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Endocrinology Flashcards

(45 cards)

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1
Q

How would you diagnose Diabetes Mellitus?

A

Random glucose >11.1 or Fasting glucose > 7

HbA1c >48

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2
Q

Which diabetes drugs can cause hypoglycaemia?

A

Insulin

Sulphonylureas e.g. gliclazide (esp if alongside metformin)

Glinides

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3
Q

Causes of Diabetes

A

Type 1 = autoimmune destruction of beta cells = reduced insulin secretion

Type 2 = insulin resistance

Steroid use
Chronic pancreatitis
Cystic fibrosis
Haemachromatosis
Acromegaly
Cushing’s
Glucagonoma

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4
Q

Diabetes & DVLA

Group 1 drivers on insulin can still drive if….

A

1) Hypoglycaemic awareness

2) <1 hypo episode requiring assistance in last year

3) No visual impairment

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5
Q

True or False:

Group 2 (e.g. HGV) drivers do NOT need to inform DLVA if on oral anti-diabetic agents

A

FALSE

Group 2 drivers must stop driving HGVs and tell the DVLA if they are diabetic and taking insulin AND/OR oral anti-diabetic agents

They do not need to inform the DVLA if their diabetes is diet controlled

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6
Q

Grave’s Disease

A

70% of all hyperthryoidism

Autoimmune disorder
- antibodies to TSH receptor

Features of hyperthyroidism
- Tachycardic/AF
- Dry skin
- Tremor

PLUS
- Thyroid eye disease
- Lid lag

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7
Q

Thyroid Eye Disease

A

NO SPECS

N - nil
O - Only signs, no symptoms e.g. eye lid retraction

S - Swelling of periorbital soft tissue e.g. eyelid swelling
P - Proptosis
E - Extra-ocular muscle involvement (ophthalmoplegia)
C - Corneal involvement
S - Sight loss (suggests compression of CN II)

URGENT referral to ophthalmology if any loss of visual acuity/colour vision

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8
Q

How would you manage a patient with Grave’s Disease?

A

CONSERVATIVE
- Eye care
- STOP smoking! (v. important)

MEDICAL
- Carbimazole titration or carbimazole + levo (“Block and replace”)
—— risk of agranulocytosis
- Beta blockers (can help with symptom control)
- Radioiodine
—- Contraindicated in thryoid eye disease

SURGICAL
- Thyroidectomy (risk of parathyroid damage)

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9
Q

Toxic Multinodular Goitre (TMG)

A

2nd most common cause of hyperthyroidism

Features of hyperthyroidism PLUS
- Goitre (can be painful/painless)

NO thyroid eye disease present!

Negative for thyroid autoantibodies

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10
Q

How would you investigate a patient in whom you suspect hyperthyroidism?

A

ECG

Bloods
- FBC, baseline renal function
- TFTs
- Thyroid autoantibodies

USS thyroid +/- CT neck or thorax (if suspicious of extension into mediastinum ?compression issues)

Thyroid Scintigraphy
- Diffuse uptake = Grave’s
- Focal/patchy uptake = TMG/thyroid adenoma

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11
Q

How would you manage a patient with Toxic Multinodular Goitre?

A

Indications for Rx =
- Cosmetic
- Compression/obstructive issues e.g. horner’s syndrome secondary to goitre
- Marked intra-thoracic extension

Management
- Radio-iodine
- Surgical resection of goitre

Antithryoid drugs not particularly helpful as thyrotoxicosis recures once Rx stops

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12
Q

Hypothyroidism

A

Most common endocrine condition
(approx 5-10% of UK)

CAUSES
- Hashimoto’s thyroiditis
- Iodine deficiency
- Iatrogenic (thyroidectomy/iodine)
- Post illness (De Quervain’s thyroiditis)
- Post partum thyroiditis
- Drugs e.g. amiodarone & lithium

Features of hypothyroidism
- Dry skin
- ?goitre
- ?macroglossia (secondary to myxoedema)
- NO eye disease
- Pleural effusions/ascites (RARE!)

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13
Q

Hashimoto’s Thyroiditis

A

Autoimmune condition

Thyroid peroxidase antibodies

F > M

Associated with:
- Coeliac disease
- T1DM
- Vitiligo
- ADDISON’S!!

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14
Q

How would you investigate a patient in whom you suspect hypothyroidism?

A

Bloods
- FBC, renal function
- TFTs
- Thyroid peroxidase antibodies

USS neck ?goitre

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15
Q

How would you manage a patient with hypothyroidism?

A

Levothyroxine
- 50-100mcg OD (starting dose)
- 25-50mcg OD if elderly or history of IHD

Check TFTs every 8-12 weeks after a dose change

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16
Q

True or false

In pregnant women with hypothyroidism, you should reduce their usual levothyroxine dose

A

FALSE

Increase their levothyroxine dose by 25-50% (esp in 1st 12 weeks)

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17
Q

Risks of levothyroxine

A

Hyperthyroidism

AF

Worsening of IHD/angina

Lowers bone mineral density –> OP

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18
Q

What is a Myxoedema Coma?

A

Severe hypothyroidism

Endocrinological emergency!

Usually precipitated by infection/MI/surgery

Features
- Bradycardic
- Hypotensive
- Hypothermic
- Hyponatraemia
- Confused

Rx = IV liothyronine and IV hydrocortisone (in case of concurrent Addison’s)

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19
Q

What is Acromegaly?

Study These Flashcards
A

Condition of increased production and secretion of Growth Hormone

CAUSES
- Pituitary macroadenoma
- Pituitary hyperplasia
- Carcinoid tumour (ectopic GH release)

5% associated with MEN-1

20
Q

What symptoms may a patient with Acromegaly notice?

Study These Flashcards
A

Increase hand/foot size - ?noticed a change in shoe size
Weight gain

Changes in vision (bitemporal hemanopia)
Headaches

Sweating

Drowsiness/somnolence (?OSA)

Proximal muscle weakness
Arthralgia

Change in bowel habit

21
Q

What are the 4 signs of active disease in Acromegaly?

Study These Flashcards
A

1) Sweating

2) Skin tags

3) HTN

4) Peripheral oedema

22
Q

Associations/Complications of Acromegaly

Study These Flashcards
A

Diabetes

HTN
LVF –> CCF (60% of deaths are due to CVD)
Cardiomyopathy
Arrhythmias

Carpal Tunnel Syndrome

OSA

Increased risk of IHD and stroke

Increased risk of colorectal cancer

23
Q

How would you investigate a patient in whom you suspect Acromegaly?

Study These Flashcards
A

Bedside
- BP
- BM
- Urine dip
- ECG

Bloods
- FBC, baseline renal function
- Calcium profile (MEN1 is also associated with hyperparathyroidism)
- Oral Glucose Tolerance Test (OGTT)
—- If fails to suppress GH to <2 = diagnostic
- IGF-1 (monitoring)

Imaging
- MRI pituitary
- Echocardiogram (CVD risk)

Special
- Visual fields and perimetry

24
Q

How would you manage a patient with Acromegaly?

Study These Flashcards
A

Surgery is first line!
- Usually transphenoidal surgery

Radiotherapy can be used as an adjunct or sole Rx in those who are unfit for surgery

MEDICAL
- Pegvisomont = GH antagonist (subcut)
- Bromocriptine = dopamine agonist (only works in <20%)
-Ocreotide = somatostatin analogue (negative feedback)

CVD risk factor management

?CPAP if OSA
?Surgery if CTS

FOLLOW UP
- Annual follow up with GH/IGF1 levels, visual fields and CVD assessment
- Low threshold for colonoscopy

25
What are the MEN syndromes?
Multiple Endocrine Neoplasia syndromes Autosomal dominant Associated with NF1, vHL and peutz jeger's
26
Outline the components of MEN1
3Ps Primary hyperparathyroidism Pancreatic tumours e.g. insulinoma Pituitary tumours e.g. prolactinoma, macroadenoma
27
Outline the components of MEN2a
2 Ps, 1M Primary hyperparathyroidism Phaeochromocytoma Medullary thyroid cancer
28
Outline the components of MEN2b
1P, 2 Ms Phaeochromocytoma Medullary thyroid cancer Marfanoid habitus
29
Causes of Hypoadrenalism?
DISORDERS OF THE ADRENAL GLANDS Addison's disease (autoimmune) Congenital adrenal hyperplasia (= excess ACTH and androgens, but low cortisol/mineralocorticoids) Infiltration of adrenal glands - Metastases - Haemochromatosis - Sarcoidosis - TB - Amyloidosis Damage to adrenal glands - Adrenal haemorrhage - Adrenalectomy DISORDERS OF THE PITUITARY - Hypopituitarism (low ACTH levels)
30
What is Addison's disease?
Autoimmune condition of the adrenal glands = reduced adrenal cortex hormones Associated with other AI disorders e.g. - T1DM - Thyroid disease - Coeliac disease - Pernicious anaemia
31
Outline features of Addison's disease
GLUCOCORTICOID LOSS - Weight loss - Anorexia - Malaise/fatigue - Postural hypotension - CIBH/vomiting MINERALOCORTICOID LOSS - Hypotension - Hyponatraemia - Hyperkalaemia ACTH EXCESS (due to feedback loop) - Pigmentation of sun exposed/pressure areas and mucosa = BRONZE skin - Amenorrhoea - Body hair loss
32
How would you investigate a patient in whom you suspect Addison's disease or hypoadrenalism?
Bedside - L+S BP - BM - Urine dip Bloods - FBC, U&Es - Glucose, HbA1c - TFTs - Morning cortisol - Short synacthen test (does cortisol level rise appropriately with synthetic ACTH?) Imaging - ?CT adrenals - ?CXR (?TB) - ?MRI pituitary
33
How would you manage a patient in whom you suspect has Addison's disease?
Education regarding steroids, sick day rules and Addisonian crises Hydrocortisone +/- fludrocortisone Monitor HbA1c
34
Outline Autoimmune Polyglandular Syndrome 1
Chronic mucocutaneous candidiasis (immunodeficiency) Hypoparathyroidism Addison's disease
35
Outline Autoimmune Polyglandular Syndrome 2
Addison's disease T1DM Hypo OR hyperthyroidism
36
What is Nelson's Syndrome? What clinical features may you see on examination?
Occurs following bilateral adrenalectomy (e.g. for Cushing's disease) Reduced cortisol = loss of negative feedback loop back to anterior pituitary = +++ ACTH production and secretion = Pituitary adenoma = Activates melanocytes = hyperpigmentation SIGNS - Abdominal rooftop incision - Bronze skin
37
What is Cushing's Syndrome?
= any condition which causes increased cortisol production (hypercortisolism) EXOGENOUS CUSHING'S - Steroid use (most common cause) ENDOGENOUS CUSHING'S *ACTH DEPENDENT* - Pituitary adenoma = increase ACTH production and then cortisol = Cushing's DISEASE! - Ectopic ACTH e.g. SCLC ENDOGENOUS CUSHING'S *ACTH INDEPENDENT* - Adrenal adenoma = increased cortisol PSEUDOCUSHING'S - Alcoholism - Severe depression
38
What is Cushing's Disease?
Pituitary adenoma resulting in increased ACTH production --> hypercortisolism
39
Features of Cushing's Syndrome
Weight gain Adipose tissue deposition on abdomen and back of neck Abdominal striae Typical cushing facies ("moon") Thin skin Easy bruising Mood disturbance Fluid retention HTN Gynaecomastia Amenorrhoea, hirsutism Acne Hyperglycaemia --> Diabetes Osteoporosis CVD risk Cataracts
40
How would you investigate someone in whom you suspect Cushing's syndrome?
Bedside - BP - BM - Urine dip - ECG Bloods - FBC - Renal function (can cause hypokalaemic metabolic acidosis) - Overnight dexamethasone suppression test (give dex at 00:00 then test cortisol level in morning) --- If ODST is positive = ACTH levels and High Dose Dex Suppression Test (identifies pituitary vs adrenal/ectopic cause) Imaging - CT adrenals or MRI pituitary - ?HRCT if suspect ectopic ACTH
41
How would you manage a patient with Cushing's syndrome?
Depends on underlying cause e.g. if on steroids, consider whether able to reduce/stop (risk vs benefits) Metyrapone (cortisol inhibitor) whilst awaiting results If PITUITARY cause = surgery/radiotherapy If ADRENAL cause = adrenalectomy Management of CVD RFs e.g. antihypertensives
42
Clinical Features of Hypopituitarism
ANTERIOR PITUITARY *Growth hormone* - Lethargy - FTT/growth failure *FSH/LH* - Reduced libido - Hair loss - Amenorrhoea - Infertility *TSH* - Features of hypothyroidism *ACTH* - Lethargy - Postural hypotension - Hypoadrenalism POSTERIOR PITUITARY *ADH* - Diabetes insipidus = polyuria & thirst
43
Causes of Hypopituitarism
Large compressive pituitary tumour Removal of a pituitary macroadenoma Pituitary haemorrhage/infarct Severe head injury Cranial radiotherapy Sarcoidosis Haemochromatosis
44
How would you investigate a patient in whom you suspect Hypopituitarism?
Bedside = L+S BP, urine dip Bloods - Baseline FBC, U&Es - Pituitary Screen = -- GH / LH & FSH / TFTs / ACTH - Synacthen test Imaging - MRI pituitary
45
How would you manage a patient with hypopituitarism?
Treat underlying cause if possible e.g. surgery if large compressive tumour Low GH = daily subcut GH Low FSH/LH = intramuscular testosterone or COCP - Refer to fertility specialists Low TFTs = levothyroxine Low ACTH = hydrocortisone (prevent addisonian crises)

PACES Revision Cards (9 decks)

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