Endo Flashcards
Causes of hyperthyroidism
Single toxic adenoma
Toxic multinodular goitre
Grave’s disease
Viral thyroiditis - thyrotoxicosis without hyperthyroidism
Secondary Hyperthyroidism
- Pituitary tumours
Presentation of hyperthyroidism
Eye disease
Palpitations (AF)
Hands
- Sweating
- Tremor
Bowels/metabolism
- Diarrhoea
- Weight loss + increased appetite
- Heat intolerance
Menstrual irregularities
Mx of hyperthyroidism
Medical
- Propranolol
- Carbimazole/PTU (either titrate to TSH, or block and replace)
Invasive
- Radioiodine (if hyperfunctioning nodule - not if eye disease in GD)
- Thyroidectomy (+ lifelong thyroid replacement)
Management of thyroid storm
Medical
- Propranolol + PTU + Hydrocortisone
Signs of hyperthyroidism
Graves
- Smooth goitre (not lumpy as a multinodular goitre would be)
- Pretibial myxoedema
- Eye disease (exophthalmos, diplopia, gritty eyes w/ increased tear production)
- Thyroid acropachy
General
- Lid lag
- Lid retraction
Causes of hypothyroidism
Autoimmune (Hashimoto’s)
Iodine deficiency
Viral thyroiditis
Post-thyroidectomy
Presentation of hypothyroidism
Fatigue Dry skin Constipation Menstrual irregularities Weight gain + reduced appetite
Mx of hypothyroidism
Medical
- Thyroid replacement (levothyroxine, titrate to TSH, or to T4 if secondary)
Mx of myxoedema coma
IV thyroxine IV hydrocortisone Fluids (with caution as possible cardiac dysfunction) Antibiotics if infection suspected Active warming if hypothermic
Differentials for thyroid lump
Thyroid adenoma (asymptomatic) Single toxic adenoma Toxic Multinodular goitre Thyroid malignancy Thyroid cyst
Investigation of thyroid lump
- TFTs
If TSH low: Indicates probably hyperfunctioning nodule
- Thyroid scintigraphy
If high uptake, hyperfunctioning nodule: Tx with
propranolol/carbimazole/Radioactive
iodine/thyroidectomy
If low uptake: do thyroid USS and FNA if
suspicious features present
If TSH high: do Thyroid USS
If suspicious features: do US-guided FNA
If no suspicious features: Monitor
Types of Thyroid malignancy
Hard irregular lump, normally non-functioning
Papillary (most common)
Medullary (associated with MEN2a - measure calcitonin)
Anaplastic
Follicular
MEN 1
Pituitary adenoma
Parathyroid hyperplasia
Pancreatic tumour
MEN 2
Medullary thyroid carcinoma
Phaeochromocytoma
Parathyroid hyperplasia
+ for MEN2b:
Mucosal neuromas
Marfanoid body habitus
Cushing’s syndrome presentation
- Centripetal Obesity
- Proximal myopathy
- Hypertension
Cosmetic
- Moon face
- Thin skin
- Purple abdominal striae
- Buffalo hump
PCOS-like
- Amenorrhoea
- Acne
- Hirsutism
Cushing’s causes
ACTH-dependent
Pituitary tumour secreting ACTH (Cushing’s disease)
Ectopic ACTH
ACTH-independent
Adrenal adenoma
Steroid excess
Secondary causes of hypertension
Renal
- RAS
- PKD
Endocrine
- Acromegaly
- Cushing’s
- Hyperaldosteronism
- Phaeo
Cushing’s Ix
Bloods
- HbA1c/BM
- U&E
Screening: 9am cortisol + Low dose dexamethasone suppression test
Inferior petrosal sinus sampling
Pituitary MRI
Cushing’s Tx
Cushing’s disease
- Medical therapy (ketoconazole, metyrapone)
- Transphenoidal hypophysectomy (1st-line)
Ectopic ACTH
- Tumour resection +/- chemotherapy/radiotherapy
Adrenal adenoma
- Adrenalectomy + lifelong steroid replacement
Acromegaly Presentation
Compressive effects
Headaches
Disconnection hyperprolactinaemia
Bitemporal hemianopia
Hormonal effects
Enlargement of hands and feet
Coarse facial features (prognathism, supraorbital ridging)
Carpal tunnel syndrome
Acromegaly Ix
Serum IGF-1
OGTT
Pituitary screen
MRI
Acromegaly Mx
Medical
Somatostatin analogues e.g, octreotide
Dopamine agonists e.g. cabergoline
Surgery (first-line)
Pituitary surgery
Radiotherapy
Addison’s causes
Primary adrenal insufficiency Autoimmune (most common UK) Adrenal malignancy Adrenal haemorrhage TB (most common worldwide)
Secondary adrenal insufficiency
Pituitary tumours
Pituitary surgery
Hypopituitarism
Anterior pituitary hormones and pathologies
GH: Acromegaly TSH: Hyperthyroidism LH/FSH: Prolactin: Hyperprolactinaemia ACTH: Cushing's
Addison’s presentation
Every non-specific symptom under the sun:
Postural hypotension Abdominal pain Weight loss (best way to monitor) Dizziness Lethargy Weakness Anorexia
Addison’s Ix
FBC
U&E
9am cortisol + Short Synacthen test
Addison’s + Addisonian crisis Mx
Addison’s
Hydrocortisone + Fludrocortisone replacement
(replicate diurnal variation, + sick day rules)
Addisonian crisis
IV 100mg hydrocortisone STAT + Saline 500ml bolus + Hydrocortisone infusion
Treat underlying cause
Phaeochromocytoma Presentation, Ix and Mx
PC: Episodic headaches, flushing, palpitations, dizziness
Ix: FBC, U&E, serum and urine metanephrines
Mx: Alpha blockade (phentolamine/phenoxybenzamine) + Beta blockade (for reflex tachycardia) + Surgery (open or laparoscopic adrenalectomy)
Carcinoid syndrome Presentation, Ix and Mx
Causes of gynaecomastia
Physiological
- elderly
- Puberty
Endocrine (more oestrogen or less testosterone)
- Pituitary tumours e.g. prolactinoma
- Adrenal tumours
- Testicular tumours
- Androgen insensitivity
Drugs
- Spironolactone
- Ketoconazole
- Digoxin
Hyperprolactinaemia causes
Prolactinoma
Pituitary stalk compression (disconnection hyperprolactinaemia)
Drugs (antipsychotics)
Hyperprolactinaemia presentation
Headache
Visual disturbance
Gynaecomastia
Galactorrhoea
Decreased libido
Sexual dysfunction (oligomenorrhoea, erectile dysfunction) - inhibits GnRH
Polyuria/Polydipsia differentials
Diabetes mellitus
Diabetes insipidus
Psychogenic polydipsia
Hypercalcaemia
Hyperparathyroidism causes
Primary:
- Parathyroid hyperplasia
- Parathyroid adenoma (most common)
Secondary:
- Hypocalcaemia (Vit. D deficiency, CKD)
Tertiary
CKD
How is calcium homeostasis mediated
PTH causes: Calcium release from bones, increased intestinal calcium absorption and intestinal phosphate excretion, increased Vit. D activation
Activated Vit. D causes: Increased calcium and phosphate reabsorption
Polyuria/Polydipsia Ix
Urine dip
HbA1c
Serum/urine osmolality
Calcium + U&Es
Water deprivation test
MRI (if cranial DI suggested)
Mx of Diabetes Insipidus
Cranial: Give intranasal desmopressin
Nephrogenic: Thiazide diuretics
Hypercalcaemia Ix
- PTH
If normal or high: Suspect Primary hyperparathyroidism
If low: Likely to be hypercalcaemia of malignancy
- Liberation of calcium from bone in bony metastases
- PTHrp release
Hypercalcaemia Mx
Loads of fluids (0.9% normal saline)
Bisphosphonates (if hypercalcaemia of malignancy)
Hyponatraemia causes
Hypovolaemic
- Diarrhoea
- Vomiting
- Diuretics (w/ raised urinary Na (>20)
Euvolaemic
- SIADH
- Hypothyroidism
- Addison’s
Hypervolaemic
- Cirrhosis/hypoalbuminaemia
- HF
- Nephrotic syndrome
-
Assessment of hyponatraemia
- Assess fluid status, review drug chart
- If not hypo or hypervolaemic, rule out thyroid disease and Addison’s
- If TFTs and synacthen test -ve, can make diagnosis of exclusion SIADH
Mx of hyponatraemia
Hypervolaemic/euvolaemic: fluid restrict + treat underlying cause
Hypovolaemic: Fluid resuscitation
Causes of SIADH
CNS pathology: Trauma, SOL, stroke
Lung pathology: malignancy, pneumonia
Drugs: SSRIs, Carbamazepine
Surgery
Mx of SIADH
Fluid restriction
Demeclocycline (induces nephrogenic DI)
Vaptans (V2 receptor antagonists)
Pseudocushing’s causes
Depression
Obesity
Alcohol excess
Hyperaldosteronism causes
Primary hyperaldosteronism
- Bilateral adrenal hyperplasia (most common)
- Adrenal adenoma
Secondary hyperaldosteronism ( low aldosterone:renin ratio) - RAS
Hyponatraemia presentation
Confusion
Anorexia
Muscle weakness
Seizures
Nausea
Endo differentials for palpitations/tremor
Phaeo
Hyperthyroidism
Anxiety
Presentation of thyroid storm
Fever
Tachycardia (possibly with AF)
Agitation/confusion
Diarrhoea, N+V, jaundice, abdo pain
Ix for thyroid storm
Find underlying cause
- Bloods (TFTs, FBC, U&E, LFTs)
- ECG
- CXR
- ABG
Complications of acromegaly (CHOD)
Cardiomegaly
Hypertension/Hyperprolactinaemia
OSA
Depression
Presentation of myxoedema coma
Hypothermia Hypoglycaemia Hyporeflexia Bradycardia Seizures Coma
RFs for phaeo
MEN1
VHL
NF1
Indications for Tx of stage 1 HTN
DM Renal disease Target organ damage Established CVD QRISK >10%
Hyperaldosteronism Ix
Bloods (FBC, U&E, hormone profile inc. plasma aldosterone/renin ratio)
CT abdo
Adrenal venous sampling
Levels of hyperkalaemia
5.5-5.9 = mild
6-6.5 = moderate
>6.5 or symptomatic/ECG changes = severe
Urgent treatment required if severe
Hyperkalaemia ECG features
Flattening of P waves
PR prolongation
Wide QRS
Tented T waves
Hyperkalaemia Mx
Stop offending medications
If <6.5 and asymptomatic, cardiac monitoring and repeat bloods
10mls 10% Ca gluconate
10U actrapid in 100mls 20% dextrose
Salbutamol NEB
Haemodialysis
Paget’s disease of the bone - What is it?
what areas of the skeleton are most often affected
Disorder of increased, aberrant bone turnover
Skull, Spine, long bones of extremities
Classical presentation of Paget’s
Older man with bone pain
Bowing of tibia, skull bossing (in untreated disease)
Paget’s Ix
Isolated raised ALP (normal Ca and phosphate)
XR: Osteolysis, progressing to mixed osteolytic/osteosclerotic lesions
Bone scintigraphy: Increased uptake
Paget’s Mx and indications for Tx
Bisphosphonates (oral or IV)
Indications:
- Bone pain
- Fracture
- Skull/long bone deformity
- Periarticular Paget’s
Causes of osteomalacia
Vitamin D deficiency
- Malnutrition
- Lack of sunlight
- CKD
- Liver disease
- Drugs
Osteomalacia Presentation
Bone pain
Bone/muscle tenderness
Fractures
Osteomalacia Ix
Bloods
Low Ca, Phosphate
High PTH and ALP
XR: Looser’s zone pseudofractures
What are the 4 types of renal tubular acidosis
Type 1: Distal - unable to excrete H+
Type 2: Proximal - unable to reabsorb HCO3 (related to osteomalacia)
Type 3: Caused by carbonic anhydrase deficiency, very rare
Type 4: Related to lack of aldosterone, causing hyperkalaemic acidosis
Assessment of risk in osteoporosis
FRAX assessment: For asymptomatic patients (women >65, Men >75)
DEXA scan:
- If under 40 with major RF for osteoporosis
- If going to be on steroids for at least 3 months and <65
- If <75 presenting with a fragility fracture
Complications of inappropriate correction of hyponatraemia and hypernatraemia
Hyponatraemia: Central pontine myelinolysis
Hypernatraemia: Cerebral oedema
Hyperaldosteronism Mx
Bilat. adrenal hyperplasia: Spironolactone + SandoK
Adrenal adenoma: Surgery
Adrenal carcinoma: Surgery + radiotherapy
Hyperkalaemia causes
Release from cells (rhabdomyolysis, acidosis) RAAS system inhibition (ACEi, ARB, spironolactone) Low aldosterone (Addison's disease, RTA)
Hypokalaemia causes
GI loss (diarrhoea > vomiting) Renal loss (aldosterone excess) Redistribution into cells (insulin, beta-agonists, alkalosis)
Hypernatraemia causes
Increased sodium intake
Fluid loss
Hypokalaemia Mx
Mild/moderate (2.5-3.5)
Oral SandoK
Severe (<2.5) or symptomatic IV KCl (IV saline + 40mmol KCl)
What is pseudohyponatraemia
hyponatraemia with a raised serum osmolality - indicating an artefact
