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Acromegally Investigations

Urine Dipstick – looking for glucose

Pituitary function screen – TSH/T4, Prolactin, FSH/LH, GH, IGF-1
Look specifically at the Serum insulin-like growth factor 1 (IGF-1) – Will be elevated and used as initial screen

MRI – pituitary and hypothalamus
CT Chest, Abdo, Pelvis only if no found cause – as this indicates it may be ectopic secretion

Special Tests:
Oral Glucose Tolerance test – GH is normally suppressed by glucose. If the glucose load fails to suppress the GH this confirms the diagnosis of acromegaly. Can also assess glucose tolerance (Diabetes associated)


Acromegally Treatment

1st line – Transphenoidal Surgery to remove tumour

2nd Line – Radiotherapy can be used in place if surgery unsuitable or non-curative
3rd Line – Somatostatin analogues (e.g. Octreotide) or Growth hormone receptor blockers (Pegvisomant) only used if surgery not available/didn’t work


Hypothyroidism Investigations:

If person has thyroid goitre or nodule use 2-week referral to see a specialist as may be cancerous (Thyroid cancer normally has normal thyroid levels)

ECG – Looking for any bradyarrhythmia’s

Thyroid function tests – T3/4 (Will be low), TSH (Will be raised in primary or low in secondary). Raised TSH and normal T4 indicates poor compliance with thyroxine
FBC – Looking for anaemia (normocytic = anaemia of chronic disease) (macrocytic = pernicious anaemia) (Microcytic = Iron deficiency due to menorrhagia)
Thyroid Autoantibodies:
Hashimotos - Anti-Thyroid Peroxidase (Anti TYO) and Anti-Thyroglobulin
Atrophic - Blocking TSH
Lipids – Hypothyroidism can cause hypercholesterolaemia
Blood Glucose – associated with Type 1 diabetes
Cortisol – They are at a higher risk of Addison’s disease as it is another autoimmune condition
Creatine Kinase – Hypothyroidism is associated with raised CK

US Goitre – If person has thyroid goitre or nodule use 2-week referral to see a specialist as may be cancerous (Thyroid cancer normally has normal thyroid levels)
Radioiodine uptake scan – Will show globally reduced uptake in Subacute (De Quervain’s Thyroiditis)


Hypothyroidism Treatment:

Give iodine replacement if low

Lifelong Levothyroxine – Start with a low dose and titrate up against TSH levels and symptoms (Start lower doses in elderly or those with ischaemic heart disease). Check thyroid function tests at 2 months – Aim is to maintain TSH not T3/4
Subacute (De Quervain’s Thyroiditis) – Treat thyroid pain with NSAIDS and steorids in severe cases
Myxoedemic coma:
IV levothyroxine
IV hydrocortisone (Many patients will have Addison’s disease)
Supportive therapy – Correct electrolyte disturbances, warm patient with blankets

Subclinical Hypothyroidism:
TSH<10 and Asymptomatic – Watch and wait
TSH<10 and symptomatic and < 65 years = Trail Levothyroxine to see if symptoms improve
TSH <10 and symptomatic and > 65 = Watch and wait
TSH>10 and < 70 = Treat
TSH>10 and >70 = Watch and wait


Hyperthyroidism Investigations:

ECG - if any palpitations or indications of AF

Thyroid function tests – T4/T3 (Raised), TSH (Low in primary hyperthyroidism, Raised in secondary)
Autoantibodies for graves – TSH-receptor antibodies (90%), Anti-Thyroid Peroxidase antibodies (75%), Antithyroglobulin
ESR– raised in subacute thyroiditis

US Goitre – If person has thyroid goitre or nodule use 2-week referral to see a specialist as may be cancerous (Thyroid cancer normally has normal thyroid levels)
Thyroid uptake scan – (Diffuse uptake = Graves) (Single hot spot = Toxic Adenoma) (Multiple Hot spots = Toxic Multinodular Goitre), Globally Reduced uptake (Subacute)
MRI Pituitary/Hypothalamus – If Secondary cause suspected

Investigations to order in a suspected Thyroid Storm:
ECG – Looking for a precipitating MI or for any arrhythmias caused by the thyroid storm (specifically AF)
Blood Glucose – Ruling out Ketoacidosis or Hyperosmolar Hyperglycaemic State
TFT’s – Raised T3/T4 (They do not have to be abnormally raised for it to be a thyroid storm)
FBC – Looking for raised WCC that may indicate precipitating infection or low Hb that may indicate precipitating bleed
ESR/CRP – Will be raised
U&E – Increased body stress can precipitate or be precipitated by Renal Failure
LFT – Increased body stress can precipitate or be precipitated by Liver Failure
Serum Calcium – Can be raised due to hyperthyroidism
CXR – Looking for a precipitating Pneumonia or heart failure
ABG – Patient will be very unwell and may have abnormal pH
Head CT may be needed to exclude other causes of coma


Hyperthyroidism Treatment:

Requires referral to endocrine specialist
If graves’ disease stop smoking – It is a risk factor for developing thyroid eye disease if you have graves

B-blockers for rate control and to reduce tremor while awaiting referral
Graves – Carbimazole, can either titrate up to correct dose or give lots and then use levothyroxine to adjust levels. 50% of people remit after 18 months so trial without the Carbimazole at this point. If Carbimazole contraindicated or not tolerated try propylthiouracil and then go onto radioiodine/thyroidectomy as last line treatments
Toxic Multinodular Goitre – Radioactive iodine treamtnet(Risk of transient worsening of hyperthyroidism after treatment), kills off thyroid leading to hypothyroidism and then treat with levothyroxine
Subacute de Quervain’s Thyroiditis – NSAIDS and supportive treatment as it is normally self-limiting (no new hormones are being made, just released in an inflammatory process and so Carbimazole has no effect).
Thyroid Eye Disease – Artificial tears and Prednisolone. In severe cases consider IV hydrocortisone or surgery for sight loss. Urgent referral if any vision loss, colour vision loss or if eye closing does not cover cornea

Thyroidectomy – Risks recurrent laryngeal nerve, hypoparathyroidism, and will lead to hypothyroidism requiring lifelong levothyroxine, not Regularly used
Removal of any pituitary/hypothalamic tumours may be indicated with specialist review


Addisons Investigations:

Capillary Glucose – Adrenal insufficiency can cause hypoglycaemia (Low cortisol levels)
ECG – If electrolyte disturbances to look for arrhythmias

U&E’s – Adrenal insufficiency causes Hyponatremia, Hyperkalaemia and sometimes Hypercalcaemia (due to reduced aldosterone levels). Will also show dehydration (Raised urea and creatinine) due to lack of aldosterone. These changes will not occur in secondary adrenal insufficiency
FBC – Looking for any associated Pernicious (normocytic) Anaemia. May also show or lymphocytosis, eosinophilia. May show precipitating infection
LFT – Looking for an underlying liver cancer that could have metastasised. Some patients will show Raised Transaminase levels
TFT’s – Raised TSH is associated with adrenal insufficiency
Prolactin levels -Hyperprolactinemia is associated with adrenal insufficiency
ABG – Patients are at risk of metabolic acidosis (Low Na levels reduce exchange of H+ and Na in the kidneys)
Adrenal Autoantibodies – Raised in Addison’s disease, 25 hydroxylase antibodies
Serum Cortisol – Used in the diagnostic phase along with ACTH to determine if the cause is primary or secondary. Can also be used in a suspected adrenal crisis to exclude an adrenal crisis as a diagnosis (e.g. Values >25 excludes an adrenal crisis but values lower than this are not diagnostic)

CXR – Looking for an underlying lung cancer that could have metastasised to the adrenals, or any TB that may have spread
Abdominal X-ray – Looking for adrenal calcification which may indicate previous TB infection
CT/MRI of adrenal glands – if primary cause suspected and autoantibodies are negative, adrenals will be enlarged in Addison’s
CT/MRI of Pituitary/Hypothalamus- if secondary cause suspected

Special Tests:
9am Cortisol – Cortisol levels peak in the early morning and these will be low
ACTH levels - Primary Insufficiency (ACTH high) Secondary insufficiency (ACTH low)
Aldosterone Levels – Unchanged in secondary causes of adrenal insufficiency
Renin Levels – Renin levels raised in primary adrenal failure due to low aldosterone causing NA loss. This lower blood Na and causes hypovolaemia. This stimulates renin production. This indicates a primary cause as aldosterone levels should be unaffected in secondary disease
Short Synachten test – Measure serum cortisol after giving Short Synachten (synthetic ACTH). Normally Cortisol/Aldosterone should rise above the patient’s baseline in response to the ACTH and thus reduced secretion of these hormones is diagnostic of a primary hypoadrenalism (the adrenal gland cannot respond to the ACTH). However, if levels rise this is indicative of a normal response or a secondary cause of adrenal insufficiency.


Addisons Treatment:

Educate the patient about the condition, specifically about the importance of not missing steroid or stopping abruptly and possible complications e.g. Adrenal crisis
Given steroid card, medical emergency bracelet and emergency hydrocortisone injection kit
Frequent Hospital Monitoring: Weight monitoring, Blood Pressure, Electrolytes, FBC, Vitamin B12, Full history and examination to see if doses are correct
Annual review for other autoimmune conditions – TFT’s, HBA1c, FBC (pernicious anaemia), B12, Coeliac Screen
Prescriptions are free

Glucocorticoid/Cortisol replacement with Hydrocortisone
Mineralocorticoid /Aldosterone replacement with Fludrocortisone – Only required in primary adrenal insufficiency
Doses of hydrocortisone but not fludrocortisone will need to be doubled if the patient is unwell/having surgery etc


Cushings Investigations:

Pregnancy test – To rule out pregnancy as cause for weight gain and central adiposity

Glucose – Cushing’s commonly causes diabetes
FBC – Some Cushing’s will have a raised WCC
U&E – To look for any electrolyte abnormality’s (E.g. Cross reaction of Cortisol at Aldosterone receptors causes Na+ exchange for K+ in the kidneys causing Hypokalaemia). If ectopic secretion from lung cancer is suspected will show any metastasise to the kidney
LFT – If ectopic secretion from lung cancer is suspected will show any metastasise to the liver
Ca2+ - Looking for a cancer if indicated
ACTH Levels – If ACTH levels are low it indicates Primary/ACTH Independent Cushing’s. However, if levels are normal or high a dexamethasone suppression test is required to differentiate between pituitary release of ACTH or ectopic release of ACTH.
ABG – Metabolic alkalosis can be caused by the hypokalaemia
Run basic hypertension bloods if present to look for end organ damage – Urinalysis, BNP, CXR

CXR – Looking for Heart Failure (Caused by long term hypertension) or to look for lung cancer
MRI pituitary gland/hypothalamus – Looking for a tumour
CT chest/abdo/pelvis – Looking ectopic ACTH secretion and Cushing’s disease bilateral adrenal hyperplasia

Special Tests:
Screening Test
Overnight Low dose Dexamethasone suppression test, 1mg of dexamethasone given at 11pm. Serum cortisol then measured at 9 am to see response. Dexamethasone is an exogenous steroid that negatively feedback on the secretion of ACTH. And thus should suppress cortisol release. If it does not cause a significant reduction in cortisol levels, then you know there is abnormal secretion of cortisol and they have Cushing’s syndrome.
Location Testing:
Serum ACTH at 9am and midnight– If low indicates an adrenal tumour (Do CT/MRI adrenals or Adrenal Vein Sampling), if high then do a high dose dexamethasone suppression test to defernite pituitary or ectopic ACTH secretion
High dose dexamethasone suppression test – Dexamethasone given over QDS for 2 days (48 hours) to see if there is any response. With very high doses of dexamethasone, the pituitary gland will reduce ACTH output, reducing cortisol levels by 50% in 48 hours (even though the pituitary is abnormally secreting ACTH and low doses had no effect), ectopic production will not be affected whatsoever.
Mimics Cushing’s features and will even give a false positive on the dexamethasone suppression test or 24-hour urinary cortisol. TO differentiate you need to do an insulin stress test.


Cushings Treatment:

Metyrapone (Glucocorticoid receptor antagonist) – Used in lead up to surgery or when surgery is contraindicated

Pituitary Adenoma – Trans sphenoidal pituitary adenectomy, radiotherapy can be used post operatively in non-curative or relapsing cases
Adrenal Adenoma – Adrenalectomy
Adrenal Carcinoma – Often palliative care required
Ectopic Production – Resection of tumour or adrenalectomy if resection of ectopic tumour not possible (As ectopic ACTH cannot cause problems if there is no adrenal gland)
After surgery patients may require hormone replacement therapy for other hormones affected e.g. Pituitary or adrenal hormones


Psoriasis Treatment:

1st Line:
Topical vitamin D analogues – Calcitriol
Topical steroids – Can cause skin thinning long term
Coal/Tar based creams
2nd Line Options: Initiated by consultants
UV Phototherapy
Both can cause tanning or increase risk of skin cancer
3rd Line options: Systemic Treatment
Systemic biological therapy – Methotrexate, Cyclosporin
Vitamin A analogues can be used
NEVER USE ORAL STEROIDS – Causes rebound flare up when stopped
When to refer – More than 1-% covered, Not controlled in first line treatments, nail disease that has functional impact, impact on QOL


Ulcerative Colitis Treatment:

Flare Ups
Mild – Oral/PR Mesalazine or PR steroids
Moderate – Oral Steroids
Severe – IV steroids

1st Line Mesalazine
If > 2 flare ups a year needing steroids Add azathioprine
If not maintained add biologics


Crohns Treatment:

Flare Ups
Mild/Moderate – Oral Steroids
Severe – IV steroids

If > 2 flare ups a year needing steroids give long term azathioprine
If not maintained add biologics


Ankylosing Spondylitis Investigations:`

HLA-B27 - Raised in 90%
ESR/CRP - Raised in 50%
Rheumatoid Factor - Will be negative. To rule out rheumatoid arthritis

Imaging: (See images next page)
Spinal X-rays:
Squaring of vertebrae
Syndesmophytes – Ossification of Annulus Fibrosis
Bamboo Spine – Late Sign
Sacroiliitis – Subchondral sclerosis and erosions

MRI – Can see changes earlier than an X-ray
Imaging relevant to any affected organs – E.g. Lungs, Heart, Kidneys

Special Tests:
Spirometry – Can show restrictive pattern due to apical fibrosis, kyphosis and ankylosis of the costovertebral joints


Ankylosing Spondylitis Treatment:

Refer to rheumatologist
Intense physiotherapy and hydrotherapy – To maintain mobility and prevent spinal fusion
Encourage regular exercise

1st line - NSAIDS For Axial Disease
2nd Line -Anti TNF Drugs (E.g. Etanercept) for severe disease
3rd Line - Intra-articular steroids for acute flare ups
Methotrexate or sulfasalazine for peripheral joint arthritis (but have no effect on axial disease)
Topical corticosteroids for uveitis.


Rheumatoid Arthritis Investigations:

FBC - Anaemia of chronic disease, GI blood loss secondary to use of NSAID. WCC low
CRP/ESR – Assess inflammation, so will be raised
LFT’s – ALP and GGT can be raised and before starting an NSAID or DMARD
Antinuclear Antibodies – Exclude SLE
Rheumatoid Factor – positive in 70%
Anti CCP - Positive in about 98% of RA patients
U&E – Before starting an NSAID or DMARD

X-ray of affected joint – LESS (Loss of joint space, Erosions – Late sign, Swelling of tissues, Soft Bones/Juxta-articular osteopenia) and Deformity

CXR – Pulmonary fibrosis/effusion


Rheumatoid Arthritis Treatment:

Diet and exercise
Refer to Rheumatologist
Reduce strain on affected joints
Walking aids
Joint supports

1st Line - Methotrexate + another DMARD (Sulfasalazine/Hydroxychloroquine) + Short term Oral Corticosteroids + NSAID for pain relief (May take 12 weeks to show improvement). If history of reflux co-prescribe a PPI and Bisphosphonate for bone protection
2nd Line (DAS28 score >5.1 after initial treatment) - Methotrexate + TNF-Alpha inhibitor (E.g. Infliximab) + NSAID for pain relief
3rd line - Methotrexate + Rituximab + NSAID for pain relief
4th Line – Methotrexate + IL-1 and IL-6 inhibitors (e.g. Anakira and Tocilizumab) + NSAID for pain relief

During Flare Ups can use NSAIDS or intraarticular/IM corticosteroids


Psoriatic Arthritis Investigations:

ESR/CRP - Raised
Rheumatoid Factor - Will be negative. Done to rule out rheumatoid arthritis
HLA-B27 - Raised in most cases
Serum IGA – Raised in psoriasis
Lipids/Glucose - Linked to metabolic disease
Uric Acid levels - exclude gout
CPPD crystals - Ruling out Pseudogout

X-ray of Hand and feet - X-ray changes may show pencil-in-cup deformity and erosion of the distal tuft of the distal phalanx
Spinal X-ray - To look for sacroiliitis
Foot X-ray -Calcaneal spur if any plantar fasciitis


Psoriatic Arthritis Treatment:

1st Line - Methotrexate + Sulfasalazine + Oral Corticosteroids + NSAID for pain relief. If history of reflux co-prescribe a PPI.
2nd Line - Methotrexate + TNF-Alpha inhibitor (E.g. Infliximab) + NSAID for pain relief
3rd line - Local steroid injections
Skin disease – Treat with topical corticosteroids (Hydrocortisone cream), Vitamin D analogues. Phototherapy can be used if not managed by medical therapy


Systemic Sclerosis Investigations:

Urinalysis - Urine protein as baseline or to see if there is any renal involvement.
ECG - May demonstrate cardiac involvement such as arrhythmias or heart failure

Serum Autoantibodies – Anti-centromere antibodies (ACA) in limited disease (limited – central antibodies), Anti-topoisomerase antibodies =, anti-RNA polymerase antibodies and anti-Scl-70 antibodies in diffuse disease
FBC - May be anaemic from chronic GI bleed, rule out any form of infection
U&E - The onset of acute renal failure is a feature of scleroderma renal crisis
ESR/CRP - Can be raised, can be normal – To rule out infection

CXR – Looking for pulmonary fibrosis, may also show areas of calcinosis. HRCT may be used if lung function tests are abnormal
Echo - Should be done at onset and on a yearly basis. RV or LV diastolic dysfunction can be seen with cardiomyopathy of scleroderma and heart failure due to pulmonary hypertension
OGD/ Barium Swallow – To look for oesophageal involvement

Special Tests:
Lung Function Tests - Important to evaluate for restrictive lung disease and for pulmonary hypertension. Should be done at onset and on a yearly basis.


Systemic Sclerosis Treatment:

There is no cure, so treatment is symptomatic control
Educate the patient – The disease is not curable, may progress and will involve constant monitoring, also educate them on the symptoms of Scleroderma Renal Crisis
Improve QOL through other methods - Stop smoking/Optimise BMI

Specific Symptoms management:
Raynaud’s – Avoid the cold and trauma to the hands. Treat with Calcium Channel Blockers (e.g. Nifedipine) and slowly warming the body/hand during attacks
Skin conditions - Azathioprine and methotrexate can reduce skin disease, protective dressings and antibiotics for ulcers, moisturiser for skin cracking
Calcinosis – May need surgical removal
Joint/Muscle pain – NSAIDS and physiotherapy
GI – Lifestyle and PPI treatments for reflux, Laxatives/Antidiarrheal and adjust fibre in diet, Cyclical antibiotics for bacterial overgrowth and malabsorption
Pulmonary Fibrosis - Cyclophosphamide and Mycophenolate mofetil, may also help skin disease
Renal Crisis - ACE inhibitors, IV vasodilators plus dialysis if necessary. 


Systemic Lupus Erythematous Investigations:

Urinalysis - To assess renal involvement (haematuria, casts (red cell, granular, tubular, or mixed) or proteinuria)
ECG - To look for any cardiac involvement

ESR/CRP – ESR will be raised, CRP could be raised (A solitary rise in ESR should make you think SLE)
Anti-Nuclear Antibody (ANA) – 99%
Anti DS DNA antibody – 70% but 99% specific
Anti-Smith Antibody 30% but 99% specific
Rheumatoid Factor – 20%
Others - Anti-Smooth muscle, anti-U1 RNP, SS-A (anti-Ro) and SS-B (anti-La)
Antiphospholipid Antibodies and Anticardiolipin antibodies (Not associated with SLE but to check for Antiphospholipid syndrome, which is associated with SLE)
Complement Protein levels - Low C3/C4 due to inflammatory process using them up
FBC - May see anaemia/Leukopenia/Thrombocytopenia that is caused by SLE
Clotting – PTT/INR will be raised in antiphospholipid syndrome which can be due to SLE but APTT will be normal
U&E - Assess renal involvement
LFT’s – To look for any renal involvement
FBC – Anaemia, thrombocytopaenia and leukopenia (All low)

CXR - If any cardiopulmonary symptoms - May see pleural effusion, infiltrates, cardiomegaly
X-Ray of any affected joints - To rule out osteoarthritis or RA
Echo – To look for any cardiac involvement
Head MRI – If any neurological involvement

Special Tests:
Test the systems affected e.g. Echo for heart, Pulmonary function tests for Lungs, Renal Ultrasound for Kidneys


Systemic Lupus Erythematous Treatment:

Use of sunblock to protect photosensitive skin
Education on chronic nature of the disease
Stop any drugs that may have caused it – Isoniazid, Terbinafine, Phenytoin, Carbamazepine
Education on association with miscarriages (Antiphospholipid syndrome in 30% of cases) and plan pregnancy 
Refer to specialist

Maintenance – NSAIDS, Hydroxychloroquine, Low dose prednisolone
Relapses – High Dose prednisolone, IV Cyclophosphamide
Complications – ACEi (For renal problems), Paracetamol (Joint Pain), Topical Steroids and Sun cream (Rash)


Hernia Treatment:

Treatment: Treat all hernias – In some cases can watch and wait, but this a senior call
If irreducible - Push with flat of hand towards contralateral shoulder
Weight loss
Stop smoking
Patients can wear a truss if surgery contraindicated

Pre-Op - Warn patients that hernias may recur, and about risk of chronic pain and the post-operative time off work needed (2 weeks laparoscopic, 4 weeks open)
Get patient to stop smoking and lose weight in build-up top surgery, improves symptoms and increases surgical results
Done laparoscopically if possible
Lichtenstein technique (Mesh technique) - Mesh reinforces the posterior wall 4 weeks off work
Bassini's technique – Apposition of the surrounding musculature, transversus abdominis and transversalis fascia and lateral rectus sheath, to the inguinal ligament, closing off openings
Strangulated hernias are a medical emergency and require surgical repair


Varcose Vein Treatment:

Indications for treatment
Severe impact on QOL
Should not cosmetic reasons

Avoid standing for extended periods
Elevate legs when possible
Regular exercise - Aid venous return
Lose weight
Compression stockings - increase venous return
Compression bandages can be used for Venous Ulcers

Endothermal Ablation (1st Line) - Radiofrequency Ablation with 120-degree catheter inserted into vein destroying it
US Guided Foam Injection sclerotherapy (2nd Line) – Sclerosant (Sodium Tetradecyl Sulphate) injected that blocks up vein.

Only used if non-surgical options failed or contraindicated
Options include Stripping or Ligation of the saphenofemoral junction with vein stripping


EWS Monitoring

EWS Score 0 = 12 hourly
EWS Score 1-4 = 6 hourly
EWS Score 5+ or 3+ in one section = Hourly
EWS 7+ = Continuous Monitoring