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Phase 3b > ENDOCRINE > Flashcards

ENDOCRINE Flashcards

1
Q

What is a steroid hormone

A

Hormone produced by adrenal cortex or gonads
Corticosteroids - hormones from adrenal cortex
Sex steroids - gonads, placenta

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2
Q

What monitoring should be put in place for pts with hyponatraemia

A

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

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3
Q

What investigations need to be considered for hyponatraemia

A

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

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4
Q

Outline an approach to assessing a patient with hyponatraemia

A
  1. Assess urgency - neurological signs, confusion, reduced GCS? Is it an acute or chronic hyponat?
  2. Assess fluid status, includ CVS + Resp exam
  3. Full neuro exam
  4. Hx - fluid focused (thirst, D&V, polyuria, dizzy, pmhx - failures, drug hx)
  5. Review drugs - SSRIs, AEDs, PPIs, ACE/ ARB
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5
Q

What is the management of hyponatraemia

A

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

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6
Q

What is the max upper limit of Na replacement in chronic hyponatraemia

A

No more than 10 mmol/L over 24 hrs

No more than 0.5 mmol/L per hour

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7
Q

What length of time is considered ‘chronic steroid use’

A

> 5mg prednisolone for 4 weeks

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8
Q

What are the symptoms of adrenal insufficiency

A

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”

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9
Q

What is the hx for adrenal insufficiency

A

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

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10
Q

What should you look for in adrenal insufficiency exam

A

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

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11
Q

What investigations would you do for adrenal insufficiency

A

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.

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12
Q

What are sick day rules for adrenal insufficiency

A

Sick day rule 1- double daily oral dose of glucocorticoids

Sick day rule 2- parenteral administration during prolonged vomiting or diarrhoea, prep colonoscopy, surgery

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13
Q

What is the emergency management of adrenal insufficiency

A

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

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14
Q

What is the range of hypercalcaemia and symptoms

A

< 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

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15
Q

What are the symptoms of hypercalcaemia

A

“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

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16
Q

What is the management of hypercalcaemia

A 
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
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17
Q

What are the possible causes of hypercalaemia

A

Hyperparathyroidism or cancer

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18
Q

What investigations should you do for hypercalcaemia

A

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

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19
Q

What blood results can you use in addition to calcium to establish cause of hypercalcaemia

A

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

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20
Q

Blood tests for hypercalcaemia

A

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

21
Q

Causes of hypercalcaemia

A

Malignancy

Primary hypoparathyroidism

22
Q

Management of hypercalcaemia

A

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

23
Q

Hypocalcaemia causes

A

Poor intake
Vitamin D deficiency
CKD - reduced resorption
Sometimes osteomalacia

24
Q

Management of hypocalcaemia

A

Mild - calcium replacement
CKD - alfacalcidol
Severe - IV calcium gluconate

25
Q

What are the risks of hypocalcaemia

A

Long QT interval - cardiac arrest

26
Q

what are the causes of adrenal insufficiency

A

Primary - autoimmune -(addisons)
Secondary - pituitary insufficiency/ pathology
Tertiary - medications (eg steroids - must keep sick day rules)

27
Q

what are sick day rules for pts on steroids

A

Sick day rule 1- double daily oral dose of glucocorticoids

Sick day rule 2- parenteral administration during prolonged vomiting or diarrhoea, prep colonoscopy, surgery

28
Q

what investigations do you need to do for someone with adrenal insufficiency to confirm

A

full bloods + 9am cortisol, SST

29
Q

What tests should you do for a pt with symptoms of cushings syndrome

A

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)

30
Q

How would you assess and manage a pt with adrenal insufficiency

A 
ABCDE
IM hydrocortisone then IV hydrocortisone 
Fluids to maintain BP 
Observations - 15 minute 
Full blood work up to identify cause
31
Q

what is cushings disease

A

acth secreting pituitary adenoma

32
Q

what are the different causes of cushings syndrome and how are they categorised

A

Primary - adrenal adenoma or cancer, adrenal hyperplasia (wont be inhibited by DST)
Secondary - cushings disease (pituitary tumour), ectopic acth tumour - carcinoid
Tertiary - steroids

33
Q

what are the different types of benign and cancerous adrenal tumours

A

Adenoma (benign)

Adenocarcinoma

34
Q

Where are carcinoid tumours usually located

A

Lungs

Gut

35
Q

what are some of the complications of steroid

A

hyperglycaemia

adrenal insufficiency

36
Q

what is the difference between thyrotoxicosis and thyroid strorm

A

Brain: CNS involvement (agitation, confusion)
Temp: Fever
Heart: V fast tachy (>130), AF
Gut: Vomiting

37
Q

what are the features of myxedema coma

A

Altered mental state (reduced GCS)
Hypothermia
Precripitating event

38
Q

what is the management of myxedema crisis

A

ITU
IV t3
Treat hypoglycaemia

39
Q

What happens to TFT results in pregnancy

A

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

40
Q

what is the management of thyroid storm

A

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

41
Q

What are the diagnostic feature of thyroid storm

A

Fever
CNS involvement - delirium, reduced GCS, coma
heart - arrhythmias, tachy, CHF (difficulty breathing, overload in lungs, JVP)
GI - vomitting

42
Q

What are hyperthyroid rest flags to look for on exam

A

Optic nerve compression - RAPD, colour desat

Heart failure signs - SOB, congestion

43
Q

What should you look for in hyperthroid exam

A 
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
44
Q

What should you ask in thyroid hx

A

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?

45
Q

What is the overlap between diabetes and hyperthyroid

A

HLA-DR3 - immunoregulatory gene

46
Q

What are the risks of untreated hypothyroidism

A

hyperlipidaemia
AF
Cardiac death
Osteoperosis

47
Q

Relationship between thyroid and skin

A

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.

48
Q

what is the appearance of myxodema skin

A

waxy, doughy, swollen (although non-pitting) and dry

49
Q

what medication is used to treat symptoms of carcinoid

A

Octreotide

Phase 3b (13 decks)

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