endo SBAs Flashcards
Target and diagnostic HbA1c levels (3 month Hb plasma glucose average) for DM
> 6.5% (48mmol/mol)
There are higher levels in T2DM due to poor control
Conditions associated with cutaneous hyperpigmentation
Addison’s disease
Cushing’s syndrome
Nelson’s syndrome
Pregnancy
1st line therapy for pregnant T2DM
CCB
Roles of insulin
Increases: glycogenesis, glycolysis, glucose uptake into muscle and adipose tissue, protein synthesis, K+ uptake into cells
Decreases: gluconeogenesis, glycogenolysis, lipolysis, ketogenesis, proteolysis
CAH: 21-hydroxylase deficiency
Low aldosterone
High androgens
Hypotension, hypoNa+, hyperK+
CAH: 11b-hydroxylase deficiency
High 11-deoxycorticosterone
High androgens
Hypertension, hyperK+
CAH: 17a-hydroxylase deficiency
High aldosterone
Low androgens
Hypertension, hypoK+
High Ca2+
High PTH
Low phosphate
Primary hyperparathyroidism
Low Ca2+
High PTH
High/normal phosphate
Secondary hyperparathyroidism
Low plasma Ca2+ e.g. due to renal failure, or secondary to Vit D deficiency where phosphate would also be low.
Hypocalaemia
caused by hypoPTH, vit D def
Convulsions Arrythmias (prolonged QT interval) Tetany Stridor/spasms (hyperreflexia) Paraesthesia/numbness
Chvostek’s and Trousseau’s sign
Hypercalcaemia
caused by hyperPTH, vit D toxicosis, mets
Bones - bone pain
Stones - kidney stones
Groans - constipation
Psychic moans - depression, fatigue, confusion
Other: abdo pain, vomit, polyuria, polydipsia, anorexia, weakness, HTN, renal failure, cardiac arrest.
Thyroid bruit is felt in…
hyperthyroisim
Plummer’s disease/toxic multinodular goitre
Goitre
Firm thyroid nodules
Overproduction of thyroid hormone
Older patients, unknown cause but usually refractory to anti-thyroid treatment
De Quervian’s thyroiditis/subacute granulomatous thyroiditis
Fever Pain in neck, jaw or ear Viral in origin/preceded by URTI Increased ESR Females 20-50 Hyperthryoid -> hypothyroid (weeks) -> euthyroid
Grave’s disease
Toxic diffuse goitre with audible bruit
Tachycardia, tremor, fatigue, palpitations, exophthalmos, heat intolerance, acropachy, pretibial myxoedema
Thyroid storm/crisis
Rapid deterioration in hyperthyroid patients. They are often stimulated by stressors e.g. infection. Patients present with acute onset of severe tachycardia, distress + hyperpyrexia
Causes of metabolic acidosis with high anion gap
Lactate
Toxins (paracetamol, iron, metformin, ethanol)
Ketones (DKA)
Renal failure (uraemia)
Impaired fasting glucose tolerance values
6-7.0
Impaired glucose tolerance values
2 hours post glucose: 7.8-11.1
Carcinoid tumours commonly occur in appendix, ileum or rectum. Can result in carcinoid syndrome which is…
….carcinoid tumours with liver metastases.
Usually present with spontaneous facial flushing, abdominal pain, and watery diarrhoea. 50% develop cardiac abnormalities e.g. tricuspid regurg or pulmonary stenosis
Hyperosmolar Hyperglycemic State (HHS) in T2DM Rx
Correct dehydration (IV 0.9% saline slowly)
Correct hyperglycaemia (IV insulin)
Heparin (HIGH RISK OF THROMBUS. This is not prophylactic anti-coagulation.)
Replace K+
Acromegaly (excess GH) investigations
- Oral glucose tolerance test (suppresses GH normally)
- IGF-1 levels
Acromegaly Rx
Surgical - remove tumour
Medical - SS analogues (octreotide), DA agonists (bromocriptine and cabergoline), GH antagonist (pegvisomant)
Addisonian crisis (hypotensive, tachycardia, pale, cold, clammy, oliguria) Rx
Rapid IV fluid rehydration
50% dextrose to correct hypoglycaemia
IV hydrocortisone (±fludrocortisone if adrenal problem)
Chronic: hydrocortisone to replace glucocorticoids. Increase in periods of stress
Replace mineralocorticoids in adrenal insufficiency with..
Fludrocortisone
Carcinoid syndrome crisis presentations
Profound/paroxysmal flushing Diarrhoea Bronchospasm + wheeze Tachycardia Fluctuating BP
Diagnose by 24hr urine collection of 5-HIAA levels
Cushing’s syndrome Rx
Surgery - remove cause
Medical - inhibit cortisol synthesis with metryapone or ketoconazole. Also treat osteoporosis
Dopamine agonists
Bromocriptine
Cabergoline
DKA treatment
IV 0.9% saline fluids
IV insulin continuous infusion (-> then sliding scale)
IV dextrose (replace K+)
Monitor BG, ketones, urine output
Antibiotics
Prophylactic anti-coagulant (heparin)
Kallman’s syndrome
Rare genetic disease
Low GnRH
Hypogonadism, infertility, variable pubertal maturation, hypo-anosmia
Klinefelter syndrome
Chr disorder
47XXY karyotype
Hypogonadism
5-a reductase deficiency
Dihydrotestosterone deficiency
Nelson’s syndrome
Occurs in patients who undergo bilateral adrenalectomies
Loss of -ve feedback over time causes pituitary macroadenoma
Secretion of ACTH
Presents like Addison’s
Sheehan syndrome
Post-partum hypopituitarism
Agalactorrhoea, amenorrhoea and hypothyroid post-pregnancy
How to distinguish between clinical features of acromegaly and hypothyroidism
Acromegaly specific features include increased sweating and coarse facial features
Renal tubular acidosis type 1
Inability of kidney to excrete H+
Metabolic acidosis
Associated with rickets/ osteomalacia and increased Ca2+ i.e. nephrocalcinosis and recurrent infections
Waterhouse-Friderichsen syndrome
Adrenal haemorrhage due to meningococcal infiltration
Hypoadrenalism signs
Younger patients
Fluid overloaded with high BP
MEN type 1
the 3 p’s
Mutation in menin gene on Chr11
Pituitary adenomas
Parathyroid neoplasia
Pancreatic endocrine tumours
MEN type 2a
Mutation in RET gene on Chr10
Parathyroid neoplasia
Medullary thyroid carcinoma
Phaeochromocytoma
MEN type 2b
Mutation in RET gene on Chr10
Mucosal neuromas (lips/tongue)
Medullary thyroid carcinomas
Phaeochromocytoma
Primary hyperparathyroidism Rx
Acute: IV fluids
Conservative: avoid hyperCa2+ e.g. stop thiazide diuretics. Ensure normal Ca2+ and vit D intake
Surgical: subtotal or total parathyroidectomy (total in MEN1/2a)
Indications for parathyroidectomy in hyperPTH
Age <50 Bone mineral density <2.5 Calculi Creatine clearance decreased by 30% Difficult to do follow-up often Elevated Ca2+
Secondary hyperparathyroidism Rx
Treat the underlying cause/renal failure
Calcium and vit D supplements
Myxoedema coma - severe hypothyroidism crisis usually in elderly. Signs + symptoms…
Hypothermia Hypoventilation HypoNa+ Heart failure Confusion Coma
Myoxedema coma Rx
Oxygen Rewarming IV fluids to rehydrate IV T3(/T4) IV hydrocortisone if it is secondary hypothyroidism
Osteopenia defined by T-score between
-1.0 and -2.5
Osteoporosis
Phaeochromocytoma rule of 10%…
Bilateral
Extra-adrenal (paragangliomas)
Malignant
MEN type 2 is associated with phaeochromocytomas. Hence when phaeos are diagnosed, it is also important to consider associated MEN type 2 conditions and measure levels of….
Calcium
Calcitonin
(in reference to parathyroid tumours)
Polycystic ovary syndrome (PCOS) criteria for diagnosis
frequently associated with obesity, IR, T2DM, dyslipidaemia
Needs 2 of the following:
- polycystic ovaries on USS
- oligo/anovulation
- clinical/biochemical androgen excess
Commonest cause of infertility in women
PCOS
also: menstrual irregularities, uterine bleeding dysfunction, hirsuitism, acne, acanthosis nigricans
PCOS hormone levels
High LH (high LH:FSH ratio)
High testosterone
High androgens
Low SHBG
SIADH Rx
Treat underlying cause
Water restrict (± demeclocyline)
V2 receptor antagonists (tolvaptan)
Severe cases, give IV hypertonic saline slow infusion
Acute hyperthyroid crisis Rx
Propylthouracil Propanolol IV hydrocortisone Potassium iodide/Lugol's Rehydrate Control temperature
Primary hyperthyroidism Rx
Medical: ATDs e.g. carbimazole and propylthouracil, B-blockers e.g. propanolol
Radioactive iodine: avoid pregnancy for 4 months, pregnant women and children for 2weeks
Surgery: for large goitres etc
Opthalmopathy: corneal protection
Hypoglycaemia (BG <3mmol/l) Rx
If low consciousness - IV 50% glucose or IM glucagon
If conscious - oral glucose e.g. lucozade, dextrose tablets, followed by starchy snack
Should not drive for 45mins
DKA complications
Thromboembolism
Cerebral oedema
Aspiration pneumonia
Low K+, Mg2+, phosphate
Main cause of hypoglycaemia in diabetic patients
Sulphonyulreas
Insulin
(increased activity, missed meal, overdose, insulinoma)
Diagnosis of T2DM requires
- Symptomatic + 1 raised BG (fasted/random)
- 2 raised BG readings or OGTT 2h >11.1 if borderline
- 2 raised HbA1c readings
- 1 raised HbA1c + elevated plasma glucose
Causes of HHS (due to insulin deficiency)
MI
Drugs
Intestinal infarct
Hypopituitarism affects the hormones in what order
GGPTA: GH Gonadotrophins (LH/FSH) Prolactin TSH ACTH
Which hyperthyroidism causes decreased isotope uptake scan results?
De Quervain’s thyroiditis
20% are malignant
Which hyperthyroidism causes increased isotope uptake scan results in a pattern that is:
(i) diffuse
(ii) multiple hot nodular
(iii) single nodular
(i) Grave’s disease
(ii) toxic multinodular goitre (plummer’s)
(iii) solitary toxic adenoma
First line Rx for toxic multinodular goitre
Radioactive iodine
24-h urine collection to measure 5-HIAA levels
Blood plasma chromogranin A + B measurements (fasting gut hormones)
Are useful in diagnosing which syndrome…?
Carcinoid syndrome
What % of MEN1 patients have carcinoid tumours
10%
Diabetic patients with signs of impotence, postural hypotension and urinary retention indicate…
autonomic neuropathy
HyperCa2+ post-renal transplantation is generally due to
Tertiary hyperparathyroidism
Pellagra (nicotinic acid def) may present with symmetrical dermatitis on sun-exposed skin, diarrhoea and depression. Risk factors include
Carcinoid syndrome
Isoniazid (anti-TB) therapy
