MKSAP13 Flashcards
What is the most likely etiology of obesity in a patient with panhypopituitarism assuming that the levothyroxine has been adequately replaced?
If pt is euthyroid then it is probably due to HYPOTHALAMIC INJURY resulting in hyperphagia
This drug has been shown to improve walking distance in pt with PAD
Cilostazol (PDE-3 inhibitor) but often try walking program first
Which medications can frequently cause a false positive for plasma metanephrines?
Tricyclic Antidepressants and Venlafaxine
Explain why it is difficult to replete Ca when there is hypomagnesemia?
Hypomagnesemia leads to a functional hypoparathyroidism bc normal magnesium levels are required for release of PTH
A patient with metastatic carcinoid tumor who has physical exam findings of Cushing likely is producing what?
ACTH; ectopic ACTH syndromes occur most frequently in carcinoid tumors and in SCLC
What is the glycemic goal of an ICU patient?
140-180, best achieved with an insulin drip as subQ can be erratic in critically ill patients
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)?
Fructosamine level
What did the ACCORD, ADVANCE, and VADT trials all essentially show?
Stricter glycemic control in older patients did NOT reduce the incidence of macrovascular complications
What is the recommended frequency of lipid screening in a patient with borderline elevated LDL?
Recheck in 4-6 years
Palmar xanthomas are pathognomonic for ______________
Abetalipoproteinemia; xanthoses occur in other familial syndromes but PALMAR xanthomas are most c/w abetalipoproteinemia
When is the best time to evaluate for Cushing syndrome in a pt in whom this is suspected who is hospitalized?
After discharge and after recovery from the stress of the hospitalization (midnight salivary cortisol or 24 hour free urinary cortisol)
What are the 4 cutoffs to make a Dx of DM
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
What are two scenarios in which DHEAS can be elevated?
Can be elevated in women with hyperadronergic states and in adrenocortical carcinoma
When is the appropriate clinical scenario to measure glucagon levels?
If you are concerned about a glucogonoma i.e. someone has severe refractory DM, necrolytic migratory erythema, weight loss, and diarrhea
The most common monogenic cause of obesity is a mutation in _______________
melanocortin-4 receptor
What is Sipple Syndrome? Wermer Syndrome?
MEN2A: Medullary Thyroid CA, Pheochromocytoma, primary hyperpara; MEN1: pNETs, pituitary adenomas, parathyroid adenomas
What sorts of changes are seen in the HPA axis in anorexia?
Often low GnRH with subsequent low FSH and LH; low levels of thyroxine but HIGH levels of cortisol
What is the appropriate use of fenofibrate?
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
What should be done for an adrenal mass incidentally noted that is >4cm in size
Consider surgical excision
What are the 3 DM meds with a proven cardiovascular benefit?
metformin, empaglifozin, and some GLP-1 agonists (Liraglutide and Semaglutide)
What is the target HbA1C for a patient with a history of hypoglycemia?
Can be around 8%
What is the most likely dx for patients with hyperglycemia that are diagnosed with adults who have a lean body mass?
MODY- Maturity Onset Diabetes of the Young and is an AD disorder often with a normal C-Peptide
The rapid onset of virilization in women should prompt evaluation for what?
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
What is the best test to initially evaluate a person that you have diagnosed asymptomatic primary hyperparathyroidism in?
DEXA of the Hip, Lumbar, and DISTAL RADIUS
When should you consider using U-500 formulations of insulin?
When they have Severe Insulin Resistance (i.e. require more than 200 units daily) this is concentrated regular insulin
Myalgias, fever, followed by anterior neck pain may be due to what
Subacute (Painful) Thyroiditis
When is bariatric surgery indicated?
If BMI >40 or if BMI >35 with comorbidities
What is the typical cholesterol profile that accompanies subclinical hypothyroidism?
High total cholesterol and high LDL
How might the presentation of a pt with an ACTH producing SCLC present differently than a pt with an adrenal adenoma?
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
Patients with premature ovarian failure should also be screened for __________
Hypothyroidism as it may be autoimmune in nature (amenorrhea before age 40)
In whom do you see chalkstick fractures?
Atypical femoral fractures seen in pt on long-term bisphosphonates, in ppl on denosumab, and in patients with Paget’s dz
What is the primary endocrine side effect of sunitinib and why?
Hypothyroidism thought to be due to involution of the gland by effects on the capillaries as it is anti-angiogenic; also causes HTN
A patient with hyperphosphaturia and elevated FGF-23 likely has _______________-
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
What is the issue with only giving synthroid and not hydrocortisone in myxedema coma
In general, if there is adrenal insufficiency, supplementation with synthroid can exacerbate if hydorcortisone is not given first
What are the two disorders that cause a painful thyroid?
Subacute painful thyroiditis; Acute suppurative bacterial thyroiditis
What is a possible etiology of a patient who is hypernatremic with low urine osm after a head trauma?
Central DI due to shearing forces from the TBI
What endocrine effects may occur in the setting of a patient with traumatic brain injury?
Can develop panhypopituitarism due to the shearing effects on the hypothalamus/stalk/and pituitary
What is the pathophysiology of X-linked Hypophosphatemic Rickett’s?
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
What class of diabetic meds has been shown to increase the risk of fractures?
TZDs; they also increase the risk of heart failure and fluid retention and are generally best avoided
What type of adrenal insufficiency would affect sodium and potassium?
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
This test should preceed a thyroidectomy in a pt with medullary thyroid CA?
Plasma metanephrines bc many are assoc with MEN2A/B w/ + RET gene mutation
What is the most appropriate next step in a patient with SIADH who is still hyponatremia despite intense fluid restriction?
Increase the solute i.e. salt tabs or urea 15 g bid
GLP-1 agonists are contraindicated in pt with FMHx of ______________
Medullary thyroid CA or MEN2A/B; rodent studies showed trophic effects on thyroid C-cells
What are the antibodies to check if you want to see if someone has new onset DM1?
GAD antibodies -Anti-Glutamic Acid Decarboxylase antibodies
What DM meds are safe in pregnancy?
Metformin and glyburide; insulin is obviously. Most will switch to insulin when pregnant though
What is present in Autoimmune polyglandular syndrome type II?
Autoimmune adrenalitis (Addison), Autoimmune thyroid dz (Hashimoto), with or without DM-1 (Anti-GAD)
What is “Ketosis-Prone DM”?
Pt with type II DM who present with DKA but are able to stop insulin and be on OHAs; no GAD abs
What is the definition of polyuria
>2.5 mL/Kg/hr (so more than 250 cc in a 100 kg person per hour)
A random cortisol level > ________ indicates normal adrenal function?
>18 confirms it; if between 10-12 it is suggestive that it is normal
What hormone is involved in 1-alpha-hydroxylation of Vitamin D?
PTH; so in situations where PTH is suppressed then there may be low 1-25 vitamin D
What is the natural history in subacute thyroiditis?
Usually thyrotoxicosis with a painful thyroid followed by 3-6 months of hypothyroidism then euthyroid
What is the best mgmt of glucocorticoid induced hyperglycemia?
Need to titrate the preprandial insulin; glucocorticoids increase the prandial glucose more so than the basal
What is the postulated mechanism of hyperprolactinemia in hypothyroidism?
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?)
What are the most typical manifestations of anatomic issues with the hypothalamus? i.e. damage after surgery?
Change in appetite, thirst, dysregulation of sleep cycles and body temp
In which type of adrenal insufficiency is the replacement of both glucocorticoid and mineralocorticoid needed?
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
A cosyntropin stimulation test is positive if after giving 250 ug of cosyntropin after one hour the cortisol is less than _______
18
How do you tell if the levothyroxine is being adequately replaced in a pt with central hypothyroidism?
Follow the free T4
This is the most appropriate tx for a pt with low urine osmolarity, hypernatremia, and high serum osmolarity one day after pituitary sugery?
DDAVP; often can get DI right after then SIADH from release of stored ADH in damaged neuron, then permanent DI possibly
What is the best approach to managing hypertriglyceridemia in a patient who also has uncontrolled DM2?
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)
What are the consequences for not following a phenylalanine free diet in children and in adults?
More serious in young children can lead to cognitive defects and demyelination; more neuropsychiatric sx in adults w/ executive dysfxn, impulsitivity, and mood disorders
Young ppl with fragility fractures should undergo testing of _____________ genes
COL1A1 and COL1A2 for Osteogenesis imperfecta
Why does adrenocortical carcinoma often lead to hypokalemia?
Excess production of glucocorticoid can stimulate the mineralocorticoid receptor leading to potassium wasting and HTN
What is non-islet cell tumor hypoglycemia?
When tumors produce IGF-2 which activates the insulin receptor; it is a paraneoplastic disorder of mesenchymal tumors etc
What is a concern in a patient with Graves or multinodular goiter who undergoes cardiac catheterization?
Iodine exposure can kick off thyrotoxicosis
Osteomalacia with hypokalemia, hypophosphatemia, NAGMA, glycosuria (but normal serum glucose) and proteinuria is likely due to _____________-
Fanconi syndrome due to poor PCT handling of the aforementioned substances
What is the most likely diagnosis in a patient with Type II polyglandular syndrome who presents with anemia, ataxia, and decreased vibratory sense?
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
What is Severe Insulin Resistance defined as? Best tx?
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
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?
Bus driver, pilot, etc.; Biguanides (metformin), DPP-4 inhibitors (Sitagliptin), and SGLT2 inhibitors (Canaglifozin)
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?
Autoimmune Polyglandular Syndrome Type II; pernicious anemia and celiac dz
Explain calcium, phosphate and active vitamin D levels in milk-alkali syndrome
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
How should you screen for osteoporosis in patients with primary hyperparathyroidism?
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
When in the course of treatment of osteoporosis would measurement of C-Telopeptide be useful?
Can be used to assess response to treatment but not upfront
What are some endocrine issues that lithium can cause?
Diabetes insipidus; hypercalcemia it affects secretion of PTH by affecting the set point at which serum calcium levels suppress PTH secretion
This is the most important first step in managing pituitary apopexy
Administration of IV hydrocortisone; if highly suspect this you would give the steroids prior to any imaging
What DM meds should be avoided in gastroparesis?
GLP-1 agonists and amylin analogues
Why do patients with hypothyroidism often get HLD?
Thyroid hormone reduces lipoprotein lipase activity and leads to downregulation of LDL receptors
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 ________
Ectopic ACTH production i.e. something like SCLC; a pt with an ACTH-producing pituitary adenoma or adrenal adenoma will have slower course
Latent Autoimmune Diabetes in Adults (LADA) is associated with what antibody?
Anti-glutamic acid decarboxylase
What is the disease where the primary issues is impaired tubular reabsorption of phosphate?
X-linked Hypophosphatemic Rickett’s; also have issues with 1-alpha-hydroxylation of vitamin D so need calcitriol supplementation
What number cutoff makes a Dx of PAD?
<0.9; walking program first then can do cilostazol; also ASA and Atorva 40-80
