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Boards Review > USMLE Endocrine > Flashcards

USMLE Endocrine Flashcards

1
Q

Acromegaly

Cancer

A

High risk of esophageal , gastric, colon cancer, Pt to under go colonoscopy on dx and q3-4 yrs.

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2
Q

Adrenal Incidentaloma

Hormone studies

  • Pheochromocytoma
  • Cushings syndrome
  • primary aldosteronism
  • Adrenocortical carcinoma

Imaging

A

Pheochromocytoma

  • HTN, palpitation, HA, Diaphoresis, Tremor
  • Epinephrins / metanephrines

Cushings

  • Cortisol (am / pm), Dexamethasone suppres

Primary aldosteronism

  • Rrenin/Aldostrone : 20 times

Imaging ( if > 4 Cm / housefield > 10, retension of contrast > 50% after 10 mins) :

  • Consider FNA / surgery follow up
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3
Q

Amiodarone induced thyrotoxicosis

Type I

Type II

  • discontinuing Amio wont help / stays in adipose tissue with half life of 100 days
  • RAI upatake low in both
  • Amiodarone has 6 mg Iodine in 200 mg tablet
A

Type I

  • Increase synthesis of T4 and T3
  • preexisting MNG or latent graves
  • US Increased Vascularity
  • Tx: Antithyroid medications (methimazole) Thryroidecdtomy for refractory cases
    • Incrase MMI

Type II

  • Release of preformed T4/T3
  • US Decreased Vascularity
  • Tx: Corticosteriods
    • Decreased _C_orticosteriods _CD_
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4
Q

ATP III Guidlines

  1. CHD or CH risk equivalent (DM / Carotid, PAD, AAA) > 20%
  2. > 2 risk factors (10 yr risk
  3. 0-1 risk factors

Total Cholestrol - HDL

A

LDL goals / Non-HDL goals

  1. < 100 mg/dL
  2. < 130 < 160
  3. < 160 < 190
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5
Q

Causes of hyperprolactinemia

A

Physiologic

  • Pregnancy / Breast feeding / Stress

Pathologic

  • Pituitary adenoma / macroprolactinoma
  • Hypothalamic dz with low dopamin
  • Drugs: Antidepresants, antipsychotics, metoclopramid,
  • Hypthyroidism
  • Chest wall injury (herpes zoster)
  • CKD
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6
Q

Causes of Low TSH and low T4

A

Central Hypothyroidism

  • LOW TSH/T4/T3
  • Pituitary hormonal Deficiencies

Subclinical Thyrotoxicosis

  • Low TSH / T4 and high T3 (seen in pt taking t3)
  • Radioactive iodine uptake and scan helpful

Euthyroid sick syndrome

  • Sick pt / Normal to low TSH/T4/T3

Medications

  • Dopamin, octerotide, steriods
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7
Q

Causes of secondary hTN

A
  • Renal artery stenosis
  • OSA
  • CKD
  • Pheochromocytoma
  • Cushing syndrom
  • Coarctation of aorta
  • Primary Hyperaldosteronism

50% of patients with hyperaldosteronism have normal K levels

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8
Q
  • Central hypothyroidism
  • Subclinical thyrotoxicosis
  • Euthyroid Sick syndrome
A
  • low TSH FT4 and FT3
  • Low TSH and FT4 with high FT3
  • Low TSH / FT4/FT3
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9
Q

CKD and hyperprolactinemia

A

Usually increased by 3 folds and decreased in clearance by 30 %

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10
Q

Comparative steriod potencies

  • Hydrocortisone (cortisol)
  • Prednisone
  • Prednisolone
  • Methylprednisolone
  • Dexamethasone
  • Betamethasone
  • Triamcinolone
  • Beclometasone
  • Fludrocortisone
A

Glucocorticoid potency / Mineralcorticoid potency / Durations

  • Hydrocortisone 1 / 1 / 8 hrs
  • Prednisone 3.5-5 / 0.8 / 16-36
  • Prednisolone 4 / 0.8 / 16-36
  • Methylprednisolone 5-7.5 / .5 / 18-40
  • Dexamethasone 25-80 / 0 / 36-54
  • Betamethasone 25-30 / 0 / 36-54
  • Triamcinolone 5 / 0 / 12-36
  • Beclometasone 8 buffs 4 X daily same as 14 mg oral prednisone once a day
  • Fludrocortisone 15 / 200 / 24
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11
Q

Criteria for Parathyroidectomy in asymptomatic PHPT

Asymptomatic means

  • no Fractures
  • no Osteoprosis
  • no kidney stones ect
A
  1. Serum **C**a > 1 mg/dL above normal
  2. Cr clearance < 60 ml/min
  3. Bone mineral density with T score < 2.5 at any site
  4. Age < 50
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12
Q

Cushing’s syndrome (test to stablish)

Flow chart after stablished.

A

Must have 2 out of 3

  • 24 hr urinary cortisol
  • Late night salvary cortisol
  • Low dose dexamethasone suppression test

First Check ACTH

  • If low Adrenal CT ( ACTH< 5)
  • If high ACTH> 5 - MRI of pituitary
    • **Pituitary < 6 mm **Inferior petrosal sinus sampling
    • Pituitary > 6 mm Hight dose dexamethason suppression
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13
Q

DDP-4 inhibitors (Gliptons)

A

Sitagliptin (januvia), Saxagliptin, Linagliptin

Decrease blood blucose by increase the endogenous incretin hormone GLP1 and GIP.

Safe with CKD

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14
Q

Diabetes Neuropathy

A
  • Topical capasiacin Cream
  • Antidepressants (amitriptyline) (younger pt)
  • Anticonvulsants(pregabalin, Valporic acid) (older)
  • Alpha lipoic acid
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15
Q

Diagnose postexercise hyperglycemia.

A

Hypoinsulinemia causes increased hepatic glucose output and decreased peripheral glucose uptake, which results in a higher blood glucose level and, ultimately, a higher hemoglobin A1c value; prolonged exercise, which further stimulates hepatic glucose release, exacerbates this condition.

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16
Q

Diagnose thyroid lymphoma.

A

Thyroid lymphoma occurs most frequently in older patients with a history of Hashimoto thyroiditis and typically presents as an enlarging neck mass, often with local and systemic symptoms.

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17
Q

Diagnose thyroid storm

A
  • Thyroid storm can be differentiated from other forms of thyrotoxicosis by the presence of temperature elevation, significant tachycardia, heart failure, abdominal discomfort, diarrhea, nausea, vomiting, and (sometimes) jaundice.
  • Treatment typically consists of a combination of antithyroid drugs (propylthiouracil or methimazole), iodine solution, high-dose corticosteroids, β-blockers, and (rarely) lithium. Even with aggressive therapy and supportive measures, mortality rates are as high as 15% to 20%.
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18
Q

DM start with meds …

A

Metformin(M) + Lifestyle changes (LC)

LC + M + Sulfas if failed

LC + M + Lantus

Or LC + M + Pioglitazone or LC + M + Exenatide

LC + M + C + sulfas

Else

LC + M + Basal insulin

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19
Q

Endocrine causes of carpal tunner syndrome:

A

Acromegaly

DM

Hypothyroidism

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20
Q

ESS

Euthyroid Sick Syndrome

A
  • Due to Decreased conversion of T4 to T3
  • Decreased T4 production and clearance
  • Altered T4 protien bining
  • Suppresion of TSH
  • Also meds like Steriods / dopamine will suppress TSH levels block T4 - > T3 conversion
  • Long term T4 will become suppressed
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21
Q

Features of anabolic steriod abuse

A
  • Acne and gynecomastia
  • Increased muscle mass
  • Psychiatric problems
  • Erythropoiesis
  • Hyperlipidemia
  • Normal Libido and Erectile function
  • Atrophic testes w low testrone and FSH/SH levels
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22
Q

Gestational DM

  • fasting BG 105 compare to 75 is 4X likely to have complications
A

Need better control then avg person

NPH idealy

  • Metformin / glyburide not CI but not enough studies
    • Category C
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23
Q

GLP 1 Receptor agonist (Exenatide)

A
  • Weight loss
  • Low hypoglycemia risk
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24
Q

Granulomatous disorders causing hypercalcemia

A

Non infectous

  • Sarcoidosis
  • Berylliosis
  • Crohn’s
  • Lymphomas

Infectious

  • TB
  • Leprosy
  • Coccidioidomycosis
  • Histo
  • PCP
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25
Q

Non PCO Disorders causing hirsutism

A

Ovarian tumors - Often sever

  • Elevated Androgen

Non classic CAH - Significant

  • increase 17 hydroxyprogesterone

Cushings syndrome - Significant

  • Overnight dexamethasone / 24 hr urinary cortisol / late evening salivary cortisol

Hypothyriodism - Mild

  • Elevated TSH

Hyperprolactinemia - Mild

  • Elevated prolactin

Drugs - Mild

  • Anabolic steriods, valproic cid, Danazol, cyclosporin
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26
Q

Hungary bone syndrome

A
  • Patients with hyperparathyroidism have increased bone formation and resorption with increase flow of calcium out of the bone. However when PTH adenoma removed the Ca flows in the the bone formation which will cause decrese calcium and phosphorus, magnesium levels.
  • IV Calcium given when patient has Ca < 7.5 mg/dl or Tetany, respiratory distress
  • Do not administer phosphorus unless levels < 1 mg/dl as it may worsen the hypocalcemia
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27
Q

Hypercalcemia with Eelvated to normal PTH

Which lab to order next

A

Urinary Calcium 24 hr collection

  • > 100
    • Primary and tertiary hyperparathyroidism
  • < 100
    • Familial hypercalcemic hypocalciuria
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28
Q

Hypercalcemia with Suppressed PTH

  • Elevated PTHrP
  • Elevated D3
  • Elevated D2
  • Normal labs
A
  • Elevated PTHrP - Tumor has no feed back
  • Elevated D3 - Sarcoid, lymphoma (CXR)
  • Elevated D2 - Vit D toxicity
  • Normal labs - Hyperthyroid / MM / Adrenal tumor / acromegaly / Immobilization
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29
Q

Hypercalcemia

Tx: IVF +

  • Calcitonin
  • Cinacalcet
  • Prednisone
  • Zoledronate
A
  • Calcitonin for Ca > 14 in cancer patients
  • Cinacalcet: Calcium mimetic drug - works on ca sensors on PTH cells to lower PTH (used in CKD and primary PTH)
  • Prednisone: Sarcoidosis and lymphoma as they produce 1-hydroxylase with excess conversion of active Vit D
  • Zolendronate is good in dz that cause excess bone resorption
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30
Q

Hyperglycemia and TAGs how to treat it

150-199

200-499

>500

A

150-199:

  • Weight reduction / activity

200-499

  • _Primary _target **LDL **(statin)
  • _Secondary _target: **non HDL **(increase statin dose and add fibrates)

>500

  • _Primary goal _is to prevent pancreatitis with fibrates/niacin
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31
Q

Hyperthyroidism

  • B-Blocker
  • Steriods
  • Methamezole
  • Radioactive iodine ablation
A

B-Blockers

  • Symptom control / painless thyroiditis / preformed hormones

Steriods

  • Type II amiodarone thryroiditis-CD Corticosteriors for Decreased vaslcular

Methimezole

  • Graves

Radioactive iodine abliation

  • Graves / toxi nodular goiter
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32
Q

Subclinical hypothyroidism / females

A

If TSH < 10

  • and Anti TPO if so then must treat with levothroxine
  • Else if patient is pregnent has a goiter, is symptomatic, ovulatory dysfunction, hypercholesterolemia must be treated.
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33
Q

Hypothyroidism and elevated transaminases

A

Muscle injury could increase transaminases - watup

34
Q

Indications for MRI in patinets with central hypogonadism

A
  • Testostrone levels
    • < 150 > 65 yrs old
    • < 200 Age < 65
  • Mass effect / HA or visual field defects
  • Multiple pituitary hormone def
  • Hyperprolactinemia
35
Q

Indications for treating prolactinoma

A

Females

  • Presence of classic symptoms / amenorrhea and glactorrhea
  • Infertility without classic symptoms
  • Osteoprosis and risk of bone loss
  • Acne and hirsutism

Males

  • Hypogonadism and gynecomastia
  • Osteoprossis

Both sexes

  • Enlarged adenoma
36
Q

Interpret thyroid function studies in an older patient.

A
  • Older patients generally should not be given levothyroxine solely for an elevated thyroid-stimulating hormone level.
  • elevated serum TSH level in older patients is not associated with detrimental medical outcomes (such as depressive symptoms and impaired cognitive function) but, in fact, is associated with a lower mortality rate
37
Q

LADA - Latent autoimmune diabetes of adulthood

A
  • Age of onset > 35 < 50
  • Acute onset of symptoms
  • BMI < 25 kg/m2
  • Personal or family history of autoimmune dz
  • Check GAD
38
Q

Levothyroxine drug intractions

A

Lower Levothyroxin absorption (increase dose)

  • Bile acid binding agents / Iron / ca / PPI

Increase TBG concentration (increase dose)

  • Estrogen, tamoxifen raloxifene / heroin, methadone

Decrease TBG concentration (decrease dose)

  • Androgens, steriods, anabolic steriods

Increase Thryoid Hormone (decrease dose)

  • Rifampicin, Phenytoin, Carbamazepine
39
Q

Manage an asymptomatic incidental adrenal mass.

A

ncidentally discovered adrenal masses that are small, are associated with no clinical or biochemical features suggestive of excess hormonal secretion, and have no imaging features suggestive of possible malignancy should be followed with observation and repeat testing in 6 to 12 months.

Neither the size (

40
Q

Manage hirsutism in polycystic ovary syndrome.

A

Initial treatment for hirsutism in women with polycystic ovary syndrome is an oral contraceptive.

Spironolactone can be very useful for the treatment of hyperandrogenism in PCOS but is added only if an oral contraceptive does not adequately improve symptoms.

Although early observational trials suggested that metformin may be effective in treating hirsutism in patients with PCOS, subsequent randomized clinical control trials have had mixed results

Dexamethasone For Tx congenital adrenal hyperplasia. This patient’s 17-hydroxyprogesterone must be measured

41
Q

MEN

MEN 2A

MEN2B

A

MEN 1

  • Pancreatic / Pitiutary /
  • _Parathyroid _

MEN IIa

  • **Parathyroid, **
  • **Medullary Thyroid CA, pheo, **

MEN IIb

  • Medullary Thyroid CA, peho,
  • marfanoid body hapitus

NOTE

MEN II - Medullary Thyroid and PHEO

42
Q

Methimazole is associated with an increased risk of fetal abnormalities

A
  • Aplasia cutis and choanal atresia, when used in the first trimester. After fetal organogenesis is complete, methimazole should be used. Methimazole is the antithyroid agent of choice except in the first trimester of pregnancy
  • Propylthiouracil is associated with a higher risk of severe hepatotoxicity than methimazole. Close monitoring of pregnant women treated with antithyroid agents is required, as is periodic fetal thyroid
43
Q

PCOD

Improving hirsutism

A
  • OCs to manage oligomenorrhea and hirsutism ( it increases sex hormone binding protien and results in decrease androgen levels also Lower LH so ovaries dont produce as much androgens)
  • if hirsutism not decrease in 6 months will need to start spironolactone
  • Metformin not approved for PCOD unless paitent has glucose intolerance
44
Q

Pertusis Criteria (actually ID)

A
  • cough > 2 weeks with one or more of following
  • Paroxysms of cough, inpiratory whoop, posttussive vomiting
45
Q

Pioglitazone (TZDs)

A

1-1.5%

  • If can not tolerate Metformin** / **sulfas
  • Weight gain, edema, CHF, bone fracture, Bladder cancer
  • Low risk of hypoglycemia
  • Can be used with renal insufficiency
46
Q

Pituitary apoplexy

Endocrine emergency:

A

Treatment

  1. High dose Steriods
  2. CT of the Head / NSGY consultation
47
Q

PTH / Vit D / Ca

axis

A
  • PTH release from parthyroid glands
    • (inhibited by 1,25 OH-D and Ca)
  • PTH** increase **Ca reabsorption from kidney and bone resorption - also helps increase 1,25 OH D conversion
  • 1,25 Vit D increase GI ca** and **po4 absorption
48
Q

Raloxifene vs tamoxifen

A
  • Raloxifene is specifically approved for the treatment of osteoporosis
  • Treat a patient with ductal carcinoma in situ with tamoxifen.
  • For premenopausal women with hormone receptor-positive ductal carcinoma in situ or invasive breast cancer, the standard of care is tamoxifen for 5 years to reduce both the risk of recurrence and the development of a new primary tumor in the ipsilateral or contralateral breast.
49
Q

PHPT

Bsiphosphonates vs Surgery ..
non surgical patients

A

Bisphosphonates

  • Increases bone mineral density in pt with PHPT without decrease ca serum levels
  • For pt who do not meet surgery criteria or wish not to have surgery

Primary Hyperparathyroidism without surgical indication

  • Can be monitored with annual serum ca and cr with DEXA Q2Y (every 2 yrs because the in order to notice difference in scan need > 5% change in bone)
50
Q

OSA and bicaronate levels

A

Hypercarbia will cause increase in Bicarb

51
Q

Insulin

A

1.5-3.5%

  • A1C > 8.5 Start basal
  • IF A1C > 10 Start basal and prandial
  • Weight gain and hypglycemia
52
Q

Risk factors for Thyroid cancer:

A
  • Hx of radiation exposure < 15 (Rx)
  • Family history of thyroid cancer
  • Other
    • Elevated TSH
    • Exterme ages < 20 or > 70
    • Male sex
    • Rapid growth
    • Hard and fix nodules
    • Elarged neck lymph node
53
Q

Insulin

Short acting - onset of action / duration

  • Regular
  • Analogs (aspart/lispro)
  • Long Acting
  • NPH
  • Glargine
  • Detemir
A
  • Regular / 2-3 / 8-10
  • Analogs (aspart/lispro) 0.5-1 / 4-6
  • Long Acting
  • NPH 4-8 / 12-18
  • Glargine None / 20-14
  • Detemir None / 16-20
54
Q

Risk of hypothalmic pituitary adrenal suppresion after steriod use

High risk : > 20 mg prednisone or equivalent for > 3 weeks / stigmata of Cushing’s syndrome

Intermediate risk : Prednisone 5-20 mg for > 3 weeks / smaller dose < 5 mg prednisone at QHS for a few weeks

Low risk: Prednisone any dose for < 3 weeks / < 5mg dialy

A

High risk

Stress dose likely to be needed during surgery / ACTH stimulation test to assess steriod requirement maybe needed

Intermediate

ACTH stimulation test to determine whether or not stress dose steriods are needed

Low risk

No testing or stress dose coverage required

55
Q

Secondary amenorrhea evaluation (b hCG -ve)

  • BMI
  • Elevated TSH
  • Elevated prolactin
  • FSH
  • Testostrone
A

BMI

  • Low - Eating Disorder
  • High - PCOS

Elevated TSH

  • Treat hyperthyroidism

Elevated prolactin

  • R/O drugs / hypothyroid / CKD
  • MRI brain

FSH

  • Low with low estrogen Hypothalmic Disorder
  • High with low estrogen ovarian fialure

Testostrone

  • Elevated > 200 Ovarian hyperandrogenism
  • Elevated < 200 Adrenal or ovarian tumor(CT abd)
56
Q

Sulfonylureas

A

1-2 %

Metformin failure

weight gain / hypoglycemia

57
Q

Synthroid dosing based on situation

  • Elderly
  • Pregnancy
  • Estrogen therapy / Oral contraceptives:
  • CAD
  • Coffee intake:
A

Elderly :

  • Start at 50 increase by 25 every 3-6 weeks

Pregnancy:

  • Increase by 30% check TSH Q4weeks

Estrogen therapy / Oral contraceptives:

  • TSH Q12Weeks, may need to increase

CAD:

  • Start 25 increase 25 q3-6weeks

Coffee intake:

  • May lower absorption by 35%
58
Q

Testostrone Def

How to dx.

A

How to dx:

  • Two low Total testostrone / Usually measure 7-10 am
  • Free levels only in Obese or advanced age

Once dx can do LH/FSH levels

  • If low means secondary hypogonadism
  • if High LH/FSH primary hypogonadism
59
Q

Threshold size for FNA

  • High risk hx and/or U/S features
  • Solid hypoechoic nodule
  • Solid isoechoic or hyperechoic nodule
  • Mixed solid / cystic nodule
  • Spongiform nodule
  • Purely Cystic nodules
A
  • High risk hx and/or U/S features > 0.5 cm
  • Solid hypoechoic nodule >1.0 cm
  • Solid isoechoic or hyperechoic nodule > 1-1.5 cm
  • Mixed solid / cystic nodule > 1.5-2 cm
  • Spongiform nodule > 2 cm
  • Purely Cystic nodules not indicated
60
Q

Thyroid nodule

  • If high cancer risk factor or suspicious ultrasound finding -> FNA
A
  • No Cancer risk factor then Measure TSH
  • if TSH high or normal -> FNA
  • Else I-123 scintigraphy
    • if hyperfunctional treat hyperthyroidism
    • Cold nodule needs FNA
61
Q

Thyroiditis Common forms - RAIU Low

Cause / mechanism / pain / Tx / test

  • Hashimotos -
  • Subacute Lymphocytic -
  • Subacute Granulomatous -
A
  • **Hashimotos **- Autoimmune / goiter + hypothyroid / minimal pain / + AntiTPO / Normal ESR / Tx Levothyroxine
  • **Subacute Lymphocytic **- Autoimmune / thyrotoxicosis with hypothyroidism / minimal pain / + AntiTPO / Normal ESR / Tx Bblker
  • Subacute Granulomatous - Viral / thyroitosicosis with hypothyroidism / tender / - AntiTPO / Elevated ESR / Tx: BBLK + NSAIDs + Steriod
62
Q

Thyrotoxicosis

RAIU uptake

  • If no uptake means there is destruction of tissue and thyroid gets released
  • If patient pregnent can use U/S or Thryotropin receptor antibodies
A

High uptake

  • Graves
  • Toxic multinodular goiter (TMNG)
  • Toxic nodule

Low uptake

  • Painless or subacute thyroiditis
  • Amiodarone induced thyroiditis
  • Surreptitious thyroid hormmone
  • Iatrogenic
  • Struma ovarii
  • Iodine induced
63
Q

Treat a macroprolactinoma.

A

•In a patient with a macroprolactinoma, administration of a dopamine agonist, such as cabergoline, is indicated as the initial treatment.

64
Q

Treatment of Osteoprosis

  1. Postmenopausal women
  2. Not to use with Patient Creatnine clearance < 35
  3. Hypocalcemia in CKD pateints
  4. Failed Bisphosphonates
  5. Modestly reduces risk of Fx / not first line
  6. Post menopausal women intolerant to bisphosphonates and at Increase risk of Breast cancer
A
  1. 1200 mg Ca and 800 IU Vit D
  2. Oral or IV bisphosphonates (alendronate, risedronate and zoledronic acid)
  3. Dnosumab (risk of skin infection)
  4. Teriparatide (Recombinant human parathyroid hormone) Have had Fx or reduced BMD (do not give with renal insufficiency / monitor Ca, uric acid and RFP)
  5. Nasal Calcitonin
  6. Selective estrogen receptor modulators (Raloxifen)
65
Q

TSH Low / FT4 high

What is next

A

Primary hperthyroidism

RAIU scan

High

  • Diffused pattern Graves
  • Nodular uptake
    • Toxic adenoma
    • Mutinodular goiter

Low

  • Measure Tg: Decreased :
    • Exogenour hormone
  • Measure TG:Elevated:
    • Thyroiditis
    • Iiodinde esposure
    • extraglanular production
66
Q

TSH Low / FT4 Normal

What is next:

A

measure FT3

Low :

  • Subclinical hyperthyroidism
  • Early pregnency
  • Nonthyroid illness

High

T3 Toxicosis (R/O graves RAIU scan)

67
Q

TSH Normal / High FT4 High

What is next

A

MRI pituitary (2nd hyperthyroidism)

68
Q

Turner’s syndrome

A

Two elevated FSH valuses

  • In a woman with primary ovarian insufficiency, Turner syndrome must be excluded as the cause by obtaining the patient’s karyotype.
  • Turner syndrome is associated with several cardiovascular malformations, including aortic valve disease, aortic dilation, and aortic coarctation; renal malformations, most commonly horseshoe kidney; and autoimmune disorders, such as thyroid disease.
69
Q

What to do after Medullary thyroid dx

A
  • Evaluate for Metastic Dz
    • Calcitonin levels corolate with extend of Dz and local lymph nodes / if Calcitonin > 400 need CT of abd/pelv
  • Coexisting tumors
  • RET mutation identification
70
Q
A
71
Q
A
81
Q

Diagnosis of Diabetes

A

• A1c>6.5%
or
• FPG>126
or
• 2-hr glucose > 200 on 75 gm OGTT
or
• Random glucose > 200** and **symptoms

101
Q

Hypoglycemia

A

A. Insulinoma
B. Surreptitious use of insulin
C. Surreptitious use of Oral meds

Tests

  • Drug levels
  • if sugar is low and insulin is low its most likely normal
  • C-peptide levels / insulin levels after fasting 72 hrs once drops > 50 need to do levels
102
Q

Hyperosmolar Nonketotic State

A
  • Glucose > 600
  • pH>7.3, CO2>15
  • Minimal ketonemia/ketonuria
  • Correct Na for hyperglycemia (for each 100 mg/dL glucose > 100 add 1.6 mg to serum sodium)
  • If K is < 3.3, hold insulin and give K
103
Q

DKA

A

IVF

K Keep > 3.3

IV insulin once K > 3.3

Once glucose 200 can reduce IV insulin 50% and change to d5W1/2

Adjunct KCL / Vasopressors / Bicarb / phosphate (no definite benefit found)

124
Q

Laboratory Diagnosis of Hypocalcemia

A

• Hypoparathyroidism (autoimmune)
low Ca, high PO4, low PTH
• Hypomagnesemia (alcohol)
low Ca, high P04, low PTH

128
Q

Paget Disease

A
  • Usually asymptomatic
  • high Bone turnover -> structurally weak bone
  • very high Alkaline phosphatase 100’s
  • Treat if pain is severe, pagetic lesions in_ weight-bearing_ areas, or _lytic lesions_

So do not treat if not symptomatic / first step to go to NSAIDs then Bisphosphonates/Calcitonin

129
Q

Familial Hypocalciuric Hypercalcemia

A
  • Rare
  • Lower Sensitivity of Ca-sensing receptor and higher Ca levels are needed to suppress PTH
  • Familial /Autosomal Dominnant
  • 24-hr urine calcium < 100

Will have a very low urine calcium | Ca / ratio < 0.01

Treatment not recommended

135
Q

tuberculosis-induced hypercalcemia.

A

excessive production of 1,25-dihydroxyvitamin D by the tuberculous granulomas. The granulomas of tuberculosis (and other granulomatous diseases, such as sarcoidosis, Crohn disease, and leprosy) are composed of macrophages that possess the 1α-hydroxylase enzyme needed to convert 25-hydroxyvitamin D to its active form, 1,25-dihydroxyvitamin D.

Low PTH, PO4 high

with Malignancy Hypercalcemia High PTH /prPTH and low PO4

137
Q

Woman with low bone mass. How to treat?

A

The NOF recommends antiosteoporotic therapy for persons whose risk of major osteoporotic fracture over the next 10 years is 20% or greater or whose risk of hip fracture over the next 10 years is 3% or greater.

Denosumab, osteoclast formation, reserved for patients with a high risk of fracture, including those with multiple risk factors for fracture or a history of previous fractures.

Estrogen is contradicted in this patients with dx of breast cancer.

Raloxifene, a selective estrogen receptor modulator, approved for osteoporosis prevention by the FDA. However, significant hot flushes.

Teriparatide (recombinant human parathyroid hormone) is also contraindicated in persons with malignancy involving bone, Paget disease, or existing hyperparathyroidism or hypercalcemia.

Bispho alendronate is the most appropriate drug to use for osteoporosis prevention in patients with osteopenia and a history of radiation therapy

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