Endocrinology, Diabetes, Metabolism 9% Flashcards
Screen for pituitary-gonadal axis
LH, FSH
Screen for pituitary-adrenalaxis
ACTH
Most sensitive determinant of pituitary fxn?
FSH, LH level
Screening for Acromegaly
IGF-1 (not GH because of pulsatile release)
CT head shows 0.8cm solid mass in pituitary. The - pt nulliparus, menustration regular. Next step?
Check all axises
- prolactin
- thyroid: T4, TSH, IGF-1
- Cushings: 1mg DMS test
Things that increase prolactin
Nipple manipulation Phenothiazines reserpine Mehydopa estrogens marijuana prgenancy hypothyroid
Prolactinoma
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
Middle aged woman wit dec libiddo adn fatigue test low, FSH low
check prolactin adn TSH
Pt wit galactorreha wtd?
check TSH and prolactin
Young woman with galactorreha on manipulation of nipple, TSH/prolactin normal
avoid manipulation of nipple
35yo F with galactorreha and amenorrhea x 6 months - preg neg prolactin 184 TFT normal wtd?
MRI r/o stalk tumor
Pt post partum continues to have galactorrhea fter finishing nursing baby - TSH 2.8, prolactin 281 takes no meds - dx?
prolactinoma - check MRI
45yo M c/o fatigue and dec libido - testosterone 18, prolactin 2500 FSH 2.2 cause?
prolactinoma
Pt with prolactinoma micro or macro - wants to concive
start dopamin agonist (bromocryptine - reduce prolactin level and induce ovulation
Pt tx’d with bromocryptine for macroadenoma and gets pregnant wtd?
d/c bromocryptine monitor visual fields - only restart if changes
Acromegaly
inc’ing shoe size, hat size, ring size, hyperglycemia, prominent jaw, wide space between teeth, big tongue, flshey palms soles, osteoarthritis changes on Xray
Screening test for acromegaly
IGF-1 (somatosatin C) - also to follow dz activity
Confirm acromegaly (after IGF-1 screening) with…
oral glucose suppression test failure to suppress GH to <2ng after 100g glucose
Tx for Acromegaly
Transphenoid surgery
Complciations of acromegaly
HTN, LVH, CHF, OSA, colonic polyps, carpel Tunnel
DM
dx FBS>126 - repeat x 1 to confirm HgA1c>=6.5 Random blood sugar >200 with sx 75g gluc load GTT >200
Pt with BP 135/80 or BMI 25 or sedentery lifestyle or >40 yo wtd?
FBG –> screen for DM (FSG, HgA1c)
Pt with DM (FSG >126) at risk for
DM and retinopathy, nephropathy
DM I vs II
check for Ab vs glutamic acid carboxylase, ab to islet cells
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
Hospitalized patient with increased glucose irrespective of reason w/ glucose 140-180
tx with basal insulin and rapid acting agent
Sulfonyureas (glipizide), glyburide, glimeperide
inc’d release insulin form B cells avoid in obese pts glyburide has increased mortality in elderly and CAD
Meglitnide - repaglinid
inc rel insulin from B cells - excreted in bile DOC in renal insufficiency rapid acting
Biguanides - metformin
dec hepatic gluconeogenesis, dec insulin resistantce, dec weight, TG, chol TOC in obese pts and with inc TGA lactic acidosis 5%
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.
Thiazolidinediones (glitazones) - pioglitazone - actos
PPAR rct - inc glucose transport dec insluin resistance dec TGA, inc LDL - avoid in NYHA II HF thigh high edema
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
Inretin memetic - DDP4
Sitagliptin (januvia s/e nausea
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
Which DM meds DO NOT CAUSE WT GAIN?
Metformin, incretin drugs (exenatide and amylin alaog pramlintide
Blood sugar goals in DM
A1c<120
Pt with BMI 32, FBS 115 fhx DM - best way to prevent DM?
Diet/excercise (aerobics and resistance training
Drugs that cause hyperglycemia
Statins, BB, HCTZ, niacin, olanzapine, PI, steroids
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
Pt with DM II and obese not well controlled on sulfonyurea (glipiz,glyburide, glimeperide)
Add metformin
What’ increases insulin sensitivity
Glitazone
Which drug improves mortality and dec early HF in DM pts
Metformin
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
If FBS with just insulin and metformin still 115- 130
start lispro insulin
Pt refuses insulin injections wtd
continue metformin add sulfonyurea or glitazone
S/E metformin
lactic acidosis
When is metformin contraindicated?
Cr >1.4 F>1.5 M and advanced HF (>NYHA II)
Pt on multiple meds Cr >1.5, CHF EF 35% wtd?
d/c metformine and glitazone, start glargine for detemir and lispro or aspart
Pt going for cardiac cath or radiocontrast study - what drug to stop?
Metformin
60yo Pt dx with DMII - Cr 3.7 - what meds to start?
repaglinide (excreted in bile)
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
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
DM pt on NPH/R in AM, supper or glardgine HS Palpitations, sweating, nocturnal awakening AM h/a wtd?
check 3am FSG
Blood sugar 3am 40
change NPH to HS or swtichto long acting insulin analog (glargine)
Persistently ele FBS 3am 200
inc supper NPH or glargine
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
FSG 180 5pm
in NPM in AM
FSG 4pm 25 and 10pm 210 pt in 36U NPH in AM
Change to 24 U NPH AM and 12U NPH PM
All post prandials high, premeals ok on basal bolus regimen
inc dose of pre-meal insulin
All pre and post prandials high
inc long acting insulin dose
FBG 115 but A1c 7.5 takes NPH/metformin wtd?
check POST prandial blood sugar
65yo M DM started on glargine insulin 30U qam with metformin with FSG going steadily up throughout day
change to glargine twice daily
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
AA M DM f/u FBS 115-130 A1c 11 etiolgoy?
hemoglobinopathy
Falsely elevated HgA1c
decreased RBC turnover (dec retic) IDA Folate/B12 def Hemoglobinopathies Sickle cell, thalassemia
Falsely LOWER HgaA1c
inc’d RC turnover (inc retic) Hemolytic anemia, HIV treating IDA, folate B12 def or blood tx
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
Pt with DM, BS 340, TG 2400 hospitalized with pancreatitis - fastest way to control TG would be to give…
Insulin
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
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
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
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
24yo Preg F 24th wk FBS 115, repeat 114 - wtd?
Metformin (ok in preg)
25yo DM pt 24th wk FBS 120, post prandial 180 on glucotrol and metformin wtf?
add insulin
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
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
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
Newly Dx DM BG 350 on insulin drops to 130 - becomes tachy adn diaphoretic wtd
keep <200 at first
DM complications
Macrovasc - CAD/PAD - aggressive LDL control autonomic peripher sensory motor polyneuropathy stock/glove distribution - amitryptyline, desipramine, gabapentin
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
Cause of DM foot ulcer
peripheral neuropathy
Best way to prevent DM foot ulcer
mon-filament testing - protective footwear
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
T/F type I DM should have annual eye exam after 5 yers after onset of DM or age 30 whichever first
T
T/F Type 2 DM pt shoudl have annual eye exam from onset of dz
T
T/F DM pt with difficulty driving at night will prob have ED
T
T/F ACCORD trial HgA1cd hypoglycemic events
T
T/F ACCORD trial BP <140./80 had more s/e
T
Current recommendations for f/u DM pt
HgA1c quarterly, microalb semi ann, lipid panel annual, opthal exam annually
Pt with BS 35 taking glipizide, metformin acarbose
admit start IV dextrose
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
Above pt still hypoglycemic - ampule D50 give, IV dextrose started next step?
glucagon then octreodtide
TRH
downreguated by T4, lithium, iodine
SICU thyroid
dec T3, normal T4 and TSH
best test to screen for thyroid dz
TSH confirm with T4, FTI
Best test to follow hypothyroid tx
TSH
Best test to follow Hyperthyroid tx
FT4 or T3 Total T4 + T3=T3RIA
Thyrotoxicosis
T3 inc->inc T3 RIA
Radioiodine uptake
inc’d Hyperthyroid states (graves, hot nodules) dec’d thyroiditis (exogenous, amiodarone)
Radionuclide scan
differentiate between hot vs cold nodules
FNA/bx
cold nodules
Ultrasound
diff solid vs cystic
Graves dz
inc FT4, inc T3, dec TSH, inc RAI
Multinodular goiter
hot nodules - inc FT4, inc T3, dec TSH, inc RAI
Toxic nodule
inc FT4, inc T3 ria, dec TSH, inc RAI
T3 thyrotoxicosis
n/dec FT4, inc T3 ria, dec TSH, inc RAI
TSH adenoma
inc FT4, inc T3RIA, inc TSH, inc RAI
Thyroiditis
inc thyroglobulins, inc FT4, inc T3 RIA, dec TSH, inc RAI
exogenous T3 (factitious)
dec FT4, inc T3RIA, dec TSH, Dec RAI
Exog T4 (factitious)
inc FT4, inc T3 RIA, dec TSH, dec RAI
Primary hypothyroid
dec FT4, Dec T3 RIA, inc TSH - RAI n/a
Hypopit hypothyroid
dec FT4, dec T3 RIA, dec TSH
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
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
Elderly pt with wk, EKG afbi, TSH dec’d - etiology of afib?
hyperthyroid
Elderly pt with apathy, wt loss, arrythmia, CHF, diarrhea, depression, sleepiness, TSH dec, T4 nlow normal T3RU >30%
apathetic thyrotoxicosis
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)
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”
40yo Pt with asympt low tsh
subclinical hyperthyroid - onitor, repeat TSH in 3months - tx only if osteoprosis or CV dz present
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
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
Can you cardiovert afib to NSR in thyroid storm?
No, not till 3 months after euthyroid - spontaneous conversion common
Pt with graves d has radioiodine ablation - 8 wks later gained wt, TSH 0.2, free T4 0.2 wtd?
start T4 (hypothyroid)
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
Pt with thyrotoxicosis and ophthalmopathy - management?
Surgery
Thyroiditis
all with dec’d RAI uptake - may present hyper,hypo or euthyroid Release of preformed hormones - thyrotoxicosis - returns to nromal Thyroglobulin inc’d….
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….
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
Ab most likley to differential graves vs thyroiditis
TSH rct autoab in graves Anti TPO + in both, TBG elev in both
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
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
Pt p/w tremor/tachycardia on asa, dig, amiodarone, IFN - T3, T4 high, TSH low, RAI < 5% - etiology?
Amiodarone or alpha interfereron
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
Hypothyroid
cold intolerance constipation, coarsening of feathers, delayed DTR, amenorrhea, elevated prolactin
TSH elev, T4 dec
primary hypothyroid
TSH dec, T4 dec, rT3 dec
hypopit hypothyroid
TSH inc, T4 nl
subclincial hypothyroid
Pt p/w fatigue, cold intolerance and delayed DTR - TSH 6, T4 1.2 (normal)
hasimotos thyroiditis - leading cuase of hypothyroid - anti-TPO+
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)
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