ENDOCRINE Flashcards
** Hypoglycaemia
Mild <
Severe <
dose of treatment?
what meds mask symptoms?
Defined as low glucose < 4mmol
CAUSE: insulin, alcohol, sepsis, Sulphonyureas, B blockers
CF: < 3.6mmol/L = Tachycardia + palpitations + anxiety
-Sweating, pallor, tremor, Cold extremities
< 2.6mmol/L (neuroglycopenia: slurred, blurred + confused) Seizures + Coma
IVX: Blood glucose and U+E
MANAGE: A-E, Check Blood glucose –> GCS 15 fast acting glucose in small doses then re-check blood glucose and if not wokring give IV glucose.
IV 100mls OF 20% IV Glucose or IM Glucagon
- check meds e.g. b blockers mask symptoms of hypos
** Diabetic ketoacidosis
3 key numbers
Glucose
Ketones
PH
Treatment:
Too much glucose → body uses all inulin → lack of insulin = metabolise fat instead → produces ketones
More common in Type 1 DM or Insulin dependent
- Triggered by infections, non-adherence with tx. or new DM presentation
3 key features:
a. GLUCOSE > 11mmol/L (often > 30)
b. KETONES > 3.0mmol in blood (finger prick)
c. PH ↓pH (<7.3) ↓HCO3- (< 15mmol/L)
CF: Initial signs: Polyuria and polydipsia → dehydration Nausea and vomiting Weight loss Confusion and drowsy Kussmaul breathing – deep hyperventilation (expel CO2 for respiratory compensation) Vague abdominal pain
MANAGEMENT:
ABCDE
1. Fluid regime – NORMAL SALINE 0.9%
-Consider initial bolus 500ml if hypotensive
-Regime: 1L over 1hr → (Then 2hr, 2hr, 4hr, 6hr, 6hr
- INSULIN: Fixed rate 0.1 units/kg/hr (pushes K+ into cells) Once GLUCOSE < 14 → start 10% glucose
- K Sulphate
+ LMWH prophylaxis
- if Mg drops = give serum Mg
Type 1 Diabetes
Digangostic criteria
Fasting
Random
Autoimmune destruction of Pancreatic B cells - decrease insulin and cant store glucose and glycogen.
Presents pre-school /teenager
CF: Triad: Polyuria, fatigue, polydipsua, weight loss, bed wetter, skin sepsis, candidia.
Diagnosis: Syx of Hyperglycaemia + Fasting glucose >7, Random glucose >11 and Hba1c > 48
Urine: Glucose and Ketones
TX: Education, diet, weight control and Insulin regimen
(Long acting basal insulin and fast acting- set routine / insulin pump)
Type 2 Diabetes
Numbers
Treatment Aims
General treatment
Annual review
↑insulin resistance due to obesity – old, fat, south Indians, +ve FHx
CF: fatigue, thirst, excessive weeing, Obesity and Acanthosis Nigricans
Diagnosis:
- Clinical symptoms of hyperglycaemia AND
- Fasting glucose ≥ 7mmol/L or
- Random plasma glucose > 11.1 mmol/L or
- OGTT – 2h post ≥11.1 mmol/L or
- HbA1c ≥ 48mmol/L (6.5%) (42-47 = pre-diabetes)
TX: HbA1c (6 months) < 48 (6.5%) target to avoid comps / 58 then ADD treatment and aim to keep below 53
- Drug THERAPY: Metformin +/- other
++ Statin and Antihypertensive
Annual review: BMI, creatinine, Cholesterol, BP, smoking status, foot and eye exam, HBa1c, Weight and BMI, Urinary ALBUMIN: CREATININE
Severe Acute Diabetic Foot infection or ischaemia
Diabetic Ischaemic Foot
a) Neuropathy – loss of protective sensation → ↑risk of damage w/o knowledge
b) Peripheral Arterial Disease – risk factor for macro and microvascular ischaemia
● Screen for annually (diabetic 9 r/v)
CF: Neuropathy = Charcot foot/joint – swelling, distortion of architecture, lost function, flat feet (planus), loss of sensation → neuropathic ulcers (plantar surface, not painful)
Ischaemia – absent foot pulse (DP.a, PT.a), ↓ABPI, Intermittent claudication
IVX: annual screening
Graves Disease : Excess release of T3/T4
(Type of Hyperthyroidism / Thyrotoxocosis)
Treatment for Thyrotoxic crisis / storm
SYX = signs of HYPERTHYROIDISM
- Eye disease – Exophthalmos, Opthalmoplegia (paralysis of muscles within or surrounding eye → diplopia)
- Pretibial myxoedma – oedematous, discoloured swelling above lateral malleoli
- Thyroid Acropatchy – extreme manifestation with clubbing, painful finger + toe swelling, periosteal reaction in limb bones
- Also Bruits (due to ↑vascularity in thyroid)
IVX: blood, CRP, TFT, Thyroid ultrasound, TSH ab, refer to endocrinologist
Management: B blocker for AF syx control
Carbimazole to inhibit T3 syx
Radioiodine or thyroidectomy
Complication:
Thyrotoxic crisis/storm – typically causes HYPERTHERMIA, mental disturbance and thyrotoxic symptoms = ↑Temp, agitation, confusion, coma, tachy, AF, D+V, goitre, bruit, acute abdomen,
- Start Tx and take serum TSH, T4, T3
- IV fluids, NG tube (if vomiting), Sedate (Chlorpromazine)
- Propranolol 40mg TDS PO – rapid control Sx
- Digoxin – slow heart
- Carbimazole 15-25mg QDS – reduce circ T3/T4
- Hydrocortisone 100mg QDS or Dexmeth 4mg TDS – to prevent peripheral conversion of T4 → T3
- Co-amoxiclav if simultaneous infection
Adrenocortical insufficiency
–> (Addison’s Disease)
Destruction of adrenal cortex → ↓adrenal hormone output of:
a) ↓Mineralocorticoids (aldosterone) ↓ Na
b) ↓Glucocorticoids (cortisol) ↓blood glucose
c) ↓Androgens → ↓testosterone
–> Addison’s disease (primary) – autoimmune (80%) destruction of adrenal gland
CF: Lean + Tired + dizzy
Bronze skin + pigmented palmar crease + buccal mucosa
Tearful + Weak
Nausea + vomiting, abdo pain, Diarrhoea + constipation
Cravings for salty food
↓Androgen symptoms – rarely affects men due to testies : ↓Sex drive, ↓Pubic hair (women)
Signs: Hyperkalaemia K Hyponatraemia Na Hypovolaemia Metabolic Acidosis (↓HCO3-)
IVX: Bloods, 9am cortisol and ACTH
DIAGNOSIS: Synacthen ACTH stimulation test= diagnostic
Manage: Endocrinologist
- HYDROCORTISONE = replaces cortisol
- FLUDROCORTISONE = replaces aldosterone
given steroid card –> double Steroid when ill (Dont Stop)
Androgen replacement: DHEA women
Hyperthyroidism
CF: Weight loss despite increased appetite, Muscle wasting → Proximal myopathy, Diarrhoea, Oligomennorhoea ± Infertility, Sweats + Heat intolerance Palpitations, Tremor, Irritable, Labile, Agitated
SIGN: Fast + Irregular pulse (often AF or SVT; rarely VT)
Warm moist skin + palmar erythema
Fine tremor + Hyper-reflexia
Thin hair
Lid lag + Lid retraction (exposure of sclera above iris)
Goitre (Grave’s)
Thyroid nodules or bruit (dependent on cause)
Causes of Goitre
Grave’s – hyperT Multinodular – hyperT Adenoma/carcinoma De Quervains – hyperT hypoT, painful Hashimoto – hypoT Riedels – hypoT
Addisonian crisis
Pain in back, abdomen or legs
Diarrhoea + Vomiting → Dehydration
↓BP → Hypovolaemic shock
NB: Waterhouse-Friderichsen syndrome
sudden ↑BP → adrenal cortex blood vessels rupture → tissue ischaemia + adrenal failure → crisis
K UP, NA DOWN, c)
Emergency admission 1. Hydrocortisone IM or IV 100mg (adult) stabilise then every 6 hours until oral 2. IV 0.9% Saline infusion (corrects ↓Na+) 3. check if need IV glucose
Type 2 Diabetes Treatment ladder
drugs and risks
48 - 58 - 53
- a Metformin (cardio protective but cant use if bad kidneys)
- b OR Sulfonylurea if cant use metformin- causes increase weight and hypo risk
- Dual therapy + add next on list
- Tripple therapy
- SGLT2- sugar lost through wee = risk of UTI
- GLP1 = Gastric emptying longer = lose weight
- Pioglitazone = pile on weight
- DDP4 = bad for pancreas - Add Insulin
Management of Addisonian Crisis
Intensive monitoring if unwell
- Parenteral steroids (i.e. IV hydrocortisone 100mg stat then 100mg every 6 hours)
- IV fluid resuscitation
- Correct hypoglycaemia
- Careful monitoring of electrolytes and fluid balance
Sick euythyroid
Patients who are really unwell with non-thyroid illnesses often have low T3 T4 and TSH
Primary hypereparathyroidism
Memo?
Low Ca- trois
(1 = hig Ca, 2 = low Ca, 3 high Ca)
THIRSTY + WEEING LOTS
Boans, stones, abdominal groans, psychiatric moans
Raised Calcium, Raised PTH, LOW phosphate
Treatment:
MILD
1. ↑FLUID INTAKE; avoid thiazide diuretics
2.Replenish Vitamin.D (Cholecalciferol – non-active)
3.Cinacalcet (calcimimetic – for those unstuitable for surgery) → ↑sensitivity of parathyroid cells to ca2+ levels → ↓PTH secretion
Moderate- thyroidectomy
Acromegaly
High levels of Growth hormone
syx: spade-like hands and growth + bitemporal hemianopia
Test: Serum IGF-1 levels
