Im 3b Endo Ratio

IM 3B ENDO 2016

MEDICINE 2017

MIDTERMS

Questions and Answers A 30 year old female consulted because of palpitations, anxiety and weight loss. Physical examination confirms a diffusely enlarged thyroid and hand tremors. Which of the following is the most common cardiovascular manifestation in this patient? A. Sinus tachycardia B. Atrial fibrillation C. Cardiomegaly D. None of the above Answer: A

The above patient is expected to have a (W. Suppressed, X. Elevated) TSH and (Y. Decreased, Z, Increased) Free T4. A. W, Y B. W, Z C. X, Y D. X, Z Answer: B If the above patient wants to have radioidine therapy, which of the following is/are absolute contraindication/s? A. Pregnancy B. Breast-feeding C. Both D. Neither Answer: C Which of the following is/are causes of primary hyperthyroidism? A. Struma ovarii B. Silent thyroiditis C. Gestational thyrotoxicosis D. All of the above Answer: A

Ratio Thyrotoxicosis may cause unexplained weight loss, despite anenhanced appetite, due to the increased metabolic rate. Weight gain occurs in 5% of patients, however, because of increased food intake. Other prominent features include hyperactivity, nervousness, and irritability, ultimately leading to a sense of easy fatigability in some patients. Insomnia and impaired concentration are common; apathetic thyrotoxicosis may be mistaken for depression in the elderly. Fine tremor is a frequent finding, best elicited by having patients stretch out their fingers while feeling the fingertips with the palm. Common neurologic manifestations include hyperreflexia, muscle wasting, and proximal myopathy without fasciculation. Chorea is rare. Thyrotoxicosis is sometimes associated with a form of hypokalemic periodic paralysis; this disorder is particularly common in Asian males with thyrotoxicosis, but it occurs in other ethnic groups as well. The most common cardiovascular manifestation is sinus tachycardia , often associated with palpitations, occasionally caused by supraventricular tachycardia. The high cardiac output produces a bounding pulse, widened widened pulse pressure, and an aortic systolic murmur and can lead to worsening of angina or heart failure in the elderly or those withpreexisting heart disease. Atrial fibrillation is more common in patients >50 years of age. Treatment of the thyrotoxic state alone converts atrial fibrillation to normal sinus rhythm in about half of patients, suggesting the existence of an underlying cardiac problem in the remainder. In Graves’ disease, the TSH  level is suppressed, and total and unbound thyroid hormone levels are increased.

Pregnancy and breast-feeding are absolute contraindications to radioiodine treatment, but patients can conceive safely 6 months after treatment.

Causes of Thyrotoxicosis Primary Hyperthyroidism Graves’ disease  Toxic multinodular goiter   Toxic adenoma  Functioning thyroid carcinoma metastases Activating mutation of the TSH receptor  Activating mutation of G (McCune-Albright syndrome)   Struma ovarii  Drugs: iodine excess (Jod-Basedow phenomenon) Thyrotoxicosis Without Hyperthyroidism Subacute thyroiditis 

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A 50 year old female consulted because of weight gain despite of poor appetite, weakness and dyspnea. On examination, she has bradycardia and dry skin. Which of the following is/are expected finding/s in this patient? A. Systolic hypertension - hyperthyroidism B. Proximal myopathy - hyperthyroidism C. Pretibial edema D. None of the above Answer: C

The above patient is expected to have a (M.

Silent thyroiditis  Other causes of thyroid destruction: amiodarone, radiation, infarction of adenoma   Ingestion of excess thyroid hormone (thyrotoxicosis factitia) or thyroid tissue Secondary Hyperthyroidism TSH-secreting pituitary adenoma  Thyroid hormone resistance syndrome: occasional patients may  have  features of thyrotoxicosis Chorionic gonadotropin-secreting tumors  Gestational thyrotoxicosis  Signs and Symptoms of Hypothyroidism (Descending Order of Frequency) Symptoms  Tiredness, weakness Dry skin  Feeling cold  Hair loss   Difficulty concentrating and poor  memory Constipation  Weight gain with poor appetite   Dyspnea  Hoarse voice Menorrhagia (later oligomenorrhea  or amenorrhea)   Paresthesia  Impaired hearing Signs Dry coarse skin; cool peripheral   extremities  Puffy face, hands, and feet (myxedema)  Diffuse alopecia   Bradycardia  Peripheral edema Delayed tendon reflex relaxation  Carpal tunnel syndrome  Serous cavity effusions  The skin is dry, and there is decreased sweating, thinning of the epidermis, and hyperkeratosis of the stratum corneum. Increased dermal glycosaminoglycan content traps water, giving rise to skin thickening without pitting (myxedema). Typical features include a puffy face with edematous eyelids and nonpitting pretibial edema. There is pallor, often with a yellow tinge to the skin due to carotene accumulation. Nail growth is retarded, and hair is dry, brittle, difficult to manage, and falls out easily. In addition to diffuse alopecia, there is thinning of the outer third of the eyebrows, although this is not a specific sign of hypothyroidism. Other common features include constipation and weight gain (despite a poor appetite). In contrast to popular perception, the weight gain is usually modest and due mainly to fluid retention in the myxedematous tissues. Libido is decreased in both sexes, and there may be oligomenorrhea or amenorrhea in long-standing disease, but menorrhagia is also co mmon. Normal TSH level excludes primary (but not secondary) hypothyroidism. If

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suppressed, N. elevated) TSH and (O. increased, P. decreased) free T4 A. M, O B. M, P C. N, O D. N, P

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the TSH is elevated, an unbound T4 level is neededto confirm the presence of clinical hypothyroidism, but T4 is inferior toTSH when used as a screening test, because it will not detect subclinicalhypothyroidism.

Answer: D

If the above patient has no evidence of heart disease and weighs 50 kg, she should be started on the following daily dose/s of levothyroxine (in micrograms) A. 12.5 B. 50 C. 150 D. All of the above

Adult patients under 60 years old without evidence of heart disease maybe started on 50 –100 μg levothyroxine (T4) daily. The dose is adjusted on the basis of TSH levels, with the goal of treatment being a normal TSH, ideally in the lower half of the r eference range.

Answer: B If primary hypothyroidism is suspected and TPOAb is positive, which of the following is the most likely cause? A. Autoimmune B. Pituitary disease C. Sick euthyroid disease D. None of the above Answer: A

A 25 year old female was noted to lose weight 4 months after giving birth to her first baby. She was noted to be tachycardic but thyroid was not enlarged. Which of the following is/are true regarding this patient’s condition? A. Occurs in up to 5% after pregnancy B. Associated with (+) TPO Ab C. Methimazole is the drug of choice D. A and B only Answer: D Treatment of the above patient during hypothyroid phase include the following: A. Prednisone B. Levothyroxine C. Both D. Neither

SILENT THYROIDITIS Painless thyroiditis , or “silent” thyroiditis, occurs in patients withunderlying autoimmune thyroid disease and has a clinical course similarto that of subacute thyroiditis. The condition occurs in up to 5% ofwomen 3 –6 months after pregnancy and is then termed  postpartumthyroiditis . Typically, patients have a brief phase of thyrotoxicosis lasting 2 –4 weeks, followed by hypothyroidism for 4 –12 weeks, and thenresolution; often, however, only one phase is apparent. The conditionis associated with the presence of TPO antibodies antepartum, and it isthree times more common in women with type 1 diabetes mellitus.

Glucocorticoid treatment is not indicated for silent thyroiditis. Severe thyrotoxic symptoms can be managed with a brief course of propranolol, 20 –40 mg three or four times daily. Thyroxine replacement may be needed for the hypothyroid phase but should be withdrawn after 6 –9 months, as recovery is the rule.

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Answer: B Which of the following thyroiditis can occur in patients taking Amiodarone? A. Acute B. Subacute C. Chronic D. All of the above Answer: D

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Causes of Thyroiditis Acute  Bacterial infection: especially Staphylococcus, Streptococcus, and Enterobacter  Fungal infection:  Aspergillus, Candida, Coccidioides, Histoplasma,  and Pneumocystis   Radiation thyroiditis after 131I treatment  Amiodarone (may also be subacute or chronic) Subacute  Viral (or granulomatous) thyroiditis  Silent thyroiditis (including postpartum thyroiditis) Mycobacterial infection  Drug induced (interferon, amiodarone)  Chronic Autoimmunity: focal thyroiditis, Hashimoto’s thyroiditis, atrophic  thyroiditis Riedel’s thyroiditis   Parasitic thyroiditis: echinococcosis, strongyloidiasis, cysticercosis  Traumatic: after palpation

A 21 year old male came for medical evaluation prior to employment. He was noted to have a 2cm thyroid nodule on palpation. Which of the following should be done next? A. Fine needle aspiration cytology B. Radionuclide scanning C. TSH D. None of the above Answer: C

Which of the following is/are risk factor/s for thyroid carcinoma in the above patient? A. Age B. Gender C. Nodule size D. All of the above Answer: B

Which of the following would be an indication for surgical excision of a parathyroid adenoma in a

Risk Factors for Thyroid Carcinoma in Patients with Thyroid Nodule History of head and neck irradiation, including total-body irradiation  for bone marrow transplant and brain radiation for childhood leukemia Exposure to ionizing radiation from fallout in childhood or  adolescence  Age 65 years  Increased nodule size (>4 cm) New or enlarging neck mass   Male gender  Family history of thyroid cancer, MEN 2, or other genetic syndromes associated with thyroid malignancy (e.g., Cowden’s syndrome, familial polyposis, Carney complex) Vocal cord paralysis, hoarse voice   Nodule fixed to adjacent structures  Extrathyroidal extension  Lateral cervical lymphadenopathy Surgical excision of the abnormal parathyroid tissue is the definitive therapy for this disease. As noted above, medical surveillance without operation for

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patient with asymptomatic hyperparathyroidism? A. Lumbar spine osteoporosis B. Creatinine 80ml/min C. Both D. Neither

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primary

Answer: A Which of the following is/are parathyroid related cause/s of hypercalcemia? A. Alumni excess B. Thiazides C. Lithium D. All of the above Answer: C

Which of the following is expected to be LOW in patients with primary hyperparathyroidism secondary to a parathyroid adenoma? A. 1,25 (OH)2 D B. Urinary calcium excretion C. Serum magnesium D. Serum phosphate Answer: D A patient was noted to have low ionized calcium after she was brought to the emergency room because of seizures. Which of the following is/are expected finding/s in this patient? A. Prolonged QT interval B. Papilledema C. Low PTH D. All of the above Answer: D

patients with mild, asymptomatic disease is, however, still preferred by some physicians and patients, particularly when the patients are more elderly. Evidence favoring surgery, if medically feasible, is growing because of concerns about skeletal, cardiovascular, and neuropsychiatric disease , even in mild hyperparathyroidism.

Classification of Causes of Hypercalcemia I. Parathyroid-Related  A. Primary hyperparathyroidism 1. Adenoma(s) 2. Multiple endocrine neoplasia 3. Carcinoma B. Lithium therapy C. Familial hypocalciurichypercalcemia II. Malignancy-Related  A. Solid tumor with metastases (breast) B. Solid tumor with humoral mediation of hypercalcemia (lung, kidney) C. Hematologic malignancies (multiple myeloma, lymphoma, leukemia) III. Vitamin D –Related  A. Vitamin D intoxication B. ↑ 1,25(OH)2D; sarcoidosis and other granulomatous diseases C. ↑ 1,25(OH)2D; impaired 1,25(OH)2D metabolism due to 24 -hydroxylase deficiency IV. Associated with High Bone Turnover  A. Hyperthyroidism B. Immobilization C. Thiazides D. Vitamin A intoxication E. Fat necrosis V. Associated with Renal Failure  A. Severe secondary hyperparathyroidism B. Aluminum intoxication C. Milk-alkali syndrome The diagnosis is typically made by detecting an elevated immunoreactive PTH level in a patient with asymptomatic hypercalcemia. Serum phosphate is usually low  but may be normal, especially if renal failure has developed.

The cause of hypocalcemia remains unclear. PTH values arereported to be low, normal, or elevated, and both resistance to PTH and impaired PTH secretion have been postulated. Neuromuscular and neurologic manifestations of chronichypocalcemia include muscle spasms, carpopedal spasm, facial grimacing, and, in extreme cases, laryngeal spasm and convulsions. Respiratory arrest may occur. Increased intracranial pressure occurs in some patients with long-standing hypocalcemia, often in association with papilledema. Mental changes include irritability, depression, and psychosis. The QT interval on the electrocardiogram is prolonged, in contrast to its shortening with hypercalcemia. Arrhythmias occur, and digitalis effectiveness may be reduced. Intestinal cramps and chronic

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malabsorption may occur. Chvostek’s or Trousseau’s sign ca n be used to confirm latent tetany. In a patient with hypocalcemia rhabdomyolysis, PTH is classified as: A. Absent B. Ineffective C. Overwhelmed D. None of the above

due

to

Answer: C

Treatment of hypocalcemia hypoparathyroidism include/s the following A. Daily 2-3g of elemental calcium B. Calcitriol 0.25-1 mcg daily C. Vitamin D at least 1000 daily D. All of the above

from

Answer: D Which of the following hydroxylation of Vitamin D? A. Phenytoin B. Barbiturates C. Ketoconazole D. All of the above

cause/s

impaired

Answer: C Which of the following is the most specific screening test for vitamin D deficiency? A. 25 (OH) D B. 1,25 (OH)2 D C. 7-Dehydrocholesterol D. None of the above Answer: A The following is/are indication/s for bone density testing: A. Postmenopausal women B. Fracture before the age of 50 C. Men over the age of 60 D. All of the above

Treatment involves replacement with vitamin D or 1,25(OH)2D (calcitriol) combined with a high oral calcium intake. In mostpatients, blood calcium and phosphate levels are satisfactorily regulated, but some patients show resistance and a brittleness, with atendency to alternate between hypocalcemia and hypercalcemia.For many patients, vitamin D in doses of 40,000 –120,000 U/d(1 –3 mg/d) combined with ≥1 g elemental calcium is satisfactory. The wide dosage range reflects the variation encountered frompatient to patient; precise regulation of each patient is required. Treatment of sarcoidosis-associated hypercalcemia with glucocorticoids,ketoconazole, or chloroquine reduces 1,25(OH)2D productionand effectively lowers serum calcium. In contrast, chloroquine has notbeen shown to lower the elevated serum 1,25(OH)2D levels in patientswith lymphoma.

The most specific screening test  for vitamin D deficiency in otherwise healthyindividuals is a serum 25(OH)D level. Although the normal rangesvary, levels of 25(OH)D5.6 mmol/L with signs and symptoms of diabetes c. 2hr post 75g OGTT >7.6mmol/L d. A1c > 5.7% ANSWER: A 2. A 30 year old male was referred to you for the treatment of diabetes mellitus. He is overweight, non-hypertensive, alcoholic and smoker. He is maintained on basal-bolus insulin since the time of diagnosis, his latest laboratory result showed uncontrolled diabetes, hyperlipidemia, hyperuricemia, and (+) ICA. Which of the following supports the diagnosis of type 1 diabetes mellitus? a. age b. weight c. immune markers d. use of insulin ANSWER: C 3. If a pregnant woman has the following 75g OGTT result: FBS 88mg/dl, 1 hr post glucose load of 197 mg/dl and 2 hr post glucose load of 154 mg/dl. According to ADA, how would you classify the patient? a. overt diabetes b. impaired glucose tolerance c. GDM d. normal glucose tolerance ANSWER: C 4. What is microalbuminuria? a. +1 protein on routine urinalysis b. urine albumin less than 300 mg/dl c. presence of bubbles in the urine d. none of the above

Ratio Criteria for DM FBG ≥126 mg/dL (≥7 mmol/L)   HbA1C ≥6.5% 2hr plasma glucose ≥11.1 mmol/L (≥200 mg/dL) during a 75g OGTT  Symptoms of DM + RBG concentration of ≥11.1 mmol/L (≥200  mg/dL)

Type 1 DM is the result of interactions of genetic, environmental, and immunologic factors that ultimately lead to the destruction of the pancreatic beta cells Type 1 DM results from autoimmune beta cell destruction, and most individuals have evidence of islet-directed autoimmunity

Criteria for Diagnosis of GDM

Microalbuminemia- defined as 30-299 mg/d in a 24 h collection or 30-299 μg/mg creatinine in a spot collection

ANSWER: B

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5. what laboratory result will differentiate DKA from HHS? a. elevated RBS b. K 3.5 mmol/L c. pH 7 d. Na 150 mmol/L ANSWER: D

6. A 19 year old type 1 diabetic patient went to an out of town trip, unfortunately he forgot to bring his insulin and can’t find nearby drugstore. Instead of going back, he was given DPP-IV inhibitor by his companion who has type 2 diabetes mellitus. What will happen to the patient? a. he will have relative insulin deficiency but will be able to survive for several days b. if the fluid intake is adequate, the rise in glucose will be neutralized c. Insulin level, as well a s insulin: glucagon ratio will decrease d. Counterregulatory hormone will also decrease because of hyperglycemia ANSWER: C 7. What is the cause of ketosis in DKA? a. lipolysis and increase FFA release b. gluconeogenesis c. poor oral intake d. glycogenolysis ANSWER: A 8. When do we use biguanides in the treatment of type 2 diabetes? a. in a newly diagnosed patient b. in a patient with renal failure c. in a patient at risk of lactic acidosis d. all of the above ANSWER: A 9. What is the difference between proliferative retinopathy and non-proliferative retinopathy? a. hemorrhages b. loss of vision c. macular edema d. neovascularization

Insulin secretagogues (ex. DPP-1) are agents that either act as a GLP-1 receptor agonist or enhance endogenous GLP-1 activity are approved for treatment of type 2 DM Do not cause hypoglycemia because of the glucose-dependent nature of incretin-stimulated insulin secretion

Ketosis results from a marked increase in free fatty acid release from adipocytes, with a resulting shift toward ketone body synthesis in the liver Reduced insulin levels, in combination with elevations in catecholamines and growth hormone, increase lipolysis and the release of FFA

Major toxicity of metformin, lactic acidosis, is very rare and can be prevented by careful patient selection Metformin should not be used in patients with renal insufficiency (GFR 350 mosmol/L)  Prerenal azotemia  Measured serum sodium may be normal or slightly low despite  marked hyperglycemia

According to ADA, the target lipid values in diabetic individuals (age >40 y/o) without CVD should be as follows: LDL 1 mmol/L (40 mg/dl) in men and >1.3 mmol/l (50 mg/dl) in  women TG 27 for whom dietary and physical activity has not been successful? c. both d. neither ANSWER: D 19. If you are going to rate behavioral therapy in terms of efficacy in the treatment of obesity, what will your number one? a. diet and stimulus control b. exercise and stress management c. stress management d. diet and exercise ANSWER: D 20. In the treatment of obesity, it is a peripherally acting medication that block absorption of dietary fats a. sibutramine b. Orlistat c. Phentermine d. Diethylpropion ANSWER: B 21. In male, what test will differentiate primary and secondary hypogonadism? a. sperm count b. total/free testosterone

concentration be low and that the symptoms resolve after glucose level is raised

Intraabdominal circumference (visceral adipose tissue) is considered most strongly related to insulin resistance and risk of diabetes and CVD, and for any given waist circumference the distribution of adipose tissue between SC and visceral depot varies substantially.

Leptin  



secreted by adipose cells high level of leptin decreases food intake and increase energy expenditures level of production provides an index of adipose energy stores

Bariatric Surgery 2  can be considered for severe obesity (BMI ≥40 kg/m ) or moderate 2 obesity (BMI ≥35 kg/m ) associated with serious medical condition

Combination of dietary modification and exercise is the most effective behavioral approach for the treatment of obesity

Choices A, C, D are all centrally acting

Because LH and FSH are trophic hormones for the testes, impaired secretion of these pituitary gonadotropins results in secondary hypogonadism Secondary hypogonadism

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c. FSH d. Estrogen ANSWER: C 22. Interpret the following laboratory results taken in male with abnormally secondary sexual characteristic, 47XXY, elevated FSH and estradiol and low testosterone. The patient has a. Klinefelter syndrome b. True hermaphroditism c. mixed gonadal dysgenesis d. Turner’s syndrome ANSWER: A 23. The most common cause of infertility in female is a. Hypothalamic-pituitary causes b. PCOS c. Primary ovarian failure d. Menopause

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low testosterone, low LH, low FSH

Klinefelter syndrome most common chromosomal disorder associated with testicular  dysfunction and male infertility Azoospermia is the rule in men with Klinefelter’s syndrome who  have 47 XXY karyotype  Low testosterone, estradiol is ncreased

Female infertility Hypothalamic-pituitary causes- 51% PCOS- 30% Premature ovarian failure- 12% Uterine or outflow tract disorders- 7%

ANSWER: A

THANK YOU!!! EVITA DEL MUNDO RUBELLE CABAL

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