ITE Endocrinology Flashcards
What is the full dose for levothyroxine initiation? What does would you start in someone who is older, or has heart disease?
A) 100 micrograms/d (1.6 micrograms/kg lean body)
B) 25-50 microgram/d
What is the treatment regimen for opioid-related hypogonadism?
STOP opioids; consider testosterone replacement in hypogonadism secondary to chronic opioid abuse
Overt presentation of what common endocrinology condition can cause hyperprolactinemia?
Hypothyroidism
How to treat hyperprolactinemia and hypothyroidism?
treat hypothyroidism first to see if hyperprolactinemia resolves
Screening for pheochromocytoma is initiated if the unenhanced attenuation of an adrenal mass is greater than what?
10 Hounsfield units
When is adrenalectomy indicated?
1) functioning tumors - Pheo, aldosterone producing tumor, hypercortisol, or suspicion for adrenal carcinoma
2) Suspicious tumor - 4cm greater, 60% or less contrast washout at 10 minutes, 10 hounsfield units
Markedly elevated DHEAS and mildly elevated serum testosterone suggests what in someone with signs including deep voice, facial hair, frontal hair loss
adrenal source; consider CT Scan when DHEAS is above 700
If testosterone levels exceed above 150 in a patient with hyperandrogenism, consider what imaging modality?
pelvic ultrasound
Patients with Type I diabetes mellitus and gastrointestinal manifestations should be screened for what?
Celiac disease (esp if rash appears) by way of IgA tissue transglutaminase antibody
What condition can develop with people who have pituitary surgery?
SIADH (low sodium); manipulation of posterior pituitary gland causes increase release of ADH
What is the treatment/management of thyroid storm?
Transferred to ICU; treat with IV beta-blockers (esmolol); thionamides, typically propylthiouracil, transitioning to methimazole when more stable; IV high-dose glucocorticoids and potassium iodide.
What lab should be monitor in a transgender male undergoing masculinizing testosterone therapy?
H/H; screening for erythrocytosis; PSA should be monitored and genetic males taking testosterone therapy to treat hypogonadism because testosterone therapy can accelerate prostate cancer cell growth.
What condition is associated with suppressed parathyroid hormone level, hypercalcemia, a high/high normal serum phosphorus level, and an elevated 1, 25 dihydroxy vitamin D level?
Vitamin D dependent hypercalcemia which can be seen in sarcoidosis, fungal infection, tuberculosis, and lymphoma.
The combination of neurologic findings and anemia in a patient taking metformin for several years is consistent with what?
Vitamin B12 deficiency
Prolonged metformin use can cause a deficiency and what vitamin?
B12
What endocrinology condition is characterized by diffuse signs and symptoms of skeletal disease, as well as, a progressive rise in total alkaline phosphatase preceding overt hypercalcemia or hyperphosphatemia?
Osteomalacia
Osteonecrosis typically occurs in what areas of the body? How to differentiate from osteomalacia?
Osteonecrosis typically occurs in the shoulders, knees, and hips. Is often bilateral but is not a diffuse disease as reflected in a whole-body bone scan
With drug is typically related to drug-induced hyperprolactinemia? What are the signs and symptoms of hyperprolactinemia?
Risperidone, metoclopramide and phenothiazines; amenorrhea and some cases galactorrhea
What is the treatment of drug-induced hyperprolactinemia?
stop the drug if possible; if not, estrogen-progesterone supplementation is necessary to avoid estrogen deficiency
Patient is receiving anabolic therapy for osteoporosis, what must be started within 1 month to complete the course of antibiotic treatment to prevent the loss of newly formed bone?
Bisphosphonate, alendronate
Generally speaking, how long should a course of teriparatide and other anabolic agents last? What are the procedure risk?
Approximately 24 months; most concerning adverse effect of teriparatide therapy is a theoretical increase in bone osteosarcoma rates
What test are used to confirm diagnosis of Cushing syndrome? What follow-up tests will be necessary once diagnosis has been confirmed?
Overnight low-dose dexamethasone suppression test, 24-hour urine free cortisol measurement, and late-night salivary cortisol measurement
Once diagnosis is made, ACTH is measured; if ACTH dependent then you would get a a milligram dexamethasone suppression test
How to differentiate between ACTH dependent Cushing’s syndrome?
High-dose dexamethasone suppression test; if ACTH is suppressed, location of hormone is likely pituitary by way of negative feedback loop; if high-dose dexamethasone suppression test fails, ACTH is likely coming from an ectopic source
In otherwise healthy, young adults, a low energy fracture is not an indication for bone mineral density measurement. What would be the appropriate management?
Lifestyle modifications
How is PCOS characterized?
Hyperandrogenemia, ovulatory dysfunction, and polycystic ovarian morphology on imaging; diagnosis is met when other causes of hyper androgenism are excluded
What drug do you start after stopping denosumab therapy?
Alendronate (or other antiresorptive therapy)
Mental status changes ranging from lethargy to psychosis and coma, coupled with hypothermia, bradycardia, hypotension, or decreased respiration rate with resultant hypoxia/hypercapnia are present and what endocrinology emergency?
Myxedema coma
In a patient with acquired hypothyroidism from transsphenoidal resection, what laboratory levels should be monitored?
Free T4; TSH cannot be relied upon since pituitary would be removed in the scenario
What is the target range for free T4 in a patient with hypothyroidism seeking pregnancy?
Greater than 2.0
Radioactive iodine uptake is high or inappropriately normal and hyperthyroidism due to Graves’ disease. In what condition can radioactive iodine uptake be low (less than 10%)?
Thyrotoxicosis due to destructive thyroiditis
How do you treat destructive thyroiditis?
Depends on symptoms and signs. For palpitations and elevated heart rate, use atenolol/other beta-blocker; if thyroid is tender, use prednisone for anti-inflammatory effects
With treatment modalities considered for patients with differentiated thyroid cancer at an intermediate to high risk for recurrence after thyroidectomy?
Postop radioactive iodine
What is a long-term medical treatment of intermediate to high risk differentiated thyroid cancer?
TSH suppression with levothyroxine
What differential must be considered in a patient with a pituitary adenoma who developed signs and symptoms consistent with severe headache, diplopia, and change in vision?
Pituitary apoplexy with mass-effect; if pituitary apoplexy is companied by visual loss, urgent neurosurgical consultation should be obtained regarding the need for decompression
What is a common side effect/response to IV Zoledronic acid?
acute phase response (fever, chills, myalgia, arthralgia)
What can change total calcium concentrations?
Serum protein (albumin), anion content, or blood pH
What lab do you check to confirm levels of calcium that may be falsely elevated (due to volume loss for instance)?
serum calcium
What is the most appropriate diabetes screening for patient with PCOS?
Screen at time of positive pregnancy test and then again at 24-28 weeks if negative
Administration of what drug/substance could cause thyrotoxicosis in some patients with multinodular goiter?
Iodinated contrast material (usually occurs 1-2 weeks after administration)
What drugs are indicated in suspected thyrotoxicosis?
Methimazole (antithyroid drug that blocks further uptake and synthesis of thyroid hormone)
Propranolol (controls heart rate)
How to diagnose primary adrenal insufficiency?
low morning cortisol level; elevated ACTH levels
What drug has been used to treat Grave’s opthalmopathy?
teprotumumab
Normal range of PTH?
10-55
Normal range of PTH?
10-55
In patients with primary hyperparathyroidism, or bone related indications for parathyroidectomy?
Fragility fractures, vertebral fractures, and a dual-energy x-ray absorptiometry T score less than -2.5
Nonthyroidal illness, such as sepsis, resultant hypothyroidism. What is the mechanism of action?
Illnesses can suppress thyrotropin releasing hormone which typically result in suppressed but detectable thyroid-stimulating hormone; thyroxine is typically low normal
Prediatbetes is always treated with what?
intensive lifestyle management
How to rule out pituitary hypersecretion in pituitary incidentaloma?
Measurement of prolactin and insulin-like growth factor 1
In addition to hypersecretion, patients with pituitary incidentaloma should also be screen for what?
Hypopituitarism; check TSH, LH, FSH, T4, and total testosterone in men
The most appropriate next step in a patient with obesity, decreased libido, and a low total testosterone level is to obtain what lab?
Free testosterone level
Drugs including immune checkpoint inhibitors (anti-PD-1: nivolumab, pembrolizumab), and (anti-CTL-4: ipilimumab, pembrolizumab) can cause what endocrinology pathology?
Hypophysitis: Headache and fatigue; findings of low cortisol and low ACTH; treat with hormone replacement and high-dose glucocorticoids
When TSH is high and T4 is normal in a patient with minimal symptoms, what should you do?
don’t treat subclinical hypothyroidism; repeat thyroid function tests in 6-8 weeks
How to choose a test for hypoglycemia?
If fasting, choose a 72-hour fast
If after eating meals, choose mixed meal test
Whenever patients develop thyroid disease while on amiodarone, what is the diagnostic test of choice?
Thyroid U/S with doppler
How to distinguish Type 1 vs Type 2 Amiodarone induced thyrotoxicosis?
Type 1: occurs in patients with Graves disease (increased vascularity)
Type 2: occurs in patients without underlying thyroid disease (decreased vascularity)
What is the appropriate treatment for primary adrenal insufficiency?
Hydrocortisone plus fludrocortisone
How to diagnose adrenal insufficiency?
Morning cortisol level less than 3 or cosyntropin stim test
Clinical history of what medical conditions warrant workup for Vitamin D malnutrition/malabsorption?
Bariatric surgery, celiac disease
In women with PCOS, what drug can be added if patient continues to have evidence of hirsutism?
Spironolactone; must be on combined oral contraceptive for at least 6 months before initiation
What should women be counseled on if diagnosed with PCOS and started on spironolactone?
They HAVE to be on oral contraceptive since spironolactone can cause demise for male fetus
Mild hypercalcemia, low 24 hour urine calcium excretion (esp if Ca/Cr clearance ratio is less than 0.01), familial history of parathyroidectomy without resolution of hypercalcemia
Familial hypocalciuric hypercalcemia
What is the first step in the workup of female infertility associated with normal menstrual cycles?
Midluteal phase serum progesterone level
The diagnosis of hypercalcemia due to immobilization can be supported by what?
elevated bone alkaline phosphatase; confirmed with durable remission of hypercalcemia with antiresorptive therapy
What is the test of choice for pheochromocytoma if there is a high suspicion of diagnosis?
plasma free metanephrines
What is the test of choice if there is a low suspicion for pheochromocytoma?
urine fractioned metanephrines and catecholamines
In patients with suspected primary hyperaldosteronism taking an ACE/ARB, what excludes the diagnosis?
elevated serum renin level (if suppressed, think primary hyperaldosteronism)
In a patient with type 2 DM and severe kidney disease, what agent is preferred?
DPP-4 (-liptin)
What vaccines should DM patients receive?
yearly influenza, 23-valent pneumococcal, and hepatitis B (18-59)
What is the best screening biomarker for acromegaly? What confirms diagnosis?
insulin-like growth factor 1; oral glucose tolerance test
Drug of choice to treat primary hyperaldosteronism ?
spironolactone/eplerenone
