Additional Flashcards
(165 cards)
1
Q
Increased PTH drives ____ (? increase, decrease) in sr. Ca2+ and ____ (? increase, decrease) in sr. PO4 levels in ______.
A
↑ PTH –> ↑ sr. Ca2+ & ↓ sr. PO4 in primary HyperPTH
*primary HyperPTH seen in
-single hyper-functioning adenoma (80%)
-Parathyroid hyperplasia (15%)
-PTH carcinoma (~5%)
2
Q
Secondary hyperPTH is driven by ___.
A
hypocalcemia that may be caused by
-Dietary calcium deficiency
-dietary/pathological Vit D deficiency
-*renal insufficiency (sr. PO4 levels are ↑)
*renal insufficiency–> ↓ Vit D production–> ↓ dietary ca2+ absorption
3
Q
Tertiary Hyper PTH due to ______ seen in _____, and is marked by __ in sr. levels of ca2+, PO4, and PTH.
A
d/t hyperplasia and autonomous hyperactivity of PTH gland seen in pts. with long standing secondary hyperPTH on dialysis;
marked by ↑ serum levels of all three (PTH, calcium and phosphate); phosphate is high because kidneys are unable to execute increased excretion of phosphate under PTH influence.
4
Q
In ectopic PTHrP secretion (lung or breast malignancy), serum PTH levels are ____ in setting of very high sr. ca2+ and normal/low sr. PO4.
A
serum PTH levels are ↓ in setting of ↑↑ sr. Ca2+ and normal/↓ sr. PO4.
5
Q
What are the s/s a/w hypercalcemia?
A
stones, bones, moans, groans, and psychiatric overtones.
6
Q
What is the initial m/m of acute hypercalcemia?
A
IV fluids (first-line t/t),
and IV calcitonin
7
Q
____ is used for long term t/t of hypercalcemia.
A
IV bisphosphonates.
8
Q
Hypercalcemia d/t malignancy is usually t/t with _____.
A
bisphosphonates.
9
Q
What is the first-line t/t of symptomatic/moderate-severe Paget’s disease of the bone?
A
Bisphosphonates
10
Q
Pts. with Paget’s disease of the bone who are intolerant to first-line bisphosphonates, can be t/t with ____.
A
Calcitonin.
11
Q
In addition to osteoarthritis and pathologic fractures, what are some other serious complications of Paget’s disease of the bone?
A
-High-output cardiac failure (d/t AV connections),
-Osteosarcoma (1% cases).
12
Q
Increased sr. Alkaline phosphatase with increased sr. Gamma-glutamyl transpeptidase (GGT) are suggestive of _____ (? liver, bone) pathology.
A
Bone pathology e.g. Paget’s disease of the bone.
13
Q
In Paget’s disease of the bone, Sr. Ca2+ and Sr. phosphate levels are ___ (? increased, normal, decreased).
A
normal;
Abnormal in Paget’s disease
-Sr. Alkaline phosphatase
-Sr. GGT levels
14
Q
What are some medications other than the best initial t/t agents bisphosphonates that can be used in t/t of osteoporosis?
A
-PTH analogues (Teriparatide) act as PTH proxy, and reduce bone resorption.
-Denosumab: monoclonal Ab to RANK-L
-Raloxifene: selective estrogen R modulator.
15
Q
Osteoporosis is the most common cause of pathological fractures in women with _____, and men over age ____ yrs.
A
-in women with low-body weight, and
-in men over age 60 yrs.
16
Q
What are the s/s of Paget disease of the bone?
A
Mostly asymptomatic and require no t/t;
for s/s remember MNEMONIC: Paget’s PANICS!
-Pain: bone pains
-Arthralgia
-Nerve compression (e.g. deafness)
-Increased bone density
-Cardiac failure (high-output)
-Skull involvement/Sclerotic vertebra/e
17
Q
Osteoporosis is confirmed with a DEXA T-score of _____.
A
2.5 SDs less than normal.
18
Q
DEXA T-score of 1-2.5 below normal is indicative of ____.
A
Osteopenia.
19
Q
DEXA screening scan is recommended for _____.
A
-women > 65 yrs age,
-men > 70 yrs. of age
-pts. with other risk factors for osteoporosis.
20
Q
Distal radius fracture (Colles fracture) following minimal trauma in an elderly pt. is suggestive of ___.
A
Osteoporosis.
21
Q
Defect in bone mineralization often caused by severe Vit D deficiency leads to ____, manifested by bone pains, _____ serum Ca2+ and PO4, and ____ PTH levels.
A
Osteomalacia; manifested by bone pains, low serum Ca2+ and PO4, and elevated PTH (Secondary HyperPTH).
22
Q
How do TRH and or TSH affect PRL hormone secretion?
A
TRH directly stimulates PRL, whereas
TSH *indirectly stimulates PRL via dopamine pathway.
*TSH –> inhibits dopamine —> relieves dopamine’s inhibitory effect on PRL.
23
Q
GnRH is inhibited by which anterior pituitary hormone?
A
PRL (thus causing lactational amenorrhea).
24
Q
What is the effect of somatostatin (SS) on GH and TSH?
A
Both are inhibited by SS.
25
A pt. with familial hypocalciuric hypercalcemia (FHH) will have ___ lab profile.
-Elevated sr. Ca2+, elevated Sr. Mg2+
-Low ur. Ca2+ (unlike other abnormal hypercalcemic states in which the kidneys filter out ↑↑ Ca2+ --> hypercalciuria).
-Normal/mildly ↑ PTH
*FHH is a rare AD disorder d/t LOF mutation of calcium sensing receptors (CaSR) in PTH gland, kidneys etc, reducing their sensitivity and thus increasing their set point for Ca2+ sensing. So increase in PTH occurs at higher levels of sr. calcium; kidneys keep on reabsorbing Ca2+ and Mg2+ until their higher levels in serum --> maintaining hyperCa2+ and HyperMg2+.
26
In _____, an inherited disorder, both the PTH gland and kidneys are insensitive to increase in sr. Ca2+ levels d/t decreased sensitivity of the Ca2+ sensing R's in the same.
FHH.
27
Severe hemorrhage (anywhere in the body) leading to pituitary infarction causing panhypopituitarism is known as _____, and is commonly seen after _____ hemorrhage.
Sheehan syndrome; postpartum hemorrhage.
28
Pituitary apoplexy results d/t ___.
Pituitary hemorrhage.
29
Which pituitary hormones are usually affected first in hypopituitary pathology?
Gonadotropins and GH.
*p/w hypogonadism in adults/adolescents, and growth retardation in children.
MN: GnRH and GH are Gone first in hypopituitarism!
30
What is the normal A.M. serum cortisol range?
3-25 mcg/dL.
31
Adrenal insufficiency is likely at serum cortisol levels of less than ____.
3 mcg/dL--> confirm etiology with ACTH levels.
32
lack of hyperpigmentation is characteristic of _______ adrenal insufficiency as ACTH levels are low.
Secondary adrenal insufficiency.
*unlike in primary adrenal insufficiency, ACTH levels are high leading to hyperpigmentation as ACTH is co-stimulatory of MSH.
33
ACTH stimulation test (aka Cosyntropin test) is indicated when AM cortisol levels are between ____ mcg/dL.
3-18 mcg/dL.
34
____ is the test of choice to diagnose hypothyroidism d/t hypopituitarism (aka secondary hypothyroidism).
Free T4;
TSH must be checked concurrently but TSH is not diagnostic as its levels may be normal or even high in sec. hypothyroidism.
35
Before starting levothyroxine for secondary hypothyroidism d/t TSH deficiency, ____ must be tested to rule out ______ to prevent adrenal crisis.
sr. ACTH levels must be tested to rule out ACTH deficiency because levothyroxine increases cortisol clearance, and can precipitate adrenal crisis in pts. who are already ACTH deficient.
36
___ should be suspected in a new onset HTN pt. with hypokalemia.
Primary hyperaldosteronism.
37
A pt. with new onset HTN develops hypokalemia upon initiation of t/t with diuretics. What is the most likely cause of his HTN.
Primary hyperaldosteronism.
38
The best screening test for primary hyperaldosteronism is _____. Positive tests must be confirmed with _____.
Early morning *PAC: PRA > 20 (& PAC > 15 mg/dL) is suggestive of primary hyperaldosteronism.
Confirm positive tests with aldosterone suppression (salt loading) test. In absence of local adrenal pathology, salt should suppress aldosterone secretion. If Sr. PAC still high--> confirm adrenal pathology with imaging (CT).
*plasma aldosterone conc. to plasma renin activity
39
In a pt. with PAC/PRA > 20, and an abnormal aldosterone suppression test, what is the next step in confirming the diagnosis of primary hyperaldosteronism.
adrenal CT scan.
40
In a pt. with suspected of primary hyperaldosteronism in whom CT scan does not reveal a discrete unilateral mass (adenoma)_____ must be done to differentiate between an adenoma and hyperplasia.
Adrenal venous sampling.
41
In a pt. with hyperosmolar hyperglycemic state (HHS), pH, sr. HCO3 and anion gap are ______ (? elevated, decreased, normal).
normal pH,
normal sr. HCO3, and
normal anion gap.
-normal/slightly ↑ serum ketones.
ABNORMAL:
-RBS > 600 mg/dL (frequently > 1000 mg/dL)
-Sr. osmolality > 320 mOsm/kg
42
What is the initial/immediate step in m/m of a pt. in HHS?
-Rehydration with IV *NS, and
-start Insulin infusion if **sr. K+ > 3.3 mEq/L
-add K+ to IVF if sr. K+ < 5.3 mEq/L
*use 0.45% NS if corrected sr. Na+ levels are normal/high after the second/third hour, or the pt. is eunatremic/hypernatremic at presentation.
Corrected Sr. Na+ =
Measured Sr. Na+ (mEq/L) + 2 mEq/L for every 100 mg/dL of glucose level at sr. glucose levels of > 100 mg/dL.
** If sr. K+ < 3.3 mEq/L, then withhold Insulin until Sr. K+ levels are raised to > 3.3 mEq/L through IV K+ replacement.
K+ replacement must continue so that levels are > 5.3 mEq/L. Insulin can be started at sr. K+ levels > 3.3 mEq/L.
43
In addition to the initial m/m with IV NS, what is the mainstay t/t of HHS?
IV Regular Insulin.
44
Serum K+ must be replaced during m/m of HHS with insulin, if levels are below ____. Why?
If sr. K+ levels are < 5.3 mEq/L;
because Insulin will rapidly drive K+ into the cells inducing hypokalemia in an already total K+ deficit state seen in HHS.
45
____ modality of t/t leads to a transient worsening of Graves opthlamopathy d/t increase in the titers of ____ after t/t initiation.
RAI;
d/t increase in titers of Thyrotropin receptor antibodies (TRAb) on TSH receptors on retro-orbital fibroblasts and adipocytes, during initial t/t phase.
46
____ can be used to prevent RAI-induced worsening of opthalmopathy in graves disease.
Glucocorticoids
47
In m/m of DKA, serum pH, electrolytes, and anion gap must be monitored every _____ hourly, and serum glucose must be monitored every ___ hours.
serum pH, electrolytes, and anion gap must be monitored every 2-4 hours, and
serum glucose must be monitored hourly.
48
_____ is the best index to monitor the response to t/t in DKA.
serum anion gap.
49
After initial infusion of IV NS in DKA, half NS (0.45%) can be started when sr. Na+ levels are _____.
≥ 135 mEq/L.
50
Dextrose can be added to infusion when sr. glucose levels reach ____ in t/t of DKA with IV insulin.
Add Dextrose when Sr. glucose < 200 mg/dL.
51
In m/m of DKA, Insulin infusion must be put on hold if sr. ____ levels are ______.
Withhold Insulin infusion, if Sr. K < 3.3 mEq/L.
52
Sr. K+ must be replaced if serum levels are below ___ in DKA.
< 5.3 mEq/L.
53
Insulin infusion must be reduced when sr. glucose levels reach ___.
below 200 mg/dL.
54
In DKA m/m, IV Insulin can be switched to subcutaneous Insulin when _____.
resolution of DKA achieved evident by normal AG, and pt. is able to eat.
55
When is sodium-bicarbonate administration indicated in t/t of DKA?
in severe DKA with blood pH ≤ 6.9.
*normal pH is 7.35-7.45.
56
Trans-sphenoidal resection of a prolactinoma is considered in pts. with _____.
very large tumors (size > 3 cm) or in symptomatic pts. who responded poorly to medical t/t with dopamine agonist such as cabergoline or bromocriptine.
57
A pituitary adenoma with sr. PRL levels > 200 ng/dL or repeat level > 200 ng/dL, suggest a ____.
Prolactinoma.
58
A pituitary microadenona is ___ in size, and macroadenoma is ___ in size.
pituitary microadenona: < 10 mm;
pituitary macroadenoma ≥ 10 mm (1 cm).
59
Initial t/t with dopamine agonists such as cabergoline or bromocriptine is considered in pts. with a ___ prolactinoma.
macro-prolactinoma, or symptomatic pts.
60
Which CNS tumor that p/w headache, visual disturbances along with s/o hypopituitarism d/t anatomic compression has a bimodal age distribution?
Craniopharyngiomas
*present between 5-14 yrs, and 50-75 years.
*Adamantinomous type in pediatric populations, and papillary type in adults.
61
What is the difference between Somogyi effect vs Dawn phenomena?
Somogyi effect is
-A.M. rebound hyperglycemia d/t midnight hypoglycemia in diabetics.
-t/t by reducing evening insulin dose.
-3 am blood glucose levels will be low.
Dawn phenomena is
-A.M. hyperglycemia d/t normal diurnal ↑ in counter regulatory hormone secretion (GH, cortisol) after midnight.
-3 am blood glucose is normal/↑.
62
Bradycardia, irregular respirations, and a widened pulse pressure in a pt. with neurological s/s are indicative of ___, and termed _____.
High ICP (intracranial pressure);
termed Cushing's triad.
63
____ is the leading cause of death in children with DKA, and occurs in about ___ % of presenting cases.
Cerebral edema; 0.2-1 %
*AVOID/PREVENT by SLOW administration of IVF and insulin so as to correct effective osmolarity over a 36-48 hr period.
64
Cerebral edema in DKA results from ?
-rapid reversal of hyperglycemia induced osmolar shifts with IVF + Insulin
-cerebral vasoconstriction d/t acidosis and hypercapnia
-cytotoxic edema
-reperfusion injury with vasogenic edema during rehydration phase of DKA t/t.
65
What factors increase the r/o cerebral edema in DKA pts.?
pts. with
-High initial BUN
-Low initial PCO2
-t/t with *bicarbonate
-refractory hyponatremia even as blood glucose levels are improving.
*some experts recommend administering bicarbonate only if pH is < 7.0
66
In absence of oral or IV access, ___ can be given to t/t severe hypoglycemia in a pt.
IM Glucagon.
67
What are the 2 main categories and their progress of hypoglycemia symptoms?
Neuroglycopenia ---> adrenergic (autonomic) activation.
Neuroglucopenic s/s include
-headache,
-blurred vision,
-confusion,
-lightheadedness.
Autonomic s/s include
-sweating
-anxiety
-pounding heart (↑HR)
68
A pt. on beta-blocker therapy may present without typical s/s of hypoglycemia or only _____ symptom when hypoglycemic.
diaphoresis as sweat glands have adrenergic activation but cholinergic innervation.
69
Sr. prolactin levels of > 200 ng/dL in a male or a non-pregnant female is most likely d/t _____.
Prolactinoma (Pituitary adenoma)
70
Methimazole use during early pregnancy is associated with which congenital defects?
-Choanal atresia
-Aplasia cutis congenita
-Duodenal atresia
-Goiter
71
Pregnant women under t/t for hyperthyroidism may be switched back to Methimazole after ____ weeks of gestation.
after 16 weeks
*Methimazole must be stopped and PTU started as soon as pregnancy is confirmed and given at least until 16 weeks or beyond.
72
Fruity odor of the breath, abdominal pain, nausea, vomiting and rapid deep breathing (Kussmaul respiration) are more common in _____ than _____ complication of diabetes.
more common in DKA than HHS.
73
For pts. motivated to change modifiable risk factors, _____ (? month/year) trial of lifestyle modifications before starting anti-diabetic medications is reasonable.
a 3-month trial,
or 6 month trial (in those with HbA1c closer to 7%)
74
_____ is the best initial therapy for adults newly diagnosed with T2DM under what specific conditions?
Metformin, under specific conditions that newly diagnosed diabetic pts.
-DO NOT HAVE marked hyperglycemia (eg. sr. glucose > 300 mg/dL or HbA1C > 9.0%), and
-Renal function is normal.
75
First-line anti-diabetic agent Metformin is CI in pts. with?
CKD with GFR < 30 mL/min.
76
In newly diagnosed T2Ds with HbA1C > 9.0% or BSL > 300 mg/dL, _______ must be used as initial therapies.
Insulin, or
GLP-1 agonist (liraglutide, semaglutide)
77
What is the MOA of metformin?
-decreases hepatic gluconeogenesis (most prominent MOA)
-Increases Insulin sensitivity
-increases peripheral glucose uptake
-increases glycolysis (? in enterocytes)
78
Adverse effects of metformin include?
-Nausea,
-Diarrhea
-Vit B12 deficiency
-Lactic acidosis (high risk in CKD).
79
____ is an example of insulin secretagogue.
Sulfonylureas (eg. Glimepiride, Glyburide, )
80
Non-thyroidal illness syndrome formerly known as _____ marked by low T3, low free T4, and low TSH is seen in ______ pts.
Euthyroid sick syndrome (ESS) is seen in pts. with critical illness (eg. ICU pts) with no prior history of thyroid/endocrine disorder.
81
ESS can be seen in ___ percent of critically ill pts.
> 75%
82
TFT should be rechecked/reassessed after ____ in pts. with ESS.
About 6 weeks after discharge from the hospital.
83
_____ is the most common genetic alteration in thyroid cancer.
BRAF mutation: in ~ 45% of sporadic papillary thyroid ca (PTC), esp. aggressive types.
PTC with BRAF mutations may progress to anaplastic thyroid ca.
PTCs:
-account for 70-80% of all thyroid ca's
-a/w RAS, BRAF, or TRK gene mutations
-a/w RET
-lymphatic spread;
-psammoma bodies
-females (30-50 yrs)
-orphan anne nuclei
-excellent prognosis
84
RET mutations are a/w ___ thyroid cancers.
medullary thyroid cancers (1-2%)
*usually part of MEN2A/2B disease spectrum
*calcitonin producing
85
Other than activating mutations of BRAF proto-oncogene, what other gene mutations may be a/w with the "most common" papillary thyroid cancer?
Activating mutations of
-RAS proto-oncogene
-TRK genes
Overexpression of
-RET proto-oncogene.
86
Large volume watery and brownish diarrhea (>1-3 liter/24hr) without blood/mucus, about >10/day, that persist even with fasting along with dehydration, muscle weakness, muscle cramps and fatigue are suggestive of ______.
VIPoma; a/w
dehydration,
hypokalemia, and
hypochlorhydria
+ hyperglycemia (~ 25-50% cases)
+ hypercalcemia (~ 25-50% cases)
87
Hyperglycemia may be present in cases of VIPoma d/t _____.
-stimulatory effect of VIP on hepatic glycogenolysis, and
-inhibitory effect of hypokalemia on insulin release in the pancreas.
88
Resolution criteria during m/m of HHS include?
-Plasma glucose levels < 200 mg/dL
-Plasma eff. osmolality < 315 mOsm/kg
-Anion gap < 10
-Sr. bicarbonate > 18 mEq/L
-Venous pH > 7.3
-Improvement of mental and hemodynamic status.
89
Anytime before or during t/t of HHS, insulin should be withheld or stopped when _______.
serum K+ levels is below 3.3 mEq/L.
*Stop/withhold insulin, add K+ to IVFs;
Restart Insulin when sr. K+ levels are > 3.3 mEq/L.
90
List the anti-diabetic drugs/classes that are either weight neutral or induce weight loss in patients.
weight neutral:
-alpha-glucosidase inhibitors such as acarbose, miglitol
-DPP IV inhibitors: "gliptins"
Weight loss inducing:
GLP-1 agonists: "tides" ~ 2.2 kg wt. loss
91
Other than dehydration, hypokalemia, and achlor-/hypochlorhydria, what other metabolic derangements may be seen in VIPoma?
Hyperglycemia and hypercalcemia in about 25-50 % cases.
92
Normally, ADH secretion is suppressed when plasma osmolality is _____.
when plasma osmolality is < 280mOsm/kg of H2O.
*normal plasma osmolality= 275-295 mOsm/kg of H2O.
93
Hyponatremia in setting of low-normal serum osmolality, high urine osmolality, and high ur. Na+ (>40 mEq/L) is suggestive of ___.
SIADH; p/w
Plasma osm is < 275 mOsm/kg.
Ur osm is > 100 mOsm/kg (n. is 50-1200)
Ur. Na+ > 40mEq/L.
94
What are some most common causes of SIADH?
CNS: stroke, hemorrhage, infection, trauma, surgery, mental illness, psychosis.
Malignancies (ectopic ADH secretion): SCLC (most common), extra-pulmonary small cell ca, Head/Neck ca, olfactory neuroblastoma.
Medications: carbamazepine/oxcarbazepine, Chlorpropamide, cyclophosphamide, SSRI
Surgery
Pulmonary: Pneumonia (mc), asthma, atelectasis, ARF, pneumothorax, mechanical ventilation.
HIV
95
The role of lithium is t/t of SIADH is very limited, and is used in t/t of ____ and/or ___ cases of SIADH.
severely symptomatic and refractory cases.
*Lithium inhibits the effects of ADH at collecting tubules.
96
The first line best t/t of SIADH includes?
Restriction of water intake to < 800ml/day.
97
What is the next best step in m/m of SIADH if a pt. does not respond to fluid restriction?
IV hypertonic saline
*slow infusion at ≤ 0.5 mEq/L/hr to avoid osmotic demyelination syndrome.
98
What are the two most important secretory products of a pheochromocytoma?
NE and Ach.
99
Preoperative medical m/m of pheochromocytoma include ____ to stabilize the BP.
α-blockade ---> β-blockade
e.g. phenoxybenzamine x 7-14 d --> propranolol
100
Systemic glucocorticoids used in m/m of thyroid storm act by ______.
reducing the peripheral conversion of T4--> T3, and may also affect the underlying autoimmune process.
101
Worldwide, ____ is the MCC of hypothyroidism, whereas in industrialized world, ____, ___, and ___ are the MCCs of hypothyroidism.
Worldwide, Iodine deficiency is the MCC;
In industrialized world, the mcc are
-Hashimoto thyroiditis
-iatrogenic hypothyroidism
-secondary: to pituitary dysfunction.
102
Enlist and describe the classification criteria for DKA.
Mild DKA
pH: 7.30 - 7.25 (n= 7.35 -7.45)
sr. HCO3: 18-15 mEq/L (n= 22-28)
Moderate DKA
pH: 7.24 -7.0
sr. HCO3: 15-10 mEq/L
Severe DKA
pH < 7.0
sr. HCO3: < 10 mEq/L
103
T1D has onset typically around which age?
5-15 yrs
104
For hyperglycemia to develop, ___ percent of beta cells must have destroyed in T1D.
80-90%
105
The autoantibodies in *classic T1D (aka autoimmune T1D) are directed against _____.
*T1D may be idiopathic (uncommon).
Any one or more of the following:
-Insulin
-Glutamic acid decarboxylase (GAD)
-Islet antigens (IA2 & IA2-beta)
-Zinc transporter (ZnT8).
106
HLA ____ alleles affect an individuals susceptibility to T1D in presence of specific environmental triggers.
HLA-DR/DQ
Remember: D for diabetes and D for D alleles.
107
Viruses strongly a/w T1D are ____ and ____.
rubella viruses (congenital rubella syndrome), and human enteroviruses.
108
T1D shares the HLA-DQ2 genotype with ____, and may occur together.
Celiac disease.
109
Starvation ketosis results from _____ resulting in lipolysis and ketone body formation.
inadequate carbohydrate intake
Remember: body first uses fat for energy during starvation.
110
Blood glucose levels are ____ (? low, high, normal) in starvation ketosis.
normal
Remember: ketosis is being induced during starvation to maintain blood glucose levels.
111
Basal-bolus insulin is the next best step in m/m of T2Ds with ______ on metformin mono-therapy, or T2Ds with ______ on at least 2 oral agents.
marked hyperglycemia (BSL > 300 mg/dL or HbA1c > 9%),
or
in pts. on at least 2 oral agents with high HbA1c.
112
Sulfonylureas can be added to the t/t regimen in pts. on metformin mono-therapy under what specific conditions?
in pts. on metformin mono-therapy who do not have "marked hyperglycemia" i.e. BSL is not more than 300 mg/dL or HbA1c is not more than 9%.
113
______ insulin is usually recommended when initiating insulin therapy in a T2D pt. with poor glycemic control on 2 or more oral anti-diabetic agents.
Long-acting insulin e.g. insulin glargine 10 units at BEDTIME.
114
List some causes of nephrogenic DI.
-chr. lithium therapy
-hypercalcemia
-hereditary gene mutations
-sickle cell disease
-severe persistent hypokalemia
115
In pts. suspected of having nephrogenic DI d/t lithium toxicity, ____ is the best test to confrm the diagnosis.
Desmopressin test;
*administering Desmopressin will not increase low ur. osm. in nephrogenic DI.
116
In a T1D p/w DKA, ____ is/are the best initial t/t, whereas a T1D pt. p/without DKA, ______ is the best initial t/t option.
Best initial t/t in T1D
-p/w DKA: IVF + continuous IV Insulin infusion.
p/without DKA: *Basal-Bolus insulin provided by MDI or continuous infusion with insulin pump.
*Basal-Bolus insulin will prevent DKA if not already present.
117
Severe hypocalcemia with sr. Ca2+ levels less than _____ mEq/L in a symptomatic pt. is t/t with _____ or ____.
Severe hypocalcemia is albumin-corrected sr. Ca2+ levels < 7.5 mEq/L;
T/t: SLOW ADMINISTRATION of IV Calcium gluconate or CaCl2.
118
Mild -moderate hypocalcemia defined by albumin-corrected sr. Ca2+ levels of ____ can be t/t with ___.
Mild -moderate hypocalcemia is albumin-corrected total sr. Ca2+ level 7.5-8.5 mEq/L
oral calcium carbonate /calcium citrate
+ Vit D.
119
Diabetic neuropathy can be of the following types.
-generalized
-Focal
-multifocal
-autonomic
120
____ is the most common type of diabetic neuropathy.
chronic sensorimotor distal symmetric polyneuropathy
*initially asymptomatic for long time --> foot ulcers;
t/t with TCA, SSRIs
121
Which major systems are involved in diabetes associated autonomic neuropathy? What are the s/s?
CVS:
-resting tachycardia,
-orthostatic hypotension,
-High mortality d/t complications such as silent MI.
GIT:
-Gastroperesis
-enteropathy p/w constipation or diarrhea
GUS:
-Erectile dysfunction
-retrograde ejaculation
-bladder dysfunction.
122
Describe the different types of peripheral neuropathies a/w diabetes?
1. Distal symmetric sensorimotor poly-neuropathy:
-most common type of neuropathy in diabetes
-involves small fiber neuropathy (SFN) affecting the A-delta (thinly myelinated) & C fibers (non-myelinated).
-progressive loss of distal sensation; "stocking & glove" fashion.
-s/s: numbness, burning, tingling, prickling pain, electric-shock like sensation, ache, tightness, touch hypersensitivity.
2. Bilateral peripheral mono-neuropathy:
-most commonly affects the median nerve at the wrist, or
-CPN (foot drop) in diabetics.
3. Diabetic Amyotrophy:
-aka Lumbosacral radiculoplexus neuropathy is the most common type of diabetic polyradiculopathy
-d/t ischemic injury d/t non-systemic microvasculitis
-causes focal pain--> proximal leg weakness
-a/w autonomic features and weight loss.
123
Small fiber neuropathy (SFN) affecting the ___ and ___ fibers is seen in which disease states?
thinly myelinated A-delta fibers and non-myelinated C fibers;
Seen in
-Diabetes (chr. sensorimotor polyneuropathy)
-Alcoholic neuropathy
-HIV/AIDS
-Amyloidosis
-leprosy.
124
____ is an asymmetric vasculitic neuropathy causing ischemic nerve damage is often seen in _____ and ____.
Mono-neuropathy multiplex;
seen in polyarteritis nodosa, and ANCA-associated vasculitides.
125
Metabolic syndrome is aka ____ or ____.
Insulin resistance syndrome or syndrome X.
126
Based on *NCEP-ATP III, what are the criteria for diagnosis of Metabolic syndrome?
*National Cholesterol Education Program-Adult Treatment Panel III.
Diagnosis of Metabolic syndrome is made when any 3 of the following conditions are met:
* BP ≥ 130/85 OR under drug t/t for HTN.
* HDL < 40 mg/dL (men) /< 50mg/dL (women), OR
drug t/t for low HDL.
*WC ≥ 40 in (102 cm) in men/≥ 35 in (88 cm) in women.
*sr. TG > 150mg/dL OR drug t/t for high TGs.
*FBS > 100 mg/dL OR drug t/t for high blood glucose.
MN: PHATS (pressure, HDL, Abd. girth, TG, Sugar)
127
Initial t/t for metabolic syndrome involves _____.
6 month period of diet and exercise
128
A newborn baby with cleft palate, abnormal facies, cardiac abnormalities p/w seizures and tetany d/t hypocalcemia, most likely has _____ syndrome d/t ____ chromosomal abnormality.
*DiGeorge syndrome d/t 22q11 deletion.
*aka CATCH-22 (aka Velocardiofacial synd.) involves
-Cardiac abnormalities:TOF, Truncus arteriosus, CoA
-Abnormal facies: low-set ears, micrognathia, hypertelorism.
-Thymic aplasia --> T-cell deficiency
-Cleft Palate
-HypoPTH--> hypocalcemia--> tetany, seizures.
129
Other than antithyroid drugs, which medications can cause hypothyroidism?
-Amiodarone: ↓ TH synthesis & secretion; ↓ T4--> T3
-Lithium: ↓ TH synthesis and secretion.
-Ethionamide (MDR-TB)
*Anti-cancer: IFN-α, TKI, Immune-checkpoint Inhibitors.
-cause destructive thyroiditis.
*Suni-tinib (TKI); Ipi-li-mumab (ICP-inhibitor)
130
Which drugs can cause decreased absorption of T4 in pts. taking levothyroxine for hypothyroidism?
-calcium carbonate (OTC antacid)
-Omeprazole (PPI)
-cholestyramine
-Colestipol
131
Which drugs can cause abnormal TFTs by increasing T4 clearance but do not cause hypothyroidism?
Anti-epileptics:
-Phenytoin
-carbamazepine
-Phenobarbital
Anti-retroviral:
-Ritonavir
132
Which drugs affect the TBG levels?
-Estrogenic: tamoxifen
-androgens
-glucocorticoids
133
In women on t/t for hypothyroidism, target TSH during pregnancy must be maintained between ____, by increasing the levothyroxine dosage.
1.0-2.5 mU/L.
134
If increase in levothyroxine is declined by the patient as pregnancy is diagnosed, then TSH levels must be checked every ______ (? days or weeks).
Immediately and every 4 weeks to assess TSH maintenance between 1.0-2.5 mU/L;
any dose adjustment must be followed by TSH check every 4 weeks as well as once every trimester for TSH maintenance.
135
What are some risk factors for adrenal hemorrhage leading to adrenal insufficiency?
-Post-operatively
-sepsis
-N. meningitis: waterhouse Friedrichson syndrome
-Pathological or iatrogenic bleeding d/t
*Anticoagulation t/t (even within therapeutic range)
*HIT
*Anti-phospholipid syndrome
136
_____ can be used as initial t/t in suspected but unconfirmed cases of adrenal insufficiency, whereas ____ is given in confirmed cases of adrenal insufficiency.
Dexamethasone (predominant GC) in unconfirmed cases of AI;
Hydrocortisone (GC and MC activity) in confirmed cases of AI.
137
IV calcium gluconate is indicated in t/t of which conditions?
-Acute severe hypocalcemia
-Hyperkalemia a/w ECG changes (Sr. K+ > 7 mEq/L)
-CCB overdose
138
The next best step in assessment of a hyper-functioning thyroid nodule (clinically+ low TSH) is ____, whereas for a hypo-functioning nodule (c/p + high/normal TSH) is ______.
radionuclide thyroid nodule scan (Scintigraphy) for hyper-functioning thyroid nodule (to characterize hot and cold nodules and thus guide further steps).
Thyroid ultrasound for hypo-functioning thyroid nodule (to assess size and nodule features to guide further steps).
139
Ultrasonographic patterns of a thyroid nodule a/w intermediate or high risk of malignancy include?
HIGH RISK (70-90% risk): Solid hypo-echoic nodule, or solid hypo-echoic component in a partially cystic nodule with any of the following:
* irregular margins
* micro-calcifications
* taller than wide shape
* rim calcifications
* e/o extra-thyroidal extension
INTERMEDIATE RISK (10-20% risk): Solid hypo-echoic nodule with smooth margins
* without micro-calcifications,
* without extra-thyroidal extension, or
* without taller-than-wide shape
140
SIADH is seen in about ___ percent of cases of SCLC, and is a/w worse outcome for the pt.
7-16%
141
Which infections are a/w SIADH?
pulmonary infectious states such as pneumonia or TB.
142
SIADH may be a/w use of ____ anti-depressants.
SSRIs
143
Best initial diagnostic test for adrenal insufficiency is ____.
morning serum cortisol (8 am-9 am)
Results interpretation:
Level < 3 μg/dL ---> suggest AI
Level > 18 μg/dL ---> rule out AI
Level 3-18 μg/dL --> require High Dose ACTH stimulation test.
144
High-dose ACTH stimulation test involves ____.
IV/IM administration of 250 μg of ACTH f/by measurement of sr. cortisol 30-60 minutes later.
145
Sr. cortisol < 18 μg/dL after high-dose ACTH stimulation test confirms ____, whereas sr. cortisol > 18 μg/dL after high-dose ACTH stimulation test may suggest _____ or ____.
Sr. cortisol < 18 μg/dL after high-dose ACTH stimulation test confirms PRIMARY AI;
sr. cortisol > 18 μg/dL after high-dose ACTH stimulation test suggest any of the following two:
-recent-onset secondary AI, or
-partial ACTH deficiency
*test with low-dose ACTH stimulation test or HPA axis test with Insulin tolerance test or metyrapone test.
146
Measurement of serum 11-deoxycortisol is indicated in hypertensive forms of CAH such as d/t _____ or ______.
CAH d/t 11 beta-hydroxylase deficiency (a/w virilization) or 17 alpha-hydroxylase deficiency (a/w feminization) .
147
A pregnant women may be diagnosed with "Overt diabetes" if her HbA1c is found to be ____ during routine tests in early pregnancy.
On the other hand, gestational diabetes mellitus (GDM) is diagnosed when standard screening done between _____ weeks of gestation are abnormal with early pregnancy HbA1c < 6.5%.
≥ 6.5%;
GDM first tested with oral GTT during 24-28 weeks of gestation; resulted positive if any of the following are present during a 75g oral GTT:
FBS: 92 mg/dL
1-hr: 180 mg/dL
2-hr: 153 mg/dL
148
What are the risk factors for GDM?
-Obesity
-personal h/o macrosomia of previous child
-past h/o GDM
-PCOS
-F/H/O T2D.
149
Maternal hyperglycemia in pregnancy is a/w?
-fetal macrosomia (BW > 4000 g)
-neonatal hypoglycemia
-polycythemia
-jaundice
-hypocalcemia
150
Insulin must be initiated in pregnant women with diabetes under what conditions?
in diabetic pts. with any of the following:
-not responding to lifestyle interventions
-in cases with symptomatic hyperglycemia
-FBS > 125 mg/dL
-RBS > 200 mg/dL
151
Which factors are a/w a worse prognosis in pts. with papillary thyroid cancer, which otherwise has a good overall prognosis in absence of distant metastasis.
-age > 45 yrs
-male sex (F/M ratio is 2.5:1)
-bone/brain/lung or other distant metastasis
-size > 1 cm
152
The follicular variant of papillary thyroid cancer is a/w ____ prognosis.
best prognosis
153
Hurthle cell (aka oncocytic) is a variant of ____ thyroid cancer, and is a/w a ___ prognosis d/t _____.
follicular thyroid cancer;
a/w a poor prognosis d/t high r/o metastasis and recurrence.
154
Hashimoto's thyroiditis is aka ___.
chronic lymphocytic thyroiditis or chronic auto-immune thyroiditis.
155
Chronic lymphocytic (Hashimoto's) thyroiditis is commonly associated with which pathologic conditions?
-T1D
-Sjogren syndrome
-Turner syndrome
-chronic HCV infection
156
The risk of thyroid lymphoma, a rare thyroid malignancy is greatly increased by approx. ____ percent in pts. with ____ thyroiditis.
~60% in pts. with chronic lymphocytic (Hashimoto's) thyroiditis.
157
What are different name designations of Riedel's thyroiditis?
Riedel's thyroiditis is aka
-Fibrous thyroiditis, or
-Invasive thyroiditis, or
-IgG4-related disease
158
Other than the thyroid gland (Riedel's thyroiditis), what other organs may get affected in IgG4 related disease ?
Multiple organ involvement causing
-autoimmune pancreatitis
-Sclerosing cholangitis
-Sialadenitis
-retroperitoneal fibrosis
159
The initial dose of levothyroxine is roughly ____ mcg/kg/day in young healthy individuals; however, lower dose of ____ per day must be started in older individuals and those with CAD.
1.6 mcg/kg/day in young healthy individuals;
25-50 mcg/day in older individuals and those with CAD.
160
Thyroxine replacement in older individuals must be less aggressive. A higher target TSH levels of ____ mIU/L must be maintained in older individuals > 65 yrs as compared to younger adults in whom a target TSH of ___ mIU/L must be maintained.
TSH levels of 4-6 mIU/L must be maintained in older individuals > 65 yrs;
target TSH of 1-3 mIU/L must be maintained in younger individuals.
161
Riedel's thyroiditis (IgG4-RD) can be differentiated from anaplastic carcinoma based on HPE which shows ___ in Riedel's thyroiditis .
HPE in Riedel's thyroiditis (IgG4-RD) shows a characteristic "cartwheel" appearance of fibroblasts and inflammatory cells and Eosinophils.
162
IgG4-related disease (IgG4-RD) is more common in ___ (?gender).
M > F
but thyroid involvement in the form of riedel's thyroditis is 4 times more common in women (F > > > > M)
163
Hyperthyroidism causes increase in BP d/t ___ in spite of low SVR; hypothyroidism causes increased BP ____.
d/t increased myocardial inotropy (& chronotropy) ;
hypothyroidism causes increased BP d/t increase in SVR.
164
____ pts. with a __-prolactinoma may be observed over time.
asymptomatic pts. with a micro-prolactinoma
165
Pts. with a macro-prolactinoma or symptomatic tumors must initially be t/t with ___, f/by ____ if initial t/t is ineffective.
Initial t/t with dopamine agonists such as carbegoline or bromocriptine (normalize PRL levels and tumor may regress in size);
If pt. is unresponsive to initial t/t or have very large tumor (> 3cm) at presentation, then trans-sphenoidal resection must be undertaken.
