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Finals > Diabetes/endocrine > Flashcards

Diabetes/endocrine Flashcards

1
Q

What is the definition of diabetic ketoacidosis?

A

Uncontrolled lipolysis resulting in free fatty acids which are converted to ketone bodies

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2
Q

What are the features of DKA?

A

*Abdominal pain
*Polyuria, polydipsia, dehydration (leading to hypotension)
*Kussmaul respiration
*Acetone smelling breath
*Increased glucose
*pH<7.3
*Low bicarbonate
*Ketones >3mmol/l

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3
Q

What is the management of DKA?

A

*Isotonic saline fluid replacement
*IV insulin: 0.1 unit per kg/hour
*5% dextrose once glucose <15mmol/l
*Correct electrolytes
*Stop short acting insulin and continue long acting

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4
Q

What are the complications of DKA?

A

*Arrhythmia due to hyperkalaemia
*AKI
*Thromboembolism
*Acute respiratory distress syndrome
* Due to fluid: cerebral oedema, hypokalaemia, hypocalcaemia

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5
Q

What is hyperosmolar hyperglycaemic state?

A

Hyperglycaemia results in osmotic diuresis with loss of Na+ and K+ . Severe volume depletion leads to raised serum osmolarity and hyperviscosity of the blood

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6
Q

What are the features of HHS?

A

*Fatigue
*Lethargy
*Nausea
*Vomiting
*Altered consciousness, headaches, papilloedema, weakness
*Hyperviscosity can cause MI or stroke
*Dehydration, hypotension
*Tachycardia

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7
Q

Explain the diagnosis of HHS?

A

*Hypovolaemia
*Marked hyperglycaemia >30mm/L without significant ketonaemia or acidosis
*Raised serum osmolarity

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8
Q

What is the management of HHS?

A

*IV saline
*Montior the serum osmolality
*Replace electrolyte loss
*Normalise blood glucose - if significant ketonaemia is not present then don’t start insulin

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9
Q

What are the causes of hypoglycaemia?

A

*Insulinoma
*Self administration of insulin or sulphonylureas
*Liver failure
*Addison’s disease
*Alcohol

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10
Q

What are the features of hypoglycaemia (<3.3mmol/l)

A

*Sweating
*Shaking
*Hunger
*Anxiety
*Nausea

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11
Q

What are the features of hypoglycaemia (<2.8mmol/l)

A

*Neuroglycopenic symptoms
*Weakness
*Vision changes
*Confusion
*Dizziness

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12
Q

What are the features of severe hypoglycaemia?

A

Convulsion and coma

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13
Q

What is the management of hypoglycaemia?

A

*Oral glucose 10-20g
*Subcutaneous or IM glucagon
*IV 20% glucose solution

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14
Q

What are the symptoms of type 1 diabetes?

A

*Polyuria
*Polydipsia
*Weight loss mainly due to dehydration

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15
Q

What investigations should you carry out in suspected type 1 diabetes mellitus?

A

*Urine dip
*Fasting and random glucose
*C-peptide (typically low)
*Auto antiboides: anti-GAD, Islet cell Ab, Insulin Autoantibodies (IAA)
*TFTs and TPO to test for associated autoimmune thyroid disease/ anti TTG for coeliac
*HBA1C

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16
Q

What is the diagnostic criteria for diabetes?

A

*Fasting glucose of ≥7.0mmol/l
*Random glucose of ≥11.1 mmol/l
*If they are asymptomatic, this must be diagnosed on two separate occasions

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17
Q

What is the management of type 1 diabetes mellitus?

A

*HBA1c every 3-6 months, target <48
*Self monitoring 4 times a day before each meal and bed (more if ill or pregnant)
*5-7mmol/l on waking
*4-7mmol/l other times of day
*Lantus (long acting) in the evening, short acting 3 times a day (actrapid)

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18
Q

What are the risk factors for type 2 diabetes?

A

*Older age
*Ethnicity
*Family history
*Obesity
*Sedentary lifestyle
*High carbohydrate diet

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19
Q

What is the presentation of type 2 diabetes mellitus?

A

*Fatigue
*Polyuria and polydipsia
*Opportunistic infection
*Slow healing
*Unintentional weight loss

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20
Q

What is the HBA1C criteria for pre-diabetes?

A

42-47

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21
Q

What are the first line medications for type 2 diabetes?

A

*Metformin
*Sulphonylurea is osmotic symptoms or intolerance of metformin

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22
Q

What are the second line medications for type 2 diabetes?

A

Add one of:
*Sulphonylurea: gliclazide
*Proglitazone: thiazolidiones
*DDP-4: sitagliptin
*SGLT-2i: empagliflozin

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23
Q

What are the macrovascular complications of diabetes?

A

*Coronary artery disease
*Peripheral ischaemia -> poor healing, ulcers, diabetic foot
*Stroke
*hypertension

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24
Q

What are the microvascular complications of diabetes?

A

*Peripheral neuropathy
*Retinopathy
*Kidney disease, particularly glomerulosclerosis

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25
Q

What are the infection related complications of diabetes?

A

*UTI
*pneumonia
*Skin and soft tissue infection
*Fungal infection, particularly oral and vaginal thrush

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26
Q

What is the presentation of hypothyroidism?

A

*Weight gain
*Cold intolerance
*Fatigue
*Dry skin and coarse hair and hair loss
*Fluid retention (oedema, pleural effusion, ascites)
*Heavy or irregular periods
*Constipation
*Cold intolerance

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27
Q

What investigations should you carry out in suspected hypothyroidism?

A

*TSH, T3 and T4 levels (high TSH in primary, low in secondary)
*Antithyroid peroxidase (anti TPO)Ab, antithyroglobulin Ab (hashimoto’s)
*Iodine

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28
Q

What are the causes of hypothyroidism?

A

*Hashimoto’s
*iodine deficiency
*Secondary to hyperthyroid treatment
*Lithium
*Hypopituitarism
*Amiodarone

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29
Q

What is hashimoto’s associated with?

A

Addisons and pernicious anaemia

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30
Q

What is the management of hypothyroidism?

A

Levothyroxine (synthetic T4), monitor the TSH, if high then increase the dose, if low then decrease

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31
Q

What are the features of hyperthyroidism?

A

*Anxiety
*Sweating
*Heat intolerance
*Tachycardia
*Weight loss
*Fatigue
*Loose stool
*Sexual dysfunction

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32
Q

What are the features unique to Grave’s disease?

A

*Diffuse goitre with no nodules
*Grave’s eye disease
*Bilateral exopthalmos
*Pretibial myxoedema

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33
Q

What are the causes of hyperthyroidism?

A

*Grave’s
*Toxic multinodular goitre
*Solitary toxic thyroid nodule -normally benign adenoma
*Thyroiditis (hashimoto’s, post partum)

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34
Q

What investigations should be carried out in suspected hyperthyroidism?

A

*TSH, T3, T4
*TSH receptor antibodies, TPO Ab
*If negative then 123I uptake scan

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35
Q

What is the management of hyperthyroidism?

A

*Carbimazole - 18mnths
*Propylthiouracil - 2nd line
*Radioactive iodine - must not be pregnant (or get pregnant within 6 months, avoid contact with kids and pregnant women for 3 weeks and limit contact with anyone for several days)
*Propranolol - blocks adrenaline related symptoms
*Surgery - removal of the whole thyroid or toxic nodules

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36
Q

What is thyroid storm?

A

*Pyrexia
*Tachycardia
*Delirium
*Requires admission for monitoring
*Treatment is the same as thyrotoxicosis, may also need fluid resuscitation, arrhythmic and beta blockers
•Happens in hyperthyroid

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37
Q

What is de Quervain’s?

A

*viral infection, fever, neck pain and tenderness, dysphagia, hyperthyroid symptoms
*Hyperthyroid phase followed by hypothyroid phase

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38
Q

What is the management of de Quervain’s?

A

*NSAIDs
*Beta blockers
*Self limiting

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39
Q

What is type 1 amiodarone thyrotoxicosis?

A

Autoimmune, treat with carbimazole

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40
Q

What is type 2 amiodarone thyrotoxicosis?

A

Destructive, treat with steroids

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41
Q

What is the presentation of addisons

A

*Lethargy
*Weakness
*Anorexia
*Nausea and vomiting
*Weight loss
*Salt craving
*Bronze hyper-pigmentation
*Vitiligo
*Loss of pubic hair in women
*Hypotension

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42
Q

What are the biochemical findings in someone with addisons?

A

*Hypoglycaemia
*Hyponatraemia
*Hyperkalaemia

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43
Q

What is addisonian crisis?

A

Collapse, shock and pyrexia

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44
Q

What is addisons?

A

Primary adrenal insufficiency, most commonly autoimmune resulting in reduced cortisol and aldosterone

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45
Q

What investigations should be carried out in suspected addison’s?

A

*Electrolytes
*Short synacthen test
*ACTH: high in primary, low in seocndary
*Adrenal autoantibodies
*CT/MRI adrenals if suspected tumour or haemorrhage
*MRI pituitary gland

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46
Q

What is the managment of an addisonian crisis?

A

*Montioring stats, electrolytes, and fluid balance
*Parenteral steroids - hydrocortisone
*IV fluid resuscitation - 1L saline over 30-60 mins
*correct hypoglycaemia

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47
Q

What is hypopituitarism?

A

Deficiency of one or more of pituitary hormones: ACTH, FSH/LH, TSH, GH, prolactin

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48
Q

What are the causes of hypopituitarism?

A

*Compression via non secretory pathway macroadenoma (also bitemporal hemianopia as a symptom)
*Pituitary apoplexy (accompanied by a sudden severe headache)
*Sheehan’s syndrome: postpartum pituitary necrosis
*Hypothalamic tumours
*Iatrogenic irradiation
*Infiltrative e.g. haemochromatosis
*Trauma

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49
Q

Low ACTH

A

*Tired
*Postural hypotension

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50
Q

Low FSH/LH

A

*Ammenorrhoea
*Infertility
*Loss of libido

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51
Q

Low TSH

A

*Feeling cold
*Constipation

52
Q

Low GH

A

If during childhood then short stature

53
Q

Low prolactin

A

Problems with lactation

54
Q

What are the investigations for hypopituitarism?

A

Hormone profile testing and imaging

55
Q

What are the features of hypokalaemia?

A

*Muscle weakness
*Hypotonia
*ECG changes: U waves, small/absent T waves , prolonged PR interval, ST depression

56
Q

Give two differentials for hypokalaemia with hypertension

A

*Cushing’s
*Conns

57
Q

Give 2 differentials for hypokalaemia without hypertension

A

*Diuretics
*GI loss
*Renal tubular acidosis

58
Q

What are the features of hyperkalaemia?

A

*Abdominal/chest pain
*Nausea
*Palpitations
*ECG changes: tall tented T waves, small p waves, widened QRS -> asystole

59
Q

What are the causes of hyperkalaemia?

A

*AKI
*Drugs: ACEi, ARBs, K+ sparing diuretics, ciclosporin, heparin
*Metabolic acidosis
*Addison’s
*Rhabdomyolysis
*Massive blood transfusion

60
Q

What is the management of hyperkalaemia?

A

*≤6 and stable renal function: change diet and medicaitons
*≥6 + ECG changes: insulin and dextrose infusion and IV calcium gluconate
*≥6.5: urgent treatment regardless of ECG
*Dialysis in severe cases

61
Q

What are the features of hyponatraemia?

A

*Nausea
*Vomiting
*Headache
*Confusion
*Muscle weakness
*Cramps

62
Q

What is pseudohyponatraemia?

A

*Sodium appears falsely low due to hyperlipidaemia, hyperglycaemia or hyperproteinaemia
*Consdier if the serum osmolality is normal or high
*Check (2 x Na) + urea + glucose

63
Q

How should you assess someone with hyponatraemia?

A

*Check the urinary sodium: is it </> 20mmol/l
*Assess the fluid status: hypovolaemic, euvolaemic or hypervolaemic

64
Q

What are the causes of hyponatraemia in someone with a urinary sodium of >20mmol/l and who is hypovolaemic?

A

Sodium depletion due to renal loss:
*Diuretics
*Addison’s
*Diuretic stage of renal failure

65
Q

What are the causes of hyponatraemia in someone with a urinary sodium of >20mmol/l and who is euvolaemic?

A

*Hypothyroidism
*Syndrome of inappropriate anti-diuretic hormone (SIADH) - urine osmolality >500

66
Q

What are the causes of hyponatraemia in someone with a urinary sodium of <20mmol/l and who is hypovolaemic/euvolaemic

A

Sodium depletion due to extra-renal loss
*Diarrhoea/vomiting
*Burns
*Sweating

67
Q

What are the causes of hyponatraemia in someone with a urinary sodium of <20mmol/l and who is hypervolaemic?

A

Water excess:
*Hyperaldosteronism
*Nephrotic syndrome
*IV dextrose

68
Q

How should you assess someone’s volume status?

A

*JVP
*Pulse
*BP
*urine output
*Oedema
*Ascites

69
Q

What are the causes of SIADH?

A

*Pulmonary infection
*Carcinoma
*AIDS
*Vomiting
*Post op pain/stress
*Amitryptiline, fluoxetine

70
Q

What is the management of hypovolaemic hyponatraemia? (not underlying cause)

A

Isotonic saline

71
Q

What is the management of euvolaemic hyponatraemia?

A

Free water restriction: 1L per 24 hours

72
Q

What is the management of hypervolaemic hyponatraemia?

A

Salt and fluid restriction ± loop diuretics

73
Q

How should you increase sodium in someone who has hyponatraemia?

A

Increase gradually, no more than 1mmol/l/hr and less than 12mmol/l/day

74
Q

What are the causes of hypernatraemia?

A

*Dehydration
*Osmotic diuresis
*Diabetes insipidus
*Excess IV saline

75
Q

What are the features of hypercalcaemia?

A
  • Painful bones due to increased PTH
  • Renal stones
  • Abdominal groans: hypercalcaemia induced ileus
  • Corneal calcification
  • Shortened QT interval
  • Hypertension
  • Lethargy/depression
  • Thirst, polyuria
76
Q

What are the causes of hypercalcaemia?

A
  • Primary hyperparathyroidism
  • malignancy PTHrP from tumour or bone mets or myeloma
  • Vitamin D intoxication
  • Thiazides
  • Thyrotoxicosis/addisons
77
Q

Investigations for hypercalcaemia

A
  • bone profile
  • PTH
  • UEs
  • ECG
78
Q

What is the management of hypercalceamia?

A
  • rehydration IV 0.9% saline 4-6litres over 24 hours
  • IV bisphosphonates
79
Q

What are the features of hypo calcaemia?

A
  • tetany: muscle twitch, cramps and spasm
  • perioral paraethesia
  • if chronic: depression and cataracts
  • ECG: prolonged QT interval
  • Trousseaus’ sign: occluded brachial artery leads to carpal spasm
  • Chvostek’s sign: tapping over the parotid causes the facial muscles to twitch
80
Q

What are the causes of hypocalcaemia?

A
  • Vitamin D deficiency
  • Chronic kidney disease
  • hypoparathyroidism
  • rhabdomyolysis
  • magnesium deficiency
  • acute pancreatitis
81
Q

What is the management of hypocalcaemia?

A
  • IV calcium gluconate if severe
  • treat the underlying cause
82
Q

What is gestational diabetes?

A

Hyperglycaemia in pregnancy below the diagnostic threshold for diabetes

83
Q

What is the presentation of gestational diabetes?

A
  • polyuria
  • polydipsia
  • fetal macrosomia in a previous pregnancy (>4.5kg)
84
Q

What are the investigations for gestational diabetes?

A

Oral glucose tolerance test
- fasting glucose between 5.6 and 7
- 2 hour plasma gluocse above 7.8

85
Q

What causes secondary diabetes?

A
  • Cystic fibrosis
  • pancreatitis
  • haemochromatosis
  • chronic pancreatitis
  • PCOS
  • Cushing’s
  • pancreatic cancer
86
Q

What is a thyroid goitre?

A

Lump in the neck caused by a swelling of the thyroid

87
Q

What are the types of goitre?

A
  • diffuse: whole thyroid enlarged
  • Uninodular goitre: single thyroid nodule (may be toxic or inactive)
  • Multinodular goitre: toxic multinodular goitre
88
Q

What type of goitre: Hashimoto’s

A

Diffuse, non-tender, firm

89
Q

What are the types of thyroid carcinoma?

A
  • Papillary
  • Follicular
  • Medullary
  • Anaplastic
  • Lymphoma
90
Q

Which of the thyroid carcinoma are most common?

91
Q

What is the presentation of thyroid carcinoma?

A
  • Asymptomatic
  • thyroid nodule
  • hoarseness (compression of the recurrent laryngeal)
  • dyspnoea
  • dysphagia
  • tracheal deviation
92
Q

What is the investigation for thyroid carcinoma?

A

Fine needle aspiration

93
Q

What is the effect of PTH?

A
  • Increases activity of the osteoclasts so more calcium is reabsorbed
  • Increases calcium absorption from the gut and the kidneys
  • increased vitamin D activity
  • All of these work to increase serum calcium
94
Q

Cause of primary hyperparathyroidism

95
Q

Cause of secondary hyperparathyroidism

A

Low vitamin D/ Chronic kidney disease

96
Q

Cause of tertiary hyperparathyroidism

A

Hyperplasia

97
Q

Calcium level in primary hyperparathyroidism

98
Q

Calcium level in secondary hyperparathyroidism

A

low/normal

99
Q

Calcium level in tertiary hyperparathyroidism

100
Q

What is Cushing’s syndrome?

A

Hypercortisolism from any cause (exogenous is more common)

101
Q

What is Cushing’s disease?

A

ACTH secreting pituitary tumour

102
Q

What are the ACTH dependent causes of Cushings?

A
  • Cushing’s disease (pit adenoma)
  • Ectopic ACTH production
103
Q

What are the ACTH independent causes of Cushing’s?

A
  • steroids
  • adrenal adenoma/carcinoma
104
Q

What is the presentation of cushing’s syndrome?

A
  • weight gain and central obesity
  • hypertension
  • Glucose intolerance or diabetes
  • depression, anxiety
  • Decreased libido
  • proximal weakness easy bruising/striae
  • moon facies
  • dorsocervial fat pads
  • low bone density
105
Q

What is the investigation to see if someone has cushing’s syndrome?

A

Overnight dexamethasone suppression test: morning cortisol spike is not suppressed

106
Q

What is the investigation to work out the cause of a confirmed cushing’s syndrome?

A

High dose dexamethasone suppression test

107
Q

Explain the results of a high dose dexamethasone suppression test

A
  • Ectopic ACTH if neither cortisol or ACTH are suppressed
  • Cushing’s disease if ACTH and cortisol are suppressed
  • Other cause if ACTH is suppressed but cortisol is not
108
Q

What is acromegaly?

A

Excessive secretion of growth hormone usually due to pituitary adenoma

109
Q

What is the presentation of acromegaly

A
  • coarsening of facial features: enlarged nose, macroglossia, frontal bossing
  • increased skin thickness
  • soft tissue hypertrophy
  • skin tags
  • increased sweating
  • carpal tunnel
  • joint pain
  • snoring
110
Q

What are the investigations for acromegaly?

A
  • Serum IGF-1 levels
  • If raised, carry out an oral glucose tolerance test: inpatients with acromegaly there should be no suppression of growth hormone with hyperglycaemia
111
Q

What are the causes of hyperprolactinaemia?

A
  • Prolactinoma
  • Acromegaly
  • Pregnancy
  • Tumours
  • Kidney failure
  • Hypothyroidism
  • Drugs
112
Q

What is the presentation of hyperprolactinaemia?

A
  • Amenorrhoea or oligomenorrhoea
  • milk production (galactorrhoea)
  • Erectile dysfunction, gynaecomastia
  • Decreased libido
113
Q

What is the presentation of polycystic ovarian syndrome?

A
  • sub/infertility
  • oligomenorrhoea and amenorrhoea
  • hirsutism, acne
  • obesity
  • acanthosis nigricans (due to insulin resistance)
114
Q

Investigations for PCOS

A
  • serum LH, FSH, prolactin, TSH, testosteorne, SHBG
  • pelvic ultrasound
  • oral glucose tolerance test
  • fasting lipid panel
115
Q

What criteria is used to diagnose PCOS?

A

Rotterdam criteria

116
Q

Explain the rotterdam criteria

A

Need 2/3 to diagnose:
- infrequent or no ovulation
- clinical or biochemical signs of hyperandrogenism
- Polycystic ovaries on USS ≥12

117
Q

What are the causes of hypomagnesaemia?

A
  • drugs: diuretics and PPIs
  • TPN
  • Diarrhoea
  • Alcohol
  • Hypokalaemia
  • Hypercalcaemia (e.g. due to primary Hyperparathyroidism)
  • Metabolic disorders
118
Q

What is the presentation of hypomagnesaemia?

A
  • Paraesthesia
  • tetany
  • seizure
  • arrhythmia
  • ECG similar to hypokalaemia
119
Q

What is the presentation of hypermagnesaemia?

A
  • weakness
  • confusion
  • decreased breathing rate
  • decreased reflexes
120
Q

What are the causes of hypermagnesaemia?

A
  • Iatrogenic
  • Renal failure
  • Tumour lysis
121
Q

What are the causes of a respiratory acidosis?

A
  • Respiratory depression
  • Guillain Barre
  • Asthma
  • COPD
  • Excessive use of mechanical ventilation
122
Q

What are the causes of metabolic acidosis with a high anion gap?

A
  • diabetic ketoacidosis
  • lactic acidosis
  • aspirin overdose
  • renal failure
123
Q

What are the causes of metabolic acidosis with a normal anion gap?

A
  • GI loss (diarrhoea, ileostomy, proximal colostomy)
  • Renal tubular disease
  • Addison’s disease
124
Q

What are the causes of metabolic alkalosis?

A
  • GI loss of H+ (diarrhoea, vomiting)
  • Renal loss of H+ (loop and thiazide diuretics, heart failure, nephrotic syndrome, cirrhosis, conns)
  • iatrogenic (addition of excess alkali)
125
Q

What are the causes of respiratory alkalosis?

A
  • pain
  • anxiety
  • hypoxia
  • pulmonary embolism
  • pneumothorax
126
Q

What causes a mixed acidosis?

A
  • Cardiac arrest
  • multi organ failure
127
Q

What causes a mixed alkalosis?

A
  • Liver cirrhosis and diuretic use
  • hyperemesis gravidarum
  • excessive ventilation

Finals (37 decks)

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