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Endocrinology Flashcards

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1
Q

Name the 8 hormones produced by the pituitary?

A 
LH
FSH
GH
ACTH
Prolactin 
TSH
ADH
Oxytocin
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2
Q

what are the causes of hypopituitarism?

A

1) Most common: anterior pituitary tumour - adenoma
2) Non-pituitary tumours - meningiomas, craniopharyngiomas
3) Infiltrative process - sarcoidosis, haemochromatosis
4) Stroke
5) Iatrogenic - irradiation, nuerosurgery
6) head injury

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3
Q

Symptoms of hypopituitarism?

A 
ACTH deficiency- Adrenal insufficiency and addisons
TSH deficiency- hypothyroidism 
FSH + LH deficiency
GH deficiency
ADH deficiency
Symptoms of SOL
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4
Q

What is a serious complication of hypopituitarism?

A

Pituitary apoplexy - infarct of the pituitary gland, causing a hypopituitary coma

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5
Q

what are the clinical features of hypopituitary coma?

A 
hormone deficiency
meningism 
visual field defects
opthalmoplegia 
reduced consciousness 
hypotension 
hypothermia 
hypoglycaemia
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6
Q

Management of hypopituitary coma?

A

IV hydrocortisone
T3 replacement - only given after hydrocortisone therapy has been started
Urgent surgery

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7
Q

Investigations of hypopituitarism?

A 
Blood glucose 
Renal function 
Electrolytes 
Hormonal assays - TFT, prolactin, gonadotrophins, testosterone, cortisol 
Pituitary function tests
Cranial MRI
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8
Q

Management of hypopituitarism?

A

Glucocorticoid and mineralocorticoid (depends on which hormones are deficient)
Thyroid hormone replacement
Gonadotropin replacement- testosterone, oestrogens and progesterone
Diabetes Insipidus management

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9
Q

what is Addisons disease?

A

Primary adrenal insufficiency, where the hormones aldosterone and cortisol are not produced in sufficient quantities

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10
Q

what are the two types of adrenal insufficiency?

A

Primary - addison’s disease (autoimmune, destruction of the gland, congenital adrenal hyperplasia)
Secondary- inadequate pituitary or hypothalamic stimulation of the adrenal glands (TB, carcinoma, trauma, radiotherapy etc)

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11
Q

what are the three zones of the adrenal glands?

A

zona glomerulosa- aldosterone
zona fasiculata - cortisol
zona reticularis- androgens

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12
Q

where does aldosterone act in the kidney?

A

Na+/K+ pump in the DCT

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13
Q

Symptoms of addisons disease/adrenal insufficiency?

A 
N+V, fatigue, dizziness
Syncope/postural hypotension 
Hypoglycaemia 
Non-specific: weakness, confusion, depression
hyperpigmentation
muscle weakness
weight loss
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14
Q

Signs of addisons disease/adrenal insufficiency on examination?

A 
Hyperpigmentation 
Hypotension 
Weight loss
Loss of body hair 
vitiligo
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15
Q

Laboratory electrolyte inbalances in adrenal insufficiency?

A 
Hyponatraemia - most important
Hyperkalaemia - Na+/K+ pump aldosterone 
Hypoglycaemia 
Low cortisol 
Caclium may be raised
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16
Q

what test is used to assess for adrenal insufficiency/addisons?

A

Short synacthen test

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17
Q

Describe the short synacthen test and results?

A

Measure cortisol levels before test
Give synthetic ACTH
Measure cortisol levels 30 mins after
Failure of cortisol to rise (less than double the baseline) indicates Addisons (primary adrenal insufficiency)

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18
Q

Investigation to differentiate between primary and secondary adrenal insufficiency?

A

Measure serum ACTH- primary = high, secondary = low

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19
Q

Investigations for adrenal insufficiency/addisons disease?

A

Electrolytes- hyponatraemia, hyperkalaemia
Short synacthen test
Serum ACTH
MRI adrenal and pituitary
Adrenal cortex antibodies, 21-hydroxylase antibodies

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20
Q

Management of addisons disease/adrenal insufficiency?

A

Glucocorticoid (hydrocortisone) and mineralocorticoid (fludrocortisone) replacement

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21
Q

What is a serious life threatening complication of addisons disease?

A

Addisonian crisis- absence of steroid hormones leads to life threatening presentation
Common in those withdrawing from long-term steroids or triggered by infection, trauma or acute illness in someone with established addisons

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22
Q

Presentation of Addisonian crises?

A 
Reduced GCS
Hypotension
Hypoglyacemia 
Hyponatraemia 
Hyperkalaemia
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23
Q

Management of Addisonian crisis?

A

IV hydrocortisone 100mg stat then 100mg every 6 hours
IV fluid resuscitation
Corrrect hypoglycaemia
Intensive monitoring

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24
Q

Causes of hypothyroidism?

A 
Hypopituitarism 
Hashimotos thyroiditis 
Iodine defiency
Secondary to treatment of hyperthyroidism
Medications
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25
Name two medications that cause hypothyroidism?
Lithium | Amiodarone
26
Presentation of hypothyroidism?
``` Weight gain Fatigue Dry skin Coarse hair and hair loss Fluid retention Heavy or irregular periods Constipation bradycardia slow reflexes carpal tunnel/peripheral neuropathy macrocytosis ```
27
what would the TSH and T3/4 levels be in primary hypothyroidism?
TSH- high | T3/4- low
28
what would the TSH and T3/4 levels be in secondary hypothyroidism?
TSH- low | T3/4- low
29
which autoantibodies are associated with hashimotos thyroiditis?
anti-TPO antibodies | antithyroglobulin antibodies
30
signs of myoxedema?
``` emotionless face peri-orbital puffiness swollen tongue intestinal obstruction cerebellar ataxia psychosis encephalopathy ```
31
what is the treatment of hypothyroidism?
levothyroxine
32
what are the causes of hyperthyroidism?
graves disease toxic multinodular goitre secondary hyperthyroidism- overstimulation by TSH due to hypothalamus or pituitary pathology
33
what is Graves disease?
autoimmune condition where the thyroid stimulating immunoglobulins bind to TSH receptor causing excessive production of T3 + T4
34
what is toxic multinodular goitre?
condition where nodules develop on the thyroid gland that act independently of the normal feedback system and continously produce excessive thyroid hormone
35
signs of hyperthyroidism?
``` exopthalmos - graves pre-tibial myoxoedema - graves diffuse goitre without nodules- graves thyroid acropatchy- graves anxiety sweating tachycardia weight loss fatigue sexual dysfunction heat intolerance ```
36
what is de quervains thyroiditis?
self-limiting viral infection with fever, neck pain and tenderness of the thyroid. There is a hyperthyroid phase followed by a hypothyroid phase due to negative feedback.
37
Features of thyrotoxicosis?
pyrexia tachycardia delirium
38
management of hyperthyroidism?
``` carbimazole propylthiouracil radioactive iodine thyrodectomy beta blockers ```
39
management of thyrotoxicosis?
``` ABCDE carbimazole after 4 bours- lugols solution hydrocortisone beta blockers ```
40
symptoms of gonadotropin deficiency?
women: oligomenorrhoea, loss of libido, dyspareunia, infertility, osteoporosis men: loss of libido, impaired sexual function, mood impairement, loss of body hair, decreased muscle mass, osteoporosis, anaemia
41
symptoms of growth hormone deficiency?
``` short stature decreased muscle mass and strength visceral obesity fatigue decreased quality of life impairement of attention and memory ```
42
what is diabetes insipidus?
hyposecretion or insensitivity to ADH
43
what are the two types of DI?
cranial: decreased secretion of ADH in the hypothalamus or pituitary dysfunction preventing its release nephrogenic: decreased ability to concentrate urine because of resistance to ADH in the kidney
44
causes of cranial DI?
``` surgery head injury infections- TB, meningitis tumours- hypothalamic or pituitary inherited infiltration - sarcoidosis ```
45
causes of nephrogenic DI?
``` familial renal disease- CKD inherited lithium sickle cell hypokalaemia hypercalcaemia ```
46
symptoms of DI?
polyuria polydypsia nocturia
47
investigations of DI?
u+E- hypernatraemia 24 hour urine collection fluid deprivation test MRI of pituitary and hypothalamus
48
describe the fluid deprivation test for DI?
Patient is deprived on fluids for up to 8 hours Urine osmolality measured Desmopression 2 micrograms is administered Urine osmolality measured again
49
What results of the fluid deprivation test for DI indicates cranial DI?
urine osmolality after deprivation- low | urine osmolality after ADH administration- high
50
what results of the fluid deprivation test for DI indicates neprhogenic DI?
urine osmolality after deprivation - low | urine osmolality after ADH administration - low
51
management of cranial DI?
ADH replacement therapy - desmopressin | regular measurements of sodium
52
management of nephrogenic DI?
thiazide like diuretic and nsaid combination | stop any medications contributing
53
what is the function of prolactin?
1) stimulates mammary glands to produce milk | 2) decreases oestrogen and testosterone levels
54
which hormone inhibits prolactin?
dopamine
55
What are the symptoms of excessive prolactin in males and females?
men: impotence, loss of libido, galactorrhoea women: amenorrhoea, galactorrhea
56
what are the causes of increased levels of prolactin?
``` pregnancy prolactinoma primary hypothyroidism PCOS physiological ```
57
management of excessive prolactin?
bromocriptine (dopamine agonist)
58
pathophysiology of SIADH?
excessive ADH release from the posterior pituitary causes and increases in V2 receptors and an increase in aquaporins. This results in a decrease in osmolality and dilution of electrolytes e.g. sodium - causing retention + oedema
59
presentation of SIADH?
``` confusion irritability headache muscular aches and pains seizures coma ```
60
causes of SIADH?
``` post-op infection paraneoplastic - SCLC medications meningitis ```
61
investigations for SIADH?
plasma osmolality - low urine osmolality - high hyponatraemic
62
Management of SIADH?
tolvaptan - ADH receptor blocker fluid restriction correct hyponatraemia
63
complication of correcting sodium levels too quickly?
central pontine myelinosis -> damage to the myelin sheath due to rapid influx of sodium ions
64
physiological role of parathyroid hormone?
regulates serum calcium levels by: 1) directly stimulating osteolclasts to increase bone reabsorption 2) acts on kidney to reduce re-absorption of phosphate (phosphate forms water insoluble salts with calcium 3) increases production of activated vitamin D which increases the amount of calcium that is absorbed in the small intestine
65
causes of hyperparathyroidism?
solitary adenoma hyperplasia of posterior pituitary multiple adenoma carcinoma
66
what is the presentation of hyperparathyroidism?
"bones, stones, abdominal moans and psychic groans" ``` polydypsia polyuria constipation pancreatitis peptic ulceration renal stones depression hypertension ```
67
investigations of hyperparathyroidism?
raised Ca (above 3.2) low phosphate PTH raised XRAY - pepperpot skull
68
management?
treat hyperCa: fluids bisphosphonates definitive management: total parathyroidectomy
69
causes of hypoparathyroidism?
``` secondary to thyroid surgery injury to parathyroidgland radiation drugs alcohol haemochromatosis + wilsons ```
70
presentation of hypoparathyrodism?
muscle twitching, cramping and spasming depression cataracts perioral paraesthesia
71
investigations of hypoparathyroidism?
``` ECG: prolonged QT interval -> may progress to ventricular fibrillation and heart block hypocalcaemia hyperphosphataemia low PTH normal ALP ```
72
management of hypoparathyroidism?
IV calcium gluconate ECG monitoring calcium, vit D and phosphate supplements human recombinant parathyroid hormone
73
signs and symptoms of T1DM?
weight loss polydypsia polyuria may present with DKA: abdominal pain, vomting, reduced consciousness level
74
what is the diagnostic criteria for DM?
fasting glucose > 7.0mmol/l random glucose > 11.1 mmol/l HbA1c > 48 mmol/l
75
what is the diagnostic criteria for pre-diabetes?
HbA1c > 42-47 mmol/l | fasting glucose > 6.1 - 6.9 mmol/l
76
what are the side effects of insulin?
hypoglycaemia weight gain lipodystrophy
77
MOA of metformin?
increase insulin sensitivity | decrease hepatic gluconeogenesis
78
S/E of metformin?
GI upset | lactic acidosis
79
MOA of sulfonylureas?
stimulate pancreatic beta cells to secrete insulin
80
S/E of sulfonylureas?
weight gain hypoglycaemia hyponatraemia
81
MOA of SGLT-2 inhibitors?
inhibits reabsorption of glucose in the kidney - so glucose is excreted via the urine
82
S/E of SGLT-2 inhibitors?
UTI
83
MOA of DPP-4 inhibitors?
increases incretin levels which inhibit glucagon secretion (which converts glycogen to glucose in the liver)
84
what is the pathophysiology of DKA?
In the absence of insulin the liver accelerates glucose production through lipolysis. This causes increase in fatty acids, which are broken down hy the liver into ketone bodies, which leads to metabolic acidosis.
85
signs and symptoms of DKA?
``` kussumal breathing - deep and laboured pear drop breath smell abdominal pain vomiting seizures ```
86
investigations of DKA?
glucose > 11 mmol/l metabolic acidosis ketones > 3mmoll or +++ on urine dipstick
87
management of DKA?
A-E NaCl replacement of fluid once blood glucose is < 15mmol/l start 5% dextrose infusion insulin sliding scale stop short acting insulin start long acting insulin correct hypokalaemia (during treatment with insulin, hypokalaemia commonly occurs as insulin shifts K+ from extracellular compartment into intracellular compartment)
88
pathophysiology of HHS?
Reduced insulin production leads to hyperglycaemic state, which is so severe that it causes plasma hyper-osmolality, which then causes and increase in urination as a response which further increases the osmolality through dehydration.
89
signs and symptoms of HHS?
``` dehydration stupor impaired consciousness seizures coma hypervisosity of blood = increased risk of MI, stroke and DVT ```
90
investigations of HHS?
``` hypovolaemia hyperglycaemia increased osmolality tachycardia hypotension RR increased ```
91
management of HHS?
IV NaCl | low dose insulin + monitoring of ketones
92
what are some eye complications of diabetes?
diabetic retinopathy cataracts external occular palsy retinal detatchment
93
why does diabetes cause eye disease?
high glucose levels leads to damage to the basement membrane and small vessels of the eye, which causes growth or friable and poor quality new blood vessels + oedema
94
pathophysiology of diabetic retinopathy?
damage to small vessels in the retina leads to microaneurysms which leads to leakage of fluids + micro-infarcts which causes haemorrhage and pulling on the retina -> retina detatchment
95
what is seen in fundoscopy of diabetic retinopathy?
cotton wool spots dot blot haemorrhages flame haemorrhages hard exudates
96
management of diabetic retinopathy?
laser treatment | anti-VEGF drugs
97
why does diabetes cause nephropathy?
high levels of glucose cause basement membrane thickening and glomerulosclerosis
98
what is the screening for diabetic nephropathy?
screened annually using urinary albumin:creatinine ratio (should be an early morning specimen)
99
management of diabetic nephropathy?
control BP using ACE-I / ARB (target <130/80) tight glycaemic control smoking cessation
100
first line treatment for painful diabetic neuropathy?
amitryptiline gabapentin duloxetine pregabalin
101
what is the pathophysiology of conns?
hyperaldosteronism - excessive production of aldosterone by the adrenal glands leading to excessive Na+/H retention and loss of K+
102
causes of hyperaldosteronism?
conns- solitary pituitary adenoma | bilateral hyerplasia of the adrenals
103
signs of hyperaldosteronism?
hypertension hypernatraemia hypokalaemia
104
investigations of hyperaldosteronism?
aldosterone: renin ratio (aldosterone high, renin low)
105
management of hyperaldosteronism?
laparoscopic adrenalectomy | spironolactone
106
causes of cushings syndrome?
cushings disease - pituitary adenoma adrenal adenoma ectopic corticotropin secretion - i.e. SCLC
107
presentation of cushings?
``` truncal obesity facial fullness moon face proximal muscle wasting oedema gonadal dysfunction, reduced libido hypertension depression thirst, polydypsia, polyuria ```
108
investigations for cushings?
``` low doxe dexamethasone test - 1mg of dex administered at 11pm and serum cortisol measured at 8am next morning high dose dexamethasone test Plasma ACTH MRI pituitary 24 hour urinary free cortisol ```
109
management of cushings disease?
trans-sphenoidal pituitary adneoma resection metyrapone ketoconazole
110
what is a phaeochromocytoma?
catecholamine secreting tumour
111
features of phaeochromocytoma?
``` hypertension headaches palpitations sweating anxiety ```
112
investigations of phaeochromoytoma?
24 hr urinary collection of metanephrines
113
management of phaeochromocytoma?
alpha-blocker given before a beta-blocker to stabilise and surgical removal of the tumour
114
what is acromegaly?
excessive growth hormone secondary to a pituitary adenoma
115
features of acromegaly?
``` coarse facial appearance frontal bossing large tongue (macroglossia) excessive sweating and oily skin (sweat gland hypertrophy) prognathism carpal tunnel syndrome features of pituitary tumour (hypopituitarism, headaches, bilateral hemianopia) raised prolactin ```
116
investigations for acromegaly?
serum IGF-1 levels - raised OGTT- confirm diagnosis (in normal patients GH is surpressed to <2 with hyperglycaemia, in acromegaly there is no supression pituitary MRI
117
management of acromegaly?
trans-sphenoidal surgery dopamine agonist (bromocriptine) somatostatin analogue - directly inhibits GH (octerotide)
118
what other endocrine condition should also be tested for in acromegaly?
diabetes- as GH is anti-insulin and over time high levels of GH lead to insulin suppression and diabetes
119
patient develops diabetes insipidus following large post-partum haemorrhage/traumatic childbirth. what is the name of this condition?
Sheehan's syndrome- pituitary ischaemia due to reduced blood flow during childbirth.
120
what are the symptoms of hypoglycaemia in diabetes?
``` sweating palpitations tremor confusion drowsiness seizures hemiparesis ```
121
what can occur to diabetic patients following repeated episodes of hypoglycaemia?
loss of awareness of hypoglycaemia- so there is loss of the initial symptoms
122
management of hypoglycaemia?
IM glycogen | IV glucose/dextrose solution
123
what are some common causes of hypoglycaemia in non-diabetics?
liver failure addisons insulin-secreting tumours hypopituitarism
124
most common cause of hypoglycaemia in diabetics?
over-administration of insulin
125
Describe the OGTT?
patient fasts overnight blood glucose measured given a drink of 75g of glucose blood glucose measured again- if >11.1 mmol/L random or at the start >7 mmol.l (fasting) then diagnosis of diabetes is given
126
what are 2 complications of surgical removal of parathyroidglands?
hypoparathyroidism | laryngeal nerve palsy
127
in diabetic neuropathy, which sensation is the first to be lost?
VIBRATION SENSE
128
what are some signs on examination of the foot of diabetic neuropathy?
charcots joint painless ulcer diminished reflexes
129
what are the types of peripheral neuropathy that can develop in diabetes?
autonomic neuropathy acute painful neuropathy autonomic gastropersis sensory peripheral neuropathy- glove and stocking distribution
130
signs and symptoms of autonomic neuropathy?
``` urinary retention constipation dysphagia, abdominal pain, vomiting tachycardia or bradycardia pupillary defect ```

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