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Diabetes and Endocrinology YR3 > General Endocrine Conditions > Flashcards

General Endocrine Conditions Flashcards

1
Q

Causes of hypercalcaemia

A
  • Hyperparathyroidism - primary or tertiary (NOT secondary)
  • Familial hypocalciuric hypercalcaemia
  • Malignancy - multiple myeloma, humoral hypercalcaemia(PTHrP), bony mets
  • Vitamin A or D intoxication
  • CKD
  • Sarcoidosis
  • Hyperthyroidism
  • Addisons
  • Drugs eg Lithium/thiazides
  • Immobilisation
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2
Q

What is familial hypocalciuric hypercalcaemia?

A

When body has problem of parathyroid detecting Ca2+ levels

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3
Q

What is tertiary hyperparathyroidism?

A

When you have had secondary hyperparathyoidism for a while and this then results in overactivity/solitary adenoma of pituitary gland

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4
Q

Clinical features of hypercalcaemia

A
  • Bones - fragility fractures, bone pain
  • Stones - renal calculi
  • Thrones - polyuria, constipation
  • Psychic moans - mood disturbance, fatigue/malaise
  • Abdominal groans - abdo pain, pancreatitis
  • Asymptomatic?
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5
Q

Complications of hypercalcaemia

A
  • Renal calculi
  • Osteoporosis
  • Pancreatitis
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6
Q

Investigations for hypercalcaemia - steps

A
  1. Find raised Ca2+
  2. Check PTH
  3. If low - screen for cancer
  4. If high PTH - check urine Ca2+ creatinine clearance ratio
  5. If low urine Ca2+ –> FHH? Do genetic testing
  6. If high urine Ca2+ - suspect primary hyperparathyroidism
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7
Q

Other investigations for hypercalcaemia

A
  • CXR
  • FBC
  • ACE - sarcoidosis
  • TFTs
  • Cortisol
  • Vitamin D
  • Myeloma screen
  • Assess for end organ damage
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8
Q

Why do assess for end organ damage in hypercalcaemia and how?

A

US KUB, DEXA scan
If end organ damage - fill criteria for surgical management

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9
Q

Indications for surgery in primary hyperparathyroidism causing hypercalcaemia

A
  • Very symptomatic
  • End organ damage - worsening kidney function, renal stones
  • Osteoporosis on DEXA
  • Ca2+ more than 3
  • Urine Ca2+ 10mmol/day
  • Age under 50
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10
Q

Surgical management for primary hyperparathyroidism

A
  • Surgical removal of adenoma or partial parathyroidectomy
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11
Q

Medical management for primary hyperparathyroidism

A
  • Only indicated if not suitable for surgery (surgery 1st line)
  • Cinacalcet - Ca2+ sensing agonist
  • Bisphosphonates
  • HRT

Medical management not first line as it will lower calcium but not affect urinary calcium

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12
Q

Emergency management for severe hypercalcaemia

A
  • If renal failure - dialysis
  • Aggressive IV hydration (if then overloaded use loop diuretics)
  • Once volume replete consider bisphosphonates
  • Calcitonin, steroids or denosumab rarely used
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13
Q

Causes of hypocalcaemia

A
  • Hypoparathyroidism
  • Iatrogenic - thyroid surgery
  • Radiation
  • Infiltration
  • Autoimmune - but we don’t really do PT autoantibodies screen
  • Familial/syndromic - DiGeorge, overactivity of Ca2+ sensing receptor
  • Magnesium deficiency
  • Drugs - PPI, Cisplatin, calcitonin, phosphate, citrate
  • Pseudohypoparathyroidism
  • Vit D deficiency/resistance
  • CKD
  • Osteoblastic mets (eg prostate Ca)
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14
Q

Symptoms of hypocalcaemia

A
  • Tingling/numbness
  • Cramps
  • Neuropsychiatric
  • Carpopedal spasm
  • Seizures
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15
Q

Signs of hypocalcaemia

A
  • Stridor
  • Chvostek’s - tap facial nerve and face spasms
  • Trousseau’s - inflate BP cuff and carpopedal spasm occurs
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16
Q

Syndromic vs iatrogenic hypocalcaemia

A

Iatrogenic hypocalcaemia behaves much more aggressively than familial/syndromic causes

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17
Q

Investigations for hypocalcaemia

A
  • Serum Ca
  • PTH
  • Vitamin D
  • Magnesium
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18
Q

Management of hypocalcaemia

A
  • Calcium supplement - aim to keep calcium level just below normal range
  • Vitamin D - alfacalcidol, calcitriol
  • PTH not approved
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19
Q

Emergency management of acute hypocalcaemia

A
  • IV calcium gluconate (20ml of 10% in 100-200ml saline) over 10 mins
  • Calcium infusion (40ml of 10% calcium gluconate in 1L saline over 24hrs)
  • Check Ca every 6 hours
  • Replace Mg as needed
20
Q
A
21
Q

Severities of hyponatraemia

A
  • Normal - 133-146mmol/L
  • Mild - 127-132
  • Moderate - 121-126
  • Severe - 120 or less
22
Q

Symptoms and signs of hyponatraemia

A
  • Changes in personality - confusion/short temper
  • Headache
  • Fatigue
  • Convulstions/seizures
  • Feeling weak
  • Loss of conc/coma
  • Low BP
  • Feeling nauseous/vomitting
23
Q

Causes of hyponatraemia

A
  • Hypervolaemic - CKD, CHF, liver cirrhosis, nephrotic syndrome
  • Euvolaemia - medications (eg diuretics thiazides), glucocorticoid deficiency, severe hypothroidism, SIADH
  • Hypovolaemia - renal or extra-renal loss of sodium
24
Q

Investigating hyponatraemia

A
  • Rule out artefactual cause - if blood sample taken from same arm as IV fluids
  • Patient diabetic? - Hyperglycaemia can cause dilutional hyponatraemia
  • Assess fluid status
  • Review relevent clinical history - CHF, CKD, liver failure, lung pathology?
  • Constituional symptoms - malignancy?
  • Consider medications
25
Q

Medications which can cause hypocalcaemia

A
  • Thiazide diuretics
  • Loop diuretics
  • Potassium sparing diuretics
  • Combined diuretics
  • Angiotensin II receptor antagonists
  • Tricyclic antidepressants
  • SSRIs
  • MAO inhibitors
  • PPIs - omeprazole
  • Anticonvulsants - carbamazepine, valproate
26
Q

Investigations for hyponatraemia

A
  • Serum and urine osmolality
  • Urine Na+ and K+
  • Plasma glucose
  • 9am serum cortisol if suspect glucocortocoid deficiency
  • Short synacthen test maybe
  • TFTs
  • Other investigatiojs depend on cause
27
Q

Criteria for diagnosing SIADH

A
  • Serum osmolality less than 275mosm/kg
  • Urine osmolality more than 100mosm/kg
  • Urine sodium more than 30mmol/L - if Na was low, suggests body holding onto Na+ and is hypovolaemic
  • Absence of adrenal, thyroid, pituitary or renal insuffiency
  • Clinically euvolaemic
28
Q

Management of hypovolaemic hyponatraemia

A
  • Rehydrate with 0.9% NaCl
  • Check U&Es after infusion and prescribe further fluids if needed
29
Q

Management of hypervolaemic hyponatraemia

A
  • Fluid and salt restriction
  • Consider diuretics
  • Treat underlying cause

Careful with diuretics, they can sometimes worsen low Na

30
Q

Treatment of euvolaemic hyponatraemia

A
  • Treat the cause - chest infection, malignancy, hormonal insuffiency
  • If SIADH - fluid restriction (750-1000mls per day)
  • If serum Na not corrected despite fluid restriction consider Tolvaptan or Demeclocylcine
31
Q

Emergency management of hyponatraemia

A
  • Within 1st hour - IV infusion of 150ml 3% hypertonic saline or equivalent (over 20mins)
  • Check Na - IV infusion of 150ml of 3% hypertonic saline
  • Repeat twice or until 5mmol/L increase in Na
32
Q

F/u management after 5mmol/L increase in Na in emergency hyponatraemia management

A
  • Stop IV infusion of hypertonic saline
  • Keep IV line open minimum volume of 0.9% saline
  • Start diagnosis specific treatment
  • Limit increase of Na+ to 10mmol/L within first 24hrs - risk of central pontine demyelination
  • Limit increase Na+ to additional 8mmol/L every 24hrs therafter until Na+ 130mmol/L
  • Check Na 6hrs, 12hrs, and daily until stable
33
Q

Severity hyponatraemia

A

mild: 130-134 mmol/L
moderate: 120-129 mmol/L
severe: < 120 mmol/L

34
Q

Two sources of hyperandrogenism in females

A
  • Ovaries = PCOS, CAH
  • Adrenals
  • Others - acromegaly, idiopathic, cushings
  • Androgen secreting tumour
35
Q

How can Cushings cause hyperandrogenism?

A

Androgens in adrenal gland are under ACTH control

36
Q

Red flags for androgen secreting tumour

A
  • Rapid onset
  • Virilisation
  • Testosterone very high - more than 5nmol/L
37
Q

Signs of virilisation

A
  • Frontal balding
  • Deepening of voice
  • Increased muscle mass
  • Clitromegaly
38
Q

Steps for investigating hyperandrogenism

A
  • Check testosterone
  • Abdo USS
  • If suspect PCOS - rule out Cushings with Dexamethasone suppression test
  • If suspect Adrenal cause - can do ACTH suppression test
  • If suspect ovarian cause, can give GnRH will should suppress
39
Q

Criteria for diagnosing PCOS

A

Rotterdam criteria - need 2/3
* infrequent or no ovulation (usually manifested as infrequent or no menstruation)
* clinical and/or biochemical signs of hyperandrogenism (such as hirsutism, acne, or elevated levels of total or free testosterone)
* polycystic ovaries on ultrasound scan

40
Q

Multiple endocrine neoplasia

A
  • Autosomal dominant inheritance
  • MEN 1, 2A and 2B
  • Each type has particular cancers associated with it
41
Q

MEN 1

A
  • Pituitary adenoma
  • Parathyroid hyperplasia
  • Pancreatic tumours

3Ps

42
Q

MEN 2A cancers

A
  • Medullary thyroid cancers
  • Parathyroid hyperplasia
  • Phaechromocytoma

2Ps

43
Q

MEN2B cancers

A
  • Medullary thyroid carcinoma
  • Phaechromocytoma
  • Marfanoid
  • Mucosal neuromas

1P

44
Q

MEN 1 vs MEN2 genes

A
  • MEN1 - MEN1 gene on chromosome 11
  • MEN2 - C-RET oncogene on chromosome 10
45
Q

Testing for medullary thyroid cancer

A

Calcitonin

46
Q
A

Diabetes and Endocrinology YR3 (28 decks)

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