Medicine Flashcards
A 55 yr old man comes with symptomatic hypocalcemia. His past medical hx is significant for chronic recurrent abdominal pain for which he was adviced to quit alcohol. The abdomen is soft, nontender. Lab-Ca-6, Mg-0.8, phosphorus-2
The most likely cause of his hypocalcemia is?
Hypomagnesiumia n hypophosphatemia
- acute pancreatitis is one cause but this patient probably has chronic pancreatitis but no evidence of acute pancreatitis.
Hypoparathyroidism in the presence of normal renal function is characterized by? Ca, phosphorus levels?
Hypocalcemia
Hyperphosphatemia
Normal values of serum
- Mg
- phosphorus
- Ca
- T3
- T4
- TSH
- Mg- 1.7-2.2 mg/dL
- phosphorus - 3-4.5
- Ca- 8-10
- T3- 80-180ng/dL
- T4- 0.9-2.4 ng/dL
- TSH- 0.5-6
A 65 yr old woman who is on alendronate for osteoporosis experiences heartburn n starts taking over the counter antacids. She also takes chlorthalidone for hypertension. Ca-12.8, Bicarbonate-34, phosphate-1.2, K-4.9, Na-143
cr-1.7The most common cause of this patient’s hypercalcemia is?
Excessive calcium carbonate intake- milk alkali syndrome
-AkI, hypercalcemia, metabolic alkalosis(high bicarbonate) in light of her recent use of antacid( calcium carbonate- other sources include vitamins for osteoporosis )
-hypercalcemia➡️renal vasoconstriction ➡️decreased glomerular blood flow;
Inhibition of Na-K-Cl cotransporter (due to activation of Ca sensing receptors in the thick ascending LH )&impaired ADH activity ➡️loss of Na n free water➡️hypovolemia➡️increased reabsorption of bicarbonate ( augmented by increased intake of alkali)
Which oral hypoglycemic drugs r preferred in those with established or increased risk for cardiovascular diseases, hypertension?
Metformin
- GLP-1 (glucagon like peptide- decrease appetite-> wt loss
- SGLT2 inhibitors- induce mild diuresis-> decreased BP; it’s also associated with wt loss
How does hypothyroidism cause irregular menses
Low thyroid hormones-> ⬆️TRH->⬆️TSH n prolactin-> ⬇️FSH, LH
A 52 yr old man presents with decreased libido, testicular atrophy, gynecomastia, normal TSH, decreased total T3, totalT4
The most likely dx?
Liver disease
- liver disease leads to decreased production of thyroid hormone binding proteins
In secondary adrenal insufficiency ( eg Sheehan syndrome), what happens to serum Na, K, ACTH?
Central Vs primary AI
Central AI-> decreased ACTH -> low cortisol
- cortisol normally acts as inhibitor of ADH secretion therefore low cortisol results in SIADH and subsequent hyponatremia.
- as the cortex is intact, unaffected aldosterone metabolism, K levels remain normal
- ️⃣in primary AI, the whole gland is affected so it’s characterized by hyperkalemia, ⬆️ACTH and skin hyperpigmentation
Thyrotoxic sxs in a 24 yr old woman, with mildly enlarged non tender gland, elevated T3, T4, suppressed TSH, LOW radio-iodine uptake
Most likely Dx?
Painless thyroiditis- brief, mild hyperthyroidism with spontaneous recovery
- postpartum thyroiditis is a variant of painless thyroiditis diagnosed within 6 months postpartum; can stay up to 12 months
DDX- dequervain/painful thyroiditis - painful, tender goiter
A 34 yr old has symptomatic low serum cortisol level n subnormal response to ACTH stimulation. She is started on oral hydrocortisone after which her sxs partially improved. She still has light headedness, she consumes excess amount of salty food. there’s hyperpigmentation of the oral mucosa n palmar creases. Na-130, K-5.5
The most appropriate next step is?
Dx- primary AI ( low cortisol, abnormal ACTH stimulation test, hyperpigmentation) r suggestive. In addition salt craving, hyperkalemia, hyponatremia…r seen as both mineralo- n glucocorticoid activities r affected in primary adrenal insufficiency.
♦️hydrocortisone has glucocorticoid n minimal mineralocorticoid activity therefore, adding a drug with mineralocorticoid activity should b the next step-FLUDROCORTISONE
A 34 yr old presents with thyrotoxic sxs. TSH < 0.001, high free T4. ECG shows sinus tachycardia 120/min. Radioactive iodine uptake is <5%, antithyroid peroxidase antibodies r present in high titer
The most appropriate drug to administer in this pt is?
Dx- painless thyroiditis which is associated with thyroid peroxidase autoantibodies and is considered a variant of chronic lymphocytic ( hashimoto’s) thyroiditis.-decreased RAIUptake, nontender thyroid r suggestive
- following self limited hyperthyroidism, pts May develop hypothyroidism and then may return to euthyroid state.
- PROPRANOLOL- symptomatic therapy, no specific anti-thyroid needed
Radioiodine therapy in Graves’ disease- resolution of hyperthyroidism, is it gradual or rapid? What happens subsequently ( side effects)
Resolution of sxs occurs gradually in 6-18wks, but the dose needed for Rx gradually leads to permanent hypothyroidism in approximately 90% of the cases
- acutely worsens graves ophthalmopathy
Untreated hyperthyroid pts r at increased risk of—( what happens to the bones)?
Bone loss leading to osteoporosis
- direct effect of thyroid hormones on osteoclasts causes bone resorption
A 40 yr old comes for general medical examination. He has been feeling fatigued n has had occasional mm aches, gained 4.5 kgs over the past year. BMI is 26; cholesterol-280, HDL-40; LDL-180; TGA- 300
The best next step in the mx is
Thyroid function test! ( NOT antilipid therapy because untreated hypothyroidism can increase the risk of statin myopathy; initiation of statins can cause worsening of hypothyroid myopathy)
A 48 yr old man comes for evaluation of rt foot ulcer noticed 3 weeks ago. He has hx of htn, DM2, hyperchlesterolemia and smoking. Ulcer is on the plantar surface of the great toe. What test best assesses this patient’s risk for foot ulcer?
A) Ankle brachial index
B) capillary refill time
C) monofilament testing
Monofilament testing.
- diabetic neuropathy is the most common underlying cause.
- ABI- is primarily for large vessel PAD and arterial ulcers r usually located at the tip of the toe, rather than the plantar surface.
