Diabetes
What is the glycemic goal for critically ill patients in the ICU?
The American Diabetes Association recommends that insulin therapy should be initiated for treatment for persistent hyperglycemia starting at a threshold of 180 mg/dL with a target glucose range of 140 to 180 mg/dL
What gene mutation is associated with MEN type 2?
RET proto-oncogene
What are the first-line diagnostic tests for Cushing syndrome?
Overnight low-dose dexamethasone suppression test, 24-hour urine free cortisol measurement, and late-night salivary cortisol measurement; two of three tests must be abnormal.
Most common cause of hypercalcemia in hospitalized patients?
Malignancy
DKA diagnosis?
-Plasma glucose level ≥200 mg/dL
-Arterial blood pH <7.30
-Bicarbonate level <18 mEq/L
-Increased anion gap >10 mEq/L (calculated as [Na+] - [Cl-] - [HCO3-])
- Positive serum or urine ketone levels.
All three diagnostic criteria must be met to establish the diagnosis of diabetic ketoacidosis: hyperglycemia (or prior history of diabetes), ketonemia or ketonuria, and metabolic acidosis
Mention 4 Drugs that inhibit conversion of T4-->T3
Amiodarone, Glucocorticoids, Propranolol (BB), PTU, iopanoic acid (oral cholecystography agent)
Mention 2 cancers associated with Acromegaly?
Esophageal cancer, gastric cancer, colon cancer, and melanoma.
A patient with lifelong mild hypercalcemia, mildly elevated PTH, and a calcium–creatinine clearance ratio <0.01 is found to have which underlying pathophysiologic defect?
Inactivating mutation of the calcium-sensing receptor [CaSR]
Patients on long-term metformin therapy should be screened for vitamin B12 deficiency beginning after _____ years of treatment and then _____ thereafter.
beginning after 4 years of treatment and then Annually
A 73-year-old woman is seen during a routine evaluation. She has been taking amiodarone for atrial fibrillation for 1 year with good control until a recurrence 1 week ago. Thyroid function tests were normal before starting amiodarone. She has no history of iodinated contrast use. She is otherwise well and takes no additional medications.
On physical examination, pulse rate is 110/min and irregular; remaining vital signs are normal. Other than an irregular tachycardia, the thyroid and remainder of the examination are normal.
Laboratory studies show a thyroid-stimulating hormone level of less than 0.01 μU/mL (0.01 mU/L) and free thyroxine level of 3.5 ng/dL (45.0 pmol/L). ECG shows atrial fibrillation.
Which of the following is the most appropriate diagnostic test?
A) Serum thyroglobulin measurement
B) Thyroid peroxidase antibody titer
C) Thyroid scintigraphy with radioactive iodine uptake
D)Thyroid ultrasonography with Doppler studies
D)Thyroid ultrasonography with Doppler studies
This patient has developed thyrotoxicosis while taking amiodarone (AIT).
Cancer medication commonly associated with hypophysitis?
Immune checkpoint inhibitors (pembrolizumab)
Indications for parathyroidectomy in patients with primary hyperparathyroidism?
Serum calcium >1 mg/dL above the upper limit of normal
Osteoporosis (T-score ≤−2.5 at any site), fragility fracture, or vertebral compression fracture
Renal involvement: nephrolithiasis, nephrocalcinosis, hypercalciuria (24-hour urine calcium >400 mg/dL), or creatinine clearance <60 mL/min
Age ≤50 years at diagnosis
Parathyroid carcinoma (when suspected clinically or biochemically)
For every 1% increase in A1C, there is an approximate ----- increase in estimated average glucose
Approximately 30 mg/dL (28-29)
eAG (mg/dL) = (28.7 × A1C) - 46.7
A 30-year-old woman has an incidentally discovered 2.3-cm solid thyroid nodule. She is asymptomatic, with no risk factors for thyroid cancer. Labs show suppressed TSH with mildly elevated T3 and normal free T4. Ultrasound shows a solid hyperechoic nodule without suspicious features. What is the best next step in evaluation?
A. Fine-needle aspiration
B. Repeat TSH level in 3-4 weeks
C. Serum anti-thyroid peroxidase antibody assay
D. Serum calcitonin assay
E. Thyroid scintigraphy
E. Thyroid scintigraphy
Most patients with normal or elevated TSH should undergo fine-needle aspiration of the nodule for cytologic assessment. Patients with a suppressed TSH should undergo thyroid scintigraphy. Hyperfunctioning nodules are rarely malignant and do not usually require fine-needle aspiration
A 46-year-old man presents with fatigue, decreased libido, and erectile dysfunction for several months.
Past history includes type 2 diabetes, hypertension, obesity, and chronic kidney disease. Medications include insulin, dapagliflozin, lisinopril, amlodipine, furosemide, and aspirin. He is a long-term smoker.
Vitals are stable; BMI 30. Exam shows mild bilateral pitting edema, but normal secondary sexual characteristics, normal testes, and normal visual fields.
Complete blood count:
HB 10.6 g/dL
MCV 84 µm3
Serum chemistry
Bicarbonate 24 mEq/L
Blood urea nitrogen 48 mg/dL
Creatinine. 2.87 mg/dL
Calcium 8.0 mg/dL
Glucose 160 mg/dL
Liver function studies
Bilirubin0.3 mg/dL
Alkaline phosphatase 95 U/L
Aspartate aminotransferase (SGOT)27 U/L
Alanine aminotransferase (SGPT)32 U/L
LH, serum4 mU/mL (normal: 6-23)
Testosterone, serum 240 ng/dL (normal: 264-916)
Hemoglobin A1c 7.9%
TSH 2.4 µU/mL
Which of the following is the best next step in management of this patient's sexual dysfunction?A.Initiate intermittent early dialysis
B. Obtain serum prolactin level
C. Order MRI of the pituitary
D. Start sildenafil therapy
E. Start testosterone replacement
B. Obtain serum prolactin level
This is 2ry hypogonadism. Hyperprolactinemia is common in chronic kidney disease due to the increased release and decreased clearance of prolactin and can cause central hypogonadism due to the downregulation of GnRH production. Prolactin levels can be normalized with dopamine agonists, but sexual dysfunction often persists due to additional contributing factors.
In patients with end-stage kidney disease who have hyperprolactinemia with no other clinical or biochemical evidence of a pituitary tumor, MRI of the pituitary may not be necessary.
A 65-year-old man sustains a low-trauma femoral neck fracture after a ground-level fall. DXA shows T score -2 in femoral neck, -2.5 in lumbar spine, and initial labs including calcium, vitamin D, TSH, and 24-hour urine calcium are normal. What is the most appropriate next step in evaluation?
A. 24-hour urine cortisol measurement
B. Serum prolactin level
C. Serum protein electrophoresis
D. Serum testosterone level
E. Urine N-telopeptide assay
D. Serum testosterone level
Osteoporosis in men is often due to 2ry causes. Elderly men with osteoporosis or fragility fractures should be evaluated for hypogonadism, even if other labs are normal. In men, hypogonadism is the most common secondary cause of osteoporosis.
A 55-year-old man is evaluated for recurrent episodes of neuroglycopenic symptoms while using his wife's fingerstick blood glucose monitor; his blood glucose level was 46 mg/dL (2.6 mmol/L) during one of these episodes. His symptoms resolve with food. He has had three similar episodes within the past month. He has no other medical concerns and takes no medications.
On physical examination, vital signs are normal. BMI is 33. The remainder of the physical examination is normal.
A random blood glucose reading is 78 mg/dL (4.3 mmol/L). Laboratory studies show a hemoglobin A1c level of 4.7%. All other laboratory results are normal.
Which of the following is the most appropriate diagnostic test?
A) 72-Hour fast
B) Mixed meal test
C) Oral glucose tolerance test
D) Pancreatic imaging study
A) 72-Hour fast
In a normal person, prolonged fasting should lead to:
Suppressed insulin
Increased glucagon
Lipolysis and ketone production
Maintenance of glucose via hepatic gluconeogenesis
If hypoglycemia occurs during fasting, it is pathologic.
What endocrine disorders associated with OSA?
Hypothyroidism, acromegaly, Cushing syndrome, and polycystic ovary syndrome.
A 46-year-old man is evaluated for decreased sexual performance and moderate fatigue over the last 2 years. He was diagnosed with sick sinus syndrome a year ago after an episode of syncope and received a permanent pacemaker. The patient takes no medications. He is married and has 2 children. Vital signs and BMI are within normal limits. Physical examination shows mild testicular atrophy without gynecomastia.
Laboratory results are as follows:
FSH, serum 5 mU/mL (5-15 mU/mL)
LH, serum 4 mU/mL (3-15 mU/mL)
Testosterone, serum 175 ng/dL (300-1200 ng/dL)
The patient should be evaluated specifically for which of the following conditions?
A. Adrenal neoplasm
B. Hereditary hemochromatosis
C. Karyotype abnormalities
D. Lyme disease
E. Varicocele
B. Hereditary hemochromatosis
Hereditary hemochromatosis is an important cause of secondary hypogonadism and is usually due to iron deposition in the pituitary gonadotrophs. Restoration of gonadal function is more likely if phlebotomy is initiated before age 40.
A 74-year-old woman is evaluated during a follow-up visit for osteoporosis. She sustained fractures in thoracic vertebra 11 and lumbar vertebra 1 without a fall 2 years earlier. Dual-energy x-ray absorptiometry scan at the time of injury showed left femur neck T-score of -2.9. Teriparatide was initiated. Which of the following is the most appropriate management?
A)Discontinue teriparatide
B)Discontinue teriparatide, start alendronate
C) Discontinue teriparatide, start romosozumab
D)Discontinue teriparatide, start abaloparatide
B)Discontinue teriparatide, start alendronate