Endo Flashcards
1
Q
What are the symptoms of hyperprolactinaemia in women?
A
Amenorrhea, galactorrhea, infertility, [compression symptoms]
2
Q
What are the symptoms of hyperprolactinaemia in men?
A
Hypogonadism, reduced libido, erectile dysfunction, gynaecomastia, galactorrhea [compression symptoms]
Often late presentation: osteoporosis, atherosclerosis - indirect results of hypogonadism)
3
Q
How do prolactin levels help determine cause of endo pathology?
A
Hypothalamic: prolactin rises
Hypopituitarism: prolactin falls
4
Q
What is the size of a macroadenoma?
A
> 1cm
5
Q
What is the most common functioning adenoma?
A
Prolactinoma
6
Q
How do non-functioning adenomas present?
A
Compression symptoms: headache, vision problems (bitemporal hemianopia or upper temporal quadrantanopia) N+V, cranial nerve palsies
7
Q
What is Sheehan’s syndrome?
A
Panhypopituitarism following massive obstetric haemorrhage (leading to infarction)
8
Q
What is pituitary apoplexy?
A
Infarction or haemorrhage of pituitary tumour (eg from HTN or major surgery)
9
Q
What are the symptoms of pituitary apoplexy?
A
Severe thunder-clap retro-orbital headache, N&V, reduced GCS, ophthalmoplegia + bitemporal hemianopia
10
Q
What is the principle for testing HYPERpituitarism?
A
Suppression tests (i.e. not suppressed)
11
Q
What is the principle for testing HYPOpituitarism?
A
Stimulation tests (i.e. not stimulated)
12
Q
What is the test for excessive growth hormone?
A
Oral GTT (+VE: doesn’t suppress)
13
Q
What is the test for excessive ACTH or CRH?
A
Dexamethasone (+VE: doesn’t suppress)
14
Q
What is the test for insufficient GH?
A
Insulin tolerance (+VE: doesn’t stimulate it)
15
Q
What is the test for insufficient cortisol?
A
Synacthen (ACTH analogue) (+VE: doesn’t stimulate it)
16
Q
What is the test for insufficient GnRH?
A
Clomifene or LH/FSH (+VE: doesn’t stimulate it)
17
Q
What are the typical lab findings in diabetes insipidus?
A
Increased plasma osmolality, decreased urine osmolality
18
Q
What is the test to differentiate between cranial and nephrogenic DI?
A
ADH stimulation:
will correct cranial DI
no effect on nephrogenic DI
19
Q
What are the typical lab findings in SIADH?
A
Decreased plasma osmolality, increased urine osmolality
Often euvolaemic and normotensive
20
Q
What is the relationship between dopamine and prolactin?
A
Dopamine inhibits prolactin
21
Q
What are physiological causes of hyperprolactinaemia?
A
Pregnancy
Puerperium
Breast stimulation
Stress
22
Q
What are intra-cranial causes of hyperprolactinaemia?
A
Pituitary tumours Tumours compressing the pituitary stalk Head injury Brain surgery or radiotherapy Post-ictal
23
Q
What are endocrine and metabolic causes of hyperprolactinaemia?
A
Hypothyroidism (because increased TRH)
Cushing’s syndrome
Cirrhosis of liver
PCOS
24
Q
Which drugs cause hyperprolactinaemia?
A
Drugs that block dopamine receptors: domperidone, metoclopramide, neuroleptics, anti-psychotics
Dopamine-depleting agents: methyldopa
Anti-depressants
(+ many more)
25
What are the initial investigations for hyperprolactinaemia?
Exclude pregnancy
Basal serum prolactin (if mildly elevated: repeat, if excessively high: likely prolactinoma)
TFTs
Visual field testing
Assessment of pituitary function
26
How is a prolactinoma managed first-line?
Dopamine agonists: cabergoline, bromocriptine, quinagolide
Usually sufficient to shrink tumour (may need several years)
27
What are the causes of cranial DI?
```
Idiopathic
Tumours
Intracranial surgery
Head injury
Granulomata
Cerebral infections
Vascular disorders
Post-radiotherapy
Inherited
```
28
What are the causes of nephrogenic DI?
```
Idiopathic
Hypokalaemia
Hypercalcaemia
CKD
Drugs, eg lithium
Renal tubular acidosis
Pregnancy
Post-obstructive uropathy
Inherited
```
29
Why may DI cause incontinence in those able to get to the toilet?
Chronic overdistension of bladder
30
How may the signs in a pt with DI?
Signs of dehydration
| Bladder may be enlarged and palpable
31
What investigations should you carry out in a patient with suspected DI?
```
24-hour urine collection
Urine specific gravity
Simultaneous plasma and urine osmolality
U&Es
Plasma glucose
Serum calcium
```
Fluid deprivation test with response to desmopressin
32
Interpreting causes of DI on basis of water deprivation and desmopressin:
Urine Osmolality:
Before: low - After: high
Before: low - After: low
Before: high - After: high
1. Cranial DI
2. Nephrogenic DI
3. Primary/ psychogenic polydipsia
33
What is the Mx of cranial DI?
Desmopressin (monitor for hyponatraemia, have tablet-free days)
34
What is the Mx of nephrogenic DI?
None just allow good access to fluids and correct metabolic abnormalities, drugs etc.
35
When may serum osmolality be normal (or increased) and urine osmolality be increased?
Dehydration, renal disease, congestive heart failure, Addison's, hypercalcaemia, hyperglycaemia, hypernatraemia, alcohol ingestion, mannitol therapy
36
When may serum osmolality be normal (or increased) and urine osmolality be decreased?
DI
37
When may serum osmolality be decreased and urine osmolality be increased?
SIADH
38
When may serum osmolality be decreased and urine osmolality be decreased?
Overhydration, hyponatraemia, adrenocortical insufficiency
39
What are the causes of acromegaly?
Pituitary adenoma
Rare:
Ectopic GH from tumour
Inherited
40
Why are those affected with acromegaly susceptible to vertebral fractures?
Low-quality bone despite high bone mass
41
Why is acromegaly not tested with random GH?
Secretion is episodic and half-life is short
42
Which cancers are screened for in acromegaly?
Colon
| Thyroid
43
What are the investigations for suspected acromegaly?
IGF-1
Assessment of other pituitary hormones as indicated: prolactin, adrenal, thyroid, gonadal
Blood glucose
Bone profile
Serum triglycerides
Visual tests
OGTT to confirm a raised IGF-1
ECG + echo
44
What is first-line management of acromegaly?
Trans-sphenoidal surgery (i.e. adenoma)
Otherwise, somatostatin analogues, eg octreotide
45
What are the causes of pseudo-acromegaly?
Insulin resistance associated with hyperinsulinaemia
46
What is the name for symptomatic hyperthyroidsm?
Thyrotoxicosis
47
What are the causes of hyperthyroidism? (7)
```
Graves
Overgrowth of gland
Tumour
Subacute thyroiditis (de Quervain's)
Ectopic thyroid tissue
Over-treatment of hypothyroidism
Drugs: amiodarone, thyroxine OD
```
48
What Ix would you carry out following TFTs?
Autoantibody screen
?Radioisotope scan (show 'hot' areas)
ECG if hyper (sinus tachy, AF)
49
What are the management options for hyperthyroidism?
Carbimazole (1 month for effect, sometimes block-and-replace)
Beta-blockers (palpitations, anxiety)
Radioiodine (slow uptake, may still need carbimazole)
Partial thyroidectomy
50
What blood finding in Graves?
Autoantibodies against TSH receptors
51
Graves eye disease:
1. What are the findings?
2. What is the cause?
3. Management
1. Exophthalmos, conjunctival oedema, lid lag, proptosis, weakening of extraocular muscles, keratitis (if trouble closing)
2. Inflammation causes lymphocyte infiltration + activation of fibroblasts secreting osmotically-active hyaluronic acid
3. STOP SMOKING, prednisoolone, lubricants
52
What is the name for symptomatic hypothyroidism?
Myxoedema
53
What are the causes of hypothyroidism? (7)
Hashimoto's
Over-treatment of hyperthyroidism
De Quervain's
Primary atrophic hypothyroidism
Dyshormogenesis (inherited defect, goitre)
Iodine deficiency
Drugs: lithium, amiodarone, excess iodine
54
How is hypothyroidism treated?
Levothyroxine
55
In emergencies, what medication is given to rectify hypothyroidism?
liothyronine (T3)
56
What are the ADRs of thyroxine?
Hyperthyroidism symptoms
57
What are the ADRs of carbimazole?
Hypothyroidism symptoms
58
In hypopituitarism, what must be corrected first?
Corticosteroids first to avoid Addisonian crisis
59
Which medications reduce absorption of thyroxine?
Calcium, iron replacements, antacids
60
What is the common sequence of symptomology experienced in Hashimoto's?
Hyper --> eu --> hypo
61
De Quervain's
1. Definition
2. Epidemiology
3. Symptoms
4. Pathology
5. Prognosis
1. Inflammation of gland by virus
2. Young, middle-age women
3. Tender, swollen + febrile illness
4. Inflammation causes destruction of follicles, then immune reaction causes granulomas to form
5. Usually left with hypo symptoms until gland recovers (days/ months)
62
Who is commonly affected by primary atrophic hypothyroidism?
Elderly - there is atrophy and fibrosis of gland.
| Thought to be end-stage of many thyroid diseases
63
Causes of goitres
Physiological: puberty, pregnancy
Hyper: Graves' (bruits, v vascular), thyroiditis
Hypo: all
Multi-nodular goitre ('toxic' if these produce hormones)
64
What might precipitate a thyroid emergency?
Surgery, radioiodine, infection, MI, stroke
65
What are the symptoms of thyrotoxic crisis (thyroid storm)?
Pyrexia, confusion, D+V, life-threatening arrhythmias, coma
66
What are the symptoms of a myxoedema coma?
Hypothermia, hyporeflexia, hypoglycaemia, bradycardia, seizures, coma
67
What TFTs would tell they require steroid therapy prior to thyroxine?
Secondary hypothyroidism (ie pituitary):
TSH LOW
T4 LOW
68
What TFTs may suggest subclinical hypothyroidism or poor compliance with thyroxine?
TSH High
| T4 NORMAL
69
What do TFTs show in sick euthyroid syndrome (non-thyroidal illness)?
```
TSH Low (or normal)
T4 Low (and esp T3)
```
70
How can steroid therapy affect TFTs?
TSH: low
T4: normal
71
What % thyroid lumps are benign?
| How should they be investigated?
80%
| TFTs + fine-needle aspiration
72
What is the mnemonic for thyroid cancers?
People forget medicine and mumble
```
Papillary
Follicular
Medullary
Anaplastic
Malignant lymphoma
```
73
Which thyroid cancer is associated with ectopic hormone production?
Medullary: arise in para-follicular cells
Calcitonin (usually asymptomatic)
ACTH (Cushing's)
5-HT (Carcinoid syndrome)
74
Describe the histology of the adrenal gland
GFR+ MEGA
G- mineralocorticoids
F- glucocorticoids
R- androgens
medulla: 20% NA-secreting / 80% adrenaline-secreting
75
```
Mineralocorticoids:
Example
What are they stimulated by? (Which isn't v significant)
Where does it act?
What does it do?
```
Aldosterone
Hyperkalaemia, ACE II and ACTH (not so much)
Acts on DCT/CD
Increases water + salt retention, excretes K+
76
Glucocorticoids:
Example
Function
How does it exert circadian rhythm?
Cortisol
Regulates metabolism of carbs + proteins, maintains glucose levels when fasting / potent anti-inflammatory + immmunosuppressant
At 6am, exerts weaker neg feedback on CRH --> ACTH
77
Where are androgens from medulla converted to more active ones - under what enzyme?
In peripheral tissues, aromatase
78
When does the cortex start secreting androgens?
Andrenarche: 7-9 years
79
What are the signs of hyperaldosteranism?
```
Water + salt retention > hypertension
[but not hypernatraemia due to other mechanisms]
Polyuria + polydipsia
Hypokalaemia
Alkalosis
Muscle weakness + spasm
```
80
What are the investigations of hyperaldosteronism?
U&Es
aldosterone
renin levels: decreased in primary, increased in secondary (eg in response to renal or heart failure)
ECG
Will need to be off certain meds
81
What is Conn's syndrome?
A cause of secondary hypertension and hyperaldosteronism, caused by adenoma of zona glomerulosa
82
What are the causes of Cushing's syndrome? (3)
Overtreatment with glucocorticoids
Ectopic ACTH production (eg oat-cell carcinomma)
Carcinoma of adrenal cortex
(Latter two: death may occur before development of cushingoid features)
83
What is Cushing's disease?
Pituitary adenoa causing bilateral enlargement of cortex
| Same symptoms + pigmented skin
84
Causes of pseudo-cushings
Depression, obesity, alcoholism
85
First-line investigation for Cushing's syndrome
24-hour urinary free cortisol (represents 1%) - ideally 3 collections
86
In whom should suspicions of Addison's be considered?
Hx of craving for salty food, postural hypotension, pigmented skin
Addisonian crisis
Unexplained recurrent hypoglycaemia
Hypothyroidism that gets worse despite thyroxine
Other auto-immune disease
87
What investigations should be carried out for adrenal insufficiency?
NB may be normal - no reserve when stressed
```
FBC
U&Es
Calcium
Glucose
LFTs
Cortisol (between 8am-9am when highest)
```
Followed by:
ACTH
Renin:aldosterone (renin usually high, aldosterone low)
Synacthen test
88
What would be done during Addison's ongoing monitoring?
Hx
Examination
Ix
Questions about symptoms, eg energy + appetite - questions about other auto-immune diseases (thyroid, diabetes, pernicious anaemia, coeliac)
Weight, BP (sitting + standing), examination of skin for pigmentation
U&Es, bone profile, TFTs, glucose + HbA1c, FBC, B12
89
What should be in an emergency Addison kit?
| What are the sick days rules?
Hydrocortisone self-injection
| Double the hydrocortisone
90
What are the typical biochem findings in Addison's?
hyponatraemia, hyperkalaemia, hypoglycaemia, tendency for hypercalcaemia
91
What are causes of acute adrenocortical failure?
| How does it present?
Bilateral haemorrhagic necrosis (sepsis/ DIC/ Waterhouse-Friderichson syndrome [meningococcal])
Stopping steroids suddenly (steroids stop ACTH production - so no endogenous cortisol for weeks)
92
How are phaechromocytomas treated?
Alpha-blockers for ~10 days, then surgery
93
Tumours where can produce same symptoms of phaechromocytomas?
Sympathetic ganglion (usually beside aortic bifurcation)
94
Order steroids in terms of mineralocorticoid content...
Fludrocortisone
Hydrocortisone (think water)
Prednisolone
Dexamethasone, betmethasone
95
What are the side-effects of steroids?
Glucocorticoids (Cushing's)
| Mineralocorticoids (like hyperaldosteronism) - be wary of prescribing alongside other meds that cause hypokalaemia
96
What should you consider prescribing alongside steroids?
Steroid-sparing agent, eg azathioprine, methotrexate
Bisphosphonates
PPIs
97
Causes of hyperglycaemia
DM
| Glucagonoma
98
Causes of hypoglycaemia
```
Anti-diabetic meds/ poor control
Alcohol
Pituitary insufficiency (reduced GH)
Insulinoma/ ectopic insulin
Drugs: quinine, salicylates, propanolol
```
99
What is MODY?
Maturity-onset Diabetes of the Young
| inherited, young patients, often not obese, at risk of DKA
100
What is LADA?
Latent Autoimmune Diabetes of Adults
| often misdiagnosed as T2DM
101
If a patient is symptomatic for DM, how can this be diagnosed?
Fasting: 7+
Random: 11.1+
HbA1C: 6.5% (48 mmol) - but normal does not rule out
102
How is an asymptomatic pt diagnosed with DM?
Two readings
103
How is pre-diabetes diagnosed?
Fasting: 6.1 - 6.9
HbA1C: 42-47
104
When should HbA1C not be used?
When RBC life is prolonged (eg asplenic), or when RBC life is shortened (eg SCD)
Children + gestational
105
What medication is first-line for hypertension in DM?
ACEi (renoprotective)
If black, ACEi + thiazide/CCB
106
How is HHS differentiated from DKA?
Ketonuria ++ in DKA
107
What are the findings in DKA?
Dehydrated (glucose + ketones form diuresis)
Metabolic acidosis (ketones)
Hypokalaemia
108
What are the complications of DKA?
Cerebral oedema in kids
| Cardiac dysarrhythmias
109
What are the causes of secondary diabetes?
Pancreatic disease: cystic fibrosis, chronic pancreatitis, pancreatectomy, ca pancreas
Endocrine: Cushing's, acromegaly, thyrotoxicosis, phaechromocytoma, glucagonoma
Drugs: CS, among others
Hereditary: Friedrich's ataxia, haemachromatosis
110
What is ideal BP if DM?
135/85
unless signs of end-stage organ damage: 130/80
111
When should short-acting insulin be injected?
15-30 mins before meal
112
How often should BM be checked if on insulin?
4 times/day (before each meal and before bed)
| every 4 hours if ill
113
What level of hypoglycaemia should be treated in hospitals?
Below 4
114
Less-obvious way for hypoglycaemia to present?
Cardiac event
115
How often should HbA1c be checked in T2DM?
3-6 monthly until stabilised
| 6 monthly thereafter
116
What is HbA1c target in T2DM?
```
48 mmol (6.5%) if on mono-therapy
7.0% if on drugs associated with hypoglycaemia
```
Consider relaxing on case-by-case basis
117
Symptoms and management of gastroparesis
Gastrc bloating and vomiting
Domperidone
118
Side-effects of metformin
Lactic acidosis
GI disturbance
Step-up gradually
119
Mechanism of metformin
Increase insulin sensitivity
| Decrease hepatic gluconeogenesis
120
Mechanism of sulfonylureas
Stimulate pancreatic beta cells
121
Side-effects of sulfonylureas
Hypoglycaemia
| Hyponatraemia
122
Examples of sulfonylureas
Gliclazide
| Glimepiride
123
What are the sick day rules for diabetics?
Keep a sick day pack with sugary food and fluids
Keep eating + drinking
Continue taking meds (inc insulin)
If T1DM: ketone sticks, 4-hourly BMs
If unable to eat and drink properly, seek medical advice
124
Normal serum calcium level
2.1 to 2.6
125
Symptoms + signs of hypocalcaemia
```
Paraesthesia
Muscle cramps
Carpopedal spasm
Chvostek's sign
Trousseau's sign
```
Seizures
Prolonged QT (leading to VF, heart block)
Laryngospasm
Bronchospasm
126
Causes of hypocalcemia
```
If low PTH:
parathyroid agenesis (eg DiGeorge's syndrome)
parathyroid destruction (surgery, radiotherapy, infiltrative disease)
autoimmune disease
```
If high PTH:
vit D deficiency
hypomagnesaemia
pseudohypoparathyroidsm (PTH resistance)
```
Other:
hyperventilation
drugs (eg bisphosphonates)
acute pancreatitis
acute rhabdomyolysis
malignancy
```
127
How to investigate hypocalcaemia?
Check: ideally take fasting blood sample fro uncuffed arm, ensure using adjusted calcium
```
U&Es (exclude CKD)
amylase (exclude acute pancreatitis)
creatinine kinase (exclude rhabdo)
Phosphate
Mg
Vit D
```
ECG
128
How do you treat acute symptomatic hypocalcaemia?
Give 10 mL of calcium gluconate 10% by slow IV injection
Repeat if necessary (up to 40 mL/24h)
(Correct hypomagnesaemia first)
129
Which hypocalcaemics are prescribed calcitriol?
Renal impairment: doesn't require hydroxylation by kidney
130
What are the symptoms of hypercalcaemia?
Mild: polyuria, polydipsia, dyspepsia, depression, mild cognitive impairment
Moderate: also muscle weakness, constipation, anorexia, nausea, fatigue
Severe: abdo pain, vomiting, dehydration, shortened QT interval, pancreatitis, coma
If long-standing, calcium deposited in soft tissues + stones
131
What are the causes of hypercalcaemia?
PTH-mediated
Malignancy
Granulomatous conditions
Others
132
What investigations for hypercalcaemia?
PTH
U&Es
Serum phosphate
ALP
(Consider urine calcium + phosphate)
133
When are PTH levels low in hypercalcaemia?
Granulomatous disease, renal dialysis, adrenal insufficiency, thyrotoxicosis
134
How should acute hypercalcaemia be administered?
IV fluids
After rehydration, bisphosphonates IV
Sometimes steroids or other drugs, depending on cause
135
Does vit D (calcitriol) increase or decrease serum calcium?
Increases absorption from gut
136
Causes of primary hyperparathyroidism
PT adenoma (80%), hyperplasia (20%)
137
Causes of secondary hyperparathyroidism
chronic renal disease
vit D deficiency/ malabsorption
ie IN RESPONSE TO LOW CALCIUM
138
When may osteitis fibrosa cystica result?
Secondary hyperparathyroidism
139
How is secondary hyperparathyroidism managed?
Diet modification/ phosphate binders
| Vit D analogues
140
What is tertiary hyperparathyroidism?
If secondary hyperparathyroidism persists, level of calcium needed resets/ autonomous secretion of PTH
141
What are the lab findings in the three types of hyperparathyroidism?
PTH increased always
1: increased calcium, decreased phosphate
2: normal/ decreased calcium, increased phosphate
3: normal/ increased calcium, normal or decreased phosphate, normal or decreased vit D, increased ALP
142
What produces calcitonin?
C cells of thyroid
143
What investigations for hyponatraemia?
```
U&Es
Glucose
Lipids
TFTs
LFTs
Plasma osmolality
```
Urine osmolality
Urine Na + K
144
What are the causes of hypernatraemia?
Pure free water loss, eg poor intake, DI
Hypotonc fluid loss, eg excessive sweating, burns, GI losses, urinary losses (eg diuresis)
Hypertonic sodiu gain, eg iatrogenic
145
What investigations for hypernatraemia?
U&Es
Calcium
Plasma glucose
Lithium levels, where appropriate (reduces lithium elimination)
If DI suspected: urine and serum osmolality
146
What is management of hypernatraemia?
Address underlying cause, withhold diuretics, lactulose
Seek specialist help so not to correct too rapidly (esp if chronic)
There are formulae to calculate amount of free water needed
147
What are the main causes of hypokalaemia?
Diuretics
| GI lossses
148
What investigations for hypokalaemia?
Check with ABG
ECG: flat t waves, ST depression, prominent U waves
```
U&Es (concurrent low sodium suggests thiazides or marked volume depletion)
Serum bicarbonate
Serum glucose
Serum chloride
Serum magnesium
```
```
Urine:
osmolality (needed to interpret urine K)
urinary potassium (high = renal loss)
urinary sodium (if low, and urinary K high = secondary hyperaldosteronism)
```
149
How to manage hypokalaemia?
Usually diet/ oral supplements
Administer KCl
Monitor 1-3 hourly
150
What investigations for hyperkalaemia?
Check: ABG
FBC
U&Es
Capillary + plasma blood glucose
24h urinary volume and electrolytes
If takes digoxin, check levels
151
What are the ECG changes in hyperkalaemia?
Tented t waves
Prolongation of PR interval
Widening of QRS
Other shit
If already has heart disease, bradycardia may be only new thing
152
How to manage hyperkalaemia?
If above 7 or ECG changes:
Stop medications that conserve potassium
Consider stopping digoxin and beta-blockers
10 mL 10% calcium gluconate (protect cardiac membrane) - up to 50 mL until ECG stabilises
Effects only last 30-60 mins
Insulin-glucose infusion (usually 10 units/25 g glucose) by IV: check BM before, during + after
Also give 10-20 mg nebulised salbutamol
Are other things to try, haemodialysis if necessary
153
MEN I
3 Ps
Parathyroid
Pituitary
Pancreas (insulinoma/ Zollinger-Ellinson)
154
MEN IIa
2 Ps
Medullary thyroid cancer
Parathyroid
Phaechromocytoma (bilateral)
155
MEN IIb
1 P
Medullary thyroid cancer
Phaechromocytoma
(Marfanoid body, neuromas)
156
PLACEHOLDER
Diabetes Meds
157
Endo causes of clubbing
Thyroid acropachy
158
Main steps in medical management of T2DM
Diet alone/ metformin: 48 mmol (6.5%)
Meds that might cause hypo, eg sulphonylurea: 53 mmol (7%)
If rises to 58 mmol (7.5%) - intensify treatment - add insulin (+metformin, +sulphonylurea)
159
Pregnancy and hyperthyroidism precaution
Carbimazole and methimazole are teratogenic
| Propylthiouracil used instead
160
Thyroid and periods
Hyper: amenorrhea
Hypo: menorrhagia
161
What produces a woody hard thyroid?
Riedel thyroiditis
typically euthyroid but can be hypothyroid due to autoimmune fibrosis
can cause compression of local structures
treat with pred
162
which common med reduces hypoglycaemic awareness
beta-blockers
