Endocrinology Flashcards
1
Q
Hypothalamus
A
Dopamine-> inhib prolactin GNRH->Growth hormone TRH->TSH CRH->ACTH GnRH->FSH/LH Post pit directly releases oxytocin/ADH
2
Q
Screening for Axis fxn
A
Hypoth-Pit-Gonadal-check serum LH/FSH
Hypothal-Pit-Thyroid -> TSH/T4
Hypothal-Pit-Adrenal Axis->ACTH (serum)
3
Q
Most sensitive determinant of pitutiary fxn?
A
FSH/LH level
4
Q
Screening for hormone excess
A
Prolactinoma->prolactin level
Hyperthyroid-<>FTI/T4, TSH
Acromegaly-> IGF-1 (not GH - is pulsatile)
Cushings -> 1mg DMS
5
Q
Pt with MVA - CT head with no bleed but 0.8cm solid mass in pituitary - pt nulliparus, menstation regular wtd?
A
check prolactin, T4/TSH/IGF-1 and 1mg DMS test (all axises)
6
Q
Things that increase prolactin
A
Nipple manipulation Phenothiazines reserpine Mehydopa estrogens marijuana prgenancy hypothyroid
7
Q
Prolactinoma
A
Prolactin >200 - macroadenoma
failure then surgery
8
Q
Middle aged woman wit dec libiddo adn fatigue test low, FSH low
A
check prolactin adn TSH
9
Q
Pt wit galactorreha wtd?
A
check TSH and prolactin
10
Q
Young woman with galactorreha on manipulation of nipple, TSH/prolactin normal
A
avoid manipulation of nipple
11
Q
35yo F with galactorreha and amenorrhea x 6 months - preg neg prolactin 184 TFT normal wtd?
A
MRI r/o stalk tumor
12
Q
Pt post partum continues to have galactorrhea fter finishing nursing baby - TSH 2.8, prolactin 281 takes no meds - dx?
A
prolactinoma - check MRI
13
Q
45yo M c/o fatigue and dec libido - testosterone 18, prolactin 2500 FSH 2.2 cause?
A
prolactinoma
14
Q
Pt with prolactinoma micro or macro - wants to concive
A
start dopamin agonist (bromocryptine - reduce prolactin level and induce ovulation
15
Q
Pt tx’d with bromocryptine for macroadenoma and gets pregnant wtd?
A
d/c bromocryptine
monitor visual fields - only restart if changes
16
Q
Acromegaly
A
inc’ing shoe size, hat size, ring size, hyperglycemia, prominent jaw, wide space between teeth, big tongue, flshey palms soles, osteoarthritis changes on Xray
17
Q
Screening test for acromegaly
A
IGF-1 (somatosatin C) - also to follow dz activity
18
Q
Confirm acromegaly (after IGF-1 screening) with…
A
oral glucose suppression test
failure to suppress GH to <2ng after 100g glucose
19
Q
Tx for Acromegaly
A
Transphenoid surgery
20
Q
Complciations of acromegaly
A
HTN, LVH, CHF, OSA, colonic polyps, carpel Tunnel
21
Q
DM
A
dx FBS>126 - repeat x 1 to confirm
HgA1c>=6.5
Random blood sugar >200 with sx
75g gluc load GTT >200
22
Q
Pt with BP 135/80 or BMI 25 or sedentery lifestyle or >40 wtd?
A
screen for DM (FSG, HgA1c)
23
Q
Pt with DM (FSG >126) at risk for
A
DM and retinopathy, nephropathy
24
Q
DM I vs II
A
check for Ab vs glutamic acid carboxylase, ab to islet cells
25
DM tx
Diet/excercise - 0.4% red A1c
Type I-> insulin
Type II sulfonyureas (hypogly), biguanide (metformin), repaglinide, glitazone, insulin, exenatid(no hypo, incretin (no hypo)
26
Insulin
All Type I DM
Type II not responding to oral hypoglycemics
Type II on oral mes but hospitalized, major surgery, infxn
pregnancy
27
Hospitalized pateint with DM
tx with basal insulin and rapid acting agent
28
Sulfonyureas (glipizide), glyburide, glimeperide
inc'd release insulin form B cells
| avoid in obese pts
29
Meglitnide - repaglinid
inc rel insulin from B cells - excreted in bile ok in renal insufficiency - rapid
30
Biguanides - metformin
dec hepatic gluconeogenesis, dec insulin resistantce, dec weight, TG, chol
bestin obese pts with inc TGA
lactic acidosis
avoid in renal failure
31
A glucosidase inhibitors - acarbose
inhbits breakdown of cardbs, dec absorption of glucose - use for post prandial hyperglycemia
32
Thiazolidinediones (glitazones) - pioglitazone - actos
PPAR rct - inc glucose transport dec insluin resistance dec TGA, inc LDL - avoid in NYHA II HF
33
Incretin mimetics - exenatide GLP1 agonist
dec hep gluconeogenesis, dec gastric emphtying wt loss, early satiety inc'd cell growth
good for obese pt failing metformin +- glit/sulf
watch out for pancreatitis
34
Inretin memetic - DDP4
Sitagliptin (januvia
| s/e nausea
35
Amylin analogue pramlintide
slows gastric emptying dec glucagon secretion, wt loss and early satiety
complementary to insulin, no hypoglycemia
good for obese pt failing insulin therapy with high post prandial BS
36
Which DM meds DO NOT CAUSE WT GAIN?
Metformin, incretin drugs (exenatide and amylin alaog pramlintide
37
Blood sugar goals in DM
A1c<120
38
Pt with BMI 32, FBS 115 fhx DM - best way to prevent DM?
Diet/excercise (aerobics and resistance training
39
Drugs that cause hyperglycemia
Statins, BB, HCTZ, niacin, olanzapine, PI, steroids
40
45yo F dx with Type II DM 4 montsh ago with FBS 170 A1c 8.9 wt 205 started on exc/diet - repeat FBS 165 wtd?
Metformin
41
Pt with DM II and obese not well controlled on sulfonyurea (glipiz,glyburide, glimeperide)
Add metformin
42
What' increases insulin sensitivity
Glitazone
43
Which drug improves mortality and dec early HF in DM pts
Metformin
44
Pt with DM2 responsds well to metformin adn sulfonyrea for years bu tnow with inc BS, no infxn, HgA1c 9 - wtd
add insulin basal - keep only metformin
45
If FBS with just insulin and metformin still 115- 130
start lispro insulin
46
Pt refuses insulin injections wtd
continue metformin add sulfonyurea or glitazone
47
S/E metformin
lactic acidosis
48
When is metformin contraindicated?
Cr >1.4 F>1.5 M and advanced HF (>NYHA II)
49
Pt on multiple meds Cr >1.5, CHF EF 35% wtd?
d/c metformine and glitazone, start glargine for detemir and lispro or aspart
50
Pt going for cardiac cath or radiocontrast study - what drug to stop?
Metformin
51
60yo Pt dx with DMII - Cr 3.7 - what meds to start?
repaglinide (excreted in bile)
52
40yo Pt with DM2 tx'd with metformin - 1 year later gaining wt as he stopped excerciseing BS also up
start exenatide (GLP-1) good for obese pt failing metformin
53
Dawn's Phenomenon - pt wakes up with fatigue, sweating h/a, vivid dreams
inc'd 4-7am gluc 2/2 insulin resistance/hormonal factors
| Tx - inc PM NPM
54
DM pt on NPH/R in AM, supper or glardgine HS
| Palpitations, sweating, nocturnal awakening AM h/a wtd?
check 3am FSG
55
Blood sugar 3am 40
change NPH to HS or swtichto long acting insulin analog (glargine)
56
Persistently ele FBS 3am 200
inc supper NPH or glargine
57
Blood sugar 30 pt passes out at 12noon on 20 U NPH and 5 U R in AM wtd?
D/C "R insulin" in AM
58
FSG 180 5pm
in NPM in AM
59
FSG 4pm 25 and 10pm 210 pt in 36U NPH in AM
Change to 24 U NPH AM and 12U NPH PM
60
All post prandials high, premeals ok on basal bolus regimen
inc dose of pre-meal insulin
61
All pre and post prandials high
inc long acting insulin dose
62
FBG 115 but A1c 7.5 takes NPH/metformin wtd?
check POST prandial blood sugar
63
65yo M DM started on glargine insulin 30U qam with metformin with FSG going steadily up throughout day
change to glargine twice daily
64
Insulin dosing
Mass kg * 0.5u/kg = total daily insulin
1/2 total daily as basal (15 daily)
1/2 total insulin as lispro TID (5 tid) premeal
65
AA M DM f/u FBS 115-130 A1c 11 etiolgoy?
hemoglobinopathy
66
Falsely elevated HgA1c
```
decreased RBC turnover (dec retic)
IDA
Folate/B12 def
Hemoglobinopathies
Sickle cell, thalassemia
```
67
Falsely LOWER HgaA1c
inc'd RC turnover (inc retic)
Hemolytic anemia, HIV
treating IDA, folate
B12 def or blood tx
68
Pt Hg 6.6 - BS ranges between 90-150 except 5pm which is 280 has fresh fuit snake at 4pm etio?
Not washing hands after fruit snack - false elevation of A1c
69
Pt with DM, BS 340, TG 2400 hospitalized with pancreatitis - fastest way to control TG would be to give...
Insulin
70
Pt IDDM with abd pain has DKA, started on insulin gtt 10u?hr, IF BS dec to 250 and IVF changed to D51/2NS and insulin gtt dec'd to 5U/hr - BS now inc'd to 375, AG 19
wtd? - inc insulin gtt
71
How to prevent DKA pt from going back into DKA when turning off insulin gtt -
give SQ insulin 30 min prior to stopping insulin gtt
72
Pt with diabetic ketoacidosis BS 725, ketones +++ started on insulin gtt, ivf 10am - BS 250 at 7pm - wtd?
start IVF D51/2NS, c/w insulin gtt
| Follow with AG if closed then overlap SQ insulin
73
Pt with DM admitted for surgery in AM - on glargine and lispro wtd morning of surgery if pt receives glargine in AM, in PM
Glargine AM schedule: 1/2 dose glargine and NO lispro
| Glargine PM schedule: d/c lispro
74
24yo Preg F 24th wk FBS 115, repeat 114 - wtd?
Metformin (ok in preg)
75
25yo DM pt 24th wk FBS 120, post prandial 180 on glucotrol and metformin wtf?
add insulin
76
Elerly pt DMII brought in with seizure - BS 1050, BUN /cr 50/1.8, ketones + dx?
Hyperosmolar non-ketotic coma -
IVF, insulin
inc 100 gluc, Na dec 1.6 up to 300
>300 inc 100 Gluc dec Na 2.5
77
Type I DM with DKA BS 725, ketones +++ on insulin gtt 10am - 10pm BS 200, ketones neg - bicarb up to 18 from 4, K dropped to 4.5 - pt with difficuulty breathing/muscle wk - +CPK, most likely cuase
hypophosphatemia - insluin drip forces lyesinto cells - no Phos to make ATP
78
Nurse calls you to let you know FBS 62
Asymptomatic - adjust regimen
| Symptomatic with tachycardia - 15gm carbs, if on acarbose then pur glucose (dextrose) and adjust tx regimen
79
Newly Dx DM BG 350 on insulin drops to 130 - becomes tachy adn diaphoretic wtd
keep <200 at first
80
DM complications
Macrovasc - CAD/PAD - aggressive LDL control autonomic
peripher sensory motor polyneuropathy
stock/glove distribution - amitryptyline, desipramine, gabapentin
81
DM Autonic neuroapthy
Impotence - tx with phospodiesterase inhibitor (viagra)
Neurogenic bladder - urinary hesitancy, dribbling, incomplete evacuation - bladder training, bethancol
orthostatic hypotension - fludrocortisone & high salt diet
Gastropareisis - wide fluctuation of BS 50-400mg
Writst/foot drop
DM foot ulcers - common bug S aur, b hem strep
82
Cause of DM foot ulcer
peripheral neuropathy
83
Best way to prevent DM foot ulcer
mon-filament testing - protective footwear
84
Pt with DM 15yr on metformin sulfonyrea/insulin with hypoglycemic attacks post prandial, early satiety, oitting BS 50 to 400 range widely dx?
Gastropareisis (autonomic neuropathy)
Best test - SCscintography of gastric contents
Tx - small frequent meals of liquid/pureed low fat, low in no-digestible fiber - metoclopramide/domeperidone
85
T/F type I DM should have annual eye exam after 5 yers after onset of DM or age 30 whichever first
T
86
T/F Type 2 DM pt shoudl have annual eye exam from onset of dz
T
87
T/F DM pt with difficulty driving at night will prob have ED
T
88
T/F ACCORD trial HgA1cd hypoglycemic events
T
89
T/F ACCORD trial BP <140./80 had more s/e
T
90
Current recommendations for f/u DM pt
HgA1c quarterly, microalb semi ann, lipid panel annual, opthal exam annually
91
Pt with BS 35 taking glipizide, metformin acarbose
admit start IV dextrose
92
22yo F recurrent dizzy attacks in ER, mother DM, blood gluc 35 - next dx test
make sure no surepticous insulin/sulfonyurea use - check urine serum sulfonyurea screen
93
Above pt still hypoglycemic - ampule D50 give, IV dextrose started next step?
glucagon then octreodtide
94
TRH
downreguated by T4, lithium, iodine
95
SICU thyroid
dec T3, normal T4 and TSH
96
best test to screen for thyroid dz
TSH
| confirm with T4, FTI
97
Best test to follow hypothyroid tx
TSH
98
Best test to follow Hyperthyroid tx
FT4 or T3
| Total T4 + T3=T3RIA
99
Thyrotoxicosis
T3 inc->inc T3 RIA
100
Radioiodine uptake
inc'd Hyperthyroid states (graves, hot nodules)
| dec'd thyroiditis (exogenous, amiodarone)
101
Radionuclide scan
differentiate between hot vs cold nodules
102
FNA/bx
cold nodules
103
Ultrasound
diff solid vs cystic
104
Graves dz
inc FT4, inc T3, dec TSH, inc RAI
105
Multinodular goiter
hot nodules - inc FT4, inc T3, dec TSH, inc RAI
106
Toxic nodule
inc FT4, inc T3 ria, dec TSH, inc RAI
107
T3 thyrotoxicosis
n/dec FT4, inc T3 ria, dec TSH, inc RAI
108
TSH adenoma
inc FT4, inc T3RIA, inc TSH, inc RAI
109
Thyroiditis
inc thyroglobulins, inc FT4, inc T3 RIA, dec TSH, inc RAI
110
exogenous T3 (factitious)
dec FT4, inc T3RIA, dec TSH, Dec RAI
111
Exog T4 (factitious)
inc FT4, inc T3 RIA, dec TSH, dec RAI
112
Primary hypothyroid
dec FT4, Dec T3 RIA, inc TSH - RAI n/a
113
Hypopit hypothyroid
dec FT4, dec T3 RIA, dec TSH
114
Pt with wt loss, feels warm in windter, tremors, inc appetite, diarrhea, palpiatins, afib, enlarged thyroid FTI inc, TSH dec wtd?
```
Radioactive uptake study
diffuse - graves
Focal - toxic nodule
uptake - thyroiditis
areas of inc and dec uptake - multinodular goiter
```
115
Pt with hyperthyroid and dec'd radioiodine uptake - how to differentiate thyroititis vs factitous thyrotoxicosis
inc'd thyroglobulin - thyroiditis (and follicular/papillary CA)
dec'd thyroglobulin - factitious thyrotoxicosis
inc'd TBG - estrogen/pegnancy
116
Elderly pt with wk, EKG afbi, TSH dec'd - etiology of afib?
hyperthyroid
117
Elderly pt with apathy, wt loss, arrythmia, CHF, diarrhea, depression, sleepiness, TSH dec, T4 nlow normal T3RU >30%
apathetic thyrotoxicosis
118
Pt with T4 elv, TSH 4.5
MRI brain (no feedback - with high T4 should be low TSH unless there is pituitary tumor secreteing TSH)
119
26yo F si/sx hyperthyroid - started on a new "diet pill recently and has been excercisign - T3 elev, TSH low and RAI uptake low
taking thyroxine in "diet pill"
120
40yo Pt with asympt low tsh
subclinical hyperthyroid - onitor, repeat TSH in 3months - tx only if osteoprosis or CV dz present
121
Tx of thyrotoxicosis (TSHr AB_, anti TPO +
Pregnancy -> 1st trim PTU (SE agranulocytosis, ANCA + ab, MPO+ (1st trimester ONLY)
Others-> radioactive Iodine-> >50% become hypothyroid in 2months
Thyroid ophthalmopathy - subtotal thyroidectomy
122
52yo F a/w PNA - exam pt confused hitting med staff and inattentive - diarrhea and family says lost 15lbs in 6 months - tmep 104, HR 140 rales at bases CXR RLL consodiation - on abx 2 days later hypotensive adn comatosed - dx?
Thyroid storm
Tx: PTU/steroids + BB, digoxin for afib
etio - infxn, surgery, trauma
123
Can you cardiovert afib to NSR in thyroid storm?
No, not till 3 months after euthyroid - spontaneous conversion common
124
Pt with graves d has radioiodine ablation - 8 wks later gained wt, TSH 0.2, free T4 0.2 wtd?
start T4 (hypothyroid)
125
hypothyroid pt started on T4 - 2 months later watery eyes, slceral injection, perioorbital edema, afferent pupillary defiect, painful eye movement - dx?
Thyroid ophthalmopathy with opti cnerve impingenment
| Tx: steroids
126
Pt with thyrotoxicosis and ophthalmopathy - management?
Surgery
127
Thyroiditis
all with dec'd RAI uptake - may present hyper,hypo or euthyroid
Release of preformed hormones - thyrotoxicosis - returns to nromal
Thyroglobulin inc'd....
128
Pt with URI, soreless in neck enlarged tender thyroid, inc'd ESR, inc T3RU, T4 normal - how to get dx?
```
RAI uptake - decreased
subacute thyroiditis - sub acute granulomatous, de Quervain's thyroitis
Tx
Palpitations with tachycardia - BB
Pain - ASA + NSAIDs
DO NOT USE antithyroid drugs
don't need to check for antibodies....
```
129
Young pt with nervousness, insomnia, irritability after uncompicated delvery - is breast feeding, thyroid endalrged, non-tender, TSH low, T4 mildly elevated - dx lyphocytis thyroitis - wtd?
BB only - avoid RAIU during lactation
| Usually transient hyperhtyroid then hypotheyroid then euthyroid after several months
130
Ab most likley to differential graves vs thyroiditis
TSH rct autoab in graves
| Anti TPO + in both, TBG elev in both
131
Young woman 4 months post partum wit huncomplicated couse with wt gain, low enverygy, delayed DTR, amenorrhea - preg neg wtd?
Check TSH, r/o hypothyroid stage or chronic lyphocytic thyroiditis
132
30yo post partum with tremor and depression - T4 high, - reassure her but coems back 1 month later with dpression now fatigue - T4 low, TSH high wtd?
start synthroid, reassure and reepeat TFT in 3 months or less
133
Pt p/w tremor/tachycardia on asa, dig, amiodarone, IFN - T3, T4 high, TSH low, RAI < 5% - etiology?
Amiodarone or alpha interfereron
134
Pt with acute illness intubated and in ICU - episode of hypotension on vasopressors - T4 nl/dec, T3 low, TSH nl/low
SICK euthyroid syndrome
| Tx: tx underlying cause - repeat TSH 2-3 wks after recovery
135
Hypothyroid
cold intolerance constipation, coarsening of feathers, delayed DTR, amenorrhea, elevated prolactin
136
TSH elev, T4 dec
primary hypothyroid
137
TSH dec, T4 dec, rT3 dec
hypopit hypothyroid
138
TSH inc, T4 nl
subclincial hypothyroid
139
Pt p/w fatigue, cold intolerance and delayed DTR - TSH 6, T4 1.2 (normal)
hasimotos thyroiditis - leading cuase of hypothyroid - anti-TPO+
140
28yo F fatigue, wk, difficulty getting up from sitting, pain in hands CPK 200, DTR slow wtd?
check TSH (joint pain, inc CPK, dec DTR)
141
In pt with CAD or elderly start...
low dose synthoid
Start 25mcg and inc 24 q4-6 wks
check TSH if inc/d same inc T4,
If TSH dec - dec T4 dose
142
Pt taking synthroid for hypothyroid T4 nl, T3 nl, TSH high wtd?
inc T4 dose
143
Hypothyroid pt on thyroixin goes on <1wk vac forget meds wtd?
restart T4 upon arrival (t1/2 T4 is 7 days)
144
Hypothyroid pt started on levothyroxine 200mcg - 3 montsh later TSH 2 T4 1.6, Te 6 - pt c/o not losing wt despite diet/exc - BMI elev
continue same dose of T4
145
Pt with refractive arrhythia - resonding to amiodarone - 4 months later with sx of hypothyroid TSH elev, T4 dec wtd?
start synthoid
146
Hashimotos thyroiditis
```
leading cuase of hypothyroid
CPK elevated before sx of hypothyroid
Indications for tx subclinical hypothyroid
inc LDL
anti-thyroid perioxidase Ab (anti TPO)+
```
147
Pt with bipolar dz responsds to leithium fo r>8yrs - past sever montsh wt gain, delayed DTR T4 borderline, TSH inc'd wtd?
start levothyroxine
148
Pt with slightly elev TSH - repeat TFT cofirm elev of TSH 12 - T3/T3 normal - asympt0omatic, BMI 30, LDL 160
Subclinical hypothyroid
| Tx - with levothyroxine - results in lowered LDL
149
Pt with 3 v CAD going for CABG TSH 11 wtd?
Clear for surgery
150
Pt with angina has cardiac cath - develops thyroid swelling T4 1.6, TSH 5
repeat T4 in 4 weeks
151
Pt with 15lb wt gain over few months unable to lose - delsyed tendon reflexes, TSH inc'd wtd?
start levothyroxine
152
Pt brought to ED on cold day, stuperous, hypothermic, bradycardic to 40/min periorbital edema, pugblic hair loss, amxillary hair loss
Myxedema coma
| Tx - Iv hydrocortisone plus T4/T3 + abx
153
Pt with hypothyroid controlled on synthroid get pregnant - what is increased requirement of synthroid
Elevated during 1st trim - till end of preg 30-50%
154
Preg pt with anti-TPO ab and started on levothyroxine - check TSH in 6 weeks - what is target TSH?
TSH<2.5
155
Thyroid nodules
Hot and cystic - benign
COld and solid - r/o malingnancy
Asyx nodule on physical exam - wtd?
check TSH
156
Pt with cold and solid nodule - TSH 1.5, US with hypoechoic nodule wtd?
FN bx (FNA)
If TSH dec and T4 inc wtd? - confirm dx with RAIU
if uptake inc'd - graves dz ->
tx: anti-thyroid meds -> radioactive iodine-> surgery
157
RAIU - Radioactive Iodine uptake test
used in dx of thyroid problems esp hyperthyroid
also used after radioactive iodide ablation to make sure no thyroid cells survived (could still be cancerous)
Low uptake suggests thyroiditis
High uptake suggests Graves dz
Uneven uptake suggest thyroid nodule
158
Pt with multinodular goiter on synthroid >1 yr p/w palpitations and wt loss - FTI inc, TSH dec, synthroid dose dec'd - 8 weeks later T4 still high, TSH still dec, T4 dose is again lowered and repeat TSH is still low wtd?
RAIU
If uptake dec then lower T4 dose and repeat TSH
If uptake high pt now euthyroid or has thyrotxicosis
stop synthoid and repeat TSH in 6 wks
159
FTI=free thyroid index
assessment of free unsaturated thryoid binding proteins - estimate of amount of circulating free thyroxine
160
Pt develops panhypopit including hypothyroid after radiotherapy to brain - TSH 0.1, replacement with levothyroxine began - how to follow this pt?
Free T4 (NOT TSH - will never go up because of hypopanpit)
161
Pt with longstanding h/o goiterous hashimotos thyroiditis p/w enlarging goiter, sob, harosenss and dysfphagia - exam with goiter tha tis hard and dosen't move on swallowing - dx?
Thyroid lymphcytic B cell type (60x more common with hashimotos)
162
Nuclear power plant disaster - what to give surrounding community?
Potassium iodide (ideally before to prevent radioactive iodine uptake from nuclear plant....)
163
Vitamin D deficiency
<20ng/ml
| Tx 50KIU/wk po then 1-2Kiu/day
164
Vit D insufficiency
<30ng/day (dec muscle strength)
| Tx 1-2K IU/day
165
Vit D sufficiency
>30ng/mL -
Maintenance
70yo 800 IU/day
166
At what vit D dose are fractures preventable
800 IU/day
167
Pt with serium Ca 11.5, repeat 11.5 - wtd next to ID etio?
check serum PTH
168
Sarcoid
inc 1,25OHD3 - inc Ca+/PO4 absorp from Gut
| in macrophages - 25OHD3--> 1,25OHD3
169
hyperPTH
inc Ca absorbp from gut, dec PO4
170
MM
inc Ca
171
ESRD
dec'd 1,25OHD3 (25OHD3-> 1,25OHD3 in kidney)
172
PTH >1000
PTHectomy
173
what does 1,25OH2D3 do?
mobilizes Ca+/PO4 from gut
174
HyperCa (bone breakdown)
fastest agent is calcitonin (2-3 days)
| then change to bisphosphonate
175
Ca inc PTH inc
```
primary hyperPTH (PO4 dec)
or Lithium tx
```
176
If Pa inc, PTH N
Familial benign hypocalciuric hypercaclcemia (FBHH)
abnormal Ca sensor in kidney - mild high serium Ca
Urine Ca to Cr ratio <0.01
NO TX NEEDED
177
If Ca inc PTH ver low
Malignance - MM - MCC hyper Ca+
PTH like sustance not measured by regular PTH assay
Skeletal survey needed
Vit D intox
measure 25OHD3
Sarcoid
check 1,25OH2D3 (inc'd bowel Ca+ absorbtion)
178
Other causes of hyper Ca+
Thiazide diruetics - dec'd Ca+ excretion
Lithium induced hyper Ca+ inc'd threshold of Ca need to dec PTH production
wtd? d/c lithium
179
Lithium induced hypothroid wtd?
treat with levothyroxine
180
Hyper PTH
inc'd PTH, inc'd Ca+, dec PO4
Bankd keratopathy, subperiodsteal bone resorption (moth eaten phalangeoal cortex on xray hand
Skull xray with punched out lesion
renal stones and muscle wkness
50% also with Vit D def - with PTH always check 25OHD3
May be in MENs syndrome
181
Leading cause of secondary HyperPTH?
Vit D dif
182
Pt with PTH elevation what to measure?
25 OH D3
183
Vit D inc'd
PTH dec (feedback), Ca inc, PO4 inc
184
Sarcoid
PTH dec, Ca inc, PO4 inc
185
hyperPTH
inc PTH, inc Ca+, dec PTH
186
Malignancy
PTH dec, Ca inc, PO4 dec
187
Milk alkali syndrome (antacids)
dec PTH, inc Ca+, dec PO4
188
MEN type I
Parathyroid - inc'd Ca+
Pituitary - MRI r/o it tumor
Pancrease - hypoglycemia
189
MEN II
Pheochromocytoma - HTN, palptiations 24 hr metaneph urine
Ca Medullary thryoid- calcitonin inc'd
Parathyroid - inc'd Ca+
190
MEN III
Ca Med thyroid
Pheochromocytoma
Mucosal neuromas
191
Pt with thyroid Mass, Ca inc'd calcitonin inc'd dnese calficiation in mass mdulalary Ca dx - screen family members?
yes - serium calcitonin RET proto oncogene
192
45yo F thyroid nodule 2.5cm, asx, TFT normal FNAB - medulalary cardinoma - serum calcitonin 1200 - scheduled for thryoidectomy - wtd prior to surgery
24hr urine metanephrine and catechol r/o pheo
193
34yo with recurren tnephorlitiasis Ca 11.5, PO4 2.3, perum PTH 225 - managment?
surgical exploration of neck for PTHoma
194
Indications for PTH surgery
Age>50
Serum Ca >2mg abv normal (11.5)
30% red in Cr clearance
Sx (osteoporosis T >-2.5, dehydration, stones)
195
40yo asx woman with minimal hyperCa, PTH 125 wtd?
refer for surgery
196
Pt with hyperPTH refused PTH ectomy wtd?
Cinacalcet (calcitonin)
197
Asx pt with Ca 10.5 - serum PTH 45 no h/o stones
check urine exretion of Ca - familal benign hypocalciuric hypercalcemia
198
35yo health concious excercise takes lot of vitamins p/w fague, constipation MM dry Ca 11.2, PTH 10 - most likely has?
Vit D intoxiation (25 OH D3)
199
45yo F c/o getting up at night ot urinate - constipated MM dry nauseous only other hx dyspepsia (takes lots of antiacids) Ca 11, Phos 2.5, PTH 15 dx?
Mild akali syndrome
| tx - change ca+ containing antacids
200
Pt with lung Ca to ER with mental obtundation Ca 17 - mamagement?
Aggressive IVF?
| long term management - zolendronate>pamidronate
201
Fastest acting hypocalcemic agent
Calcitonin - 2-3 days then resistance...
202
Least likely cuase of hyper Ca+
Prostate CA
203
32yo F with Ca 11.5, PO4 4, CXR b/l hilar LAD - whic elevated?
sarcoid - 1,25OHD3 (macrophages
204
28yo F kidney stone, Ca 11.2, PO4 4.1, serum PTH 7 dx?
sarcoid
| tx with prednisone after controlling hyper Ca+
205
HypoPTH
dec PTH, dec Ca inc PO4
206
Hypomagnesemia
Dec PTH, dec Ca, inc PO4, dec K+
207
Vit D def
inc PTH, dec Ca, dec PO4, inc alk phos
208
PTH resistance
PseudohypoPTH
CRF
inc PTH, dec Ca, inc PO4
209
Young pt with h/o irritability depression muscle wk Chvstek/trousseau's sign, dec Ca, dec PTH, inc PO4
hypo PTH
210
65yo M bone pain, osteopenia on xray, serum Ca 7, P4 1.9, alk phos 145, alb 2.2 serum protein 4.5, xray bands of radiolucense cause?
osteomalaicia 2/2 vit D def
211
Pt with fx on alendronate tx Ca 7.4, PO4 2.2, alk phos 135 dx?
Vit D def
212
Xray with SHORT 4th and 5th METACARPELS dx?
PseudohypoPTH (appropriate high PTH - tissues don't respond to PTH so Ca is still low)
etio? dec'd tissue response to PTH
213
Inc'd Ca+ in Tb/Sarcoid/leprocy
inc'd 1.25OHD3 from macrophages in granulomatous tissue
214
How to dx Osteoporosis
FRAX - clinical risk factors + femoral neck BMD with DXA (more than -2.5)
215
Clinical risk factors for osteoporosis
```
inc age
Prev fx
steroids
parental h/o hip fx
Low BMI
sedentary lifestyle
smoking
etoh
Rheum Arthritis
```
216
Secondary osteoporosis
```
Hyperthryoid
HyperPTH
MM
low Vit D
Hypogonaldism
Premature menopause
malabsorbption
Chronic liver dz
Inflamm bowel dz
Drugs - steroids 5mg/day x 3 months at least
Dilantin, long term heparin, aromatase inhibitors
LHRH agonists
```
217
Which is bigger risk factor for osteoporosis
Sedentary lifestyle
| Obestity bigger risk for osteoarthritis
218
Pt on prednisone 5mg/day > 3months
get DEXA baseline then yearly if stil on steroids
219
DEXA socre -1.5, pt on Ca/vit D wtd?
start alendronate
| If normal pt (not on steroids) T score < -2.5 then start bisphosphonate
220
52yo M pw pain in R groin and thigh for couple weeks denies trauma and walks a mile /day, alk phos normal Ca 9.2 ESR 23, Xray mild osteopenia MRI T1 def enhancement fem head T2 inc enhancement of fem head dx?
Transient osteoporosis
221
R groin pain with rheum arthritis and osteophytes on xray
secondary osteoARTHRITIS
222
R groin pain, with Rheum arthritsi xray neg, MRI double line sign on T2 dx?
```
avascular necrosis
tx: quit smoking, start bisphosphonate
calcitoin for pain
Ca 1500mg./day
Vit D 70 800 IU/day
Raloxifene
Teriparatide - dec osteoclast, inc osteoblast
```
223
65yo post menopausal F wnats to know risk for osteoporosis - past hx with renal stone 5ya - T score -.25, Z score -1.5 wtd?
Alendronate + Ca + vit D
| nephrolithiasis NOT contradindication for inc Ca in diet
224
Elderly F with hip fx DEXA -1.4 most imporant indiactor for starting alendronate ?
Hip Fx
225
Most important risk factor for fracture?
hx of hip fx with normal T score (< -2.5)
226
70yo pt with serum Ca 11.5, PTH 115 DEXA T score -2.5 hip -1.5 spine etiology of osteoporosis?
hyperPTH
227
70yo F comes to renew estrogen for osteoporosis wtd?
d/c estrogen start alendronate, Ca, Vit D
228
What medication shown to dec mortality in Pt with osteoprosis and fx
Zolendronate (S/e fever, myalgia)
229
65yo F with osteoprosis and renal insufficiency
Denosumab (RANKL inhibitor - prevents preosteoclasts from maturing into functional osteoclasts)
230
Pt taking Vit D and Ca - 48yo develops hot flashes what med for both bone health and hot flashes?
estrogen and progestin
231
T/F Local estrogen therapy helpful for vulvo vaginal atrophy
T
232
T/F Local estrogen therapy didn't releive dysparenunia
T
233
T/F Local estrogen therapy can reduce risk of recurrent UTIs
T
234
T/F hormone therapy does not reduce post menopaual osteoporotic fx's
F
235
T/F Hormonal tx within 10 years of menopaus in age less tthan 60 and use of hormonal therapy more than 5 years a/w reduction in 30% total morrtality and indicence of heart dz - not recommended assole reason for therapy
T
236
T/F Risk of heart dz increased if hormonal therapy started after menopause
T
237
T/F estrogen progestin therapy in's risk fo ischemic stroke in F > 60
T
238
T/F inc'd risk of DVT, however risk lower if started below 60
T
239
T/F unopposed estrogen tx at increased risk of endometrial Ca - so use concominant progestogens
T
240
T/F Breast Ca risk inc's with estrogen progest therapy for more than 5 years
T
241
T/F Hormonal therapy less than 5 years has signifcant impact on breast CA
F
242
T/F Hormone therapy if starte dafter age 65 can inc risk of dementia
T
243
T/F Hormonal tx started soon after menoapuse decreases risk of dementia later in life
T
244
T/F Hormonal replacement therapy in premature menopause that is in premature ovarial failure has protective effec ton CHF but don't extrapolate data to women experiencing menopause at a typical age
T
245
T/F Transdermal estrogen tx can be reconsidered if pthas concerns for DVT
T
246
T/F Estrogen therapy reduces risk of colon CA
T
247
58yo F long h/o hypothyroid on synthroid - what dx test to do (that is appropriate)
DEXA scan
248
58yo F long h/o hypothyroid on synthroid with DEXA + for osteoporosis wtd?
check TSH if low dec T4 dose (better than starting bisphosphonate
249
62yo F with DEXA scan reveals T score at spine -1.1, hip -2.5 - reason for discrepancy?
osteoarthritis of spine
250
Pt with osteoporosis T score -2.5 on alendroneate - 2 yrs later fall with fx T score -2.5 wtd?
D/c alendronate start Teriparatide
| Can use for 2 years
251
70yo M with hip fx, xray with osteopenia - Ca+, PO4 normal - skeletal survey no lytic lesions but osteopenia+ total proteins wnL protein electrophoresis slighly inc'd IgG no M spike wtd?
DEXA scan
if shows osteoporosis ->
tx with alendronate
252
79yo prostate Ca on antiadndrogen sustains hip fx - is alcoholic - DXA shows osteoporosis - reason?
decreased androgens
253
S/E bisphosphonate
osteonecrosis of jaw (mandible)
254
70yo F comes ot you reading on internet bisphophonates can cause osteonecrosis - taking alendronate for 7 years wtd?
D/C alendronate
| If > 5 years can stop - effect lasts for years
255
Paget's dz
alk phos inc'd, bone scan +
excessive breakdown and formation of bone (osteoblast, osteoclast phases)
Tx
asx - no tx
Sx - tx with alendronate/calcitonin
Sx's bone pain, spinal cord compression fx, high output heart failure
256
Paget's dz
Ca nl, Phos nl, alk phos INC, PTH nl
257
Perimenopause
50's irregular mentstual cycle, hot flashes, mood changes, insomnia, fatigue during day
Vaginal dryness, stress incontinence, dec memory
Tx - estrogen +- low dose preogestine
Complications - thromboembolic events
Dx? clinical
258
49yo F irreg menstual cycles, insomnia fatigue wtd?
estrogen challenge see if sx imoprove - FSH unreliable
259
35yo F hot flashes and early menopause wtd?
FSH level - if elevated - estrogen tx
260
52yo irreg mentstual cycle hot flash fatigue, h/o DVT in past - refuses to go on estrogen 2/2 risk of thormbus or post breast Ca tx, cancer risk wtd?
SSRI (venlafaxine, paroxetine sertraline)
261
Pt with severe mood swings prior to period so bad needs to miss work - dx?
Premenstrual dysphoric d/o
| Tx: Paroxetine (paxil)
262
Adrenal cortex
Zona Glomerulosa -> aldosterone
Zona Fasciculata -> corticosteroids
Zona Reiticularis -> Sex steroids
Adrenal Medulla -> Epi/norepi
263
Dec'd ACTH
no change aldo, dec corticosteroids, dec sex steroids, no change epi/norepi
264
Inc'd ACTH
inc'd aldo, inc'd corticosteroids, inc'd sex steroids, no change epi/norepi
265
inc'd corticosteroids
dec ACTH, dec sex steroids
266
Congential adrenal hyperplasia
21OH def - dec'd aloserone and cortisol, inc'd sex steroids
| 17 OH def less common - dec'd cortisol and sex steroids, inc'd aldosterone (mineralocorticoid)
267
Pt with hypopituitarism - started on T4 and prednisone - best way to find out adequacey of adrenal gland
DMS suppression test - stim test
268
Young woman with hirsuitism irreg peridos normal BP - 17OH progesterone level increased - pt has...
17 B hydroxlase def (CAH late onset)
269
Primary Hyperaldo
inc'd BP, dec K, inc aldosterone, dec renin (20:1 aldo:renin)
270
Reninoma
inc'd BP, dec K, inc'd aldo, inc'd renin
271
Hyporeninemic hypoaldo
dec BP inc'd K, dec aldo, dec Renin
272
45yo F routine physical BP 140/110, K 3.3, Cr 0.8, HCO3 27 on ACE, sprionolactone and BB wtd?
hold ace and sprionolactone
screening - paired serum aldo.renin if 20:1 primary hyper aldo
Best dx study
replete K, 2lts n/s over 4 hrs recheck serum aldo
273
42yo checking BP x 6 months - gradual inc - b/s also with HTN, BP 158/101, Na 134, K 2.9 wtd?
Check aldo:renin ratio or 24hr urine aldo
274
Pt dx with primary hyperaldo aldo:renin 20:1 - confirm with suppression test - CT abd wtd?
b/l adrenal vein sampling r/o adenoma vs hyperplasia
Tx Adenoma - surgery
Hyperplasia - spironolactone
275
55yo DM on insulin - BP 95/65, K 5.3, bicarb 20, Cr 2.1 BS 165 etio?
hyporeninemic hypoaldosteronism
276
When is renin low?
Primary hyperaldosteronism
Confirm with ACTH stim test (quick inc in cortisol)
Tx - flucortidsone, low K diet, lasix
(renin high in CHF and with ACEi)
277
Cushing's
pt with prox muscle wk, abd striae, fullness face, swelling back of neck, acne, facial hair irreg menstrual cycles, hyperglycemia wtd?
Med reconcililation
278
Cushing's syndrome w/u
24hr free cortisol in urine >100mcg.day confirms cushings
figure out where excess cortisol coming from
(leading cause pituitary adenoma)
279
Cushings Dz - Pituitary/ectopic
inc'd cortisol/Ucortisol, inc'd DHEA/17 ketosteroid, inc'd ACTH
Tx: Surgery
280
Adrenal adenoma
inc'd cortisol/Ucortisol, dec'd DHEA/17 keto steroid, dec'd ACTH
Tx: Surgery
281
Adrenal Carcinoma
inc'd Cortisol/Ucortisol, very inc DHEA/17 ketosteroid, dec ACTH
Tx: Surgery
282
Exogenous steroids
Dec Cortisol/UCortisol, dec DHEA/17 ketosteroid, dec ACTH
| Tx: D/C (taper) steroids
283
25yo 10lb wt gain, amenorrhea, acne, hirsuitism and is irriatable - posterior cervical fullness
check urine free cortisol
284
Pt with elev 24hr urine cortisol - dx with cushings syndrome - ACTH 50 after 8mg dexamethasone suppp ACTH and cortisol suppressed wtd?
MRI brain
285
If MRI neg in cushing's w/u or ACTH can't be suppressed then wtd?
b/l inf petrosal sinus sampling
286
Pt p/w h/o hyperpigmentation, high BP, muscle wk no h/o wt loss - K dec, BS high CT scan - nodule in lung dx?
ACTH producing tumor
| Tx Correct K, check cortisol, surgery
287
Pt with ACTH mediated cushing dz - source not localized wtd?
B/L adrenalectomy
288
Pt s/p adrenalectomy for cushings with h/a, hyperpigmentation dx?
Nelson's syndrome - rapid enlargement of pituitary adenoma after removal of b/l adrenal glands
Tx: pituitary irradiation (replace hydrocortisone first)
289
Addison's Dz
Hyperpigmentation esp palmar creases, oral mucosa, wt loss, salt craving n/v/wk, postural hypotension
290
How to confirm addison's dz?
Check cortisol level
| 18 - pituitary problem - not making ACTH
291
Pt w/ hypotension and shock - dec Na, inc K r/o addisonian crisi
Tx: NS/IV hydrocortisone
292
H/o addison's on hydrocrtisone and fludorcortisone p//w viral URI - no abx presecribed wtd?
Inc hydrocortisone dose
293
Pt dx with hypothyroid and addison's which to treat first?
Give steroids first then thyroxine - otherwise adrenal crisis will occur
294
Pt dx with PNA started on ceft and azithro - h/o asthma with exacerbation 1 month ago tx'd with nebs and taping steroids - BP 90/70, orthostatic - IVF began - wtd?
hydrocortisone
295
Pheochromocytoma
Palpitations, sweating, h/a, episodic in nature labile BP
| inc'd urinary exc of catecholamines and metabolites - part of MEN II/III
296
Screen/dx Pheo?
24 hr urine metanephrine/catecholamines
297
If pheo >10cm - wtd?
Check Meta Iodine Benzyl Guianine to r/o mets
| Tx: surgery
298
Presurgical managment of Pheo
Alpha blockade FIRST with prazosin
| then Betablockade with propranolol
299
Adrenal incidentaloma
>4-6cm - inc'd risk of malignancy
| <4-6cm - benign
300
W/U of adrenal incidentaloma
Check fxn -
1mg overnight DMS suppression - r/o cushings
Urine catecholam/metabolites - r/o Pheo
Paired renin/Aldo, K levels -> r/o hyperaldosteronism
17 OH ketosteroids - r/o Adrenal CA
301
Therapy for Adrenal incidentaloma
>6cm - surgical removal whether fxn or not
surgical removal
No Sx if <4-6 cm non-fxn and not getting bigger on serial CT
302
Pt with CT scan - 2cm mass on adrenal - BP 148/86, 1mg DMS and 17 OH ket steoid normal wtd?
Check Renin:Aldo level r/o hyperaldosteronism
| If BP normal check urine for catecholamines
303
Pt with 3cm mass on adrenal - all hormones within normal limits wtd?
Repeat CT in 4-6 months
304
45yo severe h/a not relieved with pain meds - next day stiff neck, fever, double vision - no rash - b/l temporal or homonymou hemianopsia BP 80/60, spinal tap few WBC /RBC - CTH lesion in pituitary/dense lesion in sella dx?
```
Pituitary apoplexy - bleeding into or compromised blood supply to pituitary usually a/w pitutary tumor
r/o meningits/SAH
Tx: NSx c/s for urgen decompression
Check random cortisol
give IV glucocorticoids
```
305
25yo post partum with difficult labor and delivery, lost lot of blood, unable to breast feed and no restoration of menses - fatigued, cold intolerance and delayed refelxes - TSH/FSH low dx?
Sheehan's syndrome with hypopituitarism
| tx: Replace hydrocortisone first then others....
306
32yo F with new onset severe h/a a/w vsiion changes - BP 90/70 supine and 80 si=ystolic sitting up, HR inc's on sitting up dx?
Lymphocytic hypophysitis
| Inflammation of pituitary gland from autoimmunity
307
18yo with h/a, visual distrbance, poor sexual devlopent - urine osmolarity decreased, prolactin inc'd xray dense suprasellar calcification dx?
Craniopharyngioma
308
Male Hypogonadism
```
Klinefelter's - 47XXY
primary testicular failure small testes, gynecomastia - tall stature, low normal testosterone FSH elev
Kallman's - low FSH
GnRH deficiency and can't smell
Analbolic steroids
muscular with small testes
```
309
114yo pw small penis and testes - exam with lack of pubertal and axillary hair - testosterone, LH, FSH normal wtd?
reassure - your time will come
Testosterone >350 = normal
200-350 - equivocal
<200 abnormal
310
Man with testosterone <350 wtd?
repeat early AM testosterone
311
Man with testosterone <350, BMI 35 or elderly wtd?
check sex binding globulin - dec'd with obesity and old age
| Check FREE testosterone level
312
Man with testosterone <200 wtd?
Check if takes opiod, steroid, hormone tx
313
70yo M with fague - steroids fo rCOPD testosteron 140 etio?
taper steroids - d/c steroids
| If can't d/c steroids then testosterone replacement tx
314
Pt asks if testosterone will cause prostate CA
will not change composition of prostate tissue
| Can exacerbate prostate CA if present - f/u with PSA
315
Baseline PSA 0.5, after testosterone now PSA 2 wtd?
d/c testosterone and refer for prostate Bx
| PSA SHOULD NOT more than DOUBLE with testosterone replacement tx!!
316
Erectile Dysfxn
```
Hypothal-Pit-Gonadal axis
Prolactinoma
Hypothyroid
Radiatio inducted hypopit
Klinefelters (XXY inc FSH)
Kallman (dec FSH)
```
Vasc supply - penile brachial index <6
Nerves DM neuropathy - if difficulty accomodating to pupillary reflex they have it
Psychogenic
Drugs - thiazide, SSR TCA, finasteride, BB
317
MC sexual dysfxn
premature ejaculation
| Tx SSR, sildenafil
318
Can SSRI cause retrograde ejaculation?
Yes
319
Pt with dec'd libido - testosterond 150 wtd?
check FSH
320
Pt with impotence with normal testosterone
check nocturnal penile tumescence - differentiate psychogenic vs organic
If normal r/o psychogenic or drug causes
321
nocturnal penile tumescence decreased in...
```
DM neuropathy
Vasc Insuff
HP gonadal axis problem
Prolactinoma
Hypothyroid
Marijuana
```
322
Mechanism of sildenafil
PDI5 inhib - inc nitric oxide - inc cGMP
323
Married couple comes to you cuz not having kids
Sperm count after 3 days abstinence
324
How to manage ED with pt on nitrates
Penile tumescent devices
325
How soon after using sildenafil or tadalafil can nitrates be used
24 hrs after sildenafil
| 48 hrs after tadalafil
326
Pt with CP given nitrates and sudden hypotension - had tadafanil 6hrs ago - wtd?
Put in trendelenbureg postion, IVF, phenyephrine (NOT NOREPI)
327
Gynecomastia
Puberty, elderly, obesity, cirrhosis, germ cell tumor Klinfelter's
328
15yo wiht enlargement of breast
uni or b/l - reassurance - related to puberty
| Men - unilater breast inc -> bx
329
Pt with c/o decreased libido - decreased nocturnal penil tumescence - received rad to head - FSH 5, LH 4, testosterone 160 prolactin i22 dx?
Gonadotropin deficiency
330
38yo F doing well on fluoxetine for depression unable to achieve orgasm for 2 months wtd?
add or switch to bupropion
331
Primary amenorrhea - Never had menses - web neck, short stature, low setears, intact smell, rudimentary ovaries
Turner syndrome XO
332
Primary amenorrhea no vagina, no uterus, ovaries OK breasts normal
Rokitanksy, kuster huser syndrome 46X
333
Primary amenorrhea with acne, clitoromegaly, hirsuitism no ovaries no breasts
46XY gonadal dysgenesis
334
Primary Amenorrhea wit hatrophic vagina no cervic +breasts, no pubic/axillary hair
Androgen insensitivity syndrome
testes formation in fetus - produces testosterone
No androgen rct so end organ resistance - so get vaginad and uterus as default
since excess testoerone cant work - converted to estrone -> breast formation
Testes undescended - androgen rct coded by X chromasome
335
Primary amenorrhea with anosmia (can't smell) dec LH/FSH
Kallman's syndrome
336
St. John's Wart
OCP failure
337
Bariatric surgery
Now fertile
338
Polycystic Ovarian Dz
Irreg mentstual cycle from puberty, obesity, acne, hirsuitism
inc'd testosterone, inc DHEA, inc LH/FSH ratio>3, hyperglyemia, hyperTGA
Acanthosis nigricans - muddy brown skin in acilla - w/w gastric CA, insulin resistance, obseity, PCO
Tx: anti androgen OCP
Metformin
Spironolactone
339
Premature ovarian failure
Ovary fails - dec'd estradiol, inc FSH first, then in LH
| Tx: estrogen replacement
340
Etiology of skin lesions in Vitiligo
Ab vs melanocytes
341
Amenorrhea with galactorreha Prolactin level >200 wtd?
CT /MRI head r/o prolactinoma
342
17 yo amenorrhea BM normal, preg test neg - rx for prg and gets periods - wtd?
reassurance?
343
47yo otherwise regular period with amenorrhea for 2 months wtd?
preg test
344
Young woman on OCP with no breakthru bleed wtd?
preg test
345
Pt stopped taking OCP sever months ago with no menses - preg test neg, LH/FSH normal estrogen challenge no bleed - etiology?
Asherman's syndrome (endometrial adhesions post D&C) or
| Uterine synechiae
346
Young marathon runner c/o only couple periods in last year wtd?
no further testing
Tx to get back periods - cut down on excercise
Mechanism - excess exc, inhibits LHRH -> hypogonadotropic hypogonadism
347
Pt asks how to to cut down on bone loss in addition to Ca and Vit D
OCP
348
Hirsuitism
Inc'd DHEA (adrenal) - inc ACTH, inc cortisol, inc'd 17 keto steroids=cushings
349
Pt with hirsuitsim - labs to order?
Testosterone, DHEA (17 OH ketosteroid), urine free cortisol
350
Pt with hirusitism testosterone high, corsol normal wtd?
TVUS for ovaries
351
18yo F with inc'd hair on arms/legs - family with similar hair
no further testing
