Chat transcript: Endocrine pathology

[Lorena]

20:00:17 Lorena enters this room

20:00:18 >[Lorena] Welcome to our chat. Please obey the net etiquette while chatting: try to be pleasant and polite.

20:00:54 hutals enters this room

20:01:01 [hutals] hey lor

20:01:09 [Lorena] hi hutals!

20:01:33 [hutals] how are you?

20:01:48 [Lorena] ok and you?

20:03:08 [hutals] doing ok, thanks. i'm just listening to the last minutes of one of goljans lectures. so i'll be here waiting for others, but i'll be studying at the same time if thats ok....just for the next 10 mins

20:03:26 [Lorena] ok

20:04:28 123456 enters this room

20:04:52 jwls29 enters this room

20:05:10 [123456] Hi,

20:05:13 [jwls29] hi all

20:05:13 [hutals] hey jwls and 123456

20:05:24 [Lorena] hi

20:05:59 [123456] Does anyone know how ot open the 5000 USMLE q's that we can download from this website

20:06:26 [hutals] you will need winzip for that

20:06:48 [123456] I tried by it is missing some files.

20:06:56 [hutals] winzip can be downloaded for free from winzip website

20:07:08 [123456] unale to install even though I can download

20:07:48 [hutals] it needs to be extracted correctly using winzip....do you have that program?

20:08:19 [123456] Yes I do. Please explain what you mean by extracted correctly

20:09:30 ninadnashua enters this room

20:09:44 [ninadnashua] hi all

20:10:11 [123456] hi

20:10:12 [hutals] its a tricky program in that it doesn't open automatically. from the winzip menu, you will see all the files from the 5000 question program. i cant remember the name of the file, but i think it is called setup.exe or something like that. that is the file that you need to right click and select

20:10:13 [Lorena] hi ninad

20:10:48 [hutals] open or extract or something. then it will do the rest for you. its been a while since i messed with that file. sorry i dont remember exactly how i did it

20:11:01 [hutals] hey nina

20:11:02 [ninadnashua] hi

20:11:23 [Lorena] are those questions good hutals, if you remember?

20:11:51 [123456] thx

20:12:40 [hutals] it is very basic short questions. doesnt mimic real exam, only the basic definitions and stuff like that. good for a review or for the beginning of studying, but probably not too good at this point

20:12:54 [Lorena] ok, thanks

20:13:59 [hutals] no prob. 1234, let me know if you still have problems and i'll download it again to see if i can figure it out. send me a PM if you have problems

20:14:43 [hutals] everyone ready to start on endocrine?

20:15:12 shamim enters this room

20:15:25 [hutals] hey shamim

20:15:26 [Lorena] yes

20:16:02 [hutals] what drug can be used to supress prolactinomas?

20:16:23 [Lorena] bromocriptine

20:16:32 [ninadnashua] bromocriptine

20:16:48 [jwls29] agree

20:16:58 [hutals] yep, bromocriptine is a dopa analogue....very good.

20:17:12 [hutals] what about supression of pituitary cushings?

20:17:36 [shamim] hi

20:17:57 [Lorena] high dose dexametasone

20:17:58 [ninadnashua] high dose of dexamethasone

20:18:24 [hutals] the high dose dexamethosone will supress pit cushings.....both right

20:18:25 [Lorena] hi shamim

20:18:40 [shamim] hi

20:18:57 [hutals] how to differentiate between central and nephrogenic diabetes insipidous?

20:19:18 [jwls29] give ADH

20:19:43 [jwls29] if Uosm increases >50% then it's central

20:19:52 [Lorena] give vasopressin ...if urine osmolality increases more then 50% is central

20:20:05 [jwls29] if Uosm increases <50% it's nephrogenic

20:20:08 [shamim] right

20:20:13 [ninadnashua] agree

20:20:28 [Lorena] yes

20:21:02 [hutals] exactly...very good. because the central has decreased ADH being release while the nephro has decreased receptors, so the latter doesnt matter if given adh

20:22:05 [Lorena] A 19-year-old had a mild pharyngitis, fever extensive areas of purpura. T 39.5 C, P 102/minute, RR 21/minute, and BP 80/55 mm Hg. serum sodium of 115 mmol/L, potassium 5.3 mmol/L, chloride 92 mmol/L, CO2 22 mmol/L, glucose 42 mg/dL, and creatinine 1.1 mg/dL.

20:23:02 [Lorena] diagnosis? A Idiopathic adrenalitis B Disseminated tuberculosis C Reactive systemic amyloidosis

20:23:11 [Lorena] D Sheehan syndrome

20:23:21 [Lorena] E Meningococcemia

20:23:31 [Lorena] or F Hemochromatosis

20:24:01 [jwls29] e

20:24:28 [hutals] D

20:24:34 [Lorena] and why?

20:24:34 [shamim] meningococemia

20:26:35 [Lorena] (E) CORRECT. This is acute adrenal insufficiency marked by hyponatremia, hyperkalemia, and hypoglycemia. Infection with Neisseria meningitidis can produce the Waterhouse-Friderischsen syndrome.

20:27:59 [hutals] interesting ....good question

20:28:26 [Lorena] very good jwls, shamim....i guess waterhouse friederisch syndrome is like sheehan syndrome but in adrenals....kind a...

20:29:12 [shamim] thx

20:29:33 [hutals] in hindsight, i can see that it is clearly waterhouse friederisch....good explanation

20:30:19 [Lorena] thanks, i just copied from a test i took because i thought it was interessting

20:30:32 vel enters this room

20:31:24 [hutals] 20 yo female pt has increased serum T4, normal TSH and I 131....what is possible cause of elevated T4?

20:31:34 [hutals] hey vel

20:31:50 [Lorena] hi wel

20:31:57 [Lorena] i menat vel

20:32:03 [vel] hi all

20:32:27 [jwls29] birth control pills (estrogen)

20:32:33 [Lorena] i dont remmeber normal values of I

20:33:00 [Lorena] is it elevated or decreased in this case?

20:33:33 [hutals] in this case it is normal. another hint is that she has no symptoms of hyper or hypo thyroid

20:33:57 [Lorena] agree with jwls

20:34:18 [Lorena] or maybe she is pregnant

20:35:19 [hutals] yep, anything that increases estrogen levels (bcps, pregnancy, ect) can cause an inc in synthesis of TBG which will increase the bound and total T4.....but it will not affect the free T4 so no symptoms

20:35:38 [hutals] very good

20:36:41 [shamim] yes/goodlor and jwl

20:37:10 [hutals] at the same time, androgens will decrease the total and bound T4 in the same way while leaving everything else normal

20:37:32 [hutals] sorry, not "at the same time"....i meant in the same way

20:37:54 [Lorena] exogenous intake of thyroid hormones, how would T4, TSH would be? how to differentiate from primary hyperthyroidism?

20:40:12 [hutals] I131 would be decreased in exogenous intake and and increased in hyperthyroid

20:40:35 [hutals] the rest would be the same which is an increased T4 and decreased TSH

20:40:51 [Lorena] very good hutals

20:41:00 [Lorena] can you explain why?

20:42:20 [hutals] uptake will decrease if you dont have hypertrophy of gland

20:43:30 [hutals] is that right?

20:43:49 [Lorena] yes, in exogenous intake , the gland doesnt produce T4 and atrophy will result so decreased uptake cauze less tissue

20:44:13 [hutals] thanks

20:44:31 [Lorena] in contrast in primary hyperthyroidism , the gland is overactive so uptakle is increased

20:44:57 [hutals] what is the mech involved in graves? (receptor, antibody, etc)

20:45:51 [Lorena] type II hypersensivity -ab against TSH receptor -overstimulation

20:45:54 [jwls29] autoantibody against the TSH receptor. It is a type II hypersensitivity

20:46:44 [hutals] graves is due to an autoantibody against the TSH receptor. This is a type 2 hypersensitivity reaction because antibodies involved.....very good jwls

20:46:52 [hutals] and lorena

20:47:23 [hutals] what are the signs and symptoms?

20:48:14 [Lorena] tachycardia, tremur, exophtalmos, insomnia, GI disturbances

20:48:17 [jwls29] pretibial myxedema,exophtalmos, diarrhea, anxiety,weight loss,heat intolerance, hypercalcemia

20:48:36 [Lorena] intolerance to heat

20:48:43 [shamim] infiltrative opthalmopathy plus exophthalmos

20:49:05 [hutals] tachycardia, anxiety, HTN, weight loss, heat intol, diarrhea, decr cholesterol, muscle weakness.....excellent lor, shamim, jwls

20:50:03 [hutals] what is the most common throid cancer?

20:50:34 [jwls29] papillary

20:50:38 [Lorena] papillary ?

20:50:46 [shamim] papillary adeno

20:51:13 [hutals] papillary adenocarcinoma is the most common thyroid cancer in adults and children. follicular adenoma would be MC benign.....very good

20:51:55 [Lorena] which thyroid cancer is associated with MEN II?

20:52:12 [shamim] medullary

20:52:15 [jwls29] medullary

20:52:22 [hutals] medullary carcinoma

20:52:25 [Lorena] yep, good!

20:52:32 [ninadnashua] ya

20:53:13 [hutals] what is the most common cause of hypoparathyroidism?

20:53:14 [shamim] what is plummer disease

20:53:50 [ninadnashua] toxic nodular goitre

20:54:12 [shamim] thyroid surgry

20:54:31 [Lorena] agree with shamim

20:55:09 [hutals] Hyperthyroidism with a nodular goitre due to Plummer’s adenoma. Prevalent in females; onset after 40 years of age.

20:55:35 [hutals] yep, throid surgery is MCC

20:55:36 [shamim] right hutal

20:55:53 [Lorena] ok

20:58:32 [hutals] which of following expected in diabetic ketoacidosis? A. activation of capillary lipoprotein lipase B. Inc Beta ox of Fatty acids, C. dec production of acetyl CoA D. inc fatty acid synthesis E. inhibition of homone sensitive lipase

21:00:44 [Lorena] b

21:01:00 [shamim] b

21:01:11 [jwls29] agree

21:01:15 [hutals] B inc beta oxidation of fatty acids is correct. choice A occurs in presence of insulin and inhibited in DKA, C occurs when insulin is present; acetyl CoA should be increased in DKA due to inc beta ox of fatty acids; D occurs when insulin is present; it is inhibited in DKA, E occurs when

21:01:33 [ninadnashua] b

21:01:37 [hutals] insulin is present; it is activated in DKA due to glucagon and catecholamines

21:01:49 [hutals] great job everyone

21:02:17 123456 enters this room

21:02:34 [Lorena] thats was a good one

21:03:15 [hutals] newborn with tetany, heart failure and absent thymic shadow. what failed to develop?

21:04:05 [jwls29] 3d and 4th pharyngeal pouches

21:04:17 [Lorena] agree

21:04:25 [ninadnashua] di george

21:04:29 [shamim] may be di george

21:04:47 [hutals] this is digeorges syndrome caused be failure of 3rd and 4th pharyngeal pouches to develop.....excellent!

21:05:55 [hutals] what is the most common cause of cushings syndrome?

21:06:45 [Lorena] pituitary adenoma?

21:07:00 [jwls29] long term steroid use

21:07:01 [ninadnashua] long term glucocorticoid therapy

21:07:05 [shamim] long term gluco cort therapy

21:07:23 [hutals] the most common cause of cushings syndrome is long term glucocorticoid therapy.....that got me by surprise because it means that many cases can be avoided.

21:07:42 [Lorena] ok thanx

21:08:02 [hutals] adenomas can also cause, but not as common as GCs

21:09:03 [hutals] which part of adrenal glad produces aldosterone? what about glucocorticoids? what about sex hormones?

21:10:05 [Lorena] granulosa mineralocorticoids; fasciculata glucocorticoids and Reticulata sex hormones

21:10:23 [jwls29] agree

21:10:40 [ninadnashua] zonq glomerulosa produces aldosterone, fasciculata gluco reticularis sex hormones

21:11:02 [hutals] zona glomerulosa = aldosterone, fasciculata = GC, reticularis = sex hormones....very good

21:12:09 [Lorena] which one is the only zona that would continue normal secretion even with hypopituitarism?

21:12:11 [hutals] what about epi and norepi....where?

21:12:32 [ninadnashua] adrenal medulla

21:12:40 [jwls29] epi and norepi in the medulla

21:12:45 [Lorena] medulla

21:13:37 [hutals] yep, medulla for epi and norepi......neural crest origin

21:14:10 [hutals] i think its glomerulosa??

21:14:21 [jwls29] i agree with hutals

21:14:25 [Lorena] yes

21:14:44 [Lorena] because it is regulated mostly by angiotensin II and not ACTH

21:16:24 [Lorena] very good

21:16:46 [Lorena] 55-year-old woman has had a 12 kg weight loss over the past 3 months., decreased mentation over the past 10 days. On physical examination she is afebrile and hypotensive. Bilateral papilledema . A head CT scan shows diffuse cerebral edema with effacement of the lateral ventricles. Sodium of 108 mmo

21:17:08 [Lorena] potassium 4.0 mmol/L, chloride 83 mmol/L, CO2 14 mmol/L, glucose 82 mg/dL, and creatinine 0.5 mg/dL. Which of the following is most likely to cause these findings?

21:17:53 [Lorena] Oat cell carcinoma of the lung , B)B Blunt head trauma

21:18:02 [Lorena] C Hypothalamic glioma

21:18:09 [Lorena] D Meningitis

21:18:46 [Lorena] or E) Pituitary adenoma ?

21:20:20 [hutals] pit adenoma would probably show up on CT, so i guess that is not it. i would guess either A or B....probably A because of the weight loss

21:21:00 [Lorena] very good hutals ....it is A

21:21:15 [jwls29] i think the answer is A

21:21:29 [hutals] sorry for thinking out loud....helps me narrow down the choices

21:21:43 [Lorena] (A) CORRECT. This is the most frequent cause for the syndrome of inappropriate ADH (SIADH). Paraneoplastic syndromes are often seen with oat cell carcinomas

21:21:53 [Lorena] very good guys!!!

21:21:53 [jwls29] I think she has Ca of the lung causing SIADH hence the hyponatremia

21:22:10 [Lorena] very good thinking hutals and jwls

21:22:47 [hutals] pt in upper 20s presents with HTN, palpitations, sweating, anxiety, headaches.....sounds like me when thinking about the upcoming exam . what lab should be done?

21:23:34 [jwls29] metanephrines and VMA in 24 hour urine

21:23:39 [Lorena] metabolites of cathecolamines in urine? acid mandelovalonic or something like that

21:23:44 [Lorena] lol

21:24:19 [ninadnashua] YA

21:25:17 [hutals] yep, looking for pheochromocytoma so 24 hr urine for VMA and metaphrines....very good

21:25:55 [hutals] the catecholamines demonstrated in plasma are derived from what amino acid?

21:26:08 [Lorena] why patients with pheocromocytoma have hyperglycemia ?

21:26:36 [Lorena] tyrosine?

21:26:59 [jwls29] agree with lornea

21:27:08 [jwls29] lol, i changed your name

21:27:12 [jwls29] lorena

21:27:14 [hutals] derived from tyrosine....very good

21:27:19 [ninadnashua] BECAUSE OF GLYCOGENOLYSIS AND GLUCONEOGENESIS

21:27:40 [Lorena] no prob

21:27:49 [hutals] agree with nina....the cats will increase these pathways

21:28:32 [Lorena] yes, very good, cathecolamines are stress hormones so stimulate these pathways

21:28:41 [hutals] what percent are malignant? how can you tell if malignant (trick question)?

21:28:41 [ninadnashua] thanks

21:29:08 [Lorena] 10% are malignant

21:30:23 [Lorena] but i dont know how you can tell if malignant...metastasis ?

21:30:40 [hutals] rule of 10's....10% malignant, 10% bilat, 10% extra adrenal, 10% calcify, 10% in kids, 10% familial. the only way to tell if malignant is by distant metastasis....this was a q bank question....very good lor

21:31:11 [Lorena] thanz

21:31:25 [Lorena] i mean thanx hutals

21:31:50 smb enters this room

21:32:19 [Lorena] hi smb

21:32:45 [smb] hi

21:32:51 [hutals] now this one was a previous real question. described pheochromocytoma pt like above. asked what to treat for HTN crisis. all drugs listed were B blockers>?

21:32:55 [hutals] hey smb

21:33:02 [smb] what ru disscussing

21:33:33 [hutals] we're discussing endocrine path from golijan

21:33:50 [smb] ok

21:34:21 [Lorena] a non selective maybe ? like propranolol?

21:34:51 [ninadnashua] +phentolamine

21:35:17 [hutals] propranonlol is contraindicated because only blocks beta

21:35:39 [hutals] phentolamine would be good, but alpha blockers were not an option

21:35:49 [ninadnashua] ok

21:35:50 [Lorena] but you said only B blockers were listened

21:36:54 [hutals] this was a good question because we all know that beta blockers are contraindicated in pheochromocytoma pts.....but the reason is because most beta blockers only block betas....except for 2 that we need to know....one of which is lebetolol. this drug blocks alpha and beta...but is in the beta

21:36:59 [hutals] blocker class

21:37:29 [Lorena] good one

21:37:57 [hutals] that was a real one given to us by step 1 a while back, so i wrote it down

21:38:39 [Lorena] thank you

21:38:48 [hutals] no prob

21:39:04 [Lorena] what is the other one?

21:39:32 [hutals] i cant remember off the top of my head, let me look it up real quick

21:39:57 [Lorena] i would apreciate so i can write it down

21:41:07 [hutals] carvediol

21:41:26 [hutals] a good heads up for next weeks pharm chats

21:41:29 [Lorena] thank you hutals

21:41:50 [hutals] you're welcome

21:41:56 [Lorena]

21:43:09 [Lorena] A 58-year-old man with a history of diabetes mellitus with bone pain, especially of his hands, for the past 6 months. There is no swelling or redness of his hands, and the range of motion is slightly decreased, but there is no joint deformity. Laboratory studies show sodium 139 mmol/L, potassium 4.

21:43:12 [hutals] pt presents with hypoglycemia and increased serum insulin. labs show decrease c-peptide. explain mech?

21:43:53 [Lorena] exogenous insulin

21:44:41 [jwls29] agree

21:44:52 bujjodu enters this room

21:45:03 [Lorena] , chloride 98 mmol/L, C02 22 mmol/L, glucose 153 mg/dL, creatinine 7.8 mg/dL, calcium 7.8 mg/dL (low), phosphorus 5.7 mg/dL, total protein 6.2 g/dL, and albumin 4.0 g/dL

21:45:20 [hutals] yep, exogenous insulin which will give a decreased c-peptide because of supression of endogenous insulin from the hypoglycemia. i think that the real question described a nurse as the patient (has access to insulin)

21:45:30 [hutals] good job lor and jwls

21:45:40 [Lorena] most likely to have? A Adrenal adenoma

21:45:49 [Lorena] B Medullary thyroid carcinoma

21:45:59 [Lorena] C Extra-adrenal pheochromocytoma

21:46:10 [Lorena] D Parathyroid hyperplasia

21:46:27 [Lorena] or E Pituitary adenoma ??

21:47:53 [bujjodu] ??? not getting

21:48:34 [bujjodu] answer?

21:48:39 [hutals] let me see, high calcium, high phosphate, high creatinine....most everything else normal

21:49:04 [Lorena] calcium is low

21:49:05 [smb] low ca

21:49:28 [hutals] oops....sorry, i meant low

21:49:45 [Lorena] no prob

21:50:25 [hutals] he has hypoparathyroidism....but why?

21:50:38 [Lorena] hints are the ones hutals said and also the problem in his hands, D.mellitus for long time

21:51:33 [hutals] medulary thyroid is just a guess??

21:51:35 [jwls29] i have to go guys

21:51:44 [jwls29] i'll see you guys tomorrow

21:51:50 [bujjodu] Pituitary adenoma

21:51:57 [bujjodu] answer?

21:52:00 [hutals] nite jwls

21:52:13 [Lorena] good nite jwls

21:52:14 [jwls29] nite

21:52:17 [Lorena] see you tomorrow

21:52:22 [Lorena] (D) CORRECT. He has secondary hyperparathyroidism from chronic renal failure. Retention of phosphorus drives the calcium down and parathormone secretion up, leading to osteitis fibrosa cystica

21:52:58 [Lorena] renal failure secondary to D mellitus

21:53:03 [bujjodu] nice question

21:53:09 [smb] what ru guys disscussing tomm

21:53:18 [bujjodu] thanx lorena

21:53:22 [bujjodu] good night

21:53:26 [bujjodu] bye to all

21:53:33 [Lorena] you're welcome

21:53:36 [hutals] the chronic renal failure makes sense from DM....i just couldnt figure out the link to the answer ...very good question

21:53:54 [hutals] every week nite at 8 pm eastern.

21:54:01 [Lorena] ok, guys sthese questions i brought today are from webpath

21:54:08 [Lorena] they are very good

21:54:08 [hutals] tomorrow is skin and CNS path by golijan

21:54:23 [smb] thks

21:54:24 [hutals] they are really great questions lor

21:54:36 [Lorena] whenever you have time do the tests, there are tests for each subject in pathology

21:55:05 [hutals] and its free

21:55:15 [Lorena] yes

21:56:01 [Lorena] i have to go now , we didnt discuss musculoskeletal

21:56:53 [hutals] i have to go too....your right ....maybe we can include that another day....not a very long chapter

21:57:00 [smb] bye all

21:57:23 [ninadnashua] bye

21:57:34 [Lorena] maybge we can get together on saturday and discuss what we didnt cover? yesterday we didnt talk about breast pathology

21:57:51 [ninadnashua] good

21:57:58 [Lorena] HIV we didnt either , respiratory and cardiovascular

21:58:06 [hutals] sounds good to me

21:58:20 [Lorena] excellent

21:58:22 [ninadnashua] even sunaday is better

21:58:34 [Lorena] see you tomorrow guys, thank you

21:58:43 [hutals] we can also throw it in right after pharm if you want

21:59:12 [hutals] nite all....thanks for another great chat. c ya all tomorrow

21:59:32 [ninadnashua] ok byeeeeeeee

21:59:53 [Lorena] bye ninad , see you tomorrow

22:00:05 [ninadnashua] bye lorena