SAS/Review

Question 1

How do the onset and durations of regular insulin and NPH insulin differ?

Answer 1

• Regular insulin
  
  • Onset in 30 min - 1 hr
  • Duration 5-8 hrs
• NPH insulin
  
  • Onset 1-2 hours
  • Duration 14-18h

=> if you are giving a patient with diabetes an overnight tube feed over the course of 12 hours, use NPH insulin

Even though I for some reason thougth that NPH insulin is rarely used now?

Question 2

Does teriparatide result in bone formation or bone resorption?

Answer 2

Formation

(if given intermittently)

Teriparatide = PTH analog

Question 3

For people with a uterus:

• Average age of pubertal onset:
• Average age of menarche onset:

Answer 3

• Average age of pubertal onset: 10 years (normal - 7/8 - 13)
• Average age of menarche onset: 12.5 years
  
  • ​Usually when Tanner 4 breast development is present

Question 4

What hormone levels do you expect (in general) for:

• Central precocious puberty
  
  • Gonadotropins:
  • Sex steroids:
• Peripheral precocious puberty
  
  • Gonadotropins:
  • Sex steroids:

Answer 4

• Central precocious puberty
  
  • Gonadotropins: high
  • Sex steroids: high
• Peripheral precocious puberty
  
  • Gonadotropins: low
  • Sex steroids: high

Question 5

Describe the effects of the following insulin-mediated pathways

• PI₃K:
• Ras/MAPK:

Answer 5

• PI₃K: Stores energy
  
  • GLUT4 activation
  • Glycogen synthesis
  • Lipid synthesis
  • Protein synthesis
• Ras/MAPK: Uses the energy to grow
  
  • Gene expression
  • Cell growth and differentiation

Question 6

What factors are required to diagnose hypoglycemia? (3)

Answer 6

Whipple’s triad

• Symptoms of hypoglycemia
• Low plasma glucose concentration (measured by blood draw)
• Relief of symptoms when plasma glucose level is raised

Possible sx of hypoglycemia include = behavioral change, confusion, fatigue, seizure, loss of consciousness, palpitations, tremor, anxiety, sweating, hungerm paresthesias

Question 7

What hormone levels (in general) do you expect during mini-puberty of infancy?

Answer 7

Gonadotropins: pubertal

Estradiol: pubertal

May see breast development (thelarche) and pubic hair (pubarche) - this is normal, as long as it regresses

Question 8

Which hormone is the primary driver of prenatal growth?

Answer 8

Fetal insulin

Remember; maternal insulin does not cross the placenta, but maternal glucose does

Question 9

Which diabetes medication is most likely to increase peripheral insulin sensitivity?

Answer 9

Pioglitazone

(Thiazolidinedions in general)

Question 10

Answer 10

Medullary thyroid carcinoma

• MEN-1 = Pituitary, parathyroid, pancreatic
  
  • Men have 1 PPP
• MEN-2 = Medullary thyroid, pheochromocytoma
  
  • 2A + parathyroid hyperplasia
  • 2B + Marfanoid appearance, mucosal neuromas

Question 11

When in 3% NaCl indicated to treat hyponatremia?

Answer 11

• Rapid development of hyponatremia => correction should be rapid
• Acute symptoms

Chronic hyponatremia = use conivaptan (vasopressin receptor blocker)

Question 12

Which medications would decrease the size of a somatotroph adenoma? (2)

Which would only treat the symptoms? (1)

Answer 12

Somatotroph adenoma = GH secreting pituitary adenoma

• Decrease size:
  
  • Octreotide
  • Cabergoline (use this esp if there is also prolactin secretion)
• Treat symptoms
  
  • Pegvisomant

Question 13

Which medication would help with post-prandial hyperglycemia AND cause weight gain?

1. glimepiride
2. pioglitazone
3. sitagliptin
4. canagliflozin

Answer 13

A. glimepiride

• Sulfonylureas (-amide or -ride) -> weight gain
• TDZs (-glitazones) -> weight gain, but not great for post-prandial
  
  • These drugs increase peripheral insulin sensitivity, but not fast acting
• DPP-4 inhibitors (-gliptin) -> weight neutral/modest weight loss
• SGLT-2 inhibitors (-flozin) -> cause weight loss

Question 14

What abnormal heart rhythm is associated with severe Graves’ disease?

Answer 14

Atrial fibrillation

Question 15

What electrolyte abnormalities will be present in a patinet with 21-alpha-hydroxylase deficiency? (3)

Answer 15

Acidosis

Hyponatremia

Hyperkalemia

Also dehydration, hyperpigmentation (high ACTH)

Question 16

Which lab would you order to evaulate the function of a patient’s hypothalamic-pituitary-growth axis if you could only order 1?

Answer 16

IGF-1

• Synthesized in the liver in response to GH
• GH normally has variabl elevels throughout the day; difficult to get an accurate/useful reading

Question 17

Describe the “typical” patinet with MODY

Answer 17

• Strong family hx of diabetes
  
  • Not common in T1DM
• Normal BMI, generally active/healthy
  
  • Not clinicallly consistant with T2DM

MODY is a rare cause of diabetes, but high on the ddx if the pt is young with normal BMI

Question 18

List the ranges for fasting glucose for each of the following conditions

• Normal:
• Impaired fasting glucose:
• Diabetes:

Answer 18

• Normal: <100
• Impaired fasting glucose: 100-125 (inclusive)
• Diabetes: >125

Question 19

What is the most common cause of acromegaly?

Answer 19

GH-secreting pituitary adenoma (aka somatotroph adenoma)

Question 20

Answer 20

A. Denosunab

Question 21

What kind of receptor does calcitonin have?

Answer 21

GPCR

Question 22

What medication(s) would you give to treat low testosterone and oligospermia?

Answer 22

LH and FSH

Giving testosterone alone would not stimulate spermatogenesis

Question 23

Which class of diabetes medication is associated with increased risk of candidiasis and UTI?

Answer 23

SGLT-2 inhibitors (-flozin)

Question 24

Are the changes seen in acromegaly reversible?

Answer 24

Cartilage and soft tissue changes are reversible

Bone changes are not

Question 25

What is the most likey cause of a calcified pituitary mass in a teenager?

Answer 25

Craniopharyngioma

Question 26

Answer 26

c. RET mutation analysis * The only *diagnostic* option listed

Question 27

Which electrolyte is most important to monitor when giving insulin to correct DKA?

Answer 27

Postassium * DKA will often have high serum potassium (but low absolute) * Insulin -\> increased Na/K ATPase activity -\> shovels K into cells * -\> lowers serum K * Start repleting K along with insulin as soon as the patient is no longer hyperkalemic

Question 28

When a patient comes in with elevated calcium, what is the next test you should order? (if you can only pick one)

Answer 28

Parathyroid hormone * High _or normal_ PTH =\> primary hyperparathyroidism * "inappropriately normal" in the setting of high Ca2+ * Low PTH =\> PTH-independent cause of hypercalcemia * PTH should be low in the setting of high Ca2+ * Suspect malignancy, thiazides, Vitamin D or A toxicity, Hyperthyroidism, adrenal insufficiency, sarcoidosis

Question 29

What is the body's main source of fuel on day 8 of starvation?

Answer 29

Ketone bodies (Brain is still using mostly glucose)

Question 30

Answer 30

B. Inhibition of hepatic gluconeogenesis *Insulin = storage hormone*

Question 31

How will lisinopril (an ACE inhibitor) affect renin and aldosterone levels?

Answer 31

Increased renin Decreased (to normal) aldosterone

Question 32

Which diabetes medication is most likely to decrease hepatic gluconeogenesis?

Answer 32

Metformin

Question 33

What is the mechanism behind hyperglycemia-induced complications?

Answer 33

Formation of advanced glycation end products (AGEs) * Due to non-enzymatic glycation * Also, increased sorbital may play a role

Question 34

What signaling pathway is activated when GLP-1 binds to its receptor? What are the effects? (3)

Answer 34

Gs -\> cAMP * Insulin secretion * Decreased gastric emptying * Decreased glucagon release

Question 35

Answer 35

D. Von-Hippel Lindau * Hemangioblastomas + renal masses are pathognomonic for Von-Hippel Lindau * MEN-2B no renal masses * Paraganglioma is an extra-adrenal pheochromocytoma * NFM-1 would also have skin findings (cafe-au-lait spots, subcutaneous neurofibromas)

Question 36

Answer 36

A * Decreases glucagon release * Inhibits catabolic processes * Increases glucose uptake by myocytes and adipocytes (GLUT4)

Question 37

What findings are pathognomonic for Von-Hippel Lindau? (2)

Answer 37

Hemangioblastomas + renal masses together

Question 38

Answer 38

D. Septo-optic dysplasia (Kallmann syndrome is not a midline CNS defect?)

Question 39

Malignancy can cause hypercalcemia Which mechanisms are responsible for this in the following malignancies? * Solid tumors: * Multiple myeloma: * Lymphoma, leukemia:

Answer 39

* Solid tumors: **PTHrP secretion** * **​**Squamous cell carcinoma of the lung, head/neck tumors, kidney carcinoma, ovary carcinoma * Multiple myeloma: **Local bone resorption** * Lymphoma, leukemia: **Ectopic expression of 1-alpha-hydroxylase -\> increaed calcitriol (active vitamin D)** * Renal cell cancer, if overproducing 1-alpha-hydroxylase

Question 40

List the ranges for **2-hour glucose** for each of the following conditions * Normal: * Impaired glucose tolerance: * Diabetes:

Answer 40

* Normal: **\<140** * Impaired glucose tolerance: **[****140-200)** * Diabetes: **≥200**

Question 41

How does Van Wyk Grumbach affect puberty?

Answer 41

Van Wyk Grumbach = **severe primary hypothyroidism** * High TSH * -\> Cross reacts with FSH and LH receptors * -\> **precocious puberty with delayed growth**

Question 42

Which drug is used to treat osteomalacia?

Answer 42

Calcitriol *Osteomalacia = defect in bone mineralization, usually 2/2 vitamin D deficiency*

Question 43

A patient with medullary thyroid cancer is found to have a germline mutation in the RET protooncogene What genetic syndrome do you suspect?

Answer 43

MEN-2 * 2A more likely than 2B * **Must check catecholamine levels before surgery** * Need to know if the pt has a pheo before taking them to surgery

Question 44

For a patient with with Graves' disease, which treatment would your recommend? 1. Radioiodine 2. Thyroidectomy

Answer 44

b. Thyroidectomy Radioiodine can cause exacerbation of Graves' (When thyroid is dying it can release the pre-stored thyroid hormone)

Question 45

List 2 diabetes medicaions assoiciated with weight loss

Answer 45

GLP-1 agonists SGLT2 inhibitors

Question 46

What is the effect of prolactin on LH and FSH?

Answer 46

Prolactin -\> decreased LH/FSH secretion * Increased prolactin -\> amenorrhea, galactorrhea

Question 47

Your suspect your patient has Hashimoto's thyroiditis because of hair and skin changes, lethargy, and fatigue, among other symptoms How should you manage this patient?

Answer 47

Give levothyroxine to treat hypothyroidism BUT Before you start that, **check adrenal function** * Overlap between pts with Hashimoto's and Addison's * If concurrent Addison's (hypocortisolism), need to replete cortisol first - giving levothyroixine first will further stress the adrenals -\> **CRASH**

Question 48

Which type of bone is most at risk of fracture in the setting of hyperparathyroisism?

Answer 48

Corticol bone \> trabecular bone * Trabecular bone = axial skeleton, hips, ankle * Cortical bone = long bones * Hyperparathyroidism = increase bone resorption* * reabsorption is _along the surface_ of trabecular bones, but _tunnels through_ cortical bones*

Question 49

Which MEN-1 - associated tumor has the highest penetrance?

Answer 49

Parathyroid adenoma * MEN-1 = Pituitary, **parathyroid**, pancreatic * *Men have 1 PPP* * Most will have parathyroid adenoma by age 50 *MEN-1 = mutation in menin gene on chromosome 11*

Question 50

What is the first sign of central puberty in a person with a uterus?

Answer 50

Thelarche (breast development) First sign = testicular enlargement in people with testicles

Question 51

Which insulin preparation has the longest duration of action?

Answer 51

Glargine (20-24h) Detemir is also long acting, (16-20h)

Question 52

What is your diagnosis of a patient with low TSH, low T4, and normal T3? 1. Hypothyroid 2. Euthyroid 3. Hyperthyroid

Answer 52

a. Hypothyroid * Even though the pt has normal T3, **low T4 = hypothryroid**