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RCSI Medicine > Endocrine > Flashcards

Endocrine Flashcards

1
Q

How to Dx. Di

A
  1. 8 hwater deprivation test
    Normal > 600mmols/l
    DI - <300 mmil/l
  2. Desmopressin 2 mg IM IV
    Central - > 800 mmols/l
    Nephrogenic - no correction
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2
Q

What is the plasma and urine osmolarity in DI

A

plasma osmolarity is HGIH

urine osmolarity LOW

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3
Q

Na levels in DI and clinical findings

A

HYPERNATREMIA

  • lethargy
  • confusion
  • coma
  • fits
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4
Q

Ddx DI

A 
DM 
polyuria 
psychological 
DIURETICS 
LITHIUM 
PROSTATIC HYPERTROPHY
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5
Q

Screening for cause DI

A

Centra: MRI and pituitary function test

Nephroenic

  • U/E
  • Calcium
  • Renal ULTRASOUND
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6
Q

Treatment for DI

A

Centra - mild - increase fluid intake
moderate- desmopressin and DDAVP (at lowest dose to control symp)

Nephrogenic - tx underlying disease
Diuretics - BENDOFLUMETHIAZIDE and NSAIS (prostaglandin inhibits Na )

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7
Q

side effect DDAP

A

can worsen MI in susceptible patients

Hyponatremia

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8
Q

untreated DI

A

hypernatremia
CV collapse
dehydrate
death

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9
Q

complications of acromegaly

vle

A 
Heart : HTn , CM , LVH , HF 
Pancreas: DM
Lungs: sleep apnea , pulm HTN 
Arthritis 
Neuro - HEADACHE , cerebral vascular events 
MISCILLANEOUS 
- carpal tunnel 
- colon polyps/ Ca 
Hypopituitarism 
Pyperprolactinemia 
Carpel tunnel
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10
Q

DI screening test

A

Elevated serum IGF-1 levels

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11
Q

DI diagnostic test

A

OGTT
GH is normally inhibited by glucose
2 baseline GH levels after fasting for 8 hours
Ingestion of 75g of oral glucose
GH measurement at 30, 60, 90, 120mins post oral glucose load
Active acromegaly

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12
Q

Di cause tests

A

Pituitary Anatomy
MRI pituitary: show micro or macro adenoma

CT scan: thorax, abdomen, pelvis
Non-endocrine tumours / ectopic GH secretion

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13
Q

Screening complications

A

Anterior pituitary function tests:
Decreased Serum TSH ACTH and Cortisol
Reduced Serum LHRH, LH, FSH, testosterone
Raised Serum prolactin

ECG . BP, CXR - heart failure signs cardiomegaly
Sleep studies (sleep apnea)
CoLONSCOPY
DM - screen

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14
Q

dx test chushings

A

Random cortisol (not helpful usually as peaks & troughs throughout day & varies due to stress, illness,etc)

24 hour urinary free cortisol: HIGH
Midnight cortisol- high

Overnight dexamethasone suppression test
- 1mg dexamethasone at midnight
do cortisol level at 8am - normal should decrease if not low then CS

24 hour dexamethasone suppression test

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15
Q

Screening for cushing cause

A

Where is the lesion?
Plasma ACTH: If undetectable- likely adrenal cause → CT adrenal

Plasma ACTH: if detectable-
Do corticotrophin releasing test
Cortisol rises - pituitary cause – > BRAIN MRI then inferior petrosal sinus sample
ectopic ACTH does’t else

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16
Q

riASeD BP and hypokalemia

A

Primary hypoaldosteronism

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17
Q

treatment Conns

A

Treat underlying cause
Hypokalaemia: IV potassium replacement via slow infusion
Conn’s syndrome:
Laparoscopic adrenalectomy
Spironolactone for 4 weeks pre-op for BP & K+ control
Hyperplasia
Treat medically with aldosterone antagonists e.g. spironolactone, eplerenone, amiloride
Complications & prognosis
Depends on the cause

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18
Q

lab for primary vs secondary hyperaldosteronism

A

primary - low RAS, high aldosterone

secondary - low renal perfusion so HIGH renin

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19
Q

short synacten test

A

Do plasma cortisol beofre & 30 mins after giving tetracosactide
(Synacthen 250 μg) IM
Addison’s is excluded if 30minute cortisol is >550nmol/L
( steroid drugs may interfer with this assay)

Synacthen = ACTH

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20
Q

hyponatremia symptoms

A 
Na <135 
Brain - headache, confusion 
Falls, coma,deep somnolence and seizure 
Cardioresp distress 
N V anorexia
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21
Q

hyponatremia screening for cause

A
  • U&E
  • Serum & urine osmolality
  • Urinary sodium
  • glucose (High sugar - pseudohyponatraemia (add approx. 4.3mmol/L to plasma Na + for every 10mmol/l rise in glucose above normal)
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22
Q

isotonic hyponatremia

A

hyperproteinemia

Hyperlipidemia

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23
Q

Hypertonic hypoglcyemia

A

hyperglycaemia
mannitol, orbital, glycerol, maltase
radiocontrast agents

isotonic - serum osmolarity - 280-295 mosm/kg

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24
Q

hypotonic hypovolemic hyponatremia

A

UNa<10

  • dehydration
  • diarrhea
  • vomitting
UNa > 20 
(reduced salt loses) 
- Diuretics 
- ACE inhibitors 
- Nephropathesis 
- Mineralocorticoids deficiency 
- cerebral sodium wasting syndrome
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25
Q

hypotonic euvolemic hyponatremia

A
  1. SIADH
  2. Post op hyponatremia
  3. Hypothyroidism
  4. Psychogenic polydipsia
  5. Beer potornania
  6. Drugs - diuretics, thiazide, ace -
  7. Edurance exercise
  8. adrenocorticotropin deficiency
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26
Q

hypotonic hypervolemia hyponatremia

A

OEDEMATOUS STATES

  • CCF
  • liver disease
  • Nephrotic syndrome
  • Advanced kidney disease
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27
Q

correction hyponatremia

A

hypervolemia or euvolemic - fluid restrict, water intake < 1.5

hypovolemic - give them normal saline or RINGERS

with hyponatraemia with moderate &severe symptoms, 3% saline( usually 150mls

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28
Q

How to correct low Na

A
  • Na+ at 0.5mmol / h

Not more than 12 -16 h or 0.5 - 1.0mmol per hour

Correct slowly to prevent osmotic demyelination

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29
Q

Hypernatremia vulnerable groups

A

elderly
confused,
children
unconscious

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30
Q

screen for cause HYPERNATREMIA

A

Serum osmolality ( hyperosmolar in hypernatraemia)

Urine osmolality
Low: often have Diabetes insipidus - see DI lecture
High: unreplaced GI, renal, or insensible losses or osmotic diuresis

Check glucose (to look for uncontrolled diabetes as a cause)

Urinary sodium

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31
Q

Serum and urine osmolarity in DI and SIADH

A

DI

  • low urine osmolality (can’t concentrate urine - therefore low solutes in urine)
  • High serum osmolality

SIADH

  • high urine osmolality
  • low serum osmolality
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32
Q

treatment of hypernatremia

A

h2O orally

- give IV fluids slowly to prevent cerebral oedema

33
Q

Ecg HYPERKALEMIA

A

all tented T waves, small p waves,
widened QRS- eventually becoming sinusoidal &
leading to ventricular fibrillation

34
Q

Treatment HyperKalemia - URGENT (K>6)

A

10ml calcium gluconate IV (
Insulin- dextrose e.g. 5-10 units actrapid in 50mls of 50% Dextrose IV
Nebulised salbutamol 2.5-5mg neb stat
Patients in renal failure with hyperkalaemia - dialysis

35
Q

Non urget Treatment HyperKalemia

A

find the cause
- Polystrene sulfonate resin (e.g. Calcium reosnium 15 g/ po tds) can be used as it binds K+ in the gut , bringing down K+ levels over a few days.

36
Q

Causes of HYPOKALEMIA

A

Vomiting/ nasogastric suction
Diarrhoea
Intestinal fistula
Ileostomy
Rectal villous adenoma
Renal tubular failure/ other renal losses
Medications e.g. Diuretic therapy, salbutamol
Cushing’s syndrome/ Conn’s syndrome
Alkalosis
Bowel cleansing pre-colonoscopy preparations/ laxatives
Osmotic diuresis

37
Q

Clinical Hypokalemia

A 
Usually asymptomatic
Muscle weakness
Hypotonia
Hyporeflexia
Cramps
Tetany
Palpitations
Light-headedness (arrhythmia)
38
Q

Complication of hypokalemia

A

Arrhythmia
paralysis
rhabdomyolysis
diaphragmatic weakness

39
Q

ECG hypokalemia

A 
U wAVE 
decreased T waves
ST segment depression
PR interval prolongation 
QRS prolongation
40
Q

TREATMENT hypokalemia

A

MILD-MOD
10-20kcl ORAL given 2-4 times a day

SEVERE
IV 20-40 KCL in 1 L of normal saline over 6-8 hours

41
Q

Max rate of infusion for K+

A

10-20 mmol/h

42
Q

hypomagnesium cause

A 
Severe diarrhoea
Alcohol misuse
Diuretics
Total parenteral nutrition
Renal tubular acidosis
Malabsorption/ malnutrition
Diabetic ketoacidosis
43
Q

if you correct K too fast what can happen

A

Cardiac arrest

44
Q

treatment hypomagnesium

A

Mil - oral Mg

Severe - IV Mg sulfate in a solution of normal saline or dextrose

45
Q

Clinical hypomagnesium

A 
Asymptomatic
Paraesthesia
Ataxia
Seizures
Arrhythmias
Tremor
Tetany
46
Q

treatment of hypercalemia

A

IV saline administration (watch for fluid overload)
Bisphosphonates (inhibit osteoclasts e.g. IV zolendronic acid
SE: Flu like illness, osteonecrosis of jaw, bone pain, hypocalcaemia)
Calcitonin
Steroids: used in hypercalcaemia associated with sarcoidosis

47
Q

treatment of hypercalcemia

A

Mild - ORAL vit D and calcium
- if no response on oral switch to UV

Severe- 10ml of 10% calcium glucoronate

Correct Mg if low

48
Q

what type of calcium do you use in CKD

A

Calcitriol (this is the active form and therefore prevents the kidney from activating it

49
Q

hypoglycaemia definition

A 
low blood surgery when level drops < 3.9 mmol/L 
It consistent Whipple's train 
- symptoms consistent hypoglycaemia 
measurement low plasma glucose 
relief of symptoms after plasma glucose
50
Q

Treatment

A

15-20mg fast acting carb

  • dextrose, lucosade(100mls), sweetened fruit juice
  • glucotabs - 4g each so 4-5 chewable ones

If severe with coma or confusion
- At home - IM glucagon 1mg
- Inhospital - 50% dextrose 50mls IV
200-300 of 10% dextrose IV

51
Q

2 dynamic function test for evaluating HYPOpituitarism

A

Growth hormone deficiency testing:

1) Insulin induced hypoglycaemia test- risk of seizures/ angina/ hypoglycaemia/adrenal crisis.
2) Arginine & growth hormone releasing hormone test

ACTH deficiency testing:

1) Short synacthen test to assess adrenal axis
2) Cosyntropin/ rapid ACTH stimulation test

52
Q

pheochromocytoma 10% rule

A

10% are malignant
10% are extra- adrenal
10% bilateral
10% familial

MEBF

53
Q

biochemical test for phaeochormocytoma

A

24hour urinary testing VMA, catecholamines or metenephrines ( most sensitive)
- repeat urinary testing x 3 (episodic)

Plasma catecholamines & metenephrines

54
Q

Images for phaeochormocytoma

A

MRI ( T2 weighted ) with gadolinium contrast

CT with contrast

Nuclear imaging with radioactive tracer can also be used e.g PET, MIBG scan

55
Q

subclinical hypothryodisim

A 
TSH mildly increase , T3 and T4 normal 
ONLY TX 
Reasons to treat
1.  Risk to become clinical
     - previous Graves/ autoimmune 
      - positive thyroid antibody 
     - goitre 
2. Hyperlipidaemia
3.  atherosclerosis
4. Pregnancy  or trying
5. Reduce quality of life if symptomatic
6. TSH >10
56
Q

acute thyroiditis

A

HIGH ESR

TENDER THYROID

57
Q

Most common cause of hypothyroidism and how to distinguish

A

Hashimotos thyroidisim
- HIGH ANTIBODIES TITERS
anti-thyroids peroxidase antibodies (anti TPO)
anti-thyroidgnobulin antibodies

58
Q

treatment hypothyroidism

A

Start 50-100 mcg per day
increase 25-50mcg in increments by 4-6 weeks until TSH stable

ONCE stable monitor in 6-12 months

59
Q

treatment of hypothyroidism in elderly and ischemic heart disease

A

Caution in
Start at 25micrograms daily & adjust slowly in 4 weekly increments of 25 micrograms ( risk of precipitating angina or myocardial infarction)

60
Q

Drug that interfere with absorption

with thyroxine absorption

A

AFFECTS ABSORPTION
Antacids (aluminum containing)
Iron tables
Calcium tablets

INCREASES METABLOSIM

  • anti-epileptic
  • Rifampin
61
Q

complication of hypothyroidism

A 
Myxoedema coma
Ischaemic heart disease
Weight gain/ obesity
Rare neurologic problems include reversible cerebellar ataxia, dementia, psychosis, and myxedema coma. 
Hashimoto's encephalopathy
62
Q

important additional test to get any female elderly with hypothyroidism

A
  • DEXA
63
Q

risk factors and pathogenesis for thyroid eye disease and findings

A

SMOKING

  • exopthalmous
  • ptosis
  • conjunctival edema
  • ophthalmoplegia
  • papillodema
  • loss of colour vision

RETRO - orbital inflammation and lymphocyte inflammation results in swelling of orbit

64
Q

Jod Basedow presentation

A

hyperthyroidism following administration of iodine

65
Q

causes of hyperthyroidism

A 
Graves’ disease ( 60-80% of cases)
Toxic multi-nodular goitre
Solitary toxic thyroid nodule
Thyroiditis (Hashimoto’s; deQuervains)
Post-partum thyroiditis
Ectopic thyroid tissue eg. metastatic follicular thyroid cancer, struma ovarii 
Medications eg amiodarone, l-thyroxine excess
Jod-Basedow phenomenon
66
Q

pretibial myexedema and exophthalmus in hyperthryoidism

A

DUE to TSH receptor - fibroblast behind the eye and skin have TSH receptors therefore glycoamminoglycans “DOUGH like apperenace”

67
Q

antibody in hyperthyroidism

A 
TSH receptor antibodies (graves) 
antithyroid peroxidase (autoimmune)
68
Q

Treatment of Graves

A
  1. Beta blockers - symptoms
  2. Carbimazole or Propylthiouracil (PTU)
  3. Radio-iodine
  4. Surgery
    - obstructive goitre
    - contraindication to RAI
69
Q

what precaution do u have to tell patients who start Carbimazole

A

STOP medication if they get a sore throat or mouth ulcers

- b.c can can agranulocytosis

70
Q

treatment for thyroiditis

A 
Analgesia- NSAIDS 
Beta-blockers
Steroids (taper over 2 weeks)
L- thyroxine --> if become hypothyroid
Monitor TFT’s closely- every 2-4 weeks until normalise
71
Q

reason to treat subclinical hyperthyroidism

A 
Atrial fibrillation 
Osteoporosis
Increased cardiovascular disease risk
Progression to clinical hyperthyroidism
Multi nodular Goitre
72
Q

complications of hyperthyroidism

A 
Atrial fibrillation
Heart failure
Angina 
Osteoporosis
Ophthlamopathy
Oligomenorrhoea/ amenorrhoea
Gynaecomastia
73
Q

success rate of RAI

A

10-205 FAIL frist time and require a 2nd dose

74
Q

Dx of T1DM

A

Fasting Plasma Glucose > 7.0 mmol/l ⃰ Fasting is defined as no caloric intake for at least 8 hours
Plasma glucose > 11.1 mmol/l two hours following Oral Glucose Tolerance Test. (OGTT) ⃰
Random plasma glucose >11.1 mmol/l ( in symptomatic patient)
HBA1C > 48 mmol/mol. ( >6.5%) ⃰

75
Q

antibodies in islet cell

A

AntiGAD

isle cell antibody

76
Q

blood target levels for t1DM

A

FBG: 5-7 mmol/litre
PG: 4-7 mmol/litre before meals
PG: 5-9 mmol/litre at least 90 minutes after eating

HbA1C: <6.5%

77
Q

patient suffering from depression constipation and a pain in his back

A

think hypercalemia

- measure serum Calcium levels

78
Q

22 year old complains of dizziness and feeling light headed when she stands up to go to the toilet , she noticed her scar is much darker

A

THINK ADDISONS disease
- SYNACTHEN TEST
you inject synacthen (ACTH) and you would expect their to be an increase cortisol

RCSI Medicine (6 decks)

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