Diabetes and endocrinology Flashcards
T1DM - Ix, Mx, Insulin, driving
Ix - Hyperglycemia with ketosis, weight loss, age <50, low BMI, personal/FH autoimmune disease. ALWAYS check TFTs as strong association with thyroid disease. Ab used if unclear - GAD, IA2, ZnT8.
Def - > 7 fasting >11.1 random/OGTT, HBA1C >48mmol.
Mx - Education programme, carb counting, exercise, insulin, can add metformin if overweight. Test at least 4/d and 5-7 on waking, 4-7 at other times. Check HBA1C every 6m and aim for <48mmol.
Insulin - Fast - humalog, acturapid, or novorapid. Long - insulin glargine, insulin detemir. Biphasic regimen - BD premixed insulin NovoMix (some long some short), good if regular lifestyle. QDS regimen - long acting before bed and short before meals with carb counting.
Total daily dose can be guessed as 0.3U/Kg/day.
Driving - Inform DVLA. Check blood glucose before start and every 2 hrs. Must be aware of hypos. If required others to treat hypo cant drive for 12m.
T2DM - Sy, Ix, Mx
Sy - polyuria, polydipsia and unexplained weight loss.
Ix - Random >11.1mmol or fasting >7, HBA1C >48. Just one measurement if symptomatic and two if not.
Mx - Metformin - increases insulin sensitivity and weight loss. SE N/D. Lactic acidosis in low eGFR. If HBA1C >58 16wks later add:
- DPP-4 inhibitor (gliptin) - increase insulin, weight neutral.
- Sulfonylurea (gliclazide) - increased insulin, can cause hypos and weight gain. Can also add pioglitazone, or SGLT2.
If uncontrolled on double go to triple, if uncontrolled go to insulin.
Thyrotoxicosis - Sy, Graves si, Ix, Causes, Mx, complications
Sy - diarrhoea, weight loss, appetite increase, overactive, sweats, heat intolerance, palpitations, tremor, labile emotions, oligomenorrhoea. Tachy, fine tremor, palmar erythema, lid lag, lid retraction, goitre.
Graves si - exopthalmos, opthalmoplegia, pretibial myxoedema, thyroid acropachy (clubbing, painful finger/toe swellings).
Ix - Low TSH high T3/4, thyroid antibodies.
Causes - Graves disease (most common) - IgG activates thyrotropin receptors. Also - toxic multinodular goitre, adenoma, de Quervain’s (post viral), drugs (amiodarone, lithium).
Mx - Dont smoke - eye sy. b-blockers for immidiate Mx of sy. give carbimazole +- thyroxine (decreases hypo) for 12-18m then withdraw. Carbimazole can cause AGRANULOCYTOSIS. If relapse give radioiodine or surgery.
Complications - heart failure, angina, AF, osteoporosis, thyroid storm.
Hypothyroidism (myxoedema) - Sy, Ix, Cause, Mx, comp
Sy - tired, sleepy, low mood, hates cold, weight gain, constipation, menorrhagia, hoarse voice, dementia, myalgia, cramps. Slow reflexes, ataxia, dry skin/hair, cold hands, ascites, round puffy face, CCF.
Ix - High TSH, low T4.
Causes - Primary atrophic hypothyroidism (autoimmune atrophy, no goitre), Hashimoto’s thyroiditis - older women, may have brief period of hyper. Worldwide biggest cause is iodine def.
Mx - Levothyroxine - adjust to normalise TSH, once normal check annually.
Comp - Heart disease, dementia. In pregnancy - eclampsia, anaemia, prematurity, low birth weight, stillbirth, PPH.
Hyperparathyroidism - Cause, Sy, Ix, Mx
C - Usually solitary adenoma but also gland hyperplasia.
Sy - Due to high Ca - bone pain, kidney stones, dehydrated/polyuria, depressed, abdo pain, HTN.
Also - Secondary hyperparathyroidism - caused by hypocalcaemia (RF). Can then get a tertiary hyperparathyroidism where levels are chronically high enough to raise Ca, to the detriment of bone.
Ix - High Ca and PTH, low phosphate, DEXA scan.
Mx - fluid intake, reduce Ca/vit D intake, excise adenoma or parathyroid glands. Can cause big drop in Ca (hungry bone sy post-op).
Cushings syndrome - Def, cause, Sy, Ix, Mx
D - Glucocorticoid excess, usually caused by oral steroids. N.B. may also have impact on mineralocorticoids (aldosterone) and androgens.
Cause - Usually steroids. Other ACTH independent causes - addrenal adenoma/hyperplasia. ACTH dependent - Cushings disease (pit adenoma - low dose dex has no effect but high dose does decrease), ectopic ACTH production from SCLC and carcinoid tumors (high dose dex may fail to supress).
Sy - weight gain, depression, prox weakness, gonadal dysfunction, acne, achilles tendon rupture, virilization. Central obesity, moon face, buffalo neck hump, bruises, abdo striae, osteoporosis, HTN, diabetes, gynaecomastia.
Ix - difficult as cortisol levels change with illness, time, stress. 24h urinary cortisol or low dose 24h dexamethasone suppression - should reduce cortisol to v low, if not = Cushings sy. Then do 48h or high dose suppression. Localise - Adrenal MRI. Inferior Petrosal Sinus Sampling can localise to pit or ectopic.
Mx - Iatrogenic - stop or reduce steroids. Cushings disease - trans-sphenoidal hypophysectomy, adrenalectomy in adrenal adenoma, surgery for ectopic production if has not spread.
Addison’s disease - Def, Cause, Sy, Ix, Mx, Addisonian crisis
D - Adrenal insufficiency.
C - Usually due to exogenous steroids (but also severe sepsis or metastatic cancer), Addison’s disease is rare and autoimmune causing cortisol and aldosterone def.
Sy - Lean, tanned, tired, low mood, dizzy, faints, flu-like sy, low mood, abdo pain, vomiting. Pigmented palmar creases and mucosa, postural hypotension, virtiligo.
Ix - Low NA high K (low aldosterone). PLasma cortisol, give synthacthen then repeat 30m later - cortisol will remain low. Serum autoantibodies.
Mx - 15-25mg hydrocortisone daily in 2-3 doses. Fludrocortisone for postural hypotension. Do not abruptly stop taking steroids, give steroid card. Double glucocorticoids if ill!
Addisonian crisis - Infection, trauma, surgery, missed meds cause critically low cort. ALWAYS CONSIDER if shock in someone with Addisons/steroid user forgotten/adrenal haemorrhage. Sy - hypotensive shock, hypoglycaemia. Mx - cortisol and ACTH bloods, stat 100mg hydrocortisone, IV fluid, ?glucose, change to PO steroids once condition is good.
Hyperprolactinaemia - Cause, Sy, Ix, Mx
Cause - Usually secreted from ant pit and release is inhibited by hypothalamus dopa, so may be - pit prolactinoma (micro or macro), use of dopamine antag. Also pregnancy, breastfeeding, stress.
Sy - presents early in women with amenorrhoea or oligomenorrhoea, infertility, galactorrhoea, loss of libido, weight loss, dry vagina. Presents late in with ED, loss of facial hair, galactorrhoea.
Ix - Rule out pregnancy, TFT. Prolactin levels.
Mx - dopamine ag (bromocriptine or cabergoline). Microprolactinomas - <1cm on MRI, Macroprolactinomas >1cm. Surgery if optic sy (loss of acuity, diploplia, ophthalmoplegia).
DKA - Def, Sy, Ix, Mx
Def - Ketosis because of lack of insulin causes hyperglycaemia and acidosis. Triggered by ingection, surgery, MI, pancreatitis, antipsychotics, wrong insulin dose/non-compliance.
Sy - Over hours or days. Drowsiness, vomiting, dehydration, abdo pain, polyuria, anorexia, ketotic breath, Kussmaul sign.
Ix - VBG (H and glucose >11) and ketones >3. Pregnant women and SGLT2 drugs can have DKA in lower glucose.
Mx - 500mL saline (20m), add 0.1u/kg/hr actrapid 50u/50ml. Check VBG for glucose/K/pH/bicarb at 1h, 2h and then every 2hrs. When glucose is ,14mmol start 10% dextrose. Stop insulin when ketones <0.3. CONTINUE REG LONG ACTING INSULINS.
Hyperglycaemic hyperosmolar non-ketotic state HHS - Sy, Mx
Sy - Over a week. Marked dehydration, sky high glucose, no acidosis as low ketones. High risk of occlusive events DVT or (focal neuro, leg ischaemia, rhabdomyolysis).
Mx - Slow fluid rehydration with normal saline, replace K when below 5.5, add insulin at fixed rate if ketotic or if blood glucose not falling with rehydration.
Hypoglycaemia - Def, Sy, Causes, Ix, Mx
D - Plasma glucose <3.
Sy - Autonomic - sweating, anxiety, hunger, tremor, palpitations, syncope. Neuro - confusion, drowsiness, seizures, coma.
Causes - Usually insulin or sulfonylurea treatment. In non-diabetic could be drugs (alcohol, aspirin, b-blockers), pituitary insufficiency, Addisons, insulinoma (MEN-1), post-pranial dumping syndrome in post-gastrostomy.
Ix - fingerprick.
Mx - Oral sugar and long acting starch (toast). If cant swallow dextrose IV or glucagon IM.
Diabetic foot - Neuropathy, Ischaemia, Ulceration, other neuropathies.
Neuropathy - painful loss of sensation in stocking dist, test with 10g monofilament, absent ankle jerks, deformity (pes cavus, claw toes, Charcots). Mx - paracetamol, then amytriptylline, then dueloxetine/gabapentin.
Ischaemia - feel pulses, if cant get doppler. Mx - educate and chiropody, good shoes. Surgery if abcess or deep infection.
Venous Ulcer - medial malleolus, with lipodermatosclerosis. Painless. Large, irregular, shallow, sloughing. Mx - compression stockings/bandages if ABPI >0.8. **Only Abx if Si of infection (same for all).
Arterial - shin, lat malleolus, toes. Painfull, worse on elevation. Small, punched out. Mx - neg pressure dressing.
Neuropathic - on pressure points. Painless. Regular margin, deep. Mx - Negative pressure dressing.
Neuropathies - Mononeuritis multiplex - (several nerves e.g. III and IV). Amyotrophy - painful wasting of quads. Autonomic - postural hypotension, gastroparesis, urine retention ED, diarrhoea.
Hyponatraemia - Sy, cause, Mx
Anorexia, nausea, malaise, headache, irritability, confusion, weakness, low GCS. Cardiac failure or oedema.
Cause - Low fluid status - if urinary Na is low the water and sodium loss from diarrhoea/vomiting/burns, if urinary Na high both water and Na loss from kidneys - Addison’s disease, RF, diuretic excess, osmolar diuresis (glucose).
High/normal fluid status - Dilutational caused by nephrotic sy, CCF, cirrhosis, RF. If not oedematous SIADH.
Mx - if odematous fluid restrict. If dehydrated cautiously rehydrate avoiding rapid (central pontine myelinolysis). Consider hypertonic saline in an emergency.
Hypercalcaemia - Si, Ix, Mx
Si - Bones (pain/#), stones (kidney, polydipsia/dehydration), groans (abdo pain), psychic moans (depression).
Ix - ECG shortened QT. Distinguish malignancy from hyperparathyroidism - PTH, alk phos, bone scan.
Mx - fluids, bisphophonates (pamidronate infusion - inhibit osteoclasts).
Hypocalcaemia - Sy, cause, Mx
Sy - spasms, anxious, increased muscle tone, confusion, dermatitis, Chvostek (tap on face) and Troussea’s (BP swan), long QT.
Cause - CKD, hypoparathyroidism, vit D def, osteomalacia, pancreatitis.
Mx - Ca (sup/alfacalcidol-vit D analogue), if severe give calcium gluconate IV. Always check magnesium as will be unable to increase if is low (needed for PTH).
Hypoparathyroidism - cause, Sy
Cause - Primary - gland failure, seen in Di George. Mx - Ca supplements and calcitriol (vit D - increases Ca/phos absorption and deposition in bones).
Secondary - Most common, radiation, surgery, hypomagnesaemia (required for PTH secretion).
Pseudo/pseudopseudo - genetic failure of target cells to respond to PTH, short 4/5 metacarpals.
Sy - hypercalcaemia.
Hyperaldosteronism - Sy, cause, Ix, Mx
Sy - Asy or si of HTN and hypokalaemia - weakness, cramps, parasthesiae, polyuria.
Cause - Primary - Conn’s syndrome (adrenal adenoma), bilat hyperplasia. Secondary - high renin from renal stenosis. Bartter’s syndome - AR salt wasting.
Ix - U&Es (low K), renin, aldosterone.CT/MRI adrenals.
Mx - Spironolactone, lap adrenalectomy.
Phaeochromocytoma - Path, Sy, Ix, Mx
Path - rare catecholamine-producing tumour from chromaffin cells.
Sy - episodic headache, sweating, tachycardia, HTN.
Ix - 24hr urinary metadrenaline. Abdo CT/MRI.
Mx - alpha-blocker (phenobenzamine) +- b-blocker. MIBG scan.
Thyroid nodules - Path, Ix, Sy, Mx
Path - vast majority benign. Multinodular goitre most common cause. Single nodule may be - cyst, adenoma, malignant (papillary most common, follicular in older, anaplastic elderly), first in MNG.
Ix - TFTs, Abs, USS, FNA.
Sy - usually asy. May be sensation of lump in neck, hypo/hyper sy.
Mx - Surgery if malignant (thyroidectomy followed by node excision, radioiodine), also if sy and benign.
Hypopituitarism - Pituitary’s job, cause, Sy, Ix, Mx
Ant pit secretes GH, FSH/LH, prolactin, TSH, ACTH.
Cause at 3 levels - Hypothalamus - Kallman’s sy (delayed puberty, anosmia, colourblind), tumour, infection. Pit stalk - trauma, mass, aneurysm, meningioma. Pituitary - Tumour, Sheehan’s syndrome (PPH necrosis).
Sy - LOTS, depends on def! Low GH - obesity, dry wrinkly skin, poor strength/balance, poor exercise ability, osteoporosis. Gonadotropin lack - amenorrhoea, loss of fertility and libido, ED. Also hypothyroidism, adrenal insufficiency, absent lactation.
Ix - Basal tests - LH?FSH, TFTs, IGF-1, U&Es. Also synacthen and insulin tolerance test to assess adrenal and GH axis. MRI pit.
Mx - Treat cause, replace hormones.
Pituitary tumours - Path, Sy, Ix, Mx, Pituitary apoplexy
Path - Usually benign adenomas. Micro <1cm, macro>1cm. Prolactinoma most common, then non-secretory, and GH.
Sy - Local pressure - headache, visual field defects, CN palsy, diabetes insipidus, hormonal effects.
Ix - MRI head. Relevant hormone tests.
Mx - start hormone replacement therapy if needed, prolactinoma dopa antag is first line cabergoline/ocretide. Trans-sphenoidal resection or radiotherapy.
Pituitary apoplexy - acute enlargement of pit due to bleed into tumour causing mass effect and CVS collapse due to hypopituitarism.
Acromegaly - Path, Sy, Si, Complications, Ix, Mx
Path - Pituitary adenoma secreting GH. Rarerly carcinoid.
Sy - Acroparasthesia, amenorrhoea, reduced libido, headaches, sweating, snoring, arthralgia, backache, rings/shoes dont fit, wonky bite.
Si - Large hands’jaw/feet/tongue, coarse facial features, wide nose, puffy eyes/lips, acanthosis nigricans, sleep apneoa, prox weakness, carpal tunnel.
Complications, DM, HTN, LV hypertrophy/arrhythmias, colon ca.
Ix - OGTT then check GH. High in pregnancy, stress, sleep.
Mx - Trans-sphenoidal resection or radiotherapy if unsuitable, somatostatin anologues (octreotide) if surgery fails.
Diabetes insipidus - Def, sy, Ix
Def - Passage of large vol of water due to reduced ADH secretion (cranial) or lack of response (nephrogenic). Cause - idiopathic, congenital, trauma, lithium.
Sy - Polyuria, polydipsia, dehydration, hypernatraemia.
Ix - Serum (2xNa+urea+glucose) and urine osmolarities, urine should be low despite high plasma. DDX - primary polydipsia - water deprivation test 8hrs, stop if loose >3% weight and plasma osmolarity high, then give desmopressin to DDX cranial/nephrogenic. MRI head.
Mx - IV fluids to normalise Na, desmopressin.
Hypogonadism - Def, Sy, primary vs secondary, Mx
Def - Failure or testes/ovaries to produce sex steroids.
Sy - small testes, decreased libido, ED, loss of pubic hair, gynaecomastia, low mood, if prepubertal no virilization.
Primary/hypergonadotophic - testicular failure due to local trauma, mumps, RF/LF/ETOH excess (toxic), chromosomal abnormalities (Klinefelter’s)
Secondary/hypogonadotrophic - decreased LH/FSH - hypopituitarism, prolactinoma, Kallman’s sy (anosmia, colourblind), systemic illness, Prader-Willi.
Mx - dermal testosterone gel. Treat cause.
