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Endocrinology Flashcards

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1
Q

Hormones released from the anterior pituitary gland

A 
LH
FSH
TSH
Prolactin
ACTH
GH
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2
Q

Hormones released from the posterior pituitary gland

A

Vasopressin/ADH

Oxytocin

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3
Q

Pathophysiology of T1DM

A

Autoimmune destruction of pancreatic beta cells in the islets of Langerhans

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4
Q

Pathophysiology of T2DM

A

Decreased insulin secretion and increased insulin resistance peripherally

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5
Q

Maturity onset diabetes of the young is what kind of diabetes

A

Type 2

Rare autosomal dominant

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6
Q

What is an impaired glucose tolerance?

A

Fasting <7mmol/L (otherwise this is diabetes)

2 hour glucose >7.8mmol/L but <11.1mmol/L

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7
Q

What is impaired fasting glucose?

A

Fasting >6.1 but <7mmol/L

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8
Q

What is metabolic syndrome/ syndrome X?

A 
Central obesity (BMI>30)
BP 130/85
fasting glucose >5.6
T2DM
Various forms of hyperlipidaemia
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9
Q

Diagnosis of T2DM

A

Symptoms of hyperglycaemia and raised venous glucose detected once- fasting >7mmol/L or random >11.1
OR
Raised venous glucose on two separate occassions
HbA1c >48mmol/mol

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10
Q

Symptoms of hyperglycaemia

A

Polyuria, polydipsia, unexplained weight loss, visual blurring, genital thrush, lethargy

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11
Q

Clinical features of hypoglycaemia

A

Autonomic- sweating, anxiety, hunger, tremor, palpitations, dizziness
Neuroglycopenic- confusion, drowsiness, visual trouble, seizures, coma, rarely focal neurology, personality change, restlessness

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12
Q

Definition of hypoglycaemia

A

<4mmol/L plasma glucose

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13
Q

Fasting hypoglycaemia aetiology

A 
Insulin or sulphonylurea treatment in a diabetic is the top cause
Non-diabetics 
EXogenous drugs- insulin, oral hypoglycaemics
Pituitary insufficicency 
Liver failure
Addison's disease
Islet cell tumours- insulinoma
Neoplasms
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14
Q

Effect of active T3 and T4 in the body

A

Increase cell metabolism

Increase catecholamine effects

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15
Q

Why should TFTs be taken at the same time each day?

A

Trough at 2pm and higher in the night- variation throughout

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16
Q

Sick euthyroid tests

A

All low- should recover after illness, retest once recovered

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17
Q

What are anti-TPO antibodies and when are they raised?

A

Anti-thyroid peroxidase antibodies
Raised in autoimmune disease- Hashimoto’s or Graves’ disease
If positive in Graves then there is a chance of hypothyroidism following

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18
Q

TSH receptor antibody present in

A

Graves’ disease

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19
Q

Serum thyroglobulin useful as

A

A tumour marker to monitor the treatment of carcinoma

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20
Q

Clinical features of thyrotoxicosis

A

Symptoms- diarrhoea, weight loss, increased appetite, over-active, sweaty, heat intolerant, palpitations, tremor, irritability, labile emotions, oligomenorrhoea +/- infertility
Rarely psychosis, chorea, panic, itch, alopecia, urticaria

Signs- tachycardic, irregular pulse, warm moist skin, fine tremor, palmar erythema, thin hair, lid lag, lid retraction

Examination- goitre, thyroid nodules, bruit

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21
Q

Signs specific to Graves’ disease

A

Exophthalmos, ophthalmoplegia, proptosis
Pretibial myxoedema
Thyroid acropatchy

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22
Q

Tests in thyrotoxicosis

A 
May be mild normocytic anaemia
Mild neutropenia 
Raised T3 and T4
Low TSH
Raised ESR
Raised Ca
Raised LFTs
Thyroid autoantibodies- TPO and TSH receptor antibody
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23
Q

Treatment of thyrotoxicosis

A

Symptomatic control with beta blockers- propanolol
Anti-thyroid hormone- carbimazole ‘block’
Levothyroxine ‘replace’
Radioiodine if become hypothyroid post-treatment, though beware thyroid storm
Thyroidectomy

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24
Q

Causes of thyroid goitre

A

Physiological
Graves’ disease
Hashimoto’s thyroiditis
Subacute de Quervain’s thyroiditis (self-limiting post-illness)

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25
Clinical features of hypothyroidism
Symptoms- tiredness, lethargic, decreased mood, cold intolerance, weight gain, constipation, menorrhagia, hoarse voice, decreased memory/ cognition, dementia, myalgia, cramps, weakness Signs- bradycardic, reflexes relax slowly, ataxia, dry thin hair/ skin, yawning, drowsiness, coma, cold hands, ascites, round puffy face, defeated demeanour, immobile,
26
Aetiology of hypothyroidism
Primary atrophic hypothyroidism Hashimoto's thyroiditis-goitre Drug induced- amiodarone, anti-thyroid, lithium, iodine Secondary due to hypopituitarism
27
What is myxoedema coma?
The ultimate hypothyroid state before death
28
Risks from subclinical hyperthyroidism
AF and osteoporosis
29
Actions of parathyroid hormone
Increasing osteoclast activity releasing calcium and phosphate from the bones Increases calcium reabsorption in the kidneys and acts as a phosphaturic agent Increases hydroxylation of 1-hydroxycholecalciferol in the kidney to 1,25-dihydroxycholecalciferol which acts to increase calcium uptake from the intestines
30
Primary hyperparathyroidism clinical features
Symptoms- signs relating to hypercalcaemia Bone pain, fractures and osteopenia/osteoporosis HTN
31
Signs of hypercalcaemia
``` Weak, tired, depressed, thirsty Dehydrated but polyuric Renal stones Abdominal pain Pancreatitis Ulcers Psychosis ```
32
Tests for primary hyperparathyroidism
``` Calcium (increased) PTH (increased) Phosphate (decreased) ALP (increased) Pepper pot skull on XR DEXA for osteoporosis ```
33
Secondary hyperparathyroidism
Low calcium | Appropriately raised PTH
34
Aetiology of secondary hyperparathyroidism
Decreased vitamin D intake | Chronic renal failure
35
Tertiary hyperparathyroidism
Increased calcium Inappropriately increased PTH Prolonged secondary hyperparathyroidism the glands act autonomously having undergone hyperplastic change
36
Signs of hypocalcaemia
``` Tetany- twitching, cramping, spasm Depression Cataracts QT prolongation Trousseau's sign- BP cuff inflated Chvostek's sign- tapping of parotid gland results in facial nerve twitching Perioral paraesthesia ```
37
Causes of hypocalcaemia
``` Vit D deficiency Renal disease Hypomagnesaemia Hypoparathyroidism End organ resistance to PTH or Vit D ```
38
von-Hippel Lindau syndrome
Mutation of a tumour suppressor gene resulting in renal cysts and cancer, retinal and cerebellar haemangioblastoma and phaeochromocytoma
39
Peutz-Jegher's syndrome
Mutation of a tumour suppressor gene resulting in mucocutaneous dark freckles on lips, oral mucosa, palms and soles and multiple GI polyps- raising GI cancer risk by 15 fold
40
Multiple Endocrine Neoplasm 1
Parathyroid hyperplasia Pancreas endocrine tumours- gastrinoma or insulinoma Pituitary prolactinoma or GH secreting tumour (acromegaly)
41
MEN-2a
Thyroid medullary carcinoma- 100% Phaeochromocytoma Parathyroid hyperplasia
42
MEN-2b
Similar to MEN-2a but with mucosal neuromas and marfanoid appearance without hyperparathyroidism
43
Side effects of steroids
GI- peptic ulcer, acute pancreatitis Endocrine- Cushing's syndrome- intrascapular fat pad, moon-face, thin limbs, central obesity, impaired glucose tolerance leading to T2DM, increased appetite and weight gain Immunosuppression Growth suppression in children Neutrophilia MSK- proximal muscle myopathy, osteoporosis, avascular necrosis of the femoral head Easy bruising, thinning of the skin Ophthalmic- glaucoma, cataracts Psychiatric- insomnia, psychosis, mania, depression Fluid retention Hypertension from the mineralocorticoid activity
44
Adrenal cortex areas and steroids produced
Zona glomerulosa- mineralocorticoids Zona fasciculata- glucocorticoids Zona reticularis- androgens
45
HPA axis
CRH (hypothalamus)-->ACTH (anterior pituitary)--> cortisol and androgens (cortex)
46
ACTH dependent causes of Cushing's syndrome
Cushing's disease- bilateral adrenal hyperplasia from an ACTH secreting pituitary adenoma Ectopic ACTH production- small cell lung carcinoma and carcinoid tumours
47
ACTH independent causes of Cushing's sydrome
Iatrogenic- steroids Adrenal cancer Adrenal nodular hyperplasia
48
Investigating suspected Cushing's syndrome
1st line tests Overnight dexamethasone suppression test- 1mg at midnight, serum cortisol at 8am- normally should suppress but not in Cushing's 24 hour free cortisol 2nd line tests 48 hour dexamethasone suppression test- give for 2 days and measure cortisol at 0 and 48hrs- failure to suppress cortisol in Cushing's Localising Plasma ACTH- if undetectable then ACTH independent- adrenal tumour likely
49
Treatment for Cushing's syndrome
Depends on the cause Stop medications Removal of pituitary adenoma if Cushing's disease Adrenalectomy If ectopic ACTH then locate and surgery if not spread
50
What is Addison's disease?
Primary adrenal insufficiency
51
Aetiology of Addison's disease
``` Autoimmune TB Adrenal metastases Lymphoma Opportunistic infections Adrenal haemorrhage Secondary from long term steroid use ```
52
Symptoms of Addison's disease
``` Lean, tanned, tearful and tired Weakness Anorexia Faints Myalgias and arthralgias Depression and psychosis Nausea and vomiting, abdo pain, diarrhoea or constipation ```
53
Investigations for Addison's disease
Low mineralocorticoids leading to low sodium and raised potassium Low glucose due to low glucocorticoid Raised calcium Short ACTH test- synacthen test- plasma cortisol before and after- expecting low cortisol (excluded above 550) 9AM ACTH inappropriately high 21 hydroxylase adrenal autoantibodies in 80% Plasma renin and aldosterone to assess mineralocorticoid status
54
Treatment for Addison's disease
Replace steroids- hydrocortisone and mineralocorticoid- fludrocortisone
55
Primary hyperaldosteronism
Excess production of aldosterone resulting in increased sodium and water retention and decreased renin release Hypokalaemia and alkalosis
56
Signs of hypokalaemia
Weakness, cramps, worsening DM control or polyuria Palpitations Psychological symptoms
57
Aetiology of primary hyperaldosteronism
2/3 are Conn's syndrome- aldosterone producing adenoma | 1/3 due to bilateral adrenal hyperplasia
58
Secondary hyperaldosteronism
Due to increased renin from decreased renal perfusion | Renal artery stenosis, HTN, CCF
59
Tests for hyperaldosteronism
U&Es | Renin and aldosterone ratio
60
Treatment for hyperaldosteronism
Conn's- laparoscopic adrenalectomy | Adrenal hyperplasia- medical management with an MRA
61
Classic symptoms of phaeochromocytoma
Sweating, episodic headache, tachycardia | Palpitations, anxiety, pallor
62
Investigating phaeochromocytoma
24 urinary metanephrines
63
Treatment of phaeochromocytoma
``` Alpha blockade (phenoxybenzamine) then beta blockade (to avoid unopposed alpha adrenergic stimulation) Surgery ```
64
When to think of Conn's with HTN
Hypokalaemia Refractory (more than 3 drugs) Early onset HTN <40, especially women
65
What is virilism
The appearance of male secondary sexual characteristics in women
66
Polycystic ovarian syndrome clinical features
``` Bilateral polycystic ovaries (on ultrasound) Oligo or amenorrhoea Infertility Hirsutism Obesity Acne ```
67
Management of PCOS
Healthy eating, optimize weight, shaving, laser photoepilation, wax, electrolysis Oestrogens Metformin and spironolactone Clomifene for infertility
68
The big three: organic causes of erectile dysfunction
Diabetes Smoking Alcohol
69
Workup for erectile dysfunction
Full sexual and psychological history | U&Es, LFT, glucose, TFT, LH, FSH, lipids, testosterone, prolactin and Doppler- penile arterial inflow
70
Side effects of sildenafil
Headache Flushing Dyspepsia Transient blue-green tingeing of vision
71
Features of local pressure from a pituitary adenoma
Headache Visual field defects- bilateral temporal hemianopia- compression of the optic chiasm palsy of cranial nerves III,IV,VI- pressure or invasion of the cavernous sinus Diabetes insipidus Disturbance of sleep and appetite
72
What is pituitary apoplexy?
Rapid pituitary enlargement from bleeding into a tumour Mass effects, cardiovascular collapse due to hypopituitarism Sudden headache, meningism, decreasing GCS, visual defect
73
Signs of acromegaly
``` Increased growth of hands, jaw and feet Coarsening facial features Macroglossia Skin darkening Acanthosis nigricans Obstructive sleep apnoea Goitre Proximal weakness and arthropathy Carpal tunnel signs Signs from pituitary mass ```
74
Complications of acromegaly
Impaired glucose tolerance Vascular- cardiomyopathy, increased BP, LV hypertrophy, Increased risk of colon cancer
75
Why is random GH not an accurate test for acromegaly?
Secreted in a pulsatile fashion | Samples should be collected every 30 minutes
76
What is diabetes insipidus?
Passage of large volumes of dilute urine due to impaired water resorption by the kidneys because of reduced ADH secretion from the posterior pituitary (cranial) or impaired response to ADH in the kidney (nephrogenic)
77
Causes of cranial diabetes insipidus
``` Tumour- craniopharyngioma, mets, pituitary Trauma Infiltration- sarcoidosis Vascular- haemorrhage Infection- meningoencephalitis ```
78
Causes of nephrogenic diabetes insipidus
``` Inherited Metabolic- low potassium, high calcium Drugs- lithium CKD Post-obstructive uropathy ```
79
How to calculate serum osmolality
(2xNa) + glucose + urea
80
How to exclude DI with urine and serum osmolality
If the ratio of urine:serum osmolality is greater than 2:1
81
Diagnosis of diabetes insipidus
Water deprivation test for 8 hours | Testing the kidneys ability to concentrate urine when dehydrated
82
First line antihypertensive in a black T2DM of 59 years old
ARB- eg. losartan

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