MKSAP12

Question 1

What is Reidel Thyroiditis?

Answer 1

A rare sclerosing thyroiditis that is not particularly associated with hyperthyroidism; may be concerned for anaplastic thyroid CA given sclerotic nature

Question 2

What are the pros and cons of propylthiouracil over methimazole?

Answer 2

PTU is safe in pregnancy and inhibits peripheral conversion of T4 to T3 but causes liver failure; thus, preferred agent for Graves Dz is methimazole

Question 3

Plain films showing osteolytic and sclerotic lesion in same bone is likely due to ____________

Answer 3

Paget Dz of bone often has isolated ALP; tx is w/ bisphosphonates bc decrease bony remodeling; tx if headaches, cranial nerve issues, fissure fractures

Question 4

What needs to be considered in a patient with oligomenorrhea and inflammatory acne and hirsuitism? What needs to be ruled out?

Answer 4

Consider PCOS; rule out pregnancy, hypothyroidism, hyperprolactinemia; and in this pt in particular rule out CAH with 17-Hydroxyprogesterone

Question 5

What sorts of things need to be ruled out prior to saying a woman is having amenorrhea due to functional hypothalamic dysfxn due to malnutrition and strenuous exercise?

Answer 5

Rule out premature ovarian failure (really high FSH and LH), hypothyroidism, pregnancy, and hyperprolactinemia

Question 6

What dynamic test can be used to assess hyperaldosteronism?

Answer 6

A salt suppression test; recall that the aldo:renin ratio is a static test

Question 7

Explain the radionuclide uptake results in Graves disease

Answer 7

Will be high because there is diffuse uptake of iodine given the TSH-R antibody is stimulating the TSH receptors on follicular cells leading to increased synthesis of thyroid hormone

Question 8

What is the most likely cause of thyrotoxicosis in a patient with a radioactive iodine uptake study showing low uptake?

Answer 8

Thyroiditis of some sort; bc there is low TSH and no TSH-R antibodies (as in Graves where uptake would be high) the uptake is low; another etiology could be factitious thyroiditis

Question 9

What are the two situations in which it is reasonable to start a bisphosphonate for osteoporosis?

Answer 9

If the bone mineral density test shows osteoporosis or if the patient has a fragility fracture (either fall from standing OR compression fx- defines you as osteoporotic); ALSO if pt is osteopenic with FRAX score >20% then do it

Question 10

When is it appropriate to use bisphosphonates in osteopenia?

Answer 10

Use in a woman with osteopenia whose 10 year FRAX score is >20%; can tx with bisphosphonate or if cannot tolerate then denosumab or teriparatide (analog to PTH; pulse dose helps build bone; contraindicated in Pagets and Hypercalcemia)

Question 11

Best initial tx for acute spinal compression Fx?

Answer 11

Pain control w/ tylenol; of note this also labels them as osteoporotic so check vitamin D and if replete then bisphosphonate

Question 12

What is the most appropriate step in mgmt of a pt with a thyroid nodule and low TSH and why?

Answer 12

Perform a radionuclide scan because given that the TSH is low, if this is a “hot” nodule the risk of CA is low enough that you don?t need to biopsy

Question 13

What is the mgmt of an asymptomatic pt with moderate hyponatremia who is euvolemic with SIADH?

Answer 13

Limit fluids (ideally less than 1 L but that is tough); note that Uosm >200 suggests concentrated urine so if urine sodium inappropriately elevated (and not on diuretic) it implies that the RAAS is not the issue here but that ADH is

Question 14

What two neuroendocrine type markers can be falsely elevated in patients taking PPIs?

Answer 14

Gastrin (but prob not so high that you would think of a gastrinoma); and chromogranin A, a general marker of neuroendocrine cells

Question 15

What is the preferred initial mgmt of Graves dz

Answer 15

Thionoamide (Methimazole > PTU- due to hepatic necrosis) and a BB usually propanolol but any nonselective works; thionoamides can take 4-6 weeks to start to work; if working you should wean the person off of the thionoamide after 2 years of “remission”

Question 16

In ppl on 3 HTN drugs one of which is a diuretic what are some things to consider? What about if palpable kidney? Supraclavicular fat pad?

Answer 16

Consider OSA, primary hyperaldo, Cushing (supraclavicular fat), ADPKD (palpable kidney), pheo, renal artery stenosis

Question 17

What does the cosyntropin stimulation test tell you?

Answer 17

Kind of complicated. So if the cortisol increases to >18 the person either has secondary (central) adrenal insuff that is acute, because if chronic lack of ACTH the adrenal gland would atrophy; if it does not increase to more than 18 it tells you the person has primary adrenal insuff (autoimmune adrenalitis, infiltrative dz)

Question 18

Next best step to evaluate a 2-3 cm thyroid nodule in a pt with low TSH

Answer 18

Radionuclide uptake test (if toxic adenoma, no need to Bx)

Question 19

When should you start weaning someones methimazole?

Answer 19

After about 2 years of being on it if they are in remission can start weaning

Question 20

How do you treat hypoglycemia in a patient on chronic insulin regimen for DM who has worsening CKD?

Answer 20

Decrease the insulin dose by 20% or so as it is filtered by the kidneys

Question 21

Among the ways of administering testosterone, the one associated with the most fluctuation in mood and libido is __________

Answer 21

IM Injection

Question 22

What is generally the best test to discover the etiology of thyrotoxicosis?

Answer 22

A radionuclide scan i.e. can see diffuse uptake in Graves, low uptake in thyroiditis, single hot adenoma in toxic adenoma

Question 23

What is the FDA approved weight loss drug with the greatest likelihood of producing the best effects?

Answer 23

Phenteramine and extended-release topiramate (recall contraindicated in glaucoma and nephrolithiasis)

Question 24

Explain the relationship between estrogen levels and synthroid efficacy

Answer 24

As estrogen levels increase (i.e. in pregnancy) then levels of thyroid binding globulin increase and so effective T4 may decrease

Question 25

How does a thyroid US contribute to the Dx of thyrotoxicosis?

Answer 25

It really doesnt; the test for a pt with low TSH and high T3/4 is a radionuclide scan

Question 26

When is the use of urine N-telopeptide appropriate?

Answer 26

This and urine hydroxproline can be used as markers of bone turnover to assess whether a person is doing well with bisphosphonate tx (which should lower bone turnover)

Question 27

What meds should be avoided in DM pts who are alcoholics?

Answer 27

Anything that can cause either hypoglycemia or lactic acidosis; EtOH metabolized and leads to lots of NADH which inhibits gluconeogenesis by prevening oxidation of pyruvate = more lactate and hypoglycemia bc no gluconeogenesis; so avoid metformin etc; safe = DPP4

Question 28

What is the primary therapy for Paget Disease of bone?

Answer 28

Bisphosphonates; again want to make sure vitamin D replete as can cause hypocalcemia

Question 29

How do you classify a hip fracture that occurred in someone who fell from standing?

Answer 29

That is a fragility fracture regardless of whether the persons DEXA states osteoporosis; check Vit D and if over 30 then bisphosphonate

Question 30

What are the 3 classes of drugs that do not cause hypoglycemia or weight gain

Answer 30

Biguanides (Metformin), SGLT2 inhibitors (Canaglifozin, emaglifozin), and DPP-4 inhibitors i.e. sitagliptin

Question 31

What nonhormonal agents are most appropriate for hot flashes in women with increased risk of CAD or breast CA?

Answer 31

Paroxetine and venlafaxine

Question 32

What is lid lag? Seen where?

Answer 32

When a person looks down and lid literally lags and you can still see the sclera; seen in Graves as there are GAGs deposited in retrorbital region

Question 33

What should you think if there is hypercalcemia and an elevated or inappropriately normal PTH level?

Answer 33

Primary Hyperparathyroidism; the “inappropriately normal” is important; also, HCTZ rarely causes frank hypercalcemia so don?t get confused here

Question 34

What is the most appropriate mgmt for a pt with osteoporosis who continues to lose bone mass on an oral bisphosphonate?

Answer 34

Switch to an IV bisphosphonate

Question 35

What lab abnormalities can suggest a low vitamin D level?

Answer 35

Elevated alk phos (bone remodelling trying to leech Ca and P); and mildly low Ca and P;often may have slightly elevated PTH here but recall it is ONLY hyperpara if there is also hypercalcemia with a high PTH or inappropriately normal one

Question 36

What does the presence of a thyroid bruit in a patient with thyrotoxicosis tend to suggest, especially if chronic?

Answer 36

Graves dz in particular as most forms of thyroiditis resolve more quickly; subacute thyroiditis is painful and silent is, well, silent

Question 37

What is the utility of 3% saline in SIADH? What is the osmolarity? The pH?

Answer 37

It provides more solute as if whatever you are giving has less osms than the U osm you will retain free water rather than have natriuresis followed by free water loss; 1027 osm (513 +513); pH around 5

Question 38

What are some common secondary causes of hypogonadism in men?

Answer 38

Obesity and OSA are huge; hyperprolactinemia is also possible; NOTE that testosterone is contraindicated in patients with OSA as it can increase their neck size

Question 39

What can osteoarthritis due to a DEXA score? What do you do if there are normal dexa scans but pt is losing height?

Answer 39

Can falsely elevated bone density; check plain films of spine as may have compression fx which would define them as being osteoporotic so check vitamin D and then bisphosphonate

Question 40

What are the 3 Rotterdam Criteria for PCOS?

Answer 40

Oligo or anovulation; Androgen Excess (by free testosterone or DHEAS); and polycystic ovaries seen on US (note that the LH:FSH ratio not one)

Question 41

This is the medication that is most appropriate for a fragility fracture with a normal vitamin D level? How long do you wait to start?

Answer 41

Bisphosphonate; but need to wait at least 14 days after the fracture due to theoretical risk of bone not healing; do within 90 days though

Question 42

What is the appropriate age to consider screening women for osteoporosis who have risk factors such as smoking, malabsorption (Celiac), etc.

Answer 42

Age 50 if risk factor; 65 otherwise

Question 43

In which type of thyroiditis would you expect the ESR and CRP to be elevated?

Answer 43

Subacute (Painful) Thyroiditis

Question 44

What is it called when there is thyrotoxicosis but positive TPO antibody?

Answer 44

Hashitoxicosis; this is early in the course of Hashimoto’s dz; eventually it will burn out and there will be hypothyroidism

Question 45

What is the difference between physiologic anovulatory cycles and functional hypothalamic amenorrhea?

Answer 45

Physiologic Anovulation is usually only in the first 1-2 years after menarche; functional hypothamic amenorrhea is when there is suppression of the hypothalmus due to malnutrition, etc.

Question 46

General fatigue, muscle weakness, maybe N/V and abdominal pain as well as peripheral eosinophilia are features of _____________

Answer 46

Addison Disease; Autoimmune adrenalitis; Dx test of choice is Cosyntropin Stimulation test and want to see cortisol increase to more than 18

Question 47

What does the combination of hypoglycemia and weight gain tend to suggest?

Answer 47

Possible insulinoma (or iatrogenic administration of insulin); want to look for sx of hunger, weight gain, tremulousness and palpitations

Question 48

What is the most appropriate tx for hot flashes in perimenopausal women who still have a uterus? What about who have had a total hysterectomy?

Answer 48

Combined OCP w/ estrogen + progestin to prevent endometrial hyperplasia; if uterus out can do estrogen only; LOWEST POSSIBLE DOSE FOR SHORTEST POSSIBLE TIME

Question 49

What is the best initial tx of Hypercalcemia of malignancy?

Answer 49

IV hydration (rec against furosemide); IV bisphosphonate (replete vitamin D); should lower within 48 hours; if lymphoma or granuloma then prednisone can be used; calcitonin quickest but tachyphylaxis

Question 50

What other things need to be ruled out prior to calling a person SIADH?

Answer 50

Hypothyroidism and Adrenal insufficiency; check TSH and cortisol

Question 51

Why is vitamin D deficiency a contraindication to bisphosphonates?

Answer 51

Will lead to hypocalcemia because not able to absorb calcium from GI tract due to Vitamin D and cannot leech from bone bc gave bisphosphonate

Question 52

This is due to abnormal leutenizing hormone secretion resulting in excess androgen production from the ovaries and adrenal glands

Answer 52

PCOS (an LH:FSH ratio is NOT required for dx)

Question 53

What is the female athlete triad? Pathophys?

Answer 53

Inadequate caloric intake with or without eating disorder, amenorrhea, and osteoporosis (early onset); due to functional suppression of hypothalamic hormones (no stimulation of pituitary)

Question 54

How do you confirm an ovarian source of hyperandrogenism?

Answer 54

Check a free testosterone level because the SHBG can be low

Question 55

What is the first line tx for hyperandrogenism in PCOS (i.e. hirsuitism)? What is the second line agent if that is not working?

Answer 55

Combined OCP (estrogen and progesterone); Spironolactone which is both a mineralocorticoid and androgen receptor blocker; please note that metformin is for hyperglycemia and can help with ovulation but NOT for hyperandrogenism