Endocrinology Flashcards
(227 cards)
1
Q
What are the classifications of Acromegaly?
A
Growth hormone releasing hormone (GHRH) independent:
- Pituitary adenoma (most common)
- Primary pituitary hyperplasia
GHRH dependent (rarer):
- Hypothalamic source = excess GHRH from he hypothalamus causes secondary pituitary hyperplasia
- Ectopic release = excess GHRH from ectopic tissue
2
Q
Define Acromegaly
A
A disorder caused by an excessive amount of growth hormone w/ characteristic clinical features
3
Q
What’s the difference between acromegaly and gigantism?
A
Age of onset - gigantism occurs before the epiphyseal plates close leading to excess linear growth, whilst acromegaly occurs after the plates close leading to enlargement of bones and soft tissue
4
Q
Acromegaly pathophysiology
A
- Excess GH results in the excess production of insulin-like growth factor 1 (IGF-1)
- IGF-1 receptor is widely distributed across a wide range of tissues, and excess stimulation results in abnormal growth of these tissues
- Excess GH also results in increased gluconeogenesis, lipolysis and insulin resistance
5
Q
Acromegaly features
A
Hands:
- spade-like, large, doughy hands
- Sweaty
- Thick skin w/ large pores
- Carpal tunnel syndrome
Face:
- Interdental separation
- Prognathism
- Large ears, nose, lips
- Prominent supraorbital ride and facial creases
- Macroglossia
- Acne
Visual field defects = bitemporal hemianopia/upper quadrantanopia
Axilla:
- Acanthosis nigricans
- Skin tags
Neck:
- Acanthosis nigricans
- Goitre
Chest:
- Cardiomegaly
- Pulmonary oedema
- Gynaecomastia
Legs:
- Peripheral pitting oedema
- Proximal muscle weakness
- OA
- Large feat
Back:
- Kyphoscoliosis
Systemic:
- Secondary HTN
- Organomegaly
- Increased risk of colonic polyps and thus colorectal cancer
6
Q
Acromegaly investigations
A
Bedside:
- Fundoscopy -=optic atrophy
- Visual fields testing
- Urine dip = glycosuria
- ECG = LVH due to HTN
Bloods:
- IGF-1 levels
- If raised, do confirmatory test = oral glucose tolerance test - fails to supress GH
Imaging:
- MRI pituitary
7
Q
Acromegaly management
A
Medical = if surgery is contraindicated, mechanism not due to pituitary adenoma, or is refractory to surgery:
- Somatostatin analogues (1st line) = octreotide (supress GH release)
- GH antagonists = pegvisomant
- Dopamine agonist = cabergoline
Surgery (1st line):
- Transphenoidal surgery to remove pituitary adenoma (1st line)
- Transfrontalr resection of the pituitary
- +/- radiotherapy
8
Q
Define Adrenal insufficiency
A
A clinical syndrome that arises due to the insufficient production of glucocorticoids and mineralocorticoids from the adrenal cortex
9
Q
What are the classifications of Adrenal insufficiency?
A
Primary = Addison’s disease:
- AI destruction
- Surgical removal
- Trauma
- TB
- Haemorrhage
- Infarction
- Neoplasm
- Steroid overuse
Secondary:
- Congenital disorders
- Basal skull fractures
- Pituitary surgery
- Pituitary neoplasm
- Infiltration or infection of the brain
- Corticotrophin-releasing hormone deficiency
10
Q
Adrenal insufficiency features
A
- Hypotension
- Fatigue and weakness
- GI symptoms
- Syncope
- Skin pigmentation due to increased ACTH production and thus increased melanocyte stimulating hormone
11
Q
Adrenal insufficiency investigations
A
- U&Es and serum cortisol = hyponatraemia, hyperkalaemia and low serum cortisol
- Hypoglycaemia
- ABG = hyperkalaemia, hyponatraemic metabolic acidosis
- Ab testing
- CT adrenals
- MRI pituitary
Short synacthen test is confirmatory:
- Measure cortisol before
- Give syacthen (syhnethtic ACTH)
- Measure cortisol 30 min later
- Cortisol should be >420, else probably Addison’s
12
Q
Adrenal insufficiency management
A
Chronic:
- Replace glucocorticoids (w/ hydrocortisone - 10mg in the morning, 5mg at noon, 5mg at night- or prednisolone)
- Replace mineralocorticoids (w/ fludrocortisone)
- Education on sick day riles (doubling steroid dose when ill)
Addisonian crisis:
- Aggressive fluid resuscitation
- IV/IM hydrocortisone STAT
- Glucose if hypoglycaemia
13
Q
Define Addisonian crisis
A
A life-threatening condition due to an acute deficiency in cortisol and aldosterone
Presents w/:
- Hypotension
- Hyperkalaemia
- Hyponatraemia
- Metabolic acidosis
14
Q
What are the side effects of amiodarone?
A
- Hypothyroidism
- Hyperthyroidism (rarer - amiodarone thyrotoxicosis)
- Corneal deposits
- SJS
- Grey discoloration of the skin
- Liver failure
- Pneumonitis and pulmonary fibrosis
15
Q
Define Amiodarone induced thyrotoxicosis
A
A side effect of amiodarone which is rich in iodine, presents w/ symptoms of thyrotoxicosis
Manifests in 2 types:
- AIT 1 = pt has underlying thyroid nodules, amiodarone increases thyroid hormone production due to high iodine content
- AIT 2 = pt has normal function gland, amiodarone triggers destructive thyroiditis
16
Q
Amiodarone induced thyrotoxicosis investigations
A
- TFTs
- Thyroid uptake scan - AIT 1 = normal uptake, AIT 2 = decreased uptake
- Doppler US - AIT 1 = increased vascularity, AIT 2 = reduced vascularity
17
Q
Amiodarone induced thyrotoxicosis management
A
- AIT 1 = carbimazole
- AIT 2 = corticosteroids
- Consult w/ cardio about stopping amiodarone
18
Q
What are the causes of vasopressin deficiency?
A
- Head trauma
- Inflammatory conditions e.g. sarcoidosis
- Cranial infections e.g. meningitis
- Vascular conditions e.g. sickle cell
- Rare genetic causes
19
Q
What are the causes of vasopressin resistance?
A
- Drugs e.g. lithium
- Metabolic disturbances e.g. hypercalcaemia, hypokalaemia and hyperglycaemia
- Chronic renal disease
- Rare genetic causes
20
Q
Vasopressin disorders (diabetes insipidus) features
A
- Large volumes of dilute urine (> 3L in 24 hrs and urine osmolality of <300 mOsm/kg)
- Nocturia
- Excessive thirst
21
Q
Vasopressin disorders (diabetes insipidus) investigations
A
- U&Es = sodium normal/raised
- Urine dip
- Paired serum and urine osmolality (raised serum osmolality w/ inappropriately dilute urine w/ a low osmolality)
Water deprivation test is diagnostic and can distinguish from primary polydipsia:
- Deprive pt of fluids and monitor urine osmolality and weight changes (stop if pt loses >5% body weight)
- In vasopressin disorders, urine osmolality wont decrease
- In vasopressin deficiency, urine osmolality will decrease on administration of ADH
- In vasopressin resistance, urine osmolality wont change w/ administration of ADH
22
Q
Vasopressin deficiency management
A
- Desmopressin
- Monitor sodium levels
23
Q
Vasopressin resistance management
A
- Correct underlying metabolic abnormalities
- Stop any offending drugs
- High dose desmopressin has varying results
- Thiazide diuretics and NSAIDs can reduce urine volume
24
Q
Define Carcinoid tumour
A
A slow-growing, neuroendocrine tumour which secretes hormones (usually serotonin) - most often occur in the appendix, lungs and small intestine
Can become malignant
25
What's the difference between Carcinoid tumours and Carcinoid syndrome?
Carcinoid tumour = NET secreting serotonin
Carcinoid syndrome = occurs when the serotonin enters the blood stream, usually when the tumour has spread to the liver which allows the serotonin to be released to the systemic circulation w/out being broken down
26
Carcinoid tumour symptoms
- Abdo pain
- Diarrhoea
- Flushing
- Wheeze
- Pulmonary stenosis
Pts only have symptoms if they have liver mets which allow serotonin to enter circulation
27
Carcinoid tumour investigations
- 5-HIAA urine levels = breakdown product of serotonin
- CT, MRI or octreotide scans to locate the tumour
- Tissue biopsy for definitive diagnosis
28
Carcinoid tumour management
Medical:
- Octreotide (somatostatin analogue) to inhibit serotonin production
- Chemo/radiotherapy
Surgical:
- Tumour resection
- Emobliation
- Radiofrequency ablations
29
Define Cushing's syndrome
Excess glucocorticoids (cortisol)
30
What are the causes of Cushing's syndrome?
ACTH-dependent disease:
- Pituitary tumour (Cushing's disease)
- Ectopic ACTH-production = lung/thymic carcinoid tumours
ACTH-independent disease:
- Primary adrenal disease = adrenal adenomas, adrenal carcinomas
- Exogenous steroid overuse
31
Cushing's syndrome features
- Proximal myopathy
- Striae and easy bruising
- Osteoporosis and fractures
- Glucose intolerance and DM
- Truncal obesity
- HTN
- Hypokalaemia
- Facial changes = moon face, acne
- Hirsutism in women
- Supraclavicular fat pads
- Thin extremities due to muscle wasting
- Thin skin
- Erectile dysfunction
- Depression or cognitive dysfunction
32
Cushing's syndrome investigations
- 24-hr urinary free cortisol test
- Plasma ACTH levels to distinguish between ACTH-dependent and independent
- Inferior petrosal sinus sampling for suspecting pituitary causes
- MRI pituitary
- CT chest abdo
Low dose dexamethasone suppression test to confirm and distinguish:
- Measure cortisol levels, then administer 1mg oral dex and remeasure cortisol levels 24 hrs later
- Normal response = a significant decrease in cortisol levels (<1.8)
- Cushing's disease = not supressed by low-dose, but supressed by high dose (8mg of dex)
- Cushing's syndrome = not supressed by low or high-dose dex
33
Cushing's syndrome management
Medical:
- Metyrapone = inhibitor of cortisol synthesis
- Ketoconazole = adrenolytic agent
- Mifepristone = glucocorticoid receptor antagonist
- Pasireotide = somatostatin analogue
Surgical (1st line):
- Resection of the tumour
- If its Cushing's disease pt will need exogenous steroids for life
34
Define Delayed puberty
Absence of pubertal development by 14 in boys and 13 in girls
35
What are the causes of Delayed puberty?
Constitutional delay (most common)
Low gonadotrophin secretion:
- Craniopharyngiomas
- Kallmann syndrome
- Panhypopituitarism
- Isolated gonadotrophin deficiency
- CF
- Crohn's disease
High gonadotrophin secretion:
- Turners XO
- Klinefelter's XXY
- Congenital adrenal hyperplasia
- Acquired hypogonadism e.g. post chemo
36
Delayed puberty investigations
- Clinical assessment
- Hand-wrist X-ray = to determine bone age, which is typically delayed in constitutional growth delay as the epiphyseal plates are late to fuse
- Hormone testing = FSH, LH, thyroid hormones, sex hormones - can help distinguish between causes
37
Delayed puberty management
Depends on the cause:
- Constitutional delay = monitor growth
- Low gonadotrophin secretion = hormone replacement therapy, surgery for tumours, management of underlying disease
- High gonadotrophin secretion = hormone replacement therapy, supportive care
38
T1DM features
- Polyuria
- Polydipsia
- WL (distinguishes it from T2DM)
- DKA
39
Define Maturity onset diabetes of the young (MODY)
A rare form of diabetes that presents in adolescence or early adulthood (<25)
It is due to impaired insulin secretion, however, this is not due to AI destruction like T1DM but instead 1 of 5 mutations which impair the beta cells ability to produce insulin
40
Maturity onset diabetes of the young (MODY) management
- Sulfonylureas to stimulate insulin production
- Insulin therapy (less common)
41
T1DM investigations
- Random blood glucose > 11.1 or fasting plasma gluocse > 7
- 2-hour glucose tolerance > 11.1
- HbA1C > 48
If pt is symptomatic then only needs one of those results
If pt is asymptomatic then they need 2
Can confirm w/ C-peptide levels (will be low)
42
T1DM management
Insulin therapy:
- Long actin insulin given at night time
- Short acting insulin given after meals and snacks
Tight glycaemic control:
- Pre-meal BM = 4-7
- Bedtime BM = 6-10
- HbA1c < 53
Regular BM's
Hypoglycaemic management
43
What are the sick day rules for T1DM?
- Monitor BM every 3-4 hours and adjust insulin doses
- Monitor ketones, seek help if levels > 3mmol
- Maintain normal meal patterns
- If unable to eat, replace meals w/ carbohydrate-containing drinks e.g. fruit juice
44
T2DM investigations
- Random blood glucose > 11.1
- Fasting plasma gluxose > 7
- 2 hour glucose toelrance test > 11.1
- HbA1c > 48
Need 1 if symptomatic
Need 2 on different days if asymptomatic
45
T2DM management
Conservative:
- Dietary advice
- Regular exercise
- Smoking cessation
Medical:
- Initial management = metformin
- If HbA1c > 58 on monotherapy, add pioglitazone, DDP-4 inhibitors or a sulfonylurea
- If dual therapy not working than add a 3rd agent from the list
- Always add an SGLT-2 inhibitor if pt has HF
- If triple therapy not working then switch to insulin (start w/ intermediate acting, then switch to long/short acting regime)
- If pt obese, consider a GLP-1 agonist
- ACEi if HTN (renoprotective)
46
What are examples of sulfonylureas?
Gliclazide, tolbutamide
47
What are examples of DDP-4 inhibitors?
Sitagliptin, linagliptin
48
What are examples of GLP-1 agonists?
Semaglutide, dulaglutide
49
What are examples of SGLT-2 inhibitors?
Empagliflozin, dapagliflozin
50
What are the complications of T2DM?
Macrovascular:
- CVD
- PAD
- Cardiac complications
Microvascular:
- Diabetic retinopathy
- Diabetic neuropathy
- Diabetic nephropathy (+ diabetic foot)
- Autonomic neuropathy (gastroparesis)
- Sexual dysfunction
51
What are the T2DM medication sick day rules?
- Metformin = stop if risk of dehydration (vomit/diarrhoea) to lower risk of lactic acidosis
- Sulfonylureas = may cause hypoglycaemia if reduced oral intake
- SGLT-2 inhibitors = stop if dehydrated as can cause euglycemic DKA
- GLP-1 agonists = stop if risk of dehydration to decrease risk of AKI
- Insulin = don't stop, adjust based on recommendations of diabetic team
52
Define Diabetic ketoacidosis
A medical emergency consisiting of the triad of:
- Hyperglycaemia (BM > 11)
- Ketosis (blood ketones > 3, or urinary ketones ++)
- Acidosis (pH <7.2 or bicarb <15)
53
What parameters classify a DKA as severe?
One of:
- Blood ketones > 6
- Bicarb < 5
- Blood pH < 7
- Anion gap > 16
- Hypokalaemia on admission
- GCS < 12
- O2 sats <92% on air
- Systolic BP < 90
- Brady or tachycardia
54
DKA features
Symptoms:
- N&V
- Abdo pain
- Polyuria
- Polydipsia
- Weakness
Signs:
- Dry mucous membranes
- Hypotension
- tachycardia
- Altered mental state
- Kussmaul breathing (deep, sighing breaths to compensate for metabolic acidosis by b lowing of CO2)
- Fruit-like smelling breath
55
What are common triggers for DKA?
- Infection
- Dehydration and fasting
- Missing dose of insulin
- Steroids
- Diuretics
- Surgery
- CVD
- Alcohol excess or illicit drugs
- Pancreatitis
56
DKA investigations
Bedside:
- Cap BM
- Blood or urinary ketones
- Urine dip to look for UTI
- ECG
Bloods:
- ABG
- U&Es
Imaging:
- Consider CXR for septic screen
57
Diabetic ketoacidosis management
- A-E
- IV fluid replacement = IL over 1hour, then 2L over 2 hours, then 2L over 4 hours, the 1L over 6 hours (potassium should be added after the 1st bag depending on levels)
- Then start a fixed rate insulin infusion at a rate of 0.1units/kg/hour
- Continue long-actin insulin, but stop short acting
- Once blood glucose < 14, add a 10% glucose infusion alongside the saline and insulin
Continue fixed rate insulin until:
- Ketones < 0.6
- pH > 7.3
At this point start short-acting insulin if they can eat, stop the infusion 30 min after subcut insulin is given
58
Diabetic neuropathy features
Depends on the type:
Distal symmetrical sensory neuropathy:
- Most common
- Loss of touch, vibration and proprioception in glove and stocking distribution
Small-fibre predominant neuropathy:
- Due to loss of small sensory fibres
- Loss of pain and temp sensation in glove and stocking distribution
- Often has episodes of burning pain
Diabetic amyopathy:
- Inflammation of the lumbosacral or cervical plexus
- Severe pain around the thighs and hips, along w/ proximal muscle weakness
Mononeuritis multiplex:
- Painful neuropathy of 2 distinct peripheral nerves
Autonomic neuropathy:
- Postural hypotension
- Gastroparesis
- Constipation
- Urinary retention
- Arrhythmias
- Erectile dysfunction
59
Define Charcot Arthropathy
A chronic, progressive arthropathy that occurs in pt w/ peripheral neuropathy
60
Charcot Arthropathy features
6 D's:
- Destruction of bone and joints
- Deformity
- Degeneration
- Dense bones
- Debris of bone fragments
- Dislocation
Typically affects the tarsometatarsal joints
61
Charcot Arthropathy management
- Prolonged offloading
- Bisphosphonates
- Gabapentin/pregabalin
- Resection of bony prominences
62
Define Galactorrhoea
Inappropriate and spontaneous milk secretion from the breasts unrelated to childbirth or lactation
63
What are the causes of Galactorrhoea?
- Idiopathic
- Prolactinoma
- Drugs = antipsychotics, SSRIs, cimetidine, beta blockers
- Metabolic conditions = hypothyroidism, liver disease, CKD
64
Galactorrhoea investigations
- Serum prolactin
- TFTs
- U&Es and LFTs
- MRI pituitary
65
Galactorrhoea management
- Manage underlying condition
- Stop offending drug
- Cabergoline to increase dopamine and thus decrease prolactin
66
Define Gestational diabetes
Glucose intolerance in pegnancy defined as:
- Fast blood glucose levels of 5.6 or above
- 2 hour post OGGT levels of 7.8 or above
(5678)
67
What are the risk factors for Gestational diabetes?
- Previous Hx of GDM
- Prior delivery of macrosomic baby
- Maternal obesity
- Diabetes in a 1st degree relative
68
What are the foetal complications of Gestational diabetes?
- Macrosomia (BW > 4kg)
- Pre-term delivery
- Neonatal hypoglycaemia
- Increased risk of baby developing T2DM in later life
69
What are the maternal complications of Gestational diabetes?
- Increased risk of HTN and pre-eclampsia
- Risk of having it in subsequent pregnancies
- Increased risk of T2DM
70
Gestational diabetes management
- Lifestyle modifications if fasting glucose < 7 - if not below 5.6 after 2 weeks then start metformin
- If blood glucose levels > 7 on presentation - start insulin
71
Define Goitre
An abnormal enlargement of the thyroid gland
2 types:
- Smooth = no distinct nodules
- Nodular = presence of 1 or more distinct nodule which may be hot (functioning) or cold (non-functioning)
72
What are the causes of smooth Goitres?
- Graves disease
- Hashimoto's disease
- Drugs = lithium, amiodernone
- Iodine deficiency/excess
- De Quervain's thyroiditis
- Infiltrative diseases = sarcoid, hemochromatosis
73
What are the causes of nodular Goitres?
- Toxic solitary adenoma
- Non-functioning adenoma
- Multinodular goitre
- Thyroid cyst
- Thyroid cancer
74
Goitre features
- Visible and palpable swelling in the neck which moves up on swallowing but not on tongue protrusion
- Hoarseness
- Dysphagia (in large goitres)
- Symptoms of hypo/hyperthyroidism depending on the underlying cause
75
Goitre investigations
- TFTs
- US = evaluate size, number and characteristics of nodules
- FNA = in nodular goitres to assess malignancy
76
Define Gynaecomastia
Enlargement of male breast tissue
Results from a benign increase in glandular breast tissue rather than adipose tissue
77
What are the causes of Gynaecomastia?
Occurs due to an imbalance in the actions of oestrogen (stimulates breast growth) and androgens (inhibit growth)
- Obesity = increases peripheral conversion of androgens to oestrogens
- Chronic liver disease = reduces livers capacity to metabolise oestrogen
- Anabolic steroid use
- Tumours = Sertoli cell, Leydig cell, germ cell tumours all can produce oestrogen
- Chronic illness = testosterone is supressed more than oestrogen during periods of malnourishment
- Hyperthyroidism = increases conversion of androgens to oestrogen
- Hypogonadotrophic hypogonadism = lower testosterone
- Hyperprolactinaemia
- testicular failure
- Drugs = spironolactone (anti-androgen effects), ketoconazole, GnRH agonists, chemo
- Cannabis
78
Gynaecomastia features
Symmetrical (in relation to the nipple), rubbery enlargement of the breasts in men
79
Gynaecomastia investigations
- Bloods = LFTs, U&Es, TFTs, testosterone levels, oestradiol levels, LH/FSH levels, prolactin levels
- Imagine = breast USS, testicular USS (to assess for tumours)
80
Gynaecomastia management
- Observation and reassurance = most cases resolve over time
- Treat underlying cause
- Medication = selective oestrogen receptor modulators (tamoxifen) and androgens (danazol)
- Breast reduction surgery in long standing cases where medical management has not been successful
- Psychological help
81
Define Hirsutism
A clinical condition where females have excess hair growth in a male pattern distribution including the face, back, chest and abdomen
82
What are the causes of Hirsutism?
- PCOS (most common in women of reproductive age)
- Androgen-secreting tumours
- Congenital adrenal hyperplasia
- Cushing's
- Acromegaly
- Severe insulin resistance
- Idiopathic
- Drugs = steroids, phenytoin, ciclosporin
- Anorexia nervosa
- Hypothyroidism
- Familal traits
83
Hirsutism investigations
- Serum testosterone
- Other hormone levels = DHEAS, 17-hydroxyprogesterone, prolactin, TSH as indicated
- Pelvic USS = to identify polycystic or tumours
84
Hirsutism management
- Treat underlying cause
- Cosmetic = shaving, waxing, laser hair removal
- Medical = anti-androgens (spironolactone, flutamide), OCC, insulin-sensitising drugs
85
What are the causes of Hyperaldosteronism?
Primary (increased aldosterone secretion):
- Conn's syndrome (adrenal adenoma or bilateral adrenal hyperplasia)
- Familial
- Adrenal carcinoma
Secondary (increased activation of RAAS):
- Renal artery stenosis
- HF
- Liver cirrhosis
- Reninoma
- CKD
- Acute glomerulonephritis
86
Hyperaldosteronism features
- HTN
- Hypokalaemia
- Muscle weakness/fatigue
- Assythmias
- Metabolic alkalosis
87
Describe the Renin-angiotensin-aldosterone system
1) Renin is released from the kidneys in response to low BP, low sodium or sympathetic NS activation
2) Renin converts angiotensinogen to angiotensin 1
3) Angiotensin 1 is converted to angiotensin 2 by ACE
4) Angiotensin 2 increases BP by: vasoconstriction, stimulating aldosterone release, stimulating ADH release, promoting thirst
5) Aldosterone acts on the DCT and collecting ducts where it causes the reabsorption of sodium and the excretion of potassium
88
Hyperaldosteronism investigations
1st line = Aldosterone:Renin ration - high ratio suggests hyperaldosteronism
2nd line:
- HRCT or MRI to locate adrenal lesions
- Selective venous sampling (Gold standard for locating source)
89
Hyperaldosteronism management
Medical:
- In cases of bilateral adrenal hyperplasia = K-sparing diuretics (spironolactone, amiloride, eplerenone)
Surgical:
- If due to adrenal adenoma = resection of tumour or affected adrenal gland
90
Define Hyperosmolar hyperglycaemic state (HHS)
A life-threatening condition associated w/ T2DM - it results from severe hyperglycaemia, profound dehydration and altered mental state (due to insulin deficiency and osmotic diuresis)
Suspect in pts w/:
- Marked hyperglycaemia (>30) w/out significant ketosis (<3) or acidosis (pH > 7.3, bicarb > 15))
AND
- Osmolality > 320
91
What are the risk factors associated w/ Hyperosmolar hyperglycaemic state?
- T2DM
- Advanced age
- Infections or illness
- Medications that affect glucose metabolism
92
Hyperosmolar hyperglycaemic state features
- Profound dehydration w/ dry mucous membranes
- Polydipsia and polyuria
- Altered mental state - confusion to coma
- Neuro = seizure or focal deficits
- Hypotension
- Tachycardia
93
Hyperosmolar hyperglycaemic state investigations
- BM
- Serum osmolality
- U&Es
- Urinalysis for ketones
- Evaluation of underlying cause
94
Hyperosmolar hyperglycaemic state management
- Fluid resuscitation is mainstay - w/ saline
- Glucose levels should not fall by >5mmol per hour
- Insulin (0.05 units/kg/hr) can be commenced if sugars stop falling by fluids alone, or if there is ketosis
95
What are the different types of Hyperparathyroidism?
- Primary = caused by parathyroid adenoma, hyperplasia of all 4 glands or parathyroid carcinoma
- Secondary = due to Vit D deficiency, abnormal PTH activity or inadequate Ca intake
- Tertiary = occurs after prolonged secondary hyperparathyroidism due to CKD, gland becomes hyperplastic
96
Hypercalcaemia features
- Bones= bone pain
- Stones = renal stones
- Groans = GI issues - N&V, constipation, indigestion
- Psychiatric moans = lethargy, fatigue, memory loss, psychosis, depression
97
Hyperparathyroidism investigations
- Ca levels
- Phophate levels
- PTH levels
- ALP levels
Primary HPT = high Ca, low Phos, high/normal PTH, high ALP
Secondary = low/normal Ca, low/high Phos, high PTH, high ALP
Tertiary = normal/high Ca, low/normal Phos, high PTH, high ALP
Vit D deficiency = normal/low Ca, low Phos, high PTH, high ALP
98
Hyperparathyroidism management
- Primary = parathyroidectomy
- Secondary = address underlying cause, Vit D replacement and phosphate binders
- Tertiary = total/subtotal parathyroidectomy, Cinacalcet (mimics Ca action on tissues)
99
What does PTH do?
- Stimulates osteoclasts
- Increases Ca reabsorption in the DCT
- Increases phosphate excretion
- Stimulates alpha-hydroxylate to activate vit D in the kidneys
100
What does Vitamin D do?
Stimulates osteoclast activity and Ca absorption in the gut
101
Define Thyrotoxicosis
A syndrome resulting from the presence of excessive thyroid hormones, not always due to thyroid overactivity
102
What are the causes of Hyperthyroidism?
Primary:
- Grave's
- Toxic adenoma
- Toxic multinodular goitre
- Thyroiditis
Secondary:
- Amiodarone
- Lithium
- TSH producing adenoma
- Choriocarcinoma (bHCG can activate TSH receptors)
- Gestational hyperthyroidism
- Pituitary resistance to thyroxine (-ve feedback failure)
- Struma ovarii (ectopic thyroid tissue in ovarian tumours)
103
Hyperthyroidism features
- Increased basal metabolic rate
- Heat intolerance
- Tachycardia and arrhythmias
- WL
- Diarrhoea
- Sweaty skin
- Insomnia and sleep disturbances
- Restlessness and tremor
- Goitre
- Mood disturbances
- Menstrual disturbances
Grave's specific:
- Exophthalmos, proptosis and lid lag
- Thyroid acropachy = soft tissue welling in extremities (nail clubbing and periosteal new bone growth)
- Pretibial myxoedema = mucopolysaccharide deposition in the dermis leading to oedema and skin thickening, mostly in the shins
104
Hyperthyroidism investigations
- TFTs = high T4, low TSH
- Antibody tests
- Thyroid US
- Radioiodine uptake test = diffuse uptake in Grave's, focal uptake in a toxic nodule
105
Hyperthyroidism management
Medical:
- Antithyroid drugs (1st line) = Carbimazole or propylthiouracil
- Propranolol for symptomatic relief
- Radioiodine = for definitive treatment, kills the thyroid tissue and then you replace w/ levothyroxine
Surgery:
- Thyroidectomy + replacement = for pts w/ large goitres causing compression, suspicion of malignancy or when other treatment is contraindicated or refused
106
Define Thyroid storm
A life-threatening emergency due to thyrotoxicosis
It is often triggered by stressors e.g. surgery, trauma or infection
107
Thyroid storm features
- Restlessness and agitation
- High-output heart failure
- Profound tachycardia
- Fever
- Delirium and altered mental state
108
Thyroid storm management
- Counteract peripheral action of thyroxine = propranolol and digoxin to control HR and manage cardiac symptoms
- Inhibit thyroid synthesis = propylthiouracil through a NG tube and Lugol's iodine
- Inhibit peripheral conversion of T4 to more active T3 = prednisolone or hydrocortisone
- Supportive care = fluids, cooling measures, address precipitating factors
109
Define Hypocalcaemia
Serum Ca levels < 2.1
110
What are the causes of Hypocalcaemia?
W/ low PTH:
- Hypoparathyroidism
- Impaired PTH excretion = low magnesium, calcimimetics (cinacalet), Ca receptor mutations
W/ high PTH:
- Vit D deficiency
- Pseudohypoparathyroidism
- Bisphosphonate use
Due to compartmental shift:
- Alkalosis (increases Ca affinity for binding to albumin)
- Massive blood transfusion
- Artefact
- Osteoblastic mets
- Hungry bone syndrome (after parathyroidectomy)
- Acute pancreatitis
- Severe hyperphosphataemia which leads to complex formation w/ Ca e.g. secondary to tumour lysis syndrome, rhabdomyolysis, paraentral feeding
111
Hypocalcaemia features
SPASMODIC:
- Spasms (trousseau's sign)
- Perioral paraesthesia
- Anxiety/irritability
- Seizures
- Muscle tone increase (colic, dysphagia)
- Orientation impairment (confusion)
- Dermatitis
- Impetigo herpetiformis
- Chvostek's sign
- ECG shows prolonged QTc
112
Hypocalcaemia management
- Address underlying cause
- Mild = oral supplements
- Severe (ECG changes/clinical features) = IV calcium gluconate
113
Define Hypoglycaemia
Blood glucose < 3.5
114
What are the causes of Hypoglycaemia?
- Drugs = insulin, Sulphonylureas, GLP-1 analogues, DDP-4 inhibitors, Beta-blockers
- Alcohol
- Acute liver failure
- Sepsis
- Adrenal insufficiency
- Insulinoma
- Glycogen storage disease
115
Hypoglycaemia features
Adrenergic symptoms (<3.3):
- Trembling
- Sweating
- Palpitations
- Hunger
- Headache
Neuroglycopenic symptoms (<2.8):
- Double vision
- Difficulty concentrating
- Slurred speech
- Confusion
- Coma
116
Hypoglycaemia management
Mild (pt is conscious):
- ABCDE
- 15-20g of fast acting carbohydrate (glucose tablet/gel, non-diet soda, sweets, frit juice)
- Follow up w/ slower carbohydrates (e.g. toast)
Severe (pt unconsciousness/seizing):
- ABCDE
- 200ml 10% dextrose IV (or 20% via large vein)
- If no IV access = 1mg IM glucagon (doesn't work if alcohol ingestion as alcohol blocks gluconeogenesis)
117
What are the causes of Hypogonadism?
Primary:
- Klinefelter's (XXY)
- Orchitis
- Testicular trauma
- Chemo
- Radiation
Secondary:
- Kallmann's (failure of GNRH neurons to migrate resulting in anosmia and hypogonadotropic hypogonadism)
- Pituitary adenomas
- Hyperprolactinaemia
- Anorexia nervosa
- Opioid use
- Glucocorticoid use
- HIV
- Hemochromatosis
118
Hypogonadism features
- Lethargy
- Weakness
- Weight gain
- Loss of libido
- Erectile dysfunction
- Gynecomastia
- Depression
- Infertility
- Osteoporosis
119
Hypogonadism investigations
- FBC, U&E, LFTs
- Bone profile
- Fasting glucose and lipids
- PSA
- Oestrogen, testosterone, sex hormone binding globulin (SHBG)
- LH/FSH
- Prolactin
- TSH/thyroxine
- Cortisol
- Pituitary MRI
- CXR
- Karotyping
120
Hypogonadism management
HRT = either topical, buccal, oral or IM testosterone
121
What are the causes of Hypoparathyroidism?
- Neck surgery or radiation therapy
- AI polyendocrine syndrome
- Familial forms
122
Hypoparathyroidism features
- Hypocalcaemia
- Neuropsychiatry = anxiety, depression, cognitive impairment
- Ocular symptoms = cataracts, impaired night vision
- Dental abnormalities = dental enamel hypoplasia, tooth discolouration
123
Hypoparathyroidism investigations
- Serum Ca (low) and phosphate (high)
- PTH levels (low/inappropriately normal)
- Vit D levels
- Low urinary Ca
- Prolonged QTc
124
Hypoparathyroidism management
Ca and Vit D supplementation
Close monitoring
125
What are the causes of Hypothyroidism?
- AI = Hashimoto's, atrophic thyroiditis, polyendocrine syndromes
- Iatrogenic = surgical removal, radioablations, radiation therapy
- Congenital = Thyroid aplasia, Pendred syndrome (defect in thyroxine synthesis)
- Iodine deficiency/excess
- Infiltrative disorders = sarcoid, haemochromatosis
126
Hypothyroidism features
- Peripheral = dry/thick skin, brittle hair, scanty secondary sexual hair
- Queen Anne's sign = loss of other 1/3 of eyebrows
- Cold intolerance
- Head and neck = macroglossia, puffy face, goitre
- Cardiac = bradycardia, cardiomegaly
- Neuro = carpal tunnel, slow relaxing reflexes, cerebellar ataxia, peripheral neuropathy, loss of concentration
- Joint pain
- Menorrhagia
127
Hypothyroidism investigations
- TFTs (1st line)
- Antibody testing = anti-TPO, anti-thyroglobulin, Anti-TSH receptor
- Imaging and biopsy
- Iodine levels
128
Hypothyroidism management
- Levothyroxine
- Recheck TFTs every 3 moths after initiation, and adjust dose accordingly
- Once the TSH level is stable (2 similar measurements w/in reference range 3 months apart) then check TFTs annually
- During pregnancy, LT4 is usually increased by 25-50mg
129
Define Infertility
The failure to conceive over a 2-year period despite regular (3-4x a week) unprotected sexual intercourse
130
What are the causes of Infertility?
Natrual:
- Increasing age
- Smoking and obesity
- Tight fitting underwear (males)
- Excessive alcohol
- Anabolic steroid use
- Illicit drugs
Genetic:
- Turner's
- Klinefelter's
Ovulation/endocrine:
- PCOS
- Pituitary tumours
- Sheehan's
- Hyperprolactinaemia
- Cushing's
- POI
Tubal abnormalities:
- Congenital
- Adhesions secondary to PID
Uterine abormalities:
- Bicornate
- Fibroids
- Asherman's syndrome
- Endometriosis
Cervical abnormalities:
- After biopsy or LLETZ
Testicular:
- Cryptorchidism
- Varicocele
- Cancer
- Congenital defects
Ejaculation:
- Obstruction
- Retrograde ejaculation
- Premature ejaculation
131
Infertility (female) investigations
Bedside:
- Thorough Hx
- Speculum and bimanual exam to assess for obvious abnormalities
- STI screen
Bloods:
- Serum progesterone testing (performed 7 days before period) - a rise in progesterone indicates a corpus luteum has formed
- Prolactin
- LH/FSH
- Anti-Mullerian hormone = measure ovarian reserves
- TFTs
Imaging:
-TVUS
- Hysterosalpingography
- Laparoscopy
132
Infertility (male) investigations
Bedside:
- Thorough Hx
- Testicular exam
- Semen analysis
Bloods:
- Serum testosterone
- LH/FSH
- TFTs
133
Infertility management
Treat underlying cause
Conservative:
- WL
- Smoking cessation
- Stress and alcohol reduction
Medical:
- Clomiphene (increases ovulation)
- FSH/LH injections
- GnRH or DA agonists
Surgical:
- IVF
- Intracytoplasmic sperm injection
134
MEN-1 features
3 Ps
- Parathyroid hyperplasia/adenoma
- Pancreas = gastrinomas or insulinomas
- Pituitary = prolactinomas
135
MEN-2a features
2 Ps, 1 M
- Pheochromocytomas
- Parathyroid hyperplasia/adenoma
- Medullary thyroid cancer
136
MEN-2b features
1 P, 2 Ms
- Pheochromocytomas
- Medullary thyroid cancer
- Mucosal Neuromas = on lips, tongues and eyes
(+ Marfanoid habitus = tall stature, arachnodactyly)
137
MEN investigations
- Genetic testing for mutations in MEN1 or RET genes
- Hormonal assays
- CT/MRI to look for tumours
138
What are the BMI classifications of Obesity?
- Overweight = 25 - 29.9
- Class 1 = 30 - 34.9
- Class 2 = 35 - 39.9
- Class 3 (severe) = > 40
139
Obesity management
Conservative:
- Dietary
- Exercise
- CBT and motivation counselling
Medical:
- Orlistat (lipase inhibitor)
- GLP-1 receptor agonists (e.g. liraglutide) - these should be discontinued after 12 wks if pt has not lost at least 5% of their initial body weight
Surgical - for BMI > 40, or > 35 with significant symptoms:
- Gastric bypass
- Sleeve gastrectomy
- Adjustable gastric banding
- Biliopancreatic diversion
140
Define Osteomalacia
Metabolic bone disease due to Vit D deficiency that occurs after the epiphyses close
Characterised by osteopenia and disordered bone calcification (excess osteoid and unmineralised collagenous tissue)
141
Osteomalacia features
- Pain in lower back, hips and pelvis
- Pseudofractures or Looser's zones = incomplete stress fractures
- Bone tenderness
- Muscle weakness
142
Osteomalacia investgiations
- Vit D levels, Ca and phosphate
- Bone biopsy (gold standard)
- XR
143
Osteomalacia management
- Replenish Vit D and Ca
144
Define Osteoporosis
Skeletal disease characterised by reduced bone mass and altered microarchitecture of the bone tissue
This results in increased bone fragility and increased fracture risk
Defined as DEXA scan T-score of -2.5 or lower
145
What are the risk factors for Osteoporosis?
SHATTERED FAMILY
- Steroid use
- Hyperthyroidism/parathyroidism
- Alcohol and smoking
- Thin (BMI < 22)
- Testosterone deficiency
- Early menopause
- Renal/liver failure
- Erosive/inflammatory bone disease
- Diabetes
- Family Hx
146
Osteoporosis features
- Back pain due to fractured/collapsed vertebra
- Loss of height over time
- Stooped posture
- Fractures from low-impact trauma
147
Osteoporosis investigations
- DEXA = -2.5 or lower
- X ray
- PTH, Ca and vit D levels
- FRAX score = assessment of 10-year risk of major osteoporotic fracture
148
Osteoporosis management
- Bisphosphonates = to all pts w/ T score < -2.5, or T score -1 to -1.5 w/ a high FRAX score, or to all pts > 75 with a low-energy fracture
- Denosumab
- Ca supplements
149
Define Pheochromocytoma
A catecholamine (adrenaline, noradrenaline and dopamine) secreting tumour that originates in the adrenal medulla
When a similar tumour arises in sympathetic nerve tissue = paraganglioma
150
Pheochromocytoma features
- Episodic HTN (esp when adrenals compressed)
- Anxiety
- WL
- Fatigue
- Palpitations
- Excessive sweating
- Headaches
- Flushing
- Fever
- SOB
- Abdo pain
- Tremor
151
Pheochromocytoma investigations
- Plasma metanephrines (breakdown product of catecholamines) followed by urinary metanephrines = will be elevated
- Adrenal CT
- Paragangliomas can be identified using iodine-labelled metaiodobenzylguanidine (MIBG) scans or PET scans
152
Pheochromocytoma management
- Initial alpha blockade w/ phenoxybenzamine to prevent intraoperative hypertensive crisis
- Beta blockers can then be added to manage tachycardia or arrhythmias if neccessary
- Then, surgical resection
153
What does the anterior pituitary secrete?
- Growth hormone
- Prolactin
- LH and FSH
- Thyroid stimulating hormone
- Adrenocorticotrophin
154
What does the posterior pituitary secrete?
- Oxytocin
- Vasopressin (ADH)
155
Pituitary adenoma features
- Specific hormone imbalance (if functional)
- Headache (localised to front of head, persistent)
- Bitemporal hemianopia
156
Pituitary adenoma management
- Tran-sphenoidal surgery
- Radiotherapy in cases where complete tumour removal is not possible or reoccurs
- Medication to target overproduction of functioning hormones
157
Prolactinoma features
Women:
- Oligomenorrhea or amenorrhea
- Galactorrhoea
- Infertility
- Vaginal dryness
Men:
- Erectile dysfunction
- reduced facial hair growth
Both:
- Headaches
- Visual field defects
158
What's the difference between a micro and macroprolactinoma?
- Micro < 10mm, macro > 10mm
- Micro prolactin levels < 200, macro > 200 (usually above 1000)
- Micro = hyperprolactinaemia, macro = hyperprolactinaemia + mass effects
159
Prolactinoma management
Medical:
- Dopamine agonists (cabergoline) to increase dopamine inhibition
Surgery:
- Trans-sphenoidal resection +/- radiotherapy
160
Define Hypopituitarism
Inadequate production of 1 or more pituitary hormones
Deficiencies in GH, FSH, LH, TSH, ACTH and ADH
161
Hypopituitarism features
Depends on the missing hormone
GH:
- Central obesity
- Dry skin
- Reduced muscle strength
0 Decreased exercise tolerance
FSH/LH = Hypogonadotropism
TSH = hypothyroidism
ACTH = adrenal deficiency:
- Fatigue
- Anorexia
- Sarcopenia
- Myalgia
- GI upset
ADH = vasopressin deficiency
162
Define Impaired fasting glucose
Fasting blood glucose levels between 6.1 - 6.9
163
Define Impaired glucose tolerance
2-hour oral glucose tolerance test values between 7.8 - 11.1
164
Define Pseudohypoparathyroidism
A genetic condition where the target organs (bones, kidneys and gut) fail to respond to normal levels of PTH
165
Pseudohypoparathyroidism features
- Short stature and shortened fingers
- Hypocalcaemia
- Bone pain and fractures
166
Pseudohypoparathyroidism investigations
- Hypocalcaemia on serum Ca
- Normal or elevated PTH levels
167
Pseudohypoparathyroidism management
- Calcium supplements
- Vit D supplements
168
Define Secondary diabetes
A form of diabetes where there is a clear causative factor other than the typical insulin resistance or beta cell failure associated w/ T2DM
169
What are the causes of secondary diabetes?
Pancreatic:
- Cystic fibrosis
- Chronic pancreatitis
- Haemochromatosis
- Cancer
Endocrine:
- Cushing's = elevated cortisol leads to insulin resistance
- Acromegaly = elevated GH leads to insulin resistance
- Pheochromocytoma = chronic catecholamine-induced glucose intolerance
- Thyrotoxicosis = thyroid hormone excess can enhance hepatic gluconeogenesis and glycogenolysis and impair insulin secretion
Drugs:
- Steroids
- Atypical neuroleptics
- Thiazides
- Beta blockers = can inhibit insulin secretion
Glycogen storage disease (types 1 and 2)
170
What does Cortisol do?
Metabolic:
- Increases blood sugar = glucose and glycogen synthesis in liver, breakdown of glycogen in muscles, decreases glucose uptake in muscles and adipose,
- Decreases protein synthesis
- Lipolysis
Immune:
- Prevents release of cytokines
- Inhibits T cell proliferation
Electrolytes:
- Increases Na absorption in gut
- Increases K (cellular shift due to increased Na)
171
What are the side effects of metformin?
Lactic acidosis (avoid if renal impairment) and GI disturbances (switch to modified release)
172
What are the side effects of Sulfonylureas (e.g. Gliclazide)?
Hypoglycaemia and weight gain
173
What are the side effects of Pioglitazone?
Fluid retention (worsens HF) and weight gain
174
What are the side effects of SGLT2 inhibitors?
DKA when used w/ insulin
Increased risk of UTIs
175
What are the side effects of DPP-4 inhibitors (e.g. sitagliptin)?
Hypoglycaemia, GI upsets
176
What are the side effects of GLP1 analogues?
Hypoglycaemia, GI upsets and may increase risk of pancreatitis when used w/ DPP-4 inhibitors
177
Define Subclinical hyperthyroidism
A condition where TSH levels are below the reference range, but T3 and T4 levels are w/in normal range
Pts are usually asymptomatic, but may show moderate signs of hyperthyroidism
178
What are the causes of Subclinical hyperthyroidism?
- Early Grave's disease
- Autonomic nodular disease
- Exogenous intake of thyroid hormones or iodine
- Transient thyroiditis
179
Subclinical hyperthyroidism investigations
- 2 TFT results showing supressed TSH but normal T3/4, 3-6 months apart
- Rule out transient causes
180
Define Subclinical hypothyroidism
A condition where TSH levels are slightly raised (<10) but T3 and T4 levels are normal
Pts are usually asymptomatic, but may show moderate signs of hypothyroidism
181
What are the causes of Subclinical hypothyroidism?
- Early thyroid failure
- Hashimoto's
- Lithium/amiodarone/radioiodine treatment
182
Subclinical hypothyroidism investigations
- 2 TFT results showing elevated TSH but normal T3/4, 3-6 months apart
- Rule out transient causes
183
Subclinical hypothyroidism management
Most pts require no treatment other than regular monitoring
If TSH > 10 or pt is symptomatic, consider replacing thyroxine
184
What are the causes of SIADH?
- Pituitary tumour
- Tumours = SCLC, thymoma, lymphoma
- Pulmonary disease = infections, pneumothorax, asthma, CF
- CNS = infections, head injury (SAH)
- Drugs = chemo, psychiatric drugs
- Idiopathic
185
What does ADH do?
Binds to aquaporin 2 channels in the collecting duct to increase water reabsorption
Vasoconstricts to increase BP
186
SIADH features
Symptoms largely due to resulting dilutional hyponatraemia:
- Muscle cramps
- N&V
- Confusion, coma
- Seizures
187
SIADH investigations
- U&E = hyponatraemia
- Plasma osmolality = low (<270)
- Urine sodium = high (>20)
- Urine osmolality = high (>100)
188
SIADH management
- Fluid restriction
- Treat underlying cause
- Monitor and correct sodium levels
- Demeclocycline = reduces collecting ducts sensitivity to ADH
189
What are the different types of Thyroid cancer?
- Papillary = most common, occurs at 30-40 yrs, can met to bone a lung, excellent prognosis
- Follicular = more common in women and places w/ low iodine, occurs at 30-60 yrs, mets to bone and lung
- Medullary = originates from calcitonin-producing C cells, presents w/ hypocalcaemia and diarrhoea due to increased calcitonin, associated w/ MEN 2, mets to lymph nodes, worse prognosis
- Anaplastic = rarest, occurs 60-70 yrs, rapidly growing mass w/ median survival of 8 months
- Thyroid lymphoma = NHL, occurs 50-80 yrs, strongly associated w/ Hashimoto's
190
Thyroid cancer investigations
- Thyroid USS for imaging
- FNA for cytology
- TSH and calcitonin levels
191
Thyroid cancer features
Depend on the type, common ones include:
- Lump/swelling in the neck
- Voice changes
- Dysphagia
- Pain in neck or throat
- Persistent cough
192
Thyroid cancer management
- Thyroidectomy or lobectomy followed by radioactive iodine treatment
- then lifelong replacement
- Chemo + radiation for anaplastic
193
Define Waterhouse-Friderichsen syndrome
Bilateral adrenal haemorrhage and failure due to DIC caused by a significant bacterial infection
Most commonly due to Neisseria meningitides
194
Waterhouse-Friderichsen syndrome features
- Systemic illness due to infection
- Septic shock due to adrenal insufficiency = marked hypotension, altered mental status
- Multi-organ dysfunction
195
Waterhouse-Friderichsen syndrome management
- Aggressive fluid therapy
- Vasopressor support
- Broad-spectrum abx
- Corticosteroid replacement therapy
196
Define Congenital Adrenal Hyperplasia
A group of aurtosomalresessive disorders chaarcterised by impaired steroid hormone synthesis w/in the adrenal cortex due to enzyme defects
The most common type = 21-hydroxylase deficiency (an enzyme critical for the production of gluco/mineralocorticoids, cortisol and aldosterone) - it leads to elevated 17-hydroxyprogesterone levels
197
Congenital Adrenal Hyperplasia features
Depends on the enzyme defects, typically features include:
- Ambiguous genitalia (esp in females) due to in-utero exposure to excessive androgens
- Salt wasting crisis at birth = diarrhoea and vomiting, hyponatraemia, hyperkalaemia, circulatory shock and metabolic acidosis
- Virilisation = development of masculine secondary sexual characteristics in females
- Precocious puberty in men
198
Congenital Adrenal Hyperplasia investigations
- 17-hydroxyprogesterone and ACTH are elevated in CAH
- Cortisol is low
- Corticotropin stimulation test is the gold standard for diagnosis
- Genetic testing = Can confirm the diagnosis and identify the specific enzyme defect
- Ultrasound can help in the assessment of internal sex organs in patients with ambiguous genitalia
199
Congenital Adrenal Hyperplasia management
- Addisonian crisis = fluids, NaCl replacement
- Hydrocortisone and fludrocortisone
- Sick day rules
- Surgery to fix virilisation
200
Congenital Adrenal Hyperplasia complications
- Growth suppression
- metabolic syndrome
- Infertility
201
Define Addisonian crisis
Acute, life-threatening deficiency in cortisol leading to hyponatraemia, hyperkalaemia and hypoglycaemia
202
Addisonian crisis features
Symptoms:
- Fatigue/malaise
- Abdo pain
- N&V
- Myalgia
- Headache
Signs:
- Dehydration
- Hypotension
- Hypovolaemic shock
- Low-grade fever
- Confusion or coma
- Seizures
203
Addisonian crisis management
- ABCDE
- Fluid resuscitation
- IV or IM hydrocortisone 100mg as soon as suspected
- Then regular hydrocortisone
- IV glucose to correct hypoglycaemia
204
Define Pituitary apoplexy
Infarction or haemorrhage of the pituitary gland
205
Pituitary apoplexy features
- Sudden and severe headache
- Confusion
- Fatigue
- Fever
- N&V
- Addisonian crisis due to hypopituitarism and no ACTH
206
Define Sheehan's syndrome
Hypopituitarism due to large blood loss during child birth
This leads to ischaemia of the pituitary gland
207
Define De Quervain's thyroiditis
A self-limiting inflammatory illness of the thyroid gland usually due to a viral infection
208
De Quervain's thyroiditis features
Has 4 phases:
1) Thyroid swelling and discomfort w/ thyrotoxicosis (+fever like illness)
2) Brief euthyroid phase
3) Hypothyroid phase
4) Recovery euthyroid phase
Usually resolves w/in 3-6 months
209
Define Hypokalaemia
Potassium levels < 3.5
210
What are the causes of Hypokalaemia?
Renal (urine K > 20):
- Diuretics (furosemide, thiazides)
- Renal tubular acidosis
- Endocrine = Conn's, Cushing's
- Hypomagnesaemia
Extra-renal:
- Inadequate intake
- Gut loss = dialarhoea, vomiting, ileostomy, VIPoma, Zollinger-Ellison syndrome
- Redistribution into cells = beta agonists, insulin, theophylline, alkalosis (swaps for H+)
211
Hypokalaemia features
- Muscle weakness/cramps
- Paraesthesia
- Polyuria/polydipsia
- Constipation
- ECG = flattened T waves, prominent U waves, ST depression
212
Hypokalaemia management
- K between 3-3.5 = SandoK
- K < 3 = cardiac monitoring, correct magnesium (low mag causes renal K wasting) and IV replacement (no more than 10mmol/hr in a peripheral vein)
213
Define Hyperkalaemia
Potassium > 5.5
214
Hyperkalaemia features
- Paraesthesia
- Muscle weakness
- Oliguria
- Arrhythmias (esp VF)
- ECG = Tall tented T waves, flattened P waves, widened QRS complexes
215
What are the causes of Hyperkalaemia?
Impaired excretion:
- AKI
- CKD
- ACEi
- Potassium sparing diuretics
- NSAIDs
- Heparins
- Ciclosporin
- Trimethoprim
- Renal tubular acidosis type 4
- Addison's
Increased release from cells:
- Lactic acidosis
- Insulin deficicency
- Rhabdomyolysis
- Tumour lysis syndrome
- Massive haemolysis
- Digoxin toxicity
- Beta-blockers
216
Hyperkalaemia management
- Mild = 5.5-5.9 = repeat
- Moderate = 6-6.4 = give potassium binders if can tolerate PO, give Calcium gluconate if ECG changes, give Insulin-glucose IV infusion, then give salbutamol if not coming down
- Severe = >6.5 = give potassium binders if can tolerate PO, give Calcium gluconate, give Insulin-glucose IV infusion, then give salbutamol if not coming down
217
What are the causes of Hypomagnesaemia
Decreased gut absorption:
- PPIs
- Insufficient intake
- Alcoholism
- Dialarhoea
- Malabsorption
- SB bypass
- Vomiting
- Short bowel syndrome
Redistribution to intracellular space;
- Refeeding syndrome
- Insulin
- Acute pancreatitis
- Alcohol withdrawal
Increased renal excretion:
- Loop and thiazide diuretics
- Digoxin
- Gentamicin
- Chemo
- Renal tubular acidosis
- Dialysis
- Genetic
218
Hypomagnesaemia features
- Weakness
- Paraesthesia
- Seizures
- Confusion/Coma
- Hypocalcaemia = low mag stops PTH release
- Hypokalaemia = stimulates renal K loss
- Ventricular arrhythmias
- Chondrocalcinosis
219
Hypomagnesaemia management
- Mild (0.5-0.7) = oral replacement if symptomatic
- Moderate (0.4-0.5) = magnesium salts (can cause diarrhoea) if asymptomatic, IV if symptomatic
- Severe (<0.4) = IV replacement
220
What are the causes of Hyponatraemia in a hypovolaemic patient?
Urinary Na > 20 (renal loss):
- Addison's
- Renal failure
- Diuretics
- Osmotic diuresis
Urinary Na < 20 (loss elsewhere):
- Diarrhoea & vomiting
- Fistulae
- Burns
- Small bowel obstruction
- Excessive sweating
221
What are the causes of Hyponatraemia in a euvolemic patient?
High urine osmolality = SIADH
Normal urine osmolality:
- Water intoxication
- Severe hypothyroidism
- Glucocorticoid insufficiency
222
What are the causes of Hyponatraemia in a hypervolaemic patient?
Failures = cardiac, liver, renal
Nephrotic syndrome
223
What are the causes of Hypernatraemia in a hypovolaemic patient?
Renal:
- Osmotic diuresis
- Loop diuretics
Other:
- D&V
- GI fistulae
- Burns
224
What are the causes of Hyponatraemia in a hypervolaemic patient?
- NaCL infusion
- Salt water ingestion
- Cushing's syndrome
- Conn's syndrome
225
What are the causes of Hyponatraemia in a euvolemic patient?
- Vasopressin insufficiency
- Vasopressin resistance
226
Hypernatraemia symptoms
- Fever and flushed skin
- Restlessness/irritability
- Increased BP
- Oedema
- Fluid retention
- Oliguria
227
Hyponatraemia symptoms
LOW SODIUM:
- Levels of consciousness altered
- Orthostatic hypotension
- Weakness
- Seizures
- Osmolality low (serum)
- Diarrhoea
- Increased ICP
- Urine osmolality high
- More bowel sounds
