Endocrine 2 Flashcards
Broadly outline the causes of hypopituitarism:
Hypothalamus:
- infection
- Kallmann’s syndrome
- Infection
Pituitary stalk:
- trauma
- Craniopharyngioma
- Carotid artery aneurysm
Pituitary:
- Macroadenoma (1cm)
- Pituitary apoplexy
- Infiltrative - sarcoidosis
- Sheenhan syndrome
What are the causes of adrenal insufficiency, broadly?
Addison’s - autoimmune
TB infection in the adrenals
Secondary adrenal insufficiency
- exogenous steroid use
- Macroadenoma
Metastatic cancer
- Lung
- Breast
21 alpha hydroxylase
Waterhouse- friderichsen syndrome
Drugs:
- ketoconazole
Outwith ACTH, what other test can be done to determine between primary and secondary insufficiency?
Renin- aldosterone levels
When should the Short synACThen test be done?
Early morning
When investigating for Addison’s disease what is a very important thing to remember:
To treat first
How does someone with an addisonian crisis present and what is the treatment?
• Shock
- Vasoconstricted - Oliguria - Comatose * Confused * Hypoglycaemic • Postural drop - Collapse
Causes:
• Infection - Always remember to do an infection screen * Trauma * Missed taking steroids * Surgery
Investigations:
*remember to treat if high suspicion
Bloods: • FBC • U&Es • CRP • Blood glucose \+/- • Blood cultures if suspect infection
Orifices:
• Urine sample
- Infection
X-ray:
• CXR
- Infection
ECG:
• High K+ so must be ready to manage
Special tests:
• ACTH
Management:
* IV fluids * IV hydrocortisone * IV glucose
+/- Hyperkalaemia management
+/- Sepsis management
What are some of the complications of obesity?
Metabolic Syndrome
- T2DM
- Hypertension
- Hyperlipidaemia
Coronary heart disease
Strokes
NAFLD
Restricted ventilation
- Obstructive sleep apnea
Cancers:
- Breast, uterus (hormone dependent)
PCOS
OA
What tests should be done to assess causes for obesity and diagnosis?
Bloods:
- TFTs - Cortisol and Dexamethasone suppression test
BMI testing:
• Weight kg/ height (m)2
- Kg/m2
Waist circumference
What investigations should be done when someone has obesity?
Bloods: • FBC • LFTS - NAFLD (raised transaminases) • Lipids studies • CRP levels • Blood glucose (DM)
X-rays:
• Abdominal ultrasound
- Assess the liver
ECG:
- Assessment of cardiovascular function is essential
Special tests:
• Sleep Polysomnography
What are the therapies for obesity?
1st: Life style changes:
- exercise
- diet
2nd:
- Low calorie diet >100kj drop a day
or
- Very low calorie diet - done by professionals
3rd:
Medication
- Orlistat
4th: Surgery - Gastric band - Gastric sleeve - Roux - en - Y - gastric bypass - Duodenal switch
What is a defining feature of De quervain’s syndrome that separates it from Graves disease clinically?
Tender goitre
What are the symptoms of Grave’s ophthalmopathy?
• Prominence of the eyes
• Painful watering of the eyes - Excessive lacrimation * Gritty feeling in eyes * Photophobia * Lid retraction • Corneal damage - This can occur as there is an inability to close the lid • Optic nerve compression - Reduced visual acuity - Reduced colour vision • Extraocular palsy involvement This is seen with diplopia - also seen with upward gaze abnormality
What is the investigations into Grave’s ophthalmopathy?
Visual assessment/ Visual acuity
MRI
TFTs
Ophthalmology review
What is the treatment for Grave’s ophthalmopathy?
Stop smoking
Hypromellose eye drops
Prednisolone
- for acute flares
Taping eyes shuts / wearing dark sunglasses
Sleeping up right
Surgical intervention:
- Surgical decompression
- Lid retraction
Outwith Grave’s disease name some other causes of hyperthyroidism:
Toxic multinodular Goitre
Solitary Adenoma
Drugs
- Amiodarone
- Iodine contrast media
Thyrotoxic phase of thyroiditis
- Hashimotos
- De Quervain’s syndrome
What are the side effects of Propylthiouracil and when is it used?
Hepatotoxicity
Used during pregnancy and breast feeding instead of carbimazole
When is thyroid surgery indicated in patients?
Large goitre
Poor drug compliance
Continual thyrotoxicosis despite medical management
What is the surgery done in Grave’s?
Subtotal Thyroidectomy
What are the associations with Grave’s
type 1DM
Vitiligo
Addison’s
What’s the symptoms of Hypothyroidism?
MOMS SO TIRED Memory loss Obesity Menorrhagia Slowness Skin - brittle dry - hair Onest is slow Tiredness Intolerance to cold Raised BP - yet has bradycardia Energy levels low Delayed reflexes / Depresion
What is Whipple’s triad for hypoglycemia?
Low plasma glucose < 3 / < 3.5 (Diabetes)
Symptoms in keeping with hypoglycemia
Symptoms resolve after administration of glucose
What advice should be given to people who have received radiotherapy for the thyroid?
Must stay away from:
- Pregnant
- Young children
for 3 weeks.
No breast feeding
What are the complications of untreated hyperthyroidism?
Acutely:
- AF
- Thyrotoxic storm
Long term:
- Heart failure - cardiomyopathy
- Osteoporosis
What are the symptoms of a thyrotoxic storm?
Tachycardia
Hyperthermia
Confusion
Coma
Triggered by:
- infection
- Trauma
- M.I
- Surgery
- Radioiodine
When is thyroid surgery indicated?
Failed medical therapy
- following the 12-18months
Patient preference
- cosmetic
Compression of goitre causing dyspnea
Intolerable side effects of medication
What are the findings and Treatment of thyrotoxic storm?
Clinical findings:
- Tachycardia / AF
- Hyperthermia
- Acute abdomen
- thyroid bruit
Treatment:
- endocrine advice
- IV fluid
- Beta blockers (care taken as can cause Heart Block)
- Antiarrhythmic drugs
+ - Rate control - digoxin
- Carbimazole
- Steroids - prevents peripheral break down
+/-
- antibiotics
What important advice should be given to people with addison’s disease?
Know to increase dose of steroids for illness
Carry steroid card
Wear medic - alert bracelet
Keep supply of IV/ IM steroids incase oral route is not possible
What important thing needs to be ruled out before treating someone with hyperparathyroidism?
Vitamin D
you can only have hyperparathyroidism with normal vitamin D
What are the most important investigations into hypercalcemia?
PTH
Vitamin D
Serum electrophoresis
CXR
What is the criteria for PCOS?
Rotterdam Criteria:
- Clinical biochemical evidence
- Lack of ovulation
- Cysts on ovaries
What must patient be prior to radioactive iodine therapy?
Euthyroid with medication withdrawal some 5-7 days prior.
Which patients may have worsening of their symptoms with radioactive iodine?
Those with thyroid eye disease
What are the acidophilic tumours of pituitary?
Somatotrophs - GH
Lactotrophs - prolactin
What are the symptoms of Prolactinoma? and how is it investigated?
Galactorrhea Amenorrhea Erectile dysfunction Hypogonadism Headaches Visual disturbance
Measurement of prolactin
MRI of brain
Visual field testing
If someone suddenly develops severe headache and double vision with loss of pituitary hormones what is a likely cause and how is it treated?
Pituitary apoplexy
Conservatively with hormone replacement
or
Surgical decompression
Why is there often prolactinoma in hypopituitarism disorders?
Loss of dopamine function to suppress it
What are the causes of hyperprolactinemia?
Tumours:
- Prolactinomas
- Adenomas
- suppresses the dopamine control
- Growth hormone tumours
Drugs
- Anti-dopaminergic drugs - metoclopramide
CKD
- failure of clearance
Hypothyroidism
Chest surgery
- triggers the mammary nerve reflex
PCOS
- not understood pathology
What are the symptoms of hyperprolactinemia?
Discharge from nipples Ammenorrhea Erectile dysfunction Infertility Osteoporosis - especially in postmenopausal women Delayed puberty in teen Gynecomastia
Signs and symptoms of the underlying cause:
- CKD
- Hypothyroidism etc
What investigations are warranted into hyperprolactinemia?
Repeats of prolactin level
Hypothyroidism analysis
Pituitary functioning
MRI of head
Target blood sugar levels of diabetic?
4 - 7
below 4 you hit the floor above 7 you go to heaven
Name some causes of primary gonadal- deficiency and what are the typical symptoms?
Orchiectomy Radiation Testicular torsion Klinefelter's syndrome CKD Cirrhosis
Reduced libido
Erectile dysfunction
Loss of secondary sexual characteristics - hair/ Muscle
Gynecomastia
How can you differentiate between primary and secondary hypogonadism?
Measure LH and FSH
What are the symptoms of thyrotoxic storm:
Fever Tachycardia Hypertension Diarrhea Heart failure Abnormal LFTs
