endocrine Flashcards
which T2DM drug can cause UTI?
SGLT-2 inhibitors
canagliflozin, dapagliflozin and empagliflozin.
inhibit Na - Glucose co-transporter 2 in the renal proximal convoluted tubule
increases urinary glucose excretion
can therefore increase UTI
other sfx of SGLT-2 inhibitors? eg?
lose weight
canagliflozin, dapagliflozin and empagliflozin.
DKA - initial tx - very first thing?
IV fluids
what does raised TSH, normal T3,4 mean?
subclinical hypothyroidism
does everyone need managing with subclinical hypothyroidism?
no - nice cks
if older than 80 or asymptomatic then repeat TFTs in 6/12
tx hypothyroidism:
levothyroxine
if hypothyroidism + pregnant - what to do about tx?
increase dose of levothyroxine to 150mg per day
if already on 150mcg then increase by 50%
‘unrecordable’ blood sugar measurement with confusion and abdominal pain could be?
DKA
unrecordable means high not low
mx of DKA: (5 things)
fluid replace with saline IV insulin 0.1u/kg/hr FIXED when glucose<15 -> 5% dextrose given correct hypokalaemia long acting insulin continue, short acting stop
cx of DKA?
gastric stasis VTE arrhythmia due to hyperkalaemia/iatrogenic hypokalaemia cerebral oedema ARDS AKI
Diabetes sick day rules
when unwell, If a patient is on insulin, they must not stop it due to the risk of diabetic ketoacidosis. They should continue their normal insulin regime but ensure that they are checking their blood sugars frequently
stop metformin. also drink 3L fluid a day
Grave’s disease triad:
exopthalmos, opthalmoplegia
pretibial myxoedema
clubbing, swelling hands/feet, periosteal new bone formation
tx with propranolol
specific Abs ix for Grave’s?
TSH receptor stimulating antibodies (90%)
anti-thyroid peroxidase antibodies (75%)
commonest type of hypothyroidism?
hashimoto’s thyroiditis
chronic autoimmune thyroiditis
what is hashimoto’s thyroiditis commonly associated with?
other autoimmune conditions - eg T1DM, coeliac, vitiligo
also MALT lymphoma
presentation and ix of hashimoto’s thyroiditis?
CP - hypothyroid sx
goitre, firm, non-tender
ix - anti-thyroid peroxidase (TPO) and anti-thyroglobulin (Tg) Abs
woman with br ca has worsening headaches and seizure - sx control while awaiting imaging?
Dexamethasone to prevent cerebral oedema
what is characterised by extremely high serum PTH with moderately raised serum calcium?
tertiary hyperparathyroidism
who is affected by tertiary hyperparathyroidism?
CKD patients
what commonly causes primary hyperparathyroidism?
benign tumour of parathyroid gland - adenoma
PTH (Elevated)
Ca2+ (Elevated) - mild
Phosphate (Low)
Urine calcium : creatinine clearance ratio > 0.01
primary hyperparathyroidism
PTH (Elevated)
Ca2+ (Low or normal)
Phosphate (Elevated)
Vitamin D levels (Low)
secondary hyperparathyroidism
Ca2+ (Normal or high) PTH (Elevated) Phosphate levels (Decreased or Normal) Vitamin D (Normal or decreased) Alkaline phosphatase (Elevated)
tertiary hyperparathyroidism
what can mimic cushing’s disease?
chronic alcohol excess
how can differentiate between cushing’s and pseudo-cushings?
serum cortisol and dex suppression test both normal in pseudo
hypoglycaemia with impaired GCS mx:
IV glucose with impaired GCS
definitive mx of primary hyperparathyroidism:
total parathyroidectomy
hyperparathyroidism X-Ray changes show:
osteopenia
Asymptomatic patients with an abnormal HbA1c or fasting glucose :
repeat test to confirm dx of diabetes
what tx will a child with Turner’s syndrome receive ?
Growth Hormone tx
commonest cause of thyrotoxicosis in UK?
Grave’s disease
hyperthyroid
45-F -> GP BP 165/95 mmHg. Also reports that she has had some muscle weakness. Bloods show a high aldosterone : renin ratio. CT scan shows bilateral adrenocortical hyperplasia. tx?
What is the most appropriate management plan for this woman?
spironolactone
she has primary hyperaldosteronism (Conn’s)
in elderly lady, what can over correction with levothyroxine cause?
osteoporosis
-> increased bone turnover
AF
acropachy?
dermopathy associated with Graves’ disease. It is characterized by soft-tissue swelling of the hands and clubbing of the fingers.
periosteal new bone formation
most thyroid nodules/cancerous nodules lead to what effect of thyroid?
hypothyroid
lower risk if TSH is low (hyperthyroid)
commonest thyroid cancer?
papillary - best prognosis
follicular
medullary
anaplastic
these are the others
what symptom is a red flag for thyroid ca?
hoarseness
3 conditions which make up MEN 2a?
medullary thyroid ca
phaeo
parathyroid hyperplasia
tender goitre, hyperthyroidism and raised ESR. The globally reduced uptake on technetium thyroid scan is also typical
dx?
subacute thyroiditis
which syndrome causes high LH and low T?
Kleinfelters syndrome
what is the karyotype of Kleinfelters?
XXY
in T1DM what HbA1c target should be used?
48 or 6.5%
what HbA1c needed to consider a second T2DM drug?
58
what cx can thiazides cause?
hypercalcaemia
HHS (hyperosmolar hyperglycaemic state) characterised by 3 things:
severe hyperglycaemia
dehydration and renal failure
mild/absent ketonuria
HHS dx:
- Hypovolaemia
- Marked Hyperglycaemia (>30 mmol/L) without significant ketonaemia or acidosis
- Significantly raised serum osmolarity (> 320 mosmol/kg)
Long term steroid use can cause cushings syndrome, what would this look like on a VBG?
hypokalaemic metabolic alkalosis
due to excess aldosterone which increases acid and K excretion in kidney
addison’s VBG findings:
hyperkalaemic metabolic acidosis
insufficiency of aldosterone which decreases acid secretion in the kidney and leads to the retention of potassium.
first line ix in primary hyperaldosteronism:
plasma aldosterone:renin ratio
Conn’s
A middle-aged male presents to the endocrinology clinic after needing to buy larger shoes and noticing that his hands are enlarging. An MRI brain shows a brain tumour accounting for his symptoms. He is sent for visual field testing.
What is the classical visual field deficit seen in these patients?
bitemporal hemianopia
gliclazide sfx:
hypos
weight gain
presence of which sx differentiates primary and secondary adrenal failure?
skin hyperpigmentation - primary
68-year-old male presents with headache and double vision. On examination you note pigmentation of his skin and a right CN VI palsy. He has a past medical history of a bilateral adrenalectomy 1 year ago for Cushing’s disease. An urgent MRI demonstrates a pituitary tumour that is invading the right cavernous sinus. dx?
Nelson’s syndrome
what is nelsons syndrome?
rapid enlargement of a pituitary corticotroph adenoma (ACTH producing adenoma) that occurs after the removal of both adrenal glands (bilateral adrenalectomy) which is an operation used for Cushing’s syndrome.
3 P’s make up MEN type I?
Parathyroid (95%): hyperparathyroidism due to parathyroid hyperplasia
Pituitary (70%)
Pancreas (50%): e.g. insulinoma, gastrinoma (leading to recurrent peptic ulceration)
Also: adrenal and thyroid
insulinoma: whipple’s triad:
sx hypoglycaemia
BM<2.5
reversibility of sx on administration of glucose
differentiating between insulinoma and abuse of insulin use?
C-peptide production does not fall on exogenous insulin injection in pts with insulinoma
would fall with insulin abuse
how is latent AI diabetes of adulthood (LADA) dx?
Glutamic Acid Decarboxylase (GAD) Autoantibodies
usually evidence of other AI diseases
(T1DM also anti-islet cell, ZnT8)
C-pep low/normal
what happens to periods with either thyroid disease?
hyper - oligo
hypo - menorrhagia
HbA1c underestimates the glucose levels in which condition?
hereditary spherocytosis
also sickle cell, g6pd
what is used as a monitoring tool for levothyroxine tx in hashimotos?
TSH
what is a potentially fatal complication of longstanding undertreated hypothyroidism. It may be precipitated by illness, stress, and certain drugs.?
myxoedema coma
Apart from confusion and hypothermia, patients may have non-pitting periorbital and leg oedema, reduced respiratory drive, pericardial effusions, long QT, anaemia, seizures, and other symptoms of hypothyroidism.
sglt2 sfx:
normoglycaemic ketoacidosis
UTI
risk of LL amputation - skin ulcers
standard hba1c target in type 2?
48
what opthalmological finding in graves disease means severe eye problem?
corneal involvement
The severity of Grave’s eye disease can be graded using the mnemonic NOSPECS
No signs / symptoms
Only signs (e.g: upper lid retraction)
Signs & symptoms (including soft-tissue involvement)
Proptosis
Extra-ocular muscle involvement
Corneal involvement
Sight loss due to optic nerve involvement
how often should t1dm monitor their glucose?
4 - including before each meal and before bed
what 2 things cause 90% of hypercalcaemia cases?
primary hyperparathyroidism
malignancy
others: sarcoid, vit d intox, acromegaly, thyrotoxicosis
Hyponatraemia and hyperkalaemia in a patient with lethargy is highly suggestive of
addisons disease
best test to ix addisons?
short synacthen test
give synthetic ACTH and in Addison’s this doesn’t cause the adrenals to make cortisol cos they’re fucked
Impaired glucose tolerance (IGT) is defined as
fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l
usual first line tx for burning pain in soles of t2dm feet?
amitriptyline
in pt with burning sensation in soles of feet of t2dm and BPH pt, what drug?
pregabalin
amitriptyline will cause urinary retention
hypertension, hypernatraemia, and hypokalemia - indicates?
primary hyperaldosteronism
Trousseau’s sign:
carpal spasm on inflation of BP cuff to pressure above systolic
hypocalcaemia
metabolic alkalosis with high bicarb that also shows hypokalaemia in context of HTN- which syndrome?
conns - hyperaldosteronism
which oral steroid has lowest mineralcorticoid activity?
dexamethasone
can addisons cause collapse? if so why
yes
causes hypos
Pepperpot skull is a characteristic X-ray finding of??
hyperparathyroidism
Consider adding exenatide to metformin and a sulfonylurea if:
BMI >= 35 kg/m² and high weight
BMI<35 and insulin can’t be used
DKA fluids given, what is insulin dose??
0.1 unit/kg/hr
phaeochromocytoma: iX
24h collection metanephrines
phaeochromocytoma symptoms:
hypertension (around 90% of cases, may be sustained) headaches palpitations sweating anxiety
what DM drugs have been linked to necrotising fasciitis of the genitalia or perineum (Fournier’s Gangrene)??
SGLT2is
A 34-year-old female presents with a thyroid nodule. She has a family history of thyroid disease and both her sisters have undergone total thyroidectomies. Her past medical history includes hypertension which has been difficult to manage.
medullary carcinoma
A 52-year-old woman presents with a neck swelling. Her GP reports that her TSH value is low at 0.01 mu/l. A scintigraphy demonstrates a hot nodule.
toxic adenoma