Endo Flashcards

Question

What are the symptoms of Phaeochromocytoma

Answer 1

Episodic hypertension Anxiety Weight loss Fatigue Palpitations Sweating Headaches Flushing Pyrexia Dyspnoea Abdominal pain Signs: hypertension postural hypotension tremor hypertensive retinopathy. Can be percipitated by stress, exercise, surgery, straining and various drugs such as beta blockers, anaesthetic agents and opiates

Answer 2

Plasma metanephrines followed by urinary metanehprines have the best diagnostic accuracy, with 24 hour urinary catecholamines being of less value. Adrenal imaging should not take place until the biochemical diagnosis has been confirmed. CT Chest Abdomen and Pelvis imaging is the modality of choice and can be followed up with an MRI scan. Extra-adrenal phaeochromocytomas can occur anywhere from the base of the brain to the urinary bladder (as it develops in chromaffin tissue of the sypmathetic system). Other more recently developed tests include metaiodobenzylguanidine (MIBG) labelled with iodine (which has a similar composition to noradrenaline). PET scans have also been used to help locate possible tumours.

Answer 3

The definitive treatment is surgical to resect the tumour. Pre-operatively, alpha blockade with phenoxybenzamine is started first followed by consideration of beta blockade to expand blood volume and prevent hypertensive crises.

Answer 4

Iodine deficiency - particularly, middle east, nepal and parts of south america

Answer 5

Serum IGF-1 - directly correlated to growth hormone level - if raised then move to oral glucose tolerance test

Answer 6

First line treatment for acromegaly is trans-sphenoidal surgery - post operatively IGF1 and random GH should be measured after at least 3 months and repeat imaging - also followup echocardiography and colonoscopy every 5 years to monitor bowel polyps Other options for refractory cases or for patients who cannot undergo surgery: Somatostatin receptor ligands (SLR) such as Octreotide Pegvisomant (GH analogue) Cabergoline (Dopamine agonist) Radiotherapy

Answer 7

Medical therapy to reduce cortisol excess is indicated before pituitary surgery or radiotherapy in Cushing's disease in order to get the cortisol levels under control, help to reduce the tumour size and better prepare the steroid exposed tissues for invasive treatment Pituitary tumour resection is the treatment of choice overall but normalisation of hypercortisolaemia with medical therapy prior to operating improves outcomes. Persisting high cortisol post-surgery is an indication for pituitary radiotherapy Blockers of the steroid synthesis pathway should be used first line, with Metyrapone the most commonly used. Other treatments include Ketoconazole which is an adrenolytic agent, Mifepristone which is a glucocorticoid antagonist and Pasireotide which binds to somastostatin receptors.

Answer 8

By reducing hepatic gluconeogenesis and improving glucose uptake and utilisation in peripheral tissues. Basically increases body sensitivity to insulin and increases glucose uptake into cells It should be reviewed in patients with liver failure, as tissue hypoperfusion may increase the risk of lactic acidosis.

Answer 9

iodine-induced blockage of iodine organification iodine-induced inactivation of thyroid hormones reduces TSH release through negative feedback All three mechanisms are possible

Answer 10

Capillary blood gas and capillary blood ketones - can confirm or exclude diagnosis and assess for severity of DKA - can be performed quickly and with minimal distress to the patient as capillary blood tests require finger prick rather than venepuncture - ABG can be used in adults

Answer 11

a fasting plasma glucose level of ≥5.6 mmol/L; or a 2-hour post-oral glucose tolerance test plasma glucose level of ≥7.8 mmol/L

Answer 12

Waterhouse-Friderichsen syndrome is adrenal gland failure due to bleeding into the adrenal gland. It is usually caused by severe meningococcal infection or other severe, bacterial infection. Symptoms include acute adrenal gland insufficiency, and profound shock, increased pigmentation on her skin Waterhouse-Friderichsen syndrome is most often associated with meningococcal disease (accounts for 80% of cases). - most common cause is neisseria meningitidis - The syndrome also has been associated with other bacterial pathogens, including Streptococcus pneumoniae, group A beta-hemolytic streptococci, Neisseria gonorrhoeae, Escherichia coli and many others. It may also be associated with a history of splenectomy

Answer 13

Diabetes insipidus is caused by an abnormal quantity (cranial cause) or response to antidiuretic hormone (nephrogenic cause). The condition is characterised by large volumes of dilute urine (more than 3 litres in 24 hours and a low osmolality (less than 300 mOsm/kg)). In addition to the large volumes of urine, patients tend to suffer from nocturia and excessive thirst. In children, failure to thrive and enuresis may also be noted.

Answer 14

Head trauma Inflammatory conditions e.g. sarcoidosis Cranial infections such as meningitis Vascular conditions such as sickle cell disease Rare genetic causes

Answer 15

Nephrogenic diabetes insipidus may be caused by: Drugs e.g. lithium Metabolic disturbances e.g. hypercalcaemia, hypokalaemia, hyperglycaemia Chronic renal disease Rare genetic causes (e.g. Wolfram's syndrome).

Answer 16

Baseline investigations should include urea and electrolytes, blood glucose (to rule out diabetes mellitus), urine dip, and paired serum and urine osmolality. Diabetes insipidus is present when the serum osmolality is raised (>295milliOsmol/kg) with inappropriately dilute urine (urine osmolality < 700milliOsmol/kg). A fluid deprivation test can also be performed if the diagnosis remains unclear

Answer 17

Cranial diabetes insipidus can be managed with desmopression. Sodium should be monitored routinely due to the risk of hyponatraemia.

Answer 18

Nephrogenic diabetes insipidus is managed by correcting any metabolic abnormality and stopping any offending drugs. High dose desmopressin has been used with variable results. Other possible treatments include using a thiazide diuretic and a non-steroidal anti-inflammatory drug to reduce urine volume.

Answer 19

De Quervain’s thyroiditis is a subacute thyroiditis caused by granulomatous inflammation and destruction of thyroid cells which is often precipitated by a viral infection - leads to hyperthyroidism Has a painful goitre It causes symptoms of hyperthyroidism due to excess release of thyroid hormone. Patients then have a hypothyroid phase. It also presents with a painful neck due to the inflammation. Its presentation is similar to Grave’s disease and a radioisotope scan can differentiate the two - graves has increased uptake of radioisotope. It is self-resolving.

Answer 20

Grave's disease is an autoimmune hyperthyroidism which often affects the eye. Diffuse non-tender goitre Auto-antibodies target the extraocular muscles, causing swelling behind the eye which results in proptosis of the eyeballs. - TSH receptor antibodies Signs include lid retraction, proptosis, lid lag and red, watery eyes.

Answer 21

Sub-clinical hypothyroidism is defined as high TSH in conjunction with normal T3 and T4. Patients may or may not be symptomatic.

Answer 22

Management of these patients includes: Assessment for features of hyperthyroidism Exclude causes of transiently suppressed TSH such as medication (e.g. steroids, lithium, anti-Parkinson's medications). Repeat thyroid function tests in 3-6 months. Endocrinology referral if persistent results.

Answer 23

Cushing's disease describes glucocorticoid excess caused by an ACT secreting pituitary tumour.

Answer 24

Ectopic ACTH secretion has no suppression of cortisol with low or high dose dexamethasone and ACTH is very high Ectopic ACTH is most common in small cell lung cancer and carcinoid tumours and results in increased skin pigmentation as the proprotein from which ACTH is cleaved also contains various melanotropin hormones which stimulate melanocytes

Answer 25

Sulphonylureas i.e gliclazide Sulphonylureas work to increase insulin release by closing ATP sensitive potassium channels on the cell membrane of beta cells of the pancreas. This results in the cells to depolarize and calcium channels to open leading to insulin release. The risk of hypoglycaemia is thought to be between 1.4-20% per year of sulphonylurea therapy

Answer 26

Hypoglycaemia is defined as blood glucose <4.0 mmol/L Causes: 1. Drugs Insulin Sulphonylureas GLP-1 analogues DPP-4 inhibitors Beta-blockers Alcohol 2. Acute liver failure 3. Sepsis 4. Adrenal insufficiency 5. Insulinoma 6. Glycogen storage disease

Answer 27

Checking medication history for drug causes Serum insulin, C-peptide and proinsulin – to distinguish the presence of exogenous and endogenous insulin High insulin AND high C-peptide and proinsulin = Endogenous production High insulin AND low C-peptide and proinsulin = Exogenous administration 72 hour fast test – to demonstrate episodic hypoglycaemia 8am cortisol and/or synACTHen testing – for adrenal insufficiency Abdominal CT/MRI/PET – to localise an insulinoma

Answer 28

ABCDE Eat/drink 15-20g fast acting carbohydrate such as glucose tablets, a small can of Coca-Cola, sweets or fruit juice. AVOID chocolate Eat some slower acting carbohydrate afterwards (e.g. toast)

Answer 29

ABCDE 200ml 10% dextrose IV 1mg glucagon IM if no IV access (will not work if caused by acute alcohol because of its action in blocking gluconeogenesis) Treat seizure if prolonged or repeated

Answer 30

Sodium- Dependent Glucose Cotransporter 2 inhibitor

Answer 31

Increases reabsorption of sodium into the blood and increases secretion of potassium into the urine

Answer 32

Adrenal insufficiency occurs where is destruction of the adrenal cortex leading to reduction of glucocorticoid production. This can be primary (Addison's disease) or secondary (due to insufficient pituitary or hypothalamic action on the adrenal glands). Clinical features are hypotension, fatigue and weakness, GI symptoms, syncope, pigmentation 60% of patients with autoimmune addison's disease have vitiligo or other autoimmune endocrinopathies

Answer 33

Autoimmune disorder secondary to destruction of the adrenal cortex responsible for cortisol and aldosterone synthesis. The lack of aldosterone results in hypotension due to reduced sodium reabsorption while the lack of cortisol results in weight loss and hypoglycaemia. As the disease progresses, the adrenals secrete less and less cortisol. The pituitary responds therefore by producing more ACTH. ACTH is derived from a bigger precursor molecule called pro-opiomelanocortin (POMC). POMC is also a precursor for melanocyte stimulating hormone (MSH) and as such stimulates increased melanin production leading to hyperpigmentation

Answer 34

Low sodium High potassium Low glucose Low cortisol ACTH: High in primary insufficiency, low/low normal in secondary insufficiency Renin (high in Addisons) Aldosterone (low in Addisons)

Answer 35

Adrenal auto-antibodies Chest X-ray CT scan of the adrenal glands MRI brain

Answer 36

Patients who take long terms steroid medications, should know their 'sick day' rules, carry a steroid card on their person, or have a medic-alert bracelet. If they have any form of intercurrent illness then they need to double their regular steroid medication dose. Replacement of both glucocorticoids and mineralocorticoids are required. Hydrocortisone is usually the treatment of choice for glucocorticoid treatment. Fludrocortisone is used for mineralocorticoid replacement. Complications should be screened for including an adrenal crisis and osteoporosis.

Answer 37

complications of addisonian crisis are: Low blood pressure Vomiting and diarrhoea Dehydration Shock Coma Death Management is Fluid resuscitation is hypotensive. IV hydrocortisone 100mg (Stat and then continue regularly) IV glucose if hypoglycaemic Swap back to their oral steroids after 3 days Consider fludrocortisone if there is adrenal disease

Answer 38

Lethargy, constipation, weight gain - general hypothyroidism - painless goitre - plasma cell infiltration into thyroid Associated with anti- TPO (thyroperoxidase) antibodies in 90-95% of patients

Answer 39

The most common cause of Cushing's is chronic steroid therapy. Therefore, the first step in the management in these patient is to attempting weaning prednisolone therapy on discussion with the rheumatologists.

Answer 40

DVLA guidance states that if a patient has more than one severe episode of hypoglycaemia whilst awake or one episode of severe hypoglycaemia whilst driving then they must stop driving immediately and inform the DVLA. Their license will be revoked but they can reapply after three months. A severe episode of hypoglycaemia is defined as an episode the patient required help from another person to manage.

Answer 41

A HbA1c of 6.5% is recommended as the cut point for diagnosing diabetes. It is important to note that HbA1c levels can be affected by a variety of factors including those with accelerated red cell turn over (e.g. haemoglobinopathies, malaria, anaemia)

Answer 42

High risk groups for developing GDM are those who have a family origin with a high prevalence of type 2 diabetes; Middle eastern, South Asian and Afro-Caribbean. Previous GDM is a risk factor Large babies >4.5kg Previous stillbirth or perinatal death Maternal obesity (BMI>30) Family history of diabetes in first degree relatives.

Answer 43

Rhabdomyolysis is caused by skeletal muscle breakdown. This causes the release of intracellular contents such as myoglobin and potassium into the blood stream. Excess myoglobin can precipitate in the glomerulus causing renal obstruction, direct nephrotoxicity and acute kidney injury. Causes: Trauma: prolonged immobilisation (e.g. long lie in elderly patients), crush injuries, burns, seizures, compartment syndrome. Ischaemia: embolism, surgery Toxins: Statins, fibrates, ecstasy, neuroleptics It can also present following very strenuous exercise (e.g. spin class).

Answer 44

Muscle pain, swelling Red/brown urine Acute kidney injury 10-12 hours after initial pain/injury

Answer 45

Creatine kinase - the most reliable indicator of muscle damage. A 5 fold rise from the upper limit of the reference range suggests rhabdomyolysis although the levels are often much higher. Raised LDH (suggestive of muscle damage) Hyperkalaemia (liberated from the damaged muscle) Hyperphosphatemia (liberated from the damaged muscle) Hyperuricaemia (liberated from damaged muscle) Hypocalcaemia (calcium is taken into the damaged muscle by several mechanisms). Urine tests will often be falsely positive for blood on dipstick with no red blood cells seen on microscopy. This is due to the myoglobinuria, which is the reason why the urine is typically described as tea- or cola-coloured urine

Answer 46

Creatine kinase - the most reliable indicator of muscle damage. A 5 fold rise from the upper limit of the reference range suggests rhabdomyolysis although the levels are often much higher. Raised LDH (suggestive of muscle damage) Hyperkalaemia (liberated from the damaged muscle) Hyperphosphatemia (liberated from the damaged muscle) Hyperuricaemia (liberated from damaged muscle) Hypocalcaemia (calcium is taken into the damaged muscle by several mechanisms). Urine tests will often be falsely positive for blood on dipstick with no red blood cells seen on microscopy. This is due to the myoglobinuria, which is the reason why the urine is typically described as tea- or cola-coloured urine

Answer 47

Patients are often treated with supportive therapy. This includes IV fluids and management of hyperkalaemia. Treat K+ >6.5mmol/L or any with ECG changes with the following; Give 10ml of 10% calcium gluconate (or chloride) over 10 mins - this is cardioprotective Intravenous insulin (10U soluble insulin) in 25g glucose (50mL of 50% or 125ml of 20% glucose) - insulin causes intracellular K^+^ shift and glucose to required to prevent hypoglycaemia Nebulised salbutamol - also causes intracellular K^+^ shift

Answer 48

The zona glomerulosa produces mineralocorticoids (e.g aldosterone). These are responsible for controlling sodium and potassium balance

Answer 49

The zona reticularis produces androgens which are sex hormones which have weak effects until they are converted peripherally to testosterone and dihydrotestosterone. The zona glomerulosa produces mineralocorticoids (e.g aldosterone)

Answer 50

The zona reticularis produces androgens which are sex hormones which have weak effects until they are converted peripherally to testosterone and dihydrotestosterone. The zona glomerulosa produces mineralocorticoids (e.g aldosterone)

Answer 51

The zona fasciculata produces glucocorticoids (e.g. cortisol). These affect carbohydrate, lipid and protein metabolism.

Answer 52

The adrenal medulla produces adrenaline and noradrenaline.

Answer 53

The deeper you go the better it gets, salt -> sugar -> sex

Answer 54

Galactorrhoea refers to milky secretion from the breasts Causes: Idiopathic Prolactinoma Drugs: Antipsychotics, antidepressants (SSRIs), Cimetidine, beta-blockers Metabolic conditions such as hypothyroidism, liver disease and chronic renal impairment

Answer 55

If there is a medication issue identified then it is best to discuss switching that medication for an alternative. However in the situation for example where a patient has a significant mental health disorder such as schizophrenia and they need to continue on their prescribed anti-psychotic agent such as Risperidone, then they may need to have a dopamine agonist such as Cabergoline prescribed in parallel to counter this side effect. Caution is advised when co-prescribing as it may make the original drug less effective.

Answer 56

Charcot arthropathy is a chronic destructive disease of the bone and joints in patients with neuropathy. It is characterised by painful or painless bone and joint destruction in patients with limbs that have lost sensory innervation. The most common underlying aetiology is diabetes. Diabetes leads to microvascular disease, autonomic neuropathy and peripheral neuropathy which synergistically leads to cumulative damage to the joints. Rarer causes includes syringomyelia, alcohol and syphilis. Osteomyelitis is the main differential diagnosis to rule out.

Answer 57

Charcot's Arthropathy presents with the 6Ds: Destruction Deformity Degeneration Dense bones Debris Classically, it affects the tarsometatarsal joints. - bone in foot

Answer 58

Conservative: Prolonged immobilisation (offloading) Orthotics Medications Bisphosphonates Neuropathic pain agents Topical anesthetics Surgical Resetion of bony prominences Deformity correction Amputation

Answer 59

Parathyroid adenoma - responsible for 85% of cases

Answer 60

Osteoporosis is an osteopaenic disease characterised by fragility fractures.

Answer 61

Age (>50 for women and >65 for men) Female sex Further risk factors can be remembered by the mnemonic SHATTERED FAMILY: S – Steroid use H – Hyperthyroidism, hyperparathyroidism A – Alcohol and smoking T – Thin (BMI<22) T – Testosterone deficiency E – Early menopause R – Renal/liver failure E – Erosive/inflammatory bone disease D – Diabetes FAMILY HISTORY

Answer 62

The following groups of people should have their 10 year fracture risk calculated using a tool such as FRAX or Qfracture: All men >75 All women >65 All men and women >50 if they have: Family history of hip fracture Falls history Previous fragility fracture Low BMI Drink >4U per day of alcohol Are/were on steroids Disease associated with osteoporosis (e.g. Coeliac disease, inflammatory bowel disease, hyperparathyroidism)

Answer 63

DEXA scan (Gold standard) X-rays (wrist, heel, spine, hip) if fractures suspected MRI spine (to look for vertebral fracture)

Answer 64

If patients are at risk of developing osteoporosis, they should be assessed using a scoring system such as QFracture or FRAX. All women aged over 65 should be assessed and men aged over 75. Younger patients should be assessed if they have risk fractures e.g. a previous fragility fracture of frequent use of oral corticosteroids. Depending on this score they may be offered a bone density scan of the spine and hip. A score which shows a 10 year fracture risk of greater than 10% requires further assessment using a bone density scan. T-scores compare the patient's bone density with that of a young patient of the same gender. A score of 0 is average. A positive or negative score indicates how many standard deviations away from the mean the patient's bone density is. Osteoporosis is diagnosed when patients have a T-score of less than 2.5 standard deviations below the mean. A score of between -1 and -2.5 indicates osteopenia. The Z-score corrects the bone density score for age and sex. A score of less than 2 standard deviations from the mean indicates an abnormality that cannot be explained by aging but it is not used to formally diagnose osteoporosis.

Answer 65

Lifestyle changes: Reduce risk factors - eg. stop smoking, better diabetic control Diet - adequate vitamin D, calcium, protein Regular weight bearing exercise Hip protectors in nursing home patients First line pharmacological treatment Bisphosphonates: - First line - Given weekly - Incorporated into osteoclast cells and interfere with cell function causing cells to be non-functional and apoptose - Patients should be able to tolerate sitting up for at least 30 minutes after dose and drink with glass of water to reduce the risk of developing oesophageal ulcer - Other side effects include: atrial fibrillation, osteonecrosis of the jaw, atypical stress fractures Vitamin D and calcium supplements can also be added if there is evidence of deficiency. Second line and further pharmacological treatments Denosumab - A monoclonal antibody which inhibit receptors which, when activated, lead to the maturation of osteoclasts. Raloxifene - used in postmenopausal women Binds to oestrogen receptors and exerts same protective action that oestrogen performs on bones by inhibiting osteoclastic action. Most useful in post-menopausal women. Hormone replacement therapy (in women with premature menopause) Teriparatide (a parathyroid hormone) - stimulates bone growth Strontium ranelate - reduces the rate of bone turnover and stimulates bone growth.

Answer 66

Amenorrhoea suggests gonadotrophin deficiency and occurs early in the sequence of pituitary hormone loss. Patients can also present with prolactin excess causing functional suppression of the pituitary gonadal axis

Answer 67

The deprivation test also distinguishes diabetes insipidus from primary polydipsia which is a condition characterised by similar symptoms of polydipsia and polyuria. The latter condition is usually due to a psychological cause of excessive drinking. Upon testing, urine osmolality is normal both after fluid deprivation and after desmopressin is given.

Answer 68

Low urine osmolality after water deprivation, normal urine osmolality after desmopressin IM injection

Answer 69

Low urine osmolality after water deprivation, low urine osmolality after desmopressin IM injection low osmolality following desmopressin injection indicated ADH resistance

Answer 70

Overnight dexamethasone suppression Test involves giving oral 1mg dexamethasone at 11pm the night before and testing the serum cortisol at 8am the next morning when there is normally a peak in healthy individuals

Answer 71

High Dose Dexamethasone suppression test This is useful when in the presence of high serum cortisol there is measurable ACTH and we wish to distinguish between pituitary and ectopic ACTH secretion. In the former the ACTH will be suppressible while in the latter it cannot be suppressed. This is not the initial investigation that should be used in investigating patients with suspected Cushings

Answer 72

In the elderly, an asymptomatic thyroid mass which is slow growing can represent cystic disease or a colloid nodule. These are benign and are not usually associated with any mass effects or thyroid hormone dysfunction. Patients may be concerned about their cosmetic appearance but they generally do not require any treatment. thyroid nodules are more common in females. Physical findings suggestive of a thyroid malignancy include a fixed or firm nodule, a recent history of enlargement, fixation to neighbouring tissues and regional lymphadenopathy

Answer 73

Impaired glucose tolerance is a pre-diabetic state defined as: Fasting glucose <6.9mmol/L 2h glucose 7.8-11mmol/L

Answer 74

A 75g oral glucose tolerance test ≥11.1 mmol/L (≥200 mg/dL) at 2 hours can be used as a diagnostic test for diabetes Normal fasting glucose is >6mmol/L

Answer 75

If symptomatic one of the following results is sufficient: Random blood glucose =11.1mmol/l Fasting plasma glucose =7mmol/l 2 hour glucose tolerance =11.1mmol/l HbA1C =48mmol/mol (6.5%) If the patient is asymptomatic two results are required from different days.

Answer 76

Insulin should never be held in type 1 diabetic patients; however, dose adjustments may be required in renal impairment. If the patient has a reduced oral intake, a variable-rate insulin infusion may be required. Metformin should be withheld in patients with AKI due to risk of lactic acidosis

Answer 77

Subacute granulomatous thyroiditis is a destructive thyroiditis usually of viral origin that results in the release of preformed thyroid hormones, in the form of thyroglobulin, into the circulation. Thyroglobulin is degraded by serum proteases into the thyroid hormones thyroxine (T4) and triiothyronine (T3). The thyroid is often enlarged and firm to palpation. Of note, because the thyrotoxicosis is caused by release of preformed hormone, antithyroid medications such as Thiamazole, Propylthiouracil, and Carbimazole are ineffective in reducing thyroid hormone levels.

Answer 78

Alpha-blockers are used to control hypertension and therefore prevent a hypertensive crisis. High circulating catecholamine levels stimulate alpha receptors on blood vessels and cause vasoconstriction. Phenoxybenzamine, a non-selective alpha blocker, is the most common medication used to alpha block patients prior to pheochromocytoma resection. A major disadvantage of Phenoxybenzamine is that it blocks presynaptic alpha-2 receptors enhancing the release of noradrenaline, resulting in a reflex tachycardia

Answer 79

Beta cells of the islets of langerhans produce insulin Alpha cells produce glucagon

Answer 80

Hyperaldosteronism may be primary or secondary in origin and are classically associated with high blood pressure (which is often treatment resistant to multiple agents) and low serum potassium. Conn's syndrome is primary hyperaldosteronism due to a adrenal adenoma

Answer 81

Adrenal adenoma (Conn's Syndrome) Bilateral adrenal hyperplasia Familial hyperaldosteronism Adrenal carcinoma

Answer 82

Biochemical Features Hypertension Hypokalaemia Metabolic alkalosis Clinical Features Patients can present with polyuria, polydipsia, lethargy and headaches. There is also an association with osteoporosis.

Answer 83

FBC/UE/LFT ESR Bone profile Thyroid function tests Chest X-ray ECG Aldosterone/renin ratio - initial screening test CT/MRI to locate adrenal lesions Selective adrenal venous sampling (Gold Standard)

Answer 84

Treatment of aldosterone excess is to identify the underlying cause, often using specialist imaging or adrenal venous sampling and then to surgically remove the affected adrenal gland, or if bilateral adrenal disease then to use medication such as potassium sparing diuretics (e.g. Amiloride, Spironolactone, Eplerenone).

Answer 85

Cortisol The best order to begin the replacement therapy of deficient pituitary hormones to maintain well being is Cortisol, Thyroxine, Sex hormones and if necessary, growth hormone. Administering thyroxine to cortisol deficient patients can make them very unwell

Answer 86

Somatostatin receptor ligand - i.e ocreotide

Answer 87

Bilateral adrenal hyperplasia, classically associated with hypokalaemia is the most common cause of this (60% of patients affected) Conn's syndrome is the second most common cause of mineralocorticoid excess leading to treatment resistant hypertension (35% of cases) Patients can experience moderately severe hypertension and as consequence develop cardiac failure from disproportionate left ventricular hypertrophy. Hypokalaemia is usually asymptomatic although can be associated with cardiac rhythm disturbances and ECG abnormalities. Patients may sometimes present with muscle weakness or tetany. There is also an association with osteoporosis.

Answer 88

Caused by glucocorticoid deficiency. It is associated with postural hypotension, hyponatraemia and hyperkalaemia

Answer 89

Depends on cause Psychosexual therapy Oral phosphodiesterase -5 inhibitors (Sildenafil) Vacuum aids Intra-cavernosal injections Prosthesis Sildenafil (PDE-5 inhibitor) is contraindicated in: those taking nitrates, uncontrolled hypertension (170/100)/hypotension(90/50), arrhythmias, unstable angina, stroke, recent myocardial infarction Caution in: angina, peptic ulcer, liver or kidney impairment, Peyronie's disease, complex antihypertensive regimes

Answer 90

Pituitary apoplexy is a rare emergency and is defined as bleeding into the pituitary gland that occurs in patients who have pituitary tumours There are many precipitating factors for apoplexy these include major surgery, coagulopathy and pregnancy. Classic symptoms include sudden onset headache which is usually retro-orbital in nature and nausea or vomiting. A swollen pituitary gland can compress the contents of the cavernous sinus leading to ocular palsies. 80% of patients will have deficiency of hormones, including a lack of ACTH meaning that cortisol levels are low. This is suggested here by the low sodium. When apoplexy is suspected immediate hydrocortisone should be given with MRI performed to confirm the diagnosis. If patient has ocular signs surgical decompression is warranted

Answer 91

In this condition, there is a failure of target cell response to parathyroid hormone (PTH). This results in a round face, short metacarpals (especially 4th and 5th), short stature and a low IQ. Bloods would reveal low serum calcium with raised PTH. Pseudopseudoparathyroidism presents the same but with normal biochem

Answer 92

Basal-bolus Insulin

Answer 93

Bitemporal hemianopia is associated with optic chiasm compression eg secondary to pituitary adenoma, craniopharyngioma, internal carotid artery aneurysm.

Answer 94

Diabetic peripheral neuropathy is an umbrella term for several types of peripheral neuropathies caused by diabetes. Chronic hyperglycaemia is thought to be a key factor in their pathogenesis.

Answer 95

Distal Symmetrical Sensory Neuropathy (features): Most common Caused by loss of large sensory fibres. Sensory loss in a glove and stocking distribution. Often affecting touch, vibration and proprioception. Small-fibre Predominant Neuropathy (features): Caused by loss of small sensory fibres. Presents with deficits in pain and temperature sensation in a glove and stocking distribution along with episodes of burning pain. Diabetic Amyotrophy (features): Caused by inflammation of lumbosacral plexus or cervical plexus. Severe pain around the thighs and hips. Proximal weakness. Mononeuritis Multiplex (features): Invariably painful. Neuropathies involving =2 peripheral nerves. Autonomic Neuropathy (features): Presents with postural hypotension, gastroparesis, constipation, urinary retention, arrhythmias and erectile dysfunction.

Answer 96

Pregabalin, Duloxetine, and Gabapentin or amitriptyline are considered first-line pharmacotherapies for painful diabetes mellitus. Lifestyle interventions (diet and exercise) are also recommended as they may improve neuropathic symptoms and intra-epidermal nerve fiber density in patients with neuropathy and impaired glucose tolerance

Answer 97

If patient on both long (lantus) and short acting insulin (novarapid rapid acting insulin) - stop the short acting but continue the long acting This makes it easier and safer to switch back to the patient's normal insulin regime once DKA has resolved

Answer 98

Atrial fibrillation - irregularly irregular pulse High output heat failure (if severe and prolonged)

Answer 99

Somatostatin receptor ligands (SLR) such as Octreotide Pegvisomant (GH analogue) Cabergoline (Dopamine agonist) Radiotherapy

Answer 100

Gynaecomastia refers to the presence of excessive breast tissue in men.

Answer 101

Gynaecomastia is usually caused by elevated oestrogen or deficiency of testosterone. Obesity Anabolic steroid use Tumours (Sertoli cell, Leydig cell, germ cell) Chronic illness (testosterone is suppressed more than oestrogen during periods of malnourishment) Exogenous oestrogen Hyperthyroidism Hypogonadotrophic hypogonadism Hyperprolactinaemia (e.g. pituitary disease) Testicular failure (e.g. infection, chemotherapy damage) Medications e.g. spironolactone, GnRH agonists, some chemotherapy agents, ketoconazole

Answer 102

Observation and reassurance Treat underlying cause e.g. treat hypogonadism with testosterone Tamoxifen Danazol Breast reduction surgery

Answer 103

Low gonadotrophins resulting in low testosterone production would fit the profile common cause of gynaecomastia due to the relatively increased oestrogen levels in the context of testosterone deficiency

Answer 104

140/90 if known renal, eye or cerebrovascular complication in patient with type 1 diabetes its 130/80

Answer 105

Anaplastic thyroid cancer - least common type Unless diagnosed early and found during a thyroidectomy, most cases of anaplastic thyroid cancer lead to a rapid death. It is a rare, undifferentiated form of thyroid cancer with a peak incidence in the 7th decade of life. It is characterised by the rapid growth of a firm, hard, fixed tumour. It only has a 7% 5 year survival rate

Answer 106

Symptoms include: lethargy weakness weight gain loss of libido erectile dysfunction gynaecomastia depression It is also associated with infertility and osteoporosis.

Answer 107

FBC Urea and Electrolytes Liver function tests Bone profile Fasting glucose and lipids PSA Oestrogen, testosterone, sex hormone binding globulin LH/FSH Prolactin TSH/T4/T3 Cortisol MRI pituitary Chest radiograph Karyotyping DEXA scan

Answer 108

Definitive management will depend on the cause Hormone replacement therapy in the form of topical, oral, buccal or intra-muscular injections of testosterone is the main stay of treatment in those with persistent and symptomatic hypogonadism. Monitoring of therapy needs to continue under specialist care to assess for polycythaemia (testosterone has a direct effect on erythrocytosis), bone mineral density (DEXA bone scanning, prostate status and LFT's (synthetic hormones can affect liver function). Gynaecomastia can also be caused by any condition which relates to low testosterone or elevated oestrogen levels in men eg. Klinefelter's syndrome, obesity, drugs, adrenal tumours.

Answer 109

Can cause bone marrow suppression -> agranulocytosis (a reduction in white blood cells) which is rare (0.03%) but can can lead to life-threatening sepsis. It may present with a sore throat, fever or throat/mouth ulcers. If it is suspected, warn the patient to stop the drug and get an urgent full blood count (FBC) Carbimazole inhibits thyroid peroxidase

Answer 110

A condition occurring in women with autoimmune disease difficult to distinguish from other problems such as Grave's disease Both of which are antibody positive and have the same symptoms. Postpartum thyroiditis tends to have a hyperthyroid phase in the first 3 months post pregnancy and then go into a hypothyroid phase. The risk of misdiagnosis here therefore is that if anti-thyroid medication is given to a person who is becoming hypothyroid as part of the natural course of thyroiditis then you could make them even more unwell. Watch and wait is the appropriate management

Answer 111

Maternal obesity Polyhydramanios Large previous baby >4.5kg South asian, afro-caribbean, middle eastern maternal old age

Answer 112

Diagnosis is confirmed by chromosomal analysis and low testosterone with raised FSH>LH ratio

Answer 113

TB adrenalitis is a well recognised cause of Addison's disease and is in fact the pathological finding first seen in a series of cases by Thomas Addison that caused adrenal gland destruction. Although a more common cause in the developed world is autoimmune adrenal insufficiency

Answer 114

Nelson syndrome is where where in the setting of Cushing’s syndrome a bilateral adrenalectomy has taken place. As a consequence, there is a loss of feedback to the brain and we get increased Corticotrophin-Releasing Hormone from the hypothalamus leading to increased stimulation of the anterior pituitary and enlargement of the pituitary and formation of an adenoma. This leads to symptoms of mass effect with headaches, visual field defects but also hormonal issues with compression of the posterior pituitary. Primary treatment is transphenoidal surgery headaches, blurred vision and increasing skin pigmentation

Answer 115

Laboratory measurement of serum follicle-stimulating hormone and luteinising hormone concentrations will help to differentiate patients with hypogonadotrophic hypogonadism (low levels) and hypergonadotrophic hypogonadism (elevated levels). The measurements should be performed on an early-morning blood sample using an ultrasensitive paediatric assay. It is considered a first-line test in delayed puberty.

Answer 116

Hypogonadotrophic hypogonadism results from a lack of serum gonadotrophin production or action, usually due to a hypothalamo-pituitary abnormality. Hypergonadotrophic hypogonadism results from gonadal insufficiency, and manifests with elevated serum gonadotrophin concentrations in the absence of pubertal signs at the appropriate age for puberty. Examples include Turner syndrome and Klinefelter's syndrome

Answer 117

Insulin Tolerance Test Traumatic brain injury can cause failure of anterior pituitary hormone production. This can result in a mixed presentation of hormone deficiency states. An insulin tolerance test stimulates hypoglycaemia (to less than 2.2 mmol/l) which in turn aggravates a stress response. Given that we know what the normal dynamic response to such stress would be for both ACTH/cortisol and growth hormone this makes it the best test in this situation to ascertain the functioning of the pituitary-adrenal axis. Side effects of such significant stress include seizures, cardiac arrest and death

Answer 118

Short synacthen test - test of adrenal gland function long synacthen test - test is used in patients with long term adrenal suppression, such as those on steroid medication

Answer 119

Amiodarone is a highly effective medication used predominantly in rhythm control of atrial fibrillation, but can be used to manage other arrhythmias. It is also often used in acute arrhythmias. Hypothyroidism (more common than hyperthyroidism) Hyperthyroidism Corneal deposits Stevens-Johnson syndrome Grey discoloration of the skin Liver failure

Answer 120

Thyroid crisis is a rare, serious life threatening form of hyperthroidism. It can occur in thyrotoxic patients who experience an acute stressor such as trauma / surgery / infection. It can cause marked hyperthyroid symptoms and multi-system compensation. It has a significant mortality of 30-50%. Supportive management in a high dependency setting is required, along with high dose anti-thyroid medication, the use of potassium iodide (to inhibit thyroid hormone release from the gland), beta blockers and high dose steroids (which block conversion of T4 to T3. Plasmapheresis may be used in those unresponsive to these measures

Answer 121

IV propranolol IV digoxin Propylthiouracil through NG tube followed by Lugol's iodine 6 hours later Prednisolone/hydrocortisone

Answer 122

Common features of acromegaly include coarsening of facial features, soft-tissue and skin changes (including oily skin) , carpal tunnel syndrome, joint pain, and snoring

Answer 123

In hypocalcaemia we have signs of tetany which is of nerve hyperexcitability. Chvostek sign refers to a reaction to percussion of the facial nerve in front of the ear lobe and below the zygomatic process. When present we get ipsilateral contraction of the muscles of the face. While it may be be present it does not suggest the underlying cause of the hypocalcaemia. Other features one might expect in hypocalcaemia include perioral and extremity numbness, laryngospasm and arrhythmia

Answer 124

Clinical features of hypocalcaemia can be remembered by the mnemonic 'SPASMODIC'. SPASMODIC: S – Spasms (Trousseau's sign) P – Perioral parasthaesia A – Anxiety/Irritability S – Seizures M – Muscle tone increase (colic, dysphagia) O– Orientation impairment (i.e. confusion) D – Dermatitis I – Impetigo herpetiformis C – Chvostek's sign

Answer 125

Management of acute hypocalcaemia: Mild: oral calcium supplementation Severe (spasms or ECG changes): IV calcium gluconate repeated as needed Long term management: Treat cause Encourage good dietary calcium and Vitamin D intake Calcium and Vitamin D supplementation Alphacalciferol if CKD Magnesium supplements if concurrent hypomagnesaemia

Answer 126

Threefold: stop thyroid hormone synthesis, block release of further thyroid hormone, inhibit peripheral conversion of T4 to T3. The first priority is to stop thyroid hormone synthesis and both PTU and carbimazole will achieve this. PTU is more rapid onset and also plays a role in blocking the peripheral conversion of T4 to T3, but it has liver toxicity potential. Carbimazole does not block peripheral conversion of T4 to T3 but does block thyroid hormone synthesis and does not have the potential for liver toxicity. In thyrotoxicosis, always avoid salicylates because they are associated with displacement of thyroid hormone from thyroxine-binding globulin (TBG)

Answer 127

Biguanides Lactic acidosis and GI disturbance. Sulfonylureas Hypoglycaemia and weight gain. Thiazolidinediones i.e pioglitazone Fluid retention, weight gain and worsening heart failure. SGLT2 Inhibitors i.e canagliflozin Diabetic Ketoacidosis when used with insulin and increased risk of urinary tract infections. DPP4-Inhibitors Hypoglycaemia and GI upset. GLP1 Analogues Hypoglycaemia, GI upset and may increase the risk of pancreatitis when used with DPP4-inhibitors. Intestinal alpha-glucosidase inhibitors Flatulence and GI disturbance.

Answer 128

To do this one must work out the total 24 hour insulin requirement, then we must apply this to a basal bolus regime. The purpose of this is so simulate normal insulin secretion. There is always some insulin detectable in the blood but there are peaks corresponding to glycaemic load when meals are eaten. This is what we simulate. To work out the relative doses we consider there are 3 meals a day, so three-fifths of the total insulin for the 24 hour period should cover each of the meals in this cause 72 units. We then divide this by 3 to work out the number of short acting insulin units needed to be taken with each meal in this case 24 units. This works within 10-20 minutes and lasts for 3-5 hours. The remaining 2/5th is given as a long acting insulin like Lantus this has a much broader wave of activity lasting typically 18-24 hours

Answer 129

Multiple Endocrine Neoplasia (MEN) is a group of genetic conditions characterised by the formation of hormone-producing tumours in multiple endocrine organs.

Answer 130

Caused by mutation in the MEN 1 gene Parathyroid: hyperplasia/adenomas 95% of cases Pancreas: gastrinoma, insulinoma 70% of cases Pituitary: prolactinoma 70% of cases

Answer 131

Caused by mutation in the RET gene Thyroid: medullary thyroid cancer 90% of cases Adrenal: pheochromocytoma 50% of cases Parathyroid: hyperplasia/adenomas 80%

Answer 132

Thyroid: medullary thyroid cancer Adrenal: pheochromocytoma Parathyroid: hyperplasia/adenomas Mucosal neuromas Marfanoid appearance and no hyperparathyroidism

Answer 133

24 hour urinary 5HIAA 5HIAA is the metabolite of serotonin the neurotransmitter which mediates the effects of carcinoid syndrome. It can be detected in sufficient quantities in the urine. Carcinoid syndrome is the release of endocrine products from tumours (often within the gut) which have potent effects such as flushing, sweating and and wheezing

Answer 134

Mild DKA - hyperglycaemia/ diagnosis of diabetes, blood ketones >3 mmol/L, urine ketones >2 + as well as a pH of 7.2-7.29, and/ or a bicarbonate of < 15 mmol/L Moderate - hyperglycaemia/ diagnosis of diabetes, blood ketones >3 mmol/L, urine ketones >2 + as well as a pH of 7.1-7.19 and/ or a bicarbonate of <10 mmol/L Severe - hyperglycaemia/ diagnosis of diabetes, blood ketones >3 mmol/L, urine ketones >2 + as well as a pH of <7.1 and/ or a bicarbonate of <5 mmol/L.

Answer 135

Important to first ascertain whether there is a history. of diabetes - if none and HbA1c normal then can assume steroid induced diabtes Sulphonyulrea therapy, such as Gliclazide is the first agent to use and suggested by the Joint British Diabetes Society. This option can be used to a maximum 240mg/day

Answer 136

Prolactinomas respond well to dopamine agonists and in turn decrease in size, hence why medication is stopped after resolution of symptoms. Weaning down and discontinuing the dopamine agonist after a year's worth of treatment, in the context of a pituitary microprolactinoma (less than 10mm) is a safe and appropriate thing to do. Monitoring of the serum prolactin should take place but in the majority of cases the hyperprolactinaemia will resolve. If the prolactin levels are resurgent then restarting the medication and considering definitive surgery are the next steps Transphenoidal surgery is more appropraite if the patient had a macroadenoma (>10mm)

Answer 137

Patients present with the signs, symptoms and biochemical findings of Cushing’s syndrome but the cause is not an abnormality within the hypothalamus-pituitary-adrenal axis. In Cushing’s syndrome, the diurnal variation in cortisol is completely lost, whereas in this case it is normal. Chronic alcoholism is a cause of pseudo-Cushing’s and these tests should be repeated when the patient has been abstinent from alcohol for a month.

Answer 138

Toxic adenoma, which is a solitary nodule producing T3 and T4 causing hyperthyroidism If examination reveals a lump in the neck, ultrasound should be arranged and if there is evidence of hyperthyroidism - a radioistope uptake scan should be done The ultrasound will help to identify whether there is a goitre (multi-nodular or smooth) or a single nodule, and the radioisotope scan will help to identify if any areas are ‘hot’, meaning they take up iodide and secrete thyroid hormone. The first-line management for toxic adenoma or toxic multinodular goitre is radioiodine administration.

Answer 139

Results demonstrate a fasting glucose >6mmol/L and <7mmol/L under 6 is normal

Answer 140

Papillary thyroid cancer - 60% Follicular thyroid cancer - 25% - most likely thyroid malignancy Medullary thyroid cancer + Lymphoma - 5% each Anaplastic - 1%

Answer 141

Biguanides e.g. Metformin Increase peripheral insulin sensitivity and hepatic glucose uptake. Sulfonylureas e.g. Gliclazide Depolarise islet cells in the pancreas increasing insulin release - by altering potassium channel activity Thiazolidinediones e.g. Pioglitazone Increase peripheral insulin sensitivity. SGLT2 Inhibitors e.g. Dapgliflozin Increase urinary glucose loss. DPP4-Inhibitors e.g. Sitagliptin Inhibit GLP1 breakdown. GLP1 Analogues e.g. Exenatide Increase insulin secretion and sensitivity. Intestinal Alpha-Glucosidase Inhibitors e.g. Acarbose Delay intestinal carbohydrate absorption

Answer 142

In cystic fibrosis, chronic obstruction of small airways and pancreatic ducts due to thick mucus leads to recurrent pneumonia and pancreatic failure respectively. Pancreatic failure manifests as secondary diabetes (due to lack of insulin production) and malabsorption (due to lack of digestive enzyme production)

Answer 143

Sick euthyroid syndrome is an abnormality of the thyroid function tests that can occur in any systemic illness. The most common abnormality is that the free T3 is low with a normal to low free T4 and TSH. These patients tend to have no symptoms of thyroid disease and it is usually seen in critical illness or in starvation states. Repeat thyroid function tests should be performed in 6 weeks after the patient has recovered.

Answer 144

Of the functioning pituitary adenomas, prolactin is the hormone which is most commonly excreted to excess. In women hyperprolactinaemia can cause amenorrhoea, galactorrhoea and infertility. In men it can cause gynaecomastia, erectile dysfunction, reduced sex drive and less body hair. Pituitary tumours can also can non-specific mass effects including headaches, nausea, vomiting and seizures. 75% of pituitary tumours are functional (hormone producing) and 50% of these secrete prolactin, 20% secrete growth hormone, 20% secrete ACTH and 10% are multi-functional

Answer 145

Of the functioning pituitary adenomas, prolactin is the hormone which is most commonly excreted to excess. In women hyperprolactinaemia can cause amenorrhoea, galactorrhoea and infertility. In men it can cause gynaecomastia, erectile dysfunction, reduced sex drive and less body hair. Pituitary tumours can also can non-specific mass effects including headaches, nausea, vomiting and seizures. 75% of pituitary tumours are functional (hormone producing) and 50% of these secrete prolactin, 20% secrete growth hormone, 20% secrete ACTH and 10% are multi-functional

Answer 146

First line is Bisphosphonates and common one is alendronic acid

Answer 147

growth hormone -> LH -> FSH -> thyroid -> ACTH

Answer 148

The test to screen for Addison's disease by undertaking a 9AM Cortisol blood test. The rationale for the timing of the test is due to the diurnal variation of cortisol production (highest in the morning and lowest at midnight). A low cortisol level at 9 AM suggests adrenal insufficiency, the confirmatory test to follow this is a short synacthen test

Answer 149

Hyperglycaemia and raised ketones in the absence of acidosis is known as diabetic ketosis. Although the patient does not have a previous history of diabetes, a random blood glucose of >11.1 mmol/L is suggestive of a new diagnosis. The treatment for this would be guided by trust policy and specialist advice, but would involve subcutaneous insulin, fluids (IV or oral depending on clinical picture) and careful ongoing monitoring of blood glucose and ketones

Answer 150

Medullary thyroid cancers are a cancer of the parafollicular cells and so secrete calcitonin. Medullary cancer is monitored with serum calcitonin every 3 months for 2 years, followed by every 6 months for 3 years. If levels are undetectable they can then be followed annually

Answer 151

Diabetics with ulcers commonly experience infection with gram-positive organisms such as Staphylococcus aureus, Enterococcus, and gram-negative organisms like Pseudomonas aeruginosa, Escherichia coli, Klebsiella species, Proteus species and anaerobes.

Answer 152

Gastroparesis is a recognised gastro-intestinal complication of diabetes, related to poor glycaemic control. Gastroparesis is caused by nerve damage to the autonomic nervous system. The vagus nerve is responsible for controlling the gastric muscles and if this is damaged can lead to delayed gastric emptying, offensive egg smelling burps due to bacterial overgrowth, early satiety, abnormal stomach wall movements and morning nausea There may also be fluctuations in blood glucose levels as there is often a mismatch between food ingested food a meal and the insulin dose being injected that would normally be intended to cover the glucose rise after eating that meal.

Answer 153

Treatment includes the use of motility agents such as metoclopramide or domperidone, tight glycaemic control, antibiotics such as Erythromycin to kill off the bacterial overgrowth and botox injections to relax the gastric outflow obstruction. Gastric pacemakers are occasionally used if all else fails.

Answer 154

Exogenous corticosteroid exposure is the most common cause of Cushing's syndrome. A thorough medical and medication history should reveal whether this is the cause

Answer 155

Can present similar to shcok this condition can be caused by adrenal insufficiency as a result of chronic steroid exposure. Steroids suppress the hypothalamic-pituitary-adrenal axis causing endogenous adrenal failure and an inability to respond to acute illnesses such as infections. The correct treatment for a hypotensive patient in this context is intravenous fluid, large volumes of 0.9% saline, which will help overcome circulatory collapse

Answer 156

Can present similar to shcok this condition can be caused by adrenal insufficiency as a result of chronic steroid exposure. Steroids suppress the hypothalamic-pituitary-adrenal axis causing endogenous adrenal failure and an inability to respond to acute illnesses such as infections. The correct treatment for a hypotensive patient in this context is intravenous fluid, large volumes of 0.9% saline, which will help overcome circulatory collapse

Answer 157

Vitreous haemorrhage Under the circumstances any of the following retinal features are reasons for immediate referral to an ophthalmologist; proliferative retinopathy - R3 (new blood vessels), vitreous haemorrhage, advanced retinopathy with retinal detachments

Answer 158

IV Glucose

Answer 159

Metformin is associated with lactic acidosis, particularly in conditions that also raise lactate, such as sepsis and renal impairment. In this case, it should be withheld and blood glucose monitored, with consideration of alternative antidiabetic therapy, especially while the patient remains clinically unwell. Dapagliflozin is another antidiabetic drug that can cause euglycaemic diabetic ketoacidosis.

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