Internal Medicine Essentials Questions: Endocrine and Metabolism

Question 1

In a case of suspected prolactinoma (galactorrhea, decreased libido, vaginal dryness and amenorrhea in a woman), you should first do _____________.

Answer 1

a serum prolactin level; only if that’s elevated should you do a pituitary MRI

Question 2

Lab signs of adrenal insufficiency include ________________.

Answer 2

hypoglycemia and hyponatremia (hypokalemia can occur but is less typical)

Question 3

True or false: you can have a very low TSH and still have hypothyroidism.

Answer 3

True!

Central hypothyroidism presents with a low TSH.

Question 4

Hypothyroidism can cause what blood pressure anomaly?

Answer 4

Diastolic hypertension

Question 5

All thyroid nodules greater than ________ in diameter should be biopsied.

Answer 5

1 cm

Question 6

Give the quick rule of thumb for treating hypothyroidism in pregnancy.

Answer 6

Increase levothyroxine dose by 30% in the first trimester.

Note: the first trimester is when transplacental levothyroxine is the most important.

Question 7

How should subclinical hypothyroidism be managed?

Answer 7

Repeat TSH in 6 months

Patients may report fatigue, but as long as their T4 is normal you should not give levothyroxine.

Question 8

True or false: adrenal incidentalomas require no testing if there is no history or signs/symptoms of functional tumor or malignancy.

Answer 8

False

Even if the person has no features of functional tumor, you should still do a 24-hour dexamethasone suppression test, a urine metanephrines level, and renin/aldosterone assays.

Question 9

Patients with ___________ adrenal insufficiency typically do not require mineralocorticoids.

Answer 9

central

The release of aldosterone is controlled by the renin-angiotensin-aldosterone system and thus is less dependent on ACTH.

Question 10

Which test is best at diagnosing primary hyperaldosteronism?
•CT abdomen
•Renin:aldosterone ratio
• Dexamethasone suppression test

Answer 10

Renin:aldosterone ratio

CT abdomen could detect an adrenal adenoma, but because you can have hyperaldosteronism without an adenoma it is less useful.

Dexamethasone suppression is useful in diagnosing Cushing’s syndrome, so it is only indicated in those with systemic signs of Cushing’s (e.g., striae, hirsutism, weight gain).

Question 11

During a mild illness (like a viral URI), the dose of hydrocortisone in a person with adrenal insufficiency should be ____________________.

Answer 11

increased threefold

Note: this is even if they don’t have symptoms of adrenal insufficiency.

Question 12

The best two tests for diagnosing Cushing’s syndrome are ______________.

Answer 12

24-urinary cortisol levels or midnight salivary cortisol levels

Question 13

Hypertension and what “classic triad” are pathognomonic of pheochromocytoma?

Answer 13

• Diaphoresis
• Palpitations
• Headaches

Question 14

For critically ill patients with diabetes who are admitted to the hospital, what glycemic range is recommended?

Answer 14

140 - 200

Question 15

When patients with type 1 and type 2 diabetes get diagnosed, the suite of screening tests you do differs. Why? What tests are recommended for each?

Answer 15

• Type 1: lipid panel
- Patients typically present very soon after development of the disease, there’s not enough time for retinopathy or nephropathy to develop.

•Type 2: lipid panel, urine albumin-creatinine ratio, dilated fundoscopic exam
- T2DM patients can go years without knowing that they have diabetes, so there is time for these disorders to develop.

Note: the tests for T2 are recommended in T1 after five years of disease.

Question 16

In patients with features of both types of diabetes (such as a 15-year-old who is obese), you can order ___________ to differentiate the two.

Answer 16

islet cell autoantibodies and antibodies to decarboxylase

Question 17

Explain the testing for diabetes diagnosis.

Answer 17

You need at least two of any of these things:
•A1c greater than 6.5%
•Fasting glucose 126 or greater
•Random glucose greater than 200
•Symptoms of hyperglycemia (e.g., polydipsia, polyuria, nephropathy, neuropathy, retinopathy)

If they only have one of the above, you should repeat testing.

Question 18

Per IMEQ, the best treatment for prediabetes is _____________.

Answer 18

diet and exercise

Question 19

How is hyperglycemic hyperosmolar syndrome different than DKA?

Answer 19

In HHS, there is enough insulin to suppress ketosis but not hyperglycemia, so those in HHS have hyperglycemia but are not acidotic.

Question 20

HHS is more common in type _______ DM.

Answer 20

2 (because you need some insulin to suppress ketosis.

Question 21

The goal of therapy in hyperglycemic hyperosmolar syndrome is ______________.

Answer 21

volume replacement with NS

In HHS, there is no acidosis but the hypertonic blood is filtered in excess by the kidneys and leads to volume loss.

Question 22

The USPSTF recommends that DEXA screening begin at ______ in women.

Answer 22

age 65

Question 23

In those with osteoporosis and esophageal disorders (including GERD), ___________ are recommended. Cost, however, is a frequent prohibitive factor.

Answer 23

IV zolendronic acid (basically IV alendronate)

Question 24

What is teriparatide?

Answer 24

Recombinant PTH (like the TA teaching with the PhD in the Sketchy scene)

It is reserved for severe cases of osteoporosis (T less than -3.5).

Question 25

Osteoporosis is defined by Z score 2.5 SD less than the mean or _____________.

Answer 25

fragility fractures

Question 26

Even if a person’s DEXA score is not 2.5 SD below the mean, they should still be given alendronate if ______________.

Answer 26

their 10-year risk of osteoporotic fracture is greater than 20% or the risk of hip fracture is greater than 3%

Question 27

If a man in his fifties has osteoporosis, you need to screen for _______________.

Answer 27

secondary causes; men in their fifties very rarely have primary osteoporosis