Endo

Question 1

GH deficiency in adults

Answer 1

Central obesity, increased LDL and cholesterol, reduced lean muscle mass

Question 2

Insulin’s affect on GH

Answer 2

When insulin decreases the glucose level, GH should rise, failure to do so indicates pituitary insufficiency

Question 3

Hormones to replace in panhypopituitarism

Answer 3

First: Cortisone, then thyroxine, testosterone, estrogen, recombinant human growth hormone

Question 4

2 hormones of the posterior pituitary

Answer 4

Oxytocin and ADH

Question 5

What are low in panhypopituitarism

Answer 5

TSH, thyroxine, ACTH, Cortizone, LH/FSH, testosterone, estrogen?
GH – pulsatile however, prolactin

Question 6

Cosyntropin stim test in panhypopituitarism

Answer 6

Should be normal – Cortizone will rise as the adrenal gland is normal – in response to cosyntropin, however if chronic will be decreased as the adrenal gland has atrophied

Question 7

Causes of nephrogenic DI

Answer 7

Chronic pyelonephritis, amyloidosis, myeloma, SCD
Also, hypercalcemia and hypokalemia may inhibit ADH affect on kidney
Lithium

Question 8

Treatments for nephrogenic DI

Answer 8

Hydrochlorthiazide, amiloride, indomethacin

Question 9

Unusual presentations of acromegaly

Answer 9

Carpal tunnel syndrome, body odor, deep voice, big tongue, colon polyps, skin tags, arthralgias, hypertension, cardiomegaly, CHF, erectile dysfunction – increase prolactin
GH abuse may result in similar presentation

Question 10

Diagnosis and treatment for acromegaly

Answer 10

Initial: I GF – 1
Best: glucose suppression test – glucose will not suppress GH
Will see glucose intolerance and hyperlipidemia
MRI after acromegaly is identified
Treatment: transphenoidal resection of the pituitary
Cabergoline – dopamine will inhibit GH release
Octreotide, pegvisomant- GH antagonist
Radio therapy if unresponsive

Question 11

GH and insulin

Answer 11

GH is anti-insulin, but it makes insulin like growth factor; and has insulin like effects on proteins and amino acids

Question 12

What may raise prolactin levels

Answer 12

GH release, hypothyroidism, pregnancy, exercise, renal insufficiency, chest wall stimulation, antipsychotics, methyldopa, metoclopramide, opioids, try cyclic antidepressants, verapamil– The only CCB
Dopamine and Hibbetts prolactin a lease so, meds that inhibit dopamine raise prolactin

Question 13

Test to get first if high prolactin, and when can you get an MRI

Answer 13

Thyroid function test, pregnancy test, BUN/creatinine, LFTs– Both kidney and liver failure increase prolactin
Can get an MRI after high prolactin is confirmed, secondary causes like meds are excluded, patient is not pregnant

Question 14

Treatment for hyperprolactinemia

Answer 14

Dopamine agonist: cabergoline is better than bromocriptine

If no response, transphenoidal surgery, radiation is rarely needed

Question 15

Hypothyroidism is characterized by almost all body processes being slow down except?

Answer 15

Menstrual flow, which is increased

Question 16

How to treat hypothyroidism based on TSH

Answer 16

If TSH is more than double the upper limit of normal with normal T4, replace hormone
If less than double, get anti– TPO/anti-thyroglobulin antibodies, if positive replace thyroid hormone

Question 17

What is the cause of the hyperthyroidism?
Eye and skin findings?
Tender thyroid?
Nontender, normal exam?
Involuted gland is not palpable? 
High TSH?

Answer 17

Eye and skin findings: Graves– Only one to have TSH receptor antibodies
Tender thyroid: subacute thyroiditis
Nontender, normal exam: painless – silent – thyroiditis
Involuted gland is not palpable: exogenous is thyroid hormone use
High TSH: pituitary adenoma

Question 18

Hyperthyroidism treatments

Answer 18

Methimazole > PTU: Block hormone production, PTU inhibits conversion to active form
Iodinated contrast material: block peripheral conversion to active form, also block release of existing hormone

Question 19

Treatment for eye problems in graves

Answer 19

Steroids, radiation if not responding, severe cases may need decompressive surgery

Question 20

First step if small mass found on thyroid gland without symptoms or tenderness

Answer 20

Get T4/TSH levels, if + patient has a hyperfunctioning gland, does not need immediate biopsy as malignancy is not hyperfunctioning
If normal T4/TSH and greater than 1 cm: FNA, no need for US or RAIU– These cannot exclude cancer

Question 21

Presentation of hypercalcemia

Answer 21

Acute: confusion, stupor, lethargy, constipation

Short QT interval, hypertension, osteoporosis, nephrolithiasis, DI, renal insufficiency

Question 22

When hypercalcemia does not resolve after fluids and bisphosphonates

Answer 22

Calcitonin, works rapidly whereas bisphosphonate take several days to work
Cinacalcet: may work in hyper PTH but not useful for malignancy, as PTH is already maximally suppressed
Prednisones: controls hypercalcemia from sarcoidosis or other granulomatous disease

Question 23

Treatment for hyperparathyroidism

Answer 23

Surgical removal, if not possible give cinacalcet

Question 24

Magnesium and calcium

Answer 24

Will magnesium needs to bow calcium because Magnesium is necessary for PTH to be released from the gland, low levels also lead to increased urinary loss of calcium

Question 25

Albumin and calcium

Answer 25

For every point decrease in albumin, the calcium level decreases by 0.8 However free calcium is normal

Question 26

EKG in hypocalcemia | Another unique finding?

Answer 26

Prolonged QT | slit lamp exam shows early cataracts

Question 27

Best initial tests for hypercortisolism

Answer 27

Best: 24 hour urine cortisol Next: 1 mg overnight dexamethasone suppression test, should normally suppress morning Cortizone levels, if suppressed hypercortisolism can be excluded, Does have false positives: Depression, alcoholism, obesity Another: midnight salivary cortisol

Question 28

Determining the cause of hypercortisolism

Answer 28

Best initial: ACTH if low source is adrenal If elevated, pituitary – suppresses with high dose dexamethasone Or ectopic – lung cancer, carcinoid – not suppressed: get MRI, then sample the inferior petrosal sinus after stimulating patient with CRH, as some pituitary lesions are too small to be seen on MRI If no pituitary lesion scan the chest for an ectopic source

Question 29

Affects of cortisol

Answer 29

Hyperglycemia, hyperlipidemia, hypokalemia, metabolic alkalosis– Excretes potassium and hydrogen ions at distal tubule leukocytosis from demargination of wbc's

Question 30

Presentation of chronic adrenal failure and acute adrenal crisis

Answer 30

Both: weakness, fatigue, AMS, N/V, anorexia, hypotension, hyponatremia, hyperkalemia, metabolic acidosis, hypoglycemia, high BUN, eosinophilia Chronic: hyperpigmentation Acute crisis: profound hypotension, fever, confusion, coma

Question 31

Adrenal failure diagnosis and treatment

Answer 31

Cosyntropin stimulation test fails to increased cortisol – cosyntropin is synthetic ACTH Treatment: replace steroids with Hydro Cortizone, fludrocortisonehas mineral corticoid affects

Question 32

Treatment of hyperaldosteronism

Answer 32

If unilateral: resect by laparoscopy | If bilateral: spironolactone

Question 33

Diabetes diagnosis

Answer 33

-2 fasting blood glucose levels over 125 mg/dL -Dash single glucose level above 200 mg/dl with symptoms of diabetes -Increased glucose level and oral glucose tolerance test Hemoglobin A-1 C greater than 6.5%

Question 34

Metformin

Answer 34

Works by blocking gluconeogenesis | Contra indicated in those with renal dysfunction because it can cause metabolic acidosis

Question 35

Most accurate measure of DKA severity

Answer 35

Serum bicarbonate level, as it is a measure of the anion gap, if bicarb is low the anion gap is increased

Question 36

How to prevent nephropathy in diabetics

Answer 36

Screen for microalbuminuria annually:between 30–300 mg per 24 hours is positive, Start on ace or ARB which decrease intraglomerular hypertension decreasing damage to the kidneys Dipstick for urine becomes trace positive at 300 mg per 24 hours– Not as sensitive

Question 37

Diabetic gastroparesis

Answer 37

Diabetes decreases the ability of the got to stretch, leads to decreased mobility Treat with metoclopramide and erythromycin