Endo Flashcards
what is the first line and diagnostic test for acromegaly ?
1st line - serum IGF-1
diagnostic - OGTT
what is sick euthyroid syndrome
Low T3/T4 alongside an inappropriately normal TSH in an acutely unwell patient.
what is the initial management of hyperglycaemic hyperosmolar state
IV fluids
what is the first line management of a DKA ?
Isotonic saline
which medications are helpful in the management of diabetic patients who are obese
DPP-4 Inhibitor ( Sitagliptin)
what is the diagnostic test for Graves disease
TSH hormone receptor antibodies
what is the most common cause of thyrotoxicosis
Graves
whats the most common cause of primary hyperaldosteronism
Bilateral idiopathic adrenal hyperplasia
give 2 features of Primary hyperaldosteronism
HTN + Hypokalaemia
what test can be used to distinguish the different types of diabetes
C-Peptide - will be low in T1DM and normal / high in T2DM
when should an SGLT-2 be added to metformin ? Do you need to make any changes to the metformin when you do this
- high risk of CVD
-established CVD - Chronic HF
- titrate metformin up first
What is the pattern in which diabetic neuropathy occurs
sensory loss in a ‘‘glove and stocking’’ distribution with the lower legs affected first - symmetrical and then spreading upwards
first line management of diabetic neuropathy
amitryptiline, duloxetine, gabapentin, pregabalin
which is the most sensitive test to diagnose cushings syndrome
low dose overnight dexamethasone suppression test
which is the most sensitive test to distinguish between the causes of cushings
high dose dexamethasone test
what is the first line management of hypoglycaemia
oral glucose 10-20 g in liquid gel or tablet form
what is the management of hypoglycaemia in an unconscious patient
subcutaneous / IM Glucagon
IV 20% GLUCOSE through a large vein
whats the criteria for hypoglycaemia
< 3.9 mmol/L
how do you manage changes in eye vision with thyroid disease
urgent refferal to specialist
which is the most important modifiable risk factor for the development of thyroid eye disease
smoking
what is the management of thyroid eye disease
topical lubricants
steroids
radiotherapy
surgery
what are the features of an Addisonian crisis
hyponatraemia
hypotension
hypovolaemia
hyperkalaemia
give 3 causes of an adrenal crisis
sepsis / surgery
adrenal haemorrhage
steroid withdrawal
how do you manage an addisonian crisis
hydrocortisone 100 mg im/iv
name 2 main side effects of sulfonylureas
hypoglycaemia
weight gain
when should sulfonylureas be avoided
breastfeeding, pregnancy
what is the first line investigation in suspected primary hyperaldosteronism
aldosterone / renin ratio
2 key features of hyperaldosteronism
htn and hypokalaemia
most common cause of primary hyperaldosteronism
bilateral idiopathic adrenal hyperplasia
how does a myxoedema coma present
confusion and hypothermia
how do you manage a myxoedema coma
IV Thyroid replacement
IV Fluid
IV Corticosteroids
electrolyte imbalance correction
at what rate should you prescribe insuline ( DKA)
0.1 unit / kg/ hour
which type of fluid is used in fluid resuscitation in DKA
Isotonic saline
_________ diabetes medication are associated with an increased risk of UTI’s and thrush
SGLT-2 inhibitors ( flozin ending)
which diabetes medication is linked to fourniers gangrene
SGLT-2 inhibitor
how does an SGLT-2 inhibitor act
inc glucose reabsorption , increase urinary glucose excretion
which diabetes medication is recommended for weight loss
SGLT-2
which conditions are not suppressed by the high dose dexamethasone suppresion test
cushings syndrome, ectopic ACTH syndrome
differentiate between Obese class 1,2,3
1 - 30 to 35
2- 35 to 40
3- >40
specific features seen in Graves disease
exophthalmos
pretibial myxoedema
which antibodies are present in Graves disease
TSH receptor stimulating antibodies
anti thyroid peroxidase antibodies
how is addisons disease managed
Hydrocortisone and fludrocortisone
what is given to diabetic patients on insulin for emergencies
glucagon kit
definitive management of primary hyperparathyroidism
total parathyroidectomy
how do you manage steroid dose in addisons patient with recurrent illness
double hydrocortisone
keep fludrocortisone the same
what is central pontine myelinolysis and why does it occur
it occurs when you give insulin in hyperglycaemic hyperosmolar state which causes dramatic fluid shift between compartments leading to central pontine myelinolysis. presents as dysarthria, reduced consciousness, dysphagia
what is the first line treatment for Acromegaly ?
Trans-Sphenoidal surgery
which 3 classes of medications can be used in the management of acromegaly ? Give examples
Somatostatin analogue : Octreotide
GH receptor antagonist : Pegvisomant
Dopamine agonist : Bromocriptine
In type 1 diabetes what HBA1C target should be used ?
48 mmol/mol
what is the definitive management of primary hyperparathyroidism ?
Total parathyroidectomy
what is the Hba1c target for patients on a drug which may cause hypoglycaemia ?
Sulfonylureas
how is an adrenal crisis managed
IM Hydrocortisone
name 4 drug causes of raised Prolactin
Metoclopramide
Domperidone
Phenothiazines
Haloperidol
How do you manage a DKA patient who’s ketonaemia and acidosis has not been resolved in 24 hours
Review by senior endocrinologist
how is mastoiditis diagnosed
clinical diagnosis
CT only if complications suspected
hashimotos diseases carries a small increased risk of which cancer
thyroid lymphoma
what is the diagnostic criteria for hyperglycaemic hyperosmolar state
Hypovolaemia
Marked Hyperglycaemia ( 30 mmol / L)
significantly raised serum osmolarity ( > 320 mosmol/kg)
no significant hyperketonaemia or acidosis
what is the management of hyperglycaemic hyperosmolar state
Fluid replacement ( IV 0.9% sodium)
insulin : only give if blood glucose stops falling while giving fluids
VTE prophylaxis
what are drug causes of raised prolactin
Metoclopramide + domperidone
phenothiazines
Haloperidol
rarely : SSRI, opiates
when should SGLT 2 inhibitors be the second line management for diabetes
- Patient has a high risk of developing CVD
-patient has established CVD
-Patient has chronic HF
what is the difference primary and secondary prevention when prescribing a statin
primary prevention
10 year cardiovascular risk => 10 % OR most type 1 diabetes OR CKD if eGFR < 60 m//min/m2
give atorvastatin 20 mg OD
Secondary prevention
Known ischaemic heart disease OR cerebrovascular disease OR peripheral arterial disease
atorvastatin 80 mg OD
What acid base disturbances are seen in Cushing’s syndrome
hypokalaemia metabolic alkalosis
how do you manage a patients insulin when they have diabetic ketoacidosis
continue long acting insulin
stop short acting insulin
what are the side effects of thyroxine therapy
hyperthyroidism = due to overtreatment
Reduced bone mineral density
worsening of angina AF
how can an ectopic source of ACTH present
Hypokalaemia - muscle, weakness and lethargy
metabolic alkalosis
glucose intolerance
Lymphoedema
chest pain
explain the results of water deprivation test and desmopressin test in diabetes insipidus
nephrogenic DI : low urine osmolality after water deprivation and low urine osmolality after desmopressin
cranial DI : low urine osmolality after deprivation and high urine osmolality after desmopressin
what is the hormonal picture of Klinefelter’s syndrome
elevated gonadotrophs but low testosterone
what is the most appropriate investigation for patients with increased urinary cortisol and low plasma ACTH levels
CT adrenals
when does the BNF suggest gradual removal of systemic steroids ? at what frequency
received > 40 mg prednisolone daily for > 1 week
received > 3 weeks of treatment
recently received repeated courses
reduce weekly
what are the side effects of SGLT-2 inhibitors ?
urinary and genital infection
Fournier’s gangrene
normoglycemic ketoacidosis
Increased risk of lower limb amputation - monitor feet closely
what is the action of SGLT-2 inhibitors ?
reduce glucose reabsorption and increase urinary glucose excretion
acting in the renal proximal convoluted tubule
what is the definitive investigation of Addison’s disease ?
ACTH stimulation test - short synacthen test
How is the diagnosis of Type 2 diabetes mellitus made in a symptomatic patient ? Is this different in an asymptomatic patient ?
fasting glucose >= 7.0 mmol/l
random glucose >= 11.1 mmol/l
Same criteria but must be demonstrated on 2 occasions
what are the causes of an Addisonian crisis ?
Sepsis / surgery causing acute exacerbation of chronic insufficiency ( Addisons, Hypopituitarism)
how do you manage an Addisonian crisis ?
Hydrocortisone 100 mg iv/im
saline 1 l over 30-60 mins / dextrose if hypoglycemic
What causes a lower than expected level of HbA1c ?
SCA
G6PD deficiency
hereditary spherocytosis
haemodialysis
what causes a higher than expected level of HbA1C
vit b12 / folic acid deficiency
IDA
splenectomy
what is gastroparesis ? When does it occurs + what are its symptoms + management ?
It occurs secondary to autonomic neuropathy and symptoms include erratic blood glucose control, bloating and vomiting.
management includes metoclopramide, domperidone or erythromycin
what is the most common cause of hypercalcaemia ?
primary hyperparathyroidism
what is the most common cause of primary hyperparathyroidism
parathyroid adenoma
what are the symptoms of primary hyperparathyroidism
bones
stones
groans
psychiatric moans
how would you diagnose primary hyperparathyroidism based on blood tests
raised calcium
low phosphate
PTH raised inappropriately
what sign is seen on xray in primary hyperparathyroidism
pepperpot skull
what is the definitive management of primary hyperparathyroidism
total parathyroidectomy
what is the first line management of diabetic neuropathy
amitriptyline
duloxetine
gabapentin
pregabalin
which antibodies are found in graves disease
Anti-TSH receptor antibodies
what is the Hba1c target for a patient on a drug which may cause hypoglycemia
53 mmol/mol
name 4 complications of acromegaly
HTN
Diabetes
cardiomyopathy
colorectal cancer
how does graves disease show on radioiodine uptake test ?
increased homogenous uptakee
what is the nature of inheritance of maturity onset diabetes of the young ?
autosomal dominant
what are the diabetes sick day rules regarding insulin?
if the patient is on insulin they must not stop it due to DKA
what are the diabetes sick day rules regarding oral hypoglycemics ?
temporarily stop oral hypoglycemics during an acute illness
what is Waterhouse Friderichsen syndrome ? What is it caused by? how do you manage it ?
rare but life threatening disorder associated with bilateral adrenal haemorrhage.
Can be caused by fulminant meningococcemia.
Management includes supportive therapy for sepsis + volume resuscitation
how does a benign incidental adenoma present ?
lipid rich core readily identified on CT scanning
non specific pain
what is secondary hyperparathyroidism caused by
Physiological elevation of PTH levels in response to hypocalcemia, commonly due to renal failure/ vitamin D deficiency
what is the first line treatment for acromegaly?
trans-sphenoidal surgery
what medications are used in the management of acromegaly?
somatostatin analogue : Octreotide
GH receptor antagonist : Pegvisomant
dopamine agonist : bromocriptine
what is the first line drug used in the management of thyrotoxicosis
Propylthiouracil
what is the most important blood test to assess a patient’s response to treatment with levothyroxine for Hashimoto’s thyroiditis ?
TSH
how often should insulin dependent diabetics check their blood glucose whilst driving ?
Insulin dependent diabetics
what is the action of metformin?
Acts by reducing hepatic gluconeogenesis and improving glucose uptake and utilisation in peripheral tissues.
how is a diagnosis of gestational diabetes made ?
fasting plasma glucose of >= 5.6 mmol/L
2 hour post oral glucose tolerance test plasma of >= 7.8 mmol/l
what is the most common complication of parathyroidectomy
hypocalcaemia
how long apart should calcium carbonate and levothyroxine be taken
dec absorption of oral levothyroxine so take 4 h apart
what is the most common type of thyroid cancer ?
papillary
what investigations are needed to diagnose thyroid cancer ?
thyroid ultrasound
fine needle aspiration
serum thyroid stimulating hormone
calcitonin
What are the complications of maternal gestational diabetes?
Macrosomia ( birth weight > 4 kg)
Neonatal seizures
preterm delivery –> neonatal respiratory distress syndrome
what are complications of amiodarone use ?
Hypothyroidism
hyperthyroidism /thyrotoxicosis
corneal deposits
stevens-johnson syndrome
How do you diagnose pre-diabetes
Impaired Fasting Glucose (IFG): Fasting blood glucose levels between 6.1-6.9 mmol/L
Impaired Glucose Tolerance (IGT): Two-hour oral glucose tolerance test (OGTT) values between 7.8-11.0 mmol/L
how do you investigate sub-clinical hypothyroidism
raised TSH
Normal T3 and T4
Repeat test in 3-6 months
what are the rules regarding metformin during ramadan
one-third of the normal metformin dose should be taken before sunrise and two-thirds should be taken after sunset
what are the causes of Addisonian crisis ?
sepsis / surgery causing an acute exacerbation
steroid withdrawal
adrenal haemorrhage or Waterhouse Friederichsen syndrome
what is the management of an Addisonian crisis
hydrocortisone 100 mg im / iv
1 litre normal saline infused over 30-60 mins or with dextrose if hypoglycaemic
what MEN condition is pheochromocytoma ?
MEN 2
what are the MEN 1 conditions?
pancreatic tumours ( gastrinoma, insulinoma)
pituitary tumours
what feature suggests Grave’s disease over other causes of Hyperthyroidism
Diplopia
how does tertiary hyperthyroidism present?
occurs in patient’s with CKD due to ongoing hyperplasia of the parathyroid glands resulting in excessive levels of parathyroid hormone.
how is gestational diabetes diagnosed?
fasting glucose >= 5.6 mmol/L ( <7 diet and exercise)
2 hour glucose level >= 7.8
how to assess a patient following a fragility fracture?
> 75 : start bisphosphonate without DEXA scan
<75 : DEXA
which medication is associated with angioedema
ACEi-i
how is a maintenance dose of steroid replacement split in terms of regimen
Majority of dose given in the 1st half of the day
what is the treatment of choice of toxic multinodular goitre ?
radioactive iodine
what is the management of severe PAD ?
endovascular revascularisation for short segment stenosis < 10 cm
surgical revascularisation in segments > 10 cm
what medications and lifestyle changes are recommended in the management of PAD ?
Stop smoking
treat co-morbidities : HTN, DM, Obesity
start statin, Clopidogrel
explain the results of primary polydipsia on water deprivation test ?
urine osmolality after fluid deprivation : high
urine osmolality after desmopressin : high
what are the tests and management done for pheochromocytomas ?
tests : 24h urinary collection of metanephrines
surgery is the definitive management however first medications are used :
alpha blocker ( phenoxybenzamine) followed by beta blocker ( propranolol)
what 3 conditions are associated with pheochromocytoma
MEN2
neurofibromatosis
VHL
what is the rule of 10’s in pheochromocytoma ?
bilateral in 10%
malignant in 10%
extra-adrenal in 10%
what is the most common complication of thyroid eye disease ?
exposure keratopathy
what are the phases of subacute thyroiditis ? How is it investigated ?
4 phases
phase 1 : hyperthyroidism, painful goitre and raised ESR
Phase 2 : euthyroid
Phase 3 : hypothyroidism
Phase 4 : normal
investigated by thyroid scintigraphy : globally reduced uptake of iodine
how are unilateral and bilateral causes of aldosterone excess investigated
high resolution CT and adrenal vein sampling
how is primary hyperaldosteronism managed
adrenal adenoma : laparoscopic adrenalectomy
bilateral adrenocortical hyperplasia : aldosterone antagonist - spironolactone
what is the key parameter to monitor patients with hyperglycaemic hyperosmolar state
serum osmolality
deficiency of what electrolyte can prevent adequate replacement of other electrolytes such as calcium ?
magnesium
what is the management of a prolactinoma ?
drugs are first line - cabergoline ( dopamine agonists)
second line - surgery
what is nelson’s syndrome and how does it present ?
presents due to rapid enlargement of an ACTH producing adenoma that occurs after removal of both adrenal glands. This eliminates cortisol feedback causing existing pituitary adenomas to grow unchecked.
how do non functioning pituitary adenomas present
generalised hypopituitarism
what are common drug causes of raised prolactin
metoclopramide
domperidone
phenothiazines - prochlorperazine
haloperidol
what are causes of raised prolactin
pregnancy
prolactinoma
physiological
PCOS
primary hypothyroidism
prochlorperazine, metocloPramide, domPeridone
when should addition of metformin be considered in the management of type 1 diabetes
BMI > 25
which anti-diabetic drug is contraindicated in HF
Pioglitazone
what is the action of DPP4 inhibitors ?
They increase levels of incretins ( GLP-1 and GIP)
what medication induces neutrophilia
corticosteroids
what biochemical marker are MEN1 syndromes associated with
hypercalcaemia
what treatment can worsen thyroid eye disease
radioiodine treatment
how does hypercalcaemia secondary to malignancy present ?
PTH low
ALP high
calcium high
how many hypoglycaemic episodes will result in the patient having to surrender their driving license
2
what hormone are medullary thyroid cancers associated with
calcitonin
what is the action of pioglitazone
reducing peripheral insulin resistance
what thyroid function is seen in pregnancy
raised total t3 and t4 but normal ft3 and ft4
how are patients with diabetic foot disease followed up?
referral to local diabetic foot centre
how does subacute thyroiditis show on scan
globally reduced iodine uptake on scan
what is the definition of DKA resolution
pH >7.3 and
blood ketones < 0.6 mmol/L and
bicarbonate > 15.0mmol/L
Bone pain, tenderness and proximal myopathy (→ waddling gait) → ?
osteomalacia
what is the management of osteomalacia ?
vitamin D supplementation
calcium supplementation if dietary calcium inadequate
what are the blood investigations of osteomalacia and what do they show
low vitamin D levels
low calcium, phosphate (in around 30%)
raised alkaline phosphatase (in 95-100% of patients)
how do you manage blood pressure > 180/120 mm Hg
specialist assessment : signs of retinal haemorrhage / life threatening symptoms
referral if pheochromocytoma suspected
if no warning signs :
urgent investigations for end organ damage
most common endogenous cause of Cushing’s
pituitary adenoma
what is Pseudo-cushings? How would you distinguish it from regular cushings
mimics Cushing’s
alcohol excess or depression causes it
false positive dexamethasone suppression test or 24h urinary free cortisol
insulin test used to differentiate
what are the side effects of isosorbide mononitrate
headaches, dizziness and hypotension
Thyrotoxicosis with tender goitre =
subacute (De Quervain’s) thyroiditis
How do the following show up on nuclear scintigraphy
toxic multinodular goitre
de quervain’s thyroditis
TMG - patchy uptake
DQT - globally reduced uptake
what are the high risk factor for pre-eclampsia
hypertensive disease in a previous pregnancy
chronic kidney disease
autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
type 1 or type 2 diabetes
chronic hypertension
what are the moderate risk factors for eclampsia
first pregnancy
age 40 years or older
pregnancy interval of more than 10 years
body mass index (BMI) of 35 kg/m² or more at first visit
family history of pre-eclampsia
multiple pregnancy
how is the risk of hypertensive disorders reduced in pregnancy
women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth
≥ 1 high risk factors
≥ 2 moderate factors
what urine osmolality excludes diabetes insipidus
a urine osmolality of >700 mOsm/kg
mx of nephrogenic and central diabetes insipidus
nephrogenic - thiazides, low salt + protein diet
central - desmopressin which is a Vasopressin V2 receptor agonist
give 2 important interactions of levothyroxine? how should that be managed
iron, calcium carbonate : to be given at least 4h apart
gestational diabetes : glucose >= 7 mmol/l insulin
start insulin
management of gestational diabetes
plasma glucose <7 : diet and exercise –> metformin after 1-2 weeks if targets not met –> still not met then add insulin
plasma glucose > 7 : insulin
management of de quervains thyroditis
naproxen
what type of insulin is used to treat gestational diabetes
short acting insulin only
when is glibenclamide used in the management of diabetes in pregnancy
should only be used for women who cannot tolerate metformin or those who do not meet the glucose targets with metformin but don’t want insulin
Diagnostic thresholds for gestational diabetes
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
when should women be screened for gestational diabetes ?
previous GDD: at booking and at 24-28
any other RF’s : only at 24-28 weeks
referral for a child with a palpable abdominal mass
refer very urgently < 48h for specialist assessment for neuroblastoma / Wilms
management of hypothyroidism in pregnancy
increase dose of levothyroxine by 50%
management of hyperthyroidism in pregnancy
propylthiouracil
management of MODY with HNF1A
low dose sulfonylureas
which diabetic drug creates c peptide and insulin as a by product
gliclazide
medullary carcinoma
autosomal dominant pattern, MEN2 , calcitonin secreting
high calcium with v low pth suggests -
malignancy
what cardiac complication can thyrotoxicosis cause
high output cardiac failure
At what HbA1c should the addition of a second drug be considered ?
58
secondary hypothyroidism
low TSH and T4 , generally due to pituitary insufficiency and MRI of glands should be performed
vbg picture of cushings
hypokalaemia metabolic alkalosis
TFT’s suggesting poor compliance with thyroxine
high TSH, normal T4
sick euthyroid syndrome
low T3/T4 and normal TSH
hypercalcaemia secondary to malignancy
low PTH, raised PTHrP
main cause of primary hyperaldosteronism
bilateral idiopathic adrenal hyperplasia
what does adrenal venous sampling help with
distinguishing unilateral adenoma and bilateral hyperplasia
pre-diabetes
6.1-7 - fasting glucose
HbA1c - 42-47
what acid base disturbance does hyperaldosteronism cause
metabolic alkalosis
which condition can medullary carcinoma pre-dispose you to
phaeochromocytoma
which physical feature is hashimotos associated with
goitre
where does papillary thyroid cancer spread to
cervical lymph nodes
management of patients with parathyroid adenoma not suitable for surgery
calcimimetic
how many units of insulin in 1 ml of insulin
100 units
de quervain’s thyroiditis vs sick euthyroid
de quervain’s = hyperthyroidism
sick euthyroid = hypothyroidism
Patient with diabetes who have had two hypoglycaemic episodes requiring help needs to
surrender their driving licence
can patients on Insulin hold a HGV license
if they meet certain DVLA criteria
