ENDOCRINE Flashcards
What is a steroid hormone
Hormone produced by adrenal cortex or gonads
Corticosteroids - hormones from adrenal cortex
Sex steroids - gonads, placenta
What monitoring should be put in place for pts with hyponatraemia
Repeat U&Es:
Mild/ asymptomatic (>130) = 12 hourly
Moderate (125-130) = 6 hourly
Severe = referral to ITU, seek senior help, <120 every 4-6 hrs when in stable
What investigations need to be considered for hyponatraemia
FBC - malignancy?
U&E - regularly to monitor sodium
LFT - liver failure
TFT - hypothyroid
Lipids - pseduohyponatraemia
9am cortisol - adrenal insufficiency (no aldosterone)
Paired serum and urine osmolarity - SIADH, DI
Spot (urine) sodium - SIADH (will be raised)
Serum glucose (DM)
Consider: CXR (pneumonia), CT head (tumours), ECG
Outline an approach to assessing a patient with hyponatraemia
- Assess urgency - neurological signs, confusion, reduced GCS? Is it an acute or chronic hyponat?
- Assess fluid status, includ CVS + Resp exam
- Full neuro exam
- Hx - fluid focused (thirst, D&V, polyuria, dizzy, pmhx - failures, drug hx)
- Review drugs - SSRIs, AEDs, PPIs, ACE/ ARB
What is the management of hyponatraemia
Depends on the cause
normal osmolarity - pseudohyponatraemia - check lipids
low osmolarity - euvol: identify cause and treat; hypovol: 0.9% saline replace but monitor, hypervol: fluid restrict and monitor
What is the max upper limit of Na replacement in chronic hyponatraemia
No more than 10 mmol/L over 24 hrs
No more than 0.5 mmol/L per hour
What length of time is considered ‘chronic steroid use’
> 5mg prednisolone for 4 weeks
What are the symptoms of adrenal insufficiency
Fatigue, lack of energy, weight loss, tan
Low BP, postural dizziness, hypotension (»20mmHg postural drop)
Hypovolaemic shock
Abdominal pain, tenderness, guarding, vomiting
Fever
Confusion, somnolence, delirium, coma
Cramps in back and legs reported
Primary-skin pigmentation, palmar creases, scars, oral mucosa
Secondary- pale skin, “alabaster”
What is the hx for adrenal insufficiency
Insidious onset- may help to differentiate malignancy
Check FH
Smoking- respiratory symptoms- lung lesion and ACTH
GI symptoms
Symptoms of thyroid disease
Symptomatic hypoglycaemia
DH inhalers, creams, steroid injections, alternative medication etc
Reduced axillary/pubic hair
What should you look for in adrenal insufficiency exam
General examination to rule out malignancy
BP postural- glucocorticoid and mineralocorticoid deficiency
Skin and hair- deep pigmentation, fine wrinkling pale skin of hypopituitarism, pallor of anaemia, myxoedema of hypothyroidism
Body habitus and BMI – weight loss
Musculature muscle wasting may occur
Malignancy screen- breast, thyroid, colon
What investigations would you do for adrenal insufficiency
FBC, Haematinics, U/E, LFT, Bone, Glc, 0900 cortisol, random if unwell with paired ACTH, SST, TSH FT4, HBA1c, Antibodies, Lipids, renin and aldosterone, CXR, DEXA, vitamin D levels.
What are sick day rules for adrenal insufficiency
Sick day rule 1- double daily oral dose of glucocorticoids
Sick day rule 2- parenteral administration during prolonged vomiting or diarrhoea, prep colonoscopy, surgery
What is the emergency management of adrenal insufficiency
IM hydrocortisone 100mg
Then IV hydrocortisone 200 mg over 24 hrs
IV fluids 0.9% saline 1L over 1 hr, then 4-6 L over 24 hrs
What is the range of hypercalcaemia and symptoms
< 3.0 mmol/L often asymtomatic
3.0-3.5 mmol/L if slow rise maybe tolerated but prompt treatment indicated
>3.5 mmol/L urgent correction due to dysrhythmia and coma
What are the symptoms of hypercalcaemia
“Stones, bones, abdominal moans, thrones and psychic groans”
Polyuria and thirst
Anorexia, nausea and constipation, PUD
Mood, cognitive impairment, confusion, coma
Renal impairment, Renal stones
Short QT and dysrhythmias, BP Cardiomyopathy
Band keratopathy
Weakness
What is the management of hypercalcaemia
If ca >3.5 and symptomatic IV fluids if dehydrated IV bisphoshonate to lower calcium Second line: steroids (to inhibit vit D) ECG - assess for arrhythmias Ensure patient is stable and then full work up
What are the possible causes of hypercalaemia
Hyperparathyroidism or cancer
What investigations should you do for hypercalcaemia
FBC (mal), ESR (mal), U/E (renal function - mal/ myeloma), LFT (albumin helps identify dehydration/ mal), TSH (thyrotoxicosis), vitamin D (toxicity), PTH (PHPT), calcium to creatinine clearance ratio (0.01 FHH), 24 hour urinary calcium (HFF/ CKD?), serum and urine plasma electrophoresis (malignancy), phosphate levels
ECG
CXR, AXR, USS renal tract, DEXA
Calcium sensing receptor gene sequencing
Localisation USS parathyroids and Sesta-MBI scan
Skeletal survey
Serum ACE
OGD
What blood results can you use in addition to calcium to establish cause of hypercalcaemia
Albumin and phosphate
Albumin (raised - dehydration)
Albumin normal or low, more likely malignancy
Phosphate, can tell you about Parathyroid function - if low supports PHPT
Phosphate high or normal, take an ALP
If ALP raised = increased bone turnover - bone mets, sarcoidosis
Normal ALP - myeloma, vitamin D excess
Blood tests for hypercalcaemia
1.Malignancy bloods:
FBC, LFT, U&E, ESR, ?electrophoresis - Myeloma
2.Endocrine bloods:
PTH, Phosphate, TFT, 9am cortisol
3.For rarer inherited causes
24 hour urine calcium, calcium to creatinine ratio
Causes of hypercalcaemia
Malignancy
Primary hypoparathyroidism
Management of hypercalcaemia
ABCD - focus on heart bc of cardiac risk
Dehydrated? - start fluids
IV bisphosphonate
consider iv steroid if needed to lower calcium
ECG - short QT interval, need IV bisphosphonates stat
Hypocalcaemia causes
Poor intake
Vitamin D deficiency
CKD - reduced resorption
Sometimes osteomalacia
Management of hypocalcaemia
Mild - calcium replacement
CKD - alfacalcidol
Severe - IV calcium gluconate
What are the risks of hypocalcaemia
Long QT interval - cardiac arrest
what are the causes of adrenal insufficiency
Primary - autoimmune -(addisons)
Secondary - pituitary insufficiency/ pathology
Tertiary - medications (eg steroids - must keep sick day rules)
what are sick day rules for pts on steroids
Sick day rule 1- double daily oral dose of glucocorticoids
Sick day rule 2- parenteral administration during prolonged vomiting or diarrhoea, prep colonoscopy, surgery
what investigations do you need to do for someone with adrenal insufficiency to confirm
full bloods + 9am cortisol, SST
What tests should you do for a pt with symptoms of cushings syndrome
9 am cortisol - confirm high cortisol
Overnight dexamethasone suppression test
48 hour and / or high dose dexamethasone suppression test (will identify pituitary tumour)
ACTH level - will tell you about carcinoid tumours (ectopic ACTH secreting tumours)
How would you assess and manage a pt with adrenal insufficiency
ABCDE IM hydrocortisone then IV hydrocortisone Fluids to maintain BP Observations - 15 minute Full blood work up to identify cause
what is cushings disease
acth secreting pituitary adenoma
what are the different causes of cushings syndrome and how are they categorised
Primary - adrenal adenoma or cancer, adrenal hyperplasia (wont be inhibited by DST)
Secondary - cushings disease (pituitary tumour), ectopic acth tumour - carcinoid
Tertiary - steroids
what are the different types of benign and cancerous adrenal tumours
Adenoma (benign)
Adenocarcinoma
Where are carcinoid tumours usually located
Lungs
Gut
what are some of the complications of steroid
hyperglycaemia
adrenal insufficiency
what is the difference between thyrotoxicosis and thyroid strorm
Brain: CNS involvement (agitation, confusion)
Temp: Fever
Heart: V fast tachy (>130), AF
Gut: Vomiting
what are the features of myxedema coma
Altered mental state (reduced GCS)
Hypothermia
Precripitating event
what is the management of myxedema crisis
ITU
IV t3
Treat hypoglycaemia
What happens to TFT results in pregnancy
Raised Total T4 from second trimester till the end - because of more TBG
T4 rises first trimester
TSH falls
Reverses after this but total T4 remains high bc of TBG
what is the management of thyroid storm
iv access and fluids (dehydrated)
bloods - TFT, blood cultures
?sedate - chlorpromazine
heart - stabalise. BB but not if asthma or ?CHF
thyroid - treat IV carbimazole
steroids - stop peripheral conversion of t4-3
adjust fluids and monitor
What are the diagnostic feature of thyroid storm
Fever
CNS involvement - delirium, reduced GCS, coma
heart - arrhythmias, tachy, CHF (difficulty breathing, overload in lungs, JVP)
GI - vomitting
What are hyperthyroid rest flags to look for on exam
Optic nerve compression - RAPD, colour desat
Heart failure signs - SOB, congestion
What should you look for in hyperthroid exam
Thyroid eye disease - exompthalmos, proptosis, diplopia, increased tear production, lid retraction, lid lag Goitre Brisk reflexes Fine tremor Pretibial myxoedma Fast pulse, tachycardia Thyroid/ neck mass - nodular, multinodular Look in mouth
What should you ask in thyroid hx
CVS - palpitations, fast heart rate
CNS - irritable, labile emotions, anxiety
Appetite - reduced or increased
Weight - loss or gain
Autonomic - warm moist skin, fine tremor, palmar erythema (catecholamines)
Hair - thin or thick
Thermal - heat sensitivity
GI - diarrhoea, constipation
Gynae - oligomenorrhea, or menorrhagia / infertility?
What is the overlap between diabetes and hyperthyroid
HLA-DR3 - immunoregulatory gene
What are the risks of untreated hypothyroidism
hyperlipidaemia
AF
Cardiac death
Osteoperosis
Relationship between thyroid and skin
The skin characteristics associated with thyroid hormone are classic. The name “myxedema” refers to the associated skin condition caused by increased glycosaminoglycan deposition in the skin. Generalized myxedema is still the classic cutaneous sign of hypothyroidism. It is caused by deposition of dermal acid mucopolysaccharides, notably hyaluronic acid. Despite its appearance, the skin does not pit with pressure.
what is the appearance of myxodema skin
waxy, doughy, swollen (although non-pitting) and dry
what medication is used to treat symptoms of carcinoid
Octreotide
