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200 Cards in this Set
- Front
- Back
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Osteoporosis, renal stones, high calcium
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Primary hyperparathyroidism
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Calcium level in pts with secondary hyperPTH
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Low (the hypocalcemia is the cause of the hyperPTH)
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Lab values in pts with hypercalcemia of malignancy
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Super high Ca
Normal PTH (suppressed) |
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Hypercalcemia, alkalosis, renal failure
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Milk-alkali syndrome (rare but from excessive dietary intake of calcium)
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Why do pts with sarcoidosis have hypercalcemia?
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Increased 1-alpha hydroxylase activity --> excess conversion to calcitriol --> increased calcium absorption from GI tract
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Symptoms of hypercalcemia (6)
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Constipation, polyuria, anorexia, confusion, lethargy, fatigue
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Increase in hat size and hearing loss
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Paget's disease of the bone
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Pathophys of Paget's of the bone
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Abnormal bone remodeling --> chaotic mosaic pattern (activation of osteoclasts and blasts), eventually gets burned out
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2 tests for Paget's of the bone
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Increased alk phos and urinary n telopeptide
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Pathophys of osteoporosis/hyperPTH
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Bone demineralization
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Pathophys of vita D deficiency
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Increased deposition of unmineralized osteoid
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Pathophys of fibrous dysplasia
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Fibrous replacement of bone
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Pathophys of hypervitaminosis A on the bone
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Abundant mineralization of periosteum
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2 early risks of untreated hyperthyroidism
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Rapid bone loss (increased osteoclastic bone resorption) and tachyarrythmias
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What is functional hypogonadism?
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Systemic illness (e.g. uncontrolled diabetes) --> low LH/FSH and low testosterone
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What is primary hypogonadism?
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Testicular: low testosterone w/ elevated LH/FSH (but testicle can't respond to the gonadotrophins)
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What is secondary hypogonadism?
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Central: los gonadotrophins and testosterone, often from elevated prolactin (inhibit release of GnRH)
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What type of hypogonadism does an elevated estradiol in a male indicate?
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Primary (the high FSH/LH stimulate testicular aromatase activity --> increased estradiol)
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Myopathy Sx + sluggish ankle reflexes
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Hypothyroidism (can have elevated CK level) more likely than polymyositis
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Decreased LOC, dry mucous membranes, polyuria, diffuse abdominal pain in setting of an acute URI
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DKA
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How do infections precipitate DKA?
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Cause systemic release of insulin counterregulatory hormones (catecholamines, cortisol) --> excess glucagon --> hyperglycemia
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Size cut off for a microadenoma
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<10mm
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What are the Sx of vitamin toxicity?
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Constipation, abd pain, polyuria/polydipsia (similar to those of hypercalcemia since its role in Ca absorption means it can lead to hypercalcemia)
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Weight loss, fatigue, muscle weakness, orthostatic hypotension, headache
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Adrenal insufficiency
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What are the Sx of Vitamin A toxicity (5)?
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Dry skin, headache, abd pain, blurry vision, pseudotumor cerebri
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Severe hyperglycemia in type 2 diabetics causes this (instead of DKA)
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Hyperglycemia hyperosmolar nonketoic coma
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Uncontrolled HTN, skin tags, carpal tunnel, increase in ring size, soughy/sweaty hands
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Acromegaly
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Diagnostic test for acromegaly
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Measure GH following oral glucose load (nml response is to suppress GH <1mcg/dl; pts with acromegaly cannot)
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Why is IGF1 not a good screning test for acromegaly?
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Other illnesses can lead to low IGF1 levels
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Which testicular tumor has high estradiol levels, inhibiting LH and FSH?
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Leydig cell tumors
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Which testicular tumor has beta-hCG as a tumor marker?
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Choriocarcinoma
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Which testicular tumor has AFP and beta-hCG as tumor markers?
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Teratomas
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Which testicular tumor has AFP elevated (2 names)?
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Yolk sac tumor (endodermal sinus tumor)
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4 indications for surgery in asymptomatic pts with primary hyperparathyroidism
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<50
BMD < 2.5 GFR <60 Calcium >1 above upper limit of nml |
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Scan prior to parathyroid surgery
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Sestamibi scan (to determine location of adenoma)
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Rx for symptomatic hypercalcemia (2)
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Bisphosphonate
Loop diuretics |
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Management for Grade I and II diabetic ulcers (superficial or deep to muscle, but no cellulitis)
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Debridement
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Management for Grade III diabetic ulcers (cellulitis, abscess formation, or osteo)
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IV Abx, debridement, and bone biopsy
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Management of Grade IV and V diabetic ulcers (localized or extensive gangrene)
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Surgical consult for possible amputation
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2 extrathyroidal manifestations of Graves' disease
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Infiltrative ophthalmopathy and pretibial myxedema
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Infiltrative ophthalmopathy and pretibial myxedema indicates the diagnosis is likely ___ and not ___
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Graves' disease
Toxic adenoma |
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4 mechanisms by which tumors produce hypercalcemia
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PTHrP
Cytokines Calcitriol Ectopic PTH |
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Hypcercalemia in Hodgkin's is likely due to
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Calcitriol
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Hypercalcemia in tumors that are metastatic to the bone is due to
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Cytokines, IL-1, and TNF --> local osteolysis
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Monofilament tests
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Pressure sensation
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Cause of osteomalacia
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Vita D deficiency --> defective mineralization of bone
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Vita D deficiency in kids
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Rickets
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Goal BP for diabetics
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<130/80
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Danger of ACEIs in pts with renal insufficiency
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Hyperkalemia
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Monofilament tests
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Pressure sensation
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Best intervention for diabetics w/ azotemia
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BP control (blood sugar control not as helpful at this pt, better earlier)
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Cause of osteomalacia
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Vita D deficiency --> defective mineralization of bone
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5 causes of primary adrenal insufficiency
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TB, fungal infection, CMV infection, autoimmune adrenalitis, adrenal hemorrhage (if acute)
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Vita D deficiency in kids
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Rickets
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Adrenal calcification in setting of insufficiency
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TB
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Goal BP for diabetics
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<130/80
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Adrenal leukodystrophy
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Insufficiency caused by accumulation of VLCFA (v. long chain fatty acids)
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Danger of ACEIs in pts with renal insufficiency
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Hyperkalemia
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Most common cause of primary adrenal insufficiency in the US
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Autoimmune adrenalitis
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Best intervention for diabetics w/ azotemia
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BP control (blood sugar control not as helpful at this pt, better earlier)
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5 causes of primary adrenal insufficiency
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TB, fungal infection, CMV infection, autoimmune adrenalitis, adrenal hemorrhage (if acute)
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Adrenal calcification in setting of insufficiency
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TB
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Adrenal leukodystrophy
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Insufficiency caused by accumulation of VLCFA (v. long chain fatty acids)
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Most common cause of primary adrenal insufficiency in the US
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Autoimmune adrenalitis
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Management of non-ketotic hyperglycemic coma (3)
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Fluids first!!
May decrease serum glucose on their own, large volumes required b/c of glucose induced osmotic diuresis NS; switch to 5% dextrose once <250 Also regular insulin and K+ (start once K values have normalized) |
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How to distinguish Cushing's disease and ectopic ACTH production
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Dexamethasone suppression test: 50% decrease in cortisol in Cushin's (some feedback still present in adenoma), minimal in ectopic
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Best Rx for Garves'
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Radioactive iodine
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Sick euthyroid syndrome (cause and lab findings)
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Acute illness --> abnormal TFTs (from caloric deprivations and increased cytokines)
Usually low T3; may be followed by mild increase in TSH, then resolves |
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4 lab test abnormalities that are an indication for TFTs
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Hyperlipidemia (increased incidence in hypothyroid pts)
Hyponatremia (due to excess ADH) Anemia Increased muscle enzymes (myopathy) |
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2 Abs in Hasimoto's
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Anti-thyroid peroxidase (TPO) and anti-thyroglobulin
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Ab in Graves
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Thyroid-stimulating immunoglobulins (TSI), which stimulate TSH receptors
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What thyroid tumor secretes calcitonin
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Medullary
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Psammoma bodies indicate
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Papillary thyroid cancer
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Encapsulation of papillary vs. follicular thyroid cancer
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Papillary is unencapsulated, whereas follicular is encapsulated
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How to distinguish follicular cancer from follicular adenoma
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Invasion of capsule and blood vessels
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Invasion of capsule and blood vessels in follicular cancer creates a high risk of
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Metastasis
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2 conditions to r/o before diagnosing SIADH
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Hypothyroidism
Adrenal insufficiency |
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NSAIDs can cause what syndrome?
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SIADH (b/c they potentiate the action of ADH)
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Pt with low sodium who ahs low plasma osm (<280) with a high urine osm (>100)
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SIADH
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Mineralocorticoid deficiency: lab values show
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Hypotonic hypoantremia w/ hypovolemia and high potassium
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Risk w/ Hashimoto's thyroiditis
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Thyroid lymphoma
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Compressive neck symptoms, "doughnut sign" on CT around trachea, pseudocystic appearance on US, decreased ardioactive iodine uptake
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Thyroid lymphoma
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Diagnostic test for suspected thyroid lymphoma
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Core biopsy
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Lab values in primary hyperparathyroidism
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Increased calcium, decreased phos
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Lab values in multiple myleoma
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Increased calcium, low/nml PTH
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Hypocalcemia with hyperphosphatemia
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Secondary hyperPTH from renal failure
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Hwo does renal failure cause secondary hyperPTH?
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Renal failure --> phos retention --> Increased PTH AND --> decreased Ca, which increases PTH,
AND --> decreased Vita D, which causes less PTH suppression |
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Most common cause of thyroid nodules
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Benign colloid nodules
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Second most common cause of thyroid nodules
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Follicular adenoma
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Best Rx for pheo
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Labetalol or other alpha and beta blocker
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Coarse facial features, enalrged hands/feet, prominent frotnal bones/jaw
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Acromegaly (excess GH --> excess IGF-1)
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Most common cause of death in pts with acromegaly
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Cardiac (CHF, cardiomyopathy, arrhythmia)
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MEN I, IIa, and IIb
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MEN I: pituitary, pancreatic, parathyroid
MEN IIa: parathyroid, pheo, medullary thyroid MEN IIb: pheo, medullary thyroid, mucosal neuroma |
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Which MEN syndrome has a marfanoid habitus?
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MEN IIb
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Genes associated with MEN syndromes
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MEN I: MENI
MEN II: RET |
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Two most common causes of HTN w/ low potassium
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Primary hyperaldosteronism, renovascular disease, and renin-secreting tumor
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Test and results to differentiate primary hyperaldosteronism and renovascular disease
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Plasma renin activity and plasma aldosterone level
- Both high in renovascular disease - High aldosterone, low renin in primary hyperaldosteronism |
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Multiple episodes of paralysis due to abrupt fall in serum K+ level
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Hypokalemic periodic paralysis
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Pathophys and etiology of hypokalemic periodic paralysis
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Stress/meals release epi/insulin --> potassium influx into cell
Familial or thyrotoxicosis |
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BP, aldosterone, and renin in hypokalemic periodic paralysis
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Normal
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Hypokalmia, metabolic alkalosis, elevated urine chloride, normal BP
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Bartter's syndrome (defective Na reabsorption --> hypovolemia --> RAA activation)
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Rate of correction of hyponatremia
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0.5-1 mEq/L/hr
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Rx for severe, moderate, and mild hyponatremia
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Severe: hypertonic saline
Moderate: NS w/ furosemide Mild: water restriction |
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3 consequences of diabetic autonomic neuropathy on the GI tract
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Stomach: gastroparesis
SI: diarrhea (from bacterial overgrowth) LI: Constipation |
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3 meds for diabetic gastroparesis
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Metoclopramide (dopamine antagonist): best
Erythromycin (interacts w/ motilin receptors) Bethanechol (parasym mimetic) |
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HTN, muscle weakness, and numbness
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Primary hyperaldosteronism
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Most common cause of primary hyperaldosteronism
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Aldosterone-secreting adrenal tumor
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3 groups of Paget's disease of the bone pts that need treatment
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Symptomatic
Involvement of weight-bearing bones Markedly elevated alk phos levels |
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Rx for Paget's disease
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Bisphosphonates
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First line Rx for Graves disease
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RAI
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Electrolyte problem associated with lithium
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Nephrogenic diabetes insipidus
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Rx for hypotensive, hypernatremic pts with DI
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Normal saline
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Rx for lithium-induced DI
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Amiloride: K+-sparing diuretic (prevents further lithium accumulation in renal tubules)
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How to distinguish btwn nephrogenic and central DI
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Fluid restriction test, and adminster ADH during test (no increase in urine osmolality after ADH indicates nephrogenic)
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Most common causes of thyrotoxicosis with low RAI uptake (5)
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- Subacute lymphocytic (painless) thyroiditis: usually postpartum
- Subacute granulamtous thyroiditis (De Quervain's): painful! - Iodine induced thyroid toxicosis - Levothyroxine overdose - Struma ovarii (exogenous production by ovarian tumor) |
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Hyperthyroid w/ no goiter/exophthalmos; low TSH and elevated T3/T4; decreased RAI uptake; follicular atrophy on biopsy
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Factitious thyrotoxicosis (exogenous thyroid hormone ingestion)
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Hypothyroid Sx with low T3/T4 and low or inappropriately normal TSH
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Secondary (pituitary) or tertiary (hypothalamus) hypothyroidism
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Hypothyroid with high T4/T3 and normal TSH
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Generalized resistance to thyroid hormone
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Best way to monitor response to treatment in DKA
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Serum anion gap (changes first)
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What serum test is specific for pts with androgen-producing adrenal tumors?
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DHEA-S (only produced by adrenals, whereas other androgens (DHEA, andostenedione, and testosterone) are produced by both the adrenals and the ovaries
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Cause of systolic HTN in hyperthyroidism?
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Hyperdynamic circulation
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Potential cause of HTN in hypothyroidism?
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Increased vascular resistance
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Bronze diabetes
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Hemochromatosis
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Periorbital edema, myositis, eosinophilia
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Trichinosis
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2 CBC abnormliaites in primary adrenal insufficiency
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Anemia
Eosinophilia |
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Rx for central DI
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DDAVP nasal spray
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Rx for nephrogenic DI
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Indomethacin, HCTZ
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Sodium levels in primary hyperaldosteronism
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Mild hypernatremia (due to mineralocorticoid activity)
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Pseudofractures/blurring of spine
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Osteomalacia
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Why is phosphate lower than calcium in osteomalacia
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Decreased absorption of both, which increases PTH, which helps normalize low calcium but exacerbates hypophosphatemia
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Pts at risk for adrenal hemorrhage
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Those who are anticoagulated
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Adrenal insufficiency after birth
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Congenital adrenal hyperplasia due to 21-hydroxylase deficiency
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Chronic steroid use causes what type of adrenal insufficiency?
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Tertiary (central)
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In tertiary adrenal insufficiency, what is preserved?
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Aldosterone secretion
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Somogyi effect
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Nocturnal hyoglycemia --> counterregulary hormone release (epi, NE, glucagon) --> morning hyperglycemia
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Dawn phenomenon
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Morning hypoglycemia due to increased insulin sensitivity between 3 and 8AM (from a spike in GH release after falling asleep)
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Aldosterone's effect on electrolytes
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Saves sodium and loses potassium
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Why does primary aldosteronism cause polyuria?
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Hypokalemia --> ADH resistance --> polyuria
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Immobilization can lead to what electrolyte abnormalitiy?
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Hypercalcemia
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Rx for hypercalcemia 2/2 immobilization
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Bisphosphonates
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Thyrotoxicosis after treatment for hyperthyroidism is usually due to
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Radioactive iodine destroying follicular cells --> release of thyroid hormone
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How to prevent thyrotoxicosis after RAI
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Pre-treat with anti-thyroid agents (PTU or methimazole)
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Effect of steroids on thyroid hormones
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Decrease conversion of T4--> T3, so improve hyperthyroidism
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Necrotic migratory erythema w/ hyperglycemia
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Glucagonoma
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DDx (4) for hypokalemia, alkalosis, and normotensive (and test to differentiate them)
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Low urine Cl: surreptitious vomiting
High urine Cl: diuretic abuse, Bartter syndrome, Gitelman's syndrome |
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4 causes of primary hypoparathyroidism
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Post-surgical
Congenital absence (DiGeorge syndrome) Autoimmune (polyendocrine syndrome) Defective calcium-sensing receptors |
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Requirement w/ sildenafil and alpha-blocker
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Give at least 4hrs apart to decrease risk of hypotension
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Hyponatremia in pt w/ CHF exacerbation indicates
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Severe heart failure (b/c indicates degree of water retention)
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Electrolyte abnormalitiy in pts w/ Cushings
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Hypokalemia (corticosteroids have some mineralocorticoid activity --> renal potassium wasting)
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Cause of pancreatic necrosis in pts w/ pancreatitis
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Release of pancreatic enzymes --> increased vacular permeability and systemic inflammation
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3 phases of trichinosis
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N/V/D. 1 wk later systemic hypersensitivity (splinter hemorrhage, periorbital edema), then muscle pain/weakness/swelling
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CBC abnormality in trichinosis
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Eosinophilia
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Wide pulse pressure may be due to this valve abnormality
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Aortic regurgitation
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Hypogonadism, arthropathy, pancreatic necrosis/DM, cirrhosis/hepatomegaly
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Hemochromatosis
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Autoimmune polyendocrine syndrome is also called
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Autoimmune polyendocrinopathy candidiasis ectodermal dystrophy (APECED)
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Cardiac disease associated w/ hemochromatosis
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Cardiac conduction block
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Episodic tachycardia is usually
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PSVT
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Most common mechanism of PSVT
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AV node re-entry
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How to break the rhythm in PSVT
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Vagal maneuvers (Valsalva, carotid sinus massage, cold water), which decrease conduction
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Rx for PSVT
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Adenosine
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Why avoid sedative sin COPD exacerbations?
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Can worsen alveolar hypoventilation --> hypoxia/ hypercapnia
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How does respiratory failure cause lactic acidosis?
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Progressive tissue hypoxia
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1st line DMARD for rheumatoid arthritis
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Methotrexate
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Common side effects of methotrexate
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Stomatitis, nausea, abdominal pain, hepatotoxicity, myelosuppression
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What is Felty syndrome (3)?
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RA w/ splenomegaly and granulocytopenia
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PMN cutoff for SBP
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>250
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Serum-ascites albumin gradient (SAAG) > 1.1 indicates
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Ascites is due to portal HTN
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Histologic finding of diabetic nephropathy
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Diffuse glomerulosclerosis (nodular glomerulosclerosis w/ Kimmelstiel-Wilson nodules is pathognomonic)
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What is indicated for HIV post-exposure prophylaxis, and how often is testing needed
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2-3 drugs
Immediate, 6 wks, 3mo, 6mo |
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Cause of decreased FVC and FEV1 in COPD
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Air trapping during expiration, which increases FRC and TLC
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What happens to the alveolar-capillary membrane in COPD, and what does this caused
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Destroyed --> increased distensibility and compliance
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Most common cause of malignant otitis externa
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Pseudomonas
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Possible complications of malignant otitis externa (2)
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Osteomyelitis of skull base and cranial nerve damage
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Pt being treated for HBV w/ decrease in AST/ALT but increase in PT
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Progression to fulminant liver failure
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How to distinguish EBV and CMV mononucleosis
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EBV has a positive heterophile antibody test (Monospot) w/ pharyngitis and cervical LAD; CMV has none of those
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Large basophilic lymphocytes w/ vacuolated appearance
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Atypical lymphocytes (seen in CMV/EBV)
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Why is dipyridamole used in myocardial perfusion scanning?
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Dilates vessels, but diseased vessels already maximally dilated, so get coronary steal to healthy areas and decreased perfusion in diseased areas
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Polycythemia, headache, nausea, dizzines
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CO poisoning
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No bacteria on gram stain but lots of neutrophils
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May be Legionella (gram negative, but stains poorly)
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Rx for LEgionnaire's disease
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Macrolides (azithromycin) or fluroquinolones (levofloxacin)
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Diagnostic test for Legionnaire's
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Urine antigen test or culture on chocolateagar
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Diabetic w/ severe ear pain, otorrhea, and granulation tissue in ear canal
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Malignant otitis externa
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Possible complication of succinylcholine that limits its use in pts with this lab abnormality
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Significant potassium release/ arrhythmias
Hyperkalemia |
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Pts at high risk of hyperkalemia (whom sucinlcholine is contraindicated in)
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Crush/burn injuries >8hrs old (risk of rhabdo)
Demyelinating disease (GBS) Tumor lysis syndrome |
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Utility of a receiver-operating characteristic curve (ROC)
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Determines various cut-off points, which shows the trade-off btwn sensitivity and false positives (1-specificity)
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Psychiatric problems associated w/ Cushing's
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Sleep disturbances, depression, psychosis
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Systolic-diastolic abdominal bruit may indicate
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Renal artery stenosis
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BP in right arm > left arm
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Aortic coarctation
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BP in left arm > right arm
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Subclavian atherosclerosis
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BP greater in one arm than the other with chest pain
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Aortic dissection
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Prominent bronchovascular markings, flattening of diaphragm, and normal DLCO
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Chronic bronchitis
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Hyperinflation of chest, decreased vascular markings, decreased DLC (due to destruction fo alveoli0
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Emphysema
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Panacinar emphysema is usually due to
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Alpha-1 antitrypsin deficiency
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Centracinar emphysema is usually due to
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COPD
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Kidney stones since childhood, FH, hexagonal crystals on UA, + urinary cyanide nitroprusside test
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Cystinuria (impaired amino acid transport)
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What function of the pancreas is decreased in CF?
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Exocrine
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Meniere's disease is what/where?
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Accumulation of endolymph in inner ear
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What is the attributable risk percentage?
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Excess risk in a population that can be attributed to a particular risk factor
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How to calculate the attributable risk percentage
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RR-1/RR
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Concern with a varicocele that fails to empty when recumbent
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Renal cell carcinoma (obstructing gonadal vein where it enters renal vein)
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