MKSAP Board Basics Endocrinology Flashcards
(280 cards)
1
Q
What’s the difference between type 1A and 1B diabetes mellitus?
A
Type 1A - Autoimmune with specific autoantibodies (e.g. GAD-65, IA-2) detectable.
Present in more than 90% of cases.
Type 1B - Idiopathic, no autoimmune markers,
More common in those with Asian/African ancestry.
2
Q
Is it best to give basal insulin in the morning or at night?
A
At night
3
Q
What causes “dawn phenomenon”? (Where does the glucose come from?)
A
Hepatic gluconeogenesis
4
Q
How do you fix (i.e. reset) hypoglycemia unawareness?
A
Allowing the average plasma glucose to increase for several weeks
5
Q
What percentage of type 2 diabetes mellitus patients have microvascular disease at the time of presentation?
A
20%
6
Q
What percentage of type 2 diabetes mellitus patients have macrovascular disease (e.g. CAD or peripheral vascular disease at time of presentation?
A
More than 20%
7
Q
What percentage of patients in the United States with diabetes mellitus have MODY (maturity-onset diabetes of youth)?
A
5%
8
Q
At what age does MODY present?
A
Below 25 years
9
Q
USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged ________________ who are overweight or obese.
A
40 - 70 years
10
Q
What are the risk factors for diabetes mellitus that should prompt screening?
A
Family history of diabetes mellitus
History of gestational diabetes
PCOS
Certain racial/ethnic groups.
Obese/overweight adults between 40 - 70 years old.
11
Q
The American Diabetes Association recommends screening overweight adults with one additional risk factor, and all adults aged ____.
A
Over 35 years
12
Q
What is the definition of overweight in Asian Americans?
A
BMI equal to or more than 23 kg/m2
13
Q
What are the screening tests used for diabetes mellitus?
A
Fasting plasma glucose level
2-hour post-prandial glucose during oral glucose tolerance test
HbA1c
14
Q
How many screening tests do you need to diagnosis diabetes mellitus?
A
2
If 2 simultaneous screening tests are abnormal - diagnose diabetes mellitus; if only one is abnormal then repeat the abnormal one.
15
Q
How can you diagnose diabetes mellitus on the basis of a random glucose level?
A
A single random glucose level of > 200 mg/dL along with symptoms of hyperglycemia (polyuria, polydipsia, polyphagia) is diagnostic of diabetes mellitus.
16
Q
What 2-hr glucose value during an OGTT is diagnostic of diabetes mellitus?
A
200 mg/dL or over
17
Q
What 2-hr glucose value during an OGTT is diagnostic of pre-diabetes?
A
140 - 199 mg/dL
18
Q
What reduces risk of developing diabetes mellitus in patients with pre-diabetes more - metformin or lifestyle modifications?
A
Lifestyle modifications
19
Q
Can an insulin pump increase adherence in a patient who is not adherent to multiple daily insulin injections?
A
No
20
Q
What percentage of patients taking metformin develop vitamin B12 deficiency?
A
5 - 10%
21
Q
At what GFR is metformin contraindicated?
A
Less than or equal to 30 mL/min/1.73 m2
22
Q
Which 3 diabetes mellitus drug classes cause weight loss?
A
GLP1 agonists
SGLT2 inhibitors
Amylinomimetics (pramlintide)
23
Q
How do you screen for diabetic neuropathy?
A
10 g monofilament
128-Hz tuning fork
Pedal pulses
Ankle reflex
24
Q
When should you start screening for complications in type 1 diabetes mellitus?
A
5 years after initial diagnosis (continue annually thereafter)
25
When should you start screening for complications in type 2 diabetes mellitus?
At the time of diagnosis (continue annually thereafter)
26
What are the indications for a moderate intensity statin in patients with diabetes mellitus?
Age over 40 years and an ASCVD risk of less than 7.5%
(AHA/ACC)
Age 40 - 75 years and an ASCVD risk of 10% or more
(USPSTF)
27
What are the indications for a high intensity statin in patients with diabetes mellitus?
Coronary artery disease, peripheral vascular disease or ASCVD risk of 7.5% or higher.
(AHA/ACC)
Age 40 - 75 years and an ASCVD risk of 10% or more
(USPSTF)
28
What is the goal blood pressure in patients with diabetes mellitus?
< 130/80 mmHg (ACC/AHA)
< 140/90 mmHg (ADA)
29
Urine albumin excretion higher than ______ indicates diabetic nephropathy
30 mg/g of creatinine
30
Dot-and-blot hemorrhages and clusters of hard, yellowish exudates are characteristic of _______
Non-proliferative diabetic retinopathy
31
Neovascularization (a network of new blood vessels) protruding from the optic nerve is characteristic of _______
Proliferative diabetic retinopathy
32
How can you prevent diabetic retinopathy?
Blood glucose control
Blood pressure control
Smoking cessation
33
Treatment options for severe non-proliferative diabetic retinopathy and proliferative diabetic retinopathy.
Panretinal laser photocoagulation
Intraocular injections of bevacizumab or ranibizumab
34
Treatment options for macular edema in diabetes mellitus patients.
Intraocular injections of bevacizumab or ranibizumab
35
Treatment options for gastroparesis in patients with diabetes mellitus.
Small feedings
Metoclopramide
Erythromycin
36
What is the treatment of diabetic mononeuropathy (e.g. third nerve palsy)?
Nothing.
Symptoms resolve spontaneously.
37
What is the definition of hyperglycemic hyperosmolar syndrome?
Plasma osmolality > 320 mOsm/kg H2O
Glucose > 600 mg/dL
No/low ketones.
No acidosis.
38
What diagnosis should be considered in any older patient with altered mental status and hypovolemia?
Hyperglycemic hyperosmolar syndrome
39
What fluids should you use in hyperglycemic hyperosmolar syndrome?
Normal saline first to replenish extracellular space.
Hypotonic fluids after blood pressure is restored and urine output is established.
40
When should you give IV insulin in patients with hyperglycemic hyperosmolar syndrome?
After expansion of the intravascular space has begun.
41
When should you switch to subcutaneous insulin in patients with hyperglycemic hyperosmolar syndrome?
Once blood glucose is less than 200 mg/dL and the patient is eating.
42
Which fluids should you give in diabetic ketoacidosis?
Normal saline for immediate volume replacement and switch to 0.45% saline if the sodium is high or normal after the initial bolus.
43
When should you start potassium replacement in diabetic ketoacidosis?
When potasstium is < 5.5 meq/L
44
When should you start the glucose infusion along with the insulin infusion in a patient with diabetic ketoacidosis?
When the blood glucose is less than 250 mg/dL
45
When do you replace the potassium in a patient with diabetic ketoacidosis?
When serum potassium is less than 5.5 mEq/L
46
What do you do if a patient with diabetic ketoacidosis presents with a serum potassium of less than 3.3 mEq/L?
Delay the initiation of the insulin infusion.
47
Is severe acidosis in diabetic ketoacidosis treated with bicarbonate?
No. Evidence of benefit is lacking.
48
What is the glucose goal for critically ill patients in the hospital?
140 - 180 mg/dL
49
What is the treatment for critically ill patients in the hospital with glucose levels above 180 - 200 mg/dL
Insulin infusion
50
Is tight inpatient glycemic control (80 - 110 mg/dL) recommended for hospitalized patients with diabetes mellitus?
No.
It is not consistently associated with improved outcomes and may increase mortality.
51
What is the recommended medication for hospitalized patients with diabetes mellitus?
Insulin
52
Can oral or non-insulin drugs be considered in hospitalized patients with diabetes mellitus type 2?
Only if patients are stable with no anticipated changes in nutrition or hemodynamic status.
53
How are pregnant women screened for gestational diabetes?
Screening at 24 - 28 weeks with 75 gram 2-hr OGTT
54
How often should patients with a history of gestational diabetes be screened for development of type 2 diabetes mellitus after delivery?
Annually
55
What is the target HbA1c is pregnancy to decrease risk of congenital malformations and fetal loss?
Within 1% of normal i.e. 6.6% or lower.
56
What are the glycemic targets during pregnancy?
Premeal glucose: < 95 mg/dL
1-hr post-prandial: < 140 mg/dL
2-hr post-prandial: < 120 mg/dL
57
What is the medication of choice in gestational diabetes?
Insulin
58
How often should patients with diabetes mellitus be screened for diabetic retinopathy during pregnancy?
Once per trimester
59
Which blood pressure medications can safely be used during pregnancy?
Methyldopa
Beta-blockers (except atenolol)
Calcium channel blockers
Hydralazine
60
When should you evaluate a patient for hypoglycemia?
When they meet Whipple's triad:
- Neuroglycopenic symptoms
- Glucose < 55 mg/dL
- Resolution of symptoms with glucose ingestion
61
What are the types of hypoglycemic disorders?
Fasting
Post-prandial
62
What evaluation needs to be done in all patients with fasting hypoglycemia?
Screen for use of hypoglycemic agents e.g. insulin or sulfonylurea.
63
MEN1
- Primary hyperparathyroidism (multigland)
- Pituitary adenoma
- Pancreatic neuroendocrine tumors
64
How is an insulinoma diagnosed?
72-hr fast with the following results:
Fasting plasma glucose < 45 mg/dL
Serum insulin > 5 - 6 mU/L
Elevated C-peptide level
65
What is the imaging study of choice after an insulinoma is diagnosed?
CT abdomen
66
What happens to the C-peptide levels in case of surreptitious use of oral hypoglycemic agents (e.g. sulfonylureas or meglitinide)?
Inappropriately elevated at time of hypoglycemia
67
What happens to the C-peptide levels in case of surreptitious use of insulin?
Low at the time of hypoglycemia
68
Are home glucometers accurate?
For the most part but they can be inaccurate in the hypoglycemia range.
69
Do patients who don't have Whipple's triad need to be evaluated for hypoglycemia?
No
70
How do you treat acute hypoglycemia?
Oral carbohydrates
IV glucose
IM glucagon
71
What is the most common cause of hypopituitarism?
Pituitary adenoma
72
What diagnosis should be considered when a patient presents with sudden onset headache, visual changes, ophthalmoplegia, and altered mental status?
Pituitary apoplexy (sudden pituitary hemorrhage or infarction)
73
What diagnosis should be considered in patients presenting with amenorrhea, post-partum inability to lactate, and fatigue?
Sheehan syndrome (postpartum pituitary necrosis)
74
When do most cases of lymphocytic hypophysitis occur?
During or after pregnancy
75
What are non-hormonal symptoms of pituitary adenomas (mass effect)?
- Peripheral vision loss
- Headache
76
What is the most accurate way to test for secondary adrenal insufficiency?
Metyrapone stimulation test
77
Which two steroids are measured in a metyrapone stimulation test?
- Cortisol
- 11-deoxycortisol
78
What is the imaging of choice for a pituitary problem?
Pituitary MRI
79
Should FSH/LH be measured in women with normal menstrual cycles when assessing for pituitary problems?
No
80
Should growth hormone be measured or IGF-1 - and why?
IGF-1
Growth hormone is pulsatile
81
What is the treatment of a pituitary apoplexy?
Glucocorticoids until adrenal insufficiency is ruled out.
May need urgent neurosurgical decompression.
82
What is thyroid hormone replacement based on in patients with secondary hypothyroidism?
Free T4 levels
83
What should you do before treating secondary hypothyroidism with thyroid hormone replacement?
Treat or rule out adrenal insufficiency
84
What happens to the serum sodium levels in adrenal insufficiency?
Stay normal or go low.
(Adrenal insufficiency is a cause of hyponatremia)
85
What is a pituitary microadenoma?
Pituitary adenoma less than 1 cm in size
86
What is a pituitary macroadenoma?
Pituitary adenoma 1 cm or larger in size
87
What non-pituitary conditions can cause enlargement of the pituitary gland?
- Untreated primary hypothyroidism
- Pregnancy
88
What is the confirmatory test for acromegaly?
Oral glucose tolerance test to suppress growth hormone
89
What are the tests to confirm Cushing's disease?
24-hr urine collection for cortisol
Dexamethasone suppression test
Late night salivary cortisol
ACTH (elevated or inappropriately normal in Cushing's disease)
90
Which patients with primary hyperparathyroidism need to be evaluated for a pituitary adenoma?
Those with a family history of MEN1
91
Can psychotropic agents cause hyperprolactinemia?
Yes
92
Can protease inhibitors cause hyperprolactinemia?
Yes
93
Can opiates cause hyperprolactinemia?
Yes
94
Can methyldopa cause hyperprolactinemia?
Yes
95
Can beta-blockers cause hyperprolactinemia?
No
96
Can calcium channel blockers cause hyperprolactinemia?
Yes
97
Can domperidone cause hyperprolactinemia?
Yes
98
Can metoclopramide cause hyperprolactinemia?
Yes
99
Can tricyclic antidepressants cause hyperprolactinemia?
Yes
100
Can anti-seizure medications cause hyperprolactinemia?
Yes
101
What should you get in all women with hyperprolactinemia?
Pregnancy test
TSH level
102
What should you get in all patients with hyperprolactinemia?
TSH level
(Primary hypothyroidism causes hyperprolactinemia)
103
In patients with hyperprolactinemia - what is the usual level of prolactin if this is caused by drugs or a "non-prolactinoma" condition?
< 150 ng/mL
104
What kind of pituitary adenomas should you treat with "observation"?
- Non-functioning pituitary microadenomas
- Microprolactinomas in women with normal menstrual cycles
105
What kind of pituitary adenomas should you treat with a dopamine agonist?
Prolactinoma that is symptomatic
106
What is the recurrence rate of treated prolactinomas after they disappear off imaging?
Up to 50%
107
What kind of pituitary adenomas should you treat with surgery?
- Secreting anything other than prolactin
- Causing symptoms or mass effect (vision problem, hypopituitarism)
- Prolactinomas unresponsive to dopamine agonists
108
What conditions should you test for in patients with polyuria?
- Diabetes mellitus
- Diabetes insipidus
- Hypercalcemia
109
How is the diagnosis of diabetes insipidus confirmed?
- Water deprivation test: inability to concentrate urine
- Urine osmolality < 200 mOsm/kg H2O
110
How do you differentiate between central and nephrogenic diabetes insipidus?
Desmopressin challenge test
111
What is the imaging study of choice if the desmopressin challenge test is positive (i.e. urine concentrates) in diabetes insipidus?
MRI pituitary
112
What is the imaging study of choice if the desmopressin challenge test is negative (i.e. urine does not concentrate) in diabetes insipidus?
Renal ultrasound
113
What is the treatment of lithium induced nephrogenic diabetes insipidus?
- Stop lithium
- Add amiloride
114
What is the treatment of non-drug-induced nephrogenic diabetes insipidus?
- Thiazide diuretics
- Salt restriction
115
What laboratory tests are checked in asymptomatic patients with empty sella syndrome?
Cortisol
TSH
Free or total T4
116
Is repeat imaging necessary in patients with empty sella syndrome who have negative hormonal work-up?
No
117
Is it more common to have permanent hypothyroidism following post-partum thyroiditis or subacute thyroiditis?
Post-partum thyroiditis
118
How long does it take for thyroid function tests to normalize after euthyroid sick syndrome (nonthyroidal illness syndrome)?
4 - 8 weeks after recovery from illness
119
Which medication is used to treat hypothyroidism?
Levothyroxine
120
When would you consider measuring a calcitonin level in a patient with no known thyroid disease?
- Family or personal history of MEN2
- Family history of medullary thyroid cancer
- Hypercalcemia
121
What is the most common cause of Cushing's syndrome?
Iatrogenic (exogenous steroid use)
122
What dose of prednisone typically causes hypothalamic-pituitary-adrenal axis suppression?
More than 10 - 20 mg/day for 3 or more consecutive weeks.
123
What dose of prednisone is unlikely to cause clinically significant hypothalamic-pituitary-adrenal suppression?
5 mg/day or less
124
Is facial plethora specific for Cushing's syndrome?
Yes
125
Is centripetal obesity specific for Cushing's syndrome?
Yes
126
Are supraclavicular or dorsocervical fat pads specific for Cushing's syndrome?
Yes
127
Which imaging study should you order in a Cushing's patient if the ACTH is > 20 pg/mL and cortisol is not suppressed?
Pituitary MRI (or CT).
128
Which imaging study should you order in a Cushing's patient if the ACTH is < 5 pg/mL?
CT abdomen / adrenal CT
129
What should you do if the ACTH is elevated but no pituitary tumor is identified in a Cushing's patient?
High dose (8 mg) dexamethasone suppression test to differentiate between pituitary and ectopic ACTH production.
130
What is the diagnosis if high dose (8 mg) fails to suppress cortisol?
Ectopic ACTH production
131
What are the most common ACTH-secreting malignant tumors?
- Small cell lung cancer
- Bronchial carcinoid
- Pheochromocytoma
- Medullary thyroid carcinoma
132
What is the source of ACTH if a high dose (8 mg) dexamethasone suppression test suppresses both pituitary ACTH production and adrenal cortisol production?
Source is pituitary
133
Which study is performed if high dose dexamethasone suppression test indicates pituitary source of Cushing's but no pituitary adenoma is seen on imaging?
Intrapetrosal sinus sampling (IPSS) for ACTH
134
What are some (three) common reasons for a false positive dexamethasone suppression test?
- Obesity
- Alcohol use
- Psychological disorders
135
What the treatment of choice for low bone density caused by endogenous hypercortisolism?
Bisphosphonates
136
What is the definition of an adrenal incidentaloma?
Adrenal adenoma of 1 cm or larger than is discovered incidentally.
137
All asymptomatic patients with adrenal incidentalomas should have which tests done?
- 1 mg overnight dexamethasone suppression test
- 24-hr urine measurement of metanephrines and catecholamines
138
Which patients with adrenal incidentalomas should have their plasma aldosterone and plasma renin activity ratio measured?
Patients with hypertension and/or spontaneous hypokalemia
139
Adrenal carcinoma is more common in what size adrenal mass?
> 6 cm
140
Is aldosterone synthesis ACTH dependent?
No
141
What is the most common cause of primary adrenal insufficiency?
Autoimmune adrenalitis
142
What is the most common cause of secondary adrenal insufficiency?
Exogenous glucocorticoids
143
What 8 am cortisol level diagnoses adrenal insufficiency?
< 3 microgram/dL
144
What 8 am cortisol level excludes adrenal insufficiency?
> 18 microgram/dL
145
What test is commonly used to diagnose adrenal insufficiency?
Cosyntropin stimulation test
146
What percentage of patients with Addison's disease have other autoimmune disorders?
~ 50%
147
Which steroid does not interfere with the serum cortisol assay?
Dexamethasone
148
At what dose of hydrocortisone is fludrocortisone not required in case of primary adrenal insufficiency?
> 40 mg/day
149
What genetic conditions is pheochromocytoma associated with?
- MEN2
- von Hippel-Lindau disease
- Neurofibromatosis type 1
150
Which test for pheochromocytoma is preferred when pre-test probability is low?
24-hr urine metanephrines and catecholamines
151
Which test for pheochromocytoma is preferred when pre-test probably is high?
Plasma metanephrines
152
Which test is used to localize a pheochromocytoma when CT and MRI scans are negative?
I-131 or I-123 MIBG scan
153
What happens if you give beta blockade before alpha blockade in pheochromocytoma?
This can result in severe paroxysmal hypertension.
154
What percentage of primary hyperaldosteronism is caused by aldosterone-producing adenomas?
40%
155
What percentage of primary hyperaldosteronism is by bilateral adrenal hyperplasia?
60%
156
What initial test results suggest primary hyperaldosteronism?
- Aldosterone level > 15 ng/dL
- Aldosterone/plasma renin ratio ratio > 20
157
What aldosterone level after a salt loading test rules out primary hyperaldosteronism?
Less than 5 ng/dL
158
Which anti-hypertensives should the patient not be on when testing for primary hyperaldosteronism?
- Spironolactone
- Eplerenone
159
When is adrenal vein sampling (AVS) needed?
For lateralization when imaging is unrevealing or when there is an adrenal incidentaloma on one side.
160
What percentage of patients with hyperaldosteronism do not have hypokalemia?
~ 50%
161
Which additional anti-hypertensive medication should be prescribed in patients with uncontrolled hypertension because of primary hyperaldosteronism who are already on spironolactone or eplerenone?
Thiazide diuretics
162
What percentage of cases of primary amenorrhea are caused by chromosomal disorders?
~ 50%
163
What is the most common chromosomal disorder causing primary amenorrhea?
Turner's syndrome
164
What is the karyotype in Turner's syndrome?
45, XO karoytype
165
What is the karyotype in androgen-resistance syndrome?
XY karotype
166
Can PCOS cause primary amenorrhea?
Yes
167
What is the most important test in a patient presenting amenorrhea?
Pregnancy test
168
What are some of the important investigations for primary amenorrhea?
- Pregnancy test
- Karyotype
- FSH, LH, TSH, prolactin
- Pelvic ultrasound
169
What is the definition of secondary amenorrhea?
Absence of menstruation for 3 consecutive menstrual cycles or for 6 consecutive months in a woman who previously had menses.
170
What is the most common cause of secondary amenorrhea?
Pregnancy
171
What does a progesterone challenge test tell you?
Whether a patient with secondary amenorrhea is estrogen deficient or not.
172
What do you do if there is no bleeding following a progesterone challenge test?
Indicates estrogen deficient state (hypogonadotrophic hypogonadism).
Measure estradiol level to confirm.
173
What does bleeding after a progesterone challenge test indicate and suggest?
Indicates normal estrogen state; and suggests hyperandrogenic state such as PCOS.
174
What are the causes of primary hypogonadism (hypergonadotrophic hypogonadism) in pre-menopausal aged women?
- Premature ovarian failure/ovarian insufficiency
- Chemotherapy
- Pelvic radiation
175
What is the most common cause of hirsutism with oligomenorrhea?
PCOS (polycystic ovarian syndrome)
176
What is the LH/FSH ratio in PCOS?
Greater than 2:1
177
Is PCOS a clinical diagnosis?
Yes
178
When should a testosterone or DHEAS level be ordered for a PCOS patient?
When an androgen producing tumor needs to be ruled out.
179
What should be suspected in a woman with acute onset of rapidly progressive hirsutism or virilization?
Androgen-secreting ovarian or adrenal tumor
180
Which medications can you use for ovulation induction in PCOS?
- Clomiphene citrate
- Letrozole
181
What is the treatment for patients with PCOS who do not desire fertility?
- Intensive lifestyle modification
- Oral contraceptive pills
182
What should you do if the testosterone level is equivocal in males?
Measure free testosterone by equilibrium dialysis or mass spectrometry.
183
What laboratory tests should you check if the testosterone level is low in males?
FSH
LH
Prolactin
184
Which medications can cause hypogonadotrophic hypogonadism with low testosterone levels?
Anabolic steroids
Glucocorticoids
Opiates
185
Can Kleinfelter's syndrome cause primary hypogonadism in men?
Yes
186
Can mumps cause primary hypogonadism in men?
Yes
187
Can hemochromatosis cause primary hypogonadism in men?
Yes
188
Can auto-immune destruction cause primary hypogonadism in men?
Yes
189
Can trauma cause primary hypogonadism in men?
Yes
190
Can prior chemotherapy cause primary hypogonadism in men?
Yes
191
Can pelvic radiation cause primary hypogonadism in men?
Yes
192
What is the next step after diagnosing primary hypogonadism in a man with no obvious cause?
Check karyotype (Kleinfelter's syndrome)
193
What should be done to evaluate men with secondary hypogonadism?
- Prolactin level
- MRI pituitary
- Iron studies to evaluate for hemochromatosis
- Sleep study
194
Should testosterone levels be measured in patients having regular morning erections, with no gynecomastia and normal genital examination?
No
195
What do you need to monitor other than testosterone levels in patients on testosterone replacement?
PSA
Hematocrit
196
What can result in small testicles and male infertility?
- Anabolic steroid abuse
- Testosterone replacement therapy
197
Should you treat fatigue and weakness without clear cut testosterone deficiency with testosterone replacement?
No
198
What is the most common cause of outpatient hypercalcemia?
Primary hyperparathyroidism
199
What is the most common cause of hypercalcemia in hospitalized patients?
Hypercalcemia of malignancy
200
Is lithium induced hypercalcemia PTH-mediated or non-PTH-mediated?
PTH-mediated
201
Is thiazide induced hypercalcemia PTH-mediated or non-PTH-mediated?
Non-PTH-mediated
202
What percentage of sarcoidosis patients have hypercalcemia?
10%
203
What percentage of sarcoidosis patients have hypercalciuria?
50%
204
If the X-rays show chondrocalcinosis or osteitis fibrosa cystica - then what is the diagnosis?
Primary hyperparathyroidism
205
Is PTH-related protein needed for diagnosis of hypercalcemia of malignancy?
No
206
Is the phosphorous high, normal or low in hypercalcemia associated with multiple myeloma?
High
207
Is the phosphorous high, normal or low in hypercalcemia associated with local osteolytic lesions?
Normal or low
208
Is the phosphorous high, normal or low in hypercalcemia associated with granulomatous disease or B-cell lymphoma?
High
209
Is the phosphorous high, normal or low in hypercalcemia associated with milk-alkali syndrome?
High
210
Why does hyperthyroidism cause hypercalcemia?
Direct stimulation of osteoclasts by thyroid hormone
211
How high does the serum calcium typically need to be to warrant acute intervention?
> 14 mg/dL
212
How do you differentiate true hypercalcemia from pseudohypercalcemia?
Measure ionized calcium
213
What should you do in patients with elevated PTH and calcium levels?
Measure 24-hr urine calcium and creatinine levels to exclude familial hypocalciuric hypercalcemia (FHH).
214
What is the most common manifestation of MEN1?
Primary hyperparathyroidism
215
What is the treatment of hypercalcemia caused by multiple myeloma or sarcoidosis?
Oral glucocorticoid therapy
216
What is the acute treatment of symptomatic hypercalcemia?
- IV fluids
- Calcitonin
- IV bisphosphonates
217
Are loop diuretics recommended in the treatment of hypercalcemia?
No - except in case of heart failure or renal failure where they can be used to control the volume over-load when treating with IV fluids.
218
What is the most common manifestation of MEN1?
Multi-gland primary hyperparathyroidism
219
What is the most common manifestation of MEN2?
Medullary thyroid cancer
220
MEN1
- Primary hyperparathyroidism
- Pituitary tumors
- Pancreatic neuroendocrine tumors
221
What is MEN2?
- Medullary thyroid carcinoma
- Pheochromocytoma
- Primary hyperparathyroidism
222
What percentage of patients with primary hyperparathyroidism have a coexisting vitamin D deficiency?
50%
223
What, other than the calcium and PTH, should be measured in all patients with hyperparathyroidism?
Vitamin 25 (OH) D level
224
How do you treat patients with primary hyperparathyroidism who are symptomatic but not candidates for surgery?
Cinacalcet
Bisphosphonates
225
What are the indications of parathyroidectomy in patients with primary hyperparathyroidism?
- Symptoms (anything that may be related).
- Hypercalcemia with calcium > 1 mg/dL above the upper level of normal.
- Osteoporosis (T-score: - 2.5)
- Chronic kidney disease - stage 3 or worse
- Urine calcium > 400 mg/24 hr
- Age less than 50 years
226
How much does total calcium decline by for each 1 g/dL decrement of serum albumin level?
0.8 mg/dL
227
When are the Trousseau and Chvostek signs positive?
Hypocalcemia
228
What is DiGeorge syndrome?
Congenital hypoparathyroidism
229
Polyglandular autoimmune syndrome type 1
- Autoimmune hypoparathyroidism
- Adrenal insufficiency
- Hypogonadism
- Mucocutaneous candidiasis
- Malabsorption
230
What cardiac studies do you need in hypocalcemia?
EKG to evaluate for QTc interval prolongation
231
Is the calcium level high, normal or low in rhabdomyolysis?
Low
232
Is the calcium level high, normal or low in tumor lysis syndrome?
Low
233
Is the calcium level high, normal or low in hypomagnesemia?
Low
234
What lab values are seen in pseudohypoparathyroidism (PTH resistance)?
Low calcium
High phosphorous
Normal vitamin D
High PTH
235
When can patients get "hungry bone" syndrome?
After parathyroidectomy
236
What is the treatment of acute symptomatic hypocalcemia?
IV calcium gluconate
Vitamin D supplementation
237
Which vitamin D replacement should you use when the patient has kidney disease?
Calcitriol (1,25 dihydroxy vitamin D)
238
Which vitamin D replacement should you use when the patient has liver disease?
25 hydroxycholecalciferol
239
Which vitamin D replacement should you use when the patient has vitamin D deficiency not caused by liver or kidney disease?
Ergocalciferol (D2) or Cholecalciferol (D3)
240
Who should be screened with a DXA per USPSTF?
- Women over 65 years of age.
- Post-menopausal women < 65 years at increased risk based on a formal assessment took (i.e. FRAX)
241
Should the DXA be repeated in post-menopausal women who have a previously normal DXA and no risk factors for osteoporosis?
No
242
Is primary osteoporosis associated with any specific laboratory testing in the absence of fractures?
No
243
What is a fragility fracture?
Fracture after fall from standing height or lower.
244
What is the definition of osteoporosis?
- T-score of less than - 2.5
- History of fragility fracture
245
What is the definition of osteopenia?
T-score of - 1 to - 2.4
246
What is the most common cause of osteoporosis in women?
Estrogen deficiency (menopause)
247
What is the most common cause of osteoporosis in men?
Testosterone deficiency (hypogonadism)
248
Are the following lifestyle changes important for all osteoporosis patients?
- Resistance exercises
- Stop smoking
- Limit alcohol
- Adequate supplementation of calcium and vitamin D
- Sunlight exposure
Yes
249
Which medication can treat pain from osteoporotic fractures?
Calcitonin
250
Which osteoporosis agents are contraindicated in chronic kidney disease or esophageal disease?
Oral bisphosphonates
251
What happens when you stop denosumab therapy?
Rebound vertebral fractures (effect is not sustained)
252
Is osteonecrosis of the jaw more common with oral or parenteral anti-resorptive therapy?
Parenteral (zoledronic acid and denosumab)
253
How long can you give teriparatide for?
2 years maximum
254
Is estrogen replacement therapy adequate treatment for osteoporosis in post-menopausal women?
No
255
Should you combine teriparatide with a bisphosphonate?
No
256
Can you give IV bisphosphonates in severe hypocalcemia or chronic kidney disease?
No
257
What should you consider instead of osteoporosis when you see a fracture in a nursing home resident?
Osteomalacia
258
Which lab value is the best indicator of vitamin D status?
Vitamin 25 (OH) D
259
What are the USPSTF guidelines regarding screening for vitamin D deficiency?
Evidence is insufficient to recommend for or against in asymptomatic adults.
260
Do obese patients have higher or lower levels of vitamin D?
Lower
261
Do patients with malabsorption syndromes have higher or lower levels of vitamin D?
Lower
262
Do patients with malabsorption syndromes have higher or lower levels of vitamin D?
Lower
263
Do patients on orlistat have higher or lower levels of vitamin D?
Lower
264
Do patients on glucocorticoids have higher or lower levels of vitamin D?
Lower
265
Does vitamin D and calcium supplementation prevent fractures?
There is insufficient evidence that it does.
266
What should you suspect if there is an isolated elevation of alkaline phosphatase in the absence of liver disease?
Paget's disease
267
What is the treatment of Paget's disease?
Bisphosphonates
268
What diagnostic scans are used to diagnose Paget's disease in asymptomatic patients?
Bone scan followed by X-rays of areas that localize the radionucleotide
269
What diagnostic scans are used to diagnose Paget's disease in symptomatic patients?
X-rays of the symptomatic areas
270
Which disease has a typical "cotton wool" appearance of skull?
Paget's disease
271
Is the HbA1c falsely high, falsely low or normal in hemolytic anemia?
Falsely low
272
Is the HbA1c falsely high, falsely low or normal in kidney injury?
Falsely low
273
Is the HbA1c falsely high, falsely low or normal in patients taking erythropoietin?
Falsely low
274
Does starvation cause fasting hypoglycemia due to decreased hepatic glucose production?
Yes
275
Does liver failure cause fasting hypoglycemia due to decreased hepatic glucose production?
Yes
276
Does sepsis cause fasting hypoglycemia due to decreased hepatic glucose production?
Yes
277
Does alcoholism cause fasting hypoglycemia due to decreased hepatic glucose production?
Yes
278
Does adrenal insufficiency cause fasting hypoglycemia due to decreased hepatic glucose production?
Yes
279
Does growth hormone deficiency cause fasting hypoglycemia due to decreased hepatic glucose production?
Yes
280
Are wide (>1 cm) violaceous striae specific for Cushing's syndrome?
Yes
