Endocrinology Flashcards
appropriate starting dose for levothyroxine
1.6 microgram/kg lean body weight
25-50 microgram/day for older patients and those with cardiovascular disease
Pharmacologic therapy for patients with Type 2 DM and ASCVD or risk factors for ASCVD
Glucagon-like peptide 1 receptor agonist OR sodium glucose cotransporter 2 inhibitor
Indications for adrenalectomy
1) functioning pheochromocytoma
2)  Aldosterone-producing tumor
3) Hypercortisolism
4) suspicious imaging (size > 4 cm, > 10 Hfu, Absolute contrast wash out of > 60% in 10 min
5) growth of > 1cm/year
Most appropriate diagnostic test for evaluation of cause of hyperthyroidism
Thyroid scintigraphy with radioactive iodine uptake
If RAIU contraindicated, then Thyroid-stimulating immunoglobulin or thyrotropin receptor antibodies
Elevated alkaline phosphatase, hypocalcemia, Whole-body bone scan showing increase update of technetium throughout the skeleton
Osteomalacia
First-line diagnostic test for Cushing syndrome
1) overnight Low-dose dexamethasone suppression test
2) 24- hour urine free cortisol measurement
3) Late-night salivary cortisol measurement
Next step in evaluation for unilateral, nontender, fixed breast mass in male patient
Mammography
Initial treatment for myxedema coma
IV levothyroxine
Percentage of radioactive Iodine uptake for
1) Graves’ disease
2) other causes of thyrotoxicosis such as destructive thyroiditis
1) > 30% (high)
2) < 10% (low)
Appropriate management for symptomatic thyroiditis
Beta-blockers (tachycardia and palpitations)
Anti-inflammatory (prednisone/NSAID; thyroid tenderness/pain)
Sudden hemorrhage or infarction of a pituitary adenoma
Pituitary apoplexy
Potential adverse effects of zolendronic acid that occurs within 1 to 3 days after first administration in 30% patients
Acute-phase response reaction characterized by low-grade fever, myalgia, arthralgia
Most common cause of primary hypogonadism. Typically present in adulthood with tall stature; small, firm testes; infertility; and signs of androgen deficiency
Klinefelter syndrome
Appropriate screening for diabetes mellitus in pregnant women with risk factors for type 2 DM
At time of their positive pregnancy test and again between 24 and 28 weeks gestation if initial test is negative
Diagnostic values for type 2 diabetes mellitus
Fasting glucose: > 126 mg/dL
Random glucose: > 200 mg/dL + symptoms
2-hr OGTT: > 200 mg/dL
HgbA1c: > 6.5%
Diabetes medication that is contraindicated in patients with GFR < 30 and can cause vitamin B12 deficiency
Metformin
Diabetes medications that cause weight gain
Sulfonylureas, Thiazolidinediones, Meglitinides
Diabetes medications that reduce the rates of death by CVD, all cause mortality, and are FDA approved for reduction of CV death in adults with T2DM and CVD
Empagliflozin (also reduces rate of HF hospitalization)
Liraglutide
Diabetes medications that can possibly place patients at increased risk for pancreatitis
DPP-4 inhibitors and GLP-1 mimetics
Diabetes medication that has an adverse effect of UTIs, can possibly increase risk for DKA, and should be used with caution with history of PVD
SGLT2 inhibitors
Screening for complications and patients with type 1 diabetes
Begin at 5 years after diagnosis and performed annually there after
Screening for complications in patients with type 2 diabetes
Begin at time of diagnosis and performed annually there after
1) Dot and blot hemorrhages
2) Neovascularization
1) Nonproliferative diabetic retinopathy
2) Proliferative diabetic retinopathy
Indication to treat for subclinical hyperthyroidism
TSH < 0.1 microU/L + Symptoms, cardiac respecters, heart disease, or osteoporosis
Indications for parathyroidectomy in patients with primary hyperparathyroidism
Fragility fractures, Vertebral fractures, DEXA T score < -2.5 (Lumbar, Yep, femoral neck, distal 1/3 radius)
Evaluation for symptomatic fasting hypoglycemia
Prolonged fast, up to 72 hours, with measurement of plasma glucose, C-peptide, insulin, proinsulin, BHB
Image modality to distinguish type 1 amiodarone-induced thyrotoxicosis (hyperthyroidism) from type 2 (destructive thyroiditis)
Thyroid US with Doppler studies
Diagnostic evaluation for Paget disease of bone
Whole body radionuclide bone scan
Appropriate management For gestational diabetes refractory to therapeutic lifestyle interventions
Insulin
Timing of repeat US for thyroid nodules
High-suspicion: 6 to 12 mo
Intermediate/Low-suspicion: 12-24 mo
Very low-suspicion: 24 mo or longer
Timing of when to screen pregnant women for gestational diabetes
24 to 28 weeks of gestation
Glycemic targets in pregnancy
Plasma glucose < 95 mg/dL
1hr postprandial < 140 mg/dL
2hr postprandiak < 120 mg/dL
Serum C-peptide level in surreptitious ue of insulin
Low
Serum C-peptide level in surreptitious use of oral hypoglycemic agents
High
Sudden pituitary hemorrhage or infarction associated with sudden headache, visual change, Ophthalmoplegia, AMS
Pituitary apoplexy
Silent pituitary infarction associated with obstetric hemorrhage and hypertension and follwed by amenorrhea
Sheehan syndrome (postpartum pituitary necrosis)
Preferred treatment for primary adrenal insufficiency
Hydrocortisone + fludrocortisone
Appropriate management of postmenopausal osteoporosis in patients intolerant of or incomptely responsive to bisphosphonate therapy
Denosumab
Appropriate diagnostic evaluation for patients with thyroid nodules and a suppressed TSH
Thyroid scintigrqphy with radioactive iodine uptake
ACTH-independent cortisol secretion that may result in metabolic (hyperglycemia and HTN) and bone (osteoporosis) effects of hypercortisolism, but not the more specific features of Cushing syndrome
Mild autonomous cortisol excess (MACE)
ADA recommendation for neuropathic pain
Pregabalin, gabapentin, or duloxetine
First steps in management of functional hypothalamic amenorrhea (hypogonadotropic hypogonadism in the setting of excess exercise/energy expenditure or decreased caloric intake)
Increase caloric intake to match energy expenditure and to reduce exercise
Management for the following:
1) Women with microprolactinoma and normal menses or patients with non-functioning pituitary microadenoma
2) Symptomatic prolactinoma
3) I don’t know Miss secreting GH, ACTH, TSH; or Associated with mass effect, visual field defects or hypopituitarism
1) observation
2) Medication such as dopamine agonist (carbergoline)
3) Surgery
1) diffuse homogenous increased radioactive iodine uptake (RIU)
2) Patch areas of increased RIU
3) Focal increased RIU with decreased RIU in the rest of the glan
4) Decreased or no RIU
1) Graves disease
2) Toxic multinodular goiter
3) solitary adenoma
4) Iodine load (IV contrast or Amiodarone) or Thyroiditis (silent, subacute, postpartum, amiodarone induced) or Surreptitious ingestion
Treatment of choice for toxic multinodular goiter or toxic adenoma
Radioactive iodine or surgery
First line anti-thyroid medication for most patients
Methimazole
Treatment of choice for hyperthyroidism in first trimester of pregnancy
Propylthiouracil
Indication for treatment of subclinical hypothyroidism
Pregnancy are soon to be
Levothyroxine management of hypothyroidism
1) Age < 60
2) Age > 60
3) Heart disease
4) myxedema coma
5) pregnancy 
1) full dose of 100 microg/day
2) 25-50 microg/day. Increase by 25 microg every 6 wks until TSH is 1.0-2.5
3) 12.5-25 microg/day. Increase by 12.5-25 microg every 6 wks until TSH is 1.0-2.5
4) add hydrocortisone
5) increase dose by 30%
Indication for FNA biopsy
1) Thyroid nodules > 1 cm With suspicious sonographic features in normal TSH level
2) nodules < 1 cm With risk factors for thyroid cancer or suspicious US characteristics
Appropriate lab value to obtain for the diagnosis of hypercalcemia due to immobilization
Elevated serum bone alkaline phosphatase
Treatment of choice for primary aldosteronism caused by idiopathic hyperaldosteronism
Aldosterone receptor blocker (Spironolactone or eplerenone)
First line diagnostic studies for Cushing syndrome
1) 1mg overnight dexamethasone suppression test (failure to suppress < 3 microg/dL)
2) 24hr urine cortisol level (elevated)
3) late night salivary cortisol level (elevated)
Evaluation of hypercorticolism if
1) morning ACTH elevated (>20 pg/mL)
2) morninf ACTH suppressed or normal (<5 pg/dL)
1) pituitary MRI or CT
2) Adrenal CT
Evaluation for adrenal incidentalomas in asymptomatic patients
1mg dexamethasone suppression test + 24hr urine levels of metanephrines and catecholamines
Evaluation for adrenal incidentaloma in patients with hypertension or spontaneous hypokalemia
Addition of plasma aldosterone-plasma renin ratio
Evaluation of choice for pheochromocytoma if clinical suspicion is
1) low
2) high
1) 24hr urine metabephrines and catecholamines
2) plasma metanephrines
Lab values suggesting diagnosis of primary hyperaldosteronism
Plasma aldosterone-plasma renin activity ratio > 20
Aldosterone level > 15 ng/dL
Treatment of choice for
1) adrenal hyperplasia
2) aldosterone producing adenoma
1) spironolactone or eplerenone
2) laparoscopic adrenalectomy
Hyper parathyroidism, pituitary neoplasm, pancreatic NETs
MEN 1
Hyperparathyroidism, medullary thyroid cancer, pheochromocytoma
MEN 2
First line therapy for osteoporosis
Alendronate or risedronate
Treatment for osetomalacia if secondary to Vit D deficiency
PO ergocalciferol 1000 - 2000 U/day + elemental Ca 1 g/day
Management for Vit D deficiency
50k U of either ergocalciferal or cholecalciferol followed by maintenxe therapy of 1500 to 2000 U/day
Isolated elevation of ALP in the absence of liver disease
Focal osteolysis with coarsening of the trabecular pattern, Cotton wool skull, cortical thickening
First line therapy?
Paget Disease
Bisphosphonates
Acute, asymmetric, focal onset of pain followed by weakness in the proximal leg in a diabetic patient
Diabetic amyotrophy
Causes for focal increase in bone density
Osteophytes, osteoplastic metastasis, compression fracture, Paget disease
Management for amiodarone induced hypothyroidism (high TSH, low T4)
Continue amiodarone and start levothyroxine
Amiodarone induced thyrotoxicosis (low TSH, high T4) with increase vascularity on thyroid US
Type 1 AIT
Management for type 1 AIT
1) Consider stopping amiodarone unless clinically necessary
2) Treat with methimazole
3) thyroidectomy for refractory cases
Amiodarone induced thyrotoxicosis (low TSH, high T4) with decreased vascularity on thyroid US
Type 2 AIT
Management for type 2 AIT
1) May continue amiodarone unless not indicated clinically
2) Treat with corticosteroids
