibodies are positive in both Hashimoto’s and Grave’s?
Anti-Thyroglobulin antibody and Antithyroid Peroxidase antibody
What hyperthyroid condition can cause weight gain?
Heart failure due to high cardiac output
List three non-autoimmune causes of hypothyroidism.
Thyroidectomy - Radioactive iodine - Medication (e.g. lithium amiodarone)
Treatment of acute thyroid storm?
Beta blockers first then: Oral iodine compounds - Thioamides (methimazole, carbimazole, PTU)
End stage kidney failure leads to what parathyroid problem?
Secondary hyperparathyroidism
What do lithium and hyperparathyroidism have in common?
Calcium kidney stones
What is the disorder? Anti- Thyroid Peroxidase antibody and + TSH receptor antibody
Grave’s disease
Which thyroid problem most commonly causes weight gain?
Hypothyroidism
Most common cause of hypothyroidism?
Autoimmune Hashimoto’s Thyroiditis
Which class of HIV medication can cause hyperlipidemia?
Protease inhibitors
Very high levels of which type of cholesterol may lead to pancreatitis?
Triglycerides > 500 may lead to pancreatitis
What side effects should the patient be counseled on when starting niacin?
Flushing - Pruritus - Nausea - Vomiting - Diarrhea
What is the only lipid medication which can cause angioedema?
Ezetimibe
What are the two classes of lipid medication which can cause rhabdomyolysis?
Statins and fenofibrates - Chance for rhabdomyolysis increases when combined
A 45 year old male is found on review of laboratory to have a fasting blood glucose of 116 and a HbA1c of 6.8. Can he be diagnosed with diabetes?
Yes - Criteria are fasting blood glucose >126 OR HbA1c > 6.5
A patient with medullary thyroid cancer develops hypertension resistant to treatment. What secondary hypertension cause should be ruled out?
Pheochromocytoma - MEN 2a or MEN 2b
A patient has polyuria, polydipsia and nocturia. Blood glucose and HbA1c are both normal. What labs should be checked to further investigate?
Serum sodium and osmolality (increased in diabetes insipidus) - Urine osmolality(decreased in diabetes insipidus)
Will desmopressin (an ADH analog) successfully treat nephrogenic diabetes insipidus?
No - The kidneys are resistant to ADH in nephrogenic diabetes insipidus
What lab value can assist in distinguishing hypernatremia from dehydration versus hypernatremia due to diabetes insipidus?
Urine osmolality - Diabetes insipidus: urine osmolality will be low - Dehydration: urine osmolality will be high
A 42 year old male presents with galactorrhea and visual changes which consist of temporal field loss. What imaging is appropriate?
MRI to look for pituitary adenoma
What is the specific type of procedure used to surgically treat acromegaly from a pituitary adenoma?
Trans-sphenoidal resection of pituitary
What is the cause of 95% of acromegaly?
Pituitary adenoma
A 21 year old male who is 6’8”, has acral enlargement and a BP of 160/95 mmHg presents. What imaging study would be appropriate as part of your work up?
MRI for pituitary adenoma
How will height be affected in an patient who develops acromegaly in adulthood?
Height does not change if the acromegaly develops after the growth plates have closed
How does the decreased growth hormone in pituitary dwarfism affect the growth plates?
Growth plates fibrose early but close later in children with pituitary dwarfism
What are you concerned about in a patient who has no change in ACTH levels and has increased cortisol levels on a high dose dexamethasone suppression test?
Ectopic source of ACTH - e.g. lung tumor
What is the best way to test cortisol levels in a patient with a suspect hypercortisol state?
24 hour urine cortisol
Are increased cortisol levels with a cosyntropin test consistent with primary or secondary corticoadrenal insufficiency?
Secondary
Is hyperpigmentation a sign of primary or secondary corticoadrenal insufficiency?
Primary
A dialysis patient begins to complain of vague abdominal cramping, worsening fatigue and bone pain. What disorder is likely?
Secondary hyperparathyroidism
Which type of parathyroid disorder are osteoporosis and abdominal cramping consistent with?
Hyperparathyroidism
Chronic low serum levels of which electrolyte can lead to hypoparathyroidism?
Chronic hypomagnesemia can lead to hypoparathyroidism
What three organ systems affect calcium levels in response to parathyroid hormone levels?
Intestinal absorption - Bone resorption - Renal excretion
Which parathyroid disorder is Trousseau’s and Chvostek’s sign indicative of?
Hypoparathyroidism
What findings on thyroid uptake scan would support the possibility of malignancy and warrant a fine needle aspiration of the nodule?
Cold nodule
A patient presents with radiation induced thyroiditis. Do you expect to find a tender or non-tender thyroid on exam?
Tender
A 34 year old female presents in thyroid storm with a BP of 210/110 mmHg and a heart rate of 124 bpm. What medication should be used first line?
Beta blockers are first line to deal with the emergent symptoms
What is the preferred laboratory test to establish initial dosing in hypothyroidism?
TSH
What term describes the initial hyperthyroidism that may occur prior to subsequent hypothyroidism in the beginning stages of Hashimoto’s thyroiditis?
Hashitoxicosis
List two medications which may cause either hypothyroidism or hyperthyroidism.
Amiodarone and lithium
A patient has weight gain, fatigue and brittle, dry hair. Her general screening labs find a TSH of 0.28. What is the most likely disorder?
Secondary hypothyroidism
