Endocrinology Flashcards
This is a condition caused by anything that compresses or damages the pituitary gland.
Panhypopituitarism
This patient has decreased FSH and LH from decreased GnRH, Anosmia, and renal agenesis. What is the most likely diagnosis?
Kallman Syndrome
What findings would you appreciate in an adult with growth deficiency?
Central obesity
Increased LDL and Cholesterol levels
Reduced lean muscle mass
How would you go about with the treatment of Panhypopituitarism?
Replace deficient hormone with: Cortisone Thyroxine Testosterone and estrogen Recombinant human growth hormone
How would you differentiate Central Diabetes Insipidus from Nephrogenic Diabetes Insipidus?
Central DI - decrease in amount of ADH from pituitary
Nephrogenic DI - decrease in ADH effect on kidney
How will DI present?
Extreme high-volume urine with excessive thirst resulting in volume depletion and hypernatremia
How do you diagnose DI?
Vasopressin (Desmopressin) Stimulation Test
What will be the result of Central DI and Nephrogenic DI in vasopressin test?
Central DI - urine volume will decrease and urine osmolality will increase
Nephrogenic DI - no effect on urine volume and osmolality
How would you treat Central DI?
Long term Vasopressin (Desmopressin) use
How would you treat Nephrogenic DI?
Correct underlying casue (hypokalemia or hypercalcemia)
Hydrochlorthiazide, Amiloride, Prostaglandin Inhibitors such as Indomethacin
This is defined as the overproduction of growth hormone leading to soft tissue overgrowth throughout the body
Acromegaly
This is almost always the cause of Acromegaly
Pituitary Adenoma
Patient came in with complaints of increased shoe size, body odor, pain in flexion of wrist, joint pains. Upon inspection you noticed coarse facial features, deep voice, large tongue, skin tags. What is the most likely diagnosis?
Acromegaly
What will laboratory test show in a patient with Acromegaly?
Glucose intolerance and Hyperlipidemia
What is the best initial test for Acromegaly?
Insulinlike growth factor (IGF-1_
What is the most accurate test for Acromegaly?
Glucose Suppression test
What is the most accurate test for Acromegaly?
Glucose Suppression test
*Normally, glucose should suppress growth hormone levels
What are your treatment considerations for Acromegaly?
Surgery: Transphenoidal resection
Medical: Carbegoline (Dopamine will inhibit GH release), Octreotide or Lanreotide (Somatostatin inhibits GH release), Pegvisomant (GH receptor antagonist, inhibits IGF release from liver)
Radiotherapy: for those who do not respond with surgery/medications
This is the ONLY calcium blocker that raises Prolactin levels.
Verapamil
What inhibits prolactin release?
Dopamine
Give examples of drugs that increases prolactin levels
Antipsychotic medications Methyldopa Metoclopramide Opiods Tricyclic Antidepressants Verapamil
You measured the prolactin level of a patient. After finding it to be high, what should you perform?
Thyroid function tests
Pregnancy test
BUN/Crea (Kidney disease elevates prolactin)
Liver function tests (Cirrhosis elevates prolactin)
What are your treatment options for Hyperprolactinemia?
Dopamine agonists: Cabergoline is better tolerated than Bromocriptine
Transphenoidal surgery for those not responding in medication
What are the 2 occasional cause of hypothyroidism?
Dietary deficiency of iodine
Amidarone
Hypothyroidism is characterized by almost all bodily processes being slowed down–except for _____, which is increased.
Menstrual flow
What diagnostic test will you order to determine who needs thyroid replacement when T4 is normal and TSH is high.
Antithyroid peroxidase antibodies
What is the best initial test for all thyroid diseases?
TSH
How would you treat Hypothyroidism?
Replace hormones by thyroxine (synthroid) is sufficient
All forms of hyperthyroidism have an elevated _______.
T4 level.
In a patient with an elevated T4 level and high TSH level, what will you suspect?
Pituitary Adenoma
Only Graves disease has _________.
TSH receptor antibodies
What is the best initial therapy for Graves Ophthalmopathy?
Steroids
Patient has low TSH, elevated RAIU with positive antibody testing. What is the most likely diagnosis?
Graves disease
Patient has low TSH, decreased RAIU, and tender to touch. What is the most likely diagnosis?
Subacute Thyroiditis
Patient has low TSH, decreased RAIU, and no other symptoms. What is the most likely diagnosis?
Painless “silent” thyroiditis
Patient has low TSH, decreased RAIU, and there is an history of thyroid hormone intake and involuted, nonpalpable gland. What is the most likely diagnosis?
Exogenous thyroid hormone use
Patient has high TSH, and positive MRI findings in the pituitary. What is the most likely diagnosis?
Pituitary Adenoma
How would you treat Graves disease?
Radioactive iodine
How would you treat Subacute Thyroiditis?
Aspirin
Give treatment options for Acute Hyperthyroidism and Thyroid Storm?
Propanolol Methimazole and Propylthouracil Iopanoic acid and Ipodate Steroids (Hydrocortisone) Radioactive iodine
A 46-year-old woman comes to the office because of a small mass she found on palpation of her own thyroid. A small nodule is found in the thyroid. There is no tenderness. She is otherwise asymptomatic and uses no medications.
What is the most appropriate net step in management of this patient?
a. Fine-needle aspiration
b. Radionuclide iodine uptake scan
c. T4 and TSH levels
d. Thyroid ultrasound
e. Surgical removal (excisional biopsy)
C. If the patient has a hyperfunctioning the gland, the patient does not need immediate biopsy
This is the mainstay of thyroid nodule management
Needle biopsy
What is the cut-off size of a thyroid nodule that must be biopsied by a fine-needle aspirate if there is normal thyroid function (T4/TSH).
> 1.5cm
A 46-year-old woman with a thyroid nodule is found to have a normal thyroid function testing. The fine-needle aspirate comes back as “indeterminant for follicular adenoma.”
What is the most appropriate next step in the management of this patient?
a. Neck CT
b. Surgical removal (excisional biopsy)
c. Ultrasound
d. Calcitonin levels
B. A follicular adenoma is a histologic reading that cannot exclude cancer. The only way to exclude thyroid malignancy is to remove the entire nodule. This is an indeterminant finding on fine-needle aspiration. A sonogram cannot exclude cancer. Calcitonin levels are useful if the biopsy shows medullary carcinoma.
What is the most common cause of hypercalcemia?
Primary Hyperparathyroidism
A patient came in with symptoms of confusion, stupor, lethargy, and constipation. What electrolyte imbalance is most probably present in the patient?
Hypercalcemia
What cardiovascular findings will you find in a patient with Hypercalcemia?
Short QT
Hypertension
What bone lesion is associated with Hypercalcemia?
Osteoporosis
What renal conditions are associated with Hypercalcemia?
Nephrolitiasis
Diabetes insipidus
Renal insufficiency
How would you treat acute hypercalcemia?
- Saline hydration at high volume
2. Biphosphonates: Pamidronate, Zoledronic acid
A 75-year-old man with a history of malignancy is admitted with lethargy, confusion, and abdominal pain. He is found to have a markedly elevated calcium level. After 3 liters of normal saline and pamidronate, his calcium level is still markedly elevated the following day.
What is the most appropriate next step in management?
a. Calcitonin
b. Zoledronic acid
c. Plicamycin
d. Gallium
e. Dialysis
f. Cinacalcet
A.
Calcitonin inhibits osteoclasts. The onset of action of calcitonin is very rapid, and it wears off rapidly. Bisphosphonates take several days to work. Plicamycin and gallium are older therapies for hypercalcemia that no longer have any place in management. When they are given as choices for therapy, plicamycin and gallium are always wrong. Zolendronic acid is a bisphophonate and does not add anything to the use of pamidronate. Cinacalcet is an inhibitor of PTH release. If the hypercalcemia is from malignancy, PTH should already be maximally suppressed. Dialysis would be used only for those in renal failure.
What is the standard of care for patients with Hyperparathyroidism?
Surgical removal of the involved parathyroid glands
For patients with parathyroidism where you cannot perform surgery, what would you give?
Cinicalcet - inhibits release of PTH
Give the indications for surgical removal of parathyroids.
Bone disease
Renal involvement
Age under 50 years
Calcium level consistently 1 point above normal
This is most often a complication of prior neck surgery such as thyroidectomy.
Primary hypoparathyroidism
This electrolytes is necessary for PTH to be released from the gland.
Magnesium
Low levels of this electrolyte leads to increased urinary loss of Calcium.
Magnesium
Patient came in with Chovestek sign, carpopedal spasm, perioral numbness, mental irritability, seizures, and tetany. What electrolyte imbalance does he have?
Hypocalcemia
What will you see in an EKG of a patient with hypocalcemia?
Prolonged QT
How would you treat Hypocalcemia?
Replace calcium and activated Vitamin D
This is defined as pituitary overproduction of ACTH.
Cushing disease
What is the best initial test for the presence of hypercotisolism?
24-hour urine cortisol
What is the best initial test to determine the source or location of hypercortilosim?
ACTH testing
Low ACTH mean than hypercortisolism’s source is?
Adrenal
Elevated ACTH mean that the hypercortisolism’s source is from?
Pituitary or ectopic production (lung cancer, carcinoid)
What are the effects of hypercortisolism?
Hyperglycemia Hyperlipidemia Hypokalemia Metabolic alkalosis Leukocytosis
Aside from 24-hour urine cortisol, what else can you do to diagnose Hypercortisolism?
Late-night salivary cortisol
*If normal, excludes hypercotisolism
This is a somatostatin analog that can be used if surgery was not successful for hypercortisolism.
Pasireotide
You found an incidental mass on adrenal scan. Patient is asymptomatic. What should you do?
Metanephrines of blood or urine to exclude pheochromocytoma
Renin and aldosterone levels to exclude hyperaldosteronism
1 mg overnight dexamethason suppresion test
This is also called chronic hypoadrenalism
Addison disease
What is the most common cause of Addison disease
Autoimmune destruction of the gland
What electrolyte imbalance will you expect in acute and chronic presentation of Addison disease?
Hyponatremia and Hyperkalemia
This is the most specific test of adrenal function.
Cosyntropin Stimulation Test
(You measure the cortison level before and after the administration of cosyntropin. In a patient whose health is otherwise normal, there should be a rise in cortisol level after giving cosyntropin)
You suspect the patient to have Addison Disease. You did an Cosyntropin Stimulation Test and there is no rise in cortisol levels. Further tests revealed High ACTH and Low Aldosterone. What is your diagnosis?
Primary adrenal insufficiency
You suspect the patient to have Addison Disease. You did an Cosyntropin Stimulation Test and there is no rise in cortisol levels. Further tests revealed Low ACTH and high Aldosterone. What is your diagnosis?
Secondary adrenal insufficiency; Adrenal atrophy from pituitary insufficiency
This is a symptom that develops over a long period of time in a patient with chronic adrenal insufficiency.
Hyperpigmentation
How would you treat Addison disease?
- Replace steroids with hydrocortisone
- Fludrocortisone is a steroid hormone that is particularly high in mineralocorticoid or aldosterone-like effect. Fludrocortisone is most useful if the patient has evidence of postural instability. Mineralocorticoid supplements should be used in primary adrenal insufficiency when the patient is on oral steroids such as cortisone.
TREATMENT is more important than testing in acute renal crisis
A patient is brought to the emergency department after a motor vehicle accident in which he sustains severe abdominal trauma. On the second hospital day, the patient becomes markedly hypotensive without evidence of bleeding. There is fever, a high eosinophil count, hyperkalemia, hyponatremia, and hypoglycemia.
What is the most appropriate next step in management?
a. CT scan of the adrenals
b. Draw cortisol level and administer hydrocortisone
c. Cosyntropin stimulation testing
d. ACTH level
e. Dexamethasone suppression testing
B. In a patient with suspected acute adrenal insufficiency
Patient presents with high blood pressure associated with hypokalemia. What is the most likely diagnosis?
Primary aldosteronism
Secondary Hypertension in Primary Hyperaldosteronism are most likely in those whose onset:
- is under age 30 or above 60
2. is not controlled by 3 antihypertensive medications
What is the best initial test for Primary Hyperaldosteronism?
Plasma Aldosterone : Plasma Renin (>20:1)
*an elevated plasma renin excludes primary hyperaldosteronism
What is the most accurate test to confirm the presence of unilateral adenoma in a patient with Primary Hyperaldosteronism?
Get a sample of the venous blood draining the adrenal. It will show a high aldosterone level.
Biochemical test results you would expect in a patient with Primary Hyperaldosteronism?
Low potassium
High aldosterone despote a high-salt diet
Low plasma renin level
Aldosterone-to-renin ratio >20:1 and aldosterone >15
How would you treat Unilateral adrenal adenoma?
Resect by laparoscopy
How would you treat Bilateral adrenal hyperplasia?
Eplerenone or
Spironolactone
This is a nonmalignant lesion of the adrenal medulla autonomously overproducing catecholamines despite a high blood pressure.
Pheochromocytoma
Patient came in with episodic hypertension, headache, sweating, and palpitations and tremor. What is the most likely diagnosis?
Pheochromocytoma
What is the best initial test for Pheochromocytoma?
check the levels of free metanephrines in plasma
What is the confirmatory test for Pheochromocytoma?
24-hour urine collection for metanephrines
This is a nuclear isotope scan that detects the location of pheochromocytoma that originates outside the adrenal gland.
MIBG scanning
This is an alpha blocker that is the best initial therapy of pheochromocytoma
Phenoxybenzamine
- Use Calcium blockers and beta blockers afterwards
- Surgery/ Laparoscopy to remove Pheochromocytoma
What is the definition of Diabetes Mellitus?
persistently high fasting glucose levels greater than 125 on at least 2 separate occasions;
single glucose level above 200 mg/dL with polyphagia, polydipsia, polyuria
increased glucose level on oral glucose tolerance testing
This is a diagnostic criterion for DM and is the the best test to follow response to therapy over the last several months
Hemoglobin A1C > 6.5%
What is the best initial drug therapy for DM?
Oral Metformin
This drug is contraindicated in those with renal dysfunction because it can accumulate and cause metabolic acidosis.
Metformin
This is a group of drugs that block the metabolism of incretins (GIP and GLP).
DPP-IV inhibitors (Sitagliptin, Saxagliptin, Linagliptin, Alogliptin)
Give the functions of GIP and GLP (incretins).
increase insulin and decrease glucagon release from the pancreas
These is a group of drugs that slow gastrointestinal motility and decrease weight. They are generally not given before DPP -IV inhibitors.
Incretin mimetics (exenatide, liraglutide, albiglutide, dulaglutide)
This group of drug is contraindicated in CHF because they increase fluid overload.
Thiazoladinediones
This group of drugs are added when 2 or 3 other oral hypoglycemic medications have not been effective. They inhibit the reabsorption of glucose in the proximal convoluted tubule after it has been filtered.
SGLT2 inhibtors (empagliflozin, dapagliflozin, canagliflozin)
What is the adverse effect of SGLT2 inhibitors?
Inc. the likelihood of urinary tract infections and fungal vaginitis
This drugs are stimulators of insulin release in a similar manner to sulfonylureas, but do not contain sulfa. They do not add any therapeutic benefit to sulfonylureas.
Nateglinide and Repaglinide
This group of drugs are agents that block glucose absorption in the bowel. They add half a point decrease in HgA1C. They cause flatus, diarrhea, and abdominal pain. They can be used with renal insufficiency,
Alpha glucosidase inhibitors (acarbose, miglitol)
This is an analog of a protein called Amylin that is secreted normally with insulin. Amylin decreases gastric emptying, decreases glucagon levels, and decrease appetite.
Pramlintide
What will you expect in the potassium level in a patient with Diabetic Ketoacidosis?
Hyperkalemia in blood but
decrease total body potassium because of urinary spillage
What acid-base imbalance will you expect in a patient with DKA?
Metabolic acidosis with increased anion gap
How would you treat DKA?
Large volume saline and insulin replacement
A 57-year old man is admitted to the ICU with altered mental status, hyperventilation, and a markedly elevated glucose level.
Which of the following is the most accurate measure of the severity of his condition?
a. Glucose level
b. Serum bicarbonate
c. Urine ketones
d. Blood ketones
e. pH level on blood gas
B. If the serum bicarbonate is low, the patient is at risk of death. If it is high, it does not matter how high the glucose level is, in terms of severity. Serum bicarbonate level is a way of saying ‘anion gap’. If the bicarbonate level is low, the anion gap is increased.
DM patients should receive this vaccine.
Pneumococcal vaccine
What medication will you give as maintenance for DM patients with BP greater than 140/90 and urine tests positive for microalbuminuria?
ACEI or ARBs
What medication will you give as maintenance if the LDL of DM patients is above 100 mg/dL?
Statin medications
This medication is used regularly in all diabetic patients above the age of 30.
Aspirin
What can you give for Severe Retinopathy in DM?
VEGF inhibitors (Bevacizumab)
How would you treat Proliferative DM Retinopathy?
Laser Photocoagulation
How would you treat neuropathic pain in DM?
Pregabalin, Gabapentin, or Tricyclic Antidepressants
This is the most common cause of oligomenorrhea.
Polycystic Ovary Syndrome (PCOS)
Give the criteria to diagnose PCOS.
- Clinical hirsutism and/or high testosterone/DHEA
- Irregular menstruation
- 10 cysts on pelvic sonogram with enlarged ovary (>10 cm)
2 out of 3 needed to diagnose PCOS
What can you give a patient with PCOS suffering from irregular menstruation?
Oral contraceptive containing progesterone
