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123 Cards in this Set
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What is cause of hyperkalmeia in DKA? |
usually due to lack of insulin |
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What are causes of DKA? |
most common = infection-->increase in cortisol-->leads to increased insulin demands which body cannot keep up with.
MI in older people needs to be ruled out. |
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Where do you have to admit the DKA patient? |
ICU- for insulin drip |
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What is first thing to do for DKAs? |
IV NS and insulin |
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When glucose is around 200 or so what fluids to give to a DKA patient? |
switch to D5W and insulin ggt |
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What to do in DKA once gap closed and bicarb normal? |
You can swtich to subcutaneous insulin. regular or aspart lispro |
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What is mechanism of metforim/ |
blocking gluconeogenesis |
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What is mechanism of sulfonylureas? |
increase release of insulin. |
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What is mechanism of sitagliptin and saxagliptin (DPPIV)? |
these block metabolsim of incretins like glucagon like peptide hence they increase insulin and block glucagon reslease |
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What do thiazolidnediones like rosaglitazone and pioglitazone do? |
these increase peripheral insulin sensitivity |
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What do acarbose and miglitol do? |
block intestinal absorption of glucose |
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What do nateglinide and repaglinide do? |
sulfonylureas and thse fxn the same, they increase insulin release |
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What do GLP analogs like liraglutide and exanatide do? |
They promote weight loss and lower glucose |
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What is the fist thing to do if pt has hypoglycemia episodes? |
no labs no nothing, lower the insulin dose immediately. |
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Elevated insulin but low C peptide = what problem? |
This means that pt is injecting exogenous insulin or taking too much insulin and not telling you. |
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What is the usualy cause of renal failure in DKA or in HONK? |
prerenal azeotemia |
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What is the goal for LDL for ppl with DM? |
<100 |
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What is goal for SBP for DM? |
130/80 |
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What is mechanism of hypercalcemia if patient has sarcoidosis? |
hyper vitamin D |
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What is hypercalcemia familial? |
Low calcium urine due to defect in kidney, and high serum calcium,, pts are asymptomatic |
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Why does bed bound patient get hypercalcemia? |
due to immobility |
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What first test to get once you have confirmed hypercalcemia? |
parathyroid hormone |
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Who gets parathyroidecomty? |
young ppl and symptoms like renal stones renal insufficiency too much 24 hour urine calcium higher than 12.5 serum calcium
young ppl have lots of bone to loose from calicum bone leaching. |
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What is immediate treatment for hypercalcemia? |
fluid fluids fluids( do not give lasix because they can get Diabetes insipidus if they already have it) else lasix may help
pamidronate for long term affect
calcitonin for next 48 hours Ca lowering |
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If you are having high calcium due to sarcoid high vit d what are you going to treat with? |
you have to treat with steroids along with fluids and lasix. |
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What is PTH level in cancer and in primary hyperparathyroidism? |
PTH level is high in hyperparathyroid
PTH is low in hyperparathryoid |
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What homrone is levothyroxine ? |
T4---> goes into body and gets converted to T3 in the tissues. |
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Do you do cardiac bypass before correcting hypothyroidism? |
yes always do bypass before correcting thyroid hormones |
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What is one cause of hypothyroidism? |
check for hashimotos thyroditis with antithyroglobulin and anti TSH receptor |
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When is T3 usefull? |
Post Thyroid cancer removal when patient is post thyroid cancer removal you give leothryroxine or T3 in high high levels to suppress TSH so no thyroid cancer cells are not going to be activated. do for 10 years before bringing down to normal levels.
Myxedema Coma Use high level T3 and T4 to bring them out of hypothyrodism |
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Do euthryoid sick syndrome pts have normal or abnormal TSH? |
normal TSH but Y3 and T4 maybe abnormal. |
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What is differentail for nodule on palpation of thryoid? |
graves diease - symptoms of hyper throid non-toxic goiter - just a nodule no changes in TSH toxic goiter- nodule with changes in TSH
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What is first test to do after TSH is gotten for a nodule in neck? |
do fine needle aspiration of biggest nodule only if TSH is normal (this is to rule out cancer)
if TSH is not normal then youve diagnosed either hyper or hypothyroidism and ruled out cancer at that point.
no scans in between |
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Once euthryoid goiter is done with fine needle aspiration wht to do? |
if cytology shows cancer= thyroidectomy
if cytology is benign= then monitor and see if nodule is growing. |
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Who gets thyroid cancers? |
XRT patients to neck area
older ppl |
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What is most common thyroid cancer? second most 3rd most 4th most |
papillary is common in 30-40's
second most is follicular cancer with metastasis more common.
3rd most is medullary- familial thyroid cancer also part of MEN syndrome
anaplastic cancer- invades structures in neck , but rare. |
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How do you treat thyroid cancer? |
resect thyroid and suppress with levothyroxine and T3 high doses to suppress TSH and stop any thyroid tiissue fxn. |
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What is the most accurate test for graves disease? and waht are you trying to rule out ? |
radionucelotide uptake scan
if high uptake everywhere= graves
if low uptake everywhere= subacute thyroiditis
if focal uptake high in one nodule= toxic nodular goiter. |
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What is TSH and T4 in subacute and graves disease? how to differentiate them? |
both have low TSH and high T4
subacute has a painful thyroid on palpation
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What is definitive treatment of graves? |
radioactive iodine ablation with hypothyroid levothyroxine replacement. |
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What antibody for graves disease? |
anti TSH antibody |
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What is difference between toxic nodular goiter hyperthyroidsim and graves disease in terms of physcial presentation? |
toxic nodular goiter= more cradiac manifestations and no propotosis or skin changes, so non typical hyperthyroid finding
labs and radio uptake scans are all similar or same though for both graves and toxic nodular goiter. |
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What inflammatory lab is high in subacute thyroiditis if TSH is not given? |
ESR |
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Waht is treatment fro subacute thyroiditis? |
aspirin |
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Pt has hyperthyroid symptoms but the TSH is super elevated what is the cause of this? what scan to do to prove it? |
Pituitary adenoma do an MRI of brain and remove pit adenoma
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Other than PTU and methimazole what is used for tratemnet in a thyroid storm? |
dexamethasone so that T4-->T3 conversion is blocked. |
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What is silent thyroiditis? |
hyper thyroid symptoms--> so you do a radionucleotide scan --> you find normal uptake but TSH low and T4 high so called silent thyroiditis---> thought to be due to anti thyroid peroxidsae and antithyroglobulin antibodies. |
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What is the single best test to diagnose cushing disease? |
24 hour urine cortisol |
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What is a common test to do first for cushing? what to do if positive what to do if negative |
low dose dexmethasone cortisol suppression test
ifnot able to suppress cortisol then you have to get 24 hour urine free cortisol
if able to suppress then you ruled out cushings |
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What are three causes of cushing disease? |
pituitary adenoma
ectopic paraneoplastic acth producing tumor (small cell cancer)
adrenal adenoma |
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What to do if urine free cortisol test is high? |
high = postivie for cushing disease
so get ACTH and high dose dexamethasone test |
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So if the ACTH is high what are the two types of cushing diease it can it be? |
pituitary adenoma or ectopic ACTH production aka small cell lung cancer |
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If ACTH is low and you already have high urine 24 hour cortisol what type of cushing disease is it? |
adrenal adenoma |
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If ACTH high and 24 hour urine cortisol are high and you do high dose dexamethasone suppresion test how to interpret the results? |
high or normal cortisol levels after high dose suppression with ACTH = ectopic acth production since this is a more aggresive tumor than pituitary tumors (if ACTH was low, but high dose dexameth test was done showing no lowering of cortisol, so now you are in the other type of cushings= adrenal adenoma)
suppressed cortisol high dexamet test + high ACTH = pituitary tumor (since this is a weaker tumor and can be suppressed) |
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if you have high ACTH and 24 hour urine cortisol is high and you are able to suppress cortisol levels in overnight/ high dose dexameth test and MRI is negative for pitutary adenoma what to do next? |
get a petrosal sampling of the lesion. |
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PT with hypertension that has orthostatics positive? |
this is pheochromocytoma |
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What is best accurate test to diagnose pheochromocytoma? |
urine metanephrines and catacholamines |
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What test to do if you have postivive urine mets and catecholamies? |
CT or MRI to localize the mass. |
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What is the treatment for pheochromocytoma? and what are precautions before treatment? |
phentolamine and phenoxybenzamine(alpha blockers ) dont use any other type of bp meds
only give bblockers if patient has palpitations once the BP is controled
after blood pressure controlled then you can take to surgery to get rid of the pheochromocytoma. |
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What are two causes for glactorrhea? |
pituitary adenoma and primary hypothroidism that causes pitutary to continue rleasing TSH |
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What medicines cause galactorrrhea? |
haldol. |
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What are common symptoms for prolactinoma? |
galactorrhea and amenorrhea , less likely to cause visual disturbances in women more in men.
men get gynecomastia and decreased sexual libido and present at late stage when they get visual distubances |
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What is medicines to treat prolactinoma? |
cabergoline and bromocriptine( dopamine suppressors)
check MRI Qyearly to make sure its getting smaller. |
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high prolactin does what to other hormones in the body? |
high prolactin suppresses GNRH in the pituitary |
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What is the best initial test for acromegaly? |
insulin like growth hormone factor test |
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What is the most accurate test for acromegaly? |
give glucose and check GH---> GH should go down with glucose in the body. |
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What is the treatment for acromegaly? second line treatment? |
first treatment is surgical resection
octreotide- a somatostatin analong to prvent GH release to shrink tumor
Cabergoline and bromocriptine can also be used like in prolactinoma
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What is bilateral capral tunnel syndrome indicative of? most ppl get unilateral carpal tunnel |
acromegaly, hypothyroidsm, and amylodosis |
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How do you follow up treatment for acromegaly? |
you have to follow insulin like growth factor to see if ur treatment is working. |
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hypotension+ fatigue+ weight loss+ hyperpigmentation
hyponatremia+ hypokalemia
=? |
addisons disease (pruimary adrenal insufficency)
hypermigmentation from lots of ACTH trying to activate the adrenal gland. |
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What is most accurate test for addisons disease? |
cosyntropin stimulation test(give pt ACTH measure cortison at 0 and 2 and 4 hrs) you should see 20-30% increase in cortisol = if not then you have addisons disease |
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What is a common cause of adrenal insufficiency addisons disease? |
HIV
and prednisone use
water house freidhrichson syndrome (memngitis case where the adrenals bleed and cause this) |
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What are the hormones that are low in addisons disease? |
cortisol (electrotyle abnormaltiites)
fludrocortisone (causing hypotension when low) |
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Esosinophilia in CBC + hyperpigmentation + hypotension + weight loss and fatigue + hyponatremia + hyperkalemia==? |
this is just addisons disease with esosinophilia that is sometimes present. |
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What is treatment for addisons disease? |
hydrocortisone if electrolytes are messed up and
fludrocortisone if hypotension is present. |
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What is secondary adrenal insufficiency? |
where the brain is not making ACTH and hence you dont stimulate the adrenal to make cortisol. |
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What are the symptoms of secondary adrenal insufficiency? |
just electrolyte abnormalities, no hypotension and no hyperpigmentation |
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what is treatment for secondary adrenal insufficency? |
hydrocortisone. |
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Hypertension + low renin + low potassium=? |
conns syndrome aka hyperaldosteronism
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What are the electrolyte abnormalites that happen because of hyper aldosteronism ? |
hold on to sodium and get rid of k+ and get rid of acid
so you get metabolic alkalosis |
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What hormones are high / low in primary hyper aldosteronism?
secondary hyperaldosteronism? |
primary you see high aldosterone from adrenal going and suppressing the rennin production the in the kidneys.
secondary you see high renin when you have hypovolemia ==> that causes adrenals to secrete more aldosterone |
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Waht is next step after you confirm with homrones that you have primary hyper aldosteronism? |
you get a CT scan to localize the tumor then you can get surgeyr to take it out. |
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If it is a solid tumor on CT, conns syndrome should get what treatment vs if its just hyperplasia what should you give in conns syndrome? |
solid tumor= taken out by surgeon
hyperplasia= use spironolactone. |
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what is the manner of managing dm type 1 during csection ?
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continue insulin as before the night before when she becomes npo, in the am and during the surgery u can switch to insulin drip and glucose . this is so that you can calculate how much insulin she actually needs after surgery given that her insulinrequirments will decrease post delivrry
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what is the effect on levothyroxine if you start oral contraceptives ?
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estrogen and preganancy cause increase in thyroid hormone binding protien which keeeps t4and t3 in serum instead of using in tissues. usually in euthyroid ppl they can comepensate by increasing tsh. but in hypothyroid their incease in tsh doesnnot result in more t4 so most of t4 gets bound to thyroid binding protiens which results in need to increase levothyroxine to imrove t4 levels |
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what is the cause of subclinical thyrotoxicosis ? |
subclinicall thyrotoxicosis= t4 is high and tsh is normal though, pt feels okay. this is usually due to too much levothyroxine supplementation so you should adjust dose ans recheck tsh
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What is dignosis of gestational diabetes? |
first 50g glucose load test if <140 ok else
do 100g glucose test .
if fasting 95 1 hour later 180 2 hours later 150 and 3 hours later 140 or less
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When is gestational DM investigated? |
24-26 weeks |
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What is goal sugars of pregnant women? |
<140 after 1 hour of eating and
<120 after 2 hours |
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What meds are okay to start for gestational DM? |
insulin, glyburide and metformin are okay. |
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If hyperthryoid lady comes with tachycardia and irregularly irregular beating of heart what to do first? |
b-blocker to control sympathetic activty in body. |
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What is the difference between cushing and conns syndrome? |
both have hypokalemia and both have hypertension both will have metabolic alkalosis
physical exam will show thin skinny guy for conns and fat guy for cushings
cushings will also have hyperglycemia and osteoprorosis and leukocytosis |
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What congential adrenal hyperplasia type shows up with precocious puberty? |
in 21 hydroxylase deficiency no HTN for this one
male kids get puberty at young age with hair and sexual organs enlargement |
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What is kleinfelters syndrome? |
XXY, tall height at early age. but no precocious pubetery incfact, theier LH anf FSH are high but their testicales dont make testosterone so they look feminized tall individuals |
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small elevated red rash with central clearing on arm pt has DM, and is having weight loss, diarrhea, facial flushing, abdominal cramps, pt also has angular cheliosis what is it? how to diagnose and how to treat it? |
glugagonoma -causing necrolytic migratory erythema
it can cause the diarrhea leading to multiple vitamins deficiencies
diagnose with glucagon levels
treat it by surgical removal from pancreas and liver mets
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Pt is hyperthyroid on TSh and T4 and is having lots of symptoms so on RAIU scan you see diffuse low uptake what are the three possiblities? |
its either exogenous thyrotoxicosis (should have no other antibodies and thryoid should be painless, thyroglobulin(T3) should be low )
or
postpartum thryoiriditis ( has anti TPO antibodies elevated and thryoid is painless, T3 should be high)
or
subacute granulomatous dequervians thyroiditis (post viral infection + should habe tender gland, T3 should be high) |
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What is kallman syndrome? |
anosmia, hypogonadotrophic hypogonadism, midline facial defects. defective migration of GNRH. olfactory neurons to nose during dvelopment. |
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What is typical for klienfelters syndrome presentation wise?? |
47XXY. hypogonadism with atrophy of leydig cells, testes become small and firm on palpation. no delay in puberty. |
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What hormones are high in 21 hydroxylase deficiency? what are the consequences of that? |
low cortisol and aldosterone ( so hypotension and hyperkalemia and hyponatremia)
increased testosterone (so virilization in femlaes and baby females have unambiguous genetilia)
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What is hormone deficicenies in 11 B hydroxylase? |
low cortisol and and low aldosterone(hypernatremia and hypokalemia retention and HTN)
and increased testosterone (so ambiguous genetilia in female kids) |
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What hormone deficiences in 17 alpha hydroxdylase deficiencies? |
low cortisol and increased mineralocorticoids
and low testosterone(so all patients look like female genetilia at birth) |
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What builds up if 21 hydroxylase is deficient/ |
17-oh progesterone |
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What builds up if 17 Alpha hydroxylase is deficicent? |
aldosterone builds up and progesterone |
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What builds up if 11 hydroxylase is deficient? |
you build up more testosterone |
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What is gold standard treatment for congenital adrenal hyperplasia? |
hydrocortisone( keep cortisol up to keep electrolytes nromal) and fludrocortisone( for keeping BP up) in kids
to treat virilization you will need to do surgery |
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What vitamin causes hypokalemia when starting replacement treatment? |
Vitamin B 12 . |
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pituitary tumor with lots of alpha subunits + prolactin elevated, LH and FSH low=?
what is treatment? |
gonadotroph tumor that doesn't secrete anything, so cabergoline will not be useful
treatment is resection |
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What are the painful hyperthyroid ones? what are the non painful hyperthyroid ones? |
subacute granulomatous thyroiditis(aka dequervians thyroiditis)
silent thryoiditis and lymphocytic thyroidits |
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By when is a patient considered delayed puberty? |
When patient has testicles 2.5cm or less in diameter and delay in development of other stuff by five years after enlargement of genetelia
and the bones showing either appropriate to age or older than age= delayed puberty. |
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If 1 parent has DM 1 what is risk of passing it on to child? what if both parents have DM1? |
both have DM1 = 6% chance
if only 1 has it, its 3% chance of passing it on. |
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What is subclinical hypothyroidism and when do you treat it? |
sublclinical is where the TSH is slightly elevated and the T4 is normal, patient is asymptomatic
When anti-tpo antibodies are present, when TSH is >10, or when they have symptoms like lipids messed up, or obgyn issues, or cardiac symtpms
so always check for anti TPO antibodies |
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What is amiodarones affects on the thyroid? |
amiodarone helps stop T4 to T3 conversion and hence you get higher levels of T4 |
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What is trend of T4 and T3 and Free T4, TSH in pregnant ladies? |
T3 and T4 go up in pregnancy, but TSH remains stable.
Free T4 is unrelaiable since more thyroid binding globulin takes of any Free T4. |
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What is normal TSH in pregnant ladies? |
First trimester is 0.1-0.25 Second Trimester 0.2-3.0 Third Trimester 0.3-3.0 |
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bilateral inguinal masses, breast development , but no axillary hair in a female patient 16 yrs old what is it? |
Pt is probably a XY genotypically, but phenotypically looking like a female. She may have a blind vaginal pouch + two testes that are often described as inguinal masses
They ultimately cannot respond to androgen aka androgen insensitivity syndrome is the diagnosis
wht ever testosterone made by their testicles is coverted to estrogen and it allows them to get breasts. |
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During pregnancy pt with hyperthyroid symptoms + low TSH comes to clinic what next test to do to confirm hyperthyriod? |
will need antti thyroglobulin antibodies to confirm graves
Do not to radioiodine scan during pregancy |
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How to treat hyperthyroidism in prganancy?
Hypothyroidism in pregnancy? |
you can give PTU in the first trimester and methimizole in the seocnd and third trimesters
you have to increase the dose of levothyroxine for hypothyroids by 25-30% |
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once pheochromocytoma is removed pt gets hypotensive wht to do? |
usually happens due to suddenly low levels of catecholamines,
you will need to give some fluids |
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Other than hypotension what other post op complications can pheochromocytoma pateints get? |
they can get hypoglycemia, since loss of high catecholamines means that all the insulin in the world is released. |
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When in diabetic ketoacidosis do you start cutting down the insulin drip? |
when you reach glucose <200 you can cut insulin drip in half and start dextrose, but continue fluids and continue insulin drip as long as the gap is eleavted. |
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What insulins should be given if patient has closed gap in DKA? |
one long acting
one short acting to continue to correct any glucose
stop the fluids and start PO diet |
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For diagnosed graves disease on radiouptake scan what to do next--> What is definitive therapy? |
you need to do radionuclide obliteration then give prednisone so that T4 to T3 consversion is stopped post op and pt doesn';t get excessive symptoms. LAstly, give levothyroxine replacement once TSH levels are going up again. |
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What is the antidote for pt with sulfonyl urea induced hypoglycemia? |
octreotide- somastostatin analong that decreases insulin secretion. |
