Endocrinology Flashcards
What is the treatment for a prolactinoma?
Cabergoline (dopamie agonist) and if refractory to medidcal treatment sphenoidal surgery
Female patients with a history of galactorrhea should have what labs checked?
Bhcg, prolactin, TSH (hypothyroidism), and review of medication history
What is the work up for a patient with acromegaly?
IGF-1, then a glucose suppression test (which in a normal patient would supress GH), then an MRI to visualize the tumor.
(True/False) In a patient with acromegaly medical treatment is sufficent intervention?
False, the mass should be resected
A benign tumor, derived from embryonic tissue which occurs most commonly in children but can present in any age group. The patient may complain of symptoms like headache and visual deficits.
Craniopharyngioma
Patient with hx of severe postpartum bleeding now presents with inability to lactate.
Sheehan
What measurement tells you the difference between central diabetes insipidus and peripheral diabetes insipidus?
There is more than a 50% increase in urine osmolarity in patients with central diabetes insipidus after ADH administration.
What is the treatment for patients with nephrogenic diabetes insipidus ?
HCTZ
If a patient with bipolar disorder with condition well managed with lithium has nephrogenic diabetes insipidus what is the alternative drug treatment?
Amiloride
If the urine osmolarity of Na in patient with true hyponatremia is <20 what are the potential causes for hyponatremia?
Extra-renal, GI distrubrance, skin losses
If the urine osmolarity of Na in patient with true hyponatremia is >20 what are the potential causes for hyponatremia?
Renal loss
If the urine osmolarity is >300 in a patient with true hyponatremia what is the possible cause for hyponatremia?
SIADH
If the urine osmolarity is <300 in a patient with true hyponatremia what is the possible cause for hyponatremia?
Primary poldypsia or a tea and toast diet.
What is the first step in diagnosis of a patient with hypercalcemia?
Get the PTH
What is the complication of correcting hyponatremia too quickly?
The increase in serum solute too quickly will cause fluid to leave the tissue causing pontine myelinosis
What is the complication of correcting hypernatremia too quickly.
CNS edema
What is the proper correction for hyponantremia?
It is recommended that serum sodium levels in affected individuals be raised at a rate of 0.5–1 mEq/L per hour until a total sodium correction of 4 to 6 mEq/L has been achieved in 24 hours.
What does pontine myelinosis present like?
Symptoms of ODS appear 2–6 days after correction of hyponatremia and include an altered level of consciousness (e.g., coma), locked-in syndrome, signs of cranial nerve dysfunction (e.g., dysarthria, dysphagia, diplopia), and/or worsening quadriparesis.
What is the cause of hypercalcemia in a patient that presents to your clinic with high calcium, high phosphorus, high vitamin D, and low PTH ?
Since we already know there is excess production of vitamin D we have to think about what pathologies cause increase in vitamin D. Granulomatis diseases are a primary example.
A patient presents with labs that show high calcium, low PTH, low phosphorous, and normal vitamin D, what is the cause for their hypercalcemia?
Think of a paraneoplastic syndrome like PTH related peptide from SCC
How do we diagnose between familial hypocalcuric hypercalcemia and primary hyperparathyroidism?
If 24-hour urinary calcium is low, the dx is Familial hypocalciuric hypercalcemia. Nomrally high calcium, via calcium-sensing receptors should generally decrease PTH secretion from parathyroid glands.
A patient presents with low calcium, low PTH, high phosphorus, and normal vitamin D what is the cause of hypoclacemia?
Hypoparathyroidism (can be due to DiGeorge, parathyroidectomy, thyroidectomy)
A patient presents with low calcium, high PTH, high phosphorus, and low vitamin D. What is the cause of hypocalcemia?
Renal failure
A patient with low calcium, high PTH, low phosphorus, and low vitamin D. What is the reason for hypocalcemia?
Ricketts or osteomalcia
Why do patients with recent blood transfusions have hypocalcemia?
Citrate (a negatively charged ion), which is used as an anticoagulant in blood bags, binds with free Ca2+ causing hypocalcemia
Why would a patient with respiratory alkalosis have lower levels of free calcium?
Because Ca2+ in attempt to reduce the basicity will bind to albumin.
How does hypomagnesemia affect PTH?
it inhibits PTH secretion
How does K+, Mg+, and Ca, change the QT?
If the electrolytes are high the QT interval will be shortened and if the electrolytes are low than the QT will be prolonged.
Grave’s disease is positive for what anti-body?
TSH receptor anti-body
What is exopthalmos?
We typically see exophthalmos as a complication to graves disease due to retro-orbital tissue deposition.
What is the most common arrythmia in Grave’s disease?
A fib
What is the intial step in evaluation of a patient with hyper/hypothyroid symptoms?
Always get a TSH first, then get a free T4 and T3 if the TSH is abnormal. Then you follow up with RAIU
A patient has a low TSH level elevated T3 and T4 what is the next best step in management?
This patient likely has hyperthyroidism to further investigate we would need to do a radioactive iodine uptake scan (RAIU).
A patient has a high TSH and high T3 and T4 what is the dx and what is the next step in management?
Check an MRI because this patient likely has a tumor at the level of the pituitary gland or the thalamus.
How do you determine if a patient has facticious hyperthyroidism?
Check the thyroglobulin. Remember that C-peptide = thyroglobulin. If your body is making insulin you also making C-peptide likewise if your making thyroid hormone your making thyroglobulin.
What is a side affect of using methimazole or propothiouracil have?
esophagitis and agranulocytosis
A 34 year old with a history of hyperthyroidism presents to your office with a resting heart rate of 200 bpm irregular rhythm, severely short of breath. What is the acute treatment for this patient?
For patients experiencing thyroid storms start with a beta blocker and then use propoylthiouracil (because it block the conversion of T4 –> T3 also)
What are symptoms that develop due to hypothyroidism?
ABCDE; Amenorrhea, bradyarrythmia, constipation, depression, and Edema
A mom presents with her baby that is one month old. The mother has concerns that her baby seems to have sunken fontanelles, yellowing of the skin and distorted facies. Which hormone should you check for?
TSH
What is the test we use for diagnosis of adrenal insufficiency
cosyntropin test
A patient with primary adrenal insufficiency will respond to co-syntropin test (true/false)
False, in primary adrenal insufficiency it will not respond
What is a myxedema coma?
The most severe form of hypothyroidism usually precipitated by stress, trauma, or burns
What are the antibodies for Hashimoto’s?
Anti-thyroid peroxidase (anti-microsomal antibody) and anthi-thyroglobulin antibodies
What is the most common complication of hypothyroidism?
Hodgkins lymphoma
a dermoid cyst that can cause hyperthyroid state
struma ovarii
What is the work up for a patient with a thyroid nodule?
Like hypo/hyperthyroid symptoms first start by getting the TSH and ultrasound . If the TSH is low then get RAIU. If the TSH is normal to high then do a fine needle aspiration.
What type of thyroid nodules tend to be concerning for malignancy?
The cold nodules
If a thyroid nodule has a macrofollicular pattern what is the NSIM?
follow up with periodic ultrasound
If a thyroid nodule has a microfollicular pattern what is the NSIM?
Do molecular gene testing
If a thyroid nodule comes back as non-diagnostic what is the NSIM?
repeat FNA
what is the most common cause of thyroid malignancy?
Papillary carcinoma
What is the treatment for patients with adrenal insufficiency?
Fludricortisone and hydrocortisone
In a patient with adrenal crisis what is the first step in diagnosis?
obtain the ACTH and cortisol levels.
What is the NSIM of a patient suffering from adrenal crisis?
Fluid, electrolyte, fludricortisone and hydrocortisone replacement
What are the K+ sparing diuretics?
Amiloride, triamtrene, eplereone, and spironolcatone
What is the treatment for hyperkalemia.
Hydrate, calcium gluconate/calcium chloride, beta agonists, insulin + glucose.
True or False: Type 1 diabete is an autoimmune condition that attack the beta cells of the pancreas causing no development of insulin?
True
True or False: Type II diabetes is mainly due to decreased sensitivity to insulin. Can be associated with metabolic syndrome.
True
What are the consequences of chronic elevated glucose levels?
Kidney damage, peripheral neuropathy, vasulopathy, and immunosupression
What are the tests that we can used to diagnose diabetes?
Hba1c >6.5, fasting glucose >126, or random glucose 200
What are lifestyle modifications a patient can introduce into their life if they have diabetes?
Lose weight if they are obese, exercise at least three times a week for thirty minutes, eat a healthy diet
What is the mechanism of action of metformin?
Increase the insulin sensitivity, and inhibit gluconeogenesis
What are the major side affects of metformin?
lactic acidosis
What patient is an absolute contraindication to metformin?
Kidney failure patients
What is the most common cause of chronic kidney disease?
DM
What is the most common underlying disorder for coronary artery disease?
Smoking
What are the test we do for screening of diabetes complications?
albumin; creatinine, serum creatinine
What drugs help slow the affects of diabetes on the kidneys?
ACE or ARB, they do so by dilating the efferent arteriole
What are the criteria in order to diagnose DKA
Glucose are >250, ph <7.3, and HCO is <20
What is the treatment of a patient with DKA?
ABCD’s, fluids, normalize potassium if K+ < 5.2 then correct before giving insulin.
What calculation is most helpful in determining if a patient with DKA is improving?
Anion gap
What are the primary differences between Hyperosmotic hyperosmolar syndrome and DKA?
HHS does not have elevated ketones and the serum osmolarity because of the higher amounts of sugar is usually greater than 320
What are the risk factors for developing thyroid cancer?
Radiation exposure and family history
What is the histopathological finding of papillary carcinoma?
Papillary projections, psammoma bodies, orphan annie eyes
How does follicular cancer metastisize?
via the blood
What are the endocrine tumors of MEN I
AD; parathyroid adenomas , pancreas (insulinoma, glucagonoma), pituitary
Medullary thyroid cancer secretes what endocrine hormones?
Calcitonin
A patient with medullary thyroid cancer would also need to undergo evaluation of what other pathologies?
Parathyroid, pheochromocytoma, gastrointestinal tumors. (aka MEN IIa and MENIIb)
What are the endocrine tumors of MEN IIa
Parathyroid, medullary thyroid cancer, and pheochromcytoma
What are the labs that you should often check in MEN I
Calclium and PTH
What are the endocrine tumors associtated with MEN IIb
Medullary thyroid cancer, pheochromocytoma, and gastrointestinal tumors
What labs should you commonly check in MENIIA and MENIIB?
Metanephrines, RET proto-onocogene, and calcium
What is the most common cause of cushing syndrome?
Exogenous administration of steroids
What are the arrows for primary cushing disease? Cortisol, ACTH, CRH
High ACTH, high cortisol, and low CRH
What are the arrows in cushing disease? Cortisol, CRH, ACTH
High cortisol, low CRH, and high ACTH
What are the arrows for tertiary hypercorticolism? cortisol, CRH, ACTH
High everything
What test do we use to confirm a hypercortisol disorder?
Either a 24hr urine cortisol, salivary cortisol, serum cortisol or a dexamethasone suppression test
How can a dexamethasome supression test differentiate primary, secondary, and tertiary hypercortisolism?
The first dose of dexamethasone should supress cortisol overproduction at the level of the adrenal, if cortisol levels are still high check ACTH. If ACTH is high then that’s an indication that the pituitary gland is making excess ATCH. If you do a higher dose of dexamethasone this should stop hypercorticolism if not then suspect a tertiary source.
Would a person with Conn’s syndrome have an increased plasma renin level?
No, because they are already reutaking water that the RAAS system no longer has to be engaged.
If the aldosterone to renin ratio is > ___ then the diagnosis is most likely Conn’s syndrome.
> 20
What is the next step in management if the aldosterone to renin ratio is >20?
Aldosterone suppression test
Why is spironolactone not the drug of choice for a patient with Conn’s syndrome?
Because it can cause gynecomastia because it cross reacts with androgen receptors.
What other neuroendocrine disorders are associated with pheochromocytoma?
Von hippel lindau, NF, MENIIa, and MENIIb
What is the classic triad for pheochromocytoma?
episodic HTN, headache, sweating, palpitations
What happens to bicarbonate in patients with Conn’s disease?
metabolic alkalosis
MCC of adrenal insufficiency
abrupt cessation of chronic steroids, this is because chronic steroid use inhibits the hypothalamic axis
Why do patients with Addison’s disease have hyponatremia?
Because ADH is trying to help retain as much volume as possible but its solute deplete
What are clues to help you identify a patient with primary adrenal insufficiency?
low blood pressure, hypoglycemia, and eosinophilia, hyperkalemia, weight loss, and hyperpigmentation.
What are the causes of hypoglycemia?
EXPLAIN; Exogenous insulin, pancreatitis, liver failure, adrenal insufficiency, alcohol, insulinoma, and neoplasias.
A person with diabetes wants to do a triathlon. What is your advice for his insulin taking regimen?
Because the muscle readily takes up glucose during exercise less insulin is required. So I would tell this patient to lower there long acting and short acting dose.
In primary hyperthyroidism what are the TSH, T3, T4 levels like?
TSH is low, T3 high and T4 high
Normal TSH value?
0.4 - 4.0
T4
5-12
What bone pathology is associated with malabsorbative disorders?
Osteomalacia; this disease usually occurs due to the lack of reabsorption of Vitamin .
Free T4
0.9 - 1.7
What does calcium, PTH, phosphorus, and Vitmain D look like in a patient with osteomalcia?
Ca (low to normal)
PTH (High)
PO34 (extremely low)
Vitamin D (Low)
What is the treatment for this patient?
may also see cortical thinning, pseudo-fractures, and concave vertebral bodies
cosyntropin is an analouge like?
ACTH
What are tell tell signs that you are dealing with primary adrenal insufficiency?
darkening in the color of the skin, salt cravings.
What is the difference between cushings disease and cushings syndrome?
Cushing syndrome is hypersecretion of cortisol from the adrenal glands, whereas cushing disease is overproduction of cortisol due to increased ACTH production but the pituitary gland.
How often do we check a persons A1C with diabetes?
every 3-6 months
What are the screening tests that need to be done every year for a diabetic patient?
albumin; creatinine, eye examination, foot examination,
What are risk factors that contribute to osteoporosis?
DXA < -2.5, smoking hx, alcohol history, age >65
Episodic headaches with diaphoresis, heightened emotions, and palpitations are common findings of what form of secondary HTN?
Pheochromocytoma
After confirmed diagnosis of pheochromocytoma what are other important pathologies to look for?
MEN 2, NF-1, VHL-1
Men 1
Pituitary tumors, parathyroid tumors, pancreatic tumors
Men 2A
Pheochromocytoma, parathyroid tumors, and medullary thryroid cancer
Men2B
Medullary thyroid cancer, pheochromocytoma, marfanoid habitus, oral and intestinal ganglioneuramtosis.
What is adrenal insufficency?
Its an autoimmune disease that results in reduced production of hormone from the adrenal medulla.
