Endocrine Flashcards
1
Q
What is the diagnostic criteria for diabetes
A
symptoms + 1 abnormal blood sugar
asymptomatic + 2 abnormal blood sugars
Abnormal = random >11.1 or fasting >7
2
Q
What HbA1C level would indicate diabetes?
What level would indicate the need to add a drug for a pre-existing diabetic?
A
(48) 6.5% = diagnostic
(58) 7.5% = add agent
3
Q
What are the cons/when would you be cautious about prescribing Metformin?
A
risk of lactic acidosis particularly in renal failure
GI upset
4
Q
What are the cons/when would you be cautious about prescribing Sulphonylureas?
Give an example of one?
When would you consider prescribing them first line over Metformin?
A
Gliclazide
Weight gain
Risk of hypo’s (avoid in lorry drivers)
Hyponatraemia
They are first line in CKD
5
Q
What are the cons/when would you be cautious about prescribing Sitagliptin?
What is a benefit of Sitagliptan?
A
Causes peripheral oedema
Doesn’t cause weight gain
No evidence of hypoglycaemia
6
Q
What are the cons/when would you be cautious about prescribing Pioglitazone?
A
Do not give in HF
ADRs: weight gain, fluid retention, impotence, anaemia, hepatotoxic
7
Q
What are the cons/when would you be cautious about prescribing SGLUT 2 inhibitors?
Give an example of one
A
Dapagliflozon
normoglycaemic ketoacidosis
They cause dehydration, UTIs and fournier’s gangrene
8
Q
Describe rapid acting insulins and give an example
A
Novorapid
Onset within 15 minutes
9
Q
Describe short acting insulins and give an example
A
Actrapid and Humulin S
Onset within an hour
10
Q
Describe intermediate acting insulins and give an example
A
Humulin-I and Insulatard
Onset within 2-4 hours and lasts 20
11
Q
Describe long acting insulins and give an example
A
Glargine and Lantus
Lasts 24 hours
12
Q
What could result in a misleading HbA1C result?
A
Rapid cell turnover: haemoglobinopathies haemolytic anaemia iron deficiency CKD HIV Medications that increase glucose eg steroids
13
Q
Why do you get microvascular complications in diabetes? (briefly state pathophysiology)
A
Certain systems do not require insulin to allow glucose uptake. You therefore get osmotic damage to the cells
14
Q
Describe the stages of diabetic retinopathy
A
pre-proliferative:
mild - microaneurysm
moderate - + blot haemorrhage, hard exudates, cotton wool spots, venous beading
severe - microaneurysm/blot haem in 4 quadrants or venous beading in 2 quadrants
proliferative: neovascularisation leading to vitreous haemorrhage
15
Q
What urine results would you see in diabetic nephropathy?
A
Raised urine albumin/creatinine ratio
>2.5 = microalbuminaemia
16
Q
What do the kidney of a diabetic look like?
A
bilaterally enlarged
17
Q
How do you manage diabetic nephropathy
A
ACE-I or ARB
+ BP control, statins, diet
18
Q
Describe the signs and symptoms of diabetic neuropathy
A
Glove and stocking loss of sensation
Absent ankle reflexes
Charcot foot deformity
Autonomic:
postural hypotension
urinary retention
gastroparesis
19
Q
Describe a diabetic foot ulcer
A
punched out
painless
on a hard callus
20
Q
Describe the signs and symptoms of hyperglycaemia
A
thirst, dry mouth and frequent urination abdominal pain headache weakness blurred vision
21
Q
How do you treat hypoglycaemia
A
200ml pure fruit juice
1mg IM glucagon
100ml 20% glucose IV
22
Q
What are the hallmark lab results of DKA?
A
acidotic <7.3 with raised anion gap
raised ketones >3
raised blood sugars >11
low bicarbonate <15
23
Q
What is Kussmaul breathing?
A
deep hyperventilation seen in DKA to blow off CO2
24
Q
How do you manage DKA?
A
0.1 units/kg/hour fixed rate
fluids (1L in an hour)
10% dextrose once levels are <14
40mmol K in the fluids if K<5.5
25
What can trigger DKA?
infections
surgery
MI
iatrogenic i.e. wrong insulin dose
26
What are the complications of DKA?
cerebral oedema
hypokalaemia (due to management of DKA)
VTE
arrhythmias due to electrolyte disturbances
27
How do you manage hyperosmolar hyperglycaemic state?
fluids
Only start insulin if there is significant ketones (unlikely as T2 DM and not due to low insulin)
Ensure serum osmolality is regularly monitored - rapid changes can lead to pontine demyelinolysis
28
What do blood sugars have to be for a diabetic to be allowed to drive? And when do they have to check them?
>5
| Check them every 2 hours throughout the journey
29
What blood sugars and HbA1C are diagnostic for pre-diabetes
fasting 6.1 to 7.0
| HbA1C 42-47
30
What dietary advice should you give to a diabetic?
High fibre
Low fat dairy
Oily fish
Avoid saturated fats and sucrose
31
How would diabetic gastroparesis present and how is it managed?
Erratic blood sugar control, bloating, vomiting
| Give metoclopramide or domperidone to increase gastric motility
32
Other than ulcers, what else comprises diabetic "foot disease"
ischaemia: absent foot pulses, intermittent claudication, gangrene
osteomyelitis
cellulitis
Chacots foot deformity
33
How is hypertension in a diabetic managed?
| What is their target BP?
ACE-I (no matter what age or ethnicity)
| Target is 140/90: the same as non-diabetics
34
What should a diabetic do on a "sick day"?
A) on insulin
B) on metformin
C) on any other oral agent
A) ensure to take it
B) take it unless dehydrated as risk of lactic acidosis and renal failure
C) take it
35
How often should a T1DM measure glucose and what should it be?
At least 4x/day
On waking 5-7
Rest of the day 4-7
36
When would you consider prescribing Exenatide or Liraglutide? (GLP1 mimetics)
Triple therapy has not worked and BMI >35
37
What can cause hypokalaemia
```
Thiazide and loop
Alkalosis
Cushing'ss
Conns
D&V
Hypomagnesaemia
```
38
ECG of hypokalaemia
Prolonged PR
ST depression
Flat T
U wave
39
Causes of hyperkalaemia
```
K sparing diuretics, ACE-I, ARB B-blockers, heparin, ciclosporin
Renal failure
Acidosis
Addison's
Rhabdomyolysis
Burns
Blood transfusion
```
40
ECG of hyperkalaemia
Flat P
Prolonged PR
Wide QRS
Tall tented T waves (they are higher than R wave)
Eventually sinosoidal and asystole
41
hyperkalaemia management
```
Calcium gluconate 10% IV
Insulin-dextrose infusion
Nebulised salbutamol
calcium resonium enema
haemodialysis
```
42
How can you categorise the causes of hyponatraemia? What are the causes within these categories?
URINE SODIUM HIGH:
Hypovolaemic = renal loss (diuretics or Addisons)
Euvolemic = SIADH or hypothyroid
URINE SODIUM LOW:
Hypovolaemic = extra renal loss (burns, D&V, sweat)
Hypervolaemic = psychogenic polydypsia or secondary hyperaldosteronism (HF and cirrhosis)
43
How would you manage hyponatraemia?
fluid restrict <800ml/day
Hypertonic saline to replace sodium
Conivaptan (causes water loss without electrolytes)
44
What can occur if sodium is replaced too quickly in hyponatraemia?
Central pontine demyelination aka locked in
| -dysarthria, dysphagia, seizures, paresis
45
What are the causes of hypernatraemia?
dehydration
diabetes insipidus
HHS
iatrogenic (drip-arm)
46
What complication can occur if sodium is dropped too quickly in hypernatraemia management?
Cerebral oedema
47
What is the management of hypernatraemia?
if patient Nathat found in 0.9% saline give 0.9% saline
48
What are the signs and symptoms of hyperthyroidism?
```
heat intolerance
thin hair
bulging eyes
facial flushing
weight loss
thin skin
tachycardic and hypertensive
amenorrhoea
diarrhoea
```
49
What are the causes of hyperthyroidism?
```
Grave's disease
De-Quervains (initial hyper phase before hypo)
Iatrogenic - thyroxine, amiodarone
Toxic multinodular goitre
Ovarian teratoma (ectopic tissue)
```
50
What bloods would suggest hyperthyroidism?
low TSH
| high T4
51
How can hyperthyroidism be managed?
propranolol - symptoms
carbimazole
thyroidectomy
52
What is a thyroid storm? How would it present?
hyperthyroid emergency
| fever, tachycardia, agitated, D&V, jaundice,
53
How is thyroid storm managed?
IV propranolol
| Dexamethasone
54
How would subacute thyroiditis (De Quervains) present?
Initial short hyperthyroid phase then prolonged hypothyroid
Painful goitre
Raised ESR
55
Compare the goitre of De Quervains subacute thyroiditis and Reidel thyroiditis
De Quervains = painful
| Reidel = painless, hard, fixed
56
What are the signs and symptoms of hypothyroidism?
```
cold intolerance
hair loss
thick tongue = slow speech
brittle nails
weight gain
sluggish/lethargic/tired
muscle aches and weakness
constipation
menorrhagia
```
57
What are the causes of hypothyroidism?
```
Hashimotos
Iodine deficiency
De-Quervains
Riedell's
Lithium
Hypopituitarism i.e. secondary
```
58
What bloods would suggest hypothyroidism?
raised TSH
| low T4
59
What would a low TSH and low T4 suggest?
Secondary hypothyroidism due to hypopituitarism
| Sick euthyroid
60
How is secondary hypothyroidism managed?
MRI pituitary
| Steroids prior to giving thyroxine
61
How is hypothyroidism managed?
Levothyroxine
62
How does myxoedema present?
Bradycardic
Hypothermic
Hypoglycaemic
Hyporeflexic
63
How is myxoedema managed?
T3
Hydrocortisone
IV fluids
64
What are the features of thyroid eye disease? Who is it seen in?
exophthalmos leading to dry eye
optic disc swelling
ophthalmoplegia
65
How can thyroid eye disease be prevented?
Stop smoking
| Prednisolone
66
What are complications of thyroid surgery?
recurrent laryngeal damage
Swelling and haematoma within a fixed space = airway endangered
parathyroid damage = hypocalcaemia
67
What is the HbA1C target for those with T2 diabetes?
On lifestyle or metformin - <48 (6.5%)
On sulfonylureas <53 (7%)
68
What is the management pathway for T2 diabetes?
```
Tolerate metformin
1 Lifestyle
2 >48 HbA1C - Metformin
3 >58 HbA1C - add 2nd drug
4 remain >58 - add 3rd drug or insulin
5 Insulin therapy
```
If can't tolerate metformin then skip this and go to single --> dual --> insulin
69
When is a GLP1 mimetic considered for t2 diabetes?
When on dual therapy and:
- BMI>35 + other condition assoc. with obesity OR
- BMI <35 but can't take insulin
70
Which autoantibodies are tested for in thyroid disorderS?
Anti TPO - Hashimotos
TSH receptor antibodies - Grave's
Thyroglobulin antibody
71
How does an addisonian crisis present?
What would a blood gas show?
Shock: (tachy, hypotensive, oligouric, weak, LOC)
hyperkalaemia, normal anion gap metabolic acidosis
72
What can precipitate an addisonian crisis?
Infection
Trauma
Surgery
Missed medication or withdrawal
73
How is an addisonian crisis managed?
100mg hydrocortisone IM/IV
1L Fluids over 30-60 mins (either saline or dex if hypoglycaemic)
Hydrocortisone 6 hourly and then oral after 24hr. Reduce to maintenance dose over 3-4 days
74
What are the signs of Cushing's syndrome?
```
Moon face
Personality change
Distended abdomen with striae
Thin skin
GI distress
Thin limbs
Fluid retention
Osteoporosis
Hyperglycaemia
```
M: gynaecomastia
F: amenorrhoea, hirsutism
75
What causes Cushing's?
Most commonly exogenous corticosteroids
Adrenal tumours
Cushing's disease - ACTH secreting tumour of pituitary
Ectopic ACTH - small cell lung cancer
Pseudo - excess alcohol or severe depression. Use insulin stress test
76
What would a blood gas show in Cushings?
What is an abnormal result of a low dose dexamethasone suppression test?
How would you interpret the results of a high dose dexamethasone suppression test?
Name another investigation
Hypokalaemia metabolic alkalosis
(K particularly low in ectopic ACTH secretion)
LOW DOSE:
normal = cortisol reduces
abnormal = cortisol normal
HIGH DOSE:
cortisol normal but ACTH low = adrenal adenoma
cortisol low but ACTH high = Cushings
cortisol normal but ACTH high = ectopic ACTH
24 hour urinary free cortisol
77
How is Cushing's syndrome managed?
Adrenal - Resection
Cushing's disease - trans-sphenoidal removal
Ectopic - remove tumour
78
How does Addison's disease present?
```
Hyperpigmented skin
Change to body hair distribution
Weight loss
Weak
GI disturbance
Postural hypotension
Hypoglycaemia
```
79
How is Addison's diagnosed?
Low Na and glucose
High K+ and Ca2+
Short synacthen test - should increase cortisol, if remain low then Addison's
80
How is Addison's managed?
Hydrocortisone and fludrocortisone
Patient information reg. needles, steroids etc.
81
Which hormones impact serum calcium levels
Parathyroid hormone
| Calcitriol
82
What are the actions of the parathyroid hormone and where is it secreted?
Increase serum calcium and decrease serum phosphate
- Increase bone Ca resorption
- Increase kidney Ca reabsorption in DCT --> increase phosphate excretion
- Increase Ca absorption in GI tract
It also stimulates calcitriol
Secreted from chief cells in parathyroid gland
83
What is calcitriol?
| What are the actions of calcitriol and where is it excreted?
Calcitriol is activated vit D
Increase serum calcium and serum phosphate:
- Increase Ca and phosphate reabsorption in kidney
84
How does hypercalcaemia present?
```
Constipation
Renal stones
Depression
Bone pain
Polyuria and polydipsia
Corneal calcification
Short QT
Hypertension
```
85
What can cause hypercalcaemia?
Main 2:
- Malignancy - bone mets, myeloma, PTHrP (squamous cell lung cancer)
- Primary hyperparathyroidism (adenoma)
Others:
- dehydration
- sarcoidosis
- acromegaly
- thyrotoxicosis
- thiazides
- addison's
86
How is hypercalcaemia managed?
FLUIDS - normal saline 3-4L/day
Can use bisphosphonates post rehydration
Others - calcitonin or steroids (sarcoid)
Loop diuretics if can't tolerate aggressive fluid rehab but caution due to other electrolyte disturbance
87
How does hypocalcaemia present?
Trousseau's sign (carpopedal spasm with BP cuff)
Chvostek's sign (facial nerve tap = muscles twitch)
Tetany - muscle twitch, spasm, cramp
Perioral paraesthesia
Prolong QT
Chronic - depression and cataracts
88
What is trousseau's sign?
Carpal spasm if brachial artery occluded by inflating BP cuff and maintaining pressure above systolic
- wrist flexion and fingers drawn together
89
What is chvostek's sign?
Tap parotid cause facial muscles to twitch
90
What causes hypocalcaemia?
PHOSPHATE ALSO LOW:
Vit D deficiency
acute pancreatitis
PHOSPHATE RAISED:
CKD
Hypoparathyroidism
Rhabdomyolysis - initial
91
How is hypocalcaemia managed?
10ml 10% calcium gluconate
ECG monitoring
Correct cause
92
What happens in primary hyperparathyroidism?
Tumour of the parathyroid gland
Elevated PTH --> high Ca and low PO4
Urine calcium:creatinine clearance >0.01
93
How does primary hyperparathyroidism present?
What would you see on x-ray?
Can be asymptomatic if mild
Typically elderly female with ++thirst and hypercalcaemia symptoms
Pepperpot skull, generalised osteopenia
94
What happens in secondary hyperparathyroidism?
What is the most common cause?
What blood results do you see?
Parathyroid gland hyperplasia due to low serum calcium typically due to CKD
Ca low/normal = Elevated PTH
PO4 high because of raised PTH and due to poor renal excretion
Vitamin D low
95
How does secondary hyperparathyroidism present?
Bone and Joint pain
Eventually develop bone disease, osteitis fibrosa cystica and soft tissue calcifications
96
What happens in tertiary hyperparathyroidism?
In patients who have secondary hyperparathyroidism due to CKD and subsequently have a renal transplant/dialysis, their PT gland function may not return to normal
PTH high
Ca normal/high
PO4 and vit D low or normal
ALP high
97
What are the features of tertiary hyperparathyroidism?
Metastatic calcification
Bone pain ± fracture
Nephrolithiasis
Pancreatitis
98
What are the indications for surgery in primary hyperparathyroidism?
```
Ca >1mg/dL above normal
Hypercalcuria >400mg/day
Creatinine clearance <30%
Episode of life threatening hypercalcaemia
Nephrolithiasis
Age <50
Neuromuscular symptoms
Reduction in bone mineral density >2.5SD
```
99
How is secondary hyperparathyroidism managed?
Medical therapy of the cause
Surgery if bone pain, persistent pruritus or soft tissue calcifications
100
How is tertiary hyperparathyroidism managed?
Monitor for 12 months
May req. surgery
101
What happens in hypoparathyroidism?
What is a common cause?
How does it present?
What happens in pseudohypoparathyroidism? and what is the resulting biochemistry? How is it diagnosed?
Reduced PTH --> low Ca and high PO4
Can be secondary to thyroid surgery
Symptoms of hypocalcaemia
Pseudohypoparathyroidism - target cells insensitive to PTH:
- Low Ca High PO4 high PTH
Diagnosed by measuring urinary cAMP and phosphate following PTH infusion
Pseudopseudohypoparathyroidism is similar to pseudo but normal biochem
102
What presenting features are associated with pseudohypoparathyroidism?
Low IQ
Short stature
Shortened 4th and 5th metacarpals
103
What are the types of diabetes insipidus?
Central - lack of ADH from post. pituitary
| Nephrogenic - kidney unresponsive to ADH
104
What are the features of diabetes insipidus?
Polyuria - >3L dilute urine
Polydipsia
Hypernatraemia - lethargy, thirst, weak, irritable
105
How is diabetes insipidus investigated?
High plasma osmolality, low urine osmolality
Urine osmolality >700mOsm/kg exclude DI
8 hr water deprivation test - urine should concentrate in normal people
Glucose - rule out DM
106
How is diabetes insipidus managed?
Central - desmopressin
Nephrogenic - thiazides, low salt/protein diet
107
What can cause diabetes inspidus?
Cranial - idiopathic, post head injury, pituitary tumour or post pituitary surgery, hereditary hemochromatosis
Nephrogenic - genetic, hypercalcaemia, hypokalaemia, lithium
108
What can help you work out if hypoglycaemia is due to endogenous or exogenous insulin?
C peptide - only raised if endogenous
109
What is a phaeochromocytoma?
Catecholamine secreting tumour
Rule of 10's:
10% Malignant, 10% extra-adrenal, 10% familial, 10% bilateral
110
How do phaeochromocytoma's present?
```
Symptoms are typically episodic:
Hypertension
Headache
Palpitations
Sweating
Anxiety
```
111
How is phaeochromocytoma investigated?
24 hour urinary metanephrines
| CT abdo
112
How is a phaeochromocytoma managed?
alpha blockers (phenoxybenzamine) BEFORE beta blockers
Surgical resection
113
Why do you need to ensure hydration and salt is given in phaeochromocytoma?
Avoid catecholamine induced volume contraction from unopposed alpha blockage
114
What is Conn's syndrome?
Primary hyperaldosteronism typically due to adrenal adenoma
115
What are the features of Conn's syndrome?
Aldosterone:
- Sodium and water retention --> hypertension!!
- Exchange of H+ and Na+ in tubules --> alkalosis
- Loss of potassium --> Hypokalaemia
Often presents symptomless but can be signs of hypokalaemia
116
What can cause hyperaldosteronism?
Primary:
- Adrenal adenoma
- Bilateral adrenocortical hyperplasia
Secondary:
- High renin - reduced renal perfusion in renal artery stenosis
117
How is Conn's syndrome managed?
Laparascopic adrenalectomy
Spironolactone post op
118
Which hormones impact prolactin secretion?
TRH and Oestrogen stimulate anterior pituitary to release prolactin
Dopamine inhibits secretion
119
What can cause hyperprolactinaemia?
Pituitary disturbance
Prolactinoma (pituitary tumour)
Pregnancy/ breast feeding
Drugs:
- dopamine antagonists (haloperidol, metoclopramide)
- oestrogens
120
Raised prolactin leads to what further hormone imbalances?
How does hyperprolactinaemia therefore present?
Prolactin negatively fees back to inhibit GnRH --> low FSH/LH and testosterone
Females:
- amenorrhoea, galactorrhoea, infertility, decreased libido, dry vagina
Males:
- Reduced facial hair, osteoporosis, galactorrhoea
121
How is hyperprolactinaemia managed?
Dopamine agonist - bromocriptine
122
What causes acromegaly?
Excess growth hormone due to a pituitary tumour
123
What are the features of acromegaly?
Spade like hands
Coarse facial features
Large tongue = interdental spaces and sleep apnoea
Excess sweat and oily skin
Hypopituitarism, headaches, bitemporal hemianopia
Galactorrhoea
124
How is acromegaly diagnosed?
Serum IGF1 levels first (also used to monitor disease)
To confirm - oral glucose tolerance test - in normal person, hyperglycaemia inhibit GH but in acromegaly GH levels remain high
Pituitary MRI
125
How is acromegaly managed?
Transsphenoidal surgery 1st line
Can try dopamine agonist, GH receptor antagonist, somatostatin agonist
Can try external irradiation - older or failed surgical/medical
126
What are the complications associated with acromegaly?
Hypertension
Diabetes
Cardiomyopathy
Colorectal carcinoma
127
How do you differentiate between the primary causes of hyperaldosteronism?
CT abdo
| Adrenal vein sampling to determine source of increased aldosterone
128
In hyperaldosteronism what would the results of a renin:aldosterone ratio be? Why?
raised aldosterone and low renin
| Renin is low because of the negative feedback from raised aldosterone = sodium retention
129
Briefly outline the renin-aldosterone-angiotensin feedback loop
Renin released when BP drops
converts angiotensinogen --> angiotensin 1
ACE released from lungs
converts angiotensin 1 to angiotensin 2
angiotensin 2 causes vasoconstriction and stimulates release of aldosterone from the adrenals
aldosterone causes sodium and water retention
130
What are the types of pituitary adenoma and how would they present?
prolactinoma: amenorrhoea, galactorrhoea
Non-functioning: generalised reduction in hormones
GH secreting: acromegaly
ACTH secreting: cushings
131
What is the most common type of pituitary adenoma
prolactinoma
132
What are some generalised symptoms of pituitary adenomas (not related to hormone secretion)
```
headaches due to dura stretch
bitemporal hemianopia (upper half of vision worse)
```
133
MEN 1 presents like what and why?
parathyroid adenoma = hypercalcaemia
pituitary tumour = prolactinoma
pancreatic tumour = ulcers (as the tumour is often a gastinoma)
134
MEN 2a comprises of what?
thyroid carcinoma
pheochromocytoma
parathyroid hyperplasia = hypercalcaemia
135
MEN 2b comprises of what?
As 2a (thyroid carcinoma, parathyroid hyperplasia and pheochromocytoma)
+ Marfan appearance
+ mucosa neuromas
136
What is important to be aware of with use of GLP1 analogue's and DPP4 inhibitors in diabetes management?
GLP1 given subcut and can be used with metformin for weight loss
DPP4 doesn't cause weight gain
