Endocrinology, Diabetes, Metabolism 9% Flashcards
1
Q
Screen for pituitary-gonadal axis
A
LH, FSH
2
Q
Screen for pituitary-adrenalaxis
A
ACTH
3
Q
Most sensitive determinant of pituitary fxn?
A
FSH, LH level
4
Q
Screening for Acromegaly
A
IGF-1 (not GH because of pulsatile release)
5
Q
CT head shows 0.8cm solid mass in pituitary. The - pt nulliparus, menustration regular. Next step?
A
Check all axises
- prolactin
- thyroid: T4, TSH, IGF-1
- Cushings: 1mg DMS test
6
Q
Things that increase prolactin
A
Nipple manipulation Phenothiazines reserpine Mehydopa estrogens marijuana prgenancy hypothyroid
7
Q
Prolactinoma
A
Prolactin >200 - macroadenoma <200 = micro tx:bromocryptine if elevted <100 and NO SX = OCP –> f/u mri if size >1cm -> q 6 months w/ visual field testing <1cm q yearly
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 yo wtd?
A
FBG –> 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
Pros and cons of insulin pump
pro - improved flexible lifestlye -tigheter glucose control - decreased hypoglycemic episodes cons -dka w/ malfunction - infxns - check BG 4x daily
26
Hospitalized patient with increased glucose irrespective of reason w/ glucose 140-180
tx with basal insulin and rapid acting agent
27
Sulfonyureas (glipizide), glyburide, glimeperide
inc'd release insulin form B cells avoid in obese pts glyburide has increased mortality in elderly and CAD
28
Meglitnide - repaglinid
inc rel insulin from B cells - excreted in bile DOC in renal insufficiency rapid acting
29
Biguanides - metformin
dec hepatic gluconeogenesis, dec insulin resistantce, dec weight, TG, chol TOC in obese pts and with inc TGA lactic acidosis 5%
30
A glucosidase inhibitors - acarbose, salsalate
inhbits breakdown of cardbs, dec absorption of glucose mainly for post prandial hyperglycemia salsalate decrases the need for more meds, decr TG, decr uric acid.
31
Thiazolidinediones (glitazones) - pioglitazone - actos
PPAR rct - inc glucose transport dec insluin resistance dec TGA, inc LDL - avoid in NYHA II HF thigh high edema
32
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
33
Inretin memetic - DDP4
Sitagliptin (januvia s/e nausea
34
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
35
Which DM meds DO NOT CAUSE WT GAIN?
Metformin, incretin drugs (exenatide and amylin alaog pramlintide
36
Blood sugar goals in DM
A1c\<120
37
Pt with BMI 32, FBS 115 fhx DM - best way to prevent DM?
Diet/excercise (aerobics and resistance training
38
Drugs that cause hyperglycemia
Statins, BB, HCTZ, niacin, olanzapine, PI, steroids
39
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
40
Pt with DM II and obese not well controlled on sulfonyurea (glipiz,glyburide, glimeperide)
Add metformin
41
What' increases insulin sensitivity
Glitazone
42
Which drug improves mortality and dec early HF in DM pts
Metformin
43
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
44
If FBS with just insulin and metformin still 115- 130
start lispro insulin
45
Pt refuses insulin injections wtd
continue metformin add sulfonyurea or glitazone
46
S/E metformin
lactic acidosis
47
When is metformin contraindicated?
Cr \>1.4 F\>1.5 M and advanced HF (\>NYHA II)
48
Pt on multiple meds Cr \>1.5, CHF EF 35% wtd?
d/c metformine and glitazone, start glargine for detemir and lispro or aspart
49
Pt going for cardiac cath or radiocontrast study - what drug to stop?
Metformin
50
60yo Pt dx with DMII - Cr 3.7 - what meds to start?
repaglinide (excreted in bile)
51
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
52
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
53
DM pt on NPH/R in AM, supper or glardgine HS Palpitations, sweating, nocturnal awakening AM h/a wtd?
check 3am FSG
54
Blood sugar 3am 40
change NPH to HS or swtichto long acting insulin analog (glargine)
55
Persistently ele FBS 3am 200
inc supper NPH or glargine
56
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
57
FSG 180 5pm
in NPM in AM
58
FSG 4pm 25 and 10pm 210 pt in 36U NPH in AM
Change to 24 U NPH AM and 12U NPH PM
59
All post prandials high, premeals ok on basal bolus regimen
inc dose of pre-meal insulin
60
All pre and post prandials high
inc long acting insulin dose
61
FBG 115 but A1c 7.5 takes NPH/metformin wtd?
check POST prandial blood sugar
62
65yo M DM started on glargine insulin 30U qam with metformin with FSG going steadily up throughout day
change to glargine twice daily
63
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
64
AA M DM f/u FBS 115-130 A1c 11 etiolgoy?
hemoglobinopathy
65
Falsely elevated HgA1c
decreased RBC turnover (dec retic) IDA Folate/B12 def Hemoglobinopathies Sickle cell, thalassemia
66
Falsely LOWER HgaA1c
inc'd RC turnover (inc retic) Hemolytic anemia, HIV treating IDA, folate B12 def or blood tx
67
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
68
Pt with DM, BS 340, TG 2400 hospitalized with pancreatitis - fastest way to control TG would be to give...
Insulin
69
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
70
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
71
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
72
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
73
24yo Preg F 24th wk FBS 115, repeat 114 - wtd?
Metformin (ok in preg)
74
25yo DM pt 24th wk FBS 120, post prandial 180 on glucotrol and metformin wtf?
add insulin
75
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
76
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
77
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
78
Newly Dx DM BG 350 on insulin drops to 130 - becomes tachy adn diaphoretic wtd
keep \<200 at first
79
DM complications
Macrovasc - CAD/PAD - aggressive LDL control autonomic peripher sensory motor polyneuropathy stock/glove distribution - amitryptyline, desipramine, gabapentin
80
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
81
Cause of DM foot ulcer
peripheral neuropathy
82
Best way to prevent DM foot ulcer
mon-filament testing - protective footwear
83
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
84
T/F type I DM should have annual eye exam after 5 yers after onset of DM or age 30 whichever first
T
85
T/F Type 2 DM pt shoudl have annual eye exam from onset of dz
T
86
T/F DM pt with difficulty driving at night will prob have ED
T
87
T/F ACCORD trial HgA1cd hypoglycemic events
T
88
T/F ACCORD trial BP \<140./80 had more s/e
T
89
Current recommendations for f/u DM pt
HgA1c quarterly, microalb semi ann, lipid panel annual, opthal exam annually
90
Pt with BS 35 taking glipizide, metformin acarbose
admit start IV dextrose
91
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
92
Above pt still hypoglycemic - ampule D50 give, IV dextrose started next step?
glucagon then octreodtide
93
TRH
downreguated by T4, lithium, iodine
94
SICU thyroid
dec T3, normal T4 and TSH
95
best test to screen for thyroid dz
TSH confirm with T4, FTI
96
Best test to follow hypothyroid tx
TSH
97
Best test to follow Hyperthyroid tx
FT4 or T3 Total T4 + T3=T3RIA
98
Thyrotoxicosis
T3 inc-\>inc T3 RIA
99
Radioiodine uptake
inc'd Hyperthyroid states (graves, hot nodules) dec'd thyroiditis (exogenous, amiodarone)
100
Radionuclide scan
differentiate between hot vs cold nodules
101
FNA/bx
cold nodules
102
Ultrasound
diff solid vs cystic
103
Graves dz
inc FT4, inc T3, dec TSH, inc RAI
104
Multinodular goiter
hot nodules - inc FT4, inc T3, dec TSH, inc RAI
105
Toxic nodule
inc FT4, inc T3 ria, dec TSH, inc RAI
106
T3 thyrotoxicosis
n/dec FT4, inc T3 ria, dec TSH, inc RAI
107
TSH adenoma
inc FT4, inc T3RIA, inc TSH, inc RAI
108
Thyroiditis
inc thyroglobulins, inc FT4, inc T3 RIA, dec TSH, inc RAI
109
exogenous T3 (factitious)
dec FT4, inc T3RIA, dec TSH, Dec RAI
110
Exog T4 (factitious)
inc FT4, inc T3 RIA, dec TSH, dec RAI
111
Primary hypothyroid
dec FT4, Dec T3 RIA, inc TSH - RAI n/a
112
Hypopit hypothyroid
dec FT4, dec T3 RIA, dec TSH
113
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
114
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
115
Elderly pt with wk, EKG afbi, TSH dec'd - etiology of afib?
hyperthyroid
116
Elderly pt with apathy, wt loss, arrythmia, CHF, diarrhea, depression, sleepiness, TSH dec, T4 nlow normal T3RU \>30%
apathetic thyrotoxicosis
117
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)
118
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"
119
40yo Pt with asympt low tsh
subclinical hyperthyroid - onitor, repeat TSH in 3months - tx only if osteoprosis or CV dz present
120
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
121
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
122
Can you cardiovert afib to NSR in thyroid storm?
No, not till 3 months after euthyroid - spontaneous conversion common
123
Pt with graves d has radioiodine ablation - 8 wks later gained wt, TSH 0.2, free T4 0.2 wtd?
start T4 (hypothyroid)
124
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
125
Pt with thyrotoxicosis and ophthalmopathy - management?
Surgery
126
Thyroiditis
all with dec'd RAI uptake - may present hyper,hypo or euthyroid Release of preformed hormones - thyrotoxicosis - returns to nromal Thyroglobulin inc'd....
127
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....
128
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
129
Ab most likley to differential graves vs thyroiditis
TSH rct autoab in graves Anti TPO + in both, TBG elev in both
130
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
131
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
132
Pt p/w tremor/tachycardia on asa, dig, amiodarone, IFN - T3, T4 high, TSH low, RAI \< 5% - etiology?
Amiodarone or alpha interfereron
133
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
134
Hypothyroid
cold intolerance constipation, coarsening of feathers, delayed DTR, amenorrhea, elevated prolactin
135
TSH elev, T4 dec
primary hypothyroid
136
TSH dec, T4 dec, rT3 dec
hypopit hypothyroid
137
TSH inc, T4 nl
subclincial hypothyroid
138
Pt p/w fatigue, cold intolerance and delayed DTR - TSH 6, T4 1.2 (normal)
hasimotos thyroiditis - leading cuase of hypothyroid - anti-TPO+
139
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)
140
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
141
Pt taking synthroid for hypothyroid T4 nl, T3 nl, TSH high wtd?
inc T4 dose
142
Hypothyroid pt on thyroixin goes on \<1wk vac forget meds wtd?
restart T4 upon arrival (t1/2 T4 is 7 days)
143
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
144
Pt with refractive arrhythia - resonding to amiodarone - 4 months later with sx of hypothyroid TSH elev, T4 dec wtd?
start synthoid
145
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)+
146
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
147
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
148
Pt with 3 v CAD going for CABG TSH 11 wtd?
Clear for surgery
149
Pt with angina has cardiac cath - develops thyroid swelling T4 1.6, TSH 5
repeat T4 in 4 weeks
150
Pt with 15lb wt gain over few months unable to lose - delsyed tendon reflexes, TSH inc'd wtd?
start levothyroxine
151
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
152
Pt with hypothyroid controlled on synthroid get pregnant - what is increased requirement of synthroid
Elevated during 1st trim - till end of preg 30-50%
153
Preg pt with anti-TPO ab and started on levothyroxine - check TSH in 6 weeks - what is target TSH?
TSH\<2.5
154
Thyroid nodules
Hot and cystic - benign COld and solid - r/o malingnancy Asyx nodule on physical exam - wtd? check TSH
155
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
156
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
157
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
158
FTI=free thyroid index
assessment of free unsaturated thryoid binding proteins - estimate of amount of circulating free thyroxine
159
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)
160
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)
161
Nuclear power plant disaster - what to give surrounding community?
Potassium iodide (ideally before to prevent radioactive iodine uptake from nuclear plant....)
162
Vitamin D deficiency
\<20ng/ml Tx 50KIU/wk po then 1-2Kiu/day
163
Vit D insufficiency
\<30ng/day (dec muscle strength) Tx 1-2K IU/day
164
Vit D sufficiency
\>30ng/mL - Maintenance 70yo 800 IU/day
165
At what vit D dose are fractures preventable
800 IU/day
166
Pt with serium Ca 11.5, repeat 11.5 - wtd next to ID etio?
check serum PTH
167
Sarcoid
inc 1,25OHD3 - inc Ca+/PO4 absorp from Gut in macrophages - 25OHD3--\> 1,25OHD3
168
hyperPTH
inc Ca absorbp from gut, dec PO4
169
MM
inc Ca
170
ESRD
dec'd 1,25OHD3 (25OHD3-\> 1,25OHD3 in kidney)
171
PTH \>1000
PTHectomy
172
what does 1,25OH2D3 do?
mobilizes Ca+/PO4 from gut
173
HyperCa (bone breakdown)
fastest agent is calcitonin (2-3 days) then change to bisphosphonate
174
Ca inc PTH inc
primary hyperPTH (PO4 dec) or Lithium tx
175
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
176
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)
177
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
178
Lithium induced hypothroid wtd?
treat with levothyroxine
179
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
180
Leading cause of secondary HyperPTH?
Vit D dif
181
Pt with PTH elevation what to measure?
25 OH D3
182
Vit D inc'd
PTH dec (feedback), Ca inc, PO4 inc
183
Sarcoid
PTH dec, Ca inc, PO4 inc
184
hyperPTH
inc PTH, inc Ca+, dec PTH
185
Malignancy
PTH dec, Ca inc, PO4 dec
186
Milk alkali syndrome (antacids)
dec PTH, inc Ca+, dec PO4
187
MEN type I
Parathyroid - inc'd Ca+ Pituitary - MRI r/o it tumor Pancrease - hypoglycemia
188
MEN II
Pheochromocytoma - HTN, palptiations 24 hr metaneph urine Ca Medullary thryoid- calcitonin inc'd Parathyroid - inc'd Ca+
189
MEN III
Ca Med thyroid Pheochromocytoma Mucosal neuromas
190
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
191
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
192
34yo with recurren tnephorlitiasis Ca 11.5, PO4 2.3, perum PTH 225 - managment?
surgical exploration of neck for PTHoma
193
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)
194
40yo asx woman with minimal hyperCa, PTH 125 wtd?
refer for surgery
195
Pt with hyperPTH refused PTH ectomy wtd?
Cinacalcet (calcitonin)
196
Asx pt with Ca 10.5 - serum PTH 45 no h/o stones
check urine exretion of Ca - familal benign hypocalciuric hypercalcemia
197
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)
198
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
199
Pt with lung Ca to ER with mental obtundation Ca 17 - mamagement?
Aggressive IVF? long term management - zolendronate\>pamidronate
200
Fastest acting hypocalcemic agent
Calcitonin - 2-3 days then resistance...
201
Least likely cuase of hyper Ca+
Prostate CA
202
32yo F with Ca 11.5, PO4 4, CXR b/l hilar LAD - whic elevated?
sarcoid - 1,25OHD3 (macrophages
203
28yo F kidney stone, Ca 11.2, PO4 4.1, serum PTH 7 dx?
sarcoid tx with prednisone after controlling hyper Ca+
204
HypoPTH
dec PTH, dec Ca inc PO4
205
Hypomagnesemia
Dec PTH, dec Ca, inc PO4, dec K+
206
Vit D def
inc PTH, dec Ca, dec PO4, inc alk phos
207
PTH resistance PseudohypoPTH CRF
inc PTH, dec Ca, inc PO4
208
Young pt with h/o irritability depression muscle wk Chvstek/trousseau's sign, dec Ca, dec PTH, inc PO4
hypo PTH
209
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
210
Pt with fx on alendronate tx Ca 7.4, PO4 2.2, alk phos 135 dx?
Vit D def
211
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
212
Inc'd Ca+ in Tb/Sarcoid/leprocy
inc'd 1.25OHD3 from macrophages in granulomatous tissue
213
How to dx Osteoporosis
FRAX - clinical risk factors + femoral neck BMD with DXA (more than -2.5)
214
Clinical risk factors for osteoporosis
inc age Prev fx steroids parental h/o hip fx Low BMI sedentary lifestyle smoking etoh Rheum Arthritis
215
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
216
Which is bigger risk factor for osteoporosis
Sedentary lifestyle Obestity bigger risk for osteoarthritis
217
Pt on prednisone 5mg/day \> 3months
get DEXA baseline then yearly if stil on steroids
218
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
219
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
220
R groin pain with rheum arthritis and osteophytes on xray
secondary osteoARTHRITIS
221
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
222
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)
223
Elderly F with hip fx DEXA -1.4 most imporant indiactor for starting alendronate ?
Hip Fx
224
Most important risk factor for fracture?
hx of hip fx with normal T score (\< -2.5)
225
70yo pt with serum Ca 11.5, PTH 115 DEXA T score -2.5 hip -1.5 spine etiology of osteoporosis?
hyperPTH
226
70yo F comes to renew estrogen for osteoporosis wtd?
d/c estrogen start alendronate, Ca, Vit D
227
What medication shown to dec mortality in Pt with osteoprosis and fx
Zolendronate (S/e fever, myalgia)
228
65yo F with osteoprosis and renal insufficiency
Denosumab (RANKL inhibitor - prevents preosteoclasts from maturing into functional osteoclasts)
229
Pt taking Vit D and Ca - 48yo develops hot flashes what med for both bone health and hot flashes?
estrogen and progestin
230
T/F Local estrogen therapy helpful for vulvo vaginal atrophy
T
231
T/F Local estrogen therapy didn't releive dysparenunia
T
232
T/F Local estrogen therapy can reduce risk of recurrent UTIs
T
233
T/F hormone therapy does not reduce post menopaual osteoporotic fx's
F
234
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
235
T/F Risk of heart dz increased if hormonal therapy started after menopause
T
236
T/F estrogen progestin therapy in's risk fo ischemic stroke in F \> 60
T
237
T/F inc'd risk of DVT, however risk lower if started below 60
T
238
T/F unopposed estrogen tx at increased risk of endometrial Ca - so use concominant progestogens
T
239
T/F Breast Ca risk inc's with estrogen progest therapy for more than 5 years
T
240
T/F Hormonal therapy less than 5 years has signifcant impact on breast CA
F
241
T/F Hormone therapy if starte dafter age 65 can inc risk of dementia
T
242
T/F Hormonal tx started soon after menoapuse decreases risk of dementia later in life
T
243
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
244
T/F Transdermal estrogen tx can be reconsidered if pthas concerns for DVT
T
245
T/F Estrogen therapy reduces risk of colon CA
T
246
58yo F long h/o hypothyroid on synthroid - what dx test to do (that is appropriate)
DEXA scan
247
58yo F long h/o hypothyroid on synthroid with DEXA + for osteoporosis wtd?
check TSH if low dec T4 dose (better than starting bisphosphonate
248
62yo F with DEXA scan reveals T score at spine -1.1, hip -2.5 - reason for discrepancy?
osteoarthritis of spine
249
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
250
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
251
79yo prostate Ca on antiadndrogen sustains hip fx - is alcoholic - DXA shows osteoporosis - reason?
decreased androgens
252
S/E bisphosphonate
osteonecrosis of jaw (mandible)
253
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
254
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
255
Paget's dz
Ca nl, Phos nl, alk phos INC, PTH nl
256
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
257
49yo F irreg menstual cycles, insomnia fatigue wtd?
estrogen challenge see if sx imoprove - FSH unreliable
258
35yo F hot flashes and early menopause wtd?
FSH level - if elevated - estrogen tx
259
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)
260
Pt with severe mood swings prior to period so bad needs to miss work - dx?
Premenstrual dysphoric d/o Tx: Paroxetine (paxil)
261
Adrenal cortex
Zona Glomerulosa -\> aldosterone Zona Fasciculata -\> corticosteroids Zona Reiticularis -\> Sex steroids Adrenal Medulla -\> Epi/norepi
262
Dec'd ACTH
no change aldo, dec corticosteroids, dec sex steroids, no change epi/norepi
263
Inc'd ACTH
inc'd aldo, inc'd corticosteroids, inc'd sex steroids, no change epi/norepi
264
inc'd corticosteroids
dec ACTH, dec sex steroids
265
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)
266
Pt with hypopituitarism - started on T4 and prednisone - best way to find out adequacey of adrenal gland
DMS suppression test - stim test
267
Young woman with hirsuitism irreg peridos normal BP - 17OH progesterone level increased - pt has...
17 B hydroxlase def (CAH late onset)
268
Primary Hyperaldo
inc'd BP, dec K, inc aldosterone, dec renin (20:1 aldo:renin)
269
Reninoma
inc'd BP, dec K, inc'd aldo, inc'd renin
270
Hyporeninemic hypoaldo
dec BP inc'd K, dec aldo, dec Renin
271
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
272
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
273
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
274
55yo DM on insulin - BP 95/65, K 5.3, bicarb 20, Cr 2.1 BS 165 etio?
hyporeninemic hypoaldosteronism
275
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)
276
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
277
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)
278
Cushings Dz - Pituitary/ectopic
inc'd cortisol/Ucortisol, inc'd DHEA/17 ketosteroid, inc'd ACTH Tx: Surgery
279
Adrenal adenoma
inc'd cortisol/Ucortisol, dec'd DHEA/17 keto steroid, dec'd ACTH Tx: Surgery
280
Adrenal Carcinoma
inc'd Cortisol/Ucortisol, very inc DHEA/17 ketosteroid, dec ACTH Tx: Surgery
281
Exogenous steroids
Dec Cortisol/UCortisol, dec DHEA/17 ketosteroid, dec ACTH Tx: D/C (taper) steroids
282
25yo 10lb wt gain, amenorrhea, acne, hirsuitism and is irriatable - posterior cervical fullness
check urine free cortisol
283
Pt with elev 24hr urine cortisol - dx with cushings syndrome - ACTH 50 after 8mg dexamethasone suppp ACTH and cortisol suppressed wtd?
MRI brain
284
If MRI neg in cushing's w/u or ACTH can't be suppressed then wtd?
b/l inf petrosal sinus sampling
285
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
286
Pt with ACTH mediated cushing dz - source not localized wtd?
B/L adrenalectomy
287
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)
288
Addison's Dz
Hyperpigmentation esp palmar creases, oral mucosa, wt loss, salt craving n/v/wk, postural hypotension
289
How to confirm addison's dz?
Check cortisol level 18 - pituitary problem - not making ACTH
290
Pt w/ hypotension and shock - dec Na, inc K r/o addisonian crisi
Tx: NS/IV hydrocortisone
291
H/o addison's on hydrocrtisone and fludorcortisone p//w viral URI - no abx presecribed wtd?
Inc hydrocortisone dose
292
Pt dx with hypothyroid and addison's which to treat first?
Give steroids first then thyroxine - otherwise adrenal crisis will occur
293
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
294
Pheochromocytoma
Palpitations, sweating, h/a, episodic in nature labile BP inc'd urinary exc of catecholamines and metabolites - part of MEN II/III
295
Screen/dx Pheo?
24 hr urine metanephrine/catecholamines
296
If pheo \>10cm - wtd?
Check Meta Iodine Benzyl Guianine to r/o mets Tx: surgery
297
Presurgical managment of Pheo
Alpha blockade FIRST with prazosin then Betablockade with propranolol
298
Adrenal incidentaloma
\>4-6cm - inc'd risk of malignancy \<4-6cm - benign
299
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
300
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
301
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
302
Pt with 3cm mass on adrenal - all hormones within normal limits wtd?
Repeat CT in 4-6 months
303
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
304
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....
305
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
306
18yo with h/a, visual distrbance, poor sexual devlopent - urine osmolarity decreased, prolactin inc'd xray dense suprasellar calcification dx?
Craniopharyngioma
307
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
308
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
309
Man with testosterone \<350 wtd?
repeat early AM testosterone
310
Man with testosterone \<350, BMI 35 or elderly wtd?
check sex binding globulin - dec'd with obesity and old age Check FREE testosterone level
311
Man with testosterone \<200 wtd?
Check if takes opiod, steroid, hormone tx
312
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
313
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
314
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!!
315
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
316
MC sexual dysfxn
premature ejaculation Tx SSR, sildenafil
317
Can SSRI cause retrograde ejaculation?
Yes
318
Pt with dec'd libido - testosterond 150 wtd?
check FSH
319
Pt with impotence with normal testosterone
check nocturnal penile tumescence - differentiate psychogenic vs organic If normal r/o psychogenic or drug causes
320
nocturnal penile tumescence decreased in...
DM neuropathy Vasc Insuff HP gonadal axis problem Prolactinoma Hypothyroid Marijuana
321
Mechanism of sildenafil
PDI5 inhib - inc nitric oxide - inc cGMP
322
Married couple comes to you cuz not having kids
Sperm count after 3 days abstinence
323
How to manage ED with pt on nitrates
Penile tumescent devices
324
How soon after using sildenafil or tadalafil can nitrates be used
24 hrs after sildenafil 48 hrs after tadalafil
325
Pt with CP given nitrates and sudden hypotension - had tadafanil 6hrs ago - wtd?
Put in trendelenbureg postion, IVF, phenyephrine (NOT NOREPI)
326
Gynecomastia
Puberty, elderly, obesity, cirrhosis, germ cell tumor Klinfelter's
327
15yo wiht enlargement of breast
uni or b/l - reassurance - related to puberty Men - unilater breast inc -\> bx
328
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
329
38yo F doing well on fluoxetine for depression unable to achieve orgasm for 2 months wtd?
add or switch to bupropion
330
Primary amenorrhea - Never had menses - web neck, short stature, low setears, intact smell, rudimentary ovaries
Turner syndrome XO
331
Primary amenorrhea no vagina, no uterus, ovaries OK breasts normal
Rokitanksy, kuster huser syndrome 46X
332
Primary amenorrhea with acne, clitoromegaly, hirsuitism no ovaries no breasts
46XY gonadal dysgenesis
333
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
334
Primary amenorrhea with anosmia (can't smell) dec LH/FSH
Kallman's syndrome
335
St. John's Wart
OCP failure
336
Bariatric surgery
Now fertile
337
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
338
Premature ovarian failure
Ovary fails - dec'd estradiol, inc FSH first, then in LH Tx: estrogen replacement
339
Etiology of skin lesions in Vitiligo
Ab vs melanocytes
340
Amenorrhea with galactorreha Prolactin level \>200 wtd?
CT /MRI head r/o prolactinoma
341
17 yo amenorrhea BM normal, preg test neg - rx for prg and gets periods - wtd?
reassurance?
342
47yo otherwise regular period with amenorrhea for 2 months wtd?
preg test
343
Young woman on OCP with no breakthru bleed wtd?
preg test
344
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
345
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
346
Pt asks how to to cut down on bone loss in addition to Ca and Vit D
OCP
347
Hirsuitism
Inc'd DHEA (adrenal) - inc ACTH, inc cortisol, inc'd 17 keto steroids=cushings
348
Pt with hirsuitsim - labs to order?
Testosterone, DHEA (17 OH ketosteroid), urine free cortisol
349
Pt with hirusitism testosterone high, corsol normal wtd?
TVUS for ovaries
350
18yo F with inc'd hair on arms/legs - family with similar hair
no further testing
351
Screening for cushing's syndrome
1 mg dexamethasone suppression test
