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IM Board Review > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

Women with hyperglycemia identified during the first trimester are classified as having type 2 diabetes instead of gestational diabetes.

A
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2
Q

You can use metformin as long as GFR>____

A

45

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3
Q

Empty Sella Syndrome

1)Primary: Intracranial HTN
2)Secondary: to infarction of a pituitary tumor or other causes including infection, autoimmune disease, trauma, or radiotherapy

A

Empty sella hints at some kind of pitutiary dysfunction

1) Such as Prolactinoma

it is recommended that asymptomatic patients with empty sella have repeat endocrine, radiologic, and ophthalmologic evaluation in 24 to 36 months.

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4
Q

____ is a drug associated with hypogonadism

A

Chronic Opiates

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5
Q

____ is an emerging oncological cause of panhypopit

A

Immune checkpoint inhibitor

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6
Q

Markers to assess for pitutiary hypersecretion when a pitutiary mass is found _____ and _____

A

IGF-1, Prolactin

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7
Q

Markers to assess for pitutiary hyposecretion_____

A

AM Cortisol, FSH, LH, TSH

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8
Q

Urine osmolality >750-800 mOsm/kg H2O is a normal response to water deprivation, indicating ADH production and peripheral effect are intact.

A

If dilute urine, it means no ADH to retain water

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9
Q

Desmopressin challenge is used to diagnose_______

A

Central DI

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10
Q

Test for GH excess___________

A

Glucose tolerance test

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11
Q

Women with a macroadenoma close to the optic chiasm who are planning pregnancy may benefit from surgical decompression of the pituitary tumor due to the risk of enlargement during pregnancy. Macroadenoma defined >1cm

A

Somatotrophs and gonadotrophs appear to be the most sensitive to injury, so GH as well as LH and FSH are the most common pituitary deficiencies.

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12
Q

Morning cortisol levels less than 3 µg/dL (82.8 nmol/L) are diagnostic of cortisol deficiency; however, a morning cortisol level greater than 15 µg/dL (414 nmol/L) likely rules it out. Patients with cortisol levels between 3 and 15 µg/dL (82.8-414 nmol/L) should undergo an ACTH stimulation test

A
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13
Q

Cushing disease is the result of excess____

A

ACTH

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14
Q

Once diagnosis of ACTH-dependent Cushing syndrome is established, a pituitary MRI should be performed for confirmation. If no pituitary tumor is seen or if the tumor is less than 6 mm, a high-dose 8-mg dexamethasone suppression test (DST) is done to evaluate for the presence of an ectopic ACTH-producing tumor (lung, pancreas, thymus carcinoma most commonly), which is highly resistant to dexamethasone suppression

A
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15
Q

When is petrosal vein sampling indicated: ______

A

1) MRI negative or lesion <6mm
2) S/p surgery and continued ACTH hypercortisolism

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16
Q

If medical management is needed for cushings due to non-candidacy for radiation or surgery____

A

Pasieriotide, cabergoline, ketoconazole

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17
Q

Hard to test for cushings when someone is on hormone therapy,

A

Initial Cushing test
1) Urine 24hr
2) 1mg DST (low dose)
3) late night salivary cortisol

*Repeat testing is recommended for confirmation

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18
Q

Primary aldosteronism is caused by hyperplasia of both adrenal glands (idiopathic hyperaldosteronism) in two-thirds of cases,

A

The most reliable case-detection test is calculation of an plasma aldosterone-plasma renin ratio (ARR) by measuring plasma aldosterone concentration and plasma renin activity (or direct renin concentration)

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19
Q

In patients taking an ACE inhibitor or an angiotensin receptor blocker, renin should be elevated, so in these patients, a simple initial test is plasma renin activity measurement. If the plasma renin activity is suppressed, the likelihood of primary aldosteronism is high and an ARR

A

situation where renin activity is more useful

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20
Q

Treatment of Conns syndrome

A

Medical therapy with an aldosterone receptor antagonist (spironolactone or eplerenone) is the treatment of choice for primary aldosteronism due to idiopathic hyperaldosteronism

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21
Q

Conditions associated with pheochromocytoma_____________________

A

MEN2, VHL, NF1

The classic triad of palpitations, headache, and diaphoresis is seen in fewer than 50% of patients with pheochromocytoma

Initial tests for pheochromocytoma include measurement of plasma-free metanephrine collected in a supine position or 24-hour urine fractionated metanephrine and catecholamine levels

Medications effecting test: SSRI/SNRI, Levodopa, methyphenidate,

They are typically larger on imaging>4cm, compared to Conns syndrome, catecholamine-secreting tumor is high, the next step is iodine 123 (123I)-metaiodobenzylguanidine scanning

Pre-surgery: Phenoxybenzamin, Selective α-1 receptor blockers such as doxazosin can be used as an alternative to phenoxybenzamine if availability or lack of insurance coverage of the latter is a problem.

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22
Q

MEN1 associated with ___________________

A

Gastrinoma, insulinoma, pituitary adenoma

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23
Q

The most common cause of primary adrenal insufficiency in the United States is autoimmune adrenalitis, and positive 21-hydroxylase antibodies are found in approximately 90% of those cases

A
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24
Q

Evaluating adrenal insufficiency____________

A

1) AM cortisol –> ACTH , <3 with high ACTH is already diagnostic of primary adrenal insufficiency
2) If AM cortisol 3 - 15 (indeterminate), ACTH stim test , low cortisol means adrenal insufficiency because gland did not respond

Low cortisol low ACTH = secondary adrenal insufficiency from pituitary malfunction

For minor physiologic stress states such as respiratory infection, fever, or minor surgery under local anesthesia, patients should double or triple their baseline glucocorticoid dose for 2 to 3 days. H

Patients who present with adrenal crisis should receive fluid resuscitation and an initial immediate dose of intravenous hydrocortisone (100 mg), followed by intravenous hydrocortisone (100 mg) every 8 hours for the next 24 hours, with subsequent dosing governed by clinical status

Patients with concomitant untreated adrenal insufficiency and hypothyroidism should always receive glucocorticoid replacement therapy first to prevent precipitation of adrenal crisis by thyroid hormone replacement

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25
Q

Incidental Adrenal Mass:

All patients should also be evaluated for subclinical Cushing syndrome, a condition characterized by ACTH-independent cortisol secretion that may result in metabolic (hyperglycemia and hypertension) and bone (osteoporosis) effects of hypercortisolism, but not the more specific clinical features of Cushing syndrome, such as supraclavicular fat pads, wide violaceous striae, facial plethora, and proximal muscle weakness

Initial testing for subclinical Cushing syndrome is achieved with a 1-mg overnight dexamethasone suppression test, with a cortisol level greater than 5 µg/dL (138 nmol/L) considered a positive test.

A
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26
Q

Adrenal incidentaloma (by definition>1cm)__________________

A

1) Imaging: Low housefield<10, rapid washout, <4cm suggests benign, else

2) Biochemical evaluation: low dose dex suppression, metanephrine, renin/aldosterone (high>90)

All patients with adrenal incidentaloma should be evaluated for pheochromocytoma; those with hypertension or hypokalemia should also be evaluated for primary aldosteronism, and all patients should be evaluated for subclinical Cushing syndrome.

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27
Q

Thyroid Assessment

Hyperthyroid: 1) low TSH –> thyroid radionucleotide scan (cold = biopsy)
Hypothyroid: 1) High TSH –>Ultrasound — >1cm = FNA, small = US surveillance

A

Papillary thyroid carcinoma and follicular thyroid carcinoma, collectively known as differentiated thyroid cancer, account for the most thyroid cancer diagnoses in the United States.

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28
Q

Goiter

Patients with signs or symptoms of compression require additional testing as outlined below, and surgery may be needed for symptomatic management

Diffuse Goiter

The most common cause of diffuse goiter is autoimmune thyroid disease associated with thyroid dysfunction (Hashimoto thyroiditis and Graves disease). Infiltrative disorders, such as Riedel (IgG4-related) thyroiditis, are rare causes of diffuse goiter.

A
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29
Q

Post thyroidectomy _____________________

A

Patients with persistent disease typically require lowering of their TSH level to less than 0.1 μU/mL (0.1 mU/L), whereas patients who are disease-free with a low risk of recurrence should maintain a TSH level of 0.3 to 2.0 μU/mL (0.3-2.0 mU/L).

131I therapy is also used to treat thyroid cancer recurrences not amenable to surgical resection.

131I therapy is also used to treat thyroid cancer recurrences not amenable to surgical resection.

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30
Q

Post thyroidectomy surveillance

A

After initial cancer treatment, serum thyroglobulin (Tg), a sensitive marker for the detection of persistent or recurrent disease, and thyroglobulin antibody (TgAb) titers are monitored. When TgAb is present, Tg levels are uninterpretable because TgAb can falsely lower Tg measurement. In this case, the TgAb level serves as a surrogate marker. A falling TgAb titer over time correlates with a favorable prognosis, whereas a rising titer is suspicious for persistent or recurrent disease.

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31
Q

Supplement interfering with thyroid hormone testing____________

A

Biotin

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32
Q

Graves disease pathophysiology: ________________

A

T lymphocytes become sensitized to thyroid antigens and stimulate B lymphocytes to produce antibodies against the TSH receptor (TSI or TRAb). The thyroid is diffusely enlarged, may have a bruit, and has a firm, smooth texture on examination

33
Q

Graves disease treatment

A

Methimazole/PTU

I131 ablation

Thyroidectomy in Graves hyperthyroidism is most appropriate when there is a large goiter with compressive symptoms, moderate to severe Graves ophthalmopathy, and/or with coexistent thyroid cancer or primary hyperparathyroidism.

34
Q

Toxic adenoma treatment:

A

First-line therapy for a toxic adenoma or toxic multinodular goiter is either 131I therapy or thyroid surgery

35
Q

Common causes of primary amenorrhea _____

A

Turners syndrome, intact hymen, vaginal genesis (everything else normal)

36
Q

Causes of secondary amenorrhea _________

A

Secondary amenorrhea is defined as absence of menses for more than 3 months in women who previously had regular menstrual cycles or for 6 months

Hyperprolactinemia
Ovarian insufficiency (high FSH levels at menopause levels)
Uterine adhesions (Asherman syndrome)
PCOS
Pregnancy
Thyroid

*Serum tests have to be repeated for confirmation, just like in other endocrine conditions

37
Q

Amenorrhea diagnosis

A

1) FSH Level/Pelvic Exam
2)Progestin withdrawal test : Bleeding confirms uterus is working, suspected hyper androgen (PCOS) versus hypothalamic dysfunction

After ruling out pregnancy, initial laboratory testing in both primary and secondary amenorrhea should include measurement of follicle-stimulating hormone, thyroid-stimulating hormone, free thyroxine, and prolactin.

38
Q

Hyperandrogenism

1) PCOS : High LH low FSH : Diagnosis of exclusion
2) Adrenal tumor
3) Exogenous androgens

A

PCOS does not cause high testosterone or DHEA, it more of the peripheral effect

High DHEA: Adrenal or ovarian tumor

Tx: Spironolactone , birth control

39
Q

___________ (47,XXY) is the most common congenital cause of primary hypogonadism and is associated with tall stature, small testes, developmental delay, and socialization difficulties.

A

Klinefelter syndrome

40
Q

Secondary hypogonadism in males
1) Kallmann syndrome
2)Hyperprolactinemia
3)Medications
4) Infiltrative disorders (sarcoid, hemochromatosis)

A

Dx
- In men with specific signs and symptoms, measuring an 8 AM total testosterone level is indicated. If the testosterone level is low, a second 8 AM testosterone level is measured.

An elevated LH level reflects primary hypogonadism

41
Q

Male infertility

A

Semen analysis is the initial laboratory assessment for male infertility; if results are abnormal, testing should be repeated at least 2 weeks later, with referral to a reproductive endocrinologist if results are abnormal again.

42
Q

Medications causing gynecomastia

A

Spironolactone, cimetidine

n a male presenting with painful gynecomastia, measurement of human chorionic gonadotropin, LH, morning total testosterone, and estradiol levels should be obtained if no clear cause is identified on history and physical examination.

43
Q

Common medications causing hypercalcemia

A

thiazide, lithium

44
Q

When is surgery indicated for primary parathyroidism

A

1) Serum calcium 11+
2) Evidence of osteoporosis, fractures
3) Kidney stones or kidney injury
4) Urine calcium excretion >400

45
Q

What is tertiary hyperparathyroidism :

A

Chronic stimulation of the parathyroid glands can lead to autonomous production of PTH by all four glands, resulting in hypercalcemia. Tertiary hyperparathyroidism is most commonly recognized after kidney transplantation. Although historically treated with subtotal multigland parathyroidectomy, the hypercalcemia can be resolved in most patients by treatment with paricalcitol or cinacalcet.

46
Q

Pathophysiology of FHH

A

In FHH, inactivating mutation of the CaSR gene causes the parathyroid gland to perceive serum calcium concentrations as low, resulting in increased PTH secretion and a higher serum calcium level

Although these patients appear to have primary hyperparathyroidism, FHH is a benign condition that is not treated with parathyroidectomy. Hypercalcemia will not resolve with surgery.

Characterized by low urine calcium

Patients do not have sequelae of hypercalcemia, such as stones or osteoporosis

47
Q

MEN syndromes associated with hyperparathyroidism____

A

Primary hyperparathyroidism is associated with MEN1 and MEN2A syndromes

48
Q

Vitamin D–dependent hypercalcemia is associated with normal to elevated serum phosphorus levels because vitamin D enhances intestinal absorption of phosphorus and suppressed PTH secretion reduces kidney phosphorus excretion.

A

Phos is the differentiating factor

49
Q

Unregulated conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D may occur in granulomatous tissue associated with fungal infection, tuberculosis, sarcoidosis, and lymphoma, leading to increased intestinal absorption of calcium

A
50
Q

Severe thyrotoxicosis occasionally causes hypercalcemia or hypercalciuria by increasing bone resorption.

A
51
Q

Low TSH ,normal-highT4________

A

Subclinical hyperthyroid

Treatment of subclinical hyperthyroidism is recommended for patients with serum TSH levels below 0.1 µU/mL (0.1 mU/L

52
Q

Serum markers for Graves__________, serum markers for Hashimoto_______

A

Graves: . Tests include measurement of thyroid-stimulating immunoglobulin (TSI) or thyrotropin (TSH) receptor antibodies (TRAb)

Hashimoto = TPO

53
Q

Drugs causing hypothyroid:
Amiodarone, lithium, interferon-alpha, interleukin-2, iodine, thionamides (methimazole), ethionamide, tyrosine kinase inhibitors (sunitinib), immune checkpoint inhibitors (ipilimumab)

A

Amiodarone can cause hypo and hyperthyroid

54
Q

Celiac/Hypothyroid: Malabsorptive disorders may decrease levothyroxine absorption resulting in higher than expected levothyroxine dose requirements

A

Tx: for hypothyroid in general, straight to weight based replacement = 1.6/kg

55
Q

Treatment of amiodarone induced hyperthyroid ___________

A

moderate- to high-dose prednisone that can be gradually tapered over 1 to 3 months.

56
Q

Thyroid dysfunction pregnancy:

A

In treatment-naïve pregnant women with positive TPO antibodies, levothyroxine is started if TSH level is ≥2.5 µU/mL

57
Q

Euthyroid sick syndrome: normal T4, low TSH (Body thinks your hyperthyroid), just repeat labs in 6 months

A
58
Q

Treatment of thyroid storm

A

intravenous β-blockers, thioamide, intravenous high-dose glucocorticoids, and potassium iodide are all used to manage thyroid storm.

59
Q

Treatment of myxedema coma

A

stress-dose glucocorticoids (100 mg intravenous hydrocortisone every 8 hours) are administered empirically before thyroid hormone is initiated to treat possible concomitant adrenal insufficiency.

60
Q

In patients with primary hyperparathyroidism who are undergoing parathyroidectomy surgery, identifying and correcting vitamin D deficiency is important to avoid postoperative hypocalcemia

A
61
Q

Vitamin D–dependent hypercalcemia is associated with normal to_____________ serum phosphorus levels because vitamin D enhances intestinal absorption of phosphorus and suppressed PTH secretion reduces kidney phosphorus excretion.

A

elevated

62
Q

Symptoms of hypocalcemia: ___________

A

Laryngospasm, seizure, myocardial dysfunction, and QT-interval prolongation leading to sudden cardiac death due to severe hypocalcemia (<7.5 mg/dL [1.9 mmol/L]) can occur without prodromal paresthesia or muscle cramping.

Low Mg can cause hypocalcemia, therefore needs to be checked

63
Q

Osteitis fibrosa cystica is most commonly seen in patients with chronic kidney failure and is rarely associated with severe primary hyperparathyroidism.

A
64
Q

The U.S. National Osteoporosis Foundation recommends pharmacologic treatment for patients with osteoporosis-related hip or spine fractures, those with a BMD T-score of −2.5 or less, and those with a BMD T-score between −1 and −2.5 with a 10-year risk of 3% or greater for hip fracture or risk of 20% or greater for major osteoporosis-related fracture as estimated by the Fracture Risk Assessment Tool (FRAX)

A

Key number is 3%/20%

All bisphosphonates are contraindicated in patients with reduced kidney function (glomerular filtration rate [GFR] <35 mL/min/1.73 m2) and should not be given until vitamin D deficiency and hypocalcemia are treated,
- Continue for 3-5 years, repeat DEXA
- Denosumab may be preferred in patients with stage 4 chronic kidney disease and in those intolerant of or incompletely responding to bisphosphonate therapy.

Intravenous zoledronic acid once a year is an option if patients experience upper gastrointestinal symptoms or have difficulty taking the medication as directed

The FDA has recently approved a combination pill, bazedoxifene and conjugated estrogen, for prevention of postmenopausal osteoporosis.

65
Q

Teriparatide, rhPTH (1-34), is approved for use in postmenopausal women and men or women with glucocorticoid-induced osteoporosis who are at high risk of osteoporotic fracture

A

steroid induced bone disease, hypogonadal men, not a first line

66
Q

Vitamin D loading dose

A

Loading doses using 50,000 U/d of either vitamin D2 (ergocalciferol) or vitamin D3 (cholecalciferol) once weekly for 8 weeks is appropriate in severe deficiency especially in the setting of malabsorption

67
Q

Pagets disease of bone: all patients with suspected Paget disease of bone require assessment of serum calcium, 25-hydroxyvitamin D, and a whole-body radionuclide bone scan
*ALP high

A

Bisphosphonates, particularly a one-time dose of 5 mg of intravenous zoledronic acid, often achieve the treatment goal of reducing pain and normalizing of alkaline phosphatase for up to 5 years.

Blurb: Although Paget disease of bone may present with localized symptoms, it is most commonly diagnosed in asymptomatic older patients presenting with elevated alkaline phosphatase levels or incidental radiographic findings.

Goal is normalization of ALP

68
Q

Diabetes screening = age 40+ for obese

A
69
Q

Stop metformin if GFR<____

A

30

70
Q

when to avoid SGLT2

A

PAD, lower extremity ulcer disease (increased amputation risk)

Diabetic mononeuropathy is not treated `

71
Q

Enlarged pituitary mass
1) biochemical studies
2) MRI brian

A

Prolactinemia
1)Drugs : dopamine (metoclopramide), TCA, anti epileptics
2) hypothyroid
3) Prolactinoma

Tx: Cabergoline/bromocriptine

ACTH, TSH, GH secreting tumors = automatic removal, overall these are rare

72
Q

Treatment of nephrogenic DI caused by lithium______

A

Amiloride

73
Q

Thyroid storm characterized by __________

A

fever, delerium, psychosis, cardiac decompensation

Low thyroglobin thyroid storm implies exogenous use

74
Q

Only treat subacute hypothyroid if TSH>____

A

10

75
Q

When are you looking at high dose dex suppression test?

A

elevated ACTH, MRI brain (-), therefore ectopic source

1) Test did not work : Then ectopic : small cell, pheochromocytoma, medullary thyroid cancer –> CT pan scan
2) Test suppressed: Probably pituitary source, will need petrosal vein sampling

76
Q

Pheochromocytoma associated with NF1, MEN2, VHL

A
77
Q

Conn syndrome : aldosterone/renin>20, aldosterone >15 (Adenoma)
- In contrast adrenal insufficiency is auto-immune primary insufficiency

A
78
Q

A telltale sign of sarcoid induced hypercalcemia__________

A

high urine calcium

79
Q
A

IM Board Review (13 decks)

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