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Endocrine > Adrenal - Clinical > Flashcards

Adrenal - Clinical Flashcards

1
Q

Two causes of adrenal hyposecretion

A

Primary Adrenal Insufficiency

Adrenal enzyme defects

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2
Q

Most common adrenal enzyme defect

A

21 hydroxylase

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3
Q

21OH deficiency is the most common cause of which condition

A

Congenital adrenal hyperplasia

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4
Q

Primary Adrenal Insufficiency is an aspect of which disease

A

Addison’s Disease

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5
Q

Causes of Addison’s disease

A 
Autoimmune - immune destruction
Invasion
Infiltration
Infection
Infarction
Iatrogenic
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6
Q

Finding of Autoimmune Addison’s

A

Postive autoantibodies to 21OH

Lymphocytic infiltration

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7
Q

Autoimmune diseases associated with Addison’s

A

Thyroid
Type 1 Diabetes
Premature ovarian failure

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8
Q

Symptoms of primary adrenal insufficiency

A 
Weight loss, anorexia, weakness, fatigue
Skin pigmentation or vitiligo
Hypotension
Unexplained Vomiting, Diarrhoea
Salt craving
Postural symptoms
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9
Q

Clues to diagnosis

A

Disproportion with severity of illness and circulatory collapse/hypotension/dehydration
Previous depression or weight loss
Unexplained hypoglycaemia
Hypothyroidism, body hair loss, amenorrhea

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10
Q

Diagnosing primary adrenal insufficiency

A

Non-specific symptoms
Routine bloods - U&Es, FBC, glucose
Random cortisol
Synacthen

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11
Q

Interpreting synacthen

A

Cortisol doesn’t rise, ACTH elevated - Pirmary

Rises, ACTH suppressed - Secondary

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12
Q

What steroids are given for glucocorticoid replacement?

A

Hydorcortisone
Prednisolone
Dexamethasone

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13
Q

How are doses varied for glucocorticoid replacement?

A

Reflect diurnal variation eg HC 20mg at 8am, 10 mg at 6pm

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14
Q

What is the steroid given for mineralocorticoid replacement?

A

Fludrocortisone

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15
Q

What is the action of fludrocortisone?

A

Binds to aldosterone receptors

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16
Q

How must fludrocortisone dose be adjusted?

A

Clinical status
U&Es
Plasma Renin level

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17
Q

What patients need special care when administering steroids?

A

Those receiving sufficient doses to suppress pituitary adrenal axis
Hypoadrenal patients on replacement steroids
Same treatment within last 18 months

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18
Q

What action must be taken in administering steroids to patient with minor illness or short-lived stress?

A

Double glucocorticoid dose

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19
Q

What action must be taken in administering steroids to patient with major illness or operation?

A

100mg HC iv stat
50-100 mg HC iv 8 hourly
If stress abates reduce HC by 50% per day until returned to original replacement dose

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20
Q

Self-care rules for steroid use

A

Never miss a dose
Double the HC dose in intercurrent illness
If severe vomiting or diarrhoea, call for help- will likely need IM dose

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21
Q

Most common causes of primary hyperaldosteronism

A

Unilateral adenoma

Bilateral hyperplasia

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22
Q

Rare causes of hyperaldosteronism

A 
Phaeochromocytoma
Cushing's
Acromegaly
Hyperparathyroidism
Hypothyroidism
Congenital adrenal hyperplasia
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23
Q

Causes of hypersecretion within the cortex

A

Cushing’s syndrome (cortisol, androgens)

Conn’s syndrome (aldosterone)

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24
Q

Causes of cushing’s syndrome

A

Adenoma, carcinoma, bilateral hyperplasia

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25
Q

Causes of conn’s syndrome

A

Adenoma, bilateral hyperplasia

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26
Q

Cause of hypersecretion within the medulla

A

Phaeochromocytoma

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27
Q

3 physiological changes in Cushing’s syndrome

A

Tissue breakdown
Sodium retention
Insulin antagonism

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28
Q

Symptoms of cushing’s syndrome

A 
Central obesity
Hypertension
Glucose intolerance - DM
Hirsutism
Amenorrhoea/Impotency
Purple striae
Plethoric faces
Easily bruised
Osteoporosis
Personality/Mood changes
Acne
Oedema
Headache
Poor wound healing
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29
Q

2 types of Cushing’s syndrome

A

ACTH dependent

ACTH independent

30
Q

ACTH dependent Cusing’s

A

Pituitary tumour - CUSHING’S DISEASE

Ectopic ACTH - lung carcinoid

31
Q

ACTH independent

A 
Adrenal tumour (adenoma/carcinoma)
Corticosteroid therapy (asthma, IBD)
32
Q

Investigations for Cushing’s

A

24 hour urinary free cortisol
1mg overnight dexamethasone supporession test taken at midnight

(diurnal variation of cortisol and ACTH)

33
Q

Lab results in primary hyperaldosteronism

A 
Increased aldosterone
Increased blood volume and pressure
Urine Potassium
Decreased renin
Increased A/R ratio
34
Q

Hypertension, Hyperkalaemia and increased Plasma Renin activity along with Plasma Aldosterone concentration indicate which causes of hyperaldosteronism

A

Secondary

  • Renovascular hypertension
  • Diuretics
  • Renin secreting tumour
  • Malignant Hypertension
  • Coarctation of aorta
35
Q

Decreased PRA, increased PAC indicate which cause of hyperaldosteronism

A

Primary cause

36
Q

Decreased PRA and PAC indicate which cause of hyperaldosteronsim

A 
Congential adrenal hyperplasia
Exogenous mineralocorticoid
DOC producing tumour
Cushing's syndrome
II beta HSD deficiency
Liddle's syndrome
37
Q

Screening test for hyperaldosteronism

A

PRA and PAC

Plasma Renin Activity, Plasma Aldosterone Concentration

38
Q

Confirmatory tests for hyperaldosteronism

A

24 HR urine aldosterone

Urinary sodium during 4 days salt loading

39
Q

Investigations to establish source of hyperaldosteronism

A

CT adrenal glands
Upright posture test
Plasma 18-hydroxycorticosterone
Adrenal venous sampling if CT inconclusive

40
Q

Signs and symptoms of Phaeochromocytoma

A

Hypertension

Paroxysmal attacks - headaches, sweating, palpitations, tremor, pallor, anxiety/fear

41
Q

30% of phaeochromocytoma cases are inherited. Which genes and familial syndromes are associated?

A

Genes - RET, VHL, NF1, SDH

Familial syndromes – MEN2, VHL, NF1, PGL

42
Q

What enzyme id deficient in Congenital adrenal hyperplasia?

A

21-hydroxylase

43
Q

Which 2 events can occur in severe deficiencies of 21 hydroxylase?

A 
Neonatal salt losing crisis
Ambigous genitalia (girls)
44
Q

Which 2 evetns occur in incomplete defects of 21 hydroxylase deficiency in CAH

A 
Pseudoprecocious puberty (boys)
Hirsutism (women)
45
Q

Symptoms of hyperthyroidism

A 
Weight loss
Heat intolerance
Anxiety
Bowel frequency
Lighter periods
Sweaty palms 
Palpitations
Hyperreflexia /Tremors
Goitre
Thyroid eye symptoms/signs
46
Q

Signs and symptoms of hypothyroidism

A 
Weight gain
Lethargy
Cold intolerance
Constipation
Heavy periods
Dry skin/hair
Bradycardia
Slow reflexes
Goitre
47
Q

Symptoms of severe hypothyroidism

A

Puffy face
Large tongue
Hoarsenss
Coma

48
Q

Thyroid levels in primary hypothyroidsim

A

Low free T3 and T4

Raised TSH

49
Q

Thyroid levels in Sublinical hypothyroidism

A

Raised TSH

Normal free T3 and T4

50
Q

Thyroid levels in secondary hypothyroidism

A

Low TSH

Low T3 and T4

51
Q

Congenital causes of hypothyroidism

A

Developmental (agenesis or maldevelopment)

Dyshormonogenesis (trapping, organification, dehalogenase)

52
Q

Acquired causes of hypothyroidism

A 
Autoimmune - Hashimoto's, atrophic
Iatrogenic - post op, post RAI, Radiotherapy for head and neck cancers,
Antithyroid drugs
Amiodarone
Lithium
Interferon
Chronic Iodine deficiency
Post subacute thyroiditis - Post-partum
53
Q

Secondary and tertiary causes of hypothyroidism

A

Pituitary - hypothalamic damage

  • pituiatry tumour
  • craniopharyngioma
  • post pituitary surgery/Radiotherapy
  • Sheehan’s syndrome
  • Iswolated TRH deficiency
54
Q

What is sheehan’s syndrome?

A

Post-partum pituitary gland necrosis

55
Q

Investigations for hypothyroidism

A 
TSH/Free T4 levels
Autoantibodies TPO (Thyroid peroxidase)
Full blood count
Lipids
Hyponatraemia - SIADH
Increased muscle enzymes , ALT, CK
Hyperprolactinaemia
56
Q

Treatment for hypothyroidism

A

Levothyroxine (T4)
Initial dose of 50 micrograms per day for 2 weeks , increased to 100
Continute to increase dose until TSH levels normal

57
Q

What is the half life of t4

A

7 days

58
Q

What test is ongoing in treatment of hypothyroidism?

A

Annual TSH testing once stabilised

59
Q

Which conditions require alterations in levothyroxine dose?

A

Ischaemic heart disease - lower dose
Pregnancy - need increased dose
Postpartum thyroiditis - try withdrawal and measure TFTs in 6 weeks
Myxoedema coma - Rare, emergency, IV T3

60
Q

What is the indication for treatment of subclinical hypothyroidism?

A

TSH greater than 10
TSH greater than 5 with thyroid antibodies
TSH elevated with symptoms

61
Q

What is the risk of overtreating subclinical hypothyroidism?

A

Osteopenia and Atrial fibrillation

62
Q

6 causes of goitre

A 
Physiological- Puberty and pregnancy
Autoimmune - Grave's, Hashimoto's
Thyroiditis - Acute; De Quervans, CHronic fibrotic (Reidels)
Iodine deficiency - endemic goitre
Dyshormonogenesis
Goitrogens
63
Q

Types of goitre

A 
Multinodular
Diffuse
Cysts
Tumour (adenoma, carcinoma, lypoma)
Sarcoidosis
Tuberculosis
64
Q

Which type of thyroid disease carries risk of malignancy?

A

Solitary Nodular Thyroid

65
Q

Symptoms of solitary nodular thyroid

A

Pain

Cervical lymphadenopathy

66
Q

Investigation of solitary nodular thyroid

A

TFT
Ultrasound
Fine Neele Aspiration
Isoptope scanning if low TSH - HOT NODULE , COLD NODULE

67
Q

Which type of nodule on isotope scanning indicates greater risk of cancer?

A

Cold nodule - cyst, adenoma

Hot - low risk

68
Q

2 differentiated forms of thyroid cancer

A

Papillary

Follicular

69
Q

Which type of thyroid cancer is most common?

A

Papillary

70
Q

What is the prognosis of papillary thyroid cancer?

A

Good - multifocal, local spread to lymph nodes

71
Q

What is the prognosis of follicular thyroid cancer?

A

Good if resectable
Usually single lesion
Metastasises to the lung and bone

Endocrine (3 decks)

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