Usmle 3 Endocrinology

Front 1

side effect of amiodarone?

Back 1

- check LFTs, PFTs, TFTs

Front 2

hypothyroidism secondary to amiodarone?

Back 2

- give levo

Front 3

subclinical thyrotoxicosis?

Back 3

- decreased TSH with normal T4, T3, no sx --> recheck TFTs in 6-8 wks
- etiology: levo tx, nodular thyroid dz, graves, thyroiditis

Front 4

HgA1c goal

Back 4

6.5%

Front 5

MEN-I

Back 5

- pt with hyperCa2+ and hx of gastric ulcer
- 3Ps: hyperPTH, zollinger-ellison syndrome (gastrin-secreting pancreatic tumor) pit tumor (prolactinoma is MC)
- refer for parathyroidectomy --> remove 3.5 glands

Front 6

MEN2

Back 6

- check serum calcitonin levels and metanephrine levels and free catecholamines and Ca2+ to screen for medullary thyroid and pheo and primary hyperPTH

Front 7

NPH vs regular

Back 7

- NPH is long acting
- regular is short acting

Front 8

incidental adrenal mass is found

Back 8

- do workup: dexa suppression test, 24 hr urine catecholamine, metanephrine, vanillylmandelic acid, 17-ketosteroid
- surg tx for functional tumors and malignant tumors and >4cm
- otherwise monitor with serial imaging

Front 9

management of DM1 during labor and cesarean section

Back 9

- regular regimen night before
- start on drip perioperatively

Front 10

nelson's syndrome

Back 10

- pt with cushings undergoes bilateral adrenalectomy --> pit enlarges secondary to loss of feedack --> bitemoporal hemianopsia and hyperpigmentation
- MRI shows pit microadenoma with supersellar extension
- high ACTH

Front 11

bitemoporal hemianopsia with versus without increased pigmentation?

Back 11

- with pigmentation: Nelson's syndrome
- without: prolactinoma, craniopharyngeoma

Front 12

dx and tx of pheo?

Back 12

- plasma free metanephrine, 24 hour urine catecholamine, metanephrine, vanillylmandelic acid
- tx with alpha blockade e.g. phenoxybenzamine and with liberal salt and fluid intake
- once adequate alpha blockade get MRI/CT to find tumor and then surgery
- if borderline serum/unine tests then get MIBG scan
- pt becomes hypotensive when tumor is removed then bolus fluids --> dobutamine and dopamine won't work b/c alpha blockade
- ** HY

Front 13

pt with hypoTH on levo and wants to start OCP?

Back 13

- estrogen increases TBG (binding globulin) --> increased binding of T3 and T4 --> decreased free T3 and T4 --> needs increased levo
- opposite occurs with androgens and glucocorticoids --> decreased TBG

Front 14

dx of DM

Back 14

- two fasting glucose >= 126
- one random glucose >= 200 w/ sx
- abnormal glucose tolerance test
- hgA1c > 6.5%

Front 15

tx of DM

Back 15

1. metformin
2. metformin + glyburide
3. insulin

Front 16

which DM med is C/I with CHF?

Back 16

- thiazolidinedionies: rosiglitazone and pioglitazone

Front 17

BP goal in DM vs nonDM pts
LDL goal
urine protein goal

Back 17

- 130/80 vs 140/90
- <100 or <70 if CAD and DM
- if any protein no matter how small give ACE-I even if normal BP

Front 18

tx of gastroparesis

Back 18

- metoclopromide or erythromycin
- don't need to do gastric-emptying scan

Front 19

which diseases cause hypothyroidism

Back 19

- hashimotos

Front 20

hyperTH - tender versus nontender thyroid

Back 20

- tender: subacute thyroiditis from viral etiology, tx with ASA
- nontender: silent thyroiditis from "leaking" gland, no tx

Front 21

tx of thyroid storm

Back 21

- severe, life-threatening hyperTH
- iodine to block iodine uptake
- propylthiouracil or methimazole: blocks thyroxine production
- dexamethasone: blocks peripheral conversion of T4 to T3
- propranolol: blocks target organ effect

Front 22

amiodarone's effect on thyroid hormones?

Back 22

- decreases conversion of T4 to T3 so see high T4 and low T3 = hypothyroid

Front 23

diagnosis of hashimoto's

Back 23

- check anti-TPO, should be high

Front 24

pt with medullary thyroid cancer s/p surgery w/ persistant increased calcitonin?

Back 24

- get CT head and neck to look for metastatic disease --> if no findings then get abd CT and bone scan --> if no findings then do I111 octreotide or pet scan

Front 25

thyroid nodule workup

Back 25

- get TSH
- normal TSH --> FNAC if >1cm
- decreased TSH --> radioisotope scan --> hot nodule --> observe; if cold nodule --> biopsy
- increased TSH --> Hashimoto's --> levo

Front 26

tx of papillary thyroid cancer

Back 26

- no staging is necessary, just take out thyroid (near total thyroidectomy followed by RAI
- good prognosis

Front 27

pt with DM and suspect gastroperesis?

Back 27

- get upper endoscopy 1st to r/o gastric outlet obstruction
- then get gastric emptying study

Front 28

tx gastroperesis?

Back 28

- small frequent meals; avoid high fever and high fats --> slows emptying
- erythromycin, metoclopramide

Front 29

risk of long term gluccocorticoid use?

Back 29

- if more than 3 weeks then can suppress HPA axis --> adrenal insufficiency

Front 30

tx of idiopathic hypoPTH

Back 30

- high dose vit D (calciferol) and high dose Ca2+ --> pt will have increased urinary excretion of Ca b/c decreased PTH causes decreased Ca reabsorption by kidney --> add thiazide --> increased Ca2+ renal absorption
- calcitriol (1,25 dihydroxy vit D) is used for acute hypoCa2+ e.g. post surgery

Front 31

risks and benefits of HRT

Back 31

- risks: VTE, breast caner, dementia, doesn't improve CAD
- benefits: improves lipids, decreases osteoperosis, decreases vasomotor symptoms

Front 32

pt with iron and vit D def despite normal diet?

Back 32

- malabsorption --> see vitiligo, fhx of autoimmune disease --> think celiac

Front 33

test for celiac?

Back 33

- anti-endomysial and anti-tissue transglutaminase ab

Front 34

hypocalcemia w/ hypophos versus hyperphos?

Back 34

- hypophos- think malabsorption
- hyperphos- think hypoparathyroidism

Front 35

secondary hyperPTH?

Back 35

- hyperPTH sceondary to low Ca2+

Front 36

post partum w/ sx of hyperTH?

Back 36

- post-partum thyroiditis i.e. painless thyroiditis --> will become hypoTH before recovery of thyroid fx

Front 37

RAIU in Graves vs toxic adenoma vs thyroiditis?

Back 37

- increased RAIU uptake: graves, toxic adneoma
- decreased RAIU uptake: thyroiditis

Front 38

painless vs painful thyroiditis

Back 38

- painful = dequervains = subacute granulomatous

Front 39

high thyroidglobulin

Back 39

- see in destruction of thyroid cells in thyroiditis (both painless and painful)
- also see high anti-TPO

Front 40

african american woman with lymph nodes, lung nodules and hyperCa2+

Back 40

- sarcoid, not malignancy

Front 41

c/i for 1. metofmrin, 2. TZD

Back 41

1. EtOH, CHF, Cr
2. CHF

Front 42

DM secondary to chronic pancreatitis- which DM meds are c/i?

Back 42

- glyburide- works by increasing secretion of insulin so won't work here
- acarbose - s/i is steatorrhea which pancreatitis pts already have

Front 43

tx of graves' dz?

Back 43

- RAI ablation with prednisone
- C/I in large retrosternal goiters b/c inflammation after RAI may compromise airway
- can cause thyroid storm

Front 44

tx of thyroid storm

Back 44

- glucocorticoids to decrease T4 to T3
- PTU or methimazole
- iodine 1 hr after PTU/MMI is given

Front 45

pt with DM1 presenting with decreased insulin requirement

Back 45

- look for other autoimmune dz e.g. adrenal failure

Front 46

labs for adrenal failure

Back 46

- eosinophilia, borderline Na, hyperk+, mild anion gap acidosis, prerenal azotemia, decreased blood sugar
- test with cosyntropin stimulated cortisol levels
- look for other AI dz - addison's , hypoTH (pernicious anemia), AI ovarian failure

Front 47

indications for parathyroidectomy in secondary or tertiary hyperPTH?

Back 47

1. Ca2+ >10.5 and not responding to conservative management; 2. mod to severe hyperphos; 3. PTH >1000; 4. bone pain; 5. pruritus; 6. calciphylaxis; 7. soft tissue calcification
- check to make sure alk phos is increased to r/o adynamic bone dz (low bone turnover)

Front 48

sign of glucogonoma

Back 48

- necrolytic migratory erythema --> red, itchy, painful rash that clears from the center
- check glucagon levels

Front 49

pt with oetoporosis not responding to bisphos tx

Back 49

- look for secondary causes- multiple myeloma

Front 50

pt on alendronate with anemia

Back 50

- esoph ulceration

Front 51

PTU vs MMI in pregnancy

Back 51

- PTU in first trimester --> switch to MMI second and third to decrease risk of liver failure

Front 52

decreased TSH and decreased T4

Back 52

- central hypoTH --> MRI to look for mass lesion
- also must r/o central adrenal insufficiency w/ cortisol and cosyntropin stimulation before beginning therapy

Front 53

pt with hx papillary thyroid cancer s/p thyroidectomy and RAI, goal of tx w/ levo?

Back 53

goal isn't T4 level but to suppress TSH below normal range to decrease recurrence

Front 54

pt with increased T3, T4 and TSH?

Back 54

- TSH secreting pit adenoma vs thyroid hormone resistance syndrome
- ddx by increased serum alpha-subunit in TSH secreting pit adenoma
- also TH resistance usually presents as hypoTH

Front 55

T3,T4, TSH levels in pregnancy vs dysalbuminemic hyperthyroxinemia, increased TBG?

Back 55

- pregnancy: increased T4, T3 and normal TSH
- dysalbuminemic hyperthyroxinemia: increased T4 and normal T3 and TSH (abnormal albumin that binds to T4 but not to T3)
- increased TBG: increased T3, T4, normal TSH

Front 56

albumin-calcium correction

Back 56

- for every 1g of albumin less than 4, add 0.8 to Ca2+

Front 57

Ca2+ in paraproteinemia?

Back 57

- see increased Ca2+ levels secondary to binding --> normal ionized Ca2+

Front 58

pt with positve anti-TPO and rapidly enlarging goiter?

Back 58

- Hashimoto's shouldn't have rapidly enlarging goiter --> Hashimoto's predisposes to thyroid lymphoma

Front 59

colloid goiter?

Back 59

- thyroid enlargement in adolescent girls with normal TFTs, negative anti-TPO

Front 60

increased calcitonin?

Back 60

- medullary thyroid cancer

Front 61

increased risk in DVT in progestin-estrogen vs estorgen?

Back 61

- decreased risk with estrogen only

Front 62

woman with hypogonadism, found to have decreased LH, FSH and increased alpha subunit with only mildly elevated prolactin

Back 62

- nonfunctioning pit adenoma --> gonadotropin-secretion cells of the pit gland overproduce alpha subunit but not FSH or LH
- first line: transphenoidal pit surgery
- ddx: prolactinoma where hypogonad as above but prolactin level is HUGE

Front 63

- tx prolactinomas?

Back 63

- bromocriptine and cabergoline

Front 64

pt on chronic steroids and now septic?

Back 64

- pt will be hypotensive b/c pit-adrenal axis is suppressed and need cortisol to mount stress-related changes for survival --> start on steroids; can also start in hypotensive pts not on steroids chronicially

Front 65

pt on metformin and Co2 of 12?

Back 65

- think met acidosis secondary to lactic acidosis

Front 66

goal K+ when treating DKA?

Back 66

- give K+ if < 5.3

Front 67

when to stop giving IV insulin in DKA?

Back 67

- once gap closes
- bicarb greater than or equal to 18, eating
- once BG < 200 --> half the insulin dose and switch to D51/2NS
- overlap IV insulin with subQ insulin over 2hrs

Front 68

when to give bicarb?

Back 68

- pH <7 b/c decreases heart contractility and causes systemic vasodilation

Front 69

pt with gastric bypass- which vitamin supplementation?

Back 69

- malabsorption --> need vit D and C
- if low phos, it's a sign of vit D deficiency (see before low Ca2+): low vit D --> increase PTH --> increase urinary phosphate loss --> measure vit D

Front 70

changes in thyroid function in hospitalized patients?

Back 70

- euthyroid sick syndrome aka low T3 syndrome: see decreased T3 and normal T4 and TSH

Front 71

retinal complications for DM?

Back 71

- proliferative dm retinopathy --> vitreous bleeding --> retinal detachment

Front 72

joint pain, increased Ca2+

Back 72

- paget's disease, tx with bisphos

Front 73

struma ovarri?

Back 73

- ovarian tumor that is usually 50% of thyroid tissue

Front 74

benefits of tight glucose control?

Back 74

- decreased microvascular complications: retinopathy, neuropathy, nephropathy
- no improvement on macrovascular complications: CVA, MI

Front 75

dexamethasone supression test and ACTH

Back 75

- give low dose and high dose and see if cortisol is suppressed
- not suppressed by low dose but suppressed by high dose plus high ACTH: pit tumor
- no suppressed by low dose and high dose and decreased ACTH = primary adrenal tumor
- not suppressed by low and high dose and normal to high ACTH = ectopic adrenal tumor

Front 76

calcium and iron decreased absorption of TSH

Back 76

- FYI

Front 77

sulfonylreua overdose

Back 77

- sulfas --> increased insulin secretion --> hypoglycemia --> give D50 --> transietn hyperglycemia --> increased insulin secretion --> rebound hypoglycemia --> give octreotide --> decreased insulin secretion

Front 78

pt with hypertension and hypoK+

Back 78

- hyperaldosteronism aka Conn's --> check aldo:renin --> seeincreased aldo and decreased renin
- if decreased renin and decreased aldo then check deoxycorticosterone levels which has mineralocorticoid activity

Front 79

hypoK+ --> decreased urinary concentrating abilities --> polyuria

Back 79

- FYI

Front 80

risk of DM type 1?

Back 80

- 3% if one parent pos, 6% two parents

Front 81

DM patient with renal dz?

Back 81

- stop metformin and glyburide (renally cleared --> hypoglycemia)

Front 82

when to treat subclinical hypothyroidism?

Back 82

- see decreased TSH and normal T4 (no need to check t3)
- treat if 1. positive anti-TPO ab, 2. abnormal lipid panel; 3; sx of hypoTH; 4. ovulatory and menstural dysfx; or 5. TSH >10

Front 83

pt with htn, dm, met alk?

Back 83

- cushings --> check 24 hour cortisol

Front 84

pt with fasting glucose 100-120

Back 84

- pt has impaired fasting glucose --> increased risk of CAD

Front 85

pt with viral syndrome, hyperTFTs and enlarged, tender thyroid, what do you expect on RAIU?

Back 85

- DECREASED UPTAKE
- pt has subacute thyroidits--> see decreased RAIU secondary to release of stored thyroid function hormone by inflammatory changes
- also see this in post partum thyroiditis

Front 86

pit incidentiloma

Back 86

- common and innoculus, if no hormonal dysfunction then just watch

Front 87

pt with hyperCa2+ and normal PTH?

Back 87

- increased ca should decrease pth --> most likely primary hyperPTH UNLESS check urine Ca2+ and should be increased in primary hyperPTH, if decreased then dx is familial hypocalciuric hypercalcemia --> no tx needed
- test of serum and urine protein electrophoresis only if increased Ca2+ and DECREASED PTH

Front 88

pseudohypoPTH?

Back 88

see decreased ca2+ with increased PTH
- resistance of PTH on target tissues
- type 1A: albright hereditary osteodystrophy- short 4th and 5th digit, short neck
- type 1B- no features

Front 89

hyperPTH indications for thyroidectomy?

Back 89

- serum ca2+ > 1 above upper limit of normla; Cr cl <60, T score >2.5, age >50

Front 90

pt with hyperTH after coronary angiography?

Back 90

- iodine administration during coronary angiography