Endo Flashcards
(105 cards)
1
Q
Things that make A1c unreliable
A
A1c Epo Liver disease Hemoglobinopathies (Sickle cell disease) Iron-deficiency anemia (falsely elevated due to an increase in older erythrocytes)
2
Q
How to test for symptomatic hypoglycemia
A
72-hour fast with hypoglycemic studies at the time of symptomatic hypoglycemia
3
Q
Goal A1c in diabetes
A
Less than 7% (unless older)
4
Q
Initial management of new onset diabetes
A
Metformin + lifestyle modification for 3 months
5
Q
Management of diabetes after lifestyle modification
A
- Start metformin if A1c not at goal after 3 months (even if patient making progress. you want to aggressively reduce risk of micro and macrovascular complications)
- IF A1c remains at 9% or above after 3 months –> add orals
6
Q
SE’s to know with GLP-1 agonists
A
- Pancreatitis
- Medullary thyroid carcinoma
7
Q
Physiology of osmotic diuresis following AKI
A
High urea output in urine leads to osmotic diuresis, leading to hypernatremia
8
Q
Indications for kidney biopsy
A
- Glomerular hematuria
- Severely increased albuminuria
- **Acute or chronic kidney disease of unclear cause
- kidney transplant dysfunction or monitoring
9
Q
Clinical features of cisplatin-induced kidney injury
A
Polyuria and urinary excretion of sodium leading to volume depletion + tubular injury + hypomagnesemia (urinary magnesium loss) + proximal renal tubular acidosis with fanconi syndrome
- 7 days after starting
10
Q
Lung pathology caused by paclitaxel
A
Diffuse interstitial lung disease
11
Q
How is kidney failure risk determined + variables included
A
- kidney failure risk equation
- age + sex + eGFR + albuminuria
12
Q
diseases associated with AA amyloidosis
A
Chronic inflammatory states (RA) – it’s an acute phase reactant so deposits in numerous tissues, including kidneys
13
Q
Amyloidosis labs to know
A
SPEP with polyclonal gammopathy
14
Q
Patients at high risk for RCC
A
ESRD patients
15
Q
Bilateral cysts and masses in patient with ESRD think
A
Acquired cystic kidney disease
16
Q
Management of acquired cystic kidney disease in patients with CKD
A
IF severe or higher stage –> bilateral nephrectomy (little use in partial nephrectomy given very little residual kidney function)
17
Q
When patients are initiated on dialysis
A
GFR below 7.0 OR conventional indications for dialysis (uremic symptoms, metabolic abnormalities)
18
Q
first step in workup of primary adrenal insufficiency + why
A
21-hydroxylase antibodies (looking for autoimmune adrenalitis)
19
Q
primary adrenal insufficiency means
A
localizes to adrenal gland
20
Q
primary adrenal insufficiency lab profile
A
low serum cortisol + elevated ACTH
21
Q
most common cause of primary adrenal insufficiency in US
A
autoimmune adrenalitis
22
Q
diagnosis of primary adrenal insufficiency
A
just low serum cortisol + elevated ACTh (don’t need cosyntropin stimulation test)
23
Q
management of amenorrhea + hyperprolactinemia in psych patient on risperidone
A
- pituitary MRI (rule out pituitary adenoma)
- talk to psych before discontinuing risperidone
24
Q
treatment of primary adrenal insufficiency
A
- BOTH glucocorticoid and mineralocorticoid replacement (affects all layers of the adrenal cortex)
- hydrocortisone BID (has shorter duration and BID dosing mimics circadian rhythm of endogenous cortisol secretion)
- fludrocortisone daily
25
Next step after radiographic diagnosis of Paget disease of the bone
Serum alkaline phosphatase (need a baseline. it is a marker of treatment efficacy in Paget's)
26
How bisphosphonates cause severe hypocalcemia
- people who are vitamin d deficient can't correct for calcium deficiency through increased osteoclast activity because antiresorptive drugs suppress osteoclastic bone resorption
27
what to always remember before starting zometa
Check vitamin D and correct before starting
28
Hungry bone syndrome pathophys
After parathyroidectomy for primary hyperPTH, rapid influx of calcium from blood into the skeleton causes hypocalcemia
29
Presentation of androgen-producing adrenal tumor
signs of androgen excess over short period of time (hirsutism, virilization -- deep voice, facial hair)
30
Workup of suspected androgen secreting adrenal tumor
CT abdomen
31
New term for euthyroid sick syndrome
Nonthyroidal illness syndrome
32
lab features of nonthyroidal illness syndrome
- low serum T3
- low or low-normal serum T4
- low or normal TSH
* looks like subclinical hypothyroidism but T4 and T3 or low or low normal
33
Management of Cushing patient post adrenalectomy
Daily glucocorticoid replacement (hypercortisol secretion suppresses hypothalamic axis, when this axis is recovered following removal of the source/adrenalectomy, endogenous cortisol production is impaired. You don't need fludrocortisone because mineralocorticoid secretion is not under ACTH control. Aldosterone secretion from the contralateral adrenal gland isn't impacted.
34
Definition of cushing's syndrome
presentation of cortisol excess (due to a variety of causes)
35
definition of cushing's disease
cortisol excess due to pituitary adenoma secreting ACTH
36
Use of phenoxybenzamine
Preoperative alpha-receptor blockade for 10-14 days before surgery for pheochromocytomas and paragangliomas to prevent hypertensive crises during surgery
37
How to test for hypogonadism
- Measure 8AM testosterone
| - IF low repeat, second 8AM testosternoe
38
Hypogonadism diagnosis
2 low AM testosterone levels
39
Monitoring of chronic hypoparathyroidism
- monitor urine calcium excretion (without PTH, urinary calcium excretion is higher than normal for any given serum calcium level, which can lead to complications like kidney stones and impaired GFR) -
- if calcium levels are high, calcium and/or vitamin d replacement needs to be decreased
40
Management of hypothyroidism in pregnancy
- increase synthroid dose by 30% (pregnant women with hypothyroidism are unable to augment thyroidal production of T4 and T3)
41
First step after gender incongruence diagnosed in managing transgender patient
Refer for discussion of reproductive options
42
steps in transgender medicine before surgery
- engage in at least 1 year of satisfactory social role change + consistent and compliant hormone treatment
43
Preconception counseling for diabetic women
- dilated eye exam (at increased risk of developing diabetic retinopathy because rapid increases in glycemic levels during pregnancy can worsen preexisting retinopathy)
44
Management of steroid-induced osteoporosis
- need osteoporosis screening within 6 months of initiation of long-term steroids
- Oral bisphosphonates (alendronate) for anyone with Z score less than -3 and steroid treatment of >7.5 mg/day for 6 or more months
45
Lab features of thyroid adenoma
- Elevated free T4
| - Inappropriately normal or elevated TSH level
46
"Honey moon" phase of type 1 DM
- Drastic reduction in endogenous insulin production creates glucose toxicity that impairs remaining beta cells --> as exogenous insulin improves glycemic control, remaining beta cells experience less tress and start secreting more endogenous insulin --> thus people have rapid glycemic control and low A1c's and need very little endogenous insulin
47
Management of honey moon phase of DM1
Decrease both prandial and long acting insulin
48
Denosumab trade name
xgeva
49
Management of denosumab
Continue indefinitely! and don't get DEXAs, which won't change management (it circulates in the blood for up to 9 months after subcutaneous injection, but once cleared, resorption transiently but dramatically increases, which can cause abrupt decline in bone mineral density and vertebral fractures
50
Management of patient with type 1 DM who is NPO
- decrease basal insulin (require basal insulin or will go into DKA)
- DC mealtime
- add SSI
51
Workup of adrenal incidentaloma
Screen for adrenal hyperfunction in all incidental adrenalomas
- test for pheo (even in absence if HTN because may exist in the absence of HTN and typical signs. they are now commonly discovered)
- test for Cushing
IF HTN --> screen for primary hyperaldo
52
How to test for pheos
24 hr urine total metanephrine measurement
53
Preferred screening for Cushing
1-mg overnight dexa suppression test
54
Testing required before parathyroidectomy for primary hyperparathyroidism
25-hydroxyvitamin d (avoid postoperative hypocalcemia)
55
What is subclinical cushing syndrome
- ACTH resulting in metabolic (hyperglycemia and HTN) and bone abnormalities but no Cushing syndrome (obesity, facial plethora, fat deposition, striae)
56
Primary hyperaldo aldosterone-renin ratio cutoff for diagnosis
Aldosterone-renin ratio of less than 20
57
How to screen for Cushing syndrome in a pt who works night shifts
24-hour urine free cortisol
58
Usual cause of hypothyroid patients requiring increasingly higher doses of synthroid
Malabsorption syndromes
59
Term for rash with celiacs
dermatitis herpetiformis
60
Celiac features
- abdominal pain
- weight loss
- rash
61
management of abnormal semen analysis
Repeat in 2 weeks, if abnormal, refer to reproductive endocrinologist
62
Endocrine effects of chronic opioid use
hypogonadism
63
Turner syndrome clinical features
- short
| - neck webbing, hearing loss, aortic coarctation, bicuspid aortic valve
64
Evaluation of postprandial hypoglycemia
- mixed-meal test (consisting of types of food that normally induce hypoglycemia
65
Management of secondary adrenal insufficiency (eg after discontinuation of steroids)
hydrocortisone (no mineralocorticoid deficiency in secondary AI)
66
Treatment of primary adrenal insufficiency
hydrocortisone and fludrocortisone
67
Levothyroxine dosing
* weight-based
- except in older adults (over age 65) and patients with cardiovascular disease (due to effects of thyroid hormone on myocardial oxygen demand)
68
First step after diagnosis of Cushing syndrome (hypercortisolism diagnosed)
ACTH level (to determine if ACTH dependent or independent)
69
Management of postmenopausal osteoporosis
Bisphosphonates
70
medications to hold before screening for secondary HTN
Spironolactone
71
A1c goal for older adults with complex medical history
7.5-8.0%
72
Endocrine SE's of checkpoint inhibitors
Hypophysitis (headache, pituitary enlargement, and hypopituitarism)
73
Indication for adrenalectomy with adrenal masses
- radiologic featrues suggestive of increased risk of malignancy:
size >4 cm
density >10 hounsfield units
- contrast washout <50% at 10 minutes
74
Work up of hypocalcemia
1) exclude hypomagnesemia (hypomagnesemia causes functional reversible PTH hypofunction)
2) check PTH
75
Cutoff for using metformin in CKD
EGFR>45
76
most common causes of hyperthyroidism
Toxic adenoma
| Multinodular goiter
77
Treatment of toxic adenoma
- Radioactive iodine or surgery
78
to do for initial diagnosis of DM2 visit
- dilated eye exam
- spot urine albumin-creatinine ratio
- foot exam
79
Management of diabetic patient with preprandial blood glucose levels at goal but A1c not at goal
Measure postprandial blood glucose level (may detect undetected hyperglycemia that could be treated with an increase in prandial insulin)
80
Preprandial/fasting glycemic goals
80-130
81
Management of primary hyperparathyroidism
IF asymptomatic --> monitor serum calcium and creatinine q6-12 months + DEXAs q2 years
IF calcium greater than 1 mg above upper limit OR EGFR less than 60 OR 24-hour urine calcium greater than 400 mg/day OR incrreased stone risk/renal stones OR T-score less than or equal to negative 2.5 --> parathyroidectomy
82
Indications for parathyroidectomy
- calcium greater than 1 mg above upper limit
- EGFR less than 60 OR 24-hour urine calcium greater than 400 mg/day
- increased stone risk or presence of renal stones
- T-score less than or equal to negative 2.5
83
Testing prior to parathyroidectomy
Parathyroid sestamibi scan
84
Management of hypercalcemia in patients with primary hyperparathyroidism
IF meeting indications --> parathyroidectomy
| - Cinacalcet only used in adults in whom parathyroidectomy can't be performed
85
Workup of patient with primary hyperPTH prior to endocrine referral
DEXA
86
Initial step following diagnosis of subclinical hypothyroidism
- Repeat TSH/T4 (rule out transient elevation of serum TSH)
87
Lab findings in Hashimoto thyroiditis
Positive thyroid peroxidase antibodies
88
When to measure T3
Never
89
Next 2 steps after diagnosis of primary hyperaldo
Abdominal CT --> Once adenoma confirmed, Adrenal vein sampling (confirm source of hyperaldosteronism -- in some cases adenomas aren't visualized so you need to confirm source of secretion and lateralization. Also need to confirm hyperfunctioning)
90
First step in evaluation of a thyroid nodule
Neck US (need to determine that biopsy is indicated + ensure no additional nonpalpable nodules that warrant fine needle biopsy)
91
Secondary vs. primary hypothyroidism
```
Primary = inadequate function of the gland itself
Secondary = inadequate stimulation by TSH from pituitary gland
```
92
Monitoring of secondary hypothyroidism post adrenal gland surgery
- just check T4 not TSH (patient doesn't have pituitary gland). Dose is titrated based on free T4.
93
How to tell patients to take synthroid
- On empty stomach, 1-3 hours after ingestion of food
| - take separately from calcium or iron-containing supplements (4 hours apart)
94
Management of hypoglycemic unawareness
- reduce all insulin doses (need to provide body with an opportunity to restore the ability to detect hypoglycemia) (even if patient has elevated a1c)
95
Age cutoff for osteoporosis screening
65 or older
96
First 2 steps in myxedema coma management
FIRST STEP: Empiric treat for AI with Intravenous hydrocortisone (can discontinue if cortisol normal. if AI is present, giving thyroid hormone prior to steroids can precipitate adrenal crisis by augmenting cortisol metabolism)
Second step: IV synthroid
97
Management of papillary thyroid carcinoma
Thyroid lobectomy. If completely resected, no adjuvant therapy.
98
Management of metastatic papillary thyroid carcinoma
Lobectomy with adjuvant radioactive iodine therapy
99
Diagnoses of diabetes insipidus
Urine and serum osmolality (low urine osmolality + high serum osmolality + hypernatremia in a patient with polyuria is diagnostic of DI)
- don't need to do water deprivation test or desmopressin challenge
100
Management of thyroid storm
- beta blockers
- antithyroid drug therapy
- IV steroids
- potassium iodide
101
Management of amiodarone-induced thyrotoxicosis
If type 1 (vascularity on US) --> stop amio
If type 2 (no increased vascularity + no nodules or goiter) --> give steroids, continue amio, then decide on whether to continue amio (long half life so no immediate benefit to stopping + need to weigh risks/benefits of cardiac disease)
102
Workup of rapid-onset hirsutism
- Pelvic ultrasound (looking for androgen-secreting ovarian tumors)
IF negative --> adrenal CT ( exclude adrenal cortisol-secreting neoplasm)
103
Lab profile of osteomalacia
- low 25-hydroxyvitamin D
- low calcium
- low phos
- high PTH
104
Osteogenesis imperfecta clinical features
Genetic syndrome leading to collagen abnormalities and...
- short stature
- body deformity
- hearing loss
- dental deformities
- blue sclera
105
Osteitis fibrosa cystica pathophys + classic patient
- high bone turnover after prolonged exposure of bone to high levels of PTH in hyperparathyroidsm
- CKD patients
