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34 Cards in this Set

  • Front
  • Back
how to lower bp in pheo
give alpha blockers IN CONJUNCTION WITH beta blockers

if you give a beta blocker first, you can precipitate a dangerous increase in BP
hypercalcemia with low/high PTH
low PTH: malignancy, vitD toxicity or granulomatous diseases (sarcoid)

inappropriately nl or elevated PTH: most commonly due to primary hyperparathyroidism
highly suggestive of pituitary tumor

look for glucocorticoid deficiency (weakness, fatigue, loss of appetite, EOSINOPHILIA), and hypothyroidism (cold intolerance, constipation, brady).

Testing will show low TSH, low free T4 and low cortisol

hyperpigmentation is absent in central adrenal insufficiency as ACTH and melanocyte stimulating hormones levels are low.

Aldosterone secretion from the zona glomerulosa is ACTH-independent. As a result, secondary central adrenal insufficiency does not cause hyperK or salt wasting
most common cause of thyroid nodules
colloid nodule, followed by follicular adenoma
hyperthyroidism: distinguishing between the different types
radioactive iodine uptake!

low: thyroiditis
high: graves dz

heterogenous uptake: toxic multinodular goiter, more common in older pts. cause "hot nodules" (increased uptake of iodine in the nodule with no uptake in the rest of the thyroid gland)
testosterone deficiency with inappropriately nl gonadotropin levels. next step?
indicative of secondary (central) hypogonadism)

best next step is serum prolactin level.
MRI of pituitary indicated in pts with high serum prlactin, serum testosterone < 150 ng/dL, visual field defects, or features of other pituitary hormonal dysfunction.

elevated prolactin suppresses GnRH release to cause hypogonadotropic hypogonadism.
potassium in DKA
despite nl or elevated serum K levels, pts with DKA have a total body K deficit due to excessive urinary loss caused by glucosuria-induced osmotic diuresis.

aggressive insulin therapy for DKA can lower serum K levels further and cause severe hyperK
characterized by triad of hyperglycemia, ketonemia, and anion gap metabolic acidosis
Choriocarcinoma, teratoma, seminoma, yolk sac tumor, leydig cell tumor
chorio: increased serum beta HCG

teratoma: elevation sin serum APF or beta-hCG

seminoma: serum tumor markers usually nl, although beta-hCG may be somewhat elevated with seminomas

yolk sac tumor: increase in AFP

leydig cell tumor: estrogen production increased with secondary inhibition of LH and FSH
look at 3520
classic presentation of thyrotoxicosis
weight loss, irritability, tachy, TREMORS, and LID RETRACTION

pts usually have systolic HTN and an increase in pulse pressure.

Imp to know that the hyperdynamic state!!! of hyperthyroidism causes the secondary hypertension.
diagnostic approach to hypocalcemia
check PTH hormone level to distinguish between low PTH associated conditions (parathyroid surgery, polyglandular autoimmune) and elevated PTH associated conditions (eg vitD deficiency, CKD)
vitD deficiency
can lead to osteomalacia with findings that include bone pain or tenderness, muscle weakness or cramps, gait abnl, and increased fx risk.

look for low Ca, low Phos, and high PTH
diagnosis of SIADH
low plasma osmolality and high urine osmolality
hypothyroidism can cause what kind of metabolic abnormalities
hyperlipidemia, hyponatremia and asymptomatic elevations in CK and serum transaminases

most pts have hypercholesterolemia alone or with hypertriG
mgmt of diabetic foot ulcers
in those that do not involve the bone or abscess formation or cellulitis, debridement and antibiotics good

for greater ones, typically need short period of hospitalization, surgical debridement, cx of material obtained deep in the ulcer, bone bx, and IV antibiotics. Infxn typically due to multiple organisms; therefore, antibiotics with anaerobic and gram neg coverage is usually used in pts with deep foot ulcerations.
hypercalcemia 2/2 elevated or inappropriately nl parathyroid hormone level
due to primary hyperparathyroidism or familial hypocalciuric hypercalcemia

urinary calcium creatine clearance ratio is usually < 0.01 in FHH compared to > 0.02 in PHP!!!!
hyperandrogenism in female. What is most specific measurement for this condition
DHEA-S, which is predominantly produced in the adrenal glands only.
hypercalcemia of malignancy pathogenesis
most commonly due to parathyroid hormone-related peptide (PTHrP) production.

produced locally! when the tumor metastasizes into the bone to induce bone resorption. systemic PTHrP levels are not elevated in these pts.

Other mechanisms include excess vitD production, bone metastasis with local cytokine release to induce bone resorption, and ectopic PTH production.

IN SOME MALIGNANCIES, (multiple myeloma, lymphomas, leukemia), osteoclastic bone resoprtion is increased by cytokine production.
causes of paradoxical increase in K following DKA
1) extracellulr shift of potassium in exchange to hydrogen ion, with resultant intracellular potassium deficit (metabolic acidosis)
2) impaired insulin-dependent cell entry of hte K ion
most common thyroid malignancy
papillary, followed distantly by follicular

anaplastic has worst prognosis
medullary -> ME!
thyroid lymphomas -> think hashimoto's thyroiditis (rare)
primary hyperaldo: tx for pts with bilateral adrenal hyperplasia or with unilateral adenoma who either refuse surgery or are poor surgical candidates?
spironolactone -> aldo antagonist -> look for decreased libido, gynecomastia, breast tenderness, menstrual irregularities
preferred therapy for graves' disease
radioactive iodine therapy

contraindications include pregnancy and very severe ophthalmopathy (use subtotal thyroidectomy instead, though most expensive and can be complicated by recurrent laryngeal nerve paralysis, hypoparathyroidism, and hypothyroidism)
proptosis in grave's ophthalmopathy
results from increased volume of retro-orbital tissues! (connective, muscular, and adipose tissue expansion, lymphocytic infiltration) and is a direct result of anti-thyrotropin receptor autoantibodies!
differential dx with hypokalemia, alkalosis, and normotension
1) surreptitious vomiting (look for low chloride)
2) diuretic abuse and bartter/gitelman's syndrome -> look for elevated urine chloride!
most serious side effect of anti-thyroid drugs
propylthiouracil -> severe liver injury and acute liver failure (but preferred in first trimester pregnancy d/t fetal teratogenicity with methimazole)

most common side effect is allergic reaction. most serious is agranulocytosis (0.3% of pts)!!!
how does respiratory alkalosis affect serum Ca levels
can increase affinity of serum albumin to calcium , consequently DECREASING levels of ionized calcium -> only physiologically active form which means you may see manifestations of hypocalcemia
mechanism of bisphosphonates
inhibit osteoclasts to suppress bone turnover
sick euthyroid syndome
aka low T3 syndrome

any pt with an acute, severe illness may have abnl TFTs -> called sick euthyroid syndrome, and most common thyroid hormone pattern in such patients is a fall in total and free T3 levels with nl T4 and TSH levels.
parathyroidectomy for asymptomatic hypercalcemia
at least one of the following features:
1) serum ca > 1 above upper limit of nl
2) young age < 50
3) bone mineral density < T-2.5 at any site
4) reduced renal function (estimated GFR < 60)

older pts can use medical surveillance
physical exam findings of hyperthyroidism
goiter, hypertension, tremors involving fingers/hands, hyperreflexia, proximal muscle weakness, lid lag, atrial fibrillation
pathophysiologic mechanism of paget dz
abnl bone remodeling
adrenal insufficiency with calcifications of adrenal glands
adrenal tuberculosis

continues to be prominent cause of primary adrenal insufficiency in developing countries.

in contrast, autoimmune adrenalitis is currently the most common cause of primary adrenal insufficiency in developed countries
most appropriate next step in mgmt of DKA
normal saline and regular insulin

correct hyperK