Endocrinology

Question 1

How are symptoms of hyperthyroidism different in older adults?

Answer 1

More: AF, SOB, weight loss, anorexia
Less: inc reflexes, inc sweating, heat intolerance, tremor, polydipsia and inc appetite

Question 2

What is the definition of subclinical hypothyroidism?

Answer 2

Elevated TSH with normal free T4 confirmed on repeat measure
Check anti TPO (predict risk of progression, need for ongoing monitoring)

Question 3

What is the work up for subclinical hypothyroidism?

Answer 3

Clinical evaluation and hx, drugs, comorbidities
Repeat testing of TSH and free T4 in 1-3 months

Question 4

Guidelines for treating subclinical hypothyroidism

Answer 4

TSH >= 10 Treat
TSH 7-9.9 Risk vs. benefit, consider tx if symptoms, risk of worsening CHF or CVD mortality, if 85+ just wait and see
TSH 4.5-6.9 Do not treat

Question 5

What are symptoms of hypogonadism?

Answer 5

Specific:
Incomplete/delayed sexual development
Loss of body hair
Very small testes

Suggestive:
Reduced sexual desire
Dec spontaneous erections
ED
Height loss
Low trauma fracture, low BMD

Question 6

How to diagnose hypogonadism?

Answer 6

Measure testosterone in the morning
Borderline/low normal = repeat
Low = FSH, LH, prolactin, SHBG, CFT/CBAT, TSH, ferritin, CBC, PSA

Question 7

What are the categories of hypogonadism?

Answer 7

1. Primary = testicular, low T and high FSH/LG
2. Secondary = pituitary/hypothalamic, low T and normal FSH/LH

Question 8

How do you manage hypogonadism?

Answer 8

Only treat if symptoms and clearly low on repeat tests
Don’t treat if: breast or prostate cancer, prostate nodule, PSA>4, desire for fertility, sev LUTS, inc Hb, thrombophilia, sev OSA, uncontrolled CHF or MI/stroke in last 6 mos

Question 9

What are 4 ways in which growth hormone may be beneficial?

Answer 9

Increase muscle mass
Decrease body fat
Inc bone density at some sites
Inc skin thickness

Question 10

What are 4 risks to using growth hormone?

Answer 10

Doesn’t translate in inc in strength
Joint pain
Edema
Carpal tunnel

Question 11

What are the common symptoms of hypercalcemia?

Answer 11

Confusion - depression, CI
Proximal muscle weakness
HTN
Osteoporosis
Bony/MSK pain
GI - pain, constipation, polyuria

Question 12

What is the main etiology of hypercalcemia in the elderly?

Answer 12

Primary hyperparathyroidism in community
Malignancy in institutional settings

Question 13

What are other etiologies of hypercalcemia in the elderly?

Answer 13

PTH mediated (high PTH, high Ca, low PO4)
1. Primary HyperPTH
2. Tertiary hyerPTH (renal impairment)

Non PTH/Malignancy
1. PTHrp - malignancy, sq cell lung
2. Lytic lesions - MM and mets
3. Granulomatous disease - lymphoma, sarcoid, TB

Non PTH/Other
1. Vit D toxicity
2. Milk alkali
3. FHH
4. Meds: Lithium, HCTZ, Calcium
5. Paget’s and immobilization

Question 14

What are investigations for hypercalcemia?

Answer 14

Ca, Mg, PO4
Normal lytes, Cr
Albumin, liver enzymes
PTH

SPEP, UPEP
UA, 24 hr urine Ca
PTHrp

CXR, AXR
ECG (short QT)
XR bony pain

Question 15

What is the acute treatment for hypercalcemia?

Answer 15

Treat if >3.5 or >3 with symptoms
1. IVF
2. Lasix only if fluid overloaded
3. Monitor other lytes, don’t give PO4

1. Bisphosphonates - usually if malignant, zolendronic acid vs. pamidronate
2. Calcitonin - only if severe
3. Denosumab - if severe and not responding to bisphosphonate
4. Steroids - only if granulomatous or lymphoma
5. Dialysis - if anuric and severe

Question 16

What is long term therapy for hypercalcemia?

Answer 16

Depends on the cause
Primary hyperPTH
- Surgery if meets criteria
Tertiary hyperPTH
- Vit D analogues
- Calcimimetics
- Surgery
Malignancy
- Bisphosphonate or denosumab if refractory

Question 17

What is the lab indication for treating hypercalcemia?

Answer 17

> 3 with symptoms
3.5 without symptoms