Endocrine Exam Questions and Complete Solutions Graded A+.

  How can you differentiate between Cushing and Addison disease? (in terms of secreting hormone). - Answer: Cushing: HYPERsecretion of Cortisol "C for Cushing, C for Cortisol". ADDison: HYPOsecretion of Cortisol & Aldosterone "ADD - Aldosterone" Mnemonic for Cushing - Answer: Mnemonic STRESSED Skin fragile Truncal obesity w/ small arms Rounded face "Moon face". Reproductive- amenorrhea and ED. Ecchymosis and Elevated BP Stretchmark on abdominal (purple color) Sugar extremely high (HYPERglycemia)- Polyuria & Polydipsia Excess bodily hair in women (Hirsutism). Electrolyte imbalance: HYPOkalemia. Dorsocervical fat pad (Buffalo hump) Depression. Mnemonic for Addison disease - Answer: Mnemonic STEROID Sodium and Sugar LOW: Salt craving. Tired and muscle weakness Electrolyte imbalance: HYPERkalemia and HYPERcalcemia. Reproductive changes: irregular menstrual and ED lOw BP Increased pigmentation- Hyperpigmentation (mucus) Diarrhea Depression. What are causes of Cushing disease - Answer: chronic steroid therapy or tumor What are causes of Addison disease - Answer: Immigrant: Tuberculosis Infection Cancer. Cushing disease is due to _______ secretion of __________ - Answer: excess secretion of cortisol Addison disease is due to _______ secretion of ________ - Answer: Hyposecretion of Cortisol & Aldosterone A pt presents to the clinic c/o progressive weakness. Pt reports decreased libido/amenorrhea (women), fatigue and weight gain. Vitals are significant for HTN- BP at 177/100. On Exam- you note central obesity, moon face, atrophied limbs, purple striae on abdominal and a hump on the back of his neck. What does this pt have? What medication would you use to treat his BP? (Drugs/class) What BP medication class should you avoid in this pt? Why? How would his lab look like (electrolytes)? - Answer: Cushing Aldosterone receptor antagonist- Spironolactone and Eplerenone. AVOID HCTZ- increases BG and Hypokalemia Lab: Hypernatremia, Hypokalemia, Metabolic Alkalosis What diagnostic tests can you order for pt with Cushing disease? What would the result indicate? - Answer: Initial- 24hr Low-dose dexamethasone suppression test: IF cortisol 5 (high): indicates Cushing. OR 24hr Morning Urinary Free Cortisol: If value x3 of normal= Cushing. *IF either of the 2 tests above demonstrate HIGH cortisol - order High Dose Dexamethasone suppression test. IF ACTH is suppressed by 50%, then it's d/t Cushing. Can order MRI of the brain. IF ACTH is NOT suppressed, then it indicates lung cancer or malignancy elsewhere. Order ACTH level. IF HIGH ACTH - order CT of the chest to r/o lung cancer. IF LOW ACTH - order CT of the abdomen/pelvis. How would the electrolytes look in a pt with Cushing disease? - Answer: "Everything is HIGH, except Potassium" HYPERnatremia HIGH cortisol HYPERglycemia HYPOkalemia Metabolic Alkalosis A pt presents to the clinic c/o fatigue, weight loss, n&v. Pt denies fever or recent infection. He reports craving everything salty. On Exam- pt looks tanned and has hyperpigmented buccal mucosa. You ask pt if they have recently traveled and they said no. What does this pt likely have? How would their lab (electrolytes) look? How would you manage/treat this pt? (drugs) - Answer: Addison disease Lab: HYPOnatremia, HYPERkalemia, LOW cortisol & Low Aldosterone. 1st line: Glucocorticoid and Mineralocorticoid (Aldosterone) replacement. Ex: Hydrocortisone & Fludrocortisone. Give additional dose of Hydrocortisone during stress (surgery, illness) to prevent Adrenal Crisis. Pt must carry Steroid Kit with them at all times. How would management for Addison differ for Infant vs Children? - Answer: Infant- salt supplement. Children- supplement not needed. What diagnostic test would you order for a pt with Addison disease? - Answer: Morning Serum Cortisol level. LOW cortisol strongly suggests Addison or Primary Adrenal Insufficiency. Other tests: plasma ACTH HIGH ACTH & LOW cortisol- Addison. How would lab (electrolytes) look in a pt with Addison disease? - Answer: "Everything is LOW, except Potassium" LOW Cortisol & Aldosterone HYPOnatremia HYPOglycemia HYPERkalemia Metabolic Acidosis The endocrine system works in a ______ feedback system. - Answer: negative feedback. What medication would you use to treat high BP in pt with Cushing Disease? - Answer: Aldosterone receptor antagonist Drug: Spironolactone and Eplrenone. What emergency kit must a patient with Addison disease have at all times? - Answer: Steroid kit. What medication would you prescribe to pt with Addison disease? - Answer: Glucocorticoid and Mineralocorticoid drug class Hydrocortison and Fludrocortisone. A pt presents to the clinic c/o fatigue, n&v, and craving salt. He also has respiratory sx such as cough that is purulent. He recently moved from India to the U.S. Exam is notable for hyperpigmentation of oral mucosa. Lab is significant for Hyponatremia and Hyperkalemia. What does this pt have? And what is the likely cause? - Answer: Addison disease. Tuberculosis. What is another name for Addison - Answer: primary adrenal insufficiency. What is the most common cause of hyperthyroidism? - Answer: Graves disease What is the most common cause of hypothyroidism? - Answer: Hashimoto thyroiditis A pt lab work shows HIGH TSH and LOW free T4. What does this pt have? - Answer: Hypothyroidism A pt lab work shows LOW TSH and HIGH free T4. What does this pt have? - Answer: Hyperthyroidism Antithyroid peroxidase antibodies are found in ________ - Answer: Hashmimoto Thyroiditis Decreased uptake on radioactive iodine scan is found in _____ - Answer: Hashimoto Thyroiditis Increased uptake on radioactive iodine scan is found in _____ - Answer: Graves disease A 45yrs old women presents to the clinic c/o weight loss and unexplained anxiety. She reports that she has been losing weight progressively over the past 6mo despite increased appetite. She also reports chest palpitations, tremors in her hand and can't withstand heat. On Exam, you note bilateral proptosis, exophthalmos, 3+ deep tendon reflex bilaterally, fine tremor, pretibial myxedema (non-pitting). Vital sign is notable for tachycardia- HR in 120's. What does this pt have? What is the likely cause? - Answer: Hyperthyroidism Graves disease A 45yrs old women presents to the clinic c/o weight loss and unexplained anxiety. She reports that she has been losing weight progressively over the past 6mo despite increased appetite. She also reports chest palpitations, tremors in her hand and can't withstand heat. On Exam, you note bilateral proptosis, exophthalmos, 3+ deep tendon reflex bilaterally, fine tremor, pretibial myxedema (non-pitting). Vital sign is notable for tachycardia- HR in 120's. What lab would you order? And how would it look? - Answer: TSH Low TSH and High Free T4. What is a normal TSH level - Answer: 0.5 to 5 A 45yrs old women presents to the clinic c/o weight loss and unexplained anxiety. She reports that she has been losing weight progressively over the past 6mo despite increased appetite. She also reports chest palpitations, tremors in her hand and can't withstand heat. On Exam, you note bilateral proptosis, exophthalmos, 3+ deep tendon reflex bilaterally, fine tremor, pretibial myxedema (non-pitting). Vital sign is notable for tachycardia- HR in 120's. What is the 1st line treatment for this pt? - Answer: Beta Blocker- Propranolol or Metoprolol A 45yrs old women presents to the clinic c/o weight loss and unexplained anxiety. She reports that she has been losing weight progressively over the past 6mo despite increased appetite. She also reports chest palpitations, tremors in her hand and can't withstand heat. On Exam, you note bilateral proptosis, exophthalmos, 3+ deep tendon reflex bilaterally, fine tremor, pretibial myxedema (non-pitting). Vital sign is notable for tachycardia- HR in 120's. You had previously prescribed Beta Blocker to treat her symptoms. She comes back in 2wks to f/up and reports that her symptoms remain unchanged. What medication do you order next? What are adverse effects of this drug? - Answer: Tapazole Agranulocytosis (decreased neutropenia), hepatitis, rash and joint pain. A 45yrs old women presents to the clinic c/o urinary urgency and dysuria. She reports mild lower abdominal pain, but no fever or chills or back pain. She is currently taking Tapazole for Graves disease, which was recently diagnosed. Exam is notable for suprapubic tenderness w/ deep palpation, no rebound tenderness or guarding or CVA tenderness. Vitals is notable for low grade fever. What is the most likely cause of this symptoms? What diagnostic test would you order to confirm this? And how should you manage this pt? What would be a differential diagnosis. - Answer: Symptoms is consistent of Acute Cystitis. Likely d/t Agranulocytosis from Tapazole - leaves pt vulnerable to bacteremia and infection. Check CBC w/ differentials. First step: Discontinue Tapazole. 2nd step: check BC and UA/UC, etc to look for source of infection and treat w/ broad spectrum abx. A 30yrs old woman G2P1 at 11wks presents to the clinic c/o generalized rash. She reports feeling anxiety, chest palpitations and gradual weight loss despite eating. She has a positive thyrotropin-stimulating immunoglobulin assay. And was started on two medication recently. She noticed the rash 5 nights ago and since then, has been bothering her throughout the night. What are the 2 medication prescribed previously? - Answer: Beta blocker and PTU A 30yrs old woman G2P1 at 11wks presents to the clinic c/o generalized rash. She reports feeling anxiety, chest palpitations and gradual weight loss despite eating. She has a positive thyrotropin-stimulating immunoglobulin assay. And was started on two medication recently. She noticed the rash 5 nights ago and since then, has been bothering her throughout the night. What is the 1st step of management? Had the pt not had the adverse effect to that one medication? What medication could you order at 12wks of gestation? - Answer: Discontinue PTU- adverse effects. Switch to Tapazole at 2nd trimester- IF no sx of agranulocytosis, hepatitis, or rash. A 30yrs old woman G2P1 at 11wks presents to the clinic c/o generalized rash. She reports feeling anxiety, chest palpitations and gradual weight loss despite eating. She has a positive thyrotropin-stimulating immunoglobulin assay. And was started on two medication recently. She noticed the rash 5 nights ago and since then, has been bothering her throughout the night. As a provider, you decided to discontinue PTU d/t rash and intolerance to the drug. What would be the next treatment choice for this pt? What is a complication to this therapy. - Answer: Thyroidectomy. Seizures. A 30yrs old woman G2P1 recently underwent thyroidectomy at 12wks of gestation. Her husband brings her to the clinic with intermittent muscle spasm and an episode of seizure that occurred 2 nights ago. Exam is notable for numbness and tingling of finger, toes, and around mouth. You check an ECG at the clinic and note prolonged QT. You suspect that in the process of thyroid removal, the parathyroid gland may have also been removed. What lab (electrolyte) would confirm this? What are two signs that can also confirm this electrolyte imbalance? - Answer: Hypocalcemia Chvostek and Trousseau sign. You tap a pt's facial nerve 2cm anterior to ear, which causes twitching or spasming of facial muscle. What sign is this and what does it indicate? - Answer: Chvostek sign: Hypocalcemia. You inflate the BP cuff 20mmHg above pt's systolic BP which causes carpopedal spasm (flexion @ wrist, MCP joint, extension of IP joint and adduction of thumb/fingers. What sign is this and what does it indicate? - Answer: Trousseau sign- Hypocalcemia. What is one hyperthyroid drug that you MUST avoid in non-pregnant women? - Answer: PTU- higher risk for agranulocytosis A 30yrs old woman presents to the clinic with to discuss treatment options for hyperthyroidism. She reports that she doesn't want to be on the PTU/Tapazole drug, is not ready to undergo thyroidectomy. But, states her friend underwent some radioactive treatment and recommended that for her. She is not sure what it's exactly called. On Exam, she has exophthalmos. What treatment is she talking about? What teachings would you provide in regards to this? And, what pre-treatment can you prescribe to avoid adverse effects? What medication will she be on eventually for life long? - Answer: Radioactive Iodine Ablation. AVOID in pregnant and breastfeeding women. Check urine pregnancy test and be on reliable contraceptive. No isolation required. Adverse effect- worsening hyperthyroid symptoms- such as worsening exophthalmos. Pre-treat w/ IV steroid prior to therapy. Monitor TSH and free T4. Will likely need synthroid lifelong. When is it okay for pregnant pt to have thyroidectomy? - Answer: at 12wks and above. (2nd trimester) A pt presents to the clinic c/o neck fullness and sx of Graves disease. Exam is notable for goiter- nodule 1cm. What diagnostic tests would you order? And when would you refer this pt to an endocrinologist. - Answer: Check TSH and Thyroid US. IF suspicious US and nodule 1cm, refer to Endocrinologist for Fine needle aspiration Graves disease is associated with multiple autoimmune conditions such as _____ - Answer: Lupus, Type 1 DM, vitiligo Pt's lab report shows low TSH but a normal T3 and T4. What does this pt have? - Answer: Subclinical hyperthyroidism A pt presents to the clinic reporting that her friend was recently diagnosed with Thyroid cancer. She is worried and wants you to check her for thyroid cancer. Upon further investigation, pt denies any sx of thyroid cancer or 1st degree family hx of thyroid cancer. How do you manage this pt? - Answer: UPSTF recommends against screening for thyroid cancer in pt w/o risk factors or symptoms. A pt presents to the clinic reporting that her friend was recently diagnosed with thyroid cancer. She is worried and wants you to check her for thyroid cancer. Upon further investigation, pt reports voice hoarseness, difficulty swallowing, neck pain and asymmetry neck. She also tells you that her uncle died with thyroid cancer. She also reports hx of radiation exposure. How do you manage this pt? - Answer: Screen for thyroid cancer- routine physical neck exam. A pt with hyperthyroidism presents to the clinic with Afib w/ RVR and monomorphic v-tach. Pt is stable and you suggest using anti arrhythmic agent. How will this pt be managed in the ED? What tests would you order prior to starting this therapy and why? - Answer: Amiodarone. Check TSH and PFT prior to starting therapy. Risk for Hypothyroidism and Pulmonary Fibrosis. A 30yrs old woman presents to the clinic c/o increased fatigue. She reports that she has progressively gained weight over the past 6mo. She also reports that she feels cold all the time, even though it's 80 degree outside, milk discharge from nipple and constipation. She denies being pregnant or hx of recent pregnancy. G0P0. Exam is notable for puffy face w/ periorbital edema, thin brittle hair and -1 to -2 for deep tendon reflex bilaterally. Vitals is notable for bradycardia. What does this pt have? And what is the first line treatment for this pt? She is worried about the milk discharge and is wondering if she could be worried about possible breast cancer. What do you tell her? What diagnostic test do you order? - Answer: Hypothyroidism. 1st line Synthroid Galactorrhea- no need to perform mammogram. It's d/t increased TSH and prolactinemia. not d/t cancer. Check TSH 30yrs old woman presents to the clinic c/o fatigue. She reports that she was started on Levothyroxine 2wks ago for newly diagnosed hypothyroidism. And reports no change in her symptoms. She tells you that the medication is not working. What do you tell her? Should you recheck her TSH? - Answer: Ask her how she is taking the medication- Educate- must take the pill on empty stomach w/o other pills. Takes about 4-6wks to see effect. Recheck TSH in 6-10wks. Too early to check now. Chronic use of Synthroid places pt at increased risk for _____? What do you prescribe for this pt? - Answer: Osteoporosis. Calcium, Vit D and weight bearing exercise A 30yrs old woman G1P0 presents to the clinic w/ symptoms of hypothyroidism. You check her lab and her TSH is elevated and has a decreased free T4. Should you treat this pt? And how do you manage this pt? - Answer: Yes, treat pregnant women d/t high risk of intellectual disability in offspring if left untreated. Synthroid. Complication of hyperthyroidism, if left untreated. - Answer: thyroid storm What are some medication that can precipitate or cause Hypothyroidism? - Answer: Amiodarone, lithium, high dose of iodine, dopamine. If a pt has symptoms of Hyperthyroidism. Their lab results comes back with low TSH and elevated free T4. What test do you order next? What does the result indicate - Answer: Antibody test: TRAb and TPO or TSI Thyrotropin receptor antibodies (TRAb): + also known as Thyroid-stimulating immunoglobulin (TSI) Above test indicates Graves disease Thyroid peroxidase antibody (TPO): + Positive in both Graves and Hashimoto. TPO will be positive in _____ - Answer: both graves and hashimoto disease If pt presents to the clinic with symptoms of Hypothyroidism. Their lab results come back with Elevated TSH and low free T4. What test do you order next? And, what does it confirm? - Answer: Thyroid peroxidase antibody: elevated Hashimoto thyroiditis What is the gold standard for diagnosing Hashimoto Thyroiditis? - Answer: Thyroid peroxidase antibody (TPO): elevated What are is a test that is specific for diagnosing Graves disease? - Answer: TSI: Thyroid stimulating immunoglobulin: + Also known as TRAb- Thyroid receptor antibody + Pt presents with HIGH TSH but normal T4. What is this? - Answer: Subclinical Hypothyroidism A 30yrs old woman presents to the clinic for her annual check. She is on synthroid for Hypothyroidism. Her lab results come back with TSH of 0.1. What is this? What do you suspect? - Answer: TSH 0.1 indicates Hyperthyroidism. Ask her if she is doubling her dose. What is another medication that a provider can prescribe for Hypothyroidism, instead of Synthroid? - Answer: thyroid armour tablet (from pig) A pt presents to the clinic for paroxysm severe headache, anxiety, chest palpitations, and profuse sweating. He reports that it's been on going for a while and that symptoms resolves on its own w/o him taking any medication. He did notice that his BP is generally really high 170/110 when this episodes occur. What does this pt have? And what diagnostic test do you order? And what result do you expect to see? - Answer: Pheochromocytoma Initial test: Plasma free Metanephrine level: elevated. Confirmatory: 24hr urine- Metanephrine aka Catecholamine, or VMA (Vanillyl mandolin acid): elevated. What is the treatment option for Pheochromocytoma? List them in order! - Answer: Non-specific alpha blockade- Phenoxybenzamine Beta Blocker Tumor resection A pt is brought to the clinic by her daughter. The daughter reports that her mom has been acting weird and has sudden onset of memory loss, forgetfulness, slow speech. The daughter tells you that the mother has had chronic hypothyroidism and thinks is taking all her medication but isn't sure as the mother lives alone. Pt is afebrile. You check for source of infection but it all comes back negative- UA/UC, CXR, BC, etc. You decide to check her TSH level and it comes back elevated at 15. What do you suspect this pt has? - Answer: Myxedema coma d/t not taking her synthroid. A mother brings her newborn for 3mo wellness child visit. The child was born at term, vaginally, and was uneventful for the most part other than the jaundice, which is taking longer to get rid off in comparison to her other kids. You examine the child and notice open posterior fontanelle, umbilical hernia, and mottled dry skin. The mother tells you that the child feeds slowly and sometimes it's hard to get him to drink anything. What do you suspect this child has? What diagnostic test do you order? - Answer: Congenital hypothyroidism Check TSH What is the diagnostic criteria for Precocious Puberty? And at what age? - Answer: Accelerated growth Advanced bone age pubertal level of gonadotropin (LH, FSH), Estradiol (estrogen) and testosterone Female 8yrs, Male 9yrs old How do you treat precocious puberty? - Answer: Refer to endocrinologist. Tx: long-acting GnRH antagonist What are the Phases of Puberty? - Answer: Adrenarche: secretion of androgens Gonadarche: secretion of estrogen, progesterone, testosterone. Primary sex organ- Ovaries and Testicle develops Thelarche: secondary sex develops- breast development Pubarche: pubic hair, axillary hair, thickening of voices Menarche: menstrual and ovulation Breast budding occurs in girls. What tanner stage is this? - Answer: Stage I Scrotum and Testes enlarges in boys. Scrotum becomes reddened. What tanner stage is this? - Answer: Stage II 1 mound. What tanner stage is this? - Answer: Stage III Penis lengthens the most in this stage. What tanner stage is this? - Answer: Stage III Penis widens and lengthens. Scrotum becomes darker. What tanner stage is this? - Answer: Stage IV 2 mounds develops and menses start. What tanner stage is this? - Answer: Stage IV Straight and sparse pubic hair is present. This is the beginning of puberty. What tanner stage is this? - Answer: Stage II Pubic hair appears darker, coarser/curling hair. What tanner stage is this? - Answer: Stage III This is the peak of growth spurt. Has Adult hair. What tanner stage is this? - Answer: Stage IV The appearance of 2 breast mounds or breast budding indicates what? - Answer: period will start in 2-3yrs. What is the diagnostic criteria for delayed puberty? And what age? - Answer: lack of secondary sex characteristics. Female: 13yrs, Male 14yrs A 12yrs old girl presents to the clinic for annual physical. Her menses started a month ago. She asks you about her height and if she will grow any taller. What do you tell her? - Answer: Adult height = Height at the time of Period At what age should you worry if the girl has not had her menstrual cycle? - Answer: by age 15. Refer to endocrinologist Girl comes to the clinic and c/o right breast being larger than the left. What do you tell her? - Answer: it's a normal finding. At this phase of puberty, the breast develops. - Answer: Thelarche When should you initiate synthroid? - Answer: TSH 10 or TSH 5 w/ symptoms What is a complication of Hyperthyroidism? How would it present? How would you manage this pt? - Answer: Thyroid storm or thyrotoxicosis Decreased LOC, fever, abdominal pain, high HR and BP. Worst during stress, trauma and infection. Send to ER. What is the TSH goal - Answer: 0.5 and 5 Hyperparathyroidism lab (electrolytes) - Answer: High Calcium, Low Phosphorus Hypoparathyroidism lab (electrolytes) - Answer: Low Calcium, High Phosphorus Pt has symptoms of paresthesia (numbness & tingling of finger/toes/around mouth, tetany (seizures), muscle spasms, prolonged QT, and heart block. These symptoms are caused by what electrolyte imbalance? And these symptoms are associated w/ what procedures? - Answer: Hypocalcemia Thyroid and Parathyroidectomy Mnemonic for Hyperparathyroidism presentation - Answer: "bones, stones, moans and groans". A pt presents to the clinic c/o bone pain, back pain, hx of kidney stones, abdominal pain/flank pain, and impaired concentration and increased episodes of confusion. Exam is significant for high BP. There is no underlying signs of infection. What do you suspect? What diagnostic tests do you order? - Answer: Hyperparathyroidism Serum Calcium- elevated Serum PTH: elevated Immune-mediated destruction of beta cells lead to DECREASED insulin production. Sensitive to insulin. This is pathogenesis of what type of diabetes? - Answer: type 1 Increased resistance to insulin leads to pancreatic beta cells defects. Not sensitive to insulin. This is pathogenesis of what type of diabetes? - Answer: type 2 This is associated with other autoimmune disease such as celiac disease, thyroid disorder, vitiligo. What type of diabetes is this? - Answer: type 1 This is associated w/ obesity, HTN, and metabolic syndrome. What type of diabetes is this? - Answer: type 2 What are the diagnostic criteria for diabetes? - Answer: A1C 6.5% 2 separate: fasting BG 126 2hr oral glucose tolerance test 200 Random glucose 200 w/ classic symptoms: polyuria, polydipsia, polyphagia Who should be screened for diabetes? - Answer: Age 40-70 who are overweight or obese What are risk factors for type 2 DM? - Answer: BMI 25: overweight or obese Metabolic syndrome Hx of Gestational diabetes or infants weight 9lb Abdominal obesity Sedentary lifestyle Race: Hispanic, African, Asian, Pacific islander, American indian Family hx of diabetes impaired fasting BG or oral glucose tolerance test What is the diagnostic criteria for Metabolic syndrome - Answer: Meet 3/5 criteria - Waist circumference: M 40in, F 35in - Fasting BG 100 or on meds - Triglyceride 150 - HDL: M 40, F 50 - BP 130/85 The following criteria indicates prediabetes. - Answer: A1C: 5.7-6.4% Fasting BG: 100-125 2-hr OGTT: 140-199 How frequently should you follow-up with newly diagnosed diabetes pt? What tests do you order. - Answer: Q3mo check A1C until BG controlled or when changing therapy. Then, check A1C Q6mo (twice a year) Fasting Lipid: annually Random urine Microalbumin test: annually - albumin to creatinine ratio. Check BP, weight, feet, BMI and BG at every visit Dilated Eye exam: annually- type 2 exam at time of diagnosis, type 1- exam 5yrs after diagnosis What is the earliest sign of diabetic renal disease? - Answer: microalbuminuria An increase in fasting blood glucose early in the morning (4-8am) d/t surge or hormone. What is this phenomenon? And is it normal? - Answer: Dawn Phenomenon Normal physiologic response A increase in fasting blood glucose early in the morning d/t severe nocturnal hypoglycemia. What is this phenomenon? How do you manage this? - Answer: Somogyi phenomenon. Eat a snack before bedtime or decrease bedtime NPH or regular insulin. Educate: Check BG early in the morning ~3am for up to 2wks Deformity of foot that is caused by joint and bone dislocation and fractures d/t loss of sensation to the foot and ankle? What is this? What is another name for it? - Answer: Neuropathic arthropathy Charcot Foot and Ankle What is the first line treatment for Type 2 DM (drug/class) especially in pt with obesity? Does this drug impact pt's weight? Will this drug cause Hypoglycemia? What is the side effect of this drug? Any nutritional deficiency? What patients would you avoid this medication in/when would you not initiate this drug? When would you hold this drug? When would you cut the dose in half? When would you completely discontinue this drug? What labs do you monitor closely? - Answer: Metformin- Biguainides NO impact on weight NO Hypoglycemia GI upset: nausea and diarrhea; Lactic Acidosis. B12 deficiency AVOID in pt with chronic renal disease, hepatic disease, alcoholics DO NOT initiate if pt's baseline GFR is 30-45. HOLD on day of procedure that requires IV contrast dye and 48hrs after procedure (risk for kidney injury) CUT dose in half IF GFR 46 DISCONTINUE IF GFR 30 MONITOR: Renal function (eGFR, BUN, creatinine, micro albumin) and LFT Tell me everything about Sulfonylureas! Drugs? Contraindication? Adverse effects? Impact on weight and BG? - Answer: Ends in "-ide" Ex: Glipizide, Glyburide AVOID in Type 1 DM, liver failure, kidney failure, Sulfonamide allergy, and severe cardiovascular disease. Adverse: Disulfiram-like effect/Alcohol intolerance: hangover-like sx. Blood dyscrasia: monitor CBC Weight GAIN: Monitor weight and BMI HYPOglycemia: diaphoresis, pallor, sweating, tremors, increased risk of photosensitivity What diabetic drug class ends in "-ide"? Allergy. - Answer: Sulfonylurea Sulfonamide allergy What diabetic drug class ends in "-zone"? - Answer: Glitazones (TZD)- Thiazolidinediones Tell me everything about Thiazolidinediones (Glitazones)! Drugs? Contraindication? Adverse effects? Impact on weight and BG? What labs would you monitor? - Answer: Ends in "-zone" Pioglitazone (Actos) and Rosiglitazone Toxic to liver and heart. AVOID in severe CHF, Liver disease, hx/active bladder cancer, Type 1 DM, Pregnancy Adverse: Edema, Cardiotoxicity, Osteoporosis, Fractures Weight GAIN! Less risk of Hypoglycemia OKAY with chronic kidney disease. Monitor LFT What diabetic drug class ends in "-tide"? - Answer: GLP-1 Agonist aka Incretins Tell me everything about the GLP-1 Agonist! Drugs? Contraindication? Adverse effects? Impact on weight and BG? Monitor what labs? - Answer: ends in "-tide". Ex: Liraglutide (Victoza), Exenatide Increases insulin, Decreases Glucagon release, Slows gastric emptying and Increases Satiety. AVOID: thyroid cancer, gastroparesis, and GI motility disorder. And, sulfonyurea (-ide: higher risk of hypoglycemia) Adverse: Pancreatitis/Pancreas Cancer, n&v Weight LOSS! Suppresses appetite NO Hypoglycemia (unless given w/ "-ide") Decrease Post-Prandial Hyperglycemia (decreased after-meal high BG) Monitor: Amylase and Lipase (d/t pancreatitis) What medication would you recommend for a pt with Type 2 DM, IF they require dual therapy and is looking to lose weight. And, have relatively no fear of needles. - Answer: GLP-1 Agonist What diabetic drug class ends in "-gliptin"? - Answer: DPP-4 Inhibitor Tell me everything about DPP-4 Inhibitor! Drugs? Contraindication? Adverse effects? Impact on weight and BG? - Answer: Ends in "-gliptin" Ex: Sitagliptin (Januvia) Slows gastric emptying and Increases Satiety AVOID in CKD and Liver failure and if taking GLP-1 Agonist "-tide" Adverse: GI complaints (diarrhea and nausea), Arthralgia (joint pain), Urinary and Upper Respiratory Infection. NO impact on weight NO Hypoglycemia What diabetes drug class ends in "-gliflozin" ? - Answer: SGLT-2 Inhibitors Tell me everything about SGLT-2 Inhibitor drugs! Drugs? Contraindication? Adverse effects? Impact on weight and BG? - Answer: ends in "-gliflozin" Ex: Dapagliflozin, Empagliflozin AVOID in CKD, anatomical or functional urinary tract issues, urinary incontinence, & frequent urine infection. Adverse: HYPOtension/Dehydration, UTI (increased glycosuria), Yeast infection, Polyuria, and DKA. Increased risk of leg amputation. DKA: difficulty breathing, n&v, abd pain, confusion, and sleepiness. Weight LOSS! NO Hypoglycemia Cardioprotective! Education: stay hydrated Tell me everything about Alpha-Glucosidase Inhibitors! Drugs? Contraindication? Adverse effects? Impact on weight and BG? - Answer: Drug: Acarbose and Miglitol Decreased post-prandial hyperglycemia (decreased after-meal high BG) AVOID: CKD, Inflammatory Bowel Disease, Malabsorption disorder Adverse: Fart and diarrhea NO Hypoglycemia What drug class ends in "-glinide"? - Answer: Meglitinides (Sulfonylurea Analog) Tell me everything about Meglitinides (Sulfonylurea analogs)! Drugs? Contraindication? Adverse effects? Impact on weight and BG? Education? - Answer: Ends in "-glinide" Ex: Repaglinide Similar to Sulfonylurea Rapid acting- short half-life AVOID with Sulfonylurea "-ide", Liver failure, CKD OK to use Repaglinide with CKD Adverse: Hepatotoxicity Weight GAIN! HYPOglycemia! Education: HOLD IF skipping meal Tell me everything about Amylin Mimetic/Analog! Drugs? Contraindication? Adverse effects? Impact on weight and BG? - Answer: Drug: Pramlintide or Symlin Delays gastric emptying and Increases Satiety AVOID: gastroparesis Adverse: GI complaints (nausea and diarrhea) Weight LOSS! HYPOglycemia Injectable- frequent dosing- needs training This diabetic drug class is contraindicated in CHF. - Answer: TZD "-zone"- Actos This diabetic drug class is cardio protective. - Answer: SGLT-2 inhibitor - "-Flozin"- Dapaglilflozin- "Sugar Floz through urine" GLP-1 agonist- "-Tide"- Liraglutide (Victoza)- "GLP down TIDE pods" Which 3 diabetes drug class cause WEIGHT LOSS? - Answer: GLP-1 agonist- "-tide" Victoza (IM) SGL-2 inhibitor: "-flozin" Dapagliflozin Amylin: Pramalintide (IM) Which oral diabetes drug class cause WEIGHT LOSS? - Answer: SGLT-2 "-flozin" Which 3 oral diabetes drug class cause WEIGHT GAIN? - Answer: Sulfonylurea "-ide" Meglitinides "-glinide" TZD: Thiazolidinediones "-glitazones" Actos Which diabetes drug class cause HYPOGLYCEMIA? - Answer: Sulfonylurea "-ide" Meglitinide "glinide"- short half life Diagnostic criteria for PCOS - Answer: 2/3 required: 1. Oligo-and/or anovulation 2. Clinical signs of hyperandrogenism: Hirsutism, Acne and Acanthosis nigrican. 3. Polycystic ovaries by ultrasound What is 1st line treatment choice for PCOS - Answer: lifestyle: weight loss How would you treat a woman with PCOS who is dealing with amenorrhea/anovulation, acne and hirsutism? How would you treat the woman if she has signs of insulin resistance? What is another medication that can be used to treat Hirsutism/Acne? What is a side effect of this medication in men? - Answer: Combined oral contraceptive Metformin Spironolactone (use as adjunct)- gynecomastia What type of cancer is associated with PCOS? - Answer: Endometrial cancer (d/t unopposed estrogen- decreased level of progesterone cause endometrial hyperplasia) Tell me everything about Rapid Acting Insulin! onset/peak/duration - Answer: "Rapid Insulin do not LAG- Lispro, Aspart, Glulisine" Onset: 15min Peak: 30-2hr Duration: 3-4hr Lasts one meal at a time Tell me everything about Short-Acting Insulin! onset/peak/duration. - Answer: "Regular is Short" Regular insulin Onset: 30min-1hr Peak: 2-5hr Duration: 4-12hr Lasts meal to meal Tell me everything about Intermediate Acting Insulin! onset/peak/duration. - Answer: "Intermediate is Not Particular Hastey- NPH" NPH Onset: 1-2hr Peak: 6-12hr Duration: 14-24hr Lasts breakfast to dinner Tell me everything about Long-Acting Insulin! onset/peak/duration. - Answer: "Long Lantus Levemir" Onset: 2-4hr Peak: None Duration: 24hr Lasts once a day What is the best way to determine calcium in bone? What is the UPSTF guideline for screening for Osteoporosis? - Answer: DEXA scan Women 65, adults w/ low bone mass or bone loss, Rheumatoid Arthritis, chronic steroid use. Infant doubles its birthweight by - Answer: 6mo Infant triples its birthweight by - Answer: 12mo What is the UPSFT screening guideline for Diabetes? - Answer: Age 35-70 who are obese/overweight, BMI 25. What do you assess to screen for Diabetic Foot screening? - Answer: Any changes since last eval Abnormal shape Nail thick/long/overgrown Weakness in ankle/foot Ulcer or hx of ulcer What is a diagnostic criteria for Lupus? - Answer: Meet 4/11 criteria Mnemonic: "SOAP BRAIN MD" Serositis- Pericarditis & Pleuritis Oral ulcer Arthritis Photosensitivity Blood disorder Renal issues (proteinuria) + ANA test Immunologic disorder (Anti-dsDNA) Neurologic sx (Psych, seizure) Malar Rash Discoid Rash Effects all organs: Skin, Bone, Heart, Kidney, Blood, Brain. What is a diagnosis commonly associated w/ Lupus and is notorious for causing dry eyes and dry mouth? - Answer: Sjogren Syndrome