Endocrinology Flashcards by David Felipe Ortiz Paredes

Patient with Pituitary tumor, hypercalcemia and refractory gastric ulcers. Dx and gene?

MEN 1A
Tumors of…
- Pituitary (functional tumor or not)
- Parathyroid: Hyperparathyroidism
- Pancreas: endocrine tumors like Zollinger Ellison or Insulinoma

Path: disorder of MEN gene

How well did you know this?

Not at all

Perfectly

Patient with Pituitary tumor, hypercalcemia and hypoglicemia. Dx and gene?

MEN 1A
Tumors of…
- Pituitary (functional tumor or not)
- Parathyroid: Hyperparathyroidism
- Pancreas: endocrine tumors like Zollinger Ellison or Insulinoma

Path: disorder of MEN gene

How well did you know this?

Not at all

Perfectly

Patient with pheochromocytoma, medullary thyroid cancer and hypercalcemia. Dx and gene?

MEN 2A

Path: RET protooncogene

How well did you know this?

Not at all

Perfectly

Patient with pheochromocytoma, medullary thyroid cancer and neuronal tumor. Dx and gene?

MEN 2B

Path: RET protooncogene

How well did you know this?

Not at all

Perfectly

Woman with amenorrhea + galactorrhea// Man with ↓libido and bitemporal hemianopsia. History of schizophrenia, tx with haloperidol. Dx?

Hyperprolactinemia secondary to dopamine antagonist

How well did you know this?

Not at all

Perfectly

Woman with amenorrhea + galactorrhea// Man with ↓libido and bitemporal hemianopsia. ↑↑TSH.
Dx?

Hyperprolactinemia secondary to hypothyroidism.

How well did you know this?

Not at all

Perfectly

Woman with amenorrhea + galactorrhea// Man with ↓libido and bitemporal hemianopsia. Dx, next step, tx?

Hyperprolactinemia

Next step:

1st: Review medications. Dopamine antagonist (anti-psychotic)
2nd: TSH because hypothyroidism can produce hyperprolactinemia
3rd: Prolactine level
4th: MRI

Tx:

Dopamine agonist: Cabergoline > bromocriptine
Surgery/radiation (rare)

How well did you know this?

Not at all

Perfectly

Child with excessive growth of long bones. Dx, next step and tx?

Gigantism

Next step:

1st: ILGF-1
2nd: glucose suppression test (GH doesn’t ↓ after a load of glucose)
3rd: MRI

Tx: Surgery +/- octreotide (somatostatin) to suppress the axis

How well did you know this?

Not at all

Perfectly

Adults patient with growth of hands, feet, face and visceral organs, diabetes, diastolic CHF. Dx, next step and tx?

Acromegalia

Next step:

1st: ILGF-1
2nd: glucose suppression test (GH doesn’t ↓ after a load of glucose)
3rd: MRI

Tx: Surgery +/- octreotide (somatostatin) to suppress the axis

How well did you know this?

Not at all

Perfectly

Pregnant patient with prolonged delivery who suddenly has hypotension, tachycardia, Letargy, coma. Dx, next step and tx?

Sheehan’s syndrome (Acute Hypopituitarism)

Next step:

ABC
Cortisol and T4 levels

Tx: Hormone replacement

How well did you know this?

Not at all

Perfectly

Patient with pre-existing pituitary tumor Pituitary who has suddlently stupor, nuchal rigidity, headache, N/V.

Apoplexy (Acute Hypopituitarism)

Next step:

ABC
Cortisol and T4 levels

Tx: Hormone replacement

How well did you know this?

Not at all

Perfectly

Patient with ↓libido, Fatigue, Problems with menstrual cycle. Failure to increase GH after load of insulin or vasopressin. Next step and tx?

Chronic hypopituitarism

Next step: MRI

Tx:

Hormone replacement
Treat underlying condition (e.g., Autoimmune deposition disease)

How well did you know this?

Not at all

Perfectly

Patient whose MRI shows a non-existant pitiutaria. The patient is otherwise asx. Dx and next step?

Empty sella syndrome

No treatment required

How well did you know this?

Not at all

Perfectly

Patient with pulmonary cancer, hyponatremia, ↑Urinary Na, ↑Urinary Osm, and ↓Serum Osm. Dx, type of pulmonary associated neoplasia and tx?

Syndrome of inappropriate ADH (SIADH)

Type of cancer: small cell carcinoma

Tx:

Water restriction
Demeclocycline (antibiotic) to block ADH receptor in kidney and eliminate water
Hypertonic saline if sever hypoNa

How well did you know this?

Not at all

Perfectly

Patient with hyponatremia and suspiction of Syndrome of inappropriate ADH (SIADH). Next step and tx?

Next step:

↑Urinary Na
↑Urinary Osm
↓Serum Osm

Tx:

Water restriction
Demeclocycline (antibiotic) to block ADH receptor in kidney and eliminate water
Hypertonic saline if sever hypoNa

How well did you know this?

Not at all

Perfectly

Patient with Polydipsia and polyuria. Normal glucose and no glucose in urine. Dx and next step?

Diabetes insipidus

Next step: Water deprivation test to differentiate betwen central, nephrogenic and Psychogenic polydipsia

How well did you know this?

Not at all

Perfectly

Patient with Polydipsia and polyuria. Normal glucose and no glucose in urine.
Water deprivation test: Improvement of urinary Osm after ADH administration.
Dx and tx?

Central Diabetes insipidus

Tx: DDAVP (desmopressin) intranasally

How well did you know this?

Not at all

Perfectly

Patient with Polydipsia and polyuria. Normal glucose and no glucose in urine.
Water deprivation test: Not improvement of urinary Osm after ADH administration.
Dx and tx?

Nephrogenic Diabetes insipidus

Tx: gentle diuresis with HCTZ or amiloride

How well did you know this?

Not at all

Perfectly

Patient with Polydipsia and polyuria. Normal glucose and no glucose in urine.
Water deprivation test: Improvement of urinary Osm after water deprivation, even before administration of ADH.
Dx and tx?

Psychogenic polydipsia

Tx: Stop drinking water

How well did you know this?

Not at all

Perfectly

Patient with Tachycardia, Diarrhea, Heat intolerant,↑ Deep tendon reflexes, Weight loss. on physical, exophthalmos, pretibial myxedema, universal enlargement of the thyroid.
• ↓TSH, ↑T4
• Diffuse Radioactive iodine uptake (RAIU) test

Dx, next step and tx?

Grave’s

Next step: Thyroid stimulating antibodies

Tx: Propylthiouracil (PTU) or methimazole. Surgery

How well did you know this?

Not at all

Perfectly

Patient with hyperthyroidism sx, painless thyroid, followed by hypothyroidism sx.
Thyroid peroxidase antibody (TPO) positive
Dx, tx?

Hashimoto’s

Tx: levothyroxine

How well did you know this?

Not at all

Perfectly

Patient with hyperthyroidism sx, painful thyroid, then resolution of sx.
Dx?

De Quervain’s thyroiditis

How well did you know this?

Not at all

Perfectly

Patient with Tachycardia, Diarrhea, Heat intolerant,↑ Deep tendon reflexes, Weight loss.
• ↓TSH, ↑T4
• Multiple nododules lighted up on Radioactive iodine uptake (RAIU) test

Dx and tx?

Multinodular goiter

Tx: Radioactive iodine ablation

How well did you know this?

Not at all

Perfectly

Patient with Tachycardia, Diarrhea, Heat intolerant,↑ Deep tendon reflexes, Weight loss.
• ↓TSH, ↑T4
• One big nodule lighted up on Radioactive iodine uptake (RAIU) test

Dx and tx?

Toxic adenoma

Tx: Radioactive iodine ablation

How well did you know this?

Not at all

Perfectly

Woman on multiple diets, lots of exercise, body-image issues. • ↓TSH, ↑T4 • Cold thyroid on Radioactive iodine uptake (RAIU) test Differential and next step?

Facticious vs Stroma ovari Next step: RAIU of the ovaries

Woman on multiple diets, lots of exercise, body-image issues. • ↓TSH, ↑T4 • Cold thyroid on Radioactive iodine uptake (RAIU) test • RAIU of ovaries is negative Dx?

Facticious (exogenous T4 being ingested)

``` Woman hyperthyroidism sx • ↓TSH, ↑T4 • Cold thyroid on Radioactive iodine uptake (RAIU) test • RAIU of ovaries is positive Dx and tx? ```

Stroma ovari (Ovarian lesion (dermoid cyst/teratoma) producing T4) Tx: Radioactive iodine ablation

Patient Afib, tachycardia, shock, fever, hypotensive, delirium. - ↓TSH - ↑T4 Dx and tx?

Thyroid storm ``` Tx: • 1st: IVF, cooling blankets • 2nd: B-blocker • 3rd: PTU/methimazole • 4th: steroids ```

Patient with Bradycardia, Constipation, Cold intolerance, ↓Deep tendon reflexes, Weight gain. - ↑TSH - ↓T4 Dx and tx?

Hypothyroidism levothyroxine

Definition of subclinical hypothiroidism. When to treat?

↑TSH, normal T4 Treat subclinical if TSH >10 or Sx are present

Patient Coma, hypothermic, hypotension. - ↑TSH - ↓T4 Dx and tx?

Myxedema coma Tx: • Warm IVF, warm blankets • IV T4

Patient Hodgkin lymphoma survivor, who consults with hoarseness. On physical exam he has a thyroid nodule that is Fixed, Firm, and Hard. Next step?

TSH

Patient who has a thyroid nodule that is Fixed, Firm, and Hard. ↓TSH Next step?

Radioactive iodine uptake (RAIU) test

Patient who has a thyroid nodule that is Fixed, Firm, and Hard. ↓TSH The nodule is hot on the Radioactive iodine uptake (RAIU) test Dx and next step?

Functioning thyroid nodule Next step: Treat the hyperthyroidism with Radioactive iodine ablation

Patient who consults with hoarseness. On physical exam he has a thyroid nodule that is Fixed, Firm, and Hard. ↓TSH The nodule is cold on the Radioactive iodine uptake (RAIU) test Dx and next step?

Nonfunctioning thyroid nodule Next step: FNA

Patient Hodgkin lymphoma survivor, who consults with hoarseness. On physical exam he has a thyroid nodule that is Fixed, Firm, and Hard. ↑TSH Dx and next step?

High-risk thyroid nodule Next step: U/S

Patient Hodgkin lymphoma survivor, who consults with hoarseness. On physical exam he has a thyroid nodule that is Fixed, Firm, and Hard. ↑TSH U/S shows a nodule > 1cm Next step?

High-risk thyroid nodule Next step: FNA

Patient Hodgkin lymphoma survivor, who consults with hoarseness. On physical exam he has a thyroid nodule that is Fixed, Firm, and Hard. ↑TSH U/S shows a nodule < 1cm Next step?

Repeat U/S in 6-12 months

Patient with a thyroid nodule and "inconclusive" results on FNA. Next step?

Repeat FNA immediately

Patient with thyroid nodule. FNA results: Orphan annie nuclei and psammoma bodies. Dx and Tx?

Papillary thyroid cancer Tx: Srugery

Patient with thyroid nodule. FNA results: Thyroid tissue Dx and Tx?

Follicular thyroid cancer Tx: Radioactive iodine ablation

Patient with thyroid nodule. FNA results: Medullary thyroid cancer What is this cancer associated with?

``` Associated with MEN 2a and MEN 2b -MEN 2a • Pheochromocytoma • Medullary thyroid cancer • Parathyroid ``` MEN 2b • Pheochromocytoma • Medullary thyroid cancer • Neuronal tumors Associated with RET oncogene

What is the most fatal thyroid cancer?

Anaplastic thyroid cancer

Lawers of adrenal gland?

Glomerulosa (salt): aldosterone Fasciculata (sugar): cortisol Reticularis (sex): testosterone Medulla: catecholamines

Patient with HTN, DM, Obese, Moon facies, Bad acne, Truncal obesity, Buffalo hump and Purple striae. Next step?

Late-night saliva cortisol OR 24-hr free urine cortisol AND Low-dose overnight Dexamethasone suppression test

Patient with HTN, DM, Obese, Moon facies, Bad acne, Truncal obesity, Buffalo hump and Purple striae. - 24-hr free urine cortisol (high) - Low-dose overnight Dexamethasone suppression test fails to suppress high cortisol Dx and next step?

Cushing's Next step: ACTH

Primary Cushing's (ACTH-secreting tumor in the adrenals) Next step: MRI/CT of abdomen and resect

Adrenals are ok, the problem is an overproduction of ACTH either from pituitary or paraneoplastic syndrome Next step: High dose Dexamethasone suppression test

Cushing disease (ACTH-secreting tumor in anterior pituitary) Next step: MRI of brain and resect

Paraneoplastic Syndrome: Ectopic ACTH-secreting tumor Next step: CT lungs/abdomen/pelvis

Patient witn orthostatism, hypotension, hyperpigmentation, ↓Na, ↑K. - ↓3 am cortisol < 3 Dx and next step?

Adrenal insufficiency Next step: Give exogenous ACTH to see response of cortisol and distinguish between primary and secondary

Patient witn orthostatism, hypotension, hyperpigmentation, ↓Na, ↑K. - ↓3 am cortisol < 3 - Increase of cortisol 60 mins after cosyntropin test. Dx, next step and Tx?

Secondary (central) Adrenal insufficiency Next step: MRI brain Tx: Prednisone

Patient witn orthostatism, hypotension, hyperpigmentation, ↓Na, ↑K. - ↓3 am cortisol < 3 - No response of cortisol after cosyntropin test. Dx, next step and Tx?

Addison's disease (primary adrenal insufficiency) Next step: MRI/CT abdomen Tx: Prednisone (replaces cortisol) AND Fludrocortisone (replaces aldo)

Patient with refractory HTN after 3 meds and hypokalemia. Differential and next step?

Hyperaldosteronism Next step: calculate aldo : renin

Patient with refractory HTN after 3 meds and hypokalemia. ↑Aldo ↑Renin Aldo : Renin < 10 Dx?

``` Secondary hyperaldosteronism (renovascular HTN due to CHF, cirrhosis, nephrotic syndrome, etc.) ```

Patient with refractory HTN after 3 meds and hypokalemia. ↑Aldo ↓Renin Aldo : Renin > 20 Next step?

Sal supression test (to confimr Conn's syndrome, i.e., primary hyperaldosteronism)

Patient with refractory HTN after 3 meds and hypokalemia. ↑Aldo ↓Renin Aldo : Renin > 20 Aldo remaing elevated after salt supression test Dx and Next step?

Conn's syndrome (primary hyperaldosteronism) Next step: - CT/MRI of abdomen - Adrenal vein sampling

Patient with Pain (headache), Pressure (refractory HTN), Palpitations (tachycardia), Perspiration (sweating), Pallor. Dx and next step?

Pheochromocytoma Next step: Plasma free catecholamines or 24-hour urine Vanillylmandelic acid (VMA)

Patient with Pain (headache), Pressure (refractory HTN), Palpitations (tachycardia), Perspiration (sweating), Pallor. ↑Plasma free catecholamines ↑24-hour urine Vanillylmandelic acid (VMA) MRI of abdomen shows mass in adrenal gland. Dx and tx?

Pheochromocytoma Tx: - 1st: a-blocker - 2nd: b-blocker - 3rd: resection

Incidental finding of an adrenal mass on a MRI in an otherwise ASx patient. Dx, next steps and tx?

Incidentaloma Next steps: - To rule out cushing: low dose overnight DST - To rule out Coon’s: renin:aldo - To rule out pheochromocytoma: 24-hr urine metanephrines Tx: - Not functioning and < 4cm: watch and wait - Functioning or > 4cm: resect

Screening of DM with Random blood glucose

Random blood glucose x 1 | • DM if > 200 + Sx of DM

Screening of DM with Fasting blood sugar

Fasting blood sugar x 2 • DM if > 126 • Insulin insensitivity/pre-DM 100-126 • Normal < 100

Screening of DM with 2-hr oral glucose tolerance test

2-hr oral glucose tolerance test x 1 • DM if > 200 • Insulin insensitivity/pre-DM 140-200 • Normal < 140

Screening of DM with HgbA1C

HgbA1C • DM if > 6.5% • Insulin insensitivity/pre-DM 5.7%-6.5% • Normal < 5.7%

Patient at the ER with Polyuria, polyphagia, polydipsia, weigh loss, ↑↑ blood glucose. Dx and Dx test?

DM type 1 Dx test: - GAD antibody test (best) - IA-2 antibody test

Patient with Fasting blood sugar of 115 2-hr oral glucose tolerance test of 160 HgbA1C 6% Dx and tx?

Pre-DM Tx: Lifestyle modifications and metformin

Patient with Fasting blood sugar of 130 2-hr oral glucose tolerance test of 210 HgbA1C 6.8% Dx, tx and next step?

DM type 2 Tx: Lifestyle modifications and metformin Follow-up in 3 months with HgbA1C

Patient with HgbA1C 9.5% Dx, tx and next step?

DM type 2 Tx: Lifestyle modifications and Insulin right away Follow-up in 3 months with HgbA1C

Patient with DM type 1. After 3 moths of metformin and lifestyle modifications has a HgbA1C of 7.5% Next step?

Add second agent, e.g., Glyburide (sulfonylurea)

Patient with DM type 1. After 3 moths of metformin and lifestyle modifications has a HgbA1C of 7.5%. BMI 35 Next step?

Add second agent, e.g., Exentaide or Liraglutide (GLP-1 analogs) because produces wight loss

Patient with DM type 1. After 3 moths of metformin and lifestyle modifications has a HgbA1C of 7.5%. BMI 23 Next step?

Add second agent, e.g., Sitagliptin (DDP-4-inhibitors) because it maintains weight

Contraindications of metformin?

CHF, CKD, liver disease (risk of Lactic acidosis)

Secondary effect of Sulfonylurea (Glyburide, Glipizide)

Hypoglicemia (use with caution in CKD patients)

Secondary effect of Thiazolidinediones (TZDs)?

CHF, Weight gain

Continual assessment of DM type 1 patient?

HgbA1C q 3 months: goal < 7% Annual screening for… - Retinopathy with retinal exam (tx with laser) - Nephropathy with microalbuminuria : creatinine (tx of proteinuria with ACE-i) - Neuropathy with monofilament screen (tx with gabapentin)

Patient with DM type 1. After 3 months of metformin + Glyburide (sulfonylurea) + lifestyle modifications has a HgbA1C of 7.5%. Next step?

Start with long-acting insulin (e.g., Lantus (glargine), Levemir (detemir)) at 0.1UI/Kg qOnce • Take morning glucose to titrate until morning sugar is normal or until 50UI.

Patient with DM type 1. After 3 months with 50UI of lantus (glargine) has a HgbA1C of 7.5%. Next step?

Add rapid insulin (e.g., Humalog (lispro), Novolog (aspart)) on biggest meal

How is the basal-bolus regimen for insulin management?

1. Calculate Total daily insulin (TDI) o 0.5 UI/Kg o 0.3 UI/Kg if Creatinine > 1.5, age > 65 o Then 50% basal (Lantus (glargine), Levemir (detemir)) o 50% prandial (Humalog (lispro), Novolog (aspart)): 1/3 breakfast, 1/3 lunch, 1/3 dinner. * Before each meal or before going to bed--> take blood glucose and give the corresponding insulin. * The glucose I’m measuring right now is depended on how much I eat in the previous moment of the day and how much insulin I had.

Patient in basal-bolus regimen 40UI Lantus (glargine) qHS and 13UI of prandial Humalog (lispro). The patient has high blood glucose at noon. Next step?

Increase AM Humalog (lispro)

Patient in basal-bolus regimen 40UI Levemir (detemir) qHS and 13UI of prandial Novolog (aspart). The patient has high blood glucose before breakfast. Next step?

Increase lLevemir (detemir) given qHS

Patient with failure of oral diabtic management, bad support network, scared of needles. You expect a failure of basal-bolus regimen. Next step?

Mixed regimen (AKA, idiot insulin) with either Novolin or Humulin Calculate Total daily insulin (TDI) • 0.5 UI/Kg • 0.3 UI/Kg if Creatinine > 1.5, age > 65 • Then 2/3 AM; 1/3 PM

Diabetic patient with Palpitations, Diaphoresis, and Presyncope. Glucose of 70. Tx?

PO glucose F/U: Find causes

Diabetic patient with Palpitations, Diaphoresis, Presyncope, and coma. Glucose of 70. Tx?

IV D50 F/U: Find causes

Non-diabetic with Palpitations, Diaphoresis, and Presyncope. Glucose of 60. Next step?

o C-peptide o Pro-insulin o Secretagogue screen

Non-diabetic with Palpitations, Diaphoresis, and Presyncope. Glucose of 60. ↓ C-peptide Dx?

Factitious disorder Patient is faking hypoglycemia by injecting exogenous insulin

Non-diabetic with Palpitations, Diaphoresis, and Presyncope. Glucose of 60. (+) secretagogue screen Dx?

Factitious disorder Patient is faking hypoglycemia by consuming Sulfonylurea

Non-diabetic with Palpitations, Diaphoresis, and Presyncope. Glucose of 60. (-) secretagogue screen ↑ C-peptide Dx next step?

Possible insulinoma o 72-hr fast glucose o CT/MRI Abd

Patient with type I DM in coma and dehydration. - Blood glucose 300-500 - Urine: Positive ketones - ABG: acidosis - Positive anion gap Dx and tx?

Diabetic Keto Acidosis (DKA) - 10UI of insulin IV, Followed by insulin drip - Vigorous hydration with NS or LR (When the glucose normalizes, change IVF to D5 1/2 NS) - Replace K if < 4 (insulin produces hyperkalemia) When glucose is normal and gap closes--> bridge to long-acting insulin and look for possible cause of DKA

Patient with type II DM in coma and dehydration. - Blood glucose 800-1000 - Urine: NO ketones - ABG: no acidosis - BMP: no gap Dx and tx?

Hyperosmolar Hyperglycemic Nonketotic Coma - 10UI of insulin IV, Followed by insulin drip - Vigorous hydration with NS or LR - Replace K if < 4 (insulin produces hyperkalemia) Bridge to long-acting insulin when glucose is normal and look for cause (NSTEMI or infection)

The most common cause of hypothyroidism.

Hashimoto’s thyroiditis.

Lab findings in Hashimoto’s thyroiditis.

High TSH, low T4, antimicrosomal antibodies

Exophthalmos, pretibial myxedema, and ↓ TSH.

Graves’ disease.

The most common cause of Cushing’s syndrome.

Iatrogenic corticosteroid administration. The second most common cause is Cushing’s disease.

A patient presents with signs of hypocalcemia, high | phosphorus, and low PTH.

Hypoparathyroidism.

“Stones, bones, groans, psychiatric overtones.”

Signs and symptoms of hypercalcemia.

A patient complains of headache, weakness, and polyuria; exam reveals hypertension and tetany. Labs reveal hypernatremia, hypokalemia, and metabolic alkalosis.

1° hyperaldosteronism (due to Conn’s syndrome or bilateral adrenal hyperplasia).

A patient presents with tachycardia, wild swings in BP, headache, diaphoresis, altered mental status, and a sense of panic.

Pheochromocytoma.

Should α- or β-antagonists be used fi rst in treating | pheochromocytoma?

α-antagonists (phentolamine and phenoxybenzamine).

A patient with a history of lithium use presents with copious amounts of dilute urine.

Nephrogenic diabetes insipidus (DI).

Treatment of central DI.

Administration of DDAVP ↓ serum osmolality and free water restriction.

A postoperative patient with significant pain presents with hyponatremia and normal volume status.

SIADH due to stress.

An antidiabetic agent associated with lactic acidosis.

Metformin.

A patient presents with weakness, nausea, vomiting, weight loss, and new skin pigmentation. Labs show hyponatremia and hyperkalemia. Treatment?

1° adrenal insuffi ciency (Addison’s disease). Treat with replacement glucocorticoids, mineralocorticoids, and IV fluids.

Goal HbA1c for a patient with DM.

< 7.0.

Treatment of Diabetic ketoacidosis (DKA).

Fluids, insulin, and aggressive replacement of electrolytes (e.g., K+).

Why are β-blockers contraindicated in diabetics?

They can mask symptoms of hypoglycemia.

Patient with multiple episdes of hypoglicemia. ↑ Insuline levels ↑ C-peptide (-) Sulfonylurea screen Dx, next step, tx?

Insulinoma Next step: CT scan Tx: resection

Patient with Migratory necrolytic dermatitis. Dx, next step and tx?

Glucogonoma Next steps: Glucagon levels and CT scan Tx: Resect

Endocrinology Flashcards

(108 cards)