UW Flashcards
Drugs for neuropathic pain
- TCA (be careful in older because anti-cholinergic)
- anticonvuslants (gabapentin, pregabalin) (BEST)
- opioids
- capsaicin tpical
- lidocaine topical
consider anticonvulstants or TCA for initial
radioablation for graves - SE
- permanent hypothyroidism over months to years (resolution of hyperth in 6-18 wks) (this is not happening in toxic adenoma or goiter because only the adenomas take iodine)
- worsening of Graves opthalmopathy due to increased of TSI (if mild: give steroids, if severe: prefer surgery)
Diagnostic approach of hypocalcemia
low Mg, medications, Recent blood transfusion (citrate)?
- YES –> correct it
- NO –> measure PTH
low: surgical, autoimmune, infiltrative (metast, wilson, hemochromatosis)
high: vit d def, renal failure, pancreatitis, sepsis, tumor lysis syndrome
hyperthyroidism with high TSH and high hormones - next step
brain MRI
hyperthyroidism with low TSH and high hormones - next step
graves signs (goiter, ophtalmopathy)?
- yes –> graves
- NO RAIU
high uptake: graves or nodular or adenoma
low uptake: measure thyroiglobulin (low: exogenous hormone, high: thyroditis or iodide exposure)
hyperthyroidism effect on BP
increased Myocardial contractility
decreased peripheral resistance
(in contrast, hypothyroidism causes hypertension due to increased peripheral resistance)
PAC/PRA ratio
- plasma aldosteron / plasma renin concentration
- 1st test for hypertension and hypokalemia
best initial test for patient with DM and new toe ulcer
monofilament (it predicts the risk of future ulcers: higher pressure threshold)
toe ulcer - vascular or DM
arterial are usually on the tips
DM: plantar
diagnosis of hypercalcemia
- confirm it (repeated tests + correct for albumin)
- measure PTH
- if low PTH: measure PTHrp, vitD25, vitD1,25
MCC of PTH-independent malignancy
homural hypercalcemia of malignancy (PTHrp)
PTHrp does not induce Vit D activation
a cause of hypercalcemia after accidents
immobilization (PTH independent) due to inccreased osteoblastic resorption
(4 weeks after immobilization, but in 3 days in patients with chronic renal failure)
treatment: biphosphanates
MCC of death in acromegaly
cardiovascular disease
but decreasing of the levels rapidly reduces the risk
euthyroid sick syndrome
any patient with acute severe illness may have abnormal thyroid function test
NORMAL TSH AND T4
fall in total and free t3
acute vs chronic thyrotoxic myopathy
acute: severe distal or proximal weakness, without bulbar or resp involvement
chronic: proximal
DDX for hyperandrogenism in women
- PCOS 2. Acromegaly 3. Cushing
- Hyperprolactinemia 5. ovarian/adrenal tumors
- Non-classic CAH
hypomagnesimia mediated hypoparathyroidism vs other causes of hypoparathyroidism
hypoparthyroidism associated with low Mg has normal or low P
milki alkaly syndrome
it is caused by excessive intake of calcium and absorable alkali. It can be seen in patient taking calcium bicarbonate for osteoporosis.
manifestation: symptomatic hypercalcemia, met alkalosis, acute kidney injury
thionamides - agranoulocytosis
routine WBC check it is not cost effective
- if fever + sore throat –> stop the drug and check the WBCs
if less than 1000 –> stop permanently
if more than 1500 –> it is not the cause
DM2 - when to add insulon to metformin
when HBAC1 is more than 8.5%
the MC electrolytic abnormality in primary adrenal insufficiency
hyponatremia in 90%
following cortisol discontinuation, the axis me be abnormal up to
6-12 months
suppurative (infectious) thyroditis
fever erythema and severe pain, often with asymmetric goiter due to abscess formation (usually in children and immunocompromised)
USUALLY EUTHYROD
the main substance for gluconeogenesis
alanine (from proteins breakdown), glutamine (from proteins breakdown), lactate (from anaerobic), glycerol-3-P (from lipids break down)
alanine is converted into …. during gluconeogenesis
pyruvate
clinical suspicion of acromegaly - algorithm
measure IGF-1 - normal (exclude) - elevated --> oral glucose suppression test adequate GH suppression --> exclude inadequate GH suppression --> BRAIN MRI if pituitary mass --> surgery if no mass --> search for other source
metabolic syndrome - features
3 out to 5
- abdominal obesity (waist more than 40 in males and 35 in females
- fasting glucose more than 100-110
- BP more than 13/8
- TG more than 150
- HDL cholesterol lower of 40 in male and 50 in women
how to measure corrected calcium
calcium + 0.8 (4-serum albumin)
VIPoma - clinical presentation
- watery diarrhea
- hypo or achrolorhydia due to low gastric acid secretion
- flushing, lethargy, nausea, vomiting, muscle wekaness
PANCREATIC CHOLERA
VIPoma Labs
- low K+
- high Ca2+
- high hyperglycemia (increased glycogenolysis)
- diarreha: increased sodium + osm gap less than 50
VIPoma - diagnosis
- watery diarrhea with VIP level more than 75
2. abdominal CT or MRI
Difference in labs between insulinomas and sulfonylurea
in sulfo, the proinsulin is less than 20% of the total insulin immunoreactivity
the diagnosis is confirmed by sulfonylurea measurement
severe SE caused by PTU (but not by methimazole
- hepatic failure
2. ANCA mediated vasculitis
in which situations, thyroidectomy is prefered against RAI for Graves
- very large goiter
- severe ophtalmopathy
- coexisting nodule and suspicion for malignancy
- pregnant who cannot tolerate drugs
- coexisting 1ry hyperpara
- obstructive symptoms
x-ray findings of osteomalacia
- decreased bone density with thining of cortex
- eventual codfish vertebral bodies (concave shape)
- pseudofractures (Looser zones)
screening for DM is recommended in ….
- patients with sustained BP more than 135/80
- may considered in all patients over age 45
- additional risk for DM
osteolytic metastasis can cause hypercalcemia - mechanism
stimulation of osteoblast by cytokine production
paroxysms of severe hyperteneion in pheo can be precipitated by
increases in intra-abdominal pressure (tumor palpation, position changes etc), surgical procedures, and a number of drugs, especially anesthetics
what should be done in people with medullary thyroid cancer before the surgery
check for pheo with a plasma fractionated metanephrine essay –> if found pheo, it should be resected first
thyroid peroxidase antibodies - disease?
- Hashimoto
2. painless thyroditis
thyroid antibodies that are associated with miscarriage
anti-peroxidase
small vs large fibers regarding symptoms when damaged
small –> positive symptoms (pain and paresthesia)
large -> negative symptoms (numbness, loss of propioception and vibratory sense, and diminished ankle reflex)
benefits of tight glycemic control in macrovascular and microvascular complications
decreases incidence of microvascular (retinopathy)
uncertatin for macro
hypothyroidism - lipids
- hypercholesterimia alone or hepercholisterimia with hyperTG
- hyperTG alone is rare
normal prolactin levels are less than 15. prolactin 45 + low LH + Low TSH - diagnosis
nonfunctional tumor
(slightly high prolactin due to compression on the axon)
diagnostic levels for prolactinoma are more than 200
nonfunctioning pituitary adenoma usually arises from
GnRH cells (they secrete only tha α-unit) in nonfunctioning pituitary adenomas, prolactin could be high due to compression of the axon (low dopamine)
diagnosis of conn - what is the ration of aldosterone to renin
more than 20
hyperthyroidism - bone
increased osteoclastic activity –> rapid bone loss + hypercalcemia
best markers for response to DKA therapy
- anion gap
- beta hydroxybutrate level (the predominant ketone)
diabetic gastroparesis - treatment
metoclopramide
erythromycin (esp acute)
cisapride (restricted in USA due to risk of arrhythmia and death)
confirm of hyperaldosteronism
adrenal suppression test (by salt loading)
prolactinoma - surgery or carbegolide?
- asymptomatic microprolactinoma (less than 10mm) –> no treatment
- macroprolactinoma or sympromatic micro:
sugery only if is larger than 3 cm or increases during medication
primary hyperaparathyroidism - indications for parathyroidectomy
- age less than 50
- symptomatic hypercalcemia
- complications: osteoporosis, nephrolithiasias/calcinosis, GFR less than 60
- elevated risk for complications: calcium more than 1 mg/dl above normal, urinary excretion of Ca more than 400 per day
glucagonoma - anemia?
normocytic normochronic anemia due to likely anemia of chronic disease or glucagon directly affecting erythropoiesis
glucagonoma - diabetes
mild, with normal to slightly high insulin levels and is controlled with lifestyle changes and oral medications (rarely requires insulin)
glucagonoma - how to confirm diagnosis
serum glucagon more than 500
DDX of myopathy (and ESR, CK)
- glucocorticoid induced (normal, normal)
- polymyalgia rheumatic (increased, normal)
- inflammatory myopathies (increased, increased)
- statin induced (normal, increased)
- hypothyroid (normal, increased)
glucocorticoid myopaty
- progressive proximal weakness + atrophy
- NO PAIN OR TENDERNESS
- lower extremities are more involved
- normal ESR and CK
polymyalgia rheumatic myopathy
- muscle pain + stiffness in shoulder + pelvic
- tenderness with decreased range of motion
- responds rapidly to steroids
- normal CK, elevated ESR
inflammatory myopathies
- muscle pain, tenderness
- proximal weakness
- skin rash + infl arthritis
- increased ESR + CK
statin induced myopathy
- prominent muscle pain/tenderness with or without wekaness
- rare rhabdomyolysis
- normal ESR, elevated CK
Hypothyroid myopathy
- muscle pain, cramps, weakness involving the proximal muscles
- delayed tendon reflexes + myoedema
- occasionally rhabdomyolysis
- normal ESR, increased CK
DKA + hyperosmolar - management - IV fluids
0.9% NS initially
add dextrose when glucose less than 200
DKA + hyperosmolar - management - insulin
- initial IV
- switch to SQ if: able to eat, less than 200, normal anion gap, HCO3 more than 15
- overlap SQ + IV insulin by 1-2 h
DKA + hyperosmolar - management - potassium
add K+ if less than 5.2
Hold insulin for serum k+ less than 3.3
DKA + hyperosmolar - management - phosphate
if less than 1, cardiac dysfunction or respiratory depression
(monitor calcium)
Diabetic foot ulcers - RF
- Diabetic neuropathy
- arterial insufficiency
- ESRD on dialysis
- smoking
Diabetic foot ulcers - management
- mechanical offloading
- debridement
3, wound dressing - antibiotics if infection
common causes of hypogonadism is men - categories
- primary (testicular)
- secondary (pituitary/hypothalamus)
3, combined
common causes of hypogonadism is men - 1ry (testicular)
- congenital (klinefelter, cryptorchidism)
- drugs (alkylating, ketoconazole)
- orchitis (mumps), trauma, torsion)
- chronic kidney disease)
common causes of hypogonadism is men - 2ry (pituitary, hypothalamic)
- gonadotroph damage (tumor, trauma etc)
2. gonadotropin suppression (exogenous androgens, hyperprolactinemia, DM, obesity etc)
common causes of hypogonadism is men - combined
- hypercortisolism
2. cirrhosis
signs of adrenal insufficiency –> 250 μg cosynotropin and ACTH levels –>
- basal cortisol low, high ACTH, minimal cortisol response –> 1ry adrenal insuf
- basal cortisol low, Low ACTH, minial cortisol response –> 2ry or tertiary adrenal insuf
- indeterminate –> further testing to assess pituitary
- Normal response (cortsiol level more than 20 after cosynotropin) –> no adrenal insufficiency
water deprivation test - when is 1ry polydispia
if urine osm is more than 600
primary vs secondary male hypogonadism regarding gynecomastia
more common in 1ry
DM risk factors for adults with BMI more than 25
- physical inactivity
- 1st degree relative with DM
- high risk race, ethnicity
- women with children’s birth wight more than 9lb
- history of gestational DM
- dyslipidemia (low HDL and high TG)
- History of PCOS
- history of glucose intolerance
thyroid nodule - algorithm
First clinical evaluation, TSH + US
- if cancer RF or suspicious US –> FNA
- no RF or suspicious US –> consider TSH
Normal or elevated TSH –> FNA
low TSH –> Radio –> hot (treat hyperthyroidism) vs cold or interminate (do FNA)
Joint national Committe 8 reccomendations for treating hypertension - initial diagnosis
if more than 60: more than 150 or 90
less than 60 or Chronic kidney diseas, or DM: more than 140 or 90
Joint national Committe 8 reccomendations for treating hypertension - goal BP
if more than 60: less than 150/90
less than 60 or Chronic kidney diseas, or DM: less than 140/90
Joint national Committe 8 reccomendations for treating hypertension - initial treatment choice
- black –> thiazide diruetic or CCB alone or in combination (ACEi is not 1st line)
- other ethnicities –> thiazide, ACEi, CCB alone or in combination
- all ethnicities with chronic kidney disease: ACEi alone or in combination with other drugs
evaluation of hyperthyroidism - algorithm
measure TSH, fT3, fT4
if 2ry (all high) –> pituitary MRI)
if 1ry (Low TSH, the other high):
sings of graves: if yes it is graves –> if not do Radio
RADIO: HIGH: diffuse (graves) v Nodular patttern)
LOW –> measure thyroglobulin (if low is exogenous, if high is thyroditis or IODIDE EXPOSURE)
The strongest indication for DM screening
HTN
DM - metformin is not enough , what to do
Sulfonyl or DPP-IV inhibitors
Anoher side effect of sulfonylureas
SIADH
DM - erectile dysfunction
- no routine screening except to ask
- sildanefil
initial treatment for DM2 - effective
lifestyle modification –> effective to 25%
short vs rapid acting insuling on onset
rapid: 5-15
short 30-60
NPH vs glargine on onset
NPH: 2-4
glargie: 1-2
Dermatopathy of graves
thickening and redness below the knee
Graves - Onycholysis
in 10% of cases
Klinefelter’s sundrome - treatment
testosterone
Testicular feminization
XY that looks, feels and acts like woman (No test receptors -> no penis, prostate, scrotum)
calcitonin vs biphosphonate regarding immediate action
if u need something fast, pick calcitonin
type of cortisone in addison
- acute: hydrocortisone (both gluco and mineralocorticoid effects)
- stable: prednisone
- if prednisone not enough –> fludrocortisone
water deprivation test - explain
no water for 2-3 hours –> measure urine volume and osm every h, , and serum sodium and osm every 2
- is urine osm more than 600?
yes –> 1y polydipsia
No –> urine osm stable on 2-3 h –+ plasma osm more than 295 or Na more than 145)?
a. yes: desmopressin, monitor urine osm + volume every 30 mins for 2 hours (CDI if urine osm increases, NDI if no increase)
b. no: continue until above endpoints reached
