Endocrine Flashcards
Graves’ disease triad
Goitre Eye signs Thyrotoxicosis
Test for lid retraction
Visible white below eyelid Move finger up and quickly down, lid lags behind
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)
Graves eye signs
Oedema (periorbital and chemists) Pronto sis (best assessed from side) Retraction (autonomically mediated) Exposure keratopathy Opthalmoplegia (upgaze palsy)
Graves treatment
Carbimazole low dose- 18 months- agranulocytosis 1/20 get a rash Treat and block- carbimazole and iodine Surgery Radioiodine
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
Features of cushing’s Syndrome
Cushing’s general examination
truncal obesity
moon face
supraclavicular fat pads
stooped posture- kyphosis
evidence of RA, asthma, A-V fistula—> steroids
Cushing’s hands and arms
Bruising
Decreased skin fold thickness
BP- high
shoulder abduction- myopathy
Facial features cushings
Cushing’s abdomen and legs
purple striae- underlying muscle
renal Transplant scar
stand from chair
leg ulcers
Extras in Cushing exam
palpate spine for tenderness- osteoporosis
interscapular fat pad
dip urine/ bedside BM
check visual fields- rare defects
General things to look out for in cushings
SWEDISH
Spinal tenderness
Weight- central obesity
Easy bruising
Diabetes
Interscapular fat pad
Striae
Hypertension
How to screen for hypercortisolaemia
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)
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
BP
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
