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Phase 2A > Endocrine > Flashcards

Endocrine Flashcards

1
Q

T1DM Definition

A

Metabolic disorder characterised by hyperglycaemia

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2
Q

T1DM Epidemiology

A

Young (<30yrs), lean, North Europe (can occur at any age)

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3
Q

T1DM Aetiology

A

Autoimmune = beta cells destroyed - not make insulin

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4
Q

T1DM RFs

A

FHx + PHx autoimmune disease (HLA-DR3/4)

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5
Q

T1DM Path

A

Abs against insulin, glutamic acid decarboxylase, islet auto-antigen-2.
Beta cell destruction = subclinical for months - years.
80-90% destroyed = hyperglycaemia.
Patients cannot use glucose in peripheral muscle/adipose = stimulates glucagon secretion = gluconeogenesis, glycogenolysis and ketogenesis in liver = hyperglycaemia + anion gap metabolic acidosis

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6
Q

Hyperglycaemia path

A

Hyperglycaemia = inflammation + oxidative stress = endothelial dysfunction by NO = LDLP enters vessel wall = slow inflammatory response = atherosclerosis.

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7
Q

T1DM Signs

A

Ketoacidosis, low BMI, young age, weight loss, glycosuria

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8
Q

T1DM Sx

A

Thirst (osmotic activation of hypothalamus), dry mouth, fatigue, hunger, weight loss, nausea/vomiting, skin infections, vaginal candidiasis, blurred vision

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9
Q

T1DM Investigations - 1st

A

Random glucose tolerance test (GP) >11.1mmol/L
Fasting plasma glucose, 2-hr plasma glucose, plasma, urine ketones. Low C peptide

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10
Q

T1DM Investigations - Gold

A

Glycated haemoglobin A1C (HbA1c) = av. blood sugar for past 2-3 mths = measures % glucose attached to Hb >48mmol/mol (6.5%) = diabetes

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11
Q

T1DM Treatment

A

1st: Basal-bolus insulin, pre-insulin correction dose, amylin analogue (pramlintide)
2nd: fixed insulin dose - Side effects = hypoglycaemia, weight gain, lipodystrophy

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12
Q

T1DM Complications

A

Microvascular - retinopathy, nephropathy, peripheral neuropathy
Macrovascular - CAD, cerebrovascular disease, PAD

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13
Q

T1DM Prognosis

A

Untreated = fatal (diabetic ketoacidosis). Poorly controlled = RF for blindness, renal failure, foot amputations and MIs. Life expectancy decreased (8yrs on average) - mostly from CVD

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14
Q

T2DM Definition

A

Progressive metabolic disorder = insulin deficits, increased resistance to insulin

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15
Q

T2DM Epidemiology

A

Older (>40yrs), obese, certain racial groups

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16
Q

T2DM Aetiology

A

Pancreatitis, surgery, trauma, cancer, pancreatic destruction (haemochromatosis, CF), cushing’s, acromegaly, hyperthyroidism, pregnancy

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17
Q

T2DM RFs

A

NM=older age, ethnicity (Black African/Caribbean, South Asian), FHx, gestational diabetes, M>F
M = obesity, sedentary lifestyle, high carb diet, smoking, alcohol, hypertension

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18
Q

T2DM Path

A

Repeated insulin + glucose exposure = cells in body become resistant to insulin effects = more insulin required to stimulate cells to take up and use glucose = pancreas damaged/fatigued =↓ insulin output

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19
Q

T2DM Key Presentation

A

Asymptomatic usually picked up at routine medical examinations. If severe = polyuria and polydipsia (hyperglycaemia), central obesity, gradual onset

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20
Q

T2DM Signs

A

Glycosuria, candidal/skin/UTI infections

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21
Q

T2DM Sx

A

Tiredness, thirst (gradual onset - can be asymptomatic)

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22
Q

T2DM Investigations

A

C peptide levels persist.
HbA1c
Normal <41, Pre-DM 42-47, DM >48mmol/mol

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23
Q

T2DM Treatment - 1st

A

Lifestyle advice - diet, exercise, stop smoking, reduce alcohol and fat/sugar intake
1st: metformin - increase insulin sensitivity, decrease glucose production (add SGLT-2 inhibitor if CVD/heart failure)

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24
Q

T2DM Treatment - 2nd

A

2nd: + SGLT-2 inhibitor (block glucose reabsorption in kidney), sulfonylurea (promotes insulin secretion), pioglitazone, DPP-4 inhibitor, (triple therapy, insulin therapy)

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25
Q

T2DM Monitoring

A

Annual review - check eyes, feet - wasting of small muscles of foot, clawing of toes, bleeding under hard skin, test sensation, vibration perception, ankle reflexes = high ulcer risk

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26
Q

T2DM Complications

A

Infections, retinopathy (risk = blood sugar control - balance with risk of hypoglycemia), peripheral neuropathy (glove and stocking), CKD, diabetic foot. Dry skin = cracks = entry for infection (moisturise), peripheral vascular disease = decreased perfusion. Nephropathy - DKD - leading cause of end-stage kidney disease = progressive kidney fibrosis = function loss - proteinuria
Hyperosmolar hyperglycaemic state

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27
Q

Hyperosmolar hyperglycaemic state

A

No ketones = polyuria, polydipsia, weight loss, dehydration, tachycardia, hypotension, confusion →decreased insulin insufficient to inhibit hepatic glucose production but sufficient to inhibit hepatic ketogenesis.

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28
Q

Diabetic Ketoacidosis

A

Serious complication of diabetes that can be life-threatening

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29
Q

DKA Aetiology

A

Untreated T1DM, undiagnosed DM, infection/illness, treatment errors, MI

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30
Q

DKA Path

A

Complete absence of insulin → unrestrained increased hepatic gluconeogenesis + decreased peripheral glucose uptake = hyperglycemia →osmotic diuresis →dehydration
Peripheral lipolysis → increase FFA → oxised to acetyl CoA → ketones = acidosis

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31
Q

DKA Signs

A

Hyperventilation (Kussmal’s breathing) - get rid of CO2 (reduce acid), dehydration, hypotension, tachycardia, coma, breath smell of ketones (sweet), reduced tissue turgor

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32
Q

DKA Sx

A

Over days, polyuria, thirst, nausea/vomiting, weight loss, weakness, abdo pain, drowsiness, confusion

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33
Q

DKA Investigations

A

Hyperglycemia = RPG >11mmol/L
Ketonaemia = plasma ketones >3mmol/L
Acidosis = blood pH<7.3 or bicarb <15mmol/L,
urine dipstick = glycosuria/ketonuria

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34
Q

Hyperthyroidism

A

Overproduction of thyroid hormones (T3/4) = thyrotoxicosis

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35
Q

Hyperthyroidism Epidemiology

A

Goitre >60yrs

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36
Q

Hyperthyroidism Aetiology

A

GIST: Grave’s Disease (mc), Inflammation (thyroiditis), Solitary toxic thyroid nodule, Toxic multinodular goitre, pituitary tumours (secondary), Iodine

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37
Q

Hyperthyroidism RFs

A

FHx autoimmune disease, female, smoking, amiodarone, stress

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38
Q

Graves Path

A

Graves = TSH-R autoAbs = uncontrolled stimulation (often brought on by pregnancy)

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39
Q

Hyperthyroidism Signs (General and Graves)

A

General = tachycardia, muscle wasting, fine tremor, thin hair, hair loss, possible goitre
Graves = no nodules goitre/thyroid ophthalmopathy (exophthalmos)/pretibial myxedema/hand swelling and finger clubbing.

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40
Q

Hyperthyroidism Sx

A

Heat intolerance, diarrhoea, wt loss, hyperphagia, insomnia, anxiety, oligo/a-menorrhea

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41
Q

Hyperthyroidism Investigations

A

Thyroid function tests = Primary: ↑T3/4, ↓TSH or Secondary: all ↑
Anti-TSH-R Abs (Graves), anti-TPO Abs
Radioactive uptake scan (doppler US - goitre)

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42
Q

Hyperthyroidism Treatment

A

1st: Carbimazole (titrate up) - blocks T3/4 production (CI in pregnancy - Propylthiouracil)
SE = agranulocytosis = depletion of WBCs (sore throat = stop taking)
2nd line = radioactive Iodine = destroys excess thyroid (CI = pregnancy) + then surgery

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43
Q

Hyperthyroidism Complications

A

Heart failure, osteoporosis
Thyroid storm = rapid deterioration of thyrotoxicosis + lots of T4 - systemic decompensation (AF, coma)
Tx = propylthiouracil (hepatitis risk + inhibit T4 to T3) + KI

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44
Q

Hypothyroidism

A

Underactivity of thyroid (primary or secondary)

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45
Q

Hypothyroidism Epidemiology

A

F>M, ageing, postpartum

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46
Q

Hypothyroidism Aetiology

A

Iodine deficiency (mc developing world), Hashimoto’s (mc developed world) = autoimmune, congenital, pituitary tumours, inflammation, postpartum, viral infection (De Quervain’s thyroiditis)

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47
Q

Hypothyroidism RFs

A

Female, FHx/Hx autoimmune disease, pregnancy in last 6mths, radiation to head/neck, Hx thyroid surgery/treatment

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48
Q

Hypothyroidism Pathology

A

Hashimoto’s = anti-TPO antibodies
Iodine deficiency = key component of T3/4.
Pituitary tumour (2ndary) = compress pituitary gland or interrupt blood flow = ↓TSH production

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49
Q

Hypothyroidism Signs

A

Bradycardia, slow reflexes, cold hands, goitre, pretibial myxedema, hair loss (loss of outer ⅓ of eyebrow - Hertoghe’s sign), dry skin, stiff muscles

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50
Q

Hypothyroidism Sx

A

Thirst, dry mouth, lack of energy, hunger, weight gain, nausea/vomiting, menstrual disturbances, irregular/heavy periods, cold intolerance, brittle hair/nails

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51
Q

Hypothyroidism Investigations

A

Thyroid function tests = ↑TSH, ↓free T4
Anti-TPO Abs (may also be present in Graves)
Doppler US imaging

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52
Q

Hypothyroidism Treatment

A

Levothyroxine (T4) - titrate up + careful with dose (can cause iatrogenic hyperthyroidism)

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53
Q

Hypothyroidism Monitoring

A

TFTs every 3mths until TSH stable, then annually

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54
Q

Hypothyroidism Complications

A

Myxoedema coma (with infection) rapidly decreasing T4 = hypothermia, unconscious, heart failure - Tx = levothyroxine, ABx + hydrocortisone (until adrenal insufficiency ruled out)
Heart failure, subfertility, miscarriage, pre-eclampsia, stillbirth, postpartum haemorrhage

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55
Q

Hyperparathyroidism

A

Excess Parathyroid hormone (PTH) secreted from parathyroid glands

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56
Q

Hyperparathyroidism Epidemiology

A
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57
Q

1o (MC) Hyperparathyroidism Aetiology

A

Parathyroid adenoma (mc) (or hyperplasia) - hyperparathyroid = hypercalaemia

Malignant = neoplasms (sq cell lung, breast, renal) = secrete PTHrP = ectopically mimics PTH

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58
Q

Hyperparathyroidism RFs

A

Female, age ≥50-60yrs (post-menopause), FHx of PHPT, multiple endocrine neoplasia (MEN) 1, 2A, or 4
2o/3o = conditions affecting Ca metabolism (2o = CKD, Vit D def, 3o = hyperplastic PTGs)

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59
Q

Hyperparathyroidism Key Pres

A

Commonly asymptomatic - picked up incidentally on blood tests.
Bone, Stones, Groans, Moans

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60
Q

Hyperparathyroidism Signs

A

Fractures, osteoporosis (bone resorption), hypertension

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61
Q

Hyperparathyroidism Sx

A

Non-specific - fatigue, polyuria/dipsia, constipation, abdominal pain, vomiting, confusion, depression, (bone pain + renal stones = chronic hypercalcaemia)

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62
Q

Hyperparathyroidism Investigation 1st

A

Serum PTH with paired corrected Ca

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63
Q

Hyperparathyroidism Other Ix

A

DEXA scan = osteoporosis, increase 24-hr urinary Ca excretion, abdominal X-ray = renal calculi/nephrocalcinosis, radioisotope scanning = 90% sensitive to adenomas

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64
Q

Hyperparathyroidism DDx

A

Other causes of hypercalcaemia - malignancy (high serum PTH rules out), PTH dependent/independent

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65
Q

Hyperparathyroidism Treatment

A

1o = Surgery - remove adenoma or parathyroidectomy of all 4 glands, bisphosphonates (not affect serum Ca but preserve bone density = reduce fracture risk), Cinacalcet (Ca-sensing receptor agonist) = reduce PTH secretion + tf serum Ca (if no surgery)
2o = treat underlying cause, 3o = surgery

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66
Q

Hyperparathyroidism Complications

A

1o = osteoporosis, renal impairment and calculi, pseudogout, pancreatitis, CVD, acute severe hypercalcaemia = IV fluids + bisphosphonates

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67
Q

2o Hyperparathyroidism Aetiology

A

Physiological response to low [Ca++] - compensatory hypertrophy of all glands (CKD/Vit D def) - hypocalcaemia = hyperparathyroidism

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68
Q

3o Hyperparathyroidism Aetiology

A

Years of 2o hyperPTH (mc = CKD) glands act autonomously = release PTH not -ve feedback = increase PTH regardless of [Ca]

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69
Q

Hypoparathyroidism

A

Deficiency of PTH secreted

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70
Q

Hypoparathyroidism Aetiology

A

Secondary to parathyroidectomy, congenital, Mg deficiency, vit D deficiency = less Ca, autoimmune - Di George syndrome

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71
Q

Hypoparathyroidism RFs

A

Hx thyroid/parathyroid surgery, hypomagnesaemia, moderate/chronic maternal hypercalcaemia

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72
Q

Hypoparathyroidism Signs

A

Hypocalcemia signs - convulsion, arrhythmias, tetany, Chvostek’s sign = tap over facial nerve in parotid gland region = twitching of ipsilateral facial muscles, Trousseau’s sign = carpopedal spasm induced by inflation of BP cuff to 20mmHg >systolic BP, ECG - prolonged QT interval, chronic = depression, cataracts

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73
Q

Hypoparathyroidism Sx

A

Muscle spasms, tetany, twitching, cramping, diarrhoea, anxiety, dry hair

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74
Q

Hypoparathyroidism Ix 1st

A

Serum Ca + Mg, plasma intact PTH, serum albumin

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75
Q

Hypoparathyroidism Tx

A

Ca supplement + calcitriol (active vit D), synthetic PTH

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76
Q

Pseudohypoparathyroidism

A

Abnormality in Gz protein on PTG - resistance to PTH (low Ca, High P + PTH)

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77
Q

Pseudohypoparathyroidism Ix

A

Urinary cAMP + P following infusion of PTH:
Type 1 = neither increase
Type 2 = only cAMP rises
(in hypoPTH = cAMP + P increased)

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78
Q

Pseudohypoparathyroidism Signs/Sx

A

Short stature, short metacarpals (4th/5th), subcutaneous calcification, sometimes low IQ

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79
Q

Pseudohypoparathyroidism Tx

A

Same as normal hypoPTH = Ca supplement + calcitriol (active vit D), synthetic PTH

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80
Q

Pseudopseudohypoparathyroidism

A

Same phenotype as pseudo but Ca metabolism normal

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81
Q

AVP Deficiency (Diabetes Insipidus)

A

Not enough AVP (ADH) produced or reduced response to ADH = inability to concentrate urine

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82
Q

AVP Deficiency Cranial Causes/RFs

A

Pituitary surgery, head trauma, craniopharyngioma, congenital defect in ADH gene, idiopathic

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83
Q

AVP Deficiency Nephrogenic Causes/RFs

A

Drugs (LiCl), hypokalaemia, hypercalcaemia, renal tubular acidosis, sickle cell disease, ADHR mutation

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84
Q

AVP Deficiency Path (Cranial and Nephrogenic)

A

Cranial = too little ADH from posterior pituitary
Nephrogenic = kidney does not respond to ADH
Less ADH/response to ADH = ↑H2O loss in urine; dilute high volumes

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85
Q

AVP Deficiency Signs

A

Postural hypotension, dilute urine, dehydration = dry mucous membrane, prolonged capillary refill time), hypernatremia

86
Q

AVP Deficiency Sx

A

Polyuria (>3L/day), nocturia, polydipsia, severe dehydration, confusion, coma

87
Q

AVP Deficiency 1st Ix

A

Low urine osmolality, high/normal serum osmolality, >3L on 24hr urine collection

88
Q

AVP Deficiency GS Ix

A

Water deprivation test (desmopressin stimulation test) = avoid all fluids for >8hrs before (water deprivation) the urine osmolality measured

89
Q

AVP Deficiency Other Ix

A

Cranial MRI, genetic testing, U+Es (rule out electrolyte abnormalities)

90
Q

AVP Deficiency Cranial Tx

A

Desmopressin - replace absent ADH

91
Q

AVP Deficiency Nephrogenic Tx

A

Drink plenty of water, high dose desmopressin, thiazide diuretics = more Na secretion in DCT = increased water loss = reduce GFR, NSAIDs = reduce GFR - inhibit prostaglandin synthesis (locally inhibit ADH action)

92
Q

AVP Deficiency Complications

A

CDI + desmopressin = serum Na - risk of hyponatremia

93
Q

Acromegaly

A

Prolonged elevated levels of growth hormone (GH) - post-epiphyseal fusion

94
Q

Acromegaly Epidemiology

A

Rare 3/mill/yr, M=F

95
Q

Acromegaly Aetiology

A

GH-secreting pituitary adenoma

96
Q

Acromegaly RFs

A

FHx MEN, McCune-Albright syndrome, Carney complex

97
Q

Acromegaly Path

A

Pituitary produces more growth hormone - to liver = makes more IGF-1 →usual -ve feedback inhibiting GH secretion by producing somatostatin (acts on somatotrophs) does not work

98
Q

Acromegaly Signs

A

Hypertension, heart failure, galactorrhoea, bitemporal hemianopia, carpal tunnel syndrome, macroglossia, prognathism (protruding lower jaw), enlarged hands/feet (can they take rings off?), skin thickening, interdental separation

99
Q

Acromegaly Sx

A

Sweating, headaches, visual changes (tumour).
Systemic = appearance changes, wt gain, fatigue, joint pain, voice changes, skin tags.
Prolactin symptoms = amenorrhoea, galactorrhoea, ED, reduced libido, infertility

100
Q

Acromegaly Investigations

A

1st line: IGF-1 > normal range
Gold: 75gm oral glucose tolerance test = if GH level does not reduce
Other: MRI of pituitary (adenoma), pituitary function

101
Q

Acromegaly Treatment

A

1st line = transsphenoidal pituitary surgery (microadenoma <1cm = 90%, macroadenoma >1cm=50%)
Radiotherapy - conventional multi-fractional, stereotactic single fraction = less radiation to surrounding tissues - loss of pituitary function, damage to local structures (eye nerves), control not always achieved
Medication - dopamine agonists (Ads = no hypopit, rapid, oral. Dis = side effects, relatively ineffective), somatostatin analogues, Pegvisomant (GH analogue) = very effective but £££ = block GH effect on liver

102
Q

Acromegaly Complications and Prognosis

A

Hypertension, diabetes, cardiomyopathy, colorectal cancer, arthritis, sleep apnea, carpal tunnel, sleep apnea, hypopituitarism, psychosocial impacts
Decreased life expectancy

103
Q

Hyperprolactinemia

A

High serum prolactin (lactotrophs)

104
Q

Hyperprolactinemia Epidemiology

A

Females>Males

105
Q

Hyperprolactinemia Aetiology

A

Macro/micro-prolactinoma, non-functioning pituitary tumour, antidopaminergic drugs + ecstasy (mc), hypothyroidism, PCOS, renal failure, stress, chest wall injury

105
Q

Hyperprolactinemia Signs

A

Men = low testosterone, female = low oestrogen

106
Q

Hyperprolactinemia Sx

A

Amenorrhoea, infertility, galactorrhoea, low sex drive (M+F), headache, bi-temoral hemianopia, CSF leak, ED, gynecomastia

107
Q

Hyperprolactinemia Investigations

A

↑↑ serum prolactin

108
Q

Hyperprolactinemia Tx

A

1st line = dopamine agonists (Cabergolin) = tumour shrinkage - inhibitor of prolactin

109
Q

1o Adrenal Insufficiency

A

Addison’s = decreased adrenocortical hormone production

110
Q

Adrenal Insufficiency Epidemiology

A

1o: Addison’s (autoimmune destruction - 21-hydroxylase) mc in developed world , TB in developing

2o: mc = iatrogenic (steroids), others = adrenal mets (lung, liver, breast), adrenal haemorrhage (meningococcal septicaemia)

111
Q

Adrenal Insufficiency Aetiology

A

Autoimmune adrenalitis (mc), CAH, metastasis, infection (TB), infiltration (amyloid)

112
Q

Adrenal Insufficiency RFs

A

Hx TB, postpartum bleed, cancer, steroids. FHx autoimmune, congenital diseases (MEN), female

113
Q

Adrenal Insufficiency Path (Addison’s and HPA suppression)

A

Addison’s: Auto ABs destroy adrenal cortex = ↑ACTH→stimulate POMC (melanocytes) = hyperpigmentation, ↓adrenal hormones

HPA suppression: ↓ACTH + ↓adrenal hormones + no hyperpigmentation

114
Q

Adrenal Insufficiency Signs

A

Pigmentation (high ACTH - 1o) and pallor, postural hypotension (↓aldosterone), low Na, high K, eosinophilia, borderline elevated TSH, hypoglycemia, vitiligo

115
Q

Adrenal Insufficiency Sx

A

Fatigue, weight loss, fainting, confusion, body aches, abdo pain, vomiting

116
Q

Adrenal Insufficiency 1st Ix

A

Hyponatremia (due to ↓aldosterone), Hyperkalemia (due to ↓aldosterone), ↓cortisol
ATCH: ↑in 1o, ↓/normal in 2o
↑Renin in Addison’s, ↓Aldosterone in Addison’s

117
Q

Adrenal Insufficiency GS Ix

A

Synacthen test - tests adrenal reserves (cortisol not↑)

118
Q

Adrenal Insufficiency Other Ix

A

For causes: 1o = adrenal Abs (-ve then CT scan, genetics)
2o = MRI of pituitary then genetics

119
Q

Adrenal Insufficiency Tx

A

1o = Hydrocortisone (replace cortisol) - according to weight (adults) - higher dose in am (adjust according to symptoms/signs of under/over -dose) - stressed/intense exercise = extra 5mg
Mineralocorticoid (replace aldosterone) - hypertension = reduce (not stop), increase if sweating

120
Q

Adrenal Insufficiency Monitoring

A

Must carry steroid emergency card, Mineralocorticoid = monitor U+E, BP, salt craving

121
Q

Adrenal Insufficiency Complications + Prognosis

A

Adrenal crisis = severe insufficiency ESP hypocortisolemia →n+v renal failure, LOC
Tx = immediate hydrocortisone + IV saline + dextrose if hypoglycemia
Lower quality of life and lower life expectancy

122
Q

3o Adrenal Insufficiency

A

Suppression of HA - medications (steroids, opioids)

123
Q

Cushing’s Syndrome

A

Chronic excess of glucocorticoids

124
Q

Cushing’s Syndrome Epidemiology

A

F>M

125
Q

Cushing’s Syndrome Aetiology

A

ACTH dependent = Cushing’s Disease - ACTH secreting pituitary adenoma (mc), ectopic ACTH
ACTH independent = adrenal adenoma, iatrogenic - steroid use (mc)

126
Q

Cushing’s Syndrome Signs

A

Moon face, buffalo hump (enlarged fat pad on upper back)
Hirsutism (male pattern hair on women)
Easy bruising, poor skin healing, abdominal striae
Central obesity, proximal limb muscle wasting Excess ACTH = hyperpigmentation, plethoric complexion

127
Q

Cushing’s Syndrome Sx

A

Headaches, visual field changes

128
Q

Cushing’s Syndrome 1st Ix

A

Rule out oral steroids (stop them), random serum cortisol↑(12am: normally lowest here)
Dexamethasone suppression test (overnight) - essentially cortisol (healthy = -ve feedback HPA axis + ↓ cortisol:
00:00 = Give Dexa and measure cortisol (before give dex), 08:00 = measure cortisol (non-Cushing’s = suppression >50nmol/L, Cushing’s = little/no suppression)

129
Q

Cushing’s Syndrome GS Ix

A

1st line +ve = measure plasma ACTH: ↑=ACTH dependent - look for cushing’s disease on pituitary MRI; ↓=ACTH independent - adrenal adenoma

130
Q

Cushing’s Syndrome Tx

A

Cushing’s = transphenoidal resection or bilateral adrenalectomy (Nelson’s syndrome)
Adrenal adenoma = adrenalectomy, ectopic = surgical removal

131
Q

Cushing’s Syndrome Complications

A

Hypertension, osteoporosis, DM, cataracts, myopathy

132
Q

Hyperaldosteronism

A

Primary hyperaldosteronism - independent of RAAS
Secondary - excessive renin

133
Q

Hyperaldosteronism Aetiology

A

1o: 1/3 = adrenal adenoma (Conn’s), 2/3 = bilateral adrenal hyperplasia
2o: renal artery stenosis (atherosclerosis), heart failure, liver cirrhosis/ascites

134
Q

Hyperaldosteronism RFs

A

FHx of PA, early hypertension onset/stroke

135
Q

Hyperaldosteronism Path

A

1o: ↑↑aldosterone = ↑↑Na + H2O + ↓↓K = hypertension and hypokalemia
2o: disproportionately lower kidney BP = excessive renin released = stimulates ↑ aldosterone release

136
Q

Hyperaldosteronism Signs

A

Hypertension, hypokalemia (mc with Conn’s), metabolic alkalosis

137
Q

Hyperaldosteronism 1st Ix

A

Aldosterone:Renin ratio (ARR) = screening-
1o =↑ald + ↓renin
2o =↑ald + renin

138
Q

Hyperaldosteronism GS Ix

A

↑serum aldosterone not suppressed w/0.9% saline or fludrocortisone, hypokalemic ECG

139
Q

Hyperaldosteronism Other Ix

A

CT/MRI = adrenal tumour or hyperplasia, renal artery imaging (doppler, CT angiogram) = renal artery stenosis, adrenal vein sampling

140
Q

Hyperaldosteronism Tx

A

Adrenal adenoma = surgery (adrenalectomy)
Hyperplasia = aldosterone antagonist (Spironolactone)

141
Q

Hyperaldosteronism Complications

A

Most common cause of 2o hypertension (often undiagnosed)

142
Q

Syndrome of Inappropriate ADH (SIADH)

A

Inappropriately released ADH (dilute euvolemia) from post pituitary

143
Q

SIADH Aetiology

A

Tumours (SLCL, prostate, pancreatic), Infection/inflammation (TB, meningitis, HIV), Abscesses, Drugs (SSRIs, carbamazepine), Head trauma, Post-op

144
Q

SIADH RFs

A

Age>50yrs, pulmonary conditions, nursing home residence, post-op, Hx diuretic use

145
Q

SIADH Path

A

↑ADH produced by hypothalamus and secreted by PPG = stimulate H2O reab in kidney CDs = dilute blood + ↓[Na] (hyponatremia) = more concentrated urine

146
Q

SIADH Signs

A

Brain stem herniation through Foramen Magnum (↑Na =↑compensatory H2O = enters skull + ↑ICP = hyponatremia encephalopathy), cognitive impairment, pulmonary/peripheral oedema

147
Q

SIADH Sx

A

Headache, fatigue, muscle aches, cramps, confusion, severe = seizures and reduced consciousness, vomiting

148
Q

SIADH 1st Ix

A

↓Na serum, normal K serum,↑urine osmolality

149
Q

SIADH GS Tx

A

Hyponatremia, low plasma osmolality<urine osmolality, urine [Na]>40mmol/L despite normal salt intake, euvolemia, normal thyroid + adrenal function (short synacthen test - exclude adrenal insufficiency)

150
Q

SIADH DDx

A

Adrenal insufficiency, Hx diuretic use, excessive H2O intake, C/A-KD, heart failure, liver disease

Na (salt) depletion = give 0.9% saline + SIADH = serum not normalise, Na depletion = serum normalises

151
Q

SIADH Tx

A

Fluid restriction + hypertonic saline (concentrate blood), treat underlying cause (tumour excision), chronic = drugs (furosemide, ADH antagonist)

152
Q

Hypokalaemia

A

Low Serum K <3.5mmol/L, <2.5mmol/L = emergency

153
Q

Hypokalaemia Aetiology

A

Increased excretion: drugs (thiazide, loop), renal disease, GI loss, increased aldosterone (Conn’s).
Reduced dietary intake (dietary deficiency).
Shift to intracellular (drugs - insulin, salbutamol)

154
Q

Hypokalaemia Signs

A

Arrhythmias (Esp AF), muscle paralysis, rhabdomyolysis, hypotonia, hyporeflexia

155
Q

Hypokalaemia Sx

A

Fatigue, generalised weakness, muscle cramps/pain, palpitations (can be aSx)

156
Q

Hypokalaemia Ix

A

↓[K] <3.5mmol/L, FBC, U+Es, ECG

157
Q

Hypokalaemia ECG

A

Main = ST depression,
Others = flattened/inverted T waves, U waves, prolonged PR interval, atrial/ventricular tachyarrhythmias

158
Q

Hypokalaemia Tx

A

K replacement, aldosterone antagonist

159
Q

Hyperkalaemia

A

High Serum K >5.5mmol/L

160
Q

Hyperkalaemia Aetiology

A

Increased intake (IV/diet).
Decreased kidney excretion:↓GFR in A/CKD, adrenal insufficiency (principal cells secrete less K), drugs (ACE-i, NSAIDs)
Shift to extracellular (metabolic acidosis, rhabdomyolysis)

161
Q

Hyperkalaemia Path

A

↑K decreases threshold AP = easier depolarisation = abnormal heart rhythms

162
Q

Hyperkalaemia Signs

A

ECG changes, arrhythmias, hyperreflexia, reduced power, signs of underlying cause

163
Q

Hyperkalaemia Sx

A

MURDER:
Muscle weakness
Urine (oliguria)
Resp distress
Decreased cardiac contractility
ECG changes
Reflexes = hyperreflexia or flaccid
Fatigue, chest pain, weakness, palpitations

164
Q

Hyperkalaemia Ix

A

↑[K] >5.5mmol/L (U+Es), FBC, urine osmolality, ECG

165
Q

Hyperkalaemia ECG

A

Main: tall/tented T waves (narrow base), widened QRS, absent P waves
Others: prolonged PR interval, shortened QT interval

166
Q

Hyperkalaemia Tx

A

Urgent = 30ml 10% calcium gluconate IV STAT (cardiac protective)
Non-urgent = insulin (shifts K into cells) + dextrose (glucose - prevent hypoglycaemia) + consider Salbutamol (shifts K)
W/ heart problems = stabilise cardiac membrane, then insulin and dextrose

167
Q

Hypocalcaemia

A

Low serum Ca<8.5mmol/L

168
Q

Hypocalcaemia Aetiology

A

CKD (↓VitD activation), severe Vit D deficiency, hypoPTH, drugs (bisphosphonates, calcitonin), acute pancreatitis

169
Q

Hypocalcaemia Signs

A

↑Muscle tone + contractions, Trousseau + Chvostek signs, hypotension

170
Q

Hypocalcaemia Sx

A

Can be aSx
Muscle cramps, abdominal pain, carpopedal spasming

171
Q

Hypocalcaemia Ix

A

↓Ca (corrected or free), ECG - prolonged QT/ST segments, arrhythmias

172
Q

Hypocalcaemia Tx

A

Normalise Ca levels - Ca gluconate, Vit D supplement

173
Q

Hypocalcaemia Complications

A

Osteopenia, osteoporosis, cardiac arrhythmias, tetany, seizures

174
Q

Hypercalaemia

A

High serum Ca>10.5mmol/L

175
Q

Hypercalaemia Aetiology

A

MC = hyperPTH, bone malignancy
Other = drugs (thiazides), hyperthyroid, dehydration, excess Ca intake, tumours

176
Q

Hypercalaemia Signs

A

Polyuria, ↓muscle tone + contractions (Ca inhibits fast Na influx)

177
Q

Hypercalaemia Sx

A

Can be aSx
Bones, Stones, Groans, Moans (psycho) = Bone pain, kidney stones, abdominal pain/nausea, depression, anxiety, coma, insomnia

178
Q

Hypercalaemia Ix

A

↑Ca (corrected for albumin or measure free ionised Ca)
ECG - short QT, bradycardia, AV block, Osborn wave

179
Q

Hypercalaemia Tx

A

Lower Ca levels = rehydrate (↑Ca urinary excretion), loop diuretics (inhibit Ca reab), glucocorticoids (↓gastro Ca ab), bisphosphonates/calcitonin (inhibit osteoclasts), dialysis = if renal failure

180
Q

Hypercalaemia Complications

A

Hypercalciuria = kidney stones
Osteoporosis (depletion of Ca stores), renal failure, cardiac arrhythmias, confusion, dementia, coma

181
Q

Thyroid Carcinoma

A

Tumours derived from thyroid follicular epithelium (except medullary - functional parafollicular C cells)

182
Q

Thyroid Carcinoma Epidemiology

A

Papillary (mc - 70%), follicular (25%), anaplastic, lymphoma, medullary cell

183
Q

Thyroid Carcinoma Aetiology

A

Gain of function mutation in signalling pathways (except medullary)

184
Q

Thyroid Carcinoma RFs

A

FHx, head/neck irradiation, F, age

185
Q

Thyroid Carcinoma Met Sites

A

Met sites mc; lung (50%), bone (30%), liver (10%), brain (5%)
Compression at local site = Sxs

186
Q

Thyroid Carcinoma Signs

A

Hypothyroidism, thyroid nodules - hard + irregular

187
Q

Thyroid Carcinoma Sx

A

Hoarse voice, trouble swallowing (local compression), hypothyroidism (weight gain, fatigue, cold intolerance)

188
Q

Thyroid Carcinoma 1st Ix

A

TFTs

189
Q

Thyroid Carcinoma GS Ix

A

Fine Needle Aspiration Biopsy

190
Q

Thyroid Carcinoma Other Ix

A

Ultrasound

191
Q

Thyroid Carcinoma Tx

A

Papillary and follicular = thyroidectomy and radiotherapy.
Anaplastic = palliative mostly (worst prognosis - often metastasises)

192
Q

Carcinoid Tumours and Syndrome

A

Malignant tumours of enterochromaffin cells

193
Q

Carcinoid Tumours and Syndrome Aetiology

A

Most commonly arises from GI tract (SI - terminal ileum, appendix), then lungs, liver, ovaries, thymus

194
Q

Carcinoid Tumours and Syndrome RFs

A

MEN-1

195
Q

Carcinoid Tumours and Syndrome Path

A

Tumours of enterochromaffin cells produce serotonin/5-HT
Carcinoid tumours = only neoplastic cells (no Sx/v.little)
Carcinoid syndrome - metastasises to liver = Sx

196
Q

Carcinoid Tumours and Syndrome Signs

A

Telangiectasia (dilation of capillaries = small red/purple clusters (spidery)
Tricuspid incompetence (valve lesion)
Heart failure, palpitations, bronchospasm

197
Q

Carcinoid Tumours and Syndrome Sx

A

Wheezing, abdominal pain
Mets to liver = diarrhoea + flushing (warmth, erythema)

198
Q

Carcinoid Tumours and Syndrome Ix

A

↑5-hydroxyindoleacetic acid (major metabolite of 5HT), metabolic panel, LFTs
CT/MRI = locate tumour, liver US = confirm mets

199
Q

Carcinoid Tumours and Syndrome Tx

A

Surgically excise 1o tumour (definitive), Somatostatin (SST) analogue (octreotide) can block tumour hormones

200
Q

Carcinoid Tumours and Syndrome Complications

A

Carcinoid crisis - life threatening, Sx constellation, Tx SST analogue high dose

201
Q

Phaeochromocytoma

A

Adrenal medullary tumour (chromaffin cells) secretes catecholamines (NAd, Adr)

202
Q

Phaeochromocytoma Epidemiology

A

V.rare, 30-40% genetic, 10% = bilateral, 10% cancerous, 1-% outside adrenal gland

203
Q

Phaeochromocytoma Aetiology

A

MEN 2a/b, neurofibromatosis I (tumour deposited along nerve myelin sheath), Von-Hippel Lindau Disease

204
Q

Phaeochromocytoma RFs

A

Older M

205
Q

Phaeochromocytoma Path

A

Unregulated secretion of excessive adrenaline = stimulation of sympathetic nervous system

206
Q

Phaeochromocytoma Signs

A

Hypertension, postural hypotension, tachycardic, palpitations, pallor

207
Q

Phaeochromocytoma Sx

A

Headaches, sweating, anxiety, tremor
Often episodic - Adr released in bursts = intermittent Sx

208
Q

Phaeochromocytoma Ix

A

↑plasma metanephrines + normetanephrines (more sensitive than NAd/Adr = longer ½ life)

Urinary catecholamines, CT imaging - tumour, genetic testing

209
Q

Phaeochromocytoma Tx

A

Alpha blockers (phenoxybenamine), then beta blocker (atenolol) = prevents reactive vasoconstriction
Surgery if possible - excise tumour

210
Q

Phaeochromocytoma Complications

A

Hypertensive (HTN) crisis (180/120 + BP) = give Phentolamine (alpha blocker)

Phase 2A (1 decks)

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