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2018 Awesome rev > Endocrinology, Diabetes, Metabolism 9% > Flashcards

Endocrinology, Diabetes, Metabolism 9% Flashcards

1
Q

Hypothalamus

A 
Dopamine-> inhib prolactin
GNRH->Growth hormone
TRH->TSH
CRH->ACTH
GnRH->FSH/LH
Post pit directly releases oxytocin/ADH
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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)

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3
Q

Most sensitive determinant of pitutiary fxn?

A

FSH/LH level

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4
Q

Screening for hormone excess

A

Prolactinoma->prolactin level
Hyperthyroid-<>FTI/T4, TSH
Acromegaly-> IGF-1 (not GH - is pulsatile)
Cushings -> 1mg DMS

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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)

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6
Q

Things that increase prolactin

A 
Nipple manipulation
Phenothiazines
reserpine
Mehydopa
estrogens
marijuana
prgenancy
hypothyroid
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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

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8
Q

Middle aged woman wit dec libiddo adn fatigue test low, FSH low

A

check prolactin adn TSH

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9
Q

Pt wit galactorreha wtd?

A

check TSH and prolactin

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10
Q

Young woman with galactorreha on manipulation of nipple, TSH/prolactin normal

A

avoid manipulation of nipple

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11
Q

35yo F with galactorreha and amenorrhea x 6 months - preg neg prolactin 184 TFT normal wtd?

A

MRI r/o stalk tumor

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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

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13
Q

45yo M c/o fatigue and dec libido - testosterone 18, prolactin 2500 FSH 2.2 cause?

A

prolactinoma

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14
Q

Pt with prolactinoma micro or macro - wants to concive

A

start dopamin agonist (bromocryptine - reduce prolactin level and induce ovulation

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15
Q

Pt tx’d with bromocryptine for macroadenoma and gets pregnant wtd?

A

d/c bromocryptine

monitor visual fields - only restart if changes

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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

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17
Q

Screening test for acromegaly

A

IGF-1 (somatosatin C) - also to follow dz activity

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18
Q

Confirm acromegaly (after IGF-1 screening) with…

A

oral glucose suppression test

failure to suppress GH to <2ng after 100g glucose

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19
Q

Tx for Acromegaly

A

Transphenoid surgery

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20
Q

Complciations of acromegaly

A

HTN, LVH, CHF, OSA, colonic polyps, carpel Tunnel

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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

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22
Q

Pt with BP 135/80 or BMI 25 or sedentery lifestyle or >40 yo wtd?

A

FBG –> screen for DM (FSG, HgA1c)

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23
Q

Pt with DM (FSG >126) at risk for

A

DM and retinopathy, nephropathy

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24
Q

DM I vs II

A

check for Ab vs glutamic acid carboxylase, ab to islet cells

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25
Q

Pros and cons of insulin pump

A

pro

  • improved flexible lifestlye
  • tigheter glucose control
  • decreased hypoglycemic episodes

cons

  • dka w/ malfunction
  • infxns
  • check BG 4x daily
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26
Q

Hospitalized patient with increased glucose irrespective of reason w/ glucose 140-180

A

tx with basal insulin and rapid acting agent

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27
Q

Sulfonyureas (glipizide), glyburide, glimeperide

A

inc’d release insulin form B cells
avoid in obese pts

glyburide has increased mortality in elderly and CAD

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28
Q

Meglitnide - repaglinid

A

inc rel insulin from B cells - excreted in bile

DOC in renal insufficiency

rapid acting

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29
Q

Biguanides - metformin

A 
dec hepatic gluconeogenesis, 
dec insulin resistantce, 
dec weight, TG, chol
TOC in obese pts and with inc TGA
lactic acidosis 5%
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30
Q

A glucosidase inhibitors - acarbose, salsalate

A

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.

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31
Q

Thiazolidinediones (glitazones) - pioglitazone - actos

A

PPAR rct - inc glucose transport dec insluin resistance
dec TGA, inc LDL

  • avoid in NYHA II HF

thigh high edema

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32
Q

Incretin mimetics - exenatide GLP1 agonist

A

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

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33
Q

Inretin memetic - DDP4

A

Sitagliptin (januvia

s/e nausea

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34
Q

Amylin analogue pramlintide

A

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

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35
Q

Which DM meds DO NOT CAUSE WT GAIN?

A

Metformin, incretin drugs (exenatide and amylin alaog pramlintide

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36
Q

Blood sugar goals in DM

A

A1c<120

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37
Q

Pt with BMI 32, FBS 115 fhx DM - best way to prevent DM?

A

Diet/excercise (aerobics and resistance training

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38
Q

Drugs that cause hyperglycemia

A

Statins, BB, HCTZ, niacin, olanzapine, PI, steroids

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39
Q

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?

A

Metformin

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40
Q

Pt with DM II and obese not well controlled on sulfonyurea (glipiz,glyburide, glimeperide)

A

Add metformin

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41
Q

What’ increases insulin sensitivity

A

Glitazone

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42
Q

Which drug improves mortality and dec early HF in DM pts

A

Metformin

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43
Q

Pt with DM2 responsds well to metformin adn sulfonyrea for years bu tnow with inc BS, no infxn, HgA1c 9 - wtd

A

add insulin basal - keep only metformin

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44
Q

If FBS with just insulin and metformin still 115- 130

A

start lispro insulin

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45
Q

Pt refuses insulin injections wtd

A

continue metformin add sulfonyurea or glitazone

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46
Q

S/E metformin

A

lactic acidosis

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47
Q

When is metformin contraindicated?

A

Cr >1.4 F>1.5 M and advanced HF (>NYHA II)

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48
Q

Pt on multiple meds Cr >1.5, CHF EF 35% wtd?

A

d/c metformine and glitazone, start glargine for detemir and lispro or aspart

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49
Q

Pt going for cardiac cath or radiocontrast study - what drug to stop?

A

Metformin

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50
Q

60yo Pt dx with DMII - Cr 3.7 - what meds to start?

A

repaglinide (excreted in bile)

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51
Q

40yo Pt with DM2 tx’d with metformin - 1 year later gaining wt as he stopped excerciseing BS also up

A

start exenatide (GLP-1) good for obese pt failing metformin

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52
Q

Dawn’s Phenomenon - pt wakes up with fatigue, sweating h/a, vivid dreams

A

inc’d 4-7am gluc 2/2 insulin resistance/hormonal factors

Tx - inc PM NPM

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53
Q

DM pt on NPH/R in AM, supper or glardgine HS

Palpitations, sweating, nocturnal awakening AM h/a wtd?

A

check 3am FSG

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54
Q

Blood sugar 3am 40

A

change NPH to HS or swtichto long acting insulin analog (glargine)

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55
Q

Persistently ele FBS 3am 200

A

inc supper NPH or glargine

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56
Q

Blood sugar 30 pt passes out at 12noon on 20 U NPH and 5 U R in AM wtd?

A

D/C “R insulin” in AM

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57
Q

FSG 180 5pm

A

in NPM in AM

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58
Q

FSG 4pm 25 and 10pm 210 pt in 36U NPH in AM

A

Change to 24 U NPH AM and 12U NPH PM

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59
Q

All post prandials high, premeals ok on basal bolus regimen

A

inc dose of pre-meal insulin

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60
Q

All pre and post prandials high

A

inc long acting insulin dose

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61
Q

FBG 115 but A1c 7.5 takes NPH/metformin wtd?

A

check POST prandial blood sugar

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62
Q

65yo M DM started on glargine insulin 30U qam with metformin with FSG going steadily up throughout day

A

change to glargine twice daily

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63
Q

Insulin dosing

A

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

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64
Q

AA M DM f/u FBS 115-130 A1c 11 etiolgoy?

A

hemoglobinopathy

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65
Q

Falsely elevated HgA1c

A 
decreased RBC turnover (dec retic)
IDA
Folate/B12 def
Hemoglobinopathies
Sickle cell, thalassemia
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66
Q

Falsely LOWER HgaA1c

A

inc’d RC turnover (inc retic)
Hemolytic anemia, HIV
treating IDA, folate
B12 def or blood tx

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67
Q

Pt Hg 6.6 - BS ranges between 90-150 except 5pm which is 280 has fresh fuit snake at 4pm etio?

A

Not washing hands after fruit snack - false elevation of A1c

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68
Q

Pt with DM, BS 340, TG 2400 hospitalized with pancreatitis - fastest way to control TG would be to give…

A

Insulin

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69
Q

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

A

wtd? - inc insulin gtt

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70
Q

How to prevent DKA pt from going back into DKA when turning off insulin gtt -

A

give SQ insulin 30 min prior to stopping insulin gtt

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71
Q

Pt with diabetic ketoacidosis BS 725, ketones +++ started on insulin gtt, ivf 10am - BS 250 at 7pm - wtd?

A

start IVF D51/2NS, c/w insulin gtt

Follow with AG if closed then overlap SQ insulin

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72
Q

Pt with DM admitted for surgery in AM - on glargine and lispro wtd morning of surgery if pt receives glargine in AM, in PM

A

Glargine AM schedule: 1/2 dose glargine and NO lispro

Glargine PM schedule: d/c lispro

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73
Q

24yo Preg F 24th wk FBS 115, repeat 114 - wtd?

A

Metformin (ok in preg)

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74
Q

25yo DM pt 24th wk FBS 120, post prandial 180 on glucotrol and metformin wtf?

A

add insulin

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75
Q

Elerly pt DMII brought in with seizure - BS 1050, BUN /cr 50/1.8, ketones + dx?

A

Hyperosmolar non-ketotic coma -
IVF, insulin
inc 100 gluc, Na dec 1.6 up to 300
>300 inc 100 Gluc dec Na 2.5

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76
Q

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

A

hypophosphatemia - insluin drip forces lyesinto cells - no Phos to make ATP

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77
Q

Nurse calls you to let you know FBS 62

A

Asymptomatic - adjust regimen

Symptomatic with tachycardia - 15gm carbs, if on acarbose then pur glucose (dextrose) and adjust tx regimen

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78
Q

Newly Dx DM BG 350 on insulin drops to 130 - becomes tachy adn diaphoretic wtd

A

keep <200 at first

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79
Q

DM complications

A

Macrovasc - CAD/PAD - aggressive LDL control autonomic
peripher sensory motor polyneuropathy
stock/glove distribution - amitryptyline, desipramine, gabapentin

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80
Q

DM Autonic neuroapthy

A

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

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81
Q

Cause of DM foot ulcer

A

peripheral neuropathy

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82
Q

Best way to prevent DM foot ulcer

A

mon-filament testing - protective footwear

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83
Q

Pt with DM 15yr on metformin sulfonyrea/insulin with hypoglycemic attacks post prandial, early satiety, oitting BS 50 to 400 range widely dx?

A

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

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84
Q

T/F type I DM should have annual eye exam after 5 yers after onset of DM or age 30 whichever first

A

T

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85
Q

T/F Type 2 DM pt shoudl have annual eye exam from onset of dz

A

T

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86
Q

T/F DM pt with difficulty driving at night will prob have ED

A

T

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87
Q

T/F ACCORD trial HgA1cd hypoglycemic events

A

T

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88
Q

T/F ACCORD trial BP <140./80 had more s/e

A

T

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89
Q

Current recommendations for f/u DM pt

A

HgA1c quarterly, microalb semi ann, lipid panel annual, opthal exam annually

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90
Q

Pt with BS 35 taking glipizide, metformin acarbose

A

admit start IV dextrose

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91
Q

22yo F recurrent dizzy attacks in ER, mother DM, blood gluc 35 - next dx test

A

make sure no surepticous insulin/sulfonyurea use - check urine serum sulfonyurea screen

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92
Q

Above pt still hypoglycemic - ampule D50 give, IV dextrose started next step?

A

glucagon then octreodtide

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93
Q

TRH

A

downreguated by T4, lithium, iodine

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94
Q

SICU thyroid

A

dec T3, normal T4 and TSH

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95
Q

best test to screen for thyroid dz

A

TSH

confirm with T4, FTI

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96
Q

Best test to follow hypothyroid tx

A

TSH

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97
Q

Best test to follow Hyperthyroid tx

A

FT4 or T3

Total T4 + T3=T3RIA

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98
Q

Thyrotoxicosis

A

T3 inc->inc T3 RIA

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99
Q

Radioiodine uptake

A

inc’d Hyperthyroid states (graves, hot nodules)

dec’d thyroiditis (exogenous, amiodarone)

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100
Q

Radionuclide scan

A

differentiate between hot vs cold nodules

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101
Q

FNA/bx

A

cold nodules

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102
Q

Ultrasound

A

diff solid vs cystic

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103
Q

Graves dz

A

inc FT4, inc T3, dec TSH, inc RAI

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104
Q

Multinodular goiter

A

hot nodules - inc FT4, inc T3, dec TSH, inc RAI

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105
Q

Toxic nodule

A

inc FT4, inc T3 ria, dec TSH, inc RAI

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106
Q

T3 thyrotoxicosis

A

n/dec FT4, inc T3 ria, dec TSH, inc RAI

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107
Q

TSH adenoma

A

inc FT4, inc T3RIA, inc TSH, inc RAI

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108
Q

Thyroiditis

A

inc thyroglobulins, inc FT4, inc T3 RIA, dec TSH, inc RAI

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109
Q

exogenous T3 (factitious)

A

dec FT4, inc T3RIA, dec TSH, Dec RAI

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110
Q

Exog T4 (factitious)

A

inc FT4, inc T3 RIA, dec TSH, dec RAI

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111
Q

Primary hypothyroid

A

dec FT4, Dec T3 RIA, inc TSH - RAI n/a

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112
Q

Hypopit hypothyroid

A

dec FT4, dec T3 RIA, dec TSH

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113
Q

Pt with wt loss, feels warm in windter, tremors, inc appetite, diarrhea, palpiatins, afib, enlarged thyroid FTI inc, TSH dec wtd?

A 
Radioactive uptake study
diffuse - graves
Focal - toxic nodule
uptake - thyroiditis
areas of inc and dec uptake - multinodular goiter
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114
Q

Pt with hyperthyroid and dec’d radioiodine uptake - how to differentiate thyroititis vs factitous thyrotoxicosis

A

inc’d thyroglobulin - thyroiditis (and follicular/papillary CA)
dec’d thyroglobulin - factitious thyrotoxicosis
inc’d TBG - estrogen/pegnancy

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115
Q

Elderly pt with wk, EKG afbi, TSH dec’d - etiology of afib?

A

hyperthyroid

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116
Q

Elderly pt with apathy, wt loss, arrythmia, CHF, diarrhea, depression, sleepiness, TSH dec, T4 nlow normal T3RU >30%

A

apathetic thyrotoxicosis

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117
Q

Pt with T4 elv, TSH 4.5

A

MRI brain (no feedback - with high T4 should be low TSH unless there is pituitary tumor secreteing TSH)

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118
Q

26yo F si/sx hyperthyroid - started on a new “diet pill recently and has been excercisign - T3 elev, TSH low and RAI uptake low

A

taking thyroxine in “diet pill”

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119
Q

40yo Pt with asympt low tsh

A

subclinical hyperthyroid - onitor, repeat TSH in 3months - tx only if osteoprosis or CV dz present

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120
Q

Tx of thyrotoxicosis (TSHr AB_, anti TPO +

A

Pregnancy -> 1st trim PTU (SE agranulocytosis, ANCA + ab, MPO+ (1st trimester ONLY)
Others-> radioactive Iodine-> >50% become hypothyroid in 2months
Thyroid ophthalmopathy - subtotal thyroidectomy

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121
Q

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?

A

Thyroid storm
Tx: PTU/steroids + BB, digoxin for afib
etio - infxn, surgery, trauma

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122
Q

Can you cardiovert afib to NSR in thyroid storm?

A

No, not till 3 months after euthyroid - spontaneous conversion common

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123
Q

Pt with graves d has radioiodine ablation - 8 wks later gained wt, TSH 0.2, free T4 0.2 wtd?

A

start T4 (hypothyroid)

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124
Q

hypothyroid pt started on T4 - 2 months later watery eyes, slceral injection, perioorbital edema, afferent pupillary defiect, painful eye movement - dx?

A

Thyroid ophthalmopathy with opti cnerve impingenment

Tx: steroids

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125
Q

Pt with thyrotoxicosis and ophthalmopathy - management?

A

Surgery

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126
Q

Thyroiditis

A

all with dec’d RAI uptake - may present hyper,hypo or euthyroid
Release of preformed hormones - thyrotoxicosis - returns to nromal
Thyroglobulin inc’d….

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127
Q

Pt with URI, soreless in neck enlarged tender thyroid, inc’d ESR, inc T3RU, T4 normal - how to get dx?

A 
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....
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128
Q

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?

A

BB only - avoid RAIU during lactation

Usually transient hyperhtyroid then hypotheyroid then euthyroid after several months

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129
Q

Ab most likley to differential graves vs thyroiditis

A

TSH rct autoab in graves

Anti TPO + in both, TBG elev in both

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130
Q

Young woman 4 months post partum wit huncomplicated couse with wt gain, low enverygy, delayed DTR, amenorrhea - preg neg wtd?

A

Check TSH, r/o hypothyroid stage or chronic lyphocytic thyroiditis

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131
Q

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?

A

start synthroid, reassure and reepeat TFT in 3 months or less

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132
Q

Pt p/w tremor/tachycardia on asa, dig, amiodarone, IFN - T3, T4 high, TSH low, RAI < 5% - etiology?

A

Amiodarone or alpha interfereron

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133
Q

Pt with acute illness intubated and in ICU - episode of hypotension on vasopressors - T4 nl/dec, T3 low, TSH nl/low

A

SICK euthyroid syndrome

Tx: tx underlying cause - repeat TSH 2-3 wks after recovery

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134
Q

Hypothyroid

A

cold intolerance constipation, coarsening of feathers, delayed DTR, amenorrhea, elevated prolactin

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135
Q

TSH elev, T4 dec

A

primary hypothyroid

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136
Q

TSH dec, T4 dec, rT3 dec

A

hypopit hypothyroid

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137
Q

TSH inc, T4 nl

A

subclincial hypothyroid

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138
Q

Pt p/w fatigue, cold intolerance and delayed DTR - TSH 6, T4 1.2 (normal)

A

hasimotos thyroiditis - leading cuase of hypothyroid - anti-TPO+

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139
Q

28yo F fatigue, wk, difficulty getting up from sitting, pain in hands CPK 200, DTR slow wtd?

A

check TSH (joint pain, inc CPK, dec DTR)

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140
Q

In pt with CAD or elderly start…

A

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

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141
Q

Pt taking synthroid for hypothyroid T4 nl, T3 nl, TSH high wtd?

A

inc T4 dose

142
Q

Hypothyroid pt on thyroixin goes on <1wk vac forget meds wtd?

A

restart T4 upon arrival (t1/2 T4 is 7 days)

143
Q

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

A

continue same dose of T4

144
Q

Pt with refractive arrhythia - resonding to amiodarone - 4 months later with sx of hypothyroid TSH elev, T4 dec wtd?

A

start synthoid

145
Q

Hashimotos thyroiditis

A 
leading cuase of hypothyroid
CPK elevated before sx of hypothyroid
Indications for tx subclinical hypothyroid
inc LDL
anti-thyroid perioxidase Ab (anti TPO)+
146
Q

Pt with bipolar dz responsds to leithium fo r>8yrs - past sever montsh wt gain, delayed DTR T4 borderline, TSH inc’d wtd?

A

start levothyroxine

147
Q

Pt with slightly elev TSH - repeat TFT cofirm elev of TSH 12 - T3/T3 normal - asympt0omatic, BMI 30, LDL 160

A

Subclinical hypothyroid

Tx - with levothyroxine - results in lowered LDL

148
Q

Pt with 3 v CAD going for CABG TSH 11 wtd?

A

Clear for surgery

149
Q

Pt with angina has cardiac cath - develops thyroid swelling T4 1.6, TSH 5

A

repeat T4 in 4 weeks

150
Q

Pt with 15lb wt gain over few months unable to lose - delsyed tendon reflexes, TSH inc’d wtd?

A

start levothyroxine

151
Q

Pt brought to ED on cold day, stuperous, hypothermic, bradycardic to 40/min periorbital edema, pugblic hair loss, amxillary hair loss

A

Myxedema coma

Tx - Iv hydrocortisone plus T4/T3 + abx

152
Q

Pt with hypothyroid controlled on synthroid get pregnant - what is increased requirement of synthroid

A

Elevated during 1st trim - till end of preg 30-50%

153
Q

Preg pt with anti-TPO ab and started on levothyroxine - check TSH in 6 weeks - what is target TSH?

154
Q

Thyroid nodules

A

Hot and cystic - benign
COld and solid - r/o malingnancy
Asyx nodule on physical exam - wtd?
check TSH

155
Q

Pt with cold and solid nodule - TSH 1.5, US with hypoechoic nodule wtd?

A

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
Q

RAIU - Radioactive Iodine uptake test

A

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
Q

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?

A

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
Q

FTI=free thyroid index

A

assessment of free unsaturated thryoid binding proteins - estimate of amount of circulating free thyroxine

159
Q

Pt develops panhypopit including hypothyroid after radiotherapy to brain - TSH 0.1, replacement with levothyroxine began - how to follow this pt?

A

Free T4 (NOT TSH - will never go up because of hypopanpit)

160
Q

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?

A

Thyroid lymphcytic B cell type (60x more common with hashimotos)

161
Q

Nuclear power plant disaster - what to give surrounding community?

A

Potassium iodide (ideally before to prevent radioactive iodine uptake from nuclear plant….)

162
Q

Vitamin D deficiency

A

<20ng/ml

Tx 50KIU/wk po then 1-2Kiu/day

163
Q

Vit D insufficiency

A

<30ng/day (dec muscle strength)

Tx 1-2K IU/day

164
Q

Vit D sufficiency

A

> 30ng/mL -
Maintenance
70yo 800 IU/day

165
Q

At what vit D dose are fractures preventable

A

800 IU/day

166
Q

Pt with serium Ca 11.5, repeat 11.5 - wtd next to ID etio?

A

check serum PTH

167
Q

Sarcoid

A

inc 1,25OHD3 - inc Ca+/PO4 absorp from Gut

in macrophages - 25OHD3–> 1,25OHD3

168
Q

hyperPTH

A

inc Ca absorbp from gut, dec PO4

169
Q

MM

170
Q

ESRD

A

dec’d 1,25OHD3 (25OHD3-> 1,25OHD3 in kidney)

171
Q

PTH >1000

172
Q

what does 1,25OH2D3 do?

A

mobilizes Ca+/PO4 from gut

173
Q

HyperCa (bone breakdown)

A

fastest agent is calcitonin (2-3 days)

then change to bisphosphonate

174
Q

Ca inc PTH inc

A 
primary hyperPTH (PO4 dec)
or Lithium tx
175
Q

If Pa inc, PTH N

A

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
Q

If Ca inc PTH ver low

A

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
Q

Other causes of hyper Ca+

A

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
Q

Lithium induced hypothroid wtd?

A

treat with levothyroxine

179
Q

Hyper PTH

A

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
Q

Leading cause of secondary HyperPTH?

181
Q

Pt with PTH elevation what to measure?

182
Q

Vit D inc’d

A

PTH dec (feedback), Ca inc, PO4 inc

183
Q

Sarcoid

A

PTH dec, Ca inc, PO4 inc

184
Q

hyperPTH

A

inc PTH, inc Ca+, dec PTH

185
Q

Malignancy

A

PTH dec, Ca inc, PO4 dec

186
Q

Milk alkali syndrome (antacids)

A

dec PTH, inc Ca+, dec PO4

187
Q

MEN type I

A

Parathyroid - inc’d Ca+
Pituitary - MRI r/o it tumor
Pancrease - hypoglycemia

188
Q

MEN II

A

Pheochromocytoma - HTN, palptiations 24 hr metaneph urine
Ca Medullary thryoid- calcitonin inc’d
Parathyroid - inc’d Ca+

189
Q

MEN III

A

Ca Med thyroid
Pheochromocytoma
Mucosal neuromas

190
Q

Pt with thyroid Mass, Ca inc’d calcitonin inc’d dnese calficiation in mass mdulalary Ca dx - screen family members?

A

yes - serium calcitonin RET proto oncogene

191
Q

45yo F thyroid nodule 2.5cm, asx, TFT normal FNAB - medulalary cardinoma - serum calcitonin 1200 - scheduled for thryoidectomy - wtd prior to surgery

A

24hr urine metanephrine and catechol r/o pheo

192
Q

34yo with recurren tnephorlitiasis Ca 11.5, PO4 2.3, perum PTH 225 - managment?

A

surgical exploration of neck for PTHoma

193
Q

Indications for PTH surgery

A

Age>50
Serum Ca >2mg abv normal (11.5)
30% red in Cr clearance
Sx (osteoporosis T >-2.5, dehydration, stones)

194
Q

40yo asx woman with minimal hyperCa, PTH 125 wtd?

A

refer for surgery

195
Q

Pt with hyperPTH refused PTH ectomy wtd?

A

Cinacalcet (calcitonin)

196
Q

Asx pt with Ca 10.5 - serum PTH 45 no h/o stones

A

check urine exretion of Ca - familal benign hypocalciuric hypercalcemia

197
Q

35yo health concious excercise takes lot of vitamins p/w fague, constipation MM dry Ca 11.2, PTH 10 - most likely has?

A

Vit D intoxiation (25 OH D3)

198
Q

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?

A

Mild akali syndrome

tx - change ca+ containing antacids

199
Q

Pt with lung Ca to ER with mental obtundation Ca 17 - mamagement?

A

Aggressive IVF?

long term management - zolendronate>pamidronate

200
Q

Fastest acting hypocalcemic agent

A

Calcitonin - 2-3 days then resistance…

201
Q

Least likely cuase of hyper Ca+

A

Prostate CA

202
Q

32yo F with Ca 11.5, PO4 4, CXR b/l hilar LAD - whic elevated?

A

sarcoid - 1,25OHD3 (macrophages

203
Q

28yo F kidney stone, Ca 11.2, PO4 4.1, serum PTH 7 dx?

A

sarcoid

tx with prednisone after controlling hyper Ca+

204
Q

HypoPTH

A

dec PTH, dec Ca inc PO4

205
Q

Hypomagnesemia

A

Dec PTH, dec Ca, inc PO4, dec K+

206
Q

Vit D def

A

inc PTH, dec Ca, dec PO4, inc alk phos

207
Q

PTH resistance
PseudohypoPTH
CRF

A

inc PTH, dec Ca, inc PO4

208
Q

Young pt with h/o irritability depression muscle wk Chvstek/trousseau’s sign, dec Ca, dec PTH, inc PO4

209
Q

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?

A

osteomalaicia 2/2 vit D def

210
Q

Pt with fx on alendronate tx Ca 7.4, PO4 2.2, alk phos 135 dx?

211
Q

Xray with SHORT 4th and 5th METACARPELS dx?

A

PseudohypoPTH (appropriate high PTH - tissues don’t respond to PTH so Ca is still low)
etio? dec’d tissue response to PTH

212
Q

Inc’d Ca+ in Tb/Sarcoid/leprocy

A

inc’d 1.25OHD3 from macrophages in granulomatous tissue

213
Q

How to dx Osteoporosis

A

FRAX - clinical risk factors + femoral neck BMD with DXA (more than -2.5)

214
Q

Clinical risk factors for osteoporosis

A 
inc age
Prev fx
steroids
parental h/o hip fx
Low BMI
sedentary lifestyle
smoking
etoh
Rheum Arthritis
215
Q

Secondary osteoporosis

A 
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
Q

Which is bigger risk factor for osteoporosis

A

Sedentary lifestyle

Obestity bigger risk for osteoarthritis

217
Q

Pt on prednisone 5mg/day > 3months

A

get DEXA baseline then yearly if stil on steroids

218
Q

DEXA socre -1.5, pt on Ca/vit D wtd?

A

start alendronate

If normal pt (not on steroids) T score < -2.5 then start bisphosphonate

219
Q

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?

A

Transient osteoporosis

220
Q

R groin pain with rheum arthritis and osteophytes on xray

A

secondary osteoARTHRITIS

221
Q

R groin pain, with Rheum arthritsi xray neg, MRI double line sign on T2 dx?

A 
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
Q

65yo post menopausal F wnats to know risk for osteoporosis - past hx with renal stone 5ya - T score -.25, Z score -1.5 wtd?

A

Alendronate + Ca + vit D

nephrolithiasis NOT contradindication for inc Ca in diet

223
Q

Elderly F with hip fx DEXA -1.4 most imporant indiactor for starting alendronate ?

224
Q

Most important risk factor for fracture?

A

hx of hip fx with normal T score (< -2.5)

225
Q

70yo pt with serum Ca 11.5, PTH 115 DEXA T score -2.5 hip -1.5 spine etiology of osteoporosis?

226
Q

70yo F comes to renew estrogen for osteoporosis wtd?

A

d/c estrogen start alendronate, Ca, Vit D

227
Q

What medication shown to dec mortality in Pt with osteoprosis and fx

A

Zolendronate (S/e fever, myalgia)

228
Q

65yo F with osteoprosis and renal insufficiency

A

Denosumab (RANKL inhibitor - prevents preosteoclasts from maturing into functional osteoclasts)

229
Q

Pt taking Vit D and Ca - 48yo develops hot flashes what med for both bone health and hot flashes?

A

estrogen and progestin

230
Q

T/F Local estrogen therapy helpful for vulvo vaginal atrophy

231
Q

T/F Local estrogen therapy didn’t releive dysparenunia

232
Q

T/F Local estrogen therapy can reduce risk of recurrent UTIs

233
Q

T/F hormone therapy does not reduce post menopaual osteoporotic fx’s

234
Q

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

235
Q

T/F Risk of heart dz increased if hormonal therapy started after menopause

236
Q

T/F estrogen progestin therapy in’s risk fo ischemic stroke in F > 60

237
Q

T/F inc’d risk of DVT, however risk lower if started below 60

238
Q

T/F unopposed estrogen tx at increased risk of endometrial Ca - so use concominant progestogens

239
Q

T/F Breast Ca risk inc’s with estrogen progest therapy for more than 5 years

240
Q

T/F Hormonal therapy less than 5 years has signifcant impact on breast CA

241
Q

T/F Hormone therapy if starte dafter age 65 can inc risk of dementia

242
Q

T/F Hormonal tx started soon after menoapuse decreases risk of dementia later in life

243
Q

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

244
Q

T/F Transdermal estrogen tx can be reconsidered if pthas concerns for DVT

245
Q

T/F Estrogen therapy reduces risk of colon CA

246
Q

58yo F long h/o hypothyroid on synthroid - what dx test to do (that is appropriate)

247
Q

58yo F long h/o hypothyroid on synthroid with DEXA + for osteoporosis wtd?

A

check TSH if low dec T4 dose (better than starting bisphosphonate

248
Q

62yo F with DEXA scan reveals T score at spine -1.1, hip -2.5 - reason for discrepancy?

A

osteoarthritis of spine

249
Q

Pt with osteoporosis T score -2.5 on alendroneate - 2 yrs later fall with fx T score -2.5 wtd?

A

D/c alendronate start Teriparatide

Can use for 2 years

250
Q

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?

A

DEXA scan
if shows osteoporosis ->
tx with alendronate

251
Q

79yo prostate Ca on antiadndrogen sustains hip fx - is alcoholic - DXA shows osteoporosis - reason?

A

decreased androgens

252
Q

S/E bisphosphonate

A

osteonecrosis of jaw (mandible)

253
Q

70yo F comes ot you reading on internet bisphophonates can cause osteonecrosis - taking alendronate for 7 years wtd?

A

D/C alendronate

If > 5 years can stop - effect lasts for years

254
Q

Paget’s dz

A

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
Q

Paget’s dz

A

Ca nl, Phos nl, alk phos INC, PTH nl

256
Q

Perimenopause

A

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
Q

49yo F irreg menstual cycles, insomnia fatigue wtd?

A

estrogen challenge see if sx imoprove - FSH unreliable

258
Q

35yo F hot flashes and early menopause wtd?

A

FSH level - if elevated - estrogen tx

259
Q

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?

A

SSRI (venlafaxine, paroxetine sertraline)

260
Q

Pt with severe mood swings prior to period so bad needs to miss work - dx?

A

Premenstrual dysphoric d/o

Tx: Paroxetine (paxil)

261
Q

Adrenal cortex

A

Zona Glomerulosa -> aldosterone
Zona Fasciculata -> corticosteroids
Zona Reiticularis -> Sex steroids
Adrenal Medulla -> Epi/norepi

262
Q

Dec’d ACTH

A

no change aldo, dec corticosteroids, dec sex steroids, no change epi/norepi

263
Q

Inc’d ACTH

A

inc’d aldo, inc’d corticosteroids, inc’d sex steroids, no change epi/norepi

264
Q

inc’d corticosteroids

A

dec ACTH, dec sex steroids

265
Q

Congential adrenal hyperplasia

A

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
Q

Pt with hypopituitarism - started on T4 and prednisone - best way to find out adequacey of adrenal gland

A

DMS suppression test - stim test

267
Q

Young woman with hirsuitism irreg peridos normal BP - 17OH progesterone level increased - pt has…

A

17 B hydroxlase def (CAH late onset)

268
Q

Primary Hyperaldo

A

inc’d BP, dec K, inc aldosterone, dec renin (20:1 aldo:renin)

269
Q

Reninoma

A

inc’d BP, dec K, inc’d aldo, inc’d renin

270
Q

Hyporeninemic hypoaldo

A

dec BP inc’d K, dec aldo, dec Renin

271
Q

45yo F routine physical BP 140/110, K 3.3, Cr 0.8, HCO3 27 on ACE, sprionolactone and BB wtd?

A

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
Q

42yo checking BP x 6 months - gradual inc - b/s also with HTN, BP 158/101, Na 134, K 2.9 wtd?

A

Check aldo:renin ratio or 24hr urine aldo

273
Q

Pt dx with primary hyperaldo aldo:renin 20:1 - confirm with suppression test - CT abd wtd?

A

b/l adrenal vein sampling r/o adenoma vs hyperplasia
Tx Adenoma - surgery
Hyperplasia - spironolactone

274
Q

55yo DM on insulin - BP 95/65, K 5.3, bicarb 20, Cr 2.1 BS 165 etio?

A

hyporeninemic hypoaldosteronism

275
Q

When is renin low?

A

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
Q

Cushing’s

A

pt with prox muscle wk, abd striae, fullness face, swelling back of neck, acne, facial hair irreg menstrual cycles, hyperglycemia wtd?
Med reconcililation

277
Q

Cushing’s syndrome w/u

A

24hr free cortisol in urine >100mcg.day confirms cushings
figure out where excess cortisol coming from
(leading cause pituitary adenoma)

278
Q

Cushings Dz - Pituitary/ectopic

A

inc’d cortisol/Ucortisol, inc’d DHEA/17 ketosteroid, inc’d ACTH
Tx: Surgery

279
Q

Adrenal adenoma

A

inc’d cortisol/Ucortisol, dec’d DHEA/17 keto steroid, dec’d ACTH
Tx: Surgery

280
Q

Adrenal Carcinoma

A

inc’d Cortisol/Ucortisol, very inc DHEA/17 ketosteroid, dec ACTH
Tx: Surgery

281
Q

Exogenous steroids

A

Dec Cortisol/UCortisol, dec DHEA/17 ketosteroid, dec ACTH

Tx: D/C (taper) steroids

282
Q

25yo 10lb wt gain, amenorrhea, acne, hirsuitism and is irriatable - posterior cervical fullness

A

check urine free cortisol

283
Q

Pt with elev 24hr urine cortisol - dx with cushings syndrome - ACTH 50 after 8mg dexamethasone suppp ACTH and cortisol suppressed wtd?

284
Q

If MRI neg in cushing’s w/u or ACTH can’t be suppressed then wtd?

A

b/l inf petrosal sinus sampling

285
Q

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?

A

ACTH producing tumor

Tx Correct K, check cortisol, surgery

286
Q

Pt with ACTH mediated cushing dz - source not localized wtd?

A

B/L adrenalectomy

287
Q

Pt s/p adrenalectomy for cushings with h/a, hyperpigmentation dx?

A

Nelson’s syndrome - rapid enlargement of pituitary adenoma after removal of b/l adrenal glands
Tx: pituitary irradiation (replace hydrocortisone first)

288
Q

Addison’s Dz

A

Hyperpigmentation esp palmar creases, oral mucosa, wt loss, salt craving n/v/wk, postural hypotension

289
Q

How to confirm addison’s dz?

A

Check cortisol level

18 - pituitary problem - not making ACTH

290
Q

Pt w/ hypotension and shock - dec Na, inc K r/o addisonian crisi

A

Tx: NS/IV hydrocortisone

291
Q

H/o addison’s on hydrocrtisone and fludorcortisone p//w viral URI - no abx presecribed wtd?

A

Inc hydrocortisone dose

292
Q

Pt dx with hypothyroid and addison’s which to treat first?

A

Give steroids first then thyroxine - otherwise adrenal crisis will occur

293
Q

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?

A

hydrocortisone

294
Q

Pheochromocytoma

A

Palpitations, sweating, h/a, episodic in nature labile BP

inc’d urinary exc of catecholamines and metabolites - part of MEN II/III

295
Q

Screen/dx Pheo?

A

24 hr urine metanephrine/catecholamines

296
Q

If pheo >10cm - wtd?

A

Check Meta Iodine Benzyl Guianine to r/o mets

Tx: surgery

297
Q

Presurgical managment of Pheo

A

Alpha blockade FIRST with prazosin

then Betablockade with propranolol

298
Q

Adrenal incidentaloma

A

> 4-6cm - inc’d risk of malignancy

<4-6cm - benign

299
Q

W/U of adrenal incidentaloma

A

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
Q

Therapy for Adrenal incidentaloma

A

> 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
Q

Pt with CT scan - 2cm mass on adrenal - BP 148/86, 1mg DMS and 17 OH ket steoid normal wtd?

A

Check Renin:Aldo level r/o hyperaldosteronism

If BP normal check urine for catecholamines

302
Q

Pt with 3cm mass on adrenal - all hormones within normal limits wtd?

A

Repeat CT in 4-6 months

303
Q

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?

A 
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
Q

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?

A

Sheehan’s syndrome with hypopituitarism

tx: Replace hydrocortisone first then others….

305
Q

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?

A

Lymphocytic hypophysitis

Inflammation of pituitary gland from autoimmunity

306
Q

18yo with h/a, visual distrbance, poor sexual devlopent - urine osmolarity decreased, prolactin inc’d xray dense suprasellar calcification dx?

A

Craniopharyngioma

307
Q

Male Hypogonadism

A 
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
Q

114yo pw small penis and testes - exam with lack of pubertal and axillary hair - testosterone, LH, FSH normal wtd?

A

reassure - your time will come
Testosterone >350 = normal
200-350 - equivocal
<200 abnormal

309
Q

Man with testosterone <350 wtd?

A

repeat early AM testosterone

310
Q

Man with testosterone <350, BMI 35 or elderly wtd?

A

check sex binding globulin - dec’d with obesity and old age

Check FREE testosterone level

311
Q

Man with testosterone <200 wtd?

A

Check if takes opiod, steroid, hormone tx

312
Q

70yo M with fague - steroids fo rCOPD testosteron 140 etio?

A

taper steroids - d/c steroids

If can’t d/c steroids then testosterone replacement tx

313
Q

Pt asks if testosterone will cause prostate CA

A

will not change composition of prostate tissue

Can exacerbate prostate CA if present - f/u with PSA

314
Q

Baseline PSA 0.5, after testosterone now PSA 2 wtd?

A

d/c testosterone and refer for prostate Bx

PSA SHOULD NOT more than DOUBLE with testosterone replacement tx!!

315
Q

Erectile Dysfxn

A 
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
Q

MC sexual dysfxn

A

premature ejaculation

Tx SSR, sildenafil

317
Q

Can SSRI cause retrograde ejaculation?

318
Q

Pt with dec’d libido - testosterond 150 wtd?

319
Q

Pt with impotence with normal testosterone

A

check nocturnal penile tumescence - differentiate psychogenic vs organic
If normal r/o psychogenic or drug causes

320
Q

nocturnal penile tumescence decreased in…

A 
DM neuropathy
Vasc Insuff
HP gonadal axis problem
Prolactinoma
Hypothyroid
Marijuana
321
Q

Mechanism of sildenafil

A

PDI5 inhib - inc nitric oxide - inc cGMP

322
Q

Married couple comes to you cuz not having kids

A

Sperm count after 3 days abstinence

323
Q

How to manage ED with pt on nitrates

A

Penile tumescent devices

324
Q

How soon after using sildenafil or tadalafil can nitrates be used

A

24 hrs after sildenafil

48 hrs after tadalafil

325
Q

Pt with CP given nitrates and sudden hypotension - had tadafanil 6hrs ago - wtd?

A

Put in trendelenbureg postion, IVF, phenyephrine (NOT NOREPI)

326
Q

Gynecomastia

A

Puberty, elderly, obesity, cirrhosis, germ cell tumor Klinfelter’s

327
Q

15yo wiht enlargement of breast

A

uni or b/l - reassurance - related to puberty

Men - unilater breast inc -> bx

328
Q

Pt with c/o decreased libido - decreased nocturnal penil tumescence - received rad to head - FSH 5, LH 4, testosterone 160 prolactin i22 dx?

A

Gonadotropin deficiency

329
Q

38yo F doing well on fluoxetine for depression unable to achieve orgasm for 2 months wtd?

A

add or switch to bupropion

330
Q

Primary amenorrhea - Never had menses - web neck, short stature, low setears, intact smell, rudimentary ovaries

A

Turner syndrome XO

331
Q

Primary amenorrhea no vagina, no uterus, ovaries OK breasts normal

A

Rokitanksy, kuster huser syndrome 46X

332
Q

Primary amenorrhea with acne, clitoromegaly, hirsuitism no ovaries no breasts

A

46XY gonadal dysgenesis

333
Q

Primary Amenorrhea wit hatrophic vagina no cervic +breasts, no pubic/axillary hair

A

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
Q

Primary amenorrhea with anosmia (can’t smell) dec LH/FSH

A

Kallman’s syndrome

335
Q

St. John’s Wart

A

OCP failure

336
Q

Bariatric surgery

A

Now fertile

337
Q

Polycystic Ovarian Dz

A

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
Q

Premature ovarian failure

A

Ovary fails - dec’d estradiol, inc FSH first, then in LH

Tx: estrogen replacement

339
Q

Etiology of skin lesions in Vitiligo

A

Ab vs melanocytes

340
Q

Amenorrhea with galactorreha Prolactin level >200 wtd?

A

CT /MRI head r/o prolactinoma

341
Q

17 yo amenorrhea BM normal, preg test neg - rx for prg and gets periods - wtd?

A

reassurance?

342
Q

47yo otherwise regular period with amenorrhea for 2 months wtd?

343
Q

Young woman on OCP with no breakthru bleed wtd?

344
Q

Pt stopped taking OCP sever months ago with no menses - preg test neg, LH/FSH normal estrogen challenge no bleed - etiology?

A

Asherman’s syndrome (endometrial adhesions post D&C) or

Uterine synechiae

345
Q

Young marathon runner c/o only couple periods in last year wtd?

A

no further testing
Tx to get back periods - cut down on excercise
Mechanism - excess exc, inhibits LHRH -> hypogonadotropic hypogonadism

346
Q

Pt asks how to to cut down on bone loss in addition to Ca and Vit D

347
Q

Hirsuitism

A

Inc’d DHEA (adrenal) - inc ACTH, inc cortisol, inc’d 17 keto steroids=cushings

348
Q

Pt with hirsuitsim - labs to order?

A

Testosterone, DHEA (17 OH ketosteroid), urine free cortisol

349
Q

Pt with hirusitism testosterone high, corsol normal wtd?

A

TVUS for ovaries

350
Q

18yo F with inc’d hair on arms/legs - family with similar hair

A

no further testing

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