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Phase 4 > Endo > Flashcards

Endo Flashcards

1
Q

What is Acromegaly?

A

A disorder of excessive growth hormone

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2
Q

what is the most common cause of acromegaly?

A

Pituitary adenoma - 95%

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3
Q

what is gigantism?

A

excessive GH secretion before epiphyseal closure, during childhood or adolescence leading to increased linear growth

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4
Q

what are 5 rarer causes of acromegaly?

A

Bronchial carcinoid tumour
Lung carcinoids
Pancreatic islet cell tumour
Phaeochromocytoma

Paraneoplastic syndrome due to ectopic growth hormone releasing hormone (GHRH) or growth hormone (GH) secretion

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5
Q

what 2 hormones inhibit the secretion of GH?

A

Dopamine
Somatostatin

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6
Q

what is the pathophysiology of acromegaly?

A

Increased GH => increased glucose release, muscles retain nitrogen causing them to grow => epiphyseal plates fused so can only grow in places where there is still growth => jaw, nose, hands, feet

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7
Q

5 symptoms of acromegaly?

A

Bigger hands, feet and face
excessive sweating
tiredness
weight gain
headache
deep voice/amenorrhoea

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8
Q

6 signs of acromegaly?

A

Bi-temporal hemianopia
spade like hands and feet
large tongue - macroglossia
Jaw protrusion - prognathism
interdental seperation
predominant forehead

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9
Q

what are 6 conditions related to acromegaly?

A

Hypertrophic heart
Hypertension
T2DM
Carpal tunnel syndrome
Colorectal cancer

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10
Q

what is the 1st line investigations for acromegaly?

A

Raised insulin like growth factor 1

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11
Q

What is the gold standard test for acromegaly to comfirm diagnosis after 1st line testing?

A

oral glucose tolerance test

  • in normal patients GH suppressed to <2 with hyperglycaemia
  • no suppression of GH in acromegaly
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12
Q

what scan can be used in acromegaly?

A

MRI pituitary - ?pituitary tumour

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13
Q

What is the 1st, 2nd and 3rd line management for acromegaly?

A

1st line - trans-sphenoidal surgery if pituitary adenoma

2nd line -
- Cabergoline (dopamine agonist)
- Somatostatin analogue (octreotide)
- Pegvisomant - GH receptor antagonist give SC OD

3rd line - Radiotherapy,

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14
Q

What are 5 complications of acromegaly?

A

T2DM
Arthritis and carpal tunnel
Cardiac - cardiomyopathy, heart failure, HTN
Colorectal cancer
Obstructive sleep apneoa

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15
Q

what visual field defect is associated with acromegaly?

A

Bitemporal hemianopia

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16
Q

what is the inheritance pattern for inherited multiple endocrine neoplasia?

A

autosomal dominant

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17
Q

what are the 3 different types of multiple endocrine neoplasia?

A

MEN1
MEN2A
MEN2B

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18
Q

what is the most common presentation of MEN1?

A

hypercalcaemia

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19
Q

what is the most common cancer associated with multiple endocrine neoplasia 1?

A

Pituitary adenoma - 60% of MEN1 patients

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20
Q

what is the cause of MEN1?

A

mutations in MEN1 tumour supressor gene

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21
Q

what is the presentation of multiple endocrine neoplasia (MEN) 1?

A

3Ps

Primary Hyperparathyroidism
Pancreatic neuroendocrine tumour (50%)
Pituitary Adenoma (70%)

Also adrenal and thyroid cancers

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22
Q

what is Addison’s disease?

A

Autoimmune destruction of the adrenal glands leading to reduced cortisol and aldosterone production

Most common cause of primary hypoadrenalism in UK

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23
Q

what are 5 causes of secondary adrenal insufficiency?

A

Underacting pituitary not releasing ACTH

congenital underdevelopment (hypoplasia) of pituitary
Pituitary surgery
infection
loss of blood flow to pituitary - apoplexy
Pituitary radiotherapy

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24
Q

what is the cause of tertiary adrenal insuficiency?

A

Inadequate CRH release from hypothalamus

Usually due to long term steroid use (>3 weeks) which suppresses hypothalamus

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25
Q

What are 3 risk factors for Addison’s?

A

Female
Autoimmune diseases
HIV/TB

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26
Q

What are 8 clinical presentations of Addison’s?

A

Hypotension
Metabolic acidosis
Hypoglycaemia
Hyponatraemia and Hyperkalaemia

Lethargy, weakness, anorexia
Nausea and vom
Weight loss
Salt craving
Hyperpigmentation - especially of palmar creases

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27
Q

is hyperpigmentation a feature of secondary or tertiary adrenal insuficiency?

A

NO - only primary (addisons)

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28
Q

why does Addison’s cause skin hyperpigmentation?

A

High ACTH leads to stimulation of melanocytes

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29
Q

what is the gold standard test for Addison’s?

A

ACTH stimulation test (synacthen’s test) - low

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30
Q

what is an alternative investigation for Addison’s disease if the gold standard is unavailable?

A

9am serum cortisol

> 500 - Addison’s unlikely
<100 - abnormal
100-500 - send for ACTH stimulation test

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31
Q

What is the management for Addison’s?

A

Daily -Hydrocortisone - 20-30gm per day
AND
Fludrocortisone

Emergency -
medical alert bracelets/cards
Hydrocortisone for injection

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32
Q

what are the sick day rules in addison’s disease?

A

Double glucocorticoids (hydrocortisone)

Fludrocortisone remains the same

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33
Q

what is the management of an Addisonian crisis?

A

Hydrocortisone 100mg IV/IM

1L NaCl over 30-60 mins + dextrose if hypoglycaemic

Hydrocortisone 6 hourly until stable

oral replacement after 24 hours

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34
Q

what are 3 complications of Addison’s?

A

Secondary Cushing’s syndrome (too much glucocorticoid replacement)
osteopenia/porosis
treatment related hypertension

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35
Q

What is Cushing’s syndrome?

A

features of prolonged high levels of glucocorticoids in the body

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36
Q

what are the 2 corticosteroid hormones?

A

glucocorticoids - cortisol
mineralocorticoids - aldosterone

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37
Q

what is Cushing’s disease?

A

pituitary adenoma secreting excessive adrenocorticotrophic hormone (ACTH) stimulating excessive cortisol release from adrenal

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38
Q

what are 6 actions of cortisol (glucocorticoids)?

A

Increased alertness
inhibits immune system and reduces inflammation
inhibits bone formation
Raises blood glucose
increases metabolism
Supports cardiovascular function

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39
Q

when in the day is cortisol the highest?

A

morning

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40
Q

what are 3 medication that act as glucocorticoids (cortisol)?

A

Prednisolone
Hydrocortisone
Dexamethasone

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41
Q

what is the action of mineralocorticoids (aldosterone)?

A

Increase sodium reabsorption from distal tubule
Increase potassium secretion from distal tubule
Increase hydrogen secretion from collection ducts

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42
Q

what medication mineralocorticoid?

A

fludrocortisone

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43
Q

Is Cushing’s more common in women or men?

A

women

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44
Q

what are 4 causes of Cushing’s syndrome?

A

CAPE

Cushing’s disease - pituitary adenoma releasing excessive ACTH - MOST COMMON

Adrenal adenoma - adrenal tumour secreting cortisol

Paraneoplastic syndrome

Exogenous steroids

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45
Q

what are 4 causes of pseudo cushings?

A

Alcohol excess
severe depression
obesity
pregnancy

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46
Q

what tumour commonly causes paraneoplastic cushing’s syndrome?

A

small cell lung cancer

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47
Q

What are 4 risk factors for Cushing’s?

A

Exogenous corticosteroid use
pituitary/adrenal adenoma
adrenal carcinoma
small cell lung cancer

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48
Q

What are 8 clinical manifestations of Cushing’s?

A

Moon face
Central obesity
Abdominal striae
Enlarged fat pad on back - buffalo hump
Proximal limb muscle wasting - difficulty standing from sitting
Hirsutism
Easy bruising and skin healing
Hyperpigmentation of skin

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49
Q

what are 6 complications of cushing’s syndrome?

A

Hypertension
cardiac hypertrophy
T2DM
Dyslipidaemia
Osteoporosis
Adverse mental health

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50
Q

what can be seen on blood gas in cushings?

A

hypokalaemic metabolic alkalosis

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51
Q

what investigation is used to diagnose cushing’s syndrome?

A

dexamethasone suppression test

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52
Q

what are the 3 different types of dexamethasone suppression test?

A

low dose overnight test - 1mg

low dose 48 hour test - 0.5mg every 6-8 hours

High dose 48 hour test - 2mg every 6-8 hours

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53
Q

what investigation can be used to differentiate between cushings and pseudo-cushings?

A

insulin stress testing

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54
Q

What is the management of Cushing’s?

A

1st line - treat cause - trans-sphenoidal pituitary adenectomy/ adrenalectomy/removal of small cell lung cancer

adjuncts - post surgery corticosteroid/non-corticosteroid replacement, chemo, radiotherapy on primary tumour

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55
Q

what is nelson’s syndrome?

A

development of ACTH producing pituitary tumour after the surgical removal of both adrenal glands due to lack of cortisol and negative feedback - causes skin hyperpigmentation, bitemporal hemianopia and lack of other pituitary hormones

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56
Q

is reoccurrence common with Cushing’s?

A

Yes

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57
Q

What is T1DM?

A

a metabolic autoimmune disorder characterised by hyperglycaemia due to destruction of insulin producing beta cells in the islet of langerhans in the pancreas, results in absolute insulin deficiency.

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58
Q

what are 3 risk factors for T1DM?

A

Genetics
Other autoimmune disease
Viral tiggers - coxsackie, enterovirus

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59
Q

what causes T1DM?

A

autoimmune pancreatic beta cell destruction

subclinical until 80-90% of beta cells have been destroyed

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60
Q

what is the blood glucose target fasting and at other times of day?

A

5-7 mmol/L - Fasting

4-7 mmol/L usually

5-9 mmol/L - after meals

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61
Q

How does insulin reduce blood glucose?

A

Causes cells to take up glucose

causes muscle and liver cells to store glucose as glycogen

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62
Q

where is glucagon produced?

A

Alpha cells of islets of Langerhans

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63
Q

How does glucagon increase blood glucose?

A

Breaks down glycogen in liver into glucose - glycogenolysis

Causes liver to convert fats and protein to glucose - gluconeogenesis

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64
Q

What are 8 clinical manifestations of T1DM?

A

polyuria + polydipsia + hunger
blurred vision
fatigue/tiredness
weight loss
recurrent infections
secondary enuresis
KETOACIDOSIS

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65
Q

what is an atypical presentation of T1DM and what additional test can be done?

A

> 50 year
BMI > 25

C-peptide

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66
Q

what 5 tests should a new type 1 diabetic get?

A

FBC, U+E
HbA1c
TFTs and anti-TPO
anti-TTG
Insulin antibodies, anti-GAB, islet cell antibodies

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67
Q

What is the management of T1DM?

A

1 - Basal-bolus insulin given once daily
Short acting insulin given 30 mins before carbohydrate intake

2 - fixed insulin dosing in those who cannon self-manage

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68
Q

What are 3 side effects of insulin?

A

hypoglycaemia
weight gain
lipodystrophy

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69
Q

what are 3 different types of long acting insulin and their brand names?

A

Insulin detemir - Levemir

Insulin glargine - Lantus - Abasaglar, Semglee, Toujeo

Insulin degludec - Tresiba

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70
Q

what is the onset on long acting insulins?

A

duration of action of up to 24 hours - produce steady state in 2-4 days

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71
Q

what are 3 examples of intermediate acting insulins?

A

Humalin I
Insuman basal
Insulatard

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72
Q

how long is the onset and action of intermediate insulins?

A

onset 1-2 hours with maximal effects at 3-12 hours

11-24 hour duration

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73
Q

what are 2 examples of short acting insulin?

A

Actrapid

Humulin S

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74
Q

what is the onset and duration of short acting insulin?

A

onset in 30-60 mins

up to 8 hour duration

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75
Q

what are 2 examples of rapid acting insulins?

A

Humalog - insulin lispro

Novorapid - insulin aspart

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76
Q

what is the onset and duration of rapid acting insulin?

A

Onset 15 mins

duration 2-5 hours

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77
Q

what is the 1st line long acting insulin choice?

A

Insulin detemir - levemir

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78
Q

when is metformin added in T1DM?

A

BMI >25

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79
Q

what is needed for a child to qualify for an insulin pump on the NHS?

A

> 12 years
Difficulty controlling HbA1c

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80
Q

what are 2 different types of insulin pumps?

A

tethered - replaceable infusion sets and insulin that attaches with belt around patient waist - has wires

patch - sits directly on skin without any tubing, replace entire patch when runs out

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81
Q

what are the sick day rules for T1DM?

A

Do not stop insulin
check BMs more often - every 1-2 hours
Check urine ketones
Maintain normal meal pattern if possible - replace with sugary drinks if reduced appetite
Aim to drink 3L of water

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82
Q

How often should T1 diabetics have their HbA1c measured?

A

every 3-6 months

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83
Q

How often should people with T1DM measure blood glucose?

A

4x per day Adults

5x per day children

MINIMUM

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84
Q

What are the 3 microvascular complications of Diabetes?

A

retinopathy
peripheral neuropathy
nephropathy

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85
Q

what are 4 macrovascular complications of diabetes?

A

coronary artery disease
cerebrovascular disease
peripheral artery disease
Hypertension

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86
Q

what are 4 infection related complications of diabetes?

A

UTI
Pneumonia
Skin and soft tissue infections
Fugal infections - candida

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87
Q

what are the legal requirements of a person on insulin or sulfonylureas?

A

inform DVLA of insulin use

No severe hypoglycaemia in past 12 months
Full hypoglycaemic awareness
Adequate control of condition with BM monitoring at least BD and before driving
Understand risks of hypoglycaemia
No other complication

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88
Q

what are 8 patients where HbA1c should not be used to diagnose DM?

A

<18 years
Pregnant or <2 mon PP
Symptoms <2 months
Acutely unwell
On medications that can cause hyperglycaemia
Acute pancreatic damage/surgery
End stage CKD
HIV

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89
Q

what are 4 people to use HbA1c with caution in?

A

Abnormal haemoglobin - haemoglobinopathies
anaemia
altered red cell lifespan
recent blood transfusion

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90
Q

what is T2DM?

A

A metabolic disorder of hyperglycaemia due to a combination of insulin resistance and deficiency leading to persistently high blood glucose

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91
Q

what are 6 risk factors for T2DM?

A

Non-modifiable
older age ethnicity
FHx

Modifiable
Obesity
Sedentary lifestyle
High carbohydrate diet

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92
Q

what is the pathophysiology of T2DM?

A

Repeated exposure to glucose and insulin causes cell resistance to insulin leading to more insulin needing to be produced. This fatigues the pancreas causing insulin output to be reduced

High carb diet plus insulin resistance and reduced pancreatin functioning leads to chronic hyperglycaemia and it’s micro and macovascular complications

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93
Q

what is the pathophysiology of T2DM?

A

post receptor resistance
50% of beta cell mass usually lost => greater amounts of insulin produced by fewer beta cells => hyperglycaemia and lipid excess are toxic to beta cells.

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94
Q

What are 7 clinical manifestations of T2DM?

A

polyuria, nocturia + polydypsia
Weight loss and fatigue
glycosuria
Acanthosis nigricans - black pigment on nape of neck and axillae
Opportunistic infections
slow wound healing

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95
Q

what is the HbA1c in pre-diabetes?

A

42-47 mmol/mol

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96
Q

what is the HbA1c target for a new diabetic?

A

48 mmol/mol

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97
Q

what is the HbA1c target for a patient requiring more than one antidiabetic?

A

53 mmol/mol

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98
Q

How often is HbA1c measured in T2DM?

A

3-6 monthly until stable

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99
Q

What is the 1st line management of T2DM?

A

LIFESTYLE

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100
Q

what is the 1st line medication in T2DM?

A

Metformin 500mg OD initially

Can increase up to 2g OD/1g BD

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101
Q

what is the 1st line medical management of T2DM if metformin is contraindicated?

A

with CVD - SGLT-2 inhibitor

NO CVD - DDP-4 inhibitor or pioglitazone or sulfonylurea

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102
Q

what additional medication should people with Diabetes AND CVD, heart failure or a Qrisk >10% be put on?

A

SGLT-2 inhibitor

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103
Q

what is the 2nd line management of T2DM?

A

ADD

Sulfonylurea
OR
Pioglitazone
OR
DPP-4 inhibitor
OR
SGLT-2 inhibitor

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104
Q

what is the 3rd line management of T2DM?

A

Tripple therapy - metformin + 2 others
OR
Insulin therapy

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105
Q

what is one option in T2DM if triple therapy fails in a patient with BMI >35?

A

switch one drug to GLP-1 mimetic (liraglutide)

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106
Q

what class is metformin?

A

Biguanide

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107
Q

what does metformin do?

A

increases insulin sensitivity and decreases glucose production by liver

does not cause weight gain or hypoglycaemia

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108
Q

what are 2 notable side effects of metformin?

A

GI symptoms - trial of MR formulation

Lactic acidosis - usually secondary to AKI - stop in AKI

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109
Q

what are 4 examples of SGLT-2 inhibitors?

A

empagliflozin
canagliflozin
Dapagliflozin
Ertugliflozin

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110
Q

what is the MOA of SGLT-2 inhibitors?

A

Block resorption of glucose in kidneys by sodium glucose co-transporter 2 proteins in proximal tubule

leads to reduced BMs, BP, weight loss, improves heart failure

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111
Q

what are 7 notable side effects of SGLT-2 inhibitors?

A

Normoglycaemic DKA
Glycosuria
Increased frquency and urgency
Weight loss
Genital and UTIs
lower limb amputaton
Fournier’s gangrene

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112
Q

what is the MOA of pioglitazone?

A

Thiazolidinedione that increases insulin sensitivity and decreases liver production of glucose

DOES NOT typically cause hypoglycaemia

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113
Q

what are 4 notable side effects of pioglitazone?

A

weight gain
heart failure
increased fracture risk
small increased risk of bladder cancer

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114
Q

how do sulfonylureas work?

A

stimulate insulin release from pancreas

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115
Q

what is the most common sulfonylurea?

A

gliclazide

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116
Q

what are 4 notable side effects of sulfonylureas?

A

weight gain
hypoglycaemia
SIADH
Liver dysfunction

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117
Q

what are 2 examples of DDP-4 inhibtors?

A

Sitagliptin
Alogliptin

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118
Q

how do DPP-4 inhibitors work?

A

block action of DDP-4 which allows for increased incretin (GLP-1) activity by decreasing peripheral breakdown and allowing for increased insulin secretion, inhibition of glucagon production, slower absorption from GI tract

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119
Q

what are 2 notable side effects of DPP-4 inhibitors?

A

Headaches
Acute pancreatitis

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120
Q

what are 2 examples of GLP-1 mimetics?

A

exenatide
liraglutide

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121
Q

what are 3 side effects of GLP-1 mimetics?

A

weight loss
reduced appetite
GI symptoms

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122
Q

what is seen as impaired fasting glucose?

A

fasting glucose 6.1-7.0

then >7 = diabetes

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123
Q

what is the inheritance of MODY (maturity onset diabetes of the young)?

A

Autosomal dominant

usually onset <25 years

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124
Q

what are the features of MODY?

A

Usually picked up incidentally

presents with non-ketosis hyperglycaemia and patients are often a normal weight

usually does not require treatment or can be treated with sulfonylureas or insulin

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125
Q

What is Grave’s disease?

A

An autoimmune thyroid condition associated with hyperthyroidism and over production of thyroid hormones

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126
Q

are thyroid disorders and cancers more common in men or women?

A

women

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127
Q

what causes Grave’s disease?

A

thyroid hormone overproduction stimulated by TSH receptor antibodies
can be genetic

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128
Q

What are 4 risk factors for Grave’s disease?

A

FHx
Autoimmune disease
Stress
High Iodine intake

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129
Q

What is the pathophysiology for Grave’s disease?

A

TSH receptor autoantibodies cause thyroid hormone hyperproduction as well as thyroid hypertrophy and hyperplasia of thyroid follicular cells resulting in the clinical manifestations of hyperthyroidism and diffuse goiter.

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130
Q

What are 6 clinical presentations of Grave’s disease?

A

Thyroid acropachy - clubbing, and hand swelling
Thyroid bruit
Pretibial myxoedema
Diffuse goitre
Thyroid eye disease
Hyperthyroidism signs - heat intolerance, sweating, tremor

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131
Q

What is the diagnostic test for Grave’s disease?

A

serum TSH receptor antibodies - present

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132
Q

what are 4 differential diagnoses for Grave’s disease?

A

toxic nodular goitre
post-natal thyroiditis
TSH producing pituitary adenoma
Excessive thyroxine

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133
Q

What is the management of Grave’s disease?

A

1 - Carbimazole 15-40mg OD for 4-8 weeks then reduce gradually over 12-18 months

2 - Propylthiouracil 200-400mg OD till euthyroid then reduce over time

3 - radioactive iodine treatment, thyroidectomy

Beta blockers - propranolol 10-40mg T/QDS - for symptom control

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134
Q

what are 2 adverse effects of carbimazole?

A

Acute pancreatitis
Agranulocytosis (also propylthiouracil)

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135
Q

what are 6 complications of graves disease?

A

AF
Pregnancy related issues - miscarriage, prem, thyroid dysfunction of foetus
Sight threatening orbitopathy
Osteoporosis
Congestive heart failure
Thyroid storm

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136
Q

what is thyroid storm?

A

rare but life threatening sudden significant rise in thyroid hormone levels resulting in fever, profuse sweating, diarrhoea, vomiting, delerium, profound weakness, seizure, jaundice, raised HR, BP and temp and eventually coma

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137
Q

what are 4 complications of Grave’s disease?

A

bone mineral loss
AF/congestive heart failure
sight threatening complications
elephantiasis dermopathy

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138
Q

what is Hashimoto’s thyroiditis?

A

an autoimmune-mediated lymphocytic inflammation of the thyroid gland resulting in a destructive thyroiditis with release of thyroid hormone causing transient hyperthyroidism (for 2/3 months) then permanent hypothyroidism

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139
Q

what are 3 risk factors for Hashimoto’s thyroiditis?

A

Female
Autoimmune disease
genetics - Turner’s/Down’s

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140
Q

what antibodies cause Hashimoto’s thyroiditis and what do they do?

A

ant-Thyroid peroxidase antibodies

attack thyroid cells causing fibrosis and the release of stored thyroid hormone causing transient hyperthyroidism for a few months before stores run out and permanent hypothyroidism ensues

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141
Q

what are 3 features of hashimoto’s thyroiditis?

A

Hypothyroidism features
firm non-tender goitre
anti-TPO antibodies

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142
Q

what is the gold standard test for Hashimoto’s thyroiditis?

A

serum ant-Thyroid peroxidase antibodies

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143
Q

what is the management of Hashimoto’s?

A

levothyroxine

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144
Q

what are 3 complications of Hashimoto’s?

A

Atrial fibrillation
IHD/CHF
low risk of developing Grave’s disease

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145
Q

what is the prognosis for Hashimoto’s thyroiditis?

A

Permanent hypothyroidism and treatment with levothyroxine

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146
Q

What is defined as the normal range for serum potassium?

A

3.5-5.3 mmol/L

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147
Q

what is seen as mild hyperkalaemia?

A

5.4-5.9 mmol/L

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148
Q

what is seen as moderate hyperkalaemia?

A

6-6.4 mmol/L

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149
Q

what is seen as severe hyperkalaemia?

A

> 6.5 mmol/L

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150
Q

what are 7 causes of hyperkalaemia?

A

AKI
CKD - stage 4/5
Rhabdomyolysis
Adrenal insufficiency - Addison’s disease
Tumour lysis syndrome
Massive blood transfusion
Medications

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151
Q

what are 6 medications that can cause hyperkalaemia?

A

Aldosterone antagonists - spironolactone, eplerenone
ACEi
ARBs
NSAIDs
Ciclosporin - calcineurin inhibitors
heparin

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152
Q

what are 4 clinical manifestations of hyperkalaemia?

A

Muscle cramps/ weakness
ECG changes
Paraesthesia
Palpitations

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153
Q

what 5 ECG changes are present in hyperkalaemia?

A

Tall peaked (tented) T waves
Long PR (>200ms)
Loss of P waves
Broad QRS (>100ms)
Sinusoidal wave pattern

Can cause ventricular fibrilation

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154
Q

what are the 2 indications for emergency treatment of hyperkalaemia?

A

ECG changes
Potassium >6.5 mmol/L

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155
Q

what is given in a hyperkalaemic emergency?

A

IV calcium gluconate/chloride 10ml 10% - stabilise cardiac membrane (does not lower K+)

Insulin/glucose infusion - 10 units insulin and 25g glucose - given over 15-30 mins
Nebulised salbutamol

Haemodialysis

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156
Q

what is a complication of hyperkalaemia?

A

life threatening arrhythmias and cardiac arrest

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157
Q

what can be given in hyperkalaemia to bind potassium?

A

Sodium ziconium cyclosilicate 30mg PR

Patiromer calcium

No longer recommended -Calcium polystyrene sulfonate (resonium) - enema or oral - enema more effective

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158
Q

What is the pathophysiology of Hyperosmolar Hyperglycaemic state?

A

Hyperglycaemia drives osmotic diuresis leading to fluid and electrolyte loss
Due to small amounts of insulin present lipolysis does not occur hence no ketoacidosis

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159
Q

what are 5 key features of HHS?

A

Hyperglycaemia
Hyperosmolality (>320 mosmol/Kg)
Dehydration
Electrolyte abnormalities
WITHOUT Ketoacidosis

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160
Q

what are 3 risk factors for HHS?

A

Infection
MI
Poor medication compliance

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161
Q

what are 5 clinical manifestations for HHS?

A

Weakness and leg cramps
Reduced GCS, confusion, lethargy, headache, seizure
polyuria/oliguria + polydipsia
Nausea, Vom ,abdo pain
Dehydration - tachy, hypotension, dry

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162
Q

what are the four 1st line investigations for HHS

A

Serum/urine glucose
U+Es
ABG
Blood/urinary ketones

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163
Q

what is the gold standard test for HHS?

A

serum osmolality - raised

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164
Q

How can serum osmolarity be calculated?

A

2(Na+) + Glucose + Urea

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165
Q

what is the diagnostic criteria for HHS?

A

Hyperglycaemia >30 mmol/L
Hyperosmolality >320 mOsmol/Kg
Hypovolaemia

NO hyperketonaemia
NO acidosis (pH >7.3, Bicarb >15)

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166
Q

what is the management for HHS?

A

1st line - fluid replacement (0.9% saline), potassium replacement if low

adjuncts - LMWH, restore electrolyte loss, insulin if needed

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167
Q

when should insulin be given in HHS?

A

only IF blood glucose stops falling with IV fluids alone

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168
Q

How slowly should plasma sodium fall in HHS?

A

no quicker than 10 mmol/24 hours

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169
Q

How quickly should plasma glucose fall in HHS?

A

4-6 mmol/hour

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170
Q

what are 4 complications of HHS?

A

CV - VTE, arrythmias, MI
Neuro - stroke, seizure
Renal - AKI
Iatrogenic - cerebral oedema/cerebral pontine myelinolysis

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171
Q

what are 5 causes of hyperthyroidism?

A

Grave’s disease (most common)
Toxic multinodular goitre
Thyroiditis
Thyroid cancer
subacute thyroiditis (granulomatous or De Quervain’s)

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172
Q

what are 8 risk factors for hyperthyroidism?

A

female
post-partum
60+
FHx
autoimmune diseases
radiation
lithium therapy
smoking

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173
Q

What are 5 symptoms of hyperthyroidism?

A

Heat intolerance/sweating
palpitations/tremor
irritability
menstrual irregularities/sexual dysfunction
Goitre

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174
Q

what are 5 signs of hyperthyroidism?

A

orbitopathy (Grave’s)
cardiac flow murmur (thyroid bruit)
scalp hair loss
acropachy (Grave’s)
weight loss

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175
Q

what is the gold standard investigation for hyperthyroidism?

A

serum free total T3/4

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176
Q

what are 3 investigations for hyperthyroidism?

A

TSH - high/low
TSH receptor antibodies - present in Graves
Serum free/total T3/T4 - high

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177
Q

what are 6 causes of primary hyperthyroidism?

A

Graves - most common
Toxic multinodular goitre
Toxic adenoma
Subclinical hyperthyroidism
Thyroiditis - de quervains, hashimotos, post partum
Drugs - amiodarone, lithium

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178
Q

what is toxic multinodular goitre?

A

Several autonomously functioning thyroid gland nodules resulting in hyperthyroidism - often benign but can be malignant

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179
Q

what are 3 causes of secondary hyperthyroidism?

A

Pituitary adenoma - secreting TSH
Ectopic tumour - hCG secreting tumour (choriocarcinoma)
Hypothalamic tumour

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180
Q

what is hypokalaemia?

A

serum potassium <3.5 mol/L

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181
Q

what is mild hypokalaemia?

A

3.0-3.5 mmol/L

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182
Q

what is moderate hypokalaemia?

A

2.5-3.0 mmol/L

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183
Q

what is severe hypokalaemia?

A

<2.5 mmol/L

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184
Q

what can cause hypokalaemia? (7)

A

Excessive losses - D+V, high output stoma, dialysis, burns
Reduced intake
Malabsorption
Diuretics - loop and thiazide diuretics
Insulin
Salbutamol
Metabolic alkalosis - increased pH causes increased activity of H+/K+ antiporter operating to correct alkalosis

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185
Q

what are 5 risk factors for hypokalaemia?

A

older age
Medications - salbutamol, loop and thiazide diuretics, insulin
Co-morbidities - diabetes, renal disorders
poor dietary intake
Cushing’s syndrome

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186
Q

what are 7 clinical manifestations of hypokalaemia?

A

Muscle weakness, cramps and pain
Hypotonia
Fatigue
Palpitations
Constipation - due to reduced peristalsis
Reduced deep tendon reflexes

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187
Q

what is seen in ECG in Hypokalaemia/

A

U waves - extra wave after T wave
Small/absent/inverted T waves
Prolonged PR interval
ST depression
long QT

U have no Pot and no T but a long PR and a long QT

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188
Q

what is one important medication side effect in hypokalaemia?

A

Increases risk of digoxin toxicity - take care with diuretics

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189
Q

does hypokalaemia tend to be associated with acidosis or alkalosis?

A

Alkalosis - low potassium causes influx of H+ ions into cells to allow K+ to leave cells and enter serum

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190
Q

what are 4 causes of hypokalaemia with alkalosis?

A

Vomiting
thiazide and loop diuretics
Cushing’s syndrome
Primary hyperaldosteronism

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191
Q

what are 3 causes of hypokalaemia with acidosis?

A

diarrhoea
renal tubular acidosis
acetazolamide
Partially treated DKA

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192
Q

what other electrolyte deficiency is associated with hypokalaemia?

A

hypomagnesaemia

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193
Q

what is the management of hypokalaemia?

A

Mild-moderate (>2.5) - Oral potassium replacement - Sando-K

Severe (<2.5) - IV potassium - 20-40mmol K+ in 0.9% NaCl

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194
Q

what is the fastest you can replace potassium peripherally IV?

A

10 mmol per hour

e.g 40 mmol in 1L of saline bag ran over 4 hours fastest

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195
Q

what can cause hypoparathyroidism?

A

post-surgery
genetic and autoimmune conditions - (di george syndrome)
iron and copper overload (haemochromatosis or Wilson’s disease)
idiopathic
Prolonged hypomagnesaemia can suppress PTH

196
Q

what are 3 risk factors for hypoparathyroidism?

A

thyroid/parathyroid surgery, hypomagnesianism, transfusional iron overload (in thalassaemia)

197
Q

what does parathyroid hormone do? (3)

A

Acts to increase serum calcium:

Increase renal calcium absorption and phosphate excretion

Increased production of 1,25-dihydroxyvitamin D in kidney

Increase bone calcium resorption

198
Q

what is normal serum calcium?

A

2.2-2.6 mmol/L

199
Q

what is the physiology of the parathyroid gland?

A

Chief call produce parathyroid hormone and store it in secretory granules

Serum calcium is detected by calcium sensing receptors on the cell surface which control the release of PTH

Higher serum calcium inhibits PTH release and low calcium leads to more PTH release

200
Q

what is the physiology of PTH in bone?

A

increases activity and number of osteoclasts leading to calcium and phosphate release from the bone

201
Q

What is the physiology of parathyroid action on the kidney? 3

A

1 - Stimulates calcium reabsorption in distal CT and collecting duct

2 - Decreases phosphate reabsorption in proximal CT

3 - stimulates conversion of 25-hydroxyvitamin D into the active for 1,25-dihydroxyvitamin D (CALCITRIOL)

202
Q

what is the activation pathway of vitamin D?

A

Dietary vitamin D

Converted to 25-hydroxyvitamin D by liver 25-hydroxylase enzyme

Converted to 1,25-dihydroxyvitamin D in kidney by 1-hydroxylase enzyme

203
Q

what is the name of the active form of vitamin D?

A

1,25-dihydroxyvitamin D

CALCITRIOL

204
Q

How does active vitamin D (calcitriol) affect calcium, phosphate and parathyroid? 3

A

Increases calcium and phosphate absorption in small intestine

Increases calcium and phosphate reabsorption in kidneys

Inhibits PTH release through negative feedback

205
Q

what is calcitonin?

A

a hormone excreted by thyroid parafollicular (C-cells) that acts opposite to PTH

Inhibits osteoclast activity in bone
inhibits calcium reabsorption in kidneys

206
Q

How does high phosphate affect calcium?

A

Phosphate ions bind to calcium ions to become calcium phosphate which the amount of free calcium in the blood

Lower phosphate leads to higher serum calcium

207
Q

What are 3 GI presentations of hypoparathyroidism?

A

malnutrition
malabsorption
diarrhoea

208
Q

what are 6 presentations of hypoparathyroidism?

A

muscle twitches/spasms
parasthesia, numbness and tingling
convulsions
irregular heartbeat
tachycardia
Trousseau’s and Chvostek’s signs

209
Q

what are the two examination signs for hypocalcaemia?

A

Trousseau’s sign – involuntary wrist spasm causing adduction of thumb, flexion of MCP joints and extension of interphalangeal joints with wrist flexion (Italian hand) when inflating BP cuff

Chvostek’s sign – twitching of facial muscle due to tapping over facial nerve (parotid)

210
Q

What are 3 differentials for hypoparathyroidism?

A

hypovitaminosis D
hypomagnaesaemia
renal failure/CKD

211
Q

a deficiency of what mineral exacerbates hypocalcaemia?

A

magnesium

212
Q

what are 3 complications of hypoparathyroidism?

A

Renal stones
Ectopic calcifications
Renal failure
Cataracts
arrythmia, cardiac arrest, tetany, death

213
Q

What are 5 investigations for hypoparathyroidism?

A

PTH
Calcium
phosphate
magnesium
Vitamin d

ECG - Long QT

214
Q

what are the 2 forms of thyroid hormone?

A

Triiodothyronine - T3
Thyroxine - T4

215
Q

what is the physiology of the thyroid gland?

A

Hypothalamus produces TRH

TRH stimulates anterior pituitary to secrete TSH

Thyroid gland produces T4+T3 in response to TSH by oxidising iodide to iodine and adding it onto tyrosine residues on thryroglobulin using thyroid peroxidase (TPO)

Most T3/4 is bound to thyroglobulin, only free T3/4 is active

Free thyroid hormones act on hypothalamus as -ve feedback

216
Q

which thyroid hormone is produced more?

A

T4 > T3

Free T4 more reliable indicator of thyroid function on testing

217
Q

what is the half life of T4?

A

1 week - need to wait a few weeks before retesting T4

218
Q

what is primary hypothyroidism?

A

due to pathology affecting the thyroid gland (hashimotos) OR iodine deficiency

219
Q

what is secondary hypothyroidism?

A

due to pathology affecting the pituitary - pituitary apoplexy or tumour - OR hypothalamic disorders and drugs

220
Q

What are 6 causes of primary hypothyroidism?

A

Hashimotos (most common cause in developed world)
iodine deficiency
De Quervain’s thyoiditis
Post-partum thyroiditis
Riedel’s thyroiditis
Thyroidextomy/radiation
Drugs - amiodarone, lithium, antithyroid drugs (carbimazole)

221
Q

what is De Quervain’s thyroiditis?

A

Subacute thyroiditis occurring after viral infection

Phase 1 - 3-6 weeks of hyperthyroidism, painful goitre, raised ESR
phase 2 - 1-3 weeks euthyroid
phase 3 - weeks to month - hypothyroidism
phase 4 - back to normal

222
Q

what is seen on thyroid scintigraphy in de Quervain’s thyroiditis?

A

globally reduced uptake of iodine-131

223
Q

what are 5 causes of secondary hypothyroidism?

A

Tumours - pituitary adenoma
Surgery to pituitary
radiotherapy
Sheehan syndrome - major PPH causes avascular necrosis of pituitary
Trauma

224
Q

what are 3 drugs that can inhibit TSH secretion?

A

Cocaine
Steroids
Dopamine

225
Q

what are 7 risk factors for hypothyroidism?

A

Female
Middle age
Post-partum
radiotherapy
Autoimmune conditions - T1DM, coeliac
Genetic disorders - turners, downs
FHx

226
Q

What are 8 presentations of hypothyroidism?

A

lethargy
constipation
weight gain
dry/coarse skin and hair
bradycardia
Goitre
cold sensitivity
Menorrhagia, oligomenorrhoea and amenorrhoea

227
Q

what are 3 initial investigations for hypothyroidism?

A

Thyroid function tests - TSH increased and T3/4 low in primary, both low in secondary

Antibody tests - Anti-TPO in hashimotos

Inflammatory markers - raised in De Quervain’s thyroiditis

228
Q

what is the first line management of hypothyroidism?

A

levothyroxine 50-100mcg OD starting dose

Review every 3 months initially then annually once stable

start on 25 mcg OD in >64 or Hx of IHD

229
Q

What 2 drugs reduce absorption of levothyroxine?

A

Iron
alcium carbonate

should take >4 hours apart

230
Q

what happens to thyroxine demand in pregnancy?

A

Higher demand => dose usually increased 25-50 mcg

231
Q

what are 5 complications of hypothyroidism?

A

CVD - hypercholesterolaemia
Neruo - carpal tunel, peripheral neuropathy
Myxoedema coma - confusion, hypothermia, hypoglycaemia, hypoventilation, hypotension
Increased risk of lymphoma

232
Q

what is subclinical hypothyroidism?

A

Elevated TSH but normal T4 levels - can cause or not cause symptoms

requires regular monitoring

TSH >10 + T4 normal - consider thyroxine

TSH 5.5-10 and T4 normal - consider 6 month trial of thyroxine in <65 years

233
Q

what are 4 side effects of thyroxine?

A

Hyperthyroidism
AF
Osteoporosis
Angina

234
Q

What is phaeochromocytoma?

A

A tumour arising from catecholamine-producing chromaffin cells of the adrenal medulla which produces catecholamines (ADRENALIN)

235
Q

what are 3 genetic disorders which increase risk of Phaeochromocytoma?

A

Multiple endocrine neoplasia 2 (MEN2)
Neurofibromatosis 1
Von Hippel-Lindau disease

236
Q

what % of Phaeochromocytomas are bilateral, cancerous and outside the adrenal gland?

A

10% of each

237
Q

are extra-adrenal phaeochromacytomas more common in children or adults and are they more likely to be malignant or not?

A

Children

more likely to be malignant

238
Q

what are 6 key presentations of phaeochromacytomas?

A

Episodic

Anxiety
Palpitations + tachycardia
Hypertension
Diaphoresis
Tremor
Headache

239
Q

What are 2 initial investigations for phaeochromacytomas?

A

24h urinary metanephrines

Plasma free metanephrines

240
Q

what are 4 differentials of phaeochromacytomas?

A

anxiety and panic attacks
essential hypertension
hyperthyroidism
cardiac arrhythmias

241
Q

what is the management of phaeochromacytomas?

A

Medical stabalisation THEN surgery

Alpha blockers - phenoxybenzamine or doxazosin

Beta blockers - only AFTER alpha blockers

Surgical removal of tumour - adrenalectomy

242
Q

what is 1 complication of phaeochromacytoma?

A

hypertensive crisis - if beta blockers started before alpha

243
Q

what are 3 risk factors for pituitary adenomas?

A

MEN-1
familial associated pituitary adenoma
Carney complex

244
Q

What are 4 key presentations of pituitary adenomas?

A

compressive effects - headache, bitemporal hemianopia, cranial nerve palsy, DI
Cushing’s
Acromegaly
Prolactinoma - galactorrhea, lack of libido, erectile dysfunction

245
Q

what is the most common type of pituitary adenoma?

A

prolactimona

246
Q

what is classed as a micro pituitary adenoma vs a macro pituitary adenoma?

A

micro <1cm
macro >1cm

247
Q

What are 3 investigations that can be done in pituitary adenomas?

A

Non-contrast MRI head
Visual field testing
Pituitary blood profile - GH, Prolactin, ACTH, FSH, LSH, TFTs

248
Q

what are 4 differentials for pituitary adenomas?

A

pituitary hyperplasia
craniopharyngioma
meningioma
brain mets

249
Q

what is the management of pituitary adenomas?

A

Medical
- Prolactinoma - cabergoline
- GH secreting - somatostatin analogues, GH receptor antagonists

transphenoidal surgery

radiotherapy

250
Q

what are 6 causes of raised prolactin?

A

6Ps

Pregnancy
Prolactinoma
Physiological - stress, ecercise, sleep
PCOS
Primary Hypothyroidism
Phenothiazines, metoclopramide, domperidone

251
Q

what are features of excessive prolactin in men and women?

A

Men - impotence, loss of libido, galactorrhoea

Women - amenorrhoea, galactorrhea, infertility, osteoporosis

252
Q

what are 3 complications of pituitary adenomas?

A

meningitis
Diabetes insipidus
hypopituitarism

253
Q

What is pituitary apoplexy?

A

sudden enlargement of pituitary tumour (usually non-functioning macroadenoma) secondary to haemorrhage or infarction

254
Q

what are 4 precipitating factors for pituitary apoplexy?

A

Hypertension
pregnancy
trauma
anticoagulation

255
Q

what are 6 features of pituitary apoplexy?

A

sudden onset headache
vomiting
neck stiffness
visual field defects - bitemporal superior quadrantic defect
extraocular nerve palsies
pituitary insufficiency

256
Q

what is the 1st line investigation of pituitary apoplexy?

A

MRI head

257
Q

what is the management of pituitary apoplexy?

A

Steroid replacement - due to loss of ACTH
Fluid balance
Surgery

258
Q

what is primary hyperparathyroidism?

A

Excess secretion of PTH leading to hypercalcaemia

usually due to a parathyroid adenoma

259
Q

what causes primary hyperparathyroidism?

A

80% due to benign parathyroid adenoma

Genetics -
MEN1/2A/4 , hyperparathyroidism jaw tumour syndrome, familial isolated primary hyperparathyroidism

<1% due to parathyroid malignancy

260
Q

what are 4 risk factors for primary hyperparathyroidism?

A

female
Older age - >50-60
FHx
MEN 1/2A/4

261
Q

what is the pathophysiology of primary hyperparathyroidism?

A

PTH is inappropriately not suppressed in normal or high calcium levels leading to over stimulation of bone resorption, kidney absorption and vitamin D conversion causing calcium levels to rise

262
Q

What are the 4 clinical presentations of primary hyperparathyroidism?

A

Most commonly asymptomatic

Symptoms of hypercalcaemia - bones, stones, moans, groans

Polyuria, parasthesia, muscle cramps

263
Q

what are 3 investigations of primary hyperparathyroidism?

A

Serum calcium
Serum PTH
Kidney function tests - CKD can lead to secondary/tertiary hyperparathyroidism
Vitamin D

US neck
Sestamibi scan
4D CT neck

264
Q

what are 4 differentials for primary hyperparathyroidism?

A

secondary/tertiary hyperparathyroidism

familial hypocalciuric hypercalcaemia

Malignancy - multiple myeloma

medications - thiazides

265
Q

what is the management of primary hyperparathyroidism?

A

1 - parathyroidectomy, monitoring

Calcitonin
Cinacalcet - mimics calcium to cause negative feedback
Desunomab
Bisphosphonates

266
Q

what are 4 complications of primary hyperparathyroidism?

A

Osteoporosis + fractures
Kidney stones and injury
Hypertension and CVD
GI disorders - peptic ulcers, pancreatitis, gall stones

267
Q

what are 4 indications for parathyroidectomy in primary hyperparathyroidism?

A

Symptomatic disease - hypercalcaemia, osteoporosis, renal stones
>50 years
serum calcium >2.85
eGFR <60

268
Q

what is secondary adrenal insufficiency?

A

decreased cortisol production as a result of negative feedback on the hypothalamic-pituitary-adrenal axis, caused by excess glucocorticoids

269
Q

what kind of patients is secondary adrenal insufficiency common in?

A

those treated with glucocorticoids - asthma, COPD, arthritis

270
Q

what 3 causes of secondary adrenal insufficiency?

A

exogenous glucocorticoids
glucocorticoid secreting adrenal adenomas
hypothalamic pituitary disease

271
Q

what are 2 risk factors for secondary adrenal insufficiency?

A

glucocorticoids

medroxyprogesterone use

272
Q

what is the pathophysiology of secondary adrenal insufficiency?

A

Exposure to excess glucocorticoids => negative feedback to hypothalamus-pituitary-adrenal axis => patients may have Cushing’s symptoms due to excess glucocorticoids

273
Q

What are 5 clinical presentations of secondary adrenal insufficiency?

A

tachycardia
hypotension
Cushingoid examination features
shock - fatigue, abdo pain, weakness, vomiting, hypotension

274
Q

What are 5 investigations for secondary adrenal insufficiency?

A

serum chemistry panel - electrolyte abnormalities
serum a.m cortisol - low
salivary am cortisol - low
FBC - WBCs may be elevated
thyroid function test - possible elevated free thyroxine

275
Q

what is the gold standard test for secondary adrenal insufficiency?

A

ACTH stimulation test - cortisol levels won’t rise enough in secondary adrenal insufficiency

276
Q

what are 4 differentials for secondary adrenal insufficiency?

A

primary adrenal insufficiency
pituitary compression
tumour
head trauma

277
Q

what is the treatment for primary adrenal insufficiency ?

A

hydrocortisone - in crisis
double dose corticosteroid in minor crisis
corticosteroid taper in stable patients
supportive measures

278
Q

what are 2 complications of primary adrenal insufficiency?

A

corticosteroid dependence

permanent recurrence of adrenal crisis

279
Q

What is syndrome of inappropriate ADH?

A

Continues secretion of ADH despite plasma being very dilute leading to retention of water, excess blood volume and hyponatraemia

280
Q

what is the most common electrolyte disorder?

A

hyponatraemia

281
Q

what is syndrome of inappropriate antidiuretic hormone?

A

Increased release of ADH from the posterior pituitary leading to increased water reabsorption from urine causing diluted blood and hyponatraemia

282
Q

what is the pathophysiology of SIADH?

A

either increased secretion of ADH by posterior pituitary or ectopic ADH secretion commonly from small cell lung cancer

increased ADH leads to increased water reabsorption in collecting ducts which leads to euvolaemic hyponatraemia and concentrated urine with a high osmolality

283
Q

What are 7 causes of SIADH?

A

Post operative
Malignancy - Small cell lung cancer
lung infection - atypical pneumonia, lung abscesses
Brain pathologies - head injury, stroke, IC haemorrhage, meningitis
Medication - SSRIs, carbamazepine
HIV

284
Q

what are 6 risk factors for SIADH?

A

50+
pulmonary conditions
malignancy
Drugs

285
Q

what are 6 clinical manifestations of SIADH?

A

Headache
fatigue
muscle aches and cramps
confusion

seizures

286
Q

what are 5 investigations for SIADH?

A

Serum sodium - low
Serum osmolality - low
serum urea - usually low
urine osmolality - high
urine sodium - high

287
Q

what is the plasma osmolality equation?

A

plasma osmolality = 2 (Na+) + 2(K+) + glucose + urea (all in mol/L)

288
Q

what is the management for SIADH?

A

Fluid restriction - 540-1000ml per day
Vasopression receptor antagonist - tolvaptan - causes rapid rise in sodium

289
Q

what is a complication of SIADH?

A

central pontine myelinolysis

290
Q

what can cause central pontine myelonolysis?

A

rapid sodium serum correction >12mEq/L/Day

291
Q

what is the most common endocrine malignancy?

A

thyroid cancer

292
Q

when is thyroid cancer most common?

A

early adulthood - 30s-40s

293
Q

what are the 4 most common thyroid cancers?

A

papillary
follicular
anapaestic
medullary

294
Q

what are 3 risk factors for thyroid cancer?

A

head and neck irradiation
female
FHx

295
Q

What are 6 presentations of thyroid cancer?

A

palpable thyroid nodule
hoarse voice
dyspnoea (SOB)
dysphagia
rapid neck enlargement
tracheal deviation

296
Q

what are 4 investigations for thyroid cancer?

A

Thyroid function test
Neck ultrasound - nodules
fine needle biopsy
larangoscopy

297
Q

what are 2 differentials for thyroid cancer?

A

benign thyroid nodule

goitre

298
Q

what is the management of thyroid cancer?

A

surgery - lobectomy
radioactive iodine ablation
TSH suppression
chemo

thyroid replacement after

299
Q

what are 4 complications of thyroid cancer?

A

hypocalcaemia (parathyroid injury)
airway obstruction
recurrent laryngeal nerve injury
secondary tumours

300
Q

where is erythropoietin produced and what does it do?

A

kidneys (peritubular cells)

stimulates maturation of erythrocytes

301
Q

What is the blood supply to the adrenal glands?

A

superior adrenal artery - from inferior phrenic
middle adrenal artery - from abdominal aorta
inferior adrenal artery - from renal artery

302
Q

what does the zone glomerulosa produce?

A

Mineralocorticoids - ALDOSERONE

303
Q

what does the zona fasiculata produce?

A

Glucocorticoids - CORTISOL

304
Q

what does the zona reticularis produce?

A

ANDROGENS

305
Q

what are corticosteroids?

A

mineralocorticoids + glucocorticoids (aldosterone + cortisol)

306
Q

what do mineralocorticoids do?

A

regulate body electrolytes

aldosterone - maintain salt balance, BP, RAAS

307
Q

what triggers the secretion of aldosterone?

A

release of renin by juxtaglomerular cells in afferent arterioles of kidneys

308
Q

what is the function of cortisol?

A

suppresses immune system
inhibits bone formation
increases metabolism - protein catabolism & lipolysis, gluconeogenesis, increases alertness.

309
Q

what triggers secretion of cortisol?

A

stress => hypothalamus => corticotrophin releasing hormone (CRH) => anterior pituitary => adrenocorticotropic releasing hormone (ACTH) => cortisol release from adrenal cortex

310
Q

what does adrenaline release stimulate?

A

gluconeogenesis
lipolysis
tachycardia
redistribution of circulating volume
vasoconstriction
vasodilation (due to less noradrenaline)

311
Q

what vertebral level is the thyroid located at?

A

C5-T1

312
Q

what is the connection called in the thyroid?

A

isthmus

313
Q

what arteries supply the thyroid?

A

superior and inferior thyroid arteries

314
Q

what week in utero does thyroxine begin to be releases?

A

18-20 weeks

315
Q

what is produced in the parafolicular cells/ C cells?

A

calcitonin

316
Q

what is produced in the follicular cells of the thyroid?

A

T3 and T4

317
Q

what does the follicle of the thyroid contain?

A

thyroglobulin - iodine store

318
Q

what embryological tissue is the anterior pituitary formed from?

A

Ectoderm - Rathke’s pouch

319
Q

what embryological tissue if the posterior pituitary formed from?

A

floor of the 3rd ventricle

320
Q

what 6 hormones are released by the hypothalamus?

A

corticotropin releasing hormone - CRH
GHRH
thyrotropin releasing hormone - TRH
Gonadatrophin releasing hormone - GnRH
Dopamine

321
Q

what 6 hormones are released by the anterior pituitary?

A

FSH - follicle stimulating hormone
LH - luteinizing hormone
Adrenocorticotrophic hormone - ACTH
TSH - thyroid stimulating hormone
Prolactin
Growth Hormone

FLAT PG

322
Q

What 2 hormones are released from the posterior pituitary?

A

Anti-diuretic hormone
Oxytocin

323
Q

Where in the brain is the ADH release stimulated from in the brain?

A

supraoptic nucleus

324
Q

Where in the brain is the oxytocin release stimulated from in the brain?

A

paraventricular nucleus

325
Q

what do delta cells in the pancreas release?

A

somatostatin

326
Q

What is thyroid storm?

A

A rare but life threatening condition of untreated thyrotoxicosis (hyperthyroidism) causing irritability, high systolic and low diastolic BP, tachycardia, nausea, vomiting and diarrhoea

327
Q

what is the most common cause of Primary hyperaldosteronism ?

A

Idiopathic adrenal hyperplasia

328
Q

what does the RAAS system regulate?

A

BP
Electrolyte balance
Blood vessel and cardiac remodelling

329
Q

where is renin secreted from?

A

Juxtaglomerular cells at afferent arterioles

Sense BP and increase renin production when BP is low

330
Q

where is angiotensin produced?

A

liver

331
Q

where is angiotensin I converted to angiotensin II?

A

Lungs by ACE

332
Q

what are 3 effects of angiotensin II?

A

Vasoconstriction
Hypertrophy and remodelling of heart and blood vessels if chronically high
Stimulates aldosterone release by adrenals

333
Q

what is the action of aldosterone?

A

Increases sodium reabsorption in distal tubule
Increases potassium secretion in distal tubule
Increases H+ secretion from collecting ducts

Leads to increased fluid retention, increased BP, hypernatremia and hypokalaemia

334
Q

what is the synthetic form of aldosterone?

A

Fludrocortisone

335
Q

what are 3 features of Primary hyperaldosteronism ?

A

Hypertension
Hypokalaemia
Metabolic alkalosis - due to H+ excretion

336
Q

what is the 1st line investigation for Primary hyperaldosteronism?

A

Plasma aldosterone/renin ratio

High aldosterone, low renin

337
Q

what imaging is used in Primary hyperaldosteronism ?

A

high resolution CT abdo

If normal also Adrenal venous sampling

338
Q

what is the management of Primary hyperaldosteronism?

A

Aldosterone antagonist - spironolactone or eplerenone

339
Q

What is Conn’s syndrome?

A

Primary hyperaldosteronism due to adrenal adenocarcinoma secreting aldosterone

Causes excessive sodium reabsorption leading to hypertension and suppression of renin and angiotensin II

340
Q

What is the pathophysiology of Conn’s syndrome?

A

Aldosterone producing adenoma => Excessive aldosterone production => increased sodium absorption from distal tubule => if severe hypokalaemia and metabolic acidosis

341
Q

what is the management of Conn syndrome?

A

Laparoscopic adrenalectomy (to remove adrenal adenoma)

342
Q

what organ is the major consumer of glucose in the body?

A

the brain

343
Q

what are 3 hormones that increase glucose production in liver and reduce utilisation in fat and muscle?

A

cortisol
adrenaline
GH

344
Q

what chromosome codes for insulin?

A

11

345
Q

what peptide isn’t present in synthetic insulin?

A

C peptide

346
Q

what transported proteins allow beta cells to sense glucose levels in the blood?

A

GLUT 2

347
Q

what is a diagnostic random blood glucose value for diabetes?

A

> 11 mmol/L

348
Q

what is a diagnostic fasting blood glucose level for diabetes?

A

> 7 mmol/L

349
Q

what is a diagnostic oral glucose tolerance test level for diabetes?

A

> 11 mmol/L

350
Q

what is the leading cause of death in diabetic patients?

A

CVD

351
Q

what vertebral levels are the thyroid glands located between?

A

C5-T1

352
Q

what is the connection between the 2 lobes of the thyroid gland called?

A

isthmus

353
Q

what 3 disease have diffuse goitres?

A

Grave’s
Hashimotos
De Quervain’s

354
Q

What 3 conditions have nodular goitres?

A

Multi-nodular
Adenomas/cysts
Carcinomas

355
Q

what is the most common type of thyroid carcinoma?

A

papillary

356
Q

what is thyrotoxicosis?

A

clinical manifestation of excess thyroid hormone action at the tissue level due to high circulating thyroid hormone concentrations.

357
Q

what is the antibody is grave’s disease?

A

Anti TSH antibody

358
Q

what is the treatment of a thyroid storm?

A

IV fluids
antithyroid drugs - Propylthiouracil/carbimazole
IV hydrocortisone
B Blockers

359
Q

what thyroid disorder has raised inflammatory markers?

A

De Quervain’s

360
Q

what 3 things does ACTH stimulate the release of from the adrenals?

A

mineralocorticoids
glucocorticoids
gonadocorticoids

361
Q

what does the zone glomerulosa respond to?

A

RAAS system

362
Q

what is the action of aldosterone?

A

works on kidney to increase blood volume, increase BP. May also cause hypernatraemia.

363
Q

what is the action of cortisol?

A

suppresses immune system, inhibits bone formation, increases metabolism - protein catabolism & lipolysis, gluconeogenesis, increases alertness.

364
Q

what is the action of gonadocorticoids?

A

production of oestrogen and testosterone. Main role is controlling libido.

365
Q

when are cortisol levels at their highest?

A

7-9 am

366
Q

what hormone inhibits GH secretion?

A

somatostatin

367
Q

what hormone stimulates the release of GH?

A

Ghrelin

368
Q

what is an adrenal crisis?

A

acute insufficiency of adrenocortical hormones usually caused by infection or MI causing hypotension, shock and coma

369
Q

what is the management for an adrenal crisis?

A

IV fluids
Corticosteroids - hydrocortisone IV
treat underlying cause

370
Q

what is diabetes insipidus?

A

a metabolic disorder characterised by an absolute or relative inability to concentrate urine, resulting in the production of large quantities of dilute urine due to either a lack of production or response to ADH

371
Q

where is ADH produced and secreted from?

A

produced - hypothalamus

secreted - posterior pituitary

372
Q

what are 5 nephrogenic causes of diabetes insipidus?

A

Medications - lithium
Genetics - ADH receptor gene mutations
Hypercalcaemia
Hypokalaemia
Kidney disease - polycystic kidney disease

373
Q

what is the inheritance pattern of ADH receptor gene mutations?

A

X-linked recessive

374
Q

what are 7 cranial causes of diabetes insipidus?

A

Brain tumours
Brain injury
Brain surgery
Brain infections
Genetic mutations in ADH gene
Wolfram syndrome - genetic condition causing optic atrophy, deafness, DM + DI
Infiltration - sarcoidosis, hystiocytosis

375
Q

what is the inheritance pattern of mutations in ADH gene leading to diabetes insipidus?

A

Autosomal dominant

376
Q

what are 4 manifestations of diabetes insipidus?

A

Polyuria - >3L urine/day
Polydipsia
Dehydration
Postural hypotension

377
Q

what are 4 investigations for diabetes insipidus?

A

Urine osmolality - Low
Serum osmolality - high/normal - due to increased intake
>3L in 24 hour collection
Water deprivation test

378
Q

what is the gold standard investigation for diabetes insipidus?

A

water deprivation (desmopressin suppression) test

379
Q

what is the water deprivation test?

A

no water for 8 hours - measure urine osmolality

If low - give desmopressin and measure urine osmolality again 2-3 hours

If cranial cause - after desmopressin given osmolality will be high as kidneys can still respond to synthetic ADH

If nephrogenic cause - after desmopressin given urine osmolality will still be low as kidneys cannot respond

380
Q

what are 2 management options for DI?

A

Tx cause

Cranial - Desmopressin

Nephrogenic -
ensure acess to pleanty of water
High dose desmopressin
thiazide diuretics - paradoxically decreases urine output
NSAIDs

381
Q

what is one risk associated with desmopressin?

A

Hyponatraemia

382
Q

what are the 2 most common causes of hypercalcaemia?

A

Primary hyperparathyroidism - most common

Malignancy

383
Q

what are 3 reasons malignancy can cause hypercalcaemia?

A

PTH related hormone released from tumours - small cell lung cancer, breast, renal

Bony mets

Multiple Myeloma - due to increased osteoclastic bone resorption

384
Q

what are 7 other causes of hypercalcaemia?

A

Sarcoidosis (also other granulomas)
Vitamin d intoxication
acromegaly
thyrotoxicosis
Drugs - thiazides, calcium containing antacids
Dehydration
Addison’s disease

385
Q

what are 5 manifestations of hypercalcaemia?

A

Bones, Stones, Groans Moans

Bone pain

Renal stones

GI groans - nausea, vom, constipation, anorexia

Psychic moans - confusion, lethargy, coma

also HTN, short QT and cardiac arrhythmias

386
Q

what may be seen o/e in hypercalcaemia?

A

Dehydration
Hypertonia or hyporeflexia
Bone tenderness/deformity
Abdo pain/tenderness
Psychiatric abnormalities

387
Q

what is a differential for hypercalcaemia?

A

hyperalbuminaemia - 40% of calcium is bound to albumin and therefore inactive

Look at corrected calcium

388
Q

what are the 3 classifications of hyperparathyroidism?

A

Primary - due to hyperparathyroidism or malignancy usually - due to excessive PTH release leading to increased calcium reabsorption

Secondary - occurs in response to hypocalcaemia usually due to CKD, leads to parathyroid hyperplasia

Tertiary - parathyroid glands become autonomous and secrete PTH despite normal/high calcium due to persistent parathyroid hyperplasia

389
Q

what is the management for hypercalcaemia?

A

Rehydration - 3-4L normal saline/day
THEN
Bisphosphonates

Corticosteroids - if due to granulomatous disease or lymphomas
Calcitonin
Loop diuretics - furosemide
Dialysis

390
Q

what are 4 causes of hypocalcaemia with hyperphosphataemia?

A

CKD
hypoparathyroididsm
pseudohypoparathyroidism
acute rhabdomyolysis

391
Q

what are 4 causes of hypocalcaemia with normal phosphate?

A

vitamin D deficiency
osteomalacia
acute pancreatitis
over hydration

392
Q

what are 8 manifestations of hypocalcaemia?

A

SPASMODIC

Spasms - troussau’s
Paraesthesia
anxious
seizures
Muscle tone increase
Orientation impaired
Dermatitis
Impetigo herpetiformis
Chvosteks sign - facial muscle twitches after facial nerve tapped

393
Q

what are the ECG signs of hypocalcaemia?

A

prolonged QT

ST
arrhythmia
torsade de pointes
AF

394
Q

what is the management for hypocalcaemia?

A

IV calcium suplements - calcium gluconate
10ml in 100ml NaCl over 10-20 mins
Then slow IV 10% 50ml/hour

vitamin D supplements - alfacalcidol

395
Q

what are 5 manifestations of neuroendocrine tumours?

A

diarrhoea
SOB
flushing
itching
RUQ pain - hepatic metastases

Worsened by ALCOHOL

396
Q

how is insulin secreted?

A

hyperglycaemia leads to increased glucose uptake by cells/. Glucose metabolism leads to increased levels of ATP within the cell which causes K+ channels to close leading to the depolarisation of the cell membrane. Ca2+ channels open and calcium enters the cell. Increased calcium leads to exocytosis of insulin containing vesicles so insulin is released from the pancreatic beta cells into the blood stream.

397
Q

What part of the adrenal glands are the different adrenal hormones secreted from?

A

GFR Makes Good Sex

Zona Glomerulosa - Mineralocorticoids - Aldosterone

Zona Fasiculata - Glucocorticoids - Cortisol

Zona Reticularis - Androgens - testosterone, dihydrotestosterone

398
Q

what is used for the diagnosis of toxic multinodular goitre?

A

Clinical features
TFTs - low TSH, raised T3/4

Radioisotope scan - multiple hot and cold areas

399
Q

what is the management of toxic multinodular goitre?

A

1 - Radioactive iodine

2 - Thyroidectomy

400
Q

what are 4 contraindications and 3 cautions with radioactive iodine treatment?

A

Contraindication
- pregnancy
- <16 years
- breastfeeding
- established eye disease

Caution
- no close contact with pregnant women and children for 3 weeks
- Avoid pregnancy for 6 months
- Avoid fathering children for 4 months

401
Q

what are toxic thyroid nodules?

A

AKA toxic thyroid adenoma

a singular benign autonomously functioning thyroid nodule

402
Q

what is the main risk factor for toxic thyroid nodule?

A

iodine deficiency

403
Q

how are toxic thyroid nodules investigated?

A

TFTs
TSH receptor and TPO antibodies

1 - Thyroid US

2 - Radioisotope scanning

fine needle biopsy may be needed

404
Q

what is the management of toxic thyroid nodule?

A

Radioactive iodine therapy
Thyroidectomy

405
Q

what are 3 complications of thyroidectomy?

A

Recurrent laryngeal nerve injury
Transient hypocalcaemia
Hypothyroidism

406
Q

what are 4 benign causes of thyroid nodules?

A

Multinodular goitre
Thyroid adenoma
Hashimoto’s
Cysts

407
Q

what are 5 malignant causes of thyroid nodules?

A

Papillary carcinoma - most common
Follicular carcinoma
Medullary carcinoma
Anaplastic carcinoma
Lymphoma

408
Q

what is the 1st line investigation of thyroid nodules?

A

Ultrasound

409
Q

what investigations can be done of thyroid nodules?

A

US
Radiolabelled iodine uptake scan
Fine needle aspiration
core needle biopsy
TFTs

410
Q

what is classed as hypoglycaemia?

A

BG <4.0 mmol/L

411
Q

what are 6 causes of hypoglycaemia?

A

Self administration of insulin/sulphonylures
Liver failure
Addison’s disease
Alcohol - causes exaggerated insulin secretion
Insulinoma
Nesidioblastosis

412
Q

what is the physiological response to hypoglycaemia?

A

Decreased insulin secretion
Increased glucagon release
Increased GH and cortisol release

Increased adrenergic and cholinergic neurotransmission in peripheral autonomic nervous system and CN system

413
Q

what is the usual presentation of mild-moderate hypoglycaemia (2.8-3.3)?

A

Sweating
Shaking
Hunger
Anxiety
Nausea

414
Q

what is the presentation of severe hypoglycaemia (usually <2.8)?

A

Weakness
Vision changes
Confusion
Dizziness
Convulsions
Coma

415
Q

what is C-peptide a marker of?

A

Endogenous insulin production - released from pancreas in same molar amounts as insulin

416
Q

what are 2 potential causes of high insulin, high c-peptide hypoglycaemia?

A

Endogenous insulin production

Insulinoma
Sulfonylureas

417
Q

what is the cause of high insulin, low c-peptide hypoglycaemia?

A

Exogenous insulin - overdose or factitious disorder

418
Q

what are 5 causes of low insulin, low c-peptide hypoglycaemia?

A

Alcohol induced
Critical illness - sepsis
Adrenal insufficiency
Growth hormone deficiency
Fasting/starvation

419
Q

what is the initial management of hypoglycaemia in an awake patient?

A

Oral glucose 10-20g liquid, gel or tablet

Other quick acting carbohydrate

Recheck BMs in 10-15 mins

Repeat up to 3 times!

420
Q

What is the management of hypoglycaemia in an unresponsive patient?

A

IM glucagon

IV 20% dextrose - 75-100ml

421
Q

what should be given after acute management of hypoglycaemia when BMs return to >4?

A

Long acting carbohydrate - biscuits, bread, milk, normal carbohydrate containing meal

422
Q

what is Whipple’s triad of hypoglycaemia?

A

Symptoms of hypoglycaemia
low serum glucose
resolution of symptoms with administration of glucose

423
Q

what is 1 caution to IV glucose administration?

A

Thiamine deficiency - IV glucose can precipitate wernike’s encephalopathy

Administer with B1 (thiamine)/pabrinex

424
Q

what tool is used for 10 year risk of cardiovascular disease?

A

QRISK3

425
Q

at what Qrisk should a statin be offered and at what dose?

A

10%

20mg Atorvastatin at night

426
Q

what counts as high blood pressure in clinic?

A

> 140/90 mmHg

427
Q

what counts as hypertension in ambulatory monotoring?

A

> 135/85 mmHg

428
Q

what 4 tests can be done for end organ damage in HTN diagnosis?

A

Urine sample for estimated albumin:creatinine ratio and haematuria

Bloods - HbA1c, electrolytes, eGFR, creatinine, cholesterol

Fundoscopy - for retinopathy

ECG

429
Q

what is the first line intervention for HTN?

A

LIFESTYLE ADVICE

Low salt diet <6g per day
reduce caffeine intake
Stop smoking
reduce drinking

430
Q

what is the first line medication for HTN in those <55 and of non-African family origin or anyone with T2DM or CKD?

A

ACEi (ramipril) or ARB (candestartan)

431
Q

what can ACEi cause in CKD?

A

Worse renal function
up to 25% rise in eGFR or 30% rise in creatinine is acceptable

432
Q

what is the first line medication for HTN in someone >55 or of African family origin?

A

Calcium channel blockers - amlodipine

433
Q

what can be used for HTN if a calcium channel blocker isn’t tolerated or as 3rd line medication?

A

thiazide-like diuretic (indapamide, bendroflumethiazide)

434
Q

what is the management of HTN uncontrolled by one agent?

A

ADD CCB/ACEi

OR Thiazide-like diuretic

435
Q

what is the management of HTN uncontrolled by two agents?

A

CCB + ACEi AND Thiazide-like diuretic

436
Q

what is the management of HTN not controlled by three agents?

A

Consider Spironolactone (If K+ <4.5)

Consider Beta blocker/Alpha blocker (if K+ >4.5)

437
Q

what is classed as severe hypertension?

A

180/120 mmHg

438
Q

what is stage 1 HTN?

A

Clinical - 140/80 mmHg to 159/99mmHg

Home - 135/85 - 149/94

439
Q

what is stage 2 HTN?

A

Clinical - 160/100 - 180/120
Home - 155/95 - 175/115

440
Q

what is stage 3 HTN?

A

180/120 +

441
Q

what is the white coat effect?

A

discrepancy of 20/10mmHg between clinical and home BP

442
Q

what are 5 general causes of hypertension?

A

ROPED

Renal disease
Obesity
Pregnancy and Pre-eclampsia
Endocrine
Drugs - alcohol, steroids, NSAIDs, oestrogen, liquorice

443
Q

what are 5 renal causes of secondary HTN?

A

CKD
Chronic pyelonephritis
Diabetic nephropathy
Glomerulonephritis
Polycystic kidney disease

444
Q

what are 2 vascular causes of secondary HTN?

A

coarctation of aorta
rental artery stenosis

445
Q

what is one cause of treatment resistant hypertension?

A

renal artery stenosis

446
Q

what are 5 endocrine causes of HTN?

A

Primary hyperaldosteronism (Conn syndrome)
Phaeochromocytoma
Cushings syndrome
Acromegaly
Liddle syndrome

447
Q

what are 5 drugs that can cause HTN?

A

alcohol + other substances
COCP/Oestrogens
Monoamine oxidase inhibitors
corticosteroids
NSAIDs

448
Q

what are 4 side effects of NSAIDs?

A

GI - gastritis, ulcers
renal - AKI (acute tubular necrosis), CKD
CV - HTN, heart failure, MI, stroke
exacerbation of asthma

449
Q

how do NSAIDs cause HTN?

A

block prostaglandins which cause vasodilation => use with caution in HTN

450
Q

what are 4 medications used to treat hypertensive emergency?

A

Sodium nitroprusside
Labetalol
Glyceryl trinitrate
Nicardipine

451
Q

what is the lower limit of normal BM?

A

90/60

452
Q

who are ACEi contraindicated in?

A

Pregnant women

453
Q

what are 3 side effects of ACEi?

A

Cough
Angioedema
Hyperkalaemia

454
Q

what are 3 side effects of CCB?

A

Flushing
Ankle swelling
headache

455
Q

what are 3 side effects of thiazide diuretics?

A

Hyponatraemia
Hypokalaemia
Dehydration

456
Q

what is the most common cause of secondary hypertension?

A

Primary hyperaldosteronism

457
Q

BMI =

A

weight/height squared

458
Q

what are 2 measures of obesity?

A

BMI
Waist to height ratio

459
Q

what are 6 medical conditions that can cause obesity?

A

Prader-willi
Hypothalamic damage
PCOS
Growth hormone deficiency
Cushing’s syndrome
Hypothyroidism

460
Q

what are 9 medications that increase risk of obestiy?

A

Pizotifen
beta-blockers
corticosteroids
lithium
antipsychotics
anticonvulsants
antidepressants
insulin in T2DM
oral hypoglycaemics

461
Q

what is the medical management of obesity?

A

orlistat
liraglutide

462
Q

when is orlistat used in obesity?

A

BMI >28 with 2+ risk factors
BMI >30

with continued weight loss of 5% at 3 months
use for <1 year

463
Q

how does orlistat work?

A

pancreatic lipase inhibitor

464
Q

How does liraglutide work in relation to obesity?

A

glucagon-like peptide mimetic used in T2DM given OD SC injection

465
Q

when is liraglutide used in obesity?

A

BMI > 35 kg/m²

prediabetic hyperglycaemia (e.g. HbA1c 42 - 47 mmol/mol)

466
Q

who should be referred for bariatric surgery?

A

BMI >40

467
Q

what are 5 options for bariatric surgery?

A

Laparoscopic adjustable gastric banding
Sleeve gastrectomy
Intragastric balloon
Biliopancreatic diverstion with duodenal switch
Roux-en Y gastric bypass surgery

468
Q

what is an insulinoma?

A

the most common pancreatic endocrine tumour deriving mainly from pancreatic islets of langerhans

10% are malignant
Associated with multiple endocrine neoplasia-1 (MEN1)

469
Q

what are 4 features of insulinoma?

A

Hypoglycaemia
rapid weight gain
high insulin and raised proinsulin:insulin ratio
high c-peptide

470
Q

what is used to diagnose insulinoma?

A

supervised prolonged fasting
CT pancreas

471
Q

what is the management of insulinomas?

A

Surgery

Diazoxide and soamtostatin analogues (Octreotide) if not surgical candidates

472
Q

what are 4 risk factors for insulinoma?

A

female
40-60 years
MEN-1
Neurofibromatosis 1
Von Hippen-Lindau syndrome

473
Q

what is a carcinoid tumour?

A

slow growing neuroendocrine tumour that grows in lungs, intrabdominally, in the breast, testes or ovaries and releases excessive hormones mainly SEROTONIN

474
Q

when is a carcinoid tumour problematic?

A

when metastasises to liver

if tumour is in lungs

475
Q

what are 3 risk factors for carcinoid tumours?

A

Age 50-60
MEN1
Smoking

476
Q

what are 7 features of carcinoid syndrome?

A

skin flushing
diarrhoea
SOB
abdo pain
wheeze
pansystolic murmur loudest over 4th intercostal - tricuspid regurgitation
Telangiectasia

477
Q

what are 2 investigations for carcinoid tumours?

A

urinary 5-HIAA -24h collection

Serum chromogranin A - tumour marker

478
Q

what is the management of carcinoid tumours?

A

surgey if localised tumour

somatostatin analogues - octreotide or lanreotide

479
Q

what are 4 complications of carcinoid tumours?

A

carinoid heart disease
bowel obstruction
metastasis
cushings - if tumour secretes ACTH

480
Q

what is the inheritance pattern of multiple endocrine neoplasia?

A

autosomal dominant

481
Q

what are 3 tumours that MEN-1 is a risk factor for?

A

3Ps

Parathyroid - 95%
Pituitary - 70%
Pancreas - insulinoma, gastrinoma

482
Q

what is the most common presentation of MEN1?

A

hypercalcaemia

483
Q

what are 3 tumours that MENIIa makes more likely?

A

2Ps and 1M

Medullary thyroid cancer

Parathyroid
Phaeochromocytoma

484
Q

what are 3 tumours MENIIb makes more common?

A

1P and 2Ms

Medually thyroid cancer
Marfanoid habitus and mucosal neuromas

Phaeochromocytoma

485
Q

what 2 hormones are secreted by small cell lung cencers?

A

ADH
Adrenocorticotrophic hormone (ACTH)

486
Q

what are 4 paraneoplastic features associated with squamous cell lung cancer?

A

parathyroid hormone-related protein release causing hypercalcsemia
clubbing
hypertrophic pulmonary osteoarthropathy
Hyperthyroidism due to ectopic TSH release

487
Q

what are 2 paraneoplastic features of adenocarcinoma of the lung?

A

gynaecomastia
hypertrophic pulmonary osteoarthropathy

Phase 4 (22 decks)

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