Screening tests for DM-what do you do if one of two tests is abnormal
repeat the Abnormal one
random glucose cut off for diagnosing DM
> 200 WITH sx
how do you restore hypoglycemia awareness
lower insulin dose/raise glucoses for several weeks
statin dose for >40, ASCVD <7.5, DM
moderate
follow up for someone with a history of gestational DM
yearly screening for DM
eye exams for someone with T2DM and pregnancy
trimesterly eye exams
common cause of non-diabetic post prandial hypoglycemia
gastric bypass/gastrectomy (glucose rapidly absorbed->rapid insulin secretion)
drugs to screen for if suspect surrepticious hypoglycemic use
sulfonylureas and meglinitides
MEN1 presentation
hyperparathyroid
pituitary neoplasm
pancreatic NETs including gastrinomas or insulinomas
tx for postprandial hypoglycemia after gsatric bypass
small meals with mix of protein/fat/fiber
Sheehan syndrome presentation
associated with hemorrhage/hypotension
causes possibly vascular collapse
more often amenorrhea, lack of lactation, fatigue
how do you test for growth hormone deficiency
loss of muscle mass
low IGF-1 and diminished insulin tolerance test
what happens to prolactin in hypopituitarism
may go up
what is pituitary apoplexy
bleeding into or poor blood supply of pituitary (i.e from tumor or sheehan syndrome)
how do you dose levothyroxine for central hypothyroid
T4 (NOT TSH)-also rule out and tx hypoadrenal first
non-tumor causes of large pituitary
pregnancy or primary hypothyroidism
diagnosis for acromegaly
incr. IGF
AND
OGTT will fail to suppress GH
If presentation of headache, bitemporal hemianopsia maybe other sx, first test?
imaging! (not hormone tests)
which patients get screening for pituitary adenoma
1 component of MEN1 (i.e. hyperparathyroid) + family member with MEN1
other test in hyperprolactin (other than pregnancy)
TSH (hypothyroid can cause hyperprolactin)
tx for symptomatic hyperprolactinoma
dopamine agonist i.e. cabergoline or less preferred bromocriptine
which pituitary adenomas get surgery
ACTH/GH/LH secreting, mass effect, or prolactinomas not responding to cabergoline
test once you’ve confirmed nephrogenic DI
kidney ultrasound (vs. mri brain if central)
tx for Li induced DI if you can’t stop Li
amiloride
Tx for non-drug induced nephrogenic DI
thiazide diuretic and salt restriction
presentation of postpartum thyroiditis
painless autoimmune thyroiditis within a few months postpartum
labs in thyrotoxicosis (other than thyroid)
mild hyper Ca, elevated alk phos, low HDl/total chol
next test in low tsh, nl t4
t3 (?t3 toxicosis)
test if you suspect surreptitious thyroid hormone
thyroglobulin (will be suppressed (high in hyperthyroid/thyroiditis)
side effects of radioactive iodine therapy
sialadenitis and painful radiation thyroiditis
outcomes after antithyroid meds for graves
30-50% will get a drug free remission afte ra year
why is propylthiouracil worse than methimazole
more liver failure (better in pregnancy)
same rashes/agranulocytosis
when do you avoid radioactive iodine for hyperthyroid
pregnancy/breast feeding and graves opthalmopathy
tx for thyroidstorm
propylthiouracil (!), iodine, steroids, beta blockers
likely dx in patient with fever or sore throat on methimazole/propylthiouracil
be on the look out for agranulocytosis
in general, when do you treat subclinical hypothyroid
TSH >10
tx of myxedema coma
levothyroxine + hydrocort until you rule out hypoadrenal
which thyroid nodules need FNA
ANY >1 cm + NL TSH
or <1 cm with risk factors/suspicious ultrasound
steroid amt likely to cause clinically significant endogenous suppression
> = 10-20 for 3 weeks+
1st line tests for hypercortisol (3)
low dose dex suppression
24 hr urine cort
EVENING salivary cort
Next text if:
hypercortisol confirmed
Elevated or nl TSH
No pituitary tumor on imaging
High dose dexamethasone suppression test
If it does NOT suppress cortisol: ectopic acth tumor-look for SCLC, bronchial carcinoid, pheo, medullary thyroid
If it DOES suppress cortisol: pituitary source, do intrapetrosal sinus sampling for acth to confirm
tests after identifying ANY adrenal incidentaloma
1 mg overnight dex suppression test and urine metanephrines
aldo/renin ratio if hypertension or hypokalemia
which adrenal incidentalomas get surgery
> 6 cm or functioning
follow up for non-surgical adrenal incidentalomas
repeat imaging AND functional testing in 6-12 months
steroid that doesn’t interfere with serum cortisol assay for adrenal insufficiency testing
dexamethasone
pheochromocytoma disease associations
MEN2, vonHippel-Lindau, NF type 2
when do you do 24 hr urine vs. plasma metanephrines in suspected pheo
low pretest probability-24 hr urine (i.e. adrenal incidentaloma)
high prest probability-plasma (i.e. familial syndrome)
tx of intraoperative hypertensive crisis in pheo
nitroprusside or phentolamine
vs phenoxybenzamine which is given preop
which meds need to be stopped for plasma aldorenin ratio
just eplerenone/spironolactone
Dx and etiologies (4) of secondary amenorrhea with low estradiol, nl FSH/LH
hypogonadotrophic hypogonadism
- hypothyroid
- hyperPL
- hypothalamic (stress weight loss exercise)
- pituitary (tumor, sheehan)
Dx and etiologies (3) of secondary amenorrhea with low estradiol and elevated FSH/LH
hypergonadotrophic hypogonadism
- premature ovarian failure (autoimmune)
- chemo
- pelvic radiation
Conclusions you can draw from progesterone challenge for secondary amenorrhea
+ bleed-intact ovaries/estrogen
no bleed-ovarian failure
cut off where you MUST image for hyperPL
> 100 with nl TSH
how do you prevent osteoporosis in secondary amenorrhea
give estrogen/progesterone replacement until return or until 50 yo
next tests after two low am testosterones in a male
LH, FSH, PL
Dx and etiologies (5) of male hypogonadism with low T, high LH/FSH
testicular failure
- Klinefelter
- atrophy secondary to mumps
- autoimmune
- chemo/rad
- hemochromatosis
Dx and etiologies (4) of male hypogonadism with low T, low or nl LH/FSH
secondary hypogonadism
- sleep apnea
- hyperprolactin
- pituitary/hypothalamus problem (hemochromatosis, tumor)
- opiates, anabolic steroids, glucocorticoids
tests to find etiology of male secondary hypogonadism
PL
iron studies (for hemochromatosis)
MRI
(maybe sleep study, maybe utox)
monitoring required during male testosterone therapy
Hct and PSA
Important test in a patient with hyperCa, nl PTH
urine calcium excretion for familial hypocalciuric hypercalcemia
3 hypercalcemia etiologies with low or normal phos (rest are high)
primary hyperparathyroid
malignancy (Other than MM)
local osteolytic lesions
MEN1 components
Hyperparathyroid (most common presentation)
Pituitary tumors
Pancreatic neuroendocrine
test to measure in ALL hyperparathyroid patients
check vitamin D (50% are low, can screw with serum/urine Ca)
who gets hyperparathyroidectomy
any complications (stones, symptoms…)
- Ca >1 above ULN
- decr. GFR
- T score <2.5 on dexa
- young (<50)
what is hungry bone syndrome
precipitous Ca fall after parathyroidectomy
special hyperCa tx in MM or sarcoid
remember to start steroids
what is a better way to phrase pseudohypoparathyroidism
PTH resistance
vitamin D choice in liver disease
25 OH cholecalciferol
vitamin D choice outside of liver or kidney disease
cholecalciferol or ergocalciferol
vitamin D choice in kidney disease
1,25 dihydroxy vitamin D (calcitriol)
next step after you find hypoaldosteronism to look for source
plasma vein sampling if adenoma present because non-functioning is so common
tx hyperplasia with spironolactone/eplerenone
T score cut off for osteoporosis
T score cut off for osteopenia
-1- -2.4
Frax score that is an indication for tx
risk of major fracture >20% or hip >3%
raloxifene adverse effect
VTE
teriparatide adverse effect
(osteoporosis drug)-osteosarcoma
which osteoporosis med cannot be used for hip fracture reduction
raloxifene (given if you cant tolerate oral bisphosphonates)
osteomalacia etiology and presentation
low vitamin D usually (or Ca/Phos deficiency)
- fatigue, bone pain, muscle weakness (prox), low Ca/phos, high alk phos
- can confirm wiht bone ibopsy
sceening test for vitamin D deficiency
25 OHvitamin D
Paget disease presentation (4)
bone pain/fractures
cranial/spinal nerve compression
high output cardiac failure
angioid retinal streaks
Paget disease labs
elevated alk phos
Paget disease diagnostic imaging test and findings
bone scan and xrays of affected area
-xrays show focal osteolysis cotton wool, cortical thickening
Tx of paget disease
bisphosphanates