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3B > Endocrine 2 > Flashcards

Endocrine 2 Flashcards

1
Q

DM1

A 
Autoimmune
Pancreatic beta cells destroyed
(Islets of Langerhans)
No insulin produced
Glucose ^^^
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2
Q

DM2

A

Excess adipose tissue
Relative insulin deficiency
Glucose ^

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3
Q

Prediabetes

A

Not meeting DM2 criteria
Likely to develop DM2 in next few years
Require lifestyle interventions

Fasting glucose 6.1-6.9
HbA1c 42-47

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4
Q

DM2 risk factors

A

Age ^
Family history
Non-white

Sedentary lifestyle
Obesity
Stress

GDM
PCOS

HTN
Dyslipidaemia
CVD

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5
Q

DM clinical features

A

Polydipsia
Polyuria
Weight loss
Fatigue

Visual disturbances
Abdo pain
N/V

Recurrent infections

  • Candidal
  • Skin
  • UTI
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6
Q

Polydipsia/polyuria pathophysiology

A

Glycosuria
Water follows by osmosis
= Dehydration

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7
Q

DM investigations

A

Random plasma glucose > 11

Fasting plasma glucose > 6.9

OGTT - 75g glucose - Wait 2 hours - Positive > 11

HbA1c > 48

Urine dip - Ketones +++

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8
Q

DM1 management

A

Insulin

  • SC pump
  • 0.2-0.4 units/kg/day
  • BM self-monitoring
  • Pre-meal insulin correction dose
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9
Q

DM2 management - Lifestyle

A

Lifestyle changes (HbA1c 48-53)

  • Weight loss 5-10%
  • Physical activity
  • Reduce alcohol intake - Risk of hypo
  • Smoking cessation

Diet - Reduce sugar consumption

  • High fibre
  • Low GI foods
  • Low-fat dairy produts
  • Reduced saturated fats and TFAs
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10
Q

DM sick day rules

A 
Increase frequency of BM monitoring
Increase fluid intake - 3L / 24 hours
Maintain carbohydrate intake - Sugary drinks if necessary
Access to a mobile phone 
Continue medication - Except metformin
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11
Q

DM indications for admission

A 
Inability to tolerate oral fluids
Persistent diarrhoea
Significant ketosis - Despite additional insulin
BM > 20 - Despite additional insulin
Lack of support at home
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12
Q

DM2 management

A
  1. HbA1c 48-53 - Diet and exercise
  2. Metformin
  3. If HbA1c > 58 add…
    - Gliptin
    - Sulfonylurea
    - Pioglitazone
    - SGLT-2 inhibitor - Gliflozin
  4. If HbA1c > 58 - Add another
  5. If HbA1c > 58 and BMI > 35
    - Add GLP-1 mimetic
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13
Q

DM drugs MoA

A

Metformin - CI if eGFR < 30

  • Increases insulin sensitivity
  • Decreases hepatic gluconeogenesis

Sulfonylurea - Gliclazide

  • Risk of hypoglycaemia
  • Stimulates pancreatic B cells to produce insulin

Pioglitazone

  • Promote adipogenesis and FFA uptake
  • Weight gain

Gliptins

  • Increases incretin
  • Inhibits glucagon secretion
  • Risk of pancreatitis

SGLT-2 inhibitors - Inhibits renal reabsorption of glucose

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14
Q

DM complications

A

Microvascular

  • Neuropathy
  • Retinopathy
  • Neuropathy

Macrovascular

  • CVD
  • CHF
  • Stroke

Infection
DKA
Non-ketotic hyperosmolar state

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15
Q

DKA pathophysiology

A

Insulin deficiency + Glucagon ^
Triglycerides and AAs metabolised for energy
Increased serum glycerol and FFA
Glucagon converts FFA to ketones

Hyperglycaemia causes osmotic diuresis
Marked urinary loss of water and electrolytes

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16
Q

DKA clinical features

A

N/V
Abdo pain

Altered consciousness
Dehydration

Hyperventilation - Kussmaul breathing
Ketone breath - Pear drops

Sx of DM

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17
Q

DKA investigations

A

VBG

  • Hyperkalaemia
  • Hypokalaemia = Severe DKA
  • Metabolic acidosis
  • Serum osmolality ^^^

pH < 7.3
Serum ketones > 3
BM > 11
Bicarb < 15

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18
Q

DKA management

A

Fluid replacement

  • 500ml bolus over 10-15 minutes
  • 1L over 1 hour

Correct hypokalaemia - SandoK
Insulin - FR infusion

When glucose < 14 - Give 10% Dextrose

Safe rate of glucose reduction - 4-6 mmol/hr

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19
Q

DKA complications

A

Arrhythmias - Hypo/hyperkalaemia
VTE

ARDS
Gastric stasis
AKI

Cerebral oedema

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20
Q

Hyperosmolar hyperglycaemic state pathophysiology

A 
Hyperglycaemia
Osmotic diuresis
- Electrolyte abnormalities 
- Severe dehydration 
- Raised serum osmolality
- Hyperviscosity

Typically elderly DM2 patients
Develops over many days

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21
Q

Hyperosmolar hyperglycaemic state clinical features

A

Dehydration
Hypotension
Tachycardia

Fatigue
Lethargy
Weakness
Altered consciousness

N/V
Headaches
Papilloedema

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22
Q

Hyperosmolar hyperglycaemic state diagnosis criteria and management

A
  1. Hypovolaemia
  2. Hyperglycaemia > 30 ± Ketonaemia/acidosis
  3. Serum osmolality > 320

Management

  • Fluid replacement
  • Correct electrolyte abnormalities
  • Normalise blood glucose
23
Q

Thyroid storm precipitating events

A

MIST

Media - Contrast - Acute iodine load
Infection
Surgery
Trauma

24
Q

Thyroid storm clinical features

A

Fever > 38.5

Tachycardia
Hypertension
HF

Confusion and agitation
N/V

Abnormal LFTs
Jaundice

25
Q

Thyroid storm management

A

Symptomatic - Paracetamol
BBs - IV propranolol

Carbimazole
Dex - Blocks conversion of T3 to T4

26
Q

Myxoedema coma

Symptoms and management

A

Confusion
Hypothermia

Management

  • IV thyroxine
  • IV Fluid replacement
  • IV corticosteroids
  • Correct electrolyte imbalance
  • Rewarming?
27
Q

Thyroid cancers

A

Presentation - Thyroid nodule in a woman aged 30-50

Papillary carcinoma - 70%

  • Young females
  • Excellent prognosis

Follicular adenoma - 20%
- Solitary thyroid nodule

Medullary carcinoma - 5%

  • Secrete calcitonin
  • 20% familial genetics

Anaplastic carcinoma - 1%

  • Pressure symptoms
  • Elderly females
  • Chemo ineffective

Lymphoma - Associated with Hashimoto’s

28
Q

Thyroid nodule investigations

A

TSH - Normal
USS + FNB

Laryngoscopy - Paralysed vocal cord?

CT staging

Serum calcitonin - Medullary carcinoma

29
Q

Thyroid cancer management

A

Total thyroidectomy
Radioiodine ablation

TSH suppression - Levothyroxine

Screen for recurrence - Yearly thyroglobulin levels

30
Q

Hypoadrenalism

A

Primary

  • TB
  • Metastases
  • Meningococcal septicaemia
  • HIV
  • Antiphospholipid syndrome

Secondary - Pituitary disorders

  • Tumours
  • Irradiation
  • Infiltration
31
Q

Pituitary adenoma risk factors

A

MEN-1
Familial isolated pituitary tumours - FIPA
Carney complex - CNC

32
Q

Pituitary adenoma clinical features

A

Headaches
Bitemporal hemianopia

Central adiposity
Reduced muscle mass

Hypogonadism

  • Gynaecomastia
  • Amenorrhoea
  • Infertility
  • Loss of libido
  • ED

Hypothyroidism
Fatigue
Osteopenia

Adrenal insufficiency

  • Anorexia
  • N/V
  • Weakness
33
Q

Pituitary adenoma investigations

A

Prolactin ^
IGF-1 - Low with GH deficiency

Sex hormones - LH, FSH, testosterone, oestrogen

Morning cortisol
ACTH
ACTH stimulation test

Insulin tolerance test

U&E - Hyponatraemia
FBC - Anaemia

CT/MRI

34
Q

Pituitary adenoma management

A

Pituitary apoplexy

  • Hydrocortisone
  • Levothyroxine
  • Trans-sphenoidal resection

Adenoma

  • Observation
  • Hormone replacement
  • Radiotherapy
  • Dopamine agonist - Bromocriptine / Cabergoline
  • Somatostatin analogue - Octreotide
35
Q

PTH physiology and vit D synthesis

A

PTH released in response to low Ca

  • Increased bone resorption by OCs - More Ca released
  • Increased Ca reabsorption in kidneys
  • Increased vit D synthesis in kidney
  • Increased calcium and phosphate absorption from gut

25-hydroxyvitamin D
Converted to 1,25-dihydroxyvitamin D
Absorbed in gut

36
Q

HyperPTH aetiology

A

Primary - Solitary adenoma
Secondary - Hyperplasia

Risk factors

  • Female
  • Age > 50
  • Family history
  • MEN
  • Li treatment
37
Q

HyperPTH clinical features

A

= Hypercalcaemia

Bones - Osteoporosis, osteopenia, pain 
Stones - Renal
Moans - Depression and anxiety
Groans - Abdominal pain and myalgia
Thrones - Constipation

Sleep disturbances
Fatigue
Cognitive changes
Paraesthesia

38
Q

HyperPTH investigations

A

Calcium profile

  • Calcium ^ (Low in 2)
  • Phosphate ^ (Low in 2)
  • PTH ^
  • ALP ^

Tech-99 scan
ECG - Short QT

Skeletal survey - Pepper pot skull
Knee XR - Chondrocalcinosis

39
Q

HyperPTH management

A

Parathyroidectomy

+ Vit D supplementation - Ergocalciferol
+ Alendronic acid
+ Cinacalcet

40
Q

HypoPTH aetiology

A

Thyroid/parathyroid surgery

Malnutrition
Malabsorption
Diarrhoea

Chronic alcoholism

Hypomagnesaemia

AD conditions - CASR and GATA3

41
Q

HypoPTH clinical features

A

Secondary to hypocalcaemia

Tetany - Muscle twitches, spasms, cramps
Perioral paraesthesia
Trosseau’s sign - Carpal spasm on inflation of BP cuff
Chvostek’s sign - Tapping parotid causes facial muscles to twitch

Depression
Cognitive changes
Anxiety
Dry hair and brittle nails
Cataracts
42
Q

HypoPTH investigations and management

A

Calcium profile

  • Ca - LOW
  • PTH - LOW
  • Phosphate ^
  • Vit D - LOW

Albumin

  • Low albumin will falsely lower serum calcium
  • Ionised calcium accurately reflects physiological calcium

Magnesium - LOW
ECG - Prolonged QT

Management

  • Calcium carbonate
  • Calcitriol
43
Q

Hypernatraemia aetiology

A

Dehydration
Osmotic diuresis
DI

Infancy
Old age

Renal concentrating deficit

Iatrogenic

  • IV saline
  • Lithium
  • Mannitol
44
Q

Hypernatraemia clinical features

A

CNS manifestations

  • Lethargy/weakness
  • Irritability
  • IC haemorrhage
  • Seizures
  • Stupor
  • Coma

Weight loss - Hypovolaemia
Hypo/tachy
Decreased JVP
Dry mucous membranes

45
Q

Hypernatraemia investigations and management

A

Serum sodium

Urine osmolality

  • Low - DI
  • High - Volume depletion

Serum osmolality - High

Management - Treat cause

  • Fluid replacement
  • DI - Desmopressin / Thiazide diuretic
46
Q

Carcinoid syndrome aetiology

A

Metastases in the liver
Serotonin released into systemic circulation

Risk factors - MEN-1

47
Q

Carcinoid syndrome clinical features

A

Flushing
Palpitations

Diarrhoea
Abdo cramps

Signs of RHF
Cardiac murmurs
Hepatomegaly

48
Q

Carcinoid syndrome investigations and management

A

Serum chromogranin A/B ^^^
Urinary 5-hydroxyindoleacetic acid ^^^

Creatinine ^^^
LFTs

Management - Somatostatin analogue - Octreotide

49
Q

Multiple endocrine neoplasia

A 
MEN-1 - 3Ps
- Parathyroid
- Pituitary
- Pancreas 
\+ Adrenal
\+ Thyroid

MEN-2a - 2Ps - RET oncogene

  • Medullary thyroid cancer
  • Parathyroid
  • Phaeochromocytoma

MEN-2b - 1P - RET oncogene

  • Phaeochromocytoma
  • Marfanoid body habitus
  • Neuromas
50
Q

Phaeochromocytoma

A

Catecholamine secreting tumour

Associated with

  • MEN-2
  • Neurofibromatosis
  • Von-Hippel Lindau syndrome

10% rule

  • Familial in 10%
  • Bilateral in 10%
  • Malignant in 10%
  • Extra-adrenal in 10% - Organ of Zuckerlandl
51
Q

Phaeochromocytoma clinical features

A

HTN - 90%

  1. Headaches
  2. Palpitations
  3. Diaphoresis
Hypertensive retinopathy
Pallor
DM
Orthostatic hypotension
Cafe au lait spots
52
Q

Phaeochromocytoma investigations

A

24-hour urine collection

  • Catecholamines
  • Metanephrines
  • Normetanephrines
  • Creatinine

MRI - Adrenal medulla
Genetic testing

53
Q

Phaeochromocytoma management

A

AB - Phenoxybenzamine
BB - Propranolol

+ Surgical excision

3B (23 decks)

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