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146 Cards in this Set

  • Front
  • Back
Which diabetic medications are contraindicated in diabetics?
metformin and thiazolidinediones
(insulin sensitizing medications)
What does thyrotoxicosis do to warfarin dosing?
decreases dose requirement (although it increases the metabolism because it increases turnover of clotting proteins)
What happens to digoxin metabolism during thyrotoxicosis?
increases, so need to increase dose
How is Familial hypocalciuric hypercalcemia diagnosed?
by a urinary calcium/creatinine clearance ratio <0.01 measured in a fasting morning urine spot collection.
What does MEN 1 consist of?
- hyperparathyroidism
- pancreatic tumors
- pituitary tumors (prolactinoma)
What level of testosterone is nearly always pathologic?
< 100 ng/dL
How much more cortisol do patients with Cushing's syndrome produce?
3-4 times the amount
What are the three screening tests for Cushing's syndrome?
- measurement of urine free cortisol
- the overnight dexamethasone suppression test (dexamethasone 1mg at 2300 hrs, cortisol level at 8 am)
- the late-evening salivary cortisol test (2300 hrs)
What are risk factors for hypopituitarism?
- previous macroadenoma,
- pituitary surgery
- brain radiation
What is Multiple endocrine neoplasia type 2A characterized by?
- pheochromocytoma
- medullary thyroid carcinoma
- hyperparathyroidism due to parathyroid hyperplasia
why must β-Adrenergic antagonists never be administered before α-blockers?
β-Blockade permits unopposed α-agonist activity, causing hypertensive crisis
what should be suspected in patients with persistent hypertension following resection of pheochromocytoma?
- hypertensive glomerulosclerosis
- underlying essential hypertension
- Harboring a malignant pheochromocytoma with unsuspected metastases
What are the indications for parathyroidectomy in a patient with mild, asymptomatic hypercalcemia secondary to primary hyperparathyroidism?
- age < 50
- serum Ca > 1 mg/dL above ULN
- 24-hour Ca excretion > 400 mg
- Cr clearance reduced by 30% or greater
- bone mineral density T score < 2.5 at any site
What is the clinical presentation of pituitary apoplexy?
- sudden onset of headache,
- visual disturbances,
- opthalmoplegia (CN II, III, IV & VI)
- mental status changes
- endocrine dysfunction (acute adrenal insufficiency & hypothryoidism)
How should patients with pituitary apoplexy and rapidly progressing visual disturbances and/or mental status changes be treated?
urgent neurosurgical evacuation
How can you differentiate between pituitary apoplexy & subarachnoid hemorrhage?
noncontrast CT
Which vitamin D level is a marker of body stores?
25-hydroxyvitamin D
How does vitamin D deficiency cause secondary hyperparathyroidism?
low vitamin d decreases intestinal absorption of calcium, leading to secondary hyperparathyroidism and renal phosphate clearance (hypophosphatemia)
In what states is calcitonin elevated?
medullary thyroid cancer or C-cell hyperplasia
How is subclinical hypothyroidism defined?
serum TSH level with a free T4 that is still within the population reference range
What can mimic hypoparathyroidism in an alcoholic patient?
hypomagnesemia - low Ca, high phos
What does a low IGF-1 level in combination with three or four anterior pituitary deficiencies predict?
presence of GH deficiency
What is more sensitive and specific for determining growth hormone deficiency than measuring basal hormone levels?
Growth hormone stimulation testing
What can cause pseudo-Cushing's syndrome?
depression and ETOH
How is the 2-day dexamethasone-corticotropin releasing hormone stimulation test performed?
Dexamethasone 0.5 mg is is given every 6 hrs for 8 doses. 2 hrs after last dose, CRH 1 µg/kg is administered, and serum cortisol is measured 15 minutes later
How is the 2-day dexamethasone-corticotropin releasing hormone stimulation test interpreted?
With pseudo-Cushing's, cortisol level remains suppressed at <1.4 µg/dL (38.63 nmol/L), but will be > 1.4 µg/dL with Cushing syndrome.
What is the therapy of choice for uncomplicated Paget's disease?
oral bisphosphonates
What are the usual characteristics of adrenal adenomas?
- smooth borders
- less than 4 cm in diameter
- unilateral
- homogenous in consistency
- less than 10 Hounsfield units in density
Why do you see low DHEA-S with autonomous adrenal production of cortisol?
- suppresses ACTH production, causing atrophy of contralateral adrenal and suppresses the zona reticularis
Can serum TSH be used to monitor thyroid hormone replacement in patients with central hypothyroidism?
NO
With central hypthyroidism, what is the goal of thyroid replacement therapy?
to normalize free T4
In whom is metformin contraindicated?
- renal insufficiency (Cr > 1.4)
- CHF
How do you distinguish postpartum thyroiditis from Graves' disease?
Check serum TSH immunoglobulins/TSh receptor antibodies (present with Grave's and not postpartum)
Is radioiodine uptake high or low with thryoiditis? Grave's?
- low with thyroiditis
- high with Grave's
Which neoplams produce PTHrP?
- squamous cell carcinoma
- ovarian cancer
- breast cancer
- renal cell cancer
How can you tell if hypercalcemia is caused by lymphoma?
- low PTH, low PTHrP
- high 1,25-dihydroxyvitamin D3 (converted by lymphoma tissue from 25-hydroxyvitamin D)
Are Electrolyte abnormalities usually seen with central adrenal insufficiency?
NO (usually seen with primary)
How is Multiple endocrine neoplasia (MEN) type 2A transmitted?
autosomal dominant of RET cheme on Chromosome 10
What is Pendred's syndrome? How is it characterized?
autosomal-recessive disorder of iodine organification. It is characterized by congenital sensorineural hearing loss combined with goiter.
How is Pendred's syndrome diagnosed?
positive perchlorate discharge test
What radiographic finding is pathognomonic of osteomalacia?
Looser's zones or Milkmans' fractures (pseudofractures), can be described as radiolucent bands that are usually symmetric and bilateral
What laboratory findings will you see with osteomalacia?
Hypocalcemia and hypophosphatemia
What is critical in managing a patient with hyperglycemic hyperosmolar non-ketotic syndrome?
preservation of vascular volume and supplementation with normal IV saline FOLLOWED BY IV insulin
What is the differential diagnosis in patients with apparently inappropriate TSH secretion?
TSH-producing pituitary adenoma and congenital thyroid hormone resistance
If suspect surreptitious use of levothyroxine, what can you check? what will you find?
- serum thyroglobulin levels
- they will be low or undetectable
If a patient has hypercalcemia and medication list shows use of a thiazide diuretic, what should be done next?
- discontinue thiazide diuretic.
If calcium still elevated, check PTH
What should be checked in the evaluation of a patient with galactorrhea and irregular menses?
TSH and prolactin
What is one of the most common secondary causes of hyperprolactinemia?
primary hypothyroidism
How can you differentiate central versus nephrogenic diabetes insipidus?
water deprivation will fail to concentrate urine, but desmopressin will concentrate urine in central DI
How does hyperprolactinemia cause hypogonadism?
because prolactin directly suppresses gonadotropin-releasing hormone secretion and thus luteinizing hormone and testosterone production
What is the initial treatment for prolactin-producing macroadenoma?
dopamine agonist, such as bromocriptine or cabergoline
What is a confirmatory test for Cushing's syndrome in patients with ambiguous results in screening tests?
Inferior petrosal sinus sampling
Describe how the thyroid tests will be for a euthyroid patient taking amiodarone.
- high T4 and free T4
- low T3
- normal-high TSH
How is osteoporosis diagnosed?
- presence of fragility fractures or
- by a bone mineral density value <−2.5 in patients who have not experienced a fragility fracture
What must you check in a patient with elevated prolactin?
-pregnancy test
- TSH (usually not > 200)
What is an alternative to insulin therapy in patients who have not achieved optimal glycemic control with multi-agent oral therapy?
Exenatide, an incretin mimetic that increases insulin secretion
What can be used in patients with tertiary hyperparathyroidism to control elevated PTH in patients with chronic kidney disease?
Cinacalcet hydrochloride (sensipar)
What is the classic presentation of hereditary hemochromatosis?
- hypogonadism
- diabetes mellitus
- liver dysfunction
- skin hyperpigmentation
What are the most affected organs in hereditary hemochromatosis?
pituitary gland, pancreas, liver, and heart
How is hereditary hemochromatosis inherited?
autosomal recessive
What ferritin levels are consistent with iron overload?
Serum ferritin levels greater than 200 ng/mL (200 mg/L) in women and greater than 300 ng/mL (300 mg/L) in men
What should be considered in a patient that complains of amenorrhea following D&C?
endometrial damage or formation of scar tissue causing an outflow tract obstruction (Asherman's syndrome).
How can you differentiate between uterine dysfunction and chronic anovulation?
progesterin withdrawal challenge. If bleeds, then chronic anovulation & if doesn't, then outflow tract obstruction
What are the characteristics of pheochromocytoma?
- occur in teh adrenal medulla
- rarely bilateral
- occur mostly on the right
- rarely metastatic
- usually > 2cm in diameter & heterogenous in consistency
What is the preferred study for pheochromocytomas?
Computed tomography of the abdomen with thin sections through the adrenals
What is teh concurrence of autominnune thyroiditis and Addison's disease known as?
Schmidt's syndrome
What other autoimmune diseases are patients with autoimmune thyroiditis at risk for?
- adrenal insufficiency
- pernicious anemia
- type 1 diabetes mellitus
- vitiligo
- premature ovarian failure
What would you expect to see in a patient with Addison's disease?
- hyperkalemia
- mild hypercalcemia
- fatugue
- malaise
- weight loss
- orthostatic hypotension
What are the classic symptoms of renal osteodystrophy?
- vague bone pain localized to the lower back, hips, or legs
- muscle weakness often occurs with normal muscle enzymes and nonspecific electromyography changes
Why do patients with severe hyperparathyroidism have pruritis?
deposition of calcium in the skin
What is the main radiographic feature of renal osteodystrophy?
increased bone resorption, most commonly in the subperiosteal surfaces of the hands, neck of femur, and clavicle.
- osteosclerosis gives classic "rugger-jersey" spine
What laboratory abnormalities will you see with Vitamin D deficiency?
- low vitamin D
- hypocalcemia
- hyperparathyroidism
- hypophosphatemia
How is Paget's disease diagnosed? what is seen radiographically?
- usually incidentally when pt found to have elevated alk phos
- enlargement or expansion of bone, coarsening of trabecular markings, and pathognomonic patterns of lytic and sclerotic change
What has growth hormone replacement been shown to do?
- improve body composition
- lipid parameters and
- bone mineral density
In postpartum thyroiditis, how long is the period of thyrotoxicosis? hypothyroidism?
- 2- 4 months bc of preformed thyroid hormone from damaged follicles
- 2-4 months of hypothyroidism because of gland depletion
How do you treat the hyperthroid phase of postpartum thyroiditis?
β-Blocker therapy
How is growth hormone replacement done?
started at a low dose and titrated up based on the patient's insulin-like growth factor 1 level, symptom control, and side effects of therapy
What are adverse effects of growth hormone replacement in adults?
primarily related to fluid retention and can include parasthesias, myalgias, edema, and joint pain
Should patients with active malignancies be treated with growth hormone?
NO, concern for proliferation of malignancy
What can be used in men with bilateral adrenal hyperplasia in whom spironolactone therapy causes painful gynecomastia?
eplerenone
Is surgery indicated in bilateral adrenal hyperplasia?
NO
How does osteomalacia usually present?
elevation of alkaline phosphatase in association with hypocalcemia and hypophosphatemia
Describe the pituitary function in empty sella syndrome?
usually normal
What should post-prandial glucose levels be?
30-50 mg/dL higher than pre-prandial levels
What are postmenopausal women with subclinical hyperthyroidism and an undetectable TSH at risk for?
osteoporosis?
How is subclinical hyperthyroidism defined?
- low or undetectable serum TSH
- normal free T4 and total T3 or free T3
Patients older than 60 years with subclinical hyperthyroidism and serum TSH values that are undetectable have a 3-fold increase risk of what?
atrial fibrillation (remember that postmenopausal women are at increased risk for osteoporosis)
What is the classic triad of symptoms for pheochromocytoma?
- headache
- palpitations
- diaphoresis
What is the first step in evaluating a thyroid nodule?
checking TSH. If normal (nonfunctioning 'cold'- nodule) or low (fucntioning 'hot' nodule)
What should be done to further evaluate a patient with a 'cold' nodule?
FNA biopsy of the nodule
What should be done to further evaluate a patient with a 'hot' nodule?
thyroid scan to confirm presence and determine if there are other nodules & measurement of free T4 & T3
What is measurement of serum thyroglobulin useful for?
following thyroid cancers in response to treatment
Why do germ cell tumors cause the release of excess thyroid hormone?
The receptor for hCG has homology with the TSH receptor, and hCG is a weak agonist for the TSH receptor so if high levels of hCG present with germ cell tumors, high thyroid hormone levels may be present
What is a prevalent secondary cause of male osteoporosis? Why?
- Hypogonadism
- increases the skeletal sensitivity to parathyroid hormone and decreases intestinal calcium absorption, predisposing to osteoporosis
What are risk factors for osteoporosis in males?
- BMI <18
- a history of smoking or excessive alcohol consumption
- family history of osteoporotic fractures
- hypogonadism
- history of corticosteroid use
- vitamin D deficiency
- medications causing osteomalacia or hypogonadism
Risk factors for osteoporosis in females?
- age greater than 65 years of age
- female gender
- white
- Asian
- family history of osteoporosis
- small body size or weight
- premature or surgical menopause
- inadequate calcium intake
- smoking
- excessive alcohol consumption
- eating disorders
- excessive physical activity causing amenorrhea
- medications such as corticosteroids, anticonvulsants, heparin, and certain medical conditions
What are the indications for measurement of bone mass?
- women ≥65 years of age (regardless of risk factors)
- postmenopausal women <65 years of age who have at least one risk factor for osteoporosis other than menopause
- postmenopausal women who present with fractures
- women who are considering therapy for osteoporosis and for whom bone mineral densitometry tests results would influence this decision
- women who have been receiving hormone replacement therapy for a prolonged period
- radiographic findings suggestive of osteoporosis or vertebral deformity
- corticosteroid therapy for more than 3 months
- primary hyperparathyroidism, and treatment for osteoporosis (to monitor therapeutic response).
What are patients with long-standing Paget's disease at significantly increased risk of developing?
osteogenic sarcoma in affected bone
What should you suspect when you see 'starburst' appearance in bone?
osteogenic sarcoma
What are some complications of Paget's disease?
- hypercalcemia
- high-output congestive heart failure
- deafness
- excessive bleeding during surgery due to hypervascular
What class of medications can modestly elevate prolactin levels?
psychotropic medications
How can patients with hyperprolactinemia and severe psychiatric illnesses requiring continued therapy with psychotropic agents be treated?
estrogen- and progesterone-containing oral contraceptives to restore normal menses and prevent bone loss
What study should be performed in any young male with a high FSH & primary hypoganadism?
karyotype to check for Klinefelter's syndrome
What is the most sensitive screening test for primary aldosteronism ?
plasma aldosterone-plasma renin activity ratio
What are secondary causes of hypertension?
- primary aldosteronism
- acromegaly
- pheochromocytoma
- Cushing's syndrome
What laboratory test results strongly suggests primary aldosteronism?
ARR ratio > 20, with a plasma aldosterone >15 ng/dL
What establishes the diagnosis of primary aldosteronism?
Urine aldosterone excretion >12 μg/24 hrs, with an abnormal ARR
(high aldosterone & low renin (<1 mg/ml/h)
What should be done to thyroid hormone dosing during pregnancy?
increase by 30-50% to provide thyroid hormone to the fetus
What signifies an abnormal 50-g oral glucose challenge test?
plasma glucose level greater than 140 mg/dL (7.77 mmol/L) at one hour
What is considered normal for a 3-hour 100-g oral glucose tolerance test?
- fasting glucose level, 95 mg/dL (5.27 mmol/L)
- 1-hour level, 180 mg/dL (9.99 mmol/L)
- 2-hour level, 155 mg/dL (8.6 mmol/L)
- 3-hour level, 140 mg/dL (7.77 mmol/L).
(test is abnormal if any 2 of the 4 are out of range)
Should bisphosphonates be used in primary hyperparathyroidism?
NO
With primary hyperparathyroidism, what treatment generally improves bone mineral density?
parathyroidectomy
Why do obese, insulin-resistant men generally have a reduced serum total testosterone?
primary due to low sex-hormone binding globulin
Why is hypercalcemia seen in hyperthyroidism?
Intestinal calcium absorption is reduced and osteoclastic activity is increased in hyperthyroidism, and the high levels of free T4 and free T3 likely produce hypercalcemia through excessive osteoclastic activity
How do you treat hypercalcemia due to hyperthyroidism?
you don't. should recheck when euthyroid
What does Exogenous testosterone do to sperm production? How can this be treated?
- reduces it
- start gonadotropin therapy (hCG) - usually takes 3 months of treatment
How is silent thyroiditus characterized?
- high levels of antithyroid peroxidase antibodies
- painless enlargement of the thyroid gland, and
- a triphasic course with early thyrotoxicosis followed by hypothyroidism and then a return to euthyroidism in most patients
In a patient with hypopituitarism, what should be evaluated & treated first?
documentation and therapy of adrenal insufficiency
What suggests androgenic anabolic steroid abuse?
- increased muscle mass
- irritability
- pustular acne with small testes and
-low serum testosterone and gonadotropins
What does the prevention and treatment of corticosteroid-induced osteoporosis include?
- calcium and vitamin D supplementation
- a DEXA scan at the initiation of therapy, and
- bisphosphonates in patients taking prednisone ≥5 mg/d (or its equivalent) for >3 months
What is the classic presentation of thyroid lymphoma?
an elderly woman with autoimmune thyroiditis and a rapidly expanding thyroid mass
How is thyroid lymphoma treated?
local radiotherapy and chemo (somewhat sensitive to both)
What does Chemotherapy with alkylating agents usually do to sperm production?
induces irreversible damage to sperm (cyclophosphamide)
How is subacute thyroiditis characterized?
- prodrome of arthralgias, malaise, and anorexia followed by pain in the thyroid bed and thyrotoxicosis
What will you see on laboratory studies with subacute thyroiditis? How do you treat?
- elevated ESR
- elevated serum thyroglobulin
(neither is specific)
- NSAIDs or corticosteroids
Where does nasal calcitonin increase bone mass?
in the spine
What medication can be used in patients with osteoporosis to stimulate osteoblastic bone formation?
Teriparatide (recombinant human parathyroid hormone [1-34]). can be considered in patients intolerant of bisphosphonates
What does Teriparatide (recombinant human parathyroid hormone [1-34]) increase the risk for? Who should it be avoided in?
- osteosarcoma
- patients with Paget's disease of bone, previous radiation involving the skeleton, and a history of skeletal cancer
What is an X-linked hypothalamic hypogonadism accompanied by anosmia?
Kallman's syndrome
What is a good choice of therapy for patients with unresectable or incompletely resected GH producing pituitary tumors?
- octreotide
- Pegvisomant (growth hormone receptor antagonist)
Patient with Hashimoto's thyroiditis and increasing need of levothyroxine without control of TSH. What should be considered?
- celiac disease (esp if complaints of abdominal bloating)
**Increased dose requirement for levothyroxine may occur due to malabsorption (celiac disease), accelerated metabolism, or an increased occupancy of binding proteins
What should patients with an incidentally detected adrenal mass be screened for?
- Cushing
- Pheochromocytoma
- primary aldosteronism
What should be done for adrenal lesions that are <4 cm in diameter & hormonally inactive?
imaged in 3 to 6 months to assess for sequential size changes
What should be done with adrenal masses that are greater than 4 cm in diameter or lesions that are hormonally active?
referred for resection
What antibodies are usually present in patients with autoimmune adrenal insufficiency?
Antibodies to the 21-hydroxylase enzyme (CYP21)
What do you typically see in patients with primary adrenal insufficiency?
- loss of all three layers of the adrenal cortex, causing insufficient aldosterone, cortisol, and androgen secretion
- decrease in cardiac output, increased secretion and renal response to arginine vasopressin, and diminished renal clearance of potassium
- hyponatremia, hyperkalemia and hypoglycemia
What should be suspected in a patent receiving treatment for hypogonadism and doubling of his PSA?
prostate cancer
What should be done/evaluated in patients beginning testosterone therapy?
- digital rectal exam
- PSA checked at 3, 6 and 12 months after start of therapy
What laboratory abnormalities are seen with vitamin D deficiency?
- low 25-dihydroxyvitamin D
- elevated parathyroid hormone
- low serum calcium
- low-normal phosphorus
- elevaged alkaline phosphatase
How is impaired fasting glucose defined?
fasting glucose level of 100-125 mg/dL
What class of medications can suppress gonadotropin and testosterone production?
narcotics
What is the most likely diagnosis in a short young women with primary amenorrhea?
Turner syndrome (even without associated stigmata & comorbidities)
What would serum 17-hydroxyprogesterone help assess?
androgen excess
What are the two causes of central hyperthyroidism? how can you differentiate between the two?
- TSH-producing adenoma
- Resistance to thyroid hormone syndrome
- check TSH α subunit, if elevated then due to TSH-rpoducing tumor
When should you suspect central hyperthryoidism?
- classic symptoms with;
- high-normal TSH
- elecated free T4 & free T3
What hematocrit level is a condraindication to testosterone treatment?
> 54%