Endocrine Flashcards
What is a type of subacute thyroiditis and list some clinical features of it and a key differential finding:
De
Quervain’s syndrome.
- where a viral infection leads to a period of approximately 3 weeks of hyperthyroidism followed by hypothyroidism.
Clinical features:
- Painful goitre
- raised ESR
Differential finding:
- globally reduced radio-isotope uptake
Managed:
- NSAIDS
- Steroids in severe cases of hypothyroidism
If a low dose and high dose dexamethasone test is carried out, and only the high dose suppresses the cortisol production, where is the likely pathology?
High dexamethasone supression which supresses cortisol is likely a pituitary tumour.
if a person has cushing’s syndrome and the initial tests reviel a high ACTH, What tests can be done to help localise the source of ACTH and why is this important?
It is important to localise the source as it may be a malignant tumour releasing ACTH.
Pituitary tumours (Cushing’s disease) respond to manipulation, i.e. will increase, decrease the level of ACTH and thus cortisol. Malignant tumours will not.
therefore:
CRH test can be done. if the cortisol levels increase it is likely a pituitary tumour.
A high dose dexamethasone test can also be done. if this suppresses the levels it is likely a pituitary tumour.
if there is no change then malignancy should be suspected and following test:
- CT chest/ abdo/ pelvis
should be carried out
An elevated TSH with a normal range T4 indicates what?
Subclinical hypothyroidism
If a postmenopausal woman has a fracture but has normal range calcium, what treatment should they recieve?
Calcium supplements
+
Bisphosphonates
If there is evidence of primary hyperparathyroidism, what should the next line investigations/ management be?
exploration and parathyroidectomy
What are some treatments for acromegaly and what is first line?
Transsphenoidal removal of tumour is first line.
Somatostatin analogues
- Octreotide
GH antagonists
- Pegvisomant
Dopamine agonists
Which diabetic medication is associated with an increase risk of bladder cancer?
Thiozolidinediones
If a patient is diagnosed with thyroid cancer and has an elevated calcitonin level, what is the likely tumour and what is it associated with?
Medullary thyroid cancer
MEN -2
What is the triad of diseases often seen with addison’s disease?
Type 1 DM
Thyroiditis
Addison’s
What is a major complication of Meningitis that causes adrenal insufficiency which can be fatal?
Waterhouse - Friderichsen syndrome
- massive intra-adrenal haemorrhage that leads to loss of adrenal functioning causing hypotension and loss of fluid reabsorption
What are the symptoms of addison?
Hypotension Reduced mood Nausea and vomiting Abdominal pain Pigemented mucosa and palmer Abnormal salt cravings
What investigations should be done into suspected adrenal insufficiency?
U&Es
- Low Na2+
- High k+
Blood glucose
- low
Plasma cortisol levels
Short SynATCHen test
- measure 30 mins later.
- <450nmol/L is diagnostic
What are the differentials to addison’s disease?
Iatrogenic corticosteroid suppression
Anorexia nervosa
Occult malignancy
What is the treatment for addison’s and what advice must be given?
Hydrocortisone daily ~15-25mg - 2-3 times daily \+ Fludrocortisone - to replace mineralocorticoids
- wear a steroid bracelet
- add 5-10mg during strenuous activity
- double steroids in febrile or illness
- have syringes present in case of vomiting and unable to take steroid
If a person presents with an addisonian crisis, what is the management?
Treat before results are in, as this can be lethal
- IV hydrocortisone
- IV bolus of fluids
- glucose
monitor K+ levels and supply calcium gluconate if needed
What are the causes of cushing’s syndrome?
Iatrogenic use of steroids
Pituitary tumour
Adrenal tumour
Paraneoplastic
What other investigations other than measuring the cortisol levels and performing the dexamethasone supression test should you do in cushing’s syndrome?
Chest x-ray
- lung cancer
head MRI
Abdominal CT
- adenoma tumours
What may give falsely elevated HbA1c levels?
Increased life span of RBCs
- splenectomy
What is first line treatment for prolactinomas?
Bromocriptine - dopamine agonist
In hypopituitarism, what is a gold standard investigation to adrenal and GH axis?
Insulin tolerance test
- insulin is given to induce severe hypoglycaemia which in a normal axis will induce stress and cause the release of GH and ACTH.
An insufficient rise of cortisol and GH will demonstrate hypopituitarism
What is MEN -1?
3 P's: - Parathyroid tumours - Pituitary tumours - Pancreas tumours \+ adrenal and thyroid
What is MEN - 2?
MEN 2a:
2’Ps
- Parathyroid (medullary) tumour
- Pheochromocytoma
MEN 2b: 1 P - Pheochromocytoma \+ Neuromas - schwann cell neuromas
What is the diagnostic criteria for DM type II?
Symptomatic: - symptoms \+ - fasting glucose >7mmol/L - OGTT/ random test of >11.1mmol/L - HbA1c >48 (6.5%)
Asymptomatic:
Need to abnormal results separated in time
When should an additional drug be added onto the treatemnt of DMT2?
> 58mmol/L on HbA1c
What are the core symptoms to acromegaly?
Coarse facial features/ increased hands Interdental spacing large tongue Excessive sweating / oily skin Raised prolactin
What are the broad causes of hypopituitarism?
Hypothalamic dysfunction
- Kallmann’s syndrome
- Tumour
- infection
Pituitary stalk:
- Trauma
- Surgery
- Craniopharyngioma
Pituitary gland:
- adenoma
- Pituitary apoplexy - bleeding/ infarction
- infarction - Sheehan Syndrome
- prolactinomas
- irradiation
How do you assess hypopituitarism?
Baseline of Hormones
- usually done in morning but GH and ACTH vary
Insulin Tolerance Test
MRI of brain
If a person is in hospital and has:
- normal TSH
- Normal/ low T4
- Low T3
what do they have?
Euothyroid sick syndrome
which does not produce symptoms of hypothyroidism
What is metabolic syndrome:
Obesity (BMI >30) \+ any 2 of the following: - High BP - High triglycerides - High HDLs - HIgh glucose
What is the definition of microalbuminuria that occurs in the DM? What management should be done?
This is when the urine dipstick is negative, but the Albumin: creatinine ratio is >3.
When this occurs all patients with it should be placed on an ACE - regardless of BP status as it helps protect the kidneys
What are the underlying mechanisms that lead to retinopathy in DM patients?
Diabetic Retinopathy is the number 1 cause of blindness in the world.
- Increased blood flow in the small vessels
- damages the vessels - Oxidative stress
- reduced NADPH via the sorbitol pathway - AGE products
- Neovascularization - leaky vessels
- which occurs due to ischemia induced by microthrombus and fluid shifts
What changes can you see during the process of diabetic retinopathy:
Non - proliferative:
- microaneurysm - dots
- micro haemorroghes - blots
- Lipid deposits - hard exudates
Pre - proliferative:
- infarcts - cotton wool dots
Proliferative:
- neo-vascularisation
What treatments can be done for diabetic retinopathy?
Good glycaemic control
smoking cessation
Annual Diabetic screen
Proliferative:
- pan retinal photo coagulation
- VEGF
What is a major complication of the daibetic neuropathic foot?
Charcot’s Joints
- requires bed rest and non- contact cast to prevent further damage.
What type of diabetic neuropathies can occur?
Poly peripheral neuropathies
Mononeuritis multiplex
- usually cranial nerves
Amyotrophy
- painful wasting of quads and pelvic muscles
Autonomic dysfunction
- erectile dysfunction
- gastroparesis
- orthostatic hypotension
What is the main known risk factor for thyroid eye disease?
Smoking
What are the risk factors for gestational diabetes?
Previous Gestational Diabetes Obesity >35 year old pregnancy Family history of Gestational diabetes South Asian
What are the cutt off’s for gestational diabetes?
Fasting: >5.6mmol
OGTT: >7.8mmol
What are some complications of gestational to the mother?
• Hypertensive disorders
• Caesarean
• Future risk of DM type II
Trauma to the genitals of the mother during birth
What are some complications to the child if there is gestational diabetes?
Shoulder dystonia
Baby hypoglycaemia
Childhood obesity
What are the risk factors for Grave’s disease?
Female
Smoking
Viral infections
Pregnancy
If there is Low TSH and high T4 T3, what does this suggest?
Subclinical hyperthyroidism
Which patient set should be screened regularly for thyroid dysfunction?
AF patients Hyperlipidaemia patients - 15% can have hypo DM Amiodarone and Lithium patients Down's syndrome
What are the complications of hyperthyroidism?
Heart failure - thyrotoxic cardiomyopathy
Angina
AF
Osteoporosis
Thyroid storm
What are the two medical strategies used in hyperthyroidism?
Block and replace
- give carbimazole + levothyroxine at same time
Titration
- carbimazole and slowly reduce dose
1/3rd will relapse
+ beta blockers which are non centrally acting i.e.
propranolol
What are the signs of hypothyroidism?
BRADYCARDIC
- Bradycardia
- Reflexes slow
- Ataxia
- Dry thin skin
- Yawning/ drowsy/ coma
- Cold hands
- Ascites
- Round puffy face
- Defeated demeanour
- Immobilie/ ileus
- CF - neuropathy
What type of anaemia is typically seen with hypothyroidism?
Macrocytosis
What are the most common causes of hypothyroidism?
World wide: iodine deficiency - will have a goitre
Hashimoto’s disease
Post thyroidectomy
Drug induced
- amiodarone, lithium
Subacte thyroiditis
What are the two most common antibodies in Hashimoto’s disease?
Anti peroxidase
Anti - thyroglobulin
In cretism what is the risk to the child by not getting thyroid hormones?
Mental disability
- needed for normal neurological functioning
Shortened height
delayed physical growth
If there is elevated TSH but normal T3/ T4 with no symptoms, what is this?
Subclinical hypothyroidism
* this should be treated if: TSH>10 Evidence of autoantibodies Previous Graves' other Autoimmune disease
When adjusting a patients levothyroxine how long should you wait before changing, and why? and what is the guidance used?
half life of thyroxine is 7 days so aim for 4 week changes.
Use TSH - don’t want it suppressed but don’t want it high
What must you always consider when a person has been on long term steroids and has been acutely unwell or had surgery, then develops delerium and hypotension ?
Addisonian crisis
- IV hydrocortisone should be given immediately
Name some causes of male hypogonadism:
Reduced Gonadotrophins:
- hypopituitarism
- Kallman’s syndrome
- severe systemic disease
- severe malnourishment
Hyperprolactinaemia
Primary Gonadal disease congenital:
- cryptorchidism
- Klinefelter’s
- 5 alpha reductase deficiency
Primary Gonadal disease acquired:
- testicular torsion
- Orchiectomy
- Orchitis
Androgen receptor defects
List some different types of insulin and their onset:
Rapid acting:
- Novorapid
- Humalog
- within 10mins. Last 4 hours
Short acting:
- Actrapid
- Humulin S
- within 30mins. Last 8 hours
Intermediate Acting:
- NPH
- Humulin I
- within 1 hour. Lasts 16 hours
Long acting:
- Levemir
- Degludec
- Glatamir
- Lantus
- within 1 -6 hours. Lasts 24 hours
Mixes of rapid and intermediate:
- Humalog 25
- Humalog 50
- Novomix
What are the autoantibodies looked for in DM type I?
Anti - Insulin
Anti Islet cell antibodies
Glutamic acid dehydrocaboxalase - GAD
Zinc Transporter 8 - ZnT8
What are the investigations and treatment of PCOS?
Investigations:
- Serum testosterone
- LH/ FSH
- Serum prolactin
- Serum Glucose
- lipids
- ovary ultrasound
Treatment:
- Weight loss
- Metformin
- contraceptive pill
- Spironolactone
- Finiestraite
What viruses have been implicated in T1DM?
Coxsackie B virus
Enterovirus
In type 1 diabetes when should metformin be added?
BMI >25
How long does an Hb1Ac reflect?
3 months
In a patient with suspected acromegaly, outwith blood tests and MRI scanning, what additional investigations should be done?
Echocardiogram
these people are at risk of cardiomyopathy
When is HbA1c of no use?
haemoglobinopathies haemolytic anaemia untreated iron deficiency anaemia suspected gestational diabetes children HIV chronic kidney disease people taking medication that may cause hyperglycaemia (for example corticosteroids)
How is neuropathy managed in diabetic patients:
Painful neuropathy:
- paracetamol
- TCAs
- Gabapentin
Mononeuritis multiplex:
- IV immunoglobulins
- Steroids
Amyotrophy:
- IV immunoglobulins
Autonomic Neuropathy:
- Anti-emetics
- erythromycin
- Gastric pacing
- Fludrocortisone
- Sildenafil
Which anti-thyroid medication can be used in pregnancy?
PTU
Which drugs are used during a thyroid storm?
IV fluids
Propranolol *needs careful use
Antiarrhythmics
- digoxin
Carbimazole
Steroids
- prevents peripheral breakdown
What is the treatment for myxedema coma?
Corticosteroids
+
Levothyroxine
What is first line insulin regimen for newly diagnosed T1DM?
Basal bolus
- long acting twice daily. Detemir advised
What other autoimmune conditions are T1DM at risk off?
Addison’s disease
Pernicious Anaemia
Myasthenia Gravis
Thyroid disease
What is the lifetime risk of developing T2DM if a first degree relative has it?
5-10x
When do you add a second line medication for T2DM patients?
> 7.5%/ 58mmol
What can cause falsely low valves in HbA1c testing?
Haemoglobinopathies
Haemolysis
Chronic Kidney disease
What are the key stages of diabetic retinopathy?
Non-proliferative degeneration
Proliferative degeneration
Diabetic Macular oedema
What are the main risk factors for developing diabetic retinopathy?
Consistently high HbA1c
Hypertension
Hyperlipidaemia
Nephropathy
How is diabetic retinopathy investigated?
Dilated indirect ophthalmoscopy
- conducted in first 5 years of diagnosis for T1DM and immediately following T2DM diagnosis
- annual screening thereafter
Outwith the typical glove and stocking pattern list some other ways diabetic neuropathy can present:
Orthostatic hypotension dizziness Diarrhoea Urinary incontinence Gastroparesis erectile dysfunction
Mononeuropathies
- median nerve is most common
Diabetic lumbosacral radiculoplexus
Autonomic dysfunction
- cardiovascular neuropathy - silent M.Is
- G.I dysfunction - diarrhoea/ constipation, gastroparesis
- GU dysfunction - urinary retention, urinary incontinence
- erectile dysfunction
What medication can be used to treat painful peripheral neuropathy in diabetic patients?
TCAs
Gabapentin
Pregabalin
What is the gold standard for diagnosing diabetic peripheral neuropathy?
EMGs
other investigations include:
- foot monofilament
How is diabetic nephropathy screened for?
Urine sampling of Albumin: creatinine ratio.
*early morning spot tests are best
*if unable to collect in morning try and sample at same time daily as there is diurnal variation
What are the most common precipitants to HHS?
Infection Poor insulin compliance First presentation Alter mental status thyrotoxicosis recent M.I
What physical signs may be seen with HHS?
Tachycardia Hypotension Reduced GCS Hypothermia - peripheral dilation Evidence of AKI
How is Mature onset of diabetes in the young past on?
Autosomal Dominant
What are the causes of Hypoparathyroidism and how is it treated?
Primary:
- autoimmune hypoparathyroidism
- Digeorge syndrome
Secondary:
- Thyroidectomy
- Radiation
Pseudohypoparathyroidism
- PTH receptor defective
Treatment:
- calcium supplementation
- PTH binders
- PTH replacement
In hypothyroidism how is the correct dose of levothyroxine established, when should it be taken and is there anything else that is is prescribed with?
Dose is worked out by measuring TSH levels. once they fall into normal levels, this is usually the clinically ideal dose.
Levothyroxine should be taken before bed with vitamin C
What is a serious complication of levothyroxine?
Ischemic heart disease
What is the most common cause of hypopituitarism?
Macroadenoma
What is the first hormone to be lost in hypopituitarism and how does it usually present? what are the next?
1st Growth hormone
- lethargy
- muscle weakness
- increased fat
2nd Gonadotropin loss
3rd ACTH
- remember aldosteronism will still work
- there will also be no tanning of the skin
4th TSH
How should severe hypocalcaemia be treated?
Calcium gluconate
+
Magnesium
What are the causes for obesity?
Low active lifestyles More fast food Reduced labour intensive jobs Increased processed sugars Increased input of motorised vehicles
What effects can obesity have psychological?
Depression
Anxiety
Isolation
Increased suicide rates
More likely to pass on habits to children
Prejudice towards them
What measures can be taken to reduce obesity nationally?
Sugar tax
Education
Reduced advertisement
Healthy food clubs
