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A PACES > Endo > Flashcards

Endo Flashcards

1
Q

Important questions for thyroid eye disease

A

Whats bothering them most eg vision / discomfort

Swelling / redness / puffy
-Previous hayfever

Issues with eye movements

Any visual loss/ ability to focus / double vision

Unable to close eyelids

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2
Q

Thyroid history - what would warrant same day / very urgent opthal review

A

Visual loss / symptoms

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3
Q

Neck lump history key points

A

Is this new
- goitre often very long standing
- New is more concerning

issues with swallowing or speaking

Pain

Thyroid status

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4
Q

Questions for thyroid status?

Other key parts of history?

A

Head and general
Anxiety and mood
Energy levels
Weight

Eye symptoms

neck lump / pain

Chest
Palps
chest pain

Bowel
Bowel habit changes

Periods

tremors

Social
- SMOKING - big risk for eye disease. Must council on this
- Pregnancy especially post partum
- Seaweed - lots of iodine

DH
-Amiodarone (often long time lag)
-Lithium
-Biologics (sometimes years leater)

Surgical history

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5
Q

How thyroitoxic do you need to be to have thyroid eye disease

A

You can have it and be euthyroid / without thyrotoxicosis

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6
Q

Thyroid exam

A

Eyes
- look from side
- Any redness / Swelling
- Lid retraction
- Eye movements

Vision
Snellen chart

Fundoscopy

Neck
- Throidectomy scar
- feel for lump
- feel when swallows / sticks tongue out
-Any tenderness
- Auscultate for bruis

Hands
- warm
- sweat
- tremor
- Pulse / Atrial fibrillation

Shins
- Pre tibial myoxdema (often like orange peel)
- Deep tendon reflexes

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7
Q

Throid exam and this

A

Conjunctival injection

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8
Q

When doing snellen chart what should you ask to speed things up

A

Whats the lowest line you can read

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9
Q

Someone with thyroidectomy scar but signs of thyrotoxicosis

A

May have been partial thyroidectomy

Multinodular goitre may grow back again if some tissue left

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10
Q

Why thyrotoxicosis get bruis in neck

A

Increased blood flow from metabolically active thyroid

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11
Q
A

pre tibial myxodema

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12
Q

Post partum thyroiditis painful?

A

Can be often not.

Thyroiditis not always painful - DONT get side tracked by absence of pain

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13
Q

Differentials of thyroid neck lump

A

Short time period
- Need to rule out Cancer

Longer
- Cyst
- Nodule / multi nodular goitre
- Adenoma sometimes

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14
Q

Investigations in neck lump / thyrotoxicosis

A

Bloods
- TFTs - TSH / T3/T4
- TSH receptor antibody (graves)

US

Thyroid uptake scan

Ophthalmology review if any concern

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15
Q

Who has raised TSH receptor antibody

A
  • Graves
  • Thyroid eye disease
  • Sometimes amiodarone (induces the antibodies)

[Usually negative in multi nodular goitre]

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16
Q

Why can you get thyroid eye disease without thyrotoxicosis

A

Eye disease is caused by the TSH receptor antibodies

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17
Q

Do you treat sub clinical thyrotoxicosis

A

Yes
- They have high risk of developing osteoporosis / AF if not

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18
Q

Most important red flags thyroid what would you do?

A

Visal loss including acuity

compelx opthalmoplegia

High dose steroids

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19
Q

Mild thyroid eye disease treatment

A

Stop smoking
Lubricating eye drops
Treat hyperthyroid

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20
Q

Thyroid eye disease steroids not working - whats next

A

Immunomodulators
Eg rituximab

Radiotherapy of orbits

Orbital decompression - last line

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21
Q

Hypothyroid patients often have what else on thier bloods? what do you do?

A

Raised cholesterol

Often improves with throxine replacement

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22
Q

When and how should you take thyroxine

A

on an empty stomach

Calcium eg milk reduces absorption significantly

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23
Q

Treatment for graves?
When for each?

A

Symptoms
- Propranolol 40mg TDS

Carbimazole

Propylthiouracil
- Used for women who are pregnant or breast feeding

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24
Q

Why propranolol specifically in thyrotoxicosis

A

Reduces conversion to t4 in peripheries

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25
Q

2 Main options style of thyrotoxicosis management

A

Titration

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

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26
Q

Key thing to council patients when treating with antithyroid meds

A

Agranulocytosis

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

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27
Q

When would you use radio iodine or surgery in graves

A

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

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28
Q

Key issues with radio iodine

A

2 weeks isolation at home

Especially avoid young children

Not if planning pregnancy -> fetal hypothyroidism

May end up with underactive thyroid.

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29
Q

Who must NOT get radioactive iodine

A

people with ongoing thyroid eye disease -> Makes it worse

Pregnant / planning

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30
Q

Acromegaly focused history

A

Brian
- 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

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31
Q

Acromegaly exam

A

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
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32
Q

How to present acromegaly

A

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

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33
Q

Acromegaly investigations

A

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

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34
Q

Why dont you measure GH in acromegaly

A

Anterior pit produces growth hormone in pulses
-> stimulates liver to produce Igf-1 continuously

ie GH levels vary through day

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35
Q

Acromegaly treatment

A

Education

Optomise CV health

Diabetes management

Surgery
- May have some medical management pre op Eg carbegoline

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36
Q

Acromegaly medical management

A

Dopamine agonists
- Bromocriptine / carbegoline

Somatostatin analouges
- All injectable
- Ocretide

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37
Q

Complications of pit surgery

A
  • 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
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38
Q

Pit hormone replacement in post op transient hypopit post op

A

Desmopressin
Levothyroxine
Hydrocortisone

39
Q

What happens in oral glucose tolerance test acromegally

A

Growth hormone levels dont reduce and sometimes a paradoxically elevated

[usually supressed)

40
Q

Extra blood test to rule out syndrome which may be cause of acromegaly

A

Ca - MEN 1
(Parathyroid hyperplasia)

41
Q

What is MEN1

A

autosomal dominant

Pit tumours
Parathyroid hyperplasia
Pancreas tumours

41
Q

Complications
acromegally

A

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

42
Q

Conditions which cause macroglosia

A

Downs
Acromegaly
Amyloid
Hypothyroid

DAAH

42
Q

Acanthosis nigricans found in

A

Acromegaly
T2DM
Malignancy
Normal in indian subcontinent

43
Q

MEN 2 gene? Features ? Seen in MEN2b

A

RET gene
Primary hyperparathyroid (MEN1 is hyperplasia)
Thyroid Ca
Phaeochromocytoma

MEN2B - marfanoid appwarance and mucosal neuromas

44
Q

Present examination findings in a patient with Addisons. To complete?

A

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

45
Q

Addisons differenential diagnosis

(hypoadrenalism)

A

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

46
Q

What is addisons? Most common defect

A

Autoimmune distruction of adrenal cortex
21-hydroxylase is the most common antigen.

Lack of glucocorticoid and mineral corticoid hormones

Requires >90% destruction of gland to become clinically / biochemically symptomatic

47
Q

Addisons symptoms

A

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

48
Q

Addisons signs

A
  • Hyperpigmentation (maximally in skin creases, scars and buccal mucosa)
  • Muscle wasting
  • Body hair loss
  • Dehydration and postural hypotension
49
Q

Why hyperpigmentation in addisons

A

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

ACTH stimulates melanocytes

50
Q

What characterises an addisons crisis? Key investigations? treatment?

A

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

51
Q

Addisons diagnosis

A

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

52
Q

Presents with hypoadrenalism and calcificaion of adrenals on imaging

A

Previous TB

53
Q

Addisons associations

A

Autoimmune
Vitiligo
T1DM
Hypoparathyroid
Autoimmune thyroid
Pernicious anaemia
Hepatitis

Allopecia

54
Q

Why dont you need to give fludrocortisone in acute hypoadrenal crisis

A

Hydrocortisone gives enough mineralcorticoid activity

55
Q

Long term management of addisons

A

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
56
Q

Secondary adrenalcortioid deficiency causes? Sign not found?

A

Lack of ACTH from Pituitary
- Exongenous steroids from resp/autoimmune diseases
- Panhypopituitarism eg in adenoma / Shehan syndrome

Dont get hyperpigmentation as this is secondary to the ACTH itseld

57
Q

Present cushings

A

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

58
Q

How to diagnose cushings location

A

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

59
Q

Name features of cushings

A
  • 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)

59
Q

What features on exam make you think it could be an ACTH dependent cushings syndrome (pit / ectopic Eg small cell lung Ca)

A

Cough / haemoptysis / weight loss / smoking history
Bitemporal hemaniopia
Skin pigmentation

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.

60
Q

Basics of cortisol production

A

Corticotrophin releasing hormone in hypothalamus
-> ACTH from pituitary
-> Cortisol production in zona fasiculata of adrenals

[With negative feedback on pituitary]

60
Q

Blood test to determine pituitary vs ectopic ACTH.

A

Inferior petrosal sinus sampling

  • 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
61
Q

Causes of pseudocushings

A

Alcohol exess
Depression

Liver enzyme inducers
- Eg Phenytoin, rifampicin

61
Q

Drug which can be used in those not fit for surgery in cushings

A

Metyrapone - reduces the production of cortisol in the adrenals

62
Q

Surgical removal of both adrenal glands -> bitemporal hemaniopia?

A

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.

63
Q

Thyroid mass differential

A

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

64
Q

Thyroid mass Ix?

A
  • 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

65
Q

What would make you think a thyroid mass was malignant

A

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

66
Q

Types of thyroid cancers? which is part of a syndrome

A
  • 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]
67
Q

Symptopms of large goitre

A
  • Stridor
  • Dysphagia
  • Horse voice - Recurrent laryngeal palsy
  • Occationally horners
68
Q

What does a thyroid bruis suggest?

A

Graves
-> look for further evidence

68
Q

Hyperthyroid signs

A
  • 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

69
Q

Define graves disease

A

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

70
Q

Management of hyperthyroid

A

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

71
Q

Management of thyroid storm

A

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

72
Q

Features of thyroid eye disease

A

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

73
Q

Causes of hypothroidism

A

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

Secondary
- Hypothalmus / pituitary failure

74
Q

What is hashimotos? Associated

A

Autoimmune disorder caused by anti-thyroglobulin / anti-thyroid peroxidase antibodies

  • Causes gradulal destruction of thyroid -> hpothyroid
  • Assoc - Autoimmune Addisons, T1DM
75
Q

Untreated hypothyroid in pregnancy?

A

Growth restriction
Cognitive impairment
Large tongue
[cretinism]

76
Q

Throiditis causes

A

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

77
Q

Why OSA in acromegally

A

Causes soft tissue swelling in face and throat

78
Q

OSA scoring systems

A

Epsworth sleepiness score >11
STOPBANG questionaire

79
Q

Present hypothyroid

A
  • 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

80
Q

New diagnosis hypothyroid on throxine - what would a persistent raised TSH indicate

A

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

81
Q

Complication of t4 replacement in elderly

A

Rapid correction can lead to IHD / MI

82
Q

Present hyperthyroid

A
  • 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
83
Q

What eye signs might there be in graves

A
  • Exopthalmus -> exposure keratitis and corneal ulceration
  • Lid retraction
  • Lid lag
  • Optic nerve damage
  • complex opthalmoplegia
84
Q

Causes of exopthalmous

A

Bilateral - Graves / Cavernous sinus thrombosis

Unilateral - obrital tumour / cellulitis

85
Q

Causes of hyperthryoid

A

Primary
- Graves
- Toxic nodule
- Multinodular goitre
- Iodine
- Over treatment
- Post partum thyroiditis

Secondary
- Pituitary function
- Amiodarone

86
Q

Main side effects of carbimazole

A

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

87
Q

3 main aspects to Investigation of multinodular goitre

A
  • TSH / T3 / T4
  • US - solid / cystic
  • Isotope uptake scan - Hot (with uptake) or cold

Cold, solid nodules -> Needle aspiraition as may be malignant

88
Q

Types of familal dyslipidaemia [3 basic ones so you a least have an answer]?
Raised cholesterol. / trigycleride leads to? management?

A

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

A PACES (11 decks)

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