Flashcards in Endocrinology Deck (110):
What is the strongest indication for screening for diabetes?
What is the best initial therapy for type 2 diabetes?
Diet, exercise and weight loss
What is the best initial medical therapy for type 2 diabetes?
Metformin (especially for obese b/c does not cause weight gain; no hypotension; blocks gluconeogenesis)
What is the next best step in management for a type 2 diabetic who is not controlled with lifestyle change and metformin?
Add sulfonylurea (glyburide, glimepiride, glipizide)
What are the two contraindications against using metformin for type 2 diabetes?
1. Renal insufficiency (metformin accumulates causing lactic acidosis)
2. Use of contrast agent for radiography/ angiography (leads to renal failure problem)
What are the four diagnostic tests that can be used to diagnosis Diabetes?
1. Two fasting glucose >126
2. One random glucose >200 with symptoms (polyuria, polydipsia, polyphasia)
3. Abnormal glucose tolerance test (2-hour glucose with 75 gram glucose load)
4. Hemoglobin A1C > 6.5%
What are the two major side effects of using sulfonylureas (glyburide, glimepiride, glipizide)?
(increases release of insulin from pancreas)
What is the mechanism of action of DDP-IV inhibitors ("gliptins") in the treatment of type 2 diabetes?
block metabolism of incretins --> increased incretins --> increase insulin release and block glucagon
What is the major contraindication for the use of thiazolidinediones (rosiglitazone, pioglitazone) for the treatment of type 2 diabetes?
Worsens CHF (avoid in CHF patients)
(increases peripheral insulin insensitivity)
What is the major side effect of using alpha-glucosidase inhibitors (acarbose, miglitol) for treatment of type 2 diabetes?
lactose intolerance like symptoms (diarrhea, abdominal pain, bloating, flatulence)
(blocks absorption of glucose at intestinal lining)
What is the major side effect of using insulin secretagogues (nateglinide, repaglinide) for treatment of type 2 diabetes?
(short acting; increased release of insulin from pancreas)
What is the major side effect of using SGLT inhibitors (canagliflozin) for the treatment of type 2 diabetes?
urinary tract infections
If oral medications are unable to sufficiently control glucose levels in a type 2 diabetic, what is the next best step in management of the pt?
switch to insulin (long acting- glargine once daily with short-acting insulin at mealtimes)
What is a side effect of GLP analogs (exenatide, liraglutide) that is desired in the treatment of type 2 diabetes?
(increase insulin and decrease glucagon)
What are the three long-acting insulins?
1. glargine (once daily)
3. NPH (twice daily)
A thin pt presents with poluria, polydipsia and polyphagia most likely suffers from...
Type 1 diabetes (autoimmune destruction of pancres beta cells leading to underproduction of insulin)
A pt presents extremely ill with hyperventilation, metabolic acidosis (low bicarbonate), fruity odor of the breath and confusion most likely suffers from ...
What are the six major lab findings in a pt with diabetic ketoacidosis?
1. hyperglycemia (glucose >250)
2. hyperkalemia (no insuline --> K build up outside cell)
3. low pH
4. low serum bicarbonate
5. elevated acetone, acetoacetate, beta hydroxybutyrate
6. elevated anion gap
What is the best initial diagnostic test for a pt with suspected diabetic ketoacidosis?
What is the the potassium level in acidotic states?
hyperkalemia (hydrogen goes into cell and pushes K out to compensate for acidosis)
What is the potassium level in an alkalotic state?
What is the best initial step in management of a pt presenting with suspected diabetic ketoacidosis?
order labs (chemistry, arterial blood gas, acetone level) and give bolus of normal saline
What is the next best step in management of a pt presenting with suspected diabetic ketoacidosis after labs detect high glucose and low bicarb?
administer IV insulin (as potassium level drops add potassium to IV fluids)
What is the goal of management of hypertension in a diabetic pt?
BP less than 130/80
What is the goal of management of lipids in a diabetic pt?
LDL less than 100
What is the goal of management of lipids in a diabetic pt who also has coronary artery disease?
LDL less than 70
What is a routine screening test that should be performed in every newly diagnosed diabetic patient and should continue to happen annually?
dilated eye exam (to assess for proliferative retinopathy)
What is the treatment for proliferative retinopathy in a diabetic pt?
laser photocoagulation (can also use VEGF inhibitors- ranibizumab or bevacizumab if severe)
What diagnostic test is used to assess for diabetic nephropathy?
What is the treatment of choice for any amount/form of protein in a diabetic patients urine?
ACE inhibitors (even is blood pressure is normal)
(decreases intraglomerular hypertension by dilating efferent arteriole)
What is the first line anti-hypertensive medication used in diabetics?
What is the diagnostic screening test for diabetic neuropathy?
yearly foot examinations
What is the treatment for diabetic neuropathy?
gabapentin or pregabalin
What is the treatment for erectile dysfunction secondary to diabetes?
sidenafil (or other phosphodiesterase inhibitors)
(avoid with nitrates)
What is the best treatment for gastroparesis secondary to diabetes?
metoclopramide or erthyromycin
A diabetic pt presenting with bloating, constipation, abdominal fullness and diarrhea most likely suffers from ...
(can confirm diagnosis with gastric emptying study)
A pt presents with weight gain, cold intolerance, coarse hair, dry skin, depressed mood, bradycardia, muscle weakness, diminished reflexes, fatigue and menstrual changes most likely suffers from ...
A pt presents with weight loss, heat intolerance, fine hair, moist skin, anxiety, tachycardia, muscle weakness, fatigue, and menstrual changes most likely suffers from ...
What is the best initial test for suspected hypothyroidism?
T4 (decreased) and TSH (increased)
(likely Hashimoto's thyroiditis)
What is the treatment for hypothyroidism?
T4 or thyroxine replacement
A pt presenting with signs and symptoms of hyperthyroidism along with eyes bulging, eyelids retracted, thickening and redness of skin below knee, and separation of nail from nailbed most likely suffers from ...
(exophthalmos, proptosis; dermopathy; onycolysis)
What is the best initial test for suspected hyperthyroidism?
T4 (increased) and TSH (usually suppressed) level
What is the next best step in management after confirming a pt has hyperthyoidism?
radioactive iodine uptake study
What are the two causes of hyperthyroidism that result in an elevated radioactive iodine uptake study?
1. Graves Disease
2. Pituitary adenoma
What are the two causes of hyperthyroidism that result in a decreased radioactio iodine uptake study?
1. Silent Thyroiditis
2. Subacute Thyroiditis
What is the best treatment for Graves' disease?
PTU (prophylthiouracil) or metimazole acutely followed by radioactive iodine ablate
(propanolol for sympathetic symptoms- tremors, palpitations)
A pt presenting with hyperthyroidism symptoms and a nontender thyroid gland most likely suffers from ..
(autoimmune; no treatment needed)
What is the best diagnostic test specific for silent thyroiditis?
thryoid peroxidase and anti-thyroglobuin antibodies present
A pt presenting with hyperthyroidism symptoms and a tender thyroid gland most likely suffers from ...
(RAIU is low, T4 high, TSH is low)
What is the best treatment for subacute thryoiditis?
A pt presents with hyperthyroidism symptoms and is found to have elevated T4 and TSH is most likely suffering from...
What is the diagnostic test of choice and treatment for pituitary adenoma?
brain MRI; surgical resection
A pt presents with hyperthyroidism symptoms, elevated T4, suppressed TSH but a nonpalpable/ atrophic thyroid most likely suffers from ...
exogenous thyroid hormone abuse
What four therapies are used in combination to treat thyroid storm (acute, severe, life-threatening hyperthyroidism)?
1. iodine (blocks iodine uptake & release of hormone)
2. PTU/ methimazole (blocks thyroxine production)
3. dexamethasone (blocks peripheral T4 to T3 conversion)
4. Propanolol (blocks target organs)
What is the best initial step in management for a pt with a solitary thyroid nodule?
fine needle aspiration (with use of ultrasound guidance if needed)
What is the most common cause of hypercalcemia?
A pt presents with hypercalcemia and may have associated history of kidney stones, osteoporosis/ osteomalacia/ fractures, confusion, constipand and abdominal pain most likely suffer from...
hyperparathyroidism (leading to hypercalcemia)
What is the diagnostic test for suspected hyperparathyroidism?
PTH level (elevated in presence of elevated calcium)
What are the indications for surgical removal of the parathyroid gland for hyperparathyroidism?
1. symptomatic (stones, bones, psychic moans, GI groans)
2. renal insufficiency
3. markedly elevated 24 hour urine calcium
4. very elevated serum calcium (>12.5)
What are other causes of hypercalcemia other than hyperparathyroidism? (7)
1. malignancy (PTH-like particle production)
2. granulomatous disease (make vitamin D)
3. Vitamin D intoxication
4. thiazide diuretics (reabsorb calcium)
A pt presents with confusion, constipation, polyuria, polydipsia, short QT syndrome on EKG, and renal insufficiency/ acute tubular necrosis/ kidney stone most likely suffers from ...
acute severe hypercalcemia
What is the treatment for acute severe hypercalcemia?
1. hydration (3-4 liters NS)
2. bisphosphonate (takes weeks)
3a. furosemide (after hydration)
3b. calcitonin (if hydration and furosemide dont help)
4. steroids (if granulomatous disease)
What are the two mechanisms of action by which hypercalcemia causes volume depletion?
1. high calcium inhibits ADH effect on collecting duct (inducing nephrogenic diabetes insipidus)
2. high calcium promotes osmotic diuresis
A pt presents with seizures, neural twitching (Chvostek's sign and Trousseaus's sign on wrist and cheek), and arrhythmia-prolonged QT on EKG most likely suffers from...
What are the 6 major causes of hypocalcemia?
1. surgical resection or parathyroid
2. hypomagnesemia (Mg needed to release PTH)
3. vitamin D deficiency
4. acute hyperphosphatemia (Phos binds calcium)
5. fat malabsorption (fat binds calcium in gut)
6. PTH resistance (occuring in pseudohypoparathyroidism with short 4th finger, round face and mental retardation)
What is the treatment for hypocalcemia?
calcium replacment (with vitamin D replacement if due to vitamin D deficiency or hypoparathyroidism)
What are the 4 mechanisms of action of PTH (parathryoid hormome)?
1. reabsorb calcium at distal tubule
2. excrete phosphate at proximal tubule
3. active Vitamin D from 25 to 1,25 form
4. reabsorb calcium and phosphate from bone
A pt presents with truncal obesity, moon face, buffalo hump, thin arms/legs, easy bruising, striae, hypertension, muscle wasting and hirsutism most likely suffers from ...
Cushing syndrome (any form of hyperadrenalism/ hypercortisolism)
What are the 5 lab findings associated with Cushing's syndrome?
5. metabolic alkalosis (lose urinary H)
What diagnostic tests are performed to confirm suspected Cushing's syndrome?
1. 1 mg overnight dexamethasone suppression test (abnormal if pt fails to suppress 8 a.m. cortisol level)
2. 24-hour urine cortisol (confirms abnormal 1mg dexamethasone was not falsely abnormal)
A pt presenting with Cushing's syndrome and is found to have low ACTH level most likely suffers from ...
(treat via adenoma resection)
What is the diagnostic test for confirming adrenal adenoma?
CT or MRI of adrenals
A pt presenting with Cushing's syndrome is found to have high ACTH level, what is the next best step in the management of this pt?
high-dose dexamethasone suppression test
(to distinguish between pituitary tumor/ cushing's disease and ectopic ACTH production)
A pt presenting with Cushing's syndrome and is found to have high ACTH and ACTH suppression with high dose dexamethasone suppression test most likely suffers from ...
Pituitary Adenoma (Cushing's disease)
(perform Brain MRI and pertrossal vein sampling)
A pt presenting with Cushing's syndrome and is found to have high ACTH but no ACTH suppresion with high dose dexamethasone suppression test most likely suffers from ...
Ectopic ACTH production
(perform chest X-ray and abdomenal scans looking for cancer)
What is the best initial test for suspected hypercortisolism/ cushing's syndrome?
24 hour urine cortisol
A thin pt presents with fatigue, anorexia, weight loss, weakness, hypotension, and hyperigmented skin with labs showing hyperkalemia, mild metabolic acidosis, and hyponatremia most likely suffers from ...
Adrenal insufficiency/ Addison's disease
What are the most accurate diagnostic tests for suspected adrenal insufficiency/ addison's disease?
1. cosyntropin (synthetic ACTH) stimulation test (no rise in cortisol after cosyntropin suggests addison's)
2. CT scan of adrenal gland
What is the treatment of choice for acute addisonian (hypoadrenal) crisis?
give fluids and hydrocortisone
What is the best long-term treatment for addison's disease/ adrenal insufficiency?
prednisone only (if pt stable/ non-hypotensive); add fludrocortisone (if pt hypotensive)
A pt presents with hypertension, hypokalemia, metabolic alkalosis and possibly motor weakness and nephrogenic diabetes insipidus (secondary to hypokalemia) most likely suffers from ...
What are the two best initial diagnostic tests for suspected hyperaldosteronism?
1. low renin level
2. elevated aldosterone level (despite salt loading with normal saline)
What is the confirmatory diagnostic test for a pt with low renin level and elevated aldosterone suggesting hyperaldosteronism?
CT scan of adrenal glansd
What are the two treatment options for hyperaldosteronism?
1. surgical resection (if solitary adenoma)
2. spironolactone (if adrenal hyperplasia)
A pt presents with headache, palpitations, tremors, anxiety, flushing and history of episodic hypertension most likely suffers from...
What are the two best initial tests for pheochromocytoma?
1. high plasma and urinary catecholamine levels
2. plasma free metanephrine and VMA levels
What are the two most accurate/ confirmatory tests for pheochromocytoma?
1. CT/MRI of adrenal glands
2. MIBG scan (to detect metastatic disease)
What is the 3 step treatment regimen for pheochromocytoma?
1. phenoxybenzamine initial (control BP)
2. propranolol secondly
3. surgical/ laparoscopic resection (if known metastatic)
A pt presents with hirsutism, hypotension, low aldosterone, low cortisol and elevated ACTH most likely suffers from ...
21 hydroxylase deficiency (most common type of congenital adrenal hyperplasia)
What is the diagnostic test for 21 hydroxylase deficiency type congential adrenal hyperplasia?
increased 17 hydroxyprogesterone level
A pt presents with hirsutism, hypertension, low aldosterone, low cortisol, and elevated ACTH most likely suffers from...
11 hydroxylase deficiency type of congenital adrenal hyperplasia
(elevated 11-deoxycorticosterone and androgens)
A pt presents with hypertension, low adrenal androgens, low aldosterone, low cortisol and elevated ACTH most likely suffers from ...
17 hydroxylase deficiency type of congenital adrenal hyperplasia
What is the treatment for all types of congenital adrenal hyperplasia (21 hydroxylase deficiency, 11- hydroxylase deficiency, 17- hydroxylase deficiency)?
prednisone (inhibits pituitary)
A man presents with impotence, decreased libido, gynecomastia, headache and visual disturbances most likely suffers from ..
(men present late)
A women presents with amenorrhea and galactorrhea in the absence of pregnancy most likely suffers from ..
What criteria must be true before investigating for suspected prolactinoma?
1. not pregnant
2. not using metoclopramide/ phenothiazines/ TCAs
3. prolactin > 200
4. no hypothyroidism/ nipple stimulation/ chest wall irritation/ stress/ exercise
What is the diagnostic test for prolactinoma?
What is the best initial treatment for prolactinoma?
dopamine agonists (bromocriptine/ cabergoline)
(surgical removal if no response to meds)
A pt presents with enlarging head/hat size, enlarging ring/ finger size, enlarging shoe/feet size,enlarging nose and jaw, intense sweating, joint abnormalities, amenorrhea, cardiomegaly, hypertension, and possible diabetes and/or colonic polyps most likely suffers from ...
Acromegaly (excessive secretion of growth hormone from pituitary adenoma)
What is the best initial test for suspected acromegaly?
insulin-like growth factor level (IGF)
What is the most accurate test for suspected acromegaly?
suppression of growth hormone with glucose administration (excludes acromegaly)
What are the four treatment options for acromegaly?
1. surgical resection with transphenoidal removal
2. octreotide (prevent release of GH)
3. cabergoline/ bromocriptine (prevents GH release)
4. pegvisomant (GH receptor antagonist)
A pt presents with primary amenorrhea, short stature, webbed neck, wide-spaced nipples, and scant pubic and axillary hair most likely suffers from ...
Turner's syndrome (XO karyotype)
A pt presents with primary amenorrhea and has breasts but lack cervix, fallopian tubes, ovaries, top third of vagina most likely suffers from...
testicular feminization (due to absence of testosterone receptors)
(genetic male who looks/feels/acts like woman)
What are five causes of secondary amenorrhea?
3. extreme weight loss
5. polycystic ovary syndrome
A female pt presents with obesity, secondary amenorrhea, hirsuitism, and history of infertility most likely suffers from ...
Polycystic Ovarian Syndrome (PCOS)
What is the treatment for polycystic ovarian syndrome?
(use spironolactone for virilization)
A tall male presents with hypogonadism and found to have very high FSH adn LH withoth testosterone production most likely suffers from ..
Klinefelter's syndrome (XXY)
What is the treatment for hypogonadism secondary to Klinefelter's syndrome?