Position patient with head down and hands up and look for: 1. JVD 2. Facial plethora 3. Flushing =>> Thoracic outlet syndrome

Endocrinology Flashcards by Michael Matheney

Causes of altered HgbA1c levels

IDA
Blood loss/hemolysis
Kidney disease 
Liver diseases 
Pregnancy
Blood transfusion

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What should you do with an abnormal diabetes test in a patient who has not been previously diagnosed?

Repeat testing

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Other antibody in Type I DM that you haven’t been checking

Anti-tyrosine phosphatase IA-2

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Metabolic syndrome factors

>40 cm waist circumference (35 in women)
Fasting TGL >150
HDL <40 (<50 in women)
HTN 
Fasting glucose >100

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Pramlinitide

Amylin analogue that delays gastric emptying decreases glucagon secretion, and increases mealtime satiety

Indicated for Type I patients who are having trouble achieving glycemic control

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How does metformin work again?

Decreases hepatic glucose production and increases insulin-mediated uptake of glucose in muscles

Contraindicated w/ progressive liver, kidney, or cardiac failure

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Medications you CANNOT use with sulfonylureas

DDP-4 inhibitors (sitagliptin, saxagliptin, linagliptin) as these medicines cause glucose-dependent increases in insulin secretion

-Also, increases risk of pancreatitis and may be associated w/ increased in heart failure exacerbations

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Vitamin deficiency that can develop w/ metformin use

Vitamin B12 (in up to 5% of patients)

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Cancer drugs that are associated w/ hyperglycemia

Calcineurin inhibitors (Sirolimus, tacrolimus/prograf, cyclosporine/gengraf)

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Cardiac medications that are associated w/ hyperglycemia

BBs (decrease insulin release and increase peripheral resistance)
Thiazide (decreased insulin secretion 2/2 hyperkalemia

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Psych meds associated w/ hyperglycemia

2nd generation antipsychotics

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Pathophysiology of DKA/HHS

Relative insulin deficiency state w/ subsequent ketone production, lipolysis

HHS typically more lethal due to it happening in younger people with better GFR allowing for higher glucosuria

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Thyroid nodule suspicious characteristics

Microcalcifications, irregular borders

If extrathyroidal extension, lymph node involvement, or symptoms present, you can biopsy w/ <1cm nodules

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Recommendations for nodule w/ atypia of uncertain significance or follicular lesion of uncertain significance

Repeat FNAB in 3 months

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Pemberton sign

Position patient with head down and hands up and look for:

JVD
Facial plethora
Flushing

=» Thoracic outlet syndrome

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Most common cause of goiter in geriatric patients in the US

Multinodular goiter

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Jod-Basedow Phenomenom

Administration of iodine to multinodular goiter patient causes iodine-induce hyperthyroidism

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Difference in mets in papillary thyroid carcinoma vs follicular carcinoma

Papillary-Cervical lymphadneopathy but less commonly w/ distant mets

Follicular- Mets to lung, bone but less commonly w/ follicular lymphadenopathy

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High risk features for recurrence in thyroid cancer

Extrathyroidal extension
Lymphovascular invasion
Poorly differentiated on histology
Metastatic disease

-Typically administer radioactive iodine after surgery in these patients

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Markers monitored after treatment for thyroid cancer

Throglobulin or thyroglobulin antibody (if antibody present, use this)

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Therapy for high-risk differentiated thyroid cancer

LT4 to suppress the TSH to at least less than 2 but is individualized

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Anaplastic thyroid cancer

Rare but aggressive and presents as a rapidly enlarging neck mass

Median survival is 5 months as it is usually nonresectable at diagnosis; treatment for this one is chemo

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Medullary thyroid cancer

Arises from parafollicular cells due to germline RET oncogene mutation (MEN syndromes)

Tx: Total thyroidectomy w/ central neck lymph node dissection

Scenarios in which T3 measurement is recommended

Identifying isolated T3 toxicosis
To assess the severity of hyperthyroidism and the response to therapy
To differentiate hyperthyroidism from destructive thyroiditis

What clinical indication is there to check rT3?

None

What meds can decrease LT4 absorption?

Calcium, PPIs, Iron, sucralfate

What meds increase LT4 metabolism?

Dilantin Carbamazepine Rifampin Sertraline

What drugs cause thyroiditis

Amiodarone Lithium Interferon-a (can also cause antithyroid antibodies to develop) IL-2 TKIs (sunitinib) Immune checkpoint inhibitors (nivolumab, pembrolizumab)

What drugs inhibit TSH synthesis/release?

Steroids Dobutamine Octreotide

What drugs increase TBG?

OCPs Tamoxifen Methadone

What drugs decrease TBG?

Androgens Steroids Niacin

Struma ovarii

Causes thyrotoxicosis in ovarian teratoma

Wolff-Chaikoff effect

Relative hypothyroidism when ingesting increased amounts of iodine Seen in amiodarone use in first few months but usually resolves

Goal TSH for pregnant patients

<2.5; you also start treating treatment-naive patients if found to have anti-TPO and TSH is >2.5

TSH levels not consistent w/ euthyroid sick syndrome

TSH <0.01 or TSH >20

Treatment for thyroid storm

``` Treat inciting cause AND IV BB PTU w/ transition to methimazole when stable IV dexamethasone KI (administer one hour after thioamide) ``` Plasmapheresis can be considered if no response If patient survives, thyroidectomy or radioablative therapy indicated

Med to administer empirically prior to starting treatment for myxedema coma

Glucocorticoids; after that, administer IV bolus of LT4 at 400ug

Labs that need measured in chronic hypoparathyroidism

Ca, Mg, Cr, and URINE Ca -Urine Ca should be <300mg/24hrs; if its higher, decrease calcium supplementation as this may cause urinary stones/fall in GFR

Empty sella work up

Typically, clinics assessment and 8AM cortisol and TSH Hyperprolactinemia is the most common abnormality tho as pituitary is still present, it is just in a round ring around the site of the sella

Cancers that met to the pituitary

``` Breast Lung Lymphoma Renal cell Langerhans can involve it ``` -Typically causes DI, optic nerve dysfunction, sometimes HA and CN palsies

What cancer drugs cause hypophysitis?

Check point inhibitors

Work up for pituitary tumor

Prolactin IGF-1 MRI w/out with sella turcica imaging Also check FSH, LH, TSH to see if they are LOW

Monitoring pituitary microarenkma

Repeat imaging every 1-2 years

Lab to check in patient who you are suspicious for alderosteronoma but are on an ACEI/ARB

Renin level If low, then an actual Angiotensin-Renin level is indicated

Gene to check for with medullary thyroid carcinoma and the associated cancers

RET Pheochromocytoma, parathyroid hyperplasia, mucosal neuroma, gastrointestinal ganglioneuroma, and Marfanoid body habitus (if MEN2B) (These are MEN 2A and 2B tumors so remember your chart)

Common meds that can affect biochemical testing for pheochromocytoma

Tylenol, antipsychotics, SNRIs, MOAIs, TCAs, Buspirone, caffeine, cocaine, decongestants (pseudoephedrine), ethanol Should ideally discontinue these 2 weeks prior to testing

Steroid with highest anti-inflammatory potency

Dexamethasone

Steroid with shortest half life

Hydrocortisone; this is why it requires TID dosing yah dingus

Treatment of choice for adrenal crisis

Hydrocortisone 100mg q8hrs

When adrenal insufficient patients are ill or having surgery, what should should they do with their steroid dosing?

Increase 2-3x

Testing for adrenal incidentaloma

Must be at least 1cm ``` Subclinical Cushings (Overnight dexamethasone suppression test) Pheo testing Aldosterone testing if patient has HTN or hypokalemia ```

Indications for adrenalectomy

Suspicious imaging Growth >1cm year Function tumor (pheo, aldosterone, subclinical Cushings)

Lab to check in an obese man with a low 8AM testosterone level

Free testosterone These patients have elevated SHBG leading to falsely decreased 8AM testosterone levels

Lab to check after confirming low testosterone levels

Workup of painful male gynecomastia

bHCG, estradiol, LH, 8AM testosterone

What does rapid onset of hirsutism in woman >30 years old worry you for

Androgen producing tumor

Eval of female hyperandrogenism

SHBG, 12-hydroxyprogesterone (check for CAH) hCG, prolactin, FSH, TSH, DHEA if rapid to check for tumor