Week 2

Question 1

Cushing’s Disease. What is it?

Answer 1

overproduction of cortisol, pituary caused symptoms.

Question 2

Cushing’s disease causes

Answer 2

long term use of glucocorticoid medications, steroids at high doses, Endogenous causes (excess adrenocorticotropic hormoneACTH from pituitary tumors or adrenal gland hyperproduction)

Question 3

Cushing’s disease patho

Answer 3

hypothalamus regulates ACTH, which in turn regulates the production of glucocorticoids (cortisol).
cortisol responds to physical and psychological stressors.

Question 4

clinical presentation of cushing’s disease

Answer 4

almost almost manifests with chronic changes ie rapid weight gain, loss of menses, decreased libido, weakness, bruising.
may have: HTN, glucose intolerance, insomnia.
memory disturbances, depression.

Question 5

pediatric presentation for cushings

Answer 5

Most common causes are weight gain and depressed linear growth (height)

Question 6

physical exam for cushings

Answer 6

pt will have central obesity, moon face, buffalo hump, htn, muscle weakness/wasting, hirsutism, red/purple abdominal straiae, acne, depression

Question 7

diagnostics of cushings

Answer 7

24 hour urine (for urine cortisol level >100mcg would indicate cushings),
serum cortisol at midnight ( if level is above 7.5, it indicates cushing’s),
creatinine,
ACTH suppression test (endocrine specialist does)

Question 8

management of cushings

Answer 8

consult with endocrine specialist.
depends on the source of hypercortisolism. the goal is to mitigate impact of cortisol
daily ketoconazole administration.
bone density measurement if on longterm corticosteroids due to risk for osteoporosis.
alternative therapies: to improve energy and increase physiological health: use licorice(suppressess fight of flight), st johns wort, ginseng, fish oils,sea salt

if there is a pituitary tumor- resection of tumor, chemo, radiation

Question 9

complications of cushing’s disease

Answer 9

carefully monitor complications of longterm steroid use, osteoporosis is a common complication, along with infection, htn, diabetes.

Question 10

referral/hospitalizations of cushing’s

Answer 10

if pt is in hypertensive crisis
surgical intervention of pheochromocytoma

consult to endocrine if diagnostic test suspects addison’s or cushing’s disease

Question 11

pt education and health promotion of cushing’s

Answer 11

educate about complications chronic steroid use, doubling hydrocortisone dose is required with fever and common illnesses, alert medical personal if there is surgery, trauma, infection. Wear medical alert bracelet and have emergency med kit for extraparenteral steroids

Question 12

type 2 diabetes diagnosis

Answer 12

fasting blood glucose > 126 on two separate occasions. do note need a1C to diagnose, however you can get it to establish baseline

Question 13

DM diagnostic criteria

Answer 13

1. random plasma glucose >200 and symptoms of diabetes (polyuria, polydipsia, DKA, unexplained weight loss)
   OR
2. hgba1c >6.5
   OR
3. fasting plasma glucose >126
4. results of 2 hour 75 gram OGTT >200 @ 2 hrs

should be repeated on different day unless undeniably high

Question 14

glycemic control algorithm

Answer 14

individualized goals of a1c < 6.5% for those without serious illness and at low hypoglycemic risk OR

hgb a1c >6.5% with concurrent serous illness and at risk for hypoglycemia

lifestyle therapy for all.

Question 15

glycemic control therapy plan for hgb <7.5

Answer 15

Monotherapy.
metformin,
GLP1 (-tides, oxepmic, trilicity, vietna)

SGLT2: -flozin
Empagliflozin (jardiance), canagliflozin (invokana),
Dapagliflozin (faxiga).

DPP4: sitagliptin
TZD,
AGI,
Sulfoneureas,

If they dont reach goal in 3 months, go to dual therapy

Question 16

glycemic control therapy plan for hgb > or equal to 7

Answer 16

dual therapy
metformin +basal insulin

if you dont reach goal in three months, go to triple therapy

Question 17

glycemic control therapy plan for hgb >9

Answer 17

do they have symptoms? no: dual therapy or triple therapy.
if they have symptoms: insulin +- other agents

if you don’t reach in 3 months, go to insulin

Question 18

initiation of basal insulin

Answer 18

stop sulfonyureas before starting insulin.
start insulin at dose of 0.1-0.2 units per kg for hgb a1c < 8
0.2-0.3 units per kg for hgb a1c > 8

increase by 2 units or 10 % every 2-3 days until glucose goal met
report all BG < 70

Question 19

screening for renal nephropathy in type 2 diabetes

Answer 19

most appropriate time is at diagnosis.
done by random urine collection

normal urine albumin to creatinine ratio is <30mg/g

Question 20

hirsutism

Answer 20

can be a result of cortisol excess
if cushing is suspected, perform salivary cortisol level and 24 hr urine for free cortisol or low dose overnight dexamethasone suppression test.
also perform fasting insulin, OGTT, and lipid profile

Question 21

thyroid hormone excess

Answer 21

check TSH

Question 22

causes of hirsutism

Answer 22

PCOS, adrenal hyperplasia, ovarian tumors, cushing syndrome, acromegaly,

Question 23

hyperparathyroidism. What is it?

Answer 23

Oversecretion of PTH

Calcium absorption helps body decrease phosphorus levels

Question 24

Causes of hyperparathyroidism

Answer 24

can be genetic endocrine disorders, familial hypocalciuric hypercalcemia, lithium related, radiation induced, carcinoma, thiazide related.

Question 25

primary hyperparathyroidism PHPT

Answer 25

is caused by parathyroid adenoma

Question 26

secondary hyperparathyroidism

Answer 26

is caused by renal failure (GFR < 50) or vitamin D deficiency (vit d level falls below 20). In RF, decreased calcium causes PTH production. Vitamin d deficiency causes decrease in calcium absorption.

Question 27

tertiary hyperparathyroidism

Answer 27

prolonged secondary stage. hypercalcemia is a result

Question 28

treatment for PHPT

Answer 28

close monitoring of calcium, creatinine, vitamin D, bisphosphonates, hormone replacement with estrogen, raloxifene (in patients with osteoporosis), cinicalet (cinimimetic agent that normalizes PTH and calcium ). ADEQUATE CALCIUM AND FLUID INTAKE.

Question 29

treatment for secondary HPT

Answer 29

kidney transplantation, calcitriol, vitamin D, can also have parathyroidectomy

Question 30

complications of HPT

Answer 30

``` Osteoporosis Nephrolithiasis Mortality Bone abnormalities Vascular complications Coronary valve disorders ```

Question 31

diagnostic test for hyperparathyroidism

Answer 31

Intact PTH (Stop biotin 7 days before testing) Serum calcium Albumin Vitamin d hydroxy phosphorus Bone mineral density assessment- of distal radius 24 hr urine ECG - hypercalcemia can cause shortened QT interval Renal ultrasound to rule out stones Magnesium level- for hypothyroidism only

Question 32

screening for diabetes

Answer 32

The A1c, FPG, or the 2-hour 75-gram anhydrous OGTT are all equally appropriate diabetes screening tests by the ADA, according to the revised Standards of Care (no one test is preferred.) The ADA notes that the A1c may have some advantages over the other tests (eg, convenience and less day-to-day variation, etc), but these must be balanced by the costs and availability of A1c testing and by the lower sensitivity of this test.

Question 33

testing for prediabetes in asymptomatic adults

Answer 33

Current recommendations are to test all adults beginning at age 45 years, regardless of their weight. Testing is also recommended for adults of any age who are overweight (BMI greater than or equal to 25 kg/m2 [and greater than or equal to 23 kg/m2 in Asian-Americans*]) and have additional risk factors2: Members of a high-risk ethnic population (eg, African America, Hispanic/Latino, American Indian, Alaska Native, Asian American, and Pacific Islander), First-degree relative with diabetes, History of gestational diabetes or giving birth to a baby weighing > 9 lbs, Physical inactivity, Hypertension (BP ≥ 140/90 mm Hg) or on therapy for hypertension, HDL cholesterol < 35 mg/dL (0.90 mmol/L), Fasting triglycerides (TG) > 250 mg/dL (2.82 mmol/L), Women with polycystic ovarian syndrome (PCOS) Previously noted A1c greater than or equal to 5.7%, impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) on previous testing Other clinical conditions associated with insulin resistance (e.g., acanthosis nigricans, non-alcoholic steatohepatitis, polycystic ovary syndrome [PCOS], and small-for-gestational age birth weight1) History of cardiovascular disease (CVD) Treatment with atypical antipsychotics or glucocorticoids Without the above criteria, testing for prediabetes and diabetes should begin at age 45 years. If results are normal, the ADA notes that it is “reasonable” to test again at 3-year intervals, and consider more frequent testing depending on initial results and risk status.

Question 34

reommended critria for testing for prediabetes or diabetes in asymptomatic children per ADA

Answer 34

The 2020 ADA guidelines recommend screening for type 2 diabetes or prediabetes in children and adolescents who meet the following criteria: Overweight (BMI greater than the 85th percentile for age and sex, weight for height greater than 85th percentile, or weight greater than 120% of ideal for height) AND who meet one or more of the following criteria Maternal history of gestational diabetes mellitus (GDM) during the patient’s gestation. Family history of type 2 diabetes in first- or second-degree relatives High-risk race/ethnicity (same groups as for the adults, e.g., Native American, African America, Latino, American, Asian American, and Pacific Islander) Signs of insulin resistance or conditions associated with insulin resistance (eg, acanthosis nigricans, hypertension, dyslipidemia, PCOS, or small-for-gestational-age birth weight)

Question 35

classifications of diabetes

Answer 35

1. Type 1 diabetes (Note: The correct nomenclature is “type 1” not “type I” diabetes) Immune-mediated diabetes with evidence of autoimmune β-cell destruction, typically leading to absolute insulin deficiency. N.B: There is some controversy over whether or not latent autoimmune diabetes of adults (LADA) warrants its own designation; in the current ADA, this condition is considered a slow-onset type 1 diabetes mellitus.7 Idiopathic type 1 diabetes – unclear etiology; these individuals are insulinopenic and prone to DKA, but lack evidence of β-cell autoimmunity. 2. Type 2 diabetes (Note: The correct nomenclature is “type 2” not “type II” diabetes) Typically a multifactorial process, including relative insulin insufficiency (the pancreas does release enough insulin), insulin resistance, and often unregulated gluconeogenesis in the liver (producing glucose in the face of hyperglycemia) 3. Gestational diabetes mellitus (GDM) Diabetes diagnosed during the second or third trimester of pregnancy that was not clearly present prior to gestation 4. Other specific types of diabetes Monogenic diabetes syndromes (e.g., neonatal diabetes and maturity-onset diabetes of the young [MODY]) Diseases of the exocrine pancreas (e.g., cystic fibrosis) Pancreatic insufficiency secondary to chronic/recurrent pancreatitis Drug/chemical induced (e.g., as occurs in patients treated with glucocorticoids and those treated for HIV/AIDS or after organ transplantation)

Question 36

Autoimmune disease to screen for when a pt diagnosed with typde 1 diabetes

Answer 36

The ADA recommends that physicians consider screening for thyroid disease and celiac disease soon after the type 1 diabetes diagnosis. Specific autoimmune diseases that have been reported in patients with type 1 diabetes include: Hashimoto thyroiditis, Graves disease, Addison disease, autoimmune hepatitis, dermatomyositis, myasthenia gravis, vitiligo, and pernicious anemia.

Question 37

ABCs for diabetes preventative care

Answer 37

A- a1c, aspirin or antioplatelet agents a1c: Every 6 months in patients who are meeting treatment goals of stable glycemic control Every 3 months in patients who are not at goal or whose therapies are changing B- blood pressure, goal of < 140/90 C- cholesterol at diagnosis and q 5 years in pts < 40 s- screening for neuropathy, retinopathy and nephropathy, immunizations, tobacco cessation

Question 38

children with type 1 diabetes screening:

Answer 38

celiac and hypothyroid disorders

Question 39

diabetes meds weight neutral/weight loss

Answer 39

Biguanides – metformin (Glucophage and others) Glucagon-like peptide-1 (GLP-1) receptor agonists – albiglutide (Tanzeum), dulaglutide (Trulicity), exenatide (Byetta, Bydureon), liraglutide (Victoza), lixisenatide (Lyxumia ), and semaglutide (Ozempic) Amylin agonist - pramlintide (Symlin) Dipeptidyl peptidase-4 (DPP-4) inhibitors – alogliptin (Nesina), linagliptin (Tradjenta), sitagliptin (Januvia), and saxagliptin (Onglyza) Sodium/glucose cotransporter 2 (SGLT2) inhibitors (aka gliflozins) – canagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance), and ertugliflozin (Steglatro) Pramlintide (Symlin)

Question 40

contraindication to metformin therapy

Answer 40

lactic acidosis,decompensated CHF, GFR < 30, liver failure patients, surgery, constrast dye (restart in 48 hours after dye).

Question 41

Are there any drug classes for the treatment of type 2 diabetes mellitus that have been shown to reduce cardiovascular disease?

Answer 41

SGLT2 (Empagliflozin, Canagliflozin and Dapagliflozin), cardioprotective GLP 1 Liraglutide

Question 42

Based on the AACE/ACE Algorithm, are there any recommendations of how to start insulin?

Answer 42

Yes. The AACE/ACE algorithm (updated yearly) recommends starting with a basal insulin. For persons whose A1c is less than 8%, the total daily dose (TDD) recommended is 0.1 to 0.2 U/kg. For persons whose A1c is greater than 8%, the recommended TDD is 0.2 to 0.3 U/kg. It is recommended that any sulfonylurea therapy be stopped or reduced when a basal insulin is started. Please keep in mind that treatment regimens should be individualized to each particular patient.

Question 43

Metformin :is it weight neutral or weight loss?

Answer 43

Metformin is a biguanide and is associated with weight loss.

Question 44

What types of insulin are available and what are the differences in onset, peak, and duration?

Answer 44

Rapid Acting: Onset 5 to 15 minutes, Peak 30 to 90 minutes, Duration 4 to 6 hours: Lispro (Humalog) Aspart (Novolog, Fiasp) Glulisine (Apidra) Short Acting: Onset 30 to 60 minutes, Peak 2 to 3 hours, Duration 8 to 10 hours: Regular insulin (Humulin R, Novolin R). Intermediate Acting: Onset 2 to 4 hours, Peak 4 to 10 hours, Duration 12 to 18 hours: Isophane insulin (neutral protamine Hagedorn [NPH], Humulin N, Novolin N). Long Acting: Glargine (Lantus, Basaglar, Toujeo) -- Onset 2 to 4 hours, no peak, Duration 20 to 24 hours Detemir (Levemir) -- Onset 2 to 4 hours, Peak 3 to 9 hours, Duration 6 to 24 hours Degludec (Tresiba) – Onset 1 hour, Peak 9 hours, Duration greater than 42 hours. Premixed: Onset 30 to 60 minutes, Dual Peak, Duration 10 to 16 hours 70% NPH / 30% regular insulin (Humulin 70/30)

Question 45

What are the screening recommendations for prevention of micro- and macrovascular complications of T1DM?

Answer 45

NEPHROPATHY: Annual screening for albuminuria with a random spot urine sample for albumin/creatinine ratio after child is 10 years old or older and has had diabetes for at least 5 years. Normal spot albumin/creatinine ratio is less than or equal to 30 mg/dg. RETINOPATHY: Annual comprehensive and dilated eye exam after age 10 and when child has had T1DM for at least 3 to 5 years. NEUROPATHY: Annual compressive foot exam starting at age 10 or after puberty has started (whichever is earlier) after diabetes duration of 5 years. HYPERTENSION: Cuff blood pressure at time of diagnosis and every office visit thereafter. Elevated blood pressure should be confirmed on 3 separate days. DYSLIPIDEMIA: Fasting lipid panel starting at age 10. If low-density lipoprotein (LDL) cholesterol is less than 100 mg/dL, then repeat every 3 to 5 years. If abnormal, monitor yearly. Initial therapy should consist of optimizing glucose control and medical nutrition therapy using a Step 2 American Heart Association (AHA) diet. Statin therapy is recommended after making lifestyle changes if LDL cholesterol is greater than 160 mg/dL, or greater than 130 mg/dL with 1 or more cardiovascular risk factors. Remember that statins are contraindicated in pregnancy, so consider birth control in adolescents who require statin therapy. THYROID DISEASE CELIAC DISEASE

Question 46

For a child diagnosed with type 1 diabetes mellitus (T1DM) at age 7, when should screening for diabetic retinopathy begin?

Answer 46

10 years

Question 47

Thyroid function is regulated by

Answer 47

TSH in the anterior pituitary gland. responds to TRH that is secreted by hypothalamus (negative feedback)

Question 48

diagnosing thyroid disease

Answer 48

TSH, iodine uptake exam, ultrasound/fine needle aspiration, Fluorine 18 fluourodeoxyglucose PET.

Question 49

Hypothyroidism

Answer 49

TSH > 4

Question 50

hyperthyroidism

Answer 50

TSH < 0.3 | Perform T3 if abnormal

Question 51

how to diagnose hashimoto's (hypo) or graves (hyper)

Answer 51

Autoantibodies, thyroid globulin, thyroid peroxidase TPO

Question 52

clinical presentation of Graves can have:

Answer 52

toxic nodules, or thyroiditis (hyperthyroidism)

Question 53

Fluorine 18 fluourodeoxyglucose PET scan

Answer 53

for metastatic thyroid lesions

Question 54

hyperthyroidism. what is it

Answer 54

excess production of thyroid

Question 55

hyperthyroidism diagnosis

Answer 55

THS <0.3. TSH, TRAb level in graves (antibody), liver function tests, alkaline phosphatase, total bilirubins, radioidoine uptake (to distinguish between graves and thyroiditis), ESR( will be elevated in subacute thyroiditis), free t4,

Question 56

hyperthyroidism clinical presentation

Answer 56

dry eyes, goiter (graves), tachycardia, HTN, hyperdefecation, weight loss, anorexia, amenorrhea, infertility, heat intolerance, anxiety, irritability, sleeplessness.

Question 57

pharmacologic management of hyperthyroidism

Answer 57

thioamides. in graves, treat with Beta blockers to relieve symptoms of tachycardia, tremor (avoid in pregnancy)

Question 58

Thioamide therapy in pregnancy

Answer 58

In pregnancy, start with PTU, only in first trimester. Methimazole for second trimester.

Question 59

nonpharmacologic therapy for hyperthyroidism

Answer 59

thyroidectomy. can also be done for pregnant women

Question 60

causes of secondary HTN

Answer 60

hyperthyroidism, pheochromocytoma, neuroblastoma & cushings syndrome

Question 61

when the serum free t4 concentration falls, what happens with TSH

Answer 61

it rises

Question 62

When does someone with hypothyroidism require immediate ED referral

Answer 62

``` myxedema coma (resp depression, hypotermia) requires pressors (levo), warming, vent support, glucocorticoid therapy ```

Question 63

Amiodarone

Answer 63

concentrates in thyroid. before starting patients on amiodarone, check thyroid function

Question 64

what do you hold before TFT levels

Answer 64

biotin for 3 days

Question 65

hypothyroidism. what is it

Answer 65

TSH >4

Question 66

causes of hypothyroidism

Answer 66

lithium, iodine, amiodarone, interpheron alpha, contrast, tyrosine kinase inhibitors

Question 67

clinical manifestiations of hypothyroidism

Answer 67

increased sensitivity to cold, fatigue, heavy irregular menses, dry skin, dry hair,depression, parasthesias, constipation, goiter, slow deep tendon reflexes(most prominent in achilles), weight gain, impaired energy, bradycardia, dim bowel sounds, increased diastolic BP, hypercholesterolemia, macrocytic anemia

Question 68

in subclinical hypothyroidism, what would TSH and t4 look like

Answer 68

elevated TSH, normal free t4.

Question 69

diagnostics for hypothyroidism

Answer 69

TSH, free t4, Anti TPO antibody (elevated in thyroiditis)

Question 70

management of hypothyroidism

Answer 70

levothyroxine daily referral to endo if nodule requiring biopsy monitor at 4-6 weeks once medications start daily dosing is monitored once per year

Question 71

hashimoto's thyroiditis is characterized by

Answer 71

rubbery, firm, symmetric goiter (when the antibodies are elevated). anti TPO will be elevated

Question 72

Thyroid nodule/ cancer diagnosis

Answer 72

TSH,t3 and t4 if TSH is suppressed, ultrasound, radionuclide scan, fine needle aspiration, molecular markers,

Question 73

if a nodule is benign, when do you follow up?

Answer 73

a follow up ultrasound should be performed in 6-12 months

Question 74

american thyroid association recommends WHAT in thyroid cancer?

Answer 74

recommends against doing radioactive iodine ablation in patients with low grade thyroid cancer.

Question 75

precautions for post radioiodine therapy

Answer 75

No kissing, exchanging saliva, dishes should be washed in dishwasher, no close contact with infants, avoid pregnant women for 5 days,No breast feeding, flush toilets twice, take acetaminophen or aspirin for pain, notify MD if nervous, tremulous, or palpitations.

Question 76

complications of surgery in thyroid cancer include

Answer 76

hypoparathyroidism and hoarseness

Question 77

what diabetes medication can cause parasthesias

Answer 77

metformin

Question 78

what causes increase in blood sugar for patients on insulin?

Answer 78

stress, illness, surgery

Question 79

what medication will not slow the progression of diabetic nephropathy

Answer 79

use of calcium channel blockers

Question 80

beta blocker is contraindicated for which patient

Answer 80

asthmatic patient