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Medical Finals 2020 > Endocrine > Flashcards

Endocrine Flashcards

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USMLE® Step 1 flashcards
1
Q

What is a phaeochromocytoma?

A
  • a catecholamine-secreting tumour

- 10% are familial, may be a MEN II association

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2
Q

How does a phaeochromocytoma present?

A
  • severe headache
  • palpitations
  • sweating
  • anxiety
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3
Q

What investigations do you do for a phaeochromocytoma?

A
  • 24-hour urinary collection of metanephrines

- CT if above is positive

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4
Q

How is a phaeochromocytoma managed?

A
  • surgery (definitive), usually done with alpha blockers (phenoxybenzamine)
  • beta blocker (propanolol)
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5
Q

What are some endocrine side effects of glucocorticoids?

A
  • impaired glucose secretion
  • increased appetitie/weight gain
  • hirsutism
  • hyperlipidaemia
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6
Q

What are some of the features of Cushing’s syndrome?

A
  • moon face
  • buffalo hump
  • striae
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7
Q

What are some side effects of long-term glucocorticoid use?

A
  • osteoporosis
  • muscle weakness - proximal weakness
  • avascular necrosis of femoral head
  • immunosupression (risk of TB reactivation)
  • depression, psychosis, insomnia
  • peptic ulcers (patients often prescribed omeprazole)
  • glaucoma
  • cataracts
  • growth supression
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8
Q

What do alpha, beta and delta cells produce in the pancreas?

A

Alpha - glucagon
Beta - insulin
Delta - somatostatin

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9
Q

What are the three zones in the adrenal cortex and what does each produce?

A

Zona glomerulosa - mineralcorticoids (aldosterone)
Zona fasciculata - glucocorticoids (cortisol)
Zona reticularis - androgens

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10
Q

What does an overactive thyroid mean for TSH?

A

TSH levels will be low because high activity in the thyroid will result in high levels of negative feedback suppressing the pituitary and hypothalamus

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11
Q

Give 5 symptoms of hypothyroidism

A 
Weight gain, poor appetitie
Cold intolerance
Constipation
Hypertension
Bradycardia
Goitre
Menstrual disturbance - mehorrhagia
Carpal tunnel syndrome association
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12
Q

What will you see in TFTs for hypothyroidism?

A

High TSH and low T4 - clinical hypothyroidism

High TSH and normal T4 - subclinical hypothyroidism

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13
Q

What antibodies are associated with a type of hypothyroidism?

A

TPO - Hashimotos

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14
Q

What would you see in the thyroid function test for thyrotoxicosis? (Graves)

A

Low TSH and high T4

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15
Q

What are classic symptoms of hyperparathyroidism?

A 
Pepperpot skull on XR
Tiredness, abdominal pain
Polyuria
Polydipsia
Renal stones
Depression
HTN

Raised calcium, low phosphate

Common cause is a solitary adenoma or hyperplasia

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16
Q

How do you treat Addisonian Crisis?

A

Hydrocortisone 100mg IM or IV
1L normal saline over 3–60mins (+ Dextrose if hypoglycaemia)
Continue hydrocortisone until the patient is stable

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17
Q

How is hypothyroidism treated?

A

Thyroxine/Levothyroxine (70-150micrograms)

Thyroidectomy

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18
Q

What are the 4 ways in which congenital hypothyroidism can occur?

A 
Thyroid dysgenesis
Thyroid hormone biosynthesis defect
Iodine deficiency (common in central africa, south america, not UK)
Congenital TSH deficiency
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19
Q

Give 5 symptoms of hyperthyroidism?

A 
Heat intolerance
Muscle weakness, wasting, hyperreflexia
AF
Tachycardia
Fine tremor
Weight loss with increased appetite
Thyroid eye disease (eye lid retraction, periorbital oedema, proptosis)
Diarrhoea
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20
Q

How is DMT2 diagnosed clinically?

A

Gasting glucose > 7.0

Random glucose >11.0

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21
Q

What antibodies occur in Graves’ disease?

A

TPO (thyroid peroxidase) although more common in Hashimoto’s

TSHR-Ab (anti-TSH receptor antibody)

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22
Q

What would secondary hypothyroidism present as?

A

Low TSH and low T4

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23
Q

Stress response results in an increase in which hormones and decrease in which other hormones?

A

Increase - GH, cortisol, renin, ACTH, aldosterone, prolactin, ADH, glucagon
Decrease - insulin, T, Oe

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24
Q

What is a pheochromocytoma?

A 
A neuroendocrine tumour of the medulla of the adrenal gland
Secretes catecholamines (NAd and Ad)
MEN associations, VHL associations
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25
Q

How does a pheochromocytoma present?

A

10% malignant, 10% bilateral 10% extra-adrenal
Severe headaches, severe HT
Cardiac tachyarrythmias, palpitations
Weight loss, pallor

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26
Q

How do you investigate a pheochromocytoma?

A

Urine metanephrines and catecholamines over 24hrs
Plasma catecholamines
CT/MRI

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27
Q

How do you treat a phaeochromocytoma?

A 
Stabalise the patient
Alpha blockers to reduce BP
May need to use AB during surgery
Surgery resection of adrenal gland
(If not AB then CCB)
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28
Q

What is SIADH?

A

Syndrome of Inappropriate ADH secretion

Increased ADH secretion from posterior pituitary (either from tumour SCLL or hypothalamic disorder)

Causes low sodium, nausea, irritability, headache, hyporeflexia, Cheyne-Stokes respiration

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29
Q

What would you see on investigation for someone with SIADH?

A

Low serum sodium
High urine sodium
Low plasma osmolality

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30
Q

How do you treat SIADH?

A

Water restriction
Democlocyclin - inhibits ADH’s effect on the kidney
Tolvaptan - a V2 receptor antagonist

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31
Q

What is the main difference between cranial DI and nephrogenic DI?

A 
Cranial - failure in ADH production
Nephrogenic - ADH has no effect
so
Cranial - low ADH, high plasma osmolality
Nephrogenic - high ADH, low osmolality
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32
Q

How do you differentiate between cranial DI and nephrogenic DI?

A

Water deprivation test
Withhold water - measure plasma and urine osmolality - then give patients a dugary drink with dexamethasone
Cranial DI - can now concentrate urine and plasma osmolality
Nephrogenic - no effect

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33
Q

What is a dexamethasone suppression test and what is it used for?

A

Measures how cortisol levels respond to an injection of dexamethasone. Usually causes reduction of ACTH and lower cortisol.
In Cushing’s disease there is no effect.
Use in Cushing’s Disease

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34
Q

What is Cushing’s Disease?

A

Excess cortisol
Either due to loss of feedback (high ACTH) or there is an alternate form of cortisol available (tumour producing or steroids)

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35
Q

Give 5 symptoms of Cushing’s Disease?

A

Central obesity, moon face
Weight gain, reduced height gain
HTN, diabetes (reduced glucose tolerance)
Osteoporosis
Cutaneous striae, easy bruising, skin thinning
Hair loss
Decreased libido

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36
Q

What 3 tests can you do in Cushing’s Syndrome?

A

Urine free cortisol - should be raised cortisol present
Late-night salivary cortisol - high, loss of circadium rhythm
Dexamethasone suppression test - should have no effect in disease

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37
Q

How do you treat Cushing’s Disease?

A

Removal of pituitary adenoma (adrenalectomy or pituitary radiotherapy)

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38
Q

What is the difference between ACTH-dependent and ACTH-independent Cushing’s Syndrome?

A

ACTH-dependent - ACTH normal of high, produced by pituitary tumour (Cushing’s Disease), Ectopic (SCLC, endocrine small cell tumours)

ACTH-independent - other form of cortisol suppressing ACTH - primary adrenal disease (adrenal adenoma or carcinoma), exogenous cause (steroids)

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39
Q

Name some drugs that lower cortisol.

A

Metyrapone
Ketoconaole
Mitotane

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40
Q

What is an adrenal crisis?

A

Not enough cortisol
Happens when you stop steroids because the body doesn’t produce cortisol anymore
Presents with hypotension, cardiovascular collapse

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41
Q

How do you manage an adrenal crisis?

A

Give immediate 100mg hydrocortisone

IV N/Saline

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42
Q

What is the name of the disease where there is a decrease in cortisol levels?

A

Addison’s Disease

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43
Q

How might Addison’s Disease present?

A

Low sodium
High potassium
Fatigue, weight loss, headache, adrenal crisis

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44
Q

What is a Synacthen Test and what is it used for?

A

A measure of cortisol levels before and after giving a dose of ACTH and seeing it’s effect
It should increase cortisol levels

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45
Q

How do you treat Addison’s Disease?

A

Hydrocortisone BD or TDS to replace cortisol

Fludrocortisone

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46
Q

What are sick day rules?

A

People with adrenal insufficiency should take double dose hydrocortisone when ill.
If vomiting repeat medication - there is no short-term harm

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47
Q

What are some causes of secondary adrenal insufficiency?

A

Long-term glucocorticoid use, if steroids are stopped abruptly there is no ACTH present to feedback to the pituitary
Adrenal removal
Hypopituitism

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48
Q

What is Conn’s Syndrome?

A

Primary hyperaldosteronism

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49
Q

What would you see on a blood test for Conn’s syndrome?

A

High sodium
Low potassium (hypokalaemia on ECG)
Increased aldosterone
Decreased renin

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50
Q

Give a potential causes of Conn’s Syndrome.

A 
Adrenal adenoma (mineralcorticoid producing)
Adrenal hyperplasia
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51
Q

What features might someone presenting with Conn’s Disease present with?

A

Could be asymptomatic
Hypertension (secondary to sodium retention)
Polyuria
Polydipsia
Neuromuscular weakness, flaccid paralysis, paraesthesia

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52
Q

How is Conn’s syndrome managed?

A

Adrenalectomy under spironalactone

Medically: spironolactone

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53
Q

What is Graves’ Disease?

A

Autoimmune hyperthyroidism with anti-TSH receptor antibody and sometimes thyroid peroxidase (TPO)
Increased TSH activity, so increased T3 and T4 production

54
Q

How do you treat hyperthyroidism?

A

Radioactive iodine 131
Surgery - thyroidectomy
Symptom control - Beta blockers (propanolol)
Carbimazole - antithyroid drug

55
Q

What are some side effects of carbimazole?

A

Agranulocytosis (sore throat, fever, mouth ulcers)

56
Q

What is a thyrotoxic storm?

A

An acute presentation of thyrotoxicosis
Can occur due to an acute illness
Fever, seizures, vomiting, diarrhoea, jaundice, arrythmias
Risk of death

57
Q

How do you manage a thyrotoxic storm?

A

Propranolol
Antithyroid drugs
Potassium iodide
Corticosteroids

58
Q

Give some clinical features of Graves’ Disease

A

Thyroid eye disease - proptosis, eye lid retraction, periorbital oedema
Pretibial myxoedema
Diffuse goitre (enlargement of the thyroid gland)

59
Q

What risks exist in pregnancy-induced hyperthyroidism?

A

Spontaneous abortion
Placental abruption
Post-partum haemorrhage
Low birth weight with neonatal goitre

60
Q

What hyperthyroid treatment can’t be given in pregnancy?

A

Carbimazole - has teratogenic effects
Radioiodine is contraindicated - risk of foetal hypothyroidism
PTU - Propylthiouracil

61
Q

What are some different types of thyroid cancer?

A 
Papillary
Follicular
Anaplastic - poor prognosis
Lymphoma - poor prognosis
Medullary cell
62
Q

How do you investigate thyroid lumps or suspected cancers?

A

FNAB

Fine Needle Aspirate Biopsy

63
Q

What is gluconeogenesis?

A

Amino Acids/Lactate/Glycerol => Glucose

64
Q

What is glycogenesis?

A

Glucose => Glycogen
Insulin modulates
Occurs in the liver to store glucose

65
Q

What is the effect of insulin?

A

Responds to a rise in blood glucose, released from pancreas
Stores glucose in the liver as glycogen
Inhibits glucose production from muscle and amino acids

66
Q

Give some factors in the diabetes risk score

A 
Male gender
High BMI
High waist circumference
Family history
Non-white
Older age
67
Q

What is the main pathophysiology behind Type 1 Diabetes?

A

Autoimmune destruction of the beta cells

68
Q

What symptoms would you expect to see in a Type 1 Diabetic?

A

Weight loss, thin
Polyuria, polydipsia
Ketonuria
Prone to infection, other autoummune diseases

69
Q

How do you manage type 2 diabetes? What medications are used and what are their drug class? (give 2)

A 
Lifestyle + diet
Metformin - biguanide, acts on liver to improve insulin sensitivty
Flozin - SGLT2 inhibitor
Gliclazine
Sulfonylureeas (tolbutamide, chlorpropamide, glibenclamide)
GLP1 analogues - liraglitide
Thiazolidinediones (pioglitazone)
GPP4 inhibitors
70
Q

Know at least one short acting insulin and one long-acting insulin.

A

Short acting - Humulin, peak effect 2hrs, give 20mins before a meal
Long acting - Levemir, give once daily, usually at bed

71
Q

How is insulin given? Can it be given in a normal syringe?

A

Subcutaneously
Special insulin syringe, 1ml insulin syringe will contain 100 units of insulin

GIve IV insulin if unwell

72
Q

Give some non-acute complications of diabetes

A

Diabetic paraparesis - vomiting, reduced gastric motility
Trophic changes - ulcers, varicosities
Charcot Marie Tooth - champagne bottle appearance of diabetic feet

73
Q

Give some causes of hypoglycaemia

A 
Too much insulin
Paracetamol overdose
Sulfonyluriea
Alcohol
Delayed or missed meal
74
Q

What symptoms occur in hypoglycaemia?

A

Decreased consciousness, confusion, coma, irritability, drowsiness
Adrenergic autonomic symptoms - pallor, tremor, tachycardia

75
Q

What is your immediate management in an acute hypoglycaemia case?

A

Oral glucose gel
If unresponsive IM glucagon
IV 10% dextrose

76
Q

Do you omit insulin in a hypoglycaemic crisis?

A

Not in Type 1, only in Type 2 diabetics

77
Q

What is DKA and give 5 symptoms

A

Failure of insulin production or taking medication which results in increased breakdown of fatty acids and skeletal muscle
Increased ketogenesis - increased ketones - increased acidosis

Polydipsia, thirst, urinary frequency
Vomiting - dehydration, abdominal pain, malaise
Drowsiness, confusion
Shortness of breath

High RR, high HR, low BP

78
Q

What is you immediate management of DKA?

A

IV fluids
Insulin
Replace electrolytes, especially K+
IV glucose once glucose levels drop

79
Q

Give some complications of chronic diabetes

A

Stroke risk, MI risk, HTN risk

Microvascular complications - nephrophathy, neuropathy, retinopathy

80
Q

What is the typical description of diabetic peripheral neuropathy?

A

‘Glove and stocking’ sensory loss, starts in toes and develops up the leg. Complete loss of vibration, pain and temperature.

81
Q

What hormones are made in the anterior pituitary?

A 
FSH
LH
GH
ACTH
Prolactin
Somatostatin
82
Q

How do pituitary tumours often present?

A

Visual defect - diplopia, bitemporal hemianopia with loss of colour vision
Headache
Neurological defects - raised ICP
Endocrine dysfunction

83
Q

What clinical effects might a prolactinoma have?

A

Headache, eye problems
Infertility
Menstrual irregularity
Low libido

84
Q

What medication is given to cause tumour shrinkage in prolactinomas?

A

Cabergoline

Bromocriptine

85
Q

In what order are anterior pituitary hormones affected in hypopituitarism?

A 
GH
FSH
LH
Prolactin
TSH
ACTH
86
Q

What is Kallman’s Syndrome?

A

Congenital deficiency of GnRH
Anosmia
Pubertal delay

87
Q

What is Sheehan’s Syndrome?

A

Pituitary infarctions

Occur post-partum haemorrhage

88
Q

What is Pituitary apoplexy?

A

Rapid enlargement of pituitary tumour

Causes visual field defect, ocular signs, circulatory collapse

89
Q

Give 5 features of a patient with acromegaly

A 
Thickening or bosssing of the skin
Wide jaw, greasy skin
Enlargement of hands and extremities
Excess sweating
Headache
90
Q

What is the pathophysiology behind acromegaly and what would therefore be seen on investigation?

A

Increase in growth hormone, acts on liver to result in increase in insulin-like growth factor 1
Increases insulin resistance
GTT will show supressed GH levels
Abnormal IgF-1

91
Q

What does ADH do?

A

Anti-diuretic hormone/vasopressin
Released from posterior pituitary
Stimulated by increase in plasma osmolality (which is increased electrolyes and less water) - ADH released - water reabsorbed from the collecting duct, aquaporins - water reabsorbed so osmolality decreases

92
Q

Give some health problems that obesity increases your risk of?

A

CVD, T2DM, stroke, osteoarthritis, obstructive sleep apnoea

93
Q

What are the 3 types of surgery that can be offered to obese patients?

A

Gastric banding
Gastric sleeve
Gastric bypass

94
Q

What medication can be offered to obese patients to help them lose weight?

A

Orlistat - stops fat absorption

95
Q 
What is the key abnormality in each of the following eponymous endocrine diseases?
Cushings
Conn's
Addison's
Diabetes Insipidus
SIADH
A 
Cushings - high cortisol
Conn's - high aldosterone
Addison's - low cortisol + low aldosterone
Diabetes Insipidus - low ADH
SIADH - high ADH
96
Q

What symptomatic effects can adrenal incidentalomas cause?

A

Cushingoid features
Catecholamine excess
Virilisation in woman
Endocrine hypertension

97
Q

What is carcinoid syndrome?

A 
Flushing
Diarrhoea
Abdominal pan
CCF (tricupsid regurgitation)
Vomiting
98
Q

What investigations should be done in someone presenting with carcinoid syndrome?

A

24hr urine 5HIAA
ECHO
CT/MRI + CXR

99
Q

What medication can you use to treat a carcinoid tumour?

A

Octreotine - somatostatin analogue

100
Q

Where do NET carcinoid tumours mostly originate from?

A

GI Endocrine

101
Q

Hypokalaemia and hypertension suggest…?

A

Primary hyperaldosteronism

102
Q

Is a hyperglycaemic hyperosmolar state acidotic or alkalotic on ABG?

A

Alkalotic

103
Q

If metformin is not tolerated what treatment should you give a Type 2 Diabetic?

A

Pioglitazone

DPP-4 inhibitor - sitagliptin

104
Q

In DKA what infusion of insulin should be given?

A

0.1 unit/kg/hour

so 80kg - 8 units/hour

105
Q

What is your acute management in a thyroid storm?

A

Beta adrenoceptor blocker
Thioamide - propylthiouracil
Hydrocortisone

106
Q

What is the most common cause of primary hyperparathyroidism?

A

Solitary adenoma

107
Q

What would you see on investigations for hyperparathyroidism?

A

Raised calcium
Low phosphate
PTH raised, can be normal

108
Q

In a normal physiological system a raised calcium would have what effect on PTH?

A

High calcium would result in a low PTH

109
Q

What is the pattern in investigation blood results for tertiary hyperparathyroidism?

A

Raised PTH, raised calcium
Normal vitamin D, low/normal phosphate
ALP raised

110
Q

How do you treat a myxoedema coma?

A

Levothyroxine and hydrocortisone

111
Q

What is acropachy?

If it occurs in hyperthyroidism what does it indicate?

A

Clubbing

Graves

112
Q

What level does your glucose level have to be to be considered impaired fasting glucose or impaired glucose tolerance?

A

Impaired fasting glucose - 6.-6.9
Impaired glucose tolerance <6.1
Diabetes >7

113
Q

What investigations confirm Cushings Syndrome?

A

Overnight dexamethasone suppression test

24hr urinary free cortisol

114
Q

How does aldosterone work and what drug is an aldosterone antagonist?

A

Aldosterone acts on distal tubule, in increases reabsorption of sodium and water, excreting potassium, activated by RAAS to increase BP, vasoconstrict.
Spironolactone is an aldosterone receptor antagonist, acts on collecting duct to block Na+/K+ transporter, causes sodium and potassium retention

Low aldosterone = Addisons

115
Q

What is primary ovarian failure?

A

Premature failure of ovaries before the age of 40. Caused by chemotherapy, autoimmune, radiation or idiopathic

116
Q

What can be used to treat hyperthyroidism (thyrotoxicosis) in pregnancy?

A

Propylthiouracil, beta blockers, subtotal thyroidectomy surgery (radioiodine is contraindicated)

117
Q

What is your management of hypernatraemia?

A

Treat underlying disorder

Correct dehydration by correcting fluid losses

118
Q

Synacten test; what does an increase mean?

A

Synacthen is a synthesised ACTH. A person’s cortisol level is measured, and then a dose of synacthen is given and cortisol is remeasured. An increase suggests primary adrenal insufficiency = Addison’s.

119
Q

What is the most common tumour of the pituitary and what symptoms might you see?

A

Adenoma

Headache, hydrocephalus, cranial nerve lesion, loss of appetite

120
Q

Investigations for Cushings?

A

Pituitary MRI – If primary Cushing’s Disease suspected
CT Abdomen – if adrenal tumours suspected
High dose dexamethasone suppression test – supressed = primary, not suppressed = ectopic endogenous cause such as small cell lung cancer

121
Q

Treatment for Cushings?

A

Transphenoidal surgery

Radiotherapy

122
Q

Tumours causing Cushings

A

Adrenal adenoma
Adrenal carcinoma
Pituitary tumour
Small cell lung cancer

123
Q

Investigations in acromegaly?

A

OGTT – glucose load should suppress GH levels, if not then acromegaly
Serum IGF-1 levels
Serum GH levels
MRI pituitary

124
Q

First line treatment in acromegaly?

A

Trans-sphenoidal surgery

Then…
Somatostatin analogues
Pegvisomant

125
Q

Prolacitnoma – treatment of choice?

A

Cabergoline or Bromocriptine

126
Q

What is MEN?

A

Genetic association of endocrine tumours:

•	TYPE 1
-	Pituitary adenoma
-	Parathyroid hyperplasia
-	Pancreatic tumours
•	TYPE 2A
-	Parathyroid hyperplasia
-	Medullary thyroid cancer
-	Phaeochromocytoma
•	TYPE 2B
-	Mucosal neuromas
-	Marfanoid body habitus
-	Medullary thyroid cancer
-	Phaeochromocytoma
127
Q

Give 4 signs and symptoms of Cushing’s Disease

A

Symptoms: Depression, Central weight gain, acne, muscle weakness, amenorrhoea, easy bruising, thin skin
Signs: Moon face, acne, hirsutism, thin skin, bruising, HTN, osteoporosis, pathological fractures, striae, proximal myopathy

128
Q

What are 3 actions of PTH?

A

Osteoclast activation
Prevents loss of calcium in urine
Increased calcium absorption from GI

129
Q

A myxoedema coma is a complication of…?

A

Hypothyroidism

130
Q

Myxoedema coma presents with…?

A
  • Mental deterioration – altered mental stat
  • Hypothermia
  • Non-pitting oedema
  • Cool dry skin, bradycardia, facial swelling
  • Ptosis
  • Coarse, sparse hair
  • Often precipitated by infections, amiodarone, beta blockers, surgery, stroke and trauma
131
Q

What do you treat a myxoedema coma with?

A

IV thyroid replacement
IV fluid
IV corticosteroids
Correct electrolyte abnormalities

132
Q

What are some causes of a bitemporal hemianopia?

A
  • lesion of optic chiasm
  • upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
  • lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma

Medical Finals 2020 (25 decks)

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