Endocrinology

Question 1

Pituitary

Normal feedback

Answer 1

1. Hypothalamic hormones excite or inhibit the pituitary
2. Pituitary hormone has negative feedback to the hypothalamus and stimulates the target endocrine organ
3. Target organ produces hormones which affect the target tissue and have a negative feedback to the hypothalamus

• Thyroid action:
  
  • Thyrotropin releasing hormone(TRH) produced by hypothalamus stimulates the secretion of pituitary hormones
  • Pituitary produces thyroid stimulating hormone(TSH)
  • TSH stimulates the target endocrine organ (thyroid gland) and that will result in the hormonal production of the thyroid hormone to affect target tissues like the heart, bone and skin
  • The thyroid hormone provides a negative feedback on the hypothalamic production of TRH,(turning the loop off)

Question 2

Primary vs secondary endocrine disorder

Answer 2

Primary disorder - The target organ is non functional - It is an actual disorder or abnormality of the gland; the organ itself is malfunctioning Target endocrine organ does not produce hormones

Secondary disorder - The organ functions normally but it receives an erroneous message to the gland from somewhere higher up (the defect is further up, and the gland is not stimulated properly) - Hypothalamic or pituitary dysfunction are secondary disorders Hypothalamic signaling issues are a tertiary issue

Question 3

.

Answer 3

Hypothalamus on the top - sits right above the pituitary , releases hormones to the pituitary stalk
Anterior pituitary gland - releases PRL, GH, TSH, LH/FSH, ACTH - then go to their target organs and release hormones from the target organs to where they need to go
Anterior pituitary -communicates with hypothalamus with GHRH, TRH, GNRH , CRH
Posterior pituitary - makes Oxytocin, ADH – does not release any hormone
PRL - is the only hormone that is always released, the way it regulates by hypothalamus , is that dopamine releases from the stalk to shut it off. (so dopamine from the stalk inhibits PRL )
Growth hormone - if you have an excess or deficiency - you measure IGF-1 not GH in the blood. GH and ACTH are counter regulatory hormones. - what they do they OPPOSE insulin- their job is to see that you have low blood sugar and release it

• Causes the body to release more glucose into the blood.

Adrenal gland - ACTH as it releases stimulates the adrenal glands which releases aldosterone, epinephrine/norepinephrine, adrenal androgens, cortisol.

Question 4

COUNTER- REGULATORY HORMONES:

Answer 4

GH -> Liver-> IGF-1
ACTH-> (Adrenal Gland)-> Cortisol
GH and ACTH oppose HYPOglycemia / insulin
Which means you help to release blood sugar into the bloodstream
- When you have low blood sugar, these hormones help increase sugar in the bloodstream
Excess regulatory hormones= HYPERglycemia and can cause diabetes

Question 5

Renin- Angiotensin- Aldosterone regulation of Blood Pressure and Volume

Answer 5

Renin- angiotensin system - basically means you have low serum NA+ and low renal perfusion pressure- blood volume is low , not
enough water so blood volume is low. You go through the renin angiotensin system to release angiotensin II – vasoconstriction artery and BP increases.
Talks to the adrenal glands which releases aldosterone which helps increase blood volume and increase BP - goal is to get BP up
Angiotensin II is a major contributor to release of aldosterone
Anterior pituitary releases ACTH and stimulates adrenal glands to release more aldosterone.
Aldosterone - causes you to hang on to salt, water follows salt increases blood volume and increases blood pressure

Question 6

Renin- Angiotensin- Aldosterone regulation of Blood Pressure and Volume

Answer 6

GOAL : To regulate blood pressure and volume
Activation:
HYPOtension
LOW serum sodium (Na+)
LOW perfusion through kidney
LOW blood volume
Aldosterone secreted by adrenal glands
Sodium (Na+) retention (water follows salt) = water retention= higher blood volume = HIGHER blood pressure

Remember:
Sodium (Na+) retention = potassium (K+) and proton (H+) excretion
EXCESS aldosterone= HYPOkalemia (too little K+)
DEFICIENCY in aldosterone = HYPERkalemia (too much K+)
Your goal - activate the system if you have low blood pressure – means you have low salt.
Low blood volume
When the system is activated your system secretes aldosterone - which causes you to hang onto salt and hang onto blood volume
– when you hang onto NA+ you excrete K+ and H+
So you can have HYPOkalemia (too little K+) - with excess aldosterone
- If you have a deficiency in aldosterone - you’ll have too much K+ hyperkalemia

Question 7

Anterior Pituitary Hormones * know these

Answer 7

Question 8

Posterior Pituitary Hormones * know these

Answer 8

Question 9

Signs/ Sx of hormonal excess and deficiency * know these

Answer 9

Question 10

Specific Disease Entities Associated with Endocrine Dysfunction *know this list

Answer 10

• Pituitary
  
  • Acromegaly, gigantism
  • Polycystic ovarian disease
  • Syndrome of inappropriate antidiuretic hormone (SIADH)
  • Diabetes insipidus
• Adrenal
  
  • Cushing’s syndrome and disease
  • Addison’s disease
  • Congenital adrenal hyperplasia (CAH)
  • Pheochromocytoma
    
    • MEN 1/ MENII
    • Neurofibromatosis
    • Von Hippel-Lindau syndrome
• Thyroid
  
  • Grave’s disease
  • Thyroid storm (thyrotoxicosis)
  • Apathetic hyperthyroidism
  • Transient thyroiditis
    
    • De Quervain’s syndrome (subacute painful thyroiditis/ granulomatous thyroiditis)
    • Lymphocytic (painless) thyroiditis
  • Hashimoto’s thyroiditis (chronic lymphocytic thyroiditis
• Parathyroid
  
  • Osteoporosis
  • Hypercalcemia (primary hyperparathyroidism)

Question 11

45 y.o women presents with lethargy, fatigue, weight gain, constipation, and dry skin. Menstrual cycles have been decreasing in frequency.
She has otherwise been healthy.
Meds: daily calcium (No Rx)
Social History: No tobacco , 2 alcohol beverages per week
- These are symptoms of hypothyroidism

Which of the following scenarios is consistent with this clinical picture?
A)increase TSH, free T4 decreases
B)decrease TSH, free T4 Increase
C) decrease TSH, Free T4 Decrease
D)TSH normal, Free T4 decreases

Answer 11

A)increase TSH, free T4 decreases
C) decrease TSH, Free T4 Decrease
D)TSH normal, Free T4 decreases

Explanations:
Increase T4 = hyper hypothyroidism - so we look at A, C, or D , is this a primary dysfunction or secondary
Primary- it means you have a problem with the thyroid gland itself
secondary - means you have a problem with pituitary affecting thyroid
A) Hashimoto’s thyroiditis
B) a lot of T4 released so this should tell TSH to stop releasing which it does
- Primary dysfunction, thyroid gland is oversecreting T4
C) low T4- the pituitary needs to release more TSH to bring it up but TSH is not releasing
- This is secondary - the pituitary gland itself is the problem
D) low T4 , and thyroid gland is releasing TSH and hasn’t responded to the low t4 release–
- Can be possible that the pituitary gland has not had time to respond - can be the thyroid gland itself that is the problem

Question 12

Clinical Signs in Thyroid Eye Disease

Answer 12

Lid retraction - upper & lower (“scleral show”)

• You get the stare , note to self - you should never see the upper sclera
• Conjunctival hyperemia
• Proptosis
• EOM limitation
• Optic neuropathy

Thyroid eye disease - belly of EOM and fat tissues will swell and pushes the eyeball forward causing eye retraction and proptosis
- You can also get pressure in the back of the nerve and optic neuropathy can occur

• *Thyroid Eye Disease
• Most common order of rectus muscle involvement in TED:
• Inferior> Medial> Superior> Lateral (IMSLO)
• Other orbital inflammatory disorders can mimic TED (lymphoma, pseudo tumor) -TED spares the muscle tendons on neuroimaging**

Question 13

You should be most concerned about optic neuropathy in thyroid eye disease when which EOM is involved? Medial or lateral rectus?

Answer 13

Medial rectus- because it runs closest alongside the optic nerve, especially towards the orbital apex

*Order or most common EOM involvement:
Inferior rectus > Medial rectus > Superior rectus > Lateral rectus (rare) > Obliques (rare)

IMSLO
1. Inferior rectus
2. Medial rectus
3. Superior rectus
4. Lateral
5. Superior oblique
Is the ON towards the nose or temporally –its always oriented towards the nose, inserts nasally
The MEDIAL RECTUS - if the medial rectus is large - it can make contact with the ON and cause the compression of optic neuropathy
If they have trouble ADDUCTION , eye can’t look in – look hard for optic neuropathy because there can be compression

Question 14

In TED involving the eye muscles, the muscle bellies are swollen and the tendons are spared- this can help you in your diff dx.
- Lymphoma and orbital pseudotumor are the 2nd and 3rd most common orbital inflammatory disorders and can mimic TED

Answer 14

In other orbital problems - what you’ll see is that everything is swollen
Thyroid eye disease is the muscle belly not the tendons !

Question 15

Lab testing reveals Low TSH and low free T4. which of the following would be an appropriate next step?

A) Diagnose Thyroiditis- usually results in hyperthyroidism
B) Obtain pituitary MRI
C) Begin treatment with T3 (triiodothyronine) – usually start treatment with T4 which is more likely to circulate and easier to
regulate and treat with, most people respond well with T4
D) Begin glucocorticoids– patient has hypothyroidism - and secondary hypothyroidism, there is no thyroid eye disease - which is then you would use glucocorticoids

Answer 15

B) Obtain pituitary MRI

Low free T4 - HYPOTHYROIDism - so pituitary should be signaled to increase TSH , but it’s not, so the problem is with pituitary
(secondary)

Question 16

Pituitary MRI reveals a non-functioning pituitary mass compressing the gland Which of the following can result?

A) Primary hypothyroidism- no because problem is with the pituitary
B) Adrenal insufficiency - mass taking up space so no ACTH being release from ant pituitary no there will be no stimulation of
adrenal glands
C) Hypocalcemia- calcium - more worried about parathyroid glands
D) Hypertension- no because you are not releasing ACTH not stimulating adrenal gland, not releasing aldosterone so you will be
with hypotension

Answer 16

B) Adrenal insufficiency

You can have functioning pituitary- mass it self secretes hormones - (prolactinoma - mass secreting prolactin)
Non functioning pituitary- mass growing in the pituitary is not doing anything it just compresses the pituitary which causes prevention of hormones to secrete because of the compression

Question 17

45 y.o women presents with lethargy, fatigue, weight gain, constipation, and dry skin. Menstrual cycles have been decreasing in frequency.
She has otherwise been healthy.
Meds: daily calcium (No Rx)
Social History: No tobacco , 2 alcohol beverages per week
- These are symptoms of hypothyroidism

Lab testing reveals Low TSH and low free T4.

Pituitary MRI reveals a non-functioning pituitary mass compressing the gland

If this patient is diagnosed with Cushing’s disease, which of the following are true?
A) Diabetes may develop- yes because ATCH is a counter reg hormone-too much acth release — too much acth = too much
blood sugar = Dm may develop
B) The patient may have an adrenal tumor-yes if its cushing syndrome because adrenal tumor can secrete too much cortisol which
is cushing syndrome
C) Hypotension is likely - no because cushing disease - too much adrenal stimulation too much aldosterone - hypotension
D) Hyperkalemia is likely - too much ACTH - too much adrenal stimulation too much aldosterone which hold onto sodium and
water and excrete potassium and H+

Answer 17

A) Diabetes may develop

Cushing’s disease - problem with pituitary gland itself- too much acth release — too much acth = too much adrenal gland stimulation
=too much aldosterone release = too much blood sugar = Dm may develop
Cushing syndrome- describes excess cortisol is released into the body

Question 18

45 y.o women presents with lethargy, fatigue, weight gain, constipation, and dry skin. Menstrual cycles have been decreasing in frequency.
She has otherwise been healthy.
Meds: daily calcium (No Rx)
Social History: No tobacco , 2 alcohol beverages per week
- These are symptoms of hypothyroidism

Lab testing reveals Low TSH and low free T4.

Pituitary MRI reveals a non-functioning pituitary mass compressing the gland

Patient is diagnosed with Cushing’s disease

If this is a growth hormones-secreting tumor, which of the following would be true?
A) skeletal effects will depend upon the patient’s age
B) An elevated GH level will be diagnostic - no you measure IGF
C) Cardiomyopathy may occur - large heart or organs can cause cardiomyopathy
D) Patient should be screened for Diabetes- GH counter regulatory - you secrete more glucose in the blood so you can end up
with Diabetes

Answer 18

A) skeletal effects will depend upon the patient’s age
C) Cardiomyopathy may occur - large heart or organs can cause cardiomyopathy
D) Patient should be screened for Diabetes- GH counter regulatory - you secrete more glucose in the blood so you can end up
with Diabetes

Growth hormone-secreting tumor
GH if you’re young and kid - gigantism since bones are not fully developed with excess of GH bones keep growing - exces height
Vs acromegaly in adults- bones fully formed so you get fronting bossing and lantern jaw (larger jaw) and dm , htn , heart problems
Gigantism and marfan syndrome - very different both of these individuals are very tall , share characteristics - gigantism -excess GH (endocrine problem) -test IGF- problems with heart and cardiomyopathy
Marfan - genetic Connective Tissue disorder- more connective tissue related (aortic not strong, aortic valve prolapses - heart problems deal with connective tissue related)

Question 19

Pituitary Tumors

Answer 19

Microadenomas (<10mm)
optic chiasm and pituitary gland between is 10 mm so anything touching will cause vision problems
Macroadenomas (=/>10mm)
10 mm of space between optic chiasm and pituitary tumor
Incidentalomas - pituitary tumors that are asymptomatic and don’t do anything are just there
Functional pituitary adenoma - prolactinoma - tumor that secretes prolactin
Pituitary gland - sits on sella turcica from
From pituitary gland and Optic chiasm = 10 mm apart from each other
Cavernous sinus on the either side
Ocular involvement in cavernous sinus since all the cranial nerves are in this area.
V1- corneal reflex involvement
If pituitary gland grows can crush on any of these nerves in the cavernous sinus can crush internal carotid artery as well.
cavernous sinus is wrapped in dura mater - which has sensory innervation ( a lot of pressure or congestion in the cavernous sinus can give you a bad headache)

• *Know the pituitary!
• Macroadenoma may compress the optic chiasm and result in vision loss if not detected/ treated early
• Pituitary apoplexy results from rapid enlargement of a known pituitary adenoma and is a (rare) MEDICAL EMERGENCY**

Pituitary - Macroadenoma >10mm have potential to compress optic chiasm
Pituitary apoplexy results from rapid enlargement of a known pituitary
– EMERGENCY

Question 20

Snowman sign

Answer 20

Since it sits on the hard bone saddle- pituitary sits there and bulges up the top if it gets too big.
Suprasellar - above the saddle
Sellar - in the saddle
This pituitary tumor has a cystic space in the suprasellar portion – >10mm

Question 21

77AA MALE admitted to neurology with blurry vision, diplopia and HA
Sx onset all of a sudden while driving = “my vision went haywire” i feel like i was going to hit somebody
Known pituitary macroadenoma since 2007
23x23x24mm abutting chiasm (touches the chiasm)
Mild b-temporal VF constriction
Normal central VA and color vision
No other cranial nerve deficits
Borderline- low testosterone
BCVA 20/250 OD and OS (previously 20/20) . No color vision
Poorly reactive Pupils bilaterally- no discernible APD
No optic nerve edema
Pituitary macroadenoma increased in size and pressing on everything in the cavernous sinus
– PITUITARY APOPLEXY when the pituitary macroadenoma increases out of nowhere

– MAJOR EMERGENCY . The HA is very bad that they go straight to the ER
- very rare
Rapid expansion of known pituitary macroadenoma due to acute bleed or infarction
Decreased VA, diplopia/ EOM abnormalities loss of corneal sensation etc.
Severe HA, hypopituitarism = RISK OF DEATH from hypoglycemia, hypotension, and shock secondary to ACTH/cortisol deficiency
Pituitary work up in the eye clinic
- Check BCVA
- Color vision , contrast sensitivity
- Pupils
- Eoms
- Cn testing 3,4,5(V1),6
- Threshold VF
- Fundus photos, OCT
You have to do a cavernous sinus work up

Apathetic hyperthyroidism (T/F):
A) Is commonly seen in young patients- no usually older and acting apathetic (depressed and low moods)
B) May be asymptomatic
C) May present with atrial fibrillation

Answer 21

6) Apathetic hyperthyroidism (T/F):
A) Is commonly seen in young patients- no usually older and acting apathetic (depressed and low moods) FALSE
B) May be asymptomatic TRUE
C) May present with atrial fibrillation TRUE - patients will present with a fib - will test their thyroid function

Question 22

Thyroid storm may present with (storm because it happens out of nowhere quickly)
A) Fevers
B) Tachycardia
C) Weight gain- happens with hypothyroid
D) No symptoms

Answer 22

A) Fevers
B) Tachycardia

Hyperthyroid symptoms that happen very fast -fever tachycardia

Question 23

If a patient with Addison’s disease (primary adrenal insufficiency) was found unconscious after a motor vehicle crash, which of the
following would be the most important agent to administer?
A) Glucose
B) Insulin
C) Potassium- You have a lot of potassium in this case so you don’t need more potassium
D) Cortisol
E) L-thyroxine

Answer 23

D) Cortisol

• Primary adrenal insufficiency , adrenal gland is not functioning well enough. Its a problem with adrenal gland itself- not releasing
  the hormones it should be - cortisol deficiency vs. cushings which is excess cortisol
• Most people with addison’s have an emergency bracelet on to know what to administer
• These people need cortisol since its a cortisol deficiency
• Glucose is not a wrong answer- cortisol also helps release sugar into the blood, if you put in cortisol then it ican help you
  release sugar into the body as well

Question 24

If a patient with Addison’s disease (primary adrenal insufficiency) was found unconscious after a motor vehicle crash, This same patient with addison’s disease may have hyperpigmentation

A) True
B) False

Answer 24

A) True

• A few more steps within ACTH that go into the adrenal glands
• Hypothalamus communicates with pituitary gland, CRH - comes into pituitary gland and what that does - causes release of
  POMC which is cleaved into ACTH , then b-endorphin and melanocyte-stimulating hormone
  Addison’s disease- primary adrenal insufficiency - problem in adrenal gland - no cortisol, aldosterone , androgen so ACTH is trying to be
  pumped out to help wit this problem
  But there will be excess of ACTH, endorphins and melanocyte-stimulating hormone that causes skin pigmentation - a lot of melanocytes
  cause increase skin pigmentation
  – same method for cushing’s disease - cause pituitary increase acth secretion increase b-endorphin and increase melanocytes
  stimulating hormones and pigmentation

Question 25

Which of the following patterns of cortisol secretion
A) ACTH secretion at 10pm and cortisol secretion at 12 You don’t want it secreted at 10pm or you wake up at midnight
B) ACTH and cortisol secretion simultaneously at 8am - You need ACTH secretion first then cortisol
C) ACTH secretion at 6AM and cortisol secretion at 8am
D) Cortisol secretion at 6AM and ACTH secretion at 8am

Answer 25

C) ACTH secretion at 6AM and cortisol secretion at 8am

Cortisol does not secrete first
Cortisol secretion - gets you up and gets you going - and to wake up , to secrete cortisol - you need increase ACTH

Question 26

A 45 year old man asks his doctor about a new medication for erectile dysfunction that he saw advertised on TV. Before providing a rx, it would be reasonable to ask about

A) Symptoms of diabetes- peripheral neuropathies
B) Low libido - hormonal problems
C) Angina - vascular problem
D) Smoking- vascular problem

Answer 26

A) Symptoms of diabetes- peripheral neuropathies
B) Low libido - hormonal problems
C) Angina - vascular problem
D) Smoking- vascular problem

• Could be vascular problem - not enough blood to extremities
• Could be hormonal problem of endocrine

Question 27

He responds that he has diminished libido (hormonal problem) recently and additional evaluation reveals an elevated prolactin level.
This can be caused by which of the following?
Elevated prolactin - isolate problem to pituitary problem

A) Disruption of the pituitary stalk - is incharge of dopamine getting down to decrease prolactin secretion
B) Congenital adrenal hyperplasia- elevated prolactin level – so this is a pituitary problem we are seeing not adrenal problem
which is not related to B
C) Pheochromocytoma- you have a adrenal problem, adrenal gland has too much epinephrine or norepinephrine (catecholamines)
- causing over secretion which is not involved here
D) Prolactinoma- tumor that secretes more prolactin

Answer 27

A) Disruption of the pituitary stalk

D) Prolactinoma-

Question 28

13) A 21 yo female college soccer player suffers a concussion directly after returning to play following a 2 week spell on the sideline for a
concussion. She reports increased urination and thirst- waking up in the night every hour to use the restroom and drink water. She has a
problem with which hormone?
A) Prolactin
B) Cortisol

C) Growth hormone
D) ADH- causes you to hold onto water you have the opp of polyuria

Answer 28

D) ADH- causes you to hold onto water you have the opp of polyuria

ADH is posterior pituitary hormone - secreted by hypothalamus and goes down to kidney then blood vessels- retains water

Question 29

A 21 yo female college soccer player suffers a concussion directly after returning to play following a 2 week spell on the sideline for a
concussion. She reports increased urination and thirst- waking up in the night every hour to use the restroom and drink water. She has a
problem with which hormone?

She is evaluated and found to have which problem?

A) Diabetes mellitus- blood sugar problem - hyperglycemia your body should use insulin to cut down blood sugar level (store
glucose) but body does not respond to insulin
B) Diabetes insipidus- problem is ADH - ADH insufficiency. You have pituitary injury - because of repetitive brain injuries or
pituitary is not functioning - you excrete more water than it should be ADH is releasing but kidneys are not retaining water, LIthium - causes kidneys not to retain water as well .
C) SIADH (syndrome of inappropriate ADH)- opp of diabetes insipidus - you retain water and therefore your ADH level should
decrease- if you retain water your pituitary gland should recognize to cut down on ADH and excrete water, but it doesn’t realize and it just retains water- swelling of brain causing HA confusion - Rare lung cancer that can cause SIADH

Answer 29

B) Diabetes insipidus- problem is ADH

Question 30

55 y.o women asks about her fracture risk when having an eye exam. You ask her the following questions. For each explain why you
are asking the questions
A) Do you have a history of thyroid disease
B) What do you do for exercise and how often?
C) Have you had a vitamin D level recently?- VIT D deficiency- absorb calcium in the gut and so not enough ca in the body if
VIT D deficiency instead of absorbing calc in the gut it will absorb from the bone.
D) Have you ever taken seizure or blood thinning medications?
E) Do you smoke?
F) Are you still having menstrual periods? If not, when did they stop? Post - menopausal - you don’t have estrogen as much
of it going through your body
G) Do you consume much dairy? VIT D - is what absorbs CA from gut and diet or else body gets it from the bones;

Answer 30

A) Do you have a history of thyroid disease
B) What do you do for exercise and how often?
C) Have you had a vitamin D level recently?- VIT D deficiency- absorb calcium in the gut and so not enough ca in the body if
VIT D deficiency instead of absorbing calc in the gut it will absorb from the bone.
D) Have you ever taken seizure or blood thinning medications?
E) Do you smoke?
F) Are you still having menstrual periods? If not, when did they stop? Post - menopausal - you don’t have estrogen as much
of it going through your body
G) Do you consume much dairy? VIT D - is what absorbs CA from gut and diet or else body gets it from the bones;

Question 31

Parathyroid Glands- Serum Ca2+ Regulation

Answer 31

• Calcium is essential for muscle/ nerve function, bone formation, and intracellular signaling. Free/ ionized calcium carries
out these functions
• PTH increases serum Ca2+ levels (in response to low serum Ca2+)
o Stimulates reabsorption of Ca2+ by the kidneys
o Stimulates Vitamin D activation in the gut (for gut absorption of Ca2+)
o Stimulates osteoclast activity (reabsorption of bone= harvesting of Ca2+ from bone)
• Calcitonin decreases serum Ca2+ (weakly)
o Secreted by parafollicular C cells of the thyroid Parathyroid gland - serum Ca 2+ regulation
- PTH - help reabsorb ca - stimulates kidneys to hold more ca for you or stimulate vitamin D which can pull the Ca from the gut
instead of bone. If there is not enough ca taken from a source then it will break down bone – stimulate osteoclast activity which
is a problem

Important feedback loop
- low serum Ca =stimulates PTH if too much serum CA stimulates PTH to cut back and not secrete anymore CA

• If high level of serum CA - PT gland will cut back on PTH

What if there is HIGH PTH level? PT gland is over functioning and is not working properly - primary glandular function -
hyperparathyroid problem! Too much calcium and parathyroid is still secreting PTH, so parathyroid adenoma can happen which causes hyperparathyroidism.

Question 32

Which of the following hip bone density results would be most concerning?

A) Z-score -1.0
B) T-score +2.1
C) Z-score +2.7
D) T-score - 2.6-bones are more frail, and higher neg t score is concerning because it means you have lower bone
density

Answer 32

D) T-score - 2.6-bones are more frail, and higher neg t score is concerning because it means you have lower bone
density

T-score is the right answer - the number are the SD away from normal
0 SD - you have the avg amount of bone density
Greater than 2.6 deviation away (-2.6 - less bone density from 2.6 from avg individual)
>-2.5 osteoporosis
-1-> - 2.5 osteopenia
-1 = normal
In General:
T score: compares the peak bone density among adults = score compares you to people with the same age
- Anything below -2.5 standard deviations on a T score indicates osteoporosis
- Anything between -1 and -2.5 indicates osteopenia
Z scores: looks at data from adults around the same age but does not rule out individuals with osteoporosis
- score compares you to everyone ! even people without osteoporosis

Question 33

Which of the following is the best approach to treating osteoporosis?

a) Assess fall risk and begin med if elevated
b) Treat on the basis of bone density results
c) Assess fracture risk and begin a multifaceted intervention including med if appropriate

Answer 33

c) Assess fracture risk and begin a multifaceted intervention including med if appropriate
A and B not necessarily because you need to put into consideration that the osteoporosis meds have phosphates that have a lot of side
effects so you have to weigh out the pros and cons.
Osteoporosis - meds have phosphates - a lot of side effects
Remember:
Bone Mineral Density (BMD) : assess for fracture risk
- -1.0 to -2.5 (osteopenia)
- >-2.5 (osteoporosis)
Fall risk is assessed clinically
- Observe gait
- Neurological examination
**Low BMD + High fall risk = Highest risk for fracture

Question 34

Hypercalcemia

Answer 34

• Hyperparathyroidism (usually adenoma) cancer, excessive vitamin D (intake, production in granulomatous disease),
renal disease
• “Stones, bones, moans, groans”
• Band keratopathy
o Manifestation of high serum calcium
o Most common: chronic intraocular inflammation/ dry eye syndrome

• A lot of ca release -
  A lot of band keratopathy in older patients
  More concerning for younger patients - parathyroid is functioning too much if seen in a younger patient.
  If its a swiss cheese texture - not normal