Endocrine Flashcards
Most common cause of acromegaly
Excess growth hormone secondary to a pituitary adenoma (95% of cases)
State 6 signs or symptoms in acromegaly
Spade-like hands
Increase in shoe size
Large tongue, interdental spaces
Excessive sweating and oily skin
Headaches
Bitemporal heminanopia
Galactorrhoea
What causes the visual field defect in acromegaly?
Pituitary adenoma on the optic chiasm
What serum blood test do you want to perform to screen for acromegaly?
Serum insulin like growth factor 1 (IGF-1)
Explain how an OGTT can aid the diagnosis of acromegaly
Hyperglycaemia causes NO suppression of GH after OGTT
What other endocrinological disorder would you screen for in acromegaly?
Diabetes mellitus
GH is an anti-insulin
What is the main cause of death in acromegaly patients
Cardiovascular disease
What surgery is performed to cure acromegaly in 95% of patients
Trans-sphenoidal surgery
Name 3 drugs that can cause hypothyroidism
Carbimazole
Lithium
Amiodarone
Name 4 signs and symptoms of hypothyroidism
Symptoms:
Weight gain
Lethargy
Cold intolerance
Constipation
Menorrhagia
Signs:
Dry, cold, yellowish skin
Non-pitting oedema
Dry, coarse scalp hair
Decreased reflexes
Other than iatrogenic, name 4 causes of hypothyroidism
Hashimoto
Iodine deficiency
Radioactive iodine
Thyroid surgery
What might a FBC show in hypothyroidism
Macrocytic anaemia
What will the level of TSH and T4 be in a patient with primary hypothyroidism
High TSH, low T4
How would you treat hypothyroidism medically
Levothyroxine
A patient with hypothyroidism notices white patches on the back of both of her hands - what could this represent?
Vitiligo
What anatomical structure represents the site at which the thyroid gland originated before embryological descent
Foramen caecum
What is Grave’s disease
Autoimmune condition causing hyperthyroidism caused by IgG antibodies to the TSH receptor (TSH receptor stimulating antibodies and anti-thyroid peroxidase antibodies)
Name 3 specific signs of Grave’s disease
Exophthalmos
Opthalmoplegia (Lid retraction, lid lag)
Pretibial myxedema
Acropachy / soft tissue swelling and clubbing of the fingers and toe
What would thyroid scintigraphy show in Graves’ disease
diffuse, homogenous, increased uptake of radioactive iodine
What drug class can control tremor in hyperthyroidism
Beta blocker
Name 1 drugs used in hyperthyroidism
Carbimazole
Other than Grave’s specific signs, name 3 signs of hyperthyroidism
Fine tremor
Palmar erythema / warm, sweaty hands
Tachycardia
Atrial fibrillation
Excessive thirst, weight loss and increased urine production
Urine dipstick negative for glucose
Most likely diagnosis?
Diabetes insipidus
Where is ADH secreted from?
Posterior pituitary
Diabetes insipidus
Urine osmolality?
Plasma osmolality?
Urine osmolality: low (very diluted)
Plasma osmolality: high (very concentrated) or normal (because of the excess water drinking)
Whats the difference between nephrogenic and cranial diabetes insipidus?
Cranial: lack of ADH production
Nephrogenic: lack of response to ADH
How is the water deprivation test used to diagnose diabetes insipidus and what is the differential
The differential is primary polydipsia
Water deprivation test:
DI will continue to have low urine osmolality
PP will have high urine osmolality after water deprivation
Name 1 drug used to treat the cranial type of this condition
Desmopressin
A woman recently gave birth and suffered a massive post-partum haemorrhage. She is now suffering from diabetes insipidus. What is the likely cause?
Sheehan’s syndrome (pituitary gland infarction)
3 causes of hypoglycaemia
Insulinoma
Self-administration of insulin
Alcohol (causes exagerrated insulin secretion)
Name 4 autonomic symptoms of hypoglycaemia
Sweating
Shaking
Hunger
Anxiety
Nausea
Likely cause of hypoglycaemia in an unconscious teenage boy with known diabetes
Inappropriate use of insulin (overmedicating)
Name 2 symptoms of neuroglycopenia other than coma
Weakness
Vision changes
Confusion
Dizziness
What can repeated episodes of hypoglycaemia lead to?
A lack of awareness of hypoglycaemia happening
What advice would you give to a patient and their family regarding prevention of hypoglycaemic episodes
Regular meals (never miss one)
Regular finger-prick monitoring
Keep emergency supply of glucose in pocket e.g. energy tablets
Adjust insulin appropriately in response to change in diet, activity or illness
Middle aged man complaining of persistent fungal infection in penis, tiredness, visual blurring and polyuria. What is the underlying diagnosis?
T2DM
Explain the OGTT
Plasma glucose 2h after drinking 75g glucose
Name 2 macrovascular complications and 2 microvascular complications of T2DM
Macrovascular:
Stroke
CVD
Microvascular:
Retinopathy
Neuropathy
Nephropathy
Other than Metformin, name 3 agents that could be used to treat T2DM
Sulfonyureas
Pioglitazone
DPP4 inhibitors
SGLT2 inhibitors
GLP-1 analogue
How do you confirm the diagnosis of DKA by bedside testing
Urinary ketones
Name 2 venous blood tests you may perform for the causes of DKA
FBC (infection)
U&E (electrolyte abnormality, renal failure)
pH 7.11
PO2 13.8
PCO2 2.7
BE -7.3
HCO3 18.9
What in your interpretation of this ABG?
Metabolic acidosis with respiratory compensation
What is the management of DKA?
Fluids
Insulin
Glucose when < 14
Potassium in IV fluids
Investigate and treat underlying cause e.g. infection
Chart fluids
Ketones, pH, bicarb
Explain the pathophysiology of DKA and the 3 most common precipitating factors
Uncontrolled lipolysis which results in excess free fatty acids ultimately converted to ketone bodies
Infection
Missed insulin doses
Myocardial infarction
Middle aged man with fatigue and loss of appetite, slight tanning of the skin and buccal pigmentation. PMH of vitiligo. Most likely diagnosis?
Addison’s disease
Pathophysiology of Addison’s disease
Autoimmune destruction of the adrenal glands resulting in reduced cortisol and aldosterone
Name 2 tests you would like to perform to aid the diagnosis of Addison’s disease
Diagnostic: ACTH stimulation test (short SynACTHen test) plasma cortisol is measured before and after 30 minutes after giving SynACTHen IM
If this test is not available, 9am serum cortisol >100 should prompt further synacthen test
U&Es for electrolyte abnormalities
What would a U&E show in Addison’s disease
No aldosterone = hyponatraemia, hyperkalaemia
No cortisol = hypoglycaemia
Metabolic acidosis
Apart from glucocorticoids (hydrocortisone), what drug class would you prescribe in Addison’s disease
mineralocorticoids (fludrocortisone)
Give 3 pieces of advice you would provide after prescribing glucocorticoids to a patient
Carry a steroid card and medic alert ID bracelet
Double the dose during acute illness
Do not miss a dose
Carry emergency IM hydrocortisone
What is the commonest cause of pathological hyperprolactinaemia?
Prolactinoma (pituitary adenoma)
Name 3 signs or symptoms a patient with hyperprolactinaemia may have?
Galactorrhoea
Subfertility
Decreased libido
Headache
Bitemporal hemianopia
What imaging test would you request in hyperprolactinaemia
MRI head
Name a drug used to treat hyperprolactinaemia and its mechanism of action
Cabergoline/bromocriptine (dopamine agonist)
Other than pharmacological, what other treatment is available to a patient with hyperprolactinaemia who refuses surgery
Radiotherapy
Commonest cause of primary hyperparathyroidism
Solitary adenoma (80%)
Name 4 signs or symptoms of hypercalcaemia
Bones, stones, groans and psychiatric moans
Shortened QT interval on ECG
In primary hyperparathyroidism, will the a) calcium and b) phosphate be low/normal/high
High calcium
Low phosphate
PTH may be inappropriately normal with the raised calcium as it should be low due to negative feedback
In secondary hyperparathyroidism, will the a) calcium and b) phosphate be low/normal/high
Low or normal calcium
Elevated phosphate
In tertiary hyperparathyroidism, will the a) calcium and b) phosphate be low/normal/high
Normal or high calcium
Normal or decreased phosphate
What imaging test would you order in primary hyperparathyroidism?
X-ray shows pepperpot skull
Definitive management of primary parathyroidism
Total parathyroidectomy
Complication: laryngeal nerve palsy
What is the relationship between vitamin D and calcium?
vitamin D levels increase the efficiency of calcium absorption in the gut
What type of sense diminishes first in peripheral neuropathy?
Vibration
Other than glove and stocking neuropathy, what signs may you find on diabetic foot examination
Charcot’s joint (neuropathic arthropathy)
Painless ulcer
High arched foot with clawing of toes
Diminished reflexes
Name 2 other types of neuropathy that occur in diabetes patients
Autonomic neuropathy
Diabetic amytrophy
Mononeuritis multiplex
What is key in management of preventing progression
of polyneuropathy
good glycaemic control
A man with T2DM and peripheral neuropathy has intractable vomiting, what is the likely cause?
Autonomic gastroparesis
Most serious side effect of carbimazole and signs that would alert a patient to it
Agranulocytosis
Seek medical advice if sore throat, mouth ulcers, bruising, fever, malaise
2 definitive management options for Grave’s disease
Radioiodine therapy
Thyroidectomy
Part of adrenal gland and hormone
Zona glomerulosa: aldosterone
Zona fasciculata: cortisol
Zona reticularis: androgens
Medulla: adrenaline
2 signs and 2 symptoms of Cushing’s
Symptoms: depression, insomnia, acne
Signs: moon face, buffalo hump, central obesity
Blood test and time for overnight suppression test
Serum cortisol 9am
Diagnostic criteria for DKA
D: Glucose >11 or known DM
K: Ketones >3 or urinary ketones ++
A: pH <7.3
Bicarbonate <15
Insulin rate for DKA
0.1 units / kg / hour
ABG complication of fluid overload
Hyperchloraemic metabolic acidosis
List 3 initial steps in the management of unrousable hypoglycaemia after 1 dose of glucose IV
Another dose of IV glucose
Oxygen
Collateral history
Bloods lab glucose
Urea and electrolytes
What underlying problem might explain hypoglycaemia in a T2DM on insulin
Excess insulin
Intercurrent illness
Reduced oral intake
Possible safeguarding concern in hypoglycaemia in a insulin dependent patient and how to test it
Excess exogenous insulin either by carer, family or self
Test by measuring c-peptide (measure of endogenous insulin only)
3 nephrogenic causes of DI
Genetic ADH receptor abnormality
Lithium
Haemochromatosis
Why do polyuria and polydipsia occur in hyperglycaemia
Water is dragged out of the body due to the osmotic effects of excess blood glucose being secreted in the urine
2 causes for 90% of hypercalcaemia
Primary hyperparathyroidism
Malignancy (PTHrP from tumour e.g. SCC, bone mets, myeloma)
