Endo Flashcards

Question

2 Main options style of thyrotoxicosis management

Answer 1

Titration Block and replace - Eg high dose carbimazole with thyroxine replacement (Use if significant thyroid eye disease and want very close control)

Answer 2

Agranulocytosis "If you get a severe sore throat you must stop taking this medication and present to hospital"

Answer 3

Toxic multinodular goitre - Good 1st line treatment Graves -Usually get a 12-18 month course of carbimazole then stop -In 2/3 will get relapse and then its worth thinking of more definitive treatment

Answer 4

2 weeks isolation at home Especially avoid young children Not if planning pregnancy -> fetal hypothyroidism May end up with underactive thyroid.

Answer 5

people with ongoing thyroid eye disease -> Makes it worse Pregnant / planning

Answer 6

Brain - Headaches - Visual field loss - Deafness Snoring / OSA Cardio - Hypertension - Diabetes - polyuria / dypsia - Worse control Sweating Pituitary symptoms - Libido - Menstrual history - Tired - Dizzy Bone changes - Shape of face / jaw - Hands and feet eg rings not fitting - Carpal tunnel - Dentition - Widening teeth gaps Calcium - Polyuria - Bone pain Family history - Acromegally - Endocrine - MEN1 / carney complex Social history - How affects function - Smoking / alcohol CV health

Answer 7

**Hands** - Size, sweat, coarse skin - Pulse - Pain on joints **Carpal tunnel** exam - Tinnels / phalens **BP** **Neck** - Acanthosis nigrans in neck - Goitre + palpate thyroid with swallow - Inspect face and teeth **Eyes** Fundoscopy RAPD / accomdation Visual field testing Eye mocements - I would like to complete a full cardiovascular assessment - BP - ECG (LVH) - Epsworth sleep score - Capillary blood glucose

Answer 8

This patient has prominent supaorbital ridges and a large lower jaw, ears and nose. His hands are large doughy and spade like and his skin is coarse and sweaty There is evidence of bilateral carpal tunnel syndrome with thenar eminence wasting bilaterally and impaired sensation in the distrobution of the median nerve There is increased interdental spacing and macroglosia. There is evidecne of acanthosis nigrans. He has a bitemporal hemaniopia I would like to check a blood sugar and blood pressure

Answer 9

Make the diagnosis - IGF - 1 - Glucose tolerance test with GH response -> If positive refer to endocrine and book a MRI pituitary Then assess complications - ECG +/- Echo - HBA1C, lipid profile - Pituitary profile: 9am cortisol, T4 and TSH, Prolactin, Testosterone, LSH / FH - Renal profile - Especially for hypoNa - Calcium - Parathyroid adenomas in MEN1 - Visual field testing - If OSA -> Sleep studies - If carpal tunnel -> nerve studies

Answer 10

Anterior pit produces growth hormone in pulses -> stimulates liver to produce Igf-1 continuously ie GH levels vary through day

Answer 11

Education Optomise CV health Diabetes management Surgery - May have some medical management pre op Eg carbegoline

Answer 12

Dopamine agonists - Bromocriptine / carbegoline Somatostatin analouges - All injectable - Ocretide

Answer 13

- Meningitis - Haemorrhage - Tumours close to optic chiasm - optic ischemia (often if been stretched by tumour and then sags down post op.) - Transient diabetes insipidus / hypopituitary

Answer 14

Desmopressin Levothyroxine Hydrocortisone

Answer 15

Growth hormone levels dont reduce and sometimes a paradoxically elevated [usually supressed)

Answer 16

Ca - MEN 1 (Parathyroid hyperplasia)

Answer 17

autosomal dominant Pit tumours Parathyroid hyperplasia Pancreas tumours

Answer 18

Untreated - > - diabetes - hypertension and CV disease - colonic polyps + malignancy

Answer 19

Downs Acromegaly Amyloid Hypothyroid ## Footnote DAAH

Answer 20

Acromegaly T2DM Malignancy Normal in indian subcontinent

Answer 21

RET gene Primary hyperparathyroid (MEN1 is hyperplasia) Thyroid Ca Phaeochromocytoma ## Footnote MEN2B - marfanoid appwarance and mucosal neuromas

Answer 22

Slim middle aged person there is slight bown pigmentation more prominently in skin folds. There are well demarkated areas of depigmentation (vitiligo) There is some superficial bruising on the abdominal wall suggesting possible T1DM I would like to check L/S BP and check a capilliary blood glucose level

Answer 23

Primary hypoadrenalism (addisons) TB Surgical removal of Ca Infiltration - malignancy / amyloid

Answer 24

Autoimmune distruction of adrenal cortex 21-hydroxylase is the most common antigen. Lack of glucocorticoid and mineral corticoid hormones ## Footnote Requires >90% destruction of gland to become clinically / biochemically symptomatic

Answer 25

Non specific Weight loss Anorexia Nausea and vomiting Malaise Weakness Bowel habit change Ammenorrhea Syncope Myalgia

Answer 26

- Hyperpigmentation (maximally in skin creases, scars and buccal mucosa) - Muscle wasting - Body hair loss - Dehydration and postural hypotension

Answer 27

Increased ACTH production in pituitary (due to lack of cortisol) | ACTH stimulates melanocytes

Answer 28

Hypotension and dehydration Often precipitated by illness / operation Bedside - Glucose - BP - ECG - VBG Bloods Inflamm markers Na and K+ TFTs LFTs Management Venous gas - looking at K+ and Glucose IV fluids (saline) IV hydrocortisone 100mg 6hrly

Answer 29

Measure cortisol level (<100 suggestive, >550 unlikely) The ACTH stimulation test (basline cortisol then 250ngm synacthen then cortisol in 30 mins) Stays low in addisons

Answer 30

Previous TB

Answer 31

Autoimmune Vitiligo T1DM Hypoparathyroid Autoimmune thyroid Pernicious anaemia Hepatitis Allopecia

Answer 32

Hydrocortisone gives enough mineralcorticoid activity

Answer 33

Conservative - Educate espec sick day steroid rules - Medic alert bracelet - Often carry IM hydrocortisone in emergencies Medical - Gluco/mineral coriticoid replacement - Approx 20-30mg hydrocortisone - 50-100mcg fludrocortisone - Managment of diabetes / thyroid disease

Answer 34

Lack of ACTH from Pituitary - Exongenous steroids from resp/autoimmune diseases - Panhypopituitarism eg in adenoma / Shehan syndrome ## Footnote Dont get hyperpigmentation as this is secondary to the ACTH itseld

Answer 35

This middle aged lady has cushingoid features There is an elevated BMI with central adiposity Her skin is thin and brused and there is striae over the abdomen There is a proximal myopathy and hypertension. To complete my exam I would like to dip the urine, and check a blood glucose as well as assessing for a bitemporal hemaniopia

Answer 36

Focused history for exogenous steroid use 1 Dexamethasone suppression test to confirm cushings syndrome 2 Check ACTH - ACTH high will be raised in pituitary / ectopic 'ACTH producing tumour - ACTH low in Adrenal a) If ACTH low (adrenal) -> CT/MRI adrenals 3 If ACTH high -> high dose dexamethasone supression a) Cortisol supressed -> pituitary -> MRI b) Cortisol unaffected -> CTCAP

Answer 37

- Hypertension - Cardiac hypertrophy - Type 2 diabetes - Dyslipidaemia (raised cholesterol and triglycerides) - Osteoporosis - Adverse mental health (e.g., anxiety, depression, insomnia and rarely psychosis) On inspection - Round face (known as a “moon face”) Central obesity - Abdominal striae (stretch marks) - Enlarged fat pad on the upper back (known as a “buffalo hump”) - Proximal limb muscle wasting (with difficulty standing from a sitting position without using their arms) - Male pattern facial hair in women (hirsutism) - Easy bruising and poor skin healing - Hyperpigmentation of the skin in patients with Cushing’s disease (due to high ACTH levels)

Answer 38

Cough / haemoptysis / weight loss / smoking history Bitemporal hemaniopia Skin pigmentation ## Footnote A high level of ACTH causes skin pigmentation by stimulating melanocytes in the skin to produce melanin. Excess ACTH, either from Cushing’s disease (pit adenoma) or ectopic ACTH.

Answer 39

Corticotrophin releasing hormone in hypothalamus -> ACTH from pituitary -> Cortisol production in zona fasiculata of adrenals [With negative feedback on pituitary]

Answer 40

Inferior petrosal sinus sampling ## Footnote - Small catheters are inserted into the femoral veins - The catheters are guided to the inferior petrosal sinuses - Blood samples are taken from the catheters and the main vein of the abdomen - The ACTH levels in the samples are compared to the ACTH levels in the peripheral blood

Answer 41

Alcohol exess Depression Liver enzyme inducers - Eg Phenytoin, rifampicin

Answer 42

Metyrapone - reduces the production of cortisol in the adrenals

Answer 43

Nelson’s syndrome - development of an ACTH-producing pituitary tumour \ - due to a lack of cortisol and negative feedback. -It causes **skin pigmentation** (high ACTH), **bitemporal hemianopia** and a **lack of other pituitary hormones**.

Answer 44

Single nodule - Benign adenoma - Cyst - Abscess - Carcinoma Diffuse smooth goitre - Iodine deficiency - Puberty - Graves - Hashimotos - Throiditis - eg post viral / pregnancy Multinodular - Toxic and non toxic depndent on thyroid status

Answer 45

- Bloods including TFTs and Ca - Consider isotope uptake scan to look for inactive vs hyperactive tissue within the thyroid If Hypothyroidism or cold nodule on isotope scan - **Fine needle aspiration** and US to rule out thyroid Ca (as majority are non functioning) If concerns of **tracheal compression** - CT neck and Lung function tests Either way shold have refereral to endocrinologist / ENT

Answer 46

If <16 or >65 PMH thyroid Ca Exposed to carcinogens eg radiation Rapidly enlarging or very painful Associated with cervical lymphadenoathy

Answer 47

- Papillary most common (80%) - Follicular - often in elderly - Medullary - MEN2a eg family history (PTH hyperplasia and phaeochomocytoma) (secrete ACTH and calcitonin) - Anaplastic - aggressive with compressive symtoms - Lymphoma - often seen in hashimotos thyroiditis [Squamous cell carcinoma]

Answer 48

- Stridor - Dysphagia - Horse voice - Recurrent laryngeal palsy - Occationally horners

Answer 49

Graves -> look for further evidence

Answer 50

- General Weight loss - Hands Tremor Thyroid acropachy - Head / Face Mood disturbance - eg agitation Flushing Exopthalmous / opthalmoplegia Hair loss Goitre - Heart AF / tachycardia - Abdo Diarrhoea Ammenorrhea Loss of libido - Legs Proximal myopathy Pretibial myxodema | Thyroid acropachy - swellling and clubbing of hand

Answer 51

Autoimmune disorder caused by thyroid stimulating antiboodies which activate TSH receptors -> Hyperthyroidism

Answer 52

Conservative - Patient education inc patient.co.uk website - Discuss treatmnent options Medical - Symptoms - B blocker eg propranolol - Block Propylthyrouricil / carbimazole - Consider thyroxine Radioiodine can be used for permanent option Surgical If suspected malignancy Those with compressive symptoms Occationally cosmetic

Answer 53

Investigate for cause Eg septic screen / medications / surgery T3/4/TSH FBC U&Es and BCs - 40mg propranolol TDS for symptoms of palpitations and anxiety - 100mg IV hydrocortisone 6hrly - Replace fluids / electrolytes - DW endocrine re carbamizole | Steroids - inhibit peripheral conversion of T4 into T3

Answer 54

Conjunctival oedema Oedema Exopthalmous Lid retraction Lid lag Reduced acuity Complex opthalmoplegia

Answer 55

Primary - Iodine deficiency - Hasimotos thyroiditis - Iatrogenic Too much cabrimazole / propythyouricil Thyroidectomy / radioiodine - Drugs Eg Amiodarone / lithium Secondary - Hypothalmus / pituitary failure

Answer 56

Autoimmune disorder caused by anti-thyroglobulin / anti-thyroid peroxidase antibodies - Causes gradulal destruction of thyroid -> hpothyroid - Assoc - Autoimmune Addisons, T1DM

Answer 57

Growth restriction Cognitive impairment Large tongue [cretinism]

Answer 58

Post infection Post pregnancy Post radioiodine for graves During bacterial infection with thyroid abscess

Answer 59

Causes soft tissue swelling in face and throat

Answer 60

Epsworth sleepiness score >11 STOPBANG questionaire

Answer 61

- This woman is overweight with coarse facial features. She has pale yellow dry skin. - Her hair is dry and thin - There is a loss of the outer 1/3 of her eyebrows - There is generalised non pitting swelling of the tissues - She is brady cardic - There is a firm, smyetrical goitre IF HYPOthyroid and graves -> hypothyroidism secondary to previously treated graves disease eg thyroidectomy

Answer 62

Compliane issues Taking tablets with milk Lack of absobtion other bowel issues Addisons (get raised TSH if left untreated) Pernicious anaemia

Answer 63

Rapid correction can lead to IHD / MI

Answer 64

- This middle aged woman is thin and restless - Her palms are warm and sweaty - There is a fine tremor and an irregularly ireregular pulse indicating AF - On examination of the eyes there is proptosis, lid retraction and lid lag - There is evidence of proximal myopathy - There is a warm swelling over the thyroid with a bruis

Answer 65

- Exopthalmus -> exposure keratitis and corneal ulceration - Lid retraction - Lid lag - Optic nerve damage - complex opthalmoplegia

Answer 66

Bilateral - Graves / Cavernous sinus thrombosis Unilateral - obrital tumour / cellulitis

Answer 67

Primary - Graves - Toxic nodule - Multinodular goitre - Iodine - Over treatment - Post partum thyroiditis Secondary - Pituitary function - Amiodarone

Answer 68

Rash Bone marrow supression / agranulocytosis -> seek medical advice if develop sore throat / infection

Answer 69

- TSH / T3 / T4 - US - solid / cystic - Isotope uptake scan - Hot (with uptake) or cold | Cold, solid nodules -> Needle aspiraition as may be malignant

Answer 70

Familial hypercholesterolaemia Familial hypertriglyceridaemia Familial combined hyperlipidaemia - most common [polygenic cause] Issues - Cholesterol -> accelerated astherosclerosis - coronaries nad peripheral - Triglyceride -> pancreatitis and retinal vein thrombosis Management Conservative - Weight loss / good exercise / diet - Smoking and alcohol - [Avoid B blockers / thiazide diruetics] Medical - Treatment of **Diabetes / hypothyroid** - Statins - ezetimbe - stop cholesterol absrobtion - PKS9 inhibitors eg Evolocumab - Fibrates - eg fenofibrate - Cholestryramine - stop bile acid resorbtion -> circulating cholesterol used to make