endo Flashcards
acromegaly signs on examination
prognathism macroglossia enlarged supraorbital ridges large hands / feet cardiomegaly → displaced apex beat
acromegaly management
surgical: transphenoidal resection of tumour (definitive)
medical: somatostatin analogues e.g. octreotide
GH receptor antagonists e.g. pegvisomant
radiotherapy for refractory disease
acromegaly investigations
bloods: GH, IGF1 levels + OGTT (glucose should suppress GH)
MRI → pituitary mass
visual field testing
assessment of other pituitary hormones
acromegaly complications
cardiac: HTN, arrthythmias, IHD, cardiomyopathy obstructive sleep apnoea diabetes osteoarthritis carpal tunnel syndrome
stages of diabetic retinopathy + management
background: hard exudates, microaneurysms, blot haemorrhages
→ optimise glucose control, pt education, annual screening
pre-proliferative: soft exudates
→ pan-retinal photocoagulation
proliferative: neovascularisation near optic disc
→ pan-retinal photocoagulation
maculopathy: exudates near macula
→ grid-laser therapy: targeted photocoagulation only at affected area
management DKA
- IV normal saline
bolus 10ml/kg
then 1L/4hrs until no longer dehydrated
+ potassium 40mmol/L but not in bolus fluid bag; infusion rate too high - IV insulin (fixed rate: 0.1units/kg/hr)
continue background insulin - once plasma glucose < 12mmol/L
change saline to 5% dextrose w 0.45% NaCl (150-250ml/hr) - heparin (dehydration → risk of clotting)
- ABx if infection
management T2DM
cons: patient education, diet modification, exercise, weight loss, complication monitoring
med: metformin
add sulphonylurea (e.g. glibenclamide), pioglitazone, gliptin
causes of hyperthyroidism
autoimmune: Grave’s disease
toxic thyroid nodules (multiple = Plummer’s disease)
De quervain’s thyroiditis: viral / post-partum
causes of goitre
hyperthyroid: Grave’s, Plummer’s (multinodular)
De Quervain’s thyroiditis
euthyroid: non-toxic goitre, cancer, adenoma
hypothyroid: Hashimoto’s, iodine deficiency
causes of thyroid nodule
single nodule:
colloid / hyperplastic nodules, cyst, adenoma, cancer
multinodular goitre: Plummer’s disease (toxic)
types of thyroid cancer
papillary (80%): younger pts, good prognosis, assoc w radiation exposure, psamomma bodies, orphan annie eye nuclei
follicular: middle age, Hurthle cells
medullary: MEN2A+B, calcitonin-secreting
anaplastic: rare, worst prognosis
causes of hypothyroidism
central:
pituitary: adenoma, infection, radiotherapy
hypothalamic: trauma, neoplasm
primary:
autoimmune: Hashimoto’s
iodine deficiency (most common)
drugs: amiodarone, lithium, iodine
iatrogenic: post-thyroidectomy, radiotherapy, radio-iodine
infiltration: sarcoidosis, amyloidosis, haemochromatosis
post-partum / infective thyroiditis
management Grave’s
medical:
symptomatic: beta-blockers
anti-thyroid drugs (12-28mths): carbimazole, propylthiouracil
OR block + replace: high dose antithyroid then levothyroxine
radioactive iodine
surgical: thyroidectomy
orbitopathy: prisms for diplopia, lubricant eye drops / ointments
IV methylprednisolone if sight-threatening / severe
dermatopathy: short course topical corticosteroid (if severe)
causes of diffuse goitre
autoimmune: hashimoto’s, grave’s
iodine deficiency
thyroiditis: post-partum / infective
MEN2A
medullary thyroid → calcitonin
parathyroid hyperplasia → PTH → hypercalcaemia
phaeochromocytoma → catecholamines
MEN2B
marfarnoid body habitus
medullary thyroid carcinoma → calcitonin
mucosal neuromas
phaeochromocytoma → catecholamines
MEN1
pituitary adenomas (prolactin, GH, ACTH, TSH)
parathyroid hyperplasia → PTH → hypercalcaemia
pancreatic tumours:
insulinoma → hypoglycaemia
zollinger ellison → gastrin → peptic ulcers
addison’s management
cons: MDT approach, pt education (importance of meds, concurrent illness Tx), medical bracelets
med: glucocorticoid replacement (2-3 doses frontloaded in morning) - double in concurrent illness
mineralocorticoid replacement
addison’s investigations
bloods: FBC, U&Es (↓Na, ↑K), ↓glucose
adrenal Ab (21-hydroxylase)
synACTHen test: ACTH fails to stimulate cortisol release
adrenal CT / MRI
management hypoglycaemia
conscious: short-acting carb (fruit juice, lucozade) + long-acting carb (biscuit, bread)
IM glucagon / IV dextrose if no improvement
once CBG > 4mmol/L: give long-acting carb
unconscious, unco-operative, fitting, unsafe swallow: ABC, stop insulin, IV dextrose 20% 50ml
1mg IM glucagon if no improvement
once CBG > 4mmol/L and regaining consciousness: give long-acting carb
causes of hypoglycaemia
iatrogenic: insulin / sulphonylureas poor glylcaemic control heavy alcohol consumption, renal impairment rarer causes: insulinoma addison's factitious hypoglycaemia
management prolonged hypoglycaemic coma (>5hrs)
IV mannitol + dexamethasone
constant glucose monitoring
IV glucose
causes of diabetes insipidus
cranial (insufficient ADH): tumours (pituitary / craniopharygioma), trauma, vascular (aneurysms, Sheehan syn)
nephrogenic (ADH insensitivity): idiopathic, lithium, pregnancy, osmotic diuresis (diabetes)
investigations diabetes insipidus
serum + urine osmolality
24hr urine collection
bloods: U&Es → hypernatraemia
fluid restriction test:
normal / psychogenic polydipsia: AVP → concentration of urine
DI: no change
DDAVP test:
cranial: concentration of urine
nephrogenic: no change
hypertonic saline (3%) test: normal / nephrogenic: AVP release (measured) cranial: no AVP change
management diabetes insipidus
cranial: DDAVP (desmopressin)
nephrogenic: fluids, salt restriction, thiazide diuretics (bendroglumethazide)
treat underlying cause
causes of gynaecomastia
increased oestrogen:androgen ratio
physiological (puberty)
androgen deficiency: Klinefelter’s, Kallman
liver disease
testicular failure: mumps
drugs: spironolactone, cimetidine, digoxin, cannabis
management of hyperglycaemic hyperosmolar state (HHS)
ABCDE
slow rehydration w 0.9% saline (risk cerebral oedema)
IV insulin if glucose not falling by 5mmol/L w rehydration alone / ketonaemia
correct electrolyte imbalance
monitor urine output
causes of hypoparathyroidism
primary:
genetic e.g. DiGeorge syn
acquired: anterior neck surgery, radiation
drugs: chemo / alcohol
infiltration: Wilson’s, haemochromatosis, metastases
secondary: to hypercalcaemia
investigations cushing’s
24hr urinary free cortisol (1st Ix)
9am + midnight cortisol (high midnight in Cushing’s)
low dose dexamethasone suppresion test (diagnostic): fails to suppress cortisol
high dose dexamethasone: fails to suppress cortisol if ectopic ACTH (but not in cushing’s disease)
management cushing’s
if iatrogenic: reduce steroid dose
medical:
steroidogenesis inhibitors: metyrapone, ketoconazole, etomidate
surgery:
removal of pituitary / adrenal tumour OR adrenalectomy
radiotherapy
which drugs can cause hypothyroidism
amiodarone
lithium
radioactive iodine (in treatment of hyperthyroidism / thyroid cancer)
antithyroid drugs: carbimazole, propylthiouracil
bones commonly affected in pagets
skull
spine
pelvis
long bones: femur, tibia
complications of pagets
cardiac failure (high-output)
deafness (sensorineural: CNVIII compression)
fractures
osteosarcoma
side effects of thiazolidinediones
weight gain increased fracture risk fluid retention (contraindicated in heart failure) liver impairment: monitor LFTs bladder cancer
pepperpot skull
primary hyperparathyroidism
management SIADH
fluid restriction
democycline (reduces sensitivity to ADH at collecting duct)
tolvaptan (V2 antagonist)
causes of SIADH
CNS: stroke, tumour
lung: small cell lung cancer, pneumonia, TB
other malignancies: pancreas, prostate
drugs: SSRIs, TCAs, carbamazpine
investigations SIADH
high urine osmolality + Na
low plasma osmolality
euvolaemic hyponatraemia
