Flashcards in Endocrinology Deck (351):
Dopamine-> inhib prolactin
Post pit directly releases oxytocin/ADH
Screening for Axis fxn
Hypoth-Pit-Gonadal-check serum LH/FSH
Hypothal-Pit-Thyroid -> TSH/T4
Hypothal-Pit-Adrenal Axis->ACTH (serum)
Most sensitive determinant of pitutiary fxn?
Screening for hormone excess
Acromegaly-> IGF-1 (not GH - is pulsatile)
Cushings -> 1mg DMS
Pt with MVA - CT head with no bleed but 0.8cm solid mass in pituitary - pt nulliparus, menstation regular wtd?
check prolactin, T4/TSH/IGF-1 and 1mg DMS test (all axises)
Things that increase prolactin
Prolactin >200 - macroadenoma
failure then surgery
Middle aged woman wit dec libiddo adn fatigue test low, FSH low
check prolactin adn TSH
Pt wit galactorreha wtd?
check TSH and prolactin
Young woman with galactorreha on manipulation of nipple, TSH/prolactin normal
avoid manipulation of nipple
35yo F with galactorreha and amenorrhea x 6 months - preg neg prolactin 184 TFT normal wtd?
MRI r/o stalk tumor
Pt post partum continues to have galactorrhea fter finishing nursing baby - TSH 2.8, prolactin 281 takes no meds - dx?
prolactinoma - check MRI
45yo M c/o fatigue and dec libido - testosterone 18, prolactin 2500 FSH 2.2 cause?
Pt with prolactinoma micro or macro - wants to concive
start dopamin agonist (bromocryptine - reduce prolactin level and induce ovulation
Pt tx'd with bromocryptine for macroadenoma and gets pregnant wtd?
monitor visual fields - only restart if changes
inc'ing shoe size, hat size, ring size, hyperglycemia, prominent jaw, wide space between teeth, big tongue, flshey palms soles, osteoarthritis changes on Xray
Screening test for acromegaly
IGF-1 (somatosatin C) - also to follow dz activity
Confirm acromegaly (after IGF-1 screening) with...
oral glucose suppression test
failure to suppress GH to <2ng after 100g glucose
Tx for Acromegaly
Complciations of acromegaly
HTN, LVH, CHF, OSA, colonic polyps, carpel Tunnel
dx FBS>126 - repeat x 1 to confirm
Random blood sugar >200 with sx
75g gluc load GTT >200
Pt with BP 135/80 or BMI 25 or sedentery lifestyle or >40 wtd?
screen for DM (FSG, HgA1c)
Pt with DM (FSG >126) at risk for
DM and retinopathy, nephropathy
DM I vs II
check for Ab vs glutamic acid carboxylase, ab to islet cells
Diet/excercise - 0.4% red A1c
Type I-> insulin
Type II sulfonyureas (hypogly), biguanide (metformin), repaglinide, glitazone, insulin, exenatid(no hypo, incretin (no hypo)
All Type I DM
Type II not responding to oral hypoglycemics
Type II on oral mes but hospitalized, major surgery, infxn
Hospitalized pateint with DM
tx with basal insulin and rapid acting agent
Sulfonyureas (glipizide), glyburide, glimeperide
inc'd release insulin form B cells
avoid in obese pts
Meglitnide - repaglinid
inc rel insulin from B cells - excreted in bile ok in renal insufficiency - rapid
Biguanides - metformin
dec hepatic gluconeogenesis, dec insulin resistantce, dec weight, TG, chol
bestin obese pts with inc TGA
avoid in renal failure
A glucosidase inhibitors - acarbose
inhbits breakdown of cardbs, dec absorption of glucose - use for post prandial hyperglycemia
Thiazolidinediones (glitazones) - pioglitazone - actos
PPAR rct - inc glucose transport dec insluin resistance dec TGA, inc LDL - avoid in NYHA II HF
Incretin mimetics - exenatide GLP1 agonist
dec hep gluconeogenesis, dec gastric emphtying wt loss, early satiety inc'd cell growth
good for obese pt failing metformin +- glit/sulf
watch out for pancreatitis
Inretin memetic - DDP4
Amylin analogue pramlintide
slows gastric emptying dec glucagon secretion, wt loss and early satiety
complementary to insulin, no hypoglycemia
good for obese pt failing insulin therapy with high post prandial BS
Which DM meds DO NOT CAUSE WT GAIN?
Metformin, incretin drugs (exenatide and amylin alaog pramlintide
Blood sugar goals in DM
Pt with BMI 32, FBS 115 fhx DM - best way to prevent DM?
Diet/excercise (aerobics and resistance training
Drugs that cause hyperglycemia
Statins, BB, HCTZ, niacin, olanzapine, PI, steroids
45yo F dx with Type II DM 4 montsh ago with FBS 170 A1c 8.9 wt 205 started on exc/diet - repeat FBS 165 wtd?
Pt with DM II and obese not well controlled on sulfonyurea (glipiz,glyburide, glimeperide)
What' increases insulin sensitivity
Which drug improves mortality and dec early HF in DM pts
Pt with DM2 responsds well to metformin adn sulfonyrea for years bu tnow with inc BS, no infxn, HgA1c 9 - wtd
add insulin basal - keep only metformin
If FBS with just insulin and metformin still 115- 130
start lispro insulin
Pt refuses insulin injections wtd
continue metformin add sulfonyurea or glitazone
When is metformin contraindicated?
Cr >1.4 F>1.5 M and advanced HF (>NYHA II)
Pt on multiple meds Cr >1.5, CHF EF 35% wtd?
d/c metformine and glitazone, start glargine for detemir and lispro or aspart
Pt going for cardiac cath or radiocontrast study - what drug to stop?
60yo Pt dx with DMII - Cr 3.7 - what meds to start?
repaglinide (excreted in bile)
40yo Pt with DM2 tx'd with metformin - 1 year later gaining wt as he stopped excerciseing BS also up
start exenatide (GLP-1) good for obese pt failing metformin
Dawn's Phenomenon - pt wakes up with fatigue, sweating h/a, vivid dreams
inc'd 4-7am gluc 2/2 insulin resistance/hormonal factors
Tx - inc PM NPM
DM pt on NPH/R in AM, supper or glardgine HS
Palpitations, sweating, nocturnal awakening AM h/a wtd?
check 3am FSG
Blood sugar 3am 40
change NPH to HS or swtichto long acting insulin analog (glargine)
Persistently ele FBS 3am 200
inc supper NPH or glargine
Blood sugar 30 pt passes out at 12noon on 20 U NPH and 5 U R in AM wtd?
D/C "R insulin" in AM
FSG 180 5pm
in NPM in AM
FSG 4pm 25 and 10pm 210 pt in 36U NPH in AM
Change to 24 U NPH AM and 12U NPH PM
All post prandials high, premeals ok on basal bolus regimen
inc dose of pre-meal insulin
All pre and post prandials high
inc long acting insulin dose
FBG 115 but A1c 7.5 takes NPH/metformin wtd?
check POST prandial blood sugar
65yo M DM started on glargine insulin 30U qam with metformin with FSG going steadily up throughout day
change to glargine twice daily
Mass kg * 0.5u/kg = total daily insulin
1/2 total daily as basal (15 daily)
1/2 total insulin as lispro TID (5 tid) premeal
AA M DM f/u FBS 115-130 A1c 11 etiolgoy?
Falsely elevated HgA1c
decreased RBC turnover (dec retic)
Sickle cell, thalassemia
Falsely LOWER HgaA1c
inc'd RC turnover (inc retic)
Hemolytic anemia, HIV
treating IDA, folate
B12 def or blood tx
Pt Hg 6.6 - BS ranges between 90-150 except 5pm which is 280 has fresh fuit snake at 4pm etio?
Not washing hands after fruit snack - false elevation of A1c
Pt with DM, BS 340, TG 2400 hospitalized with pancreatitis - fastest way to control TG would be to give...
Pt IDDM with abd pain has DKA, started on insulin gtt 10u?hr, IF BS dec to 250 and IVF changed to D51/2NS and insulin gtt dec'd to 5U/hr - BS now inc'd to 375, AG 19
wtd? - inc insulin gtt
How to prevent DKA pt from going back into DKA when turning off insulin gtt -
give SQ insulin 30 min prior to stopping insulin gtt
Pt with diabetic ketoacidosis BS 725, ketones +++ started on insulin gtt, ivf 10am - BS 250 at 7pm - wtd?
start IVF D51/2NS, c/w insulin gtt
Follow with AG if closed then overlap SQ insulin
Pt with DM admitted for surgery in AM - on glargine and lispro wtd morning of surgery if pt receives glargine in AM, in PM
Glargine AM schedule: 1/2 dose glargine and NO lispro
Glargine PM schedule: d/c lispro
24yo Preg F 24th wk FBS 115, repeat 114 - wtd?
Metformin (ok in preg)
25yo DM pt 24th wk FBS 120, post prandial 180 on glucotrol and metformin wtf?
Elerly pt DMII brought in with seizure - BS 1050, BUN /cr 50/1.8, ketones + dx?
Hyperosmolar non-ketotic coma -
inc 100 gluc, Na dec 1.6 up to 300
>300 inc 100 Gluc dec Na 2.5
Type I DM with DKA BS 725, ketones +++ on insulin gtt 10am - 10pm BS 200, ketones neg - bicarb up to 18 from 4, K dropped to 4.5 - pt with difficuulty breathing/muscle wk - +CPK, most likely cuase
hypophosphatemia - insluin drip forces lyesinto cells - no Phos to make ATP
Nurse calls you to let you know FBS 62
Asymptomatic - adjust regimen
Symptomatic with tachycardia - 15gm carbs, if on acarbose then pur glucose (dextrose) and adjust tx regimen
Newly Dx DM BG 350 on insulin drops to 130 - becomes tachy adn diaphoretic wtd
keep <200 at first
Macrovasc - CAD/PAD - aggressive LDL control autonomic
peripher sensory motor polyneuropathy
stock/glove distribution - amitryptyline, desipramine, gabapentin
DM Autonic neuroapthy
Impotence - tx with phospodiesterase inhibitor (viagra)
Neurogenic bladder - urinary hesitancy, dribbling, incomplete evacuation - bladder training, bethancol
orthostatic hypotension - fludrocortisone & high salt diet
Gastropareisis - wide fluctuation of BS 50-400mg
DM foot ulcers - common bug S aur, b hem strep
Cause of DM foot ulcer
Best way to prevent DM foot ulcer
mon-filament testing - protective footwear
Pt with DM 15yr on metformin sulfonyrea/insulin with hypoglycemic attacks post prandial, early satiety, oitting BS 50 to 400 range widely dx?
Gastropareisis (autonomic neuropathy)
Best test - SCscintography of gastric contents
Tx - small frequent meals of liquid/pureed low fat, low in no-digestible fiber - metoclopramide/domeperidone
T/F type I DM should have annual eye exam after 5 yers after onset of DM or age 30 whichever first
T/F Type 2 DM pt shoudl have annual eye exam from onset of dz
T/F DM pt with difficulty driving at night will prob have ED
T/F ACCORD trial HgA1cd hypoglycemic events
T/F ACCORD trial BP <140./80 had more s/e
Current recommendations for f/u DM pt
HgA1c quarterly, microalb semi ann, lipid panel annual, opthal exam annually
Pt with BS 35 taking glipizide, metformin acarbose
admit start IV dextrose
22yo F recurrent dizzy attacks in ER, mother DM, blood gluc 35 - next dx test
make sure no surepticous insulin/sulfonyurea use - check urine serum sulfonyurea screen
Above pt still hypoglycemic - ampule D50 give, IV dextrose started next step?
glucagon then octreodtide
downreguated by T4, lithium, iodine
dec T3, normal T4 and TSH
best test to screen for thyroid dz
confirm with T4, FTI
Best test to follow hypothyroid tx
Best test to follow Hyperthyroid tx
FT4 or T3
Total T4 + T3=T3RIA
T3 inc->inc T3 RIA
inc'd Hyperthyroid states (graves, hot nodules)
dec'd thyroiditis (exogenous, amiodarone)
differentiate between hot vs cold nodules
diff solid vs cystic
inc FT4, inc T3, dec TSH, inc RAI
hot nodules - inc FT4, inc T3, dec TSH, inc RAI
inc FT4, inc T3 ria, dec TSH, inc RAI
n/dec FT4, inc T3 ria, dec TSH, inc RAI
inc FT4, inc T3RIA, inc TSH, inc RAI
inc thyroglobulins, inc FT4, inc T3 RIA, dec TSH, inc RAI
exogenous T3 (factitious)
dec FT4, inc T3RIA, dec TSH, Dec RAI
Exog T4 (factitious)
inc FT4, inc T3 RIA, dec TSH, dec RAI
dec FT4, Dec T3 RIA, inc TSH - RAI n/a
dec FT4, dec T3 RIA, dec TSH
Pt with wt loss, feels warm in windter, tremors, inc appetite, diarrhea, palpiatins, afib, enlarged thyroid FTI inc, TSH dec wtd?
Radioactive uptake study
diffuse - graves
Focal - toxic nodule
uptake - thyroiditis
areas of inc and dec uptake - multinodular goiter
Pt with hyperthyroid and dec'd radioiodine uptake - how to differentiate thyroititis vs factitous thyrotoxicosis
inc'd thyroglobulin - thyroiditis (and follicular/papillary CA)
dec'd thyroglobulin - factitious thyrotoxicosis
inc'd TBG - estrogen/pegnancy
Elderly pt with wk, EKG afbi, TSH dec'd - etiology of afib?
Elderly pt with apathy, wt loss, arrythmia, CHF, diarrhea, depression, sleepiness, TSH dec, T4 nlow normal T3RU >30%
Pt with T4 elv, TSH 4.5
MRI brain (no feedback - with high T4 should be low TSH unless there is pituitary tumor secreteing TSH)
26yo F si/sx hyperthyroid - started on a new "diet pill recently and has been excercisign - T3 elev, TSH low and RAI uptake low
taking thyroxine in "diet pill"
40yo Pt with asympt low tsh
subclinical hyperthyroid - onitor, repeat TSH in 3months - tx only if osteoprosis or CV dz present
Tx of thyrotoxicosis (TSHr AB_, anti TPO +
Pregnancy -> 1st trim PTU (SE agranulocytosis, ANCA + ab, MPO+ (1st trimester ONLY)
Others-> radioactive Iodine-> >50% become hypothyroid in 2months
Thyroid ophthalmopathy - subtotal thyroidectomy
52yo F a/w PNA - exam pt confused hitting med staff and inattentive - diarrhea and family says lost 15lbs in 6 months - tmep 104, HR 140 rales at bases CXR RLL consodiation - on abx 2 days later hypotensive adn comatosed - dx?
Tx: PTU/steroids + BB, digoxin for afib
etio - infxn, surgery, trauma
Can you cardiovert afib to NSR in thyroid storm?
No, not till 3 months after euthyroid - spontaneous conversion common
Pt with graves d has radioiodine ablation - 8 wks later gained wt, TSH 0.2, free T4 0.2 wtd?
start T4 (hypothyroid)
hypothyroid pt started on T4 - 2 months later watery eyes, slceral injection, perioorbital edema, afferent pupillary defiect, painful eye movement - dx?
Thyroid ophthalmopathy with opti cnerve impingenment
Pt with thyrotoxicosis and ophthalmopathy - management?
all with dec'd RAI uptake - may present hyper,hypo or euthyroid
Release of preformed hormones - thyrotoxicosis - returns to nromal
Pt with URI, soreless in neck enlarged tender thyroid, inc'd ESR, inc T3RU, T4 normal - how to get dx?
RAI uptake - decreased
subacute thyroiditis - sub acute granulomatous, de Quervain's thyroitis
Palpitations with tachycardia - BB
Pain - ASA + NSAIDs
DO NOT USE antithyroid drugs
don't need to check for antibodies....
Young pt with nervousness, insomnia, irritability after uncompicated delvery - is breast feeding, thyroid endalrged, non-tender, TSH low, T4 mildly elevated - dx lyphocytis thyroitis - wtd?
BB only - avoid RAIU during lactation
Usually transient hyperhtyroid then hypotheyroid then euthyroid after several months
Ab most likley to differential graves vs thyroiditis
TSH rct autoab in graves
Anti TPO + in both, TBG elev in both
Young woman 4 months post partum wit huncomplicated couse with wt gain, low enverygy, delayed DTR, amenorrhea - preg neg wtd?
Check TSH, r/o hypothyroid stage or chronic lyphocytic thyroiditis
30yo post partum with tremor and depression - T4 high, - reassure her but coems back 1 month later with dpression now fatigue - T4 low, TSH high wtd?
start synthroid, reassure and reepeat TFT in 3 months or less
Pt p/w tremor/tachycardia on asa, dig, amiodarone, IFN - T3, T4 high, TSH low, RAI < 5% - etiology?
Amiodarone or alpha interfereron
Pt with acute illness intubated and in ICU - episode of hypotension on vasopressors - T4 nl/dec, T3 low, TSH nl/low
SICK euthyroid syndrome
Tx: tx underlying cause - repeat TSH 2-3 wks after recovery
cold intolerance constipation, coarsening of feathers, delayed DTR, amenorrhea, elevated prolactin
TSH elev, T4 dec
TSH dec, T4 dec, rT3 dec
TSH inc, T4 nl
Pt p/w fatigue, cold intolerance and delayed DTR - TSH 6, T4 1.2 (normal)
hasimotos thyroiditis - leading cuase of hypothyroid - anti-TPO+
28yo F fatigue, wk, difficulty getting up from sitting, pain in hands CPK 200, DTR slow wtd?
check TSH (joint pain, inc CPK, dec DTR)
In pt with CAD or elderly start...
low dose synthoid
Start 25mcg and inc 24 q4-6 wks
check TSH if inc/d same inc T4,
If TSH dec - dec T4 dose
Pt taking synthroid for hypothyroid T4 nl, T3 nl, TSH high wtd?
inc T4 dose
Hypothyroid pt on thyroixin goes on <1wk vac forget meds wtd?
restart T4 upon arrival (t1/2 T4 is 7 days)
Hypothyroid pt started on levothyroxine 200mcg - 3 montsh later TSH 2 T4 1.6, Te 6 - pt c/o not losing wt despite diet/exc - BMI elev
continue same dose of T4
Pt with refractive arrhythia - resonding to amiodarone - 4 months later with sx of hypothyroid TSH elev, T4 dec wtd?
leading cuase of hypothyroid
CPK elevated before sx of hypothyroid
Indications for tx subclinical hypothyroid
anti-thyroid perioxidase Ab (anti TPO)+
Pt with bipolar dz responsds to leithium fo r>8yrs - past sever montsh wt gain, delayed DTR T4 borderline, TSH inc'd wtd?
Pt with slightly elev TSH - repeat TFT cofirm elev of TSH 12 - T3/T3 normal - asympt0omatic, BMI 30, LDL 160
Tx - with levothyroxine - results in lowered LDL
Pt with 3 v CAD going for CABG TSH 11 wtd?
Clear for surgery
Pt with angina has cardiac cath - develops thyroid swelling T4 1.6, TSH 5
repeat T4 in 4 weeks
Pt with 15lb wt gain over few months unable to lose - delsyed tendon reflexes, TSH inc'd wtd?
Pt brought to ED on cold day, stuperous, hypothermic, bradycardic to 40/min periorbital edema, pugblic hair loss, amxillary hair loss
Tx - Iv hydrocortisone plus T4/T3 + abx
Pt with hypothyroid controlled on synthroid get pregnant - what is increased requirement of synthroid
Elevated during 1st trim - till end of preg 30-50%
Preg pt with anti-TPO ab and started on levothyroxine - check TSH in 6 weeks - what is target TSH?
Hot and cystic - benign
COld and solid - r/o malingnancy
Asyx nodule on physical exam - wtd?
Pt with cold and solid nodule - TSH 1.5, US with hypoechoic nodule wtd?
FN bx (FNA)
If TSH dec and T4 inc wtd? - confirm dx with RAIU
if uptake inc'd - graves dz ->
tx: anti-thyroid meds -> radioactive iodine-> surgery
RAIU - Radioactive Iodine uptake test
used in dx of thyroid problems esp hyperthyroid
also used after radioactive iodide ablation to make sure no thyroid cells survived (could still be cancerous)
Low uptake suggests thyroiditis
High uptake suggests Graves dz
Uneven uptake suggest thyroid nodule
Pt with multinodular goiter on synthroid >1 yr p/w palpitations and wt loss - FTI inc, TSH dec, synthroid dose dec'd - 8 weeks later T4 still high, TSH still dec, T4 dose is again lowered and repeat TSH is still low wtd?
If uptake dec then lower T4 dose and repeat TSH
If uptake high pt now euthyroid or has thyrotxicosis
stop synthoid and repeat TSH in 6 wks
FTI=free thyroid index
assessment of free unsaturated thryoid binding proteins - estimate of amount of circulating free thyroxine
Pt develops panhypopit including hypothyroid after radiotherapy to brain - TSH 0.1, replacement with levothyroxine began - how to follow this pt?
Free T4 (NOT TSH - will never go up because of hypopanpit)
Pt with longstanding h/o goiterous hashimotos thyroiditis p/w enlarging goiter, sob, harosenss and dysfphagia - exam with goiter tha tis hard and dosen't move on swallowing - dx?
Thyroid lymphcytic B cell type (60x more common with hashimotos)
Nuclear power plant disaster - what to give surrounding community?
Potassium iodide (ideally before to prevent radioactive iodine uptake from nuclear plant....)
Vitamin D deficiency
Tx 50KIU/wk po then 1-2Kiu/day
Vit D insufficiency
<30ng/day (dec muscle strength)
Tx 1-2K IU/day
Vit D sufficiency
70yo 800 IU/day
At what vit D dose are fractures preventable
Pt with serium Ca 11.5, repeat 11.5 - wtd next to ID etio?
check serum PTH
inc 1,25OHD3 - inc Ca+/PO4 absorp from Gut
in macrophages - 25OHD3--> 1,25OHD3
inc Ca absorbp from gut, dec PO4
dec'd 1,25OHD3 (25OHD3-> 1,25OHD3 in kidney)
what does 1,25OH2D3 do?
mobilizes Ca+/PO4 from gut
HyperCa (bone breakdown)
fastest agent is calcitonin (2-3 days)
then change to bisphosphonate
Ca inc PTH inc
primary hyperPTH (PO4 dec)
or Lithium tx
If Pa inc, PTH N
Familial benign hypocalciuric hypercaclcemia (FBHH)
abnormal Ca sensor in kidney - mild high serium Ca
Urine Ca to Cr ratio <0.01
NO TX NEEDED
If Ca inc PTH ver low
Malignance - MM - MCC hyper Ca+
PTH like sustance not measured by regular PTH assay
Skeletal survey needed
Vit D intox
check 1,25OH2D3 (inc'd bowel Ca+ absorbtion)
Other causes of hyper Ca+
Thiazide diruetics - dec'd Ca+ excretion
Lithium induced hyper Ca+ inc'd threshold of Ca need to dec PTH production
wtd? d/c lithium
Lithium induced hypothroid wtd?
treat with levothyroxine
inc'd PTH, inc'd Ca+, dec PO4
Bankd keratopathy, subperiodsteal bone resorption (moth eaten phalangeoal cortex on xray hand
Skull xray with punched out lesion
renal stones and muscle wkness
50% also with Vit D def - with PTH always check 25OHD3
May be in MENs syndrome
Leading cause of secondary HyperPTH?
Vit D dif
Pt with PTH elevation what to measure?
25 OH D3
Vit D inc'd
PTH dec (feedback), Ca inc, PO4 inc
PTH dec, Ca inc, PO4 inc
inc PTH, inc Ca+, dec PTH
PTH dec, Ca inc, PO4 dec
Milk alkali syndrome (antacids)
dec PTH, inc Ca+, dec PO4
MEN type I
Parathyroid - inc'd Ca+
Pituitary - MRI r/o it tumor
Pancrease - hypoglycemia
Pheochromocytoma - HTN, palptiations 24 hr metaneph urine
Ca Medullary thryoid- calcitonin inc'd
Parathyroid - inc'd Ca+
Ca Med thyroid
Pt with thyroid Mass, Ca inc'd calcitonin inc'd dnese calficiation in mass mdulalary Ca dx - screen family members?
yes - serium calcitonin RET proto oncogene
45yo F thyroid nodule 2.5cm, asx, TFT normal FNAB - medulalary cardinoma - serum calcitonin 1200 - scheduled for thryoidectomy - wtd prior to surgery
24hr urine metanephrine and catechol r/o pheo
34yo with recurren tnephorlitiasis Ca 11.5, PO4 2.3, perum PTH 225 - managment?
surgical exploration of neck for PTHoma
Indications for PTH surgery
Serum Ca >2mg abv normal (11.5)
30% red in Cr clearance
Sx (osteoporosis T >-2.5, dehydration, stones)
40yo asx woman with minimal hyperCa, PTH 125 wtd?
refer for surgery
Pt with hyperPTH refused PTH ectomy wtd?
Asx pt with Ca 10.5 - serum PTH 45 no h/o stones
check urine exretion of Ca - familal benign hypocalciuric hypercalcemia
35yo health concious excercise takes lot of vitamins p/w fague, constipation MM dry Ca 11.2, PTH 10 - most likely has?
Vit D intoxiation (25 OH D3)
45yo F c/o getting up at night ot urinate - constipated MM dry nauseous only other hx dyspepsia (takes lots of antiacids) Ca 11, Phos 2.5, PTH 15 dx?
Mild akali syndrome
tx - change ca+ containing antacids
Pt with lung Ca to ER with mental obtundation Ca 17 - mamagement?
long term management - zolendronate>pamidronate
Fastest acting hypocalcemic agent
Calcitonin - 2-3 days then resistance...
Least likely cuase of hyper Ca+
32yo F with Ca 11.5, PO4 4, CXR b/l hilar LAD - whic elevated?
sarcoid - 1,25OHD3 (macrophages
28yo F kidney stone, Ca 11.2, PO4 4.1, serum PTH 7 dx?
tx with prednisone after controlling hyper Ca+
dec PTH, dec Ca inc PO4
Dec PTH, dec Ca, inc PO4, dec K+
Vit D def
inc PTH, dec Ca, dec PO4, inc alk phos
inc PTH, dec Ca, inc PO4
Young pt with h/o irritability depression muscle wk Chvstek/trousseau's sign, dec Ca, dec PTH, inc PO4
65yo M bone pain, osteopenia on xray, serum Ca 7, P4 1.9, alk phos 145, alb 2.2 serum protein 4.5, xray bands of radiolucense cause?
osteomalaicia 2/2 vit D def
Pt with fx on alendronate tx Ca 7.4, PO4 2.2, alk phos 135 dx?
Vit D def
Xray with SHORT 4th and 5th METACARPELS dx?
PseudohypoPTH (appropriate high PTH - tissues don't respond to PTH so Ca is still low)
etio? dec'd tissue response to PTH
Inc'd Ca+ in Tb/Sarcoid/leprocy
inc'd 1.25OHD3 from macrophages in granulomatous tissue
How to dx Osteoporosis
FRAX - clinical risk factors + femoral neck BMD with DXA (more than -2.5)
Clinical risk factors for osteoporosis
parental h/o hip fx
low Vit D
Chronic liver dz
Inflamm bowel dz
Drugs - steroids 5mg/day x 3 months at least
Dilantin, long term heparin, aromatase inhibitors
Which is bigger risk factor for osteoporosis
Obestity bigger risk for osteoarthritis
Pt on prednisone 5mg/day > 3months
get DEXA baseline then yearly if stil on steroids
DEXA socre -1.5, pt on Ca/vit D wtd?
If normal pt (not on steroids) T score < -2.5 then start bisphosphonate
52yo M pw pain in R groin and thigh for couple weeks denies trauma and walks a mile /day, alk phos normal Ca 9.2 ESR 23, Xray mild osteopenia MRI T1 def enhancement fem head T2 inc enhancement of fem head dx?
R groin pain with rheum arthritis and osteophytes on xray
R groin pain, with Rheum arthritsi xray neg, MRI double line sign on T2 dx?
tx: quit smoking, start bisphosphonate
calcitoin for pain
Vit D 70 800 IU/day
Teriparatide - dec osteoclast, inc osteoblast
65yo post menopausal F wnats to know risk for osteoporosis - past hx with renal stone 5ya - T score -.25, Z score -1.5 wtd?
Alendronate + Ca + vit D
(nephrolithiasis NOT contradindication for inc Ca in diet)
Elderly F with hip fx DEXA -1.4 most imporant indiactor for starting alendronate ?
Most important risk factor for fracture?
hx of hip fx with normal T score (< -2.5)
70yo pt with serum Ca 11.5, PTH 115 DEXA T score -2.5 hip -1.5 spine etiology of osteoporosis?
70yo F comes to renew estrogen for osteoporosis wtd?
d/c estrogen start alendronate, Ca, Vit D
What medication shown to dec mortality in Pt with osteoprosis and fx
Zolendronate (S/e fever, myalgia)
65yo F with osteoprosis and renal insufficiency
Denosumab (RANKL inhibitor - prevents preosteoclasts from maturing into functional osteoclasts)
Pt taking Vit D and Ca - 48yo develops hot flashes what med for both bone health and hot flashes?
estrogen and progestin
T/F Local estrogen therapy helpful for vulvo vaginal atrophy
T/F Local estrogen therapy didn't releive dysparenunia
T/F Local estrogen therapy can reduce risk of recurrent UTIs
T/F hormone therapy does not reduce post menopaual osteoporotic fx's
T/F Hormonal tx within 10 years of menopaus in age less tthan 60 and use of hormonal therapy more than 5 years a/w reduction in 30% total morrtality and indicence of heart dz - not recommended assole reason for therapy
T/F Risk of heart dz increased if hormonal therapy started after menopause
T/F estrogen progestin therapy in's risk fo ischemic stroke in F > 60
T/F inc'd risk of DVT, however risk lower if started below 60
T/F unopposed estrogen tx at increased risk of endometrial Ca - so use concominant progestogens
T/F Breast Ca risk inc's with estrogen progest therapy for more than 5 years
T/F Hormonal therapy less than 5 years has signifcant impact on breast CA
T/F Hormone therapy if starte dafter age 65 can inc risk of dementia
T/F Hormonal tx started soon after menoapuse decreases risk of dementia later in life
T/F Hormonal replacement therapy in premature menopause that is in premature ovarial failure has protective effec ton CHF but don't extrapolate data to women experiencing menopause at a typical age
T/F Transdermal estrogen tx can be reconsidered if pthas concerns for DVT
T/F Estrogen therapy reduces risk of colon CA
58yo F long h/o hypothyroid on synthroid - what dx test to do (that is appropriate)
58yo F long h/o hypothyroid on synthroid with DEXA + for osteoporosis wtd?
check TSH if low dec T4 dose (better than starting bisphosphonate
62yo F with DEXA scan reveals T score at spine -1.1, hip -2.5 - reason for discrepancy?
osteoarthritis of spine
Pt with osteoporosis T score -2.5 on alendroneate - 2 yrs later fall with fx T score -2.5 wtd?
D/c alendronate start Teriparatide
Can use for 2 years
70yo M with hip fx, xray with osteopenia - Ca+, PO4 normal - skeletal survey no lytic lesions but osteopenia+ total proteins wnL protein electrophoresis slighly inc'd IgG no M spike wtd?
if shows osteoporosis ->
tx with alendronate
79yo prostate Ca on antiadndrogen sustains hip fx - is alcoholic - DXA shows osteoporosis - reason?
osteonecrosis of jaw (mandible)
70yo F comes ot you reading on internet bisphophonates can cause osteonecrosis - taking alendronate for 7 years wtd?
If > 5 years can stop - effect lasts for years
alk phos inc'd, bone scan +
excessive breakdown and formation of bone (osteoblast, osteoclast phases)
asx - no tx
Sx - tx with alendronate/calcitonin
Sx's bone pain, spinal cord compression fx, high output heart failure
Ca nl, Phos nl, alk phos INC, PTH nl
50's irregular mentstual cycle, hot flashes, mood changes, insomnia, fatigue during day
Vaginal dryness, stress incontinence, dec memory
Tx - estrogen +- low dose preogestine
Complications - thromboembolic events
49yo F irreg menstual cycles, insomnia fatigue wtd?
estrogen challenge see if sx imoprove - FSH unreliable
35yo F hot flashes and early menopause wtd?
FSH level - if elevated - estrogen tx
52yo irreg mentstual cycle hot flash fatigue, h/o DVT in past - refuses to go on estrogen 2/2 risk of thormbus or post breast Ca tx, cancer risk wtd?
SSRI (venlafaxine, paroxetine sertraline)
Pt with severe mood swings prior to period so bad needs to miss work - dx?
Premenstrual dysphoric d/o
Tx: Paroxetine (paxil)
Zona Glomerulosa -> aldosterone
Zona Fasciculata -> corticosteroids
Zona Reiticularis -> Sex steroids
Adrenal Medulla -> Epi/norepi
no change aldo, dec corticosteroids, dec sex steroids, no change epi/norepi
inc'd aldo, inc'd corticosteroids, inc'd sex steroids, no change epi/norepi
dec ACTH, dec sex steroids
Congential adrenal hyperplasia
21OH def - dec'd aloserone and cortisol, inc'd sex steroids
17 OH def less common - dec'd cortisol and sex steroids, inc'd aldosterone (mineralocorticoid)
Pt with hypopituitarism - started on T4 and prednisone - best way to find out adequacey of adrenal gland
DMS suppression test - stim test
Young woman with hirsuitism irreg peridos normal BP - 17OH progesterone level increased - pt has...
17 B hydroxlase def (CAH late onset)
inc'd BP, dec K, inc aldosterone, dec renin (20:1 aldo:renin)
inc'd BP, dec K, inc'd aldo, inc'd renin
dec BP inc'd K, dec aldo, dec Renin
45yo F routine physical BP 140/110, K 3.3, Cr 0.8, HCO3 27 on ACE, sprionolactone and BB wtd?
hold ace and sprionolactone
screening - paired serum aldo.renin if 20:1 primary hyper aldo
Best dx study
replete K, 2lts n/s over 4 hrs recheck serum aldo
42yo checking BP x 6 months - gradual inc - b/s also with HTN, BP 158/101, Na 134, K 2.9 wtd?
Check aldo:renin ratio or 24hr urine aldo
Pt dx with primary hyperaldo aldo:renin 20:1 - confirm with suppression test - CT abd wtd?
b/l adrenal vein sampling r/o adenoma vs hyperplasia
Tx Adenoma - surgery
Hyperplasia - spironolactone
55yo DM on insulin - BP 95/65, K 5.3, bicarb 20, Cr 2.1 BS 165 etio?
When is renin low?
Confirm with ACTH stim test (quick inc in cortisol)
Tx - flucortidsone, low K diet, lasix
(renin high in CHF and with ACEi)
pt with prox muscle wk, abd striae, fullness face, swelling back of neck, acne, facial hair irreg menstrual cycles, hyperglycemia wtd?
Cushing's syndrome w/u
24hr free cortisol in urine >100mcg.day confirms cushings
figure out where excess cortisol coming from
(leading cause pituitary adenoma)
Cushings Dz - Pituitary/ectopic
inc'd cortisol/Ucortisol, inc'd DHEA/17 ketosteroid, inc'd ACTH
inc'd cortisol/Ucortisol, dec'd DHEA/17 keto steroid, dec'd ACTH
inc'd Cortisol/Ucortisol, very inc DHEA/17 ketosteroid, dec ACTH
Dec Cortisol/UCortisol, dec DHEA/17 ketosteroid, dec ACTH
Tx: D/C (taper) steroids
25yo 10lb wt gain, amenorrhea, acne, hirsuitism and is irriatable - posterior cervical fullness
check urine free cortisol
Pt with elev 24hr urine cortisol - dx with cushings syndrome - ACTH 50 after 8mg dexamethasone suppp ACTH and cortisol suppressed wtd?
If MRI neg in cushing's w/u or ACTH can't be suppressed then wtd?
b/l inf petrosal sinus sampling
Pt p/w h/o hyperpigmentation, high BP, muscle wk no h/o wt loss - K dec, BS high CT scan - nodule in lung dx?
ACTH producing tumor
Tx Correct K, check cortisol, surgery
Pt with ACTH mediated cushing dz - source not localized wtd?
Pt s/p adrenalectomy for cushings with h/a, hyperpigmentation dx?
Nelson's syndrome - rapid enlargement of pituitary adenoma after removal of b/l adrenal glands
Tx: pituitary irradiation (replace hydrocortisone first)
Hyperpigmentation esp palmar creases, oral mucosa, wt loss, salt craving n/v/wk, postural hypotension
How to confirm addison's dz?
Check cortisol level
18 - pituitary problem - not making ACTH
Pt w/ hypotension and shock - dec Na, inc K r/o addisonian crisi
Tx: NS/IV hydrocortisone
H/o addison's on hydrocrtisone and fludorcortisone p//w viral URI - no abx presecribed wtd?
Inc hydrocortisone dose
Pt dx with hypothyroid and addison's which to treat first?
Give steroids first then thyroxine - otherwise adrenal crisis will occur
Pt dx with PNA started on ceft and azithro - h/o asthma with exacerbation 1 month ago tx'd with nebs and taping steroids - BP 90/70, orthostatic - IVF began - wtd?
Palpitations, sweating, h/a, episodic in nature labile BP
inc'd urinary exc of catecholamines and metabolites - part of MEN II/III
24 hr urine metanephrine/catecholamines
If pheo >10cm - wtd?
Check Meta Iodine Benzyl Guianine to r/o mets
Presurgical managment of Pheo
Alpha blockade FIRST with prazosin
then Betablockade with propranolol
>4-6cm - inc'd risk of malignancy
<4-6cm - benign
W/U of adrenal incidentaloma
Check fxn -
1mg overnight DMS suppression - r/o cushings
Urine catecholam/metabolites - r/o Pheo
Paired renin/Aldo, K levels -> r/o hyperaldosteronism
17 OH ketosteroids - r/o Adrenal CA
Therapy for Adrenal incidentaloma
>6cm - surgical removal whether fxn or not
No Sx if <4-6 cm non-fxn and not getting bigger on serial CT
Pt with CT scan - 2cm mass on adrenal - BP 148/86, 1mg DMS and 17 OH ket steoid normal wtd?
Check Renin:Aldo level r/o hyperaldosteronism
If BP normal check urine for catecholamines
Pt with 3cm mass on adrenal - all hormones within normal limits wtd?
Repeat CT in 4-6 months
45yo severe h/a not relieved with pain meds - next day stiff neck, fever, double vision - no rash - b/l temporal or homonymou hemianopsia BP 80/60, spinal tap few WBC /RBC - CTH lesion in pituitary/dense lesion in sella dx?
Pituitary apoplexy - bleeding into or compromised blood supply to pituitary usually a/w pitutary tumor
Tx: NSx c/s for urgen decompression
Check random cortisol
give IV glucocorticoids
25yo post partum with difficult labor and delivery, lost lot of blood, unable to breast feed and no restoration of menses - fatigued, cold intolerance and delayed refelxes - TSH/FSH low dx?
Sheehan's syndrome with hypopituitarism
tx: Replace hydrocortisone first then others....
32yo F with new onset severe h/a a/w vsiion changes - BP 90/70 supine and 80 si=ystolic sitting up, HR inc's on sitting up dx?
Inflammation of pituitary gland from autoimmunity
18yo with h/a, visual distrbance, poor sexual devlopent - urine osmolarity decreased, prolactin inc'd xray dense suprasellar calcification dx?
Klinefelter's - 47XXY
primary testicular failure small testes, gynecomastia - tall stature, low normal testosterone FSH elev
Kallman's - low FSH
GnRH deficiency and can't smell
muscular with small testes
114yo pw small penis and testes - exam with lack of pubertal and axillary hair - testosterone, LH, FSH normal wtd?
reassure - your time will come
Testosterone >350 = normal
200-350 - equivocal
Man with testosterone <350 wtd?
repeat early AM testosterone
Man with testosterone <350, BMI 35 or elderly wtd?
check sex binding globulin - dec'd with obesity and old age
Check FREE testosterone level
Man with testosterone <200 wtd?
Check if takes opiod, steroid, hormone tx
70yo M with fague - steroids fo rCOPD testosteron 140 etio?
taper steroids - d/c steroids
If can't d/c steroids then testosterone replacement tx
Pt asks if testosterone will cause prostate CA
will not change composition of prostate tissue
Can exacerbate prostate CA if present - f/u with PSA
Baseline PSA 0.5, after testosterone now PSA 2 wtd?
d/c testosterone and refer for prostate Bx
PSA SHOULD NOT more than DOUBLE with testosterone replacement tx!!
Radiatio inducted hypopit
Klinefelters (XXY inc FSH)
Kallman (dec FSH)
Vasc supply - penile brachial index <6
Nerves DM neuropathy - if difficulty accomodating to pupillary reflex they have it
Drugs - thiazide, SSR TCA, finasteride, BB
MC sexual dysfxn
Tx SSR, sildenafil
Can SSRI cause retrograde ejaculation?
Pt with dec'd libido - testosterond 150 wtd?
Pt with impotence with normal testosterone
check nocturnal penile tumescence - differentiate psychogenic vs organic
If normal r/o psychogenic or drug causes
nocturnal penile tumescence decreased in...
HP gonadal axis problem
Mechanism of sildenafil
PDI5 inhib - inc nitric oxide - inc cGMP
Married couple comes to you cuz not having kids
Sperm count after 3 days abstinence
How to manage ED with pt on nitrates
Penile tumescent devices
How soon after using sildenafil or tadalafil can nitrates be used
24 hrs after sildenafil
48 hrs after tadalafil
Pt with CP given nitrates and sudden hypotension - had tadafanil 6hrs ago - wtd?
Put in trendelenbureg postion, IVF, phenyephrine (NOT NOREPI)
Puberty, elderly, obesity, cirrhosis, germ cell tumor Klinfelter's
15yo wiht enlargement of breast
uni or b/l - reassurance - related to puberty
Men - unilater breast inc -> bx
Pt with c/o decreased libido - decreased nocturnal penil tumescence - received rad to head - FSH 5, LH 4, testosterone 160 prolactin i22 dx?
38yo F doing well on fluoxetine for depression unable to achieve orgasm for 2 months wtd?
add or switch to bupropion
Primary amenorrhea - Never had menses - web neck, short stature, low setears, intact smell, rudimentary ovaries
Turner syndrome XO
Primary amenorrhea no vagina, no uterus, ovaries OK breasts normal
Rokitanksy, kuster huser syndrome 46X
Primary amenorrhea with acne, clitoromegaly, hirsuitism no ovaries no breasts
46XY gonadal dysgenesis
Primary Amenorrhea wit hatrophic vagina no cervic +breasts, no pubic/axillary hair
Androgen insensitivity syndrome
testes formation in fetus - produces testosterone
No androgen rct so end organ resistance - so get vaginad and uterus as default
since excess testoerone cant work - converted to estrone -> breast formation
Testes undescended - androgen rct coded by X chromasome
Primary amenorrhea with anosmia (can't smell) dec LH/FSH
St. John's Wart
Polycystic Ovarian Dz
Irreg mentstual cycle from puberty, obesity, acne, hirsuitism
inc'd testosterone, inc DHEA, inc LH/FSH ratio>3, hyperglyemia, hyperTGA
Acanthosis nigricans - muddy brown skin in acilla - w/w gastric CA, insulin resistance, obseity, PCO
Tx: anti androgen OCP
Premature ovarian failure
Ovary fails - dec'd estradiol, inc FSH first, then in LH
Tx: estrogen replacement
Etiology of skin lesions in Vitiligo
Ab vs melanocytes
Amenorrhea with galactorreha Prolactin level >200 wtd?
CT /MRI head r/o prolactinoma
17 yo amenorrhea BM normal, preg test neg - rx for prg and gets periods - wtd?
47yo otherwise regular period with amenorrhea for 2 months wtd?
Young woman on OCP with no breakthru bleed wtd?
Pt stopped taking OCP sever months ago with no menses - preg test neg, LH/FSH normal estrogen challenge no bleed - etiology?
Asherman's syndrome (endometrial adhesions post D&C) or
Young marathon runner c/o only couple periods in last year wtd?
no further testing
Tx to get back periods - cut down on excercise
Mechanism - excess exc, inhibits LHRH -> hypogonadotropic hypogonadism
Pt asks how to to cut down on bone loss in addition to Ca and Vit D
Inc'd DHEA (adrenal) - inc ACTH, inc cortisol, inc'd 17 keto steroids=cushings
Pt with hirsuitsim - labs to order?
Testosterone, DHEA (17 OH ketosteroid), urine free cortisol
Pt with hirusitism testosterone high, corsol normal wtd?
TVUS for ovaries