Endocrinology Flashcards
(251 cards)
1
Q
Hypothalamus hormones (and the anterior pituitary hormones they act on) Plus Posterior Pituitary hormones
A
Hypothalamus: Dopamine (the only inhibitory signal; without it prolactin is always “on”), GHRH (GH), TRH (TSH, CRH (ACTH), GNRH (LH/FSH and posterior pituitary below)
Posterior pituitary = oxytocin and ADH
FYI- FSH is the single most important determinant of pituitary dysfunction
2
Q
Pituitary: screening for axis function
A
Hypothalamus-pituitary-
Gonadal —> LH/FSH (menses and erections)
Thyroid —> TSH
Adrenal —> ACTH
FYI- most sensitive determinant of pituitary function is FSH/LH level
3
Q
Pituitary: screening for hormone excess
A
Prolactinoma —> prolactin level
Hyperthyroidism —> TSH
Acromegaly —> IGF-1 level
Cushing’s syndrome —> 1mg dexamethasone suppression test
4
Q
In a patient with motor vehicle accident, CT of head was done which revealed no bleed, but a 0.8 cm solid mass confined to the pituitary. Patient is nulliparous and menstruation is regular. What to do next?
A
Check prolactin, TSH/T4, IGF-1, 1mg dexamethasone suppression test
Not cosyntropin, insulin stimulation test, TSH
5
Q
You suspect pituitary dysfunction (hypofunction), how do you evaluate it?
A
Check FSH first (usually normal if normal menses and no erectile dysfunction)
If FSH low then check prolactin
If prolactin high (normal is <200; really <20) then check TSH
If TSH normal then check MRI pituitary
Pituitary stalk tumor turns off dopamine which takes away the inhibitory signal so prolactin always “on” and the high amount causes additional feedback inhibition of GnRH. The Low TRH causes low TSH (hypothyroidism) and the low GnRH causes low FSH/LH (impotence and amenorrhea; there will be low testosterone or low estrogen too)
6
Q
Hyperprolactinemia DDx
A
Prolactinoma Pituitary stalk tumors Stalk Dz Hypothyroidism Pregnancy Nipple manipulation (prolactin may be normal)
Drugs: antipsychotics (risperidone, phenothiazine), methyldopa, amitriptyline, clomiprine, estrogens, marijuana, metoclopramide, CKD
7
Q
Prolactinoma signs and management
A
Prolactin level >200 and tumor >1cm (macroadenoma) or <1cm (microadenoma)
Females with galactorrhea and amenorrhea
Males with impotence and decreased libido
Tx bromocriptine or cabergoline (dopamine agonists, work within 4-6hrs, usually don’t need surgery)
If female and prolactin <100 and NO symptoms than can use OCP alone (even though already have amenorrhea, the estrogen helps prevent osteoporosis)
Follow with MRI: if size >1cm then MRI Q6mos along with visual field testing; if size <1cm then MRI Q12mos
8
Q
A middle-aged male presents with decreased libido and fatigue. Has sensitivity of his nipples when he wears T-shirts. Exam reveals fullness of the areola. Testosterone level low. LH, FSH low. Next diagnostic test OR a woman with galactorrhea. What do you check next?
A
Prolactin
Not CT head or TSH
9
Q
A 35-year-old woman presents with galactorrhea and amenorrhea for the past six months. Pregnancy test negative. FSH low. Prolactin level 184. Thyroid function tests normal. What to do next?
A
MRI Brain Not cabergoline (you have to confirm prolactinoma first)
10
Q
Patient postpartum continues to have galactorrhea after finishing nursing the baby. TSH is 2.8. Prolactin level is 281. She takes no medications. Most likely cause of her galactorrhea is?
A
Prolactinoma
Not lactation or hypothyroidism
Recall for prolactin >200 you should check an MRI next
Prolactin up to 400 is normal while pregnant not after
11
Q
Patient with prolactinoma (micro or macroadenoma) has amenorrhea and wants to conceive. What to do?
A
Start dopamine agonist cabergoline to reduce prolactin level and induce ovulation
12
Q
Patient treated with bromocriptine for macroadenoma and gets pregnant. What to do?
A
D/c bromocriptine (same if cabergoline)
Follow with visual field testing Q3mos —> no changes then do nothing; getting worse then begin/restart bromocriptine (uncertain safety with pregnancy)
13
Q
Increasing shoe size/hat size/ring size, hyperglycemia.
Prominent jaw, wide space between teeth, big tongue, fleshy (increased soft tissues) palms and soles.
Osteoarthritic changes on x-rays.
A
Acromegaly
Best screening test is IGF-1 (aka somatomedin C); also used to follow disease activity
Confirm with oral glucose tolerance test (failure to suppress GH to <1 ng after 100gm of glucose)
Tx transphenoidal surgery —> somatostatin analog (octreotide)
14
Q
Diabetes Mellitus diagnosis
A
10% of Americans
Normal blood sugar is <100 mg/dL
FBS 100-125 (or A1c 5.7-6.4)—> impaired fasting glucose —> increased incidence of DM
DM Dx: FBS >126 x2 occasions A1c >/= 6.5 Random blood sugar >/= 200 with symptoms 75g 2hr GTT >/= 200 (esp- in pregnancy, PCOD)
15
Q
Patient with fasting blood sugar 127, what next?
Patient with fasting sugar of 118 and A1c of 6.5, what next?
A
Repeat FBS
Repeat A1c (repeat the abnormal test, not the normal one)
16
Q
A 35yo with BP >135/80
OR a 36yo with BMI 26 AND sedentary lifestyle
OR a 40yo pt
What will you check next?
A
Fasting blood sugar
17
Q
Patient had a fasting blood sugar of 129. Repeat is 127. This patient has?
A
DM and is at risk for retinopathy and nephropathy NOW
18
Q
A 24-year-old patient with FBS of 140. Relatives have type two diabetes. How do you differentiate of this patient has type one or type two diabetes?
A
Check for antibodies to glutamic acid decarboxylase (anti-GAD), the earliest antibody to appear in Type I DM. Later presence of antibodies to islet cells as well.
19
Q
Insulin pump pros/cons
A
Pros:
Improved flexible lifestyle
Tighter glucose control
Fewer hypoglycemic episodes
Cons:
DKA with malfunction of the pump
Infections
Must check glucose at least x4 daily
20
Q
Sulfonylureas
A
Decrease A1c by 1% = 30 mg/dL drop in FBS
Can cause hypoglycemia and weight gain (avoid in obese)
Glimepiride
Glipizide
Glyburide (increased mortality in elderly and CAD with glyburide but not the other 2)
21
Q
Meglitinides
A
Decrease A1c by 0.6-0.8%
Can cause hypoglycemia
Excreted thru bile so drug of choice in CKD
Rapid acting
Repaglinide
22
Q
Biguanides
A
Decrease A1c by 1%
Do NOT cause hypoglycemia (so don’t need to monitor fingersticks)
Work by lowering hepatic gluconeogenesis, lowering insulin resistance, lowering weight, lowering TG’s/Cholesterol
Treatment of choice for Obese patients with hypertriglyceridemia
About 5% have lactic acidosis (higher risk if GFR <30)
Associated with B12 deficiency
Metformin
23
Q
Alpha-glucosidase inhibitors
A
Inhibits breakdown of carbohydrates and decreases absorption of glucose
**If hypoglycemic, orange juice therefore won’t work, need to give pure dextrose
Mainly for post-prandial hyperglycemia
Avoid in low GFR
Acarbose
24
Q
Thiazolidinediones
A
Decrease A1c by 1% Doesn’t cause hypoglycemia Avoid in pots with CHF NYHA class II Can cause thigh-high edema Long-term use associated with bladder cancer
“glitazones”
Pioglitazone
25
Incretin mimetic
Decrease A1c by 1%
Don’t cause hypoglycemia
Good for obese patients failing oral meds
All GLP-1 agonists can cause nausea
All mimetics can cause pancreatitis
Contraindicated if Hx pancreatitis, family Hx MEN IIA/IIB (medullary thyroid cancer)
Exenatide
Liraglutide (approved for weight loss with BMI >30 even without diabetes)
Dulaglutide
Semaglutide (GLP-1 agonist, lowers hepatic gluconeogenesis, lowers gastric emptying, leads to weight loss and early satiety, increased cell growth)
Liraglutide, dulaglutide, and semaglutide all decrease cardiovascular risk
Other mimetics include DPP-4 inhibitors: sitagliptin, saxagliptin, linagliptin, alogliptin
Decrease A1c by 0.6-0.8%
Don’t cause hypoglycemia
26
Amylin analogues
Complementary to insulin
No hypoglycemia by itself
Good for obese patients failing insulin therapy with high post-prandial glucose and gaining weight on short acting insulin agents
Pramlintide: slows gastric emptying, lowers glucagon secretion, leads to weight loss and early satiety
27
A 55-year-old man with diabetes on DPP-4 inhibitor for the past year, presents with pain in the joints of hand, wrist and shoulder for the past four weeks. Exam reveals minimal swelling. CRP elevated. Best management?
Discontinue the glinting (they can all cause arthritis)
28
SGLT2 inhibitors
Side effects:
Euglycemic DKA especially at times of extreme stress (so check anion gap with infections)
Block reabsorption of glucose by the kidney (and sodium too so good for CHF) thereby increasing excretion of glucose in urine (UA with 4+ glucose can be normal). This means increased risk for UTI’s, Fournier’s gangrene (necrotizing fasciitis of perineum), genital mycotic infections. Reduced blood pressure. Example- in a pt with pneumonia need to stop their SGLT2 inhibitor
Canagliflozin and Empagliflozin: shown to reduce incidence of end-stage renal disease and hospitalizations for heart failure; also a trend toward decreased cardiovascular death and all-cause mortality
Dapagliflozin: shown to reduce heart failure hospitalizations
29
ADA recommended blood sugar goals in DM
```
A1c:
<6.5% if microvascular disease (nephropathy, neuropathy, retinopathy)
<7% if low risk hypoglycemia
7-8% if high risk hypoglycemia
>8% if terminal or comorbid conditions
```
Preprandial glucose goal 80-130 (non-DM normal is <100)
Peak 2hr post-prandial goal <180 (non-DM normal is <140)
30
A patient with BMI 32. His FBS is 115. Family Hx is significant for DM2. Best way to prevent onset of DM2?
Diet and exercise (aerobics plus resistance training; weights target glycogen stores and decrease insulin resistance) will decrease A1c by 0.5% (anecdotally maybe by even more)
Not metformin or a glitazone
31
Drugs that can cause hyperglycemia
```
Statins (increased risk with increasing dose/intensity)
Beta blockers (except carvedilol)
Hydrochlorothiazide
Niacin
Olanzapine
Protease inhibitors
Steroids
```
32
A 45-year-old woman was diagnosed with type two diabetes four months ago with FBS of 170, A1c 8.9, weight of 205 pounds. She is started on an intensive exercise and diet regimen. Repeat FBS is 165. What to do?
```
Start a biguanide (metformin)
Not sulfonylurea (glyburide, glipizide), insulin, alpha-glucosidase inhibitor (acarbose), or insulin+sulfonylurea
```
33
Patient with type two diabetes responded well to metformin and sulfonylurea previously, for several years, but now has increasing blood sugars. No infections. A1c 9. What to do next?
Add 24hr glargine insulin (stop sulfonylurea, keep metformin)
Patients lose islet cell function with time
34
Patient with type two diabetes responded well to metformin and sulfonylurea previously, for several years, but now has increasing blood sugars. No infections. A1c 9.
Patient switches to glargine insulin at bedtime and metformin for a year and does well. Later A1c is 8.5%, but FBS 115-130 range. What to do next?
Start lispro insulin
Not increase metformin or glargine insulin
FBS is at goal but A1c is high so it must be that the post-prandial glucose is high
35
When is metformin contraindicated?
GFR <30
| Acute or unstable CHF (low blood flow and GFR unstable)
36
We can started on metformin two days ago complains of diarrhea after taking metformin. What to do?
Continue for a week (diarrhea will probably stop with continued use)
37
Patient with diabetes on metformin 500mg once daily and A1c is 7.8%. What to do?
Increase metformin dose to BID (may go up to 2000-2400/day)
38
Patient with diabetes on multiple medications. Creatinine is >1.5 and CHF with LVEF <35%. What to do?
Discontinue metformin and glitazone; start glargine or detemir and lispro or aspart
Not sulfonylurea
39
Pt is going for cardiac cath or any radiocontrast study. On beta-blocker, insulin, ACE inhibitor, and metformin. Which do you stop on the day of the procedure?
Metformin
40
A 60 year old patient diagnosed with type II diabetes and BUN/Cr is 40/3.7. Which is best medication to start?
Repaglinide (or linagliptin)
| Not glyburide, glimepiride, pioglitazone
41
A 40 year old patient with type II diabetes was treated with metformin. A year later, he starts gaining weight, as he had stopped exercising. His blood sugars go up as well. What to do?
Start liraglutide
| Not increase metformin dose, start glitazone, or start sulfonylurea
42
Dawn’s Phenomenon
Early morning growth hormone surge usually balanced by insulin.
Increased 4-7am glucose secondary to insulin resistance and hormonal factors
Tx: increase PM NPH (increased insulin at bedtime)
43
Patient with fatigue, increased sweating and waking up with headaches +/- vivid dreams (nightmares), around 2am. FBS ranges between 120-145. Takes NPH at supper. What to do?
Nocturnal hypoglycemia
Check nocturnal glucose, and if low then decrease NPH or move NPH to bedtime or change to long-acting (glargine or detemir)
FYI: somogy effect is debunked, low night glucose doesn’t always cause morning hyperglycemia (may be normal in morning).
44
Diabetic patient on NPH/R in morning and supper.
Palpitations, excessive sweating, nocturnal awakening, morning headaches. What to do?
3 am blood sugar
45
Diabetic patient on NPH/R in morning and supper.
Blood sugar 3 am is 40 mg/dL. What to do?
Change NPH to HS or switch to long-acting insulin analog (glargine)
46
Diabetic patient on NPH/R in morning and supper OR glargine HS.
Persistently elevated fasting blood sugar. The 3am blood sugar is 200. What to do?
Increase supper NPH or glargine dose
47
Diabetic patient on NPH/R in morning and supper.
Blood sugar 30 and patient passes out at 12 noon, on 20 units NPH and 4 units R in morning. What to do?
Discontinue the R in the morning
48
Diabetic patient on NPH/R in morning and supper.
Blood sugar 180 at 5pm. What to do?
Increase NPH in morning
49
Diabetic patient on NPH/R in morning and supper.
Blood sugar at 4pm is 25 and at 10 pm is is 210. Patient is on 36 units NPH in morning. What to do?
Change to 24 units NPH in AM and 12 units in PM
50
Patient with the following blood sugars:
Breakfast. Pre-meal 160. Post-meal 165
Lunch. Pre 170. Post 175
Dinner. Pre 176. Post 178
Patient is on glargine insulin 20 units at night and lispro 4 units before breakfast, lunch and dinner. What to do?
Increase dose of long-acting insulin analogue
| Pre-meal levels are high, post-meal are okay
51
Patient with the following blood sugars:
Breakfast. Pre-meal 128. Post-meal 196
Lunch. Pre 132. Post 210
Dinner. Pre 116. Post 202
Patient is on glargine insulin 20 units at night and lispro 4 units before breakfast, lunch and dinner. What to do?
Increase dose of short-acting insulin before breakfast, lunch and dinner.
Pre-meal levels are okay, post-meal are high
52
A patient with fasting blood sugar of 115. A1c is 8.5%. He takes NPH or glargine at night and metformin. What to do next?
Check postprandial blood sugar
| Postprandial is likely elevated since A1c is high with fasting sugar low
53
A 65 year old man with diabetes was started on glargine insulin 30 unites every evening in addition to the metformin he was taking.
```
Blood sugars are as follows:
Day. 7am. 12pm. 5pm. 10pm.
#1. 97. 130. 212. 202.
#2. 102. 120. 201. 194.
#3. 104. 133. 196. 203.
```
What is the best management?
Change glargine to BID (glargine is losing effect later in the day so maybe it’s not lasting 24hrs)
Not increase glargine dose, switch to detemir, or increase aspart or lispro in the evening
54
How would you start an insulin regimen of glargine and lispro in a patient who weighs 60kg?
30 units daily need (60kg x 0.5units/kg)
Give 1/2 (15 units) as glargine with supper
Give 1/2 (15 units) as lispro divided TID (5 units with each meal)
55
How start an insulin regimen of glargine 15 units with supper and lispro 5 units with each meal in a patient who weighs 60kg. You want to assess the above regimen in 2-3 weeks time. What do you check?
```
Fructosamine test (equilibrates in 2 weeks)
Not A1c (equilibrates in 3 months)
```
Recall fructosamine also better in pregnancy, hemolytic anemia, and hemoglobinopathies
56
An African American male diabetic patient returns for follow up. He shows his glucometer readings which show serial fasting glucose 115-130 range. His A1c is 11%. Most likely etiology of the discrepancy?
Hemoglobinopathy (eg- HbC, HbS, etc)
| Not glucometer malfunction
57
Causes of a falsely elevated A1c
Decreased RBC turnover (low reticulocyte count conditions)
Eg-
Iron deficiency anemia, folate and B12 deficiency
ESRD (fewer RBC per glucose molecule)
Asplenia (increased RBC lifespan)
Also with Hemoglobinopathies (sickle cell trait, thalassemia trait, etc); not because of decreased RBC turnover but because of fewer RBC per same amount of glucose
58
Causes of a falsely low A1c
Increased RBC turnover (high reticulocyte count conditions)
```
Eg-
Hemolytic anemias, HIV
Treating iron/folate/B12 deficiencies (more RBCs are coming into circulation)
Blood transfusions
ESRD on HD and erythropoietin
```
Generally decreased RBC lifespan so glucose doesn’t have enough time to bind
59
Patient with A1c of 6.6%. Preprandial and postprandial blood sugars range between 90-150 except at 5pm blood sugar is 280. She has fresh fruit snack around 4pm. What is the etiology?
The 280 pm sugar predicts a higher fasting sugar so need to figure out which is incorrect, the fasting sugar or the A1c? In this case neither, the pm sugar is incorrect.
She is most likely not washing hands after eating fruit and checking blood glucose. Educate patient to wash hands before checking about glucose.
60
Patient with diabetes with blood sugar 340, triglyceride 2400, is hospitalized with pancreatitis. The fastest way to control the triglycerides would be to give?
Insulin (and glucose)
| Not metformin or gemfibrozil
61
Patient with insulin-dependent diabetes mellitus with abdominal pain has DKA, started on insulin drip at 10 units per hour and IV fluids. Blood sugar decreased to 280 and IV fluids change to D5 1/2NS and insulin drip decreased to 5 units per hour. Labs as follows:
Admission. 3 hrs later. Now.
Na 135. 138. 138
K 4.7. 4.2. 4.4
Cl 102. 109. 106
HCO3 9. 16. 13
Glu 675. 275. 375
What to do?
Increase insulin drip to 10 units per hour
| Not continue same
62
Patient with insulin-dependent diabetes mellitus with abdominal pain has DKA, started on insulin drip at 10 units per hour and IV fluids. Blood sugar decreased to 280 and IV fluids change to D5 1/2NS and insulin drip decreased to 5 units per hour.
Subsequently blood sugar down to 175 and ketones are negative. IV insulin is stopped and sliding scale regimen is started. A couple of hours later blood sugar is 325 and ketones are again positive with an anion gap. How could you have prevented the patient from going back into DKA?
By giving subcutaneous glargine insulin 60-120 minutes before stopping IV insulin drip (and feeding them too)
63
A patient was successfully treated for DKA with closure of gap, subcutaneous basal insulin was given 60 to 120 minutes before stopping insulin drip. Six hours later, ketones are positive and anion gap is normal. What to do?
Continue current management. The ketone here that has shown up is acetone which is biochemically NEUTRAL and takes a longer time to be cleared. The ketone that caused acidosis and decay is beta-hydroxybutyric acid which has cleared as suggested by the anion gap closure.
Recall: Triglycerides —> acetoacetic acid —> acetone (forms neutral ketones) or beta-hydroxybutyrate (forms ketones that cause gap)
64
Patient presents with diabetic ketoacidosis. Blood sugar 725, ketones strongly positive. Patient started on IV insulin drip and IV fluids at 10 AM. At about 7 PM blood sugar is 200. What to do next?
Start IV infusion with D5 1/2NS and continue insulin drip
65
The best way to follow diabetic ketoacidosis management is?
Serum anion gap
| Closed gap means body is now metabolizing glucose appropriately
66
A patient with diabetes admitted for surgery in the morning. He is on glargine and lispro. What to do on the morning of surgery-
1) If he receives the glargine QAM?
2) If he receives the glargine QAM?
1) Give 1/2 glargine and discontinue the lispro
Not discontinue both and start sliding scale insulin
2) Discontinue the lispro, continue the glargine
Not discontinue lispro and start sliding scale
67
A 24-year-old pregnant woman in her 24th week. Fasting blood sugar 115, repeat fasting blood sugar 114, refuses insulin. What to do?
Metformin
Goal fasting blood sugar <95 and metformin will lower A1c by 1% (= 30 points in glucose)
68
A 26-year-old diabetic pregnant woman in her 24th week with fasting blood sugar 120 and post prandial 180 on glyburide and metformin. What to do?
Insulin
Glucose goals in pregnancy:
Fasting = 95
1hr postprandial = 140
2hr postprandial = 120
69
A 30 year old with diabetes during pregnancy and treated. Diabetes continued after pregnancy. A1c 7.2%, not responsive to oral meds and asymptomatic. Father had mildly elevated glucose as well. Dx?
GCK-MODY (glucokinase mutation-maturity onset diabetes of the young)
Tx: not needed and no micro or macro complications
70
Elderly patient with type two diabetes brought with an episode of seizure. Blood sugar 1050. BUN 50, creatinine 1.8, keto is positive.
Dx hyperosmolar nonketotic coma
Tx IVF first then insulin
71
Patient with type I diabetes presents with DKA. Blood sugar 725 and ketones strongly positive. Patient started on IV insulin drip at 10 AM. By 10 PM the same day, the blood sugar is 200 and ketones negative. Bicarb has gone up from 4 to 18. K dropped from 5.7 to 4.5. Patient complains of difficulty breathing and muscle weakness. CPK-MM increased. JVD 3 cm. Most likely cause?
Hypophosphatemia
| Not hypermagnesemia, hypercalcemia, or hypocalcemia
72
Diabetes mellitus vascular complications
Macro vascular:
CAD, PAD —> Tx aggressive LDL control
Microvascular:
Nephropathy —> microalbuminuria —> Tx ACEi or ARB
Retinopathy —> nonproliferative Tx with tight glucose control (A1c <6.5%); proliferative Tx with tight glucose control and laser therapy
73
Diabetes mellitus neurological complications
Peripheral neuropathy > Autonomic neuropathy
Peripheral Neuropathy:
Peripheral sensory motor polyneuropathy —> stock and glove paresthesias —> Tx with amitriptyline, desipramine, both better than gabapentin; in Elderly use pregabalin
Autonomic neuropathy:
Impotence —> Tx PDE-5 inhibitors
Neurogenic bladder (hesitancy, dribbling, incomplete evacuation) —> urodynamic studies show retained urine —> Tx with timed bathroom visits —> Bethanechol next
Orthostatic hypotension —> Tx stockings —> high salt diet next —> Fludrocortisone next
Gastroparesis —> evidenced by high fluctuations of blood sugar 50-400mg/day
Other:
Foot drop or wrist drop, 3rd nerve palsy, can resolve spontaneously (as blood sugar is controlled)
Risk of fragility fractures in diabetics
74
Diabetic foot ulcers
Most common bacteria: staph aureus, beta hemolytic strep
Cause of foot ulcer: peripheral neuropathy
Best way to prevent ulcer: monofilament testing (1g = neuropathy, 10g = at risk for ulcers)
75
Patient with diabetes for 15 years. On metformin + sulfonylurea/insulin with hypoglycemic attacks postprandial, early satiety and vomiting. But sugar varies from 50-400 mg/day. Dx?
Gastroparesis —> delayed absorption —> 2/2 autonomic neuropathy
Best test —> Scintiscan of residual gastric contents. Ingest isotope and scan immediately, then 2 to 4 hours later.
Tx: small frequent meals of liquid or puréed diet with high protein, low fat and low in non-digestible fiber —> metoclopramide/domperide
76
What are the current recommendations for follow up in a diabetic patient?
Quarterly A1c
| Annual microalbumin, lipid panel, and eye exam
77
A nurse calls you to let you know that a patient’s blood sugar is 62.
1) Asymptomatic, what to do?
2) Symptomatic with tachycardia, what to do?
1) Adjust treatment regimen
2) 15g of carbohydrate [glucose tablets, candy or sweetened fruit juice]; if patient is on acarbose then pure glucose [dextrose] and adjust treatment regimen.
78
Patient on insulin with loss of consciousness, blood glucose 30. There were no premonitory symptoms. Dx?
Hypoglycemia unawareness
Tx: lower insulin dose to allow blood glucose levels to increase for several weeks to restore sensitivity to hypoglycemia
79
Newly diagnosed patient with blood glucose of 350. On insulin when blood glucose drops to 130 and patient becomes tachycardic and diaphoretic. What to do?
Keep blood glucose <200 at first (for a couple of weeks before trying to lower it further)
80
Patient with blood glucose 35 and taking glipizide, metformin and acarbose. How to manage?
Discontinue glipizide, admit (long half-life) and give IV dextrose (if no IV line then give glucagon)
81
A 22 year old woman with recurrent dizzy attacks in ER. Mother is diabetic. Blood glucose is 35. The next diagnostic step to find the cause of hypoglycemia?
Surreptitious use
Check urine +/- serum sulfonylurea screen
Not CT pancreas or glucose tolerance test
82
A 22 year old woman with recurrent dizzy attacks in ER. Mother is diabetic. Blood glucose is 35.
Felt to be surreptitious use of sulfonylurea. Continues to be hypoglycemic, an ample of D50% is given and IV dextrose is started. What next?
Glucagon —> octreotide next (shuts off insulin secretion by pancreas)
83
A 40-year-old patient with confusion, tachycardia, sweating, palpitations, tremor. Finger touch glucose 54. How to evaluate?
Check blood glucose, insulin, c-peptide, beta-hydroxybutyrate (BHOB), proinsulin, sulfonylurea and meglitinide screen
```
FYI:
Proinsulin —> insulin + c-peptide
Sulfonylurea: high, high, high
Commercial insulin: normal, high, normal
Insulinoma: very high, high, high
```
84
Thyroid hormone pathway
TRH —> TSH —> T4 and T3 (blocked by lithium, iodine)
| T4 —> rT3 and T3 (blocked by propranolol, glucocorticoids, PTU, amiodarone)
85
Sick euthyroid diagnosis
Low TSH, Low/normal T4, Low T3
| High rT3
86
Thyroid tests:
1) The first test to evaluate thyroid disease:
2) The best test to follow for hypothyroidism:
3) The best test to follow for hyperthyroidism:
4) If thyroid nodule:
1) TSH
2) TSH
3) Free T4 and total T3 (FT3 is hard to get at some labs)
4) Ultrasound to differentiate high risk vs low risk in cold nodules
87
Radioactive iodine uptake in Hyperthyroid states
1) Graves’ disease
2) Multinodular goiter
3) Toxic nodule
4) TSH Adenoma
5) Thyroiditis
6) Exogenous (factitious)
1) Low TSH, increase in T3 more than increase in T4; Areas of diffuse uptake (increased is >35%)
2) Low TSH usually <0.03, high T4; Areas of increased uptake surrounded by areas of decreased uptake (polka dots)
3) Low TSH, high T4; Area of increased focal uptake surrounded by areas of decreased uptake
4) High TSH, high T4; Areas of diffuse uptake
5) Low TSH usually 0.03-0.5, increase in T4 more than increase in T3; low uptake (<5%)
6) If taking T3 then low TSH and low T4; If taking T4 then low TSH and high T4; low uptake
88
Radioactive iodine uptake in Hypothyroid states
1) Primary hypothyroidism
2) Hypopituitary hypothyroidism
1) High TSH, low T4; low uptake; monitor by following TSH (Tx goal is TSH <2.5 if symptoms; should still treat if asymptomatic if TSH >10)
2) Low/normal TSH, low T4; low uptake; monitor by following FT4
89
Thyroid scenarios, what’s the diagnosis?
Normal TSH 0.05-5.0, Normal FT4 0.9-2.4
TSH, FT4 values:
1) 0.3, 1.1
2) 1.0, 0.8
3) 20, 0.8
4) 6, 1.0
5) 10, 1.5 no symptoms
6) 15, 4
7) 4.5, 3
8) <0.01, 3.8
9) 0.2, 2.2 no symptoms
10) 0.07, 3.5
1) , 2) Hypopituitary hypothyroidism
3) , 4) Primary hypothyroidism
5) Subclinical hypothyroidism
6) , 7) TSH adenoma
8) Primary hyperthyroidism
9) Subclinical hyperthyroidism
10) Thyroiditis
90
An elderly patient brought with apathy, weight loss, arrhythmias, CHF, diarrhea, depression, sleepiness and muscle weakness. TSH <0.03, T4 3.5. Dx?
Apathetic thyrotoxicosis (compare to myxedema coma where T4 is low)
91
Pt with T4 elevated 3.5 (normal is 0.9-2.4), TSH 4.5 (normal is 0.5-5.0). Dx? What to do next?
TSH adenoma
Check MRI brain next
92
Patient presents with weight loss, feels warm in the winter, tremors positive, appetite increased, diarrhea, palpitations, atrial fibrillation. I’ll exam thyroid is enlarged. Labs show FT4 3.7, TSH <0.01. What to do next?
Radioiodine uptake (to confirm before treating)
Should r/o thyrotoxicosis by checking TSH in any patient with AFib
93
Radioactive iodine uptake in hyperthyroid states:
1) Increased diffuse:
2) Increased focal:
3) Decreased:
4) Areas of increased and decreased uptake
1) Graves’ disease
2) Toxic nodule
3) Thyroiditis or factitious thyrotoxicosis
4) Multinodular goiter
94
Patient with hypothyroidism and decreased radioiodine uptake. How will you differentiate between thyroiditis and factitious thyrotoxicosis?
Increased thyroglobulin —> Thyroiditis, residual cancer (that’s why you follow it for follicular and papillary thyroid cancer)
Decreased thyroglobulin —> factitious thyrotoxicosis
Increased thyroid binding globulin (TBG) —> estrogens and pregnancy can cause total T3 and total T4 to be elevated —> euthyroid thyrotoxinemia (TSH may be normal) —> check FT3
95
A 26-year-old woman presents with signs and symptoms of hypothyroidism. She said she was started on a new diet pill recently and has been exercising. T3 elevated, TSH is low and radioiodine uptake is <5%. Antimicrosomal antibodies negative. What is the most likely explanation?
She is taking thyroxine
Not Graves’ disease, Thyroiditis, or symptoms related to exercise
Thyroglobulin will be decreased
96
A 40-year-old patient has a complete physical and labs done as part of an insurance exam. Patient is asymptomatic. TSH 0.18, T4 11. Dx? When next? When Tx?
Subclinical hyperthyroidism
Repeat TSH in 3mos
Tx if TSH <0.3 and either age >65, heart disease, or osteoporosis
97
Patient with fatigue and unable to sleep for the past few months. No change in weight. Takes multiple vitamins including those for hair and nail growth. TSH 0.1, T4 is 16. Most likely etiology?
Biotin interference with labs (the fatigue implies not true hyperthyroid)
Biotin can also make troponin look normal with an MI
98
Thyrotoxicosis: Dx and Tx
TRAb positive or antiTPO positive
Pregnancy —> PTU in 1st trimester, Methimazole in 2nd and 3rd trimesters
All others —> radioactive iodine —> >50% become hypothyroid in <2mos
If thyroid orbitopathy —> subtotal thyroidectomy
99
A 52-year-old woman is admitted with pneumonia. Exam reveals the patient is confused. She’s hitting the medical staffing and is inattentive. She has diarrhea and family says she lost 15 pounds in the past six months. Temperature of 104.5°F, heart rate 140, rales at both bases. CXR reveals a right lower lobe consolidation. On antibiotics 2 days later, becomes hypotensive and then comatose. Dx and Tx?
Thyroid storm (for HR >120 or T >103.0 think of stuff other than just infection)
Tx: IV PTU, steroids, and beta-blockers
Infections, surgery, or trauma can precipitate this
100
Patient with Graves’ disease had radioiodine ablation. Eight weeks later he has gained weight. TSH 0.2 (normal 0.5-5.0), free T4 is 0.4 (normal 0.9-2.4). What to do next?
Start T4
The TSH is low but may be my higher than where it started so it will keep going up over time if you waited to recheck.
101
Patient with Graves’ disease had radioiodine ablation. Eight weeks later he has gained weight. TSH was 0.2 (normal 0.5-5.0), free T4 was 0.4 (normal 0.9-2.4), so you started T4 supplementation. Two months later he presents with watery eyes, scleral injection, and periorbital edema. Exam reveals an afferent pupillary defect in right eye. Painful eye movements. Most likely diagnosis?
Graves’ orbitopathy (thyroid ophthalmopathy) with optic nerve impingement
102
Patient with thyrotoxicosis with orbitopathy. Best management?
Surgery
Not radioactive iodine
Treatment of just the orbitopathy itself —> Selenium if mild; Steroid if severe
103
Thyroiditis
All have decreased radioactive iodine uptake. May present with hyper, hypo, or euthyroid states.
Release of preformed hormones —> thyrotoxicosis —> returns to normal.
Thyroglobulin increased.
104
Patient presents following URI, soreness in neck. On exam she has enlarged tender thyroid. ESR increased, T3RU increased, T4 wnl. Dx? Eval? Tx?
Dx: Subacute thyroiditis (subacute granulomatous thyroiditis, deQuervain’s thyroiditis)
RAI uptake decreased
Tx pain with aspirin, NSAIDs; palpitations with beta blockers
Don’t use anti thyroid drugs
Checking for antibodies is NOT helpful in diagnosis
Drug induced thyroiditis can be caused by amiodarone, lithium, tyrosine kinase inhibitors
105
Young patient with nervousness, insomnia, irritability after having uncomplicated delivery. She is breast-feeding. On exam thyroid enlarged, nontender. TSH 0.05, T4 will be elevated. Dx? Tx?
Lymphocytic thyroiditis
Give beta blockers alone and nothing else (if pt wasn’t breastfeeding you’d do RAI study)
Not RAI uptake and beta-blockers
Not methimazole
Usually transient hyperthyroidism —> hypothyroidism —> euthyroidism after several months
106
Young woman four months postpartum with uncomplicated course, with decreased energy, weight gain, amenorrhea, delayed deep tendon reflexes. Pregnancy test negative. What to do next?
TSH to r/o hypothyroid stage of chronic lymphocytic thyroiditis
107
Thyroid antibodies in Graves’ vs Hashimoto thyroiditis
Both: anti-TPO and anti-Tg
Graves: anti-TSHr positive (aka TRAB)
Hashimoto: anti-TSHr negative
108
A 30-year-old postpartum with tremors and depression. T4 high. You reassured her, but she comes back a month later, still with depression and now fatigue. Repeat T4 is 3 and TSH is 26. What to do?
Start synthroid, reassure and repeat TFTs in <3 months
Not reassure and repeat TFTs in 3 months, nor check for thyroid stimulating antibodies
In the question the TFTs were checked too soon. Earliest you should repeat TSH is 6-8 weeks for equilibration (maybe T4 was falsely high).
109
Patient presents with tremor and tachycardia. Patient is an aspirin, digoxin and amiodarone/IFN-alpha. Serum T3 190, T4 3.5 and TSH 0.04. RAIU is <5%. Most likely etiology?
Amiodarone and interferon
| Not digoxin or HCTZ, not Graves’ or multinodular goiter (RAIU would be high)
110
Patient with acute illness incubated and hospitalized in ICU. Episode of hypotension on vasopressors. T4 1.0 (normal 0.9-2.5), T3 60 (normal 70-195), TSH 0.5 (normal 0.5-5.0). Dx? Tx?
Euthyroid sick syndrome
Continue present care; not start T4 or T3+T4
111
Cold intolerance, constipation, coarsening of features, delayed tendon reflexes/hung up reflexes, amenorrhea, elevated prolactin. Dx and different types?
Hypothyroidism
Primary hypothyroidism: high TSH, low T4
Hypopituitary hypothyroidism: very low TSH, very low T4, low rT3
Subclinical hypothyroidism: high TSH, normal T4
Avoid doing T3 testing when patient is taking T4 because the T4 the patient is getting is converted to T3 at the CELLULAR level (not reflected in plasma T3)
112
Patient presents with fatigue, cold intolerance, and delayed deep tendon reflexes. TSH 6.0 (normal 0.5-5.0), T4 1.2 (normal 0.9-2.5). Dx? Next test?
Hashimoto thyroiditis
Not factitious thyroiditis
Anti-TPO antibodies (thyroid peroxidase positive) will most likely be positive
113
A 28 year old woman with fatigue and weakness has difficulty getting up from a sitting to standing position. She also has some pain in the joints of her hands. CPK 200. DTRs 1+ and slow. What to do next?
TSH (eval for hypothyroidism with proximal muscle weakness)
114
New diagnosis of hypothyroidism. How to treat if Hx CAD or elderly?
Low-dose. Start with 25mcg and increased by 25 mcg Q4-6wks and measure TSH. If TSH still high then increase T4 dose; if TSH very low then decrease T4 dose.
Levothyroxine should be taken 60min before coffee or breakfast.
115
Patient taking synthroid for hypothyroidism. T4 1.5 (normal 0.9-2.5), T3 3 (normal 1.5-7), TSH 12 (normal 0.5-5.0). What to do?
Increase T4 dose (goal TSH = 2.5)
116
Patient taking synthroid 200mcg for hypothyroidism. Two months later, T4 1.6 (normal 0.9-2.5), T3 1.2 (normal 1.5-7), TSH 2.5 (normal 0.5-5.0). Patient complains of not losing weight despite diet and exercise. What to do?
Continue current dose of T4 (because TSH is at goal and pt asymptomatic)
Not begin T3 or increase synthroid to 250mcg
117
Hypothyroid patient on thyroxine goes on <1 week vacation and forgets to take medications with her. What to do?
Restart thyroxine (T4) upon arrival
Half life of T4 is 7 days
118
Patient with refractive arrhythmias, responding to amiodarone OR patient on lithium. Four months later with symptoms of hypothyroidism. TSH 20 (normal 0.5-5.0), T4 is 0.6 (normal 0.9-2.5). What to do?
Start levothyroxine
119
Patient found to have slightly elevated TSH. Repeat TFTs confirm elevation of TSH 12.0, but T4 is 1.4 and T3 is 124 normal. Patient is asymptomatic. BMI 30 and LDL of 160. Dx? Tx?
Subclinical hypothyroidism
Tx with levothyroxine (since TSH >10)
FYI: Tx would result in lowering LDL, not in weight loss
120
Patient with 3 vessel CAD going for CABG. TSH is 11.0. What to do?
Clear him for surgery
121
Patient with angina had cardiac cath. He developed thyroid swelling. T4 is 1.6 and TSH is 5. What to do?
Repeat T4 in 4 weeks
Not start thyroxine or RAI uptake
(Due to iodine contrast with the cardiac cath)
122
Patient is brought to the ER on a cold winter day. Patient is stuporous, hypothermic, bradycardic with heart rate of 40. On exam periorbital edema, pubic hair loss and axillary hair loss. Dx? Tx?
Myxedema coma
Tx IV hydrocortisone plus T4 plus T3 plus antibiotics (empiric because infection is a common precipitant)
Not IV T3 or hydrocortisone by themselves
123
Patient with hypothyroidism well-controlled on synthroid gets pregnant. When is the requirement of thyroxine increased?
Elevated during first trimester and remains elevated in all trimesters of pregnancy by 30-50%. (Example- if you take six pills, then increase to nine empirically)
124
A pregnant patient has anti-TPO antibodies and you start levothyroxine. You check the TSH in six weeks. What is your target TSH?
= 2.5 (in elderly maybe <5.0 okay)
125
Asymptomatic thyroid nodule on routine physical exam. What to do next?
Check TSH (is it functioning or not)
126
Asymptomatic thyroid nodule on routine physical exam. TSH 1.5 (normal 0.5-5.0). Ultrasound reveals three hypoechoic nodules >1cm each. What to do?
Fine needle biopsy of all 3
Not RAIU
<1cm is not likely cancer
127
Asymptomatic thyroid nodule on routine physical exam. TSH 1.5 (normal 0.5-5.0). Ultrasound reveals three hypoechoic nodules >1cm each. Biopsy of all 3 are negative. Two years later ultrasound reveals hypoechoic nodule 1.4cm. What to do?
Fine needle biopsy (repeat biopsy and if negative again (x2 total) then stop surveillance)
Not RAIU or do nothing
128
Asymptomatic thyroid nodule on routine physical exam. TSH is decreased and T4 is increased. What to do?
Confirm with RAIU
If RAIU increased and pt with Graves’ disease —> antithyroid meds —> radioactive iodine —> surgery
129
Patient with multinodular goiter on Synthroid for over a year presents with palpitations and weight loss. Free T4 3.2, TSH <0.1, Synthroid dose is decreased. Eight weeks later, T4 is 3.1, TSH still decreased, T4 dose is again lowered and repeat TSH is still <0.1. What to do next?
RAI uptake scan (after holding synthroid for 1 week)
If uptake low, then decrease T4 dose
If uptake high, then patient is now euthyroid or developed thyrotoxicosis —> stop synthroid for 2 weeks and repeat TSH in 6-8 weeks
130
A patient has radiation therapy to the brain. A year later with weight gain of 15 pounds, fatigue and constipation. TSH 1.0, T4 is 0.7, replacement with levothyroxine is begun. How would you follow this patient?
```
FT4
Not TSH (there’s no more TSH production so it may continue to go down)
```
131
In a nuclear power plant disaster, what would you give to people in the surrounding community?
Potassium iodine (before exposure to prevent cancer)
132
Vitamin D deficiency vs insufficiency vs sufficiency, Dx and Tx
Deficiency <20 ng/mL (increased Fx risk) —> 50,000 IU/wk x8wks then 1-2k/d thereafter
Insufficiency <30 (decreased muscle strength) —> 1-2k/d
Sufficiency >30
FYI: maintenance for age <70 is 600/d, for age >70 is 800/d
133
At what vitamin D dose intake are fractures found to be preventable?
800/day
134
Patient with serum calcium of 11.5. Repeat is 11.6. What to do next?
Check PTH
FYI- Thiazide diuretics (decreased calcium excretion) and lithium can cause hypercalcemia as well.
135
Patient with increased serum calcium, increased PTH.
```
Primary hyperparathyroidism (serum phosphate level will be very low)
Lithium treatment mimics this (treat by stopping lithium)
```
136
Patient with increased serum calcium, normal PTH.
Familiar hypocalciuric hypercalcemia (FHH).
Abnormal calcium sensor in the kidney. Mild high serum calcium.
Urine calcium to creatinine ratio <0.01. No treatment
137
Patient with increased serum calcium, very low PTH.
1) Malignancy (multiple myeloma) is the most common cause of hypercalcemia.
PTH related protein (PTHrP) not measured by regular test.
—> Check low-dose CT scan next (in multiple myeloma looking for osteoclastic activity)
2) Vitamin D intoxication —> Measure 25-OH-D level (also for vitamin D deficiency)
3) Sarcoidosis —> Measure 1,25-OH-D level —> in sarcoidosis excess conversion occurs in macrophages (rather than kidneys per usual) and leads to increased bowel calcium absorption
138
Increased PTH, increase calcium, decreased phosphate. Band keratopathy, subperiosteal bone resorption (moth-eaten appearance of phalangeal cortex on x-ray of hand). Skull x-ray with tiny punched out lesions (salt and pepper appearance). Renal stones and muscle weakness. 50% of patients have coexisting vitamin D deficiency.
Hyperparathyroidism
Vitamin D deficiency is the leading cause of secondary hyperparathyroidism, so in a patient with PTH elevation always measure the 25-OH-D3 level
139
Are PTH, calcium, and phosphate low or high with these?
1) Vitamin D excess
2) Sarcoidosis
3) Hyperparathyroidism
4) Malignancy
5) Milk alkali syndrome
PTH, Calcium, Phosphate:
1) low, high, high
2) low, high, high
3) high, high, low
4) low, high, low
5) low, high, low
140
MEN Type I
Parathyroid (increased calcium)
Pituitary
Pancreas (hypoglycemia; eg- insulinoma, gastrinoma)
If suspect pancreatic tumor, then check PTH
If PTH high, check brain MRI (eval for MEN 1)
141
MEN Type IIA
Parathyroid (increased calcium)
Medullary thyroid cancer (calcitonin increased)
Pheochromocytoma: (HTN, palpitations; eval with 24hr urine catecholamine and urine metanephrines)
142
MEN Type IIB
Mucosal neuromas
Medullary thyroid cancer
Pheochromocytoma
143
Patient with thyroid mass. Calcium increased, calcitonin increased, dense calcification in mass, RET proto-oncogene positive. Medullary carcinoma was diagnosed. How to screen family members?
Serum calcitonin
144
A 45-year-old woman with thyroid nodule 2.5 cm, asymptomatic. TFT’s normal. Fine needle aspiration biopsy reveals medullary carcinoma of thyroid. Serum calcitonin is 1200 (normal is <30). Patient is scheduled for thyroidectomy. Prior to surgery, what tests would you do?
24hrs urine for metanephrines and cacecholamines (lots of false positives if checking these in serum)
Not repeat serum calcitonin, CT head, or ERCP of pancreas (these are incorrect means of MEN syndrome evaluation)
145
Indications for surgery in hyperparathyroidism (to prevent long-term complications)
Age <50
Serum calcium >1mg above normal (>11.5 mg/dL)
Creatinine clearance <60
Symptomatic (eg- osteoporosis with T-score <2.5, dehydration, stones)
146
A 40 year old asymptomatic woman is found to have minimal hypercalcemia. PTH 125 (normal 10-65). What next?
Refer for surgery
| Not start pamidronate, calcitonin, or repeat PTH level
147
A patient with hyperparathyroidism refused parathyroid surgery or not a candidate for surgery. What to do?
Cinacalcet
| Not alendronate
148
Asymptomatic patient found to have a serum calcium 10.5. Serum PTH is 45 (normal is 10-65). No history of stones. What next?
Measure urinary excretion of calcium (to r/o familial benign hypercalcemic hypercalciuria)
Not ACE level or serum electrophoresis
149
A 45-year-old woman presents with complaints of getting up at night to urinate. She is constipated, and mucous membranes are dry. She is nauseous. Her only other history is dyspepsia. Serum calcium is 11, phosphate 2.5, PTH is 15. Most likely diagnosis? Tx?
Milk alkali syndrome
Change the calcium containing antacid
150
Patient with lung cancer is brought to the ER with mental obtundation. Calcium is 17. What is the next step in management of this patient? Best long-term management?
Aggressive IV fluids
Not calcitonin or alendronate
For long-term, Zolendronate (once yearly) is better than pamidronate
Calcitonin is the fastest acting hypocalcemic agent but only works for 48-72hrs
151
Causes of hypercalcemia
```
Vitamin D intoxication
Sarcoidosis
Lithium treatment
Thiazide diuretics
Multiple Myeloma
Carcinoma of breast (most common solid-tumor with hypercalcemia)
Familial benign hypocalciuric hypercalcemia
Milk alkali syndrome
```
Not prostate cancer
152
A 32 year old woman presents with a serum Calcium of 11.5, phosphate 4.0. CXR shows bilateral hilar adenopathy. What is most likely elevated?
Serum 1,25-OH-Vit D3 (Dx is sarcoidosis)
| Not 25-OH-VitD, PTH, or globulins
153
A 28 year old woman presents with kidney stone. Serum calcium is 11.2, phosphate 4.1, PTH is 7 (normal 10-65). Most likely etiology? Tx?
Sarcoidosis
Not malignancy, hyperparathyroidism, lithium treatment, or familial benign hypocalciuric hypercalcemia
Tx after controlling hypercalcemia is initiating prednisone
154
Are PTH, calcium, and phosphate low or high with these?
1) Hypoparathyroidism
2) Hypomagnesemia
3) Vitamin D deficiency
4) PTH reistance
5) Psudohypoparathyroidism
6) ESRD
7) Pseudopseudophyoparathyroidism
PTH, calcium, phophate
1) low, low, high
2) low, low, high (potassium low; low magnesium suppresses PTH)
3) high, low, low (AlkPhos high)
4) high, low, high
5) high, low, high (4th and 5th MCP short)
6) high, low, high
7) normal, normal, normal (4th and 5th MCP short)
155
Pseudohypoparathyroidism
Kidney doesn’t recognize PTH —> PTH is normal but calcium is low and phosphorous is high.
Bone doesn’t recognize PTH —> bony abnormalities with short 3rd and 4th metacarpals.
156
Pseudopseudohypoparathyroidism
Kidney recognizes PTH —> PTH normal, calcium and phosphorous are normal.
Bone doesn’t recognize PTH —> bony abnormalities with short 3rd and 4th metacarpals.
157
Young patient presents with history of irritability, depression muscle weakness, cataracts, Chvostek’s/Trousseau’s sign positive. Low calcium, low PTH, high phosphorous. Dx?
Hypoparathyroidism
Measure baseline 24hr urine calcium excretion next
158
A 65 year old man presents with bone pain and osteopenia on x-rays. Serum calcium is 7, phosphorous is 1.9, AlkPhos 145, albumin 2.2, serum protein 4.5. X-ray shows looser zones (bands of radiolucency). Dx?
Osteomalacia due to Vitamin D deficiency
| Not multiple myeloma, osteoporosis, or Paget’s disease of the bone
159
Patient develops fracture on alendronate therapy. Calcium 7.4, phosphate 2.2, AlkPhos 135. Dx?
Vitamin D deficiency
160
Patient with hand x-ray showing short 4th and 5th metacarpals. Most likely Dx?
Pseudohypoparathyroidism
Or Pseudopseudohypoparathyroidism
Etiology is decreased tissue response to PTH (ie- PTH resistance)
161
Osteoporosis diagnosis
FRAX (fracture risk assessment tool)
Clinical risk factors plus femoral neck bone marrows density by DXA <2.5 (ie- more negative)
DXA -1 to -2.5 is osteopenia
162
Osteoporosis risk factors (and they are ridiculously many, including meds)
```
Age (>65 female, >70 male)
Hx fracture
Parental Hx hip fracture
Low BMI
Sedentary lifestyle
Active cigarette smoking
EtOH
```
```
Hyperthyroidism
Hyperparathyroidism
Multiple myeloma
Vitamin D deficiency
Hypogonadism
Premature menopause
Malabsorption
Chronic liver disease
Inflammatory bowel disease
```
```
Steroids
Dilantin
Long-term heparin
Aromatase inhibitors
LHRH agonists
PPI’s
```
163
Which is a bigger risk factor for osteoporosis, obesity or sedentary lifestyle?
Sedentary lifestyle
164
Patient on prednisone 5mg daily for >3 months. Surveillance plan?
DEXA at baseline then once yearly while on steroids
165
Patient on prednisone 5mg daily for >3 months. DEXA shows T-score 01.5. Patient is already on calcium and Vitamin D. What next?
Start alendronate
| Not do nothing
166
A 72 year old woman, no history of rheumatoid arthritis or taking steroids. Her mother had hip fracture at age 74. DEXA score -1.8. What to do?
Start alendronate
Not do nothing
According to FRAX score if risk for hip fracture is >3% then begin treatment
167
Osteoporosis treatment options
Quit smoking
Calcium 1200 mg/day
Vitamin D 600 units/day if <70yo; 800 units/day if >70yo
Bisphosphonate (alendronate, risedronate, zoledronate)
Denosumab for CKD (a Mab activator of RANK1)
Raloxifene
Teriparatide (for 2yrs max; longer use has increased risk of osteosarcomas)
168
Elderly woman presents with hip fracture. DEXA is -1.4. Is the most important indicator for starting alendronate T-score or hip fracture?
Hip fracture
| Not T-score
169
Which is more important risk factor for fracture, Hx hip fracture with normal T-score -1 or no history of fracture with poor T-score -2.5?
Hx hip fracture better indicator than T-score
170
A 70 year old patient is found to have serum calcium of 11.5 and PTH 115. DEXA reveals T-score of -2.5 on hip and -1.5 at the spine. Most likely etiology for her osteoporosis?
Hyperparathyroidism
| Not her age
171
A 70 year old worms comes to you to renew her estrogen for osteoporosis. What to do?
Stop estrogen, start alendronate, calcium 1200mg, and Vitamin D 800 units daily
Not continue estrogen and add calcium
FYI- 1st choice for adding calcium is 3-4 servings of dairy/day. 2nd choice is elemental calcium pills.
172
A 65 year old woman with osteoporosis and kidney disease. How to treat?
Denosumab (very expensive)
173
A patient is taking Vitamin D and calcium. She is 48 years old and develops hot flashes. What medication would help for both bone health and hot flashes?
Estrogen and progestin
| Not SSRI
174
Local estrogen therapy
Helpful for vulvovaginal atrophy
Relieves dyspareunia
Can reduce risk of recurrent UTI’s
175
Hormone replacement therapy and coronary heart disease risk
30% reduction in total mortality and in incidence of heart disease when given for >5yrs in patients that are age <60 and within 10yrs of menopause. This is NOT recommended as the sole reason for therapy.
Risk of heart disease is increased if treatment is started decades after menopause (eg- lower mortality early 50’s, higher mortality age 70’s).
Hormonal therapy in premature menopause (that is in premature ovarian failure) has protective effect on coronary heart disease but don’t extrapolate data to women experiencing menopause at a typical age.
176
Hormone replacement therapy and cancer risk
Unopposed estrogen therapy increases risk of endometrial cancer, so use with progestogens.
Breast cancer risk increases with estrogen-progestin therapy used for >5yrs. Estrogen therapy decreases risk of colon cancer.
Post-hysterectomy estrogen therapy has higher risk for cholecystitis but lower risk for breast cancer, heart disease, and mortality in younger women.
177
Hormone replacement therapy and risks/benefits other than cancer and heart disease
Reduces postmenopausal osteoporotic fractures.
Estrogen-progestin therapy increases risk of ischemic stroke in women >60yo.
Increased risk of DVT, but risk is lower if started below age 60. Transdermal estrogen therapy can be considered if patient has concerns for DVT.
Hormonal therapy started after 65yo increases risk for dementia. Hormonal therapy started soon after menopause decreases risk for dementia later in life.
Dry eye disease with dryness, burning and foreign body sensation improved with use of oral hormone replacement therapy.
178
A 58-year-old woman with long-standing history of hypothyroidism on Synthroid. Complains of diffuse bone pains. What appropriate diagnostic test to do for this patient?
Check DEXA scan
If it shows osteoporosis, then check TSH and if low then decreasing T4 dose is better than add-on bisphosphonate (won’t really work if T4 is causing the issues and osteoporosis might get better with just fixing the thyroid issues)
179
A patient with osteoporosis T-score of -2.6 is started on alendronate 70 mg/week. Two years later, patient has a fall with fracture, T score is -2.5. What to do?
Discontinue alendronate, start teriparatide
| Not increase dose of alendronate to 140mg/week
180
How long can you prescribe teriparatide?
2 years
| Beyond that you get increased risk of osteosarcomas in animal studies
181
A 70 year old man with hip fracture, x-ray shows osteopenia. Serum calcium and phosphate are normal. Skeletal survey radiographs show no lytic lesions but osteopenia positive. Total proteins are within normal limits. Protein electrophoresis look slightly increased IgG. No M spike. What to do?
DEXA scan
If positive for osteoporosis, then treat with alendronate (same if female patient)
Not testosterone
182
A 70 year old man with hip fracture, x-ray shows osteopenia. Serum calcium and phosphate are normal. Skeletal survey radiographs show no lytic lesions but osteopenia positive. Total proteins are within normal limits. Protein electrophoresis look slightly increased IgG. No M spike.
DEXA scan showed osteoporosis and patient was started on alendronate. Now presents with pain on swallowing, EGD reveals multiple small ulcers in the esophagus and pill esophagitis was diagnosed. What to do?
Discontinue alendronate and start zoledronate IV (alendronate is usually taken on an empty stomach with lots of water to prevent pill esophagitis)
183
A 79-year-old with prostate cancer on antiandrogens sustains a hip fracture. He is also an alcoholic. DEXA reveals osteoporosis. Most likely reason?
Decreased androgens
| Not alcoholism or decreased Vitamin D (both possible but not best answer)
184
Side effect of bisphosphonate?
Osteonecrosis of jaw/mandible/femoral neck due to over suppressed bone turnover causing bone fragility
185
A 70-year-old woman comes to you reading on the internet that bisphosphonates can cause osteonecrosis. She has been taking alendronate for the past seven years. What to do?
Discontinue alendronate
Not continue alendronate
If patient received bisphosphonate for >5yrs and stops it, the effect continues for several years.
186
A 72-year-old woman with no history of fractures, no family history of fractures, not on steroids, has DEXA score of -2.5 at femoral neck. She gets three years of zoledronate. T score now is -2.3. What to do?
Discontinue zoledronate
| In low risk patients, additional benefit continues for 3 more years
187
Alkaline phosphatase very increased, bone scan positive, cotton wool appearance on skull x-ray
Paget’s disease of bone
Tx: asymptomatic —> no treatment
Symptomatic —> zoledronate
Symptoms include bone pain, spinal cord compression fracture, high output heart failure (bone turnover is so high that there’s lots of blood flow in bone almost like AVMs)
188
In Paget’s disease what labs will you find?
Normal calcium, normal phosphorous, high AlkPhos, normal PTH
189
50s F with irregular menstrual cycle, hot flashes with mood changes, insomnia (fatigue during the day). Vaginal dryness, stress incontinence, decreased memory.
Perimenopause
Median time to last menstrual period is 7 years (takes 7 years to completely stop having periods.
Tx: estrogen +/- low dose progesterone
Diagnose clinically is best —> can do estrogen challenge to see if symptoms improve. FSH testing is unreliable.
190
A 35 year old woman with hot flashes and early menopause. What to do?
FSH level
If elevated then begin hormone replacement therapy with transdermal estradiol patch and cyclin progestin.
Recall that treating premature menopause before age 50 improves mortality
191
A 52-year-old with irregular menstrual cycles, hot flashes and fatigue. History of DVT in the past. She refuses to go on estrogen secondary to risk of thrombus OR post breast cancer treatment, cancer risk. What to do?
SSRI (citalopram) or SNRI (venlafaxine)
| Not black cohosh
192
A patient has severe mood swings prior to her periods, it is so bad that she has to miss work every month. Dx? Tx?
Premenstrual dysphoric disorder
| Tx Paroxetine
193
Adrenal hormones and response to ACTH
Zona glomerulosa —> aldosterone; low ACTH —> no change; high ACTH —> hyperaldosteronism
Zona fasciculata —> corticosteroids; low ACTH —> low steroids; high ACTH —> high steroids
Zona reticularis —> sex steroids (DHEA); low ACTH —> low steroids; high ACTH —> high steroids
Adrenal medulla —> Epi and Norepi; low ACTH —> no change; high ACTH —> no change
Adrenal adenoma tends to be corticosteroids only; adrenal cancer tends to be all but aldosterone.
Recall prednisone >/= 20mg/day x >/= 3wks will increase adrenal insufficiency risk
194
Non-classical congenital adrenal hyperplasia (CAH)
21-beta-hydroxylase deficiency is most common of the rare adrenal disorders (high ACTH, low cortisol). Also high progesterone and low aldosterone possible.
195
Patient with hypopituitarism, started on T4 and prednisone. Cortisol level 15. What is the best way to find out the adequacy of the adrenal gland?
ACTH stimulation test (cosyntropin test)
| Not dexamethasone suppression test, CRH, or clinically
196
Young woman with hirsutism, irregular periods, normal blood pressure. 17(OH)progesterone level is elevated. The patient most likely has?
21-beta-hydroxylase deficiency (non-classical congenital adrenal hyperplasia)
197
Medications that impact the aldosterone pathway
Angiotensinogen —> Angiotensin I (activated by Renin, blocked by beta-blockers and clonidine)
Angiotensin I —> Angiotensin II (blocked by ACE inhibitors, leads to increased renin)
Angiotensin II —> aldosterone (blocked by ARBs and nifedipine)
FYI- OCPs increase angiotensinogen (so they cause HTN)
198
Labs in 1) Primary Hyperaldosteronism and 2) Hyporeninemic Hypoaldosteronism
1) BP high, potassium low, aldosterone very high, renin low (ratio 20:1)
Hyperaldosteronism leads to super low renin and therefore hypertension with low potassium should make you check a renin:aldosterone ratio. But accurate ratio only if patient is off ACEi/ARB/Nifedipine/beta-blocker/clonidine at time of testing since these impact renin levels)
2) BP low, potassium high, aldosterone low, renin low
199
A 45 year old presents for routine physical exam. Blood pressure 140/110 and serum potassium is 3.3, creatinine 0.8, HCO3 27. On ACE inhibitor, spironolactone, nifedipine, and beta blocker. What to do?
Hold ACE inhibitor, spironolactone, beta-blocker, and nifedipine. Start verapamil, hydralazine, or alpha-blocker THEN the best screening test —> paired serum aldosterone and renin activity
If ratio >20:1 then replete potassium, give 2 liters normal saline over 4 hours, and recheck serum aldosterone level. If confirmed, then do adrenal CT next to figure out which gland is the problem. If CT unrevealing, do bilateral adrenal vein sampling next (if adenoma, then Tx surgery; if hyperplasia, then medical management).
200
In which condition will renin be low: CHF, primary hyperaldosteronism, or ACE inhibitor?
Primary hyperaldosteronism
201
Best way to confirm hyporeninemic hypoaldosteronism?
ACTH stim test shows quick increase in cortisol level
Tx fludrocortisone, low potassium diet, and furosemide
202
Patient presents with proximal muscle weakness, abdominal striae, fullness of face, swelling at the back of neck, acne, facial hair, irregular menstrual cycles, hyperglycemia. Dx? What next?
Cushing’s syndrome
Do medication reconciliation (are they on steroids?)
Check 24hr urine free cortisol —> >100 mcg/day confirms it
Next need to figure out where the excess cortisol is coming from
203
Differentiating Cushing’s syndromes with Cortisol/urine cortisol, DHEA/17-ketosteroids, and ACTH with:
1) Cushing’s disease, pituitary or ectopic
2) Adrenal adenoma
3) Adrenal carcinoma
4) Exogenous steroids
1) high, high, high
2) high, low, low
3) high, very high, low
4) low, low, low
All require surgery except exogenous (just taper off the steroids)
204
A 25 year old with 10 pound weight gain, amenorrhea, acne, hirsutism and is irritable. On exam has posterior cervical fullness. What to do next?
Urine free cortisol
Not 8am cortisol, serum ACTH level, or CT head/adrenals (all answers are okay but should confirm diagnosis as first step)
205
A 25 year old with 10 pound weight gain, amenorrhea, acne, hirsutism and is irritable. On exam has posterior cervical fullness. The 24 hour urine cortisol is 260 and Cushing’s syndrome is diagnosed. Serum ACTH is 50 (normal is 9-52). After 8 mg dexamethasone suppression test, the ACTH is <5 and serum cortisol is <5. What to do?
MRI brain
Not MRI chest or do nothing
If MRI negative or ACTH couldn’t be suppressed then check bilateral inferior petrosal sinus sampling (BIPSS) for Peripheral vein to BIPSS (PV:BIPSS) ACTH ratio. If >2.5 then check CT Chest.
206
Patient with ACTH mediated Cushing’s disease. Source of the ACTH cannot be localized. What do you do?
B/L adrenalectomy
207
Patient status post adrenalectomy for Cushing’s disease presents with headaches, hyperpigmentation of skin. Dx? Tx?
Nelson syndrome
| Tx pituitary irradiation
208
What test helps you differentiate hypercortisolism?
ACTH level
| Not cosyntropin test
209
Hyperpigmentation especially palmar creases, oral mucosa, unexplained weight loss, salt craving, nausea, vomiting, weakness and postural hypotension. History of pernicious anemia. Dx? Etiology? Eval? Tx?
Addison’s disease
Commonly due to autoimmune adrenalitis (25(OH) antibodies); the pernicious anemia in the question is because autoimmune disorders tend to hint at other autoimmune disorders.
Check ACTH stim test next
—> Cortisol <18 is primary (adrenal failure) —> Tx hydrocortisone AND fludrocortisone
—> Cortisol >18 is secondary (pituitary failure) —> Tx hydrocortisone only (aldosterone function is normal)
210
In a patient with hypotension and shock, low sodium, high potassium. How do you treat Addisionian crisis?
Give normal saline and IV hydrocortisone (fast and most biosimilar to cortisol).
211
A patient with history of Addison’s disease on hydrocortisone and fludrocortisone presents with a viral URI. You prescribe no antibiotics. What to do?
Increase hydrocortisone dose
| Not increase fludrocortisone or no change
212
Patient diagnosed with hypothyroidism and Addison disease. What to treat FIRST?
Tx with steroids first and then with thyroxine after, otherwise adrenal crisis will occur
213
A patient diagnosed with pneumonia (or post surgery) and started on ceftriaxone and azithromycin. History significant for asthma with an exacerbation about a month ago treated with nebulization and tapering doses of steroids for a couple of weeks. BP 90/70 and orthostatic. IV fluids are begun. What is the next step in management?
Hydrocortisone
214
Palpitations, sweating, headache, episodic in nature, labile blood-pressure. Part of MEN IIA and IIB. Dx? Eval? Tx?
Pheochromocytoma
Check 24hr urinary fractionated metanephrines and catecholamines.
If >10cms size, check Meta-iodobenzylguanidine (MIBG) scan to rule out mets
Tx is surgery. Prior to surgery need to use phenoxybenzamine (alpha blockade) and propranolol (beta blockade; not labetalol since it has more beta than alpha blocking effect)
215
Patient is found to have adrenal incidentaloma. How to evaluate?
Check if it’s functioning:
1) 1mg overnight dexamethasone suppression test (r/o Cushing’s Sn; 24hr urine free cortisol is supposed to be only if symptoms)
2) 24hr urine catecholamines and their metabolites (r/o Pheochromocytoma)
3) Plasma aldosterone/renin and potassium levels (r/o Hyperaldosteronism)
4) 17(OH) ketosteroids (r/o Adrenal carcinoma)
216
Patient is found to have adrenal incidentaloma. When is surgical removal indicated?
>6cms size even if not functioning
<4-6cms and functioning
Size increase by 1cm/year
No Surgery if <4-6cms and not functioning and not getting bigger on serial CT scans
217
A patient has CT scan with 2 cm mass on the adrenal gland. BP 148/86. A 1mg dexamethasone suppression test and 17(OH)ketosteroids normal. What to do?
Check aldosterone:renin level
| Not observe or surgery
218
A patient with 3cm adrenal mass, BP 120/80. 1mg dexamethasone suppression test negative. What to do?
Urine for catecholamines
| Not observe
219
A patient was found to have a 3 cm mass on the adrenal on CT scan. Work up reveals all hormones within normal limits. What to do?
Repeat adrenal CT scan in 6-12 months
| Repeat 1mg dexamethasone suppression test at 6-12 months too
220
A 45 year old with severe headache not relieved with pain medications. Next day with stiff neck, fever and double vision. No rash. BP 80/60, spinal tap shows few WBCs and RBCs. Hemianopsia (bitemporal or homonymous) or III, IV, or VI nerve palsy. CT head shows a lesion in the pituitary/dense lesion in the sella. Dx? DDx? Tx?
```
Pituitary apoplexy (essentially torsion of the pituitary gland; most pts have a preexisting macroadenoma)
DDx meningitis or subarachnoid hemorrhage (BP usually high)
Tx Neurosurgical consult for urgent decompression; check random cortisol and maybe give IV glucocorticoids
```
221
A 25-year-old postpartum patient had a difficult labor and delivery, she lost a lot of blood. She was unable to breast-feed the baby, later she had no restoration of her menses. She was fatigued, developed cold intolerance and hung up reflexes. TSH and FSH are low. Dx? Tx?
Sheehan’s syndrome with hypopituitarism
| Tx replace hydrocortisone first, then other hormones
222
A 32-year-old pregnant woman presents with new onset severe headache associated with vision changes. She also has fatigue and weakness. BP 90/70 supine and 80 systolic on sitting up. Heart rate goes up from 90 to 110 from supine to sitting. What is the most likely diagnosis?
Lymphocytic hypophysitis
| Not Sheehan’s syndrome
223
An 18-year-old with headaches, visual disturbances, poor sexual development. Urine osmolarity decreased. Prolactin increased. X-ray or CT shows dense suprasellar calcification. Dx?
Craniopharyngioma
224
Klinefelter’s syndrome
Karyotype 47 XXY (normal is 46XY) —> high FSH
| Primary testicular failure —> small testes —> gynecomastia, tall stature, low-normal testosterone
225
Kallman syndrome
Low FSH
| GnRH deficiency and can’t smell
226
A 14-year-old presents with a small penis and testes. Exam reveals lack of pubic and axillary here. Testosterone, OH, FSH are normal. What to do?
Reassurance (“your time will come”)
227
Testosterone interpretation?
What to do for the following:
1) Man with low energy, testosterone level <300.
2) Man with testosterone level <300. BMI 35 OR elderly.
3) Man with testosterone level <200.
Testosterone:
>300 is normal
200-300 is equivocal
<200 is abnormal
1) Repeat testosterone level in early morning (highest that time of day).
2) Check free testosterone level (obesity and older age —> sex binding globulin decreased so total testosterone level may look decreased).
3) Check if he is taking opioids, steroids or hormonal therapy.
228
A 70-year-old man presents with low energy. He takes steroids for COPD. This testosterone level is 140 (normal is 300-800). What is the most likely etiology? Tx?
Steroids
Tx is d/c steroids. If they can’t be stopped, then testosterone replacement therapy (transdermal, shots, etc).
229
Testosterone replacement and prostate cancer risk? Fertility impact?
Testosterone will not change composition of prostatic tissue, but it can exacerbate prostate cancer if present so must follow PSA level.
PSA level should not rise more than double with testosterone replacement therapy.
Testosterone use is the leading cause of male infertility and causes small testicles. LH, FSH will be very low. Patient regains fertility once they stop testosterone use.
230
Male patient on testosterone therapy. Baseline PSA is 0.5 (normal is <4). Repeat 6 months later is 2. What to do?
Discontinue testosterone and refer for prostate biopsy (MRI first is okay too)
231
What is the most common sexual dysfunction in males? Tx?
Premature ejaculation (within 2 minutes; normal is 3-8min)
Tx SSRI or sildenafil (increase to 9 minutes with paroxetine)
FYI- SSRI’s can cause retrograde ejaculation; mechanism of action of sildenafil is PDE5 inhibitor (increases nitric oxide which increases cGMP)
232
What to do next for these:
1) Patient with decreased libido. Testosterone level is 150.
2) Married couple comes to you because they are not having kids.
3) Patient with impotence with normal testosterone.
1) Check FSH/LH
2) Check semen analysis after 3 days of abstinence
3) Ask if there is nocturnal penile tumescence, which differentiates psychogenic versus organic. If normal, rule out psychogenic causes or drug-related next and do NOT check testosterone level. If decreased, this is due to organic impotence.
233
1) How to treat erectile dysfunction in patient on nitrates?
| 2) How soon after using sildenafil or tadalafil can nitrates be used?
1) Tx with penile tumescent device not sildenafil
2) 24hrs after sildenafil, 48hrs after tadalafil
FYI- sildenafil or tadalafil work irrespective of testosterone level, however hypogonadism should be treated first
234
Patient presents with chest pain and was given nitrates and suddenly systolic blood pressure dropped to 70. He apparently had taken tadalafil six hours ago. What to do?
Place patient in trendelenberg position and start IV fluids.
Start phenylephrine if needed (not norepinephrine since don’t want him tachycardic)
235
A 57-year-old man with BMI 32 complains of erectile dysfunction for the past several months. He has a sedentary lifestyle. Total testosterone is 300. You did a free testosterone level which was in the normal range. What to do?
Treadmill exercise test (sex = 4-5 MET equivalence)
| Not prescribe sildenafil
236
A 15 year-old boy brought with enlargement of his breast. What to do?
Reassurance, it is related to puberty. This can be unilateral or bilateral. Can also happen with marijuana use in children and adolescents.
237
A patient presents with complaints of decreased libido. He has decreased nocturnal penile tumescence. He had received radiation to the head. FSH 5 (normal is 5-15), LH 4 (normal 3-15), testosterone 160 (normal is 300-1200), prolactin 22. Most likely diagnosis?
Gonadotropin deficiency
| Not prolactinoma, primary testicular failure, or depression
238
A 38 year old woman doing well on fluoxetine for depression presents do you with complaints of inability to achieve orgasm for the past two months. What to do?
Add or switch to bupropion (d/c the SSRI or add-on bupropion)
239
A 35 year old woman status post radiation therapy and chemotherapy. OR a 36 year old wants to know her chances to conceive. What to do?
Anti-mullerian hormone to check ovarian reserve
| Not check LH or FSH
240
Woman with hypoactive sexual disorder. What to do?
Flibanserin
Avoid alcohol when using since together they cause hypotension
241
Transgender medicine
1) Born male and ID as female
2) Born female and ID as male
1) Transwoman; give estrogen + spironolactone for breast development; if breasts, then mammogram in addition to PSA as otherwise indicated
2) Transman; give testosterone to goal level 300mg (normal in women is usually <25-50); check Pap smear (if have cervix) and mammogram (if have breasts)
242
Primary amenorrhea (teenager who’s never had menses):
1) Web neck, short stature, low-set ears, intact smell, rudimentary ovaries (=> small boobs)
2) No vagina, no uterus, ovaries are okay (breasts normal)
3) Acne, clitoromegaly, hirsutism, no ovaries (no breasts)
4) Atrophic vagina, no cervix, breasts normal, no pubic or axillary hair
5) Anosmia, low LH and FSH
1) Turner’s syndrome = 45XO
2) Mullerian syndrome (Mayer-Rokitansky-Kuster-Hauser Syndrome) = 46XX (one of the X’s isn’t expressing itself)
3) Gonadal dysgenesis = 46XY (the Y isn’t expressing itself)
4) Androgen insensitivity syndrome = 46XY (no testosterone receptor so defaults to female even tho testosterone level is high, and the excess testosterone gets converted to estrogen which leads to breast formation)
5) Kallmann syndrome
243
Primary amenorrhea evaluation (never had a period; secondary amenorrhea is newly missing periods)
1) Eval for pregnancy: Check HCG
2) Eval for pituitary dysfunction: FSH, E2 (estradiol), TSH, prolactin. Maybe total testosterone too; maybe 17-hydroxyprogesterone too
3) Eval for ovarian dysfunction (eg- PCOD): Progestin withdrawal test
4) Eval for primary ovarian failure: Estrogen/Progestin withdrawal test
5) Eval for Primary uterine failure or uterine synechiae: Hysteroscopy for intrauterine adhesions
244
Irregular menstrual cycle from puberty, obesity, acne and hirsutism. High testosterone, high DHEA. High LH and FSH with ratio >3.0. Hyperglycemia, hypertriglyceridemia, acanthosis nigricans. Dx? Eval? Tx?
Polycystic ovarian syndrome
FYI - associated with increased risk of endometrial cancer due to persistent elevation of estrogen
Dx with 2 of 3:
Oligo or anovulation
Clinical or biochemical signs of hyperandrogenism (eg- high testosterone level)
Ultrasound
Tx: anti-androgen OCP; if hyperglycemia then check oral glucose tolerance test and Tx metformin; if infertility then letrozole (off-label use) > clomiphene > metformin; spironolactone also beneficial
245
Acanthosis nigricans associations
PCOS
Gastric carcinoma
Insulin resistance (high blood glucose, high insulin, exercise might help)
Obesity
246
Premature ovarian failure definition and treatment?
Compared to Polyglandular Deficiency?
Ovary fails —> very low estradiol —> high FSH first, then high LH
Tx with estrogen replacement.
Polycystic ovarian disease with diabetes mellitus (pancreas) or Grave’s disease (thyroid) is polyglandular deficiency. Formation of antibodies against multiple organ systems (eg- Addison disease, vitiligo, etc)
FYI- etiology of skin lesions in vitiligo is antibodies against melanocytes
247
What next for these women:
1) A 17 year old with amenorrhea. BMI is normal, pregnancy test negative. Patient was prescribed progesterone and she got her periods.
2) A 47 year old otherwise with regular periods presents with amenorrhea for the past 2 months.
3) A young woman on oral contraceptive with no breakthrough bleeding.
1) Reassurance
2) Pregnancy test
3) Pregnancy test
248
A patient stopped taking oral contraceptive pills several months ago. Still with no menses. Pregnancy test negative. LH and FSH normal. Estrogen challenge with no bleed. Most likely etiology?
Uterine synechiae
FYI- Asherman syndrome is intrauterine adhesions plus symptoms (eg- amenorrhea, infertility)
249
A young marathon runner presents with complaints that she had only a couple of periods in the past year. What to do?
No further testing
Not pregnancy test
If she wants to get her periods back then she should cut down on her exercise program.
If she wants to prevent bone loss, in addition to calcium and vitamin D she should start an oral contraceptive pill (not alendronate).
FYI- mechanism of the amenorrhea is excess exercise leading to inhibited GnRH release (hypogonadotropic hypogonadism).
250
Hirsutism (eg- excessive facial distribution of hair) evaluation:
Adrenal etiology: DHEA, ACTH, cortisol, 17(OH)ketosteroids
1) Cushing disease
2) Adrenal carcinoma
3) Non-classical CAH (21-beta-hydroxylase deficiency)
4) Adrenal adenoma
Ovarian etiology: testosterone, 17(OH)ketosteroids, LH:FSH ratio
5) Ovarian cancer
6) Polycystic ovarian syndrome
1) high, high, high, high
2) high, low, high, high
3) high, high, very low, high (17(OH)progesterone high too)
4) high, low, high, low
5) very high testosterone
6) high, high, >3.0
251
1) Patient with hirsutism. Testosterone levels very high, cortisol normal. What next?
2) An 18 year old female comes to you with increased hair on her arms and legs. Her family has similar. What to do?
1) Transvaginal ultrasound of ovaries
| 2) No further testing
