Endocrine Flashcards

Question

Endocrine

Answer 1

Subacute thyroiditis is an uncommon cause of thyrotoxicosis that presents following a viral upper respiratory tract infection and is distinguished by a tender or painful thyroid, suppressed thyroid-stimulating hormone, and elevated serum free thyroxine. Nodular thyroid disease (toxic adenoma and multinodular goiter) is the next most common cause of thyrotoxicosis after Graves disease and is more commonly seen in older adults. This patient lacks palpable thyroid nodules on examination, which is usually seen with hyperthyroidism from nodular thyroid disease. In addition, neither Graves disease nor nodular thyroid disease cause thyroid pain.

Answer 2

Potent antiresorptive drugs can cause severe hypocalcemia by impairing efflux of calcium from the skeleton in patients with vitamin D deficiency; it is important to assess vitamin D levels and correct deficiency before beginning treatment with an antiresorptive drug. High baseline bone turnover and abrupt alteration in calcium flux between blood and bone are also features of hungry bone syndrome. However, this syndrome specifically occurs after parathyroidectomy for primary hyperparathyroidism. It is caused by rapid influx of calcium from the blood into the skeleton.

Answer 3

Signs of androgen excess such as progressive hirsutism and virilization over a short period of time in female patients suggest the diagnosis of an androgen-producing adrenal or ovarian tumor. A pelvic ultrasound is recommended as the first imaging study if testosterone is above 150 ng/dL (5.2 nmol/L). This patient's testosterone level was only mildly elevated, but the DHEAS was quite elevated making a testosterone-producing ovarian tumor less likely than an adrenal tumor.

Answer 4

Nonthyroidal illness syndrome (euthyroid sick syndrome) is characterized by reduced serum T3, low or low-normal serum T4, and normal or low (but detectable) serum TSH levels.

Answer 5

Following adrenalectomy for Cushing syndrome, patients require daily glucocorticoid replacement therapy to allow recovery from prolonged suppression due to hypercortisolism; recovery of adrenal function may take up to 1 year or longer depending on the severity of Cushing syndrome. fludrocortisone therapy is not required following adrenalectomy as mineralocorticoid secretion is not under ACTH control.

Answer 6

Following adrenalectomy for Cushing syndrome, patients require daily glucocorticoid replacement therapy to allow recovery from prolonged suppression due to hypercortisolism; recovery of adrenal function may take up to 1 year or longer depending on the severity of Cushing syndrome. fludrocortisone therapy is not required following adrenalectomy as mineralocorticoid secretion is not under ACTH control.

Answer 7

In men with specific signs and symptoms of hypogonadism, measuring an 8 AM total testosterone level is indicated; if the testosterone level is low, a second 8 AM confirmatory testosterone level is measured.

Answer 8

Graves disease: Treat with BB like propanolol and / Methimizazoine Use PTU in 1st trimester and for stroem

Answer 9

Treat large toxic gotiers with ablation

Answer 10

For thyroid storm, this is one of the few times you want yo use PTU. Then use iodide, then BB for sx control, glucocorticoids.

Answer 11

Hypothyroid: Pregancy, and hypothyroidm will need to increased thyroid meds. For hyperthyroid, goal is to keep a normal t4, use PTU

Answer 12

Thyroid nodules, screen is high risk like radiation, concerning features- solid with calcifications, irreg margins, fixed, hard, LAD, focal uptake, - Check TSH, if low check do the uptake for toxic nodule if TSH normal or high. ultrasound thrpid Bx with FINA if it has calcium, irreg borderd, size, PET +

Answer 13

Any thyroidits will have low up take because the gland is being destryoed. Graves will have high uptake

Answer 14

ACTH acts on the adrenal mainly regulates cortisol Renin- regulated aldosterone DHEAS- regulates anrogens Adrenal medulla- makes catecholamines

Answer 15

Primary adrenal insuffiency, most connonly addisions, where there is high ACTh but it is unable to act on the adrenals due to automimune attack. dx with ACTH stim test and you will see cortison fail to rise Dex to treat HIGH ACTH means hyperigmentation

Answer 16

Treat pheochromocytoma wiith alpha blockers, like terazosin

Answer 17

Make sure new adrenal incidentalolas are not functina;. check 1mg dex test and for pheo. If not functional then can monitor with imaging.

Answer 18

To diagnose hypogonadism in men, you need an 8am testosterone that is low ON TWO OCCASIONS If testosterone is low, measure LH, FSH, prolactin

Answer 19

In chronic hypoparathyroidism, the goals of therapy are to eliminate symptoms while avoiding complications of therapy; monitoring urine calcium excretion is mandatory because hypercalciuria often limits therapy.

Answer 20

Once Cushing syndrome is confirmed, the next step in the diagnosis is to categorize Cushing syndrome into ACTH-dependent and ACTH-independent types, which in turn governs subsequent localization tests. A low serum ACTH level, as in this patient, indicates ACTH-independent Cushing syndrome.

Answer 21

For women with hypothyroidism adequately treated with levothyroxine before pregnancy, dosing can be empirically increased by 30% when pregnancy is confirmed.

Answer 22

Many medications cause falsely high levels of catecholamines or metanephrines including certain antidepressants that inhibit norepinephrine uptake; therefore discontinuation of these agents at least 2 weeks prior to testing for pheochromocytoma is recommended.

Answer 23

For low-risk osteoporotic women, treatment with antiresorptive therapy for 5 years is sufficient. Trial Long-term Extension (FLEX) trial showed that continuing alendronate treatment for 10 years compared with stopping after 5 years resulted in a small decrease in the incidence of clinical vertebral fractures but not nonvertebral fractures

Answer 24

Oral contraceptive agents are first-line pharmacologic therapy for hirsutism, acne, and menstrual dysfunction unless fertility is desired in a patient with polycystic ovary syndrome. The prolonged clinical course and absence of the more concerning findings of virilization also support the diagnosis of polycystic ovary syndrome. Given that this patient is most concerned about hirsutism and acne, oral contraceptive therapy is the first-line therapeutic agent. Oral contraceptive therapy suppresses gonadotropin secretion and resultant ovarian androgen production.

Answer 25

Oral contraceptive agents are first-line pharmacologic therapy for hirsutism, acne, and menstrual dysfunction unless fertility is desired in a patient with polycystic ovary syndrome. The prolonged clinical course and absence of the more concerning findings of virilization also support the diagnosis of polycystic ovary syndrome. Given that this patient is most concerned about hirsutism and acne, oral contraceptive therapy is the first-line therapeutic agent. Oral contraceptive therapy suppresses gonadotropin secretion and resultant ovarian androgen production.

Answer 26

In patients with pituitary tumors, pituitary hypersecretion should be ruled out by biochemical testing. When a pituitary tumor is incidentally noted, investigation must determine (1) whether it is causing a mass effect, (2) whether it is secreting excess hormones, and (3) whether it has a propensity to grow and cause problems in the future all patients should be evaluated for hormone hyposecretion in order to identify and replace hormone deficiencies. Initial tests to evaluate for hormone deficiency should include measurement of 8 AM cortisol, thyroid-stimulating hormone (TSH), free (or total) thyroxine (T4), follicle stimulating hormone (FSH), testosterone in men and menstrual history in women (normal menstrual cycles eliminates the need to measure hormone levels). Prolactin and IGF-1 are measured to rule out pituitary hormone hypersecretion.

Answer 27

An α-receptor blockade with phenoxybenzamine or another α-blocker is required prior to adrenalectomy for pheochromocytoma to prevent potential hypertensive crisis during anesthesia induction and/or manipulation of the tumor.

Answer 28

Empagliflozin has been shown to reduce cardiovascular-related events and all-cause mortality in patients with type 2 diabetes mellitus and cardiovascular disease. The dipeptidyl peptidase-4 (DPP-4) inhibitor, sitagliptin, could reduces systolic blood pressure and cause pancreatitis liraglutide also has postmarketing reports of pancreatitis associated n

Answer 29

After ruling out pregnancy, the initial laboratory evaluation in secondary amenorrhea includes measurement of follicle-stimulating hormone, thyroid-stimulating hormone, and prolactin levels.

Answer 30

To manage in-patient hyperglycemia, scheduled basal insulin or basal insulin plus correction insulin is appropriate for patients who are fasting or who have poor oral intake.

Answer 31

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a common complication of pituitary surgery that may occur 3 to 7 days following surgery; treatment with fluid restriction will prevent further reduction in sodium levels.

Answer 32

Dopamine agonist therapy should be used to treat hyperprolactinemia in women with irregular periods who are trying to conceive.

Answer 33

Primary hyperparathyroidism may be the first sign of multiple endocrine neoplasia syndrome 1 (MEN1) in persons with a family history of recurrent primary hyperparathyroidism and neuroendocrine tumors arising from the pancreas and tumors of the pituitary gland.

Answer 34

An elevated 1,25-dihydroxyvitamin D level and suppressed parathyroid hormone is diagnostic of vitamin D-dependent hypercalcemia.

Answer 35

Women with type 1 or type 2 diabetes mellitus who are planning pregnancy should be counseled on the risk of development or progression of diabetic retinopathy; rapid improvements in glycemic levels during pregnancy can temporarily worsen preexisting retinopathy.

Answer 36

Oral bisphosphonates (alendronate) are recommended as first-line therapy in adult men and women on chronic glucocorticoid therapy with moderate to high fracture risk regardless of age. Zoledronic acid is indicated for the treatment and prevention of glucocorticoid-induced osteoporosis in patients who cannot tolerate oral bisphosphonates.

Answer 37

Signs and symptoms of a thyroid-stimulating hormone-secreting adenoma are those seen in hyperthyroidism, although laboratory evaluation reveals an elevated free thyroxine (T4) level with an inappropriately normal or elevated thyroid-stimulating hormone level.

Answer 38

bisphosphonate can be considered for stopping after 5 years but When administered subcutaneously twice yearly, denosumab suppresses bone resorption, increases bone density, and reduces the incidence of osteoporotic fractures in men and women; the effects of denosumab are not sustained when treatment is stopped.

Answer 39

In fasting hospitalized patients with type 1 diabetes mellitus, the basal insulin dose should be decreased, the prandial insulin held to avoid hypoglycemia, and a correction insulin regimen should be added to help manage hyperglycemia.

Answer 40

Biochemical testing for pheochromocytoma should be undertaken in all patients with an adrenal mass that is clearly not an adenoma, even in the absence of typical symptoms or hypertension.

Answer 41

Initial testing for subclinical Cushing syndrome is a 1-mg overnight dexamethasone suppression test; a cortisol level greater than 5 µg/dL (138 nmol/L) is considered a positive test.

Answer 42

When testing for cortisol excess in someone who works night shift, The 24-hour urine free cortisol test for Cushing syndrome is the best test because it is not impacted by either estrogen therapy or sleeping patterns. Of note serum cortisol measurement is unreliable in this patient as she is on oral estrogen, which leads to an increase in cortisol binding proteins and subsequent elevation of serum total cortisol levels

Answer 43

Gynecomastia can be an adverse effect of medications; spironolactone causes an imbalance between free estrogen and free androgen resulting in glandular breast tissue enlargement.

Answer 44

Malabsorptive disorders (Like CELIAC) may decrease levothyroxine absorption resulting in higher than expected levothyroxine dose requirements.

Answer 45

In women over the age of 35 years, an infertility evaluation is initiated after 6 months of unprotected intercourse; in women under the age of 35, an infertility evaluation is initiated after 1 year of regular unprotected intercourse.

Answer 46

Chronic opioid use suppresses gonadotroph function, resulting in hypogonadotropic hypogonadism, which is increasingly recognized as a cause of secondary hypogonadism.

Answer 47

A mixed-meal test consisting of the types of food that normally induce the hypoglycemia should be performed to determine the cause of postprandial hypoglycemia. Postprandial hypoglycemia can develop 2 to 3 years after Roux-en-Y gastric bypass surgery.

Answer 48

This patient has secondary adrenal insufficiency, and hydrocortisone is the most appropriate treatment. An early morning (8 AM) serum cortisol of less than 3 μg/dL (82.8 nmol/L) is consistent with cortisol deficiency, Fludrocortisone is needed only in primary adrenal insufficiency.

Answer 49

Levothyroxine is the treatment of choice for thyroid hormone deficiency; for most younger adults without cardiac disease, a weight-based replacement dose of levothyroxine (1.6 µg/kg lean body weight) is recommended. older adults (age 65 years and older) and patients with cardiovascular disease should be prescribed a lower initial dose (25-50 µg/day) due to the effects of thyroid hormone on myocardial oxygen demand.

Answer 50

An adrenocorticotropic hormone (ACTH) measurement should be obtained once the diagnosis of Cushing syndrome is established to determine if it is ACTH dependent or ACTH independent. Cushing disease is the term used to indicate excess cortisol production due to an ACTH-secreting pituitary adenoma. Cushing syndrome refers to hypercortisolism from any cause, exogenous or endogenous, ACTH-dependent or not. At least two first-line tests should be diagnostically abnormal before the diagnosis is confirmed. Initial tests include the overnight low-dose dexamethasone suppression test, 24-hour urine free cortisol, and late-night salivary cortisol. The 24-hour urine free cortisol and late night salivary cortisol tests should be performed at least twice to ensure reproducibility of results.

Answer 51

In patients receiving thyroxine replacement therapy, initiation of estrogen or raloxifene increases thyroxine-binding globulin levels whereas testosterone reduces thyroxine-binding globulin levels; in either situation a change in thyroxine dosage may be required.

Answer 52

Alendronate, risedronate, zoledronic acid, and denosumab have been shown to reduce the risk for spine, hip, and nonvertebral fractures, and are generally well tolerated with low risk for serious adverse effects. Denosumab is effective for prevention of vertebral fracture in postmenopausal women, yet it is expensive and, once started, should be continued indefinitely.

Answer 53

Sulfonylureas stimulate insulin secretion, and they pose risk for hypoglycemia, especially drugs with long half-lives, such as glyburide, or in older persons.

Answer 54

Spironolactone and eplerenone can significantly interfere with interpretation of the plasma aldosterone-plasma renin ratio (ARR) and therefore should be discontinued approximately 6 weeks prior to screening for primary aldosteronism.

Answer 55

A hemoglobin A1c goal of 7.5% to 8% is recommended for older adults with complex medical history and significant comorbidities. A hemoglobin A1c goal of 7.5% to 8% is recommended for older adults with complex medical history and significant comorbidities.

Answer 56

Checkpoint inhibitors such as nivolumab, ipilimumab, and pembrolizumab have been associated with the development of hypophysitis with most patients presenting with the combination of headache, pituitary enlargement, and hypopituitarism.

Answer 57

Adrenalectomy is recommended for incidental adrenal masses with radiologic features that suggest increased risk of an adrenal malignancy (size >4 cm, density ≥10 Hounsfield units, and absolute contrast washout <50% at 10 minutes). Benign adrenal adenomas tend to be small (<4 cm), often have an intracytoplasmic fat content and appear less dense on noncontrast CT scan (<10 Hounsfield units), and exhibit rapid contrast washout during delayed contrast imaging (>50% at 10 minutes). T

Answer 58

Hypomagnesemia causes functional, reversible parathyroid hypofunction and must be excluded before a low or inappropriately normal parathyroid level is attributed to hypoparathyroidism. ionized calcium should only be checked when the patient's albumin is low

Answer 59

First-line therapy for toxic adenoma is radioactive iodine (131I) therapy or surgery.

Answer 60

Patients with primary hyperparathyroidism who do not undergo surgery require monitoring of serum calcium and creatinine every 6 to 12 months and bone mineral density of the lumbar spine, hip, and distal radius every 2 years. indications for parathyroidectomy include increase in serum calcium level ≥1 mg/dL (0.25 mmol/L) above upper limit of normal; creatinine clearance <60 mL/min, 24-hour urine calcium >400 mg/day (>10 mmol/day), or increased stone risk by biochemical stone risk analysis; presence of nephrolithiasis or Cinacalcet is indicated to treat symptomatic, severe hypercalcemia in adults with primary hyperparathyroidism for whom parathyroidectomy cannot be performed

Answer 61

Subclinical hypothyroidism is characterized by a serum thyroid-stimulating hormone (TSH) level above the upper limit of the reference range and normal free thyroxine (T4) level; before making this diagnosis, however, transient elevation of serum TSH should be ruled out by repeating the measurement of TSH in 2 to 3 months. Thyrotropin receptor antibodies would be more consistent with Graves disease

Answer 62

Ultrasound can confirm the presence of thyroid nodules palpated on examination and based on findings can help to determine if fine-needle aspiration is needed to assess for malignancy. Ultrasound can confirm the presence of thyroid nodules palpated on examination and those detected on other imaging studies. Ultrasound must be performed prior to fine-needle aspiration biopsy (FNAB) to confirm the presence of a nodule, determine that biopsy is indicated,

Answer 63

Serum thyroid-stimulating hormone level cannot be used to monitor and assess for adequacy of thyroid hormone replacement dosing in secondary hypothyroidism; the levothyroxine dose is adjusted based on free thyroxine (T4) levels with the goal of obtaining a value within the upper half of the normal reference range.

Answer 64

Treatment for hypoglycemic unawareness is to reduce the insulin dose and avoid hypoglycemia in order to provide the body an opportunity to restore the ability to detect hypoglycemia.

Answer 65

Antithyroid (Methimazole) drug-related agranulocytosis affects between one in 300 and one in 500 patients taking therapy and may present with fever and sore throat; initial management includes stopping the drug and assessment of the neutrophil count. granulocytosis from methimazole usually occurs within the first several months of initiating therapy but generally is not seen with doses below 20 mg per day

Answer 66

An increased risk of diabetic ketoacidosis with mild to moderate glucose elevations has been associated with the use of all the approved sodium-glucose transporter-2 (SGLT2) inhibitors (canagliflozin, dapagliflozin, and empagliflozin). Glipizide is a sulfonylurea. Sulfonylurea agents work by stimulating insulin secretion. Sulfonylurea agents are associated with weight gain, and they can cause hypoglycemia. T

Answer 67

Secondary hypogonadism is characterized by low testosterone level and low or inappropriately normal serum luteinizing hormone and follicle-stimulating hormone concentrations; MRI of the pituitary is typically performed to evaluate secondary hypogonadism in the absence of obvious reversible causes such as drugs.

Answer 68

In patients with myxedema coma, intravenous hydrocortisone should be administered before thyroid hormones to treat possible adrenal insufficiency. Following the administration of glucocorticoids, intravenous thyroid hormone replacement should be initiated. Treatment with levothyroxine is universally recommended

Answer 69

Iron-deficiency anemia can erroneously increase the hemoglobin A1c level due to an increase in the proportion of older erythrocytes.

Answer 70

Lobectomy is the treatment of choice for low-risk papillary thyroid cancer that is confined to the thyroid gland, completely resected at surgery, does not demonstrate aggressive pathologic features (lymphovascular invasion or tall cell variant), and has not metastasized.

Answer 71

A low urine osmolality in the setting of a high serum osmolality and high serum sodium in a patient with polyuria is diagnostic of diabetes insipidus.

Answer 72

Thyroid storm is a severe manifestation of thyrotoxicosis with life-threatening secondary systemic decompensation; it occurs most commonly with underlying Graves disease coupled with a precipitating factor such as surgery. patients with adrenal crisis usually present with hypotension, hyponatremia, and hyperkalemia, in addition to gastrointestinal manifestations.

Answer 73

In patients with diabetic ketoacidosis, intravenous insulin therapy should be continued until complete resolution of the anion gap acidosis; as acidosis improves, it may be necessary to reduce the insulin infusion rate and add intravenous dextrose to prevent hypoglycemia.

Answer 74

In patients with diabetic ketoacidosis, intravenous insulin therapy should be continued until complete resolution of the anion gap acidosis; as acidosis improves, it may be necessary to reduce the insulin infusion rate and add intravenous dextrose to prevent hypoglycemia.

Answer 75

Type 2 amiodarone-induced thyrotoxicosis (destructive thyroiditis) can be treated with moderate- to high-dose prednisone that can be gradually tapered over 1 to 3 months. Methimazole is most effective in treating type 1 (hyperthyroidism) amiodarone-induced thyrotoxicosis, which occurs in patients with Graves disease or thyroid nodules.

Answer 76

An androgen-secreting ovarian tumor should be considered in patients with abrupt, rapidly progressive, or severe hyperandrogenism as well as in women with marked hyperandrogenemia (total testosterone >150 ng/dL [5.2 nmol/L]).

Answer 77

Osteomalacia related to malabsorption or dietary factors is characterized by low 25-hydroxyvitamin D, calcium, and phosphate levels and elevated parathyroid hormone and alkaline phosphatase levels.

Answer 78

The two goals of evaluation are to determine if an adenoma is functioning and if it is malignant.

Answer 79

indications for Adrenalectomy * Suspicious imaging - Growth >20% plus 5 mm increase in diameter on repeat imaging - greater than 4 cm - Unilateral adrenal tumor with clinically significant hormone excess

Answer 80

1. low-dose (1-mg) dexamethasone suppression test 2. Catecholamines: test for urine or plasma metanephrines or urine catecholemines

Answer 81

Surgery is recommended for adrenal masses >4 cm in diameter or functioning tumors.

Answer 82

Insulin is the preferred treatment for achieving inpatient glycemic control.

Answer 83

Critically ill patients with type 2 diabetes are treated with IV insulin infusion when plasma glucose levels exceed 180 to 200 mg/dL. Glucose goals are 140 to 180 mg/dL.

Answer 84

For non–critically ill patients who are eating, the insulin regimen should incorporate both basal and prandial coverage. Prandial coverage can be supplemented with correction factor insulin for preprandial hyperglycemia.

Answer 85

Do not select sliding scale insulin alone to treat in-hospital hyperglycemia.

Answer 86

Continuing outpatient oral or noninsulin injectable agents is not recommended when patients are hospitalized because of the potential for hemodynamic or nutritional changes.

Answer 87

insufficient arginine vasopressin (AVP, ADH) release (central DI)

Answer 88

nephrogenic DI

Answer 89

An inappropriately low urine osmolality in the setting of an elevated serum osmolality and hypernatremia in a patient with polyuria is diagnostic OF Diabetes Insipidus.

Answer 90

Central DI is treated with desmopressin.

Answer 91

A water deprivation test can be performed when the diagnosis is uncertain. Following water deprivation, an elevated serum osmolality or hypernatremia with inappropriately dilute urine is diagnostic.

Answer 92

Following water deprivation, an elevated serum osmolality or hypernatremia with inappropriately dilute urine is diagnostic.

Answer 93

Evaluating the response to desmopressin can help differentiate central from nephrogenic DI. If the desmopressin challenge test is positive (urine concentrates, indicating central DI), order an MRI of the pituitary gland. If the test is negative (urine does not concentrate, indicating nephrogenic DI), order kidney ultrasonography.

Answer 94

Measuring antibodies to GAD65 and IA-2 is recommended for initial confirmation.

Answer 95

Too much rapid-acting insulin at breakfast or too much morning NPH insulin

Answer 96

Too much basal insulin

Answer 97

Not enough rapid-acting insulin at dinner

Answer 98

Not enough rapid-acting insulin at lunch or not enough morning NPH insulin

Answer 99

Not enough rapid-acting insulin at breakfast or not enough morning NPH insulin

Answer 100

Not enough basal insulin

Answer 101

Too much rapid-acting insulin at lunch or dinner or too much morning NPH

Answer 102

Lowering the insulin dose and allowing the average plasma glucose level to increase for several weeks may restore sensitivity to hypoglycemia.

Answer 103

The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 35 to 70 years who are overweight or obese. The ADA recommends screening overweight adults (BMI ≥25; ≥23 in Asian Americans) with at least one additional risk factor and all patients >45 years.

Answer 104

If two separate tests are done simultaneously and both are abnormal, diagnose diabetes. If only one of the two tests is abnormal, repeat the abnormal test.

Answer 105

A random plasma glucose level ≥200 mg/dL with hyperglycemic symptoms is diagnostic of diabetes and does not warrant repeat measurement.

Answer 106

Hemoglobin A1c will be falsely low in patients with hemolytic anemia, patients taking erythropoietin, or patients with kidney injury.

Answer 107

Metformin is the recommended first-line oral agent for newly diagnosed type 2 diabetes.

Answer 108

If not at goal, next preferred therapy is an SGLT2 inhibitor or a glucagon-like peptide 1 (GLP-1) receptor agonist for patients at risk for or with established ASCVD or with established kidney disease, and an SGLT2 inhibitor for HF.

Answer 109

In most patients who need the greater glucose-lowering effect of an injectable medication, GLP-1 receptor agonists are preferred to insulin.

Answer 110

If weight loss is a desired effect, GLP-1 receptor agonists and SGLT2 inhibitors are the best choices.

Answer 111

GLP-1 receptor agonists and SGLT2 inhibitors

Answer 112

SGLT2 inhibitors

Answer 113

Nonproliferative Diabetic Retinopathy, Dot-and-blot hemorrhages and clusters of hard, yellowish exudates are characteristic of nonproliferative diabetic retinopathy.

Answer 114

Proliferative Diabetic Retinopathy, A network of new vessels (neovascularization) is shown protruding from the optic nerve.

Answer 115

Empty Sella Syndrome

Answer 116

In asymptomatic persons, obtain cortisol, TSH, and free (or total) T4 measurements.

Answer 117

In patients without an obvious cause, obtain hCG and 8 AM fasting testosterone and estradiol levels.

Answer 118

Primary hyperparathyroidism is the most common cause of hypercalcemia in outpatients.

Answer 119

Hypercalcemia may also occur with the use of lithium (PTH mediated) or thiazide diuretics (non-PTH mediated) and in the setting of excessive ingestion of vitamin D and calcium.

Answer 120

Malignancy is the most common cause of hypercalcemia in hospitalized patients.

Answer 121

Sarcoidosis may be associated with hypercalcemia (10% of patients) and hypercalciuria (50% of patients).

Answer 122

Primary hyperparathyroidism

Answer 123

Humoral hypercalcemia of malignancy

Answer 124

Local osteolytic lesions

Answer 125

Multiple myeloma

Answer 126

Granulomatous disease (sarcoidosis and TB) and B-cell lymphoma

Answer 127

Milk-alkali syndrome

Answer 128

In patients with hypercalcemia and normal PTH levels, measure urinary calcium excretion to exclude familial hypocalciuric hypercalcemia.

Answer 129

Diagnose with serum and urine protein immunoelectrophoresis

Answer 130

Primary hyperparathyroidism is the most common manifestation of MEN1.

Answer 131

For severe, symptomatic hypercalcemia, select: * volume resuscitation with 0.9% saline * IV bisphosphonates * oral glucocorticoid therapy (if caused by multiple myeloma, B-cell lymphoma, or sarcoidosis)

Answer 132

Parathyroidectomy is indicated for patients with primary hyperparathyroidism and hypercalcemic complications, such as kidney stones, bone disease, or previous episodes of hypercalcemic crisis.

Answer 133

hungry bone” syndrome

Answer 134

Loop diuretics are not recommended in the treatment of hypercalcemia unless kidney failure or HF is present, in which case, volume expansion should precede the administration of loop diuretics to avoid hypotension and further kidney injury.

Answer 135

The most common cause of Cushing syndrome is the use of systemic, topical, intra- articular, or inhaled glucocorticoids.

Answer 136

1. ACTH-dependent causes of Cushing syndrome are defined by ACTH levels elevated or inappropriately “normal” in relation to the cortisol level: 2. ACTH-independent causes of Cushing syndrome are defined by low or “normal” ACTH levels in relation to the cortisol level

Answer 137

Cushing syndrome

Answer 138

adrenal adenomas * adrenal carcinomas

Answer 139

* ACTH-secreting pituitary adenomas (Cushing disease) * ACTH-secreting carcinomas and carcinoid tumors

Answer 140

* 1-mg overnight dexamethasone suppression test (failure to suppress serum cortisol to <3 μg/dL) * 24-hour urine cortisol level (elevated) * late night salivary cortisol level (elevated)

Answer 141

If the cortisol level is elevated (or not suppressible), obtain an ACTH level to differentiate ACTH-dependent from ACTH-independent hypercortisolism.

Answer 142

Pituitary MRI or CT

Answer 143

Adrenal CT

Answer 144

False-positive results (failure to suppress cortisol) with the 1-mg dexamethasone suppression test are common owing to alcohol use, obesity, and psychological disorders.

Answer 145

Surgical resection is the definitive treatment for benign and malignant cortisol- secreting adrenal tumors.

Answer 146

Hyperglycemic hyperosmolar syndrome

Answer 147

Reducing the insulin infusion before complete clearing of ketones will cause a relapse of DKA.

Answer 148

When plasma glucose level reaches 200 mg/dL in patients with DKA or 300 mg/dL in HHS in the setting of continued IV insulin, switch to 5% dextrose with 0.45% saline at 150-250 mL/h to avoid hypoglycemia.

Answer 149

If serum potassium is <3.3 mEq/L, do not start insulin;

Answer 150

If pH is <6.9, consider sodium bicarbonate,

Answer 151

The most common causes of hyperthyroidism are Graves disease and toxic adenoma(s).

Answer 152

Graves disease

Answer 153

Order serum TSH and free T4 levels to make the diagnosis of thyrotoxicosis.

Answer 154

If TSH is suppressed but T4 is normal, order free T3 to diagnose T3 toxicosis (rare).

Answer 155

Intake of exogenous thyroid hormone suppresses thyroglobulin levels, which makes its measurement useful (when low) in patients with thyrotoxicosis caused by surreptitious use of thyroid hormone.

Answer 156

An elevated serum ESR supports thyroiditis, whereas TSH-receptor antibodies and thyroid-stimulating immunoglobulins are associated with Graves disease.

Answer 157

Primary hyperthyroidism

Answer 158

Primary hyperthyroidism with T3 toxicosis

Answer 159

Subclinical hyperthyroidism

Answer 160

Secondary hyperthyroidism from a pituitary tumor (central hyperthyroidism, very rare)

Answer 161

Graves disease

Answer 162

Toxic multinodular goiter

Answer 163

Solitary adenoma

Answer 164

Iodine load (IV contrast or amiodarone) Thyroiditis (silent, subacute, postpartum, or amiodarone induced) Surreptitious ingestion of excessive thyroid hormone

Answer 165

Most patients with thyrotoxicosis benefit from β-blockers to reduce adrenergic symptoms rapidly.

Answer 166

Radioactive iodine is not used during pregnancy or breastfeeding and may aggravate Graves ophthalmopathy.

Answer 167

Moderate to severe Graves ophthalmopathy may require treatment with glucocorticoids, surgery, or teprotumumab.

Answer 168

Methimazole

Answer 169

Methimazole

Answer 170

Agranulocytosis

Answer 171

Propylthiouracil

Answer 172

PTU is preferred in thyroid storm (inhibits peripheral T4-T3 conversion)

Answer 173

Subclinical hyperthyroidism

Answer 174

Treatment is recommended for TSH <0.1 μU/L and patients with symptoms.

Answer 175

Atenolol or propranolol

Answer 176

Methimazole or thyroidectomy Avoid radioactive iodine

Answer 177

Propylthiouracil in first trimester of pregnancy; methimazole thereafter. Radioactive iodine is contraindicated

Answer 178

Methimazole if TSH <0.1 μU/mL

Answer 179

NSAIDs or glucocorticoids for pain management, atenolol or propranolol for symptoms of hyperthyroidism, levothyroxine for symptomatic hypothyroidism, and periodic thyroid studies.

Answer 180

Propylthiouracil (preferred) or methimazole, iodine-potassium solutions, glucocorticoids, and β-blockers

Answer 181

A fever or sore throat in a patient taking methimazole or propylthiouracil should be presumed to be agranulocytosis until proven otherwise.

Answer 182

Autoimmune adrenalitis is the most common cause of primary insufficiency.

Answer 183

Glucocorticoid use is the most common cause of secondary insufficiency (hypothalamic-pituitary suppression).

Answer 184

An 8:00 AM serum cortisol <3 μg/dL confirms cortisol deficiency and values >18 μg/dL exclude the diagnosis.

Answer 185

For patients with unequivocally low cortisol levels, a morning ACTH level can help distinguish between primary and secondary adrenal insufficiency.

Answer 186

Adrenal CT

Answer 187

Pituitary MRI

Answer 188

For nondiagnostic cortisol values, select stimulation testing with synthetic ACTH (cosyntropin). A stimulated serum cortisol >18 μg/dL excludes adrenal insufficiency.

Answer 189

If acute adrenal insufficiency is suspected, treat empirically with high-dose (4 mg) dexamethasone and IV saline without waiting for the ACTH and cortisol level results to return from the laboratory.

Answer 190

Dexamethasone does not interfere with the serum cortisol assay.

Answer 191

IV hydrocortisone 100 mg followed by 50 mg every 6 h for major stress (major surgery, trauma, critical illness, childbirth)

Answer 192

fludrocortisone is not required in primary adrenal insufficiency if the hydrocortisone dose >40 mg/d

Answer 193

hyponatremia and hyperkalemia (primary adrenal insufficiency only)

Answer 194

Most cases of hypocalcemia are caused by low serum albumin levels; the ionized calcium concentration is normal.

Answer 195

Total calcium declines by 0.8 mg/dL for each 1 g/dL decrement in serum albumin concentration.

Answer 196

A positive Trousseau's sign is characterized by the appearance of a carpopedal spasm which involves flexion of the wrist, thumb, and MCP joints along with hyperextension of the IP joints. This spasm results from the ischemia that is induced by compression through the inflated cuff.

Answer 197

Order calcium, phosphate, magnesium, creatinine, PTH, 25-hydroxyvitamin D, albumin, and/or ionized calcium tests. Order an ECG to evaluate for QT interval prolongation.

Answer 198

“Hungry bone” syndrome

Answer 199

Impaired PTH secretion and PTH resistance

Answer 200

Vitamin D deficiency

Answer 201

Hypoparathyroidism

Answer 202

Treat acute symptomatic hypocalcemia with IV calcium gluconate and vitamin D.

Answer 203

Chronic hypocalcemia is treated with oral calcium supplements and vitamin D.

Answer 204

Postprandial hypoglycemia

Answer 205

Suspect Surreptitious use of oral hypoglycemic agents. Perform urine screen for sulfonylurea and meglitinide metabolites.

Answer 206

Surreptitious use of insulin Patient has access to insulin. Serum C-peptide levels are low at time of hypoglycemia.

Answer 207

Perform 72-hour fast and document fasting plasma glucose level <45 mg/dL, serum insulin >5-6 mU/L, and elevated C-peptide levels. If positive, schedule abdominal CT.

Answer 208

Begin the evaluation of all patients with fasting hypoglycemia with screening for surreptitious use of an oral hypoglycemia agent, such as a sulfonylurea or insulin.

Answer 209

MEN1 can present as hyperparathyroidism, pituitary neoplasms, or pancreatic NETs. Pancreatic NETs include gastrinomas that can cause PUD and insulinomas that can cause hypoglycemia.

Answer 210

Do not use home glucometers to document hypoglycemia, because they may be inaccurate.

Answer 211

Asymptomatic hypoglycemia with a plasma glucose level <60 mg/dL is often found after fasting in patients without underlying disease and does not require evaluation.

Answer 212

Treat acute hypoglycemia with oral carbohydrates, IV glucose, or glucagon.

Answer 213

For management of postprandial hypoglycemia associated with previous gastrectomy or gastric bypass surgery, choose small mixed meals containing protein, fat, and high- fiber complex carbohydrates.

Answer 214

Serum C-peptide levels are from endogenous insulin. If someone is ingesting insulin, c pep should be normal

Answer 215

Central hypothyroidism results from pituitary disease or from previous surgery or radiation therapy to the sella. TSH and free T4 are suppressed.

Answer 216

Central hypothyroidism

Answer 217

Medication-induced hypothyroidism can occur with the use of certain drugs, including lithium carbonate, interferon alfa, interleukin-2, and amiodarone.

Answer 218

Order TSH and free T4 to make the diagnosis. Measurement of T3 levels is generally not necessary.

Answer 219

The most common causes of hypothyroidism include: * chronic lymphocytic (Hashimoto) thyroiditis * thyroidectomy * previous radioactive iodine ablation * history of external beam radiation to the neck

Answer 220

An antithyroid peroxidase antibody assay is associated with Hashimoto thyroiditis but is not needed to make the diagnosis; high levels are associated with an increased risk of permanent hypothyroidism.

Answer 221

Nonthyroidal illness syndrome occurs in patients who are acutely ill with a nonthyroidal illness. Testing reveals low or normal free T4 and suppressed TSH (initially), followed by elevated TSH (recovery phase). Normalization of thyroid function tests occurs 4 to 8 weeks after recovery.

Answer 222

Normalization of thyroid function tests occurs 4 to 8 weeks after recovery.

Answer 223

Thyroid scan and radioactive iodine uptake tests are not used to make the diagnosis of hypothyroidism.

Answer 224

Primary hypothyroidism

Answer 225

Subclinical hypothyroidism

Answer 226

Secondary (central) hypothyroidism; consider hypopituitarism

Answer 227

Levothyroxine is used to treat hypothyroidism.

Answer 228

Most guidelines support these treatment indications for subclinical hypothyroidism (TSH >10 μU/mL): * symptomatic * pregnant or planning to become pregnant * possibly age <30 years

Answer 229

Recall that celiac disease, calcium and iron supplements, and PPIs can decrease levothyroxine absorption; medications affecting absorption should be taken at least 4 hours apart from levothyroxine.

Answer 230

Check thyroid function tests frequently during pregnancy in women with a known diagnosis of hypothyroidism taking thyroxine, because maternal thyroxine demand increases by 30% to 50%.

Answer 231

Begin levothyroxine at 25-50 μg/d Increase by 25 μg every 6 weeks until TSH level is 1.0-2.5 μU/mL

Answer 232

Infertility is defined as the inability to conceive after 1 year of intercourse without contraception in women <35 years and after 6 months in women ≥35 years.

Answer 233

Male hypogonadism is present when sperm or testosterone production is decreased. It can be a primary (testicular) or secondary (typically hypothalamic-pituitary) condition.

Answer 234

Testosterone deficiency is diagnosed with two 8:00 AM total testosterone levels below the reference range.

Answer 235

if the testosterone measurement is equivocal, measure free testosterone.

Answer 236

If the testosterone level is low, measure LH, FSH, and prolactin levels.

Answer 237

Elevated LH and FSH values indicate primary testicular failure.

Answer 238

Low or normal LH and FSH levels indicate secondary hypogonadism.

Answer 239

If secondary hypogonadism is confirmed, in addition to measuring prolactin, check iron studies to rule out hemochromatosis and obtain an MRI to evaluate for hypothalamic or pituitary lesions.

Answer 240

Men who self-administer anabolic steroids can come to medical attention because of infertility. Physical examination typically reveals acne, muscular hypertrophy, testicular atrophy, and gynecomastia (if the patient is using testosterone).

Answer 241

Do not measure serum testosterone if a patient is having regular morning erections, has no gynecomastia on examination, and has a normal genital examination.

Answer 242

Before initiation of testosterone replacement and during therapy, routinely monitor hematocrit and PSA to screen for the development of erythrocytosis and prostate cancer, respectively.

Answer 243

Pituitary neoplasms and pancreatic NETS: Pancreatic NETs associated with gastrinoma (diarrhea, ulcers), insulinoma (fasting hypoglycemia), vasoactive intestinal polypeptide-secreting tumor (watery diarrhea, hypokalemia), carcinoid syndrome (diarrhea, flushing, right heart valvular lesion) Pituitary neoplasms associated with prolactinoma(amenorrhea, erectile dysfunction), acromegaly (enlargement of hands, feet, tongue; frontal bossing), Cushing disease (bruising, hypertension, central obesity, hirsutism)

Answer 244

About 50% of patients with primary hyperparathyroidism have coexisting vitamin D deficiency, and serum and urine calcium levels may be decreased. Select measurement of serum vitamin D levels in all patients with hyperparathyroidism.

Answer 245

Osteomalacia results from failure of the organic matrix of bone to mineralize because of lack of available calcium or phosphorus.

Answer 246

Evaluate for underlying conditions that may lead to intestinal malabsorption of vitamin D, such as celiac disease, or abnormalities in vitamin D metabolism, such as liver and kidney disease.

Answer 247

Diagnosis is confirmed with bone biopsy when necessary.

Answer 248

The USPSTF recommends screening bone mineral density with DEXA in women ≥65 years and in postmenopausal women <65 years who are at increased risk as determined by a formal clinical risk assessment tool (e.g., FRAX).

Answer 249

Do not repeat annual DEXA in women with normal DEXA results without risk factors. The optimal screening interval is unknown.

Answer 250

Osteoporosis is characterized by an increased predisposition to fractures. * DEXA T-score of −1.0 to −2.4 defines osteopenia. * DEXA T-score of ≤−2.5 defines osteoporosis.

Answer 251

The most common cause of osteoporosis in women is estrogen deficiency and in men is testosterone deficiency.

Answer 252

Treatment options for osteoporosis include alendronate or risedronate is first-line therapy

Answer 253

denosumab (monoclonal antibody that inhibits osteoclast activation) may be preferred in patients with stage 4 CKD and in those intolerant of or incompletely responding to bisphosphonates

Answer 254

Oral bisphosphonates are contraindicated in patients with CKD or esophageal disease. IV zoledronate (once yearly) is an alternative therapeutic option.

Answer 255

Oral bisphosphonates are contraindicated in patients with CKD or esophageal disease. IV zoledronate (once yearly) is an alternative therapeutic option.

Answer 256

Paget disease is a focal disorder of bone remodeling that leads to greatly accelerated rates of bone turnover, disruption of the normal architecture of bone, and sometimes gross deformities of bone (enlargement of the skull, bowing of the femur or tibia).

Answer 257

Most patients are asymptomatic, and the disease is suspected when an isolated elevation of alkaline phosphatase is detected in the absence of liver disease.

Answer 258

Pagets disease

Answer 259

Pagets, X-ray showing “cotton wool” appearance of the skull typical of Paget disease.

Answer 260

Pheochromocytomas are rare tumors arising in the chromaffin cells of the adrenal medulla that secrete biogenic amines (norepinephrine, epinephrine, or dopamine) or their metabolites.

Answer 261

Pheochromocytoma is associated with MEN2, von Hippel-Lindau disease, and neurofibromatosis type 1.

Answer 262

Twenty-four–hour urine measurements of metanephrines and catecholamines or measurement of plasma metanephrines is preferred.

Answer 263

Positive biochemical tests are followed by abdominal and pelvic CT with contrast.

Answer 264

Surgery is the treatment of choice. Use phenoxybenzamine to control BP preoperatively.

Answer 265

Use phenoxybenzamine to control BP preoperatively.

Answer 266

Use phenoxybenzamine to control BP preoperatively. Give IV normal saline to maintain intravascular volume; nitroprusside or phentolamine is indicated for treating intraoperative hypertensive crisis.+

Answer 267

For control of hypertension in patients with pheochromocytoma, select α- adrenergic blockers first. α-Adrenergic blockade before adequate β-adrenergic blockade can result in severe paroxysmal hypertension.

Answer 268

Pituitary adenomas are benign tumors that originate from one of the different anterior pituitary cell types. They are classified based on size as microadenomas (<10 mm) or macroadenomas (≥10 mm).

Answer 269

Most incidentally noted pituitary masses in asymptomatic patients are benign, nonfunctional pituitary adenomas. * Obtain dedicated pituitary MRI. * Assess possible pituitary hypersecretion (measure prolactin and IGF-1).

Answer 270

Screen patients for hypopituitarism with pituitary tumors regardless of symptoms with measurement of: * FSH, LH * cortisol * TSH, T4 * total testosterone (men)

Answer 271

Prolactinoma Serum prolactin level

Answer 272

Acromegaly Serum IGF-1 OGTT (fails to suppress GH)

Answer 273

Cushing disease 24-Hour urine cortisol excretion, dexamethasone suppression test, or late-night salivary cortisol level (elevated), serum ACTH level (elevated or inappropriately “normal”)

Answer 274

Prolactinoma

Answer 275

Prolactinoma. A discrete area of hypolucency (arrow) is seen in an otherwise normal-sized pituitary gland of homogeneous density.

Answer 276

Choose a dopamine agonist (cabergoline preferred to bromocriptine) for symptomatic prolactinoma.

Answer 277

Choose surgery for adenomas secreting GH, ACTH, or TSH; for adenomas associated with mass effect, visual field defects, or hypopituitarism; and for prolactinomas unresponsive to dopamine agonists.

Answer 278

Choose observation for women with microprolactinoma and normal menses or for patients with nonfunctioning pituitary microadenomas.

Answer 279

Lymphocytic hypophysitis

Answer 280

Postpartum pituitary necrosis (Sheehan syndrome)

Answer 281

Pituitary apoplexy

Answer 282

The posterior pituitary releases vasopressin and oxytocin directly into the systemic circulation. Look for symptoms of posterior pituitary dysfunction: * polydipsia, polyuria, and nocturia (DI secondary to ADH deficiency)

Answer 283

Patients with panhypopituitarism require daily thyroxine and cortisol replacement.

Answer 284

* Thyroxine dosing for central hypothyroidism is based on serum free T4 rather than TSH levels.

Answer 285

After documenting pituitary hormone deficiency, select dedicated pituitary MRI.

Answer 286

PCOS is the most common cause of hirsutism with oligomenorrhea.

Answer 287

An androgen-secreting ovarian or adrenal tumor should be suspected in a woman with acute onset of rapidly progressive hirsutism or virilization.

Answer 288

Weight loss is a first-line intervention.

Answer 289

Choose metformin for prediabetes/diabetes.

Answer 290

If fertility is not desired, choose oral contraceptive for treatment of hirsutism and regulation of menses; can add spironolactone if hirsutism remains a problem.

Answer 291

If fertility is desired, ovulation can be induced with clomiphene citrate or letrozole.

Answer 292

Women with a history of gestational diabetes are at very high risk for developing type 2 diabetes and require annual screening following delivery.

Answer 293

Antihypertensive agents that can be safely used during pregnancy include methyldopa, β-blockers (except atenolol), calcium channel blockers, and hydralazine.

Answer 294

Stopping therapy after 3 years (IV therapy) or 5 years (oral therapy) is reasonable in women who have a stable BMI, have no history of fracture, and are at low risk for fracture.

Answer 295

Drugs for osteoporosis have various adverse effects: * IV bisphosphonate therapy and denosumab can lead to osteonecrosis of the jaw.

Answer 296

* Oral bisphosphonate therapy may lead to erosive esophagitis and atypical hip fracture.

Answer 297

Testing indications are: * untreated hypertension with sustained BP >150/100 mm Hg * resistant hypertension (>140/90 mm Hg) with three-drug therapy including a diuretic * hypertension and an incidentally discovered adrenal mass * hypertension associated with spontaneous or diuretic-induced hypokalemia * hypertension in the setting of a first-degree relative with primary aldosteronism * hypertension in the setting of family history of hypertension onset <40 years of age

Answer 298

Evaluate patients using simultaneous measurements of plasma aldosterone and plasma renin activity. In patients taking an ACE inhibitor or an ARB, a nonsuppressed plasma renin level rules out mineralocorticoid excess.

Answer 299

A plasma aldosterone–plasma renin activity ratio >20, with a plasma aldosterone level >15 ng/dL, strongly suggests primary hyperaldosteronism.

Answer 300

The diagnosis is confirmed by demonstrating nonsuppressibility of elevated plasma aldosterone in response to a high salt load given intravenously or orally.

Answer 301

Testing can be done in patients receiving treatment with all antihypertensive agents except spironolactone and eplerenone, both of which antagonize the aldosterone receptor.

Answer 302

After autonomous hyperaldosteronism is diagnosed, select CT of the adrenal glands.

Answer 303

Adrenal vein sampling is needed before surgery to confirm the source of aldosterone secretion when imaging is unrevealing and to confirm lateralization when imaging demonstrates an adrenal adenoma.

Answer 304

Spironolactone or eplerenone is the treatment of choice for adrenal hyperplasia. Laparoscopic adrenalectomy is indicated for an aldosterone-producing adenoma.

Answer 305

Secondary amenorrhea is defined as absence of menses for more than 3 months in women who previously had regular menstrual cycles or 6 months in women who have irregular menses.

Answer 306

Test all women with secondary amenorrhea for pregnancy, the most common cause.

Answer 307

In the absence of pregnancy, assess hormonal status with estradiol, FSH, LH, TSH, and prolactin levels.

Answer 308

In the absence of pregnancy, assess hormonal status with estradiol, FSH, LH, TSH, and prolactin levels.

Answer 309

Low estradiol and low or inappropriately normal FSH and LH indicate hypogonadotrophic hypogonadism.

Answer 310

A progesterone challenge test is performed in these patients. * No bleeding following a progesterone challenge indicates low estrogen because of hypothalamic hypogonadism; measure estradiol level to confirm.

Answer 311

* No bleeding following a progesterone challenge indicates low estrogen because of hypothalamic hypogonadism; measure estradiol level to confirm.

Answer 312

Bleeding following progesterone challenge indicates a normal estrogen state and suggests possible hyperandrogenism (e.g., PCOS).

Answer 313

Low estradiol and elevated FSH and LH levels indicate hypergonadotrophic hypogonadism. Consider: * premature ovarian insufficiency (autoimmune) * chemotherapy * pelvic radiation

Answer 314

When a nodule is discovered, assess thyroid function with a serum TSH level.

Answer 315

obtain radioisotope scan scintigraphy to confirm the diagnosis of autonomously functioning thyroid adenoma and to rule out additional nonfunctioning nodules.

Answer 316

Normal or high TSH → obtain ultrasonography.

Answer 317

FNAB is indicated for: * all thyroid nodules >1 cm with suspicious sonographic features and a normal TSH level

Answer 318

FNAB is indicated for: * nodules <1 cm in patients with risk factors for thyroid cancer or suspicious ultrasound characteristics

Answer 319

A hyperfunctioning nodule is shown on the lateral aspect of the left thyroid lobe on thyroid scan.

Answer 320

Calcitonin measurement is considered only in patients with hypercalcemia or a family history of thyroid cancer or MEN2.

Answer 321

Treat hyperfunctioning solitary thyroid nodules with radioactive iodine ablation or hemithyroidectomy.

Answer 322

Surgery is indicated for patients with: * continued nodule growth despite normal initial FNAB results * nondiagnostic results on repeat FNAB * malignant cytology * large multinodular goiters with compressive symptoms

Answer 323

In assessing serum levels of vitamin D, concentrations of 25-hydroxyvitamin D are the best indicator of vitamin D status. The Institute of Medicine has determined that a vitamin D level of ≥20 ng/mL is sufficient.

Answer 324

In patients with metabolic alkalosis, urine chloride can differentiate saline-unresponsive (eg, primary hyperaldosteronism) from saline-responsive (eg, vomiting, recent diuretic use) causes. Urine chloride is low (<20 mEq/L) in saline-responsive cases.

Answer 325

Urine chloride is low (<20 mEq/L) in saline-responsive cases. Low urine CI- (<20 mEq/L), as in this patient, reflects the kidneys' attempt to increase Cl- reabsorption in volume-depleted patients (ie, saline responsive).

Answer 326

Hypervolemic etiologies include excess mineralocorticoid activity (eg, primary hyperaldosteronism), which causes hypertension (Choice C). Hypovolemic etiologies include disordered renal handling of Na* and CI-(ie, Bartter and Gitelman syndromes).

Answer 327

Metabolic alkalosis causes include surreptitious vomiting and Diuretic misuse. Difference is dieurrtic use has HIGH urine cl

Answer 328

Two laboratory features commonly present with hypomagnesemia are hypocalcemia (40% of patients) and hypokalemia (60% of patients). Hypocalcemia is due to decreased parathyroid hormone (PTH) secretion and PTH resistance (impaired calcium mobilization from bone). Hypokalemia is due to renal potassium wasting. In a patient with hypomagnesemia, administration of potassium typically does not restore serum potassium concentration to normal until body magnesium stores are replenished.

Answer 329

In Adult-Onset Still Disease, Serum ferritin levels >2500 ng/mL are highly specific for this condition and reflect disease activity.

Answer 330

Adult-Onset Still Disease

Answer 331

NSAIDs are generally used as first-line agents in management of mild disease; glucocorticoids are useful in patients with more severe disease. Life-threatening disease is treated with glucocorticoids and an interleukin-1 receptor antagonist, such as anakinra or canakinumab.

Answer 332

Infectious. Also has Positive Gram stainb ; positive culturec

Answer 333

Crystal Induced

Answer 334

Inflammatory

Answer 335

Noninflammatory

Answer 336

Gout crystals are shaped like a needle and are negatively birefringent. Pseudogout crystals are rhomboid shaped and positively birefingent

Endocrine Flashcards

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