Internal Endo/ID Flashcards
1
Q
Fever and sore throat, pt taking anti-thyroid meds
A
Agranulocytosis (not strep)
2
Q
Which patients are most likely to develop Rhizopus/mucormycosis (Fever, necrotic invasion of orbit/palate/maxillary bones, purulent nasal discharge)
A
Diabetics
Tx infection with surgical debridgement and amphotericin b
3
Q
Tx for asymptomatic TB vs Sx
A
No symptoms: Isoniazid, with added Pyridoxine (to prevent peripheral neuropathy)
Symptomatic: RIPE (P = pyrazinamide)
4
Q
branching filamentous rods partially acid-fast
A
Nocardia (vs TB: strongly acid fast; vs Actinomycyes: grows on gram stains)
- ->Pulmonary disease, may also have CNS and skin involvement
- ->Imaging: nodular/cavitary lesions in upper lobes (so easily confused with TB)
- ->Immunocompromised pts
- ->Sulfonamides, i.e. Bactrim
5
Q
After a URI, glomerulonephritis can be due to:
A
PSGN IgA Nephropathy (DONT FORGET THIS ONE)
6
Q
PSGN vs IgA Nephropathy
both have gross hematuria aka dark urine
A
PSGN: 10-21 days after URI; children; low C3; renal biopsy = c3 deposits
IgA Neph: 5 days after URI; young adults; normal complement; mesangial IgA deposits;
7
Q
Bicarb, Chloride, Potassium in pt with vomiting
A
Elevated Bicarb (because losing H+) Hypochloremia, Hypokalemia (losing KCl and HCl)
8
Q
Tx for patient with vomiting
A
Normal Saline + Potassium
vomiting = hypochloremic, hypokalemic metabolic alkalosis
9
Q
Explain contraction alkalosis
A
Fluid depletion from vomiting –> RAAS triggered –> conserve Na and H20 –>Aldosterone retains water at the cost of excreting sodium and potassium in urine (already a hypokalemic, alkalotic state with vomiting)
–>Volume resuscitation with NS corrects this
10
Q
HIV patient, African american, nephrotic syndrome
A
Focal Segmental. Also big for diabetics, hispanics, SCD
11
Q
What happens to H+ and K+ in states of high aldosterone?
A
Aldosterone Saves Sodium and Pushes Potassium Out –> Metabolic Alkalosis. Also, HTN.
12
Q
Which drug can cause cyanide toxicity?
A
Nitroprusside…given during HTN emergency. Flushing, AMS, Metabolic acidosis
13
Q
Indications for hemodialysis
A
Acidosis
Electrolyte abnormalities (Hyper-K+)
Ingestion (alcohol, salicylate, Li, sodium valproate, carbamazepime)
Overload (Volume overload refractory to diuretics)
Uremia (sxs= eneceph, pericarditis, bleeding)
14
Q
when should metformin not be given/held?
A
Increases risk of lactic acidosis in patients with :
- acute renal failure
- liver failure
- SEPSIS
15
Q
Urinary retention secondary to anticholinergic use (i.e. 1st gen H1 blocker) is due to:
A
detrusor hypocontractility
16
Q
+Urinary cyanide nitroprusside test
A
Cystinuria (hereditary condition leading to hx of nephrolithiasis)
Hexagonal crystals
17
Q
Main danger of rhabdomyolysis? (immobilization and cocaine abuse are big risk factors)
A
Acute renal failure (ATN) secondary to myoglobinuria
18
Q
Tx for SIADH:
A
IV HYPERTONIC SALINE
Fluid Restriction
Demeclocycline
Vaptans
19
Q
Extrahepatic manifestations of Hep C
A
Arthralgias, fatigue, Porphyria Cutaneous Tarda = photosensitive skin that develops vesciles/bullae with trauma/sun exposure
20
Q
yeast + granulomatous skin lesion + pulmonary complications, seen in Central USA
A
Blastomycosis
21
Q
Yeast infection that mimics sarcoidosis (non-caseating granulomas), especially in Ohio/Mississippi river, arthralgias
A
Histoplasmosis
22
Q
Epididymitis causes
A
> 35: E coli (bladder obstruction)
<35: NG/Chlamydia
Don’t pick mumps unless theres parotiditis/prodromal viral sxs
23
Q
TIck bite + elevated transaminases + thrombocytopenia/leukopenia + no rash
A
Ehrlichosis
24
Q
How often should IVDU and MSM be screened for HIV?
A
Annually
25
Tx for meningococcal meningitis
Ceftriaxone + Vancomycin
26
Tx of choice for Lyme dz in pregnant pt
Can't give doxy, so give Amoxicillin
27
Who gets PCP pneumonia?
HIV <200
| or Chronic Glucocorticoids
28
Manifestations of vibrio vulnificus
Rapidly progressive, cellulitis, hemorrhagic bullae, nec fas, septicemia
- ->marine environments/oysters
- ->IV Ceftriaxone + Doxycycline
29
How to do you make the dx of C dif?
Stool toxin testing
30
Sxs of Coccioides
Community-acquired pneumonia, arthralgias, erythema nodosum, erythema multiforme
31
What metabolic abnormalities does hypothyroidism cause?
Hyperlipidemia (hypercholesterolemia +/- hypertriglyeridemia), Hyponatremia, sxs elevated transaminases and CK
32
Side effects of sulfonylureas
weight gain, hypoglycemia
33
Which anti-diabetic is good for weight loss and maintaining glucose control?
GLP-1 agonist (exenatide)
34
Side effects of TZDs (pioglitazone)
weight gain, CHF, edema, bone fracture, bladder cancer
35
T/F: Hashimoto thyroiditis (hypothyroid) ass with increase risk of lymphoma
True. Including thyroid lymphoma
36
Tx of DKA
Normal Saline + Insulin
37
central hypopituitarism vs primary adrenal insuff
Both have low T4 and Cortisol. Normal Aldosterone in central hypoP, vs decreased in adrenal insuff (b/c Aldosterone secretion regulated by RAAS, not AP)
38
Next step in patient with hypercalcemia
measure PTH.
High PTH = Primary hyperparathyroid, Familial Hypocalciuric hypercalcemia, Lithium
Suppressed PTH = Malignancy (PTHrP), granulomatous dz, vit D toxicity, etc
39
Toxicity of Methimazole/PTU (hyperthyroid drugs)
Agranulocytosis, aplastic anemia, skin rash.
PTU: hepatotoxicity
M: teratogen (aplasia cutis)
40
Criteria for Metabolic syndrome
* 3/5:
1. Abdominal obesity (Male waist>40, F waist>35)
2. Fasting glucose >100-110
3. BP >130/80
4. TG > 150
5. HDL: Men <40, Female <50
41
Key pathogenic factor in development of T2DM and metabolic syndrome
Insulin resistance
42
Adverse effects of radioiodine ablation for hyperthyroidism
Worsening eye problems, permanent hypothyroidism, radiation side effects
43
Adverse effects of surgery for hyperthyrodism
permanent hypothyroidism, recurrent laryngeal nerve damage, hypoparathyroidism
44
Eye problems with graves dz
Proptosis, swelling of periorbital tissue, diplopia, discomfort with ocular movements
-->made worse by therapeutic radioiodine ablation
45
T/F: Myopathy occurs in 1/3 of pts with hypothyroidism
True. Typically elevated CK, Myalgias, Muscle weakness
46
necrolytic migratory erythema, diabetes
Glucagonoma.
| erythematous, papular/plaque/blistering rash affecting perioral region and LE
47
causes of Cushing syndrome
Cushings dz (ACTH-producing pit adenomas), exogenous glucocorticoid use, ectopic ACTH (small cell lung cancer)
48
Conn syndrome
Primary Hyperaldosteronism (Adrenal tumor): HTN, low renin, high aldosterone, high bicarb, high Na, low K
49
Hyperthyroidism + decreased radio-iodine uptake
means that its not from excess production of thyroid hormone (i.e. not Graves)
release of preformed thyroid hormone = painless thyroiditis
50
Steattorhea effect on PTH
Lose out Vitamin D cause its a fat-soluble vitamin, shit it all out. so you can't absorb calcium and phosphate so these are low, and get reflexive increase in PTH
51
how do you test for acromegaly?
IGF-1 levels (can't do GH levels because they fluctuate a lot)
52
T1DM or T2DM: DKA vs Hyperosmolar Hyperglycemic State
T1: DKA
T2: HHS
53
Hyperthyroid, low radio-iodine uptake, high anti-TPO. Dx and Tx?
Dx: Painless thyroiditis (variant of Hashimoto thyroiditis). Self limited hyper-thyroid state followed by hypothyroid and then euthyroid. Does not require methimazole or PTU!!!
Give a beta-blocker for sx mgmt
54
how to diff btwn Psychogenic polydipsia and Diabetes Insipidus?
PP: Low Serum Na
DI: Normal/High Serum Na
55
Types of DI
Central: Dec ADH rel from PP (hypernatremia due to impaired thirst)
Nephrogenic: renal ADH resistance (normal sodium b/c intact thirst mechanism)
56
Polyuria in non-hospitalized patient
Psychogenic Polydipsia and Diabetes Insipidus
57
causes of central Diabetes Insipidus
Pituitary tumor, trauma, surgery, ischemic encephalopathy
58
causes of nephrogenic Diabetes Insipidus
Lithium, Hereditary, 2nd to
59
weight gain, psych sxs, hirsutism, proximal mm weakness, hypertension, hyperglycemia
Cushings Syndrome
60
Causes of Cushings Syndrome
Cushings Disease (ACTH-secreting pituitary adenoma)
Exogenous glucocorticoid
Ectopic ACTH
Primary Adrenal Dz
61
Dx of Cushings Syndrome
2/3 positive:
- 24 hour urinary cortisol excretion
- late night salivary cortisol assay
- low dose dexamethasone suppression test
62
T/F: Successful intensive glycemic index control in T2DM improves all-cause mortality
False. It improves microvesicular complications (retinopathy, nephropathy) but not macrovesicular complications ( MI/stroke)
63
what does ankle-brachial reflex help you assess?
Peripheral vascular disease
64
Which antithyroid drug can you use in pregnancy?
PTU in the first trimester. Can also do thyroidectomy if preg
65
non alpha/non beta pancreatic islet cell tumor
VIPoma
66
features of VIPoma
Watery diarrhea, Hypokalemia, Achlorhydria.
- flushing, muscle cramps, lethargy, N/V
- pancreatic tail tumor
67
When should you not use Amitriptyline for peripheral neuropathic pain?
It is not recommended in age >65 due to anticholinergic effects; also, not recommended in patients with pre-existing cardiac dz
68
Drugs to tx neuropathic pain (i.e. diabetic nephropathy)
TCA (Amitryptiline), Anticonvulsants (Gabapentin/Pregabalin), Opioids, Topical capsaicin or lidocaine
69
Plasma aldosterone/renin ratio > _____ suggests hyperaldosteronism
20
70
which electrolyte abnormalities can cause muscle weakness?
Hypokalemia, Hypomagnesemia
71
most common cause of Cushing syndrome
exogenous glucocorticoid
72
Primary Hyperparathyroidism (adenoma/hyperplasia) labs
Elevated Calcium, which normally suppresses PTH but this will show High PTH.
Phosphorous is USUALLY NORMAL SO DON'T BE A PEASANT
73
Tx for prolactinoma
```
Dopamine agonists (Bromocriptine or Cabergoline)
-->inhibit prolactin secretion
```
NOT INITIAL SURGICAL RESECTION EVEN IF ITS A PITUITARY TUMOR PEASANTRY
74
Relationship btwn prolactin, GnRH, dopamine
Prolactin inhibits GnRH
| Prolactin stimulates Dopamine (which inhibits AP-->Prolactin)
75
how does hypomagnesemia cause hypocalcemia?
inducing PTH resistance and decreased PTH secretion
| not a major cause though
76
Hypocalcemia + Hyperphosphatemia + increased PTH levels
Secondary Hyperparathyroidism secondary to Chronic Renal Failure
-->dec GFR = Phosphate retention...P binds circulating Ca and interferes with renal vit D production...= dec intestinal Ca absorption = increased PTH secretion. High P also directly stimulates PTH.
77
Fever, neck pain, tender goiter following URI. Increased ESR.
Subacute Thyroiditis (de Quervain is associated with pain)
78
low Ca, low Phosphate, high PTH, low vit D, elevated alk phos, bone pain/muscle weakness
Osteomalacia (caused by
malabsorption/intestinal bypass/celiac/chronic liver/chronic kidney) is "due to defective mineralization of organic bone matrix" (and not "accelerated focal bone remodeling"= Paget)
79
When do you use metoclopromide?
Gastroparesis (diabetic or post-op). Also, anti-emetic
80
What is gastroparesis?
Delayed emptying of the stomach...typically due to diabetic autonomic neuropathy.
81
T/F: Diabetic patients can have hypoglycemia with insulin injections if they have impaired gastric emptying/delayed absorption
True. I.e. Gastroparesis
82
Does diabetic neuropathy affect long or short axons first?
Long. Its a length-dependant neuropathy.
83
Small fiber vs large fiber diabetic neuropathy
Small: Positive sxs --> pain, paresthesias, allodynia (ordinarily painless stimuli = painful)
Large: Negative sxs --> loss of MVP, numbness, loss of reflex
84
Sxs that PCOS does and does not share with Cushing
Both: obesity, irregular menstrual periods, hyperandrogenism (acne, hirsutism, irreg menstrual)
Cushings only: skin atrophy, bruisability, muscle weakness, increased cutaneous fungal infections (tinea), hyperpigmentation, lanugo
85
Does cushings have hyper or hypo androgenism?
Hyper (menstrual irregularities, acne, hirsutism)
- ->due to co-secretion of Cortisol and Androgen (adrenals)
- ->absent in iatrogenic steroid use...exogenous steroid inhibits adrenal
86
Does cushings have hyper or hypo glycemia?
Hyper
| -->due to decreased glucose tolerance (diabetes)...peripheral insulin resistance + cortisol induced gluconeogenesis
87
what are the MSK effects of Cushing's and why do they occur?
Proximal muscle weakness/wasting, osteoporosis, aseptic necrosis of femoral head
-->Cortisol increases protein catabolism and impairs collagen production
88
How do you workup Cushing syndrome to determine presence and cause?
1. Overnight low-dose dexamethasone suppression or 24 hour urinary free cortisol level
- ->if normal, not cushings
- ->if cortisol >5, its Cushings syndrome. now figure out etiology
2. Measure ACTH
- ->low: Adrenal imaging for tumor/hyperplasia
- ->high: High Dose-Dexamethasone suppression test
- ->ACTH suppressed: Cushings disease
- -->ACTH not suppressed: ectopic ACTH tumor
89
when would you suspect ectopic ACTH-producing tumor and what are the dx steps?
When High cortisol with low-dose dex + high ACTH with high-dose dex suppression tests.
Get Chest CT, Abdominal CT, Ocreotide scan
90
who gets parathyroidectomy in primary hyperparathyroidism?
- Symptomatic hypercalcemia (stones, bones, groans)
- Complications: Osteoporosis, nephrolithiasis, impaired renal f(x)
- Age <50
- Serum calcium >1 above normal; Urine calcium >400
91
T/F: Patients with HHS develop neuro complications including lethargy, blurry vision, obtundation
True (Hyperosmolar Hyperglycemic State...T2DM)
92
T/F: DKA and HHS patients typically have normal serum and total potassium levels
False. Will typically have normal serum values but depleted total K (loss of insulin = all the K comes out of the cells and gives false picture of K state...also have excessive urinary loss due to osmotic diuresis)
93
DHEA vs DHEAS
Ovaries and adrenals both produce DHEA, only adrenals produce DHEAS (and thus controlled by ACTH, whereas ovaries conducted by LH).
so Adrenal tumor: Both are up
Ovarian tumor: DHEA up, DHEAS normal
94
how can blood transfusion affect calcium levels?
Hypocalcemia
-->citrate in transfused blood binds ionized calcium (typically seen in pts with hepatic dysf(x) because liver can normally get rid of citrate)
95
What should diabetic patient between 40-75 with normal total cholesterol but high triglycerides use?
dont be a peasant: all diabetics btwn 40-75 get statins b/c proven decrease in cardiac events (they want you to pick fibrates)
96
T/F: Hirsutism in females is always due to PCOS
FALSE YOU PEASANT. WHEN THEY SEE HIRSUTISM + IRREGULAR MENSTRUAL, DO NOT always AUTO JUMP PCOS.
-->PCOS (most common), CAH, OVARIAN/ADRENAL TUMORS, CUSHING, ACROMEGALY, High Prolactin
97
What dx steps if you think woman has androgen-secreting tumor (acute-onset hirsutism/androgenism)?
Its either Adrenal or Ovarian Tumor. Order Testosterone and DHEAS.
IF T and DHEAS both up: Adrenal tumor (DHEAS only adrenal)
If T up with normal DHEAS: Ovarian tumor (more common)
Note: DHEA is made by both, so need DHEA-S
98
Next step if patient has high calcitonin + malignant thyroid tumor
=Medullary thyroid cancer. Associated with MEN 2a and b, which have Pheochromocytoma. Get plasma metanephrines.
99
Sxs of pheochromocytoma
Pressure (BP), Pain (HA), Perspiration, Palpitation, Pallor
100
Sxs of carcinoid
Episodic flushing, secretory diarrhea, bronchospasm, cardiac valvular abnormalties.
--> cause increased production of Serotonin from Tryptophan (req for niacin synth) = niacin def = pellagra = dermatitis, diarrhea, dementia
101
T/F: If a patient with syphillis is penicillin allergic, you treat with doxycycline
True: don't need to do desensitization for early syphillis.
If CNS affected, multiple tx failures with alternatives, or PREGNANT PATIENTS, then you do desensitization
102
T/F: Toxoplasmosis causes fungal meningitis particularly in HIV patients
False. it is a PARASITE, that causes brain abscess/lesion in HIV patients
103
Tx for cryptococcal meningitis
Amphotericin + Flucytosine, followed up with Fluconazole
104
Cardiac block, erythematous rash, lightheadedness, syncope, myalgia
Lyme
105
T/F: Acyclovir, ganciclovir, and valcyclovir all work well against CMV
False...only Ganciclovir
106
most common cause of odynophagia/dysphagia in HIV patients
```
Candida esophagitis
(CMV esophagitis will be if there are linear ulcers/intracytoplasmic and intranuclear inclusion bodies)
```
107
Rheumatic fever vs Infective Endocarditis
RF - Strep pyo: JONES
IE - several organisms staph/strep/enterococci: Fever, Roth Spots, Osler Nodes, Murmur, Janeway lesions, Anemia, Nail-bed hemorrhage, Emboli
108
causes of Infective Endocarditis
Staph aureus/epidermidis: prosthetic valves, intravascular catheters, pacemaker, IVDU
Enterococci: Nocosomial UTIs
Strep viridans: dental procedure
109
Sxs of Pheochromo
```
Episodic hyperadrenergic sxs:
Pulse
Pressure
Pallor
Pain (HA)
Palpitations (Tachycardia)
```
110
T/F: Once you discover a thyroid nodule, next step is FNA
False. Next step is TSH level, US, and clinical eval. FNA if US/clinical shows signs of cancer
111
Patient has thyroid nodule. TSH is low. Next step?
Radio-iodine...if hot nodule (low risk), tx hyperthyroidism; if cold nodule (higher risk), FNA
112
Patient has thyroid nodule. TSH is normal or elevated. Next step?
FNA
113
T/F: Anti-TPO associated with misscariages
True. Hashimoto's can cause miscarriage (so not always antiphospholipid)
114
What is it called when a patient has abnormal thyroid function tests after a severe illness but no hx of thyroid dz?
Euthyroid sick syndrome (low T3 syndrome) --> normal TSH, T4, but low T3
115
best markers for DKA resolution:
1. Anion gap
| 2. beta-hydroxybutyrate (and NOT acetoacetate)
116
Anorexic gets admitted and given NG feeds. what might you expect? labs and cause
Refeeding syndrome: Surge in INSULIN
- ->causes uptake (DECREASE IN) PHOSPHATE, MAGNESIUM, POTASSIUM
- ->cardiopulmonary distress/failure
117
What hormones do you look at to differentiate between 3 most common causes of secondary amenorrhea?
Prolactin (hyperprolactinemia)
TSH (hypothyroidism)
FSH (premature ovarian failure. young lady 20s-30s, increased FSH and LH, low estrogen)
(could do hysteroscopy if prior uterine procedure/infx and worried about an Ashermans)
118
Dx of metabolic syndrome
3/5:
1. Abdominal obesity (M: waist>40in. F: wait>35)
2. Fasting glucose >100-110
3. BP >130/80
4. Triglyceride>150
5. HDL (M: <40. F: <50)
119
____ ____ plays a central role in metabolic syndrome
Insulin Resistance
120
T/F: Subacute (de quervian) thyroiditis is a postviral inflammatory illness associated with pain and hypothyroidism
False, everything true but its HYPERthyroidism
121
T/F: "Thyroiditis" is always hyperthyroid state
False.
- Subacute thyroiditis (-TPO) and painless thyroiditis (+TPO) = hyperthyroid
- Hashimoto thyroiditis (+TPO) = hypothyroidism
122
What is chronic lymphocytic thyroiditis?
aka Hashimoto's habibti
123
T/F: Tx of subacute thyroiditis is reassurance
Nah, give beta blockers (thyrotoxic sxs) and nsaids (pain )
124
Think of hypercalcemia as : (1) or (2)
PTH dependent: high PTH (Primary; familial hypocalciuric; lithium)
PTH independent: low PTH (malignancy i.e. PTHrP, VIt D, Granuloma, thiazides, milk-alkali)
125
Hyperosmolar Hyperglycemic state = high glucose/osmolarity due to insulin _____ and _____ counterregulatory hormones (cortisol/glucogon/GH/catecholamines)
insulin def
| elevated counter-reg
126
What precipitates HHS in T2DM?
Infection (most common)
Meds (STEROIDS, thiazides, atypical antipsychotics)
Trauma/MI/stroke
127
dif btwn euthyroid sick syndrome and subclinical hypothyroidism
Euthryoid: "Low t3 syndrome" in a patient thats sick (t4, tsh normal)
Subclinical: elevated TSH, normal T4 and T3 (t3 can dec late)
128
Patient with hypertension has hypernatremia and hypokalemia. What are you suspecting and what's the workup?
Hyper-aldosteronism.
1. MEASURE free Renin:Aldosterone RATIO. >20 = likely
2. if likely, Adrenal suppression testing (salt loading). +test = inabiity to suppress
3. next, get CT to decide if its hyperplasia or adenoma
(if CT doesn't diff, do adrenal vein sampling). Resect adenoma, medical for hyperplasia
129
T/F: Patient w/hypertension, hypernatremia and hypokalemia. Suspecting hyper-aldosteronism so get dexamethasoen supp test
False. You have to get Renin:aldosterone ratio (look for >20) and salt (adrenal) suppression testing
130
T/F: DKA is characterized by osmotic diuresis that reduces total body K even though serum K may be elevated
TRUE!
- ->osmotic diuresis = losing shit ton of K through kidneys
- ->acidosis and low insulin causes extracellular shift of K
131
why does infection precipitate DKA?
systemic release of counter-regulatory hormones (cortisol, catecholamines, glucagon)....resultant excess glucagon = hyperglycemia, ketonemia, osmotic diuresis
132
what is the state of hepatic gluconeogenesis in DKA?
its actually increased even though glucose levels are high af.
- ->high glucagon (counter-reg hormone), cortisol, catecholamines
- ->low insulin
133
most common cause of central adrenal insufficiency?
Exogenous steroids!! i.e. PMR or autoimmune pt.
| -->suppress CRH from hypothal and ACTH from AP
134
Labs in central (exogenous steroids) vs peripheral adrenal (autoimmune) insufficiency
Central: Low ACTH, Low cortisol; normal aldosterone
Peripheral: High ACTH, low cortisol, low aldosterone
135
clinical features of central vs peripheral adrenal insuff
Peripheral (primary): Much worse...hyperpigmentation, hyperkalemia, hyponatremia, hypotension
Central: mild...no hyperpig or hyperkalemia
136
how do you differentiate follicular thyroid carcinoma from benign follicular adenoma (both have follicular cells in similar organization i.e. clusters/clumps)
Follicular cancer: invasion of tumor capsule/blood vessels. Mets via hematogenous spread.
137
what are the cardiac manifestations of carcinoid?
right-sided valvular lesions...i.e. tricuspid regurg
138
T/F: Carcinoid can cause paraneoplastic ACTH secretion just like small cell (and lead to Cushings)
True
139
How do you interpret RAIU scan in hyperthyroid patients (wouldn't need if signs of graves present i.e. exopthalmos and goiter)?
LOW: measure THYROGLOBULIN.
- ->Low: Exogenous hormone
- ->High: Thyroiditis; Iodide exposure
HIGH: look at uptake pattern
- ->Diffuse: Graves
- ->Nodular: Toxic adenoma; Multinodular goiter
140
why is fetal hyperthyroidism seen in graves patients?
TSH receptor antibody crosses placenta
141
Risk of untreated hyperthyroidism?
Bone loss/osteoporosis
142
management of hypothyroidism patient during pregnancy?
increase levothyroxine ONCE THE pregnancy is detected
143
Total T4, free T4, TSH levels during pregnancy
Total T4 Increased, Free T4 unchanged/inc, TSH dec.
- ->b-hCG stimulates Thyroid hormone in 1st sem (so dec TSH)
- ->Estrogen stim TBG, and thus thyroid gland has to make more to keep free t4 levels steady ( so total increases)
144
hyperthyroidism with diffuse, nontender enlargement of thyroid gland
= goiter + hyperthyroidism = GRAVES GRAVES GRAVES
145
Sxs of thyroid (thyrotoxic crisis) storm (seen in patients with un-dx/poorly controlled hyperthyroidism)
fever, hemodynamic instability, cardiac instability, CHF, seizures
146
precipitants of thyroid storm (in pt w/un-dx or poorly controlled hyperthyroidism)
Surgery, infection, trauma, iodine contrast (i.e. CT w/contrast), childbirth etc
147
what labs would you expect in a patient with hyperosmolar hyperglycemic state?
pH: normal
anion gap: normal
Glucose>1000
serum osmolality>320 ((2xNa) + (plasma glucose/18))
148
most important step in tx of HS
FLUIDS (normal saline). and then, IV Insulin (not subq)
149
hemodynamic effects of thyroid storm
systolic htn (increase contractility), widened pulse pressure, increase CO, decrease systemic vascular resistance, increase myocardial O2 demand
150
how does hyper prolactinemia lead to hypogonadism?
Suppression of GnRH (so get low FSH, LH and T)
151
myalgias, progressive proximal mm weakness, elevated CK-MB, normal ESR, fatigue, delayed reflexes ("sluggish ankle jerks bilaterally")
Hypothyroid myopathy
152
T/F: Hot nodules are almost always benign and can be treated like hyperthyroidism
True. "Hot" = increased isotope uptake/hyperfunctioning
153
Insensitivity of FSH and LH receptors, so have low testosterone but high FSH and LH.
Klinefelter. Also have testicular atrophy, 47 XXY, infertility, eunuchoid body shape. Tx with testosterone
154
low GnRH, low FSH LH, low testosterone. Anosmia
Kallmans
155
how do you differentiate btwn Gonadotropin-dependent and gonadotropin-independent precocious puberty?
(workup for kid with advanced bone age and low basal level of LH)
Dependent (central): GnRH stimulation test = high LH (may have high basal LH with advanced bone age)
-->80% = idiopathic precocious puberty (only females). premature HPA axis activation
Independent (peripheral): GnRH stim test = low LH
-->late-onset (nonclassical) CAH (severe acne, course pubic/axillary hair)
-->exogenous testosterone
-->Leydig cell tumor (unilateral enlargement)
etc
156
complicated delivery + lactation failure, hypotension, anorexia, hypotension
Sheehan (ischemic necrosis AP)
157
effect of ACE-I on renin
Increases!!
| -->So not converting AG1->AG2. Aldosterone is decreased so renin is reflexively increased
158
Why isnt clinically significant hypernatremia and edema seen in primary hyperaldosteronism?
Aldosterone escape
-->HTN caused by initial increase in aldosterone causes reflexive increased in renal blood flow and GFR and increasing Na excretion, mitigating the effects
159
_____ may present with androgenic alopecia in females
PCOS
160
PCOS patients should be screened for:
Diabetes with oral glucose tolerance test
161
In the tx of PCOS, _____ are for controlling menstrual irregularities; _____ is for inducing ovulation
OCP
| Clomiphene citrate
162
In females with precocious puberty, source of premature adrenarche vs thelarce
Adrenarche (hair/acne): Adrenals (androgens)
Thelarche (boobs): Ovaries
-->although ovaries make some testosterone (esp in PCOS), you would expect thelarche with ovarian excess
163
Diabetes meds:
- wt gain
- wt neutral
- wt loss
Gain: sulfonylureas, TZD (pioglitazone)
Neutral: metformin, DPP4,
Loss: GLP-1 agonist (exenatide)
164
prolactinoma vs pituitary adenoma
Prolactinoma: primary prolactin secreting tumor, levels >200 are diagnostic
Adenoma: nonfunctional, sxs from mass effect. mild increase in prolactin but not that high. central hypogonadism and hypothyroidism (look for dude with libido and tired probs)
165
who gets diuretic-induced hypokalemia?
Primary hyperaldosteronism patients. may not have a lot at rest but withdiuretic sig hypokalemia
166
ddx: htn and hypokalemia; increased renin, increased aldosterone
- diuretic
- cirrhosis, chf
- renovascular htn
- Renin secreting tumor
- malignant htn
- coarctation aorta
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ddx: htn and hypokalemia; decreased renin, increased aldosterone
primary hyperaldosteronism. get adrenal CT
168
ddx: htn and hypokalemia; decreased renin, decreased aldosterone
- CAH
- Cushings
- glucocorticoid resistance
- exogenous mineralocorticoid
169
polyuria in a non-hospitalized patient
- DM
- DI
- PP
170
how do sodium values differentiate PP and DI in a patient with polyuria
<135 -->PP
| >145 -->DI
171
Thyroid changes of pregnancy
Estrogen: increases thyroid-binding globulin = increase total t4
hCG: stimulates TSH receptors causing increase in free T4, T3
so on the hyperthyroid side of things (lab wise not sx)
172
Patient undergoes surgery and is fucked up after. How do you differentiate malignant hyperthermia from thyroid storm?
MH: hypercarbia, sinus tachy, MUSCLE RIGIDITY, elevated Creatine Kinase, HYPERKALEMIA, hyperthermia
TS: tachycardia, hypertension, high fever, tremor, cardiac arrythmias (i.e. afib), altered mentation, LID LAG
173
tx thyroid storm
beta blocker (dec adrenergic sxs)
PTU with iodine solution (dec T4 synth)
steroids (dec peripheral T4-->T3 conversion)
(all)
174
how to tx Graves?
Options:
1. Antithyroid drugs (PTU/M): old people! pregnancy! mild dz
2. Radioactive iodine: moderate-severe
3. Thyroidectomy: large goiter, possible cancer, also hyper parathyroid, severe opthalmopathy,
175
T/F: Failure to suppress GH with glucose admin r/o Acromegaly
false, this makes the dx of Acromegaly
| so suppression of GH by glucose r/o acro
176
Tx of acromegaly
surgical resection (pituitary)
- octreotide
- pegvisomant (GH receptor antagonist)
- cabergoline/bromocriptine
177
cause of death in acromegaly
cardiac
| -->concentric myocardial hypertrophy, diastolic dysfx, global hypokinesis
178
why do alcoholics have hypocalcemia?
due to hypomagnesemia (dec release and sensitivity of pth)
179
best markers indicating resolution/improved DKA
serum anion gap and beta-hydroxybutyrate levels
180
pt has signs of hyperthyroidism. RAIU shows uptake <5% and anti-TPO present in high titers. dz and tx
Silent (painless) thyroiditis. will have nontender enlarged goiter also.
SO because not uptaking a lot, youre not making increase thyroid hormone so dont use anti-thyroid drugs or radioactive iodine.
The TPO antibodies (normally hashimoto) tell you youre just releasing pre-formed hormone, will ultimately become hypothyroid and then euthyroid. give beta blockers rn
181
Despite normal/elevated serum levels, patients with which disease have total K deficit due to excessive urinary loss
DKA or HHS. Cause by glucose induced osmotic diuresis
