Endo Block II Flashcards
1
Q
What is the MOST COMMON medical d/o
A
Obesity
2
Q
A BMI of 18.5 or less is…
A
Underweight
3
Q
What is a normal BMI
A
18.5-24.9
4
Q
What is an overwieght BMI
A
25-29.9
5
Q
What is Class I obesity BMI
A
30-34.9
6
Q
What is class II obesity BMI
A
35-39.9
7
Q
What is the class III obesity BMI
A
Any BMI greater than 40
8
Q
What are the wiast measurments for high risk metabolic syndrome
A
Men greater than 40 in or women greater than 35
9
Q
What two cancers are highly assoiated with obestity
A
Breast cancer and Uterine Cancer
10
Q
What is prader-willi syndrome
A
The most common cause of marked genetic obesity
Presents with hypotonia, feeding difficulities with subsequent hyperphagia and wt gain, almond shaped eyes, narrowed bifrontal diameter, and a thin upper lip, developmental delays, hypogonadism
Short development, OSA, and morbid obesity
11
Q
An infant presents with almond shaped eyes, norrowed bifrontal diameter and a thin upper lip with difficult feeding
Think
A
Early Stage of Prader-Willi syndrome
12
Q
What is the key to wt loss
A
Behavior modification
13
Q
When can pharmicological intervention be indicated in pt with obestity
A
BMI >30
Or
BMI> 27 with HTN, DM2, or CVD
14
Q
What is orlistat
A
GI agent wt loss mediaction
inhibits intestinal lipase & reduces dietary fat absorption
Common SE: oily stools, diarrhea, fecal incontinence, reduced fat-soluble vitamin absorption
15
Q
What is the relationship between orlistat and vitmains ADEK
A
Decreaded absoption of fat soluable vitamins
16
Q
What is phentermine
A
CNS stimulatnt
Increases reuptake of norepi & dopamine to suppress appetite
Schedule IV drug with abuse potential
Common SE: mood changes, fatigue, insomnia
C/I hyperthyroidism, glaucoma
D/c if no weigth loss in 4 weeks
17
Q
What is buproprion/ naltrexone
A
Regulates activity in dopamine reward system
Controls cravings & overeating behaviors
May assist with quitting smoking/ETOH
Antidepressant/ opiod antagonist
Only use in pts with simple pych d/o
SE: GI upset
Caution with history of psychiatric disorders
Contraindicated in seizures, eating disorders, hypertension, opioid use
18
Q
What is liraglutide
A
-TIDE (GLP-1) (can cause wt loss)
increases glucose dependent insulin secretion, decreases inappropriate glucagon, slows gastric emptying
Common SE: GI upset, HA, hypoglycemia
Contraindicated in patients with history of medullary thyroid cancer and MEN 2
19
Q
What are the general C/I for the use of wt loss medications
A
Uncontrolled cardiovascular disease
Pregnancy and/or lactation
History of psychiatric disease
Age < 18 years
Use of certain incompatible medications (monoamine oxidase inhibitors - MAOIs)
20
Q
What is the indication for bariatric surgery
A
BMI greater than 40, or BMI greater than 35 with HTN, DM2, or CVD
21
Q
What is a Roux-en-Y surgery
A
Basically bipass srgry
Combination restrictive and malabsorptive surgery
Distal stomach is resected
Remaining gastric pouch is anastomosed to a retro-colic
Roux-en-Y segment of jejunum
Gastric remnant capacity – 30-50 ml
22
Q
What are the cells in the testes than make sperm
A
Sertoli cells
23
Q
When should free testosterone be measured
A
First thing in the MORNING when they are NOT fasting
24
Q
What testosterone level is hypogonadism
A
A serum less than 291 (240) or (150-300)
or
a free T less than 70 (or less than 30 in a pt over 70 y/o)
25
Failure to enter puberty before what age…. Is hypogonadism
14
26
What is the difference between early and late prenatal testosterone deficiency
In early, they have ambigious genitellia and in late prenatal they have micropenis or cryptorchidism
27
What does eunichoidal porpotions mean
Arm span is greater than hieght by 5+ cm and the crown of the pubis < than the pubis floor
From long bones continuing to grow under the influence of growth hormone in hypogonadism
28
What is the most common autosomal abnm in males
Klinefelters (47XXY)
Assoc with seminiferous tubule dysgenesis
29
A male pt presents with gyno at puberty, Testes normal during childhood, but during adolescence the testes become firm, fibrotic, nontender to palpation, and small <2cm (>3.5 nl), Tall in stature, with decrease facial and pubic hair
Klinefelter Syndrome
30
If testes are left undecended in cryptorchidsm.. what is the pt at an increased rsk of
Infertiliy and testicular cancer
31
When should T levels be checked after initiating Test treatment
14 days after initiation and then 6 months at a minimum
| Also should have lipids, LFTs, and H/h along with a DRE every 6-12 months
32
What is the most common form of congenital hypogonadism
Kallmann Syndrome ( X linked inheritance)
33
A pt presents with anosmia and an impaired sense of smell, is a male and has low T and FH and LSH
Think
Kallmann Syndrome
34
A pt presents with well developed breast without a period, think of..
Complete androgen insufficiency or a 46XY male
35
What are the major endocrine hormones of the pancreas
Insulin, glucagon, somatastatin, gherlin
36
A pt presents with frequent vag candida.. think
DM2
37
What is C-peptide
Fragment of pro insulin, should mimic insulin levels
38
What does a serum fructonase measure
A 1-2 week look at the “A1c”
39
MNT can decrease A1C by
1-1.9% for DM1
| Or 0.3-2% for DM2
40
How do you admin insulin to a DM2
Continue oral agents at same dose except Stop sulfonylureas,
Add single bed time dose, if not at target at daytime at day time dose.,
41
What is the difference between dawn and somogyi phenomenon
Dawn will be elevated at 0200 and somogyi will by hypoglycemic at 0200
Dawn you increase the insulin at bedtime and somogyi you decrease the bed time insulin
42
What is the most common complication in DM pts treated with insulin
Hypoglycemia ( BG less than 60)
43
Drinking ETOH triggers what physiological glucose responce
Gluconeogenesis ( this can be a problem for T1DM)
44
A pt presents with irratability and confusion, diploploa, fatigue, HA, and aphasia
What is the BG
Below 50
Anything below 50 can lead to LOC and SZR
45
What is the best Tx for hypoglycemia
PREVENTION!
46
What is the Tx approach to mild hypoglycemia
Eat or drink
Like 2-3 glucose tabs, 6oz of OJ, regular soda, 1/3 cup of raisins, or 5 lifesaver candies
Check glucose in 15 min, treat again if below a BG of 60
Aka 15-15-15
47
What is the Tx approach to severe hypoglycemia
If at home: Glucagon rescue kit
```
Inpt:
IV glucose ( 50 ml of 50% glucose solution)
```
If IV glucose is not avail. Then use glucagon 1 mg injection
If no glucagon is avial,. Small amounts of honey, syrup, or glucose in a buccal pouch
Once pt is conscious then oral glucose should be given
48
What is often the initial presentation of T1DM
DKA
49
What are the RSK fxs to developing DKA
MC in T1DM
Recent infex
Lapse in insulin dosage
Truma, ETOH, steroids (glucocorticoids)
Idiopathic (WE DONT KNOW)
50
What are the sick day guidlines for prevention of DKA
Test urine ketones every 2-4 hours
Pts is to call if urine ketones for more than 6 hours
Test BG regularly
At least 4x a day
Pt is to call if BG is greater than 250 for more than 6 hrs
51
What is a typical BG in DKA
350-900 with postive ketones (uring and serum)
52
What is typical BG in DKA
250-900 with postive ketones
53
What is the 1st step in the treatment of DKA
FLUIDS!
54
What is the lab that can test for microalbuminiuria
Morning spot urin albumin.creatine ratio
55
What is the most common type of DM neuropathy
Distal symmetric polyneuropathy
56
Charcot joint is specific to what kind of neuropthay
Distal symmetric
57
What type of neuropathy is associated with CN III palsy
Isolated
58
ED is a DM pt is what kind of neuropathy
Autonomic
59
What is papaverine used for
Erectile dysfunction
60
What is the leading cause of death in DM pts
HEART DISEASE/ MI
61
Does a diabetic female have the “female advantage” of reduced heart disease risk ?
NO! DM pts have 3-5x increased risk of HDz
62
What is the BP goal for DM pts
Less than 140/90
63
What is the MGMT for PVD in a DM pts
```
Keep BP below 140/90 (ACE, ARB)
(Remember BB mask glyccemia)
Low dose Asprin (81mg)
Stop smoking
STATINS! (LDL less than 100 or 70 2nd prevention, HDL greater than 40, TG less than 150)
```
Regular excercise program.
64
What is the minimum requiirment for foot checks on DM
Annually
65
What does a DM consult require at every visit
BP, Pulse, H/W, Foot exam !
66
What is the Fasting CMP goal for gl
110-120
67
When should microalbumin be checked in a DM1 and DM2
DM1 after five years then annually
| DM2 at Dx and then annually
68
What all do DM pts need at encounter appointment
Statin, Glycemic meds, Baseline ECG, ACE or ARB, BG checking kit, Med bracelets +/- glucagon rescue kits
69
What is the role Ca2+
Muscle contraction and nerve function
70
What stimulates and suppresses PTH
Fallin free Ca2+ levels stimulate and high levels inhibit
Hypo magnesium stimulates PTH and hypermag inhibits
71
A pt presetns with hypercalcemia and VERY high PTH levels
Think ..
Parathyroid Cancer
72
What is a autosomal dominant hypercalcemia disorder assoc with lifelong hypercalcemia with hypocalcuria
Familillia hypocalciuric hypercalcemia
73
What kind of parathyroid substance do malignant pts/ tumors secrete
PTH related protein, presents with severe hypercalcemia
74
A pt with severe hypercalcemia and a low PTH, that should prompt what other lab
PTHrP
Find the cancer
75
What is the most concerning reason for low PTH
Cancer (SQUAMOUS cell of the lungs, not small cell)
76
What is the triad of milk alkali syndrome
Hypercalcemia, Met alki , and AKI
Due to large amounts of calcuim ingestions
Pt presents with LOW pth
77
How does thyrotoxicos effect bone growth
High bone turn over/. Resorbtion
78
What is the tx approach to Hypercalcemia
Mobilaztion, fluid maintenance
Furosemide- produces caluresis
Avoid thiazid diuretics
Avoid vitamins A and D ( Fat soluable and can lead to AKI)
Avoid Antacids- vitamin rich
Dialysis may be benificial for CHF, HyperK, or renal failure pts
Parathyroid ectomy
79
What is the role of IV bisphosphate
Used to treat hyperCa2+
Temp inhibits bone resorption
Used for prolonged immobilization, malignancy, or hyperparathyroid
80
How often should pts with hypercalcemia have thier levels checked
AS/s pts calcium and albumin 2x per year
Check renal function 1x year
Check bone denisty q1-2 years
Consider estrogen replacement in post menopausual
81
What is the most common cuase of hypoCa2+
CKD
82
Elderly pts with hypoCa2+ and an elevated PTH has what common vitamin deficiency
Vit D
83
What is a corrected serioum calcium level
Serum Ca +0.8(4-serum albumin)
84
A pt presents with parasthesias, muscle cramps, irratabilty, confusion, anxiety, depression , SZR, tetany
Think
Hypocalcemia
85
What is chvosteks sign
Hypocalcemia
Tapping on the facial nerve causes a spasm
86
What is trousseuas phenomenon
Hypocalcemia
Carpal spasm when BP cuff is inflated above SBP for 3 minutes
87
What does the Mnemonic CATS go numb
Stand for
Hypocalcemia
Convulsions
Arrythmias
Teatny
SZR
Nubness
88
What is the testing approach to Hypocalcemia
1 check serum calcium
2 in true hypocalcemia scheck ionized CA is also low
3 Check mag levels, correct if necessary
4. Check pTH level
5. Check vit D level
89
A pt presents with hypocalcemia, with short stature, round faceis, and short 4th and 5th metacarslas.. think
Albrights heriditary osteodystrophy
May have both PTH resistnace, and TSH, FSH and LH resistnace
90
What are the two types of Vit D deficiency
Child: rickets
(Prro bone formation at growth plates)
Adult: osteomalacia
(Abnormal bone mineralization
Major clinical finding: bone pain
X-rays of long bones may reveal thin radiolucent lines perpendicular to the cortex (‘Looser’s lines’)
91
What are two causes of hypomag
ETOH abuse or malabsorption
Both can lead to hypoparathyroidism
92
What is the tx approach to inpt hypocalcemia tetany (severe)
Airway MGMT
Correct the mag 1st with IV mag sulfate
Then correct hypocalcemia with calcium gluconate
Follow up with oral calcium and vit d ASAP with 1-2 g per day with meals
Transplantation of cryopreserved parathyroid tissue removed during prior surgery restores normocalcemia in about ¼ of patients
IT IS IMPORTANT to maintain Seurm Ca level lightly low (8.0-8.6)
F/u monitor CA levels q 3months
93
Each year, the metabolic drive decreases by what percent?
2%
94
What provides the most convenient population-level measure of overweight and obesity currently available
BMI
95
What the NML hip to waist ratio in men and women
Less than 1 in men , and less than 0.85 in women
96
Obese pts underestimate the amount of food eaten by..
30-40%
97
What are the later in life complications on prader-will syndrome
Short Stature, OSA, morbid obestity
98
What is the W/ for obestity
Good FMHx
Age of onset
Ocupation Hx
Previous wt loss attempts and methods
Eating/ Behaviour
ETOH/ Smoking Hx
Depression/ Eating D/O?
99
What is a common cause of 2ndary obestity
Hypothyroidism! (TSH/T4)
| Cushing Syndrome
Suspect with rapid onset in an otherwise health pt
100
What effect does semistarvation have on wt gain
Semi starvation can cause wt gain fue to basal energy expendeture decrease ( Famine and Fasting States)
101
What is the proper exercise regiment for obestity
150 minutes of moderate intensity exercise (tennis or brisk walking)
75 minutes of vigorous (high) intensity exercise (jogging or swimming laps) OR
An equivalent combination of moderate and vigorous exercise, with each episode lasting more than 10 minutes
Weight resistance is recommended at least twice per week
102
Why should you not use lorcaserin for wt loss
Pulled from the market in 2020 due to assoc cancer
103
A pt is taking phentermine for 4 weeks and has seen no wt loss, what is the next step
D/c the medication and attempt a new approach
104
If a pt is taking a MAO-I should they be started on wt loss drugs
NO or use caution
105
What is the ADE of Sleeve gastrectomy
Ghrelin levels may be decreased for up to 1 year post srgry
106
What are the typical complications of bariatric srgry
Peptic ulcers
Outlet stenosis
Leakage leading to spesis
Staple disruption
```
Needs for surgical revision
Wound problems
Abdominal wall hernias
Gallstone common
Pulmonary Edema
Dumping syndrome
```
107
When should obestity pts be referred
BMI > 30 (or >27 with weight-related comorbidities)
—Obesity medicine specialist
BMI > 40 (or >35 with weight-related comorbidities)
—Bariatric surgeon
108
What are the levels of the adrenal cortex from outer most layer to inner most layer
GFR COR
Glomerulus
Fasciculata
Reticularis
Cortex
109
What is the pathphsy of hirsutism
Androgen production acts on sex hormone responsive hair follicles. Converting vellus hairs to terminal hairs
Androgens also increase sebaceous gland activy, which leads to excess acne and oily skin
110
Half of women with hirsutism have what underlying condition
hyperandrogenism
111
What are the two types of Hirsutism
Elevated levels of circulating androgens (pathology) – will have elevated labs
OR
Increased sensitivity of hair follicles to normal levels of androgens (familial/genetic) – will have normal labs
112
What is the Ferriman-Gallwey score
Hirsutism Can be quantitated using Ferriman-Gallwey score
Hirsutism is graded from 0 to 4 in 9 areas of the body
Max score = 36
Score of ≥8 defines hirsutism!!!!
Severe: >15
Moderate: 8-15
113
A score of greater than 8 on the Ferriman-Gallway score=
Hirsutism
Greater than 15 is severe
114
What are the major androgens in females that cause Hirsutism
DHEA, Androstenedione (from the Ovaries/ Adrenals), Testosterone
115
Peripheral conversion of androstenedione leads to what
Terstosterone
116
Free testosterone is converted to DHT by what in the skin
5a-reductase
117
What does DHT stimulate in the skin
Hair follice growth
118
What are the 5 causes of Hirsutism
Idiopathic/ Familial
Polycystic Ovarian Syndrome
Steroidgenic enzyme defects
Neoplastic D/o
Pharmecologic
119
Familial Hirsutism is most common in what demographic
medeterrainan and Middle eastern
120
A female pt from the middle east presents with normal androgen levels, with slow progression of hair growth at the onset of puberty
NML menses,
What is this type of hirsutism
Familial
121
What is the most common cause of Hirsutism in women
Polycystic ovarian syndrome
Its often familial and is transmitted bu an autosomal dominatant trait
122
What is the triad of criteria that must be meat to dx polycystic ovarian syndrome
1. androgen excess with clinical hyperandrogenism or elevated testosterone
2 - ovarian dysfunction or polycystic ovary morphology
—Oligomenorrhea/amenorrhea with anovulation (50%)
—Infertility
3 - absence of other causes of testosterone excess
(Pregnancy, Thyroid D/o, Cushings)
123
What are the two etiologies of steriodgenic Hirsutism
Congenital adrenal hyperplasia (21-hydroxylase deficiency)
Cortisol def=increase ACTH=hyperplasia
124
What is classic vs nonclassic steroidgenic hisrutism
Classic: (complete deficiency of 21-h) ambiguous genitalia, may become virilized unless treated with corticosteroids
Non-Classic: (Partial 21-hydroxylase deficiency)
2% of women with adult-onset hirsutism
—PCOS and adrenal adenomas are more likely to develop in these women
—Features (non-classic CAH): Irregular menses since menarche, Gradual onset of hirsutism
125
What are the three causes of neoplastic Hirstism
```
Ovarian tumors
(Arrhenoblastomas, Sertoli-Leydig cell tumors, dysgerminomas, and hilar cell tumors)
```
Adrenal Carcinoma leading to cushings or hypogonadism!
Pure androgen secreting tumors (rare)
(50% are malignant)
126
A female pt presents with Hirsutism, onset was outside to perimenarchal periodm, and they have rapid and severe hair growth, the have recent onset of menstral irregularity
What kind of hirsitsm is this
neoplastic (investigate for a tumor or cancer)
127
What are 5 drugs that can cause hirsutism
Minoxadil
Cyclosporine
Phynetoin
Anabolic steroids
Norethindrone (contraceptive)
128
What is virilizzation
Frontal balding (androgenic alopecia)
Increased muscularity
Clitoromegaly
Deepening of voice
Consider a NEOPLASMIC source
129
What are the imporatant labs in Hirsutism
Labs: serum androgen testing is mostly useful to find the adrenal/ovarian neoplasms
Free and total testosterone—most important!!!
Androstenedione
DHEA-S
130
If a female pt have a Total T above 200 or a Free T above 40, what exam must be performed
Pelvic exam and US !
If both are negative then order a bilateral adrenal CT scan
131
A pt with a serum androstenedione of greater than 10000 suggest what…
Ovarian adrenal neoplasm
| (Perfrom a pelvic exam AND bilateral adreanl CT
132
A pt with a serum DHEA S greaer than 700mcg/dl suggest what
An adreanl source of excess androgens (hirsutism)
| (Perform bilat adrenal ct scan)
133
What is a NML androstenedione level
0.7-3.5
134
What is a NML DHEA S level
Less than 10
135
What is the Tx approach to Hirsutim
If its neoplastic then cut it out
(Think postmenopuasal women with severe hirsutsim)
Spirinolactone can reduce Hirsutism (often combined with OCPS)
Flutamide (combined with OCPS) (nonsteroidal antiandrogen)
Finasteride (5a-reductase inhibitor)
(Use only in postmenopausal women)
(Can cause genitalia problems in fetuses)
```
Oral contraceptives (estradiol) (progesterone)
(DVT RSK!)
```
Metformin (if PCOS) (use with spirinolcatone)
Simvastatin (use with OCPs)
Clomiphene- Used in PCOS for infertitlity
136
OCP are C/I in what pts
smokers, migraine with aura, age 39+, HTN, Hx of DVT
137
What is vaniqa cream
Vaniqa cream (eflornithine HCl)
Topical which reduces hair growth
4-8 week until improvement…sxs return when d/c
Works well with laser tx
138
What are the two things that convert testosterone
Testosterone exerts effects directly on androgen receptors, and is also converted to either
1) estradiol by the aromatase enzyme
0r
2)to DHT by the 5 alpha reductase enzyme
139
What is the pathway that secretes the negative feedback inhibin molecule
GnRH (hypothalmus) goes to the AntPit, FSH is released which goes to the sertoli cells, whcih secrete Inhibin, that then shuts off the Hypothalmus and AntPit
140
LH woks on the leydig cells to make what
Testosterone
141
If a male pt is over 70 years old, what is the cutoff for hypogonadism
Less than 30 on a free T test
142
What is HYPERgonadatrophic Hypogonadism
Low test with elevated LH and FSH
Primary hypogonadsim
143
What is HYPOgonadatropic hypogonadism
Low test and low FSH/LH
Secondary Hypogonadism
144
A pt with a normal T level and elevated LH and FSH, think
LH and FSH should go down if the Test is normal or elevated, so think of a defect in androgen resistance
145
A male pt presents with delayed puberty, an deminished libido./erections
+fatigue, depression, and reducced excercise tolerance
May have small or NML testes
Think
Hypogonadsim
| Order a Free T level and A LH/FSH level
146
A pt presnts at around age 14-15 with poor muscel development, high pitched voice, and sparse axiallary and pubic hair
With lack of sexual differentiation
Think?
T deficieny at puberty onset
147
What is the effect o testosterone on growth plates
Normally testosterone closes epiphyses
lack of testosterone causes increased long bone growth
148
A 30 year old male presents with decreased libido, impotence, low energy, with fine wrinkilin around the eyes and mouth
Testes may be nomral or small in size
Think
Post-pubertal testosterone deficiency
149
What are the 3 cuases of congenital primary hypogonadism
Klinefelter syndrome
Cryptorchidism
Bilateral anorchia
150
What are the 4 causes of aquired primary hypogonadism
Infection (mumps etc)
Aging
Trauma
Chemotherapy/ radiation therapy
151
A pt has seminiferous tubule dysgenesis
Think
Klinefetlers
152
A pt has recently had a child with a 47XXY deficinecy but cant remember the name, what is this child at risk of developing and what is the condition
Klinefelters
```
Breast cancer—increased incidence
Chronic pulmonary disease
Varicosities of legs
Diabetes mellitus/impaired glucose tolerance (27% of patients)
Osteoporosis
```
153
What is the PE appraoch to testing for cryptorchidism
Must be distinguished from retractile testes
Examine in warm, relaxed environment
Begin exam at inguinal canal & move downward
Look for asymmetry & contralateral hypertrophy
L side affected more!
154
What is the Tx approach to Cryptorchism and what do we no longer do..
Orchiolexy is the tx at 12-24 months
We no longer do a hCG injection.
155
Does orchioplexy eliminate the risk of testicular cancer in cryptorchid pts
No 2-3 fold risk still remains
156
If you were to give a pt with bilateral anorchia a hCG test (no longer used) what would happen
You would see no increase in the testosterone level
An increase would mean they have undescended testes
157
You are testing a pt for hypogonadism and the labs show a low T and low FSH/LH
Think
Hypothalamic Pituitary abnml
(2nd dary cause)
Order a prolactin level and Pit MRI
158
You order a LH/FSH level and a T level and it comes back with low FSH/LH and Low/NML Test
On PE you do not find testes in the scrotum
What is your appraoch
THink Primary test abnomrality
No testes= hCG stimulation
Increased Test= Cryptorshidsm
No Test response= Anorchia
159
You order a LH/FSH level and a T level and it comes back with an elevated FSH/LH and Low/NML Test
On PE you DO find testes in the scrotum
What is your appraoch
Primary Test abmnormality
Testes present, so check size and consistency
Small and firm= possible klinefelters ( order a karyotype)
NML or Soft= Acquired primary hypogonadims ( mumps, ect)
160
How should Test replacement be admin’d
IM injections q 2-3 weeks
Or transdemral patches
Can use topical on the thighs, but caution with transfer to females
Can also be admin’d buccal q12 hrs
(Do not hcew or swallow)
Intranasal and oral are also available
(I/N has severe URI s/s)
161
What are the ADE of testosterone replacement
```
Acne
Decreased HDL levels
Gynecomastia—IM
Erythrocytosis—IM
OSA
```
162
If a pt has active prostate cancer, can they get T replacement Tx
NO!
163
What is the age cut off for T replacemnt Tx
Cant be younger than 13
Avoid due to premature epiphyseal closure and short stature
164
A pt presetns with Eunuchoid proportions, gyno, and prepubertal testes are small and rubery
Think
Kallmans
165
What is the MC cause of hyperprolactinemia
Pituitary adenomas
Inhibits normal GnRH release
Inhibits the action of testosterone
Decreases the effectiveness of LH
166
WHat are some common causes of secondary hypogonadism
Obestiy (BMI>40)
Renal failure, CHF
```
Aging
ETOH use
Marijuana
Cushings
Hypothyroid
Cancer
AIDS
```
167
A female pt presetns with eleveated levels of FSH/LH and elevated T
Think
Complete androgen insensitivity
External female genitalia is observed—appears a normal pre-pubertal GIRL
There is no uterus or fallopian tubes
There are no male accessory sex organs, testes are cryptorchid
Abnormal receptors in the pituitary gland do not recognize testosterone so development proceeds as if there is a lack of testosterone
168
IF testosterone is not recognized in the receptor, what is it converted to
Testosterone is not recognized so it is converted to estradiol by aromatase in adipose tissue
Happens in complete androgen insensitivity
169
What is the approach to Tx for Complete or Incomplete Androgen Insensitivity Syndrome - Testicular Feminization
There are no Tx to restore androgen receptors
Removal of intra-abdomial testes to reduce malignancy rsk
Estrogen tx if desired
Family counselling for gender
170
A pt presents with blind vaginal pounch, amenorrhea, and an absent uterus, has well breast development
You order a panel and it comes back with high FSH/LH and HIGH T
Think
Androgen Insentisty syndrome
| Testes are in the abdomin, but the pt developed as a girl
171
What is needed of rmasculinization of external genitalia in utero
DHT
Which required 5-a-reductase
172
At what week gestation is 5-a-reductase needed for development of target organs
8-12
173
A female child pt has a penis development at age 12 has what condition
5-alpha reductase deficiency
174
What is a NML serus Ca2+ level
8.5-10.5
175
What is the function of PTH
Stimulates resorption (or dissolution) of bone to increase calcium and phosphorus in circulation in the blood
Stimulates renal tubular reabsorption of calcium and inhibits phosphate reabsorption (increases serum calcium)
Indirectly stimulates intestinal activation of vitamin D (Increases calcium absoprtion)
Vitamin D enhances intestinal absorption of calcium
176
What is the role of VIT D on calcium and phosphate
Vitamin D increases calcium and phosphate absorption from the intestines
177
What is the role of calcitonin
Inhibits osteoclaast activity, (decreasing calcium breakdown from bones)
Increases calcium storage in bones
increase renal excrteion of Calcium
178
What is the most common cause of HyperCa2+
Primary hyperparathyroidism – most common cause
—Parathyroid adenoma (80%),
—parathyroid hyperplasia (20%) or —parathyroid cancer (less than 1%)
179
A pt presents with hyperCa2+ and a low PTH
Think
Secondary malignancy (not parathyroid CA)
180
A calcium level above 14 is an indication of
MAlignancy
181
What effect does hypercalcemia have on the EKG
short QTi
182
What is Stones, bones, groans, moans, and overtones
HYPERcalcemia
Stones: kidney stones, nephrocalcinosis, thirst, polyuria, metabolic acidosis
Bones: bone pain and fractures – osteitis fibrosa cystica
Groans: anorexia, dyspepsia, constipation
Moans: myalgia, proximal muscle weakness, joint pain
Overtones: depression, memory loss, confusion, lethargy, coma
183
If a pt presents with an increased PTH think
Parathyroid adenoma
Hyperplasia
Or CA
184
A pt presents with High serum calcium
High urine calcium and a high PTH
Think
Parathyroid adenoma (MCC)
185
What is the imaging approach to parathyroid ademonas
Imaging not necessary
May be used prior to surgery
U/S can be used or CT/MRI if negative US
186
What are the indications for SRGYRY in a pt with Hypercalcemia and aparathyroid adenoma
If + stones, bones, groans, overtoans
```
Or if Ca2+ level is above 11.5
Urine Ca level greater than 400
CrCl is less than 60
Nephrolithiasis
Severe Osteoporosis
IF the pt is level than 50 y.o
Pregnant pts with CA >11
```
187
A pt has elevated Calcium levels with an elevated PTH, BUT is aS/s
What is the f/u criteria
Observation:
Follow-up every 6 months
BP every 6 months
Serum Calcium every 6 months
Urine Calcium yearly
Kidney function yearly
Bone density every 2 years
188
What is the Tx approach to Parathyroid hyperplasia
Subtotal parathyroid removal
189
What is the Tx for PArathyroid Cancer
Tumor resection along with the affected thyroid lobe
190
What is the MOA of PTHrP
PTH related protein
Causes bone resorption and hypercalcemia similar to the action of PTH
191
Taking too much vitamin D can do what to PTH
Suppress it
192
What are some common causes of excess endogenous Vit D production
```
Lymphomas
Sarcoidosis
TB
Histoiplasmosis
Coccidiomycosis
```
193
Immobilization in the ICU has waht effect on calcium
Marked resorption of calcium from bone
Seen in ICU patients
Suppresses the PTH with a HIGH calcium level
194
What is the TxOC in malignancy associated hypercalcemia
IV bisphosphonates
195
How does hypoalbunimeia effect serum calcium
Hypoalbuminemia is a common cause of low total serum calcium
Hypocalcemia due to hypoalbuminemia is not clinically significant, if ionized Calcium is normal
196
Severe hypocalcemia requires what intervention
IV calcium gluconate
197
A pt presents with hypocalcemia yet an elevated PTH
Think
PTH resistance
The receptors are not working in the renal receptors
Bone breakdown continues to happen by the renal system pees out the calcium
Leasd to patho fxs, cyctis lesions in the bones
198
What are three medications what can decrease Vit D processing
Isoniazid, rifampin, phenytoin
Can lead to hypocalcemia with elevated PTH
199
Sprue and Chorns Dz effects vit d how
They are bot malabsorption issues that can lead to hypocalcemia with elevated PTH
200
If a pt presents with hypocalcemia , and low PTH and a elevated VIt D level
Think
```
VitD resistance
(Genetic defects in VIT D metabolism)
```
201
What is the aS/s tx to hypocalcemia
Oral calcium supplements (800-1000mg)
Oral vitamin D supplements (1000-5000IU)
(Individuals resistant to vitamin D will not benefit)
Increase exposure to sunlight
Goal of treatment is to keep the serum calcium level in the low-normal range
202
What is the most common fx of osteoporosis
Vertebral fx
203
In pts older than 50 or hypogonadism pts … alwasy look for what bone problem
Osteoporosis
204
What does a T score (DEXA) of -1.0 to -2.5
Osteopenia
205
What does a T score (DEXA) of -2.5 tell you
Osteoporosis
206
A T score of -2.5 with a fracture means
Severe Osteoporosis
Can also just be a Tscore below -3.5
207
When can bisphophonate be used for osteoporosis
Is a pt has a DEXA T score from -1.5 to -2.5
Or a 10 year hip fx risk greater than 3%
Or major fx risk greater than 20%
208
Drugs that end in -Dronate
Bisphophonates
209
What are the ADE of bisphosphonates
Oral: nausea, CP, hoarseness
(Don’t use oral if pt has Barrett esophagus)
IV: acute-phase response lasting several days
Fever, chills, flushing (20%)
MSK pain(20%)
—Loratidine helps
N/V/D (8%)
Fatigue, dyspnea, edema, HA, dizziness (22%)
210
If a pt has Barretts esophagus and osteoporosis
What is the Tx approapriate
IV!!! Bisphosphonates
Do not use oral meds
211
What do Beta cells of the pancreas secrete
Insulin
212
What do alpha cells of the pancrease secrete
Glucagon
213
What do delta cells of the pancreas secrete
Somatastatin
214
What is MODY DM
```
Non-insulin dependent DM
Age of onset: <25 yrs
Non-obese
Due to impaired glucose-induced secretion of insulin
Autosomal dominant inheritance
```
215
A pt presents with elevated TGs, Low HDL, and elevated LDL, HTN, and Elevated CRP, has hyperruecemia, and abdonmial obesity
Think
metabollic syndrome
216
A pt presents with blurred vision , and poly dypsna, polyuria, and poly phagia, and recent wt loss
+/- postural HOTN, parasthesia, Ketoacidosis
Think
T1DM
217
What are 3 chronic skin infections associteed with DM2
Candida, General Pruritis, and Vaginitis
218
What is Acanthosis Nigricans
Darking of skin folds seen in type 2 DM
| From insulin resisstnace
219
What is the criterai to screen for DM is aS/s adults
```
Any pt that is overwt or obese
African america, latino, or native america
History of CVD
HTN
HDL less than 35
TriGs over 250
```
Women with polycyctic ovarian syndrome
Any pt with prediabetes should be screened annually
Women with GDM q 3 years
220
If a pt has ketonuria greater than 3.0..
| they need..
ADMIT!
221
What can cause falsely low A1C
Acute blood loss, anemia, hemolysuis, recent transfusion
| Heavy bleeding
222
What can cause falsely high A1C
Iron, B12, or folate deficiency
Liver/Kidney Failure
223
What is the tx approach to a pt with pre diabetes
Diet and excercise
224
What is the approtiate counselling to DM pts and ETOH consumption
Alcohol use in moderation:
Men: not more than 2 drinks/day
Women: not more than 1 drink/day
Drink = 12 oz. beer, 5 oz. wine, or 1 ½ oz. spirits = 2 fat exchanges
Warn patient about hypoglycemia
225
When should DM pts receive thier vax
Influenza—annually
Pneumococcal vaccine
At diagnosis
Repeat at age 65 (if initially given prior to 65)
226
All Dm pts should receive what medication to prevent ASCVD
ASA and statins And ACE/ARBS
227
What is the effect of metformin on HOgl and wt
HOgl neutral
| With slight wt loss
228
What is the MOA of metfromin
Suppresses hepatic gluconeogenesis;
increases hepatic insulin sensitivity
Metformin (Glucophage) –1st line therapy for new DM2
229
What is the HOgl and Wt effects of DPP-4s
Neutral to both
230
What is the major ADE of DDP-4
Pancrreatitis
231
What are the HOgl and Wt effects of GLP-1
HOgl neutral
| Wt loss!
232
How should GLP-1 be used as part of DM2 tx
Add on tx ONLY!
| With either metformin or a SU
233
What is the major ADE of GLP-1
Thyroid Cancer
234
What is the HOgl and wt effects of SGLT-2
HOgl neutral
| Wt loss!
235
What SGLT-2 has been approved for reducing CV risk in DM2 pts
Empaglaflozin
236
What is the HOgl effect and wt effect of TZDs
HOgl neutral and WT GAIN!
237
What are the major ADE of TZDs
Heart problems, edema, Osteoposris, angina and WT GAIN!
238
What are the HOgl and wt effects of SUs and Meglitinides
Severe HOgl and WT GAIN!
239
DO not use glyburide becasue it is long acting and has the most HOgl of the SUs
240
What are the glucose goals in DM
preprandial 90-130
Postprandial less than 150
Ave. Bedtime gl 110-150
A1C less than 7 ( or 8 in eldery)
241
What type of insulin is used for DKA tx
Regular (short acting)
242
What is Lente insulin
intemediate acting ( NPH is aslo in this class)
243
When should T1DM pts be referred
When to refer: Patients with type 1 diabetes should be referred to an endocrinologist for co-management with a primary care provider.
244
Where can you NOT inject insulin
Within 2inch of the navel/ umbilicus
245
What is the insulin of choice in an insulin pump
Lispro
246
How should weekly insulin adjumstmens be titrated in type2DM
Increase insulin dose weekly
Increase 4U if FBG >180mg/dl
Increase 2U if FBG 120-180mg/dl
247
Addisons pts with DM are at an increased rsk of
HOgl
| Due to ortisol deficiency
248
Remember BB mask the effects of HOgl
tachyardia (bb block this)
Palpatatoins (bb prevent this)
Tremors (bb symopathetic tone)
Sweating
249
DKA Pathogenesis
Insulin deficiency
glucose cannot enter cells for use
rapid mobilization of energy stores in muscle/fat
Increased flux to the liver of: amino acids for conversion to glucose and fatty acids to ketones.
250
What is the mainstay of tx for dka
IV fluids, insulin, potassium, bicarb +/-, ABX +/-
251
What is the serum gl goal in a DKA pt
250-300
252
If a pt has DKA with a pH less than 7.0
What adjunct should be considered
Bicarb
253
What are the 2 Rx that can precipitate HHS
Thiazide diuretics and glucocorticoids
254
What is the BUN level in HHS
Greater than 100
255
What is the major cause of death of T1dm and T2dm
T1: Major cause of death – complications from end stage renal disease
T2: Major cause of death – macrovascular disease leading to MI and stroke
256
What are the major ocular complications of DM
Cataracts, reinopathy, Gluacoma
257
What is the MC cause of visual impariment in DM2
Non proliferative Retinopathy
Microaneurysms
Dot hemorrhages
Exudates
Retinal edema
258
What are cotton wool spots in the retina
Growth of new capillaries due to retinal hypoxia
Increased risk of macular edema & retinal detachment
259
What is the tx approach to DM retinopathy
BLOOD gl control and smoking cessation
| Laser tx are available, and bevacizumab
260
When should you refer a pt with Retinopathy
DM pt with sudden loss of vision or retinal detachment
—Emergent to ophthalmologist
Proliferative retinopathy or macular involvement
—Urgent to ophthalmologist
Severe nonproliferative retinopathy
—Early referral to ophthalmologist
261
What is the MC cause of ESRF (CKD)
DM nephropathy
262
What is the assay of choice for microalbuniimia
A morning spot urine screen for the albumin/creatinine ratio is the assay of choice
If albumin/creatinine ratio is 30-300 mcg/mg, confirm with at least 2 of 3 positive collections performed within 3-6 months before diagnosing
263
What is the tx approach to microalbunima
STRICT gl controll (6.5)
ACE or ARBs
Low protein diet
Monitor Albumin/Cr ration q 6 months
264
Can DM pts get contrast
Avoid in pts with CrCl above 3
265
What are the Rx options to distal symetric polyneuropathy
```
Nortriptyline
Gabapentin (Neurontin)
Pregabalin (Lyrica)
Duloxetine (Cymbalta)
Capsaicin cream
Lidocaine patches
```
266
What are the MC envolved nerves of Isolated Peripheral Neuropathy
Femoral or Cranial nerves
267
A pt presetns with hyperseniticity to light touch, and a severe burning pain at night
What kind of neuropathy is this and what is the Tx approach
painful DM neuropathy
Tx: amitriptyline (TCAs)
gabapentin (anticonvulsants)
duloxetine (SNRI) (Cymbalta)
Capsaicin cream
268
What is a Rx option for GI system neuropathy in DM pts
Metoclopramide
269
What is the treatment option for postmenopausual women with hirsutism
If severe then surgery
Rx option: Finasteride
Risk of ambiguous genitalia in 1st trimester exposure
So only use it in women that cant get pregnant
270
What is the recommendation of using OCPS in pts with hirsutism
Use low dose estradiaol
