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Part 1 > endo > Flashcards

endo Flashcards

1
Q

Addisonion crisis

A

Causes
sepsis or surgery causing an acute exacerbation of chronic insufficiency (Addison’s, Hypopituitarism)
adrenal haemorrhage eg Waterhouse-Friderichsen syndrome (fulminant meningococcemia)
steroid withdrawal

Management
hydrocortisone 100 mg im or iv
1 litre normal saline infused over 30-60 mins or with dextrose if hypoglycaemic
continue hydrocortisone 6 hourly until the patient is stable. No fludrocortisone is required because high cortisol exerts weak mineralocorticoid action
oral replacement may begin after 24 hours and be reduced to maintenance over 3-4 days

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2
Q

Gieltman’s syndrome

A

salt wasting nephropathy

Gitelman’s syndrome is due to a defect in the thiazide-sensitive Na+ Cl- transporter in the distal convoluted tubule.

Features
normotension
hypokalaemia
hypocalciuria
hypomagnesaemia
metabolic alkalosis
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3
Q

Kallman’s syndrome

A

failure of GnRH-secreting neurons to migrate to the hypothalamus.

Features
‘delayed puberty’
hypogonadism, cryptorchidism
anosmia
sex hormone levels are low
LH, FSH levels are inappropriately low/normal
patients are typically of normal or above average height

Cleft lip/palate and visual/hearing defects are also seen in some patients

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4
Q

Thiazolidinediones

A

agonists of PPAR-gamma receptors, reducing peripheral insulin resistance

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5
Q

hypercalcaemia

A

Two conditions account for 90% of cases of hypercalcaemia:

  1. Primary hyperparathyroidism: commonest cause in non-hospitalised patients
  2. Malignancy: the commonest cause in hospitalised patients. This may be due to number of processes, including; bone metastases, myeloma, PTHrP from squamous cell lung cancer
Other causes include
sarcoidosis*
vitamin D intoxication
acromegaly
thyrotoxicosis
Milk-alkali syndrome
drugs: thiazides, calcium containing antacids
dehydration
Addison's disease
Paget's disease of the bone**
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6
Q

hypertension
hypokalaemia (e.g. muscle weakness). This is a classical feature in exams but studies suggest this is seen in only 10-40% of patients
alkalosis

A

Conn’s (hyperaldosteronism) adrenal adenoma

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7
Q

Conn’s Ix

A

renin angiotensin ratio
high aldosterone levels alongside low renin levels (negative feedback due to sodium retention from aldosterone)
following this a high-resolution CT abdomen and adrenal vein sampling is used to differentiate between unilateral and bilateral sources of aldosterone excess

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8
Q

Conn’s Mx

A

Management
adrenal adenoma: surgery
bilateral adrenocortical hyperplasia: aldosterone antagonist e.g. spironolactone

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9
Q

most consistent PCOS feature

A

cysts in ovaries.. obviously

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10
Q

PCOS Ix

A

pelvic ultrasound: multiple cysts on the ovaries
FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes
check for impaired glucose tolerance

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11
Q

PCOS features

A

subfertility and infertility
menstrual disturbances: oligomenorrhea and amenorrhoea
hirsutism, acne (due to hyperandrogenism)
obesity
acanthosis nigricans (due to insulin resistance)

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12
Q

This is characterised as monomorphic papular rash without comedones or cysts

A

drug induced acne (systemic glucocortoids)

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13
Q

T1DM pathophysiology

A

autoimmune disease
antibodies against beta cells of pancreas
HLA DR4 > HLA DR3
various antibodies such as islet-associated antigen (IAA) antibody and glutamic acid decarboxylase (GAD) antibody are detected in patients who later go on to develop type 1 DM - their prognostic significance is not yet clear

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14
Q

T2DM HbA1c level

A

you can titrate up metformin and encourage lifestyle changes to aim for a HbA1c of 48 mmol/mol (6.5%), but should only add a second drug if the HbA1c rises to 58 mmol/mol (7.5%)

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15
Q

carbimazole

A

Carbimazole is used in the management of thyrotoxicosis. It is typically given in high doses for 6 weeks until the patient becomes euthyroid before being reduced.

Mechanism of action
blocks thyroid peroxidase from coupling and iodinating the tyrosine residues on thyroglobulin → reducing thyroid hormone production
in contrast propylthiouracil as well as this central mechanism of action also has a peripheral action by inhibiting 5’-deiodinase which reduces peripheral conversion of T4 to T3

Adverse effects
agranulocytosis
crosses the placenta, but may be used in low doses during pregnancy

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16
Q

metformin increases peripheral insulin sensitivity in PCOS leading to..

A

increased fertility in hypothalamic pituitary gonadal axis

not well understood.

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17
Q

graves autoantibodies

A

Autoantibodies
TSH receptor stimulating antibodies (90%)
anti-thyroid peroxidase antibodies (75%)

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18
Q

graves features

A

Features
typical features of thyrotoxicosis
specific signs limited to Grave’s (see below)

Features seen in Graves’ but not in other causes of thyrotoxicosis
eye signs (30% of patients): exophthalmos, ophthalmoplegia
pretibial myxoedema
thyroid acropachy

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19
Q

myxodaemic coma Rx

A

levothyroxine and hydrocortisone

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20
Q

pseudohypoparathyroidism

A

target cells being insensitive to PTH
due to abnormality in a G protein
associated with low IQ, short stature, shortened 4th and 5th metacarpals
low calcium, high phosphate, high PTH

diagnosis is made by measuring urinary cAMP and phosphate levels following an infusion of PTH.

In hypoparathyroidism this will cause an increase in both cAMP and phosphate levels. In pseudohypoparathyroidism type I neither cAMP nor phosphate levels are increased whilst in pseudohypoparathyroidism type II only cAMP rises.

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21
Q

SGLT2 inhibitors (sodium glucose transporter) - flozins

A

act in early distal convoluted tubules preventing glucose reabsorption

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22
Q

Mature Onset Diabetes of Young (<25)

Autosomal dominant

A

MODY 3
60% of cases
due to a defect in the HNF-1 alpha gene
is associated with an increased risk of HCC

MODY 2
20% of cases
due to a defect in the glucokinase gene

Features of MODY
typically develops in patients < 25 years
a family history of early onset diabetes is often present
ketosis is not a feature at presentation
patients with the most common form are very sensitive to sulfonylureas, insulin is not usually necessary

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23
Q

metabolic syndrome

A

elevated waist circumference: men > 102 cm, women > 88 cm
elevated triglycerides: > 1.7 mmol/L
reduced HDL: < 1.03 mmol/L in males and < 1.29 mmol/L in females
raised blood pressure: > 130/85 mmHg, or active treatment of hypertension
raised fasting plasma glucose > 5.6 mmol/L, or previously diagnosed type 2 diabetes

Other associated features include:
raised uric acid levels
non-alcoholic fatty liver disease
polycystic ovarian syndrome

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24
Q

MEN 2B

A

Medullary thyroid cancer

1 P
Phaeochromocytoma

Marfanoid body habitus
Neuromas

RET Oncogene

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25
Q

MEN 2A

A

Medullary thyroid cancer (70%)

2 P’s
Parathyroid (60%)
Phaeochromocytom

RET Oncogene

(not marfanoid)

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26
Q

Men 1

A

3 P’s
Parathyroid (95%): hyperparathyroidism due to parathyroid hyperplasia
Pituitary (70%)
Pancreas (50%): e.g. insulinoma, gastrinoma (leading to recurrent peptic ulceration)

Also: adrenal and thyroid

MEN1 gene

Most common presentation = hypercalcaemia

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27
Q

Sick euthyroid syndrome

A

TSH normal / low; thyroxine low; T3 low

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28
Q

Thyrotoxicosis with tender goitre =

A

subacute (De Quervain’s) thyroiditis

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
thyroid scintigraphy: globally reduced uptake of iodine-131

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

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29
Q

radioiodine can cause

A

worsening in thyroid eye disease in 15% grave’s

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30
Q

weight gain by which diabetic med

A

gliclazide (sulfonylurea)

increasing pancreatic insulin secretion and hence are only effective if functional B-cells are present. On a molecular level they bind to an ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta cells.

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31
Q

hba1c 10% (86) average glucose level

A

15.5 over 2 months

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32
Q

prediabetes

A

a fasting plasma glucose of 6.1-6.9 mmol/l or an HbA1c level of 42-47 mmol/mol (6.0-6.4%) indicates high risk

start metformin if worsening

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33
Q

Impaired glucose tolerance (IGT) is defined as fasting

A

plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l

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34
Q

hba1c target in T1DM

A

48 (6.5%)

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35
Q

acromegaly Rx pregmisovent

A

GH receptor antagonist - prevents dimerization of the GH receptor
once daily s/c administration
very effective - decreases IGF-1 levels in 90% of patients to normal
doesn’t reduce tumour volume therefore surgery still needed if mass effect

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36
Q

Acromegaly Rx

A

1st line - trans sphenoidal surgery

somatostatin analogues (ocreotide)
Dopamine agonists (bromocriptine)
pregmisovent
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37
Q

somatostatin analogues in acromegaly

A

directly inhibits the release of growth hormone
for example octreotide
effective in 50-70% of patients
may be used as an adjunct to surgery

38
Q

gastrointestinal autonomic neuropathy Sx in diabetes

A

Gastroparesis
symptoms include erratic blood glucose control, bloating and vomiting
management options include metoclopramide, domperidone or erythromycin (prokinetic agents)

Chronic diarrhoea
often occurs at night

Gastro-oesophageal reflux disease
caused by decreased lower esophageal sphincter (LES) pressure

39
Q

how to test diabetic neuropathy in feet

A

10g monofilament

40
Q

commonest cause of primary hyperaldosteronism

A

adrenal hyperplasia

41
Q

klinefelters’s (47XXY) gronadotrophin elvels

A

raised lh fsh/ low testosterone

often taller than average
lack of secondary sexual characteristics
small, firm testes
infertile
gynaecomastia - increased incidence of breast cancer
elevated gonadotrophin levels but low testosterone

42
Q

Grave’s on carbimazole, what are you monitoring?

A

TSH levels

should slowly rise as TSH receptor autoantibodies decline

43
Q

acromegaly related malignancy

A

colorectal carcinoma

44
Q

GLP-1 in diabetes

A

glucagon like peptide low in T2DM

Mimetics such as exenatide increase insulin secretion and inhibit glucagon secretion.

45
Q

overactive bladder

A

antimuscarinics - toltoredine
Immediate release oxybutynin should, however, be avoided in ‘frail older women’

mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients

46
Q

Insulin stress test

A

dydx cushing’s from pseudocushings
for hypopituitarism

Basics
used in investigation of hypopituitarism
IV insulin given, GH and cortisol levels measured
with normal pituitary function GH and cortisol should rise

Contraindications
epilepsy
ischaemic heart disease
adrenal insufficiency

47
Q

exanatide only in

A

obese 30+bmi

48
Q

Cushing’s Ix

A

overnight dex suppression test or 24 hour urine cortisol collection

49
Q

Riedel’s thyroiditis

A

hypothyroidism

dense fibrous tissue replacing the normal thyroid parenchyma.

hard, fixed, painless goitre is noted.
middle-aged women.
assw/ retroperitoneal fibrosis.

50
Q

easily provoked hypokalaemia (by ACEI)

A

consider primary hyperaldoseronism

51
Q

thyroid eye disease pathophysiology

A

it is thought to be caused by an autoimmune response against an autoantigen, possibly the TSH receptor → retro-orbital inflammation
the inflammation results in glycosaminoglycan and collagen deposition in the muscles

52
Q

thyroid eye disease prevention

A

smoking is the most important modifiable risk factor

radioiodine treatment may increase the inflammatory symptoms seen in thyroid eye disease. In a recent study of patients with Graves’ disease around 15% developed, or had worsening of, eye disease. Prednisolone may help reduce the risk

53
Q

features of thyroid eye disease

A

the patient may be eu-, hypo- or hyperthyroid at the time of presentation
exophthalmos
conjunctival oedema
optic disc swelling
ophthalmoplegia
inability to close the eye lids may lead to sore, dry eyes. If severe and untreated patients can be at risk of exposure keratopathy

54
Q

acarbose

A

inhibitor of intestinal alpha glucosidases, which results in decreased absorption of starch and sucrose.

flatulance

55
Q

cushing’s metabolic what

A

hypokalaemic metabolic alkalosis

56
Q

T2DM diagnosis

A

If the patient is symptomatic: (polyuria polydipsia)
fasting glucose greater than or equal to 7.0 mmol/l
random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)

57
Q

diabetic neuropathy of feet pain

A

first-line treatment: amitriptyline, duloxetine, gabapentin or pregabalin

58
Q

radioiodine most frequent side effect

A

hypthyroidism

59
Q

amitryptilline + BPH

A

retention

60
Q

iron reduces absorption of

A

thyroxine

61
Q

sulfonylureas

A

gliclazide and tolbutamide

62
Q

Congenital adrenal hyperplasia

A

21 hydroxylase defiency

63
Q

Anaplastic thyroid cancer

A

aggressive, difficult to treat and often causes pressure symptoms
like hoarse voice etc

locally invasive

Treatment is by resection where possible, palliation may be achieved through isthmusectomy and radiotherapy.

64
Q

hirsuitism in PCOS Rx

A

a COC pill may be used help manage hirsutism. Possible options include a third generation COC which has fewer androgenic effects or co-cyprindiol which has an anti-androgen action. Both of these types of COC may carry an increased risk of venous thromboembolism
if doesn’t respond to COC then topical eflornithine may be tried
spironolactone, flutamide and finasteride may be used under specialist supervision

65
Q

pioglitasone

A

Thiazolidinediones

can cause fluid retention
agonists to the PPAR-gamma receptor and reduce peripheral insulin resistance

66
Q

Anticholinergics for urge incontinence are associated with confusion in elderly people

A

mirabegron is preferred

beta 3 agonist

67
Q

DKA back to normal, how do you start the insulin

A

continue long acting insulin throughout fixed rate infusion during DKA

don’t leave a gap where there is no insulin cover

68
Q

DKA features

A

Features
abdominal pain
polyuria, polydipsia, dehydration
Kussmaul respiration (deep hyperventilation)
Acetone-smelling breath (‘pear drops’ smell)

69
Q

Congenital adrenal hyperplasia

A

Overview
group of autosomal recessive disorders
affect adrenal steroid biosynthesis
in response to resultant low cortisol levels the anterior pituitary secretes high levels of ACTH
ACTH stimulates the production of adrenal androgens that may virilize a female infant

Cause
21-hydroxylase deficiency (90%)
11-beta hydroxylase deficiency (5%)
17-hydroxylase deficiency (very rare)

70
Q

Subclinical hypothyroidism Mx

Basics
TSH raised but T3, T4 normal
no obvious symptoms

Significance
risk of progressing to overt hypothyroidism is 2-5% per year (higher in men)
risk increased by the presence of thyroid autoantibodies

A

TSH 4-10

  • <65 with symptoms trial levothyroxine, stop if no improvement
  • elderly, esp 80+ watch and wait
  • ASx - watch and wait repeat in 6months
TSH >10
start treatment (even if asymptomatic) with levothyroxine if <= 70 years
'in older people (especially those aged over 80 years) follow a 'watch and wait' strategy, generally avoiding hormonal treatment'
71
Q

Primary hyperparathyroidism

A

PTH over-secretion usually from a parathyroid adenoma
both PTH and calcium are elevated
surgery to remove the adenoma is the most effective treatment
conservative measures such as bisphosphonates can be used

72
Q

Secondary hyperparathyroidism

A

chronic kidney disease typically
can be secondary to vitamin D deficiency
PTH released due to low calcium, high phosphate and lack of vitamin D activation by diseased kidneys

PTH level high with calcium levels being low or normal
medical management primarily: phosphate binders, calcium and vitamin D supplementation

73
Q

Tertiary hyperparathyroidism

A

autonomous hypersecretion of PTH due to hypertrophied parathyroid glands
occurs after a period of long standing secondary hyperparathyroidism
treatment involves parathyroidectomy

74
Q

Pseudohypoparathyroidism

A

PTH resistance and is associated with low calcium and high PTH levels

75
Q 
usually presents in childhood, e.g. Failure to thrive
polyuria, polydipsia
hypokalaemia
normotension
weakness
A

Bartter’s Syndrome
autosomal recessive) of severe hypokalaemia due to defective chloride absorption at the Na+ K+ 2Cl- cotransporter (NKCC2) in the ascending loop of Henle.

think of it like taking a lot of furosemide

76
Q

Mx of thyrotoxic storm

A

Management:
symptomatic treatment e.g. paracetamol
treatment of underlying precipitating event
beta-blockers: typically IV propranolol
anti-thyroid drugs: e.g. methimazole or propylthiouracil
Lugol’s iodine
dexamethasone - e.g. 4mg IV qds - blocks the conversion of T4 to T3

77
Q

Remnant hyperlipidaemia

A 
mixed hyperlipidaemia (cholesterol and triglyceride)
high incidence of ischaemic heart disease and peripheral vascular disease
 impaired removal of intermediate density lipoprotein from the circulation by the liver

Features
yellow palmar creases
palmer xanthomas
tuberous xanthomas

Mx - fibrates

AKA Fredrickson type III hyperlipidaemia, broad-beta disease and dysbetalipoproteinaemia
associated with apo-e2 homozygosity

78
Q

T1DM and insulin and BMI >25

A

consider metformin

79
Q

: unopposed oestrogen increases risk of

A

endometrial cancer

80
Q

sweating in acromegaly caused by

A

sweat gland hypertrophy

81
Q

Insulin, TRH and LHRH are given to the patient following which the serum glucose, cortisol, growth hormone, TSH, LH and FSH levels are recorded at regular intervals. Prolactin levels are also sometimes measured*

A

A normal dynamic pituitary function test has the following characteristics:
GH level rises > 20mu/l
cortisol level rises > 550 mmol/l
TSH level rises by > 2 mu/l from baseline level
LH and FSH should double

82
Q

Meglitinides

A

Meglitinides (e.g. repaglinide, nateglinide)
increase pancreatic insulin secretion
like sulfonylureas they bind to an ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta cells
often used for patients with an erratic lifestyle
adverse effects include weight gain and hypoglycaemia (less so than sulfonylureas)

83
Q

pseudohypoparathyroidism

insensitivity to pth

A

Bloods
PTH: high
calcium: low
phosphate: high

Features
short fourth and fifth metacarpals
short stature
cognitive impairment
obesity
round face

Investigation
infusion of PTH followed by measurement of urinary phosphate and cAMP measurement - this can help differentiate between type I (neither phosphate or cAMP levels rise) and II (cAMP rises but phosphate levels do not change)

84
Q

acromegaly Ix

A

Serum IGF-1 levels have now overtaken the oral glucose tolerance test (OGTT) with serial GH measurements as the first-line test. The OGTT test is recommended to confirm the diagnosis if IGF-1 levels are raised

Oral glucose tolerance test
in normal patients GH is suppressed to < 2 mu/L with hyperglycaemia
in acromegaly there is no suppression of GH
may also demonstrate impaired glucose tolerance which is associated with acromegaly

85
Q

SGLT-2 inhibitors like dapagliflozin promote increased glucose excretion because they inhibit glucose reabsorption in the kidney

however can

A

increase HDL and LDL

86
Q

Sulfonylureas -

A

bind to an ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta cells

87
Q

Features of MODY

A

typically develops in patients < 25 years
a family history of early onset diabetes is often present
ketosis is not a feature at presentation
patients with the most common form are very sensitive to sulfonylureas, insulin is not usually necessary

young and slim

88
Q

The PTH level in primary hyperparathyroidism

A

may be normal

89
Q

Hashimoto’s thyroiditis is associated with what cancer

A

thyroid lymphoma

90
Q

thyroid eye disease when to urgently see opthal

A

unexplained deterioration in vision
awareness of change in intensity or quality of colour vision in one or both eyes
history of eye suddenly ‘popping out’ (globe subluxation)
obvious corneal opacity
cornea still visible when the eyelids are closed
disc swelling

91
Q

A normal short synacthen test does not exclude adrenocortical insufficiency due to

A

pituitary failure

92
Q

Non-functioning pituitary tumours present with

A

hypopituitarism and pressure effects

prolactin can be slightly raised due to reduced negative pressure as dopamine is not released as much

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