Endocrine Flashcards by O M

Graves’ disease triad

Goitre Eye signs Thyrotoxicosis

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Test for lid retraction

Visible white below eyelid Move finger up and quickly down, lid lags behind

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Features on peripheral thyroid status

-lid retraction and lid lag -clubbing and onycholysis -fine tremor and moist palms -tachycardia, AF -biceps reflex, normal upstroke, slow delay -slow relaxation- hypothyroid -proximal myopathy- elbows up, chair without hands -pretibial myxoedema- thyroid dermopathy (non-pitting)

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Graves eye signs

Oedema (periorbital and chemists) Pronto sis (best assessed from side) Retraction (autonomically mediated) Exposure keratopathy Opthalmoplegia (upgaze palsy)

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Graves treatment

Carbimazole low dose- 18 months- agranulocytosis 1/20 get a rash Treat and block- carbimazole and iodine Surgery Radioiodine

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Features of hypothyroidism

-gruff voice, slow cerebration -coarse facial features -dry, cold scaly skin -slow pulse and slow relaxation of biceps jerk -goitre- Hashimoto’s -myoedema

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Features of cushing’s Syndrome

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Cushing’s general examination

truncal obesity

moon face

supraclavicular fat pads

stooped posture- kyphosis

evidence of RA, asthma, A-V fistula—> steroids

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Cushing’s hands and arms

Bruising

Decreased skin fold thickness

BP- high

shoulder abduction- myopathy

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Facial features cushings

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Cushing’s abdomen and legs

purple striae- underlying muscle

renal Transplant scar

stand from chair

leg ulcers

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Extras in Cushing exam

palpate spine for tenderness- osteoporosis

interscapular fat pad

dip urine/ bedside BM

check visual fields- rare defects

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General things to look out for in cushings

SWEDISH

Spinal tenderness

Weight- central obesity

Easy bruising

Diabetes

Interscapular fat pad

Striae

Hypertension

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How to screen for hypercortisolaemia

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Causes of Cushing’s syndrome

exogenous steroids

pituitary Adenoma- Cushing’s disease

adrenal Adenoma or carcinoma

ectopic ACTH synthesis (wasting due to Carcinoma, pigmentation Dan hypokalaemia)

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How to distinguish adrenal from pituitary disease

ACTH levels are high in Cushing’s disease

Low in adrenal Cushing’s syndrome

ACTH levels are difficult as degrade quickly

high dose suppression test is unreliable

What is acromegaly?

Acromegaly hand features

Size- increased

wasting of thenar eminence if carpal tunnel

sensation in median nerve distribution

increased sweating

boggy palms

skin fold thickness increased in active disease

Facial features in acromegaly

Prominent supraorbital ridge

big ears, nose, lips, tongue

look from side for prognathism

wide separation of teeth

raised JVP- acromegaly cardiomegaly and biventricular failure

Features of acromegaly

ABCDEF

Arthropathy- accelerated OA

Carpal tunnel

Diabetes

Enlarged features

Fields- bitemporal hemianopia

Acromegaly diagnostics

Failure of GH suppression during oral glucose tolerance test

GH is a glucose antagonist

average of hourly growth hormone levels (single unreliable as pulsation release)

insulin-like growth factor levels

Acromegaly examination

Acromegaly management

What is Addison’s?

Autoimmune adrenalitis

commoner in women

associated with vitiligo and other organ specific autoimmune diseases

presents insidiously

Features of adrenal crisis

usually precipitated by Trauma or infection emergency occassionally caused by sudden withdrawal of steroids coma and hypotension take blood for cortisol level, but don’t wait for results FBC, U&E and blood cultures check for hypoglycaemia, and give IV dextrose if needed treat with IV steroids, saline (Na depletion) and antibiotics

Clinical findings in chronic adrenal insufficiency

Non-specific symptoms: lassitude, nausea, abdominal pain, diarrhoea dizziness due to postural hypotension pigmentation due to ACTH- hand creases, buccaneers mucosa, scars hypoglycaemia- due to loss of one of the main insulin antagonists

Investigations in adrenal insufficiency

hypocortisolaemia- basal levels may be normal or show low morning levels may need dynamic test of adrenal reserve to prove insufficiency- synacthen test electrolytes often normal may show low Na, and high K especially in crisis

Questions in acromegaly

Headaches vision changes tingling in hands tingling in feet - diabetic neuropathy sweat easily difficult with getting/ maintaining an errection increase in shoe, hat, glove size

Extra in acromegaly

Visual fields BP urine glucose axillary and pubic hair- hypopituitaryism feet and heel pads serial photographs from the past goiter- 10% have due to increased GH

Other causes of macroglossia

Acromegaly imaging

lateral radiographs with tomographs of the pituitary fossa. CT/MRI shows extent

Symptoms of hyperthyroidism

Weight loss increased appetite heat intolerance sweating fatigue and weakness irritability, nervousness, restlessness, insomnia diarrhoea palpitations loss of libido

Signs specific to graves disease

Exopthalmos opthalmoplegia conjunctival oedema periorbital oedema pretibial myxoedema clubbing

Pathophysiology of Graves’ disease

TSH receptor IgG antibodies binding to the TSH receptor, stimulating production of thyroid hormones

Complications of untreated hypothyroidism

Short term - AF - angina - thyroid storm long-term - osteoporosis - heart failure

Indications for a thyroidectomy

Patient choice pressure to local structures drug side effects poor compliance with drug therapy relapse of hyperthyroidism after withdrawal of medication

Complications of thyroidectomy

2 Acute, early, severe- bleeding (airway compression), thyroid crisis 2 local- recurrent laryngeal nerve (outside pre-tracheal fascia), hypoparathyroidism 2 common, late- hypothyroidism (30%), recurrent hyperthyroidism (15%)

Causes of hypothyroidism

Autoimmune iodine deficiency thyroidectomy/radioiodine therapy drugs (amiodarone) congenital