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endo Flashcards

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1
Q

Addisonion crisis

A

Causes
sepsis or surgery causing an acute exacerbation of chronic insufficiency (Addison’s, Hypopituitarism)
adrenal haemorrhage eg Waterhouse-Friderichsen syndrome (fulminant meningococcemia)
steroid withdrawal

Management
hydrocortisone 100 mg im or iv
1 litre normal saline infused over 30-60 mins or with dextrose if hypoglycaemic
continue hydrocortisone 6 hourly until the patient is stable. No fludrocortisone is required because high cortisol exerts weak mineralocorticoid action
oral replacement may begin after 24 hours and be reduced to maintenance over 3-4 days

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2
Q

Gieltman’s syndrome

A

salt wasting nephropathy

Gitelman’s syndrome is due to a defect in the thiazide-sensitive Na+ Cl- transporter in the distal convoluted tubule.

Features
normotension
hypokalaemia
hypocalciuria
hypomagnesaemia
metabolic alkalosis
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3
Q

Kallman’s syndrome

A

failure of GnRH-secreting neurons to migrate to the hypothalamus.

Features
‘delayed puberty’
hypogonadism, cryptorchidism
anosmia
sex hormone levels are low
LH, FSH levels are inappropriately low/normal
patients are typically of normal or above average height

Cleft lip/palate and visual/hearing defects are also seen in some patients

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4
Q

Thiazolidinediones

A

agonists of PPAR-gamma receptors, reducing peripheral insulin resistance

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5
Q

hypercalcaemia

A

Two conditions account for 90% of cases of hypercalcaemia:

  1. Primary hyperparathyroidism: commonest cause in non-hospitalised patients
  2. Malignancy: the commonest cause in hospitalised patients. This may be due to number of processes, including; bone metastases, myeloma, PTHrP from squamous cell lung cancer
Other causes include
sarcoidosis*
vitamin D intoxication
acromegaly
thyrotoxicosis
Milk-alkali syndrome
drugs: thiazides, calcium containing antacids
dehydration
Addison's disease
Paget's disease of the bone**
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6
Q

hypertension
hypokalaemia (e.g. muscle weakness). This is a classical feature in exams but studies suggest this is seen in only 10-40% of patients
alkalosis

A

Conn’s (hyperaldosteronism) adrenal adenoma

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7
Q

Conn’s Ix

A

renin angiotensin ratio
high aldosterone levels alongside low renin levels (negative feedback due to sodium retention from aldosterone)
following this a high-resolution CT abdomen and adrenal vein sampling is used to differentiate between unilateral and bilateral sources of aldosterone excess

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8
Q

Conn’s Mx

A

Management
adrenal adenoma: surgery
bilateral adrenocortical hyperplasia: aldosterone antagonist e.g. spironolactone

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9
Q

most consistent PCOS feature

A

cysts in ovaries.. obviously

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10
Q

PCOS Ix

A

pelvic ultrasound: multiple cysts on the ovaries
FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
check for impaired glucose tolerance

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11
Q

PCOS features

A

subfertility and infertility
menstrual disturbances: oligomenorrhea and amenorrhoea
hirsutism, acne (due to hyperandrogenism)
obesity
acanthosis nigricans (due to insulin resistance)

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12
Q

This is characterised as monomorphic papular rash without comedones or cysts

A

drug induced acne (systemic glucocortoids)

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13
Q

T1DM pathophysiology

A

autoimmune disease
antibodies against beta cells of pancreas
HLA DR4 > HLA DR3
various antibodies such as islet-associated antigen (IAA) antibody and glutamic acid decarboxylase (GAD) antibody are detected in patients who later go on to develop type 1 DM - their prognostic significance is not yet clear

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14
Q

T2DM HbA1c level

A

you can titrate up metformin and encourage lifestyle changes to aim for a HbA1c of 48 mmol/mol (6.5%), but should only add a second drug if the HbA1c rises to 58 mmol/mol (7.5%)

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15
Q

carbimazole

A

Carbimazole is used in the management of thyrotoxicosis. It is typically given in high doses for 6 weeks until the patient becomes euthyroid before being reduced.

Mechanism of action
blocks thyroid peroxidase from coupling and iodinating the tyrosine residues on thyroglobulin → reducing thyroid hormone production
in contrast propylthiouracil as well as this central mechanism of action also has a peripheral action by inhibiting 5’-deiodinase which reduces peripheral conversion of T4 to T3

Adverse effects
agranulocytosis
crosses the placenta, but may be used in low doses during pregnancy

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16
Q

metformin increases peripheral insulin sensitivity in PCOS leading to..

A

increased fertility in hypothalamic pituitary gonadal axis

not well understood.

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17
Q

graves autoantibodies

A

Autoantibodies
TSH receptor stimulating antibodies (90%)
anti-thyroid peroxidase antibodies (75%)

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18
Q

graves features

A

Features
typical features of thyrotoxicosis
specific signs limited to Grave’s (see below)

Features seen in Graves’ but not in other causes of thyrotoxicosis
eye signs (30% of patients): exophthalmos, ophthalmoplegia
pretibial myxoedema
thyroid acropachy

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19
Q

myxodaemic coma Rx

A

levothyroxine and hydrocortisone

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20
Q

pseudohypoparathyroidism

A

target cells being insensitive to PTH
due to abnormality in a G protein
associated with low IQ, short stature, shortened 4th and 5th metacarpals
low calcium, high phosphate, high PTH

diagnosis is made by measuring urinary cAMP and phosphate levels following an infusion of PTH.

In hypoparathyroidism this will cause an increase in both cAMP and phosphate levels. In pseudohypoparathyroidism type I neither cAMP nor phosphate levels are increased whilst in pseudohypoparathyroidism type II only cAMP rises.

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21
Q

SGLT2 inhibitors (sodium glucose transporter) - flozins

A

act in early distal convoluted tubules preventing glucose reabsorption

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22
Q

Mature Onset Diabetes of Young (<25)

Autosomal dominant

A

MODY 3
60% of cases
due to a defect in the HNF-1 alpha gene
is associated with an increased risk of HCC

MODY 2
20% of cases
due to a defect in the glucokinase gene

Features of MODY
typically develops in patients < 25 years
a family history of early onset diabetes is often present
ketosis is not a feature at presentation
patients with the most common form are very sensitive to sulfonylureas, insulin is not usually necessary

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23
Q

metabolic syndrome

A

elevated waist circumference: men > 102 cm, women > 88 cm
elevated triglycerides: > 1.7 mmol/L
reduced HDL: < 1.03 mmol/L in males and < 1.29 mmol/L in females
raised blood pressure: > 130/85 mmHg, or active treatment of hypertension
raised fasting plasma glucose > 5.6 mmol/L, or previously diagnosed type 2 diabetes

Other associated features include:
raised uric acid levels
non-alcoholic fatty liver disease
polycystic ovarian syndrome

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24
Q

MEN 2B

A

Medullary thyroid cancer

1 P
Phaeochromocytoma

Marfanoid body habitus
Neuromas

RET Oncogene

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25
MEN 2A
Medullary thyroid cancer (70%) 2 P's Parathyroid (60%) Phaeochromocytom RET Oncogene (not marfanoid)
26
Men 1
3 P's Parathyroid (95%): hyperparathyroidism due to parathyroid hyperplasia Pituitary (70%) Pancreas (50%): e.g. insulinoma, gastrinoma (leading to recurrent peptic ulceration) Also: adrenal and thyroid MEN1 gene Most common presentation = hypercalcaemia
27
Sick euthyroid syndrome
TSH normal / low; thyroxine low; T3 low
28
Thyrotoxicosis with tender goitre =
subacute (De Quervain's) thyroiditis ``` There are typically 4 phases; phase 1 (lasts 3-6 weeks): hyperthyroidism, painful goitre, raised ESR phase 2 (1-3 weeks): euthyroid phase 3 (weeks - months): hypothyroidism phase 4: thyroid structure and function goes back to normal ``` Investigations thyroid scintigraphy: globally reduced uptake of iodine-131 Management usually self-limiting - most patients do not require treatment thyroid pain may respond to aspirin or other NSAIDs in more severe cases steroids are used, particularly if hypothyroidism develops
29
radioiodine can cause
worsening in thyroid eye disease in 15% grave's
30
weight gain by which diabetic med
gliclazide (sulfonylurea) increasing pancreatic insulin secretion and hence are only effective if functional B-cells are present. On a molecular level they bind to an ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta cells.
31
hba1c 10% (86) average glucose level
15.5 over 2 months
32
prediabetes
a fasting plasma glucose of 6.1-6.9 mmol/l or an HbA1c level of 42-47 mmol/mol (6.0-6.4%) indicates high risk start metformin if worsening
33
Impaired glucose tolerance (IGT) is defined as fasting
plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l
34
hba1c target in T1DM
48 (6.5%)
35
acromegaly Rx pregmisovent
GH receptor antagonist - prevents dimerization of the GH receptor once daily s/c administration very effective - decreases IGF-1 levels in 90% of patients to normal doesn't reduce tumour volume therefore surgery still needed if mass effect
36
Acromegaly Rx
1st line - trans sphenoidal surgery ``` somatostatin analogues (ocreotide) Dopamine agonists (bromocriptine) pregmisovent ```
37
somatostatin analogues in acromegaly
directly inhibits the release of growth hormone for example octreotide effective in 50-70% of patients may be used as an adjunct to surgery
38
gastrointestinal autonomic neuropathy Sx in diabetes
Gastroparesis symptoms include erratic blood glucose control, bloating and vomiting management options include metoclopramide, domperidone or erythromycin (prokinetic agents) Chronic diarrhoea often occurs at night Gastro-oesophageal reflux disease caused by decreased lower esophageal sphincter (LES) pressure
39
how to test diabetic neuropathy in feet
10g monofilament
40
commonest cause of primary hyperaldosteronism
adrenal hyperplasia
41
klinefelters's (47XXY) gronadotrophin elvels
raised lh fsh/ low testosterone often taller than average lack of secondary sexual characteristics small, firm testes infertile gynaecomastia - increased incidence of breast cancer elevated gonadotrophin levels but low testosterone
42
Grave's on carbimazole, what are you monitoring?
TSH levels | should slowly rise as TSH receptor autoantibodies decline
43
acromegaly related malignancy
colorectal carcinoma
44
GLP-1 in diabetes
glucagon like peptide low in T2DM Mimetics such as exenatide increase insulin secretion and inhibit glucagon secretion.
45
overactive bladder
antimuscarinics - toltoredine Immediate release oxybutynin should, however, be avoided in 'frail older women' mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
46
Insulin stress test
dydx cushing's from pseudocushings for hypopituitarism Basics used in investigation of hypopituitarism IV insulin given, GH and cortisol levels measured with normal pituitary function GH and cortisol should rise Contraindications epilepsy ischaemic heart disease adrenal insufficiency
47
exanatide only in
obese 30+bmi
48
Cushing's Ix
overnight dex suppression test or 24 hour urine cortisol collection
49
Riedel's thyroiditis
hypothyroidism dense fibrous tissue replacing the normal thyroid parenchyma. hard, fixed, painless goitre is noted. middle-aged women. assw/ retroperitoneal fibrosis.
50
easily provoked hypokalaemia (by ACEI)
consider primary hyperaldoseronism
51
thyroid eye disease pathophysiology
it is thought to be caused by an autoimmune response against an autoantigen, possibly the TSH receptor → retro-orbital inflammation the inflammation results in glycosaminoglycan and collagen deposition in the muscles
52
thyroid eye disease prevention
smoking is the most important modifiable risk factor radioiodine treatment may increase the inflammatory symptoms seen in thyroid eye disease. In a recent study of patients with Graves' disease around 15% developed, or had worsening of, eye disease. Prednisolone may help reduce the risk
53
features of thyroid eye disease
the patient may be eu-, hypo- or hyperthyroid at the time of presentation exophthalmos conjunctival oedema optic disc swelling ophthalmoplegia inability to close the eye lids may lead to sore, dry eyes. If severe and untreated patients can be at risk of exposure keratopathy
54
acarbose
inhibitor of intestinal alpha glucosidases, which results in decreased absorption of starch and sucrose. flatulance
55
cushing's metabolic what
hypokalaemic metabolic alkalosis
56
T2DM diagnosis
If the patient is symptomatic: (polyuria polydipsia) fasting glucose greater than or equal to 7.0 mmol/l random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)
57
diabetic neuropathy of feet pain
first-line treatment: amitriptyline, duloxetine, gabapentin or pregabalin
58
radioiodine most frequent side effect
hypthyroidism
59
amitryptilline + BPH
retention
60
iron reduces absorption of
thyroxine
61
sulfonylureas
gliclazide and tolbutamide
62
Congenital adrenal hyperplasia
21 hydroxylase defiency
63
Anaplastic thyroid cancer
aggressive, difficult to treat and often causes pressure symptoms like hoarse voice etc locally invasive Treatment is by resection where possible, palliation may be achieved through isthmusectomy and radiotherapy.
64
hirsuitism in PCOS Rx
a COC pill may be used help manage hirsutism. Possible options include a third generation COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action. Both of these types of COC may carry an increased risk of venous thromboembolism if doesn't respond to COC then topical eflornithine may be tried spironolactone, flutamide and finasteride may be used under specialist supervision
65
pioglitasone
Thiazolidinediones can cause fluid retention agonists to the PPAR-gamma receptor and reduce peripheral insulin resistance
66
Anticholinergics for urge incontinence are associated with confusion in elderly people
mirabegron is preferred beta 3 agonist
67
DKA back to normal, how do you start the insulin
continue long acting insulin throughout fixed rate infusion during DKA don't leave a gap where there is no insulin cover
68
DKA features
Features abdominal pain polyuria, polydipsia, dehydration Kussmaul respiration (deep hyperventilation) Acetone-smelling breath ('pear drops' smell)
69
Congenital adrenal hyperplasia
Overview group of autosomal recessive disorders affect adrenal steroid biosynthesis in response to resultant low cortisol levels the anterior pituitary secretes high levels of ACTH ACTH stimulates the production of adrenal androgens that may virilize a female infant Cause 21-hydroxylase deficiency (90%) 11-beta hydroxylase deficiency (5%) 17-hydroxylase deficiency (very rare)
70
Subclinical hypothyroidism Mx Basics TSH raised but T3, T4 normal no obvious symptoms Significance risk of progressing to overt hypothyroidism is 2-5% per year (higher in men) risk increased by the presence of thyroid autoantibodies
TSH 4-10 - <65 with symptoms trial levothyroxine, stop if no improvement - elderly, esp 80+ watch and wait - ASx - watch and wait repeat in 6months ``` TSH >10 start treatment (even if asymptomatic) with levothyroxine if <= 70 years 'in older people (especially those aged over 80 years) follow a 'watch and wait' strategy, generally avoiding hormonal treatment' ```
71
Primary hyperparathyroidism
PTH over-secretion usually from a parathyroid adenoma both PTH and calcium are elevated surgery to remove the adenoma is the most effective treatment conservative measures such as bisphosphonates can be used
72
Secondary hyperparathyroidism
chronic kidney disease typically can be secondary to vitamin D deficiency PTH released due to low calcium, high phosphate and lack of vitamin D activation by diseased kidneys PTH level high with calcium levels being low or normal medical management primarily: phosphate binders, calcium and vitamin D supplementation
73
Tertiary hyperparathyroidism
autonomous hypersecretion of PTH due to hypertrophied parathyroid glands occurs after a period of long standing secondary hyperparathyroidism treatment involves parathyroidectomy
74
Pseudohypoparathyroidism
PTH resistance and is associated with low calcium and high PTH levels
75
``` usually presents in childhood, e.g. Failure to thrive polyuria, polydipsia hypokalaemia normotension weakness ```
Bartter's Syndrome autosomal recessive) of severe hypokalaemia due to defective chloride absorption at the Na+ K+ 2Cl- cotransporter (NKCC2) in the ascending loop of Henle. think of it like taking a lot of furosemide
76
Mx of thyrotoxic storm
Management: symptomatic treatment e.g. paracetamol treatment of underlying precipitating event beta-blockers: typically IV propranolol anti-thyroid drugs: e.g. methimazole or propylthiouracil Lugol's iodine dexamethasone - e.g. 4mg IV qds - blocks the conversion of T4 to T3
77
Remnant hyperlipidaemia
``` mixed hyperlipidaemia (cholesterol and triglyceride) high incidence of ischaemic heart disease and peripheral vascular disease impaired removal of intermediate density lipoprotein from the circulation by the liver ``` Features yellow palmar creases palmer xanthomas tuberous xanthomas Mx - fibrates AKA Fredrickson type III hyperlipidaemia, broad-beta disease and dysbetalipoproteinaemia associated with apo-e2 homozygosity
78
T1DM and insulin and BMI >25
consider metformin
79
: unopposed oestrogen increases risk of
endometrial cancer
80
sweating in acromegaly caused by
sweat gland hypertrophy
81
Insulin, TRH and LHRH are given to the patient following which the serum glucose, cortisol, growth hormone, TSH, LH and FSH levels are recorded at regular intervals. Prolactin levels are also sometimes measured*
A normal dynamic pituitary function test has the following characteristics: GH level rises > 20mu/l cortisol level rises > 550 mmol/l TSH level rises by > 2 mu/l from baseline level LH and FSH should double
82
Meglitinides
Meglitinides (e.g. repaglinide, nateglinide) increase pancreatic insulin secretion like sulfonylureas they bind to an ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta cells often used for patients with an erratic lifestyle adverse effects include weight gain and hypoglycaemia (less so than sulfonylureas)
83
pseudohypoparathyroidism insensitivity to pth
Bloods PTH: high calcium: low phosphate: high ``` Features short fourth and fifth metacarpals short stature cognitive impairment obesity round face ``` Investigation infusion of PTH followed by measurement of urinary phosphate and cAMP measurement - this can help differentiate between type I (neither phosphate or cAMP levels rise) and II (cAMP rises but phosphate levels do not change)
84
acromegaly Ix
Serum IGF-1 levels have now overtaken the oral glucose tolerance test (OGTT) with serial GH measurements as the first-line test. The OGTT test is recommended to confirm the diagnosis if IGF-1 levels are raised Oral glucose tolerance test in normal patients GH is suppressed to < 2 mu/L with hyperglycaemia in acromegaly there is no suppression of GH may also demonstrate impaired glucose tolerance which is associated with acromegaly
85
SGLT-2 inhibitors like dapagliflozin promote increased glucose excretion because they inhibit glucose reabsorption in the kidney however can
increase HDL and LDL
86
Sulfonylureas -
bind to an ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta cells
87
Features of MODY
typically develops in patients < 25 years a family history of early onset diabetes is often present ketosis is not a feature at presentation patients with the most common form are very sensitive to sulfonylureas, insulin is not usually necessary young and slim
88
The PTH level in primary hyperparathyroidism
may be normal
89
Hashimoto's thyroiditis is associated with what cancer
thyroid lymphoma
90
thyroid eye disease when to urgently see opthal
unexplained deterioration in vision awareness of change in intensity or quality of colour vision in one or both eyes history of eye suddenly 'popping out' (globe subluxation) obvious corneal opacity cornea still visible when the eyelids are closed disc swelling
91
A normal short synacthen test does not exclude adrenocortical insufficiency due to
pituitary failure
92
Non-functioning pituitary tumours present with
hypopituitarism and pressure effects | prolactin can be slightly raised due to reduced negative pressure as dopamine is not released as much

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