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Clin Medicine > Kirila Endo Repro > Flashcards

Kirila Endo Repro Flashcards

1
Q

Parathyroid disorders

A

Ok

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2
Q

45 yo male no complaints. Normal but calcium of 11 (normal 8-11) and phosphorus 1.6 (2.2-4.8). PMH negative,

Is albumin protein bound

Ionized non protein bound and active.

Next step?

A

Blood work to include renal function and parathyroid hormone

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3
Q

If PTH high what is diagnosis

A

Hyperparathyroidism

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4
Q

Increase ca and decrease PO4

A

Ok

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5
Q

If ca is low, PO4 high

A

Ok

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6
Q

What is ca and PO4 move the same

A

Vitamin D issue

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7
Q

PTH low which is not a possible explanation

Malignant, multiple myeloma, VD intoxication, exercise induced, granulomatous disease

A

Vitamin d intoxication

Granulomatous-joint pain, lupus, RA

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8
Q

If PTH low

A

Malignancy, granulomatous disease, drugs, Mets, MM, lymphoma, vit d intoxication,

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9
Q

Do you work up further hypercal if pth is low

A

YES

Keep doing work up

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10
Q

Primary hyperparathyroidism

A

Solitary nodules, parathyroid CA, MEN

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11
Q

Which of following is associated with rapid development of hypercalcemia

Pulmonary edema, dehydration, psychiatric issues, kidney stones, pneumonia

A

Hyperosmoal state

Dehydration

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12
Q

Acute

A

Rapid development

Polyuria, dehydration, renal impairment (not long term)

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13
Q

Slow development hypercalcemia

A

Stones, bone problems (if in serum not in bone), psychiatric issues,

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14
Q

Patients now presents to you with a depressed moos, was diagnosed with kidney stone last year and developed stress fractures after trying to jog regularly. How approach manage

A

Begin bisphosphoate as an outpatient

At time of stone-IV hydration

Bed rest restricted activity-more osteoclast activity-so never rest with bone strength issues

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15
Q

Treat chronic hypercalcemis

A

Increase fluids, monitor, labs periodically, if comorbidities meds

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16
Q

What med use if this patient got HTN with hypercalcemia

A

Loop diuretics-take out calcium
Excrete ca

Thiazides-resorb calcium

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17
Q

What are risk of increasing ca excretion

A

Stones, fluid shifting and volume depletion (meds)

Discuss with patient so have informed consent

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18
Q

84 yo female resides in a nursing home and requires help with activities of daily living (ADL)
Normal renal and hepatic function

Ca 7.5 (8-11) and phosphorus 1,5 (2.2-4.8)
Albumin 3.5 (3.5-5)

A

Vitamin D hypovitaminosis

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19
Q

What lab order now

A

1,25 oh VD

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20
Q

Who get VD defiency

A

Old shut ins

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21
Q

25 oh vit s

A

Converted in kidney

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22
Q

25 oh

A

Stored to convert

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23
Q

Free ionized calcium is metabolically active

A

Yup

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24
Q

What is not influenced by rote in binding

A

Ionized calcium-it is free not bound and active

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25
Q

How correct for low albumin

A

Ca=measured ca(mg/dL)+ .8 (4-serum albumin(g/dL)

7.6+.8(4-3.5)=8 corrected

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26
Q

Treat low calcium

A

Build storage as long as can make usable vd

Aggressive
Mile 8-8.4
Moderate<8, >7.5
Severe

Acute change-tumor

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27
Q 
93 yo female is residing in a nursing home and requires help with ADL
Cr-1.1
Ca 10.5 (8-11), PO4 1.5
Albumin 3
What is corrected ca
A

11.3 mg//dL

Actually hypercalcemia

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28
Q

82 yo woman ca 9.1 phos 2.5 albumin is 3 (3.5-4) what is serum calcium

A

Normal

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29
Q

And so the phosphate level would be normal too. But what would th concentration of ca in urine be

A

Increased

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30
Q

Patients need help doing everything and doesn’t move unless someone moves her

A

Increased osteoclast activity

Bone resorption ca increase in blood

PTH suppressed by of neg feedback from high ca in ecf and calcuria begins))

Kidneys as long as are able with maintain homeostasis

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31
Q 
56 male renal insuffiency secondary to diabetic nephropathy. HTN BMI 41. BUN 34 (8-25) cr 2.3 (.6-1.5), albumin 3,4 (3.5-50 calcium 8.1, phos 5.3
Gfr 30 (100)

Why ca so low but PTH is up

A

Stage III-IV kidney fail

Kidneys are damaged enough so ca is not resorted and vd is not active

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32
Q

PTH high

A

Renal failure cant convert VD to active

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33
Q

Why is phos high when vd is low

A

Chronic kidney disease negatively impacts phosphate wasting

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34
Q

33 yo female presents with bl foot pain. Breast feeding her 4 month baby girl g3p1. Shin splints, mid back pain, thin and wearing wrk out clothes, bit fatigues which present for 8 months. But wore last four months , chapped lips, murmur , scoliosis , calcaneous pain plantar fasciitis ,

X ray long bone demineralized,

A

Get PTH VD

Not just old women can be anorexics , dietary restrictions, STEROID TREATMENT IN MEN
Usually older female but don’t discount

Osteophytes on calcaneal

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35
Q

MRI after scoliosis x ray

A

Wear shin bones see if anything metabolis or traumatic cased it

Of spin-wedge fracture,

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36
Q

What do

A

DEXA get

Wrist heels legs fingers-peripheral screening

For her do central test-lower spine and hip its more accurate DO IT HERE

Do low back and hip DEXA

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37
Q

How treat this woman

A

Social, physical, stretching, counseling

Ca carbonate (recommended

If on meds for stomach acidity give calcium citrate

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38
Q

78 yo right hilar mass on cxr. Squamous cell carcinoma of lung, albumin 2.5 ca 16, would you expect pth high low or normal
His ekg shoes shortened qt segment-initial treatment

A

Low

Already in hospital, ca high ——iv hydration to allow kidney to get rid of it with increase perfusion. No thiazide maybe loop diuretics

May add bisphosphnate wont act as quickly

Acute situation

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39
Q

Hypercalcemia ekg

A

Short qt

Long qt low ca

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40
Q

Want to check 25 oh first

A

To see storage first want to know if its intact
Need to see stores

Not 1,25 oh VD - would probably check both

If peripheral DEXA bad from screening send to central screening

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41
Q

Thyroid

A

Ok

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42
Q

Ft3 and 4

A

Free unbound

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43
Q

Increase tsh decrease pt4

A

Primary hypothyroidism

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44
Q

Decrease tsh and increase ft4

A

Primary hyperthyroidism

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45
Q

25 yo female increased frequency ensues, cant sit still, hungry, no weight gain, throat is bigger and tight . What lab

A

First. Complete your history , ROS and PE

Then TSH FT4 and FT3

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46
Q

You notice she cant sit still what is number one differential

A

Secondary constipation due to GI obstruction -NO

Manic phase, viral thyroiditis, pituitary adenoma

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47
Q

Symptoms of hyperthyroid include what

A

Warm. Moist skin, increased HR, goiter, muscle weakness.

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48
Q

Which finding may not get better even with proper treatment

A

Exophthalmos

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49
Q

Ophthalmic hyperthyroidism

A

Lid lag, exophthalmos

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50
Q

Bruits hyperthyroid

A

Over thyroid enlargement

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51
Q

Other symptoms

A

HR up, rhythm quality, tremor, warm moist, gynecomastia, sweat, diarrhea, polyuria, weight loss, fatigue weak, oligomenorrhea, dry skin, heat intolerance, sweating, palpitations

Opposite with hypothyroidism

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52
Q

For Graves’ disease, which antibody test

A

TSI antibody

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53
Q

Diagnose graces

A

TSH-but not needed

Thyroid scan shoe uptake -but not needed TSI not needed

All need is clinical!!!!!!!!!!!!!!!!!!!!!

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54
Q

Graces hot nodule

A

Difffuse

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55
Q

Only )) wild eterine if the actual uptake is increased as expected in graves scan

A

Iodine

Iodine scan want

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56
Q

Treat graves

A

Bb will decrease symptomas as quickly as possible

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57
Q

PTU can be used in preg not methimazole

A

Alter dose every month

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58
Q

Thyrotoxicosis

A

Extreme hyperthyroidism

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59
Q

Graves

A

Exophthalmos
Clubbing
Pretibial myxedema

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60
Q

47 year old male lump in throat noticeable when turn head or shaving ….fullness on right side . What test critical to workup

A

TSH..it is your go to

Also get ft4

TSH

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61
Q

Why tsh

A

Know if nodule is hyperfunctioning

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62
Q

If tsh low then what

A

Thyroid scan with iodine

Radioactive iodine ablation-graves

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63
Q

Low TSH

A

Thyroid scan

Nodule may be hot producing thyroid hormone
Something suppressing tsh

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64
Q

Normal TSH

A

FNA

Have to see what nodule is doing. Nodule may be cold

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65
Q

If scan unilaterally hot what is it

Graves-everything turn up

Hypothyroidism-nothing light up

A

Toxic multinodular goiter

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66
Q

What if just one spot light up

A

Toxic nodule

67
Q

Post op evaluation

A

Look for signs of ca disorder

Also recurrent laryngeal nerve int here. So listen for hoarseness.

68
Q

FNA

A

Sensitive and specific

Limited by poor technique or a hypocellular sample may not be adequate

Unless the nodule is causing problems, watchful waiting is usually all that i needed

69
Q

WHICH OF THE FOLLOWING HEPLS support a benign nodule diagnosis

A

Tenderness-

Very young or old, firm fixed, male more likely to be non benign , history of neck irradiation, LAD

70
Q

27 yo female agitated, 15 lb weight loss. Worried impact ability to get pregnant. Unable to it still. Hard time holding coffee mug since started shaking with 406 weeks ago

A

Hyperthyroidism

71
Q

TSH up now what

A

Check t4

72
Q

Why is tsh high and hyperthyroid

A

There is continuous production and unopposed rebased of tsh trying to stimulate thyroid

73
Q

TSH adenoma

A

Increased and unopposed tsh production

Feedback loop no alter tsh

74
Q

Hashimoto burn out

A

Start hyper then hypo

75
Q

Viral thyroiditis

A

Hypothyroidism. Scan with not much hotness

Puffy face, puffy eyes skin thickening

76
Q

Hypothyroidism

A

Bradycardia,

77
Q

Just tsh it may mislead you so get what

A

Free t4

78
Q

Myxedematous

A

Slow ..like thyrotoxicosis extreme of hypothyroid. Get puffy
Hypothyroid

79
Q

Illl 4 month ago viral uri lost 15 lb and diarrhea at time .

A

Hasimoto…was in hyper and now in hype

80
Q

Low functioning thyroid

A

Hasimoto burn out

Viral thyroiditis

Painless thyroiditis

Subacute thyroiditis
External irradiation to neck
Prior rai therapy for graves
Acute illnesss

81
Q

Euthyroid

A

Condition is normal. Euthyroid sick

82
Q

Iodine defiency

A

Africa

83
Q

Clincial aspects of diabetes mellitus

A

Ok

84
Q

Can adults be diagnosed with type 1

A

Yup

85
Q

Finger stick/subcutaneous

A

Capillary glucose monitoring

86
Q

Venous sample

A

Out of vein

87
Q

Basal/bolus insulin need both

A

Basal-steady state rate long acting insulin to achieve more steady state

Bolus-can be adjusted at mealtime and things

NEED BOTHHHHHHHHHHs

88
Q

Sliding scale

A

Based on patient blood sugar (capillary or venous sample) can proactively dose or retroactive get high gluose and dos insulin

89
Q

Retroactive

A

Don’t want to treat old news..means didn’t cover them leading up it it, but in acute care hospital setting this is important to adjust basal and bolus rates

90
Q

Hba1c

A

Average of 3-4 months glucose rbc binding to glucose (120 days)

Glycosylaed hemoglobin

91
Q

What effects HBa1c

A

Anemia, rbc abnormality,

92
Q

Presentation of CM

A

Mental status change, abdominal pain, dehydration

93
Q

Mental status change

A

Insulin should be on the differential (high or low)

94
Q

Abdominal pain

A

Diabetic ketoacidosis with ketone breath-type 1 more prone

95
Q

DKA (more likely in type 1) and NKHS (more likely in type 2)

A

Nothing absolute

96
Q

DKA

A

Nail polish remover smell/fruity breath, ketones, acidosis, hyperglycemia , coma

97
Q

Unresponsive 18 y/o male DM1 since 6 and intermittent control
Grave digger from MN-8 am, not good compliance
Insulin NPH premix , doesn’t follow set eating schedule or end schedule
Mucus membrane dry, skin tumor poor
Tachypnea, high temp but not 100.4, cant tell ab pain bc unresponsive, kussmal

A 
Thorough skin and MSK survery-look for trauma and infection
Chest x ray
Urine sample for drug
Alcohol level
UA for infection
98
Q

Brain last thing to go

A

Insulin independent glucose utilization

99
Q

What cause DKA

A

Infection-pneumonia, uti, gastroenteritis, sepsis

Inadequate insulin

Ate more carbs didn’t plan and dose appropriate

New diagnose not sure how to do it

100
Q

Infarction DKA

A

Coronary, cerebral, mesenteric, peripheral
Surgery
Drugs (cocain)
-more predisposed to DKA bc put stress on body

101
Q

Symptoms DKA

A

Anorexia, n/v, polyuria, thirst

102
Q

Signs DKA

A

Kussmal0rapid deep breaths
Acetone breath
Dry mucous membranes and poor skin tumor

103
Q

Lab DKA

A

Hyperglycemia

Kenos is

Metabolic acidosis

  • calculate anion fap-increased in DKA
  • K effected bu it shift k out of cells
104
Q

High anion gap

A

Methanol, uremia, diabetic ketoacidosis, paraldehyde , isopropyl alcohol, iron INH (isoniazid), lactic acidosis, ethylene glycol, salicylate

105
Q

Kid gramma purse get isoniazid

A

Baby high anion cap acidosis

106
Q

Correction na

A

Serum not abnormal and may look high bc acidosis, DKA actually

107
Q

Correct K

A

Serum may be normal or high, actually total body defect

108
Q

Hyhyperamylasemia

A

Can be salivary

Diabetic and glucose metabolism disorders bc have pancreatitis that is origin

109
Q

Leukocytosis DKA

A

Stress

110
Q

Treat DKA if in Er and not turned around year

A

ICU bc can crash quickly bc greater nurse to patient ratio, safer and can put on monitor and do more aggressive treatment
-acid base status, renal function, K and other electrolytes *

If had turned around fast maybe med SURG floor

111
Q

Frequent monitor what

A

Urine consistently , status, vitals, glucose, blood gas, K

112
Q

1-2-3 rule fluid replacement

A

2-3 L normal saline 1-3 hours .9%

Then 1/2 strength saline at 150 ml/hr

When glucose reaches 250, switch to D51/2NS at 100-200 ml/hr

Fluid deficit is often 3-5 L

113
Q

Fluid deficit in DKA

A

3-5 L (8-10 L in other)

114
Q

Initial insulin

A

10-20 units IV or IM

Then 5-10 units/hr continuous IC

Increase if no response in 1-2 hours-orders can be written with guidelines to titrate

115
Q

eval for underlying causes

A

Cultures, ekg, cxr, drug screen, seek additional history from family or patient as mental status approves

116
Q

Blood work initial

A

BSG at least hourly

Electrolytes q 2-4 hours with or without ABG

117
Q

K replacement

A

Monitor electrolytes every 2 hours

Once below 5.5 consider adding K

118
Q

When supplementing K

A

Renal function, ekg, verify urinary output

119
Q

Foley

A

3 types three lumen, 2 lumen, 1 lumen

Indwelling-imply balloon so can stay in
3rd lumen irrigation, med, chemo can send med or fluid through that

Straight cath-single lumen to get urinary sample do not want to put this in if anticipate leaving Catheter in place. If know will stay in use indwelling style

120
Q

DKA treatment goal

A

Increase rate of glucose utilization in insulin dependent tissues
-150-250

Reverse ketonemia and acidosis

Correct depletion of water and electrolytes

121
Q

Start intermittent or long term insulin

A

When can eat(seen by status improves, no n/v, no ab pain)
Anion gap normali

Allow overlap timing of IV with SQ insulin-usually by 30-60 minutes ——dont wanna stop IV and nothing to back it up, start oral or SQ and resume wait hour for effect

122
Q

Non ketones hyperosmolar state NKHS

A

Woo

123
Q

Who gets it

A

Old , frail, refusing food medicine, history T2DM on insulin and oral agents

124
Q

NKHS what precipitates

A

Relative insulin defiency, inadequate flui intake, osmotic diuresis induced by hyperglycemia

Refusing food and meds, decreased fluid intake

If sugar up dry u out bc osmotic diuresis

125
Q

Precipitating factor

A

Sepsis, MI, glucocorticoids, phenytoin, thiazide diuretics, impaired access to water

126
Q

Symptoms

A

Polyuria, thirst, altered mental state

Absent generalized body complaints, no kussmal, no acidosis , no ab pain

127
Q

Serum acetone level NKHS

A

Mild lactic acidosis, moderate ketonuria from starvation, corrected serum Na usually increased

Can have a bit of ketones and acidosis-but wont be extreme

Corrected Na increased

128
Q

ICU

A

Yes!! Frequent monitoring of gen status, vitals, glucose,
Acid base
Renal function
K

At least first 12-24 hours then go from there!!!!!

129
Q

Fluid

A

2-3 L NA for 1-3 hours (opposed to 1)

Fluid deficit is 8-10 L
-reverse over next 24-48 hours using 1/2 strength saline (.45)

When glucose reaches 250 switch to D51/2NS at 100-200 ml/r

130
Q

Insulin

A

Regular over IC
5-10 units IV bolus
3-7. Units continuous
Transition to eating as with DKA when awake and number turning around

Monitor K

131
Q

Similarities

A 
Insulin-absolute or relative
Glucagon excess
Volume depletion
Mental status
Both ICU until where they are and how quickly changin
132
Q

Differences

A

Fluid deficit much greater NKHS
Some drugs can contribute to NKHS**
NV ab pain ketoacidosis not in NKHS

133
Q

Diagnosis of T2DM what end organ damage already have

A

Lots already Look for neuropathy, retinopathy, nephropathy, heart disease

May not be aware that they already have thes

Get baseline ekg , ask about activity tolerance,

134
Q

56 yo T2DM hba1c 9, refuses insulin secondary to job demands, heavy manual labor for 30 years, chest pain sent him to the Er

A

MI
-dramatic increase in cardiovascular mortality in people with T2DM

Better control less risk but still risk-vascular damage with disease process

135
Q

When present with DM

A

Check for CVD

136
Q

HBA1c less than 6

A

Lower risk of CVD mortality and all events

137
Q

Hba1c

A

Average 3 month

138
Q

Is lower better

A

Less than 7 considered satisfactory

But too low can get glucose spread-difference between highest and lowest in 24 hours period, if spread larger then shown greater risk of vascular damage

May not be lower always better

139
Q

If lower better and under tight control

A

Risk of falling , if old could die

140
Q

Autonomic neuropathy vs peripheral

A

Peripheral-pain hands feet numb

Autonomic -central see gastric emptying

141
Q

Gastric pacemaker

A

Has wave forms and can help with gastric emptying

142
Q

Diabetes a grit emptying

A

Delayed emptying->if gave insulin but didn’t get the food in to back dosing up so drop down then have stomach empty when weren’t covered by insulin so peak in glucose

143
Q

Prob with insulin and autonomic

A

More frequent needle stick and monitoring

All bets are off with dosing

Some patients N/V bc stomach cant hold stuff get malnutrition

*insulin unpredictable high low sugar when normally be able to guess how to dose!!!! Issue

144
Q

If decreased insulin requirements

A

Decreased clearing of insulin-imply (used to need 10 unit and 5 now)

Kidney is failing -erratic control vs wow his diabetes is better! No! Things are BAD

145
Q

85 yo man has DM 2 20 years. Quarterly office follow up. Good dosing, noticed his sugars seemed much more easily controlled with less meds.

A

Worsening renal function

146
Q

Gastropathy

A

Very erratic and absorption so hard to control

147
Q

Peripheral neuropathy

A

On healing ulcers

148
Q

Autonomic

A

Tummy prob

149
Q

Declining kidney functions yp1 or 2

A

Either!

150
Q

Screening for proteinuria

A

Spot urine sample
-protein standard urine dipstick not sensitive if proteinuria <300 mg/24 hr

Most common type is albumin

151
Q

Standard urine dipstick

A

No detect if lesss than 300

152
Q

Get UA

A

Can get results if protein (albumin) is high enough to trigger over 300

153
Q

Protein smaller microabumni

A

Need special request to get
A type dipstick

More sensitive

30-300 mg

154
Q

Random urine sample

A

Don’t need to fast or collect, just pee in cup and do

155
Q

Microalbumin /Cr

A

More accurate than. Measuring microalbumin alone-ratio corrects for variations due to urine concentration

156
Q

Microalbumin Emma

A

30-300

157
Q

Absolute number of protein spilled

A

24 horus
Need to get serum cr at the same time to determine cr clearance

Difficult to do!!

Usually do when at point to see nephrologist

158
Q

37 T2DM non healing foot ulcer
A1C 13.3
700-800 now able to comply had other circumstances in life work
Adjust meds came back in

A

DM is an immune compromised state glucose>150 interferes with neutrophil function

Debilitated from lac of circulation to tissue

Peripheral neuropathy-show changes and adjustments

Multiple comorbidities-immune compromised

159
Q

Monofilament testing

A

Nylon fiber 10 guage touch patients foot have look away and

Feet and legs go before upper extremities test it on their hand first

Once a year, but do foot inspection quarterly

160
Q

Foot care

A

Plastic mirror
Never be barefoot

Moisturize, but not between or under toes

Prescription shoes-Medicare pay for one pair a year

Podiatry

161
Q

Best treatment

A

TLC-lifestyle changes!!

Walk up stairs not escalator

162
Q

Quarterly

A

A1C, glucose logs(SGM), foot inspection

163
Q

Annual

A

Dilated eye exam
Urine protein screening (microalbumin/Cr ration)
Monofilament testing

Clin Medicine (28 decks)

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