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Clin Med 2 > Exam 5 > Flashcards

Exam 5 Flashcards

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1
Q

C peptide

A

Will be high if they are insulin resistant, but low if they are insulin deficient (type 1)

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2
Q

Microvascular complications

A

Retinopathy
Nephropathy
Neuropathy

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3
Q

Macrovascular

A

Cardiovascular disease

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4
Q

Type 1 major cause of death

A

Chronic kidney disease

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5
Q

Type 2 major cause of death

A

MI, CVA

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6
Q

What is 2-4x higher in diabetes?

A

Heart disease and stroke

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7
Q

GDM and future diabetes

A

Increases mom’s risk by 40% over 20 years

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8
Q

Which type is more prone to ketoacidosis?

A

Type 1

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9
Q

Type 1A

A

Lymphocytic attack on beta cells

Central to pathology

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10
Q

Type 1B

A

Idiopathic

Inflammation but no antibodies

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11
Q

LADA

Latent autoimmune diabetes of adulthood

A

Autoantibodies
Adult age
Don’t need insulting in first 6 months after dx

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12
Q

Classic new onset of T1DM

A

Hyperglycemia without acidosis

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13
Q

Most important contributor of insulin resistance

A

Obesity!! Visceral fat more

Bad adipokines- TNF and resistin

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14
Q

Metabolic syndrome

A 
3 more more of the following:
Insulin resistance
Increase TG
low HDL
HTN
Apple shape
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15
Q

Early T2DM

A

Hyperplasia of beta cells

Fasting hyperinsulinism

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16
Q

Progression of T2DM

A

Hypoinsulinemia eventually, beta cell function eventually poops out

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17
Q

If you only rely on fasting glucose…

A

You will miss a ton of patients with diabetes

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18
Q

MODY

Maturity onset diabetes of the young

A

Rare, mild form of non insulin dependent diabetes

Autosomal dominant inheritance, less than 25 years old

Impaired glucose induced secretion of insulin

Not obese, few microvascular complications

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19
Q

Kussmaul

A

Respirations of DKA

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20
Q

OGTT

A

Best to detect T2DM at an earlier stage

Carb restriction, then 8 hour fast

Blood draw at zero and 120 minutes

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21
Q

HbA1c

A

Diagnostic

Reflects blood sugar levels over preceding 8-12 weeks and mostly previous month

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22
Q

Serum fructosamine

A

Evaluates glucose levels in the preceding 1-2 weeks, esp…

During pregnancy
Monitoring recent changes in treatment
Hemoglobinopathies

**greatly affected by serum albumin levels

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23
Q

Criteria for DM diagnosis

A

fasting plasma glucose: >126

2 hour OGTT: >200

HbA1c: >6.5

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24
Q

Dianogisis made after…

A

Repeat test on another day or two different diagnostic tests on the same day

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25
Ketonuria suggests...
Type 1
26
Diabetic retinopathy
Most common in type 1, will 100% have it after 30 years
27
Nonproliferation diabetic retinopathy
Most common cause of visual impairment of T2 Earliest stages, usually nosymptoms Dot hemorrhages, exudates
28
Proliferative diabetic retinopathy
Leading cause of blindness in US New, fragile capillaries that cause hemorrhages Retinal detachment
29
Retinopathy management
T1's after 3-5 years | T2's at time of diagnosis and annually
30
Diabetic nephropathy
More common in type 1 Microalbuminuria/proteinuria 2 out of three tests abnormal over 3-6 months to make diagnosis
31
Diabetic nephropathy tests
Micoalbuminuria: 30-300 | Proteinuria >300
32
Distal symmetric neuropathy
Most common Stocking glove pattern, longer nerves more vulnerable Delayed sensory and motor nerve conduction
33
Distal symmetric neuropathy findings
Bilateral and symmetric dulled perception of vibration, pain and temperature Callus and ulceration formation, high pressure areas
34
Charcot arthropathy
Develops from untreated neuropathy and trauma Rocker bottom deformity, joint subluxation and periarticular fractures Osteoclastic destruction and deraned/unstable joints in the mid foot
35
Isolated peripheral neuropathy
Sudden onset with subsequent recovery Vascular ischemia or traumatic damage Cranial or femoral nerves **motor abnormalities predominate Self. Limited!
36
Painful diabetic neuropathy
Mild or severe, tends to be at night Sensory disturbances, progressive positive symptoms like... Burning, hot poker Deep, aching pain Creepy crawlies
37
Autonomic neuropathy
Dysfunction of ANS due to poor glucose control and vascular risk factors
38
CV neuropathies
Exercise intolerance, OH, tachy, silent MI
39
Peripheral autonomic dysfunction
Changes in skin, itching Edema, venous prominence Callus, loss of nails, sweating
40
GI autonomic neuropathy
Esophageal motility | Gastroparesis
41
GU autonomic neuropathy
Bladder dysfunction Retrograde ejaculation ED Dyspareunia
42
CV complications of DM
MI is the leading cause of death in T2
43
PVD in DM
Atherosclerosis is markedly accelerated Ischemia of lower extremities Gangrene!
44
Traetment of gangrene
Avoid tobacco!! Avoid propranolol Debridement
45
Sporadic monitoring
<1 time per day
46
Systematic monitoring
1-2 times per day
47
Block monitoring
Up to 8 times a day for 3-4 days in a row, 1-2 blocks per month
48
Postprandial monitoring
2 hours after a meal
49
Intensive daily monitoring
Greater than 4 times per day
50
Limitations of glucometers
Need to be calibrated Less accurate numbers if at extremes Real time readings not always accurate
51
Con of continuous glucose monitor
30 minute sensor lag
52
Diabetics hospitalized
Stress induced changes Insulin preferred in this setting, easier to match with individual needs Morbidity and mortality is twice that of non diabetics
53
DKA triad
Hyperglycemia Ketonemia Anion gap metabolic acidosis
54
develop DKA from 3 factors
Insulin deficiency Increased counterregulatory hormones Dehydration
55
DKA presentation
Coma Marked fatigue/weakness NV Weight loss Kussmaul breathing Fruity breath Tachy, HOTN
56
DKA goals of treatment
Restore plasma volume and tissue perfusion
57
Levels of DKA treatment
Mild- treated in ED Moderate- admit to hospital, alert or drowsy Severe- admit to hospital, stupor/coma
58
Fluid replacement in DKA
Cornerstone of treatment- shortcome of traetment is usually failure to restore normal perfusion
59
If BS around 250...
Change IVF to 5% glucose in order to prevent hypoglycemia and cerebral edema
60
Sodium bicarbonate replacement
Repeat until pH is 7.1 then discontinue
61
Hypoglycemia in diabetics occurs...
When BS drops below 60 from Over medication Fasting Exercise Insulin adjustment
62
Hypoglycemia presentation
Tachy, palpitations, sweating, tumor Nausea, hunger Confusion, difficulty speaking, blurred vision, headache, seizures, LOC
63
Hypoglycemic unawareness
Repeated episodes of hypoglycemia causing an adaptive process Neuroglycopenic symptoms first, need to keep BS high for several weeks
64
Insulinomas causing hypoglycemia
Adenoma of islets of langerhands, usually single and benign
65
Whipple triad
Pancreatic beta cell tumor presentation Hx of hypoglycemic symptoms Fasting BS less than 45 Glucose administration leads to immediate recovery
66
Critical diagnostic test of beta cell tumor
Inappropriately elevated serum insulin levels at time when hypoglycemia is present Elevated proinsulin and c peptide
67
Postprandial alimentary hypoglycemia
Rapid gastric emptying of food after gastrectomy procedures causing reactive hypoglycemia
68
NIPHS aka islet cell hyperplasia
Hyperinsulinemic hypoglycemia AFTER MEALS but not with fasting (unlike beta cell tumors) Positive calcium stimulated angiography
69
Functional alimentary hypoglycemia
Increased sympathetic activity after meals Everything WNL
70
Occult diabetes
Exaggerated insulin release occurs after initial hyperglycemia from GTT Potential diabetics Weight loss and reduced carb diet
71
Immunopathologic hypoglycemia
Anti insulin antibodies (more common) Antibodies to insulin receptors (extremely rare) 3-4 hours after meals High insulin levels and titers of insulin antibodies
72
Production of thyroid hormone controlled by...
Iodine intake
73
T3 versus t4
T3 is more active than t4
74
TSH
Best initial lab for screening Used to monitor traetment of hypothyroid
75
Free t4
Gives an earlier picture of function Monitors efficacy of treatment in hyperthyroid
76
Most common cause worldwide of hypothyroid
Iodine deficiency
77
Most common cause where adequate iodine intake of hypothyroid
Hashimoto
78
Drug induced hypothyroid
Amiodarone | Lithium
79
Hypothyroid presentation
``` Fatigue Cold intolerant Constipation Dry skin Cramping Menorrhagia Depression ```
80
Primary hypothyroid diagnosis
High TSH | Low free t4
81
Secondary hypothyroid
Low or normal TSH | Low or normal free t4
82
Sub clinical hypothyroid
Elevated TSH | Normal free t4
83
Myxedema crisis
Severe hypothyroid AMS, hypothermia, bradycardia, hyponatremia Emergent!
84
CHF and CAD can be exacerbated by...
Levothyroxine
85
Hyperthyroid presentation
``` Nervous, anxious Heat intolerance Palpitations Sweating Weight loss Loose stool Amenorrhea Tremors ```
86
Graves' disease
Goiter and thyrotoxicosis Autoimmune 20-40 Proptosis
87
Toxic multinodular goiter
Iodine deficient areas Enlarged thyroid with multiple nodules >65 years old
88
Toxic nodule- adenoma
Younger patients, autonomously functioning thyroid nodule
89
Subacute thyroiditis
Benign Viral infections usually Painful, swollen thyroid Elevated ESR Thyrotoxicosis for about 3-6 weeks
90
Postpartum thyroiditis
Autoimmune, thyrotoxicosis 2-6 weeks postpartum for up to 12 weeks Anti TPO positivity is predictive Painless goiter, can develop permanent hypothyroid
91
Silent thyroiditis
Anti thyroid antibodies possibly Medication or spontaneous trigger
92
Amiodarone induced hyperthyroid
Contains a lot of iodine, can happen up to 3 years after stating medication Produces a destructive autoimmune process
93
Hyperthyroid labs
Low TSH High t4 (or normal) High t3
94
Graves labs
TSI elevated | Anti thyroid peroxidase significantly elevated
95
Thyroid storm
Rare Fever, tachy, CNS dysfunction, dehydration, delirium No time for labs, treat! Hypermetabolic state
96
Complications of hyperthyroid
Arrhythmias Hypercalcemia Osteoporosis
97
Triphasic course of thyroiditis
Thyrotoxic, hypothyroid, recovery
98
Hashimotos features
High anti TPO Has a relation to celiac 30-50 years old
99
Suppurative thyroiditis
Immunosuppression Fever, pain, fluctuation, tender thyroid Elevated ESR, abscess
100
Riedel's thyroiditis
Systemic fibrosis, 30-60 years old Rock hard goiter, esophageal or tracheal impression Hypothyroid from scar tissue in gland
101
Endemic goiter
Low dietary iodine intake Impaired thyroid hormone synthesis and hyperplasia of thyroid tissue, can be euthyroid Compressive symptoms
102
Anterior pituitary function
Synthesizes and realizes peptide hormones
103
Posterior pituitary function
Secretes nuerohormones made in hypothalamus
104
Infindubulum
Attaches hypothalamus and pituitary
105
Sella turcica
In sphenoid bone, where the pituitary plans sits (just below optic chiasm)
106
Anterior gland receives...
Hormone signals
107
Posterior glad receives...
Direct tracts from hypothalamus
108
Posterior gland hormones
Oxytocin ADH aka vasopressin
109
Somatostatin is...
Inhibitory
110
Acromegaly/gigantism general
Excess growth hormone Usually pituitary adenoma Acromegaly is after the epiphyseal plates close
111
Acromegaly presentation
``` Large doughy hands Widened fingers, feet, head Coarse facial features Spreading teeth Amenorrhea ```
112
Temporal hemianopia
Peripheral vision loss due to compression of optic chiasm by mass Any pituitary mass can do it, seen in acromegaly
113
Labs in acromegaly/gigantism
IGF-1 is always elevated. If its not, this is ruled out Glucose challenge with measured GH if high IGF
114
Imaging with pituitary
Always MRI of sella turcica >10 mm is macro
115
Acromegaly traetment
Transsphenoid approach for surgery Medical management with DA agonists or somatostatin analogs
116
Incidentaloma pituitary
Check prolactin GH ACTH All to rule out hypersecretion Then image or monitor
117
Dwarfism general
GH deficiency of anterior pituitary secretion in childhood Generally don't undergo puberty
118
Achondroplastic dwarfism
Different from GH deficiency, this is cartilage not being converted to bone
119
Prolactinoma
Hyperprolactinemia from pituitary tumor In females could have infertility, galactorrhea, amenorrhea Males, infertility, gynecomastia, etc.
120
Anterior hypopituitarism
Partial or complete deficiency of one or more pituitary hormones Hypothalamus or pituitary dysfunction *hormone substitution
121
Pituitary apoplexy
Sudden neurological impairment, like HA, visual changes, AMS, hormonal abnormalities Hemorrhagic or ischemic High dose steroids!
122
Cortex zones
Glomerulosa Fasciculata Reticularis
123
Glomersulosa
Aldosterone
124
Fasciculata
Cortisol
125
Reticularis
Estrogen/androgen
126
Medulla
Secretes catecholamines, like epinephrine and NE
127
Aldosterone
Salt retention to regulate blood pressure, suppression of renin If excess, HTN, hypokalemia, cardiac events
128
Test all HTN patients with hypokalemia for...
Aldosterone levels and plasma renin activity
129
Conn syndrome
Hyperaldosteronism from adrenal adenoma secreting aldosterone
130
Random potential cause of hypokalemia
Black licorice
131
Most common cause of refractory HTN in young/middle aged patients?
Hyperaldosteronism
132
Adrenal insufficiency
Basically cortisol insufficiency with or without mineralocorticoid deficiency
133
Primary adrenal insufficiency
Addison's disease Adrenal absence or dysfunction
134
Secondary adrenal insufficiency
Deficienct secretion of ACTH
135
Acute adrenal crisis
Emergency! Could be stress, acute ACTH deficiency, etc
136
Adrenal insuffiency presentation
Weakness, abd pain, fever, confusion, hypotension, hyperkalemia, hyperpigmenttion
137
ACTH stimulation test
For adrenal insufficiency Pre test serum cortisol, then administer synthetic ACTH Cortisol Should double within an hour
138
Cushing syndrome
Hypercortisolemia Obesity, striae, osteoporosis, HTN, leukocytosis, hypokalemia, moon face, buffalo hump, glaucoma
139
Testing for cushing's
Dexamethasone suppression test Give dexamethasone at 11 pm, check cortisol at 8 am If a low cortisol, then diagnosis excluded
140
Follow dexamethason suppression test with...
24 hour free urine cortisol and creatinine
141
Pheochromocytoma
Tumor arising from adrenal medulla Produces catecholamines
142
Pheochromocytoma presentation
Classic triad of severe HA, tachy/palpitations, perspiration Bursts of NE and epi, the symptoms that go along with that
143
Adrenal cancer
A non functional tumor >6 cm is highest risk Varied endocrine presentations
144
Adrenal hemorrhage
Pain is the major symptom CT imaging
145
Multiple endocrine neoplasia (MEN)
Autosomal dominant inheritance Multiglandular endocrine tumors, can develop at any time
146
Calcium homeostasis general
Ca modulates neuron permeability to sodium Hypocalcemia causes hyperexcitability Hypercalcemia depresses neuronal activity
147
Parathyroid hormone
Released in response to low calcium levels Causes bone resorption(osteoclast activity) Renal reabsorption Increased intestinal absorption
148
Calcitrol
Produced in kidney in response to PTH Active form increases GI absorption of calcium
149
Calcitonin
Produced in thyroid Opposite effect of PTH Decreases bone resorption, increases renal excretion
150
Hypoparathyroidism
Hypocalcemia | Can be caused by many things
151
Acute hypoparathyroidism presentation
``` Tetany Muscle spasms, cramps Stridor Tingling AMS Convulsions ```
152
Chronic hypoparathyroid presentation
Lethargy or anxiety Cataracts EKG changes- prolonged QT Or asymptomatic!
153
Chvostek sign
Facial twitch with tapping facial nerve Related to hypocalcemia
154
Trousseau phenomenon
Carpal spasm with BP cuff inflation sustained for 2-3 minutes Associated with hypocalcemia
155
Labs in hypoparathyroidism
Decreased serum calcium Increased serum phosphate Decreased urinary calcium Low PTH Serum ca is highly protein bound, so check free Ca
156
Pseudohypoparathyroidism
Congenital renal resistance to PTH Hypercalcuria Hypocalcemia Increased bone resorption PTH still behaving normally at the level of the bone
157
Pseudohypoparathyroidism presentation
``` Osteodystrophy Short stature Ectopic bone formation Short 4th metacarpal Hypocalcemia ```
158
Hyperparathyroidism
Most common cause of hypercalcemia Hypersecretion of PTH, usually single adenoma but could be more
159
Secondary hyperparathyroidism
CKD or dialysis, not great renal function so phosphate not getting excreted Makes the parathyroid glands think the body is hypocalecemic
160
Tertiary hyperparathyroidism
Stimulated glands from secondary become large and autonomous
161
Parathyroid carcinoma
Extreme hypercalcemia Half are palpable Half are extended locally or have mets
162
Hyperparathyroidism presentation
Bones, stones, abdominal groans, psychics moans with fatigue overtones ``` Increased bone resorption, brown tumors, compression fractures Kidney stones Constipation, NV Depression, AMS Fatigue, malaise, weakness ```
163
Labs of hyperparathyroidism
Elevated serum calcium | Normal or elevated urine calcium
164
Calciphylaxis
Tertiary hyper PTH due to CKD Calcification of skin, soft tissue, and arteries Necrosis and gangrene, arrhythmia and respiratory failure
165
Post op secondary hyper PTH
Transient, due to hungry bones that soak of Ca Persistently low Ca triggers PTH release
166
Osteoporosis
Reduced bone mass/integrity leading to fx risk Most common in postmenopausal women
167
Osteoporosis manifestations
Backache | Loss of height- vertebral fractures, dowagers hump
168
Osteoporosis diagnostics
DEXA scan, usually lumbar spine and hip, reports a T score
169
T scores
Normal- >-1 Low bone mass- -1 to -2.5 Osteoporosis- less than or equal to -2.5
170
Screening for osteoporosis
DXA screening of women greater than 65, or below 65 with increased risk The worse the T score, the more often you have to get a DXA
171
Osteomalacia
Defective mineralization of bones Rickets in peds
172
Osteomalacia cause
Vitamin D deficiency is the most common Anything that disrupts Ca and or phos mineralization of the bone
173
Paget disease of bone | Osteitis deformans
Excess bony mass but with poor integrity Bone pain, tibial bowing, chalfstick fractures
174
Osteogenesis imperfecta
Type 1 collagen mutation Severe osteoporosis Spontaneous fx in utero or childhood Blue ish sclera
175
Odds higher for thyroid cancer in...
Nodules found in young patients
176
Symptoms of thyroid nodules
Rare ``` Goiter Cervical LAD Hoarseness (recurrent laryngeal n compression) Dyspnea Superior vena cava syndrome ```
177
Thyroid nodule imaging
Ultrasound! First line
178
Thyroid scintigraphy does not...
Distinguish benign versus malignant Cold nodules 5-10% are malignant, FNA recommended Hot nodules are less likely to be cancer
179
Thyroid nodule therapy
Levothyroxine, therapeutic if increased TSH Can use with normal TSH because reduces development of new nodules. Needs to be >2 cm Surgery if malignant
180
Mets in thyroid cancer
Nodes Lung Bone
181
Papillary thyroid cancer
Most common 30-50 years Solitary or multifocal Can easily spread
182
Papillary thyroid cancer prognosis
Good, even if advanced Just need to treat
183
Follicular thyroid cancer
Less common, more aggressive 40-60 Can cause hyperthyroidism Elevated serum thyroglobulin Better differentiation, less risk of mets and better prognosis
184
Medullary thyroid cancer
Parafollicular cells Secrete calcitonin, CEA and others (markers for cancer) Thyroid function is normal Can present with flushing and diarrhea
185
Anaplastic thyroid cancer
Undifferentiated and explosively aggressive Always stage IV diagnosis
186
4 t's of anterior mediastinal mass
Thymus Teratoma Terrible lymphoma Thyroid

Clin Med 2 (8 decks)

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