Endocrinology

Question 1

The majority of patients with _________ are asymptomatic. Recurrent nephrolithiasis may be one of the presentations.

Answer 1

Hyperparathyroidism

Question 2

Measurement of parathyroid levels would be the initial laboratory test for the evaluation of _______.

Answer 2

Hypercalcemia

Question 3

_______ is the recommended treatment for overactive thyroid tissue in patients without risk for subsequent thyroid cancer, leukemia, or other malignancies.

Answer 3

Radioactive iodine

Question 4

What is the best initial step for the examination of a palpable thyroid nodule?

Answer 4

Ultrasound is the best initial step for evaluation of a palpable thyroid nodule. Microcalcifications, hypoechogenicity, a solid nodule, irregular nodule margins, chaotic intranodular vasculature, and a nodule that is more tall than wide are poor prognostic indicators. The combination of fine needle aspiration and radioisotope scanning of a solitary thyroid nodule provides the best diagnostic yield. Because cold nodules may be cancerous, they are generally referred for surgical removal.

Question 5

While awaiting operative removal of pheochromocytoma, which of the following classes of medications are used for control of hypertension?

Answer 5

Alpha-adrenergic blockers are used preoperatively to control hypertension in a patient with pheochromocytoma that occurs from unopposed alpha stimulation when the tumor is manipulated.

Question 6

2 key RFs for thyroid nodules are:

Answer 6

1. Extremes of age (very young, >60)

2. History of head/neck irradiation

Question 7

Most thyroid nodules found in _____ are benign. Most thyroid nodules found in _____ and _____ are malignant.

Answer 7

Women- benign (follicular adenoma or cysts)

Men and children- malignant

• Only 10% are malignant
• *Papillary cancer most common in women

Question 8

What are the S&S of thyroid nodules?

Answer 8

1. Most are ASYMPTOMATIC

2. Compressive sx- trouble swallowing, neck/jaw/ear pain, hoarseness

Question 9

PE findgins for thyroid nodules include:

Answer 9

1. Malignant- rapid growth, fixed in place, no movement with swallowing
2. Benign- varies

Thyroid function tests- most patients are euthyroid

Question 10

What is the best initial test to evaluate a thyroid nodule?

Answer 10

FNA with biopsy

Question 11

What is the most common type of thyroid nodule?

Answer 11

Follicular adenoma (50-60%)- >90% of nodules are benign

Question 12

When do you decide to do a radioactive iodine uptake scan?

Answer 12

• Usually performed if FNA is indeterminate

- Cold nodules (no/low iodine uptake) are highly suspicious for malignancy!!

Question 13

____ is used to obtain a specimen during a FNA. It also helps the provider monitor a suspicious nodule or to see if a nodule is growing or shrinking.

Answer 13

High resolution US

Question 14

How are thyroid nodules treated and managed?

Answer 14

1. Surgery- if thyroid cancer is suspected or if an indeterminate FNA with a cold thyroid scan
2. Observation- usually every 6-12 months with US

Question 15

Papillary and follicular cancers are well differentiated with a _____ (better/worse) prognosis. Anaplastic is poorly differentiated with a (good/poor) prognosis.

Answer 15

Better; poor

Question 16

_____ is the most common type of thyroid cancer.

Answer 16

Papillary

• RF- radiation exposure
• *MC in young females
• **Treatment- total or subtotal thyroidectomy (can be coupled with radioiodine therapy)

Question 17

_____ thyroid cancer is associated with iodine deficiency. It is more aggressive than papillary but also slow growing.

Answer 17

Follicular

• Distant METS common (lung, brain, bone, liver, skin)
• *Excellent prognosis, same treatment options as papillary ca

Question 18

______ is the most aggressive form of thyroid cancer and is MC in men > 65y.

Answer 18

Anaplastic

• Local and distant METS
• *May invade trachea
• **Poor prognosis- most don’t live 1y after dx
• ***Treatment- resection, chemotherapy, palliative tracheostomy in 20% to maintain airway

Question 19

_______ exhibits an excess of PTH production.

Answer 19

Primary Hyperparathyroidism

• MC type!!
• *Parathyroid adenoma is MC cause
• **Occurs in 20% of patients taking lithium

Question 20

_______ exhibits an excess of PTH due to hypocalcemia or Vitamin D deficiency.

Answer 20

Secondary Hyperparathyroidism

Question 21

_____ is the MC cause of secondary hyperparathyroidism

Answer 21

Chronic kidney failure (kidneys convert Vitamin D to its usable form)

*Also severe calcium and vitamin D deficiency

Question 22

Clinical manifestations of hyperparathyroidism include:

Answer 22

Signs of HYPERcalcemia and decreased DTRs

Question 23

Triad of Hyperparathyroidism is:

Answer 23

1. Hypercalcemia
2. Intact PTH
3. Decreased phosphate

Question 24

What would you find on a bone scan of a patient with hyperparathyroidism?

Answer 24

Osteopenia

*May have a parathyroid adenoma

Question 25

How is hyperparathyroidism treated?

Answer 25

1. Surgery- parathyroidectomy | 2. Vit D/Ca2+ supplementation if secondary. Treat hypercalcemia if symptomatic with IV fluids and Lasix

Question 26

Adrenal cancer's age distribution

Answer 26

Bimodal- peaks before 5y and in the 4th & 5th decades of life Women > Men

Question 27

Pathophysiology of Adrenal Cancer....

Answer 27

Rare, often aggressive tumors that may be functional and cause Cushing's Syndrome and/or virilization or nonfunctional and present as an abdominal mass or an incidental finding

Question 28

Glucocorticoid excess may lead to:

Answer 28

Weight gain, weakness, insomnia, usually develops rapidly (over 3-6mos)

Question 29

How is adrenal cancer diagnosed?

Answer 29

CT initially- larger size, irregular borders, calcifications, invasion of surrounding structures or lymph node enlargement - MRI * FNA CANNOT distinguish between a benign adrenal mass and an adrenal carcinoma. It can distinguish between an adrenal tumor and a metastatic tumor

Question 30

How is adrenal cancer treated?

Answer 30

Surgery- complete resection (hormonal assessment to be performed first) +/- chemo

Question 31

What is Pheochromocytoma?

Answer 31

CATECHOLAMINE-SECRETING RENAL/ADRENAL TUMOR *Secretes norepinephrine and epinephrine autonomously and intermittently (triggers include surgery, stress, exercise, pregnancy, meds- TCA, opiates, Metoclopramide, glucagon, histamine) **90% are benign!

Question 32

What are the S&S of pheochromocytoma?

Answer 32

HTN most consistent finding! PHE--> Palpitations, HA, Excessive sweating

Question 33

How is pheochromocytoma diagnosed?

Answer 33

1. Increase in 24hr urinary catecholamines including metabolites (increase in metanephrine and vanillylmandelic acid) 2. MRI or CT can visualize the tumor 3. Labs--> hyperglycemia and hypokalemia

Question 34

Treatment of pheochromocytoma involves:

Answer 34

Complete adrenalectomy: - Preoperative nonselective A-BLOCKADE: PHENOXYBENZAMINE PHENTOLAMINE x 7-14 days followed by beta blockers to control HTN - DO NOT initiate therapy with beta blockade to prevent unopposed a-constriction during catecholamine release triggered by surgery or spontaneously, which could lead to life-threatening HTN