Endo

Question 1

T1DM blood glucose targets

Answer 1

5-7 mmol/l on waking and
4-7 mmol/l before meals at other times of the day

recommend testing at least 4 times a day, including before each meal and before bed

Question 2

MEtformin in T1?

Answer 2

NICE recommend considering adding metformin if the BMI >= 25 kg/m²

Question 3

What is De Quarvain’s thyroiditis? Treatment/ management?

Answer 3

Subacute thyroiditis (also known as De Quervain’s thyroiditis and subacute granulomatous thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism.

There are typically 4 phases;
phase 1 (lasts 3-6 weeks): hyperthyroidism, painful goitre, raised ESR
phase 2 (1-3 weeks): euthyroid
phase 3 (weeks - months): hypothyroidism
phase 4: thyroid structure and function goes back to normal

Investigations
globally reduced uptake on iodine-131 scan

Management
usually self-limiting - most patients do not require treatment
thyroid pain may respond to aspirin or other NSAIDs
in more severe cases steroids are used, particularly if hypothyroidism develops

Question 4

Hypopit causes

Answer 4

Hypothalamus
		Kallmann syndrome
			Rare genetic, failure to start or complete puberty - anosmia or hyposmia - GnRH deficiency
		Infection
			Meningitis
		Tumour
		Inflammation
	Pituitary stalk
		Mass lesion e.g. craniopharyngioma
		Meningioma
		Carotid artery aneurysm
		Trauma
		Surgery
	Pituitary
		Autoimmune hypophysitis
		Irradiation
		Tumour
		Ischaemia
			DIC
				Snake bite in India assoc with kidney failure
			Sheehan's syndrome - necrosis after postpartum haemorrhage
Pituitary apoplexy

Question 5

Hypopit features GH

Answer 5

Central obesity
		Atyherosclerosis
		Dry wrinkly skin
		Osteoposois
		Hypoglycaemia
		Decreased strength
		Tiredness 
Decreased CO

Question 6

hypopit features LH/FSH

Answer 6

Decreased muscle bulk
			Hypogonadism
				Less hair
				Less ejaculate
				Small testes
			Decreased libido
			Low mood
			Tiredness
		Female
			Low libido
			Amen/oligomenorrhea
			Dyspareunia
			Decreased breast tissue atrophy
Osteoporosis

Question 7

hypopit features not GH and LF/FSH

Answer 7

Corticotroph
		Addisons without pigmentation
	Prolactin
		None usually, decreased breast milk production
	Thiotrophs
		Hypothyroidism
	If tumour
		May secrete one of the hormones 
Mass effect - bitemporal hemi and mass effect

Question 8

Hypopit diagnosis

Answer 8

Static (one may be high)
TSH - t4
GH - insluin like growth factor (IGH-1) better marker though (GHRH)
Cortisol
LH/FSH - testosterone/ oestradiol (GnRH)
Prolactin - may be high due to loss of dopamine
U&E - cortisol, Na low from dilution
Low Hb from thyroid normochromic normocytic
Dynamic
ITT - Give insulin - release cortisol, glucose should be induced below2.2 and patient should be symptomatic when cortisol and GH are measured
Short Synacthen - Should supress ACTH and increase glucose?
Arginine and growth hormone-releasing test - should stimulate growth hormone

Question 9

Hypopit treatment

Answer 9

Endo referral - treatment of underlying cause
	Replacement
		Gonadotrophs
			Male
				Testogel
				IM injection
				(buccal monoadhesive tablets)
			Female
				OCP contains enough for maintainence
				Patch or oral 
				Testoesterone - may help
			Gonadotrop therapy to induce fertility in both
		Glucocorticoids
			Hydrocortisone 15mg oral
		Thyrotrophs
			Thyroxine
		Somatotrophs
			Growth hormone - somatotrophin better as less fat gain/ muscle loss
Lactotrophs

Question 10

Pit adenomas classification

Answer 10

Chromophobe (no colour on staining) - 70%, very common e.g. microadenomas (<1cm) which are common. Most likely to be ‘non functioning’ i.e. no hormones secreted so revealed by mass effect or hypopit. Some can secrete
Acidophil 15% Rarer local pressure effect. PRL or GH
Basocphil 15% Rarer local pressure effect. ACHT
** 99% of functioning secrete ACTH, PRL, GH. 30% are non functioning

Question 11

Pit adenomas symptoms

Answer 11

Hypopituitarism
	Cushings/ Acromegaly/ Prolactinoma
	Mass effect
		Headache
		Visual disturbance
			Bitemporalhemianopia - optic chiasm
			CN III,IV, VI (all muscles of eye) - If infiltrated into cavernous sinus
		Hypothalmic disturbance
			Sleep control
			Temperature control
Diabetes Insipidous (rarely pit cause)

Question 12

Pit adenoma diangosis

Answer 12

Static
		TSH
		Cortisol
		LH/FSH
		GH/ IGF-1
		Prolactin
		ADH
	Dynamic
		Water suppression test - 
			Stage 1 - no drink for 8 hours, measure weight and urine osmolality
			Stage 2 - Give Desmopressin (like ADH) if nephrogenic there will be no response (if nephrogenic give hydrochlorothiazide or amiloride)
		Short acting Synacthen test
		OGTT
	Imaging
MRI - look at mass effect

Question 13

Pit adenoma treatment

Answer 13

Hormone replacement
	Treat Cushings, Acromegal
	If prolactinoma
		Dopamine - cabergoline
	Other
		Transphenoidal resection
		Transfrontal resection if adenoma is supra-stela extension (stellar=saddle)
Radiotherapy (stereotactic) - if recurrent

Question 14

Complications of pit adenoma

Answer 14

Post op recurrence - need monitoring.
Post op hormone deficiency
Pituitary apopexy
Bleeding in large adenoma, can be life threatening due to sudden hypopituitarism. - headache, menigism, similar to subachacnoid
Urgent steroids and fluid balance and surgery

Question 15

Hyperthyroidism causes

Answer 15

Autoimmune - 
		Grave's disease 
	Toxic multinodular goitre
		Second most common
		Elderly caused by iodine deficiency
		(Surgery if compressive e.g. dysphagia or dyspnoea)
		(radioactive iodine give
	Toxic adenoma
		Solitary nodule
		(Hot on isiotope scan - malig is white)
	Exogenous Levothyroxine, idoine exess e.g. food contam or contrast medium 
	Ectopic thyroid tissue
	NSAIDs
	Post viral (painful goitre)
	Postpartum
	TB
Amiodarone, lithium (hypo more common)

Question 16

Symptoms of hyperthyroid

Answer 16

General
		Heat intolerance
		Agitation
		Sleep disturbance
		Weight loss
		Hair loss
		Osteoporosis
		Tremor
	GI
		Diarrhoea
		Increased appetite (some may get paradoxical weight gain)
		Sweats
	Cardiac
		Palpations
	GU
		Oligomen/ infert
	Psych
		Psychosis
		Chorea
		Labile emotions
	Opthalmology
		Eye discomfort
		Grittiness
		Tears Photophobia
		Diploria
Less acuity/ colour (more likely if less protrusion as more compression)

Question 17

Signs of hyperthyroidism

Answer 17

Tachycardia
	HBP
	Arrythmia
	Anaemia 
	Lig lad/ retraction
	Goitre/ nodules/ bruit
	Graves
		Pretibial myxoedema - swelling above lateral malleoli
		Exomphalmos
Thyroid acropachy - clubbing, periosteal reaction in limb bones, painful finger and toe swelling

Question 18

Complications of hyperthy

Answer 18

AF
	HF
	Osteoporosis
	Thyroid storm
	Opthalmology
Gynacomastia

Question 19

Diagnosis of hyperthyroidism

Answer 19

Blood
		Haem
			FBC - normocytic anamia
				In graves can get neutropenia
			Bio chem
			Immunology
				TPO - anti thyroid peroxidase (more hashimoto)
				Antithyroglobulin antibody
				TSH receptor antibody (more graves)
			Special
				T4/T3 (normal or high)
				TSH (low)
		Imagine
Isotope scan - for cause - nuclear scintigraphy

Question 20

Treatment hyper

Answer 20

Rapid contorl of symptoms with propanolol
Carbimazole
Titration with T4 levels
Blockade - high dose and then Thyroxine
Risk of agranularcytosis e.g. temp, sore throat/ mouth ulcers
Radioactive iodine
Most become hypothyroid
Surgical resection - total thyroidectomy

Question 21

Raised TSH and normal T4

Answer 21

subclinical hypothyroidism or treated

Question 22

If everything low thyroid

Answer 22

sick euthyroid

Question 23

Use of isotope scan in thyroid

Answer 23

Ionie and tachnetiu, pertechnetate
Detect goitre, ectopic thyroid tissue or thyroid mets
Isotope scan - malignant parts tend to have no ‘hot’ nodules

Question 24

Use of US thyroid

Answer 24

Cystic from malignant/ benign nodules - can do with fine needle aspiration

US not enough, also need fNAC and hemithyroidectomy

Question 25

Hypothyroid causes

Answer 25

``` Autoimmune 1 -Hashimoto 2 - Primary atrophic thyroiditis Less common Iodine deficiency Thyroid resection Drugs - amioderone lithium Secondary Hypopituitarism/ pituitary adenoma ```

Question 26

Symptoms of hypothyroidism

Answer 26

``` Tiredness Constipation Hair loss Lethargy Depression Weight gain Cold intolerance Menorrhagia Dementia Myalgia ```

Question 27

Signs of hypothyroid

Answer 27

``` BRADY Reflexes - slow Ataxia - cerebella Dry thin hair/skin - Yawn - tiredness/coma Cold hands Ascites - non pitting oedema (hands, lids,feet) Round/ puffy fac/ obese Defeated demenour Immobile - contipation CCF ```

Question 28

Complications of hypo

Answer 28

``` Preggers PPH Eclampsia Anaemia Prematurity Myxiedema coma High assoc with CCF and dementia untreated0. ```

Question 29

Diagnosis hypothyroids

Answer 29

``` TSH, T4, T3 TPO or TGB Isotope scan Cholesterol and TG raised Macrocytosis - rarely anaemia ```

Question 30

Treatment hypothyroidism

Answer 30

Oral levothyroixine - Aim to Keep TSH normal, small increase has log effects on TSH - tell patients Elderly - start low due to risk of Angina/MI Excess thyroxine can cause osteoporosis and AF so monitor

Question 31

Addisons Causes

Answer 31

``` Primary (loss of cortico and mineralo) 80% autoimmune adrenalitis (may also affect thyroid or panc) TB Mets HIV SLE Antiphospholipid syndrome Low ACTH Rare Hypopituitarism Pituitary adenoma Iatrogenic: Steroid withdrawal, adrenectomy (kidney) In above mineralo is normally fine ```

Question 32

Addisons sympoms and signs

Answer 32

``` Symptoms Pigmentation - high ACTHTiredness/ lethargy/ coma Low BP Hypoglycaemia - dizziness/ confusion Weakness Weight loss/ anorexia - muscle loss Amennorrhea/ ED Hair loss Myalgia/ arthraligua Depression/ psychosis GI abdo pain and vomiting (high K) ``` ``` Signs Low BP - postural too Tachy Low BM Pigmentation ```

Question 33

AD Diagnosis

Answer 33

Low Na and high K due to loss of mineralocorticoid Hypercalcaemia Hypoglcaemia Metabolic acidosis (loss of aldosterone and less Na resorbition in DCT) ACTH 9am Short synacthen test Should result in increased cortisol within 30mins (Check before too) Pos = low cortisol - to do with rise. Why not just adrenal If not do long test between secondary and privary. Higher dose and look more than 1 hr. Secondary = normal response but lower Autoantibodies (21 hydroylase adrenal antibodies), if not then TB, mets, HIV, SLE Plasma renin & aldosterone AXR/ CXR if thinking TB

Question 34

AD treatment

Answer 34

teroid replacement Hydrocortisone 20mgish e.g. 10/5/5 at diff times Late can cause insomnia Fludrocortisone ``` Patient info Steroid card Double in febrile or illness or stress Increase with strenous activity Teach IM in case of vomiting Follow up yearly - risk of associated pernicious anaemia ```

Question 35

hyperaldosteronism causes

Answer 35

2/3 - Aldosterone secreting adrenal adenoma/ Conn's (30-50years) 1/3 - bilateral adrenal hyperplasia (idiopathic) Others Adrenal carcinoma Glucocorticoid remediable aldosteronism (GRA) (hyperresponsive to ACTH (normally only angiotensin II) ACTH regulated aldosterone Secondary hyperaldosteronism Renal artery stenosis/ diuretic, CCF, Hepatic failure High renin (low perfusion) High aldosterone Bartter's syndrome Leaky loop of henley Polydipsia Polyuria (volume depletion = high renin) Genetic Aut recessive Failure to thrive in chuildren, poly uria and polydipsia Treatment - K replacement, NSAIDs ACEi

Question 36

hyperaldosteronism symptoms

Answer 36

Hypertension (may be normal), Parasthesia, weakness, cramps polyuria/polydipsia (high Na),

Question 37

Hyperaldosteronism diag

Answer 37

``` High Na Low K (normal in 20%) U &Es Adrenal vein sampling - catheter to look if hormone production is bilateral or not Check Renin aldosterone levels GRA - genetic testing ```

Question 38

Hyperaldosteronism treatment

Answer 38

Conn's- surgery/ spirono pre op Adrenal hyperplasia - spirono or amiloride GRA Steroids should fix - can remain with high BP so give spirono

Question 39

MEN symptoms

Answer 39

MEN1 Parathy Pancreas Pituitary MEN2a Thyroid medulla Parathyroid Pheo ``` MEN 2b Thyroid Pheo Marfans Mucosal neuroma ```

Question 40

Hyperparathyroidism causes

Answer 40

• Primary - Solitary adenoma =80%, 20% bilateal hyperplasia, PT cacer • Secondary - Hypocalcaemia e.g. renal failure, Lit Vit D intake • Tertiary - prolonged hypocalcaemia leading to autologous PTH secretion and a raised Ca Malignant hyperpara - PTHrP by SCC, breast and RCC (low PTH in assays)

Question 41

Hyperparathyroidism symp

Answer 41

• Stones, thrones, abdominal groans, bones, psychiatric overtones • Stones = renal calculi • Thrones = polyuria (polydipsia) and constipation • Groans = Abdominal pain • Painful bones = pain, pathological fractures, osteoporosis Psychiatric = lethargy, depression, psychosis, delerium, ataxia

Question 42

Sings of Hyperpara

Answer 42

• Dehydration (paradoxical to polyuria) | HBP!!

Question 43

Investigation of hyperpara

Answer 43

• Serum Ca and PTH • PO4 (usually low as PTH increases excretion) • Increased ALP from bone activity • Us and Es • Osteitis fibrosa cystica shows as suboeriosteal erosions, cysts or tumours of phalagnes and acro osteolysis, may be operpper pot • DEXA US and MIBI (isotope) to localise adenoma

Question 44

Treatment of hyperpara

Answer 44

``` • Medical ○ Mild § Fluid § Ca § Vit D § Avoid thiazides • Surgical removal of adenoma - indicated if high Ca or complications Cinacalcet can sensitise PTH secretion to Ca and decrease it ```

Question 45

Symptoms of hypoparathyroid

Answer 45

Hypocalcaemia Tetany/ chorea/ spasm SPASMODIC Other autoimmune features

Question 46

Investigation

Answer 46

High PO4 Low Ca Normal ALP

Question 47

treatment hypopara

Answer 47

Ca supp and calcitriol or synthetic PTH

Question 48

Hypocalcaemia causes

Answer 48

``` High PO4 Renal failure Hypo parathyroid Rhabdo hypomagnesaemia Normal PO4 or low Pancreatitis Vit D deficiency Osteomalacia Over hydration Resp alk (less ionised Ca due to increase pH) ```

Question 49

Hypocalcaemia symptoms and signs

Answer 49

``` Symptoms Spasm Periorbital parasthesiae Anxiety/ irritation Seizure Muscle tone increased Constipation Dysphagia Dyspnoea Orientation impaired Dermatitis (atopic) Impetigo herpeticum (emergency) Chvostek sign Cardiomyopathy (long QT)Chorea Catact (chronic) ``` Signs - Chvostek's - tap on parotid and facial nerve twitches Trousseau's sign - inflate cuff and wrist and fingers flex

Question 50

Emergency presentation symptoms of hypercalcaemia

Answer 50

Usually but also Confusion Pyrexia Cardiac arrest (dec QT)

Question 51

Causes of gonad failure in men

Answer 51

``` Primary Teticular failure from Local trauma Torsion Chemo/irradiation Post-orcitis e.g. mumps, HIV, leptrsoy Renal failure Cirrhosis Alcohol excess (toxic to Leydig) Klinefelters Delayed sexual development Small testes Gynaecomastia Androgen insensitivity syndrome (look female) Secondary Hypopit Prolactinoma Kallman's syndrome (isolated (GNRH hormone) Age ```

Question 52

Describe Klinefelter's syndrome

Answer 52

Klinefelter's syndrome is associated with karyotype 47, XXY ``` Features • often taller than average • lack of secondary sexual characteristics • small, firm testes • infertile • gynaecomastia - increased incidence of breast cancer • elevated gonadotrophin levels Diagnosis is by chromosomal analysis ```

Question 53

Describe Turner's syndrome

Answer 53

Turner's syndrome is a chromosomal disorder affecting around 1 in 2,500 females. It is caused by either the presence of only one sex chromosome (X) or a deletion of the short arm of one of the X chromosomes. Turner's syndrome is denoted as 45,XO or 45,X Features • short stature • shield chest, widely spaced nipples • webbed neck • bicuspid aortic valve (15%), coarctation of the aorta (5-10%) • primary amenorrhoea • cystic hygroma (often diagnosed prenatally) • high-arched palate • short fourth metacarpal • multiple pigmented naevi • lymphoedema in neonates (especially feet) There is also an increased incidence of autoimmune disease (especially autoimmune thyroiditis) and Crohn's disease From

Question 54

Describe MODY

Answer 54

``` MODY - mat onset dm of young Genetic production of insulin impaired Similar to T2DM Prog to comp such as DKA Hepatic nuclear factor 1 alpha Give sulfonylureas as very sensitive <25ywars Fx of early onset present ```

Question 55

Describe LADA

Answer 55

``` Latent Autoimmune DM of adulthood - LADA Assoc with graves Weight loss, poly dip, poly urea Don’t require insulin in early stages Similar to T1 Islet failure not resistance ```

Question 56

Causes of hypoglycaemia

Answer 56

``` DM EXPLAIN EXogenous drugs - body builders, alcohol binge with no food, ACEi Pit insufficiency Liver failure Addisons Islet cell tumours Non-pancreatic neoplasms e.g. fibrosarcoma ```

Question 57

Insulinoma diagnosis and treatment

Answer 57

``` Whipple's triad Symptoms with fasting or exercise Recorded hypoglycaemia with symptoms Symptoms relieved by glucose May be with MEN1 CT/MRI and hypoglycaemia and insulin on prolonged fast Treatment Excision ```

Question 58

Acromegaly cause

Answer 58

In acromegaly there is excess growth hormone secondary to a pituitary adenoma in over 95% of cases. A minority of cases are caused by ectopic GHRH or GH production by tumours e.g. pancreatic

Question 59

Acrogmegaly features and comp;lications

Answer 59

• coarse facial appearance, spade-like hands, increase in shoe size • large tongue, prognathism, interdental spaces • excessive sweating and oily skin • features of pituitary tumour: hypopituitarism, headaches, bitemporal hemianopia • raised prolactin in 1/3 of cases → galactorrhoea • 6% of patients have MEN-1 Complications • hypertension • diabetes (>10%) • cardiomyopathy colorectal cancer

Question 60

investigations acromegaly

Answer 60

OGTT with serym GH or IGF-1 | Pit MRI

Question 61

Treatment

Answer 61

Transphenoidal surgery first line Somatostatin (inhibirs GH realease) analogue as adjunct e.g. octreotide Dopamine agonist (bromocriptine) Pegvisomant (GH receptor antagonist)