General Internal Medicine&nbsp;&nbsp;&nbsp;

Would the diagnostic yield for ABIs or peripheral arterial duplex doppler in a patient with metal rods in both legs be similar or acceptable in comparison to those tests in a patient without metal rods?

How should clinicians balance the use of finerenone with other heart failure treatments like SGLT2 inhibitors, considering their glycemic benefits?

Butt et al., PMID 39818225

Do you recommend the use of albumin-adjusted calcium measurement formulas to accurately assess calcium levels?

Desgagnés et al., PMID 39836424

Besides treadmill, what other exercises may be considered for post-exercise ABIs, and are their diagnostic parameters identical to standard post-exercise ABIs?

What is the optimal management of pain and loss of function due to pathologic compression fractures?

Assume no epidural/cord compromise. Is kypho/vertebroplasty, radiation therapy, or conservative management (brace, antiresorptive therapy) the superio...

What treatment options would you consider for a young patient with limited mobility, low bone mass and multiple vertebral compression fractures who is on dialysis for advanced kidney disease?

Should GLP-1 agonists be held during chemotherapy?

Do you recommend combined baseline cortisol and DHEA-S testing to improve the efficiency and accuracy of adrenal insufficiency diagnosis?

Is there a role for cinacalcet suppression testing when evaluating patients for suspected primary hyperparathyroidism who also have recurrent calcium containing kidney stone disease?

Would you expect cinacalcet to lower calcium levels in a patient with Familial Hypocalciuric Hypercalcemia (FHH)?

If a patient who has Familial Hypocalciuric Hypercalcemia (FHH) is misdiagnosed as PHPT (Primary Hyperparathyroidism) and treated with Cinacalcet, wil...

What 24 hr urine calcium cut off value do you use for recommending parathyroidectomy in patients with asymptomatic hyperparathyroidism?

Changes in criteria for hyperparathyroid surgery. In the 2022 5th International conference on asymptomatic hyperparathyroidism, the experts have chang...

How do you approach a patient with biochemical evidence of primary hyperparathyroidism, but normal parathyroid scan?

5 Answers available

Do you have any specific recommendations to prevent large fluctuations in sodium levels during a colonoscopy prep in patients with central diabetes insipidus on DDAVP?

Would elevated bone mineral density/T-score be enough to make a diagnosis of osteopetrosis?

How many days prior to surgery do you recommend stopping SGLT2 inhibitors and when is it safe to resume therapy?

What is the likelihood of recovery of parathyroid gland function for patients who underwent total thyroidectomy, found to have embedded parathyroid glands intra-operatively and then subsequently had them re-implanted into neck muscle?

Do you interpret failure to develop hypernatremia with prolonged water deprivation (such as for 12 hours) as evidence against diabetes insipidus even if the urine osmolality is just below normal?

For a patient whose sodium remains 142 despite water deprivation from 8 pm to 8 am, with urine osm of about 500, is further testing needed?

Is there a role for use of GLP1 R agonist or dual agonist therapy for management of post bariatric hypoglycemia and dumping syndrome?

Do patients with central adrenal insufficiency on maintenance hydrocortisone therapy require doubling of their corticosteroid during chemotherapy cycles?

How do you medically manage uncontrolled Graves' disease in a patient awaiting surgery who is intolerant to methimazole and PTU and refusing RAI?

Patient had intolerance to methimazole and then developed agranulocytosis with PTU. FT4 is 2.9 (upper normal range is 1.7). I have started the patient...

What clinical sign or symptom do you consider to be the most specific for Cushing syndrome?

How do you interpret the presence of GAD antibody in a middle-aged patient with diabetes when all other type 1 diabetes antibodies are absent?

What is the utility of checking reverse T3 in clinical practice?

Can you explain the block and replace approach in the treatment of thyrotoxicosis, including when it is most appropriate to use and how it compares to other treatment options?

What is the clinical significance of positive anti-thyroid antibodies in a patient that is post-thyroidectomy?

Would you consider treating empirically for AVP deficiency in a patient who had pituitary surgery 6 months earlier and complaints of polyuria/polydipsia with dilute urine (without performing water deprivation studies)?

When should metformin be stopped before surgery and when is it considered safe to resume?

Do you recommend parathyroid adenoma resection or ablation for patients with primary hyperparathyroidism and recurrent nephrolithiasis who are found to have a single gland adenoma on parathyroid ultrasound and nuclear medicine imaging?

For patients with central hypothyroidism and a clear etiology (such as recent head irradiation), do you recommend brain imaging prior to starting thyroid hormone replacement therapy?

In your practice, when do you opt to treat unilateral primary hyperaldosteronism medically rather than surgically?

Do progesterone only oral contraceptive pills affect cortisol binding globulin?

What 60 minute cortisol threshold value do you use for diagnosis of adrenal insufficiency after ACTH stimulation?

Zha et al., PMID 35487459

5 Answers available

Which fracture sites outside of the classical spine and hip are considered to be osteoporotic fractures even in the absence of a bone density diagnosis?

In obese men presenting with gynecomastia, elevated estrogens, and hypogonadism, what clinical factors would push you to obtain testicular and/or adrenal imaging to rule out an estrogen-producing tumor?

Do you base the decision off of the acuity and course of symptoms? The degree of estradiol elevation? Other factors?

Do you recommend parathyroid imaging testing for patients with recurrent nephrolithiasis who are incidentally found to have an elevated PTH but who do not have hypercalciuria, hypercalcemia, hypovitaminosis D, or chronic kidney disease?

Would you add cholecalciferol or ergocalciferol to calcitriol therapy in patients with post operative hypoparathyroidism who have low 25 OH vitamin D levels?

Can 25 OH vitamin D be converted to activated vitamin D outside of PTH mediated mechanisms in some organs?

What is your approach to progressive calvarial hyperostosis found in an elderly adult not caused by Pagets, acromegaly or hypercalcemia?

No evidence for acromegaly or Pagets.

Given the risk of hypocalcemia in dialysis dependent patients treated with denosumab, what is the best method of treatment for osteoporosis for these patients, and should we be transitioning to a different agent?

What is your approach to managing patients with new laboratory evidence of hypopituitarism (e.g. very low plasma ACTH level and low morning serum cortisol) and a remote history of trans-sphenoidal surgery for NFPA?

Should GLP1 R agonists be used as first line glucose lowering agents in patients with ESKD and DM2?

In patients presenting with classical findings of primary hyperparathyroidism (i.e mild hypercalcemia, high 24hr urine calcium, elevated 1,25 Vit D but normal PTH), can spontaneous normalization of calcium be explained by episodic hypersecretion of PTH?

Does growth hormone (GH) replacement therapy reduce the risk of fractures in patients with GH deficiency?

What are the clinical indications and major limitations of lipoprotein apheresis?

Does biotin interfere with the measurement of other metabolites of the Vitamin D pathway outside of the 25-hydroxy Vitamin D assay?

What is the utility of an oral calcium loading test to differentiate FHH from secondary hyperparathyroidism due to low calcium intake?

The patient has very low urinary calcium despite calcium supplements, vitamin D used to be low now normal. Continues to have elevated PTH with normal ...

What specific markers or symptoms guide your decision to adjust or stop prophylactic calcium supplementation and calcitriol in managing postoperative hypoparathyroidism following thyroidectomy?

Would you consider exploratory surgery in a young patient with normocalcemic hyperparathyroidism that meets one or more criteria for parathyroidectomy but has no localized pathology on advanced neck imaging?

In what clinical scenarios should we use the 2-day 2mg DST instead of the 1mg overnight DST for screening of Cushing syndrome?

Is ABI (Ankle Brachial index) lower limb arterial doppler not recommended if patient already has arterial stents in the legs, and if so, what other imaging modality would you consider as first-line?

What is your approach to differentiating primary from secondary hyperparathyroidism in recurrent kidney stone formers who also have chronic kidney disease, an elevated PTH, and hypercalcemia?

Do you routinely check a TSH level in patients with recurrent kidney stones who have hypercalciuria of unknown cause?

What is your approach to managing osteoporosis in patients with end stage kidney disease?

In SIADH due to malignancy, do you prefer to use free water restriction or salt tablets?

Or other therapy - e.g., tolvaptan? Free water restriction may hinder QOL. Salt tablets may raise levels more quickly but have risks of edema and hype...

When do you check macroprolactin in the evaluation of hyperprolactinemia?

Should patients who develop primary hyperparathyroidism after 5 years of Prolia treatment for osteoporosis be referred for parathyroidectomy?

If so, when? Does surgery need to be timed with last dose of Prolia injection?

How do you distinguish between primary and tertiary hyperparathyroidism in a patient with ESRD?

Can romosozumab be used in patients on dialysis?

What is the next step in management of a thyroid nodule that was biopsied and classified as Bethesda III, but Afirma genetic testing reveals parathyroid signature?

Patient does not have hypercalcemia.

Do patients with an elevated IGF-1 level and features of acromegaly need to have confirmatory growth hormone suppression testing with OGTT?

Can a diagnosis of acromegaly be made with just an elevated IGF-1 level in patients with features of acromegaly?

What is your approach to a patient with a low alkaline phosphatase?

What level or additional signs/symptoms trigger a workup? What does your workup typically consist of?

5 Answers available

Is history of radiation an absolute contraindication to using parathyroid hormone (PTH) analogues?

Does it depend on location of radiation, length of radiation, and time since radiation?

Should oral combined contraceptives be held prior to overnight dexamethasone suppression test to rule out Cushings?

If so, how long should OCPs be held to reliably trust the dex suppression test results?

Can combined oral contraceptive use cause falsely elevated 24-hour urine-free cortisol?

In patients with secondary osteoporosis due to primary hyperparathyroidism, should parathyroidectomy be recommended in the setting of recent prior bisphosphonate use?

Is it possible to have undetectable cortisol levels in secondary adrenal insufficiency?

Young, previously healthy male with normal growth presenting with two syncopal episodes. Currently, only symptom is mild fatigue. Labs showed: Cortiso...

What is your approach to using bisphosphonates in those with severe hypercalcemia and chronic kidney disease?

How often would you repeat testing in a patient suspected of Cyclic Cushing's?

And is there a preferred diagnostic test? Whenever cyclic hypercortisolemia is suspected, it is advised that evaluation should be repeated for months,...

Do you recommend continuing SGLT2 inhibitors in patients with diabetic kidney disease and congestive heart failure who have been taking the medication for several years and later develop end stage kidney disease?

Can joint replacement surgery be performed in someone with active Paget’s disease elsewhere?

What further work-up (if any) should be considered in patients with pituitary microadenoma and stigmata of Cushing's disease but low ACTH and repeatedly normal plasma, urinary, and salivary cortisol levels?

What is the differential for elevated T3 (with suppressed T4 and normal TSH) in a patient not taking any thyroid hormones?

Female is in her later 40s with surgical oophorectomy taking Sertraline 50 mg daily and prn Trazodone and Lamotrigine. Has some weight loss and fatigu...

Is there an indication for adrenalectomy in patients with subclinical Cushing syndrome and adrenal nodule?

How do you counsel cancer patients when they ask if they should avoid sugar?

9 Answers available

Are there instances when you would recommend against pursuing adrenal vein sampling in a patient with primary hyperaldosteronism and normal adrenal imaging?

Which medications do you deem necessary to stop prior to measuring plasma renin and plasma aldosterone when evaluating a patient for possible primary aldosteronism?

What is your preferred method for confirming the diagnosis of primary aldosteronism in a patient with an elevated plasma aldosterone to renin ratio?

Is a significant rise in cortisol post cosyntropin stimulation sufficient to rule out adrenal insufficiency in patients with low albumin?

Does your goal rate of correction in patients with chronic hypoosmolar hyponatremia differ based on the degree of hypoosmolarity?

4 Answers available

Are there any concerns regarding side effects in changing from denosumab to zolendronic acid or vice versa?

In a patient with bisphosphonate induced bilateral atypical femur fractures, how would you approach timing of alternative osteoporosis treatments and surgical management?

Do you initiate management of new onset diabetes in a patient on immunotherapy or refer immediately to endocrinology given the risk of rapid worsening?

Do you treat secondary erythrocytosis caused by SGLT2 inhibitor?

In a patient with inflammatory orbital disease without a discrete mass to biopsy and recent bisphosphonate use, how much additional workup would you do if basic labs, urine studies, ANCA serologies, thyroid studies, chest imaging (to r/out sarcoid) are normal, before concluding that the process is likely secondary to bisphosphonate use?

Without a discrete mass to biopsy, is there any utility of any blind biopsies to rule out IgG4 related disease, infectious or neoplastic process?

How do you diagnose and treat patients who develop uveitis while on bisphosphonate therapy for osteoporosis?

Are there specific features that suggest drug-induced uveitis versus de novo uveitis?

How do you approach peri-operative management of anti-resorptive therapies such as denosumab in patients undergoing joint replacement?

Does denosumab effect knee replacement or hip replacement? Should replacement occur right before or after injection?

Are stress-dose steroids indicated in patients with adrenal insufficiency receiving radiation therapy?