Primary Aldosteronism (PA)
- Screen: Aldosterone-Renin Ratio (ARR > 30 with aldo > 15)
- Confirm: salt loading / saline infusion / fludrocortisone / captopril
- Localize: CT adrenal
- AVS: 想 surgery + imaging 不確定時做
第 10 考前重點觀念 (TL;DR)
糖尿病 (DM) 高頻考點
DM 藥物 CV/Renal Outcomes (高頻必考)
| 藥類 | CV outcome | HF | CKD | 體重 | Hypoglycemia | 代表 trial |
|---|---|---|---|---|---|---|
| GLP-1 RA | MACE ↓ | 中性 | albuminuria ↓ | ↓↓ | 無 (alone) | LEADER, SUSTAIN-6, REWIND |
| SGLT2i | MACE ↓ + HF ↓↓ + CV death ↓ | ↓↓ | ↓↓ (DAPA-CKD, EMPA-KIDNEY) | ↓ | 無 (alone) | EMPA-REG, CANVAS, DECLARE |
| DPP-4i | 中性 (saxagliptin HF↑) | neutral or ↑ | neutral | 中性 | 無 (alone) | TECOS, SAVOR-TIMI |
| Sulfonylurea | 中性 (CAROLINA) | 中性 | 慎用 | ↑ | 有 | CAROLINA |
| TZD (Pioglitazone) | NASH ↓, stroke ↓ (IRIS) | ↑ (黑框) | 中性 | ↑ | 無 (alone) | IRIS, PROactive |
| Metformin | 一線, 中性 | 中性 | 不影響 | 中性 / 微 ↓ | 無 (alone) | UKPDS |
| Insulin | 一線生命 | 中性 | 不影響 | ↑ | 有 | DCCT, UKPDS |
HbA1c 目標
- 一般成人: < 7%
- 年輕、無 comorbidity、新確診: < 6.5%
- 老年、frail、long-standing DM、嚴重 CKD/CV: 7.5-8.5%
- 臨終照護: 避免 hyperglycemic crisis 即可
Insulinoma 鑑別流程 (每年都考！)
- Whipple’s triad 確認: (1) 低血糖症狀 + (2) 同時血糖 < 55 mg/dL + (3) 給 glucose 後緩解
- 72-hour fasting test (gold standard): 同步測 glucose, insulin, C-peptide, proinsulin, β-hydroxybutyrate, sulfonylurea screen
- 影像定位: CT → MRI → EUS → SACI test (selective arterial calcium injection)
- 手術切除: 90% benign, 多 < 2 cm, single
甲狀腺高頻考點
甲狀腺炎 5 大鑑別
| 類型 | 痛 | 三相 | TSH/fT4 (early) | RAIU | Anti-TPO | ESR | 治療 |
|---|---|---|---|---|---|---|---|
| Graves’ | 無 | 無 | ↓/↑ | ↑↑ | 中 | 正常 | Anti-thyroid → RAI / surgery |
| Hashimoto’s | 無 | 無 (純 hypo) | ↑/↓ | 低 | +++ | 正常 | Levothyroxine |
| de Quervain’s | +++ creeping | + | ↓/↑ → ↑/↓ | ↓↓ | 弱 | ↑↑↑ | NSAID → steroid |
| Painless / postpartum | 無 | + | ↓/↑ → ↑/↓ | ↓↓ | + | 正常 | Beta-blocker, observe |
| Acute suppurative | +++ 紅熱腫 | 無 | 多 normal | normal | 正常 | ↑↑↑ + WBC ↑ | 抗生素 + drainage |
副甲狀腺・鈣磷骨高頻考點
PHPT 手術 indication (≥1 即可手術)
- 年齡 < 50 歲
- Ca > 1 mg/dL above ULN (即 > ~11.5 mg/dL)
- eGFR < 60
- 腎結石或結石負擔 (24h urine Ca > 400 mg)
- DXA T-score ≤ -2.5 或脆性骨折
HyperCa workup
第一步測 PTH:
- PTH ↑ or 不適當正常 → PHPT, FHH, Lithium, Tertiary HPT
- PTH ↓ → Malignancy (PTHrP, bone mets, lymphoma 1,25-OHD), Vit D excess, Granulomatous, Hyperthyroid, Vit A, Immobilization
HHM 急救
- IV NS 200-500 mL/h (rehydration)
- Loop diuretic (補水後加，避免初期 dehydration)
- IV bisphosphonate (zoledronate 4 mg / pamidronate 60-90 mg) — 24-72 hr 起效
- Calcitonin 4-8 IU/kg q6-12h — acute bridge (4-6 hr 起效，48 hr tachyphylaxis)
- Denosumab if zoledronate 抗藥 / CKD
- Glucocorticoid for lymphoma / myeloma / vit D-induced
- HD for 嚴重 + 腎衰竭
腎上腺高頻考點
Cushing 流程
- Screen (3 testing options, ≥ 2 positive):
- 24-hr UFC × 2
- 1-mg overnight dexamethasone
- Late-night salivary cortisol × 2
- ACTH measurement:
- < 5 pg/mL → ACTH-independent (adrenal source)
- > 20 pg/mL → ACTH-dependent
- ACTH-dep → MRI pituitary + CT chest/abd; HDDST + CRH stimulation
- IPSS (gold standard) for ambiguous cases
Pheo workup
- Plasma free metanephrine (or 24h urine fractionated metanephrine) — sensitivity 99%
- CT/MRI adrenal — after biochemical confirmation
- ¹²³I-MIBG / ⁶⁸Ga-DOTATATE PET for paraganglioma / metastatic
- Pre-op: α-blocker × 7-14 d → volume expansion → β-blocker after α
- Genetic test (30-40% germline): VHL, RET, NF1, SDHx
腦下垂體高頻考點 (詳見前/後葉 PDFs)
- Hypopituitarism 搶救順序: 先 IV hydrocortisone 100 mg → 後 levothyroxine (避免 adrenal crisis)
- Prolactinoma: Cabergoline first (即使 macroadenoma); 高劑量 (> 3 mg/週) → 年度 echo
- Acromegaly 診斷: IGF-1 ↑ + OGTT GH suppression failure (GH > 1 ng/mL after 75g glucose)
- Cushing’s disease 鑑別 (vs ectopic): HDDST + CRH + IPSS gold standard
- DI: copeptin-based testing (新標準) — 高張食鹽水 + copeptin > 4.9 = PP; ≤ 4.9 = central DI
- Triphasic response (post-pit surgery): DI (3-5 d) → SIADH (5-10 d) → permanent DI (約 20-30%)
其他高頻考點
MEN syndromes
| 類型 | 基因 | 主要表徵 |
|---|---|---|
| MEN 1 | MEN1 (11q13) | 3P: Parathyroid (PHPT, multi-gland) + Pancreatic NET (gastrinoma, insulinoma) + Pituitary adenoma |
| MEN 2A | RET (10q11, 多 codon 634) | MTC (100%) + Pheo (50%) + PHPT (20%) |
| MEN 2B | RET (codon 918) | MTC (100%, very early/aggressive) + Pheo + Marfanoid + 黏膜 neuromas |
| FMTC | RET 多種 | Familial MTC only |
APS (Autoimmune Polyendocrine Syndrome)
| 類型 | 基因 | Triad |
|---|---|---|
| APS-1 (APECED) | AIRE (chromosome 21, AR) | Mucocutaneous candidiasis + Hypoparathyroid + Addison’s |
| APS-2 (Schmidt’s) | HLA-DR3/DR4 (polygenic) | Addison’s + Autoimmune thyroid + T1DM |
NET 治療階梯
- Localized: surgery
- Metastatic NET G1/G2: SSA (octreotide LAR / lanreotide) → progress → PRRT (¹⁷⁷Lu-DOTATATE) / everolimus / sunitinib (PNET) / CAPTEM
- NEC G3 (poorly diff): chemo (cisplatin + etoposide, like SCLC)
Paraneoplastic 經典
- SCLC: SIADH (most common), Cushing’s (ectopic ACTH), Eaton-Lambert syndrome, cerebellar degeneration, encephalitis
- SCC of lung / H&N / cervix: HHM (PTHrP)
- RCC, hepatoma, hemangioblastoma: polycythemia (EPO)
- Mesothelioma, fibrosarcoma: NICTH (BIG-IGF2 hypoglycemia)
- Midgut NET (ileum): carcinoid syndrome (after liver mets)
重要 cut-offs 速查
| 項目 | Cut-off |
|---|---|
| HbA1c 目標 (一般) | < 7% (老年/frail 7.5-8.5%) |
| LDL-C (DM + ASCVD 高極風險) | < 55 mg/dL |
| Metformin 停藥 | eGFR < 30 |
| SGLT2i 適用 | eGFR ≥ 20 (CKD 標籤) |
| GLP-1 RA 適用 | 多 eGFR > 15 |
| PHPT 手術 (Ca above ULN) | > 1 mg/dL |
| Adrenal incidentaloma 手術 | ≥ 4 cm or functional |
| TSH (亞臨床甲低治療) | > 10 (or > 4 + 症狀) |
| FHH (Ca/Cr clearance) | < 0.01 |
| 1 mg dex 抑制 cortisol | < 1.8 μg/dL (excludes hypercortisolism) |
| Plasma free metanephrine | 4× ULN → high probability pheo |
| 72-hr fast (insulinoma) | glucose < 55 + insulin > 3 + C-peptide > 0.6 |
22E 內分泌章節對應
- Ch 392-394: Pituitary, neuroendocrine
- Ch 395-396: Thyroid (anatomy + disorders)
- Ch 397: Adrenal disorders
- Ch 399: Calcium, parathyroid, bone metabolism
- Ch 400-402: Diabetes mellitus (pathophysiology, complications, treatment)
- Ch 403: Lipid disorders / dyslipidemia
- Ch 404: Obesity / weight regulation
- Ch 411-412: MEN, paraneoplastic endocrine syndromes