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RW Year 6 > Endocrinology > Flashcards

Endocrinology Flashcards

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1
Q

MEN syndromes

A

MEN I (3 Ps) – Pituitary, Parathyroid, Pancreas

MEN IIa (1M,2Ps) – Medullary Thyroid Carcinoma, Pheochromocytoma, Parathyroid

  • OR “I am meant to sit in an AC room” – 3Cs Calcium, Calcitonin, Catecholamines

MEN IIb (2Ms,1P) – Medullary Thyroid Carcinoma, Marfanoid habitus/mucosal neuroma, Pheochromocytoma

  • Every man wants to be a Pharaoh with Medium Cars on Mars with New Romans”
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2
Q

Management of Hypoglycaemia

A
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3
Q

Whipple’s triad

A
  1. Plasma hypoglycaemia
  2. Symptoms due to low blood glucose
  3. Resolution of symptoms with correction of hypoglycaemia
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4
Q

Known hypopituitarism –> Gradual onset

Pituitary apoplexy sudden onset

Panhypopituitarism

Reduced GCS

Hypotension

Hypoglycaemia

Diagnosis? Tx?

A

Hypopituitary coma

  • URGENT IV Hydrocortisone
  • Then, T3 replacement
  • Then treat underlying cause
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5
Q

Simmond’s disease

vs

Sheehan’s syndrome

vs

Pituitary apoplexy

A
  • Simmond’s disease
    • Insidious onset
    • Hypopituitarism
  • Sheehan’s syndrome
    • Women
    • PPH
    • Sudden onset
    • Hypopituitarism
  • Pituitary apoplexy
    • Pre-existing pitutiary adenoma –> acute infarction
    • Rapid onset
    • Headache
    • Xanthochroma
    • Hypopituitarism
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6
Q

Ix for GH deficiency

Tx

A

Insulin (hypoglycaemia is a potent stimulus for GH release)

Normal = GH release

Pituitary dwarfism –> no GH release

Tx: Somatotropin (recombinant GH)

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7
Q

Excess GH is associated with

A

High levels of GH has prolactin-like effects

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8
Q

Ix for Acromegaly

A

IGF-1: high (inital Ix)

OGTT (definitive Ix)

  • Normal: Glucose load –> ↓ GH levels
  • Acromegaly: Glucose load –> Paradoxical ↑ GH levels
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9
Q

Tx for acromegaly

A

(1) Trans-sphenoidal surgery
(2) Somatostatin analogue (Octreotide) or Cabergoline (DA agonist)
(3) GH antagonist
(4) Radiotherapy

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10
Q

Complications of Acromegaly

A

Cardiac complications (40%)

Diabetes mellitus

Colonic adenocarcinoma

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11
Q

Micro vs Macroadeoma

A
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12
Q

Hypothalamic - Pitutiary axes

A
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13
Q

Signs of hypernatraemia

A
  • Thirst
  • Loss of appetite
  • Restlessness
  • ↑ Tone (Spasticity)
  • Hyper-reflexia
  • Tremor
  • Seizures
  • Ataxia
  • Lethargy –> Stupor –> Coma
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14
Q

Signs of hyponataremia

A

If Na+ < 120 mM –> Generalised weakness, Poor mental function, N&V, Irritability

If Na+ < 110 mM –> Confusion, Drowsiness, Seizures, Coma (↓ GCS), Death

SALT LOSS

  • Stupor
  • Anorexia
  • Lethargy
  • Tendon reflexes ↓
  • Limp muscles (weakness)
  • Orthostatic hypotension
  • Seizures
  • Stomach cramps
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15
Q

Signs of hypokalaemia

ECG changes

Tx

A

Sx

  • Muscle weakness
  • Cardiac arrhythmias
  • Polyuria/Polydipsia
  • Constipation

ECG

  • Prolonged PR
  • Flattening of T wave
  • ST depression
  • U wave

Tx

  • Oral/IV Potassium chloride (<10mmol/hr)
  • Treat underlying cause
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16
Q

Sx and ECG changes of hyperkalaemia

A

ECG:

  • Bradycardia
  • Loss of p waves / Flattened p waves
  • Prolonged PR
  • Broad QRS
  • Depressed ST
  • Peaked T waves

Sx of hyperkalaemia MURDER

  • Muscle cramps –> Weakness –> Paralysis
  • Drowsiness
  • Hypotension
  • Arrhthmias
  • Abdominal cramps
  • Diarrhoea
  • Oliguria
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17
Q

Ix for diabetes insipidus

A

Serum osmolality: ↑

Urine osmolality: ↓ (i.e. dilute urine)

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18
Q

Tx for DI

A

Cranial DI –> Desmopressin

Nephrogenic DI –> Thiazide diuretics (Bendroflumethiazide)

==> retain urine volume and bypass VP’s concentrating mechanism

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19
Q

Ix in SIADH

Examination findings

A
  • Plasma osmolality: ↓ plasma osmolality, ↓ Na+
  • Urine osmolality: ↑ urine osmolality, ↑ Urine Na+
  • Euvolaemic

Tx

  • Treat underlying cause
  • Treat hyponataremia
    • Fluid restriction
    • +/- IV Hypertonic 3% saline
      • Avoid increasing Na too quickly (central pontine myelinolysis)
    • +/- Furosemide
  • Long term –> cause nephrogenic DI
    • Lithium
    • DMCT
    • Tolvaptan
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20
Q

Sx of hypopituitarism

A
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21
Q

Tx for thyroid storm

A
  • ABCDE
  • High-dose anti-thyroid drug (Aim to remove excess T4/T3 QUICKLY)
    • Carbimazole
    • Propylthiouracil
  • + Corticosteroids
  • + β-blockers
  • + Iodine (Lugol solution)
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22
Q

Tx for Grave’s disease

A
  • Anti-thyroid drugs (Carbimazole or Propylthiouracil)
    • High dose and titrate or Block and replace
    • Takes time to work due to existing T4/T3 in colloid
    • Given with B-blockers
  • β blockers (Propranolol)
  • Radioactive iodine
  • Surgery
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23
Q

Smooth diffuse goitre

Fever (ALWAYS PRESENT)

Extreme agitation

Confusion / Delirium

Nausea & Vomiting

Tachycardia

Cardiac failure

Liver failure / Jaundice

Signs of dehydration / volume depletion

Diagnosis?

A

Thyroid storm

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24
Q

Thyroid scan in

Grave’s

Plummer’s (toxic nodular goitre)

Toxic adenoma

A

Grave = smooth uptake

Plummer’s (toxic nodular goitre) = hot nodules and cold areas

Toxic adenoma = hot nodule

Viral thyroiditis = no uptake

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25
Thyroid goitre Ix
**TFTs** **Neck USS +/- Fine needle aspiration** **Thyroid scan**
26
Tx for toxic nodule
* Medical * **Anti-thyroid drugs (Carbimazole, Propylthiouracil)** * **Beta-blockers** * **Radio-iodine** * Surgical * **Subtotal/Total Thyroidectomy**
27
Antibody in Hashimoto's thyroiditis
**Anti-TPO Ab / Anti-thyroglobulin Ab: +ve**
28
Causes of Cushing's syndrome
* ACTH dependent * **Pituitary adenoma** (Cushing's disease) * **Ectopic ACTH production** * ACTH indepedent * **Iatrogenic / Exogenous steroids** * **Adrenal adenoma**
29
Ix for Cushing's syndrome
* 24 hour urine cortisol * 9am and Midnight cortisol * Low dose dexamethasone supression test (Gold standard) * High dose dexamethasone supression test Adrenal adenoma * ↓ ACTH * ↑ Cortisol Ectopic ACTH * ↑ ACTH * ↑ Cortisol – remains high in high-dose suppression test Cushing’s disease * ↑ ACTH * ↑ Cortisol on low dose suppression BUT supressed on high-dose suppression test
30
Tx for Cushing's syndrome
* Conservative * *_If iatrogenic_* --\> ↓ steroid dose * Medical * **Metyrapone** (↓ Cortisol synthesis, ↑ aldosterone, ↑ adrenal androgens) * **Ketoconazole** (↓ Cortisol synthesis, ↓ aldosterone, ↓ adrenal androgens) * Surgical * *_If Cushing's disease_* --\> **Trans-sphenoidal hypophysectomy** * *_If ectopic ACTH_* --\> **remove tumour** * *_If adrenal adenoma_* --\> **adrenalectomy** * *_If non-operable_* **--\> Radiotherapy**
31
Tx of Conn's syndrome
* Medical * MR antagonist * **Spironolactone** * **Epleronone** * Anti-hypertensives * Surgery * Laparoscopic **adrenalectomy**: remove the tumour N.B. If bilateral adrenal hyperplasia, stay on spironolactone (do not remove both adrenals as cannot respond to stress)
32
****_P_**alpitations** ****_H_**eadache** ****_E_**pisodic sweating** (diaphoresis) **Episodic severe hypertension** (may cause stroke) Diagnosis? Ix? Tx?
**Phaeochromocytoma** **24 hour urinary catecholamines** (adrenaline, noradrenaline, dopamine) : ↑ **Plasma catecholamines levels**: ↑ Long term * Pre-operative * FIRST, **α blockade** (Phenoxybenzamine) * THEN, **β blockade** (Propanolol) * Surgery * **Laparoscopic adrenalectomy**
33
**Vomiting** **Abdo pain** **Tachycardia** **Weakness** **Pale, Cold, Clammy, Oliguria** **Hypoglycaemia** **Hypovolaemic shock** **+/- Trigger** Diagnosis? Ix? Tx?
Addisonian crisis ↓ Na+, ↑ K+ * **High dose IV Hydrocortisone** * **IV 0.9% saline** (1L over 30-60min) * Aim to restore BP & replace salt that is lost * **5% Dextrose** (prevent hypoglycaemia) *
34
Ix and Tx of Addion's disease
Ix * **9am cortisol** * If normal: HIGH (normally high in the morning) * Addison’s: LOW Cortisol (\< 100nmol/L is diagnostic) * **ACTH** * Addison’s (Primary): HIGH ACTH * **SynACTHen test + Measure Cortisol (before & after)** * _If normal_: ↑ cortisol * _If Addison’s_: no/little increase Tx for Addisonian crisis * **High dose IV Hydrocortisone** * **IV 0.9% saline** (1L over 30-60min) * **5% Dextrose** (prevent hypoglycaemia) Long term Tx * **Hydrocortisone** (replace glucocorticoid) * Advice: Increase dosage if (1) acute illness or (2) surgery or (3) stress * **Fludrocortisone** (replace mineralocorticoid)
35
**↓ Na+, ↑ K+ Hypotension + Hyperkalaemia** Diagnosis? Causes?
**Addison's disease** Autoimmune TB Iatrogenic
36
**Hypertension** **Hypokalaemia** Diagnosis?
**Hyperaldosteronism** * Primary * Conn's * Bilateral adrenocortical hyperplasia * Secondary * RAS * Renin-secreting tumour
37
Steroid synthesis pathway
38
Complete 21-OH deficiency (most common) Sx Ix Tx
39
Partial 21-OH deficiency 11-OH deficiency 17-OH deficiency
40
Causes of hypercalcaemia
41
Sx and Tx of hypercalcaemia
Sx * Bones - bone pain +/- fractures * Stones - renal calculi * Abdo moans - constipation, pancreatitis * Psychic groans - confusion, seizures, coma * Thrones - polyuria, polydipsia Tx * **IV 0.9% saline ++++++++++** * **+/- Bisphosphonates** * ONLY indication = Hypercalcaemia of Malignancy * Otherwise avoid! * **Treat underlying cause**
42
Hypocalcemia - Sx, Causes, Tx
* CATS go numb * Convulsions * Arrhythmias * Tetany * Trousseau's * Chvostek's * Paraesthesia * Causes * ↓ Ca2+ and ↑ PTH * Vitamin D deficinecy * CKD * Pseudohypoparathyroidism (PTH resistance) * ↓ Ca2+ and ↓ PTH * Surgical (post-thyroidiectomy) * Tx * Ca - IV Calcium Gluconate * Vitamin D
43
* **Bone pain and tenderness** * Typically lower extremities, lower spine, ribs & pelvis * **Proximal myopathy / Muscle wasting** * **Waddling gait** * **↑ risk of fractures** * **Signs of hypocalcaemia** * Trousseau’s sign * Chvostek’s sign Diagnosis? Ix? Tx?
Ostemalacia (Vitamin D deficiency) ↓ Ca2+ , ↓ PO43- , ↑ ALP Tx: Vitamin D
44
Types of Vitamin D supplementation
* If normal renal function, give precursor (they can convert) * **Ergocalciferol** (25 OH D2) * **Cholecalciferol** (25 OH D3) * If renal failure (inadequate 1𝝰 hydroxylation) * **Alfacalcidol**
45
Types of hyperparathyroidism
46
X-ray changes in Primary hyperparathyroidism
* **Pepper pot skull** (diffuse porotic mottling of skull) * **Rugger jersey spine** (sclerosis of sup / inf vertebral margins w central deminerlisation)
47
Pathology and Signs of pseudohypoparathyroidism
PTH resistance ## Footnote Hypocalcaemia Abnormal 4th and 5th metacarpal joint "Knuckle knuckle dimple dimple" sign
48
Osteoporosis - Sx, Ix, Tx
Osteoporosis Asymptomatic until fracture Ix * DEXA score (T score \< -2.5 (healthy reference) and Z-score (age-matched control) * Normal Ca2+, PO43-, ALP * FRAX score / QFRACTURE tool Tx * (1) **Bisphosphonates** * **+ Ca and Vitamin D supplementation** * (2) **Denosumab** (RANKL inhibitor --\> inhibitor osteoclasts) * (3) **Teriparatide** (recombinant PTH --\> osteoblasts \> osteoclasts) * **Strontium ranelate** * **SERMs** * **HRT**
49
**Paget's disease** X-ray changes Biochemistry Tx Cx
**ALP: ↑↑↑** Ca2+ & PO43-: normal PTH: normal Vitamin D: normal X-ray: **Cotton-wool appearance** *_Tx_*: **Bisphosphonates** +/- Analgesia *_Cx_*: Fractures, **Osteosarcoma** (1%), Sensorineurlal deafness
50
Definitions of diabetes
* **Fasting blood glucose: \> 7 mmol/L** in Diabetes * **OGTT: \> 11.1 mmol/L** in Diabetes * **HbA1c: \> 48 mmol/mol** is diagnostic for Diabetes (\> 6.5%) *
51
Tx for T2DM
(1) **Diet & Exercise** (2) **Metformin** (3) *See image*
52
Complications of T2DM
53
Tx of Hypoglycaemia
54
**Altered mental status** (Confusion ==\> Coma) **Severely dehydration** **Hyperglycaemia** **↑↑ osmolality** **↑ Na+** **No ketones** Diagnosis? Tx?
**Hyperglycaemic Hyperosmolar State** * **IV 0.9% saline** * Rehydrate with normal saline SLOWLY * If corrected too quickly --\> cerebral oedema (high mortality) * If blood glucose is not falling ==\> **IV Insulin** * **+/- Anticoagulation**
55
Diabetic retinopathy - Stages, Findings, Tx
56
**Diabetic nephropathy** Features Ix Tx
Sx * **Progressive proteinuria** * ↑BP Ix * **Albumin:Creatinine ratio** (ACR) * eGFR * Proteinuria Tx * **ACE inhibitors** (aim for BP \< 130/80mmHg)
57
**Diarrhoea** **Flushing** **+/- Wheezing** **Abdo Pain** **Telangiectasia** Diagnosis? Ix? Tx?
Carcinoid syndrome Ix: * **Serum Chromogranin A/B**: ↑ * Tumour marker * **24hr urine collection** of **5-hydroxyindoleacetic acid**: ↑ * 5-hydroxyindoleacetic acid is a serotonin metabolite Tx * Acute * **IV Octreotide** +/- IV Hydrocortisone * Long-term * **Surgical resection**
58
Tx for Obesity
* Conservative * **Diet & Exercise** * Medical * **Orlistat**: lipase inhibitor --\> ↓ absorption of dietary fat * **Lorcaserin**: serotonin receptor agonist --\> ↓ appetite * **Liraglutide**: GLP-1 receptor agonist --\> ↓ appetite * Manage comorbidities * Surgical * Criteria: * BMI \> 40 * All other measures ineffective * Fit for anaesthesia and surgery * Committed to need for long-term follow up * Options * **Roux-en-Y gastric bypass** * **Adjustable gastric banding (Laparoscopic)** * **Sleeve gastrectomy** * **Duodenal switch with biliopancreatic diversion**
59
Tx for hypercholesterolaemia / hyperlipidaemia
(1) **Statins** (2) **Ezetimibe** (3) Fibrates (**Gemfiibrozil**)
60
DDx Goitre
* **Iodine deficiency** * Autoimmune * **Grave's disease** * **Hashimoto's** * Infection * **Viral thyroiditis** * Malignancy * **Pituitary adenoma** * Physiological * **Pregnancy** * **Puberty**

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