endocrine Flashcards
Addison and SIADH pathophysiology
Na/K exchange in the distal tubule in kidney leading to Na loss in the urine (high urine Na) and also hyperkalemia. This is due to aldosterone deficiency secondary to adrenal insufficiency. confirmed with synacthen test and will see no increase in cortisol after admin of ACTH.
appearance of a sudden midline lump
acute haemorrhage into o a thyroid cyst or a fast growing thyroid carcinoma (anaplastic) subacute thyrioditis
anaplastic carcinoma can cause what symptom?
vagus nerve involvement can cause ear pain.
midline neck lump goitre - ask about what symptoms?
pressure- stridor, dyspnoea, dysphagia, and changes in voice quality
type 1 diabetes, pernicious anemia, and addison’s disease are associated with what 2 thyriod disorders?
graves and Hashimoto’s thyroiditis
risk factors for thyriod malignancy
previous radiation to the neck hodgkins lymphoma for papillary gland carcinoma. (papillary thyriod carcinoma)
hereditary forms of thryiod carcinoma
familial medullary thryiod carcinoma
simple investigations for a nodule on the thyroid
bloods: TSH, free tri-iodothyronine (T3) and free thyroxine (T4),
thyroid peroxidase antibodies serum calcitonin
if the TSH is low what is that consistant with?
hyperthyriodism (if thyriod issue)
What is a high TSH consistent with?
hypothyroidism
if the TSH is high what other test may you consider?
thyroid peroxidase antibodies for hashimotos
is the TSH is low what test would you consider next?
free tri-iodothyronine and free thyroxine (T4)
what if there is a significant family history fo thyriod cancer?
serum calcitonin also if (MEN 2 positivity) MTC is a tumour of the calcitonin secreting parafollicular C cells.
Take me through what you would do for investigations in a man or woman with a single nodule on the thyroid
- fine needle aspiration (US guided to determine if solid, cystic or mixed- solid and mixed higher chance of malignancy)
- can give radionuclide scanning to determine whether the nodule is functioning or non-functioning (hot nodules are almost always benign) 5-20% of cold are malignant
- MRI and CT not routinely used unless (retrosternal goitre, invasive tumours, and heamoptysis)
How are the results reported in a fine needle biopsy?
They are reported in 5 stages:
- not enough aspirate to make a diagnosis
- benign
- follicular lesion
- suspicious of malignancy
- confirmed malignancy
What are the limitations of the fine needle aspiration?
it cannot distinguish between a follicular adenoma that is bending vs. malignant there needs to be a histological diagnosis to make final decision.
What is the treatment for a patient who is suspected to have thyroid carcinoma?
- surgery separated into high and low risk (lobectomy vs near total thyroidectomy)
- T3 replacement
- 13I ablation (for those patients who have undergone total or near total thyroidectomy)
- T4 suppression
- follow-up TSH and TG
determining whether or not a patient is high or low risk for thyriod carcinoma?
age, being male, poorly differentiated histological features, tumour size greater than 4 cm, extrathyriodal invasion, and metastatic spread.
treatment to remove a thyroglossal cyst
sistrunk’s procedure
to eliminate small chance of carcinoma in the cyst
to eliminate chance of further infection
cosmesis
what is the the treatment for graves’ disease
- anti-thyroid medication: carbimazole and propylthiouracil (for up to 18 months) if this remits
- radio-active iodine or surgery
- symptomatic relief- B blockers negative ionotrope to slow down great rate
- radioactive iodine (131 i) graves eye disease relative contraindication. avoid pregnancy 6 months after, household contacts need to take precautions for 2 weeks
- total thyriodectomy then given levo thyroxine
What are the MEN syndromes?
AD, 1 (Ps) parathyroid (hyperplasia, adenoma) pituitary (prolactinoma or growth secreting tumour) and pancreas (insulinoma, gastrinoma, non-functioning) 2A (TAP) thyroid (MTC) adrenal hyperplasia (pheaochromocytoma) Parathyroid (hyperplasia or adenoma) 2B (bath MAT) Mucutaneaous neuroma adrenal (pheochromcytoma) Thyriod (MTC)
what are the types of thyriod neoplasms?
papillary 60% follicular 25% medullary 5% lymphoma 5% anaplastic (worse prognosis but rare) mets
indication for prophylactic thyriodectomy
Men 2a before 5
MEN 2B before 1 year
FMTC after 10 years
complications of thyroidectomy
- recurrent laryngeal nerve 1:100
- superior laryngeal nerve- shouting and singing
- transient voice change
- hypoparathryoid
- hyperthyroid storm
- post op haemorrhage
general complication - anaesthetic risk
- thromboembolism
- infection
- scarring
ddx for a breast lump in a less than 30 yo
physiological normal lumpy breast benign cystic change fibroadenoma abcess galactocele
breast lump in a 35-45 year old
benign cystic change cyst abcess carcinoma
breast lump 45-60
cyst abcess (in smokers) ca
greater than 60 yo breast lump
carcinoma
risk of developing a fibroadenoma
highest in early 20s
risk of developing benign cystic change
35-45 years old
risk of developing a cyst in breast
around 55
risk of developing a breast Ca
increases exponentially after 50
what is a galactocele
develops during or shortly after lactation mass (most often subareloar) caused by obstructino fo the lactiferous duct. duct becomes distended with milk and epithelial cells
common organism mastitis
S aureus and staph epidermidis
breast lump triple assessment
- clinical examination
- radiological examination
- fine needle aspiration or a core biopsy
treatment for a fibroadenoma
conservative
non-conservative surgical excision indications are patient preference, lump that is proven to be increasing in size due to US scanning confirmation or clinical confirmation or a lump that is causing discomfort.
after confirmation of breast carcinoma on triple assessment what other further investigations are you going to do
breast ca commonly metastases to the liver, lung, bone and brain therefore the patient should have a
CT abdomen
axial skeleton CT
if signs of chest pathology CT chest
CT brain if focal neurological signs of raised inter-cranial pressure or seizures
treatment options for breast ca
local: surgery and radiotherapy
systemic: chemotherapy, hormonal therapy, monoclonal antibodies (herceptin)
if ER or PR positive then given hormonal therapy
breast abcess treatment
(breast abcess irregular firm mass that is tethered with fever and erythema) started on appropriate antibiotic cover and will have to have referral to surgeons for aspiration. Residual solid lump will need triple assessment.
what will a cyst appear like on Us?
hypoechoic mass
causes of gyncomastia in males
liver disease
drugs (cimetidine, spirolactone, phenothiazine, finasteride, anabolic steroids)
primary testicular failure (an orchid, bilateral cryptorchidism)
acquired testicular failure (mumps orchitis)
secondary testicular failure (panhypopituitarism)
endocrine tumours (testicular, adrenal, pituitary)
non-endocrine tumours (bronchial carcinoma)
what factors determine the prognosis with breast cancer
tumour staging tumour grading hormone receptor status tumour type (lobar or ductal) patient age treatment type
what is the difference between skin fixity and skin tethering?
skin- cannot be moved independent of the overlying skin
if the lesion is tethered to the skin it can somewhat be moved independly of the skin.
difference between adjuvant and neo-adjuvant therapy
adjuvant is used after surgery in order to treat any micro-mets
neo=adjuvant is used before surgery in order to decrease the size of the primary tumour as well as minimising the tumour burden.
what is the way to organise the finding of breast cancer in one acronym?
P- physical examination R- radiological exam C- cytology B- biopsy then number it 1: normal 2: benign 3: probably benign 4: probably malignant 5: malignant
ddx for a breast lump in a less than 30 yo
physiological normal lumpy breast benign cystic change fibroadenoma abcess galactocele
breast lump in a 35-45 year old
benign cystic change cyst abcess carcinoma
breast lump 45-60
cyst abcess (in smokers) ca
greater than 60 yo breast lump
carcinoma
risk of developing a fibroadenoma
highest in early 20s
risk of developing benign cystic change
35-45 years old
risk of developing a cyst in breast
around 55
risk of developing a breast Ca
increases exponentially after 50
what is a galactocele
develops during or shortly after lactation mass (most often subareloar) caused by obstructino fo the lactiferous duct. duct becomes distended with milk and epithelial cells
common organism mastitis
S aureus and staph epidermidis
What about the PSA test for screening?
only useful for patients that are symptomatic (prostatism and bone pain)
yes if the PSA is greater than 10 ng/ml
no if PSA is between 3-10 unnecessary worry
what is the treatment for in situ low risk prostate ca
active surveillance
alt- radical treatment (prostatectomy or radial therapy with hormonal treatment
in situ intermediate risk prostate ca treatment
radical treatment (prostatectomy or radiotherapy with hormonal therapy)
in situ high risk prostate ca
radical treatment if realistic prospect of long term disease control
locally invasive prostate ca
radical treatment plus or minus pelvic radiotherapy
met prostatic ca
bilateral orchidectomy or hormonal therapy
alt Docetaxel, dexamethasone
palliative care
What is low risk prostate ca defined by
PSA less than 10 and a gleason score of less than 6 and clinical staging T1-T2a
What is intermediate risk prostate ca defined by?
PSA 10-20 or a gleasons score of 7 or clinical staging T2b
What is the high risk prostate ca defined as?
PSA greater than 20 or a gleasons score of 8-10 or clinical stage T2c- T4
what is the definition of polyuria
increased amounts of urination volumes greater than 3 L in 24 hours
urine osmolarity in polyuria explain what it help to differentiate
hyperosmolar kidney having trouble reasoning solutes like glucose or urea * greater than 300 mOsm
hyposmoolar urine due to distal tubule pathology or deficient ADH low urine mOsm (less than 250)
what e- in excess can cause polydipsia?
Ca
what are the two subtypes of diabetes incipidus?
cranial (problems in the hypothalamic pathway and ADH secretion is either reduced or absent) causes- mets, head injury, pit tumours, vascaulr lesion and meningitis.
nephrogenic- less sensitive to ADH do not respond to signals to concentrate the urine *renal damage low K high ca, lithium, pyelonephritis or hydronephrosis
what is the water deprivation test?
used to distinguish between a nephrogenic or cranial cause to diabete incipidus . Normal response is increased ADH from the pit
if desmopressin given an ADH analogue if the proble is central the patients will be able to once again concentrate urine.
Before you have to confirm polyuria by 24 hour urine collection of greater than 3 L risk of hypovolemia.
what is the treatment for cranial diabetes incipidus
- MRI to rule out cranial pathology
2. replacement of ADH.
In an elderly patient with polydipsia what should you do?
rule out hypercalcemia due to bone mets
FBC- anemia
LFT- alk phos increased bone mets but not multiple myeloma
serum and urine electrophoresis- paraprotien in MM
lumbar radiograph- bone mets causing pain.
what is the pathology of HHS * hyperosmolar hyperglycaemia state
This is a complication of type 2 diabetes
- fluid shift from the extravascular to the intravascular compartment causing cellular hypovolemia
- osmotic diuresis hypovolaemia.
