Endo q - USMLE Forums
USMLE Forums Logo
USMLE Forums         Your Reliable USMLE Online Community     Members     Posts
Home
USMLE Articles
USMLE News
USMLE Polls
USMLE Books
USMLE Apps
Go Back   USMLE Forums > USMLE Step 2 CK Forum

USMLE Step 2 CK Forum USMLE Step 2 CK Discussion Forum: Let's talk about anything related to USMLE Step 2 CK exam


Reply
 
Thread Tools Search this Thread Display Modes
  #1  
Old 05-08-2016
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 656
Threads: 10
Thanked 300 Times in 254 Posts
Reputation: 310
Default Endo q

22 year old male diagnosed with diabetes presents to the primary care physician as he is concerned about his insulin therapy. He is on a basal-bolus insulin regimen, which he says he strictly adheres to. Over the last couple of weeks, he had noticed that his blood glucose level at 7 AM in the morning has been around 350-375 mg/dl. He checked his blood sugar early in the morning around 3 AM for the past two days which remained around 340-360 mg/dl. His previous blood glucose levels around the same time were about 135-155 mg/dl. Which of the following is the next step in the treatment of this patient?
1. Reassurance
2. Decrease exogenous insulin
3. Administer insulin via continous intravenous pump
4. Increase exogenous insulin
5. Oral metformin
Reply With Quote Quick reply to this message



  #2  
Old 05-08-2016
maymed's Avatar
USMLE Forums Addict
 
Steps History: 1 + CK
Posts: 100
Threads: 7
Thanked 60 Times in 36 Posts
Reputation: 70
Default

Quote:
Originally Posted by saxo View Post
22 year old male diagnosed with diabetes presents to the primary care physician as he is concerned about his insulin therapy. He is on a basal-bolus insulin regimen, which he says he strictly adheres to. Over the last couple of weeks, he had noticed that his blood glucose level at 7 AM in the morning has been around 350-375 mg/dl. He checked his blood sugar early in the morning around 3 AM for the past two days which remained around 340-360 mg/dl. His previous blood glucose levels around the same time were about 135-155 mg/dl. Which of the following is the next step in the treatment of this patient?
1. Reassurance
2. Decrease exogenous insulin
3. Administer insulin via continous intravenous pump
4. Increase exogenous insulin
5. Oral metformin
#5 and #2 are wrong, in my opinion.

#1 seems wrong ... his pervious levels were between 135-155.

my final answer is #4
. I would be too scared to give the continuous pump may cause hypoglycemia.

This is the dawn phenomenon?
__________________
You are capable of more than you know. Choose a goal that seems right for you and strive to be the best, however hard the path. Persist! the world needs all you can give.
Reply With Quote Quick reply to this message
  #3  
Old 05-08-2016
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 656
Threads: 10
Thanked 300 Times in 254 Posts
Reputation: 310
Default

Quote:
Originally Posted by maymed View Post
#5 and #2 are wrong, in my opinion.

#1 seems wrong ... his pervious levels were between 135-155.

my final answer is #4
. I would be too scared to give the continuous pump may cause hypoglycemia.

This is the dawn phenomenon?
Bingo!
Reply With Quote Quick reply to this message
 
  #4  
Old 05-08-2016
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 656
Threads: 10
Thanked 300 Times in 254 Posts
Reputation: 310
Default

Honeymoon or remission phase - seen in type I DM due to functional beta cells after Dx of DM. Decreased exogenous insulin needs and frequent episodes of hypoglycemia 2/2 endogenous insulin production. Reduce exogenous insulin till the patient develops frank DM (increasing blood glucose, A1C)

Dawn phenomenon - between 2 AM and 8 AM - 2/2 increased nocturnal GH secretion and hypoinsulinemia leading to nocturnal and morning hyperglycemia - increase exogenous insulin

Somyogi hypothesis - nocturnal hypoglycemia 2/2 hyperinsulinemia was thought to be responsible for rebound morning hyperglycemia - has been now discredited
Reply With Quote Quick reply to this message
The above post was thanked by:
maymed (05-08-2016)
  #5  
Old 05-08-2016
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 656
Threads: 10
Thanked 300 Times in 254 Posts
Reputation: 310
Default

34 year old female presents to the primary care physician with weakness of both arms, weight gain and anorexia. It had started around 3 months back but she had too busy with her work to visit the clinic. On further questions, she reports that her last menstrual period was 2 months back. She previously had regular 28 day cycles. Physical examination reveals obesity and increased supraclavicular/dorsocervical fat pads. Remainder of the systemic examination is within normal limits. Low dose dexamethason supression test confirms the diagnosis. Which of the following is the next best step in further evaluation of the patient?
1. 24 hour urine free cortisol excretion
2. High dose dexamethasone supression test
3. Brain MRI
4. Plasma ACTH level
5. Inferior petrosal venous sampling
6. CRH stimulation test
Reply With Quote Quick reply to this message
  #6  
Old 05-08-2016
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 656
Threads: 10
Thanked 300 Times in 254 Posts
Reputation: 310
Default Edit

34 year old female presents to the primary care physician with weakness of both arms, weight gain and anorexia. It had started around 3 months back but she had too busy with her work to visit the clinic. On further questions, she reports that her last menstrual period was 2 months back. She previously had regular 28 day cycles. Physical examination reveals obesity and increased supraclavicular/dorsocervical fat pads. Remainder of the systemic examination is within normal limits. Low dose dexamethasone supression test and late night salivary cortisol on 2 occasions confirms the diagnosis. Which of the following is the next best step in further evaluation of the patient?
1. 24 hour urine free cortisol excretion
2. High dose dexamethasone supression test
3. Brain MRI
4. Plasma ACTH level
5. Inferior petrosal venous sampling
6. CRH stimulation test
Reply With Quote Quick reply to this message
  #7  
Old 05-08-2016
maymed's Avatar
USMLE Forums Addict
 
Steps History: 1 + CK
Posts: 100
Threads: 7
Thanked 60 Times in 36 Posts
Reputation: 70
Default

Quote:
Originally Posted by saxo View Post
Bingo!
Yaaya!
__________________
You are capable of more than you know. Choose a goal that seems right for you and strive to be the best, however hard the path. Persist! the world needs all you can give.
Reply With Quote Quick reply to this message
  #8  
Old 05-08-2016
maymed's Avatar
USMLE Forums Addict
 
Steps History: 1 + CK
Posts: 100
Threads: 7
Thanked 60 Times in 36 Posts
Reputation: 70
Default

Quote:
Originally Posted by saxo View Post
34 year old female presents to the primary care physician with weakness of both arms, weight gain and anorexia. It had started around 3 months back but she had too busy with her work to visit the clinic. On further questions, she reports that her last menstrual period was 2 months back. She previously had regular 28 day cycles. Physical examination reveals obesity and increased supraclavicular/dorsocervical fat pads. Remainder of the systemic examination is within normal limits. Low dose dexamethasone supression test and late night salivary cortisol on 2 occasions confirms the diagnosis. Which of the following is the next best step in further evaluation of the patient?
1. 24 hour urine free cortisol excretion
2. High dose dexamethasone supression test
3. Brain MRI
4. Plasma ACTH level
5. Inferior petrosal venous sampling
6. CRH stimulation test
I don't know this one. If the low does suppression test confirms diagnosis that means its an adrenal tumor and the next best step would be to do an MRI of the abdomen looking for the tumor

uhmmm...
__________________
You are capable of more than you know. Choose a goal that seems right for you and strive to be the best, however hard the path. Persist! the world needs all you can give.
Reply With Quote Quick reply to this message
  #9  
Old 05-08-2016
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 656
Threads: 10
Thanked 300 Times in 254 Posts
Reputation: 310
Default

Quote:
Originally Posted by maymed View Post
I don't know this one. If the low does suppression test confirms diagnosis that means its an adrenal tumor and the next best step would be to do an MRI of the abdomen looking for the tumor

uhmmm...
Its 4. Plasma ACTH level.
Basically positive low dose dexamethasone test alone cannot be used in the diagnosis of cushing syndrome. Abnormal result on TWO of the following first line tests confirms the diagnosis of CS: 24 hour urine free cortisol, late night salivary cortisol and low dose DST (Dx of CS in this patient was made after both low dose DST and late night salivary cortisol. 2 abnormal tests are required to rule of physiologic hypercortisolism due to depression, pregnancy, etc)
Once the Dx is made first step is to do ACTH level
Reply With Quote Quick reply to this message
The above post was thanked by:
maymed (05-10-2016)
  #10  
Old 05-08-2016
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 656
Threads: 10
Thanked 300 Times in 254 Posts
Reputation: 310
Default Kaplan IM messed it on this topic btw

Cushing syndrome

Hypercortisolism - central or centripetal obesity, supraclavicular fat pads, buffalo hump or dorsocervical fat pad, moon facies, proximal muscle weakness, skin atrophy, purple striae, easy bruising, glucose intolerance, hypertension, hypokalemia, osteoporosis/osteonecrosis, psychosis/depression/behavioral abnormalities, acne, oligomenorrhea or amenorrhea, hirsutism

Dx of hypercortisolism/cushing syndrome - with high index of clinical suspicion (multiple signs and symptoms of CS) do two of the following initial/first-line tests : late night salivary cortisol (on 2 occasions), 24 hour urine free cortisol excretion(on 2 occasions), and low dose dexamethasone supression test (1mg)

The low-dose dexamethasone test should not be used as the sole criterion for the diagnosis of CS. At least one additional test should be done to establish or exclude the diagnosis. The diagnosis of CS is established when at least two different first-line tests are unequivocally abnormal and physiologic hypercortisolism has been excluded

Once the Dx of cushing syndrome is made, cause has to be established. Cushing syndrome can be ACTH-independent (high cortisol, low ACTH) 2/2 adrenal causes (adrenal adenoma, micronodular/macronodular adrenal hyperplasia and adrenal carcinoma) (OR) ACTH-dependent (high ACTH and high cortisol) 2/2 either pituitary corticotroph adenoma (Cushing's disease) or ectopic ACTH from small cell lung cancer. First step to evaluate the cause is to measure plasma ACTH level. ACTH level is measured ideally between 11 PM and midnight (can be done on the blood samples taken for late night cortisol or low dose dexamethasone supression tests) 1. Low ACTH (<5pg/ml) is consistent with ACTH-independent disease - thin section CT scan of adrenal glands is the next step in evaluation 2. Normal or high ACTH (>20pg/ml) is consistent with ACTH-dependent disease. Next step is to either do a pituitary MRI or high dose dexamethasone supression test + CRH stimulation test. If pituitary MRI reveals a mass >6 mm (then do high dose DST + CRH stimulation test) and there is supression with high dose dexamethasone + increased ACTH release with CRH stimulation, Dx of Cushing's disease is made. If pituitary MRI is inconclusive or reveals a lesion <6 mm or high dose dexamethasone test/CRH stimulation test are negative/mixed, inferior pertrosal sinus sampling is performed. Increased central to peripheral ACTH gradient in both inferior petrosal venous blood (drains pituitary gland) confirms the diagnosis of Cushing's disease while absence of central to peripheral ACTH gradient confirms the diagnosis of ectopic ACTH from small cell lung cancer 3. Intermediate ACTH level (5-20 pg/ml) is followed by CRH stimulation test. Increase in ACTH suggests Cushing's disease. Patients with ectopic ACTH tumors do not respond to CRH stimulation as pituitary ACTH secretion is supressed.
Reply With Quote Quick reply to this message
The above post was thanked by:
maymed (05-10-2016)
  #11  
Old 05-08-2016
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 656
Threads: 10
Thanked 300 Times in 254 Posts
Reputation: 310
Default

Attached file
Attached Thumbnails
Endo q-imported-file.pdf  
Reply With Quote Quick reply to this message
The above post was thanked by:
maymed (05-10-2016)
  #12  
Old 05-10-2016
maymed's Avatar
USMLE Forums Addict
 
Steps History: 1 + CK
Posts: 100
Threads: 7
Thanked 60 Times in 36 Posts
Reputation: 70
Default

Thanks saxo for the updated guidelines.

In FA for step 1, it says to do low does DST to differentiate between ATCH-dependent and ATCH-independent CS.

But now its we need two different abnormal tests (24hr urine free cortisol, late night salivary, and low dose DST), THEN you do measure ATCH levels to differentiate between ATCH-dependent and -independent causes!

But if you have only one abnormal test? does that happen? Then do we say it due to physiologic hypercortisolism ... and you don't proceed to measure ATCH?
__________________
You are capable of more than you know. Choose a goal that seems right for you and strive to be the best, however hard the path. Persist! the world needs all you can give.
Reply With Quote Quick reply to this message
  #13  
Old 05-10-2016
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 656
Threads: 10
Thanked 300 Times in 254 Posts
Reputation: 310
Default Source:uptodate

Quote:
Originally Posted by maymed View Post
Thanks saxo for the updated guidelines.

In FA for step 1, it says to do low does DST to differentiate between ATCH-dependent and ATCH-independent CS.

But now its we need two different abnormal tests (24hr urine free cortisol, late night salivary, and low dose DST), THEN you do measure ATCH levels to differentiate between ATCH-dependent and -independent causes!

But if you have only one abnormal test? does that happen? Then do we say it due to physiologic hypercortisolism ... and you don't proceed to measure ATCH?
2 abnormal different first line tests - Dx Cushing syndrome
2 Normal different first line tests - No CS/physiologic hypercortisolism
1 abnormal first line test - referral to an endocrinologist for additional/repeated evaluation (so probably they will not ask us this)
Reply With Quote Quick reply to this message
The above post was thanked by:
maymed (05-10-2016)
  #14  
Old 05-10-2016
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 656
Threads: 10
Thanked 300 Times in 254 Posts
Reputation: 310
Default

My endo notes..hope it will be helpful
Attached Thumbnails
Endo q-endocrinology.pdf  
Reply With Quote Quick reply to this message
The above post was thanked by:
maymed (05-11-2016)
  #15  
Old 05-11-2016
maymed's Avatar
USMLE Forums Addict
 
Steps History: 1 + CK
Posts: 100
Threads: 7
Thanked 60 Times in 36 Posts
Reputation: 70
Default

Quote:
Originally Posted by saxo View Post
My endo notes..hope it will be helpful
Thanks saxo, do you get these notes from uptodate or are they your own?
__________________
You are capable of more than you know. Choose a goal that seems right for you and strive to be the best, however hard the path. Persist! the world needs all you can give.
Reply With Quote Quick reply to this message



  #16  
Old 05-11-2016
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 656
Threads: 10
Thanked 300 Times in 254 Posts
Reputation: 310
Default

Quote:
Originally Posted by maymed View Post
Thanks saxo, do you get these notes from uptodate or are they your own?
Yes. I am basically typing the notes after reading kaplan and uptodate
Reply With Quote Quick reply to this message
  #17  
Old 05-11-2016
maymed's Avatar
USMLE Forums Addict
 
Steps History: 1 + CK
Posts: 100
Threads: 7
Thanked 60 Times in 36 Posts
Reputation: 70
Default

Quote:
Originally Posted by saxo View Post
Yes. I am basically typing the notes after reading kaplan and uptodate
Good for you! Your notes are awesome!
__________________
You are capable of more than you know. Choose a goal that seems right for you and strive to be the best, however hard the path. Persist! the world needs all you can give.
Reply With Quote Quick reply to this message
The above post was thanked by:
saxo (05-11-2016)
  #18  
Old 05-14-2016
USMLE Forums Scout
 
Steps History: Not yet
Posts: 45
Threads: 2
Thanked 21 Times in 18 Posts
Reputation: 31
Default

Thanks for the Notes Saxo .. Please share other as you finish them .. Greatly appreciated
Reply With Quote Quick reply to this message
  #19  
Old 05-14-2016
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 656
Threads: 10
Thanked 300 Times in 254 Posts
Reputation: 310
Default

Quote:
Originally Posted by compaq1 View Post
Thanks for the Notes Saxo .. Please share other as you finish them .. Greatly appreciated
No problem. I have attached my preventive medicine notes. I am having issues with my health and won't be spending the next 2 weeks preparing for the exam. Hopefully I will recover and get back to studying as quickly as possible.
Attached Thumbnails
Endo q-preventive-medicine.pdf  
Reply With Quote Quick reply to this message
The above post was thanked by:
maymed (05-15-2016)
  #20  
Old 05-15-2016
maymed's Avatar
USMLE Forums Addict
 
Steps History: 1 + CK
Posts: 100
Threads: 7
Thanked 60 Times in 36 Posts
Reputation: 70
Default

Quote:
Originally Posted by saxo View Post
No problem. I have attached my preventive medicine notes. I am having issues with my health and won't be spending the next 2 weeks preparing for the exam. Hopefully I will recover and get back to studying as quickly as possible.
I hope you feel better!
__________________
You are capable of more than you know. Choose a goal that seems right for you and strive to be the best, however hard the path. Persist! the world needs all you can give.
Reply With Quote Quick reply to this message
  #21  
Old 05-15-2016
USMLE Forums Scout
 
Steps History: Not yet
Posts: 45
Threads: 2
Thanked 21 Times in 18 Posts
Reputation: 31
Default

Hope you Feel better .
Reply With Quote Quick reply to this message
  #22  
Old 05-17-2016
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 656
Threads: 10
Thanked 300 Times in 254 Posts
Reputation: 310
Default

Thanks folks. I have recovered by God's grace, so thank God for that!
A wasted week, but health above everything else right. I have 2 months and I will make every day count. Good luck to you people as well
Reply With Quote Quick reply to this message
  #23  
Old 05-20-2016
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 656
Threads: 10
Thanked 300 Times in 254 Posts
Reputation: 310
Default

Rheum notes
Attached Thumbnails
Endo q-rheumatology.pdf   Endo q-rheumatology-2.pdf  
Reply With Quote Quick reply to this message
The above post was thanked by:
compaq1 (05-22-2016), maymed (05-22-2016)
  #24  
Old 05-25-2016
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 656
Threads: 10
Thanked 300 Times in 254 Posts
Reputation: 310
Default Cardiology

Much of it condensed from uptodate as I did not have enough time to prepare notes
Attached Thumbnails
Endo q-cardiology.pdf  
Reply With Quote Quick reply to this message
The above post was thanked by:
maymed (05-25-2016)
  #25  
Old 05-25-2016
maymed's Avatar
USMLE Forums Addict
 
Steps History: 1 + CK
Posts: 100
Threads: 7
Thanked 60 Times in 36 Posts
Reputation: 70
Default

Quote:
Originally Posted by saxo View Post
Much of it condensed from uptodate as I did not have enough time to prepare notes
but its still good! Thanks
__________________
You are capable of more than you know. Choose a goal that seems right for you and strive to be the best, however hard the path. Persist! the world needs all you can give.
Reply With Quote Quick reply to this message






Reply

Quick Reply
Message:
Options

Register Now

In order to be able to post messages on the USMLE Forums forums, you must first register.
Please enter your desired user name, your email address and other required details in the form below.
User Name:
Password
Please enter a password for your user account. Note that passwords are case-sensitive.
Password:
Confirm Password:
Email Address
Please enter a valid email address for yourself.
Email Address:
Medical School
Choose "---" if you don't want to tell. AMG for US & Canadian medical schools. IMG for all other medical schools.
USMLE Steps History
What steps finished! Example: 1+CK+CS+3 = Passed Step 1, Step 2 CK, Step 2 CS, and Step 3.

Choose "---" if you don't want to tell.

Favorite USMLE Books
What USMLE books you really think are useful. Leave blank if you don't want to tell.
Location
Where you live. Leave blank if you don't want to tell.

Log-in

Human Verification

In order to verify that you are a human and not a spam bot, please enter the answer into the following box below based on the instructions contained in the graphic.



Thread Tools Search this Thread
Search this Thread:

Advanced Search
Display Modes


Similar Threads
Thread Thread Starter Forum Replies Last Post
Endo-Neuro Question Dr.MonMon USMLE Step 1 Forum 14 06-15-2012 04:55 AM

RSS Feed
Find Us on Facebook
vBulletin Security provided by vBSecurity v2.2.2 (Pro) - vBulletin Mods & Addons Copyright © 2017 DragonByte Technologies Ltd.

USMLE® & other trade marks belong to their respective owners, read full disclaimer
USMLE Forums created under Creative Commons 3.0 License. (2009-2014)