Endocrinology Flashcards

Question

Syndrome that occurs during post partum and presents with acute intrapituitary hemorrhagic vascular events can cause substantial damage to the pituitary and surrounding sellar structures.

Answer 1

Sheehan's syndrome

Answer 2

ACTH and cortisol levels during insulin-induced hypoglycemia Administering insulin to induce hypoglycemia is contraindicated in patients with active coronary artery disease or known seizure disorders

Answer 3

(Laron syndrome)

Answer 4

The sequential order of hormone loss is usually GH → FSH/LH → TSH → ACTH.

Answer 5

insulin-induced (0.05–0.1 U/kg) hypoglycemia

Answer 6

About 90% of healthy adults exhibit GH responses >5 μg/L; AGHD is defined by a peak GH response to hypoglycemia of <3 μg/L. Contraindicated in patients with diabetes, ischemic heart disease, cerebrovascular disease, or epilepsy and in elderly patients. Alternative stimulatory tests include intravenous arginine (30 g), GHRH (1 μg/kg), oral ghrelin receptor agonist (0.5 mg/kg), and glucagon (1 mg).

Answer 7

Contraindications to therapy include the presence of an active neoplasm, intracranial hypertension, and uncontrolled diabetes and retinopathy Women require higher doses than men, and elderly patients require less GH.

Answer 8

Hypogonadism

Answer 9

rare invasive suprasellar mass surrounding the frontal or middle fossa or the optic nerves or invading posteriorly behind the clivus, which may require transcranial approaches.

Answer 10

Dopamine agonists

Answer 11

For acromegaly, somatostatin receptor ligands (SRLs) and a GH receptor antagonist are indicated.

Answer 12

Craniopharyngiomas Hypopituitarism is documented in ~90%, and diabetes insipidus occurs in ~10% of patients.

Answer 13

Treatment usually involves transcranial or transsphenoidal surgical resection followed by postoperative radiation of residual tumor.

Answer 14

Pituitary adenomas

Answer 15

Carney Complex

Answer 16

McCune Albright

Answer 17

Hyperprolactinemia

Answer 18

Elevates by decreasing clearance

Answer 19

Amenorrhea, galactorrhea, and infertility

Answer 20

the inappropriate discharge of milk-containing fluid from the breast, is considered abnormal if it persists longer than6 months after childbirth or discontinuation of breast-feeding.

Answer 21

1 cm Tumor size generally correlates directly with PRL concentrations; values >250 μg/L usually are associated with macroadenomas.

Answer 22

Bromocriptine B for buntis

Answer 23

cardiovascular

Answer 24

The diagnosis of acromegaly is confirmed by demonstrating the failure of GH suppression to <0.4 μg/L within 1–2 h of an oral glucose load (75 g)

Answer 25

Surgical resection of GH-secreting adenomas is the initial treatment for most patients Transsphenoidal surgical resection by an experienced surgeon is the preferred primary treatment for both microadenomas (remission rate ~70%) and macroadenomas (<50% in remission).

Answer 26

Pegvisomant

Answer 27

Somatostatin receptor ligands eg. octreotide, lanreotide, pasireotide

Answer 28

Pituitary corticotrope adenomas (Cushing’s disease)

Answer 29

iatrogenic hypercortisolism

Answer 30

Cardiovascular

Answer 31

Obesity and Thick skin

Answer 32

24hr urinary free cortisol Alternatively, overnight 1mg dexa test

Answer 33

Selective transphenoidal resection The remission rate for this procedure is ~80% for microadenomas but <50% for macroadenomas

Answer 34

Notably, hyperglycemia and new-onset diabetes develop in up to 70% of patients, likely due to suppressed pancreatic secretion of insulin and incretins.

Answer 35

Osilodrostat (2 mg twice daily titrated up to 30 mg twice daily) Elevated adrenal hormone precursors may lead to hypokalemia and hypertension. QTc prolongation and possibly increased tumor volume are also reported.

Answer 36

Mifepristone (300–1200 mg/d) Because the drug does not target the pituitary tumor, both ACTH and cortisol levels remain elevated, thus obviating a reliable circulating biomarker. Side effects are largely due to general antagonism of other steroid hormones and include hypokalemia, endometrial hyperplasia, hypoadrenalism, and hypertension.

Answer 37

Metyrapone (2–4 g/d)

Answer 38

Nelson’s

Answer 39

non functioning pituitary adenoma

Answer 40

a nonfunctioning adenoma causing pituitary stalk compression should be considered

Answer 41

Bronchial, abdominal carcinoid Small-cell lung cancer Thymoma

Answer 42

Iodide uptake

Answer 43

pendrin gene

Answer 44

Wolff-Chaikoff effect

Answer 45

(1) the transient increase in hCG during the first trimester, which weakly stimulates the TSH-R (2) the estrogen-induced rise in TBG during the first trimester, which is sustained during pregnancy (3) alterations in the immune system, leading to the onset, exacerbation, or amelioration of an underlying autoimmune thyroid disease (4) increased thyroid hormone metabolism by the placental type III deiodinase; and (5) increased urinary iodide excretion, which can cause impaired thyroid hormone production in areas of marginal iodine sufficiency.

Answer 46

propranolol, ipodate, iopanoic acid, amiodarone

Answer 47

Increased unbound T4, T3 Normal or increased TSH Individuals with RTH do not, in general, exhibit signs and symptoms that are typical of hypothyroidism because hormone resistance is partial and is compensated by increased levels of thyroid hormone.

Answer 48

(Pemberton’s sign)

Answer 49

falsely low

Answer 50

thyrotoxicosis factitia

Answer 51

Sonographic patterns that combine suspicious sonographic features are highly suggestive of malignancy (e.g., hypoechoic solid nodules with infiltrative borders and microcalcifications, >90% cancer risk)

Answer 52

(isoechoic solid nodules, 5–10% cancer risk). Some patterns suggest benignity (e.g., spongiform nodules, defined as those with multiple small internal cystic areas, or simple cysts, <3% cancer risk)

Answer 53

When the diagnosis is confirmed, T4 is instituted at a dose of 10–15 μg/kg per d,

Answer 54

symptom: tiredness, weakness sign: dry coarse skin, weak peripheral pulses

Answer 55

Request for TPO antibodies if symptomatic, consider LT4 tx if asymptomatic, annual ff up

Answer 56

If there is no residual thyroid function, the daily replacement dose of LT4 is usually 1.6 μg/kg body weight (typically 100–150 μg), ideally taken at least 30 min before breakfast.

Answer 57

Patients may not experience full relief from symptoms until 3–6 months after normal TSH levels are restored

Answer 58

Because T4 has a long half-life (7 days), patients who miss a dose can be advised to take two doses of the skipped tablets at once

Answer 59

There are no universally accepted recommendations for the management of subclinical hypothyroidism, but LT4 is recommended if the patient is a woman who wishes to conceive or is pregnant or when TSH levels are >10 mIU/L.

Answer 60

Because of the known increase in thyroid hormone requirements during pregnancy in hypothyroid women, LT4 therapy should be targeted to maintain a serum TSH in the normal range but <2.5 mIU/L prior to conception

Answer 61

thyroid function should be evaluated immediately after pregnancy is confirmed and every 4 weeks during the first half of the pregnancy, with less frequent testing after 20 weeks’ gestation (every 6–8 weeks depending on whether LT4 dose adjustment is ongoing).

Answer 62

20 In the elderly, especially patients with known coronary artery disease, the starting dose of LT4 is 12.5–25 μg/d with similar increments every 2–3 months until TSH is normalized

Answer 63

LT4 can initially be administered as a single IV bolus of 200–400 μg, which serves as a loading dose, followed by a daily oral dose of 1.6 μg/kg per d, reduced by 25% if administered IV Because T4 → T3 conversion is impaired in myxedema coma, there is a rationale for adding liothyronine (T3 ) intravenously or via nasogastric tube to LT4 treatment, although excess liothyronine has the potential to provoke arrhythmias. An initial loading dose of 5–20 μg liothyronine should be followed by 2.5–10 μg every 8 h, with lower doses chosen for smaller or older patients and those at cardiovascular risk Parenteral hydrocortisone (50 mg every 6 h) should be administered because there is impaired adrenal reserve in profound hypothyroidism

Answer 64

Graves’ disease accounts for 60–80% of thyrotoxicosis

Answer 65

symptom: hyperactivity, irritability, dysphoria sign: tachycardia, AF in elderly

Answer 66

The most common cardiovascular manifestation is sinus tachycardia, often associated with palpitations, occasionally caused by supraventricular tachycardia

Answer 67

There may be a thrill or bruit, best detected at the inferolateral margins of the thyroid lobes, due to the increased vascularity of the gland and the hyperdynamic circulation

Answer 68

The earliest manifestations of ophthalmopathy are usually a sensation of grittiness, eye discomfort, and excess tearing

Answer 69

Thyroid acropachy

Answer 70

Thyroid dermopathy occurs in <5% of patients with Graves’ disease , almost always in the presence of moderate or severe ophthalmopathy. Although most frequent over the anterior and lateral aspects of the lower leg (hence the term pretibial myxedema), skin changes can occur at other sites, particularly after trauma. The typical lesion is a noninflamed, indurated plaque with a deep pink or purple color and an “orange skin” appearance

Answer 71

TSH-secreting pituitary adenoma or thyroid hormone resistance syndrome

Answer 72

measure unbound t3

Answer 73

6-12 weeks

Answer 74

The clinical course of ophthalmopathy does not follow that of the thyroid disease, although thyroid dysfunction can worsen eye signs. Ophthalmopathy typically worsens over the initial 3–6 months, followed by a plateau phase over the next 12–18 months, and then some spontaneous improvement, particularly in the soft tissue changes

Answer 75

Thyroid function tests and clinical manifestations are reviewed 4–6 weeks after starting treatment, and the dose is titrated based on unbound T4 levels. Most patients do not achieve euthyroidism until 6–8 weeks after treatment is initiated

Answer 76

Carbimazole or methimazole must be stopped 2–3 days before radioiodine administration to achieve optimum iodine uptake and can be restarted 3–7 days after radioiodine in those at risk of complications from worsening thyrotoxicosis

Answer 77

The risk of hypothyroidism after radioiodine depends on the dosage but is at 10–20% in the first year and 5% per year thereafter.

Answer 78

In general, patients need to avoid close, prolonged contact with children and pregnant women for 5–7 days because of possible transmission of residual isotope and exposure to radiation emanating from the gland

Answer 79

Careful control of thyrotoxicosis with antithyroid drugs, followed by potassium iodide (SSKI; 1–2 drops orally tid for 10 days), is needed prior to surgery to avoid thyrotoxic crisis and to reduce the vascularity of the gland

Answer 80

Aplasia cutis PTU should be used until 14-16 weeks However, because of its rare association with hepatotoxicity, propylthiouracil should be limited to the first trimester and then maternal therapy should be converted to methimazole (or carbimazole) at a ratio of 15–20 mg of propylthiouracil to 1 mg of methimazole

Answer 81

Large doses of propylthiouracil (500–1000 mg loading dose and 250 mg every 4 h) should be given orally or by nasogastric tube or per rectum; the drug’s inhibitory action on T4 → T3 conversion makes it the antithyroid drug of choice. If not available, methimazole can be used in doses of 20 mg every 6 h. One hour after the first dose of propylthiouracil, stable iodide (5 drops SSKI every 6 h) is given to block thyroid hormone synthesis via the Wolff-Chaikoff effect (the delay allows the antithyroid drug to prevent the excess iodine from being incorporated into new hormone). Propranolol should also be given to reduce tachycardia and other adrenergic manifestations (60–80 mg PO every 4 h, or 2 mg IV every 4 h).

Answer 82

Pulse therapy with IV methylprednisolone (e.g., 500 mg of methylprednisolone once weekly for 6 weeks, then 250 mg once weekly for 6 weeks) is preferable to oral glucocorticoids, which are used for moderately active disease

Answer 83

presence of a piriform sinus usually due to a bacterial infection

Answer 84

de Quervain’s thyroiditis, granulomatous thyroiditis, or viral thyroiditis The patient usually presents with a painful and enlarged thyroid, sometimes accompanied by fever

Answer 85

Relatively large doses of aspirin (e.g., 600 mg every 4–6 h) or nonsteroidal anti-inflammatory drugs (NSAIDs) are sufficient to control symptoms in many cases. If this treatment is inadequate, or if the patient has marked local or systemic symptoms, glucocorticoids should be given. The usual starting dose is 15–40 mg of prednisone, depending on severity. The dose is gradually tapered over 6–8 weeks, in response to improvement in symptoms and the ESR

Answer 86

Painless thyroiditis, or “silent” thyroiditis, occurs in patients with underlying autoimmune thyroid disease and has a clinical course similar to that of subacute thyroiditis. The condition occurs in up to 5% of women 3–6 months after pregnancy and is then termed postpartum thyroiditis

Answer 87

Glucocorticoid treatment is not indicated for silent thyroiditis. Severe thyrotoxic symptoms can be managed with a brief course of propranolol, 20–40 mg three or four times daily. Thyroxine replacement may be needed for the hypothyroid phase but should be withdrawn after 6–9 months, as recovery is the rule

Answer 88

Hashimoto’s thyroiditis

Answer 89

a decrease in total and unbound T3 levels (low T3 syndrome) with normal levels of T4 and TSH.

Answer 90

Acute liver disease is associated with an initial rise in total (but not unbound) T3 and T4 levels due to TBG release . A transient increase in total and unbound T4 levels, usually with a normal T3 level, is seen in 5–30% of acutely ill psychiatric patients. TSH values may be transiently low, normal, or high in these patients. In the early stage of HIV infection, T3 and T4 levels rise, even if there is weight loss. T3 levels fall with progression to AIDS, but TSH usually remains normal. Renal disease is often accompanied by low T3 concentrations, but with normal rather than increased rT3 levels, due to an unknown factor that increases uptake of rT3 into the liver

Answer 91

thyroidectomy

Answer 92

True to exclude thyrotoxicosis or hypothyroidism

Answer 93

Thyroid carcinoma

Answer 94

RET-RAS-BRAF

Answer 95

F Micrometastases, defined as <2 mm of cancer in a lymph node, do not affect prognosis However, gross metastatic involvement of multiple 2- to 3-cm lymph nodes indicates a 25–30% chance of recurrence and may increase mortality in older patients

Answer 96

Because most tumors are still TSH-responsive, LT4 suppression of TSH is a mainstay of thyroid cancer treatment

Answer 97

low risk = 0.5–2.0 mIU/L Intermediate = 0.1–0.5 mIU/L high risk of recurrence and known mets <0.1 mIU/L

Answer 98

Serum thyroglobulin

Answer 99

The prognosis is poor, and most patients die within 6 months of diagnosis

Answer 100

DLBCL highly sensitive to external radiation Surgery should be avoided (may spread dse)

Answer 101

consider molecular testing 25–40% risk of malignancy

Answer 102

Repeat or consider molecular testing ~10–30% risk of malignancy

Answer 103

The 24-h urine volume exceeds 40 mL/ kg body weight, and the 24-h urine osmolarity is <280 mosm/L

Answer 104

collecting a 24-h urine on unrestricted fluid intake If the osmolarity is <280 mosm/L and the volume >50 mL/kg per day, the patient has DI and should be evaluated further to determine the type.

Answer 105

Get the basal plasma AVP

Answer 106

Pituitary bright spot is present in primary polydipsia since it reflects AVP stores

Answer 107

administering water orally if the patient is alert and cooperative or by infusing hypotonic fluids (0.45% saline or 5% dextrose and water) if the patient is not

Answer 108

The most common is one in which the AVP secretion responds normally to osmotic stimulation and suppression but the threshold or set point of the system is lower than normal

Answer 109

30 mL/kg per day

Answer 110

Infusion of 3% saline at a rate of ~0.05 mL/kg body weight per min raises serum sodium at a rate of ~1–2 meq/L per h, not only by replacing the slight sodium deficit but also by promoting a solute diuresis, which reduces total body water. Alternatively, a vaptan can be used to reduce body water by increasing urine output.

Answer 111

to assess glucocorticoid deficiency, ACTH stimulation of cortisol production is used

Answer 112

The standard ACTH stimulation test involves administration of cosyntropin (ACTH 1-24), 0.25 mg IM or IV, and collection of blood samples at 0, 30, and 60 min for cortisol. A normal response is defined as a cortisol level >15–20 μg/dL (>400–550 nmol/L) 30–60 min after cosyntropin stimulation, with the precise cutoff dependent on the assay used

Answer 113

The ITT involves administration of regular insulin 0.1 U/kg IV (dose should be lower if hypopituitarism is likely) and collection of blood samples at 0, 30, 60, and 120 min for glucose, cortisol, and growth hormone (GH), if also assessing the GH axis. Oral or IV glucose is administered after the patient has achieved symptomatic hypoglycemia (usually plasma glucose <40 mg/dL). A normal response is defined as a cortisol >20 μg/dL and GH >5.1 μg/L, again with assay-specific cutoff variability.

Answer 114

11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2) Cortisol and aldosterone bind the mineralocorticoid receptor (MR) with equal affinity; however, cortisol circulates in the bloodstream at about a 1000-fold higher concentration. Thus, only rapid inactivation of cortisol to cortisone by 11β-HSD2 prevents MR activation by excess cortisol, thereby acting as a tissue-specific modulator of the MR pathway

Answer 115

lung, but also in thymus or pancreas.

Answer 116

Get ACTH level

Answer 117

UNenhanced CT of the adrenals

Answer 118

magnetic resonance image (MRI) of the pituitary but it may not show an abnormality in up to 40% of cases because of small tumors below the sensitivity of detection

Answer 119

primary aldosteronism

Answer 120

hypokalemic hypertension

Answer 121

exhibit hypertension associated with drug resistance hypokalemia an adrenal mass or onset of disease before the age of 40 years

Answer 122

ARR screening is positive if the ratio is >750 pmol/L per ng/mL per hour, with a concurrently high normal or increased aldosterone

Answer 123

The most straightforward is the saline infusion test, which involves the IV administration of 2 L of physiologic saline over a 4-h period. Failure of aldosterone to suppress <140 pmol/L (5 ng/dL) is indicative of autonomous mineralocorticoid excess. Alternative tests are the oral sodium loading test (300 mmol NaCl/d for 3 days) or the fludrocortisone suppression test (0.1 mg q6h with 30 mmol NaCl q8h for 4 days);

Answer 124

Screen for glucocorticoid remediable aldosteronism; if positive, start Dexa 0.125-0.5 mg/day

Answer 125

Tumor >= 4cm and >=20 HU

Answer 126

mitotane (o,p’DDD) Adjuvant mitotane should be continued for at least 2 years, if side effects are tolerated. Regular monitoring of plasma mitotane levels is mandatory (therapeutic range 14–20 mg/L; neurotoxic complications more frequent at >20 mg/L). Mitotane is usually started at 500 mg tid, with stepwise increases to a maximum dose of 2000 mg tid in days (high-dose saturation) or weeks (low-dose saturation) as tolerated.

Answer 127

Hypothalamic-pituitary origin of disease

Answer 128

autoimmune adrenalitis

Answer 129

adrenal insufficiency and is found in 80% of patients at presentation. Hyperkalemia is present in 40% of patients at initial diagnosis.

Answer 130

The diagnosis of adrenal insufficiency is established by the short cosyntropin test The cutoff for failure is usually defined at cortisol levels of <450–500 nmol/L (16–18 μg/dL) sampled 30–60 min after ACTH stimulation; ** same lang ang screening and confirmatory for adrenal insufficiency

Answer 131

Once adrenal insufficiency is confirmed, measurement of plasma ACTH, renin and aldosterone is the next step

Answer 132

Acute adrenal insufficiency requires immediate initiation of rehydration, usually carried out by saline infusion at initial rates of 1 L/h with continuous cardiac monitoring. Glucocorticoid replacement should be initiated by bolus injection of 100 mg hydrocortisone, followed by the administration of 200 mg hydrocortisone over 24 h, preferably by continuous infusion or alternatively by bolus IV or IM injections. Mineralocorticoid replacement can be initiated once the daily hydrocortisone dose has been reduced to <50 mg because at higher doses hydrocortisone provides sufficient stimulation of MRs.

Answer 133

Mineralocorticoid replacement can be initiated once the daily hydrocortisone dose has been reduced to <50 mg because at higher doses hydrocortisone provides sufficient stimulation of MRs. Mineralocorticoid replacement in primary adrenal insufficiency should be initiated at a dose of 100–150 μg fludrocortisone.

Answer 134

The adequacy of treatment can be evaluated by measuring blood pressure, sitting and standing, to detect a postural drop indicative of hypovolemia. In addition, serum sodium, potassium, and plasma renin should be measured regularly. Renin levels should be kept in the upper normal reference range

Answer 135

Adrenal autoantibodies

Answer 136

MRI of the pituitary

Answer 137

Prader-Willi syndrome (PWS)

Answer 138

The largest effects are on colorectal, kidney, and pancreatic cancer, adenocarcinoma of the esophagus, and, in women, endometrial carcinoma

Answer 139

500–750 kcal/d Alternatively, a diet of 1200–1500 kcal/d for women and 1500–1800 kcal/d for men (adjusted for the individual’s body weight) can be prescribed

Answer 140

The primary purpose of a VLCD is to promote a rapid and significant (13- to 23-kg) short-term weight loss over a 3- to 6-month period. The proprietary formulas designed for this purpose typically supply ≤800 kcal, 50–80 g of protein, and 100% of the recommended daily intake for vitamins and minerals

Answer 141

5-HT2C receptor agonist

Answer 142

Streptomyces toxytricini.

Answer 143

severe obesity (BMI ≥40 kg/m2 ) or for those with moderate obesity (BMI ≥35 kg/m2 )

Answer 144

ADA recommends that women with a history of GDM undergo lifelong screening for the development of diabetes or prediabetes at least every 3 years

Answer 145

3.9 mmol/L (70 mg/dL)

Answer 146

transcription factor 7-like 2 gene

Answer 147

60 yrs BMI >=35

Answer 148

The ADA recommends annual screening for distal symmetric polyneuropathy beginning with the initial diagnosis of diabetes and annual screening for autonomic neuropathy 5 years after diagnosis of type 1 DM and at the time of diagnosis of type 2 DM. This testing is aimed at detecting loss of protective sensation (LOPS) caused by diabetic neuropathy mnemonic: T2DM--> 2day mo na itest

Answer 149

microvascular

Answer 150

The American Diabetes Association (ADA) recommends blood pressure control <130/80 mmHg for individuals with high cardiovascular risk and <140/90 mmHg for individuals with lower cardiovascular risk.

Answer 151

The appearance of neovascularization in response to retinal hypoxemia is the hallmark of proliferative diabetic retinopathy

Answer 152

commence 5 years after the onset of type 1 DM and at the time of diagnosis of type 2 DM basically same timeline with dx dystal symmetric neuropathy

Answer 153

0.8 mg/kg of body weight/day

Answer 154

30 mL/min per 1.743 m2 20 mL/min per 1.73 m2

Answer 155

delayed gastric emptying (gastroparesis) and altered small- and large-bowel motility (constipation or diarrhea).

Answer 156

Diabetic cystopathy should be treated with scheduled voiding or self-catheterization.

Answer 157

SGLT-2 inhibitor therapy.

Answer 158

The most common pattern of dyslipidemia is hypertriglyceridemia and reduced HDL cholesterol levels.

Answer 159

Atorvastatin

Answer 160

ankle-brachial index testing

Answer 161

xerosis and pruritus

Answer 162

Whipple’s triad: (1) symptoms consistent with hypoglycemia, (2) a low plasma glucose concentration measured with a precise method, and (3) relief of symptoms after the plasma glucose level is raised.

Answer 163

~4h Thus, cortisol and growth hormone play no role in defense against acute hypoglycemia.

Answer 164

Critical diagnostic findings are a plasma insulin concentration ≥3 μU/mL (≥18 pmol/L), a plasma C-peptide concentration ≥0.6 ng/ mL (≥0.2 nmol/L), and a plasma proinsulin concentration ≥5.0 pmol/L when the plasma glucose concentration is <55 mg/dL (<3.0 mmol/L) with symptoms of hypoglycemia. A low plasma β-hydroxybutyrate concentration (≤2.7 mmol/L) and an increment in plasma glucose level of >25 mg/dL (>1.4 mmol/L) after IV administration of glucagon (1.0 mg) indicate increased insulin (or IGF) actions

Answer 165

Surgical resection of a solitary insulinoma is generally curative. Diazoxide, which inhibits insulin secretion, or octreotide can be used to treat hypoglycemia in patients with unresectable tumors everolimus, an mTOR inhibitor, has also been successful in combination with the above approaches

Answer 166

If the patient is able and willing, oral treatment with glucose tablets or glucose-containing fluids, candy, or food is appropriate. A reasonable initial dose is 15–20 g of glucose. If the patient is unable or unwilling (because of neuroglycopenia) to take carbohydrates orally, parenteral therapy is necessary. IV administration of glucose (25 g) should be followed by a glucose infusion guided by serial plasma glucose measurements. If IV therapy is not practical, SC or IM glucagon (1.0 mg in adults) can be used, particularly in patients with T1DM. oral glucose --> IV glucose --> SC/IM glucagon

Answer 167

<11.1 mmol/L (200 mg/dL)

Answer 168

(2) >14 mmol/L (250 mg/ dL) (3) <5.0 mmol/L (90 mg/dL) In individuals with type 2 DM, exercise-related hypoglycemia is less common but can occur in individuals taking either insulin or insulin secretagogues.

Answer 169

twice per year.

Answer 170

<10 min 30–45 min

Answer 171

Biguanides and sulfonylureas

Answer 172

GLP 1 agonists

Answer 173

SGLT 2 inh

Answer 174

a glucosidase inhibitor

Answer 175

DPP4 inhibitor

Answer 176

Thiozolidinediones ** also contraindicated in hepatic insuffiency

Answer 177

Biguanides

Answer 178

TZD and Insulin secretagogues

Answer 179

These agents should not be used in individuals with inflammatory bowel disease, gastroparesis, or a serum creatinine >177 μmol/L (2 mg/dL)

Answer 180

Rosiglitazone raises low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides slightly. (Lipid profile rose sa rosi-glitazone) Pioglitazone raises HDL to a greater degree and LDL a lesser degree but lowers triglycerides

Answer 181

dapagliflozin

Answer 182

(1.6-mmol/L [1.6-meq] reduction in serum sodium for each 5.6-mmol/L [100-mg/dL] rise in the serum glucose)

Answer 183

The change to 0.45% saline or using lactated Ringer’s helps to reduce the trend toward hyperchloremia later in the course of DKA

Answer 184

Long-acting insulin, in combination with SC short-acting insulin, should be administered as soon as the patient resumes eating, because this facilitates transition to an outpatient insulin regimen and reduces length of hospital stay. It is crucial to continue the insulin infusion or insulin SC until adequate insulin levels are achieved by administering long-acting insulin by the SC route. Even relatively brief periods of inadequate insulin administration in this transition phase may result in DKA relapse

Answer 185

4.2–5.6 mmol/L (50–100 mg/dL)

Answer 186

11.1– 13.9 mmol/L (200–250 mg/dL) More rapid correction of the serum glucose can precipitate the development of cerebral edema

Answer 187

in the presence of severe acidosis (arterial pH <7.0), sodium bicarbonate (50 mmol [meq/L] in 200 mL of sterile water with 10 meq/L KCl per h) may be administered for the first 2 h until the pH is >7.0

Answer 188

0.32 mmol/L (1 mg/dL)

Answer 189

.The ADA suggests the following glycemic goals for hospitalized patients: (1) in critically or non–critically ill patients: glucose of 7.8–10.0 mmol/L or 140–180 mg/dL; (2) in selected patients: glucose of 6.1–7.8 mmol/L or 110–140 mg/dL with avoidance of hypoglycemia; (3) the target range in the perioperative period should be 80–180 mg/dL (4.4–10.0 mmol/L)

Answer 190

0.5–1.0 units

Answer 191

insulin resistance

Answer 192

hyperTAG The other major lipoprotein disturbance in the metabolic syndrome is a reduction in HDL cholesterol.

Answer 193

Nicotinic acid nicotinic acid can increase HDL cholesterol by up to 30% above baseline

Answer 194

An algorithm to correct for protein changes adjusts the total serum calcium (in mg/dL) upward by 0.8 times the deficit in serum albumin (g/dL) or by 0.5 times the deficit in serum immunoglobulin (in g/dL).

Answer 195

basal, fatsing state due to wide variation throughout the day

Answer 196

CLCN5 features include hypercalciuria, hypophosphatemia, and recurrent kidney stones

Answer 197

0.5–0.8 mmol/L (1.5–2.5 mg/dL).

Answer 198

See table Hypocalcemia, if present, should be corrected before administering IV phosphate

Answer 199

1.8 mmol/L (5.5 mg/dL) same with K

Answer 200

>Volume expansion may enhance renal phosphate clearance. >Aluminum hydroxide antacids or sevelamer may be helpful in chelating and limiting absorption of offending phosphate salts present in the intestine. >Hemodialysis is the most effective therapeutic strategy and should be considered early in the course of severe hyperphosphatemia, especially in the setting of renal failure and symptomatic hypocalcemia

Answer 201

MgSO4 may be given IV instead of MgCl2 , although the sulfate anions may bind calcium in serum and urine and aggravate hypocalcemia

Answer 202

Mild, asymptomatic hypomagnesemia may be treated with oral magnesium salts (MgCl2 , MgO, Mg[OH]2 ) in divided doses totaling 20–30 mmol/d (40–60 meq/d). More severe hypomagnesemia should be treated parenterally, preferably with IV MgCl2 , which can be administered safely as a continuous infusion of 50 mmol/d (100 meq Mg2+/d) if renal function is normal. If GFR is reduced, the infusion rate should be lowered by 50–75%.

Answer 203

Serum magnesium should be monitored at intervals of 12–24 h during therapy, which may continue for several days because of impaired renal conservation of magnesium (only 50–70% of the daily IV magnesium dose is retained) and delayed repletion of intracellular deficits, which may be as high as 1–1.5 mmol/kg (2–3 meq/kg

Answer 204

2 mmol/L (>4 meq/L; >4.8 mg/dL)

Answer 205

Vigorous IV hydration should be attempted, if appropriate. Hemodialysis is effective and may be required in patients with significant renal insufficiency. Calcium, administered IV in doses of 100–200 mg over 1–2 h, has been reported to provide temporary improvement in signs and symptoms of hypermagnesemia

Answer 206

serum 25(OH)D level.

Answer 207

50 nmol/L (>20 ng/mL)

Answer 208

100–250 Levels >250 mg/24 h predispose to nephrolithiasis and should lead to a reduction in vitamin D dosage and/or calciums supplementation

Answer 209

hyperparathyroidism If hypercalcemia has been manifest for >1 year, malignancy can usually be excluded as the caus

Answer 210

malignancy

Answer 211

3.2 mmol/L (12.8 mg/dL) 3.7–4.5 mmol/L (14.8–18.0 mg/dL) **factor is 4 in converting mmol to mg/dL

Answer 212

osteitis fibrosa cystica

Answer 213

Annually lahat except for skeletal (1-2 yrs)

Answer 214

A decline in serum calcium occurs within 24 h after successful surgery; usually, blood calcium falls to low-normal values for 3–5 days until the remaining parathyroid tissue resumes full hormone secretion

Answer 215

Signs of hypocalcemia include symptoms such as muscle twitching, a general sense of anxiety, and positive Chvostek’s and Trousseau’s signs coupled with serum calcium consistently <2 mmol/L (8 mg/dL)

Answer 216

An infusion of 0.5–2 mg/kg per hour or 30–100 mL/h of a 1-mg/mL solution usually suffices to relieve symptoms. Usually, parenteral therapy is required for only a few days. If symptoms worsen or if parenteral calcium is needed for >2–3 days, therapy with a vitamin D analogue and/or oral calcium (2–4 g/d) should be started. It is cost-effective to use calcitriol (doses of 0.5–1 μg/d) because of the rapidity of onset of effect and prompt cessation of action when stopped, in comparison to other forms of vitamin D

Answer 217

If magnesium deficiency is present, it can complicate the postoperative course since magnesium deficiency impairs the secretion of PTH

Answer 218

Squamous cell tumors are most frequently associated with hypercalcemia, particularly tumors of the lung, kidney, head and neck, and urogenital tract.

Answer 219

renal osteodystrophy

Answer 220

> includes reduction of excessive blood phosphate by restriction of dietary phosphate, the use of nonabsorbable phosphate binders, and careful, selective addition of calcitriol (0.25–2 μg/d) or related analogues. >Calcium carbonate became preferred over aluminum containing antacids to prevent aluminum-induced bone disease. However, synthetic gels that also bind phosphate (such as sevelamer) are now widely used, with the advantage of avoiding not only aluminum retention but also excess calcium loading, which may contribute to cardiovascular calcifications. >Intravenous calcitriol (or related analogues), administered as several pulses each week, helps control secondary hyperparathyroidism.

Answer 221

Asymptomatic

Answer 222

The immunoassay for PTH usually separates hyperparathyroidism from all other causes of hypercalcemia (exceptions are very rare reports of ectopic production of excess PTH by nonparathyroid tumors). Patients with hyperparathyroidism have elevated PTH levels despite hypercalcemia, whereas patients with malignancy and the other causes of hypercalcemia (except for disorders mediated by PTH such as lithium-induced hypercalcemia) have levels of hormone below normal or undetectable

Answer 223

1,25(OH)2 D levels are elevated in many (but not all) patients with primary hyperparathyroidism. In other disorders associated with hypercalcemia, concentrations of 1,25(OH)2 D are low or, at the most, normal Measurement of 1,25(OH)2 D is critically valuable in establishing the cause of hypercalcemia in sarcoidosis and certain lymphomas.

Answer 224

Pamidronate P-eber

Answer 225

Calcitonin

Answer 226

Calcitonin, after 24 h of use, is no longer effective in lowering calcium

Answer 227

multiple myeloma, leukemia, Hodgkin’s disease, other lymphomas, and carcinoma of the breast, at least early in the course of the diseases

Answer 228

Severe hypercalcemia (≥3.7 mmol/L [15 mg/dL]) requires rapid correction. IV pamidronate or zoledronate or subcutaneous denosumab should be administered. In addition, for the first 24–48 h, aggressive sodium-calcium diuresis with IV saline should be given and, following rehydration, large doses of furosemide or ethacrynic acid, but only if appropriate monitoring is available and cardiac and renal function are adequate

Answer 229

2.5 standard deviations (SDs) or more below the mean for young healthy adults of the same sex and race—also referred to as a T-score of –2.5. Patients who present with hip or spine fractures by definition have osteoporosis and will require treatment for both the fractureitself and the underlying skeletal disorder

Answer 230

Vitamin D insufficiency leads to compensatory secondary hyperparathyroidism and is an important risk factor for osteoporosis and fractures

Answer 231

Estrogen deficiency causes bone loss by two distinct but interrelated mechanisms: (1) activation of new bone remodeling sites and (2) initiation or exaggeration of an imbalance between bone formation and resorption, in favor of the latter Loss of estrogen increases production of RANKL and reduces production of osteoprotegerin, increasing osteoclast formation and recruitment

Answer 232

See table Glucocorticoids are the most common cause of medication-induced osteoporosis

Answer 233

24-h urine histamine collection or serum tryptase

Answer 234

Bazedoxifene

Answer 235

uterine unlike raloxifene

Answer 236

contraindicated in patients who have stricture or inadequate emptying of the esophagus

Answer 237

All bisphosphonates have been associated with some musculoskeletal and joint pains of unclear etiology, which are occasionally severe. There is potential for renal toxicity, and bisphosphonates are contraindicated in those with an estimated glomerular filtration rate <30–35 mL/min. Hypocalcemia can occur. Also associated with osteonecrosis of the jaw and atypical femoral fracture

Answer 238

When denosumab is discontinued, there is a rebound increase in bone turnover and an apparent acceleration of bone loss. This likely reflects the maturation of osteoclast precursors that have accumulated in marrow when the drug was administered and can become mature bone resorbing cells once the drug is withdrawn

Answer 239

romosozumab

Answer 240

odanacatib

Answer 241

collagen C-telopeptide osteocalcin or propeptide of type 1 collagen (P1NP)

Answer 242

3 If only one skeletal site can be measured, it is best to assess the spine in individuals <60 years and the hip in those >60 years.

Answer 243

C. Serum potassium is < 3.3 ug/L in less than 10 percent of cases

Answer 244

C. Strongyloides

Answer 245

A. Coxsackie virus

Answer 246

B. Latent autoimmune diabetes of the adult

Answer 247

A. Now then every year thereafter

Answer 248

B. Fenofibrate

Answer 249

C. 50-55 mg/dL

Answer 250

B. 50 year old man, asymptomatic, TSH of 15 mIU/L since TSH >10

Answer 251

C. Subclinical hyperthyroidism

Answer 252

A. Discontinue the drug and have a CBC done

Answer 253

B. Colloid nodule

Answer 254

D. TSH suppression therapy

Answer 255

A. <0.1 mIU/L

Answer 256

A. High ACTH, high renin, low aldosterone

Answer 257

C. Perform contrast-enhanced adrenal CT scan

Answer 258

C. Increase in bone mineral density

Answer 259

C. Liver disease Others: unexplained vaginal bleeding, VTE, thrombophilia

Answer 260

C. Orlistat Weight loss 9-10%/yr

Answer 261

C. Previous history of increased fasting glucose (IFG)

Answer 262

Duloxetine and Pregabalin

Answer 263

B. Filipino female, with HDL of 45 mg/dL HDL<50 in F

Answer 264

-1 to -2.5

Answer 265

B. 30-year old woman with lupus, on prednisone 10mg/day for the last 6 months prednisone >5 mg/day for >3 mos

Answer 266

b. 15–20 mg of propylthiouracil to 1 mg of methimazole

Answer 267

b. Cortisol is <5 ug/dL after high-dose dexamethasone suppression 24 hr urine free cortisol is elevated in both High dose Dexa suppression test will be able to inhibit cortisol production in ACTH-dependent pituitary tumors via the feedback mechanism but has NO EFFECT on ECTOPIC ACTH sources Rapid onset of symptoms and pigmentation are associated with ECTOPIC ACTH secretion Basal inferior petrosal : peripheral vein ACTH ratio of <2 is consistent with ECTOPIC ACTH secretion

Answer 268

b. FNA or CT-guided biopsy of an adrenal mass is rarely indicated.

Answer 269

Hyperreninemia PRIMARY ADRENAL INSUFFICIENCY Characterized by the loss of both glucocorticoid and mineralocorticoid secretion A distinguishing feature of primary adrenal insufficiency is hyperpigmentation, which is caused by excess ACTH stimulation of melanocytes. Hyponatremia can be present in both mineralocorticoid deficiency and in secondary adrenal insufficiency due to diminished inhibition of ADH release by cortisol. Increased plasma renin will confirm presence of mineralocorticoid deficiency Low BP and postural hypotension can be present in both

Answer 270

b. A common insulin-to-carbohydrate ratio is 1 unit per 15 g of carbohydrate. a. In general, Type 1 DM patients require 1-2 units/kg per day of insulin. In general, individuals with type 1 DM require 0.3-0.7 units/kg per day c. Insulin is given as multiple doses with 70% given as basal insulin. --> 50% d. Supplemental insulin is given at 2 units of insulin for every 50 mg/dL over glucose target. --> 1-2u for every 30-60 over target

Answer 271

a. Dapagliflozin

Answer 272

d. 55/F with tuberculosis-related cachexia Insulin is the safest and most effective option in such cases to achieve glycemic control and prevent further catabolic effects of hyperglycemia. Insulin should be considered as part of the initial therapy in type 2 DM, particularly in: * lean individuals * those with severe weight loss * in individuals with underlying renal or hepatic disease that precludes oral glucose-lowering agents * In individuals who are hospitalized or acutely ill.

Answer 273

c. Measure electrolytes and anion gap every 4 hours for first 24 hours. a. Administer short-acting regular insulin IV (0.1 units/kg) bolus then 0.1 units/kg/hr by infusion. - Hook to kcl first b. Give 150 mEqs sodium bicarbonate bolus then give additional 250 mEqs by infusion over 24 hours.- not indicated since pH 7.2 d. Run 2-3 L of 0.45% saline at 10-20 mL/kg/hr over the first 1-3 hours.- should be PNSS since Na is only 122

Answer 274

b. Regular insulin as intravenous infusion IV regular insulin is the standard of care for critically ill patients because: It provides rapid onset and precise control of blood glucose levels. It allows for easy titration and adjustment based on frequent glucose monitoring, which is essential in ICU settings. It is recommended in situations like sepsis, acute illness, or respiratory failure where glycemic variability is high.

Answer 275

a. Failure of insulin secretion to fall during hypoglycemia The patient's symptoms of frequent lightheadedness, diaphoresis, palpitations, and low CBG levels (45–80 mg/dL), along with the finding of a 1.0 cm pancreatic head mass, suggest an insulinoma.

Answer 276

d. Omega-3 FA Omega-3 fatty acids are highly effective for lowering triglycerides, especially in severe cases. Statins are primarily used for lowering LDL cholesterol and reducing cardiovascular risk. While they have a modest triglyceride-lowering effect (10–30%), they are not sufficient for severe hypertriglyceridemia (≥500 mg/dL). Bile acid sequestrants lower LDL cholesterol but can raise triglyceride levels, especially in patients with baseline hypertriglyceridemia.

Answer 277

c. Nelson syndrome NELSON’S SYNDROME A disorder characterized by rapid pituitary tumor enlargement and increased pigmentation secondary to high ACTH levels. Prophylactic radiation therapy may be indicated to prevent the development of Nelson’s syndrome after adrenalectomy.

Answer 278

c. No pituitary bright spot on MRI Acute hypernatremia and increased volume of urine in the setting of post-cranial surgery is highly suggestive of post-op pituitary diabetes insipidus Urine osmolarity of <300 mosm/L is present in pituitary DI, primary polydipsia and nephrogenic DI Plasma AVP <1 pg/mL is present in both primary polydipsia and pituitary DI The pituitary bright spot is almost always absent or abnormally small in patients with pituitary DI Plasma osmolarity of >300 can be present in both DI and non-DI etiologies

Answer 279

b. Proximal myopathy A diagnosis of Cushing’s should be considered when several clinical features are found in the same patient, in particular when more specific features are found. These include fragility of the skin, with easy bruising broad (>1 cm), purplish striae signs of proximal myopathy, which becomes most obvious when trying to stand up from a chair without the use of hands or when climbing stairs

Answer 280

d. Continue telmisartan and correct hypokalemia prior to ARR measurement The accepted screening test is concurrent measurement of plasma renin and aldosterone with subsequent calculation of the aldosterone-renin ratio (ARR) Serum potassium should be normalized prior to testing Stopping antihypertensive medication can be cumbersome, particularly in patients with severe hypertension. For practical purposes, in the first instance the patient can remain on the usual antihypertensive medications, with the exception that MR antagonists need to be ceased at least 4 weeks prior to ARR measurement. Carvedilol can falsely increase ARR

Answer 281

c. MODY 3 MONOGENIC FORMS OF DM MODY 1, MODY 3, and MODY 5 are caused by mutations in hepatocyte nuclear transcription factor (HNF) 4a, HNF-1a, and HNF-1B, respectively. Individuals with an HNF-1a mutation (MODY 3) have a progressive decline in glycemic control but may respond to sulfonylureas. Individuals with MODY 2, the result of mutations in the glucokinase gene, have mild-to-moderate, but stable hyperglycemia that does not respond to oral hypoglycemic agents MODY 4 is a rare variant caused by mutations in pancreatic and duodenal homeobox 1, a transcription factor that regulates pancreatic development and insulin gene transcription

Answer 282

c. Blood pressure assessment every 3 months Lipids annually Diabetes-related kidney disease testing annually Blood pressure assessment quarterly Foot examination 1-2 times/year by provider Daily by patient

Answer 283

d. Nocturnal hyperglycemia will be reflected in the HbA1c. ASSESSMENT OF LONG TERM GLYCEMIC CONTROL Measurement of glycated hemoglobin (HbA1c) is the standard method for assessing long-term glycemic control. Glycemic level in the preceding month contributes about 50% to the HbA1c value As the primary predictor of long-term complications of DM, the HbA1c should mirror, to a certain extent, the short-term measurements of SMBG These two measurements are complementary in that recent intercurrent illnesses may impact the SMBG measurements but not the HbA1c Likewise, postprandial and nocturnal hyperglycemia may not be detected by the SMBG of fasting and preprandial capillary plasma glucose but will be reflected in the HbA1c The HbA1c is an “average” and thus does not detect glycemic variability in the way SMBG and CGM can.

Answer 284

b. DPP-IV inhibitors begin to lower the plasma glucose immediately Insulin secretagogues, biguanides, GLP-1 receptor agonists, and thiazolidinediones improve glycemic control to a similar degree (1–2% reduction in HbA 1c) and are more effective than a-glucosidase inhibitors, DPP-IV inhibitors, and SGLT2 inhibitors Assuming a similar degree of glycemic improvement, the clinical advantage of one class of drugs is not clear; any therapy that improves glycemic control is likely beneficial. Insulin secretagogues, GLP-1 receptor agonists, DPP-IV inhibitors, a-glucosidase inhibitors, and SGLT2 inhibitors begin to lower the plasma glucose immediately, whereas the glucose-lowering effects of the biguanides and thiazolidinediones are delayed by weeks . Not all agents are effective in all individuals with type 2 DM. Biguanides, a-glucosidase inhibitors, GLP-1 receptor agonists, DPP-IV inhibitors, thiazolidinediones, and SGLT2 inhibitors do not directly cause hypoglycemia Most individuals will eventually require treatment with more than one class of oral glucose-lowering agents or insulin, reflecting the progressive nature of type 2 DM Durability of glycemic control is slightly less for sulfonylureas compared to metformin or thiazolidinediones

Answer 285

a. Diagnosed DM since 50 years of age Duration of DM and degree of glycemic control are the BEST PREDICTORS of the development of retinopathy. Nonproliferative retinopathy is found in many individuals who have had DM for >20 years. Hypertension, nephropathy and dyslipidemia are also risk factors. Although there is genetic susceptibility for retinopathy, it confers less influence than either duration of DM or degree of glycemic control.

Answer 286

b. There is no benefit in starting ACE-inhibitors prior to onset of albuminuria. Either ACE inhibitors or ARBs should be used to reduce the albuminuria and the associated decline in GFR that accompanies it in individuals with type 1 or type 2 DM. Most experts believe that the two classes of drugs are equivalent in patient with diabetes. ARBs can be used as an alternative in patients who develop ACE inhibitor–associated cough or angioedema. After initiation of therapy, some increase the dose and monitor the urinary albumin. There is no benefit of intervention prior to onset of albuminuria or using a combination of an ACE inhibitor and an ARB. If use of either ACE inhibitors or ARBs is not possible or the blood pressure is not controlled, then, diuretics, calcium channel blockers (nondihydropyridine class), or beta blockers should be used.

Answer 287

a. Transaminase elevation of 3x the normal levels in the absence of symptoms does not warrant discontinuation of the drug. the magnitude of LDL lowering associated with statin treatment varies widely among individuals, but once a patient is on a statin, the doubling of the statin dose produces an ~6% further reduction in the level of plasma LDL-C Statins also reduce plasma TGs in a dose-dependent fashion, which is roughly proportional to their LDL-C–lowering effects Statins have a modest HDL-raising effect (5–10%) that is not generally dose-dependent. Serum CK levels need not be monitored on a routine basis in patients taking statins, because an elevated CK in the absence of symptoms does not predict the development of myopathy and does not necessarily suggest the need for discontinuing the drug . Substantial (greater than three times the upper limit of normal) elevation in transaminases is relatively rare, and mild-to-moderate (one to three times normal) elevation in transaminases in the absence of symptoms need not mandate discontinuing the medication

Answer 288

b. Caloric restriction In general, recommendations for weight loss include a combination of caloric restriction, increased physical activity, and behavior modification. Caloric restriction is the most important component, whereas increases in physical activity are important for maintenance of weight loss.

Answer 289

a. Normal levels of 1,25(OH)2D The most specific screening test for vitamin D deficiency in otherwise healthy individuals is a serum 25(OH)D level. The National Academy of Medicine has defined vitamin D sufficiency as a vitamin D level >50 nmol/L (>20 ng/mL) Vitamin D deficiency leads to impaired intestinal absorption of calcium, resulting in decreased serum total and ionized calcium values. This hypocalcemia results in secondary hyperparathyroidism . In addition to increasing bone resorption, PTH decreases urinary calcium excretion while promoting phosphaturia. This results in hypophosphatemia . Since PTH is a major stimulus for the renal 25(OH)D 1a-hydroxylase, there is increased synthesis of the active hormone, 1,25(OH)2D. Paradoxically, levels of this hormone are often normal in severe vitamin D deficiency. Therefore, measurements of 1,25(OH)2D are not accurate reflections of vitamin D stores and should not be used to diagnose vitamin D deficiency in patients with normal renal function

Answer 290

d. Start Calcitonin 200 IU nasal spray, 1 spray per nostril Patient has Hypercalcemia of Malignancy (from Lung CA). His PE indicates that he has pulmonary congestion Although hydration is the initial choice of treatment for hypercalcemia, it is contraindicated for this patient. Hydration + forced diuresis is likewise contraindicated Zolendronate cannot be used due to elevated creatinine. Calcitonin is the best strategy for rapid correction of hypercalcemia, followed by hemodialysis for this patient.

Answer 291

b. de Quervain’s thyroiditis AKA granulomatous thyroiditis

Answer 292

c. Increased thyroid hormone metabolism by the placenta. Inc TBG and urinary iodine excretion in pregnancy

Answer 293

c. Hyperglycemia Catecholamines (especially epinephrine) stimulate glycogenolysis and gluconeogenesis, leading to transient hyperglycemia. This is a common finding in pheochromocytoma and can sometimes mimic diabetes or impaired glucose tolerance.

Answer 294

B. Start bromocriptine Still the first line is dopamine agonists Surgery is indicated if: The tumor is resistant to medical therapy. There is acute visual loss or other signs of neurological compromise that cannot wait for medical therapy to take effect.

Answer 295

D. Thyroid scan

Answer 296

A. Request for a 75-gram OGTT The patient has polycystic ovary syndrome (PCOS), which is associated with insulin resistance and an increased risk of type 2 diabetes mellitus (T2DM). Her fasting blood sugar (FBS) of 121 mg/dL falls into the range of impaired fasting glucose (IFG) (100–125 mg/dL). To confirm the diagnosis of prediabetes or diabetes, further testing is necessary.

Answer 297

D. Initiate therapy with zolendronate Bisphosphonates, such as zoledronate, are first-line treatments for hypercalcemia of malignancy. They inhibit osteoclast-mediated bone resorption and provide sustained calcium reduction over several days to weeks.

Answer 298

c. Request for TSH

Answer 299

b. Order chest and abdomen CT scan Most likely ectopic source of ACTH since no suppression on high dose dexa Hypokalemia <3.3 also more common in ectopic source

Answer 300

a. Type 2 Diabetes Mellitus

Answer 301

B. Impaired fasting glucose (IFG)

Answer 302

A. 1 The patient in this case has pre-diabetes (IGT). Individuals with IFG, IGT, or an HbA1c of 5.7–6.4% should be monitored annually to determine if diagnostic criteria for diabetes are present. The ADA suggests that metformin be considered in individuals with both IFG and IGT who are at very high risk for progression to diabetes (age <60 years, BMI ≥35 kg/m2, and women with a history of GDM).

Answer 303

D. Semaglutide Pioglitazone and GLP1 agonists may be added to metformin if still uncontrolled Semaglutide has been shown to decrease CV events. Pioglitazone is contraindicated since the patient had a recent MI and may precipitate heart failure.

Answer 304

D. Olmesartan Many other drugs have been associated with hypoglycemia. These include commonly used drugs such as angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists, β-adrenergic receptor antagonists, quinolone antibiotics, indomethacin, quinine, and sulfonamides

Answer 305

A. Small cell lung CA SCCA-most common malignancy cause of hypercalcemia

Answer 306

B. Continue Insulin Drip, and hydrate using 0.45% Saline Solution Once hemodynamically stable, PNSS should be shifted to 0.45 to reduce hyperchloremic acidosis

Answer 307

A. Advice weight loss

Answer 308

A. ApoB There is increasing evidence that measurement of plasma ApoB levels may provide a better assessment of cardiovascular risk than the LDL-C level, and even the non-HDL-C level, and is recommended by some experts. While this has not yet become standard clinical practice, the data supporting the use of ApoB as a risk marker and guide to therapeutic intervention are quite strong. There is also increasing interest in Lp(a), an independent ASCVD risk factor that is highly heritable and may be helpful in risk stratification.

Answer 309

C. TSH and free T4 If with features of graves, no need for TPO ab Needed only in the hypothyroidism algorithm

Answer 310

B. Intake of verapamil Drug-induced inhibition or disruption of dopaminergic receptor function is a common cause of hyperprolactinemia. Verapamil blocks dopamine release leading to hyperprolactinemia.

Answer 311

A. Basal plasma AVP

Answer 312

A. Give levothyroxine as single IV bolus Given the clinical vignette, the patient seems to have myxedema coma. Clinical manifestations include reduced level of consciousness, sometimes associated with seizures, as well as the other features of hypothyroidism. LT4 can initially be administered as a single IV bolus of 200–400 μg, which serves as a loading dose, followed by a daily oral dose of 1.6 μg/kg per day, reduced by 25% if administered IV.

Answer 313

C. Thyroid Storm Thyrotoxic crisis, or thyroid storm, is rare and presents as a life-threatening exacerbation of hyperthyroidism, accompanied by fever, delirium, seizures, coma, vomiting, diarrhea, and jaundice. Thyrotoxic crisis is usually precipitated by acute illness (e.g., stroke, infection, trauma, DKA), surgery (especially on the thyroid), or radioiodine treatment of a patient with partially treated or untreated hyperthyroidism. B - A condition in the elderly where features of thyrotoxicosis may be subtle or masked, and patients may present mainly with fatigue and weight loss. D - Caused by the inhibition of T4 to T3 conversion due to Amiodarone intake

Answer 314

D. She has increased risk of osteoporosis

Answer 315

D. A 60-year-old postmenopausal female with height loss of 0.9 inches

Answer 316

B. He needs adjuvant mitotane. Patients with confirmed ACC and successful removal of the primary tumor should receive adjuvant treatment with mitotane, particularly in patients with a high risk of recurrence as determined by tumor size >8 cm, histopathologic signs of vascular invasion, capsule invasion or violation, and a Ki67 proliferation index ≥10%. Adjuvant mitotane should be continued for at least 2 years, if side effects are tolerated.

Answer 317

D. High dose dexamethasone test To further differentiate if acth dependent or not since ACTH not >15 or <5

Answer 318

C. Transphenoidal pituitary surgery POSITIVE if: ● Low dose DEX test (Plasma cortisol >50 nmol/L after 0.5 mg DEX q6h for 2 days or a single dose of 8 mg overnight) ● High dose DEX test (Cortisol suppression >50% after q6h 2 mg DEX for 2 days)

Answer 319

D. A calorie deficit of at least 500 kcal/day compared to patient’s usual diet to achieve goal weight of 1-2 lbs/week A calorie deficit of 500–750 kcal/day is recommended to achieve a weight loss of approximately 1–2 pounds (0.45–0.9 kg) per week. 1,500–1,800 kcal/day for men or individuals with higher calorie needs.

Answer 320

B. Renal tumors secrete parathyroid hormone related peptide which cause increase bone resorption and lead to hypercalcemia, hypophosphatemia even in the absence of bone mets

Answer 321

A. The recommended daily allowance for supplemental Vitamin D is 1000 to 2000 IU to maintain 25 OHD >30 ng/ml If not at risk of osteporosis - only need >20 ng/mL but since with risk since menopause , need to maintain >30

Answer 322

B. Discontinue recombinant GH therapy and monitor patient A peak GH level ≥5 µg/L during hypoglycemia (glucose <40 mg/dL) indicates sufficient GH reserve in adults, ruling out GH deficiency.

Answer 323

C. Starting dose of hydrocortisone replacement preferably should generally not exceed 20mg daily, divided into 2-3 doses Hydrocortisone is preferred over prednisone for adrenal insufficiency because: It has a shorter half-life, better mimicking the natural diurnal rhythm of cortisol secretion. It is easier to titrate to physiologic doses.

Answer 324

C. Occurring as 2 or more autoantibodies in 80% of T1DM after a 15-year follow-up.

Answer 325

A. Abnormal lipid metabolism inc hepatic glucose synthesis Systemic low grade inflammation

Answer 326

C. Presence of amyloid fibrillar deposits

Answer 327

B. Higher risk for fractures They decrease bone mineral density by promoting adipocyte differentiation at the expense of osteoblastogenesis, leading to reduced bone formation. Same with canagliflozin

Answer 328

D. Sitagliptin Dpp4 inhibitors --> incretin

Answer 329

C. Metformin 1000 mg/tab, 1 tab twice a day after breakfast and supper Metformin is a first-line therapy for T2DM and works by reducing hepatic glucose production (primarily gluconeogenesis). It improves insulin sensitivity in the liver and peripheral tissues. By addressing excessive hepatic glucose output, metformin is particularly effective in reducing fasting blood glucose levels.

Answer 330

B. Autonomous aldosterone excess caused by somatic mutations in the potassium channel GIRK4, encoded by KCNJ5

Answer 331

C. Glucocorticoid-remediable aldosteronism (GRA)

Answer 332

B. Cerebrovascular events at < 40 years of age

Answer 333

A. Alendronate Alendronate, a bisphosphonate, impairs osteoclast activity primarily by inducing osteoclast apoptosis and inhibiting bone resorption Calcitonin inhibits osteoclast activity by directly binding to calcitonin receptors on osteoclasts, leading to decreased bone resorption. However, it does not induce apoptosis Denosumab is a monoclonal antibody that targets RANKL, preventing it from binding to its receptor (RANK) on osteoclast precursors. This inhibits the formation, function, and survival of osteoclasts but does not directly induce apoptosis. Raloxifene is a selective estrogen receptor modulator (SERM) that mimics estrogen’s effects on bone by reducing bone resorption. It has no direct impact on osteoclast apoptosis.

Answer 334

d. HDL= 0.80 mmol/L HDL 0.8 mmol/L x 38.67 (conversion factor) =30.9 TAG should be > 2.82

Answer 335

c. Monitor glucose during exercise and ingest carbohydrate to prevent hypoglycemia.

Answer 336

c. The combination of insulin deficiency and hyperglycemia reduces the hepatic level of fructose-2,6-bisphosphate.

Answer 337

b. If the serum phosphate is <0.32mmol/L, then phosphate supplementation should be considered. Hypophosphatemia may result from increased glucose usage, but randomized clinical trials have not demonstrated that phosphate replacement is beneficial in DKA. If the serum phosphate is <0.32 mmol/L (1 mg/dL), then phosphate supplement should be considered and the serum calcium monitored

Answer 338

c. Fenofibrate Fibrates are first-line therapy for patients with severe hypertriglyceridemia (TG >500 mg/dL) to prevent pancreatitis. Niacin may cause insulin resistance

Answer 339

c. decreased expiratory reserve volume

Answer 340

c. Determine growth hormone level after 75 grams oral glucose load Age-matched serum IGF-1 levels are elevated in acromegaly. Consequently, an IGF-1 level provides a useful laboratory screening measure when clinical features raise the possibility of acromegaly. The diagnosis of acromegaly is confirmed by demonstrating the failure of GH suppression to <0.4 μg/L within 1–2 h of an oral glucose load (75 g). When ultrasensitive GH assays are used, normal nadir GH levels are even lower (<0.05 μg/L).

Answer 341

b. Nephrogenic Diabetes Insipidus

Answer 342

c. A.F, a 42-year-old male with low cortisol and ACTH Adrenal insufficiency is a well-recognized risk factor for generalized osteoporosis. a. should be hyper not hypothyroidism b. hyper not hypo prolactinemia

Answer 343

a. Evaluate pituitary function. The patient has low free T4 (fT4) and free T3 (fT3) with a normal TSH. This pattern suggests central (secondary or tertiary) hypothyroidism, which is caused by dysfunction at the level of the pituitary or hypothalamus

Answer 344

b. Parenteral hydrocortisone (50mg every 6 h) should be administered. D also correct but steroids first due to decreased adrenal reserve

Answer 345

d. TSH-secreting Pituitary Adenoma The patient presents with symptoms of thyrotoxicosis, normal TSH, and elevated free T4 (fT4) and free T3 (fT3). This pattern suggests inappropriate TSH secretion despite elevated thyroid hormones, which is most consistent with a TSH-secreting pituitary adenoma (TSHoma). Subclinical is low TSH but normal TFTs hence not the answer

Answer 346

c. Levothyroxine replacement may be needed if the hypothyroid phase is prolonged, but doses should be 50–100 μg/day Patient has subacute thyroiditis (de Quervain’s thyroiditis) a. Aspirin 80mg/tablet may be given at a dose of 5-6 tablets every 4-6 hours. --> Relatively large doses of aspirin (e.g., 600 mg every 4–6 h) or nonsteroidal anti-inflammatory drugs (NSAIDs) are sufficient to control symptoms in many cases. 600 = 7-8 tabs b. Either PTU or Methimazole can be given during the thyrotoxic phase, but preferably Methimazole. ----> Antithyroid drugs play no role in treatment of the thyrotoxic phase. LT4 replacement may be needed if the hypothyroid phase is prolonged, but doses should be low enough (50–100 μg daily) to allow TSH-mediated recovery. d. If Aspirin or NSAID is not sufficient, Prednisone may be given at a dose of 3-4mg/kg/day for 8 to 12 weeks and must be tapered based on patient’s symptoms. --> 6-8 weeks

Answer 347

a. Request for radionuclide scan

Answer 348

c. Perform inferior petrosal sinus sampling Equivocal results in DDX 2

Answer 349

d. Ectopic ACTH Syndrome The elevated urinary cortisol and ACTH levels point to an ACTH-dependent cause of hypercortisolism, with ectopic ACTH syndrome (EAS) being the most likely diagnosis based on the clinical and biochemical findings.

Answer 350

c. Start treatment with Spironolactone

Answer 351

d. Perform MRI of the pituitary gland

Endocrinology Flashcards

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