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ENDO Flashcards

1
Q

A patient presents with signs and symptoms of acromegaly. What is the most appropriate initial screening test?

A

Serum IGF-1 (insulin-like growth factor)

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2
Q

A man with galactorrhoea has a serum prolactin of 1260U/L. MRI shows a microprolactinoma. How should you proceed?

A

Initiate medical treatment with cabergoline or brompcriptine (dopamine agonists: dopamine inhibits prolactin secretion)

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3
Q

What is Hoffman’s syndrome?

A

A specific form of hypothyroid myopathy causing: PAINFUL proximal myopathy, muscular pseudo-hypertrophy.
In hypothyroidism you often get myalgia, weakness, stiffness, cramps and fatigability, but these 2 symptoms are specific to Hoffman’s. It can present without an overt clinical picture of hypothyroidism.

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4
Q

76-year old female presents to A&E with cognitive impairment (MMSE 19/30). O/E: periorbital oedema, alopecia, slow-relaxing reflexes.

What is the most likely cause of her symptoms?

A

Hypothyroidism

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5
Q

What can happen if you give amiodarone to someone with underlying hypothyroidism or iodine deficiency?

A

AmIODarone (contains iodine and is structurally similar to thyroxine). This causes thyroid stimulation and unregulated thyroid hormone production leading to hyperthyroidism (Jod-Basedow effect)

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6
Q

You give a patient with previously normal thyroid function amiodarone and they develop hypothyroidism, what has happened?

A

Amiodarone contains iodine and is structurally similar to thyroxine. It causes auto-regulation (negative feedback) to decrease thyroid hormone production leading to hypothyroidism (Wolff-Chaikoff effect)

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7
Q

What ECG changes would you see in someone with hypercalcaemia?

A

Shortened QT interval

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8
Q

Thyroid function test:

Increased TSH
Decreased T4

What is the syndrome? Differentials…

A

Hypothyroidism

Differentials:
Primary atrophic hypothyroidism
Hashimoto's thyroiditis
Iodine deficiency
Secondary to hypopituitarism
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9
Q

Thyroid function tests:

Increased TSH
Normal T4

What is the syndrome?

A

Subclinical hypothyroidism or hypothyroidism treated with thyroxine

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10
Q

Thyroid function test:

Increased TSH
Increased T4

What is the syndrome?

Differentials…

A

Secondary hyperthyroidism (TSH secreting tumour)

Or possibly thyroid hormone resistance

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11
Q

Thyroid function tests:

Decreased TSH
Increased T4 or T3

What is the syndrome?

Differentials…

A

Hyperthyroidism

Differentials:
Graves' disease (2/3 of hyperthyroidism)
Toxic multinodular goitre
Toxic adenoma
Ectopic thyroid hormone production via metastatic follicular thyroid cancer
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12
Q

What is given in hyperthyroidism for initial management of symptoms?

A

Propranolol 40mg/6hr

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13
Q

Describe the block-replace therapy for hyperthyroidism.

A

Give carbimazole and thyroxine simultaneously. Give for 12-18 months. Then withdraw. 50% will relapse: indication for radioiodine or surgery.

SE CARBIMAZOLE: can cause agranulocytosis (decreased neutrophils leading to sepsis in 0.03% of cases) so STOP medication and get urgent FBC if signs of any infection.

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14
Q

What are the complications of hyperthyroidism?

A

Heart failure (thyrotoxic cardiomyopathy), angina, AF (in 10-25% so control hyperthyroidism and warfarinize if not contraindicated), osteoporosis (may be due to calcitonin?), ophthalmopathy, gynaecomastia

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15
Q

What proportion of patients with Graves’ disease get thyroid eye disease? What is the main risk factor?

A

25-50%

Smoking

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16
Q

What are the signs and symptoms of thyroid eye disease?

A

Symptoms
Eye discomfort, grittiness, increasing tear production, photophobia, diplopia,
Signs
RAPD (suggestive of optic nerve compression), exophthalmos, conjunctival oedema, corneal ulceration, papilloedema, ophthalmoplegia

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17
Q

What are the signs and symptoms of hypothyroidism?

A 
Reflexes relax slowly
Cerebellar ataxia
Dry thin hair and skin
Yawning and drowsiness
Cold hands
Ascites, non-pitting oedema
Obesity, round puffy face
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18
Q

What are the features of hypocalcaemia?

A 
SPASMODIC
S Spasms (carpopedal=trousseau's)
P Periorbital paraesthesiae
A Anxious, irritable, irrational
S Seizures
M Muscle tone increase (smooth musc)
O Orientation impaired
D Dermatitis
I Impetigo herpatiformis
C Chvostek's sign (mouth twitches on tapping of facial nerve
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19
Q

What is the most common cause of thyrotoxicosis?

A

Graves

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20
Q

What is the HbA1c of someone with prediabeties?

A

6.0-6.4%

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21
Q

Side effects of thyroxine

A

Hyperthyroidism (overtreatment)
Worsening of angina
AF
reduced bone mineral density

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22
Q

What is the diagnostic test for acromegaly?

A

Oral glucose tolerance test with GH measurements

IGF -1 good for screening or sometimes to monitor disease

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23
Q

What is good for neuropathic pain (eg diabetic feet)

A

1st line is amitriptyline, duloxetine, gabapentin or pregabalin

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24
Q

What is subacute thyroidistis?

A

Painful goitre
Raised ESR
Hyerthyroid
After virus

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25
What is fludrocortisone?
Modified hydrocortisone | But Replaces aldosterone in pts with primary adrenal insufficiency
26
What is the difference biochemically between 1 and 2 adrenal insufficiency?
K High in 1 Normal in 2 Uraemia and metabolic acidosis in 1 (Ca high, low Na, low BM in both)
27
What can cause haemorrhagic destruction of adrenal glands?
Meningococcal sepsis
28
How can you tell the difference between 1 and 2 adrenal insufficiency?
1 no response to synacthen (tetracosacitide) (ACTH) short or long 2 no response to short but delayed normal response to long
29
What is cushings disease?
Bilateral adrenal hyperplasia due to a ACTH secreting pituitary adenoma (usually micro) Low dose dex test shows no change High dies might half early morning cortisol
30
How does ectopic ACTH production present?
- classical cushings features may be absent - pigmentation due to ++ ACTH - weight loss, hypokalaemia (minerlocorticoid activity) metabolic alkalosis - dex suppression test won't work even at high levels
31
What cx can produce CRF leading to Cushings Syn?
Prostate Some thyroid medullary cx RARE
32
What is the 1st line test for diagnosing cushings,
Overnight dex suppression test
33
What is Cushing's syndrome?
Glucocorticoids excess? AND loss of normal feedback mechs of hypothalamo-pit-adrenal access and loss of circadian rhythm of cortisol secretion
34
What is nelsons syndrome?
Complication of removal of bilateral adrenalectomy if Cushings diagnosed and source unfound. ++ skin pigmentation due to ++ ACTH as adrenalectomy removed the neg feedback mech Responds to pit radiation
35
What is the tx for adrenal cx?
Adrenalectomy- cures adenomas but rarely cures cancer. | Radiotherapy and adrenolytic drugs (mitotane)
36
What drugs suppress cortisol secretion? Might be useful pre op
Metyrapone, ketoconazole, fluconazole
37
What drugs can be used for severe ACTH induced psychosis?
Mifepristone | Etomidate
38
What are the findings of primary hyperaldosterone?
HTN Hypo k --> symptoms (polyuria,polydipsia, quadriparesis, cramps, parasthesia, weakness) Maybe high Na INDEPENDENT of RAAS systems 2/3 are due to solitary aldosterone producing adenomas (CONNS Syn) 1/3 due to bilateral adrenocortical hyperplasia
39
How do you treat CONNS? | Hyperplasia?
Laparoscopic adrenalectomy Spirolactone 4w before to control BP and K TreT hyperplasia medically - Spirolactone, amiloride, eplerenone (less SE than Spirolactone ) Suspect CONNS in people with HTN not responsive to meds
40
What is glucocorticoid remediable aldosteronism?
Aldosterone production is in control on ACTH due to gene fusion Tx- dex for 4w normalises biochem, if BP still high after 4w add Spirolactone.
41
What is 2 hyperaldosteronism?
Due to high renin because if renal hypoperfusion - ras - accelerated HTN - diuretics - CCF - liver failure
42
What is bartters syndrome?
Congenital salt wasting Failure to thrive, polyuria, polyuria, bp normal, Na loss, vol depletion Get HIGH renin and ald and hypokalaemia Give k and ACEi
43
When operating to remove a phaeo, what must you do pre op?
Give a blocker- phenoxybenzamine- then add b blocker to avoid unapposed a adrenergic stimulation Immediate management - invasive monitoring and volume expansion
44
Treatment of PCOS?
Oestrogens- Yasmin -metformin and Spirolactone (Associated with insulin resistance)
45
What is kallsmans syndrome?
Isolated gonadotropin hormone deficiency, colour blindness, anosmia 2 hypogonadism
46
What is the first line therapy for someone with ED?
Sildenafil 1 hr before sex Flush, headache, stuffy nose Can't use if use nitrates, HTN, arrhythmias, unstable angina, MI , marked renal impairment
47
If you have a progressive loss of pituitary function which hormones and lost first and last?
First- GH and LH, FSH Last- ACTH, TSH Rather than prolactin deficiency, get high levels early on as loss of tonic control by dopamine
48
What is sheehans syndrome?
Post partum get decreased blood supply to pit due to hypovolemic shock. Then ischemic necrosis after childbirth Hypopituitarism
49
When replacing put function what should you give before thyroxine?
Steriods- | Thyroxine cab precipitate adrenal crisis
50
What should you do post op when removed a pit adenoma?
Retest > reset needs Wait 6w for dynamic adrenal function Can give radiotherapy for residual/recurrent adenomas- tumour rate control and normalisation of excess hormone secretion
51
How can pit apoplexy present?
``` Mass effect Decreased GCS Visual field defect Maybe like SAH frontal headache Can cause CV collapse due to acute hypopit death ``` Urgent hydrocortisone and cabergloine Anti phos lipid Syn?
52
Where does crainiooharyngioma arise from?
``` Rathkes pouch (pituitary and 3rd vertical floor) Rare but. Im min childhood intracranial tumour MAy present in adult with pit dysfunction Calcification CT/MRI ```
53
What are dopamine agtagonist examples? What can they do?
``` Increase prolactin (ED, amenorrhea) Haloperidol Clozapine Risperidone Olanzapine ```
54
What can bromocriptine and cabergloine cause?
Fibrosis so need ECHOs
55
What is the effect of GH on insulin?
Glucose decreases GH High GH can result in insulin resistance Normally GH increases insulin so promotes bone and soft tissue growth
56
Excess GH (aka somatotropin) - acromegaly - typical biochem findings?
High glucose, ca, po4
57
What is the first line therapy for acromegaly? | And if it doesn't work?
Transpenoidal surgery If IGF1 and GH still high give GH analogues and radiotherapy eg octreotide - monthly Im Or give pegvisomant- GH blocker need to follow up as can increase tumour size
58
What increases TBG?
Hepatitis Pregnancy HRT So total T3 and T4 measure confounded- better to measure free T3 and T4 amount
59
Causes of high TSH, high T4, low T3
Deiodinase deficiency Euthyroid hyperthyroxinaemia Thyroid hormone Ab artefact
60
Genetic associations with graves
CTLA4 | PTPN22
61
What are the signs of hypothyroidism?
``` BRADYCARDIC bradycardic Reflexes relax slowly Ataxia Dry thin hair and skin Yawning/drowsy Cold hands Ascities / non putting oedema Round puffy face Defeated demeanour Immobile CCF ```
62
What anti abs are found in hashimotos?
Anti- TPO anti -TG Histological diagnosis FNA excludes malignancy Anaemia common Lifelong thyroid replacement therapy- levothyroxine sodium- over replacement: osteoporosis Need to wait 4w before changing as thyroxines half life is 7 days
63
What dies parathyroid hormone do?
Triggered by low Ca, acts to increase Ca and decrease PO4 overall Increases oesteoclast activity and increases Ca reabsorption and decreases PO4 reabsorption in kidney. Increase VitD activation
64
Signs of high Ca
``` Weak Tired Depressed Thirsty Dehydrated Renal stones Abdominal pain Pancreatitis Ulcers- mostly duodenal -imaging see ostetitis fibrosa cystica ``` HTN!
65
What is cinacalet?
Increases PT cells to Ca so decreases PTH secretion | But if there is high calcium due to parathyroid adenoma then remove surgically
66
What are the features of secondary hyperparathyroid?
LOW Ca HIGH PTH Cause- low Vit D uptake, renal failure
67
What are the features of tertiary hyperparathyroid?
HIGH Ca VERY high PTH Occurs after prolonged 2 hyperparathyroid - glands act independently having undergone adenomatous change Chronic renal failure
68
What is malignant hyperparathyroidism?
Parathyroid related protein is produced by SC lung Cx and RCC PTH is low as PTHrP is not detected on the assay Mimics PTH so increases CA
69
Features of hypoparathyroid hormone
Low Ca high PO4 DiGeorge syndrome Treat with Ca and calcitriol
70
MEN 1 | MEN 2a
Men 1- PPP PTH- high Ca Pancreas - gastinoma, insulinoma Pituitary - prolactinoma, GH secreting Men 2a TAP Thyroid - medullary thyroid cx Adrenal - phaeno PTH Men 2b Simular to 2a but mardanoid appearance and mucosal neuromas
71
What is a myxodema coma?
Hypothyroid state before death Hypoglycaemia , low HR, seizures., goitre, cyanosis Carefully give T3
72
What us is Thyrotoxic storm?
``` High temp Agitation Confusion Coma High HR AF D+V Acute abdo ``` Tx- carbimazole and after 4h give lugolds If unsuccessful thyroidectomy
73
What us classification for Thyroid cx? | US and FNA
Thy1 not enough cells or cystic contents Thy 2 Normal Thy 3 intdeterminant Thy 4 probably Thy 5 definite
74
Where is the TSH receptor?
Follicular cells
75
When is bariatriv surgery indicated?
Bmi >50 BMI >40 BMI >35 -40 and other significant disease and all other things been tried
76
What is impaired glucose tolerance ?
>\= 6.1mmol/L but \= 7.8 but
77
What is the criteria for metabolic syndrome?
BMI >30 or increased waist circumference And 2 of: 130/85 HDL 1.7
78
What DM drug can cause hypos?
Sulfonylurea
79
What is the problem in DI?
Too little ADH from post pit | Pass lots of water, impaired water resorption
80
What drugs can cause DI?
Lithium | Demeclocycline (tetracycline)
81
How do you treat crainial DI?
Desmopressin (Syn ADH) This doesn't work in neohrogenic DI- the kidney still produces dilute urine
82
How do you treat nephrogenic DI?
Bendroflumethiazide Li toxicity- amiloride
83
What drug Can you not give in DM with HF?
Glitazones- oedema
84
What aab is MOST associated with hashimotos?
Anti thyroidperoxidase
85
What is sick euthyroid syndrome?
Everything is low - TSH may be NR | Systemic illness - changes reverse when you get better
86
Which test is best to diagnose Cushings?
Overnight dex suppression test

MBBS3 (6 decks)

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