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
