ENDO1

Question 1

Phaeo symptoms

Answer 1

Palps Anxiety Sweating Headache Tremor Hypertension Nausea

Question 2

Phaeo Cause

Answer 2

Catecholamine producing tumour in adrenal medulla

Question 3

Phaeo Ix

Answer 3

Free plasma metanephrines. 24 urinary catecholamines and metanephrines

Question 4

Phaeo Mx

Answer 4

Surgery - remove tumor Whilst they wait - add phenoxybenzamine 10mg bd till get to target BP of 120/80 Alphablockade often causes reflex tachy So ONCE evidence of 1) symptoms stopped 2) target BP reached 3) Postural drop is 20/10 then can start metoprolol 50mg bd

Question 5

Cushings sx

Answer 5

Thin skin Facial puffiness/swelling Peripheral Oedema Hypertension Diabetes Buffalo hump Hirsutism (With androgens) Proximal myopathy Central obesity with striae Depression Psychosis Osteoporosis with pathological fracture Avascular necrosis of head of femur amenorrhea loss of libido

Question 6

Cushings Initial investigations?

Answer 6

Overnight 1mg dexamethasone test PLUS one of: Free 24 hr urinary cortisol (two measurements) Free late night salivary cortisol (two measurements) When 2 of these tests are abnormal - diagnosis. If only one positive -needs further evaluation to exclude physiologic hypercortisolism and confirm diagnosis - REFER TO ENDO

Question 7

What are the Sx of hyperthyroidism?

Answer 7

weightloss, tremors, flushing, heat intolerance, anxiety, increased frequency of defecation, increased appetite, psychosis, palpitations NB: A patient may just present with anxiety

Question 8

What are the examination findings of hyperthyroidism?

Answer 8

Tachycardia, Postural tremor , warm/sweaty peripheries, may have atrial fibrilliation, proximal muscle weakness, hyperactive reflexes, thyroid enlargement or irregularity, Pempertons sign (thoracic inlet obstruction) (IN GRAVES - thyroid acropachy, pretibial myxoedema, opthalmopathy - exopthalmos, proptosis, lid lag, lid retraction, keratitis/chemosis, opthalmoplegia) NB: elderly pt may present only with HF or AF

Question 9

Suppressed TSH with Normal T3/T4

Answer 9

Subclinical hyperthyroid

Question 10

Suppressed TSH with elevated T3/T4

Answer 10

overt hyperthyroidism

Question 11

Elevated TSH, with elevated T3/T4

Answer 11

TSH producing pituitary adenoma - check TRH

Question 12

Uptake will be increased on radioactive iodine scan

Answer 12

TMNG, TA, Graves

Question 13

Uptake will be decreased on radioactive iodine scan

Answer 13

Thyroiditis

Question 14

A person with diabetes who presents unconscious, drowsy or unable to swallow AND Hypoglycaemia - Mx?

Answer 14

Management is as follows: • Commence appropriate resuscitation protocols. • Give an injection of glucagon 1 mg intramuscular or subcutaneous if available. • If intravenous access is obtained, glucose 50% – 20 mL intravenous via a securely positioned cannula (optimally the antecubital veins). Use 10% glucose in children, as hyperosmolality has caused harm. • Phone for an ambulance (dial 000) stating a ‘diabetic emergency’. • Wait with the patient until the ambulance arrives. • When the person regains full consciousness and can swallow, they can then be orally given a source of carbohydrate.

Question 15

Contraindications for radioactive iodine?

Answer 15

Pregnancy, breastfeeding, or planning pregnancy within 6 months of treatment

Question 16

Sideeffects of antithyroid drugs? Minor and major?

Answer 16

Minor: Pruritis Urticaria Gastrointestinal upset arthralgia fever altered taste Major: AGRANULOCYTOSIS (check FBE - leukopenia) thrombocytopenia aplastic anaemia cholestatic jaundice (carbimazole) hepatitis (propylthiouracil)

Question 17

Compare and contrast the treatments for Graves disease?

Answer 17

Question 18

Firstline treatement for Graves?

Answer 18

Antithyroid meds

Question 19

Firstline treatment for TMNG?

Answer 19

RAI unless contraindicated

Question 20

Firstline treatment for TA?

Answer 20

RAI unless contraindicated

Question 21

How does postpartum thyroiditis clinically present?

Answer 21

• Typically 1-6 months after delivery
• Common in women with T1DM
• Diffuse, small goitre
• Hyperthyroid for 1-2 months followed by hypothyroid for 4-6months
• Hypothyroidism may be permanent (20%)

Question 22

Treatment of postpartum thyroiditis?

Answer 22

Betablocker for hyperthyroid symptoms

THyroxine if hypothyroid phase is prolonged and/or symptomatic, breastfeeding or trying to conceive

TPO Ab will have high titre because autoimmune basis

Question 23

Cause of subacute thyroiditis?

Clinical features?

Answer 23

Post viral syndrome, destruction of thyroid follicles with released of stored thyroid hormone

Features:

Female to Male 5:1

Peak age of onset 20-60

TENDER goitre

Often following acute URTI

Hyperthyroid for 1-2 months followed by hypothyroid for 4-6 months (hypo may be permanent in 10%)

Question 24

Tests to order in hyperthyroidism?

Answer 24

TSH initially - repeat in 4 weeks if asymptomatic or immediately if symptoms

T3 and T4

TSH recepter antibodies (specific for Graves)

Thyroid antibodies - antithryoglobulin, antimicrosomal, antithyroperoxidase (anti TPO - best if there is an autoimmune cause eg thyroiditis, can also be positive in graves)

ESR will be elevated in subacute granulomatous thyroiditis

TRH only check if tsh, t3 and t4 are elevated - looking for TSHoma

Imaging: U/S and radioisotope scan

Question 25

When does a radionuclide scan not need to be ordered in hyperthyroidism?

Answer 25

diffusely swollen goitre, recent onset of opthalmopathy, moderate to severe thyrotoxicosis - presumptive dx of graves -

Question 26

Management of Graves disease?

Answer 26

1. Establish diagnosis and confirm complicatins (cardiac and osteoporosis) 2. Treat Tachycardia with BB if symptomatic: PROPRANOLOL 10mg BD Orally initially, increase to 40mg BD according to Heart rate 3. Antithyroid medications USUALLY Carbimazole (less sideeffects) than PTU Initial dose: 10 to 20mg orally daily - can increase up to 45mg in 2-3 divided doses IF PREGNANT T1: PTU (carbimazole- embryotoxicity) then convert to carbimazole in T2 and T3 (as PTU can cause a hepatitis) PTU dose: 200mg orally daily (can increase up to 600mg a day in 2 -3 divided doses). 4. Educated patient about important major sideeffects - Attend clinic if any fever, infection, mouth ulcers, sore throat, for Full blood examination (both CBZ and PTU can cause agranulocytosis) Attend if severe itchiness, fatigue, nausea, abdo pain, pale stools, jaundice, - PTU can cause a hepatitis/CBZ can cause hepatocellular jaundice)

Question 27

What is the acute management of agranulocytosis?

Answer 27

Urgent transfer to Emergency deparment for admission Intravenous antibiotics Intravenous G-CSF (granulocyte colony stimulating factors)

Question 28

How would you treat subacute thyroiditis?

Answer 28

1. Betablocker for tachycardia - Propranolol 10mg bd orally intially increasing up to 40mg three times a day if needed. 2. Non steroidal anti inflammatory for pain: Ibuprofen 400mg three times a day orally 3. For prolonged syptoms - Prednisolone 40mg orally once daily. Wean over 2 - 4 week period.

Question 29

What is an adrenal incidentaloma

Answer 29

An adrenal lesion (greater than or equal to 1cm) that is found incidentally on imaging for other purposes.

Question 30

Which initial screening tests/biochemical evaluation do you perform an adrenal incidentaloma?

Answer 30

**1. 1mg overnight dexamethasone suppression test.** **2. 24 hr urinary metanephrines and catecholamines** **IF HYPERTENSIVE:** **3. Plasma aldosterone: Plasma Renin activity Ratio** IF ANY of the above are **positive**: then if symptomatic - refer to surgeon for adrenalectomy. If asymptomatic - Refer patients under the age of 40. Over the age of 40 and Unfit for surgery - surveillance IF the tests are negative - and either greater than or equal to 4cm OR suspicious imagin findings - refer to surgeon for adrenalectomy (cos maybe malignant) If negative and less than 4cm in size and benign looking on Imaging - Surveillance - Yearly Biochem eval for five years; Repeat CT in 6 months then yearly for two years.

Question 31

Infant presents with failure to thrive, salt losing enteropathy and virilisation/ambiguous genitalia. What is the most likely cause?

Answer 31

Congenital adrenal hyperplasia

Question 32

What is the genetic inheritance pattern and pathophysiology of congenital adrenal hyperplasia?

Answer 32

Autosomal recessive. (Therefore more common in consanguinous relationships, may have Fam hx of neonatal death). Usually Lacking 21-hydroxylase which helps turn adrenal precusor molecules to 1) cortisol and 2) aldosterone. This means that when ACTH stimulates the adrenal all those precursor molecules turn into androgens. Presents with virilisation, failure to thrive +/- salt losing crisis(diarrhoea/vomiting) (hyponatraemia and hyperkalaemia)

Question 33

How does Congenital adrenal hyperplasia usually present?

Answer 33

1. In early infancy - with virilisation of female genitalia. 2. Failure to thrive. 3. Diarrheoa and vomiting as part of salt losing crisis. (Endocrine emergency).

Question 34

How do you manage Congenital adrenal hyperplasia?

Answer 34

1. Lifelong glucocorticoid and mineralocorticoid replacement. (hydrocortisone and fludrocortisone) 2. Screen all first degree relatives for CAH.

Question 35

What are the causes of Addissons disease?

Answer 35

Most common in West – Autoimmune adrenalitis Worldwide – TB, fungal infections (Cryptococcus/histoplasmosis), CMV Acute haemorrhage (eg meningococcal septicaemia)

Question 36

What is the underlying pathology in Addisons disease?

Answer 36

Destruction of adrenal cortex.

Question 37

What are the types of adrenal insufficiency?

Answer 37

Primary – a) autoimmune adrenalitis b) congenital adrenal hyperplasia c) adenoma d) idiopathic Secondary – Reduced ACTH from hypopitutarism

Question 38

What are the signs and symptoms of Addisons disease?

Answer 38

Symptoms of cortisol deficiency: weakness, fatigue, anorexia, weight loss, diarrheoa and vomiting, hypoglycaemia, Symptoms of aldosterone deficiency: Hyponatraemia, Hyperkalaemia, acidosis, tachycardia, hypotension, salt cravings Symptoms of ACTH increase( in primary adrenal insuff): Generalised hyperpigmentation (look especially in non sun exposed areas eg palmar creases and axilla)

Question 39

When should an acute adrenal crisis be considered?

Answer 39

Any one of the following: altered conscious state, circulatory collapse, hyponatraemia, hypoglycaemia, hyperkalaemia,

Question 40

Investigations in acute adrenal insufficiency?

Answer 40

Serum glucose, urea, sodium, potassium, blood gas analysis

Question 41

Management of Acute adrenal insufficiency

Answer 41

Urgent transfer to hospital for emergency management IV therapy If severe dehydrated – 20ml/kg 0.9 NACL Intravenous bolus If moderate dehydration – 10ml/kg 0.9 NACL IV Maintenance – 5% dextrose Steroid replacement with IV hydrocortisone (100mg initially) Correct hypoglycaemia Correct hyperkalaemia (with fluids initially) if K+ is greater than 6 – ECG and cardiac monitoring

Question 42

What advice would you give to someone with addisons disease to prevent an acute adrenal crisis?

Answer 42

Emergency Action plan Emergency identification – Medic Alert bracelet Triple normal oral Glucocorticoid maintenance dose for 2-3 days during stress (fever/fracture) Administer IM hydrocortisone if oral medication not tolerated (vomiting) Consider Increase parenteral dose of hydrocortisone before anaesthesia and post operatively Ensure patients have ambulance cover and ready to use IM hydrocortisone vial (Act-O-Vial) for emergencies

Question 43

What is the definitive test for Addisons disease?

Answer 43

Short synathcen test

Question 44

What hormones are secreted by the anterior pituitary gland?

Answer 44

Adrenocorticotophic hormone (ACTH) Thyroid stimulating hormone (TSH) Growth hormone (GH) Prolactin Follicle stimulating hormone (FSH) Luteinising hormone (LH)

Question 45

What hormones are secreted by the posterior pituitary?

Answer 45

Arginine vasopressin (Antidiuretic hormone) Oxytocin

Question 46

What are the symptoms of hypopituitarism in adults?

Answer 46

Amenorrhea Sexual dysfunction Fatigue Depression Altered mental state Cold intolerance Postural light headedness

Question 47

What are the physical signs of hypopituitarism in adults?

Answer 47

Marked pallor Loss or lack of body heair Fine wrinkling of the face Delay in return of reflexes Testicular atrophy Orthostatic hypotension

Question 48

What are symptoms and signs of hypopituitarism in children?

Answer 48

Hypoglycaemia – due to combined ACTH and GH def Prolonged neonatal jaundice (giant cell hepatitis) Micropenis Undescended testes in infancy Growth failure Delayed puberty

Question 49

What biochemical findings suggestive of hypopituitarism?

Answer 49

Low T4 in the absence of high TSH Adults – low estrogen and androgens without elevated LH or FSH

Question 50

What causes hypopituitarism in adults?

Answer 50

Commonly pituitary adenoma Others- prior cranial radiotherapy, head injury, SAH, post partum haemorrhage

Question 51

Causes of hypopituitarism in children?

Answer 51

Genetic Post surgery or radiotherapy

Question 52

Causes of myocarditis?

Answer 52

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Question 53

Advantages and Disadvantages of Anti thyroid meds in Graves

Answer 53

**Advantages:** 1. *non invasive* 2. *no exac of opthalmopathy* 3. *cheap* 4. *outpatient therapy* 5. *low risk of hypthyroid* **Disadvantages** 1. *Low rate of long term remission* 2. *Adverse drug effects* 3. *Compliance* 4. *Monitoring*

Question 54

Advantages and disadvantages of radioactive iodine for treatment of graves?

Answer 54

**Advantages** 1. Most *_cost effective_* (not cheapest) 2. Few advers effects 3. Outpatient therapy 4. Reduction in goitre size **Disadvantages** 1. Can lead to permanent hypothyroid 2. Development or exacerbation of ophthalmopathy in 15% 3. Need to delay preg and avoid b/feeding 4. Radiation safety precautions 5. Radiation thyroiditis in 10%

Question 55

Advantages and disadvantages of thyroidectomy for graves

Answer 55

**Advantages** 1. Rapid and effective 2. Likely no exacerbation of opthalmopathy, but requires further study **Disadvantages** 1. Permanent hypothyroidism 2. Surgical complications (recurrent laryngeal nervedamage, hypoparathyroid) 3. Most expensive option 4. Scarring 5. Post operative pain or discomfort