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
