Fellowship Flashcards
What is the starting dose of Simvastatin?
40 mg. (To practice evidence based medicine you have to do what they do)
Hyperthyroidism: How would you dose methimazole if the free T4 is less than 2 ng/L?
10 mg/day.
Hyperthyroidism: How would you dose methimazole if the free T4 is 2 - 4 ng/L?
20 mg/day.
Hyperthyroidism: How would you dose methimazole if the free T4 is 4 - 6 ng/L?
30 mg/day
Hyperthyroidism: How would you dose methimazole if the free T4 is more than 7.8 ng/L?
20 - 30 mg bid or tid. Doses more than 40 mg/day not really more effective.
What should you check in all females before starting anti-thyroid drugs?
Pregnancy test.
Which anti-thyroid drug can be used in the first trimester of pregnancy?
PTU (Propylthiouracil).
If a patient with hyperthyroidism is pregnant and in the second or third trimester then which anti-thyroid drug would you use?
Methimazole.
Which five antibodies are associated with diabetes mellitus type 1?
- Anti-GAD (glutamic acid decarboxylase) 65 antibody.
- Islet cell antibody.
- Insulinoma associated protein 2 auto-antibody.
- Insulin auto-antibody.
- Zinc transporter 8 antibody
How long after starting anti-thyroid drugs should the WBC be checked?
3 - 7 days.
How should you change the dose of levothyroxine during pregnancy?
Increase by 20%. (Give 1 - 2 extra pills on the weekend).
Does it matter whether or not metformin is given in divided doses?
No it does not.
Why is metformin given in divided doses?
Because it causes diarrhea and GI upset if given all together.
How long does metformin take to show effects?
About 6 weeks.
Ideal method of initiating a patient on metformin.
Start with 250 mg after breakfast and dinner everyday. After a week or two 500 mg after dinner and breakfast. After another week or two 750 mg twice a day and then 1000 mg twice a day. This reduces GI complaints.
What is the likelihood of an identical twin having type 1 diabetes mellitus if the other twin has it?
About 30%.
What is the likelihood of an identical twin having type 2 diabetes if the other twin has it?
Almost 100%.
If the blood glucose is very high then why do the patients need very large amounts of insulin and take a long time to come back to normal?
They have hyperglycemic toxicity or glucose toxicity.
It’s better to just put them on a drip in the beginning to bring them down to normal sooner.
If you have diabetic retinopathy then do you have nephropathy?
You can. But not necessarily.
What’s the best treatment for very high triglyceridemia in a diabetic?
Insulin
What test can you order to determine a patient’s average blood glucose over the past 2 - 3 weeks?
Fructosamine test. (Glucose also binds to albumin, not just hemoglobin; and albumin only stays in circulation for 2 - 3 weeks.
What’s the most common cause of death in DKA patients?
Arrhythmias secondary to hypokalemia.
What does intensive treatment of hyperglycemia do to retinopathy in diabetic pregnant women?
Makes it worse in the short term. Long term treatment improves retinopathy regardless.
What are the main risk factors for developing lactic acidosis with metformin?
Older age and chronic kidney disease with creatinine clearance of less than 60.
What class of drugs does Saxagliptan belong to?
DPP-4 inhibitor. (Dipeptidyl peptidase-4)
Name the rapid acting insulins.
- Aspart (Novolog). 2. Lispro (Humalog). 3. Glulisine (Apidra).
Name the short acting insulins.
Regular insulin that comes under the name of: 1. Humulin R. 2. Novolin R.
Why is regular insulin used in a drip and not a shorter acting insulin?
Because duration of action is based on absorption from the subcutaneous tissue. All insulins have the same duration of action (and act exactly the same way) once they reach the intravascular space. Regular insulin is the cheapest so that’s why it is the one used.
Name the intermediate acting insulins.
NPH (protamine added to regular insulin) Trade names: 1. Novolin N. 2. Humulin N. 3. Novolin NPH. 4. NPH Iletin II. 5. Isophane.
Name the long acting insulins.
- Glargine. 2. Detemir.
Name the ultra-long acting insulins.
Degludec (Tresiba).
What is Ryzodeg?
Combination of Degludec and Aspart.
What is the onset of action for rapid acting insulins?
15 min.
When do rapid acting insulins peak?
60 minutes.
What is the duration of action of rapid acting insulins?
3-4 hours.
What is the onset of action of short acting insulins?
30-45 minutes.
When do short acting insulins peak?
90 minutes.
What is the duration of action of short acting insulins?
4-6 hours.
What is the onset of action of intermediate acting insulin?
2 hours.
When do intermediate acting insulins peak?
4-5 hours.
What is the duration of action of intermediate acting insulins?
8-12 hours.
What is the onset of action of long acting insulins?
4 hours.
When do long acting insulins peak?
They are not supposed to have a peak.
What is the onset of action for ultra-long acting insulin?
4 hours.
When does ultra-long acting insulin peak?
It should not have a peak.
What is the duration of action of ultra long acting insulin?
48-72 hours.
What is the duration of action of long acting insulins?
20-24 hours.
How much calcium is in an 8 ounce glass of milk?
200 - 250 mg.
Which foods contain oxalate and increase the risk of kidney stone formation?
- Chocolate. 2. Spinach (And rhubarb and beets) 3. Nuts (peanuts and almonds, as well as other nuts). 4. Tea 5. Wheat bran and strawberries.
What categories of nutrition do you need to ask about in someone with kidney stones?
- Dairy. 2. Salt. 3. Meat. 4. Oxalate.
What ketones are measured when you check for urinary ketones?
Acetoacetate.
What ketones are not measured when you check for urinary ketones?
Acetone and beta-hydroxybutyrate.
What is the likely cause of worsening ketosis in a patient with DKA who is already on an insulin infusion and fluids?
The acetone and beta-hydroxybutyrate is being converted to acetoacetate and therefore showing up in the measured urinary ketones.
What is the maximal allowable dose of metformin?
2500 mg
What is the maximal effective dose of metformin?
2000 mg
What is the approximate potassium deficit in a patient with diabetic ketoacidosis?
5 - 7 mEq/kg.
Next steps in a patient with DKA, normal renal function and an elevated potassium.
Start insulin and fluids. Recheck the potassium after 4 hours.
Next steps in a patient with DKA, normal renal function and a normal potassium.
Start insulin, fluids and put potassium in the fluids.
Next steps in a patient with DKA, normal renal function and a low potassium.
This is a bad prognostic sign. Do not start fluids immediately. Give potassium, wait for an hour and then start insulin and fluids with potassium in it.
How fast can you give potassium through a peripheral line?
10 mEq/hr.
How fast can you give potassium through a central line?
20 mEq/hr.
What is the fastest route to replace potassium?
Oral
Next steps in a patient with DKA, decreased renal function and an elevated potassium.
Start insulin and fluids.
Next steps in a patient with DKA, decreased renal function and a normal potassium.
Start insulin and fluids.
Next steps in a patient with DKA, decreased renal function and a low potassium.
Give insulin and fluids with potassium in it.
What are the criteria for diagnosing diabetes?
- HbA1c greater than or equal to 6.5%. 2. Fasting plasma glucose more than or equal to 126 mg/dl. 3. Oral glucose tolerance test with a two hour glucose of 200 mg/dl or more. 4. Patient with classic symptoms of hyperglycemia with a random blood glucose of 200 mg/dl or more.
How long without food is considered fasting for the purpose of testing for diabetes?
8 hours or more.
Name the sulfonylureas.
Glipizide. Glyburide. Glimeripride.
What is the mechanism of action of sulfonylureas?
Glucose independent increased insulin sensitivity.
How much do sulfonylureas decrease the HbA1c?
1 - 2%
What are the significant side effects of sulfonylureas?
Hypoglycemia and weight gain.
Are sulfonylureas a long term solution for type 2 diabetes mellitus?
They gradually become less effective and therefore only be used temporarily.
What vitamin do you need to check and replace if a patient is on metformin?
Vitamin B12
What is the recommended daily calcium intake for someone with primary hyperparathyroidism?
A moderate calcium intake. 1000 mg per day.
If the testosterone is less than 1.5 and the patient has secondary hypogonadism - what should you do?
Check a pituitary MRI.
What is the pooled testosterone level?
A level is checked in the morning; followed by two other levels 20 minutes apart. Then they are added. This is to minimize errors caused by cyclical variation in testosterone.
When is the FRAX score used to make decisions about treatment?
When a patient has osteopenia (not osteoporosis).
Do you need basal insulin with U500 as it’s regular insulin?
No. Because it behaves more like NPH.
How many types of amiodarone induced hyperthyroidism and mechanisms?
Type I: increased production because of iodine load. Type II: thyroiditis because of direct destruction by amiodarone. Type II is more common.
Do you have to give methimazole in divided doses?
No.
Why is methimazole given in divided doses?
Because it causes nausea.
How soon after beginning aminoglycosides can patients develop nephropathy?
4-5 days.
How soon after contrast is given can patients get acute renal failure from it?
Immediately.
Which statin causes the least myalgia complaints?
Pitavastatin (Livalo)
How much hydrocortisone is 5 mg of prednisone equivalent to?
20 mg.
If the baseline cortisol is above ____ then the patient does not have adrenal insufficiency.
15 - 18 mcg/dl.
How old does a woman need to be before you can make a diagnosis of osteoporosis?
50 years or older.
How can HIV cause osteopenia/osteoporosis?
- HIV proteins cause osteoblast apoptosis. 2. Chronic cytokine release causes increase osteoclastic activity. 3. Independent risk factor for causing low bone mineral density. 4. May cause hypogonadism.
Does chronic hepatitis C cause decreased bone mineral density?
Yes.
What kind of cancer can Hurthle cell neoplasm be classified as?
Thyroid follicular cancer.
What other electrolyte could be low if a patient remains hypocalcemic despite replacement?
Magnesium.
What endocrine cause do you need to check for in someone with a persistently high LDL despite being on a statin?
Check a TSH for hypothyroidism.
If a hypothyroid patient is having runs of ventricular tachycardia, will giving him thyroid hormone exacerbate this?
No, there is no evidence to suggest this. The thyroid situation is not causing the ventricular tachycardia.
If there is tenderness over the sternum and anterior thighs what can this indicate?
Osteomalacia.
What diagnosis do you need to think of if a patient has abnormal fat distribution, an abnormal lipid panel and a family history of abnormal lipids?
Lipodystrophy.
Young Indian patients with pancreatitis and diabetes may have it because of…
Genetic mutation… Pancreas has calcifications.
A patient presenting with new onset diabetes and a new onset blistering rash… What will you think of?
Glucogonoma.
Can vitamin D deficiency in utero and childhood increase the risk of hip fracture later on life?
Yes
What does sunlight do to excess vitamin D?
Destroys it.
Which form of vitamin D is available by prescription in the US?
Vitamin D2
What does low magnesium do to the parathyroid hormone in the setting of vitamin D deficiency?
Blunts the response so instead of increasing the parathyroid hormone levels are normal.
What does vitamin D deficiency do to muscles?
Causes muscle weakness.
True or false. Vitamin D deficiency can make you more susceptible to tuberculosis.
True.
What do bisphosphonates do to osteoclasts?
Inhibit activity.
Which bisphosphonate is the most potent?
Zoledronic Acid
Do nitrogen-containing bisphosphonates accumulate in the body?
Yes. Bind to hydroxyapatite crystals.
Name four bisphosphonates in order of potency.
Zoledronic Acid (1) Risedronate (3) Alendronate (17) Pamidronate (67)
What is the bioavailability of oral bisphosphonates?
Less than 1%
What is the bioavailability of IV bisphosphonates?
100%
Infusion time for zoledronic acid?
15 min
Infusion time for pamidronate.
1 - 4 hours.
Infusion time for Ibandronate.
15 - 30 sec.
How much zoledronic acid is excreted renally and how much remains in the skeleton?
Excreted renally: 40% Remains in skeleton: 60%
What can be used to reduce incidence and severity of side effects from zoledronic acid infusion?
Acetominophen four times daily for three days.
Name some symptoms caused by zoledronic acid infusion.
Fever Eye inflammation Musculoskeletal pain GI symptoms Fatigue Influenza-like symptoms
What kind of renal injury can zoledronic acid cause?
Acute tubular necrosis
Why does the infusion of zoledronic acid have to be given over 15 minutes?
To reduce renal toxicity.
How would you try to reduce renal toxicity in a patient who is more at risk of nephrotoxicity from zoledronic acid?
Increase time taken to infuse to 30 minutes.
What creatinine clearance is zoledronic acid contraindicated at?
Less than 35 ml/min for 5 mg dose. Less than 30 ml/min for 4 mg dose. Dose adjustment for under 60 ml/mg possible.
In bisphosphonate therapy - what is the risk of osteonecrosis of the jaw dependent on?
Potency and duration of treatment.
How long after bisphosphonate therapy can osteonecrosis of the jaw develop?
Months to years.
First line drug for osteoporosis in men according to Endocrine Society Guidelines 2012. (Regular old osteoporosis)
Oral alendronate (generic)
When to use zoledronic acid instead of alendronate for osteoporosis in men?
- Secondary prevention of hip fracture. 2. GERD, malabsorption, cognitive problems, inability to be compliant because of too many meds or some other reason. 3. Non-metastatic prostate cancer on ADT. 4. HIV patients (they have been found to be more non-compliant) with orals.
Should you use heparin to lower triglycerides?
Usually not. You don’t want to transform it to hemorrhagic pancreatitis.
What type of cholesterol is responsible for triglycerides in the blood?
Chylomicrons and VLDL.
Pale pink blood vessels in the retina secondary to very high triglycerides.
Lipemia retinalis.
What kind of lesions can appear on back etc if the triglycerides are very high?
Eruptive xanthomas.
How long after radioactive iodine does TSH remain suppressed?
Months.
Are malignant thyroid nodules hypo- or hyperechoic?
Hypoechoic.
If a thyroid nodule has micro calcifications what does it make you think of?
Malignancy.
What are the indications for parathyroidectomy in primary hyperparathyroidism?
- Age less than 50 years. 2. Creatinine clearance less than 60. 3. Calcium more than 1 g/dl above the reference range for normal for that lab. 4. Osteoporosis on DEXA scan
What happens to the 1,25 OH vitamin D level in primary hyperparathyroidism?
It increases.
Can you treat osteoporosis in patients with cancer especially prostrate with PTH?
No. It would increase the likelihood of bone metastasis.
If someone has osteoporosis with few risk factors what should you think of?
Increased calcium excretion in the urine. Measure 24 hour calcium excretion.
How should you treat people who have osteoporosis due to increased calcium excretion in the urine?
Thiazide diuretics. These can increase BMD about as much as bisphosphonates in these patients.
Can hyperglycemia increase risk of getting dementia?
Yes
How many grams of carbohydrates in one can of Fibersource HN?
It has 250 ml of liquid nutrition. And 40 grams of carbohydrates.
Can LDL be checked without the triglycerides needed for calculation?
Yes, it can be directly measured.
What do nitrates do to bone mineral density and fracture risk?
Nitrates increase the nitric oxide levels which is associated with increased bone mineral density and deceased fracture risk.
Does metformin cause hypoglycemia?
Not on its own.
Does metformin play a role in causing hypoglycemia in patients on multiple anti diabetic medications?
Yes, it can exacerbate hypoglycemia caused by other agents.
Name two biguanides.
Metformin Phenformin
Why was phenformin withdrawn from the US market in 1976?
High rate of severe lactic acidosis
Should you give metformin if a patient has hepatic insufficiency?
No
Mechanisms by which metformin causes lactic acidosis.
- Promotes conversion of glucose to lactate in the splanchnic bed of the small intestine. 2. Inhibits gluconeogenesis from lactate, pyruvate, and alanine, resulting in additional lactate and substrate for lactate production.
How much does the sodium drop for every 100 mg/dl of glucose?
1.6 - 2.4 mEq/L
Is there any evidence that insulin can cause transaminitis?
Only case reports.
How are glucose levels related to risk of dementia?
Higher average glucose values result in higher risk for dementia; even in people without diabetes. Even an average glucose of 115 mg/dl compared to 100 mg/dl confers a higher risk - shown by study published in NEJM in August, 2013.
Which hormone secreted by the liver and white fat induces pancreatic beta cells to proliferate - as discovered in 2013.
Betatrophin. New discovery reported by Nature in April, 2013; and published in NEJM in August, 2013.
What are the criteria for surgery in primary hyperparathyroidism?
- Calcium more than 1 mg/dl above reference range for normal. 2. T score less than -2.5 on DEXA. 3. Stage 3 chronic kidney disease or worse. 4. Urine calcium more than 400 mg (old recommendation) 5. Age less than 50 years.
Goal for TSH in pregnancy.
Less than 2.5.
Does insulin resistance change during the day?
Increased insulin resistance during the day time so more basal requirement during the day time.
What is the mechanism of action of canagliflozin?
Decreases the renal threshold for excreting glucose so glucose starts appearing in the urine at 70 mg/dl.
What takes up sestamibi?
Metabolically active mitochondria.
How much calcium % is in calcium gluconate?
9%
What happens to bone density if you have continuous PTH exposure?
Bone density decreases.
What happens to bone density if you give PTH in a pulsatile fashion?
Bone density increases.
How much does a normal parathyroid gland weigh?
40 mg
Which statin causes the most transaminitis?
Atorvastatin.
Which statin has an FDA warning for increased concentrations and side effects in Asians?
Rosuvastatin
What statin and what dose is commonly used in patients who have had a coronary event?
Atorvastatin 80 mg qday.
What do statins do LDL receptors?
Increases expression of LDL receptors in the hepatocytes.
Do statins increase the risk of cancer?
No.
Do statins increase the risk of developing diabetes?
Yes.
Do statins cause cognitive dysfunction?
Yes. Memory loss, forgetfulness, confusion.
What happens if you give bile acid sequesters to patients with high triglycerides?
Their triglycerides and cholesterol may get worse.
Are lower doses of ezetimibe effective at reducing LDL?
Yes.
Can gemfibrozil monotherapy reduce vascular events?
1 - 2 trials have shown benefit in selected patients.
Which tests are good at identifying which women do not have gestational diabetes?
- Oral glucose tolerance test. 2. Fasting plasma glucose level. - at 24 weeks of gestation.
Which test is best at identifying women withgestational diabetes mellitus?
Oral glucose tolerance test.
Name three main complications that treating gestational diabetes mellitus prevents?
- Macrosomia. 2. Shoulder dystocia. 3. Pre-eclampsia.
Short-duration studies - what does salsalate do to glycemia?
Salsalate improves glycemia in patients with type 2 diabetes mellitus and decreases inflammatory mediators.
Name the commonly used statins in increasing order of potency.
Fluvastatin (80 mg) = Lovastatin and Pravastatin (40 mg) = Simvastatin (20 mg) = Atorvastatin (10 mg) = Rosuvastatin (5 mg)
Should you start metformin in pre-diabetics?
You can with the idea of slowing their progression to diabetes.
What are the limitations of thyroid nodule pathologic evaluation?
There is substantial inter- and intraobserver variability in cytopathologic and histopathologic evaluation of thyroid nodule confirming an inherent limitation of visual microscopic diagnosis.
Should you use a GLP-1 agonist in someone with a history of pancreatitis?
No. It’s contra-indicated.
What does metolazone do to calcium excretion?
Decreases calcium excretion thus causing hypercalcemia.
If the Achilles’ tendon is thick and nodular; what should you think of?
Tendon xanthoma.
Does adrenal insufficiency typically cause somnolence?
No.
How long after giving methimazole can you give propylthiouracil?
8 hours
If a patient has an LDL that is not at goal and triglycerides over 500 mg/dl then what do you treat first?
Triglycerides to reduce the risk of pancreatitis.
When is progesterone elevated in a female (above 1 ng/ml)?
- Pregnancy 2. Luteal phase (second phase of menstrual cycle).
What does estrogen do to cortisol?
Increases the total cortisol because estrogen increases the cortisol binding globulins.
What’s the loading dose of methimazole in thyroid storm?
60 mg.
What is the loading dose of propylthiouracil for thyroid storm?
1000 mg
What rate should you run a calcium gluconate drip at for someone with severe hypocalcemia?
0.5 mg/kg every hour. Run it a little slower in ESRD as patient will not be able to urinate it out.
How many ml in one ampule of calcium gluconate?
10 ml
How many mg of calcium gluconate in one ampule?
1000 mg (100 mg/ml)
How many mg of elemental calcium in one ampule of calcium gluconate?
93 mg
What’s the maximum amount of calcium carbonate you can absorb at one time?
600 mg. So makes more sense to give it more frequently.
What strength does Armour thyroid come in?
15 mg and 30 mg.
Is there any way to make a hyperthyroid patient euthyroid faster for surgery?
Can try iopanoic acid in addition to conventional treatment. It’s an iodine containing radiocontrast medium.
How much hydrocortisone is equivalent to 1 mg of dexamethasone?
26 mg
What do you need to check before starting a woman on high dose methimazole for suspected thyroid storm?
Pregnancy test.
If a woman is not having periods and therefore has unopposed estrogen what does she need to have done?
Endometrial biopsy to rule out endometrial cancer.
Which osteoporosis medications cause atypical fractures?
Bisphosphonates Donesumab
What dosages (mcg) does levothyroxine come in?
25, 50, 75, 88, 100, 112, 125, 137, 150, 175, 200, 300.
Why should you ask or check if the patient has had any imaging studies within the past few weeks/months if they come in with thyrotoxicosis?
To see if they have had IV contrast (iodine load) that may have contributed.
Does radioactive iodine ablation play a role in anaplastic thyroid cancer after thyroidectomy?
No. It is not effective.
1 mg of prednisone is how many mg of hydrocortisone?
4 mg
1 mg of dexamethasone is how many mg of hydrocortisone?
25 mg
What happens to 1,25 OH-vit D in sarcoidosis?
It increases.
Which thionamide causes agranulocytosis?
Methimazole and propylthiouracil both do.
What is the genetic defect in familial dysbetalipoproteinemia?
Presence of two apo E2 alleles.
What is the mechanism of action of spironolactone?
Competitive binding of receptors at the aldosterone-dependent sodium-potassium exchange site in the distal convoluted renal tubule
How long does a patient need to be off spironolactone to screen for primary hyperaldosteronism?
4 - 6 weeks.
What are the porphyrias?
Metabolic disorders caused by the deficiency of enzymes involved in the 8 steps of heme synthesis.
What is the half life of free T3
3.5 days
What happens to the aldosterone level when a patient is on spironolactone?
Aldosterone increases.
What happens to the renin level when a patient is on spironolactone?
The renin level increases.
How long do hypothyroidism symptoms take to disappear after starting treatment?
A few days - as the free T3 and free T4 begin to normalize then the symptoms of hypothyroidism disappear.
What is Wilson’s syndrome?
Alternative medicine diagnosis not accepted by ATA. Decreased conversion of T4 to T3 resulting in subnormal temperatures; treated with sustained release tri-iodothyronine.
What’s the difference between NPH and regular insulin when looking at it?
NPH is cloudy and regular is clear. Any insulin with NPH is cloudy.
What’s the dose of sodium thiosulfate for calciphylaxis?
Initial dose 12.5 g dissolved in 100 ml of normal saline given over the last 30 - 60 minutes of dialysis. Followed by 25 g (two vials) dissolved in 100 ml normal saline with each dialysis session.
What should the calcium x phosphorus product be maintained at in calciphylaxis?
55 mg2/dL2 or less.
What kind of vasculitis is associated with PTU?
ANCA positive vasculitis.
How would you monitor the levothyroxine dose in a patient with panhypopituitarism?
Free T4 level
Where is IGF-1 released from?
Liver
What dosage forms does injectable testosterone come in?
200 mg/ml Comes in 1 ml and 10 ml vials.
What do you replace growth hormone with?
Somatropin.
If a patient has a COPD exacerbation what treatment could cause an abnormal TSH?
Steroids.
What do steroids do to TSH?
Suppress it.
If you have an iodinated contrast allergy can you get radioactive iodine ablation?
Yes. We eat iodine all the time in food. The oral radioactive iodine should not cause the same allergic response.
If someone has hyperthyroidism and is on medication and develops vasculitis what should you think of?
p-ANCA associated vasculitis secondary to the PTU. Not enough data to support association between methimazole and ANCA positive vasculitis.
If a patient has positive thyroid antibodies should you treat them with steroids?
No.
When you order ‘bone age’ x-rays what part of the body do you get x-rayed?
Hand and forearm.
Other than medications, what medical conditions are you looking for when you evaluate a patient for high LDL?
- Hypothyroidism - Nephrotic syndrome or kidney leading to nephrotic range proteinuria. - Primary biliary cirrhosis or other causes of obstructive jaundice.
Does Cushing’s cause high LDL?
No
Does high LDL cause fatty liver?
No.
What component of the lipid panel does estrogen raise?
Triglycerides.
In a cosyntropin stimulation test; is the timing of the cortisol rise important or just the magnitude?
Just the magnitude.
When is the replacement dose of 1.6 mcg/kg used for levothyroxine?
When someone is hypothyroid because of thyroidectomy or radioactive iodine ablation and therefore has no thyroid function at all.
What time of day should testosterone be measured?
8 am
What happens to the glucose reading when alcohol is still left on the finger after cleaning and not waiting for it to dry before checking?
Falsely lowered.
What happens to the glucose reading when you don’t completely fill the yellow box with blood on the glucose meter?
Falsely elevated.
How do you calculate someone’s ‘carb ratio’?
500/Total daily dose of insulin
How do you calculate someone’s ‘sensitivity factor’?
1800/total daily insulin dose of that person
What’s the risk of taking fibrates in renal insufficiency?
Increased risk of rhabdomyolysis.
Can the calcium/creatinine ratio be less than 0.01 in patients with primary hyperparathyroidism?
Yes. In about 20% of patients.
What should you think of if someone has minimal fat on extremities and otherwise abdominal fat and Cushingoid appearance?
Lipodystrophy.
What does fish oil do to warfarin?
Potentiates affect of warfarin causing elevated INR. Warfarin dose would have to be adjusted.
What is a physiological dose of hydrocortisone?
20 mg in the morning, and 10 mg in the afternoon.
Cyclobenzoprine and urine metanephrines.
Falsely elevated.
Duloxetine and urine metanephrines.
Falsely elevated.
Venlafaxine and urine metanephrines.
Falsely elevated
What does phenobarbital do to dexamethasone?
Increases the metabolism of dexamethasone.
How long do intra-articular joint steroid injection (kenalog) last (for the purpose of steroid suppression)?
3 months.
If a woman has hirsutism and secondary amenorrhea with isolated testosterone elevation - how high should the testosterone be to be very concerning for testosterone secreting tumor?
200 or higher.
Which HIV medication increases risk of osteoporosis significantly?
Tenofovir
Does subclinical hypothyroidism have an affect on LDL?
Not really. No significant effect in studies.
When should the labs be drawn during a 72 hour fast for evaluation of hypoglycemia?
When the blood glucose is below 60 mg/dl.
What do you usually do to the insulin when a patient goes into labor?
Hold it. Labor uses up all the glucose so insulin may actually make them hypoglycemic.
Which vitamin D level do you use to determine a patient’s vitamin D status?
25-hydroxy vitamin D.
When is a 24-hour urine calcium not helpful in distinguishing primary hyperparathyroidism from familial hypocalciuric hypercalcemia?
If a patient has significant renal impairment or is on medications that effect calcium excretion.
How much NPH is 20 units of glargine equal to?
10 units BID. Because the glargine is released slowly.
How do you mix NPH and regular insulin - which one do you draw up first?
Regular insulin is drawn up first. You don’t want to get the regular insulin cloudy with the NPH.
What does acetaminophen (Tylenol) do to evaluation for pheochromocytoma?
May elevate the plasma metanephrines in general in some assays.
What are the endocrine diseases that can cause hypercalcemia?
Primary hyperparathyroidism Thyrotoxicosis Adrenal insufficiency Pheochromocytoma
What are the endocrine diseases that can cause weight loss?
Uncontrolled diabetes mellitus Thyrotoxicosis Adrenal insufficiency
If a patient brings in a log book with most glucose numbers ending in ‘0’ and ‘5’ then what do you suspect?
That the numbers are made up.
Does the cosyntropin stimulation test have to be done at 8 am?
No. It can be done any time.
Which medication can decrease severity and frequency of attacks in thyrotoxic periodic paralysis?
Propranolol (40 - 120 mg) per day.
What should you be careful of when repleting potassium in a patient with thyrotoxic periodic paralysis?
It needs to be done slowly and carefully to avoid rebound hyperkalemia.
What do you give before levothyroxine in myxema coma?
Dexamethasone.
What does carvedilol do to glycemic control?
Increases insulin sensitivity.
What happens to the glycemic effects of carvedilol in the presence of ACE inhibitors?
The effect is blunted and they don’t have insulin sensitivity.
Is carvedilol’s effect on insulin sensitivity long term?
No it is not. This has been shown in heart failure trials.
How long before a nuclear medicine radioactive iodine uptake scan does the methimazole need to be stopped?
5 days.
What do you need to make sure of in empty sella syndrome?
That there is no deficiency of pituitary hormones.
The higher the uptake of radioactive iodine on a thyroid scan, the _____ the dose of radioactive iodine required for ablation.
Lower
What’s the target for prolactin levels for a patient with a prolactinoma being treated with dopamine agonists?
Suppress the prolactin to at least 20 ng/ml, and hope the prolactinoma shrinks.
Why is it not advisable to run dextrose through a permacath in a hypoglycemic patient?
Because that would increase risk of infection.
Blood glucose target 2 hours after meals?
40 - 80 units higher than pre-meal readings.
When you have a plan to do a sestimibi scan and an US neck at the same time, what will the radiologist prefer to do first and why?
Sestimibi scan - because it will light up (if positive) and they will know where on the ultrasonogram to look for the adenoma.
Which enzyme does PTH act on to convert 25-hydroxycholecalciferol to 1,25-dihydroxycholecalciferol?
1-alpha-hydroxylase.
What should the posterior pituitary look like on a normal contrast MRI?
It will light up.
Can you get galactorrhea with a slightly high prolactin?
Yes
Should you make dose adjustments based on free T4 in patients with panhypopituitarism even if the dose of levothyroxine was changed recently i.e. A week or two ago.
Yes. Free T4 levels can change in a few days to a week or so.
At what age is it safe to start statins?
10 years.
What treatment options are available for homozygous familial hypercholestrolemia?
LDL apheresis MTP (microsomal triglyceride transfer protein) inhibitor. Apo B-100 inhibitor.
Name the MTP inhibitor recently approved for homozygous familial hypercholestrolemia.
Lomitapide.
Name the apo B-100 synthesis inhibitor recently approved for homozygous familial hypercholestrolemia.
Mipomerson.
How many months supply of testosterone can you prescribe at a time?
6 months.
What are the two main side effects of lomitapide?
GI side effects Hepatoxicity
What fruit can increase lactation?
Papaya
What fruit can cause an abortion in the first trimester of pregnancy?
Papaya
How much elemental calcium does one tablet of 750 mg TUMS contain?
300 mg.
How high does TSH need to be to do radioactive ablation of thyroid cancer?
Above 30.
How many milligrams of calcium carbonate do regular TUMS contain?
500 mg
How many milligrams of elemental calcium do regular TUMS contain?
200 mg
What happens to 1,25 OH vitamin D in primary hyperparathyroidism?
Increases.
What do thiazide diuretics do to urinary calcium excretion?
Decrease it.
When urinary sodium is high what is usually the cause?
Excess sodium in diet.
Why do you check a pH with ionized calcium?
As a safety measure to see if the sample was collected appropriately. If the pH has changed that may mean that the sample was not put on ice immediately and is therefore inaccurate.
Which form of DDAVP gives a more reliable level in the blood in outpatients?
Nasal spray.
Can you give NPH/reg 70/30 mix every 6 hours in patients on continuous tube feeds?
Yes
Can you give NPH every 6 hours to patients on continuous tube feeds?
Yes.
If someone already had atrial fibrillation along with hypothyroidism - should making them euthyroid have any impact on their heart rate?
Not theoretically.
Has metformin been shown to decrease progression to overt diabetes mellitus in patients with pre-diabetes?
Yes
What other electrolyte (besides calcium) can fall after palmidronate treatment of hypercalcemia of malignancy?
Magnesium.
How can gabapentin make diabetes mellitus worse?
By increasing appetite and therefore making you gain weight.
Do you have to give levothyroxine in one big dose in myxedema coma?
You don’t have to. You can give half a dose, wait and see how the patient tolerates it and then give the rest.
How high does the blood glucose have to be on the meter for it to read ‘high’?
Above 550 - 600 mg/dl.
How often should an insulin infusion set be changed out when patient is in an insulin pump?
Every 3 days.
How high does the 24-hour urine sodium need to be to indicate that adequate salt loading was done when testing for hyperaldosteronism?
Over 200 mmol/24 hours
Name two tests you need to do putting the tube on ice immediately after collection?
- ACTH 2. Ionized calcium
What’s the difference between Cushing’s disease and syndrome?
Cushing’s disease is when the pituitary is secreting too much ACTH. Cushing’s syndrome is when there is a source of excess steroids producing Cushingoid features.
What is the maximum age the FRAX calculator calculates fracture risk for?
90 years.
What dose of pamidronate has been shown to effectively decrease calcium concentrations in patients presenting with symptomatic hypercalcemia?
90 mg IV infused over 4 hours.
What is the initial dose of calcitonin?
4 IU/kg q12h for 2 - 4 doses.
Can hypothyroidism cause glomerulonephritis?
Yes
Is sodium thiosulfate acidic or alkaline?
Acidic.
How much do bisphosphonates decease fracture risk?
50%
Do you calculate a FRAX score in patients on bisphosphonates?
No. Because the fracture risk will be even lower when on treatment and not accurate.
What does diarrhea do to oxalate levels in the urine?
Increases it.
What does metabolic syndrome do to uric acid levels?
Increases uric acid levels.
How do you know if adequate salt loading has been done when checking 24 hour urine for hyperaldosteronism?
24-hour urine sodium needs to be over 200 meq.
There is only one drug in one country approved for the treatment of pre-diabetes. Name the country and the drug.
Japan. Acarbose.
What are the drugs that increase insulin sensitivity and keep it sustained?
GLP-1 receptors agonists. TZDs
What are the drugs that inhibit glucagon?
DDP 4 inhibitors GLP-1 receptor agonists
What is the only true class of drugs that improves the insulin resistance in the muscles?
TZDs
How fast the does the GLP-1 and GIP level go up when you start eating?
2 minutes. (K and L cells in the stomach secrete the GLP-1 and GIP when coming in contact with food).
Do GLP-1 receptor analogues make you hypoglycemic?
No
What effect does GLP-1 have on gastric emptying?
Delays gastric emptying.
What does diabetes do to gastric emptying?
Increases rate of gastric emptying.
What does GLP-1 do to food intake?
Decreases it.
Why does Bydureon last longer in the body than Byetta?
Extended release exenetide is given in higher doses and contained in little microspheres that are slowly released and therefore last longer.
How long does Bydureon take to reach steady state in the body?
8 weeks.
Should patients with mostly post-prandial hyperglycemia be on Byetta or Bydureon?
Byetta
Why are exenetide and liraglutide started at lower doses and then moved up?
Because they cause nausea. Once you get through the GI side effects you can increase the dose.
What does prolonged heparin use do to bone mineral density?
Decreases it.
What mutations that can cause bilateral pheochromocytomas.
RET VHL SDHD SDHB TMEM127
Has warfarin been shown to decrease bone mineral density?
There is no concrete evidence.
How do you convert IV hydrocortisone to PO hydrocortisone?
It’s a 1:1 ratio.
What is the urine pH in renal tubular acidosis type 4?
Less than 5.5.
What usually happens to potassium in hyporeninemic hypoaldosteronism?
It is elevated.
What kind of calcium increases the risk of kidney stones?
Calcium carbonate.
What should you look for in adult patients developing lanugo hair all over body?
Cancer. Any kind - usually solid tumor.
Which criteria does the endocrine society recommend for diagnosis of PCOS?
Rotternham criteria.
What should you worry about if the DHEA-S is more than 700?
Adrenal tumor.
Does medullary thyroid cancer respond to radioactive iodine?
No
What should happen to the cortisol if the patient is on vasopressors?
No data to show what happens.
What does the insulin on board feature on a pump do and what is it typically set at?
Prevents insulin stacking. 3 - 4 hours.
If gonads are in the inguinal canal what are they usually?
Testes.
What do ACEI and ARBs do to renin?
Elevate it.
What is the physiologic dose of hydrocortisone?
20 mg in the morning and 10 mg in the afternoon.
What kind of imaging is best to see thyroid nodules?
Ultrasonography.
How long before radioactive iodine ablation does the methimazole need to be stopped?
5 - 7 days.
How long after radioactive iodine ablation should a patient have a separate bathroom and room to avoid radiation exposure to contacts or children?
2 - 3 days.
How far away should a patient who underwent radioactive ablation stay from close contacts to avoid radiation exposure?
6 feet.
What are the maximum number of units you can inject with the Novo Nordisk Flexpen at one time?
60 units.
What is the maximum number of units you can inject with the Novo Nordisk Flexpen at one time?
60 units.
How do you tell which adrenal the aldosterone is coming from in hyperaldosteronism?
Adrenal venous sampling.
What happens to insulin requirements gradually as pregnancy progresses?
Insulin requirements increase.
What happens to insulin requirements immediately after the third trimester of pregnancy?
They go down and then go back up again.
How many pens do you get in a box of Novo Nordisk Flexpens?
5 pens per box.
The 70:30 Flexpen should not be used when there are less than ___ units of insulin in the pen.
12 units
How long do you have to keep the needle in when injecting with the Novo Nordisk Flexpen?
6 seconds.
What pen can you use if you want to inject 0.5 units of insulin e.g. in pediatric or elderly patients?
Novopen 3 Novopen Junior
What volume of liraglutide is present in a Victoza pen?
3 ml
How much hydrocortisone is 1 mg of dexamethasone equal to?
25 mg
How many milligrams of liraglutide in a Victoza pen?
18 mg
How many mg/ml of liraglutide in a Victoza pen?
6 mg/ml
If you prescribe 1.2 mg of liraglutide per day then how many pens per box of Victoza will the patient receive?
2 pens/box
If you prescribe 1.8 mg of liraglutide per day then how many pens per box of Victoza will the patient receive?
3 pens/box
What is the size of a Novofine needle?
30 gauge, 1/3 inch.
What is the size of the Novotwist needle?
32 gauge, 1/4 inch.
How do you check if the Flexpen is working okay with a Novofine needle?
Inject 20 units into the cap. It should fill to the plastic ridges coming together.
What size is the safety needle used with Flexpens?
30 gauge, 1/3 inch (8 mm)
What feature of the safety needle used with Flexpens makes it good for institutional use?
Needle has a covering that always stay on and just retracts when actually injecting.
Flexpens usually come in boxes of…
5
The Medtronic Mini Med insulin pump has needle infusion sets in two sizes. What are they?
6 mm 9 mm
Screening for visceral fat clinically is usually done by…
Serial waist circumference screening.
Can you use acetaminophen with continuous glucose monitoring?
No. It interferes with the readings.
What do ACEIs and ARBs do to GFR?
Decrease it.
Target for proteinuria if diabetic patient is on an ACEI/ARB.
Less than 300.
What is the only NIH sponsored study that failed all three of its objectives?
ACCORD
What are the maximum number of units you can inject with the Lantus Solostar Flexpen at one time?
80 Units.
What are the maximum number of units you can inject with the recently approved Levemir Flexpen at one time?
80 units
What is the Accu-Chek Nano by Roche and what does it look like?
Blood Glucose Meter Small, black, rounded corners, contrast screen.
Which blood glucose meter has a good, ‘not very painful’ lancet device per patient reports?
Accu-Chek Nano.
Why is it recommended to check blood glucose in the finger tips and not other sites?
Because blood glucose value change faster in these capillaries and the results are more likely to be accurate,
Is it possible to check blood glucose from blood from sites other than the finger tips?
Yes
When is it okay to check blood glucose from the palm?
When fasting and before meals.
When is it not okay to check blood glucose from the palm?
- Symptoms of hypoglycemia. - Illness - Post-prandial (up to 2 hours) - After exercise - After injecting insulin. - If patient has hypoglycemia unawareness.
Does fludrocortisone have corticosteroid side effects?
No
Why is TSH checked in hypogonadism patients?
Hypothyroidism can cause decreased gonadotropins.
TRH stimulates which two hormones?
TSH Prolactin
What happens to gonadotropins if the prolactin level is too high?
Decreased.
What is the starting dose of Byetta?
5 mcg subcutaneous BID
Can protease inhibitors cause impaired glucose tolerance and diabetes?
Yes
What colors are the dialysate bags for peritoneal dialysis in order of glucose concentration from least concentrated to most concentrated?
Yellow Green Red
Does androgen deprivation therapy have any effect on diabetes mellitus?
It causes weight gain and worsens diabetes control.
Does having diabetes mellitus type 1 have any effect on bone health?
It deceases bone density and increases risk of fractures.
Does diabetes mellitus type 2 have any effect on bone health?
Osteoporosis has now been included as a complication of diabetes.
By what mechanism to TZDs decease bone density?
Problem with production as there is decreased differentiation into osteoblastic cells.
What’s the bone turn-over rate of trabecular bone?
30%
What is the turn over rate of cortical bone?
6%
Do blood glucose meters usually read lower or higher than laboratory values?
Lower
How many blood glucose values can the Accu-Chek Nano store?
500
What forms does Exenatide come in?
- 5 mg dosage pen - 10 mg dosage pen
What is the least amount of time after an iodinated contrast study that you can give a patient radioactive iodine ablation?
4 weeks
Is there such a thing as dangerously low testosterone?
No.
Can hyperprolactinemia cause hypogonadism?
Yes
Can hypogonadism cause erectile dysfunction without causing decreased libido?
Yes
What do adipose cells do to testosterone?
Aromatize testosterone into estradiol.
What is the triple phase response after pituitary surgery?
First phase: acute diabetes insipidus (4 - 7 days). Second phase: SIADH (transient) Third phase: permanent central diabetes insipidus.
What HbA1c does an average blood glucose of approximately 300 mg/dl correspond to?
12%
What blood glucose does the ADA recommend before a meal?
70 - 130 mg/dl
What blood glucose does AACE recommend before a meal?
Less than 110 mg/dl
How many good lumber vertebrae are needed to properly read a bone density?
2
What is the conversion ratio from hydrocortisone to cortisol?
1:1 ratio
Describe the saline suppression test protocol.
- Place peripheral IV line. 2. Patient should be on bed rest 30 min prior to first blood draw and for the entire duration of the test. 3. Following labs drawn: renin, aldosterone, electrolytes, BUN, creatinine, 18-hydroxycorticosteroid. 4. Infuse 2 litres of normal saline over 4 hours (500 cc/hr). 5. At 4 hours following labs drawn: renin, aldosterone, electrolytes, 18-hydroxycorticosteroid. 6. After completion remove IV lines and the patient can be discharged.
What are the contra-indications for using PTH for osteoporosis?
- Any malignancy that likes to go to bone. - Paget’s disease. - Secondary PTH from renal disease.
What is the dose for safe daily intake of vitamin D recommended?
800 - 4000 IU/day
What blood glucose does ADA recommend 1 - 2 hours after the start of a meal?
Less than 180 mg/dl
What does AACE recommend the blood glucose to be 2 hours after the start of a meal?
Less than 140 mg/dl
What happens to glucagon levels after roux-en-Y gastric bypass surgery?
Post-prandial hyperglucagonemia.
Do you calculate a FRAX score in someone who has already been on bisphosphonates for sometime in the past but is no longer on them?
No
What does chromium deficiency do to glucose tolerance?
Makes it worse. Chromium deficiency worsens diabetic control.
Will Gemfibrozil lower triglycerides if someone is not eating?
No. It lowers dietary triglycerides.
What do you do to the dose of insulin after delivery of the baby?
Cut the dose in half
What if there is suspicion for thyroid storm but you think that there is some other reason for the symptoms?
Still treat as if the patient has thyroid storm because there is no harm in aggressively treating for a few days.
How long does denosumab last in the system/body?
6 months
What are the three things that indicate a thyroid nodule is malignant?
- Microcalcifications. 2. Size greater than 2 cm. 3. Solid nodule (as opposed to cystic).
Can Graves ophthalmopathy cause color blindness?
Yes. Because of compression of outside fibers of optic nerve.
Does fenofibrate make creatinine go up?
It can. It is thought to be benign as it goes back down if you stop it.
Is 400 mcg of levothtroxine too much?
Not if they need it.
Does it matter what time the testosterone is drawn if someone is on testosterone injections?
No
Testosterone replacement can cause irritability and losing temper more easily. True or false?
True.
What issues do patients with Klinefelter’s syndrome normally die of?
Cardiac problems.
What do positive 21-hydroxylase antibodies tell us?
That the patient has autoimmune adrenal insufficiency.
What effect does hyperthyroidism have on warfarin dosing?
Makes patients more sensitive to it so they need less.
Is pre-albumin a reliable indicator of nutrition in the setting of infection?
No
What’s the chance of getting pregnant if you’ve been trying for 1 month?
25%
How long does a patient need to be on a low iodine diet before radioactive iodine ablation of the thyroid?
10 days in the literature. (1 - 3 weeks depending on clinical practice)
How long do you tell patients to follow radiation precautions after radioactive iodine ablation for thyroid cancer?
48 hours per nuclear medicine department.
What is the reason for hypokalemia in thyrotoxic periodic paralysis?
Potassium shifts into the cell.
How successful is cabergoline in treating acromegaly?
Successful in 10 - 30%
Can you monitor growth hormone levels on pegvisoment (somavert)?
No. They remain high.
Can you monitor growth hormone levels on octeotride when treating acromegaly?
Yes.
Is growth hormone level a good screening test for acromegaly?
No.
Is glucagon present in type 1 diabetes mellitus?
It’s almost always absent.
What happens to the armpit hair in people with Addison’s disease?
Decreases.
What color is the 100 mcg levothyroxine pill?
Yellow.
What color is the 150 mcg levothyroxine pill?
Blue
What color is the 175 mcg levothyroxine pill?
Purple.
How much vitamin D do you need to give to raise the vitamin D level by 1 pg?
100 IU/day
What kind of lipid abnormality can obstructive liver disease cause?
Hypercholestrolemia (elevated LDL)
What happens to the glucose concentration in the hepatic portal vein after Roux-en-Y gastric bypass surgery?
Increases.
What do the glucose sensors in the portal vein cause when there is a high glucose concentration in the portal vein?
- Increase hepatic glucose uptake causing the uptake at other sites to decrease. 2. Increase islet cell hormone secretion (more insulin).
What two diagnoses should be excluded in a woman of reproductive age who presents with amenorrhea and galactorrhea?
- Pregnancy 2. Hypothyroidism
What happens to the pituitary gland in pregnancy?
It enlarges.
If a woman of reproductive age has mild hyperprolactinemia; what should you exclude before imaging the pituitary?
- Pregnancy 2. Hypothyroidism
What happens to the alpha-subunit levels in pregnancy?
They are elevated.
What effect does estrogen have on thyroid binding globulins?
Increases the liver synthesis of TBG.
What happens to the levels of TBG (thyroid binding globulins) during pregnancy?
The levels increase.
Why can pregnancy make a patient mildly hypothyroid even though she’s taking the same dose of levothyroxine that kept her euthyroid before pregnancy?
Because of increased TBG (thyroid binding globulin).
How does primary hypothyroidism lead to hyperprolactinemia?
Primary hypothyroidism causes increased secretion of TRH from the hypothalamus that stimulates both TSH and Prolactin (and causes thyrotrope and lactotrope hyperplasia leading to pituitary enlargement).
What happens to the bony epiphyses in congenital adrenal hyperplasia?
There is premature closure.
What percentage of women presenting with hyperandrogenism have congenital adrenal hyperplasia?
2 - 4%
How can you restore normal ovulation in women with non-classical congenital adrenal hyperplasia?
Corticosteroid therapy.
How can you exclude a diagnosis of non-classical congenital adrenal hyperplasia?
An early morning basal 17-OH progesterone value of less than 200 ng/dl.
Are multiple cysts seen in the ovaries on pelvic ultrasound diagnostic of polycystic ovarian syndrome?
No. They are common with multiple etiologies of androgen excess. And also found in 25% woman will normal periods.
Treatment of severe premenstrual syndrome symptoms.
SSRIs. They can be administered daily throughout menstrual cycle or daily during luteal phase only.
What is the treatment of infertility in women with PCOS?
Clomiphene.
What do you think of in a man with hypogonadotrophic hypogonadism and chondrocalcinosis?
Hemochromatosis.
What is a common cause of male infertility in Pakistan?
Testicular tuberculosis.
Which gene is affected in X-linked Kallman Syndrome?
Deletions in the KAL1 gene.
What test should be performed in all patients with primary ovarian failure?
Karotype (to rule out Turner Syndrome/ or other forms of gonadal dysgenesis).
Which gene mutations happen in patients with Kallman syndrome and midline abnormalities (colobomas, cleft palate, horseshoe kidney, or renal agenesis) and synkinesia?
KAL1 gene mutations.
What gene mutations are present in patients with Kallman syndrome with cleft palate but not horseshoe kidney, coloboma, or synkinesia?
FGFR1 gene mutation.
What pattern of inheritance does an FGFR1 gene mutation have?
Autosomal (usually dominant)
What kind of inheritance does KAL1 gene mutation have?
X-linked mutation.
What are GPR54 gene mutations associated with?
Congenital hypogonadotropism.
Which hormone is high when you have acanthosis nigricans?
Insulin.
What can cause xanthalasmas in a patient with a non- remarkable lipid panel?
Sitosterolemia.
By how much do triglycerides go up after a fatty meal and how long so they stay up?
20% 4 hours.
What happens to SHBG levels in men with Klinefelter’s syndrome?
They are increased.
Why are SHBG elevated in patients with Klinefelter’s syndrome?
Because of increased estrogen production.
Does radiotherapy of a pituitary tumor shrink it?
No. But in some people’s experience they do shrink. However, they definitely do not shrink quickly (so cannot fix an acute neurological question).
When looking at Hounsfield units for adrenal masses - should the CT be with or without contrast?
Without contrast.
What is a DAX1 (also called NROB1) gene mutation associated with?
Hypogonadotrophic hypogonadism plus primary hypoadrenalism.
Does an adrenal tumor usually cause gynecomastia and isolated estradiol production?
No.
Which syndrome should you suspect in patients with premature ovarian failure who have a family history of mental retardation, autism, or premature ovarian failure?
Fragile X syndrome.
How do you test for fragile X syndrome?
FMR-1 genotyping.
If a young woman has premature menopause (secondary amenorrhea with elevated FSH levels) then what is the most likely cause?
Turner’s syndrome.
Which two tests are important to do in a patient who has been diagnosed with Turner’s syndrome?
- Echocardiography. 2. EKG.
What is the most common side effect of androgen replacement therapy?
Acne.
Can hyperthyroidism cause tender gynecomastia?
Yes.
Does hyperthyroidism cause suppression of gonadotropins?
No.
A well virilized man presents with low libido and tender gynecomastia plus low testosterone, very high estrogen, and suppressed gonadotropin levels. Diagnosis?
Sertoli cell tumor. Leydig cell tumor that makes estradiol.
If post menopausal women take unopposed estrogen for 5 years, what does it significantly increase the risk of?
- Stroke - Cardiovascular disease - Symptomatic cholethiasis - Deep venous thrombosis
Does hormone therapy reduce the risk of osteoporosis-related fractures in post menopausal women?
Yes
How do you test for anovulation?
Serum progesterone of 3 or less on day 20 - 24 of cycle.
Slowly progressive virilization. Diagnosis?
Hyperthecosis ovarii (benign ovarian androgen-producing tumors).
What does the absence of fructose in the seminal fluid suggest?
Obstruction distal to the seminal vesicles.
In what conditions do you see high serum testosterone levels with low gonadotropin levels?
- hCG-producing tumors. - hCG abuse. - testosterone abuse. - androgen-secreting Leydig tumors or adrenal tumors.
What happens to sex hormones in males with thyrotoxicosis?
- high total testosterone. - high total estradiol. - high SHBG levels. - lowish free testosterone levels. - lowish free testosterone to free estradiol levels.
Is a history of deep venous thrombosis an absolute contraindication to all oral estrogen-progesterone contraceptive use?
Yes
Do non-oral progesterone-only contraceptives increase the risk of thromboembolism?
No.
How often does amenorrhea occur in patients taking OCPs?
5 - 10%
What is macroprolactinemia?
High molecular mass prolactin with little to no bioactivity.
How common is macroprolactinemia?
About 20%.
What is the first line treatment for hirsutism in a patient with polycystic ovarian syndrome?
Oral contraceptives.
What should you give a pre-menopausal age woman with amenorrhea secondary to hyperprolactinemia?
Low dose oral contraceptive pills.
Patient presenting with delayed puberty, hypogonadotrophic hypogonadism, with history of vague abdominal complaints and skin hyperpigmentation. Diagnosis?
Adrenal hypoplasia congentina (X-linked recessive disorder).
What percentage of Grave’s disease patients have Grave’s ophthalmopathy?
25%
What are the extra thyroidal manifestations of Grave’s disease?
- Grave’s ophthalomopathy. - Thyroid dermopathy. - Thyroid acropachy.
What percentage of patients with hyperthyroidism have normal serum levels of free T4 but elevated levels of free T3 (T3 thyrotoxicosis)?
2 - 4 %
What tests should you order for initial assessment of a patient you suspect of having hyperthyroidism?
- TSH - Free T4 - Free T3
Which antibody is specific for Grave’s disease?
TSH receptor antibody (TRAb). 98.3% sensitivity; 99.2% specificity. (thyroglobulin stimulating antibody).
In hyperthyroid patients, what is the diagnosis of Grave’s disease usually based on?
- Anti-TSH-receptor antibody assays. - Thyroid ultrasonography.
Does the addition of cholestyramine together with propylthiouracil accelerate the decline in serum levels of thyroid hormones?
Yes
Is the dose-response relationship clearer with propylthiouracil or methimazole?
Propylthiouracil.
What is the incidence agranulocytosis in patients treated with methimazole?
0.1 - 0.5%
Can radioactive iodine ablation worsen hyperthyroidism symptoms?
Yes, by causing destructive thyroiditis.
Pre-treatment with which anti-thyroid medication introduces a greater degree of resistance to iodine ablation?
Propylthiouracil.
Is there increased incidence of cancer with radioactive iodine ablation treatment?
Most studies have showed no association.
