Endocrine Flashcards
Why might diabetic patients gradually start presenting in hypo/DKA more commonly as they get older?
Loss of awareness of symptoms due to autonomic neuropathy
Teenager with DKA patient is treated and develops irritability, drowsiness, blurred vision and focal neurological symptoms - what are you worried about?
Next steps?
Cerebral oedema
Risk esp in young patients until about 25
Request CT head immediately
High calcium, low phosphate but normal PTH?
Still primary hyperparathyroidism probably from adenoma because PTH is inappropriately normal
Driving and insulin-dependent diabetes?
Driving and on tablets/exenatide
All patients treated with insulin must inform DVLA (applies to both T1 and T2)
Can drive if:
- No more than 1 hypo in past 12 months requiring assistance of other person
- Adequate hypoglycaemic awareness
- Regular BM monitoring shows good glycemic control
- Shows understanding of risk of hypo
No need to inform DVLA if on tablets/exenatide
If hypo induced (e.g. gliclazide) then must have been no more than 1 hypo in past year
Diagnosis of acromegaly?
Measure serum IGF-1 levels
If raised, then to OGTT:
- If GH doesn’t lower to <2mu/L after glucose then acromegaly confirmed
pituitary MRI may demonstrate tumour
Management of acromegaly?
Trans-sphenoidal surgery 1st line in majority
If inoperable/surgery ineffective then:
- Somatostatin analogue (Octreotide) - inhibits release
- GH receptor antagonist (Pegvisomant) - doesn’t reduce mass effect
- Dopamine agonist (Bromocriptine)
Features of acromegaly on:
- limbs?
- face?
- skin?
- mass effect?
- 1/3 also have?
- 6% related to?
- spade-like hands, rings no longer fit, increase shoe size (gigantism if epiphyseal fusion not occurred)
- Macrognathia, macroglossia, interdental spacing, coarse facial appearance
- excessive sweating and oily skin (acne) due to gland hypertrophy
- hypopituitarism, headache, bitemporal hemianopia
- Raised prolactin - galactorrhoea
- MEN1
4 complications of acromegaly?
Hypertension
Diabetes
Cardiomyopathy
Colorectal cancer
Rule of thumb for imaging in endocrine?
MRI for pituitary, CT for others
These are structural tests - if there is a structural abnormality (atrophy/adenoma) a nuclear medicine test may be required
Nuclear medicine test is giving radio-labelled precursors to see how they are taken up
How to test for tremor in hyperthyroidism?
Exercise tolerance?
Menstrual patterns?
Put a bit of paper on back of hands
Reduced - due to tachycardia/AF
Scanty periods/amenorrhiea
99.8% of thyroid hormone is bound to what?
What does this mean in terms of practice?
Thyroid binding globulin
Transthyretin
Albumin
It is best to measure free hormone levels rather than total - uninfluenced by factors like oestrogen and enzyme inducers
Primary vs secondary hyperthyroidism?
Primary - TSH low and T3/T4 high
Secondary - problem outwith thyroid - TSH inappropriately normal/high with High T3/T4
Causes of hyperthyroidism, primary and secondary?
Why does thyroiditis cause hyperthyroidism?
Primary: Toxic multinodular goitre Grave's disease Solitary toxic adenoma Subacute/silent thyroiditis
Secondary:
TSH- secreting tumour
Factitious administration of T3/T4
Ectopic thyroid tumour (struma ovarii)
Pre-formed hormone is stored in gland in vesicles, with inflammation these are all released causing transient hyperthyroidism
Causes: viral, hashimoto’s, post-partum
Ig in Grave’s?
3 signs of Grave’s?
Trabs antibodies (thyroid receptor antibodies)
Eye disease, pretibial myxoedema, acropachy (type of clubbing - much rarer)
Cause of thyroid eye disease?
Does it happen at the same time as thyrotoxicosis?
Rx for thyroid eye disease?
Antbodies binding to extra-ocular muscles causing swelling
Can happen at different time - either before or years after thyrotoxicosis
Selenium can help
Oral steroids, followed by IV steroids if severe
Rarely, may need radiotherapy or in emergency surgery to crack open orbit and relieve swelling
Basic diagnostic investigation ladder for hyperthyroidism?
- TSH, fT4, fT3, TRAbs
- Ultrasound
- Nuclear medicine (technetium) uptake scan
2 rare SE of carbimazole?
How is it teratogenic?
PTU rare SE?
How to titrate treatment?
Agranulocytosis, cholestasis jaundice
Aplasia cutis (blad patch on head) and midline problems
Autoimmune hepatits
Titrate every 6 weeks until euthyroid.
Grave’s has 50% chance of cure in 18 months, other causes - control symptoms but not cure
2 specific risks of thyroidectomy?
Recurrent laryngeal nerve injury
Parathyroid damage - hypocalcaemia
often temporary ‘stunning’ of gland but sometimes permanent
Radioactive iodine: how long after before trying to conceive?
6 months
Thyroid storm
Symptomatic:
Lots of IV fluids (very dehydrated from diarrhoea/sweating)
Propanolol
PTU
Hydrocortisone (in case of addison’s as can be concomitant)
Stop thyroid:
Give lots of iodine - stuns thyroid briefly for about 10 days (to get thyroidectomy)
Lithium can be used - stops conversion of T4 to T3 in periphery
Supportive: Electrolytes Paracetamol (temp) Phenobarbital/Dantrolene (helps reduce shaking/seizure) Furosemide/ACEI if HF from arrhythmia
Selected:
Mechanical ventilation
Cooled mastresses
why do you get low Na and high MCV in hypothyroidism?
Need thyroxine to excrete water from kidneys, so retain fluid causing haemodilution
(can also get pedal oedema for this reason)
If someone has addison’s and has an infection what should they do with their meds?
Double hydrocortisone dose
(since no endogenous cortisol production so may not be able to mount a stress response)
Same Fludrocortisone dose
Why does splenectomy give falsely high HbA1c?
What else overestimates HbA1c?
Due to increased lifespan of RBC’s
Over-estimates:
- Iron deficiency anaemia
- B12/folate deficiency
Under-estimates:
- Sickle cell
- Spherocytosis
- G6PD deficiency
Dosing of hydrocortisone for addison’s?
Usually around 30mg a day - 20mg at 8am and 10mg at 5pm
Treatment of thyroid storm?
PTU Propanolol Dexamethasone (blocks peripheral conversion of T4 -> T3) Paracetamol Lots of fluids
Treat underlying cause
Management of myxoedema coma?
IV thyroxine IV fluid IV corticosteroids (until addison's ruled out) correct electrolytes Rewarming may be needed
Causes of addisonian crisis?
Management of addisonian crisis?
- Sepsis or surgery, causing acute exacerbation of chronic insufficiency (addison’s or hypopituitarism)
- Adrenal haemorrhage (Waterhouse friedrichson syndrome from mengicoccaemia)
- Steroid withdrawal
- 100mg hydrocortisone IM/IV
- 1L normal saline over 30-60 mins, with dextrose if hypoglycaemic
- Continue hydrocortisone 6 hourly
- Oral replacement after 23 hours, to be reduced to maintenance over 3-4 days
(no fludrocortisone needed as high dose hydrocortisone exerts weak mineralocorticoid effect)
Management of diabetic gastroparesis?
Options: - metoclopramide - domperidone - erythromycin (pro kinetic agents)
Why is goserilin given in prostate cancer?
How does it cause gynaecomastia?
Normally GnRH is released in a pulsatile manner to cause sperm production. When given high dose and long term, the endogenous feedback loops are lost, causing hypoandrogenism. This causes gynaecomastia
Why can antiemetics metoclopramide and domperidone cause galactorrhea?
Dopamine antagonists
Therefore can cause increased Prolactin
Haloperidol can also
How many units in 1ml insulin?
100
What drugs interfere with thyroxine absorption?
Iron and calcium tablets
Take at least 4 hours apart
Why to acromegaly patients get an echo?
Cardiomyopathy
Progression of de quervain’s thyroiditis?
Ix if unsure of diagnosis?
Rx?
1: hyperthyroid, tender goitre, raised ESR (3-6 weeks0
2: euthyroid (1-3 weeks)
3: hypothyroid (weeks-months)
4: normal
Scintigraphy: reduced uptake globally
Rx: usually none required - steroids if really bad
3 dangerous but rare side effects of SGLT2 inhibitors?
urinary/genital infection -> Fourniere’s gangrene
Normoglycaemic ketoacidosis
Increased risk of lower limb amputation - special attention to feet
Glucose targets for T1DM before meals?
5-7 on waking before breakfast
4-7 other meals
Main cause of hyperaldosteronism?
BAH
Can present even later in life in 50’s etc
Causes 70% cases
In DKA how is insulin administered?
0.1 units/kg/hour
Add in infusion of 5% dextrose once glucose <15mmol/L
Continue any long-acting insulin in regimen, but stop short-acting for the time being
K+ will need replaced as well - DO NOT exceed 20mmol/hr
Which 3 hormones are reduced in stress response e.g. after major surgery?
Which 3 stay the same?
Decrease:
insulin
Testosterone
Oestrogen
Same:
TSH
LH/FSH
The rest all go up (cortisol, ACTH, renin, aldosterone, PRL, ADH, glucagon)
Thyroid monitoring:
- After thyroidectomy for medullary cancer?
- After thyroidectomy for papillary cancer?
- For goitre and diagnosis if hashimoto’s?
- goitre and diagnosis of graves?
Serum calcitonin
Thyroglobulin antibodies (thyroglobulin is major constituent of colloid and precursor of hormones) - not clinically useful in distinguishing between different types of thyroid disease but used for cancer follow up
Thyroid peroxidase antibodies
(found in 100% hashimoto’s and 70% grave’s)
TSH receptor antibodies (TRAb)
Management of acute asthma exacerbation?
Salbutamol 1 puff every min for 10 puffs
If not improved repeat and sent to hospital
Oxygen
Salbutamol + ipratropium nebs
Prednisolone
(consider adding MgSO4 to neb if <92% sats)
IV salbutamol
Aminophylline if unresponsive and life-threatening
IV MgSO4 and phone anaesthetist
Asthma management in <5 y/o?
- SABA
- SABA + 8-week trial moderate dose ICS
Stop ICS - if recurs within 4 weeks then continue low-dose
- if recurs past 8 weeks then retry 8 week trial
- SABA + low-dose ICS + LTRA
- Stop LTRA and refer to specialist
Asthma management in 5+ y/o?
- SABA
- SABA + low-dose ICS
- SABA + low-dose ICS + LTRA
- SABA + low-dose ICS + LABA
- SABA + MART (dual LABA/ICS)
- SABA + moderate dose MART
OR
SABA + mod-dose ICS + LABA - SABA + high dose (ICS+LABA)/MART OR mod + theophylline
AND refer
APGAR?
Appearance
Pulse - 2 >100; 1 <100; 0 absent
Grimace - 2 cries on stimulation; 1 grimace; 0 none
Activity - 2 active movement; 1 limb flexion; 0 flaccid
Resp - 2 strong cry; 1 weak/irregular resp; 0 absent
7+ = normal 4-6 = moderately low 3- = critically low
Done at 1 and 5 mins after birth
Doesn’t predict long-term outcomes
Centor criteria?
- fever
- no cough
- tender cervical lymph
- exudate
3/4 for abx (pen v/clarith)
Scarlet fever school exclusion?
Until rash disappears
Characteristics of innocent murmur?
asymptomatic, no radiation/thrill, made worse with fever, change with respiration/position (increase when lying down)
Ejection murmur:
- soft systolic murmur best heart in 2-4 intercostal spaces, turbulent outflow
Venous hum:
- Continuous murmur heard below clavicles when child lies down due to turbulent flow in head/neck veins
Still’s murmur:
- Low pitched heart sound at lower left sternal border
Ventricular septal defect?
- Loud pan systolic murmur at lower left sternal edge
- Radiates through praecordium
- May be thrills/signs of HF
Atrial septal defect?
Soft ejection systolic murmur best heard at left upper sternal border with fixed splitting of S2
Coarctation murmur?
- Ejection systolic murmur best heard between the shoulder blades
- Weak femoral pulse and radio-radial delay
PDA murmur?
Continuous machine like murmur best heard below clavicle
Presentation of GORD in kids?
Regurgitation following feeds, chronic hiccups, unexplained refusal to feed/failure to thrive - typically develops <8 weeks
Clinical diagnosis
- feed at 30 degrees, sit upright afterwards
- thickened feeds
- Alginates (Gaviscon) (not with thickened feeds)
- PPI if distress behaviour/faltering growth
- metoclopramide under specialists
- fundoplication last resort
Intususseption:
- features?
- age?
- Ix?
- Rx?
Intermittent vomiting (milky, yellow), red jelly stool, sausage shaped mass
6 months old
USS - target lesion
Rx: air enema, or surgery if that fails
Green bilious vomiting <1 y/o?
Ix?
Volvolus until proven otherwise
AXR
2nd line upper GI contrast series
Ix for chronic diarrhoea?
Blood - anti-TTG
Sweat test
Stool culture
Growth chart (if normal unlikely to be malabsorption/inflammatory)
If all normal & no visible food trial cow’s milk free diet
When to test urine in kids?
Signs/symptoms suggestive of UTI
Unexplained fever >38
Collect using MSSU if possible, if not use urine collection pads
<3 months - immediate referral to paeds for assessment of renal tract (USS)
> 3 months:
- upper - referral or abx 7-10 days
- lower - abx 3 days
- recurrent - referral for USS
Measles cause? Presentation? Ix? Management? Complications?
RNA paramyxovirus
- Prodromal cough, fever, nasal discharge
- Koplik spots
- Maculopapular rash - after 4 days, starts behind ears/on face, then rapidly covers whole body
Ix: IgM -> ELISA
Management: supportive, notify
Complications: pneumonia, otitis media, subacute sclerosis panencephalitis
Mumps cause? Presentation? Ix? Management? Comps?
RNA paramyxovirus
- fever, malaise
- bilateral parotid swelling
- boys - orchitis
Salivary IgM (throat swab)
Isolation and supportive
Pancreatitis, aseptic meningitis
Rubella cause? Presentation? Ix? Management? Pregnancy?
AKA german measles
RNA rubella virus
- pink discrete maculopapular rash -> starts on face then rapidly spreads to body
- sub-occipital/post-auricular lymphadenopathy
Ix: rubella IgM
Management: supportive
Pregnancy:
- assoc w congenital heart disease, deafness and reduced IQ
- screened for at booking
- Management: Ig
Site of atopic dermatitis in infants?
Infants: face, trunk and extensors
Older kids: classic flexural distribution
Emollients +/- steroids
Foetal/neonatal CMV infection?
Hepatosplenomegaly
Microcephaly
pinpoint ‘blueberry muffin’ petechiae skin rash
Sensorineural deafness
What is genetic anticipation? 2 things which show it?
Younger age of onset with each generation
Huntington’s
Myotonic dystrophy
Duodenal atresia? Jejunal atresia? Meconium ileus? Malrotation with volvulus? NEC?
Duodenal atresia:
Bilious vomiting first day of life, AXR Double bubble sign, Higher rate in Down’s
Jejunal atresia:
Bilious vomiting first day of life, AXR shows fluid level
Meconium ileus:
Bilious vomiting 1-2 days after birth, abdo distension, failure to pass meconium, AXR shows distension & fluid level, sweat test to rule out CF
Malrotation with volvulus:
bilious vomiting 3-7 days after birth, peritonism, haemodynamic compromise, USS abnormal location of SMA/V, upper GI contrast shows DJ flexure medially
NEC:
2nd week of life, bilious vomiting, bloody loose stool, dilated bowel loops with air cysts - stop feeds and broad spec abx
Moro reflex? Grasp reflex? Rooting? Stepping? Tonic neck? Suck?
Moro - head extension causes abduction then adduction of arms - disappears by 3-4 months
Grasp - disappears at 4-5 months
Rooting - when corner of mouth is stroked baby turns head to follow stroking - disappears at 4 months
Stepping - steps when held upright - disappears at 2 months
Tonic neck - when head is turned, they will stick that arm out and bend opposite arm (like fencing pose) - lasts 5-7 months
Suck reflex - disappears at 6-7 months - doesn’t fully develop until 36 weeks so premature babies may have weak suck reflex
Meconium aspiration syndrome:
XR - patchy infiltrates, atelectasis
Subacute thyroiditis:
- cause?
- stages?
- Ix?
- management?
Usually after a viral infection
Stages:
- painful goitre, hyperthyroid, raised ESR (3-6 weeks)
- euthyroid (1-3 weeks)
- hypothyroid (weeks-months)
- normal
Ix:
scintigraphy - reduced uptake globally
Management:
- NSAIDs if painful goitre
- Usually no Rx
- steroids if severe, especially in hypothyroidism
Causes of hypercalcaemia?
CHIMPANZEES
C - calcium supplements H - hyperparathyroid/hereditary (FHH) I - iatrogenic/immobility M - multiple myeloma, medication (lithium) P - parathyroid adenoma A - alcohol, Addison's N - neoplasm (breast, lung) Z - zollinger-ellison syndrome E - excess VitD E - excess VitA S - Sarcoidosis (granuloma can 1a hydroxylate VitD)
Why can calcium cause high urea?
dehydration
High urea and normal/borderline high creatinine points to dehydration/pre-renal cause
If hypercalcaemia and give bisphosphonates, how long does it take to see results?
3 days
Cannot give more than once per week - risk of osteonecrosis of jaw (or rarely pelvis)
Can lithium be given in thyrotoxicosis?
Yes, low down the order after B blockers, PTU, dexamethasone and considering Lugol’s iodine
Lithium blocks peripheral conversion of T4 to T3
In panhypopituitarism what is given first between?
Cortisol - because giving thyroxine first increases metabolic rate but won’t have enough cortisol to keep up with this
Order of loss of pituitary hormones if a pituitary tumour?
GH Gonadotrophin (LH/FSH) ACTH PRL TSH
Causes of polyuria:
- common?
- less common?
- very rare?
Common:
- diuretics, caffeine, alcohol
- diabetes mellitus
- heart failure
- lithium
less common:
- hypercalcaemia
- hypokalaemia
- hyperthyroidism
- CKD
- primary polydipsia
Very rare:
- diabetes insipidus
How long to wait after having radioactive iodine before getting pregnant?
12 months both male and female
What diabetes meds are good in previous MI?
GLP-1 agonists
SGLT2 inhibitors
Methods of testosterone replacement in men?
SE to be careful of?
Daily gel or daily gel
- Growth of undiagnosed prostate malignancy
- Aggressive behaviours
- Polycythaemia - secondary - increases Hb production
What to do with metformin if very unwell e.g. AKI/sepsis?
Stop it until better, risk of lactic acidosis
ABG profile with hyperaldosteronism?
Hyperchloraemic metabolic alkalosis
Ca happen mildly in Conn’s, get it more in ectopic production of ACTH e.g. lung cancer
Why do you get hoarseness in hypothyroidism?
Fluid retention around larynx
If someone has Grave’s eye disease, what supplement can sometimes be given to help it?
What antithyroid treatment cannot be given?
Oral selenium
CANNOT give radioactive iodine - makes it worse
Cushing’s ABG pattern?
Hypokalaemia metabolic alkalosis
HbA1c targets in diabetes?
Standard = 48
If risk of hypoglycaemia (e.g. on gliclazide) target = 53
In DKA - what should happen to their regular insulin when treating the patient?
Continue long acting
Stop short acting
What calcium results are expected in CKD?
low Ca (low vitD) High phosphate (inability to excrete) High ALP (bone resorption) High PTH
Causes of a lower than expected HbA1c?
Things that decrease RBC lifespan:
Haemolysis (G6PD, spherocytosis)
Sickle cell
Causes of a higher than expected HbA1c?
Things that increase RBC lifespan:
B12/folate def
Iron def
Splenectomy
