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Medical Finals 2020 > Endocrine > Flashcards

Endocrine 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
How does a pheochromocytoma present?
10% malignant, 10% bilateral 10% extra-adrenal Severe headaches, severe HT Cardiac tachyarrythmias, palpitations Weight loss, pallor
26
How do you investigate a pheochromocytoma?
Urine metanephrines and catecholamines over 24hrs Plasma catecholamines CT/MRI
27
How do you treat a phaeochromocytoma?
``` 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) ```
28
What is SIADH?
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
29
What would you see on investigation for someone with SIADH?
Low serum sodium High urine sodium Low plasma osmolality
30
How do you treat SIADH?
Water restriction Democlocyclin - inhibits ADH's effect on the kidney Tolvaptan - a V2 receptor antagonist
31
What is the main difference between cranial DI and nephrogenic DI?
``` Cranial - failure in ADH production Nephrogenic - ADH has no effect so Cranial - low ADH, high plasma osmolality Nephrogenic - high ADH, low osmolality ```
32
How do you differentiate between cranial DI and nephrogenic DI?
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
33
What is a dexamethasone suppression test and what is it used for?
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
34
What is Cushing's Disease?
Excess cortisol Either due to loss of feedback (high ACTH) or there is an alternate form of cortisol available (tumour producing or steroids)
35
Give 5 symptoms of Cushing's Disease?
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
36
What 3 tests can you do in Cushing's Syndrome?
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
37
How do you treat Cushing's Disease?
Removal of pituitary adenoma (adrenalectomy or pituitary radiotherapy)
38
What is the difference between ACTH-dependent and ACTH-independent Cushing's Syndrome?
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)
39
Name some drugs that lower cortisol.
Metyrapone Ketoconaole Mitotane
40
What is an adrenal crisis?
Not enough cortisol Happens when you stop steroids because the body doesn't produce cortisol anymore Presents with hypotension, cardiovascular collapse
41
How do you manage an adrenal crisis?
Give immediate 100mg hydrocortisone | IV N/Saline
42
What is the name of the disease where there is a decrease in cortisol levels?
Addison's Disease
43
How might Addison's Disease present?
Low sodium High potassium Fatigue, weight loss, headache, adrenal crisis
44
What is a Synacthen Test and what is it used for?
A measure of cortisol levels before and after giving a dose of ACTH and seeing it's effect It should increase cortisol levels
45
How do you treat Addison's Disease?
Hydrocortisone BD or TDS to replace cortisol | Fludrocortisone
46
What are sick day rules?
People with adrenal insufficiency should take double dose hydrocortisone when ill. If vomiting repeat medication - there is no short-term harm
47
What are some causes of secondary adrenal insufficiency?
Long-term glucocorticoid use, if steroids are stopped abruptly there is no ACTH present to feedback to the pituitary Adrenal removal Hypopituitism
48
What is Conn's Syndrome?
Primary hyperaldosteronism
49
What would you see on a blood test for Conn's syndrome?
High sodium Low potassium (hypokalaemia on ECG) Increased aldosterone Decreased renin
50
Give a potential causes of Conn's Syndrome.
``` Adrenal adenoma (mineralcorticoid producing) Adrenal hyperplasia ```
51
What features might someone presenting with Conn's Disease present with?
Could be asymptomatic Hypertension (secondary to sodium retention) Polyuria Polydipsia Neuromuscular weakness, flaccid paralysis, paraesthesia
52
How is Conn's syndrome managed?
Adrenalectomy under spironalactone | Medically: spironolactone
53
What is Graves' Disease?
Autoimmune hyperthyroidism with anti-TSH receptor antibody and sometimes thyroid peroxidase (TPO) Increased TSH activity, so increased T3 and T4 production
54
How do you treat hyperthyroidism?
Radioactive iodine 131 Surgery - thyroidectomy Symptom control - Beta blockers (propanolol) Carbimazole - antithyroid drug
55
What are some side effects of carbimazole?
Agranulocytosis (sore throat, fever, mouth ulcers)
56
What is a thyrotoxic storm?
An acute presentation of thyrotoxicosis Can occur due to an acute illness Fever, seizures, vomiting, diarrhoea, jaundice, arrythmias Risk of death
57
How do you manage a thyrotoxic storm?
Propranolol Antithyroid drugs Potassium iodide Corticosteroids
58
Give some clinical features of Graves' Disease
Thyroid eye disease - proptosis, eye lid retraction, periorbital oedema Pretibial myxoedema Diffuse goitre (enlargement of the thyroid gland)
59
What risks exist in pregnancy-induced hyperthyroidism?
Spontaneous abortion Placental abruption Post-partum haemorrhage Low birth weight with neonatal goitre
60
What hyperthyroid treatment can't be given in pregnancy?
Carbimazole - has teratogenic effects Radioiodine is contraindicated - risk of foetal hypothyroidism PTU - Propylthiouracil
61
What are some different types of thyroid cancer?
``` Papillary Follicular Anaplastic - poor prognosis Lymphoma - poor prognosis Medullary cell ```
62
How do you investigate thyroid lumps or suspected cancers?
FNAB | Fine Needle Aspirate Biopsy
63
What is gluconeogenesis?
Amino Acids/Lactate/Glycerol => Glucose
64
What is glycogenesis?
Glucose => Glycogen Insulin modulates Occurs in the liver to store glucose
65
What is the effect of insulin?
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
Give some factors in the diabetes risk score
``` Male gender High BMI High waist circumference Family history Non-white Older age ```
67
What is the main pathophysiology behind Type 1 Diabetes?
Autoimmune destruction of the beta cells
68
What symptoms would you expect to see in a Type 1 Diabetic?
Weight loss, thin Polyuria, polydipsia Ketonuria Prone to infection, other autoummune diseases
69
How do you manage type 2 diabetes? What medications are used and what are their drug class? (give 2)
``` 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
Know at least one short acting insulin and one long-acting insulin.
Short acting - Humulin, peak effect 2hrs, give 20mins before a meal Long acting - Levemir, give once daily, usually at bed
71
How is insulin given? Can it be given in a normal syringe?
Subcutaneously Special insulin syringe, 1ml insulin syringe will contain 100 units of insulin GIve IV insulin if unwell
72
Give some non-acute complications of diabetes
Diabetic paraparesis - vomiting, reduced gastric motility Trophic changes - ulcers, varicosities Charcot Marie Tooth - champagne bottle appearance of diabetic feet
73
Give some causes of hypoglycaemia
``` Too much insulin Paracetamol overdose Sulfonyluriea Alcohol Delayed or missed meal ```
74
What symptoms occur in hypoglycaemia?
Decreased consciousness, confusion, coma, irritability, drowsiness Adrenergic autonomic symptoms - pallor, tremor, tachycardia
75
What is your immediate management in an acute hypoglycaemia case?
Oral glucose gel If unresponsive IM glucagon IV 10% dextrose
76
Do you omit insulin in a hypoglycaemic crisis?
Not in Type 1, only in Type 2 diabetics
77
What is DKA and give 5 symptoms
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
What is you immediate management of DKA?
IV fluids Insulin Replace electrolytes, especially K+ IV glucose once glucose levels drop
79
Give some complications of chronic diabetes
Stroke risk, MI risk, HTN risk | Microvascular complications - nephrophathy, neuropathy, retinopathy
80
What is the typical description of diabetic peripheral neuropathy?
'Glove and stocking' sensory loss, starts in toes and develops up the leg. Complete loss of vibration, pain and temperature.
81
What hormones are made in the anterior pituitary?
``` FSH LH GH ACTH Prolactin Somatostatin ```
82
How do pituitary tumours often present?
Visual defect - diplopia, bitemporal hemianopia with loss of colour vision Headache Neurological defects - raised ICP Endocrine dysfunction
83
What clinical effects might a prolactinoma have?
Headache, eye problems Infertility Menstrual irregularity Low libido
84
What medication is given to cause tumour shrinkage in prolactinomas?
Cabergoline | Bromocriptine
85
In what order are anterior pituitary hormones affected in hypopituitarism?
``` GH FSH LH Prolactin TSH ACTH ```
86
What is Kallman's Syndrome?
Congenital deficiency of GnRH Anosmia Pubertal delay
87
What is Sheehan's Syndrome?
Pituitary infarctions | Occur post-partum haemorrhage
88
What is Pituitary apoplexy?
Rapid enlargement of pituitary tumour | Causes visual field defect, ocular signs, circulatory collapse
89
Give 5 features of a patient with acromegaly
``` Thickening or bosssing of the skin Wide jaw, greasy skin Enlargement of hands and extremities Excess sweating Headache ```
90
What is the pathophysiology behind acromegaly and what would therefore be seen on investigation?
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
What does ADH do?
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
Give some health problems that obesity increases your risk of?
CVD, T2DM, stroke, osteoarthritis, obstructive sleep apnoea
93
What are the 3 types of surgery that can be offered to obese patients?
Gastric banding Gastric sleeve Gastric bypass
94
What medication can be offered to obese patients to help them lose weight?
Orlistat - stops fat absorption
95
``` What is the key abnormality in each of the following eponymous endocrine diseases? Cushings Conn's Addison's Diabetes Insipidus SIADH ```
``` Cushings - high cortisol Conn's - high aldosterone Addison's - low cortisol + low aldosterone Diabetes Insipidus - low ADH SIADH - high ADH ```
96
What symptomatic effects can adrenal incidentalomas cause?
Cushingoid features Catecholamine excess Virilisation in woman Endocrine hypertension
97
What is carcinoid syndrome?
``` Flushing Diarrhoea Abdominal pan CCF (tricupsid regurgitation) Vomiting ```
98
What investigations should be done in someone presenting with carcinoid syndrome?
24hr urine 5HIAA ECHO CT/MRI + CXR
99
What medication can you use to treat a carcinoid tumour?
Octreotine - somatostatin analogue
100
Where do NET carcinoid tumours mostly originate from?
GI Endocrine
101
Hypokalaemia and hypertension suggest...?
Primary hyperaldosteronism
102
Is a hyperglycaemic hyperosmolar state acidotic or alkalotic on ABG?
Alkalotic
103
If metformin is not tolerated what treatment should you give a Type 2 Diabetic?
Pioglitazone | DPP-4 inhibitor - sitagliptin
104
In DKA what infusion of insulin should be given?
0.1 unit/kg/hour | so 80kg - 8 units/hour
105
What is your acute management in a thyroid storm?
Beta adrenoceptor blocker Thioamide - propylthiouracil Hydrocortisone
106
What is the most common cause of primary hyperparathyroidism?
Solitary adenoma
107
What would you see on investigations for hyperparathyroidism?
Raised calcium Low phosphate PTH raised, can be normal
108
In a normal physiological system a raised calcium would have what effect on PTH?
High calcium would result in a low PTH
109
What is the pattern in investigation blood results for tertiary hyperparathyroidism?
Raised PTH, raised calcium Normal vitamin D, low/normal phosphate ALP raised
110
How do you treat a myxoedema coma?
Levothyroxine and hydrocortisone
111
What is acropachy? | If it occurs in hyperthyroidism what does it indicate?
Clubbing | Graves
112
What level does your glucose level have to be to be considered impaired fasting glucose or impaired glucose tolerance?
Impaired fasting glucose - 6.-6.9 Impaired glucose tolerance <6.1 Diabetes >7
113
What investigations confirm Cushings Syndrome?
Overnight dexamethasone suppression test | 24hr urinary free cortisol
114
How does aldosterone work and what drug is an aldosterone antagonist?
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
What is primary ovarian failure?
Premature failure of ovaries before the age of 40. Caused by chemotherapy, autoimmune, radiation or idiopathic
116
What can be used to treat hyperthyroidism (thyrotoxicosis) in pregnancy?
Propylthiouracil, beta blockers, subtotal thyroidectomy surgery (radioiodine is contraindicated)
117
What is your management of hypernatraemia?
Treat underlying disorder | Correct dehydration by correcting fluid losses
118
Synacten test; what does an increase mean?
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
What is the most common tumour of the pituitary and what symptoms might you see?
Adenoma | Headache, hydrocephalus, cranial nerve lesion, loss of appetite
120
Investigations for Cushings?
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
Treatment for Cushings?
Transphenoidal surgery | Radiotherapy
122
Tumours causing Cushings
Adrenal adenoma Adrenal carcinoma Pituitary tumour Small cell lung cancer
123
Investigations in acromegaly?
OGTT – glucose load should suppress GH levels, if not then acromegaly Serum IGF-1 levels Serum GH levels MRI pituitary
124
First line treatment in acromegaly?
Trans-sphenoidal surgery Then... Somatostatin analogues Pegvisomant
125
Prolacitnoma – treatment of choice?
Cabergoline or Bromocriptine
126
What is MEN?
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
Give 4 signs and symptoms of Cushing’s Disease
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
What are 3 actions of PTH?
Osteoclast activation Prevents loss of calcium in urine Increased calcium absorption from GI
129
A myxoedema coma is a complication of…?
Hypothyroidism
130
Myxoedema coma presents with…?
- 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
What do you treat a myxoedema coma with?
IV thyroid replacement IV fluid IV corticosteroids Correct electrolyte abnormalities
132
What are some causes of a bitemporal hemianopia?
* 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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