UW Endo Flashcards
(196 cards)
1
Q
What is the next best step after serum calcium levels are found to be low in a pt. ?
A
-Confirm with a repeat test, and *correct/adjust if serum albumin is low, OR measure ionized calcium.
*Sr. Ca2+ decreases by 0.8 mg/dL for ever 1gm/L drop in sr. albumin levels; hence,
corrected calcium= measured total calcium + [0.8 x (4 g/dL -measured sr. albumin in g/dL)].
2
Q
What is the next best approach after low serum calcium levels are confirmed by repeat testing as well as corrected for low serum albumin?
A
-Check Sr. Mg2+ (n: 1.5-2 mg/dL): replace if low
-Evaluate medication history (?loop diuretics)
-Check for h/o recent blood transfusion? (high citrate, volume).
*Check PTH levels if all of the above are normal.
3
Q
Normal serum Ca2+ level is ____,
Normal sr. phosphorus (i) level is ______.
Normal sr. Mg2+ level is ______.
Normal serum albumin level is ______.
A
Normal range of
-sr. Mg2+ : 1.5-2 mg/dL
-sr. phosphorus (i): 3.0-4.5 mg/dL.
-sr. Ca2+ : 8.4-10.2 mg/dL.
Serum albumin: 3.5-5.5 g/dL.
4
Q
How does HypoMg2+ (commonly seen in alcoholics) drive hypoCa2+?
A
By
-inducing resistance to PTH, as well as
-decreasing the secretion of PTH.
*normally/abnormally HypoPTH is a/w elevated phosphorus levels; however, in hypoMg2+ induced hypoPTH, sr. phosphate levels are normal or low possibly d/t IC phosphorus depletion. .
5
Q
What is the cause of HypoMg2+ in alcoholics?
A
multifactorial etiology
-urinary loss of Mg2+
-malnutrition
-acute pancreatitis
-diarrhea
6
Q
PTH levels return to normal rapidly after Mg2+ is replaced in pts. with hypoMg+ induced hypocalcemia but ____ takes longer to improve because _____ takes time to normalize.
A
hypocalcemia may persist because PTH resistance induced by hypoMg2+ takes longer to normalize.
7
Q
Hypocalcemia d/t extracellular deposition of Ca2+ may occur in _____ conditions.
A
hyperphosphatemia,
osteoblastic bone metastasis,
acute pancreatitis.
8
Q
In addition to hypoMg2+ and consequent hypocalcemia, ____ e- disturbance may also coexist in alcoholics.
A
hypophosphatemia.
9
Q
The best initial t/t for acromegaly d/t a somatotroph adenoma is _____.
A
trans-sphenoidal resection of the tumor.
10
Q
Medical therapy with ______ or ______ is instituted in which cases of acromegaly?
A
somatostatin analogues (Octeotride), or
GHRB (Pegvisomant);
indicated in pts. with residual or unresectable tumors.
11
Q
What is the next best test in pts. suspected of GH hyper-secretion with equivocal IGF-1 results (best initial test)?
A
Oral Glucose suppression test.
*load of glucose must suppress GH levels; in hyper-secreting tumors, no suppression will occur.
12
Q
Circulating levels of PTH and calcium are _____ (? elevated, low, normal) in osteoporosis.
A
normal
13
Q
PTH-dependent hypercalcemia (a/w increased or high-normal PTH) is seen in _____ conditions.
A
-primary hyperPTH: PTH gland adenoma (~80%), hyperplasia (~15%), parathyroid cancer.
-FHH
-Lithium
14
Q
PTH-independent hypercalcemia (low PTH) is seen in _____ conditions.
A
-Elevated PTHrP (malignancy)
-Vit D toxicity (measure 25-H Vit D)
-Vit A toxicity
-drug-induced (thiazides)
-granulomatous d (*Sarcoidosis)
-milk-alkali syndrome
-Thyrotoxicosis
-Immobilization.
*measure 1, 25-DH Vit. D (extra-renal conversion of 25-H vit D to 1, 25-DH vit. D).
15
Q
Cirrhosis leads to hypogonadism by which mechanisms?
A
-primary gonadal injury
-hypothalamic-pituitary dysfunction
-High estrogen state c/by increased conversion from androgens.
16
Q
Cirrhosis is a high ____ state d/t increased conversion from androgens, leading to s/s such as telangiectasias, palmar erythema, testicular atrophy and bilateral/unilateral gynecomastia (men).
A
estrogen state (estradiol)
17
Q
In cirrhosis, total T4 and total T3 levels are _____ (? low, high) d/t ________, and free T3, T4 and TSH levels are ____ (? low, high, normal).
A
total T3 & T4 level is low d/t decreased hepatic synthesis of THBP (TH binding proteins such as TBG, transthyretin, albumin, lipoproteins).
free T3 , free T4 and TSH levels are normal indicating a euthyroid state.
18
Q
True/False? All pts. with adrenal insufficiency p/w features of hypogonadism.
A
False;
only women with AI p/w hypogonadism (loss of libido, decreased pubic hair) d/t decreased adrenal production of androgens.
Men with AI do not p/w hypogonadism in AI because androgens are primarily produced in testes in men.
*Men p/w s/s of hypogonadism (testicular atrophy) plus gynecomastia in high estrogen states such as hepatic cirrhosis.
19
Q
The first best step in evaluation of a thyroid nodule is ____.
A
serum TSH and thyroid USG.
20
Q
_____ sonographic features in a thyroid nodule carry a much higher risk of malignancy as compared to features such as _____.
A
solid (hypoechoic), micro-calcifications, irregular margins, internal vascularity in a thyroid nodule carry a much higher risk of malignancy as compared to cystic or spongiform features in a nodule.
21
Q
Thyroid nodules of ____ size with high-risk features, and all non-cystic nodules of _____ size must undergo FNAC examination.
A
> 1cm with high risk features (micro-calcifications, irregular margins, internal vascularity +/- normal/high TSH), and
> 2cm all non-cystic nodules +/- normal/high TSH.
*normal/high TSH may suggest a hypo-functioning (COLD) nodule.
22
Q
A pt. with a thyroid nodule and low TSH (hyperthyroid) must undergo ____, for evaluation of a potential malignancy.
A
radionuclide thyroid scan (e.g. Radioactive iodine scintigraphy).
Nodule with increased iodine uptake–> HOT nodule (low r/o malignancy).
Nodule with decreased iodine uptake–> COLD nodule (high r/o malignancy).
23
Q
____ is a useful tumor marker in suspected medullary thyroid cancers, and ______ is post-thyroidectomy tumor marker for papillary and follicular thyroid cancers.
A
Calcitonin for suspected medullary Thyroid ca;
serum thyroglobulin for post-surgical follow-up for papillary and follicular thyroid ca.
24
Q
In hypercalcemia d/t malignancy, serum calcium levels are very high, usually more than ____ mg/dL.
A
usually > 14 mg/dL.
*normal sr. Ca2+ level is 8.4 - 10.2 mg/dL (narrow range and rigid control in plasma).
25
In hypothyroidism, increased total cholesterol and LDL levels are due to ______, and increased triglyceride levels are due to ________.
increased total cholesterol and LDL levels d/t
-decreased expression and activity of LDL receptor
Increased triglyceride levels are d/t
-decreased activity of LPL
26
Pts. with newly diagnosed hypercholesterolemia must undergo ___ tested to screen for underlying ____.
serum TSH to screen for underlying hypothyroidism.
27
If not tested prior, serum ___ must be tested before initiation of statin therapy because underlying untreated ____ will increase the r/o statin-associated myopathy.
serum TSH; underlying hypothyroidism.
*Statins also increase hypothyroidism associated myopathy.
28
exogenous androgen use is a/w dyslipidemias such as increase in ____ and ____ , decreased ____ but normal ___.
increase in TC and LDL , and decreased HDL, but normal triglycerides (TGs).
29
Hypothyroidism increases the r/o coronary atherosclerosis by causing ___.
dyslipidemia.
30
Euthyroid sick syndrome (ESS) aka _____ or _____, is characterized by _____ in setting of _____.
ESS is aka Non-thyroidal illness syndrome (NTI) or Low T3 syndrome.
-characterized by alterations in TFTs in setting of a non-thyroidal illness and no prior h/o endocrine/thyroid illness.
Most prominent alterations include
-low T3
-T4 & TSH may initially be normal but as illness increases in severity, all decrease.
Increase in rT3 (non-functional)
See attached Image for details.
Image courtesy: Medscape
31
Thyroid function tests must be interpreted with caution in acutely ill patients d/t ____.
the possibility of ESS in acutely ill pts.
Thyroid function must be reassessed after recovery from the acute illness, and t/t initiated only of thyroid abnormality persists.
32
In an acutely ill pt. what are the possible factors responsible for decrease in peripheral deiodination of T4 ?
-high endogenous cortisol levels
-inflammatory cytokines (TNF)
-starvation (to decrease T3 mediated catabolism?)
-medications such as glucocorticoids, amiodarone.
33
Hospitalized/ICU pts. may have low total T4 levels (but normal free T4) d/t ______.
decrease in levels of hormone/other binding proteins such as TBG, transthyretin, albumin.
34
Thyroid hormones undergo enterohepatic circulation and are reabsorbed in _____; hence, excessive fecal loss of thyroid hormones can occur in _____.
reabsorbed in ileum and jejunum;
hence, excessive fecal loss of thyroid hormones can occur in small intestine diseases such as Crohn disease and celiac disease.
35
Carcinoids are slow growing neuroendocrine tumors most commonly originating in _____.
distal small intestine, proximal colon, and lungs;
*metastasis to liver most commonly occurs from from GI carcinoid.
36
Deficiency of vitamin ____ can occur in carcinoid syndrome, as tumor cells use ____ to synthesize _____ .
Vit. B3 (Niacin); as carcinoid tumor cells use *tryptophan to synthesize serotonin; tryptophan is normally used in synthesis of Vit B3.
B3 deficiency aka PELLAGRA is manifested by 3 D's:
diarrhea (also occurs independently in carcinoid syn.), dermatitis, and dementia.
37
What are some common skin manifestations in carcinoid syndrome?
Flushing (d/t vasoactive peptides),
telangiectasias,
cyanosis (bronchospasm induced).
38
What is the most common secondary cause of hyper-prolactinemia?
pregnancy.
39
A pt. p/w h/o a painful/pruritic papules on extremities, groin and/or face that coalesce to form plaques with scaling and central clearing along with h/o diarrhea, weight loss, abdominal pain and hyperglycemia/diabetes. What is the most likely disorder?
Glucagonoma, a pancreatic NE tumor that causes excessive production of catalytic hormone glucagon.
40
____ skin manifestation is the presenting feature in about 70% cases of Glucagonoma.
Necrolytic migratory erythema (NME) (see Image) is characterized by initial painful/pruritic ring-shaped red rash that blisters, erodes and crusts leaving a brown mark.
-may affect any site but most often affects the genital and anal region, the buttocks, groin and lower legs.
-The rash fluctuates in severity.
Image: DermNet NZ @Dermnetnz.org
41
Serum glucagon levels are markedly elevated in glucagonoma to about _____, as compared to other conditions that raise glucagon such as hypoglycemia, Cushing syndrome, and pancreatitis where mild elevations in glucagon levels are noted.
>500 pg/dL
42
Milk-alkali syndrome is characterized by ____, ____ and ___.
hypercalcemia, renal insufficiency, and metabolic alkalosis.
43
What is the percentage of occurrence of each of the 3 Ps in autosomal dominant MEN1 syndrome?
Pituitary adenomas: in 10-20% cases
Parathyroid (Primary HyperPTH): > 90% cases
Pancreatic/GIT NE tumors: in 60-70% cases
44
Rapid onset hirsutism (< 1 yr duration) in a female accompanied by s/o virilization (temporal balding, excessive muscular development, and/or enlargement of clitoris) is suggestive of very high androgen levels (> 3 x normal), most likely d/t _______ .
androgen secreting tumor of the ovaries or adrenals.
45
List the androgens produced by the ovaries.
testosterone,
androstenedione,
dehydro-epi-andro-sterone (DHEA).
46
List the androgens produced by the adrenals.
testosterone,
androstenedione,
dehydroepiandrosterone (DHEA), and
dehydroepiandrosterone sulfate (DHEAS).
47
Elevated testosterone levels with normal DHEAS levels in a women under evaluation for hirsutism and virilization suggests ___ source of hyper-androgenism.
ovarian source
*Ovarian > > adrenal, hyperandrosteronism.
48
Elevated testosterone and DHEAS levels in a women under evaluation for hirsutism and virilization suggests ___ source of hyper-androgenism.
adrenal source of hyperandrogenism.
49
What are the common causes of hyperandrogenism and their differentiating features?
1. PCOS (↑ LH---> ↑ testosterone ---> ↑ estrogen)
2. Non-classic CAH (↑ 17-hydroxyprogesterone level)
3. Ovarian/adrenal tumors: old age, rapidly progressing; ↑↑↑ androgen levels.
4. Hyper-PRL: amenorrhea, galactorrhea; ↑ PRL
5. Cushing syndrome: non-suppressible dexa suppression test; ↑ 24 hr. ur free cortisol levels
6. Acromegaly: ↑ IGF-1
50
What is the difference between classic and non-classic CAH, d/t 21-alpha hydroxylase (21 OHD) deficiency?
Classic CAH: d/t 98-100% 21 OHD deficiency
-At Birth, p/w ambiguous genitalia in female infants
-precocious puberty in male children.
Non-classic CAH: d/t PARTIAL 21OHD deficiency.
-p/w slowly progressing hyperandrogenism starting in adolescence-early adulthood.
For diagnosis, check 17-hydroxyprogesterone (17OHP) or ACTH stimulation test. See Image: myendoconsult.com.
51
Which anti-diabetic agents have a cardioprotective and weight loss profile?
GLP-1 Receptor Agonists (Exenatide, Liraglutide), and
SGLT-2 inhibitors (Canagliflozin, Empagliflozin).
MN: The GLP tides!
MN: SGLT gliflozins!
52
Which anti-diabetic agents have a low risk of hypoglycemia?
GLP-1 Receptor Agonists (Exenatide, Liraglutide), and
SGLT-2 inhibitors (Canagliflozin, Empagliflozin).
53
What is the MOA of GLP-1 Receptor agonists (exenatide, liraglutide)?
-Suppress Glucagon, and
-increase glucose dependent insulin release from the pancreas (hence, low r/o hypoglycemia).
-suppress appetite by delaying gastric emptying, and thus promote weight loss.
54
What is the MOA of SGLT-2 inhibitors (Canagliflozin, Empagliflozin)?
-Inhibit SGLT2 pump in renal PCTs--> Increasing glucose and Na+ excretion --> weight loss and mild diuresis.
*reduce HF-associated mortality, and
*reduce progression of diabetic nephropathy.
55
What is the MOA of dipeptidyl-peptidase 4 (DPP-4) inhibitors "gliptins"?
Inhibit DPP-4 --> inhibit GLP-1 degradation thus acting like GLP-1 receptor agonists but do not provide weight loss or cardio-protective benefits.
56
Which anti-diabetic agents are a/w weight gain and high risk of hypoglycemia?
Insulin,
sulfonylureas, and
Thiazolidinediones ("-glitazones").
57
High estrogens levels increase TBG levels by _____ and _____.
by inhibiting TBG catabolism, and increasing TBG synthesis in the liver.
THINK: estrogens favor pregnancy, and pregnancy demands increase in THs; so estrogens facilitate increase in TBG so that more THs are available, raising total T4 (but free T4 and TSH remain normal).
58
Increased TBG levels are seen in which conditions/states?
-high estrogen states: pregnancy, OCPs, HRT,
-Estrogenic medications: tamoxifen
-Liver: Acute hepatitis, cirrhosis
-Hypothyroidism
59
Decreased TBG levels are seen in which conditions/states?
-High androgenic states: androgenic hormones
-Glucocorticoids/hypercortisolism
-Hypoproteinemia: nephrotic syndrome, starvation
-LIVER: chronic liver disease.
60
Displacement of thyroid hormones from binding proteins will initially _____ (? increase, decrease) free T4 levels, which will lead to decreased TH production d/t ____, ultimately leading to ____ total T4.
Displacement of thyroid hormones from binding proteins will initially increase free T4 levels, which will lead to decreased TH production d/t negative feedback to the hypothalamus/ant. pituitary ultimately leading to low total T4 (and normal free T3/T3 levels).
61
Which medications can displace T4 from its binding proteins in plasma?
salicylates,
Loop diuretic: furosemide,
heparin.
62
Preservation of morning erections in a man with decreased libido and failure to maintain erections during sexual intercourse most likely suggests _____ cause of erectile dysfunction.
psychogenic cause of ED.
63
A pt. with normal BMI p/w diabetes, joint pains, hypogonadism, and hepatomegaly, most likely has _____.
Hereditary hemochromatosis (HH)
64
How is hypogonadism induced in hereditary hemochromatosis?
d/t iron deposition in pituitary -->decrease in gonadotropins--> testicular atrophy and ↓ testosterone.
65
A 59 yr old female pt. on t/t for osteoporosis p/w AKI, hypercalcemia and metabolic alkalosis. What is the most likely disorder?
Milk-alkali syndrome;
d/t ingestion of calcium carbonate antacids to relieve heartburn caused by Alendronate t/t for osteoporosis.
66
What is the mechanism of AKI in milk-alkali syndrome?
Hypercalcemia leads to
-renal vasoconstriction--> ↓ GFR
-Ca2+-R activation in thick Al-LOH--> ↓ Na-K-2Cl cotransporter--> loss of Na+ & free water.
-Impaired activity of ADH--> loss of Na+ & free water.
All of the above--> hypovolemia--> AKI, and
--> increased reabsorption of HCO3 --> met. alkalosis.
67
What are some risk factors a/w development of milk-alkali syndrome?
-pre-existing CKD and concurrent use of thiazides, ACEIs, NSAIDS.
68
What are some additional lab findings in milk-alkali syndrome?
-suppressed PTH (d/t hypercalcemia)
-HypoPO4 (d/t intestinal binding by CaCO3)
-HypoMg2+ (d/t decreased renal reabsorption).
69
Difficulty combing hair or seating in and out of chair are signs of _______.
proximal muscle weakness.
70
Proximal muscle weakness can be seen in which conditions/disease states?
-Drugs: Glucocorticoid use
-Autoimmune diseases: Polymyositis/Dermatomyositis
-Endocrine: Hypo-/Hyperthyroidism, Cushing disease
-Neuromuscular: Myasthenia gravis, Lambert-eaton syndrome.
71
DTR are usually _____ (? increased, decreased, normal) in hyperthyroidism.
Increased (hyperreflexia) or frequently normal.
72
Peripheral motor neuropathy typically p/w _______ (? proximal, distal) muscle weakness and _____ (? increased, decreased, normal) DTRs with associated sensory symptoms.
distal muscle weakness and decreased DTR's.
73
Hypoglycemia associated autonomic failure can be described as_____.
Reduced awareness of hypoglycemia and thus progressively worsening episodes of hypoglycemia d/t blunting of autonomic response in diabetics caused by recurrent and/or severe hypoglycemia.
74
In pts. with hypoglycemia associated autonomic failure, hypoglycemia awareness can be restored by _______.
by STRICTLY avoiding hypoglycemia.
75
In diabetics, intensive glycemic control to a target HbA1c of less than _____, and BP less than ______ mmHg is associated with reduced progression to DKD.
HbA1c < 7%, and BP < 130/80 mmHg
76
Which clinical tests are used for screening/evaluation for diabetic kidney disease (DKD)?
-Serum creatinine: s/o advanced DKD.
-*Urine spot albumin: creatinine ratio (uACR), or
24-hr urine protein.
-Urinalysis/microscopy: to rule out other causes.
*See image
** 24 hr. urine protein of 30-300 mg indicates albuminuria; 24 hr. urine protein of > 300 mg indicates severely increased albuminuria
77
Which drugs are a/w reduced progression to DKD?
-ACEIs/ARB's (for strict BP control in diabetics).
-SGLT2 Inhibitors (most effective at GFR ≥ 30 mL/min/1.73 m2)
*SGLT2 inhibitors include "flozin's" such as Dapagliflozin, Empagliflozin etc.
78
Normal serum osmolality is _____, and normal urine osmolality is ______.
normal serum osmolality: 275-290 mOsm/kg of H2O.
urine osmolality: 50-1200 mOsm/kg of H2O.
*Ur. osmolality < 300 mOsm/kg of H2O is considered low.
79
Urine specific gravity of ____ is considered low.
< 1.006.
80
How can high serum osmolality d/t hyperglycemia in diabetes mellitus be differentiated from high serum osmolality in Diabetes Insipidus (ADH deficiency or peripheral resistance to ADH)?
High serum osmolality in DM is a/w high urinary osmolality (> 600 mOsm/kg H2O) and high urinary specific gravity d/t osmotic diuresis (presence of glucose/solutes with water in urine).
Whereas, high serum osmolality in Diabetes Insipidus is a/w low urine osmolality and low ur. specific gravity because of excess free water in the urine.
81
List some events that can trigger a thyroid storm in pts. with undiagnosed or inadequately t/t hyperthyroidism?
Events such as
-Trauma
-Surgery
-acute infection
-Iodine contrast (CT contrast)
-childbirth.
82
Thyroid storm can lead to which life threatening conditions in patients?
Hemodynamic instability (hypotension, shock), cardiac arrhythmias, congestive heart failure, seizures, cardiopulmonary arrest leading to death.
83
What is the C/P of a pt. experiencing thyroid storm?
-High fever, tachycardia, HTN, nausea, vomiting, diarrhea, agitation/delirium
+ any of the following progressive states
-Congestive HF, arrhythmias (AF, VT/VF, any),
-delirium, seizure --> coma
-Goiter, lid lag, tremor
-Jaundice
-cardiopulmonary arrest
84
_____, and ____ are the recommended add-on t/t agents in diabetic pts. with poor glycemic control who also have established ASCVD.
-SGLT2 inhibitors, and
-GLP1 Analogues (Semaglutide, Liraglutide).
*SGLT2 inhibitors are also renoprotective.
85
What are the primary causes (testicular) of hypogonadism in men?
Congenital: Klinefelter syndrome, cryptorchidism.
Drugs: alkylating agents, ketoconazole
Infection/injury: orchitis (mumps), trauma, torsion
CKD
86
What are the secondary causes (pituitary/hypothalamic) of hypogonadism?
Gonadotroph DAMAGE d/t
-tumor
-trauma
-infiltrative disease: hemochromatosis
-apoplexy
Gonadotroph SUPPRESSION d/t
-exogenous androgens
-Hyperprolactinemia (Hyper-PRL)
-Diabetes Mellitis
-morbid obesity (high estrogen state)
87
Combined primary and secondary hypogonadism results from _____.
-Hypercortisolism
-Excessive alcohol: ↓ LH release by Pituitary, and directly ↓↓ testosterone production in testes.
-Cirrhosis
88
Hypopituitarism with mild-moderate increase in PRL levels suggests _______ adenoma.
non-functioning/*minimal functioning gonadotroph adenoma
*most gonadotrophic tumors involve hypersecretion of
hypo-functional α-subunit of the LH/FSH dimer which produce no or minimal symptoms of hypergonadism; instead c/p d/t mass effects such as headache, blurred vision and suppression of other pituitary hormones such as low TSH/T4 and **mild-mod ↑ in PRL (d/t mechanical compression of the hypothalamic dopaminergic pathways) is more common when the tumor enlarges in size.
** serum PRL levels are very high (↑↑↑) such as > 200 ng/mL in PRL secreting adenomas (Prolactinomas).
89
Levels of ____ adrenal hormone are normal in central adrenal insufficiency due to hypopituiatrism.
Aldosterone
*Aldosterone levels are affected either in primary adrenal insufficiency, or under RAAS pathway.
Central adrenal insufficiency is caused d/t low ACTH (hypo/non-functional pituitary)
90
Hypercarotenemia marked by ______ is usually a/w ______ d/t excessive consumption of low-calories carotene rich foods (carrots, squash etc) and decreased hepatic clearance.
yellowing of the skin of palms;
usually a/w anorexia nervosa (AN).
91
Medical complications of anorexia nervosa include?
-Dry skin --> scratching and excoriations
-Amenorrhea/infertility (HPO disruption)
-Lanugo
-Gastroparesis
-↑↑ sr cholesterol d/t accelerated choles. metabolism
-Hypotension, Bradycardia, arrhythmias
-cardiac atrophy
-Seizures
-Edema (d/t e- and fluid disturbances)
-Decreased bone mineral density: d/t endocrine disruption, hypercortisolism, and GH resistance.
92
in HHS/DKA, total body potassium deficit is due to ______ and ______. However, sr. K+ levels may result normal/ slightly elevated d/t ______.
Total body K+ deficit is d/t
-glucose-induced osmotic diuresis --> ur. K+ loss, and
-sec. hyperaldosteronism d/t volume contracted state.
But sr. K+ levels may result normal/slightly elevated d/t
-Hyperosmolality that draws fluid & K+ into ECS, and
-Insulin deficiency which reduces cellular uptake of K+.
*Replace K+ if sr. K+ levels are < 5.3 mEq/L while m/m HHS/DKA, and
withhold insulin if sr. K+ < 3 mEq/L; correct K+ first, then start insulin (because Insulin will quickly drive K+ into the cells rapidly inducing hypokalemia).
93
Any pt. who has received glucocorticoid t/t for more than _____ (? weeks, months) is at r/o developing secondary AI upon discontinuation of exogenous steroids.
≥ 3 weeks;
HPA axis takes about 6-12 months to meet up the physiological demands after discontinuation of exogenous steroids; hence, glucocorticoids must be gradually tapered.
94
Peripheral eosinophilia may be seen in states of low cortisol d/t _____.
reduced migration of eosinophils from bloodstream into tissues.
95
Failure to increase levothyroxine dose during pregnancy in an hypothyroid pregnant women can lead to adverse maternal and fetal outcomes such as ?
gestational HTN
pre-eclampsia
premature delivery
PPH
96
Dose of thyroid replacement t/t must be increased by approx. ___ percent when pregnancy is detected.
30%
*followed by TSH based adjustment in 4 weeks increments using pregnancy specific norms. Total T4 must also be followed and maintained.
97
Most common complication of thyroidectomy is _____ d/t ____.
hypocalcemia d/t loss of parathyroid gland during thyroidectomy.
98
Pts. with hypocalcemia p/w?
Initially asymptomatic or non-specific s/s as
-fatigue
-anxiety
-depression
severe hypocalcemia
-tetany involving lips, face and extremities
-seizures
-QT interval prolongation
99
What is the difference between constitutional growth delay and Familial short stature?
See Image
100
How can short stature d/t GH deficiency be differentiated from other causes of growth delays/deficits such as constitutional delay, and familial short stature?
In GH deficiency, linear growth velocity is slowed typically presenting as declining height percentiles, crossing 2 major percentiles (50th and 25th).
In constitutional delay, and familial short stature the linear growth velocity stays stable even though the height is below the percentile for their age.
101
Degenerative arthritis involving the 2nd and 3rd MCP joint is seen in _____.
hereditary hemochromatosis.
*Other Xray findings:
-periarticular osteophytes
-narrowed joint spaces.
-chondrocalcinosis.
102
Bone and soft tissue enlargement in distal extremities manifesting as clubbing, arthropathy, periostosis of long bones (wrists), and joint effusions are characteristic findings in _____ seen in pts. with _____.
hypertrophic osteoarthropathy (paraneoplastic syndrome) seen in pts. with underlying malignancy most commonly a pulmonary adenocarcinoma.
103
Hyperplasia of articular chondrocytes, and synovial hypertrophy leading to widening of joint space ultimately leading to cartilage degeneration (similar to that in osteoarthritis) is seen in _____.
Acromegaly.
104
Pts. with Sheehan syndrome (pituitary infarction caused by PPH) can manifest with s/s caused by _____.
loss of multiples pituitary hormones such as
-inability to lactate (loss of PRL secretion)
-dry/cool skin and fatigue (loss of TSH)
-decreased body hair (loss of LH and FSH)
-hypocortisolism i.e. sec. AI (loss of ACTH)
105
What are the clinical s/s of hypocortisolism?
GI: abd. pain, nausea, anorexia
CVS:
-loss of vascular tone --> orthostatic hypotension.
-adrenal crisis (vascular collapse): during physiological stress (infections, trauma etc.).
-Hyponatremia d/t loss of cortisol mediated inhibition of ADH.
106
Cortisol has a _________ (?stimulatory, inhibitory) effect on ADH.
inhibitory effect on ADH.
Therefore, ADH effects are enhanced in cortisol deficiency states such as in adrenal insufficiency.
107
Primary AI can be differentiated from secondary AI by measuring ______, and ____ levels.
ACTH and Sr. K+ levels.
Primary AI (e.g Addisons disease):
-High ACTH (normal HPA feedback)
-hyperpigmentation (↑↑ ACTH--> ↑↑ MSH)
-↓ sr. Na+ (d/t low Aldosterone--> salt loss)
-↓↓ BP (d/t low Aldosterone--> H2O & salt loss)
-↑↑ sr. K+ (d/t low Aldosterone)
Secondary AI (pituitary/hypothalamic AI)
-Low ACTH levels --> AI but Aldosterone normal
-normal/mild↓ in BP
-no hyperpigmentation
-No hyperkalemia as aldosterone is normal.
-No hyponatremia as aldosterone is normal.
108
____ is the only t/t modality considered in thyrotoxic/hyperthyroid pregnant women and very elderly pts. with limited life expectancy.
Anti-thyroid drugs (ATDs)
109
Potassium iodide (KI) _____ (? inhibits, stimulates) thyroid hormone synthesis and release.
inhibits
*used in preparation for thyroidectomy in grave's disease, and in t/t of thyroid storm.
110
Systemic glucocorticoids may be used to manage which hyperthyroid states?
-thyroid storm,
-amiodarone-induced thyrotoxicosis,
-severe cases of subacute thyroiditis.
111
Thyroidectomy is preferred over RAI in which patients with Graves disease?
In pts. with
-a large goiter or co-existing thyroid nodule
-Severe graves ophthalmopathy (RAI is CI)
112
What are some late GI manifestations of celiac disease?
-Ulcerative jejunitis
-enteropathy associated T-cell lymphoma
113
What major nutritional deficiencies are common in celiac disease?
Iron deficiency--> microcytic anemia
Fat-soluble vitamins (A, E, D, K) deficiencies
* Vit D deficiency--> ↑↑ PTH --> ↑/normal sr. Ca2+ but ↓↓↓ sr. PO4 levels
*Increased PTH restores sr. Ca2+ to normal/mildly low, but decreases serum phosphate levels to VERY LOW, also d/t additional effect of GI malabsorption.
114
Normally, in hypocalcemia induced hyperparathyroidism, serum phosphate levels are low because of PTH induced increased renal clearance of phosphate. In which disease state, serum phosphate levels will be high in presence of hypocalcemia induced hyperparathyroidism?
CKD;
*kidneys are unable to execute renal clearance of phosphate under orders of PTH.
Thus, CKD manifests as
-hypocalcemia d/t renal Vit D deficiency
-sec. hyperPTH d/t calcium malabsorption.
-Hyperphosphatemia (d/t poor renal clearance)
115
What are some inciting factors for hyperosmolar hyperglycemic state (HHS)?
-acute illness, trauma, infection
-Insulin non-adherence
-Medications: Glucocorticoids, diuretics, atypical antipsychotics (e.g. Olanzapine).
116
Bisphosphonates reduce the risk of _____ and ____ fractures d/t osteoporosis.
vertebral and hip fractures.
117
Anti-resorptive therapy is warranted in pts. with DEXA T-score of ______ indicating presence of osteoporosis.
T-score ≤ -2.5
*Anti-resorptive therapy also considered in pts. with T-score between -1 to -2.5
118
After initiation of anti-resorptive therapy with first-line bisphosphonates, bone density must be re-measured after ____ years to assess pts. response to t/t.
2 (to 5) years.
*shorter time re-evaluation may be undertaken in pts. at risk of accelerated bone loss such as d/t glucocorticoid therapy for another disease state.
119
Bisphosphonates are recommended to be used only for ___ years due to ____.
5 years d/t the risk of atypical fractures after prolonged use.
120
RAI can worsen Graves ophthalmopathy d/t _____.
Increase in titers of TSI following RAI ablation of the gland.
*even though increase is TSI is transient, it is enough to worsen the ophthalmopathy.
121
The resolution of hyperthyroidism occurs in about ____ weeks following RAI.
6-18 weeks ---> permanent hypothyroidism in > 90% pts.
122
The target HbA1c goal in healthy and or younger diabetics is _____.
≤ 7%.
123
The target HbA1c goal in older diabetics with comorbidities or limited life expectancy is _____.
≤ 8%.
124
Of the systemic oral corticosteroids, ___ has only glucocorticoid (GC) activity, ____ has only mineralocorticoid (MC) activity, and ____ has both GC and MC activity (slight).
Dexamethasone: only GC activity.
Fludrocortisone: only MC activity, and
Hydrocortisone: both GC & MC (mild) activity
*Remember: D-F-H (in alphabetical order) are
Gc-Mc-Gc/Mc (1-1-2 in numerical & alphabetical order)
125
_____ is the most feared adverse effect of oral antithyroid drugs (ATDs) which usually presents within ____ days of t/t initiation with s/s such as _______.
Agranulocytosis (d/t immune destruction);
p/within 90 days of t/t initiation, with
fever and sore throat.
126
True/False? ATD dose must be immediately reduced if a pt. on the same reports fever and sore throat.
False;
ATD must be immediately STOPPED and NEVER RESTARTED if the WBC count is less than 1000 cells/cubic mm.
If WBC count is > 1500 cells/cubic mm, then ATD is less likely to be responsible for fever and sore throat.
127
In addition to immediately stopping the ATD, what additional t/t must be instituted in a pt. with ATD induced agranulocytosis?
Throat culture
+ oral penicillin/ IV Antibiotics (bs for pseudomonas coverage)
+ Acetaminophen
+/- G-CSF
128
Small fiber neuropathy in diabetes predominantly causes ___ in diabetics.
pain, allodynia, and parasthesias.
129
large fiber neuropathy in diabetes predominantly causes ___ in diabetics.
numbness, loss of vibration and proprioception and loss of ankle reflexes.
130
True/False? both small and large fibers involvement is seen in diabetic sensorimotor neuropathy.
true
131
Initial t/t for painful diabetic neuropathy includes drugs such as ?
-TCAs (amitriptyline),
-SNRI (Duloxetine)
-Pregabalin, Gabapentin: GABA analogs/anticonvulsant
132
Amitriptyline should be used with caution in pts. over ___ yrs. of age d/t its ____ properties.
> 65 yrs. of age d/t its anti-cholinergic effects.
133
Amitriptyline is not recommended in pts. with pre-existing cardiac disease d/t the risk of ____.
precipitating conduction abnormalities.
134
Moderately increased albuminuria is urinary protein loss of _____ per 24 hrs.
30-300 mg/24 hrs;
*previously known as "microalbuminuria"
135
Severely increased albuminuria is urinary protein loss of _____ per 24 hrs.
> 300 mg/24 hrs
136
SGLT2 inhibitors are most effective at slowing the progression of DKD in pts. with ____.
GFR ≥ 30 ml/min/1.73 m square.
137
Testicular hypogonadism (1°) can be differentiated from pituitary/hypothalamic hypogonadism (2°) by which lab tests?
sr. LH, FSH levels, and LH/FSH ratio
LH/FSH ratio is ↑ in Testicular hypogonadism, whereas
LH/FSH ratio is ↓/normal in pituitary hypogonadism.
138
_____ is the most common cause of primary adrenal insufficiency (AI).
Autoimmune adrenalitis.
139
What is the pathophysiological mechanism behind autoimmune adrenalitis?
both humoral and cell-mediated destruction of the adrenal cortex.
140
Hyperpigmentation in setting of s/s of severe mineralocorticoid deficiency (mod-severe hypotension, hyponatremia and hyperkalemia) suggest _____.
primary AI.
141
C/P of glucocorticoid deficiency, plus hypogonadism and hypothyroidism suggests ____.
Panhypopituitarism characterized by
-↓ ACTH --> ↓ sr. cortisol (*central AI)
-↓ LH, FSH -->↓testosterone -->↓libido, testicular atrophy.
-↓ TSH --> ↓ T3, T4 (hypothyroidism)
*mild ↓ BP in central AI d/t ↓ PVR and mild hyponatremia d/t ADH release but NO SEVERE ↓↓↓ BP as aldosterone secretion is unaffected.
142
Thyroid hormone production increases during pregnancy under the effects of ____ and ____.
Estrogen (↑ TBG and ↓ TBG clearance)--> ↑ Total T4, and
β-hCG (directly stimulates TSH R's)--> ↑ TH synthesis.
143
How is β-hCG able to directly stimulate TSH R's, and thus increase thyroid hormone synthesis during pregnancy?
β-hCG shares a common alpha-subunit and a very similar beta-subunit with TSH. Hence, it is able to directly stimulate TSH receptors.
144
____ and ____ are catecholamine-producing tumors arising from chromaffin cells of the adrenal medulla or extra-adrenal paraganglia, respectively.
pheochromocytoma and paraganglionomas
145
Almost all pts. experiencing thyroid storm have ____ in addition to other classic acute s/s of thyrotoxic state such as severe regular/irregular tachycardia, high BP, sweating etc.
pyrexia
146
Serotonin syndrome seen with initiation or titration of SSRIs is characterized by ____, ___ and ____.
altered mental status, autonomic hyperactivity, and muscle rigidity with hyperreflexia.
147
An infant or a newborn p/w new-onset seizures. What should be the diagnostic approach?
Check for
1. Infectious: fever, fontanelles, CBC
2. Structural: Brain imaging
3. Metabolic:
-hypoglycemia
-hyponatremia
-inborn errors of metabolism: sr. amino acid analysis
148
Post-thyroidectomy adjuvant therapy for cases with high chance of *recurrence incudes t/t such as?
-RAI ablation of residual thyroid tissue, or
-TSH suppressive doses of thyroid hormones.
*increased risk of tumor recurrence is seen in large tumor, extra-thyroidal invasion, LN metastasis, incomplete resection.
149
In PTHrP induced hypercalcemia of malignancy, PTH levels will be ____ but 1, 25-dihydroxyvitamin D levels (1,25(OH)2D) will be _____ because _____.
PTH levels will be low (suppressed) but 1,25(OH)2D levels will be normal/low-normal because PTHrP does not facilitate conversion of 25(OH)D to 1,25(OH)2D like PTH.
150
Plasma calcium exists in which three forms?
-Ionized calcium ~ 45%
-Albumin bound calcium ~ 40%
-Calcium bound to organic/inorganic anions ~ 15%
151
Which form of plasma calcium is physiologically active?
Ionized calcium (~ 45%)
152
How does plasma pH affect calcium homestasis?
In acidosis (low pH d/t ↑↑↑ H+ OR ↓↓↓ HCO3-, in ECS), MORE H+ are bound to albumin--> more Ca2+ in its active unionized form--> hypercalcemic state.
In alkalosis (high pH d/t ↓↓↓ H+ OR ↑↑↑ HCO3), LESS H+ are bound to albumin--> more Ca2+ can bind to albumin--> ↓ active unionized form--> hypocalcemic state (eg. can be seen in a severely tachypneic pt. who develops respiratory alkalosis freeing H+ binding sites on albumin which causes ionized ca2+ to quickly bind with albumin--> hypocalcemia.
SEE IMAGE for clarification: Reference: UWorld
153
How are three main types of thyroiditis vis. chronic autoimmune (Hashimoto's) thyroiditis, painless/silent thyroiditis and subacute (de Quervain) thyroiditis differentiated from each other clinically?
1. GOITER
-Diffuse in chronic AI (Hashimoto) thyroiditis,
-Small, non-tender in painless/silent thyroiditis,
-painful/tender in subacute (de Quervain) thyroiditis.
2. Clinical presentation
-hypothyroidism in Hashimoto thyroiditis.
-mild/brief hyperthyroid ph.--> recovery in painless/silent thyroiditis.
-post-viral; fever, ↑ ESR, ↑ CRP, hyperTH in subacute (de Quervain) thyroiditis (--> hypoTH--> Euthyroid)
3. RAI uptake
-variable in chronic AI (Hashimoto) thyroiditis,
-LOW in painless/silent thyroiditis,
-LOW in subacute (de Quervain) thyroiditis.
154
Subacute (de Quervain) thyroiditis can be managed with ?
-Beta-blockers for s/s of hyperTH
+ NSAIDS (pain relief)/Glucocorticoids (severe pain unresponsive to NSAIDS)
155
Patients are usually in ___ (? hypo, hyper, eu) thyroid state in suppurative thyroiditis.
euthyroid state with ↑↑↑ fever and severe localized pain
156
PCOS and Cushing syndrome share a number of features such as obesity, irregular menses, and hyperandrogenism. How can the two conditions be differentiated on clinical exam?
skin atrophy, muscle weakness, and easy bruisability are characteristic features of Cushing syndrome and not usually seen in isolated PCOS.
157
At least ____ hours of fasting is required to deplete hepatic glycogen stores.
24-48 hours.
158
Pts. with pancreatogenic diabetes on exogenous insulin t/t are at increased r/o hypoglycemia due to ____.
concomitant loss of glucagon secreting alpha-cells in pancreas (loss of counter-regulatory hypoglycemia response hormone).
159
Post-partum thyroiditis is a TPO ___ (? positive, negative) and TRAb _____(? positive, negative) auto-immune disorder characterized by lymphocytic infiltration and destruction of follicles with onset within ____ ? months/weeks after parturition.
TPO positive (marker for autoimmune thyroid disease), and
TRAb negative (Thyrotropin receptor Ab; marker for Graves disease);
onset within 12 months following parturition.
160
Levothyroxine can be given to which pts. in hypothyroid phase of post-partum thyroiditis?
Pts. who fulfill any of the following criteria:
-breastfeeding
-are symptomatic for hypothyroidism
-High TSH > 6 months.
161
Describe the clinical progress in postpartum thyroiditis.
Clinical phases in postpartum thyroiditis
hyperTH (months)--> hypoTH (wks-months)--> euthyroid state
162
Hyperthyroidism with suppressed TSH d/t painless thyroiditis or graves disease can be differentiated based on _____, which reveals _____.
RAIU study results in
-Painless thyroiditis: diffusely decreased RAIU indicating hyperTH d/t release of preformed THs caused by autoimmune destruction of follicles.
-Graves disease: diffusely increased RAIU indicating highly active gland secreting lot of THs.
163
How can the different types of diabetes insipidus be differentiated based on serum Na+ levels?
Serum Na+ levels are
-Very High; > 150mEq/L in central DI: d/t associated impaired thirst mechanism.
-slightly high/normal in nephrogenic DI as thirst mechanism is intact causing the pt. to drink adequate water to compensate for excessive urinary loss.
-Low in primary (psychogenic) polydipsia: d/t excessive water intake (Psychiatric pts., CNS disorders)
164
Hypernatremia (sr. Na+ > 145 mEq/L) with polyuria excludes the diagnosis of ____ and favors ____ as cause of polyuria with polydipsia.
excludes primary (psychogenic) polydipsia, and favors DI.
165
Transient Hyperglycemia without pre-existing DM (normal HbA1c) in setting of a high risk factor such as major trauma/hemorrhage, burns, fever, serious infection, sepsis, ICU admission and hypoxia is most likely ______.
Stress hyperglycemia.
166
What are the principles of m/m of stress hyperglycemia?
-Correct severe blood glucose elevations (> 180-200 mg/dL) with short-acting insulin.
-Maintain blood glucose levels between 140-180 mg/dL with short acting insulin to avoid insulin induced hypoglycemia.
-Mild elevations do not require t/t.
167
Clinical and lab evidence of hyperthyroidism with low RAIU may be seen with _____ and ____.
-autoimmune thyroiditis, and
-exogenous TH intake (certain weight loss supplements).
168
How can thyroiditis be differentiated from exogenous TH intake, both of which p/w hyperthyroidism with low RAIU?
Check serum thyroglobulin levels which are
-increased with increased endogenous TH release.
-decreased with exogenous TH intake (Factitious hyperthyroidism).
169
Bisphosphonates are not recommended in pts. with ____.
renal impairment
170
Long term use of bisphosphonates is a/w ____.
atypical fractures.
*avoid t/t for > 5 years;
-assess bone density every 2 yrs (earlier in pts. on glucocorticoids) while pt. is on bisphosphonate t/t.
171
Precocious puberty is development of secondary sexual characteristics (pubic/axillary hair, cystic acne, accelerated growth) in girls < ___ age, and boy < ___ age.
in girls < 8 yrs age, and boy < 9 yrs. of age.
172
True precocious puberty is marked by ____.
advanced bone age
(> 2 SD above the chronological age).
173
Premature thelarche (isolated breast development) or premature adrenarche (isolated pubic hair development) are marked by _____.
normal age appropriate bone-age.
174
In pts. with advanced bone age, ______ levels can help differentiate between central and peripheral precocious puberty.
LH levels;
-High LH levels in central precocious puberty (hypothalamic/pituitary cause)
-Low/normal LH levels in peripheral precocious puberty: d/t feedback inhibition by high circulating androgens secreted by gonads or adrenals. Seen in non-classic CAH (classic CAH will be diagnosed at birth d/t significant mineralocorticoid and glucocorticoid deficiencies).
175
Central aka gonadotropin dependent precocious puberty is seen in which conditions?
-premature activation of HP-gonadal axis (Idiopathic precocious puberty)
-Pituitary micro-adenomas
176
Severe rapid onset symptomatic hypercalcemia is characteristic of ___.
Humoral hypercalcemia of malignancy (HHM)
*severe (sr. Ca2+ > 14 mg/dL)
177
Humoral hypercalcemia of malignancy (HHM) is most commonly induced by ______, and less commonly by _____ and _______.
most commonly by PTHrP:
-SCC (lung),
-renal/bladder,
-breast/ovarian
less commonly by
-bone metastasis (↑osteolysis): breast ca, *MM
-1, 25 DH Vit D (↑ ca2+ absorption): Lymphoma
*Multiple myeloma
178
Induction of CYP24A1 (aka 24 hydroxylase) expression by medications such as _____ can lead to deficiency of Vit. D d/t excessive catabolism to inactive forms.
carbamazepine and other anti-convulsants (phenytoin).
*CYP24A1 catabolizes both 25 (OH) D and 1, 25 (OH)2 D forms of Vit. D.
179
Supplemental estrogen therapy such as OCPs or HRT can increase levels of Vit. D d/t ____.
increased synthesis of Vit. D binding protein (DBP); in DBP-bound form, Vit. D is resistant to degradation.
180
Signs of androgen excess in a pt. with PCOS are manifested by what s/s?
-acne (nodulo-cystic, acne on back),
-male pattern baldness, and
-hirsutism
in an obese female with menstrual irregularities.
181
Menstrual irregularities in an obese female with PCOS is a sign of ____.
oligo-ovulation or anovulation.
182
BRCA mutation testing is indicated in which patients?
in pts. with any of the following
-F/H/O ovarian cancer at any age.
-H/O breast ca in 1st-deg relative at age ≤ 50 yrs
-personal H/O breast ca at age ≤ 50 yrs
183
Describe the clinical spectrum of hypothyroid myopathy.
Myopathy can occur in over 1/3rd pts. with hypothyroidism, and can range from
-asymptomatic elevation in CK to
-myalgias,
muscle hypertrophy,
proximal muscle weakness, and
Rhabdomyolysis.
184
In pts. with chronic DM, intensive glycemic control with insulin reduces the risk of ______ complications, but has no/UNCERTAIN effect on risk of ______ complications.
Intensive glycemic control (HbA1c 6-7%) with insulin
-reduces the risk of microvascular complications such as retinopathy and nephropathy, but
-has UNCERTAIN effect on risk of macro-vascular complications (stroke/ MI) and overall mortality.
185
Very rigid glycemic control (HbA1c ≤ 6.5%) is a/w ____ (? increased, decreased) risk of hypoglycemia and CVS mortality.
increased risk
186
The recommended HbA1c target for non-elderly diabetic pts. is ____, and for elderly it is ____.
HbA1c target for
-non-elderly diabetic pts. is 7%
-elderly diabetic pt. is 8%.
187
What are some important risk factors for male breast cancer?
-family h/o breast ca.
-BRCA1, BRCA2 mutation.
-Abnormal estrogen/androgen ratio: klinefelter, obesity, cirrhosis
188
What is the most common breast ca type in males?
HR +ve invasive ductal carcinoma
189
Which medications can cause secondary hypogonadism in males?
-Opioids
-glucocorticoids
-exogenous androgens (withdrawal phase)
190
Early morning cortisol test has low utility in evaluation of ____ d/t significant overlap in cortisol levels with normal subjects. Rather, early morning cortisol test is preferred in initial assessment for _____.
Early morning cortisol test has low utility in evaluation of *hypercortisolism.
Early morning cortisol test is preferred in initial assessment for primary AI (low/low-normal).
*Initial tests for choice for hypercortisolism include (2 must be positive to diagnose):
-late night salivary cortisol assay
-24-hr urine free cortisol measurement
+/- overnight low-dose DMST
191
___ test is done after hypercortisolism is confirmed with late night salivary cortisol assay, 24-hr urine free cortisol measurement, and/or overnight low-dose DMST.
ACTH level measurement;
*to differentiate between ACTH-dependent and ACTH-independent hypercortisolism.
192
Diabetic neuropathic ulcers most commonly occur in the feet ______ (?location).
under bony prominences such as under metatarsal heads.
193
Neurologic symptoms ranging from confusion to coma are seen in Hyperglycemic hyperosmolar state (HHS) primarily d/t _____ with levels more than ______.
d/t high plasma osmolality with level > 320 mOsm/kg.
Plasma Osm=
(2 x Na+)+ (Glucose/18)+(BUN/2.8)+(ethanol/4.6)
194
In HHS, the effective serum sodium must be corrected for hyperglycemia with the formula __.
Corrected sr. Na+=
measured sr. Na+ (+) 2mEq/L Na+ for every 100mg/dL glucose > 100mg/dL.
195
In descending order of frequency, describe the involvement of especially axial skeleton in Paget's disease.
Single bone or multifocal involvement
-Spine
-pelvis,
-femur,
-sacrum, and
-skull
*but any other bone may also be affected.
196
What is the cause of high output cardiac failure in Paget disease?
Due to increased vascularity in pts. with extensive bony involvement.
