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ABIM > MKSAP13 > Flashcards

MKSAP13 Flashcards

1
Q

What is the most likely etiology of obesity in a patient with panhypopituitarism assuming that the levothyroxine has been adequately replaced?

A

If pt is euthyroid then it is probably due to HYPOTHALAMIC INJURY resulting in hyperphagia

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2
Q

This drug has been shown to improve walking distance in pt with PAD

A

Cilostazol (PDE-3 inhibitor) but often try walking program first

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3
Q

Which medications can frequently cause a false positive for plasma metanephrines?

A

Tricyclic Antidepressants and Venlafaxine

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4
Q

Explain why it is difficult to replete Ca when there is hypomagnesemia?

A

Hypomagnesemia leads to a functional hypoparathyroidism bc normal magnesium levels are required for release of PTH

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5
Q

A patient with metastatic carcinoid tumor who has physical exam findings of Cushing likely is producing what?

A

ACTH; ectopic ACTH syndromes occur most frequently in carcinoid tumors and in SCLC

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6
Q

What is the glycemic goal of an ICU patient?

A

140-180, best achieved with an insulin drip as subQ can be erratic in critically ill patients

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7
Q

What level can be checked if there are concerns that the glycated hemoglobin is not accurate (anemia, hemoglobinopathies, or the fingerstick values are way different than the A1C)?

A

Fructosamine level

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8
Q

What did the ACCORD, ADVANCE, and VADT trials all essentially show?

A

Stricter glycemic control in older patients did NOT reduce the incidence of macrovascular complications

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9
Q

What is the recommended frequency of lipid screening in a patient with borderline elevated LDL?

A

Recheck in 4-6 years

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10
Q

Palmar xanthomas are pathognomonic for ______________

A

Abetalipoproteinemia; xanthoses occur in other familial syndromes but PALMAR xanthomas are most c/w abetalipoproteinemia

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11
Q

When is the best time to evaluate for Cushing syndrome in a pt in whom this is suspected who is hospitalized?

A

After discharge and after recovery from the stress of the hospitalization (midnight salivary cortisol or 24 hour free urinary cortisol)

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12
Q

What are the 4 cutoffs to make a Dx of DM

A

Eight Hour Fasting glucose >126, HbA1C >6.5%, Plasma glucose >200 after a 75 g oral glucose tolerance test, or a random plasma glucose >200 with classic sx

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13
Q

What are two scenarios in which DHEAS can be elevated?

A

Can be elevated in women with hyperadronergic states and in adrenocortical carcinoma

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14
Q

When is the appropriate clinical scenario to measure glucagon levels?

A

If you are concerned about a glucogonoma i.e. someone has severe refractory DM, necrolytic migratory erythema, weight loss, and diarrhea

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15
Q

The most common monogenic cause of obesity is a mutation in _______________

A

melanocortin-4 receptor

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16
Q

What is Sipple Syndrome? Wermer Syndrome?

A

MEN2A: Medullary Thyroid CA, Pheochromocytoma, primary hyperpara; MEN1: pNETs, pituitary adenomas, parathyroid adenomas

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17
Q

What sorts of changes are seen in the HPA axis in anorexia?

A

Often low GnRH with subsequent low FSH and LH; low levels of thyroxine but HIGH levels of cortisol

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18
Q

What is the appropriate use of fenofibrate?

A

If the TGs are >1000 because then it decreases the risk of pancreatitis; however, there is no evidence of coronary benefit from lowering TGs with fibrates

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19
Q

What should be done for an adrenal mass incidentally noted that is >4cm in size

A

Consider surgical excision

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20
Q

What are the 3 DM meds with a proven cardiovascular benefit?

A

metformin, empaglifozin, and some GLP-1 agonists (Liraglutide and Semaglutide)

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21
Q

What is the target HbA1C for a patient with a history of hypoglycemia?

A

Can be around 8%

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22
Q

What is the most likely dx for patients with hyperglycemia that are diagnosed with adults who have a lean body mass?

A

MODY- Maturity Onset Diabetes of the Young and is an AD disorder often with a normal C-Peptide

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23
Q

The rapid onset of virilization in women should prompt evaluation for what?

A

An androgen secreting tumor i.e. of the ovaries or adrenal gland; so when a woman has virilization it is important to know the temporal history and not to just assume it is PCOS

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24
Q

What is the best test to initially evaluate a person that you have diagnosed asymptomatic primary hyperparathyroidism in?

A

DEXA of the Hip, Lumbar, and DISTAL RADIUS

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25
Q

When should you consider using U-500 formulations of insulin?

A

When they have Severe Insulin Resistance (i.e. require more than 200 units daily) this is concentrated regular insulin

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26
Q

Myalgias, fever, followed by anterior neck pain may be due to what

A

Subacute (Painful) Thyroiditis

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27
Q

When is bariatric surgery indicated?

A

If BMI >40 or if BMI >35 with comorbidities

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28
Q

What is the typical cholesterol profile that accompanies subclinical hypothyroidism?

A

High total cholesterol and high LDL

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29
Q

How might the presentation of a pt with an ACTH producing SCLC present differently than a pt with an adrenal adenoma?

A

The SCLC pt would have a faster course, they would have more metabolic deficits such as hyperglycemia, hypokalemia, met alkalosis and maybe even WEIGHT LOSS; an adrenal adenoma would take longer and would likely have weight gain d/t central adiposity

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30
Q

Patients with premature ovarian failure should also be screened for __________

A

Hypothyroidism as it may be autoimmune in nature (amenorrhea before age 40)

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31
Q

In whom do you see chalkstick fractures?

A

Atypical femoral fractures seen in pt on long-term bisphosphonates, in ppl on denosumab, and in patients with Paget’s dz

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32
Q

What is the primary endocrine side effect of sunitinib and why?

A

Hypothyroidism thought to be due to involution of the gland by effects on the capillaries as it is anti-angiogenic; also causes HTN

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33
Q

A patient with hyperphosphaturia and elevated FGF-23 likely has _______________-

A

Oncogenic osteomalacia; FGF-23 causes phosphate loss in the urine leading to leeching from bone, bone pain, and elevated alk phos (bone isoform); small mesenchymal tumors usually the etiology

34
Q

What is the issue with only giving synthroid and not hydrocortisone in myxedema coma

A

In general, if there is adrenal insufficiency, supplementation with synthroid can exacerbate if hydorcortisone is not given first

35
Q

What are the two disorders that cause a painful thyroid?

A

Subacute painful thyroiditis; Acute suppurative bacterial thyroiditis

36
Q

What is a possible etiology of a patient who is hypernatremic with low urine osm after a head trauma?

A

Central DI due to shearing forces from the TBI

37
Q

What endocrine effects may occur in the setting of a patient with traumatic brain injury?

A

Can develop panhypopituitarism due to the shearing effects on the hypothalamus/stalk/and pituitary

38
Q

What is the pathophysiology of X-linked Hypophosphatemic Rickett’s?

A

There is a defect in tubular reabsorption of phosphate AND inability to perform 1-alpha-hydroxylation of vitamin D so pts need both calcitriol and phosphate supplementation

39
Q

What class of diabetic meds has been shown to increase the risk of fractures?

A

TZDs; they also increase the risk of heart failure and fluid retention and are generally best avoided

40
Q

What type of adrenal insufficiency would affect sodium and potassium?

A

Primary only bc it would knock out the whole adrenal including the aldosterone synthesis; in central adrenal insufficiency, the RAAS still manages Na/K via aldo

41
Q

This test should preceed a thyroidectomy in a pt with medullary thyroid CA?

A

Plasma metanephrines bc many are assoc with MEN2A/B w/ + RET gene mutation

42
Q

What is the most appropriate next step in a patient with SIADH who is still hyponatremia despite intense fluid restriction?

A

Increase the solute i.e. salt tabs or urea 15 g bid

43
Q

GLP-1 agonists are contraindicated in pt with FMHx of ______________

A

Medullary thyroid CA or MEN2A/B; rodent studies showed trophic effects on thyroid C-cells

44
Q

What are the antibodies to check if you want to see if someone has new onset DM1?

A

GAD antibodies -Anti-Glutamic Acid Decarboxylase antibodies

45
Q

What DM meds are safe in pregnancy?

A

Metformin and glyburide; insulin is obviously. Most will switch to insulin when pregnant though

46
Q

What is present in Autoimmune polyglandular syndrome type II?

A

Autoimmune adrenalitis (Addison), Autoimmune thyroid dz (Hashimoto), with or without DM-1 (Anti-GAD)

47
Q

What is “Ketosis-Prone DM”?

A

Pt with type II DM who present with DKA but are able to stop insulin and be on OHAs; no GAD abs

48
Q

What is the definition of polyuria

A

>2.5 mL/Kg/hr (so more than 250 cc in a 100 kg person per hour)

49
Q

A random cortisol level > ________ indicates normal adrenal function?

A

>18 confirms it; if between 10-12 it is suggestive that it is normal

50
Q

What hormone is involved in 1-alpha-hydroxylation of Vitamin D?

A

PTH; so in situations where PTH is suppressed then there may be low 1-25 vitamin D

51
Q

What is the natural history in subacute thyroiditis?

A

Usually thyrotoxicosis with a painful thyroid followed by 3-6 months of hypothyroidism then euthyroid

52
Q

What is the best mgmt of glucocorticoid induced hyperglycemia?

A

Need to titrate the preprandial insulin; glucocorticoids increase the prandial glucose more so than the basal

53
Q

What is the postulated mechanism of hyperprolactinemia in hypothyroidism?

A

Postulated that there is increased hypothalamic TRH synthesis which may increase prolactin production (real question then is do you still get hyperprolactinemia in central hypothyroidism?)

54
Q

What are the most typical manifestations of anatomic issues with the hypothalamus? i.e. damage after surgery?

A

Change in appetite, thirst, dysregulation of sleep cycles and body temp

55
Q

In which type of adrenal insufficiency is the replacement of both glucocorticoid and mineralocorticoid needed?

A

If it is primary adrenal insufficiency i.e. due to an issue with the adrenal gland; if it is central, then the RAAS will take care of the aldosterone

56
Q

A cosyntropin stimulation test is positive if after giving 250 ug of cosyntropin after one hour the cortisol is less than _______

A

18

57
Q

How do you tell if the levothyroxine is being adequately replaced in a pt with central hypothyroidism?

A

Follow the free T4

58
Q

This is the most appropriate tx for a pt with low urine osmolarity, hypernatremia, and high serum osmolarity one day after pituitary sugery?

A

DDAVP; often can get DI right after then SIADH from release of stored ADH in damaged neuron, then permanent DI possibly

59
Q

What is the best approach to managing hypertriglyceridemia in a patient who also has uncontrolled DM2?

A

Control the glucose first i.e. try metformin (but if the pt is at the appropriate age for a statin would start that as well)

60
Q

What are the consequences for not following a phenylalanine free diet in children and in adults?

A

More serious in young children can lead to cognitive defects and demyelination; more neuropsychiatric sx in adults w/ executive dysfxn, impulsitivity, and mood disorders

61
Q

Young ppl with fragility fractures should undergo testing of _____________ genes

A

COL1A1 and COL1A2 for Osteogenesis imperfecta

62
Q

Why does adrenocortical carcinoma often lead to hypokalemia?

A

Excess production of glucocorticoid can stimulate the mineralocorticoid receptor leading to potassium wasting and HTN

63
Q

What is non-islet cell tumor hypoglycemia?

A

When tumors produce IGF-2 which activates the insulin receptor; it is a paraneoplastic disorder of mesenchymal tumors etc

64
Q

What is a concern in a patient with Graves or multinodular goiter who undergoes cardiac catheterization?

A

Iodine exposure can kick off thyrotoxicosis

65
Q

Osteomalacia with hypokalemia, hypophosphatemia, NAGMA, glycosuria (but normal serum glucose) and proteinuria is likely due to _____________-

A

Fanconi syndrome due to poor PCT handling of the aforementioned substances

66
Q

What is the most likely diagnosis in a patient with Type II polyglandular syndrome who presents with anemia, ataxia, and decreased vibratory sense?

A

Pernicious Anemia; Dx w/ intrinsic factor Ab, low B12, and elevated MMA; Pt with autoimmune polyglandular syndrome type II are at increased risk of this as well as Celiac which can cause iron def

67
Q

What is Severe Insulin Resistance defined as? Best tx?

A

The requirement of > 200 units of insulin in 24 hours; often need to use the U-500 formulations as these have 500 units of insulin in 1 mL rather than 100

68
Q

What are some high risk professions to avoid things like hypoglycemia in? What are 3 classes of DM meds that do not typically cause hypoglycemia?

A

Bus driver, pilot, etc.; Biguanides (metformin), DPP-4 inhibitors (Sitagliptin), and SGLT2 inhibitors (Canaglifozin)

69
Q

The syndrome of both autoimmune adrenalitis and autoimmune thyroid dz with or without DM1 is _________. What other two diseases need do you need to look for?

A

Autoimmune Polyglandular Syndrome Type II; pernicious anemia and celiac dz

70
Q

Explain calcium, phosphate and active vitamin D levels in milk-alkali syndrome

A

High calcium due to taking in calcium containing stuff; the calcium suppresses PTH leading to hypophosphatemia and since PTH is low there is less 1-alpha-hydroxylation of vitamin D

71
Q

How should you screen for osteoporosis in patients with primary hyperparathyroidism?

A

DEXA but should include the distal 3rd of the radius bc there is more cortical bone there which is more sensitive to effects of PTH

72
Q

When in the course of treatment of osteoporosis would measurement of C-Telopeptide be useful?

A

Can be used to assess response to treatment but not upfront

73
Q

What are some endocrine issues that lithium can cause?

A

Diabetes insipidus; hypercalcemia it affects secretion of PTH by affecting the set point at which serum calcium levels suppress PTH secretion

74
Q

This is the most important first step in managing pituitary apopexy

A

Administration of IV hydrocortisone; if highly suspect this you would give the steroids prior to any imaging

75
Q

What DM meds should be avoided in gastroparesis?

A

GLP-1 agonists and amylin analogues

76
Q

Why do patients with hypothyroidism often get HLD?

A

Thyroid hormone reduces lipoprotein lipase activity and leads to downregulation of LDL receptors

77
Q

The findings of the metabolic abnormalities of Cushings such as hypokalemia, metabolic alkalosis, and hyperglycemia with only modest evidence of Cushing physical exam is suggestive of ________

A

Ectopic ACTH production i.e. something like SCLC; a pt with an ACTH-producing pituitary adenoma or adrenal adenoma will have slower course

78
Q

Latent Autoimmune Diabetes in Adults (LADA) is associated with what antibody?

A

Anti-glutamic acid decarboxylase

79
Q

What is the disease where the primary issues is impaired tubular reabsorption of phosphate?

A

X-linked Hypophosphatemic Rickett’s; also have issues with 1-alpha-hydroxylation of vitamin D so need calcitriol supplementation

80
Q

What number cutoff makes a Dx of PAD?

A

<0.9; walking program first then can do cilostazol; also ASA and Atorva 40-80

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