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170 Cards in this Set
- Front
- Back
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DM LDL goal?
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LDL < 100
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Aspirin guidelines in DM?
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>40 or other cardio risk factors
low dose aspirin |
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What should be done to distinguish Somogyi vs Dawn phenonomenon?
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check 3AM glucose
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What causes the Dawn phenomenon?
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Increased GH overnight
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How long should one excersize weekly if DM?
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150 min
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Contraindications to metformin use?
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creatinine >1.6
risk of metabolic acidosis advanced heart failure (acidosis poses larger risk) |
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Considerations in administering IV contrast to diabetic?
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consider nephropathy
Discontinue metformin, give large bolus of IV fluid, start up metformin in 48 hours |
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Routine testing for patients on thiazolidinediones?
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routine LFTs
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Contraindictions of thiazolidinediones?
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advanced heart failure
liver dysfunction |
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Morning glucose goal if on insulin therapy?
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<100
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How is insulin initially started if alongside metformin/sulfonylurea?
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NPH or glargine single dose
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Major side effect of exenitide?
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Nausea in 40% - precludes continuation
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By what route, how often is exenitide taken?
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IV twice a day
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In a basal bolus regimen what percentage of insulin is in basal dose? What percentage in bolus?
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40-50% basal
50-60% meal bolus |
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Post prandial glucose goal if on insulin therapy?
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90-130
excursions limitned to 30-50 above premeal values |
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Insulin adjustment for excersize?
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decrease 1-2 units per 20-30 minutes of activity
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Major symptoms in honk
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dehydration related symptoms - hypotension, tachycardia
Hyperosmolarity - seizures, lethargy, convulsions, coma |
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Initial treatment of HONK in terms of fluids, insulin, glucose?
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NS (1 L in first hour, 2nd in next two)
Switch to half normal once stabilized IV insulin (5-10 U bolus, 2-4 U per hour) 5% glucose when glucose hits 250 |
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Sodium correction by glucose in HONK?
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1.6 for every 100 of glucose above 100
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Why is glucose given in HONK treatment?
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Rapid lowering leads to cerebral edema
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Dx of HONK?
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Hyperglycemia (glucose >600)
Hyperosmolarity (>320) No acidosis (pH > 7.3, HCO3>15) |
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How often should diabetics be screened for retinopathy?
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Screen T1DM annually after 5 years from dx
Do not screen prepubescent Screen T2DM annually |
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What sort of retinopathy is most common in diabetes?
Findings on fundoscopic exam? Mechanism of visual loss |
Background
Proliferative is less common hemorrhages, exudates, microaneurysms, venous dilatation edema of macula - HTN, fluid retention exacerbate |
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Complications of proliferative retinopathy?
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vitreal hemorrhage
retinal detachement |
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Which cranial nerve is most commonly involved in DM?
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CNIII
Watch out for CN IV, VI involvment |
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Sign of DM related CN III palsy?
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CN III loss without pupillary involvement.
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Which peripheral neuropathies are most common in DM and features?
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Ulnar, peroneal
Lumbosacral plexopathy - severe thigh pain, atrophy in thigh, hip; weeks to months to heal Truncal neuropathy - pain in intercostal nerve distribution |
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Insulin regimens for T1DM?
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evening glargine, lispro or aspart before meals
NPH twice daily, lispro or aspart before breakfast, dinner Pump |
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Screening for DM?
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HbA1c every 3-6 months
Annual fasting lipid panel Annual microalbuminuria Foot exam at every visit Annual dilated fundoscopic exam Annual BUN, creatinine |
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Sick day management of DM?
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increase frequency of blood glucose monitoring
measure urinary or fingerstick ketones continue insulin, maintain fluids |
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Dx of DKA?
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Hyperglycemia (>250)
arterial pH <7.3 ketoacidosis (serum ketones, bicarb <15) |
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When should glucose be administered and how much in DKA?
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5-10% after glucose <250
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Initial bolus of insulin, infusion of insulin in DKA?
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.1 U/kg infusion of regular
.1 U/kg bolus of regular |
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At what glucose level do symptoms of hypoglycemia emerge?
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40-50
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What is Whipple's triad?
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true hypoglycemia
symptoms when fasting levels <50 when symptomatic response to glucose |
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Dx of insulinoma?
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72 hour fast
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Treatment of hypoglycemia?
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Food PO if possible.
If not D50W, later D10W once glucse >100 |
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Consideration in treatment of hypoglycemia in alcoholic?
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Administer thiamine
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What test is abnormal in insulinoma and surreptitious insuliln use but normal in sulfonylurea use?
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proinsulin is elevated in insulinoma, decreased in surreptitious insulin use
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Dx of Zoliinger Ellison?
Gastrin levels? |
Secretin injection test
Gastrin increases in ZE but decreases if normal Basal output is <10 mEq/hr, in ZE its >15 |
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Treatment of ZE?
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High dose PPIs
Exploratory surgery for all Resect if resectable Debulking, chemo otherwise |
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What does necrotizing migratory erythema below the waist indicate?
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Glucagonoma
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Features of glucagonoma?
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Glossitis
Stomatitis DM Hypergycemia with low AA levels |
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Signs of somatostatinoma?
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Triad of gallstones, DM, steatorrhea
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Signs of VIPoma?
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diarrhea - dehydration, hypokalemia, acidosis
achlorhydria hyperglycemia hypercalcemia |
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When should lipid screening begin?
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20-35
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How often should one be screened for dyslipidemia after a normal test?
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Every 5 years
If risk factors more frequently |
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What are medications that may cause dyslipidemia?
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Estrogens
Corticosteroids Thiazide diuretics Beta blockers Androgenic steroids |
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LDL goals?
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<100 for CHD or risk factor equivalent
<130 for 2+ risk factors Cigarette use HTN Older age Low HDL Family history <160 for low risk |
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Trigyceride level classification?
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<150 - normal
150-200 - borderline 200-500 - high >500 - very high |
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Criteria for metabolic syndrome?
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3 of:
obesity by circumference triglycerides > 150 HDL < 50 BP > 130/85 Fasting glucose > 110 |
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Routine testing for HMG CoA inhibitors and how often?
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LFTs every 6-12 months
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What lipid meds are HMG CoA inhibitors synergistic with?
Which combination should be avoided? Why? |
synergistic with bile acid binding resins
combination with fibrates increases risk of myalgias |
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How do fibrates affect HDL, LDL, triglycerides?
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50% reduction in triglycerides
15% increase in HDL Does not reduce LDL reliably |
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With what comorbid conditions should fibrates be used cautiously?
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Renal insufficiency, Gall bladder disease
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Mechanism of Niacin?
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Reduces hepati production of B containing lipoprotein
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What is Niacin most effective for?
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Raising HDL level: 20-25%
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Niacin side effects?
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Nausea
Glucose intolerance Gout Elevated uric acid levels Raises insulin resistance in DM |
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Problems associated with over the counter preperations of niacin?
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Hepatic toxicity
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How do you minimize flushing with niacin?
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aspirin 1 hour before dosing
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Contraindications for bile acid binding resins?
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triglycerides > 300
GI motility disorders also interferes with other drug absorption |
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What type of drug is ezetimibe?
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intestinal cholesterol absorption blocker
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What cholesterol drugs should intestinal cholesterol absorption blockers be used with and what should they be avoided with
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use with statins
don't use with fibrates, resins |
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Contraindications to intestinal cholesterol absorption blockers?
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active liver disease, elevated transaminases
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How should dyslipidemia be handled when first discovered?
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try 6 months of diet, exercise before starting drugs
start drugs earlier if CHD or high CHD risk or LDL is more than 30 above goal |
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Which drugs decrease peripheral conversion of thyroid hormone?
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propanolol
glucocorticoids PTU amiodarone |
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Neck sign in Grave's?
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Thyroid bruit
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What are causes of isolated T3 elevations?
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Toxic multinodular goiter
Autoomously functinoing thyroid nodules |
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What are the primary features of apathetic thyrotoxicosis?
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apathy, depression
hyperthyroid fewer adrenergic symptoms predominance of cardiac findings (a-fib, CHF) occurs in elderly |
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What is Plummer's disease?
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Multinodular toxic goiter
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In what population does multinodular toxic goiter occur?
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elderly
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How does the radioactive T3 test work? <look this up further>
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binds to TBG or resin
Only binds to resin if TBG is occupied If high resin uptake --> high T4 displacing T3, or low TBG If high TBG --> consider pregnancy |
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What are causes of hyperthyroid that have reduced RAIU?
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sporadic hyperthyroid
postpartum hyperthyroid subacute thyroiditis |
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What are causes of hyperthyroid that have increased RAIU?
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Graves
Toxic multinodular goiter Autonomous thyroid nodules |
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Major side effect of thionamides?
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Agranulocytosis
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What do sodium ipodate and iopanoic acid do?
When are they used? |
Lower serum T3, T4 levels
Acute management of severe hyperthyroidism |
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What are some drugs used in acute severe hyperthyroidism? <>
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Cooling blankets, dexamethasone (inhibits peripheral conversion)
Antithyroid drugs (PTU q2) beta blockers sodium ipodate, iopanoic acid Radioactive iodine Large iodine load (precludes radioactive iodine use for months) |
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What are contraindications for radioiodine use in hyperthyroid?
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pregnancy, breast feeding
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When should surgery be used for hyperthyroid disease?
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very large goiters, allergy to antithyroid drugs
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How should Grave's disease be treated in the nonpregnant?
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methimaxole and beta-blocker
Taper beta blockade in 4-8 weeks continue methimazole for 1-2 years Measure IgG at 1 year Discontinue if absent Treat relapses with 1 year of methimazole |
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How should Grave's disease be treated in pregnant folks?
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PTU and endocrinology consult
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In whom should radioactive iodine ablation therapy be used for hyperthyroidism?
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Elderly patients with graves
solitary toxic nodule disease refractory to drugs (relapse, agranulocytosis) |
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At what TSH levels should asymptomatic patients not desiring pregnancy not be treated for hypothyroidism?
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5-10
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In what endocrine condition do heavy periods, carpal tunnel, loss of lateral eyebrows, and anemia occur? (not primary features)
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hypothyroidism
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How long does it take before the effect of levothyroxine is evident?
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2-4 weeks
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How much should levothyroxine dosage be increased in pregnancy?
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30%
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How common is post partum thyroiditis?
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5-15% of pregnancies
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Course of postpartum thyroiditis
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2-4 month hyperthyroid period
2-4 month hypothyroid period 75% recover in 6-9 months 25% develop permanent disease |
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How often should subclinical hypothyroidism be monitored?
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every 4 to 6 months
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Features of myxedema coma?
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obtundation
hypothermia hypotension bradycardia |
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Events triggering myxedema coma?
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infection, trauma, cold exposure, sedative use
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In whom and when does myxedema coma occur?
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elderly women in winter
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Treatment for myxedema coma?
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IV hydrocortisone, IV thyroxine
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What causes subacute thyroiditis?
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viral illness
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What should be used for pain associated with subacute thyroiditis?
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NSAIDs, aspirin for mild symptoms, corticosteroids for severe
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For which thyroid cancer is FNA unreliable?
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follicular cancer
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What genetic syndromes are associated with papillary thyroid cancer?
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Gardner's, Cowden's syndromes
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How should papillary carcinoma be managed?
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Lobectomy with isthmusectomy
Total thyroidectomy if >3 cm, advanced tumor, distant mets TSH suppression, radioiodine adjuvant |
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What is the most common cause of adrenalitis in the US and in the world?
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autoimmune in US
TB in world |
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Infectious and neoplastic sourcs infiltrate adrenals?
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TB, CMV, crypto, toxo, pneumocystis
Mets from lung and breast |
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How does the cosyntropin stimulation test work and what is it used for?
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Adrenal insufficiency
Give ACTH Get baseline, 30 minute, 60 minute cortisol Rise in cortisol of >18 ug rules out adrenal insufficiency |
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What is a good way of distinguishing primary from secondary adrenal insufficiency?
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8 AM ACTH and cortisol
ACTH elevation >100 rules out primary |
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How does Addison's appear on CT?
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normal looking adrenal glands. Get CT to distinguish between this and other causes
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Initial test in adrenal insufficiency?
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ACTH and cortisol levels
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Immediate management of adrenal insufficiency?
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give high dose glucocorticoids, large volume IV saline without waiting for results
If less critically ill, oral hydrocortisone |
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Agent used in long term management of primary adrenal insufficiency as opposed to secondary?
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fludrocortisone daily
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What is the most common endogenous cause of Cushing's?
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ACTH secreting pituitary tumors
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24 hour urine cortisol level at which Cushing's is dx?
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3 x normal
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Overnight dexamethasone suppression test results ruling out Cushings?
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cortisol <5
if >5 do high dose |
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What does a CRH stim test test for?
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rise in ACTH, cortisol suggests cushing's disease
otherwise ectopic tumor |
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Initial approach to increased cortisol levels? levels?
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measure plasma ACTH
basal levels <10 in adrenal disease >10 in ACTH dependant disease |
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What are some ACTH producing tumors?
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small cell of lung
bronchial carcinoid pheo medullary thyroid carcinoma |
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What is the most common cause of hyperaldosteronism?
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2/3 adrenal adenoma
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Diagnostic test for hyperaldosteronism?
Common and gold standard tests? |
8 AM plasma aldosterone level with simultaneous plasma renin activity
Saline infusion - decreases aldosterone to <8.5 in normal patients |
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Treatment for bilateral adrenal hyperplasia causing hyperaldosteronism?
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Spironolactone primarily
antihypertensive meds |
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Treatment for idiopathic hyperaldosteronism?
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Spironolactone
antihypertensive meds |
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Alternative to spironolactone in hyperaldosteronoism?
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eplerenone if unable to tolerate spironolactone side effects?
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What are side effects of spironolactone?
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decreased libido, impotence, gynecomastia
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What advantage do urine metanephrines have over serum metanephrines in dx of pheochromocytoma?
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Plasma has high false positives
urine are more specific |
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What must be done before VMA collection for pheo diagnosis if necessary?
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special diet necessary?
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If a pheo is producing epineprhine what does this indicate?
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must be near adrenal gland as only enzymes located in adrenal tissue can convert norepinepinephrine to epineprhine
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What tests are used to localize pheo
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CT is first choice
MRI and I-metiodobenzylguanidie (131I) |
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Diagnosis of CAH with 21 hydroxylase deficiency?
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17 OH P levels elevated
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DEXA T scores for osteopenia?
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1-2.5
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What is the difference between DEXA T scores and Z scores?
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Z scores are age and gender matched
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In whom are DEXA Z scores used?
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age <40
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When should women younger than 65 be screened for osteoporosis?
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post menopausal women < 65 with 1 risk factor
Younger women with amenorrhea for >1 year Chronic disease associated with bone loss Anticonvulsants, renal failure, immobilization >1 year, solid organ or BM transplant |
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When should you screen osteoporosis patients for secondary cause?
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premenopausal woman
man < 75 |
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What is recommended Ca intake by age, sex?
Women on estrogens? Pregnant, nursing women? |
Men
25-65 1000 >65 1500 Women 25-50 - 1000 > 50 1500 on estrogens - 1000 pregnant or nursing - 1200-1500 |
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How should Ca intake be estimated?
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multipy dairy product servings by 300 and add 250
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Recommended Vit D intake for adults?
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400-600 IU if >50
800 IU for risk of deficiency elderly, chroinically ill, home bound, instituitionalized |
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What are indications for drug therapy in osteoporosis?
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T - 2.0
T - 1.5 and risk factors Any previous fragility vertebral or hip fractures |
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What is first line drug therapy for osteoporosis? Mechanism?
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Bisphosphonate
Antiresorptive agents |
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Bisphosphonate contraindications?
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renal disease
esophageal disease |
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What fractures does raloxifene reduce risk for?
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vertebral fractures specifically, not hip fractures
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What does raloxifene increase risk of?
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thromboembolism risk
vasomotor symptom |
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Route, frequency, duration of administration for tariperitide?
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subcutaneous injection once daily for 18 months
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Why can't tariparetide be used for >18 months?
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osteosarcoma risk
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In whom is calcitonin used as therapy?
How is it administered? |
patients with bone pain from fractures
patients with contraindications to other therapies Nasal spray |
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How often should osteoporosis patients get DEXA scans?
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q 12-24 months
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What is the most common cause of hypoparathyroidism?
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surgery
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Reflexes in hypoparathyroidism?
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Brisk
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Urine test for hypoparathyroidism?
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Urine cAMP - low levels in hypocalcemia
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What is the cause of hyperparathyroidism most commonly?
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Adenoma
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Complications of primary hyperparathyroidism?
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gout
osteitis fibrosa cystica peptic ulcer disease (gastrin upregulation) constipation weight loss |
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Urine test in hyperparathyroidism?
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Urine cAMP elevation
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What serum test is diagnostic of primary hyperparathyroism?
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Chloride to phosphorus ratio of >33
(chloride is high secondary to renal bicarb wasting - PTH effect) |
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How is parathyroid hyperplasia treated?
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remove all four and implant tissue into forearm
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How should parathyroid malignancy be treated?
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remove tumor, ipsilateral thyroid lobe, all enlarged nodes
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What urine calcium level indicates surgery in hyperparathyroidism?
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>400 mg/24 hours
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What are causes of secondary hyperparathyroidism?
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Renal failure
Hypercalciuria Vit D deficiency |
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Size cutoff for pituitary microadenoma?
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<10 mm is micro
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What meds can cause hyperprolactinoma?
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psych meds
H2 blockers metoclopramide verapamil estrogen |
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What conditions can cause hyperprolactinoma?
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Renal failure, hypothyroidism
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How long should prolactinomas be treated with cabergoline or bromocriptine?
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2 years
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What prolactin levels suggest prolactinoma?
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>100-200
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Why does hypothyroidism cause prolactin production?
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TRH stimualates prolactin production directly
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Heart changes in acromegaly?
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hypertrophic cardiomyopathy
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What percentage of people with acromegaly have hyperprolactinemia?
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30%
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Diagnostic tests for acromegaly?
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IGF-1 levels (somatomedin C)
Oral glucose suppression test for confirmation if IGF levels are equivocal |
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Treatment to persistant post surgical IGF elevations in acromegaly?
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Rads
Octreotide to suppress GH |
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Which pituitary hormones are likely to be lost first in hypopituitarism? Which are less likely
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LH, FSH, GH
TSH, ACTH are resistant |
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What is a major sign of GH deficiency in adults?
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loss of muscle mass
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What is a sign of MSH deficiency?
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decreased skin and hair pigmentation?
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Acquired causes of nephrogenic DI?
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hypokalemia
hypocalcemia lithium demeclocycline pyelonephritis |
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What drug can be used in central DI to increase ADH secretion and enhance its effect?
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Chlorpropamide
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How is nephrogenic DI treated?
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thiazide diuretics
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Which meds may cause SIADH?
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vincristine, SSRI, chlorpropamide, oxytocin, morphine, desmopressin
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What is a water load test used for?
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SIADH - if pt exretes more than 65% in 4 hours then positive
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Rx for SIADH?
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If asymptomatic
water restriction Lithium or demecycline is useful vaptans If symptomatic isotonic saline infusion or if severe hypertonic saline |
