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Endocrine And Breast Surgery Flashcards

1
Q

How often is diabetes retinopathy screened?

A
  1. Well controlled DM - every 2 yearly (dilated fundus exam and visual acuity assessment)
  2. Poorly controlled DM or complicated with Hypertension and dyslipidemia - atleast yearly screening
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2
Q

When to screen for diabetic neuropathy

A

At the diagnosis of DM and yearly using simple clinical tests

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3
Q

How to screen diabetes nephropathy?

A

Every yearly by albuminuria( not by urine dipstick test) and by eGFR)

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4
Q

How often should HbA1c done

A

Every 3-6 months

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5
Q

How often should lipids be checked

A

Every 3 yearly if low cvs risk
And yearly if risk is high or clinically permits

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6
Q

What are the causes of Thyrotoxicosis 4

A

Graves’ disease (70%)
Toxic multinodular goiter(15%)
Toxic adenoma (5%)
Thyroiditis(5%)

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7
Q

What’s are the symptoms of Thyrotoxicosis

A

Excessive TSH affects all body systems by stimulating of metabolic processes and activating sympathetic system

  1. Weight loss (weight gain in 10% due to increased appetite)
  2. Heat intolerance
  3. palpitations and tachycardia
  4. Breathlessness
  5. Heart failure in elderly
  6. Irritability and insomnia
  7. Anxiety
  8. Tiredness or lethargy
  9. Diarrhea
  10. Fine tremor with proximal muscle weakness
  11. Sweating
    12.goiter
  12. Vertigo and alopecia
  13. Pretibial myxedema
  14. Wide pulse pressure
  15. Eye changes - proptosis, eye muscle involvement, optic nerve compression, lid lag, lid retraction
  16. Muscular symptoms - vary from mild myasthenia to profound muscle weakness and atrophy, extreme cases shows atrophy of temporal or interossei muscles.
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8
Q

When do you see hip pain in thyroid disease and how

A

Seen in hypothyroidism due to excess fluid accumulation in joint space and swelling

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9
Q

Why does goiters occur and how

A

Goiter is enlarged thyroid gland
Causes are autoimmune diseases, iodine deficiency and formation of thyroid nodules

Goiters occur when thyroid hormone synthesis reduces due to biosynthesis defects or/and iodine deficiency, leading to increased TSH. This stimulates thyroid gland growth as a compensatory mechanism to overcome reduced thyroid hormones

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10
Q

What’s pemberton sign

A

Subalterns goiter may obstruct the thoracic inlet. Permberton sign is faintness with evidence of facial congestion and cyanosis( reddish face) due to external compression of jugular vein , when arms are raised above the head, where thyroid gland was drawn into thoracic inlet

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11
Q

In goiters when is an urgent surgery is indicated

A
  1. In troublesome compressive symptoms( positive pemberton sign)

And/or

  1. Fail to respond to medical therapy
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12
Q

What are the causes of goiter

A

Hashimoto thyroiditis
Graves’ disease
Familial or sporadic multinodular goiter
Iodine deficiency
Follicular adenoma
Colloid nodule or cyst
thyroid cancer

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13
Q

What are the three phases of physiological gynecomastia

A
  1. Neonatal period sue to transplacental passage of estrogen. Almost resolves spontaneously within first year of life
  2. During puberty when palpable breast tissue and increase in breast size occurs. Peak incidence in 13-14 years and declines in 17-18 years
  3. Third peak around 50- 80 years
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14
Q

What are the pathological causes of gynecomastia 7

A
  1. Medications and drug abuse
  2. Hypogonadism
  3. Chronic liver and kidney disease
  4. Hyperthyroidism
  5. Tumors - testicular or adrenal
  6. Malnutrition
  7. Idiopathic- 25%
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15
Q

When does pubertal gynecomastia settles

A

After 6 months to 2 years. Should only reassure

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16
Q

Does asthma meds cause gynecomastia

A

No asthma meds including sal and steroids cause gynecomastia

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17
Q

When can we give testosterone injections

A

In hypogonadism. But not given merely for gynecomastia

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18
Q

What are the causes of pathological gynecomastia

A
  1. Anti androgens -
    Cyproterone acetate
    Finestride
    Spironolactone
    Ketoconazole
    Lavender oil
  2. Drug abuse - alcohol, amphetamines, marijuana, heroin
  3. Hormones - estrogens, growth hormone , anabolic steroids, chorionic gonadotrophin
  4. Antibiotics - ketoconazole, Metronidazole
  5. Anti ulcer drugs - cimetidine, Omeprazole, ranitidine
  6. Antipsychotics - Haloperidol, phenothiazines, diazepam
  7. Cardiovascular drugs - ACE inhibitors, CCBs( diltiazem, nifedipine)
  8. Other - metoclopromide, theophylline, phenytoin, domperidone, HAART( highly active retroviral therapy)
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19
Q

What are the four characteristics of gynecomastia

A

Centrally located
Symmetrical in shape
Usually bilateral
Tender to palpation

Gynecomastia is not palpable unless the diameter of glandular tissue exceeds 0.5cm

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20
Q

What is macromastia

A

Gynecomastia with more than 5cm diameter. More cases has a pathological rather than physiological etiology specially if unilateral

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21
Q

Common features of breast cancer in male

A

Stony hard lump, usually immobile with probable skin dimpling ,lymphadenopathy and nipple discharge or ulceration in advanced disease

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22
Q

What are the histological categories of benign breast diseases

A

1.Non proliferative (not associated with high risk of breast cancer) simple cysts, paplillary apocrine change , epithelial related calcification, mild hyperplasia of usual type ( terms like fibromyalgia changes, fibrocystic disease, chronic cystic mastitis, mammary dysplasia refer to non proliferative disease)

  1. Proliferative without Atypia (mildly increased risk of breast cancer) ductal hyperplasia, intraductal papillomas, sclerosis adenoids, radial scars. FINROADENOMAS- risky if they are complicated with adjacent proliferative disease or with positive family history
  2. Proliferative with atypical hyperplasia (high risk of ca)
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23
Q

What’s the risk of first full term pregnancy after age of 35

A

Increased risk of breast cancer

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24
Q

Risk factors of breast ca

A

Highest RF-
1. Advanced age >65y
2. Atypical hyperplasia in biopsy
3. BRCA1, BRCA2, ATM, TP53
4. Ca breast in multiple first degree relatives.
5. Ductal or lobular in situ
6. Exposure to ionizing radiation <30y
7. Family hx of early ovarian ca <50y

Moderate RF-
High estrogen and testosterone levels post menopausal
Full term pregnancy after 35y
Very dense breast
One 1st degree relat of breast ca
Atypical proliferative breast dx

Mild risk-
Alcohol
30-35 at first full term pregnancy
Diethylsilbesterol expsre in utero
Early menarche <12y

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25
Characteristic malignant features of breast ca
Hypoechogenicity Irregular and ill defined borders Speculated margins Being taller than broader Posterior acoustic shadowing Microcalcifications
26
Clinical manifestations of DM autonomic neuropathy
Skin- dry skin Eye- poor dark adaptation, sensitivity to bright light CVS- postural lightheadedness, fainting, Orthostatic tachycardia/bradycardia/hypotension Urinary- urgency, incontinence, dribbling and bladder emptying abnormalities Gastrointestinal- diarrhea, constipation, nausea vomiting Sexual- ED, ejaculatory failure in men, loss of ability to reach sexual climax in women
27
Pathophysiology of diabetic foot ulcers
Peripheral neuropathy and ischemia from peripheral vascular disease. And poor resistance against infections. Mechanism differ from autonomic dysfunction
28
RF of thyroid cancers
Gender- 3 times more common in women than in men Hereditary conditions- MEN 2 syndrome (pheochromocytoma, parathyroid tumors, medullary thyroid cancers) , familial non- medullary thyroid carcinoma, FAP FAMILY history of thyroid ca Autoimmune THYROIDITIS Acromegaly SLE Graves’ disease DM PERSONAL history of BENIGN thyroid conditions( not family) Low iodine diet Radiation exposure Obesity smoking *family history of benign conditions are not risk factors.
29
What’s the first line treatment for osteoporosis
Most commonly used anti-resorptive agent in osteoporosis are BISPHOSPHONATES. Alendronate( 10mg/day or 70mg/ once a week) Residronate( 5mg/day or 35mg/once a week orally) Zolwndronic acid Bisohosphonates should use for atleast 12 months before the treatment efficacy is assessed In rare cases where two or more minimal trauma fractures despite being on sufficient doses of anti resorptive drug, commencement of teriparatide is justified
30
What’s teriparatide
Synthetic parathyroid hormone which increases osteoblasts(bone forming cells) and by inducing new osteoblast formation. Costly drug and must be used for 18 months for effectiveness. Only encourages in severe osteoporosis if BMD Tscore of =<3.0 Or Two or more minimal trauma # Or Atleast one symptomatic # after atleast 12 months of continuous anti-resorptive therapy
31
Why raloxifen in osteoporosis
Raloxifene is a selective estrogen receptor modulator(SERM) for treatment of post menopausal osteoporosis. Has benefits of estrogen effects on bones without increasing the risk of estrogen dependent cancers( breast, endometrial) Has a preventive effect on breast cancer therefore appropriate for post menopausal women with family or personal history of breast cancer in whom VERTEBRAL FRACTURES due to osteoporosis is a concern. ( not much effective for non vertebral fractures)
32
What is strontium renelate
Effective second line drug for reducing risk of further osteoporotic fractures in post menopausal women. ( CI in women with previous cvs events and or uncontrolled hypertension)
33
What’s the role of estrogen in treatment of osteoporosis
Option for treatment and prevention of osteoporosis in women who are near or at menopause , particularly for patient with menopausal vasomotor symptoms (eg- hot flushes) but must consider risk of THROMBOEMBOLISM, CARDIOVASCULAR DISEASE and BREAST CANCER. They should be weight and discusses with patient
34
How does atropine act
Anticholinergic agent that counteract with parasympathetic effects such as bradycardia
35
Why do MRI in ulcers
If you suspect osteomyelitis as a complication of ulcer 1.Ulcer not responsive to antibiotic therapy. 2. Bone is touched when probing 3. Bone visible in the wound 4. X-ray suggestive of bone involvement.
36
What’s the most initial step in diabetes related foot ulcer (DRFU) management
DEBRIDEMENT 1. allows comprehensive evaluation of wound,wound bed and actual wound size. 2. Debridement can convert a chronic wound into an acute one with accelerated healing. 3. removes local pressure off the wound.
37
In an diabetic related foot ulcer if the ulcer has odorless( clear and non infective) discharge and no inflammation or no cellulitis . What to do
After initial Debridement and deep wound swabs continue daily warm wet dressings and daily check to assess healing process
38
Initial investigation for hypercalcemia
PTH levels Commonest causes are primary hyperparathyroidism and malignancy Malignancy- Intact PTH concentrations are generally undetectable or very low. Primary hyperparathyroidism- elevated or high-normal.
39
Patient with anxiety (impending doom feeling) , tachycardia, pals sweating,high blood pressure. How to workout the dds
Causes can be Generalized anxiety Panic attack Hyperthyroidism Pheochromocytoma Increased BP is not seen in generalized anxiety and panic attacks In pheochromocytoma it’s episodic and episodic headache is prominent( triad is episodic headache, sweating and palpitations) In hyperthyroidism most frequent features are Nervousness, heat intolerance, palpitations, fatigue, weight loss. Signs of agitation, systolic hypertension, sinus tachycardia, fine tremors So most likely hyperthyroidism
40
What are features of panic attack
Palpitations or pounding heartbeat Anxiety Sweating Trembling or shaking Choking or smothering Sense of impending doom Feeling of losing control, dying, going crazy Normally episodic and lasting for 20-30 mins at a time
41
When overtreatment of hypothyroidism causes Thyrotoxicosis , after adjusting the doses how often should you do follow up TSH levels
4 to 6 weekly follow up TSH should be done to adjust dose or to stop thyroxine according to results
42
How to further manage femoral neck fracture (following a fall from short height) after surgery
Falling from a short height/minor indicates osteoporosis as the most common cause. But unlike in women osteoporosis is almost always due to a secondary cause Possible causes- Renal or liver disease Hyperparathyroidism Cushing’s syndrome Coeliac disease Malabsorption Hypercalciuria So you have to investigate for above causes And always should start on osteoporosis treatments with or without bone scan for BMD measurement. First line is bisphosphonates
43
How to prevent venous thrombosis embolism following hip surgery
Patients undergoing hip surgery is among highest risk category for venous thrombosis embolism just by the surgery itself. So to manage that the best option is LMWH which is often given for 10-14 days Warfarin is not recommended bcos it has to be monitored with INR levels, which is difficult,
44
How to manage vitamin D deficiency
Treatment of choice for vit D deficiency is Calcitriol 0.25mg/daily. It’s important to correct vitamin D levels upto 50mmol/L before starting the management of osteoporosis Also calcium supplements should not be added to calcitriol bcos of the risk of hypercalcemia
45
What’s the treatment of choice in osteoporosis with hypogonadism
Testosterone replacement therapy Normal testosterone levels are 8-50 ng/dL Lower margin level doesn’t mean hypogonadism.
46
What’s Paget’s disease
Scaly, raw, vesicular or ulcerated lesion that begins in nipple and spreads to areola. If nipple discharge presents it’ll be bloody than clear
47
Is there a nipple discharge in fibroadenoma
Nope
48
Are bisphosphonates appropriate for premenopausal women ? If not what’s the alternative for osteoporosis ?
No. Because they are teratogenic and also remains in blood for longer period. So not recommended for premenopausal women They should be treated with supplemental calcium and vitamin D
49
What’s the commonest cause of hypothyroidism ?
Most commonest worldwide is iodine deficiency But in Australia and other iodine replenish countries commonest cause Is autoimmune chronic lymphocytic thyroiditis( Hashimoto’s thyroiditis) Primary hypothyroidism accounts for 95%
50
Muscle weakness, proximal myopathy, chronic periarthritis, calcification tendinitis are seen in
Hyperthyroidism But most commonly joint pain occurs in hypothyroidism due to hypo metabolic state leading to joint space fluid accumulation and swelling
51
Fine tremors, wide pulse pressure ,hyper reflexia seen in
Hyperthyroidism and opposite seen in hypothyroidism
52
What are common features of hypo and hyperthyroidism
Decreased libido Psychosis
53
How long should bisphosphonates be continued
For 5 to 7 years for good results, and need to review BMD every 1-2 years
54
Which breast disease causes by vitamin A deficiency
Periductal mastitis
55
In osteoporosis medical treatment is indicated in
1. Those with minimal trauma fractures 2. Those aged 70y and over 3. Those with Tscore of -2.5 or lower 4. Those currently on prolonged (3 months) of corticosteroid and with a Tscore of less than -1.5
56
What are medical treatment options for osteoporosis
Bisphosphonates as first line Estrogen receptor modulators( Raloxifen) Strontium ralenate Teriparatide Whenever bisphosphonates are considered first vitamin D status should be checked and should be corrected ( upto 50mmol/L level) prior to commencement of treatment
57
Vitamin D treatment is indicated in
1. Those with proven vitamin D deficiency( by blood tests) 2. Institutionalized or household people 3. Women who are shrouded for cultural reasons
58
Management of hypocalcemia
Hypocalcemia with symptoms of paresthesia of hands, feet and perioral area with calcium level below reference range and those with asymptomatic hypocalcemia whose calcium levels fallen below 1.9mmol/L are recommended urgently of IV calcium 10-20ml of 10% calcium gloconate in 50-100 of 5% Dexteose should be given over 10-20 minutes while monitoring ECG. Should be repeated until patient is asymptomatic. It should be followed with a cal gluconate infusion If the case was asymptomatic hypocalcemia( with >1.9 calcium levels) oral calcium with or without vitamin D is the choice
59
What’s the prolactin level in prolactinoma
More than 5000 mU/L If less than that it could be drug induced, hypothyroidism, stress related illness ,etc
60
How to manage adrenal crisis in adrenal insufficiency
Parenteral corticosteroids (hydrocortisone)
61
What’s the first line therapy for osteoporosis with history of breast cancer?
With or without breast cancer first line for osteoporosis is bisphosponates.
62
Strotonium renelate
For severe osteoporosis
63
What’s the second line therapy for post menopausal women for osteoporosis (after bisphosphonate)
Raloxifen

Endocrine And Breast Surgery (1 decks)

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