Endo Flashcards
Pregnant patient - TFTs
TSH can be mildly suppressed in up to 13% of pregnancy in first trim. T3 and T4 can slightly increased too due to HCG stimulation
T-binding globulin has twofold increase due to reduced hepatic clearance and increased synthesis due to oestrogen
Best management for hirtuism in PCOS
weight loss
5% weight loss has 40% improvement of hirtuism
Crypterone acetate& ethinyloestradiol or COCP can be used
Patient collapses. Raised c peptide, hypoglycemic
Could be sulphonylurea abuse, esp if family member has T2DM
Could be insulinoma, but rare
Could be Addisonian crisis - low BP, hyperkal hyponat
Insulin abuse would have suppressed c peptide
Management of prolactinoma
Cabergoline, very effective, unlikely to need surgery
Management for acromegaly
Treat with Somatostatin Analogues (Octreotide) then transphenoidal surgery
Patient with hyperthyroidism on amiodarone due to paroxysmal VT. On Doppler USS blood flow is increased
Management
Start carbimazole 40mg OD
Amiodarone should ideally be stopped but given the VT this is difficult
USS with increased blood flow is Type 1 amiodarone hyperthy, treat with carbimazole
decreased blood flow is Type 2, corticosteroids
Type 2 is usually with no underlying disease
Thyrotoxicosis in pregnancy…management
propylthiouracil in first trim, then carbimazole
If painful goitre, raised ESR could be subacute so NSAIDs
Bartter Vs gittelman
Bartter is usually in childhood with failure to thrive
Also has elevated urinary calcium excretion
77 with Colles wrist fracture. Management
Start alendronate in patients >= 75 years following a fragility fracture, without waiting for a DEXA scan
Cause of adrenal insufficiency in developing world
TB is most common cause
Remember can get transient low T4 , but corrects with steroid replacement
Management of patient that presents with hypoglycemia. BG of T2DM, on metformin and gliclazide
Not responsive to 10% dextrose
What is management
Octreotide in sulphonylurea OD
- blocks insulin secretion
(aka Sandostatin - synthetic somatostatin)
Most likely cause of Low TSH levels in hospitalised patients
Sick thyroid syndrome 3x more likely than hyperthyroidism
Management of gestational diabetes
Fasting >=5.6
2hr glucose >= 7.8
Fasting glucose 5.6 - 7 then diet,+/- Metformin after 1-2/52
6-6.9 with complications -macrosomia or hydramnios, then offer insulin
Fasting >7 then start insulin
Management of subclinical hypothyroidism
Treat if TSH above 10 (if younger than 70)
TSH 4-10 then treat if symptomatic
Hyponatremia with normal osmolarity
Pseudohyponatraemia
… serum Na is measured as a ratio of Na to plasma volume. If the patients plasma has high amounts of proteins or lipids, the plasma volume will be increased resulting in a measured hyponatraemia. This is not a true hyponatraemia as the actual ratio of sodium to plasma fluid will be normal.
So look out for hyperproteinaemia (e.g. TPN, IVIG) and hyperlipidaemia (in particular hypertriglyceridemia)
Management for patient with familial hypercholesterolemia
First line: high dose statins.
Second line: Ezetimibe (inhibits the intestinal absorption of cholesterol)
Calcium in adrenal Insufficiency
hypercalcemia—
combination of increased calcium input into the extracellular space and reduced calcium removal by the kidney
hyponatraemia in 85–90%
hyperkalaemia in 60–65%,
“hypercalcaemia is a rare occurrence”
familial benign hypocalciuric hypercalcaemia Vs primary hyperparathyroidism
Both may have high calcium with high or (inappropriately) normal PTH
But FHH has low urinary calcium
High calcium should lead to high urinary calcium
FHH is auto dom asymp hypercal - defect in the calcium-sensing receptor
What is familial benign hypocalciuric hypercalcaemia
FHH is auto dom asymp hypercal - defect in the calcium-sensing receptor
macroadenoma with high prolactin management
If prolactin extremely high (>6000) then prolactinoma, so treat with bromocriptine or cabergoline (dopamine-R agonist)
In macroadenoma, other may be reduced and prolactin can be raised ( 600–3000 mU/L) secondary to pit stalk blockage w prevention of dopamine reaching the pituitary
Mx Trans-sphenoidal surgery
Management of insulinoma
CT scan - 10% are malignant 10% are multiple
50% are MEN1
Refer to surgery
Diazoxide and somatostatin are tx options if not surgery
52y w galactorrhoea. Generally fatigued. Prolactin 440, what is next test?
Pregnancy, TFTs (hypothy common cause)
MRI if these ruled out
Management of hyperparathyroidism
Total parathyroidectomy
Conservative if calcium less than 0.25 above AND under 50y AND not symptomatic (fragility#, renal stones) AND eGFR over 60
Can use calcimemetics like cinacalcet
Hypokal differentials
CCL (Cushing’s Conn’s liddle) hypertension
Gitelman gentleman (older but still only 20s), decreased Ca urine
Bart has a Cat (bart is also child)
Liddle you get when you’re little
Diagnosis of growth hormone deficiency
First line: IGF-1 may be raised (but N in 30-40%)
If unsure: oral glucose tolerance test (OGTT) with serial GH measurements
(normally would get suppressed to <2 in hypergly)
Contraindicated w IHD or seizures so use arginine-GHRH simulation test
Management of acute thyrotoxicosis
IV propranolol
Propylthiouracil or Methimazole
Lugol’s iodine
Dexamethasone (blocks T4 to T3 conversion
Stop aspirin as it can worsen storm by displacing T4 from thyroid binding globulin
Markers of severe DKA
pH <7 Blood ketones >6 Bicarb <5 Anon gap >16 K <3.5 on admission Tachy or Bradycardia Sys BP <90 O2<92 GCS<12
Myxedema coma management
Combo of levo and liothyronine
Fluid resus
Not great evidence for T3 because of lack of RCT but T3 has faster onset
Pregnant woman with history of Graves
thyrotrophin (TSH) receptor stimulating antibodies should be checked at 30-36 weeks gestation - helps to determine the risk of neonatal thyroid problems
Management of papillary thyroid cancer
Thyroidectomy and radio iodide therapy
Progression of Subacute (De Quervain’s) thyroiditis
4 phases
1) lasts 3-6/52, hyperthy, painful goitre, raised ESR, decreased uptake
2) 1-3/52 euthy
3) weeks-months hypothy
4) goes back to normal
Incidental 3mm thyroid mass found on CT. Asymptomatic
non-palpable nodule found on imaging that are < 1cm don’t need biopsy, managed in primary care
Signs of congenital adrenal deficiency pneumonic
2 1 def- Low mineralocorticoids - Increased androgens (normal BP - virilizing)
1 7 def- Increased mineralocoticoids- Low androgens (HTN - non virilizing)
1 1 def- Increased mineralocorticoids- Increased androgens (HTN - virilizing)
Electrolytes suggestive of laxative abuse
Hypokal with reduced k urinary excretion
Kidneys trying to hold on to it
May have calluses on hand from vomiting
CK and thyroid disease
CK is modestly elevated (<10x upper limit) in up to 90% of untreated hypothy, and up to 79% complain of muscle symptoms
Polymyositis unlikely if <1000
Pt has hx of phaeochromocytoma and presents w thyroid swelling. What is the most appropriate next test to confirm the diagnosis?
Calcitonin levels
- as could be MEN 2a or b, with a Medullary thyroid cancer parafollicular (C) cells, which secrete calcitonin)
classic hx of pseudo-cushings
severe psychotic depression or alcohol use mildly raised 24-h urinary free cortisol (unlike 3x upper limit in Cushing's) low dose (1mg) dex ... cortisol 55 nmol/L (<50)
interpretation of raised dehydroepiandrosterone sulphate in PCOS investigations
DHEA is produced by adrenal cortex
If raised it points to an adrenal rather than an ovarian source, making ovarian tumour unlikely
urinary sodium in vol depletion
low urinary sodium (appropriate response to volume depletion)
hyperthyroid in pregnancy
propylthiouracil in first trimester then carbimazole
post-partum thyroiditis
usually hyper (don't treat, maybe propanolol then hypothy (can treat) then euthyroid
severe psychotic depression mildly raised 24-h urinary free cortisol low dose (1mg) dex ... cortisol 55 nmol/L (<50)
classic hx of pseudo-cushings
often due to alcohol excess or severe depression
cause of amenorrhoea in low BMI
hypothalamic amenorrhoea
The history of T1DM and coeliac, with a new likely diagnosis of Hashimotos….. probable diagnosis and what test?
Very suggestive of Autoimmune polyendocrinopathy syndrome type 2, which Addisons is strongly linked to
treating for Hashmitos which could result in an Addisonian crisis
short synacthen test
low calcium, high phosphate, high PTH
could be secondary hyperparathyroidism
in context of CKD
- CKD leads to high phosphate, and low Vit D… causing osteomalacia
or pseudohypoparathyroidism, where there is receptor insensitivity to PTH due to G-protein mutation... audo dom short fourth and fifth metacarpals cognitive impairment obesity round face
pseudohypoparathyroidism types
1a Has a characteristic phenotypic appearance (Albright’s hereditary osteodystrophy)
Type 1b and 2 no phenotype but has biochem
but 2 has normal cAMP response to PTH stimulation
pt w low Ca, Mg, and PTH
Magnesium deficiency causes hypocalcaemia
Without sufficient levels of magnesium, PTH cannot function properly
e.g. due to PPI
Secondary hyperparathyroidism vs vit d deficiency/osteomalacia
both low calcium high PTH
vit d def usually has low Phosphate too, whereas that’s high in secondary hyperpara
(CKD leads to low Vit D and high phosphate -reduced excretion)
Vit D def /Osteomalacia has raised ALP
Low Calcium, Raised ALP
could be osteomalacia - check Vit D
esp if phenytoin, Coeliacs, cirrhosis, Type 2 RTA (hypokal)
hx of weight loss
Low TSH and T4. Management?
In approximately 5% of patients with clinical and biochemical hyperthyroidism, T3 may be elevated prior to T4. This is known as T3 toxicosis.
If TSH and T4 T3 are low then its subclinical thyrotoxicosis
Management of secondary hyperparathyroidism
Reduce phosphate in diet
- reduction in foods like chocolate, nuts, shellfish and cola
Next step is a phosphate binder like Sevelamer or Lanthanum carbonate
Vit D replacement alfacalcidol
Can have parathyroidectomy
Common consequences of acromegaly
T2DM
Hypertension
LVH, doesn’t improve after treatment
33% have sleep apnoea, but tends to improve after treatment
30% have premalig colononic polyps, and 5% develop cancer
colonoscopic screening, starting at the age of 40 years
