Transcript Block 9 Board Review Part 2

Block 9 Board Review
Part 3
Endocrine
7March2014
Chauncey D. Tarrant, M.D.
Chief of Residents 13-14
Why are we STILL reviewing
ENDOCRINE???
3.5% of Initial Certifying Exam!!!
Pediatrics In Review Articles
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Type 2 Diabetes Mellitus
Cushing’s Disease
Grave’s Disease
Puberty/Delayed Puberty
PIR Quizzes
Among the following factors, which is most likely
to protect a 13-year-old patient against type 2
diabetes mellitus (DM)?
A. Adolescent age.
B. Female sex.
C. History of being breastfed.
D. Mother who had gestational diabetes.
E. Native American race
Among the following factors, which is most likely
to protect a 13-year-old patient against type 2
diabetes mellitus (DM)?
A. Adolescent age.
B. Female sex.
C. History of being breastfed.
D. Mother who had gestational diabetes.
E. Native American race
It can be difficult to distinguish between type 1 and
type 2 DM in a child who presents with
ketoacidosis.
Among the following, which clinical finding is most
suggestive of type 2 DM?
A. Acanthosis nigricans.
B. Polydipsia.
C. Polyphagia.
D. Polyuria.
E. Weight loss
It can be difficult to distinguish between type 1 and
type 2 DM in a child who presents with
ketoacidosis.
Among the following, which clinical finding is most
suggestive of type 2 DM?
A. Acanthosis nigricans.
B. Polydipsia.
C. Polyphagia.
D. Polyuria.
E. Weight loss
In your management of a 7-year-old boy with
type 1 DM, which of the following parameters
are you likely to assess every 3 months?
A. Albuminuria.
B. Hemoglobin A1c.
C. Lipid profile.
D. Liver function tests.
E. Signs of sleep apnea
In your management of a 7-year-old boy with
type 1 DM, which of the following parameters
are you likely to assess every 3 months?
A. Albuminuria.
B. Hemoglobin A1c.
C. Lipid profile.
D. Liver function tests.
E. Signs of sleep apnea
In addition to diet and exercise, you are considering
pharmacotherapy for a 15-year-old girl who has had
type 2 DM for the past year. Among the following,
which is the only drug approved by the US Food and
Drug Administration for someone her age?
A. Acarbose.
B. Exenatide.
C. Glipizide.
D. Metformin.
E. Pioglitazone.
In addition to diet and exercise, you are considering
pharmacotherapy for a 15-year-old girl who has had
type 2 DM for the past year. Among the following,
which is the only drug approved by the US Food and
Drug Administration for someone her age?
A. Acarbose.
B. Exenatide.
C. Glipizide.
D. Metformin.
E. Pioglitazone.
In a patient with newly diagnosed type 2 DM,
initiation of insulin therapy is recommended if
which one of the following findings is present?
A. Fasting blood glucose level of 140 mg/dL (7.8
mmol/L).
B. Hemoglobin A1c level of 8.0% (0.08).
C. Hemoglobin A1c level of 8.5% (0.09).
D. Random blood glucose level of 200 mg/dL (11.1
mmol/L).
E. Random blood glucose 275 mg/dL (15.3 mmol/L).
In a patient with newly diagnosed type 2 DM, initiation of
insulin therapy is recommended if which one of the
following findings is present?
A. Fasting blood glucose level of 140 mg/dL (7.8 mmol/L).
B. Hemoglobin A1c level of 8.0% (0.08).
C. Hemoglobin A1c level of 8.5% (0.09).
D. Random blood glucose level of 200 mg/dL (11.1
mmol/L).
E. Random blood glucose 275 mg/dL (15.3 mmol/L).
1. Which of the following statements about normal puberty
in children is true?
A. Bone age correlates better with pubertal development
than chronologic age.
B. Gonadotropin-releasing hormone (GnRH) secretion in
response to negative feedback from sex steroids is
constant throughout life.
C. Growth hormone secretion is the sole determinant of the
pubertal growth spurt.
D. Menarche is the first stage of puberty in girls.
E. Normal pubertal development is unrelated to nutritional
status.
1. Which of the following statements about normal puberty
in children is true?
A. Bone age correlates better with pubertal development
than chronologic age.
B. Gonadotropin-releasing hormone (GnRH) secretion in
response to negative feedback from sex steroids is
constant throughout life.
C. Growth hormone secretion is the sole determinant of the
pubertal growth spurt.
D. Menarche is the first stage of puberty in girls.
E. Normal pubertal development is unrelated to nutritional
status.
2. Which of the following statements best
describes adrenarche?
A. Breast development becomes evident in girls.
B. Hypothalamic production of
adrenocorticotropin hormone increases.
C. Maternal estrogens are withdrawn, causing
neonatal acne.
D. Spermatozoa begin to appear in seminal fluid.
E. The adrenal gland increases production of
dehydroepiandrosterone sulfate.
2. Which of the following statements best
describes adrenarche?
A. Breast development becomes evident in girls.
B. Hypothalamic production of
adrenocorticotropin hormone increases.
C. Maternal estrogens are withdrawn, causing
neonatal acne.
D. Spermatozoa begin to appear in seminal fluid.
E. The adrenal gland increases production of
dehydroepiandrosterone sulfate.
3. Which of the following is the primary action of
luteinizing hormone?
A. Secretion of follicle-stimulating hormone.
B. Secretion of GnRH from the pituitary gland.
C. Stimulation of gametogenesis in the testes.
D. Stimulation of the gonads to produce
androgens.
E. Stimulation of the ovarian follicle to produce
estrogen
3. Which of the following is the primary action of
luteinizing hormone?
A. Secretion of follicle-stimulating hormone.
B. Secretion of GnRH from the pituitary gland.
C. Stimulation of gametogenesis in the testes.
D. Stimulation of the gonads to produce
androgens.
E. Stimulation of the ovarian follicle to produce
estrogen
4. At which of the following phases of the
menstrual cycle is the concentration of
progesterone the highest?
A. The beginning of the follicular phase.
B. The beginning of the luteal phase.
C. The end of the luteal phase.
D. The middle of the follicular phase.
E. The middle of the luteal phase.
4. At which of the following phases of the
menstrual cycle is the concentration of
progesterone the highest?
A. The beginning of the follicular phase.
B. The beginning of the luteal phase.
C. The end of the luteal phase.
D. The middle of the follicular phase.
E. The middle of the luteal phase.
6. Normal pubertal development varies according to a child’s
weight and ethnicity. Which of the following
clinical findings indicates premature pubertal development?
A. Penile enlargement in a 10-year-old African American
male of normal weight.
B. Stage 3 pubic hair in a 7-year-old Mexican American girl of
normal weight.
C. Testicular enlargement in a 9-year-old white boy who is
obese.
D. Thelarche in a 7-year-old African American girl of normal
weight.
E. Thelarche in a 9-year-old white girl who is obese.
Normal pubertal development varies according to a child’s
weight and ethnicity. Which of the following
clinical findings indicates premature pubertal development?
A. Penile enlargement in a 10-year-old African American
male of normal weight.
B. Stage 3 pubic hair in a 7-year-old Mexican American girl of
normal weight
C. Testicular enlargement in a 9-year-old white boy who is
obese.
D. Thelarche in a 7-year-old African American girl of normal
weight.
E. Thelarche in a 9-year-old white girl who is obese.
7. You are seeing a 13-year-old girl who experienced
menarche 3 months ago. Her physical examination
shows that the areolae form a secondary mound above
the contour of her breasts. Her pubic hair is curly and
coarse and covers the lower portion of her mons pubis.
Which of the following is the most accurate description
of her Sexual Maturity Rating?
A. Breast: stage 2, pubic hair: stage 3.
B. Breast: stage 3, pubic hair: stage 3.
C. Breast: stage 3, pubic hair: stage 4.
D. Breast: stage 4, pubic hair: stage 4.
E. Breast: stage 4, pubic hair: stage 5.
You are seeing a 13-year-old girl who experienced
menarche 3 months ago. Her physical examination
shows that the areolae form a secondary mound above
the contour of her breasts. Her pubic hair is curly and
coarse and covers the lower portion of her mons pubis.
Which of the following is the most accurate description
of her Sexual Maturity Rating?
A. Breast: stage 2, pubic hair: stage 3.
B. Breast: stage 3, pubic hair: stage 3.
C. Breast: stage 3, pubic hair: stage 4.
D. Breast: stage 4, pubic hair: stage 4.
E. Breast: stage 4, pubic hair: stage 5.
8. Which of the following is a true statement regarding
normal pubertal development?
A. Behavioral changes in adolescence are a direct
manifestation of increases in sex hormone
concentrations.
B. Bone age is an accurate determinant of height potential in
boys and girls.
C. Most girls miss periods for 90 days within 1 year of
menarche.
D. Pubertal gynecomastia is rare and should prompt an
investigation.
E. The pubertal growth spurt in girls typically occurs within 2
to 3 months after menarche.
8. Which of the following is a true statement regarding
normal pubertal development?
A. Behavioral changes in adolescence are a direct
manifestation of increases in sex hormone concentrations.
B. Bone age is an accurate determinant of height potential in
boys and girls.
C. Most girls miss periods for 90 days within 1 year of
menarche.
D. Pubertal gynecomastia is rare and should prompt an
investigation.
E. The pubertal growth spurt in girls typically occurs within 2
to 3 months after menarche.
9. Which of the following patients should undergo an
evaluation to rule out organic pathology as a cause for
abnormal pubertal development at this time?
A. A 6-year-old white girl who has unilateral thelarche,
normal growth velocity, and no pubic hair development.
B. A 7-year-old Mexican American boy who has breast
development and testicular enlargement.
C. A 13-year-old African American girl who has a recent
growth spurt and no menarche.
D. A 13-year-old white boy who has no testicular
enlargement and normal growth velocity.
E. A 16-year-old African American girl who has excessive
pubic hair and normal menstrual cycles.
9. Which of the following patients should undergo an
evaluation to rule out organic pathology as a cause for
abnormal pubertal development at this time?
A. A 6-year-old white girl who has unilateral thelarche,
normal growth velocity, and no pubic hair development.
B. A 7-year-old Mexican American boy who has breast
development and testicular enlargement.
C. A 13-year-old African American girl who has a recent
growth spurt and no menarche.
D. A 13-year-old white boy who has no testicular
enlargement and normal growth velocity.
E. A 16-year-old African American girl who has excessive
pubic hair and normal menstrual cycles.
Match the clinical scenario with the most likely diagnosis.
6. 13–11/12-year-old girl who has secondary amenorrhea and a body mass
index of 13 kg/m2.
7. 14–10/12-year-old girl who has primary amenorrhea and is a competitive
gymnast.
8. 15–1/12-year-old tall boy who has small testes and Sexual Maturity
Rating 5 pubic hair.
9. 16–9/12-year-old short girl who has primary amenorrhea and a webbed
neck.
10. 17–5/12-year-old boy who has small testes and anosmia.
A. Constitutional delayed puberty.
B. Functional gonadotropin deficiency.
C. Kallman syndrome.
D. Klinefelter syndrome.
E. Turner syndrome.
Match the clinical scenario with the most likely diagnosis.
13–11/12-year-old girl who has secondary amenorrhea and a body mass
index of 13 kg/m2. B
14–10/12-year-old girl who has primary amenorrhea and is a competitive
gymnast. B
15–1/12-year-old tall boy who has small testes and Sexual Maturity Rating 5
pubic hair. D
16–9/12-year-old short girl who has primary amenorrhea and a webbed
neck. E
10. 17–5/12-year-old boy who has small testes and anosmia. C
A. Constitutional delayed puberty.
B. Functional gonadotropin deficiency.
C. Kallman syndrome.
D. Klinefelter syndrome.
E. Turner syndrome.
CONTENT SPECS!!!
Type 2 Diabetes Mellitus
How can you tell the difference
between Type 1 and Type 2 DM?
What the difference between Type 1
and Type 2 DM?
Sometimes the difference is hard to distinguish
Type 1: Autoimmune destruction of B cells,
thus no insulin
Type 2: Increased insulin resistance with
relative insulin deficiency
What is Acanthosis Nigricans a marker
for?
What is Acanthosis Nigricans a marker
for?
• Insulin Resistance
What are the treatment approaches to
Type 2 DM?
What are the treatment approaches to
Type 2 DM?
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Diabetes “team”
Diet and Exercise modification
Insulin in for random glc on >250
Metformin in >10yrs
What screening tests should you do for
a patient with Type 2 DM?
What screening tests should you do for
a patient with Type 2 DM?
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Hbgb A1C q3mo
BP qvisit
LFTs at diagnosis and annually
Eye exam at diagnosis and annually
Lipid panel at diagnosis and annually
UA at diagnosis and annually
Assess for symptoms of sleep apnea at
diagnosis and annually
What are long term complications of
Type 2 DM?
What are long term complications of
Type 2 DM?
• Microvascular (retinopathy, neuropathy,
nephropathy)
• Macrovascualr (HTN, hyperlipidemia)
– May be present at diagnosis
Cushing’s Syndrome
What are the signs and symptoms of
Cushing Syndrome?
What are the signs and symptoms of
Cushing Syndrome?
• Obesity
• Delayed or absent linear growth
– May or may not be present
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Acne
Virilization
Hirsuitism
Round Facies
HTN
Lethargy/Depression
Osteoporosis
Myopathy
Striae
Buffalo hump
What is the most common cause of
Cushing Syndrome?
What is the most common cause of
Cushing Syndrome?
• Protracted use of Exogenous Corticosteroids
(including topical, oral, and inhaled)
What is the lab evaluation for a patient
with suspected Cushing Syndrome?
What is the lab eval for a patient with
suspected Cushing Syndrome?
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24hr urine free cortisol
Midnight Plasma and Salivary Cortisol
Low dose Dexamethasone suppression
1mg Dexamethasone suppression
Hyperthyroidism
What are the signs and symptoms of
Grave’s Disease?
What are the signs and symptoms of
Grave’s Disease?
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tachycardia
weight loss
increased appetite
heat intolerance
Tremor
Exophthalmos
eyelid lag
moist skin
fine hair
Restlessness
emotional lability
short attention span
declining school performance
fatigue
What are the signs and symptoms of
Neonatal Hyperthyroidism?
What are the signs and symptoms of
Neonatal Hyperthyroidism?
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Irritability
Tremor
Flushing
Hyperactivity
Increased bowel motility
Thrombocytopenia
Cardiac dysfunction
hepatosplenomegaly
What are the treatment options for
hyperthyroidism?
What are the treatment options for
hyperthyroidism?
• Antithyroid medications
• Radioiodine Ablation
• Surgery
Puberty
Distinguish between Normal and
Abnormal Gynecomastia in males
Distinguish between Normal and
Abnormal Gynecomastia in males
• Normal
– Occurs after the onset of genital development in
50%
– Usually last less than 1 year
• Abnormal
– Any variation from this
– Prior to puberty is ABNORMAL
What is the significance of a breast
mass in an adolescent girl?
What is the significance of a breast
mass in an adolescent girl?
• Likely benign
What is the differential diagnosis for
precocious puberty?
What is the differential diagnosis for
precocious puberty?
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CNS tumors
Ovarian tumors
Ovarian Cysts
Feminizing Adrenal tumors
McCune Albright
CAH
Leydig Cell tumors
Familial Male Precocious Puberty
What is premature thelarche?
What is premature thelarche?
• Early breast development without other signs
of puberty in girls
• Common in ages 1-4yrs
• Regresses spontaneously
• Breast development before puberty (without
other signs of puberty) in boys is
ABNORMAL! RULE OUT NEOPLASM!
What tumors may produce precocious
puberty?
What tumors may produce precocious
puberty?
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Liver
CNS
Ovary
Testes
Adrenal Glands
What are the causes of precocious
puberty?
What are the causes of precocious
puberty?
• early activation of the HPG axis, with gonadotropins
stimulating sex hormone production
• More common in girls than boys
• Idiopathic
• CNS disorders (more common in boys)
• Overweight/obesity
• Gonadotropin Independent (adrenal/gonad disorders)
or exogenous hormones
• McCune Albright Syndrome (non classic CAH)
• Neoplasms (rare)
What are the signs and symptoms of
delayed puberty?
What are the signs and symptoms of
delayed puberty?
• Delayed puberty is defined as lack of breast
development by age 13.0 years in girls and
lack of pubertal testicular development
(genital stage 2) by age 14.0 years in boys
• Slowing of linear growth
What are the causes of delayed
puberty?
What are causes of delayed puberty?
What is the natural history of
constitutional delayed puberty?
What is the natural history of
constitutional delayed puberty?
• Once puberty begins, its course and tempo
are normal, and catch-up growth to target
height occurs
– No puberty by age 18 in boys= PATHOLOGIC
When is treatment for constitutional
delayed puberty indicated?
When is treatment for constitutional
delayed puberty indicated?
• If a negative self image is present
What are the therapeutic options for
delayed puberty??
What are the therapeutic options for
delayed puberty??
• Testosterone
– IM
– Oral
– Transdermal
• Gels
• Patch
• Estrogen
– Oral
– Transdermal
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