Endo Flashcards
why is pH normal in HHS but not in DKA
there is relatively normal insulin in HHS, so this prevents lypolysis and hence ketongenesis
Because pH remains normal, it may go unoticed until glucose levels severely high
Most common cause of hypothyroidism in developed world
Hashimoto’s
10 X most common in women
Anti TPO and anti Thyroglobulin antibodies
Associated with other autoimmune and also development of MALT lymphoma
Most common autoantibodies in Graves’
TSH receptor stimulating antibodies
Examination in thyroid disease
Head to toe
Weight
Hands - sweaty, dry, tremor, Thyroid acropachy
Pulse - tachy etc
Brain - mood, energy, sleep
Hair loss
Eyes - pain, change in vision, double vision
Mouth - smoking!
Neck - lumps, pain (thyroiditis), bruie
Chest - palpitations
Pelvis - change in bowels , periods, pregnancy
Legs - proximal myopathy, pretibial myxoedema
Previous Meds
Contraindications of radioiodine therapy
- Pregnancy (incl 4-6months after radioio treatment)
- Age <16yr
- Thyroid eye disease may get worse so relative contraindication
supplements that might affect thyroid
iodine containing products…seaweed!
Thyrotoxicosis in pregnancy…management
- propylthiouracil in first trim
- then carbimazole
• If painful goitre, raised ESR could be subacute so NSAIDs only
Common consequences of acromegaly
- T2DM
- Hypertension
- Cardiovascular disease - ischaemic and LVH, doesn’t improve after treatment
- Bitemporal hemianopia
- 33% have sleep apnoea, but tends to improve after treatment
- 30% have premalig colononic polyps, and 5% develop cancer
colonoscopic screening, starting at the age of 40 years
Severe thyroid eye disease management
Refer
High dose methylpred (60mg) or IV
Can use selenium for mild moderate disease
Topical lubricants
Can consider immunomodulators or radiotherapy or surgery
When you consider Crit Care in DKA
GCS <12
SpO2 <92
K < 2.5
Confirmation of DKA
Glucose >11
pH <7.3 and/or bicarb <15
Blood ketones >3 or urine present
Main side effect of carbimazole
Risk of agranulocytosis
Also advised to use Propylthiouracil if trying for baby/first trimester
Treatment timeline with hyperthyroidism
Offer Medical, radioiodine, or surgery - patient preference
Carbimazole for 18-24 months
Trial stopping
30% that’s it forever
Toxic multinodular goitre radioiodine works really well if first place though
Management of acute thyrotoxicosis
- IV Propranolol
- Propylthiouracil
- Potassium iodide (Lugol’s iodine)
- Dexamethasone (blocks T4 to T3 conversion)
Pseudohypoparathyroidism
PTH receptor malfunction
So low Ca and high Phos, but PTH is appropriately high (due to the low level of calcium in the blood)
Shortening of fourth and/or fifth metacarpal
Albright’s hereditary osteodystrophy
pseudohypopara
-hypocalcaemia and elevated PTH levels -
Antibodies in Addison’s
adrenal antibodies
Most common associated autoimmune conditions in Addison’s
Vitiligo
Risks of hyperthyroidism
- Arrhythmias and osteoporosis
- Higher all cause mortality
- Worse outcomes in preg
meta-analysis found subclinical hyperthy was associated with a 24% increased risk of all-cause mortality and 29% increased risk of coronary heart disease mortality (!)
what are the investigations to confirm Cushing’s
Midnight Cortisol Dexamethasone suppression test 24h urinary cortisol Salivary cortisol Inferior petrosal sinus sampling to determine if there is a pituitary source MRI or CT
Management of prolactinoma
Cabergoline, very effective, unlikely to need surgery
Management for acromegaly
Treat with Somatostatin Analogues (Octreotide) then transphenoidal surgery
+/- radiotherapy
Multiple endocrine neoplasia 1
3 Ps
• Parathyroid (95%)
• Pituitary (70%)
• Pancreas (50%) insulinoma, gastrinoma (causing Zollinger-Ellison syndrome: epigastric pain and diarrhoea)
.. hypercalcaemia
Patient presenting with lactating, amenorrhoea, previous surgery for “high calcium”
Previous hyperparathyroidism
? MEN 1
Endo causes of hypertension
- Primary aldosteronism (High Na, Low K, alkalosis, tetany, muscle weakness, nocturia, or polyuria) …elevated aldosterone/renin ratios
- Phaechromocytoma (rare but important; 10% are malig)
- Cushing’s syndrome
- Acromegaly
- Obesity
- OSA
- Hypo/Hyperthyroidism
- Primary hyperparathyroidism
How do you test / manage primary hyperaldosteronism
- elevated aldosterone/renin ratios
- Stop ACEi, beta blocker, CCB
- Fludrocortisone suppression test measuring aldosterone
- Or salt loading test
- Lifelong mineralocorticoid receptor antagonists (Spiro) for bilat
- Adrenalectomy for uni
Diagnosis of Acromegaly
- Raised IGF-1
- Non‐suppression of GH after an oral glucose tolerance test
- CT/MRI pituitary fossa: pituitary adenoma
- and test other pituitary function
Diabetes Management
• Metformin
• Add SGLT2 inhib (gliflozin) if CVD IHD or QRISK >10%
•
Management of osteoporosis
High risk:
• All women > 65y, and all men > 75y
• > 50y with fragility #, risk factors, history of falls
Get DXA scan if :
• 10-year fracture risk of > 10% (FRAX score)
• >50y and fragility #
• <40 with major risk factor
If T-score is lower than -2.5 • Exercise • Bisphosphonates • Calcium / Vit D • Consider HRT
SE of bisphosphonates
- GI disturbance
- bone/joint pain
Rarely:
• Osteonecrosis of the jaw - jaw pain, swelling, and redness
====> So get dental check up first!
• Atypical stress fractures = new onset hip, groin, or thigh pain
Causes of thyrotoxicosis
• Graves’ disease (most common)
- Toxic multinodular goitre (non-tender thyroid nodules, usually older presentation)
- De quervain’s thyroiditis (painful, post viral)
- Amiodarone-induced thyroiditis
- Subacute thyroiditis (painless, e.g. post partum)
• Hashimoto’s (can be hyper in early stages)
Presentation of toxic multinodulr goitre
- non-tender
- thyroid nodules
- usually older presentation than graves’
- (second most common hyperthy after Graves’)
How to get an insulin pump?
• Buy one (£2000-3000, lasts 4-8 years)
NICE recommends if:
• You can’t get to target HbA1c without severe hypos
• HbA1c >69 despite multiple injections
Your consultant might recommend if you’re:
• regularly injecting insulin
• checking your blood glucose at least 4 times a day
• carb counting
needle phobic diabetic?
- MDT approach to assess
- Might be options with fewer injections a day (mixed /biphasic regimens)
- Can offer therapy e.g. CBT
- needle-free insulin devices using high-pressure
different hyperparathyroidisms
• Primary hyperpara
- high or normal PTH
- high Ca
- (usually low Phos)
• Secondary hyperpara
- low Ca
- high PTH
- (usually high Phos)
• Tertiary hyperpara (hx of CKD and 2nd hyperpara)
- high PTH
- high Ca
- (usually high Phos)
