Endocrinology Flashcards
[diagnosis]
50/F overweight, polyuria, nocturia, weakness, acanthosis nigricans
FBS 140 HBA1C 6
Dx: TDM
Next step: repeat FBS
Initial tx: MNT
Initial medical tx: metformin
recommended age to start screening for DM
Age 45 years old
every 3 years
screen earlier if patient BMI >25 + one additional risk factors for DM
What is the most common pattern of dyslipidemia in DM
Hypertriglyceridemia
Reduced HDL
[Diagnosis of DM]
HbA1c
> = 6.5%
[Diagnosis of DM]
FBS
> =126
[Diagnosis of DM]
2hour plasma 75g OGTT
> = 200
[Diagnosis of DM]
RBS
> = 200 with 3 Ps
What are the contraindications of metformin monotherapy?
- Renal insufficiency
- Any form of acidosis
- Unstable CHF
- Liver disease
- Severe hypoxemia
[DM Treatment]
First line monotherapy drug
Metformin
[DM Treatment]
When will you start dual combination therapy in DM?
A1C >= 9%
[DM Treatment]
When will you start combination injectable therapy in DM?
A1C >= 10%
Metformin is considered for the prevention of T2DM in ____
Prediabetics
- BMI >35
- Age <60
- Prior GDM
- Rising HbA1c
Promotes weight gain
Sulfonylureas
TZD
Insulin
Promotes weight loss
Metformin
SGLT2 inhibitor
GLP1 receptor agonist
Weight neutral
DPP4 inhibitor
What are the effects of incretins affect __ insulin and ___ glucagon
Increase insulin
Decrease glucagon
What are the effects of GLP affect __ glucose, ___ FFA, glucagon
GLP increases glucose
GLP increases FFA
GLP decreases glucagon
What are examples of sulfonylureas?
Gliclazide
Glibenclamide
Glimepiride
Glipizide
Secretagogues
What are examples of non-sulfonylureas?
Repaglinide
Nateglinide
Secretagogues
What are examples of biguanides?
Metformin
insulin sensitizers
What are examples of TZD?
Pioglitazone
insulin sensitizers
What are examples of alpha-glucosidse inhibitors?
Acarbose
Miglitol
inhibit intestinal absorption of sugar
What are examples of DPP-IV inhibitors?
Sitagliptin
Saxagliptin
Linagliptin
Vildagliptin
Incretin-related drugs; prolongs endogenous action of GLP-1
What are examples of GLP-1 agonist?
Exenatide
Liraglutide
Incretin-related drugs; prolongs endogenous action of GLP-1
What are examples of SGLT2 inhibitors?
Dapagliflzin
Canagliflozin
Empagliflozin
increase urinary glucose excretion
What are examples of rapid acting insulin?
Lispro
Aspart
Glulisine
What are examples of short acting insulin?
Human regular
What are examples of intermediate-acting insulin?
isophane/Human NPH
What are examples of basal insulin analogs?
Glargine
Detemir
Degludec
What is the first defense of the body against hypoglycemia?
decrease insulin secretion
What is the second defense of the body against hypoglycemia?
glucagon
What is the third defense of the body against hypoglycemia?
epinephrine
[Goals for treatment]
HbA1c
<7
[Goals for treatment]
preprandial capillary plasma glucose
80-130
[Goals for treatment]
postprandial capillary plasma glucose
<180
[Goals for treatment]
BP goal in patients with DM
<140/90
[Goals for treatment]
frequency of eye exam
annual
[Goals for treatment]
frequency of foot exam
every visit
which is 2-3 months
[Goals for treatment]
frequency of follow-up
every 2-3 months
Whipple Triad of hypoglycemia
- Symptoms of hypoglycemoa
- Low plasma glucose
- relief of symptoms after plasma glucose is raised
What is the action of ACEi in the efferent arteriole?
dilate the efferent arteriole
What is the most common form of diabetic neuropathy is
distal symmetric polyneuropathy
One of the earliest sign of diabetic neuropathy
- erectile dysfunction
2. retrograde ejaculation
what is the most common skin manifestation of DM
- Xerosis
2. Pruritus
[diagnosis]
22/M T1Dm, poorly compliant with insulin.
Nausea, vomiting, abdominal pain. PE: pale, diaphoretic, fruity breath
100/70 110bpm
Glucose 450 HAGMA, postivie ketones
Dx: DKA
Next step: IV hydration, insulin administration
[Management of DKA]
How will you hydrate the patient
- 2-3L of 0.9% pNSS over the first 3 hours (10-20 mL/kg/hour)
- Add D5 containing once the blood glucose reaches 250mg/dL
[Management of DKA]
How will you give the insulin?
Regular insulin IV (0.1 units/kg) bolus then continous infusion
[DKA vs HHNS]
Nausea/vomiting, abdominal pain
Glucose >450
pH < 7.3
fruity breath, dehydration
DKA
[DKA vs HHNS]
Glucose >900
Hyperosmolarity >320
pH >7.3
HHNS
What are the components of metabolic syndrome?
- Waist M >=40; F >= 35 inches
- Glucose 100mg/dL
- Hypertriglyceridemia >=150
- Hypertension >= 130/85
- HDL <40 or <50
3H WG
Recite the Hypothalamic-Pituitary-Thyroid Axis
TRH»_space;> TSH»_space;> Thyroid gland»_space;> T4 and T3
Peripherally, T4»_space;> T3
T4 an T3 has negative feedback to the ___
pituitary gland and the hypothalamus
T4 an T3 has negative feedback to the ___
pituitary gland and the hypothalamus
Hyperthyroidism due to excessive intake of exogenous iodine
Jod-Basedow phenomenon
What are the different grading for the ophthalmologic findings in Graaves?
1=No signs 2=Only signs (lid lag) 3= Soft tissue involvement (periorbital) 4 = EOM (diplopia) 5 = corneal involvement 6 = sight
Iodine-deprived thyroid is exposed suddenly to an iodine-rich diet
Jod-Basedow phenomenon
T4 an T3 has negative feedback to the ___
pituitary gland and the hypothalamus
Iodine-deprived thyroid is exposed suddenly to an iodine-rich diet
Jod-Basedow phenomenon
what is the most common cardiovascular manifestation of graves disease?
sinus tachycardia
[Diagnose: thyrotoxicosis]
TSH low
T4 unbound, high
Primary thyrotoxicosis
[Diagnose: thyrotoxicosis]
TSH low
T4 unbound normal
T3 high
T3 toxicosis
[Diagnose: thyrotoxicosis]
TSH low
T4 unbound normal
T3 normal
subclinical hyperthyroidism
[Diagnose: thyrotoxicosis]
TSH normal
T4 unbound high
- TSH-secreting primary adenoma
2. Thyroid hormone resistance syndrome
What is the most serious manifestation of Grave’s ophthalmopathy?
optic nerve compression
Damage to parathyroid glands can lead to what electrolyte imbalances?
- HypoCa
2. HyperPhos
What is the drug of choice for thyroid storm?
PTU
What is the DOC to reduce adrenergic manifestation of graves and decrease peripheral conversion of T4 to T3?
Propranolol
What treatment blocks thyroid hormone synthesis via Wolff-Chaikoff effect?
Stable iodide
Cite the Burch-Wartofsky score
10 Temp: 37.8 to 38.2 10 Mild Agitatation 10 Diarrhea 10 tachycardia 110-119 10 moderate CHF 10 present AFib 10 with precipitant history
what is the most common cardiovascular manifestation of graves disease?
sinus tachycardia
[Diagnose: thyrotoxicosis]
TSH low
T4 unbound, high
Primary thyrotoxicosis
[Diagnose: thyrotoxicosis]
TSH low
T4 unbound normal
T3 high
T3 toxicosis
[Diagnose: thyrotoxicosis]
TSH low
T4 unbound normal
T3 normal
subclinical hyperthyroidism
[Diagnose: thyrotoxicosis]
TSH normal
T4 unbound high
- TSH-secreting primary adenoma
2. Thyroid hormone resistance syndrome
What is the most serious manifestation of Grave’s ophthalmopathy?
optic nerve compression
Damage to parathyroid glands can lead to what electrolyte imbalances?
- HypoCa
2. HyperPhos
What is the drug of choice for thyroid storm?
PTU
What is the DOC to reduce adrenergic manifestation of graves and decrease peripheral conversion of T4 to T3?
Propranolol
most common early consequence of estrogen deficiency
vertebral fractures
Cite the Burch-Wartofsky score
10 Temp: 37.8 to 38.2 10 Mild Agitatation 10 Diarrhea 10 tachycardia 110-119 10 moderate CHF 10 present AFib 10 with precipitant history
To inhibit hormone release, KISS is initiated how many hours after PTU administration?
1 hour
Antithyroid drug class that inhibits organification
- Iodide
2. Thioamides
What is the treatment for subacute thyroiditis?
- Aspirin
2. Glucocorticoid
[diagnosis]
32F fatigue, weakness, weight gain, menstrual abnormality for the past 3 months.
PE: puffy eye lids, dry skin, enlarged thyroid, bradycardia, delayed DTRs
Dx: hypothyroidism
best screening test: TSH
Tx: Levothyroxine
What is the size of the nodule to be detectable on palpation?
> 1cm in diameter
After obtaining low TSH, what is the next step in the evaluation of a thyroid nodule
Thyroid scan
If a thyroid scan was done and the TSH is high, what is the next step?
ultrasound-guided FNAB
What is the operational definition of osteoporosis?
BMD <2.5 SD from normal peak bone mass
T-score less than -2.5
What are the target sites of PTH in the body
- Proximal tubules of kidney
- Osteoclasts
- Intestine
What is the net effect of PTH?
To increase Calcium by
- Reabsorption in kidneys
- Bone resorption
- Dietary absorption
What are the target sites of calcitonin?
- Distal convoluted tubules
2. Osteoblast
What is the net effect of calcitonin?
To decrease serum calcium
- Secretion in urine
- Bone formation
most common early consequence of estrogen deficiency
vertebral fractures
[Diagnose]
High calcium
low phosphate
high alkaline phosphatase
Hyperparathyroidism
[diagnose]
normal to low calcium, high alkaline phosphatase
osteomalacia
[diagnose]
very high alkaline phosphatase
paget disease
Drug that is a selective-estrogen modulator used in the prevention of osteoporosis and reduction of invasive breast CA
Raloxifene
[diagnose]
cortisol: HIGH
ACTH: High
High dose DST: No effect
CRH: No response
Ectopic Cushing Syndrome
What is the best initial diagnostic test if cushing’s syndrome is considered?
- 1mg overnight Dexamethasone suppresion test
2. 24 hours urine cortisol
What is the next best step if the patient has hypercortisolism?
Plasma ACTH measurement
What is the sequence of trophic hormone failure associated with pituitary compression?
GH»_space;> FSH/LH»_space;> TSH»_space;> ACTH
in adults, what is the earliest symptom of cushing’s syndrome?
hypogonadism
[Trace the hormone release]
To produce T3 and T4
- TRH
- TSH
- T4 T3
[Trace the hormone release]
to produce milk
- Prolactin-releasing factor
- PRL
- Mammary gland
[Trace the hormone release]
to produce cortisol
- CRH
- ACTH
- Adrenals (fasciculata)
[Trace the hormone release]
to stimulate the ovary
- GNRH
- LH/FSH
- Ovaries
What is the drug of choice for pregnant women with cushing syndrome?
metyrapone
What inhibits GH release?
somatostatin
An excess cortisol release from ACTH-producing pituitary adenoma is called
Cushing’s disease
[diagnose]
cortisol: HIGH
ACTH: decreased
High dose DST: no effect
CRH: no response
Adrenal cushing syndrome
[diagnose]
cortisol: HIGH
ACTH: High
High dose DST: suppressed
CRH: response
Pituitary Cushing Syndrome
[diagnose]
cortisol: HIGH
ACTH: High
High dose DST: No effect
CRH: No response
Ectopic Cushing Syndrome
how will you conduct the Dexamethasone suppression test?
- Give 1mg dexamethasone PO at 11pm
2. Take serum cortisol at 8am
Why will you still do a 24-hour urine cortisol test despite the Dexa suppression test?
To confirm that an overnight dexamethasone suppression test is not falsely abnormal
What are the components of MEN 2B?
- Marfanoid
- Multiple mucosal neuromas
- Medullary thyroid CA
- Pheochromocytoma
what is the treatment of choice for cushing disease?
selective removal of the pituitary corticotrope via trans-sphenoidal approach
What is the treatment of choice in ACTH-independent disease
surgical removal of the adrenal tumor
[diagnose]
Aldosterone: increased
Renin: increased
Edema: present
Na excretion: present
- Renal artery stenosis
2. Renin-secreting tumor
What drug is a good adrenolytic agent which is also good for reducing cortisol (a derivative of DDT)
Mitotane
What is the drug of choice for adrenocortical carcinoma
mitotane
What is the drug of choice for pregnant women with cushing syndrome?
metyrapone
What hormone is involved in defense against prolonged hypoglycemia?
cortisol
What is the first diagnostic step in pheochromocytoma (traditionally)?
measure catecholamines
In pheochromocytoma, what is the most sensitive and less susceptible to false-positive elevations from stress?
measurements of plasma metanephrine
[Treatment of pheochromicytoma]
alpha adrenergic blocker
Phenoxybenzamine
[Treatment of pheochromicytoma]
while waiting for phenoxybenzamine to take effect, what will you give?
Prazosin/Phentolamine
[Treatment of pheochromicytoma]
what is the method of choice in the surgical management
Atraumatic Endoscopic Surgery
What are the components of MEN 2A?
- Hyperparathyroidism
- Pheochromocytoma
- Medullary Thyroid CA
What are the components of MEN 2B?
- Marfanoid
- Multiple mucosal neuromas
- Medullary thyroid CA
- Pheochromocytoma
[diagnose]
32M LE weakness. BP 180/90 on all extremities. Serum K 2.1
Dx: Hyperaldosteronism
Most common cause: primary hyperaldosteronism
Hallmark: Hypokalemic hypertension
Treatment: Spironolactone
[diagnose]
Aldosterone: increased
Renin: decreased
Edema: absent
Na excretion: no change
Primary hyperaldosteronism, Conn syndrome
[diagnose]
Aldosterone: increased
Renin: increased
Edema: present
Na excretion: present
- Renal artery stenosis
2. Renin-secreting tumor
[diagnose]
CRH: increased ACTH: increased Aldosterone: decreased Cortisol: decreased Androgens: decreased
Hypotension present
dark skin discoloration
Primary adrenal insufficiency, Addision
[diagnose]
CRH: increased ACTH: decreased Aldosterone: normal Cortisol: decreased Androgens: decreased
Hypotension absent
pale skin
Secondary adrenal insufficiency
[diagnose]
CRH: decreased ACTH: decreased Aldosterone: normal Cortisol: decreased Androgens: decreased
Hypotension absent
pale skin
Tertiary Adrenal insufficiency
What hormone is involved in defense against prolonged hypoglycemia?
cortisol
Cite causes of thyrotoxicosis without hyperthyroidism
- Subacute thyroiditis
- Silent thyroiditis
- Amiodarone
- radiation
- infarction adenoma
- ingestion of excess hormone or tissue