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ENDO 2 Exam II (2017) > Kinder Endo CIS > Flashcards

Kinder Endo CIS Flashcards

1
Q

we have a concern of prolactinemia in a patient. What labs should we order?

A

pituitary hormones
PRL especially but also the TRH (can increase prolactin)

liver enzymes

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2
Q

what should we check in a woman who has not had menses in 3 months?

A

pregnancy

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3
Q

Differential Diagnosis of Sella Turcica Mass

A 
Pituitary Adenoma
Pituitary Hyperplasia
Craniopharyngioma
Meningioma
Germ Cell Tumor
Chordoma
Primary Lymphoma
Cyst
Abscess
Arteriovenous Fistula of the Cavernous Sinus
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4
Q

Hyperprolactinemia etiologies

A 
Physiologic
Pituitary and hypothalamic disorders
Systemic disorders
Pharmacologic (esp. antipsychotics, anticonvulsants)
Toxins
Inheritable
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5
Q

physiologic causes of hyperpolactinemia

A 
Pregnancy
Lactation
Breast stimulation/breastfeeding
Sexual activity
Exercise
Sleep
Stress
Eating
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6
Q

Pituitary and hypothalamic disorders that cause hyperprolactinemia

A

Tumors of the Pituitary:
Prolactinoma
Micro or Macroadenoma
Nonprolactin macroadenoma due to stalk compression
Adenoma with multihoromone secretion
E.g. 25% of tumors that secrete growth hormone also secrete prolactin

Other tumors (that block the path of dopamine to the pituitary):
Craniopharyngioma, meningioma, germinoma, and metastatic

Infiltrative diseases
Sarcoidosis, tuberculosis, and Langerhans cell histiocytosis

Radiation
Trauma
Surgery
Rathkes cyst
Empty sella syndrome (pituitary is squished, stretching the stalk)
Lymphocyctic hypophysitis
Pseudotumor cerebri
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7
Q

Systemic Disorders leading to hyperprolactinemia

A 
Chest wall
Trauma, surgery, nipple piercing, and herpes zoster
Renal failure
Cirrhosis
Seizures
PCOS
Adrenal insufficiency
Hypothyroidisim
Pseudocyesis- false pregnancy
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8
Q

drugs leading to hyperprolactinemia

A 
Antipsychotics (dopamine antagonists)
Antidepressants
Anticonvulsants
Opiates
H2 Blockers
Estrogens
Protease inhibitors
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9
Q

heavy metals that can cause hyperprolactinemia

A

E.g barium, lead

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10
Q

genetic disorders leading to hyperprolactinemia

A

Multiple endocrine neoplasia type I – Autosomal Dominant
Parathyroid tumors, gastropancreatic tumors, and anterior pituitary tumors

Carney complex – Autosomal Dominant
Myxomas, increased endocrine activity, schwannomas, and spotty skin pigmentation

McCune-Albright syndrome – Random mutation of GNAS gene
Fibrous dysplasia of bone, endocrine abnormalities, and café au lait spots

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11
Q

where do the dopamine-secreting neurons reside?

A

hypothalamus

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12
Q

hyperprolactinemia secondary causes

A

Inhibition of dopamine release by hypothalamus

  • Medications
  • Estrogen
  • Breast Stimulation

Interruption of dopamine delivery from hypothalamus to pituitary
- “Stalk effect”, e.g. secondary to trauma

Increased TRH release
- Hypothyroidism

Prolactin secreting tumors

Decreased renal or hepatic clearance

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13
Q

physiologic and pathologic effects of prolactin

A

Physiologic Effects of Prolactin
Induces and maintains lactation
Inhibits release of FSH and LH
Reduces gonadal steroidgenesis

Pathologic Effects of Prolactin
Galactorrhea, gynecomastia
Amenorrhea
hypogonadism

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14
Q

treatment of prolactinonma

A

Dopamine Agonists are first line treatment

  • Cabergoline preferred over bromocriptine (longer half-life)
  • Should be discontinued with pregnancy

Estrogen or testosterone therapy for long-term hypogonadism secondary to drug induced hyperprolactinemia

Surgery when unresponsive to medications

Radiation therapy for prolactinomas that are aggressive, malignant, or unresponsive to surgery

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15
Q

treatment monitoring for prolactinoma

A

Serum prolactin levels in one month
Repeat prolactin level every 4-6 months
If levels not normalized after 6 months, consider surgery
MRI at 3 months for macroadenoma or 1 year for microadenoma, repeat sooner for increased galactorrhea, visual disturbances, or headaches
Visual field testing

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16
Q

how long do we treat for prolactinoma?

A

Indication for stopping dopamine agonist:
Consider tapering after 2 or more years of treatment
- Normal prolactin level
- No tumor remnant on MRI
Stop after menopause in women with microadenoma
Discontinue with pregnancy

Dopamine agonist tapering:
Reduce by 50% over 3 months and check prolactin levels
Discontinue after 1 year at reduced dosage if prolactin normal
Check prolactin level every 3 months for one year, then yearly
MRI if prolactin level elevated

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17
Q

hyperpolactinemia presentation in men, elderly, post-menopausal, children

A

Men
- Erectile dysfunction, reduced libido, and gynecomastia

Elderly Men
- Headache, vision loss, and osteoporotic fractures

Postmenopausal Women

  • Headache, vision loss, and osteoporotic fractures
  • Decreased libido, vaginal dryness, and dyspareunia

Children

  • Menstrual irregularities or amenorrhea
  • Galactorrhea
  • Headache
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18
Q

What is the mechanism of bitemporal hemianopsia?

A

pressure in the optic chiasm

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19
Q

acromegaly- lab testing

A

Serum insulin-like growth factor-1(IGF-1) level

Growth hormone after Oral Glucose Tolerance Testing
75 g of oral glucose given to patient
- Check growth hormone level every 30 minutes for 2 hours
- Growth hormone under 1 mcg/L after oral glucose tolerance test is considered normal

Prolactin level
- 25% of acromegaly patients have hyperprolactinemia

Calcium level
- Assess for hyperparathyroidism and MEN I

Blood Glucose

Anterior and Posterior Pituitary Function

  • TSH and FT4
  • Cortisol
  • Usom/Posm (normal 1-3; <1 Diabetes insipidus)
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20
Q

Amenorrhea and galactorrhea in Acromegaly

A

Growth hormone stimulation of the prolactin receptor
Growth hormone adenoma may cosecrete prolactin
Macroadenoma may push on the pituitary stalk and block dopamine secretion
Interference with gonadotropin secretion by the pituitary

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21
Q

typical findings in acromegaly

A

Increasing hat and glove size, macroglossia, hands and feet are enlarged,
Fingers with tufting on x-rays, and skin tags

Change in bite, snoring at night, dental malocclusion, frontal bossing and a deep sonorous voice…

Acanthosis nigricans and skin tags

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22
Q

Etiologies of Acromegaly

A 
Pituitary adenoma >90%
Familial Syndromes:
- McCune-Albright Syndrome
- Carney’s Syndrome
- Familial acromegaly
Pituitary Carcinoma – rare
Pancreatic islet cell tumors
Lymphoma
Somatotroph hyperplasia caused by excess GHRH by
- Hypothalamic tumors
- Peripheral neuroendocrine tumors
----Pheochromocytoma
----Medullary thyroid carcinoma
----Adrenal adenoma
----Small cell lung cancer
----Bronchial carcinoid		
Exogenous use of human growth hormone
23
Q

Complications of a growth hormone secreting adenoma

A

Direct tumor effect

  • Headaches
  • Visual disturbances

Additional Hormone production
- Prolactin

Interference with other hormones
- Decreased ACTH, TSH, and other hormones

24
Q

Growth hormone adenoma Associated Conditions

A

Multiple endocrine neoplasia type I
- Pituitary adenoma, hyperparathyroidism, and pancreatic islet cell adenomas

Hyperprolactinemia
- 25% of growth hormone secreting adenomas cosecrete prolactin

McCune-Albright syndrome
- Triad of café au lait skin changes, precocious puberty, and fibrous dysplasia

Malignancy
- Thyroid cancer, bladder, and kidney

Carney Syndrome
- Cutaneous pigmentation, fibromyxoid tumors of the skin, myxomas of the heart, and endocrine overactivity

25
Q

acromegaly Treatment

A

Surgery is the treatment of choice using a transsphenoidal approach.

Medical Treatment
- Octreotide – somatostatin analog
- Dopamine agonists – cabergoline
- Growth hormone receptor antagonist – pegvisomant
Radiation Therapy
26
Q

follow up monitoring of growth hormone adenoma

A

Annual MRI
Annual testing of IGF-1 and Growth Hormone
Consider OGTT and GH

27
Q

Signs and symptoms of Acromegaly

A 
Tumor Mass Effect
- Visual Loss
- Cranial Nerve Palsies
- Hypopituitarism
Coarsening of facial Features
-- Frontal bossing/widening of nose
Prognathism, tooth separation, dental occlusion
Macroglossia
Deepening of the voice
Acral enlargement and thickening of the skin
Depression
Headaches
Arthralgias, joint hypermobility, arthropathy, carpal tunnel syndrome
Goiter/Thyroid nodules
Sleep Apnea, snoring
Hyperhidrosis, skin oiliness, skin tags
Hypertension, LVH, Valvular disease, Heart Failure
Hypogonadism(low sex hormone binding globulin) and menstrual irregularities
Hyperprolactinemia/galactorrhea
Insulin resistance and diabetes
Hypertriglyceridemia
Hypercalciuria/hyperphosphatemia
Osteoporosis/vertebral fractures
Increased colon polyps
Fatigue
28
Q

dx for polyuria

A 
Central Diabetes Insipidus
Nephrogenic Diabetes Insipidus
Psychogenic Polydipsia
Osmotic Diuresis
- Diabetes Mellitus
Hypercalcemia or Hypokalemia
Decreased aldosterone production
Increased Cortisol
Post-obstructive Diuresis
Post renal failure
Drugs:
- Lithium
- Demeclocycline
- Cis-platinum
- Diuretics
Caffeine
Ethanol
29
Q

Osmolality Calculation

A

2[Na] + [Glucose]/18 + [BUN]/2.8

30
Q

testing in polyuria

A

Confirm hypotonic polyuria with 24 hour urine for volume and osmolality

Check serum electrolytes, BUN, Creatinine and glucose
- Calculate serum osmolality

If serum osmolality (> 295 mOsm/kg) and high plasma sodium levels (>143 mEq/L)

    • Primary polydipsia unlikely
    • Vasopressin challenge test to confirm central diabetes insipidus and distinguish it from nephrogenic diabetes insipidus

If plasma osmolality and serum sodium normal, induce hyperosmolar states with a water deprivation test or hypertonic saline infusion, then proceed with a vasopressin challenge test

31
Q

24-hour urine for volume and osmolality

A

Urine volume typically greater than 3 liters per day in diabetes insipidus
Urine osmolality < 300 mOsm/kg

32
Q

Water Deprivation Test

A

Not needed if elevated plasma osmolality (>295 mOsm/kg), high sodium level (>143 mEq/L), and low urine osmolality
– Go straight to the vasopressin challenge test
Check plasma arginine vasopressin level at baseline
Monitor weight, blood pressure, heart rate, serum sodium, plasma osmolality, urine osmolality, and urine volume hourly

Stop test for any of the following
Body weight decreases by 3-5%
Orthostatic blood pressure changes
Urine osmolality plateaus (less than 10% change over 3 consecutive measurements)
Urine osmolality normalizes (> 750 mOsm/kg)
Plasma osmolality > 295-300 mOsm/kg
Serum sodium > 143-145 mEq/L
Check plasma arginine vasopressin level at the end of the test

33
Q

Stop water deprivation test for any of the following

A

Body weight decreases by 3-5%
Orthostatic blood pressure changes
Urine osmolality plateaus (less than 10% change over 3 consecutive measurements)
Urine osmolality normalizes (> 750 mOsm/kg)
Plasma osmolality > 295-300 mOsm/kg
Serum sodium > 143-145 mEq/L

Check plasma arginine vasopressin level at the end of the test

34
Q

interpreting water deprivation test

A

Little or no increase in urine osmolality (under 300 mOsm/kg) consistent with complete diabetes insipidus

Small increase ( 400-500 mOsm/kg) consistent with partial diabetes insipidus or primary polydipsia

Normal individuals

  • Serum osmolality increased
  • Urine osmolality maximized to > 800 mOsm/kg
  • No increase in urine osmolality with administration of arginine vasopressin
35
Q

Vasopressin/desmopressin challenge test

A

Perform in hyperosmolar states after water deprivation test
Administer vasopressin or DDAVP
Check urine osmolality every 30 minutes for 2-4 hours
If urine osmolality increases > 50%, likely central diabetes insipidus
If no change in urine osmolality, likely nephrogenic diabetes insipidus
If urine osmolality increases by under 50% may be partial central or nephrogenic diabetes insipidus

36
Q

Central Diabetes Insipidus etiologies

A

Idiopathic 20-50%

Lymphocytic hypophysitis:

  • Primary – unknown etiology (20% associated with thyroiditis, hypoparathyroidism, vitiligo, pernicious anemia, myasthenia gravis, or systemic lupus erythematosis)
  • Secondary (Sarcoidosis, Langerhans cell histiocytosis, Viral, fungal, bacterial, Tb)

Trauma/Surgery

CNS neoplasms/Leukemia

Hypoxic injury

Meningitis/Encephalitis

Vascular – Internal carotid aneurysm

Congenital: Wolfram Syndrome (DIDMOAD)

  • Rare autosomal recessive
  • DI
  • DM
  • Optic Atrophy
  • Deafness
37
Q

Stalk thickening may be seen with?

A

Lymphocytic hypophysitis/Infiltrative Disorders/Autoimmune

38
Q

Treatment of Central Diabetes Insipidus

A

Desmopressin(DDAVP)

  • Synthetic analog of arginine vasopressin(AVP)
  • Titrated to control polyuria and polydipsia
  • Patients should drink no more than is necessary to satisfy thirst to avoid hyponatremia

Other treatments

  • Carbamazepine
  • Chlorpropamide
  • Hydrochlorothiazide
39
Q

Etiology of Nephrogenic Diabetes Insipidus

A

Lithium Therapy
- 55% of patients on long term lithium therapy
Metabolic
- Hypercalcemia, hypercalciuria, and hypokalemia
Release of Urinary Obstruction
Protein Malnutrition
Aging
Chronic Pyelonephritis
Other Drugs
- Demeclocycline, rifampin, cisplatin, amphotericin B
Infiltrative Conditions
- Amyloidosis, sarcoidosis, or sarcoma
Vascular Disease
- Sickle cell disease, ischemia
Congenital
- Arginine vasopressin receptor 2 mutations (X-linked)
- Aquaporin-2 water channel gene mutations
- Urea transporter-B gene mutations

40
Q

Signs and Symptoms of Hypopituitarism

A

loss of growth hormone, gonadotropin, TSH, ACTH

41
Q

Growth Hormone Loss–>

A 
Decreased sense of well being
Decreased muscle and bone mass
Increased central fat
Decreased cardiac output
Increased cholesterol
42
Q

Gonadotropin Loss–>

A 
Fine wrinkling of the skin
Decreased Libido
Hair Loss
Gynecomastia
Atrophic Testes
Vaginal Dryness
Alopecia
43
Q

TSH Loss–>

A 
Fatigue
Constipation
Dry skin
Puffiness
Alopecia
Cold Intolerance
Weight gain
Increased Cholesterol
44
Q

ACTH Loss–>

A 
Weakness
Fatigue
Low grade fever
Orthostasis
Loss of genital hair
Pallor
Hypoglycemia
Abdominal pain
Nausea/vomiting
Weight loss
Low Na, normal K
45
Q

Etiology of Anterior Pituitary Failure

A 
Pituitary Tumors
Non Pituitary Tumors (Craniopharyngioma, Meiningioma, Glioma, Chordoma, Epednymoma, Germinoma, Metastasis)
Traumatic Brain Injury
Neurosurgery
Subarachnoid hemorrhage
Stroke
Cranial Radiation
Postpartum hemorrhage- Sheehan syndrome
Empty Sella Syndrome
Inflammatory conditions (Sarcoidosis, Hypophysitis, Tuberculosis, Granulomatosis with polyangiitis) 
Infections (Abscess, Meningitis, Encephalitis)
Pituitary apoplexy
Carotid aneurysm
Hemochromatosis
Histiocytosis X
Granulomatous diseases
Idiopathic
Congenital (Pituitary hypoplasia, Holoprosencephaly, Asphyxia/abnormal delivery, Genetic- PROP1 mutations)
46
Q

in what order do we lose anterior pituitary failure

A

GH
Gonadotropins
thyroid
ACTH

replace them in reverse order

47
Q

Testing for Anterior Pituitary Hormone Deficiencies

A

Basal Secretion Tests, Stimulation Tests

48
Q

Basal Secretion Tests

A 
IGF-I
FSH and LH
Early AM serum testosterone in males and estradiol in females
TSH and Free T4
Morning serum or salivary cortisol
Morning plasma ACTH
Basal serum prolactin levels
49
Q

Stimulation Tests

A

Insulin Tolerance Test
Glucagon stimulation test
ACTH stimulation test (cosyntropin test)
Serum prolactin level after injection with TRH

50
Q

Growth Hormone Deficiency stimulation tests

A

Low IGF-I (under 85mcg/L)

Stimulation Tests may be needed:
Insulin Tolerance Test
Glucagon Stimulation Test
Exercise
GH < 5 ng/mL confirms deficiency
51
Q

Gonadotropin Hormone Deficiency testing

A

Exclude hyperprolactinemia
Males:
Exclude low sex hormone-binding globulin
Early morning testosterone level < 280 ng/dL
Low or normal LH and FSH

Females:
Serum estradiol under 27 pg/mL
Low or normal LH and FSH

52
Q

Thyroid-stimulating hormone deficiency testing

A

Serum TSH
Free T4
Low T4 without an elevation of TSH consistent insufficiency of TSH

53
Q

ACTH hormone deficiency testing

A

AM cortisol level (6-9 AM)

  • 18.1 mcg/dL intact hypothalamic-pituitary-adrenal axis
  • 2.9-18.1 mcg/dL require further testing
  • under 3 mcg/dL indicate adrenal insufficiency

Plasma ACTH (6-9 AM)

  • > 100 pg/mL indicates primary adrenal insufficiency
  • under 50 pg/mL indicates secondary adrenal insufficiency

ACTH stimulation test (cosyntropin test)

  • ACTH 250 mcg IV or IM
  • Measure cortisol 30-60 minutes later
  • Normal – peak cortisol 18.1-21.7 mcg/dL
  • Adrenal insufficiency – peak cortisol < 18 mcg/dL
54
Q

prolactin and hypopituitarism

A

Prolactin level may be high or low in hypopituitarism

ENDO 2 Exam II (2017) (19 decks)

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