Endocrine Secrets

Name: Endocrine Secrets
Brand: Elsevier
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Michael T. McDermott(Author)

Elsevier (Publisher)

5th Edition

Published on 1. March 2009

600 pages

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Content

Front Cover
Endocrine Secrets
Copyright Page
Dedication Page
Contents
Preface
Contributing Authors
Top 100 Secrets
I. Fuel Metabolism
Chapter 1: Diabetes Mellitus
1. What is diabetes mellitus?
2. What is the prevalence of diabetes?
3. Is screening for type 1 diabetes recommended?
4. Who should be screened for type 2 diabetes?
5. How is diabetes diagnosed?
6. What are the genetics of type 1 diabetes?
7. What are the genetics of type 2 diabetes?
8. Describe the pathogenesis of type 1 diabetes
9. Describe the pathogenesis of type 2 diabetes
10. Can diabetes be prevented?
11. What techniques are available to assess insulin resistance?
12. Describe metabolic syndrome
13. What causes beta-cell failure in type 2 diabetes?
14. What are the standards of care for management of diabetes mellitus?
15. Describe the current management approach to type 1 diabetes and the role of intensive therapy modeled by the Diabetes Control and Complications Trial (DCCT)
16. Is intensive diabetes therapy cost-effective?
17. What is the United Kingdom Prospective Diabetes Study (UKPDS)?
18. What is the current management approach with type 2 diabetes?
19. Based on the UKPDS and other studies, describe the optimal treatment for type 2 diabetes
20. What are insulin analogs?
21. What is inhaled insulin?
22. What is amylin?
23. What are incretins?
24. How are incretins used to treat type 2 diabetes?
25. What are the classes of oral diabetes medications? How do they work?
Bibliography
Chapter 2: Acute and Chronic Complications of Diabetes
1. What are the acute complications of diabetes?
2. Describe the symptoms of hyperglycemia
3. What is DKA?
4. What causes DKA?
5. What illnesses may trigger DKA?
6. How can deficiencies in education trigger DKA?
7. What are the signs and symptoms of DKA?
8. How is DKA diagnosed?
9. Is ketone testing always positive with DKA?
10. What lab tests are recommended in the first hour of treatment for DKA?
11. Summarize the strategy for fluid and potassium administration in the first hour
12. How should insulin treatment be started with DKA?
13. What assessments should be made in the second hour of treatment?
14. Summarize the strategy for fluid and potassium administration in the second hour of treatment
15. How should insulin be adjusted during treatment?
16. Summarize the basic strategy after the second hour of treatment
17. When can the insulin infusion be discontinued?
18. What other interventions may be necessary in the treatment of DKA?
19. What is a possible complication of DKA? How should it be treated?
20. What is hyperosmolar hyperglycemic syndrome?
21. Who is at risk for HHS and why?
22. What are the signs of HHS?
23. Why is metabolic acidosis typically not seen in HHS?
24. What are the symptoms of HHS?
25. What is the most common presenting symptom of HHS?
26. List other possible causes of impaired mental status
27. What other neurologic signs may be associated with HHS?
28. What is the hallmark laboratory finding in patients with HHS?
30. What is the first step in treating HHS?
31. Should isotonic or hypotonic fluids be used?
32. Summarize the management of electrolytes in HHS
33. What role does insulin play in the treatment of HHS?
34. Describe the signs and symptoms of hypoglycemia
35. Discuss therapy-related causes of hypoglycemia in diabetes
36. What other factors may contribute to the development of hypoglycemia?
37. Are some diabetic patients more susceptible to hypoglycemia than others?
38. What is "hypoglycemia unawareness"?
39. Can hypoglycemia unawareness be prevented?
40. How is hypoglycemia treated?
41. What should be done if the patient is unconscious?
42. Discuss the role of education in treating hypoglycemia
43. Summarize the common long-term complications of diabetes mellitus
44. What basic mechanism underlies the development of long-term diabetic complications?
45. What other mechanisms may be involved?
46. Describe the characteristics of nonproliferative diabetic retinopathy
47. Describe the characteristics of proliferative retinopathy
48. How common is diabetic retinopathy?
49. What are the risk factors for development of diabetic retinopathy?
50. List the other ophthalmologic complications of diabetes
51. How serious a problem is diabetic nephropathy?
52. What is the risk that a diabetic person will develop nephropathy?
53. What factors affect the development of diabetic nephropathy?
54. Name the most common type of diabetic neuropathy
55. Summarize the symptoms of distal symmetric polyneuropathy
56. Explain the basic pathophysiology of distal symmetric polyneuropathy
57. What causes the foot problems in patients with diabetes?
58. How are foot problems treated surgically?
59. How common is diabetic autonomic neuropathy? How does it affect survival rates?
60. Describe the classic signs of diabetic autonomic neuropathy
61. How is diabetic autonomic neuropathy diagnosed?
62. Describe the treatment for diabetic retinopathy
63. How is diabetic nephropathy managed?
64. Discuss the management of postural hypotension
65. What treatments are effective for sensory loss due to diabetic neuropathy?
66. How is painful diabetic neuropathy treated?
67. How are the symptoms of gastroparesis treated?
68. What are the risks associated with macrovascular disease in diabetes?
69. Which factors specific to diabetes increase the risk for CVD?
70. How can macrovascular disease be prevented in the diabetic population?
71. Does aggressive lipid-lowering therapy improve cardiac outcomes in diabetic patients?
72. How important is glycemic control in preventing the chronic complications of diabetes mellitus?
73. Does improved glycemic control in hospitalized patients affect outcome?
Bibliography
Chapter 3: Intensive Insulin Therapy
1. What is intensive insulin therapy?
2. List the other critical components of intensive therapy
3. Summarize studies that support optimal diabetes management to decrease chronic complications from diabetes mellitus
4. Which patients are candidates for IIT?
5. Explain the difference between basal and bolus insulin coverage
6. What are the currently available long-acting insulins?
7. How are long-acting insulins used with an MDI regimen?
8. What are the currently available bolus insulins?
9. Describe the pharmacodynamics of the bolus and basal insulins
10. When should bolus insulin be taken?
11. When should basal insulin be taken?
12. What is pramlintide (Symlin)?
13. What is an insulin pump?
14. What are the patient's responsibilities before insulin pump therapy can be initiated?
15. Describe the benefits of insulin pump therapy
16. What risks are associated with pump use?
17. What is a glucose sensor?
18. Define carbohydrate counting. How is it used with IIT?
19. List common foods that contain dietary carbohydrates
20. How are carbohydrates counted?
21. Explain the carbohydrate-to-insulin (C:I) ratio
22. How do you determine an initial C:I ratio?
23. Give an example of an initial C:I ratio when changing to basal and bolus insulins
24. How do you adjust the C:I ratio once the initial ratio has been established?
25. What are common causes of high BG?
26. What are the mysterious or random causes of high BG readings?
27. What causes high postprandial BG readings that are difficult to explain?
28. How is supplemental insulin added for high BG before meals?
29. Give an example of determining an initial CF
30. Give an example of CF usage
31. When is a CF used?
32. What can be done for a high postprandial BG reading?
33. Provide an example of using a 1/2CF
34. Calculate an initial basal rate for insulin pump therapy
35. Calculate an example of an initial basal rate for insulin pump therapy
36. When are nighttime basal rate adjustments made?
37. List recommendations to follow during the nighttime basal rate verification process
38. How are nighttime basal rate adjustments made?
39. Describe the procedure for making daytime basal rate adjustments
40. What is the recommended carbohydrate for the treatment of hypoglycemia?
41. How does the use of rapid-acting insulin impact the treatment of hypoglycemia with MDI and pump therapy?
42. Why does rebound hyperglycemia occur after hypoglycemia?
43. Discuss the use of glucagon to treat severe hypoglycemia
Bibliography
Recommended Patient Reading
Chapter 4: Inpatient Management of Diabetes and Hyperglycemia
1. Does evidence support intensive management of blood glucose in the hospital setting?
2. What are the glycemic targets for the critically ill patient population? How "low" should we go?
3. What are the glycemic targets for the general medical-surgical patients?
4. What are the glycemic targets for pregnant patients?
5. Why is poor glycemic control so common in hospitalized patients?
6. What can we do to help prevent hypoglycemia in the hospital setting?
7. What is the best agent available for inpatient management of diabetes?
8. Are oral agents appropriate to use in hospitalized patients?
9. Discuss the use of the various oral agents in the hospital setting
10. List the indications for intravenous insulin therapy
11. Why is the intravenous route superior to the subcutaneous route for insulin?
12. At what rate should an insulin infusion be started?
13. How should the IV insulin infusion rate be adjusted?
14. Discuss the treatment of hypoglycemia (BG &60mg/dL)
15. When should the physician be notified?
16. How do I transition a patient off an insulin drip?
17. What is a "sliding-scale," and how does it differ from correction-dose insulin?
18. How do I write admit orders if I do not know whether the patient will require insulin?
19. What is considered effective insulin therapy in the hospital?
20. How should you select a basal insulin dose?
21. How should you select a prandial dose for patients on insulin?
22. How should you choose the correction dose of insulin?
23. How should you deal with diabetic patients undergoing surgery or hospital procedures?
24. Characterize steroid-induced hyperglycemia and describe how it is best treated
25. How should hyperglycemic patients on Total Parenteral Nutrition or enteral feedings be treated?
26. How should daily insulin doses be adjusted?
27. How do I decide what to order when the patient is sent home?
28. How can the hospital system work to improve glycemic outcomes?
Bibliography
Chapter 5: Diabetes in Pregnancy
1. How does normal pregnancy affect fuel metabolism?
2. Summarize the changes in the first trimester of pregnancy
3. Summarize the changes in the second and third trimesters and immediatepostpartum period
4. Is glucose the only fuel altered in normal pregnancy?
5. Explain the effect of the metabolic changes in pregnancy on diabetesmanagement in the first trimester
6. How do metabolic changes in pregnancy affect the management of diabetesin the second and third trimesters?
7. What is the most important preconception recommendation in counselinga diabetic woman who wants to become pregnant?
8. Why is maintenance of glucose control essential for the well-being of the fetus?
9. Describe the relationship among HbA1C, the teratogenic effects of hyperglycemia, and abnormal fetal growth
10. How has the incidence of congenital abnormalities in the offspring of diabetic mothers changed over the past decade?
11. What are the risks if a woman conceives while taking an oral hypoglycemic agent?
12. How is glyburide different from the other sulfonylureas?
13. Can oral hypoglycemic agents be continued in pregnancy?
14. Summarize the evidence related to the role of metformin during pregnancy
15. How should hypertensive women who take angiotensin-converting enzyme inhibitors or have risk factors for coronary artery disease be counseled...
16. How does pregnancy affect the morbidity and mortality of coronary arterydisease in diabetic women?
17. Should statins be discontinued before conception?
18. Should diabetic women take folic acid supplements before conception?
19. Summarize the effect of smoking during pregnancy
20. How does pregnancy affect diabetic nephropathy?
21. Does nephropathy increase the risk of preeclampsia?
22. How does renal transplantation affect the outcome in pregnant women?
23. Summarize the effects of pregnancy on diabetic retinopathy
24. What is the White Classification of diabetes in pregnancy?
25. Why is the White Classification used by obstetricians?
26. What are the goals of glucose control for pregnant women with diabetes?
27. What is the role of continuous glucose monitoring system in pregnancy?
28. Discuss the role of the insulin pump during pregnancy
29. Discuss the role of glargine during pregnancy
30. What is the role of short-acting insulin analogs in pregnancy?
31. How common is hypoglycemia in pregnant women with type 1 diabetes?
32. Discuss special concerns in pregnant women with type 2 diabetes as compared with type 1 diabetes
33. What is the risk of diabetic ketoacidosis in pregnancy?
34. How should the risk of DKA be managed?
35. How does maternal DKA affect the fetus?
36. What must the physician remember about DKA in pregnant women?
37. What is gestational diabetes mellitus?
38. How is GDM diagnosed?
39. Summarize the recommendations for low-risk status
40. What are the recommendations for high-risk status?
41. How should women of average risk be approached?
42. Describe the 50-g glucose challenge
43. Describe the 100-g, 3-hour OGTT
44. Summarize the risks to the mother with GDM
45. What factors increase the risk of subsequently developing type 2 diabetes?
46. What factors may reduce the risk of developing type 2 diabetes?
47. What is the incidence of complications in the infant of a mother with GDM?
48. Summarize the basic mechanism behind complications related to GDM
49. What is the most common complication of GDM?
50. What other complications may result from GDM or pre-existing diabetes?
51. Explain the fetoplacental glucose steal phenomenon
52. Describe the fetal-based strategy to manage GDM
53. Discuss the long-term sequelae of GDM or pre-existing diabetes in offspring ofaffected mothers
54. How does in utero hyperglycemia affect the long-term sequelae of infants bornto diabetic mothers?
55. What causes women to get GDM?
56. What causes increased hepatic glucose production?
57. Summarize the role of impaired insulin secretion
58. What is the best therapy for women with GDM?
59. Discuss the role of oral diabetes medication in the management of GDM
60. When should insulin be used to treat GDM?
61. What is the role of exercise in patients with GDM or pre-existing diabetes?
62. When is a controlled exercise program contraindicated?
63. What important postpartum management issues should be addressed in women with pregestational or gestational diabetes?
64. Explain the value of diet and exercise in the postpartum period
65. Discuss the importance of monitoring during the postpartum period
66. Why is a diagnosis of impaired glucose tolerance or ''prediabetes'' of critical importance?
67. Summarize the role of ACE inhibitors in the postpartum period
68. Should women with GDM breast-feed their infants?
69. How common is postpartum thyroiditis in women with type 1 diabetes? Whendoes it appear?
70. Summarize the long-term follow-up of nondiabetic women with a history of GDM
71. Which contraceptive agents can be used by women with diabetes or a history of GDM?
72. Summarize the role of low-dose combined oral contraceptives
73. What other contraceptive options are appropriate?
Bibliography
Chapter 6: Lipid Disorders
1. What are the major lipids in the bloodstream?
2. What are lipoproteins?
3. What are the major lipoproteins in the bloodstream?
4. What are the apoproteins?
5. Name other enzymes and transport proteins that are important in lipoprotein metabolism
6. Explain the function and metabolism of TGs
7. Describe the function and metabolism of LDL
8. What is the function of HDL?
9. Describe the pathogenesis of the atherosclerotic plaque and arterial thrombosis
10. Are elevated serum TG levels harmful?
11. What is metabolic syndrome?
12. What is lipoprotein(a)?
13. What are the primary dyslipidemias?
14. What is familial hypercholesterolemia?
15. What is familial combined hyperlipidemia?
16. What is familial dysbetalipoproteinemia?
17. What is polygenic hypercholesterolemia?
18. What are familial hypertriglyceridemia and familial hyperchylomicronemia?
19. How do you distinguish between familial combined hyperlipidemia and familial dysbetalipoproteinemia?
20. What causes familial low HDL?
21. Name the secondary dyslipidemias
22. What is the cause of severe elevations of serum TGs?
23. Summarize the revised (2004) CAD risk stratification from the Adult TreatmentPanel III (ATP III) of the National Cholesterol Education...
24. What are the revised (2004) lipoprotein treatment goals from the ATP III?
25. What treatment approaches are recommended for lipoprotein levels abovethese goals?
26. What medications most effectively lower serum LDL cholesterol?
27. How do the currently available statin medications differ?
28. What medications significantly lower TGs?
29. What medications most effectively raise serum HDL cholesterol levels?
30. Once a statin is being used, how effective are subsequent dose increments?
31. How effective and safe are combinations of lipid-lowering medications?
32. Does aggressive cholesterol lowering therapy effectively and safely reduce the risk of coronary artery disease?
33. Do interventions that raise serum HDL cholesterol or lower serum TGs have a significant effect on coronary events?
34. Should all high-risk patients be treated with lipid-lowering therapy regardless of LDL cholesterol level?
35. Is measurement of inflammatory markers a useful tool in CAD risk assessment?
36. Should we be using measurements of lipoprotein size and number?
37. How should the patient with severe hypertriglyceridemia be managed?
Bibliography
Chapter 7: Obesity
1. Define the terms "overweight" and "obesity
2. Does fat distribution affect the assessment of risk in an overweight or obese patient?
3. Explain the role of waist circumference in risk stratification
4. How is waist circumference measured?
5. What adverse health consequences are associated with obesity?
6. Summarize the economic consequences of obesity
7. What are the psychological complications of obesity?
8. How common is obesity?
9. What caused the dramatic rise in the prevalence of obesity between 1980 and 2004?
10. Describe the current model for obesity as a chronic disease
11. Do abnormal genes cause obesity?
12. What is leptin?
13. Does leptin deficiency cause human obesity?
14. Explain how the melanocortin system is involved in weight regulation
15. What is ghrelin?
16. Does a decrease in energy expenditure play a role in the development of obesity?
17. What are the components of energy expenditure
18. Explain the concept of energy balance
19. What options are available for treating the obese patient?
20. What is the goal of a weight loss program?
21. Is a 5% to 10% reduction helpful in terms of health improvement?
22. How can a patient's readiness to change his or her diet or physical activity be assessed?
23. Define the precontemplative stage
24. What is the contemplative stage?
25. What happens in the relapse stage?
26. What is "motivational interviewing," and how is it used in counseling an obese patient?
27. Discuss the role of diet in the treatment of the obese patient
28. Should patients be encouraged to attend a commercial weight loss program?
29. Are meal replacements useful in a weight loss program?
30. What is a very low-caloric diet? When should its use be considered?
31. What is the Atkins diet? Does it work?
32. Describe the Zone Diet
33. Discuss the Ornish diet
34. What is the South Beach Diet?
35. Which popular diet book is the "best"?
36. What drugs are available to treat obesity?
37. Are phentermine and amphetamine related?
38. Is phentermine effective? How much does it cost?
39. Discuss the side effects of phentermine
40. How does orlistat work? What is the usual dose? How much does it cost?
41. What are the side effects of orlistat?
42. How does sibutramine work?
43. How effective is sibutramine? How much does it cost?
44. Discuss the side effects of sibutramine
45. Discuss the role of bupropion in the treatment of obesity
46. Does topiramate have a role in the treatment of obesity?
47. How long will a weight loss medication need to be taken?
48. Discuss the role of exercise in a weight loss program
49. How much physical activity is necessary to lose weight and maintain a reduced weight?
50. What are pedometers? How are they used?
51. What are the two categories of weight loss surgeries?
52. Who are good candidates for surgical treatment of obesity?
53. What are the expected outcomes and health benefits of weight loss surgery?
54. What is the mortality rate associated with bariatric surgery?
55. What are the most common complications of bariatric surgery?
56. What is a rare cause of hypoglycemia following RYGB?
57. What vitamin and micronutrient deficiencies are patients at risk for following bariatric surgery?
58. What laboratory tests should be performed when following a patient who has had weight loss surgery?
Bibliography
II. Bone And Mineral DisordersMichael T.McDermott
Chapter 8: Osteoporosis
1. What is osteoporosis?
2. What is a fragility fracture?
3. What are the complications of osteoporotic fractures?
4. What factors contribute most to the risk of developing an osteoporotic fracture?
5. What are the currently accepted indications for bone mass measurement?
6. How is bone mass currently measured?
7. How do you read a bone densitometry report?
8. How is the diagnosis of osteoporosis made?
9. What are the major risk factors for developing low bone mass?
10. What other conditions must be considered as causes of low bone mass?
11. Outline a cost-effective evaluation to rule out these possibilities
12. What is the best way to determine whether a patient has had a previous vertebral fracture?
13. What are the most significant risk factors for sustaining a fall from the upright position?
14. What nonpharmacologic measures are useful for preventing and treating osteoporosis?
15. How do you clinically assess a patient's dietary calcium intake?
16. How do you ensure adequate intake of calcium?
17. How does one best achieve appropriate intake of vitamin D?
18. When should medical therapy be initiated for the prevention and treatment of osteoporosis?
19. Describe bone remodeling
20. Explain the roles of Receptor Activator of Nuclear Factor K (RANK), RANK ligand, and osteoprotegerin in normal bone physiology?
21. How do the pharmacologic agents for the prevention and treatment of osteoporosis work?
22. Which bisphosphonates are available for the treatment of osteoporosis, and how are they used?
23. How effective are the bisphosphonates in reducing the risk of fragility fractures?
24. Discuss the use of raloxifene in the management of osteoporosis
25. Does calcitonin also reduce osteoporotic fractures?
26. Briefly discuss the issues regarding hormone replacement therapy
27. What other antiresorptive medications are being developed?
28. What is osteonecrosis of the jaw, and how common is it in patients using antiresorptive medications?
29. How could PTH be an anabolic agent for treating osteoporosis?
30. Does teriparatide effectively and safely reduce fractures in osteoporotic patients?
31. Are other anabolic agents being developed for the treatment of osteoporosis?
32. Are combinations of osteoporosis medications more effective than single agents?
33. How should providers interpret serial BMD changes when monitoring patients on osteoporosis therapy?
34. What markers are available to assess bone remodeling, and how are they used?
35. What is the role of vertebroplasty and kyphoplasty following vertebral fractures?
36. How common is osteoporosis in men?
37. How is the diagnosis of osteoporosis made in men?
38. What are the causes of osteoporosis in men?
39. How effective is pharmacologic therapy in men with osteoporosis?
40. How can falls be prevented?
Bibliography
Chapter 9: Glucocorticoid-Induced Osteoporosis
1. How common is glucocorticoid-induced osteoporosis (GIOP)?
2. What are the important determinants of bone loss with glucocorticoid therapy?
3. Explain the pathogenesis of GIOP
4. What are the BMD criteria for a diagnosis of GIOP?
5. In which patients on glucocorticoids should BMD be tested?
6. When should BMD be tested?
7. What measures should be instituted in all patients on glucocorticoids?
8. Which medications are effective in preventing and treating GIOP?
9. Which glucocorticoid-treated patients should receive active intervention?
10. When should gonadal steroids be considered?
11. List the indications for thiazide diuretics
Bibliography
Chapter 10: Measurement of Bone Mass
1. Why measure bone mass?
2. Is bone mass the only factor that determines whether a bone will fracture?
3. How does bone densitometry measure bone mass?
4. What techniques are available to measure bone mass?
5. What is the preferred method for measuring bone mass?
6. Discuss the advantages and disadvantages of DXA
7. What are the indications for the measurement of bone mass?
8. What do bone densitometry results mean?
9. What are T-scores?
10. What do Z-scores tell us about the patient?
11. How is bone mass classified?
12. How should the WHO classification be used?
13. How are bone density measurements interpreted in men and non-Caucasians?
14. Discuss how bone mass measurements are used to determine the need fortreatment of osteoporosis
15. Which bone(s) should be selected for measurement of bone mass?
16. What is the role for bone mass measurements of the forearm?
17. How often should bone mass measurements be repeated?
18. What conditions limit the accuracy of bone mass measurements?
19. Interpret the bone mineral density results from the following four patients
Bibliography
Chapter 11: Osteomalacia and Rickets
1. What are osteomalacia and rickets?
2. Why is it important to know about osteomalacia and rickets?
3. List the causes of osteomalacia and rickets
4. Describe how vitamin D is metabolized
5. Discuss the disease processes that interfere with the metabolism of vitamin D
6. List genetic disorders that interfere with vitamin D synthesis or action
7. What conditions associated with abnormalities of phosphate metabolism result in osteomalacia or rickets?
8. Does chronic renal failure cause osteomalacia and rickets?
9. What clinical symptoms and findings are associated with osteomalacia?
10. Describe the clinical findings in children with rickets
11. What are the biochemical abnormalities associated with osteomalacia and rickets caused by vitamin D deficiency?
12. What are the vitamin D metabolite concentrations associated with the diseases that interfere with vitamin D metabolism or action?
13. Describe the laboratory finding in disorders associated with the hypophosphatemic osteomalacia syndromes
14. What radiographic findings are associated with osteomalacia and rickets?
15. Discuss the histologic features of osteomalacia
16. Describe the therapy for vitamin D deficiency
17. What are the treatments for osteomalacia and rickets not caused by vitamin D deficiency?
18. What are the complications of treatment with vitamin D2 or vitamin D metabolites?
Bibliography
Chapter 12: Paget's Disease of Bone
1. What is Paget's disease of bone?
2. Discuss how Paget's disease is diagnosed
3. What are the clinical manifestations of Paget's disease?
4. What disorders are associated with Paget's disease of bone?
5. What are the three phases of Paget's disease of bone?
6. Describe the radiographic findings associated with the osteolytic phase of Paget's disease
7. What are the radiographic findings most commonly found in the osteoblastic phase of the disease?
8. What is the best radiographic test to determine the extent of Paget's disease?
9. Which bones are involved in Paget's disease?
10. Discuss the laboratory abnormalities associated with Paget's disease
11. Which laboratory test should be used to follow patients with Paget's disease?
12. What are the histological findings in bone affected by Paget's disease?
13. Which patients are most likely to have Paget's disease?
14. What is the cause of Paget's disease?
15. What medications are available to treat Paget's disease?
16. Which agents are the treatment of choice for Paget's disease of bone?
17. Does resistance to therapy for Paget's disease of bone occur?
18. What is osteonecrosis of the jaw, and do patients with Paget's disease treated with bisphosphonates get this disorder?
19. What are the indications for treatment of Paget's disease?
20. In asymptomatic patients with Paget's disease, at what concentration of alkaline phosphatase should treatment begin?
21. What is the most serious complication of Paget's disease of bone?
22. When should malignant sarcoma in a pagetic bone lesion be suspected?
Bibliography
Chapter 13: Hypercalcemia
1. What is hypercalcemia? How does protein binding affect the calcium level?
2. How common are hypercalcemia and its main associated conditions?
3. How would you classify mild, moderate, and severe hypercalcemia?
4. Discuss the signs and symptoms of hypercalcemia
5. What are the sources of serum calcium?
6. What are the major anatomic and physiologic determinants of vitamin D?
7. What are the classical and nonclassical effects of vitamin D and what is the role of the vitamin D receptor?
8. What is the CaR and what role does it play in calcium metabolism?
9. What is the function of the CaR in the kidney?
10. What are the overall effects of PTH and vitamin D on calcium metabolism?
11. How do calcium and phosphate interact with calcium-regulating hormones?
12. List the main causes of hypercalcemia
13. How do various causes of hypercalcemia increase the serum calcium?
14. What are the mechanisms and causes of hypercalcemia?
15. What is the relative frequency of skeletal lesions in patients with advanced cancer?
16. What is the incidence of hypercalcemia in patients with cancer?
17. What are the multiple endocrine neoplasia syndromes?
18. How would you diagnose familial hypocalciuric hypercalcemia?
19. What is the likely cause of hypercalcemia in the following patient?
20. What therapy is useful for hypercalcemia?
21. Describe the mechanisms of action of drug therapies for hypercalcemia
22. How might calcimimetic drugs be useful in therapy of hypercalcemia?
23. How does lithium cause hypercalcemia?
Bibliography
Chapter 14: Hyperparathyroidism
1. What is hyperparathyroidism?
2. How common is primary HPT?
3. What causes primary HPT?
4. What anatomic alterations occur in HPT?
5. How do you diagnose HPT?
6. How does age complicate the diagnosis of HPT?
7. How might you make the diagnosis of primary HPT more certain before recommending parathyroidectomy?
8. When lab results are not specific for primary HPT, what other classic laboratory changes may help with diagnosis?
9. What differentiates familial hypocalciuric hypercalcemia from primary HPT?
10. How does chronic kidney disease (CKD) complicate the diagnosis of HPT?
11. What changes occur in renal failure that may complicate the PTH assay?
12. What are the symptoms and signs of primary HPT?
13. What is band keratopathy?
14. What are the classic radiographic findings in HPT?
15. What is the differential diagnosis of primary HPT?
16. What lab tests help to distinguish the three types of HPT?
17. What pathophysiologic changes occur in primary HPT?
18. What pathophysiologic changes occur in secondary HPT?
19. What pathophysiologic changes occur in tertiary HPT?
20. How is HHM distinguished from primary HPT?
21. How do PTHrP and PTH differ?
22. What hormonal and laboratory changes occur in HPT?
23. What PTH assay is most useful in the workup of hypercalcemia?
24. What methods best localize the parathyroid tumor in HPT?
25. When should you use preoperative localization of a parathyroid adenoma?
26. Do all asymptomatic patients with HPT require surgical treatment?
27. What are the indications for parathyroidectomy as recommended by the April 2002 National Institutes of Health-sponsored...
28. How should you monitor patients with asymptomatic HPT who have not had parathyroidectomy?
29. How would you estimate the creatinine clearance or GFR without doing a 24-hour urine collection?
30. How would you estimate the GFR for a 60-year-old Caucasian woman with serum creatinine of 0.8 mg/dL and a weight of 60 kg?
31. How would you estimate the 24-hour urine calcium excretion without doing a 24-hour urine collection?
32. What therapeutic options are available for patients unable to undergo surgery for HPT?
33. How would you evaluate and treat a patient with normocalcemic HPT?
Bibliography
Chapter 15: Hypercalcemia Of Malignancy
1. What are the two major categories of hypercalcemia of malignancy?
2. What types of cancer are associated with HHM?
3. What is the cause of HHM?
4. What is PTHrp?
5. How does PTHrp cause hypercalcemia in patients with cancer?
6. How do you make a diagnosis of HHM?
7. What types of cancer are associated with LOH?
8. What is the cause of LOH?
9. How do you make a diagnosis of LOH?
10. Can lymphomas cause hypercalcemia by other mechanisms?
11. What is the prognosis for patients with hypercalcemia of malignancy?
12. How do you treat hypercalcemia of malignancy?
Bibliography
Chapter 16: Hypocalcemia
1. Define hypocalcemia
2. How are serum calcium and serum albumin levels related?
3. How is the total serum calcium corrected for a low serum albumin level?
4. What is the most common cause of low total serum calcium?
5. What factors other than albumin influence the levels of serum ionized calcium?
6. How is serum calcium regulated?
7. What steps in vitamin D metabolism may influence serum calcium levels?
8. What are the major causes of hypocalcemia?
9. What physical signs suggest hypocalcemia?
10. What laboratory tests are clinically useful in distinguishing among the causes of hypocalcemia?
11. Describe the symptoms of hypocalcemia
12. What radiographic findings may be present with hypocalcemia?
13. What is cerebral tetany, and how does it differ from a true seizure?
14. How does hypocalcemia affect cardiac function?
15. What are the potential ophthalmologic findings in hypocalcemia?
16. With which autoimmune disorders is hypocalcemia sometimes associated?
17. Hypocalcemia is frequently encountered in intensive care settings. What are the potential causes?
18. Hypercalcemia is not unusual in patients with cancer. What conditions may lead to hypocalcemia in this patient group?
19. What drugs may cause hypocalcemia?
20. Which vitamin D metabolite is best for assessing total body vitamin D stores, 25-hydroxyvitamin D or 1,25-dihyd...
21. How is hypocalcemia treated?
22. When is treatment with 1,25 dihydroxyvitamin D (calcitriol) indicated?
23. Can recombinant human PTH (rhPTH) be used in the treatment of hypocalcemia?
Bibliography
Chapter 17: Nephrolithiasis
1. Define hypercalciuria, kidney stones, renal calculi, nephrolithiasis, urolithiasis, renal lithiasis, and nephrocalcinosis
2. Who is at risk of developing kidney stones?
3. What are the composition and approximate frequency of most kidney stones?
4. What are the main causes of nephrolithiasis?
5. Describe the conditions associated with both renal stone disease and hypercalciuria
6. What are the most important causes of normocalciuric calcium nephrolithiasis?
7. Describe the process of renal stone formation
8. Discuss the pathophysiologic factors that influence formation of renal stones
9. What are the main chemical precursors of renal stones?
10. What are the main inhibitors of renal stone formation? How do they work?
11. What is nephrocalcin? What role does it play in formation of renal stones?
12. What are promoters of renal stone formation?
13. What are the basic determinants of serum calcium?
14. How does the kidney handle calcium?
15. Calculate the normal filtered and excreted load of calcium per day
16. How do serum calcium and dietary sodium affect hypercalciuria?
17. What are the etiology and pathophysiology of IH?
18. Distinguish among the various forms of IH
19. When is it necessary to distinguish among the various forms of IH?
20. Explain the differences in serum levels of phosphorus and PTH in AH-III and RH
21. Explain the differences in 24-hour calcium urine levels on a restricted calcium diet
22. Define low serum phosphorus level on an 800-mg/day phosphorus-restricted diet
23. What causes hyperoxaluria?
24. Why is hyperoxaluria important in nephrolithiasis?
25. How does hyperuricosuria contribute to renal stones?
26. How does urinary pH relate to renal stones?
27. What conditions cause low levels of urinary citrate?
28. What is the role of diet in the formation of kidney stones?
29. Summarize the presenting symptoms and signs of renal stones
30. What elements of the history and physical examination are important in patients with kidney stones?
31. What lab tests are appropriate in the diagnosis of kidney stones?
32. Summarize the therapeutic approach to patients with kidney stones
33. Describe the clinical significance of urinalysis in patients with renal stones
34. What are the characteristics of urinary crystals in patients with renal stones?
35. How do radiographic tests help to evaluate patients with renal stones?
36. Which medications are useful for treating the various stone-forming conditions?
37. What are special considerations in the drug therapy of nephrolithiasis?
38. Why are thiazide diuretics the first-line therapy for hypercalciuria-induced nephrolithiasis?
39. How should you treat a symptomatic patient with a renal stone 1 to 2 cm in size?
40. How should you treat an asymptomatic patient with a renal stone of the same size?
41. What treatment should be used if the stone is larger than 3 cm?
Bibliography
III. Pituitary and hypothalamic disordersWilliam J.Georgitis
Chapter 18: Pituitary Insufficiency
1. What causes pituitary insufficiency?
2. When the pituitary stalk is severed, what happens to anterior pituitary hormone levels?
3. Which parasellar disorders cause pituitary dysfunction?
4. What is a craniopharyngioma?
5. How does a pineal dysgerminoma present?
6. What is pituitary apoplexy?
7. Define empty sella
8. What is the distinction between primary and secondary empty sella?
9. What is Sheehan's syndrome? How common is it?
10. Do the clinical presentations of pituitary insufficiency differ between children and adults?
11. Is there an easy way to tell whether the sella turcica is enlarged?
12. What tests should be considered for hypopituitary patients?
13. What is the Houssay phenomenon?
14. What characteristics of adrenal insufficiency are present in ACTH-deficient patients?
15. Define secondary hypothyroidism
16. Why are thyroid hormone levels low in secondary hypothyroidism?
17. What cortisol level is consistent with adrenal insufficiency?
18. Is secondary adrenal insufficiency as common as gonadotropin deficiency in patients with pituitary tumor?
19. Is life expectancy altered by hypopituitarism?
20. Are health-related costs greater for patients with hypopituitarism?
21. What is the most important hormone deficiency to identify and treat in patients with anterior pituitary disease?
22. Why is aldosterone deficiency generally absent in hypopituitarism?
23. Is anterior pituitary hormone deficiency always a commitment to lifelong replacement?
24. When one hormone deficiency in hypopituitarism is diagnosed, why is it important to define whether other hormone deficiencies are present?
25. What is the treatment of pituitary insufficiency?
26. Who should receive GH treatment?
Bibliography
Chapter 19: Nonfunctioning Pituitary Tumors
1. Name the functioning pituitary tumors
2. What is a nonfunctioning pituitary tumor?
3. What is the alpha subunit?
4. What other lesions can resemble nonfunctioning pituitary tumors?
5. Differentiate between a microadenoma and a macroadenoma
6. Which structures may be damaged by growth of a pituitary tumor outside the sella turcica?
7. What are the clinical features of nonfunctioning pituitary tumors?
8. What anatomic evaluation is necessary for a pituitary tumor?
9. What evaluation is necessary to determine that a pituitary tumor is nonfunctioning?
10. Does an elevated level of serum prolactin mean that a tumor is functioning?
11. What is the primary treatment for a nonfunctioning pituitary tumor?
12. Is postoperative radiation therapy recommended for incompletely resected tumors?
13. What endocrine complications occur in the immediate postoperative period?
14. What is the management of postoperative diabetes insipidus and water intoxication?
15. What endocrine problems may occur during long-term follow-up?
16. Summarize the long-term management of pituitary insufficiency
17. Describe the clinical features of pituitary carcinomas
18. What is the treatment for pituitary carcinoma?
19. What is the prognosis for pituitary carcinoma?
20. Which cancers metastasize to the pituitary gland?
Bibliography
Chapter 20: Prolactin-Secreting Pituitary Tumors
1. Describe the normal control of prolactin secretion. How is it altered in prolactin-secreting tumors?
2. What are the normal levels of serum prolactin? Are they different in men and women? What levels are seen in patients with prolactin-secreting...
3. What are the physiologic causes of an elevated prolactin level that must be considered in the differential diagnosis of prolactin-secreting...
4. List the abnormal causes of an elevated serum prolactin level other than a prolactin-secreting tumor, and state the mechanism underlying the...
5. What are the typical levels of serum prolactin associated with these causes?
6. How does prolactin elevation result in gonadal dysfunction? What are the symptoms associated with gonadal dysfunction?
7. What is galactorrhea? Do most patients with prolactin-secreting tumors present with this symptom?
8. Why do men with prolactin-secreting tumors often present with more advanced disease than do women?
9. What is the imaging technique of choice when a prolactin-secreting tumor is suspected? Why?
10. Bone metabolism is altered when prolactin levels are elevated. What is the mechanism for this effect? Is it reversible?
11. If a prolactinoma is left untreated, what is the risk of tumor enlargement?
12. Is medical treatment available for prolactin-secreting tumors? What is the mode of action?
13. Describe the mode of action of commonly used drugs
14. If a woman with a prolactin-secreting tumor becomes pregnant while on medical treatment, should the treatment be continued? Should she be...
15. How long does it take for medical treatment to reduce the serum prolactin level? To reduce the size of the tumor?
16. How long is medical treatment of prolactin-secreting tumors required? Why?
17. When is surgical removal of a prolactin-secreting tumor indicated?
18. When is radiotherapy indicated to treat a prolactin-secreting tumor?
Bibliography
Chapter 21: Growth Hormone-Secreting Pituitary Tumors
1. What is the normal function of growth hormone in children and adults?
2. How are levels of GH normally regulated?
3. Does GH directly affect peripheral tissues?
4. What are the clinical features of excessive production of GH in children?
5. Describe the clinical features of excessive production of GH in adults
6. What is the single best clue in examining a patient suspected of having acromegaly?
7. From what do patients with acromegaly die?
8. In patients with acromegaly, are skin tags all over the neck and chest a relevant finding?
9. The husband of the patient with acromegaly complains that he cannot sleep because his wife snores so loudly. Is this complaint...
10. If I suspect that a patient may have acromegaly, what test should I order?
11. The patient's IGF-1 level is not elevated, but I still think that she may have acromegaly. What other test should I do?
12. After the biochemical diagnosis of acromegaly or gigantism is made, what is the next step?
13. What causes GH-secreting pituitary tumors?
14. Are other endocrine syndromes possible in patients with acromegaly or gigantism?
15. Do other tumors besides pituitary tumors make GH and cause acromegaly or gigantism?
16. Do tumors ever cause acromegaly or gigantism by making excessive GH-RH?
17. If MRI of the pituitary confirms a tumor in the acromegalic patient, what issues other than the metabolic effects of excessive...
18. How big are GH-secreting pituitary tumors?
19. How should acromegaly or gigantism be treated?
20. What if surgery does not cure the patient? Should I recommend radiation therapy?
21. Are there any options for medical therapy of acromegaly?
22. Discuss the mechanisms of action of octreotide
23. How effective is octreotide?
24. Describe the mechanism of action of pegvisomant. When is it used?
25. What are the side effects of octreotide and pegvisomant?
26. How can one tell whether a patient has been cured of acromegaly?
27. The patient has undergone transsphenoidal surgery for acromegaly and now has normal postoperative fasting levels of GH, suppre...
28. The patient asks which symptoms and physical abnormalities will improve after cure is confirmed. What is the appropriate...
29. For bonus points, name an actor with acromegaly and the movie in which he starred
Bibliography
Chapter 22: Glycoprotein-Secreting Pituitary Tumors
1. What are glycoprotein hormones?
2. Name two types of glycoprotein-secreting pituitary tumors
3. Do pituitary tumors secrete only a single hormone?
4. Under what circumstances should a TSH-secreting tumor be considered?
5. Describe the differential diagnosis for patients with a transient increase in serum total T4 and a detectable or elevated level of serum TSH
6. Describe the differential diagnosis for patients with a permanent increase in serum total T4 and detectable or elevated level of serum TSH
7. What tests are useful in the differential diagnosis of the patient with an elevated serum total T4 and a detectable or elevate serum TSH?
8. How can one distinguish between the hyperthyroid patient with thyroid hormone resistance and the patient with a pituitary tumor?
9. Describe how to calculate an alpha/TSH molar ratio
10. Name the treatment of choice for TSH-secreting tumors and its likelihood of success
11. How effective is radiation as the sole therapy?
12. List the medical therapies used for TSH-secreting tumors
13. Summarize the role of thyroid gland ablation in the treatment of TSH-secreting tumors
14. Do all patients with an enlarged pituitary gland and an elevated level of serum TSH have thyrotropinomas?
15. What clinical features raise suspicion of a TSH-secreting pseudotumor?
16. Does the presence of abnormal visual fields help to distinguish betweenpatients with pituitary hyperplasia due to primary hypothyroidism and...
17. Does family history provide any clues in distinguishing these disorders?
18. Which hormones are elevated in the serum of patients with gonadotroph adenomas?
19. List the presenting symptoms of patients with gonadotropinomas
20. When gonadotropin levels are elevated, how can one distinguish clinically between a gonadotroph adenoma and primary hypogonadism?
21. What laboratory tests are helpful?
22. How are gonadotropinomas treated?
23. Is medical therapy effective?
24. Are pituitary tumors malignant?
25. What causes pituitary tumors?
Bibliography
Chapter 23: Cushing's Syndrome
1. Describe the normal function of cortisol in healthy people
2. How are cortisol levels normally regulated?
3. What are the clinical symptoms of excessive levels of cortisol?
4. All of my clinic patients look like they have cushing's syndrome. Are some clinical findings more specific for cushing's...
5. A patient presents with a history of obesity, hypertension, irregular menses, and depression. Does she have excessive production of cortisol?
6. The patient also complains of excessive hair growth and has increased terminal hair on the chin, along the upper lip, and on the upper back...
7. The patient also has increased pigmentation of the areolae, palmar creases, and an old surgical scar. Are these findings relevant?
8. What is the cause of death in patients with Cushing's syndrome?
9. What causes Cushing's syndrome?
10. Of the various types of Cushing's syndrome, which is the most common?
11. Do age and gender matter in the differential diagnosis of Cushing's syndrome?
12. The patient with obesity, hypertension, irregular menses, depression, and hirsutism looks like she may have Cushing's syndrome...
13. The patient had a cortisol level drawn after a 1-mg dose of dexamethasone. The level is 12 mg/dL. Does she have Cushing's syndrome?
14. The patient has an elevated 24-hour urinary level of free cortisol, and serum cortisol levels are not suppressed after overnight 1-mg...
15. I am not convinced that the patient has Cushing's syndrome. How can I confirm it?
16. The patient has elevated cortisol levels at night and an abnormal dexamethasone-CRH test. Now I am convinced that she...
17. The patient's ACTH level is "normal." Was the original suspicion of Cushing's syndrome incorrect?
18. What happened to the 2-day low-dose and high-dose dexamethasone tests for the differential diagnosis of Cushing's syndrome?
19. After diagnosis of ACTH-dependent cushing's syndrome, what is the next step?
20. The pituitary MRI in the patient with ACTH-dependent cushing's syndrome is normal. Is the next step a search for...
21. The pituitary MRI shows a 3-mm hypodense area in the lateral aspect of the pituitary gland. Is it time to call the neurosurgeon?
22. So what is the next step?
23. IPSS shows no gradient in ACTH levels. Now what?
24. IPSS shows a marked central-to-peripheral gradient in ACTH levels. Now what?
25. What if surgery is unsuccessful?
26. Why not just take out the patient's adrenal glands?
27. What are the correct diagnostic and treatment options for patients with ACTH-independent (adrenal) Cushing's syndrome?
28. What happens to the hypothalamic-pituitary-adrenal axis after a patient undergoes successful removal of an ACTH-secreting pituitary adenoma...
29. What would be the most likely diagnosis if the original patient had all the signs of Cushing's syndrome but low urinary and...
30. Do tumors ever cause Cushing's syndrome by making excessive CRH?
Bibliography
Chapter 24: Water Metabolism
1. What is the water composition of the human body?
2. Where is water located within the body?
3. What is transcellular water (TCW)? What is its importance?
4. Explain the significance of TCW
5. What controls distribution of body water?
6. What is ECV?
7. How do baroreceptors affect ECV?
8. How does vascular pressure as sensed by the baroreceptors relate to ECV andhyponatremia?
9. Define osmolality and tonicity and outline their effects on water movement
10. What formulas are useful in evaluating osmolality and tonicity?
11. How does PNa relate to TBW?
12. How does PK relate to PNa and TBW?
13. Describe the input and output of water
14. What are the normal limits of urine output?
15. What are the main factors controlling water metabolism?
16. What are the stimuli of thirst?
17. What hormonal mechanisms are involved in control of body water?
18. What are the major conditions that influence ADH secretion?
19. What are the major causes of ADH secretion?
20. How does the kidney handle salt and water?
21. What are the consequences and causes of decreased renal excretion of water?
22. How do hypothyroidism and adrenal insufficiency cause hyponatremia?
23. What PNa concentrations are causes for concern?
24. What causes the symptoms and signs of increased or decreased TBW?
25. What are the symptoms and signs of hyponatremia and hypernatremia?
26. How does the brain adapt to hyponatremia?
27. How does the brain adapt to hypernatremia?
28. How should you approach the patient with hyponatremia?
29. What is the importance of an initial thorough volume assessment in patientswith hyponatremia?
30. How should you characterize and diagnose the patient with syndrome ofinappropriate antidiuretic hormone?
31. How do you treat the patient with SIADH?
32. What are the four patterns of SIADH?
33. Define polyuria and list the main causes
34. How do you distinguish polyuric patients with the various forms of DI fromexcessive water drinking?
35. How is the WRT performed?
36. How do you interpret the results of the WRT?
37. What are the expected plasma ADH concentrations and urinary osmolality inpolyuric patients after water restriction?
38. How should you approach the patient with hypernatremia?
39. How should you diagnose and manage the patient with DI?
40. How quickly should you correct states of water excess or deficiency?
41. How do frequent measurements of urinary Na and K help with hyponatremiatherapy?
42. What are vasopressin receptor antagonists, and when would you use themfor hyponatremia therapy?
43. What is the appropriate PNa correction factor for hyperglycemia?
44. A 75-year-old woman presents with confusion but no focal neurologic signs. She has type 2 diabetes mellitus. Blood pressure is 110/54 mm Hg...
45. You admit a 35-year-old schizophrenic because of a change in mentalfunction and excessive urine output. Uosm = 70 mOsm/kg. Posm = 280 mOsm/kg...
46. A 45-year-old-man with a 30-pack-year history of smoking presents with cough, dyspnea, fatigue, and a 15-lb weight loss. Chest x-ray shows...
47. A 34-year-old, 60-kg woman presents 12 hours after discharge following cholecystectomy. She has headache, confusion, muscle cramps, weakness...
48. An 80-year-old woman who rarely leaves her home is brought to the hospital after being found confused. Three weeks ago, she saw her physician...
49. A 35-year-old female marathon runner collapses, unable to finish a 42-km race averaging 5 mph. She water-loaded before the race and drank as...
50. A 67-year-old man with longstanding hypertension presents to the ER alert, somewhat confused, and with sudden onset of a severe headache he...
51. A 23-year-old woman presents to your clinic with morning nausea and mild headache. She has a normal examination with exception of midline...
Bibliography
Chapter 25: Disorders of Growth
1. Summarize normal growth velocity for children until the pubertal growth spurt
2. Summarize growth velocity during the pubertal growth spurt
3. How is height measured accurately?
4. What technique is used for infants up to 2 years of age?
5. Describe the technique for children 2 years of age and older
6. How is height recorded?
7. List the common errors in plotting growth charts
8. What is meant by appropriate growth chart?
9. How do age and position affect growth measurements?
10. What historic information is necessary for interpreting a growth chart?
11. What physical examination findings help interpret a growth chart?
12. How does radiologic imaging help interpret a growth chart?
13. Explain the significance of parental target height or ''midparental height''
14. What is the most important factor in identifying an abnormal growth curve?
15. What causes abnormal growth in children?
16. Which syndromes are associated with abnormal growth?
17. List nonendocrine diseases and treatments that may be associated with poor growth
18. Using the tools of growth curve, bone age, and height, how does one distinguish between familial (genetic) short stature and other causes?
19. Give an example of familial short stature versus other causes of short stature
20. Other than familial short stature, what is the most common cause ofshort stature?
21. How is the diagnosis of constitutional delay of growth made?
22. What is the effect of testosterone therapy on boys with constitutional delayof growth?
23. List the endocrine causes for short stature in children in order of prevalence
24. What laboratory measures should be considered in evaluating a patient forshort stature?
25. Which laboratory tests help to exclude undiagnosed chronic illness?
26. Which laboratory tests help to exclude gastrointestinal disorders associated with poor growth?
27. List the laboratory tests for genetic disorders associated with poor growth
28. Which hormonal disorders should be excluded by laboratory results?
29. Describe the causes of GH deficiency
30. How is GH deficiency diagnosed?
31. List the components of the laboratory evaluation for GH deficiency
32. Why are serum levels of IGF-1 important?
33. Do normal levels of IGF-1 exclude GH deficiency?
34. Do low serum levels of IGF-1 confirm the diagnosis of GH deficiency?
35. How is GH testing done?
36. How are the results of GH testing interpreted?
37. How is idiopathic GH deficiency diagnosed?
38. How is idiopathic GH deficiency treated?
39. What is the prognosis for adult height in treated children with idiopathic GH deficiency?
40. When is GH therapy discontinued?
41. What other syndromes are considered indications for GH therapy?
42. What is the prognosis for girls with Turner's syndrome treated with GH?
43. What are the potential risks of human GH therapy?
44. List the common but clinically unimportant side effects of GH therapy
45. List the uncommon side effects with potential clinical importance
46. What rare or theoretical side effects may be associated with GH therapy?
47. Should children with idiopathic short stature (without GH deficiency) be treated with GH?
48. How does the pattern of growth in children with excessive glucocorticoids differ from the pattern in children with exogenous obesity?
49. What conditions are associated with excessive growth in childhood?
50. Explain constitutional advanced growth
51. List the hormonal causes of excessive growth
52. Summarize the characteristics of GH excess in childhood
53. With what findings is androgen excess associated?
54. With what findings is estrogen excess associated?
55. List the genetic syndromes associated with excessive growth
Bibliography
Chapter 26: Growth Hormone and Insulin Use and Abuse
1. What is growth hormone?
2. How is the release of GH regulated?
3. List the actions of GH
4. Does GH exert all of its effects directly?
5. What causes excessive GH secretion, and what are the consequences?
6. What conditions are associated with a deficiency of GH?
7. What are some common signs and symptoms of GH deficiency?
8. Where do we get the GH used therapeutically?
9. Besides availability, what problem was associated with GH derived from human cadavers?
10. List the FDA-approved uses of GH
11. List the potential uses of GH
12. How does GH help GH-deficient adults?
13. What are the therapeutic doses of GH? How is it administered?
14. Why is GH used as an ergogenic aid by athletes?
15. How is abuse detected?
16. Why is GH abuse so difficult to detect?
17. What is currently being tried to detect GH?
18. How prevalent is GH use among athletes?
19. What are the adverse effects of the therapeutic use of GH in adults?
20. What are the adverse effects of GH in children?
21. What malignancy has been linked to GH use?
22. What adverse effects occur in athletes using GH?
23. GH is the proverbial fountain of youth. True or false?
Bibliography
IV. Adrenal Disorders
Chapter 27: Primary Aldosteronism
1. Define primary aldosteronism
2. How common are these disorders?
3. What are the common clinical manifestations of primary aldosteronism?
4. When and in whom is primary aldosteronism most common?
5. What is the most common form of primary aldosteronism?
6. What is the second most common cause of primary aldosteronism?
7. How do adenomas produce symptoms of hyperaldosteronism?
8. How do symptoms of IHA differ from symptoms of APAs?
9. How commonly does adrenal cancer cause primary aldosteronism?
10. What is PAH?
11. What is glucocorticoid-remediable aldosteronism?
12. How is aldosterone synthesis regulated in the human body?
13. Explain the genetic basis of glucocorticoid-remediable aldosteronism
14. How is primary aldosteronism diagnosed?
15. How are patients screened for primary aldosteronism?
16. How is the diagnosis of primary aldosteronism confirmed?
17. After confirmation of primary aldosteronism, why is it important to differentiate APA from IHA?
18. Does computed tomography or magnetic resonance imaging aid in differentiation?
19. Which localizing test is required if CT or MRI identify an APA in a patient aged over 40 years?
20. Explain the difficulty with adrenal venous sampling
21. How accurate is adrenal venous sampling?
22. How is the patient with APA managed?
23. What should be done after the APA is localized?
24. Do all patients with APA require surgery?
25. How is a patient with IHA managed?
26. What is the agent of choice for pharmacologic treatment of IHA?
27. What other pharmacological options are available?
28. Describe the management of a patient with PAH
29. How is a patient with glucocorticoid-remediable aldosteronism managed?
Bibliography
Chapter 28: Pheochromocytoma
1. What is a pheochromocytoma?
2. How common are pheochromocytomas?
3. Where are pheochromocytomas located?
4. Where are paragangliomas found?
5. Can pheochromocytomas metastasize?
6. What is the rule of 10s for pheochromocytomas?
7. What are the common clinical features of a pheochromocytoma?
8. What are some of the nonclassic manifestations of pheochromocytomas?
9. Discuss the cardiovascular manifestations of pheochromocytomas
10. Describe the intracerebral symptoms related to pheochromocytoma
11. What do pheochromocytomas elaborate?
12. Why is the blood pressure response among patients with pheochromocytomas so variable?
13. How is a pheochromocytoma diagnosed?
14. How is pheochromocytoma differentiated from essential hypertension?
15. What conditions may alter the diagnostic tests discussed earlier?
16. Which drugs alter the metabolism of catecholamines?
17. What other medications may interfere with test results?
18. List two other conditions that may interfere with test results
19. What other biochemical tests are available?
20. Compare computed tomography and magnetic resonance imaging (MRI) for localization of pheochromocytomas
21. What other modalities are useful for localization of pheochromocytomas?
22. Summarize the performance criteria of each localizing procedure
23. How are pheochromocytomas treated?
24. Why is preoperative preparation with alpha blockade recommended?
25. Discuss the role of beta-blocker and other agents in the preoperative period
26. How are malignant pheochromocytomas treated?
27. Discuss the role of combination chemotherapy and MIBG ablation
28. What is the prognosis for patients with malignant pheochromocytoma?
29. Which medical conditions are associated with pheochromocytomas?
Bibliography
Chapter 29: Adrenal Malignancies
1. What types of cancer occur in the adrenal glands?
2. Do adrenocortical carcinomas produce hormones?
3. What are the clinical features of functioning adrenocortical carcinomas?
4. What are the clinical features of nonfunctioning adrenocortical carcinomas?
5. What clues are most suggestive that an adrenocortical tumor is malignant?
6. Describe the initial treatment for an adrenocortical carcinoma
7. What studies are most commonly used to identify recurrent or metastatic adrenal cortical carcinoma?
8. What measures show the most promise for the treatment of metastatic adrenal cortical carcinoma?
9. What is the prognosis for patients with adrenocortical carcinoma?
10. How often are pheochromocytomas malignant?
11. What are the clinical features of a malignant pheochromocytoma?
12. What clues suggest that a pheochromocytoma is malignant?
13. What is the treatment for a malignant pheochromocytoma?
14. What is the prognosis for malignant pheochromocytoma?
15. What tumors metastasize to the adrenal glands?
16. What is the clinical significance of metastatic disease to the adrenal glands?
17. How should the incidentally discovered adrenal mass be evaluated?
18. How should the incidentally discovered adrenal mass be managed?
Bibliography
Chapter 30: Adrenal Insufficiency
1. What is adrenal insufficiency, and how is it categorized?
2. What are common causes of adrenal insufficiency?
3. What are other causes of adrenal insufficiency?
4. What are common symptoms of adrenal insufficiency?
5. How does adrenal insufficiency usually present clinically?
6. What laboratory abnormalities can be found in adrenal insufficiency?
7. How do the clinical presentations of primary and central adrenal insufficiency differ?
8. How is adrenal insufficiency usually diagnosed biochemically?
9. What other methods are available for testing for adrenal insufficiency?
10. What about the low dose cosyntropin stimulation test?
11. What testing can be used to distinguish primary from secondary/tertiary adrenal insufficiency?
12. When can the results of the ACTH stimulation test be misleading?
13. When are imaging tests appropriate?
14. When should the diagnosis of adrenal crisis be considered?
15. How is adrenal crisis managed?
16. How is adrenal insufficiency diagnosed in the critical care setting?
17. When and how should glucocorticoids be used in the critical care setting?
18. How do I manage chronic adrenal insufficiency, and when should I consider prescribing fludrocortisone?
19. Should I recommend dehydroepiandrosterone replacement for my adrenally insufficient patient?
20. What are the relative potencies of available glucocorticoids?
21. How is treatment for chronic adrenal insufficiency monitored?
22. When do individuals with chronic adrenal insufficiency require "stress-dose" glucocorticoids?
23. What are recommended stress doses of glucocorticoids?
24. How should glucocorticoids be tapered after stress dosing?
25. What are some unusual causes of exogenous Cushing's syndrome?
26. What is the difference between adrenal suppression and adrenal insufficiency in patients on exogenous glucocorticoids?
27. How should steroids be tapered in patients on pharmacologic dosages of steroids to treat nonadrenal diseases?
28. How long can it take for patients who have had successful resection of the tumor causing Cushing's syndrome to be tapered...
Bibliography
Chapter 31: Congenital Adrenal Hyperplasia
1. Define congenital adrenal hyperplasia
2. What Enzyme Defects can Lead to CAH?
3. Describe the Functions of the Three Hydroxylases
4. How is CAH inherited?
5. What is the Most Common form of CAH?
6. Which Genes Encode for 21-Hydroxylase?
7. What Causes Most of the Genetic Events Responsible for CYP21A2 deficiencies?
8. What Determines the Patient's Phenotype?
9. What is the Second Most Common Cause of CAH?
10. Summarize the rarer forms of CAH
11. How common is CAH?
12. What Percentage of the Population at Large are Heterozygote Carriers of the 12-Hydroxylase Defect?
13. How Common is 11-Hydroxylase Deficiency?
14. Explain Why Adrenal Hyperplasia Develops
15. What is the Most Serious Clinical Consequence of CAH?
16. What are Other Clinical Consequences of CAH in females?
17. What are Other Clinical Consequences of CAH in males?
18. How do Patients with 17 alpha-Hydroxylase Deficiency Present?
19. How do Patients with Nonclassic CAH present?
20. Summarize the Relationship Between Adrenal "Incidentalomas" and CAH
21. How do the Manifestations of CAH Differ in Males?
22. Describe the Presentation of Males with CAD due to Deficiency of Other Enzyme Activity
23. Describe the Clinical Features that Suggest the Possibility of CAH.
24. What Clinical Clues Help to Support or Refute the Diagnosis of CAH in a Newborn with Ambiguous Genitalia?
25. Discuss the role of Molecular Biology Techniques in the Diagnosis of CAH
26. How is the Diagnosis of CAH confirmed?
27. How are Specific Genetic Defects Confirmed?
28. What Should be Done When Nonclassic CAH is Suspected in Older Patients?
29. Describe the Classic Test used for Newborn Screening.
30. What Other Tests May be Used?
31. How is CAH treated in neonates?
32. When is Surgical Correction of Ambiguous Genitalia Carried Out?
33. Describe the treatment of CAH in children
34. How is CAH Treated in Adolescents and Adults?
35. What Factors Favor the Achievement of Predicted Adult Height?
36. What Changes in Therapy are Necessary as a Result of Medically Significant Stress?
37. What Changes in Therapy are Necessary During Pregnancy?
38. How is Treatment Monitored?
39. What Other Monitoring Tools May be Beneficial?
40. What Genetic Counseling is Appropriate for a Couple Who Previously had a Child with CAH?
41. Are Any Prenatal Treatments Available for the Fetus with CAH?
Bibliography
V. Thyroid Disorders
Chapter 32: Thyroid Testing
1. What is the single best test to screen for abnormal function of the thyroid gland?
2. How do you interpret the serum TSH level in the evaluation of suspected thyroid disease?
3. Explain how the serum TSH is used to manage patients on thyroid hormone therapy
4. Discuss the advantages of free thyroid hormone assays
5. What do total T4 and T3 assays measure?
6. Name the major disorders of thyroid hormone-binding proteins
7. What antithyroid antibody measurements are clinically useful?
8. How useful are thyroglobulin measurements?
9. Under what circumstances should a serum calcitonin level be measured?
10. Discuss the utility and interpretation of the radioactive iodine uptake (RAIU) test
11. When and why should a thyroid scan be ordered?
12. What is Thyrogen? How is it used?
13. How can heterophile antimouse antibodies interfere with assessment of thyroid function?
Bibliography
Chapter 33: Hyperthyroidism
1. What is the difference between thyrotoxicosis and hyperthyroidism?
2. Define the term "autonomy" as it applies to thyroid hyperfunction
3. What is subclinical thyrotoxicosis?
4. What are the long-term consequences of subclinical thyrotoxicosis?
5. List the three most common causes of hyperthyroidism
6. Define Graves' disease
7. Explain TMNG
8. What are AFTNs?
9. What is the Jod-Basedow phenomenon?
10. What are some rarer causes of hyperthyroidism?
11. How do thyrotoxic patients present clinically?
12. What is apathetic hyperthyroidism?
13. Describe the physical signs of thyrotoxicosis
14. How does hyperthyroidism cause eye disease?
15. What laboratory testing should be performed to confirm thyrotoxicosis?
16. When is thyroid antibody testing necessary for the diagnosis of hyperthyroidism?
17. What is the difference between a thyroid scan and an uptake?
18. How should hyperthyroidism be treated?
19. When is surgery indicated for hyperthyroidism?
20. What is the role of iodine in the treatment of hyperthyroidism? What is the Wolff-Chaikoff effect?
21. Are other treatments available to lower thyroid hormone levels?
22. Which medications block peripheral conversion of T4 to T3?
23. How effective are ATDs?
24. What side effects are associated with ATDs?
25. What lab tests should be monitored in patients taking ATDs?
26. How does radioactive iodine work?
27. When is pretreatment with ATDs indicated before 131I ablation?
28. How long after 131I treatment should women wait before becoming pregnant or resuming breast-feeding?
29. Does 131I cause or worsen ophthalmopathy in Graves' disease?
30. How is thyrotoxicosis managed in pregnancy?
Bibliography
Chapter 34: Hypothyroidism
1. How Common is Hypothyroidism?
2. What is Subclinical Hypothyroidism?
3. How is Subclinical Hypothyroidism Treated?
4. What are the Two Most Common Causes of Hypothyroidism?
5. How Common is Postpartum Thyroiditis?
6. List the Less Common Causes of Hypothyroidism
7. List the Symptoms Commonly Associated with Hypothyroidism
8. What Findings on Physical Examination are Consistent with Hypothyroidism?
9. What does Palpation of the Thyroid Reveal?
10. Summarize Unusual Presentation of Hypothyroidism
11. Describe the Laboratory Tests that May Show Abnormal Results During Hypothyroidism
12. What Tests Best Confirm the Diagnosis of Hypothyroidism in the Outpatient Setting?
13. How Should Total T4 Levels be Interpreted?
14. Explain Why Thyroid Function Tests are More Difficult to Interpret in Acutely Ill Inpatients
15. How do You Diagnose Hypothyroidism in Acutely Ill Inpatients?
16. Which Thyroid Hormone Preparation Should You Use?
17. What Other Thyroid Hormone Preparations are Available?
18. What is the Recommended Dose of LT4 for Replacement Therapy in a Hypothyroid Patient?
19. What is the Appropriate Goal for TSH in the Treatment of Primary Hypothyroidism?
20. Discuss the Evidence Supporting Combination T4/T3 therapy
21. When Should You Consider Combination T4/T3 therapy?
22. How Should the Clinician Approach Surgery in the Hypothyroid Patient?
23. Summarize the Current Recommendations for Emergent Surgery
24. How does Myxedema Differ from Hypothyroidism?
Bibliography
Chapter 35: Thyroiditis
1. Give the differential diagnosis for thyroiditis
2. What causes acute thyroiditis?
3. How is acute thyroiditis managed?
4. Describe the four stages of subacute thyroiditis
5. Summarize the natural history of subacute thyroiditis
6. What is the most common cause of thyroiditis?
7. Give the clinical characteristics of autoimmune thyroid disease
8. Does postpartum thyroiditis follow a different clinical course from other types of autoimmune thyroiditis?
9. How common is postpartum thyroiditis?
10. Summarize the differences between subacute and postpartum thyroiditis
11. Why do women develop postpartum thyroiditis?
12. Does thyroid function in patients with postpartum thyroiditis return to normal, as it does in subacute thyroiditis?
13. Do any factors identify women at increased risk for developing postpartum thyroiditis?
14. What is painless thyroiditis?
15. What causes painless thyroiditis?
16. What is destruction-induced thyroiditis?
17. When a patient presents with hyperthyroid symptoms, an elevated level of T4, and a suppressed level of TSH, what is the next test that should be...
18. What is the appropriate therapy for patients with any type of destructive thyroiditis?
19. Which drugs can induce thyroiditis?
20. Does amiodarone induce only thyroiditis?
21. What is Riedel's struma?
22. How is Riedel's thyroiditis treated?
23. Are there any other causes of thyroiditis?
Bibliography
Chapter 36: Thyroid Nodules and Goiter
1. What is a Goiter?
2. How does a nontoxic goiter develop?
3. Describe the natural history of diffuse nontoxic goiter
4. How does lithium affect thyroid function?
5. Describe the mechanism by which lithium produces goiter and hypothyroidism
6. How common are thyroid nodules?
7. List the differential diagnosis for a thyroid nodule
8. Can the nature of a thyroid nodule be determined from the family history?
9. Do personal history and physical examination help to determine the nature of a thyroid nodule?
10. How are most thyroid cancers discovered?
11. What diagnosis should be suspected when a thyroid nodule is first discovered because of neck pain?
12. If a nodule is cancer, what kind is it likely to be?
13. How does the appearance of the fluid help in diagnosing thyroid cysts?
14. How does the amount of thyroid cyst fluid help guide management?
15. How important is sampling of the solid component of the complex nodule?
16. Is the risk of cancer less in multinodular goiter or Hashimoto's disease than in solitary thyroid nodules?
17. Summarize the role of FNA in the evaluation of thyroid nodules
18. Is FNA helpful in diagnosing follicular neoplasms?
19. Should an FNA be performed for a palpable nodule if the TSH is low?
20. If the TSH is found to be low, what is the next step?
21. Explain the distinction between cold and hot nodules.
22. What is the significance of a warm nodule?
23. Who invented the incision used for thyroidectomy?
24. Which treatment was used first for diffuse toxic goiter (Graves' disease): radioactive iodine or antithyroid medications?
25. What goitrous thyroid conditions are treated with radioactive iodine?
26. What does recent evidence reveal about the role of suppression therapy with thyroxine?
27. When is suppression therapy with thyroxine useful?
Bibliography
Chapter 37: Thyroid Cancer
1. Describe the Types of Thyroid Cancer
2. Summarize the Frequency of Each Type of Thyroid Cancer
3. Describe the Histology of the Two Differentiated Forms of Thyroid Carcinoma
4. How is Follicular Carcinoma Differentiated from Benign Follicular Adenomas?
5. Summarize the Types of Papillary Carcinoma
6. Distinguish the Clinical Behavior of Papillary and Follicular Carcinomas
7. Who Gets Papillary Carcinoma?
8. Describe the Clinical Course of Papillary Carcinoma
9. Discuss the Significance of Lymph Node Metastases of Papillary Carcinoma
10. How Common is Metastasis of Papillary Carcinoma to Sites Other than Lymph Nodes?
11. Who Gets Follicular Carcinoma?
12. Describe the Clinical Course of Follicular Carcinoma
13. How Common are Metastases of Follicular Carcinomas?
14. Discuss the relationship between Graves' disease and DTC
15. How is Chronic Lymphocytic Thyroiditis Related to DTC?
16. How Does Metastatic Disease Affect the Prognosis of DTC?
17. How are the DTCs treated?
18. What Factors Favor Limited Surgery?
19. Why do Most Surgeons Favor More Extensive Surgery?
20. Are Lymph Nodes Removed Surgically?
21. How does 131I Therapy Benefit the Patient?
22. How can the Efficacy of Whole-Body Scans be Optimized?
23. How is the Whole-Body Scan Performed?
24. How much 131I is Administered to the Patient After Surgical Removal of a Single, Small Papillary Tumor without Extrathyroidal...
25. How much 131I is Administered to the Patient After Surgical Removal of a Large or Aggressive Tumor or Extrathyroidal Lesions?
26. Discuss the Early Complications of 131I therapy
27. What are the late complications of 131I therapy?
28. How are Bony and Pulmonary Metastases Treated?
29. How are Patients Monitored for Recurrent Disease?
30. When is a Whole-Body Scan Used?
31. Discuss the Alternative to Withdrawal of Thyroid Hormone Before a Whole-Body Scan
32. Which Malignancy is Associated with Prior Radiation Exposure?
33. What is a Huumlrthle Cell?
34. What is Anaplastic Thyroid Carcinoma?
35. Discuss the Histologic Variants of Anaplastic Carcinoma
36. Who Gets Anaplastic Carcinoma?
37. How does Anaplastic Carcinoma Present?
38. Summarize the Prognosis for Patients with Anaplastic Carcinoma
39. What is MTC?
40. Describe the Function of Parafollicular Cells
41. How Does Neoplastic Transformation Affect the Parafollicular Cells?
42. How common is MTC?
43. Describe the presentation of sporadic MTC
44. Summarize the forms in which hereditary MTC May Occur Within Kindreds
45. How does hereditary MTC present?
46. Are Extrathyroidal Manifestations Associated with MTC?
47. How can CT be Used as a Clinically Useful Tumor Marker?
48. How is CT Related to MTC distinguished from CT of non-MTC sources?
49. What Test May be Used if Pentagastrin is not Available?
50. How is MTC treated?
51. What are the survival rates of patients with MTC?
52. Summarize the Prevalence and Detection of Thyroid Nodules
53. What is the Primary Responsibility of the Internist in Regard to Thyroid Nodules?
54. What is the First Test Performed on a Palpable Thyroid Nodule?
55. Discuss the Role of Radionuclide Scans
56. How Does Ultrasound Examination Contribute to the Evaluation?
57. How is the FNA Sample Interpreted?
58. How do the results of FNA Affect Further Management?
59. Is Surgery Justified for a Nodule Judged as Benign by FNA?
60. Has a Molecular Defect Been Associated with Thyroid Carcinoma?
61. Discuss the Potential Role of the Ras Protooncogene
62. How may the G-stimulatory (Gs) Proteins be Related to Thyroid Cancer?
63. Discuss the potential role of the Ret/ptc oncogene
64. How is Abnormal Protein p53 Implicated in Thyroid Cancer?
Bibliography
Chapter 38: Thyroid Emergencies
1. What is Thyroid Storm?
2. How do patients develop thyroid storm?
3. What are the clinical manifestations of thyroid storm?
4. What laboratory abnormalities are seen in thyroid storm?
5. How is the diagnosis of thyroid storm made?
6. What other conditions may mimic thyroid storm?
7. How should patients with thyroid storm be treated?
8. What drugs are used to decrease thyroid hormone synthesis?
9. List drugs used to inhibit thyroid hormone release
10. What drugs are used to reduce the heart rate?
11. List agents used to support the circulation
12. What is the prognosis for patients with thyroid storm?
13. Define myxedema coma
14. How do patients develop myxedema coma?
15. What are the clinical manifestations of myxedema coma?
16. What laboratory abnormalities are seen in myxedema coma?
17. How is the diagnosis of myxedema coma made?
18. How should patients with myxedema coma be treated?
19. How are circulating thyroid hormones replaced?
20. What agent is used for glucocorticoid replacement?
21. What agents and modalities are used to support vital functions?
22. What is the prognosis for patients with myxedema coma?
Bibliography
Chapter 39: Euthyroid Sick Syndrome
1. What is euthyroid sick syndrome?
2. What hormone changes occur in patients with mild-to-moderate nonthyroidal illnesses?
3. Describe the hormone changes in patients with moderate-to-severe nonthyroidal illnesses
4. Describe the hormone changes associated with recovery from nonthyroidal illnesses
5. How can euthyroid sick syndrome be distinguished from hypothyroidism?
6. What causes euthyroid sick syndrome?
7. Is euthyroid sick syndrome an adaptive mechanism, or is it harmful?
8. Should patients with euthyroid sick syndrome be treated with thyroid hormones?
9. Does euthyroid sick syndrome have any prognostic significance?
10. Are levels of thyroid hormone ever elevated in patients with nonthyroid diseases?
Bibliography
Chapter 40: Thyroid Disease in Pregnancy
1. How does normal pregnancy affect maternal thyroid function?
2. Why must thyroid function tests be interpreted cautiously in pregnancy?
3. What particular effects may be seen during the first trimester?
4. Why must the mother significantly increase thyroid hormone production during pregnancy?
5. What factors may compromise maternal ability to increase thyroid hormone production?
6. What is the "goiter of pregnancy"?
7. Why do iodine requirements increase in pregnancy?
8. What is the recommended iodine intake during pregnancy and how can it be met?
9. What happens if iodine intake is insufficient?
10. What happens to thyroid gland volume in iodine-replete areas during pregnancy?
11. Does thyroid hormone cross the placenta?
12. Does iodine cross the placenta?
13. What about thyrotropin-releasing hormone and TSH?
14. Summarize the ability of thyroid-related antibodies to cross the placenta
15. List common medications that cross the placenta
16. When does the fetus begin making thyroid hormone?
17. Is fetal thyroid hormone production independent of the mother?
18. What is gestational transient thyrotoxicosis or thyrotoxicosis related to hyperemesis gravidarum?
19. What are the most common causes of hyperthyroidism in pregnancy? During what period of gestation is hyperthyroidism most...
20. Summarize the diagnostic approach to the pregnant woman with hyperthyroidism
21. How can the various causes of hyperthyroidism be differentiated with certainty?
22. What findings help distinguish between Graves' disease and hyperemesis gravidarum?
23. Why is it important to distinguish GTT from Graves' disease?
24. Why is the woman's original country of residence significant?
25. What are the risks of Graves' disease to the mother?
26. What are the risks to the fetus of maternal Graves' disease?
27. Describe the possible effects on the fetus of high levels of TSH-receptor-stimulating antibodies and how it...
28. How are such effects treated?
29. Why is neonatal hyperthyroidism more common than fetal hyperthyroidism?
30. How does neonatal hyperthyroidism manifest?
31. What is the mortality rate of neonatal hyperthyroidism?
32. How should hyperthyroid infants be treated?
33. How can pregnant women with Graves' disease be safely treated in pregnancy?
34. Should subclinical hyperthyroidism be treated in pregnancy?
35. Which is preferable in pregnant and breast-feeding women, PTU or MMI?
36. How are PTU and MMI dosed during pregnancy?
37. When can doses of PTU and MMI be reduced?
38. Discuss the role of beta-blockers during pregnancy
39. Why is radioactive iodine contraindicated in pregnancy?
40. Can cold iodine be given during pregnancy?
41. Does surgery have a role during pregnancy?
42. Should a woman be counseled to terminate a pregnancy if she inadvertently receives a 123I scan or an ablative dose of 131I?
43. How may the risk to the fetus be minimized?
44. How should women with Graves' disease be counseled about treatment alternatives before becoming pregnant?
45. Describe the natural history of Graves' disease in the postpartum period
46. What treatment options can be recommended for women who wish to breast-feed?
47. Can a nursing mother undergo a diagnostic 123I scan if the cause of the hyperthyroidism is in question?
48. Can ablative therapy with 131I be offered to nursing women?
49. Can beta-blockers be used in nursing women?
50. When should a nursing woman take antithyroid drugs?
51. Does hypothyroidism pose a risk to the pregnant patient and should all pregnant women be screened?
52. Should pregnant women with recurrent pregnancy loss be screened for TPO antibodies and if found, should thyroid hormone be...
53. How do thyroid hormone requirements change during pregnancy?
54. What causes the rapid increase in thyroid hormone requirements?
55. When should serum TSH levels be checked, and at what level of TSH should therapy be directed?
56. When should a pregnant woman take her thyroid hormone?
57. What is the risk of abnormal fetal and neonatal intellectual development in infants born to mothers who are hypothyroid during...
58. What strategies can reduce the risk to the fetus?
59. How should a thyroid nodule be evaluated during pregnancy?
60. What is the likelihood that thyroid nodules discovered during pregnancy are malignant?
61. How should a thyroid nodule be managed during pregnancy?
62. How common is postpartum thyroiditis? Who is at risk?
63. Characterize the histopathology of postpartum thyroiditis
64. Summarize the clinical course of postpartum thyroiditis
65. Describe phase 1 of postpartum thyroiditis
66. How can phase 1 of postpartum thyroiditis be distinguished from Graves' disease?
67. Describe phase 2 of postpartum thyroiditis
68. How is phase 2 of postpartum thyroiditis treated?
69. Describe the natural history of postpartum thyroiditis
Bibliography
Chapter 41: Psychiatric Disorders and Thyroid Disease
1. How well established is the relationship between thyroid disease and psychiatric symptoms?
2. What abnormalities of thyroid function are found in psychiatric disorders?
3. What abnormalities of TRH stimulation may be observed in the depressed patient?
4. Describe the mechanism for blunted TSH response in affective disorders
5. Can abnormalities in the TSH circadian rhythm be identified in depression?
6. Is autoimmune thyroid disease frequently present in the depressed patient?
7. What is the frequency of elevated thyroxine values in the psychiatric patient?
8. What is the most consistent abnormality of the thyroid axis in hospitalized depressed patients?
9. What is the prevalence of hypothyroid dysfunction seen in psychiatric populations?
10. Which medications affect thyroid function and thyroid function tests?
11. How does lithium affect the pituitary-thyroidal axis?
12. What is the most common thyroid disorder in lithium-treated patients?
13. How does phenytoin affect laboratory tests and the function of the thyroid?
14. Describe the effects of carbamazepine on thyroid function
15. How do phenobarbital, valproic acid, and other psychotropic medications affect thyroid function?
16. How do antidepressant therapies affect thyroid function?
17. Are there caveats of antidepressant usage in individuals with thyroid disease?
18. Has thyroxine been used as sole treatment for depression?
19. Are neuropsychiatric abnormalities demonstrable among patients with mild thyroid failure?
20. How effective is the combination of l-thyroxine and T3 in the treatment of neuropsychiatric symptoms of hypothyroidism?
21. Can combination thyroid hormone and antidepressant enhance response to depression treatment?
22. How effective is thyroid hormone for the acceleration of the antidepressant response?
23. Can triiodothyronine augment the clinical antidepressant response?
24. What evidence is there that the effect of SSRIs and ECT may be enhanced by the addition of T3?
25. Are any psychiatric conditions recognized to respond to pharmacological doses of thyroxine?
26. Are mechanisms of thyroid hormone action on the brain known?
27. Should T4 or T3 be used in treating the depressed patient?
28. Describe the proposed mechanisms linking thyroid function and depression
29. Do antidepressant medications have a mechanistic connection to the action of thyroid hormone in the brain?
30. What recommendations can be made for the thyroid evaluation in the psychiatric patient?
31. Who should receive thyroid hormone with the intent of relieving psychiatric symptoms?
Bibliography
VI. Reproductive Endocrinology
Chapter 42: Disorders of Sexual Differentiation
1. Describe the first level of sexual differentiation
2. What is the next level of sex determination?
3. Discuss the development of the external genitalia
4. How is the decision about sex assignment made?
5. What is testis-determining factor?
6. Describe the Lyon hypothesis. In which cells are two X chromosomes necessary for normal development?
7. Discuss normal male sexual differentiation
8. Describe normal female sexual differentiation
9. How is external genital development determined?
10. The differential diagnosis of sexual differentiation disorders is complex but may be simplified by an approach based on an understanding...
11. What is a virilized female?
12. What is the most common cause of a virilized female?
13. How do virilized female infants present?
14. What is an undervirilized male?
15. Which boys with hypospadias should be evaluated for sexual ambiguity?
16. What is gonadal dysgenesis?
17. An infant is born with ambiguous genitalia, and the sex of the infant is uncertain. How do you approach the parents?
18. What history is necessary to evaluate the infant?
19. How should you direct the physical examination?
20. What other areas should be evaluated?
21. Explain which radiographic studies are necessary
22. Explain the role of karyotyping
23. What laboratory test is very helpful?
24. How is further evaluation directed?
25. The infant has no palpable gonads and has fused labioscrotal folds and a prominent phallus. The ultrasound reveals...
26. An undervirilized male represents a more complex diagnostic dilemma. In an infant with palpable gonads, no...
27. Discuss the two remaining defects that involve deficiencies of testicular, rather than adrenal, enzymes
28. What other possibilities should be investigated?
29. What is complete androgen insensitivity?
30. How do infants with complete androgen insensitivity present?
31. When should intra-abdominal testicular tissue be removed?
32. Summarize the physiologic results of 5-alpha-reductase deficiency
33. Describe the clinical picture in children with 5-alpha-reductase deficiency
34. What is a ''true hermaphrodite''?
35. Why is a multidisciplinary team necessary in approaching an infant with sexual ambiguity?
36. After the etiology of sexual ambiguity has been determined in an infant, what factors should be considered in assigning a sex of rearing?
37. What other factors must be considered?
38. To which gender are virilized females usually assigned?
39. How is sex assignment determined in undervirilized males?
40. Summarize the factors that determine sex assignment in patients with gonadal dysgenesis
41. How is sex assignment determined in true hermaphrodites?
42. What principles should be kept in mind when sex assignments are made?
Bibliography
Chapter 43: Disorders of Puberty
1. What physiologic events initiate puberty?
2. Define adrenarche
3. What is the normal pattern of puberty in males?
4. Describe the normal pattern of female pubertal development
5. What controls the pubertal growth spurt?
6. How is pubertal development measured?
7. What constitutes sexual precocity in boys and girls?
8. What clinical findings are associated with precocious puberty?
9. In which sex is precocity more prevalent?
10. Which two common benign conditions in girls are often confused with precocious puberty?
11. How is benign premature thelarche diagnosed?
12. How is benign premature thelarche treated?
13. How is benign premature adrenarche diagnosed?
14. How is benign premature adrenarche treated?
15. How does GnRH-dependent (central) precocious puberty differ from GnRH-independent (peripheral) precocious puber
16. How is the diagnosis of precocious puberty made?
17. After making the general diagnosis of precocity, how do I proceed to a specific diagnosis?
18. What is the single most important test in establishing a specific diagnosis?
19. When is a magnetic resonance imaging study of the brain indicated?
20. What findings suggest peripheral precocious puberty?
21. How is central idiopathic precocious puberty treated?
22. What is the association of hypothyroidism with precocity?
23. What is McCune-Albright syndrome? How is it treated?
24. How is McCune-Albright treated?
25. Describe testotoxicosis. How is it treated?
26. How does 21-hydroxylase-deficient CAH present in boys?
27. Summarize the treatment of CAH
28. What is adolescent gynecomastia? When and how should it be treated?
29. At what age does failure to enter puberty necessitate investigation?
30. What is constitutional growth delay? How does it affect puberty?
31. When is hypogonadism diagnosed?
32. What causes hypogonadotropic hypogonadism?
33. What is Kallmann syndrome?
34. What causes hypergonadotropic hypogonadism?
35. How is gonadal failure with no apparent cause evaluated in boys?
36. Describe the evaluation of gonadal failure in girls
37. What is Turner syndrome?
38. What are the clinical findings in patients with Turner syndrome?
39. How is Turner syndrome treated?
40. Why do boys with Klinefelter syndrome have pubertal delay?
41. What features help to diagnose Klinefelter syndrome?
42. Describe the appropriate history for an adolescent with pubertal delay
43. Describe the physical examination of an adolescent with pubertal delay
44. How are radiographic studies and gonadotropin levels helpful in the diagnosis of pubertal delay?
45. What other lab tests may be needed?
46. How is delayed puberty managed?
47. Describe the treatment of boys with hypogonadism.
48. How is estrogen treatment given for girls with hypogonadism?
49. How do body habitus and lifestyle influence the timing of puberty?
50. Define amenorrhea
51. How do you begin to evaluate a girl with amenorrhea?
52. What causes amenorrhea in girls who are producing estrogen and do not have an outflow tract obstruction?
Bibliography
Chapter 44: Male Hypogonadism
1. Define male hypogonadism
2. What are the manifestations of in utero hypogonadism?
3. Describe the manifestations of peripubertal hypogonadism
4. Summarize the manifestations of hypogonadism in early adulthood
5. What are the manifestations of hypogonadism in mid-to-late adulthood?
6. How is production of testosterone normally regulated?
7. What are some conditions associated with decreased or increased serum SHBG levels?
8. Describe how production of sperm is normally regulated
9. Define primary hypogonadism and secondary hypogonadism
10. List the congenital causes of primary hypogonadism
11. List the acquired causes of primary hypogonadism
12. Is normal aging associated with primary hypogonadism?
13. Discuss the causes of secondary hypogonadism
14. What is the most common pituitary tumor in adults?
15. How do other pituitary adenomas cause hypogonadism?
16. What clinical symptoms are seen in male hypogonadism?
17. How does hypogonadism affect bone architecture?
18. What laboratory tests help to confirm a suspected diagnosis of male hypogonadism?
19. Can laboratory tests help to distinguish primary from secondary hypogonadism?
20. What other diagnostic tests are useful in defining the cause of male hypogonadism?
21. Define hermaphrodite
22. Define pseudohermaphrodite
23. How is hypogonadism treated?
24. What are the potential adverse effects of testosterone treatment?
25. Does testosterone replacement affect the prostate in older men?
26. How does one treat the deficiency of sperm production in primary hypogonadism?
27. How does one treat deficient sperm production in secondary hypogonadism?
28. What reproductive alternative is available to men with hypogonadism who do not respond to therapy?
Bibliography
Chapter 45: Impotence
1. What is impotence?
2. Do men with erectile dysfunction have disturbances in other sexual functions?
3. Is impotence common?
4. How does a normal erection occur?
5. Explain the role of the nervous system in achieving erection
6. Explain the hormonal aspects of erection
7. What vascular changes in the penis result in erection?
8. What types of nerves and neurotransmitters play a role in penile erection?
9. How does detumescence occur?
10. What are the common causes of impotence?
11. What lifestyles are associated with impotence?
12. Besides diabetes mellitus, what are the three most common endocrine causes of impotence?
13. Describe the most common drugs known to induce impotence
14. Which antihypertensive agents should be used in patients with impotence?
15. What is ``stuttering´´ impotence? What is its significance?
16. What historical information helps to separate organic from psychogenic impotence?
17. Name the essential components of a physical examination in a man complaining of impotence
18. What is the appropriate laboratory assessment for men with impotence?
19. Should prolactin levels be measured in all impotent men?
20. What is a penile brachial index?
21. What is nocturnal penile tumescence monitoring?
22. What are the therapeutic options in the treatment of impotence?
23. What options are available for medical treatment?
24. Summarize the role of intracavernosal injections
25. List the surgical procedures used to treat impotence
26. What are the advantages and disadvantages of the various forms of androgen replacement therapy?
27. What parameters should be monitored in men on testosterone therapy?
28. In what conditions is testosterone therapy absolutely or relatively contraindicated?
29. How effective are PD5 inhibitors?
30. Discuss the side effects of PD5 inhibitors.
31. What drug interactions are associated with PD5 inhibitors?
32. When are intracavernosal or intraurethral injections recommended?
33. Discuss the side effects of intracavernosal and intraurethral injections
34. Does the onset of impotence have other health implications?
35. What future treatments may be forthcoming?
36. What other modalities are available to treat impotent men?
Bibliography
Chapter 46: Gynecomastia
1. Define gynecomastia
2. How does gynecomastia present clinically?
3. What is the significance of painful gynecomastia?
4. Is gynecomastia always bilateral?
5. Summarize the pathophysiology of gynecomastia
6. Where are estrogens produced in the male?
7. What is the most common cause of gynecomastia?
8. Why does gynecomastia occur so commonly during these stages of life?
9. What are the other causes of gynecomastia?
10. What drugs cause gynecomastia?
11. How do testicular tumors cause gynecomastia?
12. What extragonadal tumors cause gynecomastia?
13. Who should undergo evaluation for gynecomastia?
14. What information is significant in the history?
15. What should be noted on the physical examination?
16. Should laboratory tests be ordered?
17. What findings raise the suspicion of breast cancer?
18. Will gynecomastia spontaneously regress?
19. What is the treatment when gynecomastia does not regress?
Bibliography
Chapter 47: Amenorrhea
1. Define amenorrhea
2. Describe the normal timing of puberty
3. Summarize the underlying process of pubertal development
4. What types of disorders cause primary amenorrhea?
5. What are hypothalamic and pituitary causes of primary amenorrhea?
6. Summarize the ovarian causes of primary amenorrhea
7. What disorders cause secondary amenorrhea?
8. How do you evaluate a patient with amenorrhea?
9. Discuss the major congenital causes of hypogonadotropic hypogonadism
10. What are the most frequent acquired forms of amenorrhea due to hypogonadotropic hypogonadism?
11. How does hyperprolactinemia cause amenorrhea?
12. What is hypothalamic amenorrhea?
13. What types of GnRH pulse generator defects cause hypothalamic amenorrhea?
14. How do you make a diagnosis of hypothalamic amenorrhea?
15. What are the consequences of estrogen deficiency?
16. What treatment options are available for hypothalamic amenorrhea?
17. What disorders cause amenorrhea with hypergonadotropic hypogonadism?
18. How do you make a diagnosis of premature ovarian failure?
19. What other disorders may coexist with premature ovarian failure?
20. What are the treatment options for women with premature ovarian failure?
21. What is hyperandrogenic anovulation?
22. How do tumors cause hyperandrogenic anovulation?
23. What clinical and biochemical features suggest a patient with hirsutism has CAH?
24. When should you suspect obesity-induced amenorrhea?
25. Describe the pathophysiology of obesity-induced amenorrhea
26. How does the patient with PCOS present clinically?
27. Describe the pathogenesis of PCOS
28. What are the criteria for diagnosis of PCOS?
29. What are the treatment options for patients with PCOS?
30. Is there a role for insulin sensitizers in the treatment of women with PCOS?
31. What are the long-term consequences of PCOS?
Bibliography
Chapter 48: Galactorrhea
1. Define galactorrhea
2. Which hormones affect lactation?
3. How common is galactorrhea?
4. Does galactorrhea have the appearance of milk?
5. Is galactorrhea always expressed from both breasts?
6. List a differential diagnosis for galactorrhea?
7. Which medications cause galactorrhea?
8. How often should one obtain a menstrual history from a woman with galactorrhea?
9. What percentage of women with hyperprolactinemia have galactorrhea?
10. Discuss the physiological variations in prolactin levels
11. How does the degree of prolactin elevation help determine the cause for galactorrhea?
12. What other lab tests should be included in the evaluation of galactorrhea?
13. It seems odd that hyperthyroidism is listed just below hypothyroidism as a cause for galactorrhea. How did that come about?
14. Describe the proposed mechanism for galactorrhea following thoracic surgery or associated with painful chest wall lesions
15. Galactorrhea in renal failure seems odd. What is the connection?
16. Can galactorrhea occur in the absence of prolactin excess?
17. Is galactorrhea associated with an increased risk of breast cancer?
18. Are medications used for postpartum galactorrhea?
19. What about galactorrhea in men?
20. Does galactorrhea always require treatment?
21. Do microadenomas require treatment?
22. Why should macroadenomas be treated?
23. How are macroadenomas treated?
24. How do dopamine agonists work in the treatment of macroadenomas?
25. What is macroprolactinemia?
26. What is the syndrome signaled by failure to lactate postpartum?
27. Did Hippocrates speak of amenorrhea or galactorrhea?
Bibliography
Chapter 49: Hirsutism and Virilization
1. Define hirsutism
2. Define virilization
3. Where are androgens produced?
4. What causes hirsutism?
5. List the conditions that result in hirsutism
6. Describe the pathophysiology of PCOS
7. How does PCOS present?
8. Describe the pathophysiology of the hyperandrogenism in CAH
9. Do any other causes of CAH result in hirsutism?
10. Describe the pathophysiology of idiopathic and familial hirsutism.
11. How do Cushing's syndrome, prolactinomas, and hypothyroidism cause hirsutism?
12. What is the pathophysiology of the hyperandrogenism in ovarian hyperthecosis?
13. Which medications can cause hirsutism?
14. What conditions cause virilization?
15. When should a patient be evaluated for hirsutism?
16. What information is important in the history?
17. What findings are important on physical examination?
18. What laboratory tests should be ordered for a patient with hirsutism?
19. How are the results of these laboratory tests interpreted?
20. What do you do if a patient has borderline (200-500 ng/dL) elevations of 17-OHP?
21. What laboratory tests should be ordered in a patient with virilization?
22. How is PCOS treated in a patient desiring pregnancy?
23. How is PCOS treated in a patient not desiring pregnancy?
24. What can be done about the hyperinsulinemia of PCOS?
25. What is the treatment for CAH?
26. Describe how oral contraceptive pills are used for the treatment of hirsutism
27. Describe how antiandrogens are used for the treatment of hirsutism
28. Describe how GnRH agonists are used for the treatment of hirsutism
29. What topical agent is approved for the treatment of hirsutism?
30. What cosmetic measures can be used for the treatment of hirsutism?
31. How do you choose the appropriate therapy for the patient's hirsutism?
Bibliography
Chapter 50: Menopause
1. Define menopause
2. When do ovulatory cycles decrease in frequency?
3. When does menopause usually occur?
4. What determines the timing of menopause?
5. What is premature ovarian failure? What causes it?
6. Does the age of menopause vary with race, body size, age of menarche, geography, or socioeconomic conditions?
7. Does the appearance of the ovaries change with menopause?
8. What is the predominant circulating estrogen in menopause?
9. What is a hot flash? Should it be called a flush?
10. Hot flushes are accompanied by surges in luteinizing hormone. Does excess luteinizing hormone trigger the spells?
11. Do all women develop menopausal vasomotor hot flushes? Do they last indefinitely?
12. Are all menopausal symptoms clearly related to estrogen deficiency?
13. What important physiologic changes accompany menopause?
14. What is the principal cause of death in postmenopausal women?
15. Does male menopause exist?
16. Historical records indicate the age of menarche has decreased over the centuries, perhaps as a result of improved nutrition...
17. How does one establish a diagnosis of menopause?
18. What routes of administration can be used for menopausal hormone replacement, and how effective are estrogens in relieving...
19. What are the most common indications for menopausal hormone replacement therapy?
20. What levels of estradiol and estrone are achieved with replacement?
21. Can gonadotropin levels be used to monitor adequacy or safety of replacement?
22. A major shift away from the use of estrogen replacement resulted from results of trials sponsored by the Women's Health Initia...
23. What happened to sales of premarin?
24. What alternative therapies may be used for the menopausal woman in lieu of estrogen replacement?
25. What about the diagnosis of androgen deficiency and its treatment in menopause?
26. What web textbook might you recommend for providers seeking information about menopause?
27. What websites have good materials on menopause for patients?
Bibliography
Chapter 51: Use and Abuse of Anabolic-Androgenic Steroids and Androgen Precursors
1. What are anabolic-androgenic steroids?
2. Summarize the biological effects of AASs
3. How do AASs exert their effects?
4. Where are androgen receptors located?
5. Why is it necessary to modify testosterone to make clinically useful AASs?
6. How is testosterone modified to make AASs?
7. What routes of administration are available?
8. What are the indications for AAS therapy?
9. Are there any other potential uses for AASs?
10. Which of the indications in question 8 is the most common use of AASs?
11. How common is abuse of AASs?
12. Who is at risk for using illegal AASs?
13. Do AASs truly help athletes?
14. How do AASs help athletes?
15. What doses of AASs are used in attempts to enhance sports performance and appearance?
16. How do athletes get AASs?
17. What are the potential adverse effects of AAS use?
18. What about side effects in women and children?
19. Which AASs have the least potential to cause adverse effects?
20. What has been done on a national and worldwide level to prevent AAS abuse?
21. What has been done on an individual level to prevent AASs abuse?
22. What screening tests are used to detect AASs in athletes?
23. What are the so-called androgen precursors or prohormones?
24. What are the effects if any of androgen precursors?
25. Have androgen precursors, such as androstenedione and dehydroepiandrosterone, been shown to raise serum testosterone levels in...
26. Have androgen precursors been shown to be anabolic in men or women?
Bibliography
VII. Miscellaneous TopicsArnold A.Asp
Chapter 52: Multiple Endocrine Neoplasia
1. What are the multiple endocrine neoplasia (MEN) syndromes?
2. Define MEN-I
3. Define MEN-IIa
4. Define MEN-IIb
5. How can so many various endocrine organs be affected in these syndromes?
6. What is Wermer's syndrome?
7. How common is Werner's syndrome?
8. Is hyperparathyroidism in MEN-I similar to sporadic primary hyperparathyroidism?
9. What causes the hyperplasia of parathyroid glands affected by MEN-I?
10. Summarize the therapy for hypoplastic parathyroid glands
11. How common is neoplastic transformation of pancreatic islet cells in MEN-I?
12. What types of pancreatic tumors are found in MEN-I syndrome?
13. What is the most common type of pancreatic tumor in MEN-I?
14. Describe the symptoms of gastrinomas associated with MEN-I
15. What other conditions may cause hypergastrinemia?
16. How are gastrinomas distinguished from other causes of hypergastrinemia?
17. What is the second most common type of pancreatic tumor in MEN-I?
18. What other pancreatic tumors may be seen in MEN-I?
19. How are the most common pancreatic tumors of MEN-I Treated?
20. Summarize the approach to treatment of hypoglycemia associated with insulinomas
21. Which pituitary tumors are associated with MEN-I?
22. What pituitary tumors are most commonly associated with MEN-I?
23. What is the second most common pituitary tumor in MEN-I?
24. What other pituitary tumors may be seen in MEN-I?
25. What causes MEN-I?
26. How should a kindred be screened after the proband is identified?
27. At what age should screening begin?
28. Summarize the tests used for screening of MEN-I individuals
29. What is Sipple's syndrome?
30. Is the form of MTC associated with MEN-IIa similar to the sporadic form of MTC?
31. Summarize the essential characteristics of MTC associated with MEN-IIa
32. How common is diarrhea in MTC associated with MEN-IIa?
33. How is MEN-II-associated MTC treated?
34. How is C-cell hyperplasia detected?
35. What is the second most common neoplasm associated with MEN-IIa?
36. Summarize the treatment of pheochromocytomas associated with MEN-IIa
37. Is hyperparathyroidism associated with MEN-IIa similar to that found in MEN-I?
38. What is the genetic basis for the MEN-IIa syndrome?
39. How should a kindred be screened after the proband with MEN-IIa is identified?
40. How is MEN-IIa treated?
41. What comprises the MEN-IIb syndrome?
42. What findings raise the suspicion of MEN-IIb syndrome?
43. How should MEN-IIb be treated?
44. What is the overall mortality rate associated with MEN-IIb?
45. Summarize the screening recommendations for MEN-IIb
46. What causes MEN-IIb?
47. Have the clinical presentations and prognoses of the MEN syndromes changed since the time of their original descriptions?
Bibliography
Chapter 53: Autoimmune Polyendocrine Syndromes
1. Define the autoimmune polyendocrine syndromes. How many clinical forms are there?
2. Is evidence of nonendocrine autoimmune dysfunction associated with APSs?
3. What constitutes APS type 1?
4. Are nonendocrine manifestations associated with APS type 1?
5. Explain the etiology of APS type 1
6. What therapy can be offered?
7. What disorders are associated with APS type 2?
8. What is most common presenting disorder in APS type 2?
9. What thyroid disorders are associated with APS type 2?
10. Summarize the significance of cytoplasmic islet-cell antibodies (ICAs) in APS type 2
11. How common is gonadal failure in APS type 2?
12. Are nonendocrine abnormalities described in APS type 2?
13. How should kindreds with suspected APS type 2 be screened?
14. Explain the etiology of APS type 2
15. What is POEMS syndrome?
16. What eponym is associated with POEMS?
17. How does POEMS usually present?
18. How does the organomegaly manifest?
19. Which endocrine systems are involved?
20. What skin changes have been encountered?
21. How is POEMS treated?
Bibliography
Chapter 54: Pancreatic Endocrine Tumors
1. What are the pancreatic endocrine tumors?
2. Are pancreatic endocrine tumors usually benign or malignant?
3. Are pancreatic endocrine tumors associated with other endocrine disorders?
4. What are insulinomas?
5. What is Whipple's triad?
6. What glucose levels are considered to be hypoglycemia?
7. What are the symptoms of hypoglycemia?
8. How is the diagnosis of an insulinoma made?
9. How can insulinomas be distinguished from other causes of hyperinsulinemic hypoglycemia?
10. How can an insulinoma be localized?
11. What is the treatment for an insulinoma?
12. What are the clinical manifestations of gastrinomas?
13. Do gastrinomas always arise from pancreatic islet cells?
14. How is the diagnosis of gastrinoma made?
15. What is the best way to localize a gastrinoma?
16. How are gastrinomas managed?
17. How do you treat a malignant gastrinoma?
18. What are the characteristics of glucagonomas?
19. How are glucagonomas treated?
20. What are the characteristics of somatostatinomas?
21. What is the treatment for somatostatinoma?
22. What are the characteristics of VIPomas?
23. How are VIPomas treated?
24. Briefly discuss the remaining pancreatic endocrine tumors
Bibliography
Chapter 55: Carcinoid Syndrome
1. What are carcinoid tumors? How are they classified?
2. Define carcinoid syndrome
3. What are the biochemical mediators of the carcinoid syndrome?
4. Why does pellagra sometimes accompany the carcinoid syndrome?
5. Why do intestinal carcinoid tumors so infrequently cause carcinoid syndrome?
6. Do carcinoid tumors cause any other humoral syndromes?
7. How is the diagnosis of carcinoid syndrome made?
8. What is the treatment for carcinoid syndrome?
9. How does one control the symptoms of carcinoid syndrome?
10. What chemotherapy regimens are most effective in carcinoid tumors?
11. What is a carcinoid crisis?
12. How can a carcinoid crisis be prevented?
13. Can a carcinoid crisis be predicted?
14. Describe the management of a carcinoid crisis
Bibliography
Chapter 56: Cutaneous Manifestations of Diabetes Mellitus and Thyroid Disease
1. How often do patients with diabetes mellitus demonstrate an associated skin disorder?
2. Are any skin disorders pathognomonic of diabetes mellitus?
3. What is bullous diabeticorum?
4. What are the skin disorders most likely to be encountered in diabetics?
5. What are finger pebbles?
6. What is acanthosis nigricans?
7. What does acanthosis nigricans look like?
8. What is diabetic dermopathy?
9. What is necrobiosis lipoidica diabeticorum?
10. What is the relationship of necrobiosis lipoidica diabeticorum to diabetes mellitus?
11. How should necrobiosis lipoidica diabeticorum be treated?
12. Are skin infections more common in diabetics than in control populations?
13. What are the most common bacterial skin infections associated with diabetes mellitus?
14. What is the most common fungal mucocutaneous infection associated with diabetes mellitus?
15. Why are diabetics in ketoacidosis especially prone to mucormycosis?
16. Are any skin complications associated with the treatment of diabetes mellitus?
17. What is scleredema adultorum?
18. What are the most important cutaneous manifestations of the hypothyroid state?
19. Why do hypothyroid patients often have yellow skin?
20. What are the clinical findings in generalized myxedema?
21. What is the pathogenesis of generalized myxedema?
22. What is the difference between generalized myxedema and pretibial myxedema?
23. What are the clinical manifestations of pretibial myxedema?
24. How is pretibial myxedema treated?
25. What are the skin manifestations of hyperthyroidism?
26. What effect does obesity have on skin function and physiology?
27. What are some of the cutaneous manifestations of obesity?
28. Does obesity aggravate any skin diseases?
Bibliography
Chapter 57: Aging And Endocrinology
1. What effect does aging have on body weight?
2. What changes in lean body mass occur with aging?
3. What changes in bone mass and density occur with aging?
4. Does menopause have an independent effect on bone mass?
5. Can weight-bearing exercise prevent the menopause-related loss of bone mineral in women?
6. Do sex hormones influence the skeletal response to exercise?
7. Does fat mass increase or redistribute with aging?
8. Does menopause trigger an increase in abdominal obesity in women?
9. What are the results of prospective studies of voluntary weight loss in the elderly?
10. Why is vitamin D status important in older adults?
11. What are the recommendations for vitamin D daily intake in older adults?
12. What interventions have been associated with increased longevity, and have they been shown to work in humans?
13. What happens to testosterone and estradiol levels with aging in men?
14. What is the cause of decreases in male testosterone levels with aging?
15. What is the prevalence of hypogonadism in older men?
16. Are there benefits of testosterone supplementation for older men?
17. Is there evidence for adverse effects of testosterone supplementation?
18. Should healthy older men receive testosterone supplementation?
19. Should estrogen therapy be given to postmenopausal women?
20. How does dehydroepiandrosterone concentration change with aging?
21. What are the biological effects of DHEA/S?
22. What are the hormonal effects of DHEA supplementation?
23. Summarize the controlled studies of DHEA administration to older adults
24. Describe the changes in the growth hormone/IGF-1 axis with aging
25. Is the decline in the GH/IGF-1 axis related to age-related changes in body composition and function?
26. Is GH replacement recommended for the healthy elderly?
27. Does GHRH supplementation affect GH secretion, sleep, and cognition?
28. What happens to the hypothalamic-pituitary-adrenal (HPA) axis with aging?
29. What is a normal thyroid-stimulating hormone (TSH) level in older adults?
30. What thyroid conditions are more prevalent with aging?
31. Should subclinical hypothyroidism be treated in the elderly?
32. What implications could prescribing generic thyroid hormones have in the elderly?
33. What factors are necessary to take into account when determining treatment goals for the management of type 2 diabetes in...
34. What medications should be considered for the treatment of diabetes in older adults?
Bibliography
Chapter 58: Endocrine Surgery
Thyroid
1. List the possible results of fine-needle aspiration of thyroid nodules and describe the appropriate surgical intervention
2. Should ultrasound guidance be used for all FNAs of thyroid nodules?
3. What are the differences between total, near-total, and subtotal thyroidectomy?
4. What is the appropriate extent of thyroidectomy for differentiated thyroid carcinoma?
5. A patient underwent a thyroid lobectomy for a suspicious thyroid nodule, and the final pathology revealed papillary carcinoma. How...
6. Is the risk of complication higher in patients treated with lobectomy followed by completion thyroidectomy compared..
7. Describe the appropriate surgical management for medullary thyroid carcinoma
8. Discuss the role of surgery in anaplastic carcinoma of the thyroid
9. What is a central and modified radical neck dissection?
10. What is the incidence of lymph node metastasis in well-differentiated thyroid cancer, and when is a neck dissection indicated?
11. When is surgery indicated for recurrent thyroid cancer?
12. How many times should a thyroid cyst be aspirated if it reaccumulates fluid? Should the cyst fluid be sent for cytology?
13. List the indications for thyroidectomy in hyperthyroidism
14. List possible indications for thyroidectomy in patients with hyperthyroidism
15. How should patients with hyperthyroidism be prepared for surgery?
16. What is the extent of thyroidectomy for hyperthyroidism?
17. What are the complications of thyroidectomy?
18. What is the significance of an incidentally noted thyroid hot spot on positron emission tomography scan?
19. What is the appropriate therapy for an intrathoracic goiter?
20. When should thyroglossal duct cysts be removed? Describe the operation
Parathyroid
21. Discuss the indications for parathyroidectomy
22. When should preoperative parathyroid localization studies be performed?
23. Define minimally invasive parathyroidectomy
24. What is minimally invasive radio-guided parathyroidectomy?
25. Summarize the advantages of minimally invasive approaches
26. Describe when an ioPTH assay should be used
27. What is the expected success of surgery for primary hyperparathyroidism?
28. Describe the appropriate management of a ''missing'' parathyroid
29. List the likely locations for an ectopic inferior parathyroid gland
30. List the likely locations for an ectopic superior parathyroid gland
31. What if a patient has multiglandular parathyroid disease?
32. Discuss the advantages and disadvantages of SPTx versus TPTx + AT
33. How is autotransplantation performed?
34. List the complications of parathyroidectomy and their prevalence
35. Define persistent or recurrent hyperparathyroidism
36. Discuss the approach to patients with persistent or recurrent hyperparathyroidism
37. Discuss the options for treatment of persistent or recurrent hyperparathyroidism
38. How does one recognize parathyroid cancer?
39. Describe the management of parathyroid cancer
40. Give the recurrence and survival rates for parathyroid cancer
Adrenal Glands
41. Should all incidentally discovered adrenal masses be resected?
42. Summarize the appropriate laboratory evaluation of an adrenal mass
43. What imaging studies are available for evaluating adrenal pathology?
44. What findings on CT or MRI help to distinguish between benign and malignant tumors?
45. Discuss the role of percutaneous biopsy in the evaluation of an adrenal mass
46. List the indications for surgery
47. Describe the open technique for adrenalectomy
48. Discuss the role of laparoscopic surgery
49. What approaches are used for laparoscopic surgery?
50. Summarize the long-term success of adrenalectomy for functional tumors
51. Describe the appropriate management of adrenal malignancy
52. Describe the appropriate management of pheochromocytoma
53. What is a cortical-sparing adrenalectomy, and when is it indicated?
54. How should patients with pheochromocytoma be prepared for surgery?
Neuroendocrine tumors of the pancreas and gastrointestinal tract
55. How common are pancreatic endocrine tumors?
56. Are most PETs functional?
57. What are the types of functional PETs?
58. How should functional PETs be imaged?
59. How important is it to localize functional PETs before surgery?
60. What is the appropriate surgical approach for insulinomas?
61. Describe the surgical approach to gastrinomas
62. How should other sporadically occurring islet cell tumors be managed?
63. Should PETs occurring in patients with MEN 1 be approached differently than those occurring sporadically?
64. Discuss the role of surgery for liver metastases from neuroendocrine tumors
65. Describe the presentation of nonpancreatic neuroendocrine tumors (carcinoid tumors)
66. Describe the carcinoid syndrome
67. After a patient is diagnosed with carcinoid syndrome, what is the next step?
68. Describe the appropriate surgical management for carcinoid tumors
69. Discuss the role of surgery in carcinoid syndrome
Bariatric Surgery
70. Define obesity. How common is it?
71. What are the limitations of BMI?
72. How successful is nonsurgical treatment of obesity?
73. What are the indications for surgery for obesity?
74. List the contraindications to bariatric operations
75. Categorize the various surgical options for weight reduction
76. List the options for restrictive surgery
77. What is the option for malabsorptive surgery?
78. Explain the combined option.
79. How much weight do patients lose following bariatric surgery?
80. What are the effects of bariatric surgery on obesity-related comorbidities?
81. What are the complications of bariatric surgery?
82. Give the incidence of complications following laparoscopic bariatric procedures in general.
Bibliography
Thyroid
Parathyroid
Adrenal glands
Neuroendocrine tumors of the pancreas and gastrointestinal tract
Bariatric surgery
Chapter 59: Endocrinology in the managed care environment
1. Define managed care
2. Is there only one type of managed care?
3. Who is the patient's initial contact in a managed care environment?
4. Do pediatricians and gynecologists function as PCPs?
5. How does the patient make contact with a subspecialist?
6. What is a meant by the MCO's ''panel'' of providers?
7. Explain the MCO directory
8. Explain the POS option
9. How do MCOs compare with other business units?
10. What is the difference between a PPO and an HMO?
11. Are there other types of MCO plans?
12. What are blended policies?
13. How does an endocrinologist join an HMO?
14. How does an HMO patient get to your office?
15. What can you expect to be able to do for the patient at the initial consultation or at subsequent follow-up visits?
16. Can you use your own physician office laboratory (POL) for HMO patients?
17. What potentially serious problem may arise in regard to pathology services?
18. What happens if your patient changes jobs and receives health insurance from a company for which you are not providing services, or if the...
19. Describe the process by which the endocrinologist submits the bill for patient services
20. Why are payments often delayed?
21. What problems may result from such practices?
22. Is it advisable to continue seeing patients for MCOs if such problems exist?
23. Explain why doctors must be involved in all aspects of the MCO relationship
24. What special concerns apply to doctors in small groups?
25. What pitfalls should doctors avoid in making decisions about participation in MCOs?
26. What factors should be taken into account in deciding whether to renew a specific MCO contract?
27. Explain revenue tracking
28. What factors are relevant to handling of claims?
29. How do you evaluate the fee schedule?
30. Should doctors consult a lawyer before signing an MCO contract?
31. Can doctors negotiate the terms of MCO contracts?
32. Does the physician have to be a good businessperson to survive in the managed care environment?
Bibliography
Chapter 60: Sleep and Endocrinology
1. Do sleep disorders cause endocrine disease or does endocrine disease cause sleep disorders?
2. What are the stages of sleep?
3. What is the progression of sleep stages in a usual night of sleep?
4. What are the fundamental changes in the nervous system in NREM versus REM sleep, and what other differences are...
5. What are the two brain mechanisms responsible for anterior pituitary hormone cycling in a 24-hour period?
6. How do the sleep stages change during one's life span?
7. Name the two hormones that are elevated early in sleep and the two hormones that are elevated late in sleep.
8. How do the gonadotropins levels vary with sleep?
9. Is the LH pattern the same in women?
10. Do the gonadal steroid hormones follow the LH and FSH changes mentioned in the question above?
11. What factors influence thyroid stimulating hormone (TSH) release?
12. Since TSH and cortisol release are circadian, are their levels parallel through the night and day?
13. What changes in sleep will influence cortisol levels?
14. How do circadian and sleep-wake processes influence glucose and insulin levels?
15. How does aging change hormonal release?
16. What is the definition of sleep disordered breathing (SDB) and how does this differ from obstructive sleep apnea (OSA)?
17. What are respiratory events?
18. What is the prevalence of OSA?
19. Define sleep deprivation. How common is it?
20. What are the key features of sleep deprivation versus sleep apnea?
21. In view of increased SNS tone in OSA, (see question 4), does the co-morbidity of OSA interfere with the assessment of...
22. What endocrine diseases are associated with OSA?
23. How is the sleep apnea of GH excess different from the sleep apnea of thyroid hormone deficiency?
24. How does sleep deprivation influence glucose tolerance?
25. What is the evidence linking OSA to abnormal glucose metabolism?
26. What are the two main mechanisms underlying the development abnormal glucose metabolism in sleep apnea patients?
27. With respect to causality, does the use of CPAP improve abnormal glucose metabolism parameters?
28. Does the effective use of CPAP in the OSA patient lead to weight loss?
29. What are the effects of sleep deprivation on leptin (the satiety hormone) and ghrelin (hunger hormone)?
30. Is the testosterone decline observed with aging related to the changes associated with sleep pattern of aging?
31. How does androgen influence sleep?
32. How does the testosterone panel change with OSA and does OSA treatment influence the panel?
33. How well are providers in diabetes clinics screening their patients for OSA? What are good tools for screening historically and on physical exam?
Bibliography
Chapter 61: Endocrine Case Studies
1. A 34-year-old woman has new-onset hypertension. Her serum potassium level is 2.7 mEq/L. Initial hormone...
2. A 32-year-old business executive develops amenorrhea. She has not recently lost weight but states that her job...
3. A nulliparous 48-year-old woman presents with symptoms of thyrotoxicosis. She has a modest, nontender goiter and...
4. A 38-year-old man has coronary artery disease, xanthomas of the Achilles tendons, and the following serum...
5. A 28-year-old man presents because of infertility. He is found to have small, firm testes and gynecomastia...
6. A 38-year-old nurse presents in a stuporous state
the blood glucose level is 14 mg/dL. Additional blood is ...
7. A 28-year-old woman with type 1 diabetes develops amenorrhea. Further testing reveals the following serum...
8. A 34-year-old woman presents with galactorrhea, amenorrhea, headaches, fatigue, and weight gain. Laboratory...
9. A 6-year-old girl has recently developed breast enlargement and some pubic hair. She has not complained of...
10. A 19-year-old man presents with excessive thirst and urination. Laboratory evaluation shows the following:...
11. A 25-year-old woman presents with a cushingoid appearance. The results of hormone testing are as follows...
12. An 8-year-old boy with known adrenal insufficiency complains of paresthesias of the lips, hands, and feet and...
13. A 52-year-old man has a personal and family history of early coronary artery disease, minimal alcohol consumptio...
14. A 58-year-old man has recently developed diabetes mellitus, weight loss, and a skin rash that is most prominent...
15. A 29-year-old woman has asymptomatic hypercalcemia. Her mother and a sister also have hypercalcemia and have had...
16. A 39-year-old HIV-positive man with Pneumocystis carinii pneumonia has the following serum thyroid hormon...
17. An 18-year-old girl has not yet begun menstruating. She has a height of 56 inches, a small uterus, and no breas...
18. A 62-year-old woman presents for evaluation of recent nephrolithiasis and low back pain. Her estimated calcium...
19. A 32-year-old woman presents with the recent onset of fatigue, palpitations, profuse sweating, and emotional...
20. A 70-year-old man complains of a 1-year history of weakness, weight loss, and hand tremors. He has been...
21. A 20-year-old man presents for failure to enter puberty. He has small, soft testes, no gynecomastia, normal...
22. A 32-year-old man complains of impotence and retro-orbital headaches intermittently for the past year...
23. A 52-year-old woman complains of a 1-year history of progressive fatigue, puffy eyes, dry skin, and mild...
24. A 32-year-old woman complains of deep pain in both thighs. She was diagnosed as having type 1 diabetes mellitus...
25. A 42-year-old man presents for evaluation of a skin rash that has recently developed. He has known type 2 diabet...
26. A 26-year-old woman requests to be tested for a type of thyroid cancer that has recently been found in her mother...
27. A 68-year-old man complains of a 10-year history of progressive pain in the shins, knees, and left arm...
28. A 19-year-old man has experienced fatigue, muscle weakness, and dizziness for the past 3 weeks. This morning...
Chapter 62: Famous People With Endocrine Disorders
1. Name the former college basketball star from Gonzaga University who was diagnosed with type 1 diabetes at age 14.
2. This female track star recovered from Graves disease and went on to win the title of ``Fastest Woman in the World´´...
3. Name the dwarf actor who gained fame for his role as Tattoo on the television series Fantasy Island (1977-1984)...
4. Television and film actress Mary Tyler Moore has what endocrine disorder?
5. George Bush and his wife Barbara were both diagnosed with Graves disease during his presidency (1989-1993). How did the...
6. Pulitzer Prize-winning film critic Roger Ebert was diagnosed with what endocrine disorder at age 59?
7. Name the acromegalic giant who played the character Jaws in the James Bond films The Spy Who Loved Me (1977)...
8. Name the 2 foot, 8 inch, dwarf actor best known for his role as Mini-Me in the film Austin Powers: The Spy Who Shagged...
9. What late actor, who appeared in the film Young Frankenstein (1974), had obvious Graves ophthalmopathy?
10. Ancient Egyptian sculptures and paintings suggest that Tutankhamen (1357-1339 b.c.) and other pharaohs of the...
11. What famous male ice skater overcame growth failure related to a childhood illness to win the gold medal at the 1984 Winter...
12. How was Scott Hamilton's craniopharyngioma treated?
13. In 1999, Tipper Gore, the wife of former Vice President Al Gore, had surgery for what endocrine disorder?
14. Name the late professional wrestler (and actor) who was well known for his height and acromegalic facial features.
15. Charles Sherwood Stratton (1838-1883) reached an adult height of only 3 feet, 4 inches. what was his circus name?
16. Actress Catherine Bell, who starred as Lt. Col. Sarah ``Mac´´ MacKenzie on the television series JAG...
17. Oscar award-winning actress Halle Berry was diagnosed with what endocrine disorder at age 21?
18. After successful treatment for Graves disease, this professional golfer captained the United States team to the 1999 Ryder...
19. Vocalist Rod Stewart has had surgery for what endocrine disorder?
20. Ron Santo won six Golden Glove Awards and played in nine All Star games while playing third base for the Chicago Cubs. He was...
21. Name the 3-foot, 7-inch, 65-pound midget who batted one time for the St. Louis Browns on August 19, 1951...
22. Gheorghe Muresan of the Washington Bullets is the tallest player in the history of the NBA (7 feet, 7 inches). What treatments...
23. In his 6-year NBA career (Washington Bullets 1993-1997
New Jersey Nets 1998-2000), Muresan twice led the...
24. Regardless of their acting ability, it seems like every famous giant gets an acting role in a movie. Gheorghe Muresan starred...
25. The late actor Rondo ``The Creeper´´ Hatton had severe acromegalic facial features. He played the villain in...
26. Nicole Johnson was 24 years old when she was crowned Miss America 1999. At age 19, she was diagnosed with what endocrine...
27. Name the former chief justice of the U.S. Supreme Court who died of anaplastic thyroid cancer at age 80
28. Grammy award-winning vocalists Johnny Cash (1932-2003), Ella Fitzgerald (1917-1996), Waylon Jennings...
29. Track star Carl Lewis competed in five consecutive Olympics. He is one of only three athletes who have won nine gold medals...
30. Name the American swimmer who was diagnosed with type 1 diabetes 18 months before he won two gold medals at the 2000 Olympics...
31. Carla Overbeck, women's soccer star and captain of the 1996 U.S. gold medal Olympic team, was diagnosed with what endocrine...
32. Based on a true story, the film Lorenzo's Oil (1992) portrays a family's struggle with what rare adrenal disorder?
33. Despite his type 1 diabetes, this former National Hockey League star led the Philadelphia Flyers to back-to-back...
34. The demanding ironman Triathlon requires a 2.4-mile swim followed by a 112-mile bike ride and a 26.2-mile...
Bibliography
Chapter 63: Interesting Endocrine Facts and Figures
1. Who is the tallest man on record?
2. Name the tallest woman on record.
3. How tall was the shortest man on record?
4. Who is the shortest woman on record?
5. Who had the most variable adult stature?
6. Which is the tallest tribe in Africa?
7. Which is the shortest tribe?
8. Who was the heaviest man on record?
9. How much did the heaviest woman on record weigh?
10. What is the greatest rate of weight gain ever recorded?
11. What is the largest recorded waist size?
12. Who are the heaviest twins on record?
13. What is the longest anyone has ever survived without food or water?
14. What is the greatest known number of children born to one woman in a lifetime?
15. Who is the oldest known woman to give birth?
16. What is the highest reported number of multiple births for a single gestation?
17. What is the highest single birth weight ever recorded?
18. What is the oldest age to which a human has been documented to live?
19. What is the highest blood glucose level ever reported?
20. What is the record for most kidney stones produced by one individual?
21. What is the largest tumor ever reported?
22. What is the longest hair ever recorded?
23. What is the record distance walked by an individual in 24 hours?
24. Did King David of Israel have an endocrine disorder?
25. What endocrine disorder might Goliath of Gath have had?
26. What endocrine disorder did President John F. Kennedy have?
Bibliography
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