day3 Flashcards
acute tenderness in goitre in a diffuse swelling, sometimes with severe pain is suggest of
acute viral thyroiditis (de quervains)
in multi nodular goitre what is the thyroid levels usually
euthyroid
what is the most common cause of tracheal and or oesophageal compression and can lead to laryngeal nerve palsy
multi nodular goitre
you get fibrotic nodular goitre in
riedels thyroiditis
what should be a concern in a solitary nodule
malignancy
are majority of solitary nodules cystic or benign
yes
most thyroid cancers are
painless and slow growing
fibrotic goitre producing a woody gland
riedels thyroidits
a goitre associated with euthyroidism rarely requires intervention and the patient can be reassured that spontaneous resolution is likely during
puberty and pregnancy
carcinomas derived from thyroid epithelium may be
papillary, folliciular or anaplastic
medullary carcinomas arise from calcitonin producing c cells
most common thyroid carcinoma
papillary
papillary carcinoma is common in what kind of people
young
what can be used as a tumour marker in thyroid carcinomas after thyroid ablation
thyroglobulin
what do you use for residual thyroid tissue post op
RAI ablation
what can you give to minimise risk of recurrence of papillary and follicular carcinomas
levothyroxine
when is the measurement of thyroglobulin(tumour marker) most sensitive
when TSH is high so requires withdrawal of levothyroxine
what can be used to stimulate thyroglobulin without stopping levothyroxine
recombinant TSH
what suggests recurrence of papillary/follcular carcinomas
detectable thyroglobulin
medullary carcinoma is often associated with
Men2
approx 1 in 4 patients diagnosed with medullary thyroid cancer have a mutation on the
RET proto oncogene
people with MEN2 mutations are advised to have what as early of 5 years of age to prevent the development of medullary thyroid carcinoma
prophylactic thyroidectomy
is local invasion or metastasis frequent in medullary thyroid carcinoma
yes
what is usually indicated in medullary thyroid carcinoma
total thyroidectomy and wide lymph node clearance
what controls progression through puberty and the capacity for reproduction
hypothalamo- pituitary gonadal axis
what is primary amenorrhoea
failure to begin spontaneous menstruation by age 16
what is secondary amenorrhoea
absence of menstruatuon for 3 months in a woman who has previously had cycles
GnRH is released from where
hypothalamus
GnRH stimulates
LH and FSH release from the pituitary
in males, LH stimulates
testosterone
FSH stimulates what cells in males to produce mature sperm
Sertoli cells
in females, LH and FSH stimulates
androgen and oestrogen production
in females, LH and FSH stimulates
androgen and oestrogen production
what indicates primary gonadal disease
high gonadotrophins with low testosterone or oestradiol
normal or low LH/FSH with low testosterone/oestridiol
hypothalamic pituitary disease
what test to exclude hypogonadism in males
basal testosterone
what test in female to exclude hypogonadism
basal oestradiol
male with an extra X chromosome
klinefelters syndrome
early indications of klinefelters syndrome
cryptochidism (absence of a test) , behavioural problems, tall stature and learning difficulties
pea sized but firm tsts
klinefelters syndrome
isolated GnRH deficiency
kallmans syndrome
what is gynaecomastia
development of breast tissue in the male
causes of gynaecomastia
hyperthyroidism, hyperprolactinaemia, renal and liver disease, hypogonadism drugs
common drugs to cause gynaecomastia
digoxin and spironolactone
cause of gynaecomastia in young person
oestrogen excess
cause of gynaecomastia in older male
aromatase activity increases
low testosterone increases risk of
osteoporosis
most common presentation of female gonadal disease
amenorrohea (absence of periods)
what is oligomenorrhoea
irregular infrequent periods
what is the most common cause of oligomenorrhoea and amenorrhoea
polycystic ovary syndrome
premature menopause before the age of 40 is called
premature ovarian insufficiency
what is a cause of premature ovarian insufficiency, frequently with delayed puberty and primary amonohorrea
turners syndrome
phenotype is a female with female external genitalia
turners
features of turners
short stature, webbing of the neck, wide carrying angle of the elbows, high arched palate and low seat ears
what confirms diagnosis of premature ovarian insuffiecny
elevation of LH and FSH to menopausal levels
if oestrogen deficiency is not reversed in premature ovarian insuffiency what should be given
hormone replacement therapy
increased hair in sex hormone dependent areas is most likely
polycystic ovary syndrome
excess hair in sex dependent hormone areas is due to
increased ovarian adrenal androgen production
most common cause of hirsutism
polycystic ovary syndrome
what is characterised by multiple small cysts within the ovary and and by excess androgen production from the ovaries
polycystic ovary syndrome
what is PCOS associated with
hyperinsulinaemia and insulin resistance, hypertension, hyperlipidaemia and increased cardiovascular risk
most patients with PCOS present with what
amonehoorhoea/oligomenorrhoea and or hirsutism and acne shortly after starting period
should diet and exercise be indicated in polycystic ovarian syndrome
yes
what worsens androgen excess and insulin resistance
obesity
what is in oral contraceptives
oestrogen
increasing SBHG levels does what
reduce free androgens
treatment if only symptom if menstrual disturbance
cyclical oestrogen/ progestogen
treatment for fertility in PCOS
clomifene or ietrozole
what is a strong determinant of timing of puberty
timing of parental puberty
GHRH is under inhibitory control by
somatostatin
gh binds to a receptor in the
liver
-increasing collagen and protein synthesis
- promoting retention of calcium, phosphorus and nitrogen(necessary substrates for anabolism)
-opposing action of insulin
are
metabolic actions from growth hormones
gh release is mainly
nocturnal
what stimulates gh
stress and exercise
what suppresses gh
hyperglycaemia
inhibition of GnRH
initiating puberty
what peptide plays a crucial role in the regulation of GnRH production and timing of puberty
KISS1R
what are low in the prepubertal child
Lh and FSH
what is more helpful than current height in measuring growth
height velocity
what is associated with short stature in females
turners
hypo or hyper thyroids can cause short stature
hypothyroidism
chromosomal abnoramlitites that can cause tall stature
klinefelters syndrome and marfans syndrome
in obesity are SHBG levels reduced or increased and same with androgens
shbg reduced and androgens increased
specific features of acromegaly
prognathism(extension or bulging out of lower jaw), interdental separation, large tongue, spade like hands and feet
gh excess causes what in children and what in adults
gigantism in children and acromegaly in adults
gigantism and acromegaly are due to gh secreting pituitary tumour called
somatotroph adenoma
acromegaly usually occurs
sporadically
what is common in acromegaly
sleep apnoea
what is very common in acromegaly
headaches
how useful is gh levels in acromegaly
may exclude acromegaly if they are undetectable but a detectable value is not diagnostic alone
what test for acromegaly is diagnostic if there ice no suppression of gh
glucose tolerance test
example of a visual defect in acromegaly
bitemporal hemianopia
what do people die from in acromegaly
heart failure, coronary artery disease or hypertension
first line therapy in acromegaly
trans-sphenoidal surgery
3 receptor targets in acromegaly
pituitary somatostatin receptors
dopamine receptors
Gh receptors
side effects of somatostatin analogues eg octreotide and ianreotide
gallstones
what drugs are most effective in GH producing or prolactin producing tumours
dopamine agonists
growth hormone antagonist
pegvisomant
what is mainly controlled by tonic inhibition by hypothalamic dopamine
prolactin
what stimulates JAK2
prolactin
what does prolactin do
stimulate milk secretion (but not breast tissue development) and inhibits gonadal activity
what produces hypogonadism even when the pituitary gonadal axis is intact
prolactin
what can these drugs cause:
oestrogen (contraceptive pill)
dopamine antagonists
antidepressants
antiemetics eg metoclopramide
verapamil
common signs in hyperprolactinaemia
galactorrhea (nipple milk discharge)
oligomenorrhoea
decreased libido (sex drive)
common signs in hyperprolactinaemia
galactorrhea (nipple milk discharge)
oligomenorrhoea
decreased libido (sex drive)
how is hyperprolactinaemia confirmed
repeat measurements
what can be a cause of hyperprolactinaemia
primary hypothyroidism
hyperprolactinaemia is controlled with a dopamine agonist eg
cabergoline
in prolactianemia what is done If dopamine agonists aren’t working
transphenoidal surgery- only for micro adenoma
where is ash synthesised
hypothalamus
predominant site of adh/vasopressin
kidneys
what does vasopressin do
allows collecting ducts to to become permeable to water
vasopressin results
retention of water
problems involving vasopressin
diabetes insipidus and SIADH
what is a common cause of hyponatraemia in hospital patients
syndrome of inappropriate antidiuretic hormone (SIADH)
most common cause of diabetes insidipidus
hypothalamic pituitary surgery
excess secretion of dilute urine so compensatory increase in thrust so can lead to dehydration
diabetes insipidus
what can mask diabetes insidious
cortisol defiency
absent or poorly developed posterior pituitary
DIDMOAD syndrome
treatment of choice in cranial DI
synthetic vasopressin called desmopressin
polyuria can be helped with
thiazide diuretics
water deprivation test for
DI and primary polydipsia
psychiatric disturbance characterised by the excessive intake of water
primary polydipsia
retention of water and hyponatraemia
SIADH
retention of water and hypernatraemia in plasma
DI
is there oedema in SIADH
no
symptoms of SIADH
vague with confusion, nausea and can lead to coma
what is absent in SIADH
hypokalaemia or hypotension
management fo SIADH
fluid intake restriction
what drug inhibits the action of vasopressin o the kidney and can eb used for SIADH
demeclocycline
serum calcium levels are mainly controlled by which 2 things
parathyroid hormone and vitamin D
serum calcium levels are mainly controlled by which 2 things
parathyroid hormone and vitamin D
mild hypercalcaemia is mainly due to
primary hyperthyroidism
what cells secrete parathyroid hormone
chief cells
parathyroid levels rise as
serum ionised calcium falls
PTH acts to
increase plasma calcium
what does these:
increase osteoclastic resorption of bone
increase intestinal absorption of calcium
increase excretion of phosphate
PTH
most common cause of excess pTH secretion
primary hyperparathyroidism but adenoma is still common
most primary hyperparathyroidism is caused by what
single parathyroid adenomas
secondary hyperparathyroidism is compensatory of
hypocalcaemia
when is there hypocalacemia often
chronic kidney disease or vitamin D deficient
genereal symptoms of hypercalcaermia
tiredness, malaise, dehydration and depression
brown tumours occurs in advanced disease of
hyeprcalcemia
corneal calcification is a marker of
longstanding hypercalcaemia
severe hypercalcemia is usually associated with
malignant disease, hyperparathyroidism, chronic kidney disease, or vitamin D therapy
what is the hallmark of primary hyperparathyroidism
hypercalcaemia and hypophosphataemia with detectable PTH LEVELS DURING HYPERCALCAEMIA
if undetectable PTH level in context of hypercalcemia need to exclude
malignancy
medical management for primary hyperparathyroidism
high fluid intake and replaectn of vitamin d if needed
how does acute hypercalaemia present
dehydration, nausea, vomiting,nocturia(causes you to wake up in night to pee), polyuria, drowsiness and altered consciousness
treatments for acute severe hypercalcemia
rehydrate
IV Biphosphanates (treatment of choic)
what is the major danger after operation
hypocalcemia
causes of hypocalcaemia
chronic kidney disease and phosphate therapy (increased phosphate levels)
acute pancreatitis
calcitonin , biphosphanatates
ostemalacis/rickets
surgery around neck
severe vitamin D deficiency
most common cause fo hypocalcemia is
chronic kidney disease
hypocalcemia presents as
neuromuscular irritability, paraesthesia, anxiety, tetany
2 signs of hypocalcemia
chvosteks sign and trousseaus sign
what sign is this: gentle tapping over the facial nerves causes twitching of the ipsilateral facial muscles
chvosteks sign
what sign is this: inflation of the sphygmomanometer cuff above systolic pressure for 3 min induces titanic spasm of the fingers and wrist
trousseaus sign
what may cause prolonged qt interval on ecg
hypocalcemia
diagnostic of hypocalcemia
Low serum calcium
most appropriate treatment fro hypcalcemia if vitamin d deficient
cholecalciferol
presenting features fo insulinoma
Diplopia (seeing double)
sweating, palpitations
confusion
classic presentation of insulinoma
fasting hypoglycaemia
whiles triad for insulinoma:
symptoms are associated with fasting or exercise
hypoglycaemia is confirmed during these episodes
glucose relieves the symptoms
medical treatment for insulinomas
diazoxide
what is a problem in acute hepatic failure
hypocalcemia
drugs that can cause hypoglycaemia
sulphonylureas
propanolol
alcohol inhibits what
gluconeogenesis
can alcohol cause hypoglycaemia
yes
what is the name given to the simultaneous occurrence of tumours involving a number of endocrine glands
multiple endocrine neoplasias (MEN)
men 2 caused by mutations of
RET on chromosome 10
all glands are typically involved in
MEN1
essence of management in MEN is
annual screening
first manifestation of MEN1
hyperparathyroidism
useful tumour marker in medullary carcinoma of the thyroid
calcitonin
carcinoid syndrome is due to what tumour
neuroendocrine
