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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)
|
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What happens to digoxin metabolism during thyrotoxicosis?
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increases, so need to increase dose
|
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How is Familial hypocalciuric hypercalcemia diagnosed?
|
by a urinary calcium/creatinine clearance ratio <0.01 measured in a fasting morning urine spot collection.
|
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What does MEN 1 consist of?
|
- hyperparathyroidism
- pancreatic tumors - pituitary tumors (prolactinoma) |
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What level of testosterone is nearly always pathologic?
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< 100 ng/dL
|
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How much more cortisol do patients with Cushing's syndrome produce?
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3-4 times the amount
|
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What are the three screening tests for Cushing's syndrome?
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- 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) |
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What are risk factors for hypopituitarism?
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- previous macroadenoma,
- pituitary surgery - brain radiation |
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What is Multiple endocrine neoplasia type 2A characterized by?
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- pheochromocytoma
- medullary thyroid carcinoma - hyperparathyroidism due to parathyroid hyperplasia |
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why must β-Adrenergic antagonists never be administered before α-blockers?
|
β-Blockade permits unopposed α-agonist activity, causing hypertensive crisis
|
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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 |
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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 |
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What is the clinical presentation of pituitary apoplexy?
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- sudden onset of headache,
- visual disturbances, - opthalmoplegia (CN II, III, IV & VI) - mental status changes - endocrine dysfunction (acute adrenal insufficiency & hypothryoidism) |
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How should patients with pituitary apoplexy and rapidly progressing visual disturbances and/or mental status changes be treated?
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urgent neurosurgical evacuation
|
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How can you differentiate between pituitary apoplexy & subarachnoid hemorrhage?
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noncontrast CT
|
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Which vitamin D level is a marker of body stores?
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25-hydroxyvitamin D
|
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How does vitamin D deficiency cause secondary hyperparathyroidism?
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low vitamin d decreases intestinal absorption of calcium, leading to secondary hyperparathyroidism and renal phosphate clearance (hypophosphatemia)
|
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In what states is calcitonin elevated?
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medullary thyroid cancer or C-cell hyperplasia
|
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How is subclinical hypothyroidism defined?
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serum TSH level with a free T4 that is still within the population reference range
|
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What can mimic hypoparathyroidism in an alcoholic patient?
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hypomagnesemia - low Ca, high phos
|
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What does a low IGF-1 level in combination with three or four anterior pituitary deficiencies predict?
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presence of GH deficiency
|
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What is more sensitive and specific for determining growth hormone deficiency than measuring basal hormone levels?
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Growth hormone stimulation testing
|
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What can cause pseudo-Cushing's syndrome?
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depression and ETOH
|
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How is the 2-day dexamethasone-corticotropin releasing hormone stimulation test performed?
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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
|
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How is the 2-day dexamethasone-corticotropin releasing hormone stimulation test interpreted?
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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.
|
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What is the therapy of choice for uncomplicated Paget's disease?
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oral bisphosphonates
|
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What are the usual characteristics of adrenal adenomas?
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- smooth borders
- less than 4 cm in diameter - unilateral - homogenous in consistency - less than 10 Hounsfield units in density |
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Why do you see low DHEA-S with autonomous adrenal production of cortisol?
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- suppresses ACTH production, causing atrophy of contralateral adrenal and suppresses the zona reticularis
|
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Can serum TSH be used to monitor thyroid hormone replacement in patients with central hypothyroidism?
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NO
|
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With central hypthyroidism, what is the goal of thyroid replacement therapy?
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to normalize free T4
|
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In whom is metformin contraindicated?
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- renal insufficiency (Cr > 1.4)
- CHF |
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How do you distinguish postpartum thyroiditis from Graves' disease?
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Check serum TSH immunoglobulins/TSh receptor antibodies (present with Grave's and not postpartum)
|
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Is radioiodine uptake high or low with thryoiditis? Grave's?
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- low with thyroiditis
- high with Grave's |
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Which neoplams produce PTHrP?
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- squamous cell carcinoma
- ovarian cancer - breast cancer - renal cell cancer |
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How can you tell if hypercalcemia is caused by lymphoma?
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- low PTH, low PTHrP
- high 1,25-dihydroxyvitamin D3 (converted by lymphoma tissue from 25-hydroxyvitamin D) |
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Are Electrolyte abnormalities usually seen with central adrenal insufficiency?
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NO (usually seen with primary)
|
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How is Multiple endocrine neoplasia (MEN) type 2A transmitted?
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autosomal dominant of RET cheme on Chromosome 10
|
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What is Pendred's syndrome? How is it characterized?
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autosomal-recessive disorder of iodine organification. It is characterized by congenital sensorineural hearing loss combined with goiter.
|
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How is Pendred's syndrome diagnosed?
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positive perchlorate discharge test
|
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What radiographic finding is pathognomonic of osteomalacia?
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Looser's zones or Milkmans' fractures (pseudofractures), can be described as radiolucent bands that are usually symmetric and bilateral
|
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What laboratory findings will you see with osteomalacia?
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Hypocalcemia and hypophosphatemia
|
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What is critical in managing a patient with hyperglycemic hyperosmolar non-ketotic syndrome?
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preservation of vascular volume and supplementation with normal IV saline FOLLOWED BY IV insulin
|
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What is the differential diagnosis in patients with apparently inappropriate TSH secretion?
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TSH-producing pituitary adenoma and congenital thyroid hormone resistance
|
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If suspect surreptitious use of levothyroxine, what can you check? what will you find?
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- serum thyroglobulin levels
- they will be low or undetectable |
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If a patient has hypercalcemia and medication list shows use of a thiazide diuretic, what should be done next?
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- discontinue thiazide diuretic.
If calcium still elevated, check PTH |
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What should be checked in the evaluation of a patient with galactorrhea and irregular menses?
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TSH and prolactin
|
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What is one of the most common secondary causes of hyperprolactinemia?
|
primary hypothyroidism
|
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How can you differentiate central versus nephrogenic diabetes insipidus?
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water deprivation will fail to concentrate urine, but desmopressin will concentrate urine in central DI
|
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How does hyperprolactinemia cause hypogonadism?
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because prolactin directly suppresses gonadotropin-releasing hormone secretion and thus luteinizing hormone and testosterone production
|
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What is the initial treatment for prolactin-producing macroadenoma?
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dopamine agonist, such as bromocriptine or cabergoline
|
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What is a confirmatory test for Cushing's syndrome in patients with ambiguous results in screening tests?
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Inferior petrosal sinus sampling
|
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Describe how the thyroid tests will be for a euthyroid patient taking amiodarone.
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- high T4 and free T4
- low T3 - normal-high TSH |
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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 |
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What must you check in a patient with elevated prolactin?
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-pregnancy test
- TSH (usually not > 200) |
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What is an alternative to insulin therapy in patients who have not achieved optimal glycemic control with multi-agent oral therapy?
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Exenatide, an incretin mimetic that increases insulin secretion
|
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What can be used in patients with tertiary hyperparathyroidism to control elevated PTH in patients with chronic kidney disease?
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Cinacalcet hydrochloride (sensipar)
|
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What is the classic presentation of hereditary hemochromatosis?
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- hypogonadism
- diabetes mellitus - liver dysfunction - skin hyperpigmentation |
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What are the most affected organs in hereditary hemochromatosis?
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pituitary gland, pancreas, liver, and heart
|
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How is hereditary hemochromatosis inherited?
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autosomal recessive
|
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What ferritin levels are consistent with iron overload?
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Serum ferritin levels greater than 200 ng/mL (200 mg/L) in women and greater than 300 ng/mL (300 mg/L) in men
|
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What should be considered in a patient that complains of amenorrhea following D&C?
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endometrial damage or formation of scar tissue causing an outflow tract obstruction (Asherman's syndrome).
|
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How can you differentiate between uterine dysfunction and chronic anovulation?
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progesterin withdrawal challenge. If bleeds, then chronic anovulation & if doesn't, then outflow tract obstruction
|
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What are the characteristics of pheochromocytoma?
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- occur in teh adrenal medulla
- rarely bilateral - occur mostly on the right - rarely metastatic - usually > 2cm in diameter & heterogenous in consistency |
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What is the preferred study for pheochromocytomas?
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Computed tomography of the abdomen with thin sections through the adrenals
|
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What is teh concurrence of autominnune thyroiditis and Addison's disease known as?
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Schmidt's syndrome
|
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What other autoimmune diseases are patients with autoimmune thyroiditis at risk for?
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- adrenal insufficiency
- pernicious anemia - type 1 diabetes mellitus - vitiligo - premature ovarian failure |
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What would you expect to see in a patient with Addison's disease?
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- hyperkalemia
- mild hypercalcemia - fatugue - malaise - weight loss - orthostatic hypotension |
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What are the classic symptoms of renal osteodystrophy?
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- vague bone pain localized to the lower back, hips, or legs
- muscle weakness often occurs with normal muscle enzymes and nonspecific electromyography changes |
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Why do patients with severe hyperparathyroidism have pruritis?
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deposition of calcium in the skin
|
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What is the main radiographic feature of renal osteodystrophy?
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increased bone resorption, most commonly in the subperiosteal surfaces of the hands, neck of femur, and clavicle.
- osteosclerosis gives classic "rugger-jersey" spine |
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What laboratory abnormalities will you see with Vitamin D deficiency?
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- low vitamin D
- hypocalcemia - hyperparathyroidism - hypophosphatemia |
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How is Paget's disease diagnosed? what is seen radiographically?
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- 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 |
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What has growth hormone replacement been shown to do?
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- improve body composition
- lipid parameters and - bone mineral density |
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In postpartum thyroiditis, how long is the period of thyrotoxicosis? hypothyroidism?
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- 2- 4 months bc of preformed thyroid hormone from damaged follicles
- 2-4 months of hypothyroidism because of gland depletion |
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How do you treat the hyperthroid phase of postpartum thyroiditis?
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β-Blocker therapy
|
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How is growth hormone replacement done?
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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
|
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What are adverse effects of growth hormone replacement in adults?
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primarily related to fluid retention and can include parasthesias, myalgias, edema, and joint pain
|
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Should patients with active malignancies be treated with growth hormone?
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NO, concern for proliferation of malignancy
|
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What can be used in men with bilateral adrenal hyperplasia in whom spironolactone therapy causes painful gynecomastia?
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eplerenone
|
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Is surgery indicated in bilateral adrenal hyperplasia?
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NO
|
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How does osteomalacia usually present?
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elevation of alkaline phosphatase in association with hypocalcemia and hypophosphatemia
|
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Describe the pituitary function in empty sella syndrome?
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usually normal
|
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What should post-prandial glucose levels be?
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30-50 mg/dL higher than pre-prandial levels
|
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What are postmenopausal women with subclinical hyperthyroidism and an undetectable TSH at risk for?
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osteoporosis?
|
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How is subclinical hyperthyroidism defined?
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- low or undetectable serum TSH
- normal free T4 and total T3 or free T3 |
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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)
|
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What is the classic triad of symptoms for pheochromocytoma?
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- headache
- palpitations - diaphoresis |
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What is the first step in evaluating a thyroid nodule?
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checking TSH. If normal (nonfunctioning 'cold'- nodule) or low (fucntioning 'hot' nodule)
|
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What should be done to further evaluate a patient with a 'cold' nodule?
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FNA biopsy of the nodule
|
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What should be done to further evaluate a patient with a 'hot' nodule?
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thyroid scan to confirm presence and determine if there are other nodules & measurement of free T4 & T3
|
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What is measurement of serum thyroglobulin useful for?
|
following thyroid cancers in response to treatment
|
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Why do germ cell tumors cause the release of excess thyroid hormone?
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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
|
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What is a prevalent secondary cause of male osteoporosis? Why?
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- Hypogonadism
- increases the skeletal sensitivity to parathyroid hormone and decreases intestinal calcium absorption, predisposing to osteoporosis |
|
What are risk factors for osteoporosis in males?
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- 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 |
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Risk factors for osteoporosis in females?
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- 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 |
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What are the indications for measurement of bone mass?
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- 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). |
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What are patients with long-standing Paget's disease at significantly increased risk of developing?
|
osteogenic sarcoma in affected bone
|
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What should you suspect when you see 'starburst' appearance in bone?
|
osteogenic sarcoma
|
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What are some complications of Paget's disease?
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- hypercalcemia
- high-output congestive heart failure - deafness - excessive bleeding during surgery due to hypervascular |
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What class of medications can modestly elevate prolactin levels?
|
psychotropic medications
|
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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
|
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What study should be performed in any young male with a high FSH & primary hypoganadism?
|
karyotype to check for Klinefelter's syndrome
|
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What is the most sensitive screening test for primary aldosteronism ?
|
plasma aldosterone-plasma renin activity ratio
|
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What are secondary causes of hypertension?
|
- primary aldosteronism
- acromegaly - pheochromocytoma - Cushing's syndrome |
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What laboratory test results strongly suggests primary aldosteronism?
|
ARR ratio > 20, with a plasma aldosterone >15 ng/dL
|
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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
|
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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
|
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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%
|