Endo Flashcards
Goserelin is a GnRH analogue… name the gonadotophins
FSH and LH
what are 2 key findings f addisonian crisis
severe hypotension
electrolyte imbalances
what are the 3 steps in managing addisonian crisi
- Aggressive fluid resus
- IV steroids emphaisis on IV
- Glucose (in hypoglycaemia
Elderly female pt w/ unilateral swelling on the neck, slowly growing larger over years
Sx: no hoarse voice/ swallowing difficlties
exam: uneven goitre, no bruit, not fixed/firm
Bloods - TFTs normal.
what is the management of the underlying cause
do not require tx
this is a Thyroiid cyst ( elderly female, aSx neck mss, slow growing = thyroid cyst
thyroid malignancy would have been =- fixed/firm nodule, recent enlargement, lymphadenopathy)
3 clinical features of diabetes insipidus
large volumes dilute urine (>3L dilute urine in 24hrs & urine osmolality <300mOsm/kg)
nocturia
excess thrist
and
—-
give 4x cuases for each
diabetes insipuds can be CRANIAL or NEPHROGENIC
cranial: head trauma, inflammatory conditions (sarcoidosis), cranial infection (meningitis), vascular conditions (sickle cell disease)
nephrogenic: drugs (lithium), metabolic disturubances (hypercalcaemia, hypokalaemia, hyporglycaemia), CKD.
both; rare genetic causes (Wolframs syndrome for nephrogenic diabetes insipidus )
stepwise management options in acromegaly
1st line Surgical: Transsphenoidal surgery
if surgery C/I or nto responsive to surgery: Somastostatin analogues ( octreotide, lanreoride) (1st line medical)
GH antagonist ( pegvisomant)
dopamine agonist ( bromocriptine )
aggressive & resistant to surgery/meds: radiotheray
50 yo female w/ uncontrolled HTN , muscle cramps and fequent urination
what electrolyte imbalance is likely to be fouund
how would this appear on an ECG
what are the 2 management options
electrolyte imbalance - hypokalaemia (<3.5mmol/L)
uncontrolled HTN + muscle cramps + frequent urination + hypokalaemia = hyperaldosteronism
ECG - (only where K<2.7mmom/l)
- raise Pwave
- prolonged PR interval
- widespread ST depression & Twave flattening/inversion
Prominent Uwaves( V2 and V3)
Long QT interval
uncontrolled HTN = not responding despite multiple anti-HTN
Mx:
- surgical ( if lesion/tumour)
- medical: potassium -sparin diruectics ( Amiloride, spiroolactone, eplerenone) ( in bilateral adrenal disease
what is the difference between hyperaldosteronism and Conns
Conn’s = primary hyperaldosteronism
autonomous overproduction
Is Hashimoto’s disease a form of hyper or hypothryoid?
What are the 3 examination findings of the thyroid in this condition>
hypothyroid
smooth, non-tender, goitre,
what is the most common cause of hyperthyoroidsi ,
how does the thyroid present
graves disease
Smooth goitre
( goitre = abnormal enlargement of thyrouid gland)
what form of thyroiditis is triggered by a viral infection?
does this cause hyper or hypothryroid
How does the thyroid present
De Quervain’s thyroiditis
Hypothyroid
Painful smooth goitre ( painful as it enlarges rapidly)
Give 3 causes of nodular goite
multinodular goitre, thyroid cyst, thyroid cancer
what examination finding suggests thyroglossal cyst?
rises with BOTH swallowing & tongue protrusion
(unlike e.g. hashimotos which just rises ith swallowing)
give clinical features of a thyroid storm
thyroid storm = severe thyrotoxicosis, life-threateneing form of hyperthyroid
hyroid storm
- fever, sweting, HR>140, DNV, coma
thyrotoxicosis
unexplained wieghtloss, tachycardia, arrhythmia, uscles weakness, nervsoius/anxious/irritable. shaky, heat sensitivity, menstrual changes
what is the immediate management in suspected post-partum thyroiditis
watch and wait
a) difficult to differentiate from graves
b) have 3 months hyperthyroid followed by hypothyroid ( so meds could make them unwell)
what group of women are at increased risk of post-partum thyroiditis
havign autoimmmune disease
Graves: What is the 2nd line Med for breastfeeding women, why can’t the 1st line be used?
2nd line - Betablockers
( tx thyrotoxic Sx)
carbimazole (1st line) contains propylthiouracil, which passess through breast milk
Graves: What is the 2nd line Med for breastfeeding women, why can’t the 1st line be used?
carbimazole
can cause congenital abnormalities, so Propylthiouracil used in 1st trimester, the Carbmiazole for 2nd &3rd trimester ( as propylthiouracil can cause severe hepatic injury).
Mx in thyroid storm
suportive ( IV fluids, analgesia, propanolol for tachycardia) propylthiouracil/carbimazole ( stop thyroid hormone synthesis
what signs are seen in hypocalcaemia
trousseau’s sign = carpopedal spasm caused by the inflation of a blood pressure cuff
Chvosteks sign - ipsilateral facial twitching when tappin6g on6 the contralateral cheek
what antibodies are found in the most common cause of hypothyroidism?
Most common cause of hypothyroid : Hashimotos (UK)
Ab:
anti-thyroid peroxidase (anti-TPO)
anti-thyroglobulin (anti-Tg) a
most common cause of hypothyroid UK, Worldwid
UK - hashimotos
world - iodine deficiency
what are the 4 tx options for hyperthyroid
Carbimazole ( main 1st line, but not to be used in 1st trimester)
Propylthiouracil (1st trimester, but long term causes hepatic injury)
Radioactive iodine
Thyroid surgery
Give 4 causes of primary hypothyroid (aside from autoimmun - Hashimotos, and iodine deficiency)
Lithium (inhibits T3 &T4 production)
Amiodarone
Hyperthroid Mx: Carbimazole, propylthiouracil, radioactive iodine, thyroid surgery
Causes of secondary hypothyoroidism ( x5)
Tumours: pituitary adenonma
surgery to pituitary
radiotherapy
sheehans (avascular necrosis of pituitary gland)
trauma
1st and 2nd line options in hypothyroid tx
Oral levothyroxine
- titrated every 40weeks based on TSH level
2nd Liothyronine sodium - synthetic T3 (specialist care)
what is subclinical hypothyroidism
thyroid hormones (T3 and T4) are normal and thyroid-stimulating hormone (TSH) is suppressed (low).
There may be absent or mild symptoms.
what is the most common cause of hypethyroid? and whag antibodies are associated with it
Graves - autoimmune disease
TSH receptor antibodies
what are the 4 causes of hyperthyroidism
GIST
Graves disease
Inflammation (thyroiditis)
Solitary toxic thyroid nodule
Toxic multinodular goitre
Give the 4 causes of thyroiditis
thyroiditis include:
* De Quervain’s thyroiditis
* Hashimoto’s thyroiditis
* Postpartum thyroiditis
* Drug-induced thyroiditis
what is the hand swelling and finger clubbing in Graves disease called
Thyroid acropachy
what are the 3 phases in De Quervains Thyroiditis
aka subacute thyroiditis
- Thyrotoxicosis
2 Hypothyroid
3 return to nornmal
what are the 4 features of the thyrotixic phase of De Quervains thyoriditis
- Excessive thyroid hormones
- Thyroid swelling and tenderness
- Flu-like illness (fever, aches and fatigue)
- Raised inflammatory markers (CRP and ESR)
what is the management in De Quervains thyroiditis
supportive, its a self-limiting condition
NSAIDS - sx pain/inflammation
B-blockers (hyperthyoid Sx
Levothyroixine (hypothyroid Sx)
what is the difference between a thyroid storm and thyrotoxici crisis
same thing
4 features of thyroid storm/thyrotoxic crisis
1 Features of hyperthyroidism
2 fever
3 tachycardia
4 delirium
Management in thryroid storm
same as with thyrotoxicosis ( supportive, NSAIDs for analagesia) also
- fluid resus
- anti-arrhythmic meds
- beta-blockers
What GI condition are patients on carbimazole at risk of ( hint: causes severe epigastric pain radiating to the back)
acute pancreatitis
what acute blood condition can be caused by Carbimazole and Propylthiouracil
Carbimazole/ Propylthiouracil - agranulocytosis
Carbimazole - acute pancreatitis
Propylthiouracil - hepatic damage
Typical: patient with a sore throat on carbimazole or propylthiouracil, the cause is likely agranulocytosis. They need an urgent full blood count and aggressive treatment of any infections.
which b-blocker is most commonly used to bloc the adrenalin-related symptoms of hyperthyroidism
propanolol
what are the risks of thyrotoxicosis in pregnancy>
foetal loss
maternal lheart failure
premature labour
what is the most common cause of thyrotoxicossi in pregnancy
Graves disease
can radioiodine therapy be used in hyperthyroid in pregnancy?
no: Contraindicated
how does the management on hypothyroidism change in pregnancy
thyroxine is safe in pregnancy and breastfeeding
dose should be raised
when should pts with subclinical hypothyroidism be Tx?
if symptomatic, and < 65 years old.
repeat TSH & T4 conducted 3 months later, is still raised TSh w/ normal T4, give Tx
otherwise they will become hypothyroid
(subclinical hypothyroidisim: TSH is raised but Thyroid hormones are normal)
which 5 causes of thyroid disease lead to a goitre
Lithium
Hashimotos
Iodine deficiency
toxic multinodular goitre/
Graves
what is sick euthyroid syndrome
most commonly seen in chronically ill patients/ in starvation. TFTs are low and the patient clinically euthyroid.
what triad of symptoms does T1DM typically present with
polyuria, polydipsia, weightloss ( sx of hyperglycaemia)
or DKA
what are 3 key features of DKA
Ketoacidosis
dehydration
postassium imbalance (high/normal - potassium normally driven into cells by insulin, non insulin –> no cell potassium. May be normal as kidneys secrete excess)
important to correct as these are what will kill t
what is the criteria for diagnosing DKA
all three of:
*Hyperglycaemia ( > 11 mmol/L)
* Ketosis ( >3 mmol/L)
* Acidosis (< pH 7.3)
what is the management in DKA
FIG-PICK
Fluids - IV hartmanns, 1L in 1st hr, then 1L/2hrs
Insulin -fixed rate infusion
Glucose - closely monitor blood glucose, add infusion when <14mmol/L
Potassium - add to IV fluids and monitor closely (insulin infusion –> drives K into cells –>? hypokalaemia –> arrhythmia)
Infection - may be underlying trigger of DKA so tx
C- chart fluid balance
Ketones - monitor ketones. pH, bicarbonate
what are the 4 key complications of DKA Mx
- Hypoglycaemia
*Hypokalaemia
*Cerebral oedema, esp in kids
*Pulmonary oedema (secondary to fluid overload)/ acute respiratory distress syndrome
what autoantibodies are associated with T1DM
- Anti-islet cell antibodies
- Anti-GAD antibodies
- Anti-insulin antibodies
What is the longterm complication of injecting insulin into the same spot
lipodystrophy
hypoglycaemia can be tx with rapid-acting glucose (high content drink), what are the medical options
IV dextrose and IM glucagone
what are rhe tx targets in T2DM
- 48 mmol/mol for new type 2 diabetics
- 53 mmol/mol for patients requiring more than one antidiabetic medication
what are the 1st, 2nd and 3rd line medical mx in T2DM
1st - metfromin (w/ SGLT2-i dapagliflozin if CVD as well)
2nd line - Metformin + sulfonylurea/pioglitazone/DPP-4i/ SGLT2 i
3rd line - triple therapy: metformin + 2 secondline drugs OR insulin therapy
metformin
- 2 main SE
- does it cause hypoglycaemia
- does it cause weight gain
SE
GI Sx (pain, nausea, diarrhoea)
Lactic acidosis (2ndary to AKI)
Hypoglycaemia - no
weight gain - no
SGLT-2 i
- give 2 drug names
- give 2 main S/E
- what positive S/E does it have
suffix -gliflozin
e.g. empagliflozin, dapagliflozin
- raised risk of thrush/UTI
- DKA
(also hypo)
Positive: improves HF and CVD
which diabetic meds cause a risk of hypo
SGLT-i (eg dapaglitazone)
sulfonyluria (gliclazide)
insulin
According to the (DVLA) guidelines, are insulin-treated diabetics allowed to drive heavy goods vehicles (HGVs)
yes, if they fulfil very STRICT criteria
- there has not been any severe hypoglycaemic event in the previous 12 months
- the driver has full hypoglycaemic awareness
- the driver must show adequate control of the condition by regular blood glucose monitoring*, at least twice daily and at times relevant to driving
- the driver must demonstrate an understanding of the risks of hypoglycaemia
- here are no other debarring complications of diabetes
what is the 1st line Mx for HTN any T2DFM patient
ACEi (also used in CKD)
how does HHS ( hyperosmolar hyperglycaemic state) present?
hyperosmolality (from water loss, so blood very concentrated),
hyperglycaemia
absence of ketones (so not DKA)
present with: polyuria, polydipsia, weight loss, dehydration, tachycardia, hypotension, confusion
what 2 measurements are used to screen for diabetic nephropath
albumin: creatinine ratio
U&Es
what is the management in diabetic nephropathy
ACEi - for HTN and diabetic nephropathy
optimising Blood glucose
what is the difference between hyperaldosteronism and Conns syndrome
hypersaldosteronism high levels of aldosterone
conns - high levels of adolsterone due to adrenal adenoma
what is the key presenting feature of hyperaldosteronism
hypertension
what is the role of aldosterone
- Increase sodium reabsorption from the distal tubule
- Increase potassium secretion from the distal tubule
- Increase hydrogen secretion from the collecting ducts
(so overall hypokalaemia)
what are the 3 causes of primary hyperaldosteronism
bilateral adrenal hyperplasia ( most common)
adrenal adenoma (Conn’s syndrome)
Familial hyperaldosteronism (rare)
what will
aldosterone
renin
levels look like in
primary hyperaldosteronism
secondary hyperaldosteronism
primary
aldosterone: high
renin: low ( suppressed by raised BP)
secondary
aldosterone: high
renin: high renin stimulates the release of aldosterone
measured by “plasma aldosterone/renin ratio”
give 3 causes of secondary hyperaldosteronism
secondary - raised renin
- Renal artery stenosis
- Heart failure
- Liver cirrhosis and ascites
give 4 investigations used in hyperaldosteronism
aldosterone-to-renin ratio
screeining for primary aldosteronism ( renin low, aldosterone high)
vs secondary (renin high, so aldosterone high)
BP (hypertension)
Hypokalaemia (as aldosterone excretes K for Na retention)
ABG/VBG - alkalosis ( as aldosterone secretes H+)
what are the appropriate Ix for hyperaldosteronism (x3)
CT/MRI - adrenal tumour/hyperplasia
Renal artery imaging (doppler US/CTA/MR angiography) - renal artery stenosis
Adrenal vein blood sampling (both adrenal glands)
1st line ix - aldosteron-rening ratio, THEN CT abdo & adrenal artery sampling to differentiate between uni and bilateral disease
what is the management in hyperaldosteronism (x3)
Aldosterone antagonists (eplerenone/spironolactone)
tx underlying cause (surgery in adenomal, percutaneous renal artery angioplasty in stensosis )
what is the most common endocrine cause of secondary hypertension
hyperaldosteronism ( inc. conns)
expect in younger people/ failure to respond to tx / hypokalaemia
what form of neurological disturbance is found in diabetic peripheral neuropath
sensory ( not motor) *may also cause pain
in glove and stocking distribution (legs affected first) “ having loss of sensation on both of his legs up to his knees and some sensory loss in his fingertips.
there are 4 drug options in diabetic neuropathy
neuropathic anbalgesics:
amitriptyline, duloxetine, gabapentine, pregabalin
tramadol as rescue med in exacerbations
aside from sensory loss, what other neuropathic complication occurs in diabetes
gastrointestinal autonomic nueorpathy - gastrioparsis (Sx: erratic blood glucose control, bloating, vomiting)
what is the Mx of diabetic- related gastroparesis
prokinetic agents - metoclopramide, domperidone or erythromicin
what HBA1C indicates prediabetes
- %
- mmol/mol
42-47mmol/mol
5.7 - 6.4 %
what HbA1c indicates diabetes
- mmol/mol
- %
- > 48mmol/mol
- > 6.5%
what is the recommended HBA1c treatment target in new TIIDM pts
48mmol
what is the recommended treatment target for diabetic pts on 2 or more antidiabetic medication
53 mmol/mol
cause of cushings
prolonged high levels of glucocorticoids ( cortisol)
what is the difference between cushing’s disease and cushing’s syndrome
cushings disease - pituitary adenoma secretes excess ACTH
cushing syndrome - prololonged cortisol from any source including exogenous sortisol ( prednisolone or dexamethasone)
give 5 metabolic conditions that may arise in people with cushings
HTN
Cardiac hypeertrophy
TIIDM
Dyslipaedaemia
osteoporosis
causes of cushings syndrome
CAPE
Cushing’s disease -pit adenoma, high ACTH
Adrenal adenoma
Paraneoplastic syndrom
Exogenous steroids
high levels of which hormone ( in Cushings / primary adrenal insufficiency) causes skin pigmentation
ACTH - allows you to determine the cause as excess ACTH, either from Cushing’s disease or ectopic ACTH
what test is used to diagnose cushings syndrome
dexamethasone suppression test
normal: dex given –> negative feedback (hypothalamus; CRH)–> negative feedback ( pit. ACTH) –> cortisol suppression
there are 3 dexamethasone tests used to test for cushings syndrom; which is used to screen for to exclude cushings syndrome
low dose overnight test
1mg dex given 10/11pm
checked at 9am
normal - supressed cortisol
abnormal - not supressed –> further assessment required
there are 3 dexamethasone tests used to test for cushings syndrom; which is used to test for cushings syndrome
low-dose 48-hour test
dex (0.5mg) taken every 6hrs ( 8 doses)
cortisoll levels checked
- 9am day 1
- 9am day 3
normal: cortisol production supressed
there are 3 dexamethasone tests used to test for cushing’s syndrome; which is used to determine the cause of cushing’s syndrome
high -dose 48 hour test
dex (2mg) taken every 6hrs ( 8 doses)
cortisoll levels checked
- 9am day 1
- 9am day 3
Cushings disease ( pit. adenoma) - cortisol supressed
adrenal adenoma/ ectopic ACTH - not supressed
Tx in cushings syndrome
- cushings disease
- adrenal tumour
- ectopic tumour
cushings disease - transphenoidal pituitary adenoma removal
adrenal tumour - surgical removal
ectopic tumour producing ACTH - surgical removal
otherwise, bilateral adrenalectomy and life-long steroid replacement therapy
