Hello friends so let's review some Endocrinology questions we got 20 of them here so question one a 61-year-old male with Stage 3B small cell lung cancer presents to the Ed with lethargy blood pressure is stable at 125 over 80 he's uvalic physical exam is unremarkable labs are drawn and reveal and these are all in standard us uh milligrams per deciliter units that you'll have on the USMLE and you'll be given the normal values of all these sodium is 121 potassium 3.8 chloride 103 bicarb 25 bu 22 creatinine 1.2 and glucose 133 urine osmolarity is 355 milliosmoles per kilogram which is elevated CBC is unremarkable in addition to admission which of the following is the best next step in the management of this patient a fluid restriction B administration of 3% NAC C normal saline Bolis D hydrochlorizide or E amide okay so the answer here is a fluid restriction so this is a patient who is stable um I mean he's got lethargy but that's not a life-threatening condition as long as we're keeping keeping an eye on him uh he's uvalic uh but he does have hyponatremia and the fact that he has small cell lung cancer the fact that he's uvalic the fact that he's got hyponatremia and the fact that his uranos marity most importantly is still elevated clearly indicates that this is a patient with siadh which we would expect with small cell lung cancer I mean small cell lung cancer plus hyponatremia should immediately make you think of siadh so when you have siadh uh as a uh as a a condition secondary to cancer um it generally comes on very slowly and we know that it came on very slowly because he's one he's stable and two he's uvalic so if it were to if you had hyponatremia that came on quickly let's say due to vomiting due to pancreatitis um due to RTA due to con syndrome if you had a deficiency of mineralocorticoid U in that case you would have a uh a quick hyponatremia in other words the patient would quickly develop the hyponatremia and they would develop life-threatening symptoms like for instance seizures or um or they would be comos uh and in that case we would want to correct their sodium quickly if the patient develops the hyponatremia quickly we we need to treat it quickly however if they develop it slowly then we can treat it slower and the good thing about treating hyponatremia slower is that you don't run the risk of correcting it too fast that that's kind of logical but what happens if you correct it too fast you can cause swelling of the brain and if you swell the brain what happens is you can have Central pontine myelinolysis which is the primary uh complication of of correcting sodium too quickly so you don't ever want to correct sodium faster than one to two points and by points I mean milligrams per deil faster than 1 to two points per hour uh you really want to correct it uh slower um rather than faster if you can get away with it so patients who are uvalic and and they're stable and um and they're well you can correct it with just water restriction if they have any uh significant symptoms uh or if you know that they have any kind of condition where you may think they have lost their sodium quickly like Burns or vomiting or RTA or uh ketonuria or or anything like this um generally they're going to be uvalic but you're going to want to treat them then a little bit faster um so uh you'll treat them with uh with fluid replacement and then uh and then 3% NAC but we try to avoid the na 3% NAC if we can and in siadh it's very rarely needed so in this case we just will need water restriction that's it but you will need to admit the patient to keep an eye on the uh those sodium values okay question two a 48-year-old woman presents for her annual checkup her medical history includes hypertension which is controlled and psoriasis she denies any new complaints physical exam reveals a small nodule on the left side of the thyroid thyroid function tests are drawn and reveals a TSH of 2.1 which is normal which of the following is the next best step in the management of this patient a reassurance B RI uptake scan C FAL aspiration D surgical removal or E metho okay the answer here is C fine needle aspiration so you may be wondering why are we not doing a uh iodine uptake scan considering that uh that this is a patient who has a uh a thyroid nle and the fact is you can do an REI uptake scan and that can show you if the nodule is a functioning nodule or in other words a hot nodule or a non-functioning nodule which is a cold nodule however you don't need to do the scan to make the diagnosis and what the diagnoses were concerned about here because the patient has a normal TSH because the patient does not not have any signs of of a toxic nodule which would be signs of of hyperthyroidism what we're concerned about is cancer and so uh I mean this woman is in the right age group she's a woman she's got uh she's got risk factors for thyroid cancer and so uh what we want to do what's what's most important to do is a fine needle aspiration and we don't need to know uh I mean we know where the where the nodule is cuz we can feel it but we don't need to do any kind of scan because we we do the fine needle aspiration under ultrasound guidance so fine needle aspiration is the best first step after you've located a nodule and you know that it's not a toxic nodule and by toxic nodule I mean a nodule that's causing the patient to have hyperthyroid symptoms or a depressed TSH now a an REI uptake scan can be done but usually it's going to be done by a surgeon before they do their actual surgical removal and that would be for instance if you had a toxic nodule so fine needle aspiration is the best Next Step question three 29-year-old woman presents the Ed complaining of severe headache and anxiety she denies any recent drug use or alcohol consumption blood pressure is 195 over 115 heart rate 110 respiration's 18 temperature 98.7 fhe EKG reveals sinus tack hydrazine is administered but the blood pressure remains elevated at 193 over 115 plasma metainference come back elevated which of the following is the best next step in the management of this patient a LOLOL B esmolol C prusin D phoxy benzamine or E emergent surgery and the answer here is D phoxy benzamine so what does this patient have she's got a uh really high blood pressure she's got a severe headache and she has a blood pressure that is not responsive to traditional anti-hypertensives and then she's got those plasma metan nephrin that come back elevated which is the dead giveaway she's got a FOC chromosoma it's rare foch chromos cyas are extremely rare they're less than 1% of of emergent hypertensive cases uh however uh they're important to know about because they have a high mortality rate because if they're not treated quickly enough uh they they uh they they'll lead to death I suppose that was that was kind of a redundancy but anyhow you need to know uh what these look like but they're very obvious uh because uh generally on the US mle you'll be given the plasma metan nephrine coming back elevated um and another thing is uh is high blood pressure in conjunction with a headache particularly in a young patient young patients don't just get malignant hypertension so if you got a young patient with severe hypertension you better be thinking uh of of foch chromosoma and getting those plasma metrin luckily here the plasma metan nephrin were already ordered now what do you use to lower the blood pressure you have to use Alpha uh Alpha Inhibitors so you cannot use beta blockers if you use beta blockers you're actually likely going to cause the patient to die so beta blockers will actually cause the blood pressure to go up even more so LOLOL and esmolol are both beta blockers as far as what kind of alpha Blocker we want to use well I mean Alpha blocker is better than a beta blocker however a non- selective Alpha blocker would be the best and pricin is a selective alpha 1 blocker and phoxy benzamine is a non- selective of alpha blocker so phenoxybenzamine or phentolamine those are both good choices for uh for foch chromosoma as far as emergent surgery well yes we will eventually do surgery on this patient however you don't ever do emergent surgery on a FOC chrom oyoma because uh you have to get the blood pressure down and stabilized before you can actually remove the uh the the tumor itself so you'll use an alpha blocker and then a beta blocker uh and and then you can go ahead with surgery remember Alpha before beta just like in the Greek alphabet okay so we got the same patient we've administered IV phenoxyamine and her blood pressure drops to 135 over 90 good Labs return and reveal a serum calcium abnormally elevated at 11.4 mg per DEC which of the following is the most likely diagnosis in this patient a men one syndrome B men2a syndrome C men Tob syndrome D hyperthyroidism or E renal artery stenosis and the answer here is B men TOA syndrome so you should memorize these uh a lot of the USMLE loves to give these questions out and really if you just memorize them you'll get the question right because they're really just trivia questions so remember with men one syndrome you've got the three piece pituitary parathyroid and pancreatic uh with men two in general you have foch chromosoma and thyroid cancer with a you have parathyroid hyperplasia like in men one and with men B men 2B you've got a marfanoid body habitus and mucosal neuromas so um with both of the men two syndromes you've got thyroid carcinoma and focom oyoma but 2 a you've got parathyroid hyperplasia 2 B you've got the body habitus and mucosal neuroma both in men 2A and Men 2B syndrome if they're diagnosed with that then you're going to do a prophylactic total thyroid ectomy because 100% of these patients go on to develop medular thyroid cancer which is very deadly so we'll just remove the thyroid even without thyroid symptoms okay so the parathyroid hyperplasia here is what caused her calcium to be elevated okay question five 16-year-old Mal presents to the clinic with his concerned mother that's never good she's worried because he doesn't seem to be growing like all the other boys in his grade physical exam reveals an apparently healthy boy at 65 185 lbs seems to be growing to me with sparse pubic hair and a large aular diameter his arms are long and his hip girdle seems somewhat wide now you can see why Mom's concerned the testes are firm 1.2 cm in diameter penile length is 3.5 CM flaccid which of the following is most likely to be found in this patient a anosmia b webbed neck c 45x kype d 47xxy karot type or e low serum LH and let me add here that this patient also uh had difficult y uh with uh learning how to read in uh grade school and he's a couple grades behind with his reading but he's fine with math okay the answer here is 47xxy karot type so this is a patient with Klein felter syndrome and there's two things to think of when you have a patient uh such as this patient who's 16 years old by all means he should be in puberty well into puberty who is not developing secondary sex characteristics clearly he's growing he's got he's six 6' five he's quite tall uh but he's not developing the secondary sex characteristics the sex characteristics that we would expect in a man uh he's got sparse pubic hair he's got a large AAL or diameter well that's strange that should happen in women uh his he's got long arms and his hip girdle is wide that happens in women too because they need to have a hip girdle to deliver a baby uh he's also got a micropenis and he's got small testes so this is all consistent with Klein felter syndrome plus what I added there the fact that he had difficulty with reading that's very very very common in kleinfelter syndrome so anosmia would be uh could be something that you may see in a patient that has uh that has uh delayed puberty however that would be in calman syndrome and with cman syndrome generally you don't get the learning delays and they're not quite as tall um as as patient with Klein filters U and also in the USMLE you'll if it's a Colman's patient you'll be given anosmia in the question because that's such a that's such a uh a a a a a present symptom uh webbed neck is a feature of Turner syndrome which happens in uh in phenotype girls uh so and that's also the 45x z kot type so both of those are Turner syndrome and that's kind of like the girl equivalent of of uh of of Klein felter syndrome so in Turner syndrome they where a normal girl would be XX they only get one X chromosome uh Klein felter syndrome as mentioned it's the xxy carot type so these are boys that got an extra X chromosome and they and low serum lutenizing hormone would be a hypogonadotropic hypogonadism okay so these are some features that you would see in a uh patient with Klein felters so of course the lack of of pubic hair and facial hair gynecomastia uh along with that uh that increased a diameter very long arms testicular atrophy small penis size and long legs look at this patient here very very very long legs he been great swimmer but look at look at the look at that hip girdle here you see he's very very thin but he's got a wide hi very wide hips he's got that typical hourglass shape that you would you would see in women so this is uh this is very unusual for a boy this patient in fact does have uh Klein felter syndrome and then this is a uh a kot type this is the most uh this is the most accurate diagnos for uh for uh for Klein felters this is the most uh this this is the gold standard okay so we got the same patient here which of the following is the best next step in the management of this patient a lolide b recombinant growth hormone C intramuscular testosterone D chopine or E an asrol all right so the answer here is C intramuscular testosterone so obviously this patient doesn't have any problems growing he's 6'5 185 PBS so we're not getting growth hormone okay uh lupoli is a uh is a a uh medication that actually will decrease LH and FSH production and we don't want to do that because we want this patient to we want to give him uh we want his testosterone level to increase we want him to develop we want him devel to develop man sex characteristics presumably male SE sex characteristics uh so we want him to have testosterone lolide is not going to help generate testosterone really the only way we can get patients with Klein felter syndrome we can get them to have testosterone is to give them testosterone so intramuscular testosterone is is the best choice chopine will uh it's a selective estrogen receptor modulator um that will increase LH and FSH production but it does not increase testosterone and an asrol is a an aromatase inhibitor that would increase your testosterone but it doesn't boost testosterone production which is what we want to do uh an asrol would simply uh block conversion of testosterone to estrogen so in patients with Klein felter syndrome to get to get these boys to develop secondary sex characteristics we need to them testosterone because they're not producing enough now these patients with Klein felter syndrome will need testosterone throughout their lifespan uh in order to maintain their secondary sex characteristics and uh often times to uh to to keep their libido uh so they'll need ongoing care uh with testosterone and you're not going to be doing this this will be done by a pediatric endocrinologist but you need to know that for uh for Klein felter syndrome they need testosterone okay question 7 42-year-old woman presents to your clinic complaining of difficulty losing weight she says that she's been exercising and closely monitoring her diet her medical history is significant for hypertension which was diagnosed at her last visit 3 months ago today her blood pressure is 130 over 90 physical exam reveals an overweight woman uh with a BMI of 29.8 you should know that BMI should be under 25 anything above that is overweight anything above 30 is obese with a conspicuously increased distribution of fat over the abdomen you note faint vious stri and what appears to be periorbital edema her current medications include hydrochlorizide TSH is 1.7 which is normal which of the following is the best next step in the management of this patient a serum cortisol level B hyos methasone suppression test C low do dexamethasone suppression test D serum act level or e a CT of the abdomen okay so the answer here is a lowd do dexamethasone supression test so this is a patient who has uh signs and symptoms and a history consistent with uh with with Cushing syndrome so uh here's the uh Here's the the little tree that I gave you uh in the uh in the hyperadrenalism lecture now if you suspect Cushing syndrome then the best initial diagnostic step is a lowd Doos dexamethasone suppression test why is that the best first step because in any patient who is secreting uh excess cortisol a lowd do dexamethasone suppression test will not suppress it and a patient who has a uh who has a normal cortisol then the lowd do dexamethasone that will suppress their cortisol so if they have a suppressed or normal cortisol less than 1.8 micrograms per deciliter you don't need to know that level for the test if they have a suppressed or normal cortisol level with the lowd do dexamethasone suppression test then they do not have Cushing syndrome at all ever ever ever ever if though they have an elevated cortisol despite your low do dexamethasone remember dexamethasone suppresses cortisol production if they still have an elevated cortisol after the lowd do dexamethasone suppression they will have uh they do likely have Cushing syndrome and remember Cushing syndrome is any cause of uh cortisol secretion excess cortisol secretion now you have the option of doing a 24-hour urinefree cortisol um and what that is is because there are possible false positives uh when you do a lowd do dexamethasone suppression test most of the time they they are true positives but there sometimes you can get a false positive a 24-hour urine free cortisol is is more accurate than a lowd dose dexamethasone suppression test however the best initial test is the lowd dose dexamethasone suppression test because it's it's an easier faster test to do uh and there it's very reliable uh if there's anything that makes you think that this patient may be at risk for false positives which we have no reason to think so in this patient we weren't given any reasons then you can do a 24-hour urine free cortisol but you don't need to do that in in this patient so a lowd do dexamethasone suppression test is always the best initial diagnostic step in a patient where you suspect Cushing syndrome after you get the lowd dose dexamethasone suppression test and you still have elevated cortisol then you do a highd do dexamethasone suppression test and what a high do dexamethasone suppression test does is it diff it weeds out the the pituitary adenomas from the other cause of Cushing syndrome so in a high dose dexamethasone suppression test that will turn off the cortisol production in pituitary adenomas so you'll have a reduction in plasma cortisol after you've given the highd do dexamethasone if you don't have a response then you know that it's either an act secreting tumor or an adrenal neoplasia act secreting tumors secrete AC which stimulates the production of cortisol so that's secondary adrenal neoplasias directly secrete cortisol so what you do then if you have no response the hydrostone you know it's either act secreting or adrenal neoplasia then you just get the ACT level in patients with an act secreting tumor then you know they've got a high act level level with patients that have adrenal neoplasias they're going to have a low act level because they've got the cortisol coming back and giving negative feedback to the pituitary secretion of act so they'll have very very low act levels so in those patients you know they have adrenal neoplasias and in patients with adrenal neoplasia then you will get the abdominal CT to visualize it patients with ACTH secreting tumors those tend to be in the chest so you'll get a chest CT so in this patient you get a lowd dose dexamethasone suppression test that's the first test we get when we suspect Cushing syndrome remember Cushing's syndrome is any thing that causes hypercortisolism Cushing's disease is strictly a pituitary adenoma which is a is in the realm of Cushing syndrome okay question 8 a 20-year-old male presents to the Ed via EMS paramedics say that he claps during his college physics lab and had what appeared to be a tonic clonic seizure history is unknown vitals are stable physical exam reveals an unresponsive male with generalized muscle stiffness 5 milligram of lorazapam were administered in the ambulance Labs reveal calcium of 8.1 which is low CBC shows a hemoglobin of 9.4 hematocrit of 28.1 white blood cell count of 9.4 platelets of 234 and a total Billy ruin of 2.1 which is elevated which of the following is the best next step in the management of this patient a repeat 5 mg of lorazapam B phenobarbitol C vitamin D replacement uh D calcium gluconate or E IV fluids followed by hydrochloride all right and the answer here is D calcium gluconate so this is a patient who has hypocalcemia you know that because his calcium level is 8.1 seizures are a possibility and a a certainly a very common presenting complaint for that matter with uh with hypocalcemia remember what calcium does it stabilizes membranes it stabilizes the uh membranes of The myocardium it stabilizes all cell membranes so any patient who has hypocalcemia IA is going to be is going to have neuronal hyperactivity so things like seizures with patients who have hypercalcemia they will be uh have neuronal hypoactivity so they'll have things more like uh uh sluggishness or lethargy or coma so this is a patient who clearly with his low calcium and with a possibly life-threatening condition needs to have his calcium replaced so you would give calcium gluconate um we don't need to repeat the 5 Mig of lorazapam unless he goes back into atonic clonic seizure um but certainly we need to treat the underlying cause uh first so he's already been given the lorazapam and he's no longer in tonic clonic seizure uh phenobarbital is given um if uh that's given if if he's not responsive to the Pam and seizure but what you should know here is that because he's got a low calcium and he's got symptoms of hypocalcemia you have to replace the calcium okay and then IV fluids followed by hydrochlorizide you should know that's the treatment for hypercalcemia okay a 39-year-old male presents to the Ed with sharp right lower quadrant abdominal pain it's continuous and it's been going on for the last hour it does not radiate he rates it as A+ 9 out of 10 vitals are stable soas sign is positive abdominal CT is consistent with a apendicitis his Labs show a sodium of 131 potassium of 5.2 chloride of 107 bicarb of 30 bu of 24 creatinine of 0.9 and glucose of 114 uh on CBC he's got a hemoglobin of 12.2 with a hematocrit of 37.1 white blood cells are at 13.1 and his PL are 314 he's admitted and placed on NPO for surgery however prior to surgery his blood pressure drops to 75 over 40 fluids are administered but his blood pressure only Rises to 83 over 55 which of the following is the best next step in the management of this patient a 3% naacl Administration B normal saline Bolis C flut cortisone D methyl pricone or E epinephrine and the answer here is D methyl pricone so here you have a patient with acute stress he's got an inflammatory reaction going on and he also happens to have a hyponatremia with a hyperemia and a metabolic alkalosis well he's got a an elevated B carb I guess we don't know that he's got alkalosis because we don't know his blood pH but he possibly has metabolic alkalosis because his bicarb is High um so this hyponatremia plus a hyperemia when you have a patient that has those two things and they're not on diuretics you are thinking hyper or sorry hypoadrenalism so we don't know necessarily the cause of this patient's hypoadrenalism uh of this patient's low cortisol and really it doesn't matter uh what matters is that we have to treat his hypoadrenalism and a lot of times patients with hypoadrenalism can go subclinical until they get some kind of acute stress and then they develop this uh significant drop and blood pressure and life-threatening conditions so the fact that he's got appendicitis uh is likely what triggered his uh hypoadrenal crisis uh so likely what he has is Addison's Disease but we don't necessarily know that because uh you know it could be any cause of of hypoadrenalism what matters though is that we recognize he's got a low sodium a high potassium and a high bicarb that's consistent with hypoadrenalism and so because he's got this low blood pressure and we're giving him fluids and it's not responding we've got to give him steroids and what we're going to give him is glucocorticoids and that would be methyl pricone fludrocortisone uh certainly is is uh a something that he'll eventually need if he has Addison's disease but that is not that that doesn't replace cortisol it replaces aldosterone so we don't use fluer cortisone 3% any Administration that's to that that would be to correct hyponatremia we're not doing that here we're trying to save this patient's life so not that normal saline Bolis we already tried that it didn't work too well and epinephrine um that's not right because we know this patient's got hypo hypocortisolism so we've got to treat uh his hypocortisolism and we're going to give him methyl pricone 100 to 300 milligrams and then we're going to order a cortisol level U and that cortisol level if it comes back low then we know that we've got to continue to treat his hypocortisolism and that's going to be important because uh before he goes into surgery we're going to need to give him more cortisol uh more methyl pricone so the answer here is D methyl pricone we are treating his addisonian crisis okay question 10 a 27-year-old male presents to your clinic complaining of loss of vision he says it came on slowly and he saw his optometrist who is bewildered and suggested he see his MD physical exam reveals visual field deficits in the lateral fields in both eyes there are no other symptoms present which of the following is the best next step in the management of this patient a prapin level B TSH c a CT of the head D reassurance or E referral to off Opthalmology and answer here is a prolactin level so a prolactin secreting adenoma is the number one cause of pituitary adenomas pituitary adenomas are the number one cause of uh bitemporal hemianopsia in younger patients so this is uh what we want to have we want to have a prolactin level because a prolactin level would show us if we have a prolactinoma and a prolactinoma is what we suspect because he's got Boral hemianopsia which is visual field deficits in both lateral Fields so a TSH level uh is not correct because that's for thyroid problems a CT of the head eventually yes we will get that but a prolactin level is what we want first CTS are more expensive and they uh they expose the patient to radiation so we want to have a prolactin level first prolactinomas in men tend to be uh macro adenomas and so they're very likely to cause these uh these bitemporal hemianopsia reassurance uh no because we want to uh we want to see if he's got a prolactinoma and referral on the USMLE is never the right answer okay question 11 a 47-year-old woman presents to your clinic for a followup on her fasting blood glucose results she's had two readings which were 131 and 129 mg per diler she's had uh she has a medical history of hypertension which is controlled with hydrochlorizide physical reveals a mildly overweight woman with a BMI of 27.9 but no other significant findings in addition to diet and exercise which of the following is the best medical therapy for this patient a insulin therapy B metformin c rigzone d Glipizide or exenatide and uh I'm just going to add here that this patient uh has a uh has a hemoglobin A1c of 7% so the correct answer here is going to be B metformin and you should uh be aware that metformin is the Cornerstone of medical therapy for type two diabetes so insulin therapy the only time we start okay first off how do we diagnose this patient with type 2 diabetes Well we know she's got type 2 diabetes because she has had two readings which were above 126 milligram per deciliter and those are fasting blood glucose levels so because of that she's stamped with type two diabetes Now the rules are uh the the most recent uh sorry the most the most recent recommendations are uh if the uh if if the patient has a uh if if actually I'm forgetting this now if the patient has a uh a a A1c of less than 7.5 uh then we start them on monotherapy if it's 7.5 to 9 we start them on Dual therapy and if it's greater than nine without symptoms it's triple therapy and greater than nine with uh with symptoms and by symptoms I mean uh for instance uh if she were to have uh if she were to have paresthesias if she were to have endstage renal disease uh diabetic renal disease um and so forth uh then we would start her immediately on insulin therapy um I don't know about those exact numbers they just came out recently so check my uh check my uh check my diabetes lecture uh because I I had it fresh on my mind there's something like that 7.5 to9 I think is the cut off any either way if we're going to start a patient with diabetes uh on a medical therapy uh and it's not insulin because she doesn't have uh any any diabetes symptoms as far as diabetic neuropathy um diabetic retinopathy Etc then metformin is the first drug we go to metformin is the corn Corner Stone uh rosone is a thadine diione that could be a good add-on therapy if we needed to use two drugs uh same with Glipizide and exenatide Glipizide is a suano Ura and exenatide is uh a uh a gpp1 Agonist so we don't go right to insulin therapy in this patient because she doesn't have uh she doesn't have the the end stage symptoms of diabetes okay 65-year-old man presents to your clinic complaining of numbness and tingling of his feet his medical history includes hypertension which is controlled with cappro and uh type 2 diabetes melodus for which he takes metformin and exenatide physical exam reveals decreased pin prick sensation in his feet bilaterally along with a small ulcer on his right heel otherwise unremarkable hemoglobin A1c is elevated at 99.5% which of the following is the best next the management of this patient a Gabapentin b carbamazapine c add a third oral anti-hyperglycemic drug D CT of the spine or E switch to insulin therapy all right I probably gave you some hints on the last explanation here answer here is going to be to switch to insulin therapy so he has symptoms of diabetic neuropathy and so therefore we want to switch him to insulin therapy to get the best control of his glucose um so gabapentin and carbamazapine would be fine drugs to treat the symptoms of diabetic neuropathy but to treat the uh to treat his diabetes uh we want to to treat his blood glucose level we need to switch him to insulin therapy that's first and foremost okay here we go uh yes okay so I was right uh so 6.5 to 7.5 uh we give them monotherapy um we start with metformin uh and then with a uh with A1C uh we uh at 7.6 to9 we uh we do dual therapy um and if they're not responsive to that we can start them on triple therapy and if their A1C is greater than nine uh and they've got no symptoms then we uh we start them on triple therapy if they've got symptoms then we put them on uh insulin okay question 13 a 56-year-old man presents to your clinic complaining of weight gain he is presently being treated for type 2 diabetes melodus over the last 6 months his weight has increased from 215 PBS to 250 PBS his current diabetes regimen includes metformin and Glipizide his he says that his blood glucose levels are well controlled his hemoglobin A1c is 6.5 clearly reflecting that which of the following medication switches would be most appropriate in this patient a stop both metformin and Glipizide and start insulin B stop Glipizide and start pazone C stop metformin and start pazone D stop Glipizide and start exenatide e stop metformin and start exenatide and answer here is D stop glyphid and start exenatide so this patient has weight gain from his regimen of diabetes and um so what we have here is metformin and Glipizide metformin is not associated with weight gain Glipizide as a suano Ura is associated with weight gain so we want to get him off his Glide so that's going to eliminate c and e we have no need to switch him to insulin and as a matter of fact uh we don't want to do that because his his hemoglobin A1c is on good control what increas or what what will help you lose weight in diabetes it's going to be exenatide and liraglutide so the glp1 uh and gp1 Agonist and dpp4 Inhibitors are both drugs that are uh I mean they're expensive but they are uh they're much better than the Sano Sano uas and thadine diones because uh they're safer um the uh with the glp1 agonists it uh increases weight loss so you have weight loss with gp1 Agonist with dpp4 uh Inhibitors you don't get the weight loss uh but the important thing to remember is that suono uras will cause weight gain and glp1 agonists like exenatide and llyde those cause weight loss so if you have a patient that has gained weight and they've got good control over their blood glucose uh you can take them off of Sano Ura and put them on a glp1 uh Agonist now the thing with glp1 agonists are that they have to be taken subdermally so that's something that patients have to uh get used to um but in general the patients will be very very happy to take these drugs because they're very effective with weight loss okay I wanted to go back to one thing here uh with this woman here that uh we put on Metformin uh we I just wanted to add and it has nothing to do with the question but uh the fact that she is controlled with her hypertension on hydrochlorizide now that she's been diagnosed with diabetes we want to take her off hydrochlorizide and put her on an Ace inhibitor because uh whenever we treat hypertension in conjunction with diabetes ACE inhibitors are the best because they're renal protective so use like listen April or captopril okay so a uh question 14 a 17-year-old female presents to the Ed via EMS her mother called 911 because her daughter was delirious and sweating vitals show blood pressure of 135 over 90 heart rate 115 respirations 20 temperature of 101.4 fhe EKG reveals sinus tachicardia physical exam reveals an agit a confused patient in distress her face is flushed and there is excessive sweating she has a mild goer IV fluids are started and prop Propranolol is administered which of the following is the next best step in the management of this patient a IV methol B IV propo urisol C emergent thyroidectomy D radio iodine oblation or E netop all right the answer here is going to be B IV propath uril so this is a patient who's got thyroid storm and what you may have been uh thinking about is aren't methol and propath urasil both equal and the fact is yes they are equal if we're treating hyperthyroidism but if we're treating thyroid storm propath uracil is preferred so use PTU if it's thyroid storm but if it's uh if it's a patient with just plain old hyperthyroidism you could use whichever one you want uh emergent thyroidectomy uh there really isn't any such thing uh radio iodine oblation will eventually be good in this patient but of course we need to treat the thyroid storm that's the first thing we do actually the first thing you do uh was given here you're going to administer Propranolol uh that's to to help with the uh to help with the tachicardia because one of the leading causes of death in patients with thyroid storm is is uh is the uh the tachic cardia causing a uh a arhythmia so we want to administer Propranolol first but then we'll go right into giving propath osil to uh to treat the thyroid storm okay uh 26-year-old woman G 3p3 presents to your clinic she recently gave birth to a healthy baby girl via normal vaginal delivery her pregnancy uh was uncomplicated she has had difficulty breastfeeding which she says happened after both of her previous pregnancies and she attributes it to her small breast size she is concerned however because her hair has thinned out and she's gained 20 lbs since delivery she also has not menstruated yet physical exam is unremarkable which of the following is the most most likely mechanism of disease in this patient a herniation of arachnoid Mater into suprasellar space b lymphocytic infiltration of the thyroid C Hemorrhage into the pituitary gland D severe fibrosis of the thyroid gland e esic necrosis of the pituitary gland all right so the answer here is e es schic necrosis of the pituitary gland so this is a patient who has hypothyroidism she's got thin hair she's gained 20 pounds and she's got sign well signs of hypothyroidism I should say and she's got signs of uh of uh low LH and FSH because she has not menstruated and it's 6 months after her delivery and she's not breastfeeding normally a woman should start to get her period uh no more than three months after delivery so uh with both of those signs um low thyroid hormone level and a uh possibly a low LH and FSH level uh that's suspicious for shean syndrome and shean syndrome is es schic necrosis of the pituitary gland herniation of a rachid Mater into suprasellar space uh that would be empty cell syndrome that happens tends to happen in heavier women um but it tend tends to be asymptomatic lymphocytic infiltration of the thyroid is uh is Subacute thyroiditis um I suppose it could be eloh Hashimoto thyroiditis but that would not explain the uh the the fact that this happened acutely after pregnancy and the fact that she's not menstruating now um well I suppose it could explain that she hasn't menstruated yet but this happened acutely after pregnancy and she's had difficulty breastfeeding uh Hemorrhage into the pituitary gland that's pituitary apoplexy that's acute and life-threatening so that's definitely not in this patient uh severe fibrosis of the thyroid gland that's uh redel thyroiditis and uh ischemic necrosis of the pituitary gland is indeed what we have here that's shean syndrome so think shean syndrome when you've got signs of panhypopituitarism so difficulty breastfeeding uh no menstruation prol long long after pregnancy signs of hypothyroidism uh when it's after pregnancy you think shean syndrome and that's esic necrosis of the pituitary gland okay 51-year-old male presents the clinic complaining of uh generalized pain over the last several months you've known this patient for some time and note a distinct change in his appearance his jaw has become more prominent and when he smiles his teeth are separated he is also not wearing his wedding ring he he says he and his wife are getting along fine but his ring stopped fitting him based on these findings which of the following initial diagnostic tests would be most relevant a igf1 levels B CT of the head C testosterone levels D GH levels or EGR levels all right so this is a patient who has acromegaly so we want to get igf1 level on this patient um igf-1 levels are the first test you're going to get when you suspect acral why do we think this patient has acromegaly well he's got uh a enlarging jaw and that's very characteristic of of uh of acromegaly so two things you would think uh you would see facial wise in acral is coarsening of the facial features so a more prominent jaw and when you get a when when when the jaw enlarges you actually will get this separation of the teeth so those are two things that are highly correlated with acral another thing that fits with acral here is the fact that his ring doesn't fit him anymore and that's because of the fact that his his uh fingers are are are enlarging so in acral the bones actually widen and that's different from uh a growth hormone secreting tumor in a child where they would have gigantism they would uh their bones get longer so they get taller so in uh in patients where we suspect acromegaly we're going to get igf-1 levels if they come back positive then we'll get a uh growth hormone levels with glucose suppression question 17 a 33-year-old woman presents to your clinic complaining of difficulty managing her weight she's tried to manage her diet and exercise but remains at a BMI of 30 on physical exam you see an obese woman mild facial acne no gliter trunkal obesity and pubic hair extending up her abdomen past the navl pelvic exam reveals no masses but while you're examining her she says that her menstrual cycles have been erratic lately vital signs are normal TSH is 1.4 which of the following therapies will most likely benefit this patient a tamoxifen B medroxy progesterone C conjugated estrogen D an asrol or e flutamide all right the answer here is B mroy progesterone so this is a woman with polycystic ovarian syndrome U more than likely we would actually have to get a uh an ultrasound of her ovaries to confirm that but with polycystic ovarian syndrome uh what you have is uh an obese woman almost almost always that's an obese woman or mildly overweight women uh and you have androgenized signs and you have uh erratic menstrual cycles so by androgenized signs I mean things like acne things like heroism uh trunkal obesity and by uh by menstrual cycle uh erratic I mean either aena or oo manaria so she's not getting her period any more than uh either ever or no more than uh every six weeks so uh the the three Cardinal symptoms or Cardinal findings in uh in uh polycystic ovarian syndrome are androgenized signs Amenia legomena and then the polycystic ovaries on on uh on on your sonogram but uh the question here was which of the following therapies will most likely benefit this patient and we have to uh are presumptive diagnosis here of course we're not going to treat the patient without doing uh the sonogram uh because we I mean it's we we have to get that to make the formal diagnosis but what we can do here is we can rule out uh the fact that it may be caused from hypothyroidism which may cause uh delayed menstrual cycles um so uh we know it's not that because of TSH is normal and we've got the androgenized signs we've got the Obesity and we've got the algam Manara so those are all those are all consistent with polycystic Varian syndrome what do we use in polycystic Varian syndrome two the the two best drugs are medroxy progesterone or ethanol estradiol so um the rest of these drugs are not appropriate for polycystic variant syndrome and this would be uh the uh the sonogram that would confirm polycystic ovarian syndrome so I think the cut off is 12 12 cysts that you have to see uh and uh clearly there's more than that here there's like almost 20 here okay so uh let me just say though you will normally see a couple of these cysts in an ovary what these are are just uh they're their eggs getting ready to ovulate um but in in women who have polycystic ovarian syndrome the eggs sort of get ready to ovulate but they just don't get there all the way so that's why they've got multiple of them okay question 18 so A 42-year-old male presents to your clinic for annual checkup over the past year he's gained 30 pounds and now has a BMI of 25.9 he's employed as a gym teacher at the local elementary school and says that he has been watching his diet exercising as you usual but has been somewhat more tired lately on physical exam you knowe brittle hair power and decreased bowel sounds vital signs are normal which of the f following is the best next step in the management of this patient a serum TSH level B lowd do dexamethasone suppression test C high do dexamethasone suppression test D lipid panel or E iodine supplementation and the answer here is a serum TSH level so this is a relatively straightforward question the guy has weight gain he's watching his diet he's been tired uh and he's got brittle hair and decreased fowel sounds and power those are all signs of hypothyroidism hypothyroidism is rather common however it's it's a little less common to show up in a in a man but anytime you've got somebody with with an unexplainable weight gain in a a person that's really watching their diet and clearly this is a guy who's active he's a gym teacher he's watching his diet he's exercising as usual um but he's got this weight gain and fatigue and particularly the brittle hair uh and the decreased bowel uh sounds um those all point you towards hypothyroidism and so you want to get a serum TSH level we're not thinking Cushing's Disease or Cushing syndrome in this patient because he doesn't have the stria he doesn't have a buffalo hump he doesn't have moon faces uh and so forth um furthermore a serum TSH level would be more appropriate because a uh barring any specific signs of Cushings Disease uh thyroid disease is far more likely uh lipid panel will eventually be appropriate in this patient because he does have hypothyroidism and and because uh elevated cholesterol is uh associated with hypothyroidism but we have to establish the diagnosis first and iodine supplementation is appropriate in patients who have hypothyroidism due to endemic goer but that's not this guy people in the US very rarely have endemic gler and plus we have to establish the diagnosis first and that's done with a serum TSH level okay 51y old woman presents to your clinic for annual checkup as she is over 50 you recommend she get a DEA scan to screen for osteoporosis uh which standard deviation is the cut off to begin bis phosphinate therapy for osteoporosis a below1 and these are T scores by the way below1 below 1.5 below -2 below -2 .5 or below -3 so the answer here is D below -2.5 so um the tcore is just a standard deviation from uh in in bone density from the bone density of a healthy patient in their 20s uh and so any patient who's negative uh who's 1 to 2.5 standard deviations below uh that level is considered to have osteopenia and if it's below 2.5 standard deviations uh then it's uh going to be osteoporosis so here's zero normal bone density uh that's your uh control and then -1 to -2.5 so Tores that's standard deviations below zero uh that's osteopenia and then if it's more 2.5 standard deviations below uh normal then it's osteoporosis and we treat this with bis phosphinates alendronate abrate Etc okay final question a 36-year-old woman presents to your clinic complaining of neck pain which has been getting worse over the past month physical exam reveals a diffusely tender thyroid no nodules are appreciated TSH is 1.3 which is normal which of the following is the best next step in the management of this patient a methol b levothyroxine c cyclophosphamide d prednisone or E RI scan all right answer here is D pronone so this is a patient with DeQuan thyroiditis um DeQuan thyroiditis is the only thyroiditis that's painful and so because this patient has a painful thyroiditis we have to treat her uh with prednizone so uh and that's done to reduce the inflammation now with dequine thyroiditis it's an immune attack on the thyroid so you will have an initial uh hyper thyroid stage then you'll go into a normal thyroid stage and then you'll go into a hypothyroid stage she's clearly in the you thyroid stage so um we don't need to treat uh anything uh we we don't need to treat any thyroid related symptoms and dequ vein's thyroiditis is self-limited so really all we need to do is try to reduce the inflammation and we can treat her pain too we would give her something like aspirin um but we don't really need to do anything but treat the disease itself now meth methol of course that's for hyperthyroidism so we don't use that levo thyroxine would be if she were hypothyroid and symptomatic which is not the case cyclophosphamide is way out that's a that's that's for autoimmune diseases like like uh lupus and uh Wagner's granulomatosis uh prazone is the best choice here all right and that's it