ENDO Flashcards
6Oyo Male pt presents with tiredeness, weight loss, polyuria, polydipsia and irritation on the tip of his penis.
What are you thinking?
T2DM
Why do you have polyuria and polydipsia in t2dm?
It results from osmotic diuresis that results from elevated blood glucose.
What is an irritation on the tip of the penis in a diabetic picture?
Candida
causing balantis in males
causing pruritus vulvae in females
It’s an opportunistic infection activated in subacute diabetic presentations.
What is diagnostic for symptomatic diabetes?
Single raised plasma glucose reading.
What is diagnostic for asymptomatic diabetes?
2 abnormal readings in fasting plasma glucose
or 2 random plasma values
PC of hypothyroidism
Tiredeness Cold intolerance Depression Constipation Weight gain
What are the main causes of hypothyroidism
Iodine deficiency
Autoimmune pathology - Hashimotos thyroiditis
Post partum thyroiditis
A 33yo obese female pt just gave birth and is feeling depressed, gained weight, has anorexia, tiredness.
What are you thinking?
And what should you not get tricked into thinking by Karim Meeran?
Think hypothyroidism
Dont think post-partum depression, its a trick.
Post partum depression should only have psychological signs including: confusion, low mood, delusional thought (think their child is evil), anhedonia, anergia. Anorexia and weight gain aren’t matching the picture.
When do you use urinary catecholamines?
In diagnosing a phaeochromocytoma
Recognise the presenting symptoms of Cushing’s syndrome
- Increasing weight “my jeans keep getting tighter”
- Fatigue
- Muscle weakness
- Myalgia
- Thin skin
- Easy bruising
- Poor wound healing
- Fractures
- Hirsuitism
- Acne
- Frontal balding
- Oligomenorrhoea/amenorrhoea
- Depression or psychosis
Whats the first investigation you do when a patient presents with cushingoid symptoms?
LOW dose dexamethasone test
give 0,5mg of dexamethasone every 6 hrs for 48 hrs
measure serum cortisol after 48hrs
CUSHINGS = RAISED cortisol (even after supression test)
Normal = lower cortisol
What’s the next step when the cortisol is raised after a low dose dexamethasone test?
HIGH dose dexamethasone test
give 8mg of dexamethasone
ACTH dependent disease aka cushings disease = LOW cortisol –> indicating pituitary adenoma or ectopic acth from lung cancer.
ACTH independent disease aka cushings syndrome = HIGH cortisol –> indicating benign adrenal carcenoma or adrenal carcinoma
49yo male pt has difficulty sleeping
reports tiredeness, weakness, weight gain, sweats very easily lately, dizzines, visual changes.
OE: coarse facial features
What are you thinking?
Classic acromegaly
Explanation:
Difficulty sleeping is due to enlargement of the soft tissues in the pharynx which collapse during sleep causing obstructive sleep apnoea. Hence the tiredness and weakness.
Weight gain - people usually report “tighter shoes” “tighter watch” in acromegaly
Add all the above + sweats = acromegaly for sure.
Visual changes happen because the most common cause of acromegaly is a pituitary tumour and it can compress the optic chiasm causing bilateral quadranopia or hemianopia in progressive disease. This is also the cause of dizziness.
What’s the most common cause of acromegaly?
Pituitary adenoma
Whats the gold standard test for acromegaly?
Oral glucose supression test
You give 75mg oral glucose and you expect GH to be supressed
Its not in pts with acromegaly.
What is a screening test for acromegaly?
serum IGF-1 is raised
A 42yo female pt presents with visual disturbance - double vision
She also reports being breathless very easily and having palpitations
OE: painless lesions on her shins
What is this
Hypothyroidism - classic
Explanation:
visual disturbances because antibodies which bind to the tsh receptor causing an increase in th can also bing to the extraoculer muscles leading to gaze abnormalities.
The same antibodies can also bind to the shins causing raised lesions known as ‘pretibial myxoedema’
What type of antibodies are bind to the TSH receptor in graves?
IgG
16yo female pt presents with swelling in her neck
She is feeling more irritable but this is transient
OE: there is diffuse swelling
There is no bruit on auscultation of the bruit
What are you thinking?
Simple idiopathic goitre
don’t get tricked into thinking hyperthyroidism or things like that because the irritability is due to her being a teenager - transient is the key word
Absence of a thyroid bruit = not hyperthyroidism
What should you suspect with a major haemodynamic collapse?
Acute adrenal failure
What is the reason for the increased pigmentation in addison’s
ACTH is derived from POMC and so is MSH (melanocyte-stimulating hormones) thats why you get pigmentation.
What do you expect with the shortsynacthen test in addisons?
Giving ACTH should normaly increase serum cortisol production.
In adrenal failure giving ACTH will not increase serum cortisol (<550nmol/L serum cortisol)
Whats the dose of the short synacthen test?
tetrocosactrin 250μg IM
What is the purpose of the long synacthen test?
To differentiate between 1’,2’ and 3’ adrenal insufficiency
What results of the long synacthen test do you expect for 1’ adrenal insufficiency?
There is no increase in cortisol after the 6th hour measurment
How does the long synacthen test work?
1 mg synthetic ACTH administered
Measure serum cortisol at 0, 30, 60, 90 and 120 minutes Then measure again at 4, 6, 8, 12 and 24 hours
What’s the mx of chronic addison’s
Hydrocortisone (to replace glucocorticoids, and increase dose during stress)
Fludrocortisone (to replace mineralocorticoids)
Wear med alert bracelet, have gc with you, have steroid warning card.
What are the complications of addisons?
HYPERkalemia
Addisonian crisis
What do you expect in u&e’s in addisonian crisi?
Low Na+
High K+
Whats the mx of addisonian crisis
RAPID iv fluid rehydration
50ml of 50% dextrose
IV hydrocortisone 200mg (and give every 6hrs until bp is stable)
What do you expect in a water deprivation test normally and what is the result for diabetes insipidus?
Normally you expect to get a rise in urine osmolarity and normal range serum osmolarity
In DI you get high serum osmolarity with no compensation in the urine part - so you get dilute urine as well.
What do you do to differentiate between cranial and nephrogenic DI?
You administer desmopressin
If the pt responds to desmopressin = cranial
if the pt doesn’t respond to desmopressin = nephrogenic
Whats the normal response to the plantar reflex?
Downwards response of toes
aka: negative babinski
aka: flexor plantar reflex
Whats an abnormal response of the plantar reflex?
Upwards response of toes and fanning
aka: positive babinski
aka: extensor plantar reflex
What does a positive babinski sign indicate?
upper motor neuron lesion cerebral palsy strokes brain injury or brain tumors spinal cord tumor or injury multiple sclerosis (MS) meningitis severe hyponytraemia *
What are some causes of SIADH?
Brain: haemorrhage, meningitis, tumour, Guillain-Barre
Lung: pneumonia, TB
Tumours: leukaemia, small cell lung cancer, lymphoma
Drugs: opiates, Carbamezapine (anti-convulsant)
Metabolic: alcohol withdrawl, porphyria, Hypothyroidism, Addisons
What are the PC of moderate/severe SIADH
Hyponatremia symptoms: headache nausea and vomiting muscle cramps muscle weakness irritability confusion drowsiness convulsions coma
What are the signs OE for hyponatremia?
Hyporeflexia
Positive babinski sign
Patients are euvolemic - no signs of oedema
What results give you a diagnosis of SIADH?
LOW plasma osmolality
LOW serum Na+
HIGH urine osmolality
HIGH urine Na+
What’s the mx of SIADH?
Treat underlying cause
Fluid restriction
VP receptor antagonists
Severe case: slow IV hypotonic saline + furosemide
What are complications of SIADH?
Convulsions
Coma
Death
Central pontine myelinosis *
What is central pontine myelinosis
When you correct hyponatremia way too fast
- quadriparesis (weakness in all 4 limbs)
- respiratory arrest
- fits
50% mortality
