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garden-of-everything · 7 years

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ABIM: Endocrinology

ABIM syllabus can be found here Let me know if you find any errors Sources: UWorld, MKSAP 16/17, Rizk Review Course, Louisville Lectures, Knowmedge (free version)

Adrenal Disorders

Primary aldosteronism and mineralocorticoid excess: - Sx: HYPERNATREMIA, hypokalemia, metabolic alkalosis, HTN - Dx: aldosterone:renin >20 (aldosterone >15 with low renin levels), salt challenge fails to decrease aldosterone levels --> get CT scan - Tx: thiazide for BP control, spironolactone for hyperplasia, surgery for adenoma Adrenal insufficiency: - Addison’s = primary: tan, orthostatic HTN, hyponatremia, hyperkalemia, hypoglycemia, prolonged QTc - Dx: morning cortisol levels --> cosyntropin stimulation test <18mcg/dL = adrenal insufficiency --> check morning ACTH levels (if decreased ACTH, MRI brain; if increased ACTH, CT adrenals) - acute Tx: dexamethasone - chronic Tx: hydrocortisone +/- fludrocortisone only if primary - x2-10 dose of steroids during stress Pheochromocytoma: - associated with MENIIa and IIb (increased calcitonin/medullary thyroid cancer is also associated with both MENII’s; if IIa: hypercalcemia/parathyroid, if IIb: Marfan’s/neuromas) - Dx: serum or 24 hour urine metanephrines --> MRI/CT ab --> if negative: T-MIBG Tx: surgery: - pre-op BP control with phenoxybenzamine/doxazosin/nicardipine - intra-op HTN crisis: nitroprusside or phentolamine Incidentaloma: - if <4cm, f/u CT; if >6cm, surgery - Dx with 1mg overnight dex suppression test (Cushings) + urine metanephrines (PCC) +/i if hypertensive: aldosterone:renin ratio (hyperaldosteronism if elevated)

Thyroid Disorders

Hyperthyroidism: - Grave’s: anti-TSHR Ab - associated with vitiligo - Tx: Methimazole (AE: sore throat/agranulocytosis, hepatotoxicity) > PTU (for first trimester; AE: hepatotoxicity) Hypothyroidism: - Hashimoto’s: anti-TPO antibodies - associated with primary thyroid lymphoma - Tx if TSH>10 or planning pregnancy or symptomatic *FYI: increase Synthroid dose in pregnancy and in CELIAC DISEASE Thyroiditis: 1. subacute/DeQuervain’s: PAINFUL, Tx with NSAIDs only 2. Peripartum: painless, autoimmune 3. amiodarone-induced *subclinical presentation (decreased TSH, normal T4): repeat TFT in 4-6mo Thyroid nodules: - if <1cm and doesn’t look cancerous, repeat US in 3-6 months - if >1cm, FNA > Sx Euthyroid sick syndrome: transient and mild, weird TSH/T3/T4 levels during illness without prior thyroid issues; usually T3 is decreased while TSH/T4 is normal - Tx underlying illness only (no need for Synthroid) Thyroid storm: fever, HF, psych changes/coma; Tx: PTU, propranolol/BB, steroids (vs. Myxedema coma from hypothyroidism: hypothermia/hypotension/bradycardia/bradypnea, desaturation, AMS, hyponatremia, hypoglycemia; Tx with Synthroid + hydrocortisone) *if TSH/T3/T4 are all weirdly increased or decreased, cause is likely a pituitary tumor *suspect toxic multinodular goiter when patient experiences hyperthyroid symptoms after receiving IV iodine contrast

Hypertension

Hyperaldosteronism: - hypernatremia, hypokalemia, metabolic alkalosis (basically the opposite of RTA type 4) - Tx with thiazide Renal artery stenosis: Tx with ACEi Cushing’s Disease: - round and squishy - Dx: elevated 24 hour urine cortisol, 1mg dexamethasone suppression test (positive if fails to bring cortisol <5), elevated late salivary cortisol

Lipid disorders

- start screening every 5 years in >35yoM, >45yoF; or >20 if +CAD risk - goals: LDL<160, Cholesterol <190; pretty much decrease both goals by 30 for every additional CAD risk up to 3 times - diet > exercise - offer Orlistat if BMI>30 - offer Bariatric surgery if BMI >40 OR >35 with obesity-related condition

Ovarian disorders and female reproductive health

Polycystic ovary syndrome: - amenorrhea and virilization - Dx: bleeds with progesterone challenge, has elevated LH - Tx hirsuitism with OCP --> if fails: spirnolactone; use clomiphene if wants babies Amenorrhea: 1. primary ovarian insufficiency: elevated FSH = menopause --> if normal: check karyotype to r/o Turner’s (obtain cardiac imagining and kidney US for all patients with Turner’s) *if amenorrheic because of super athleticism: screen for bulimia 2. hypothalamic cause: functional/tumor/lymphoma; has decreased FSH and NO withdrawal bleed after progesterone challenge 3. anatomic cause/Asherman syndrome: adhesions basically retain periods; also has no withdrawal bleeding --> Tx: surgery Ovarian cancer: - hyperandrogenism; normal DHEA levels but elevated total testosterone levels >200 in a woman = ovarian cancer until proven otherwise - Dx: TVUS --> adrenal CT

Testes and male reproductive health

Male hypogonadism: total testosterone <200 +: - increased LH/FSH = primary testicular failure (Klinefelter’s, Mumps orchitis, XRT, autoimmune) - normal/decreased LH/FSH, elevated prolactin = secondary cause (prolactinoma --> MRI brain, opiates, steroids) --> obtain iron study to rule out hemochromatosis* *Hemochromatosis presents as tan Diabetes with elevated transaminases, and hypogonadism; has OA symptoms and is associated with CPPD/Pseudogout Male infertility: - Cystic Fibrosis is associated with azospermia, bilateral absence of vas deferens Gynecomastia: associated with anabolic steroids, marijuana, spironolactone - if elevated estradiol --> check testicular ultrasound to r/o neoplasm --> chest/adrenal CT to r/o choriocarcinoma (elevated beta hCG, lung infiltrates, hemoptysis) - if elevated LH, decreased testosterone --> check karyotype to r/o Klinefelters (associated with increased risk of breast cancer) *testosterone therapy can worsen OSA, erythrocytosis, and increases risk of clots

Diabetes mellitus

Type I: - associated with other autoimmune diseases (Celiac, vitiligo, thyroid) - DKA Type II: - Dx with two of the following on separate days: (1) fasting >126, (2) A1c >6.5%, (3) random >200, or just one of this: (4) 2 hour gtt >200 *if a health-seeming patient >35yo with h/o CAD or 2 CAD risk factors wants to do a vigorous exercise program --> do an exercise stress test first Diabetes mellitus and pregnancy: STOP ACE/ARB/statin (teratogenic!) - obtain eye exam once/trimester - BP control with methyldopa, BB (labetalol), CCB, Hydralazine - goal: preprandial BG <90, 1 hour postprandial <120 using NPH and short-acting insulin (NOT long-acting insulin or orals) - require annual DM screening after delivery Diabetes goals: - BP <140/90: use ACEi - start statin regardless of LDL if cholesterol >135 and check yearly - cholesterol goal <135 > LDL goal <100 - annual eye exam with Q3-5 year dilated eye exam - urine albumin excretion <30; if >30, start ACEi/ARB Indications for continuous BG monitoring: (1) postprandial hyperglycemia (2) Dawn phenomenon: morning hyperglycemia (vs. Somogyi = rebound hyperglycemia) (3) overnight hypoglycemia Diabetes complications: - acute mononeuropathy: spontaneously resolves, no Tx - gastroparesis: Tx: small meals, Reglan/Erythromycin (vs. Rifaximin for Scleroderma-related bacterial overgrowth that presents similarly as bloating) - orthostatic hypotension: Tx with compression stockings +/- fludrocortisone - peripheral neuropathy: BG control --> DULOXETINE > pregabalin - HHS: plasma osm >320, BG >600-1000, normal pH/ketones; Tx with NS --> insulin --> when BG<200 and tolerating PO --> SQ insulin - DKA: pH <7.3, bicarb <15, BG >250, elevated ketones elevated AG vs. Diabetes insipidus: excessive thirst for cold water, can’t concentrate urine - r/o DM, hypercalcemia - Dx: water deprivation test --> if urine osm still <200 --> desmopressin challenge: (1) can concentrate after challenge = positive test --> brain MRI; Tx intranasal or PO desmo/vasopressin (2) still can’t concentrate after desmo: negative test --> kidney ultrasound; Tx sodium restriction and thiazide *if Lithium-induced: Tx Amiloride

Disorders of calcium metabolism and bone

Hypercalcemia: - hyperparathyroidism associated with MEN I and IIa (increased PTH or normal PTH with increased calcium and decreased phos), chondrocalcinosis, bone cyst --> Dx: Sestamibi scan --> Surgery *Indications for parathyroidectomy: (1) Age <50yo (2) Ca >12 or 1 above baseline (3) GFR<60 (4) 24 hour urine Ca >400 (5) symptoms of hypercalcemia - drug-induced hypercalcemia: lithium, thiazide - sarcoidosis: increased calcitriol = active Vit D = 1, 25 Vit D - cancer / multiple myeloma: CRAB, difference in urine vs dipstick protein due to presence of undetected light chain, hypervitaminosis D - Dx: check ionized calcium first --> r/o decreased TSH --> PTH/Ca/Phos/25Vit D levels --> decreased urine calcium ( = familial hypocalciuric hypercalcemia --> Dx: CASR mutation, urine Ca;Cr ratio <0.01) Hypocalcemia: check ionized level, because may be due to hypoalbuminemia - associated with DiGeorge - symptoms include circumoral paresthesia, Chvostek cheek tap, Trousseau BP cuff Hyperphosphatemia: - CKD (increased PTH, decreased Vit D) --> Tx: Calcitriol/1,25VitD - hypoparathyroid (decreased PTH) - pseudohypoparathyroid (increased PTH, normal Vit D) Hypophosphatemia: - bone tenderness due to vitamin deficiency Paget’s: - hat size changes, bone pains, fractures, femur/tibia bowing, cranial nerve compressions; heart failure - elevated alk phos --> bone scan - Tx: bisphosphonate Osteoporosis: T-score<-2.5 (ignore age-adjusted Z-score) - get DEXA every 10 years (if normal) in woman >65 OR younger if FRAX >9.3% (they smoke, have h/o hip fx, steroid use, etc) Vitamin D deficiency and osteomalacia: - proximal muscle weakness/falls (especially in elderly), bone pain - decreased calcium, phosphate; increased alk phos - associated with Celiac disease, liver disease, kidney disease - Dx: bone marrow biopsy (BMB) - Tx: ergocalciferol/Vit D2 Renal osteodystrophy: ESRD pt w decreased Ca, Vit D; increased Phos, PTH; chondrocalcinosis at knees and pubic symphysis

Anterior pituitary disorders

Pituitary tumors: MRI (order first if mass effect) - associated with MEN I, pregnancy, and check TSH! (1) Prolactinoma: prolactin >500, galactorrhea/amenorrhea/erectile dysfunction; Tx: Cabergoline (2) Acromegaly: Dx: IgF1 or oral glucose tolerance test that fails to decrease GH; Tx: surgery (3) Cushing’s: HTN, DM, proximal muscle weakness; Dx: 24 hour urine cortisol, elevated late night salivary cortisol --> elevated morning ACTH = pituitary tumor --> Tx: surgery > XRT - incidental pituitary tumors: f/u repeat MRI with prolactin levels - Rx (TCA, CCB, Reglan, opiates) and pregnancy can cause elevated prolactin! Hypopituitarism: (1) apoplexy: sudden HA, vision change, AMS; Tx: steroids (2) Sheehans (after pregnancy): amenorrhea, no lactation (3) lymphocytic hypophysitis (occurs peripregnancy): sellar mass with anti-pituitary antibody; Tx: steroids OR if vision changes, surgery

Posterior pituitary and water metabolism

Hypernatremia: DI: polyuria, inability to concentrate urine; Dx: water deprivation --> desmopressin: (1) concentrates urine (urine osms goes up) = MRI brain and Tx w desmo/vasopressin; (2) still doesn’t concentrate (urine osms stay low) = kidney ultrasound and Tx with salt restriction, thiazide Hyponatremia: SIADH: urine osm > serum osm, urine osm >500, euvolemic (vs. psychogenic polydipsia where decreased serum AND urine osm)

Endocrine tumors and endocrine manifestations of tumors

Pancreatic tumors associated with MENI (hypercalcemia/hyperparathyroid, prolactinoma/pituitary tumor): - Insulinoma: Dx 72 hour fast (BG<45, insulin >5) --> CT abdomen --> still not detected?: check endoscopic ultrasound - VIPOMA: watery diarrhea - Gastrinoma/Zollinger-Ellison syndrome: severe dyspepsia; Dx: gastrin levels --> secretin stimulation test causing increased gastrin >200 - Glucagonoma: hyperglycemia, pustular rash, diarrhea, DVTs - Carcinoid: flushing, N/V/D/AP; Dx: 24 hour urine 5-HIAA Malignancy-associated hypercalcemia (squamous cell): decreased PTH, normal/decreased phosphate, increased PTHrpeptide Ectopic ACTH (Cushing’s) due to tumor: associated with small cell, medullary thyroid cancer (elevated calcitonin), bronchial carcinoid (flushing, wheezing) SIADH from tumor: associated with small cell; hyponatremia and euvolemia; urine osm >500

Hypoglycemia

- most commonly after gastrectomy/gastric bypass - insulin use: decreased C-peptide - sulfonylurea: increased C-peptide --> check for medication in urine - insulinoma: seen in MEN I with hypercalcemia/hyperparathyroid, prolactinoma/pituitary adenoma; Dx with 72 hour fast: if BG <45 and insulin >5 --> CT abdomen - exercise-induced delayed hypoglycemia: Tx: complex carbs

Polyglandular disorders

MENI (”3P’s”): (1) Pituitary: prolactinoma, acromegaly, Cushings (2) Pancreas: insulinoma hypoglycemia, VIPoma diarrhea, gastrinoma GERD, carcinoid flushing, glucagonoma hyperglycemia (3) Parathyroid: hypercalcemia MENIIa: (1) Parathyroid: hypercalcemia (2) PCC: hypertension (3) Medullary thyroid cancer: elevated calcitonin MENIIb: (1) Marfan’s/neuromas (2) PCC: hypertension (3) Medullary thyroid cancer: elevated calcitonin

#me #endocrinology #abim #internal medicine #im #exam #test #diabetes #metabolism #medical #medicine #study #notes

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whatshouldinamethisblog · 5 years

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STOP

NEURO:

TCAs (Brain, Eyes, Heart, Colon, Prostate):

- with dementia.

- with glaucoma.

- with cardiac conductive abnormalities (pro-arrhythmic effects).

- with constipation or medication likely to cause constipation.

- with prostatism or prior history or urinary retention.

BDZs (withdraw slowly if taken for longer than 4 weeks):

- with acute respiratory failure (PO2 or PCO2).

- if fallen in past 3 months.

- for longer than 4 weeks.

Antipsychotics (Anticholinergic, Extrapyramidal Symptoms):

- long term > 1 month as hypnotics.

- long term > 1 month in Parkinson’s or Lewy Body Disease (likely to worsen extrapyramidal symptoms).

- with moderate-severe antimuscarinic/anticholinergic effects

- with a history of prostatism or previous urinary retention.

- as hypnotics unless sleep disorder if due to psychosis or dementia.

- in patients with behavioural or psychological symptoms of dementia unless symptoms are severe and other non pharmacological treatments have failed.

Levodopa or Dopaminergic Agonists:

- for benign essential tremor.

Phenothiazines (antimuscarinic):

- in patients with epilepsy (may lower seizure threshold).

- as first line tretament for anything except in palliative care where prochloprerazine for N/V/Vertigo, Chlorpromazine for hiccoughs, and Levomepromazine for N/V.

Anticholinergics:

- to treat extra-pyramidal side effects of antipsychotics medications.

- in patients with delirium or dementia.

- including first generation antihistamines.

Cholinesterase Inhibitors (Heart Block):

- with known history of bradycardia, heart block or recurrent unexplained syncope or concurrent treatment with drugs that reduce heart rate such as B-Blockers, Ca++ Blockers, and Digoxin.

SSRIs (Hyponatremia, GI Bleeding):

- with history of clinically significant hyponatremia (<130).

Citalopram and Escitalopram:

- with QT prolongation.

- or with drugs that prolong QT.

Opiates:

- for first line therapy of mild to moderate pain.

- slow release in severe pain without short acting breakthru.

- regular more than two weeks in chronic constipation without laxatives.

- long term in those with recurrent falls.

- long term in those with dementia unless for palliative care or chronic pain.

ENDO: ***Sulfonylureas of long duration of action (Hypoglycemia).

***Metformin if eGFR < 30 (Renal Failure).

Pioglitazone in patients with heart failure.

Estrogens (Breast Cancer, Uterine Cancer, DVT):

- history of breast cancer.

- history of DVT or PE.

- without progesterone in patients with intact uterus.

Any Hormone Replacement Therapy (Liver Disease, Estrogen Dependent CA, Vaginal Bleeding, Acute DVT):

- acute liver disease.

- estrogen dependent cancer.

- undiagnosed vaginal bleeding or untreated endometrial hyperplasia.

- active DVT or thrombophilic disorder.

- active or recent arterial thromboembolic disease (eg: angina or MI).

Androgens:

- in absense of primary or secondary hypogonadism.

Bisphosphonates:

- if greater than 3-5 years duration for drug holiday.

- if unexplained thigh hip or groin pain.

- given orally in patients with current or recent history of GI disease (dysphagia, esophagitis, gastritis, duodenitis, PUD, UGI Bleeding).

- if low risk of fracture (FRAX tool).

Denosumab:

- if low risk of fracture.

- if unable to have regular dental checkups.

CARDIO:

Digoxin:

- for heart failure with normal systoic ventricular function.

- for left systolic ventricular function where key interventions have not been tried.

- at long term dose greater than 125 mc/day if eGFR < 30 (risk of toxicity if digoxin plasma levels not measured as eGFR may not be an accurate indicator of clearance).

Thiazide Diuretic (Hypokalemia, Hyponatremia, Hypercalcemia, Gout):

- with current significant hypokalemia, hyponatremia, hypercalcemia or with recent or concurrent gout.

Loop Diuretic:

- as treatment for Hypertension.

- for dependent ankle edema without clinical, biochemical or radiological evidence of heart failure, liver failure, nephrotic syndrome or renal failure (leg elevation or compression hosery usually more appropriate).

Aldosterone Antagonists:

- spironolactone, eplerenone and ARBs, particularly if co-prescribed with potassium conserving drugs like ACE, amilioride or triamterene... without monitoring of serum potassium.

Verpamil or Diltiazem:

- with heart failure.

Nicorandil:

- if ulceration of the GI Tract, skin or mucosa including eyes.

- ulcers caused by Nicorandil do not respond to conventional Rx.

ACE or ARB:

- in patients with hyperkalemia.

- in combination with each other.

Centrally Acting Antihypertensives:

- methyldopa, clonidine, monoxidine.

- unless clear intolerance or or lack of efficacy with other classes of antihypertensives.

Amiodarone:

- as first line antiarrthythmic therapy in SVT.

Non-Selective B-Blockers:

- with recent history of bradycardia, heart block or uncontrolled heart failure, or asthma requiring treatment.

ANTICOAGULANTS AND ANTIPLATELETS:

Any:

- with concurrent significant bleeding risk, ie: uncontrolled severe hypertension, bleeding diathesis, recent non-trivial spontaneous bleeding.

ASA:

- long term ASA > 150 mg/day.

- with recent past history of PUD without PPI.

- in combination with Warfarin or NAOCs in patients with chronic A-Fib.

- as monotherapy for stroke prevention in A-Fib.

ASA + Clopidogrel:

- as secondary stroke prevention unless the patient has a coronary stent inserted in the previous 12 months or concurrent acute ACS or has a high grade symptomatic carotid artery stenosis (no added benefit over clopidogrel monotherapy).

Antiplatelet Agents with Warfarin or NAOCs:

- in patients with stable coronoary, cerebrovascular or perpheral artery disease (no added benefit drom dual therapy).

Warfarin or NOACs:

- for first DVT > 6 months without continuing provoking risk factors (eg:thrombophilia).

- for first PE > 6 months without continuing provoking risk factors (eg:thrombophilia).

Direct Thrombin Inhibitors (eg: Dabigatran):

- if eGFR < 30.

Factor Xa Inhibitors (eg: Rivaroxaban, Apixaban):

- if egFR < 15.

RESP:

Antimuscarinic Bronchodilators (Ipratropium, Tiotropium):

- with history of narrow angle glaucoma.

- with history of bladder outflow obstruction.

Theophylline:

- as monotherapy for Asthma or COPD.

Systemic Corticosteroids (Bleeding, Hypertension, Hyperglycemia, Hypercholesterolemia):

- instead of inhaled corticosteroids for maintenance therapy in moderate-severe COPD.

GI:

Metacloprmide and Perchlorperazine (Parkinson’s):

- with Parkinsons’s.

- after maximum treatment 5 days (metaclopromide).

***Domperidone (Heart Problems):

- for treatment other than N/V.

- after maximum treatment time of one week.

- in patients with serious underlying heart conditions.

- if receiving other medications known to prolong QT or with potent CYP3A4 inhibitors.

***PPI (Pneumonia, C-Diff, Osteoporosis):

- for uncomplicated PUD at full theraputic dose after 1-2 months (if healed, offer low dose maintenance treatment possibly on an as required basis - review anually).

Drugs likely to cause Constipation:

- anticholinergic drugs, oral iron, opioids, verapamil, aluminum antacids in patients with chronic constipation where non-constipating alternatives are available.

- for diarrhea of unknown cause, consider possibility of Clostridium Difficile infection (CDI) if there is a history of antibiotic use in the last 8 weeks or recent hospital discharge. If CDI suspected stop 1. Antimotility Drugs, 2. unnecessary antibiotics, and 3. unnecessary PPI use.

Antimotility Drugs:

- should be avoided if there is blood and mucus in stools or high fever during severe infective gastroenteritis.

Simple Antacids:

- Long term frequent dose continuous prescribing of simple antacids that relieve symptoms rather than preventing them.

Known Precipitants:

- that are associated with dyspepsia or reflux, including smoking, alcohol, coffee, chocolate and fatty foods.

GU (Orthostatic Hypotension, Dementia, Glaucoma, Prostatism):

A1-Receptor Blockers:

- in those with symptomatic orthostatic hypotension.

- in micturition syncope.

Anticholinergic Drugs:

- in dementia.

- in narrow angle glaucoma.

- chronic prostatism.

Phosphodiesterase Type 5 Inhibitors:

- in severe heart failure with hypotension.

- concurrent nitrate therapy for angina.

Diuretics:

- or other drugs that increase urinary flow with urinary incontinence.

MSK:

***NSAIDs (Bleeding, Hypertension, CHF):

- long term > 3 months for symptom relief of MSK pain where simple analgesia or topical NSAID has not been tried.

- with history of PUD or GI Bleeding unless concurrent appropriate gastroprotection.

- with concurrent oral corticosteroids or antiplatelet or antidepressant (SSRI, Venlafaxine) without concurrent appropriate GI protection.

- with severe or uncontrolled Hypertersion.

- with moderate severe Heart Failure.

- if eGFR < 50.

- with Warfarin or NAOCs.

Long Term NSAID or Colchicine:

- > 3 months for chonic treatment of gout where there is no contraindication to Allopurinol.

Diclofenac, COX-2, Ibuprofen:

- with heart failure.

- with concurrent CAD, CVD.

***Long Term Corticosteroids:

- > 3 months as monotherapy for RA.

Corticosteroids:

- other than injections, for OA.

Colchcine:

- if eGFR < 10.

Quinine:

- trial break q 3 months.

- if no benefit in leg symptoms after four weeks.

https://www.herefordshireccg.nhs.uk/library/medicines-optimisation/prescribing-guidelines/deprescribing/748-stopp-start-herefordshire-october-2016/file

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