UW Flashcards
(95 cards)
1
Q
Drugs for neuropathic pain
A
- TCA (be careful in older because anti-cholinergic)
- anticonvuslants (gabapentin, pregabalin) (BEST)
- opioids
- capsaicin tpical
- lidocaine topical
consider anticonvulstants or TCA for initial
2
Q
radioablation for graves - SE
A
- permanent hypothyroidism over months to years (resolution of hyperth in 6-18 wks) (this is not happening in toxic adenoma or goiter because only the adenomas take iodine)
- worsening of Graves opthalmopathy due to increased of TSI (if mild: give steroids, if severe: prefer surgery)
3
Q
Diagnostic approach of hypocalcemia
A
low Mg, medications, Recent blood transfusion (citrate)?
- YES –> correct it
- NO –> measure PTH
low: surgical, autoimmune, infiltrative (metast, wilson, hemochromatosis)
high: vit d def, renal failure, pancreatitis, sepsis, tumor lysis syndrome
4
Q
hyperthyroidism with high TSH and high hormones - next step
A
brain MRI
5
Q
hyperthyroidism with low TSH and high hormones - next step
A
graves signs (goiter, ophtalmopathy)?
- yes –> graves
- NO RAIU
high uptake: graves or nodular or adenoma
low uptake: measure thyroiglobulin (low: exogenous hormone, high: thyroditis or iodide exposure)
6
Q
hyperthyroidism effect on BP
A
increased Myocardial contractility
decreased peripheral resistance
(in contrast, hypothyroidism causes hypertension due to increased peripheral resistance)
7
Q
PAC/PRA ratio
A
- plasma aldosteron / plasma renin concentration
- 1st test for hypertension and hypokalemia
8
Q
best initial test for patient with DM and new toe ulcer
A
monofilament (it predicts the risk of future ulcers: higher pressure threshold)
9
Q
toe ulcer - vascular or DM
A
arterial are usually on the tips
DM: plantar
10
Q
diagnosis of hypercalcemia
A
- confirm it (repeated tests + correct for albumin)
- measure PTH
- if low PTH: measure PTHrp, vitD25, vitD1,25
11
Q
MCC of PTH-independent malignancy
A
homural hypercalcemia of malignancy (PTHrp)
PTHrp does not induce Vit D activation
12
Q
a cause of hypercalcemia after accidents
A
immobilization (PTH independent) due to inccreased osteoblastic resorption
(4 weeks after immobilization, but in 3 days in patients with chronic renal failure)
treatment: biphosphanates
13
Q
MCC of death in acromegaly
A
cardiovascular disease
but decreasing of the levels rapidly reduces the risk
14
Q
euthyroid sick syndrome
A
any patient with acute severe illness may have abnormal thyroid function test
NORMAL TSH AND T4
fall in total and free t3
15
Q
acute vs chronic thyrotoxic myopathy
A
acute: severe distal or proximal weakness, without bulbar or resp involvement
chronic: proximal
16
Q
DDX for hyperandrogenism in women
A
- PCOS 2. Acromegaly 3. Cushing
- Hyperprolactinemia 5. ovarian/adrenal tumors
- Non-classic CAH
17
Q
hypomagnesimia mediated hypoparathyroidism vs other causes of hypoparathyroidism
A
hypoparthyroidism associated with low Mg has normal or low P
18
Q
milki alkaly syndrome
A
it is caused by excessive intake of calcium and absorable alkali. It can be seen in patient taking calcium bicarbonate for osteoporosis.
manifestation: symptomatic hypercalcemia, met alkalosis, acute kidney injury
19
Q
thionamides - agranoulocytosis
A
routine WBC check it is not cost effective
- if fever + sore throat –> stop the drug and check the WBCs
if less than 1000 –> stop permanently
if more than 1500 –> it is not the cause
20
Q
DM2 - when to add insulon to metformin
A
when HBAC1 is more than 8.5%
21
Q
the MC electrolytic abnormality in primary adrenal insufficiency
A
hyponatremia in 90%
22
Q
following cortisol discontinuation, the axis me be abnormal up to
A
6-12 months
23
Q
suppurative (infectious) thyroditis
A
fever erythema and severe pain, often with asymmetric goiter due to abscess formation (usually in children and immunocompromised)
USUALLY EUTHYROD
24
Q
the main substance for gluconeogenesis
A
alanine (from proteins breakdown), glutamine (from proteins breakdown), lactate (from anaerobic), glycerol-3-P (from lipids break down)
25
alanine is converted into .... during gluconeogenesis
pyruvate
26
clinical suspicion of acromegaly - algorithm
```
measure IGF-1
- normal (exclude)
- elevated --> oral glucose suppression test
adequate GH suppression --> exclude
inadequate GH suppression --> BRAIN MRI
if pituitary mass --> surgery
if no mass --> search for other source
```
27
metabolic syndrome - features
3 out to 5
1. abdominal obesity (waist more than 40 in males and 35 in females
2. fasting glucose more than 100-110
3. BP more than 13/8
4. TG more than 150
5. HDL cholesterol lower of 40 in male and 50 in women
28
how to measure corrected calcium
calcium + 0.8 (4-serum albumin)
29
VIPoma - clinical presentation
1. watery diarrhea
2. hypo or achrolorhydia due to low gastric acid secretion
3. flushing, lethargy, nausea, vomiting, muscle wekaness
PANCREATIC CHOLERA
30
VIPoma Labs
1. low K+
2. high Ca2+
3. high hyperglycemia (increased glycogenolysis)
4. diarreha: increased sodium + osm gap less than 50
31
VIPoma - diagnosis
1. watery diarrhea with VIP level more than 75
| 2. abdominal CT or MRI
32
Difference in labs between insulinomas and sulfonylurea
in sulfo, the proinsulin is less than 20% of the total insulin immunoreactivity
the diagnosis is confirmed by sulfonylurea measurement
33
severe SE caused by PTU (but not by methimazole
1. hepatic failure
| 2. ANCA mediated vasculitis
34
in which situations, thyroidectomy is prefered against RAI for Graves
1. very large goiter
2. severe ophtalmopathy
3. coexisting nodule and suspicion for malignancy
4. pregnant who cannot tolerate drugs
5. coexisting 1ry hyperpara
6. obstructive symptoms
35
x-ray findings of osteomalacia
1. decreased bone density with thining of cortex
2. eventual codfish vertebral bodies (concave shape)
3. pseudofractures (Looser zones)
36
screening for DM is recommended in ....
1. patients with sustained BP more than 135/80
2. may considered in all patients over age 45
3. additional risk for DM
37
osteolytic metastasis can cause hypercalcemia - mechanism
stimulation of osteoblast by cytokine production
38
paroxysms of severe hyperteneion in pheo can be precipitated by
increases in intra-abdominal pressure (tumor palpation, position changes etc), surgical procedures, and a number of drugs, especially anesthetics
39
what should be done in people with medullary thyroid cancer before the surgery
check for pheo with a plasma fractionated metanephrine essay --> if found pheo, it should be resected first
40
thyroid peroxidase antibodies - disease?
1. Hashimoto
| 2. painless thyroditis
41
thyroid antibodies that are associated with miscarriage
anti-peroxidase
42
small vs large fibers regarding symptoms when damaged
small --> positive symptoms (pain and paresthesia)
| large -> negative symptoms (numbness, loss of propioception and vibratory sense, and diminished ankle reflex)
43
benefits of tight glycemic control in macrovascular and microvascular complications
decreases incidence of microvascular (retinopathy)
| uncertatin for macro
44
hypothyroidism - lipids
- hypercholesterimia alone or hepercholisterimia with hyperTG
- hyperTG alone is rare
45
normal prolactin levels are less than 15. prolactin 45 + low LH + Low TSH - diagnosis
nonfunctional tumor
(slightly high prolactin due to compression on the axon)
diagnostic levels for prolactinoma are more than 200
46
nonfunctioning pituitary adenoma usually arises from
```
GnRH cells (they secrete only tha α-unit)
in nonfunctioning pituitary adenomas, prolactin could be high due to compression of the axon (low dopamine)
```
47
diagnosis of conn - what is the ration of aldosterone to renin
more than 20
48
hyperthyroidism - bone
increased osteoclastic activity --> rapid bone loss + hypercalcemia
49
best markers for response to DKA therapy
- anion gap
| - beta hydroxybutrate level (the predominant ketone)
50
diabetic gastroparesis - treatment
metoclopramide
erythromycin (esp acute)
cisapride (restricted in USA due to risk of arrhythmia and death)
51
confirm of hyperaldosteronism
adrenal suppression test (by salt loading)
52
prolactinoma - surgery or carbegolide?
- asymptomatic microprolactinoma (less than 10mm) --> no treatment
- macroprolactinoma or sympromatic micro:
sugery only if is larger than 3 cm or increases during medication
53
primary hyperaparathyroidism - indications for parathyroidectomy
1. age less than 50
2. symptomatic hypercalcemia
3. complications: osteoporosis, nephrolithiasias/calcinosis, GFR less than 60
5. elevated risk for complications: calcium more than 1 mg/dl above normal, urinary excretion of Ca more than 400 per day
54
glucagonoma - anemia?
normocytic normochronic anemia due to likely anemia of chronic disease or glucagon directly affecting erythropoiesis
55
glucagonoma - diabetes
mild, with normal to slightly high insulin levels and is controlled with lifestyle changes and oral medications (rarely requires insulin)
56
glucagonoma - how to confirm diagnosis
serum glucagon more than 500
57
DDX of myopathy (and ESR, CK)
1. glucocorticoid induced (normal, normal)
2. polymyalgia rheumatic (increased, normal)
3. inflammatory myopathies (increased, increased)
4. statin induced (normal, increased)
5. hypothyroid (normal, increased)
58
glucocorticoid myopaty
- progressive proximal weakness + atrophy
- NO PAIN OR TENDERNESS
- lower extremities are more involved
- normal ESR and CK
59
polymyalgia rheumatic myopathy
- muscle pain + stiffness in shoulder + pelvic
- tenderness with decreased range of motion
- responds rapidly to steroids
- normal CK, elevated ESR
60
inflammatory myopathies
- muscle pain, tenderness
- proximal weakness
- skin rash + infl arthritis
- increased ESR + CK
61
statin induced myopathy
- prominent muscle pain/tenderness with or without wekaness
- rare rhabdomyolysis
- normal ESR, elevated CK
62
Hypothyroid myopathy
- muscle pain, cramps, weakness involving the proximal muscles
- delayed tendon reflexes + myoedema
- occasionally rhabdomyolysis
- normal ESR, increased CK
63
DKA + hyperosmolar - management - IV fluids
0.9% NS initially
| add dextrose when glucose less than 200
64
DKA + hyperosmolar - management - insulin
- initial IV
- switch to SQ if: able to eat, less than 200, normal anion gap, HCO3 more than 15
- overlap SQ + IV insulin by 1-2 h
65
DKA + hyperosmolar - management - potassium
add K+ if less than 5.2
| Hold insulin for serum k+ less than 3.3
66
DKA + hyperosmolar - management - phosphate
if less than 1, cardiac dysfunction or respiratory depression
(monitor calcium)
67
Diabetic foot ulcers - RF
1. Diabetic neuropathy
2. arterial insufficiency
3. ESRD on dialysis
4. smoking
68
Diabetic foot ulcers - management
1. mechanical offloading
2. debridement
3, wound dressing
3. antibiotics if infection
69
common causes of hypogonadism is men - categories
1. primary (testicular)
2. secondary (pituitary/hypothalamus)
3, combined
70
common causes of hypogonadism is men - 1ry (testicular)
1. congenital (klinefelter, cryptorchidism)
2. drugs (alkylating, ketoconazole)
3. orchitis (mumps), trauma, torsion)
4. chronic kidney disease)
71
common causes of hypogonadism is men - 2ry (pituitary, hypothalamic)
1. gonadotroph damage (tumor, trauma etc)
| 2. gonadotropin suppression (exogenous androgens, hyperprolactinemia, DM, obesity etc)
72
common causes of hypogonadism is men - combined
1. hypercortisolism
| 2. cirrhosis
73
signs of adrenal insufficiency --> 250 μg cosynotropin and ACTH levels -->
1. basal cortisol low, high ACTH, minimal cortisol response --> 1ry adrenal insuf
2. basal cortisol low, Low ACTH, minial cortisol response --> 2ry or tertiary adrenal insuf
3. indeterminate --> further testing to assess pituitary
4. Normal response (cortsiol level more than 20 after cosynotropin) --> no adrenal insufficiency
74
water deprivation test - when is 1ry polydispia
if urine osm is more than 600
75
primary vs secondary male hypogonadism regarding gynecomastia
more common in 1ry
76
DM risk factors for adults with BMI more than 25
1. physical inactivity
2. 1st degree relative with DM
3. high risk race, ethnicity
4. women with children's birth wight more than 9lb
5. history of gestational DM
6. dyslipidemia (low HDL and high TG)
7. History of PCOS
8. history of glucose intolerance
77
thyroid nodule - algorithm
First clinical evaluation, TSH + US
- if cancer RF or suspicious US --> FNA
- no RF or suspicious US --> consider TSH
Normal or elevated TSH --> FNA
low TSH --> Radio --> hot (treat hyperthyroidism) vs cold or interminate (do FNA)
78
Joint national Committe 8 reccomendations for treating hypertension - initial diagnosis
if more than 60: more than 150 or 90
| less than 60 or Chronic kidney diseas, or DM: more than 140 or 90
79
Joint national Committe 8 reccomendations for treating hypertension - goal BP
if more than 60: less than 150/90
| less than 60 or Chronic kidney diseas, or DM: less than 140/90
80
Joint national Committe 8 reccomendations for treating hypertension - initial treatment choice
1. black --> thiazide diruetic or CCB alone or in combination (ACEi is not 1st line)
2. other ethnicities --> thiazide, ACEi, CCB alone or in combination
3. all ethnicities with chronic kidney disease: ACEi alone or in combination with other drugs
81
evaluation of hyperthyroidism - algorithm
measure TSH, fT3, fT4
if 2ry (all high) --> pituitary MRI)
if 1ry (Low TSH, the other high):
sings of graves: if yes it is graves --> if not do Radio
RADIO: HIGH: diffuse (graves) v Nodular patttern)
LOW --> measure thyroglobulin (if low is exogenous, if high is thyroditis or IODIDE EXPOSURE)
82
The strongest indication for DM screening
HTN
83
DM - metformin is not enough , what to do
Sulfonyl or DPP-IV inhibitors
84
Anoher side effect of sulfonylureas
SIADH
85
DM - erectile dysfunction
- no routine screening except to ask
| - sildanefil
86
initial treatment for DM2 - effective
lifestyle modification --> effective to 25%
87
short vs rapid acting insuling on onset
rapid: 5-15
| short 30-60
88
NPH vs glargine on onset
NPH: 2-4
glargie: 1-2
89
Dermatopathy of graves
thickening and redness below the knee
90
Graves - Onycholysis
in 10% of cases
91
Klinefelter's sundrome - treatment
testosterone
92
Testicular feminization
XY that looks, feels and acts like woman (No test receptors -> no penis, prostate, scrotum)
93
calcitonin vs biphosphonate regarding immediate action
if u need something fast, pick calcitonin
94
type of cortisone in addison
- acute: hydrocortisone (both gluco and mineralocorticoid effects)
- stable: prednisone
- if prednisone not enough --> fludrocortisone
95
water deprivation test - explain
no water for 2-3 hours --> measure urine volume and osm every h, , and serum sodium and osm every 2
- is urine osm more than 600?
yes --> 1y polydipsia
No --> urine osm stable on 2-3 h --+ plasma osm more than 295 or Na more than 145)?
a. yes: desmopressin, monitor urine osm + volume every 30 mins for 2 hours (CDI if urine osm increases, NDI if no increase)
b. no: continue until above endpoints reached
