Endocrine Core Conditions Flashcards
How many people in the UK have type I DM?
1 in 300
What % of DM is type I?
5-10%
Who gets Type I DM?
Childhood disease
Peak presentation at puberty
First degree relative affected increases risk by 6%
MZ twins have 30% concurrence
Causes of type I DM?
Autoimmune (HLA associated immune-mediated organ specific disease)
Polygenic susceptibility
Anti-islet cell Ab is in circulation
Risk factors for Type I DM?
FHx
Genetics
Other autoimmune diseases (Grave’s, Hashimoto’s, thyroiditis, Addison’s, MS, pernicious anaemia)
Symptoms of Type I DM?
Polyuria Thirst Weight loss Regular thrush Blurred vision Cramps Skin infections Ketonuria Retinopathy
Differentials for Type I DM?
Type II DM Diabetic ketoacidosis Lead nephropathy Drug induced glucose intolerance Beign renal glycosuria Pancreatitis CF Prader-Willi syndrome Salicylate poisoning
Investigations for Type I DM?
Urinalysis GTT HbA1c U+Es, eGFR TFTs Lipid profile
Treatment for Type I DM?
SC Insulin injection
Types of insulin?
Rapid acting analogue (before, with or after food)
Long acting analogue (once a day - background)
Short acting (15-30 mins before the meal)
Medium acting and long acting (once or twice a day)
Mixed insulin (short and medium acting)
Mixed analogue (medium and rapid)
Insulin pump therapy is an alternative to SC injections
Who gets Type II DM?
> 40y/o
Increasingly common
Elderly
Asian men
Causes of Type II DM?
Pancreas doesn't produce enough insulin Body is insulin resistant Genetics 80% concordance MZ twins BMI >30 High fat/salt diet Pregnancy Glucocorticosteroids Thiazides Atypical antipsych Cushing's Hyperthyroidism Phaeochromocytoma Pancreatic surgery
Risk factors for Type II DM?
Increasing age FHx Ethnicity (South Asian, Afro-Caribbean) Obese Lack of exercise
Symptoms of Type II DM?
Polyuria Thirst Weight loss Fatigue Recurrent thrush Blurred vision Cramps Skin infections Check BP, eyes, peripheral pulses and feet for ulcers Acanthosis nigricans
Differentials for Type II DM?
Type I DM Gestational DM Lead nephropathy Drug induced glucose intolerance Benign renal glycosuria CF PWS Salicylate poisoning
Investigations for Type II DM?
Urinalysis GTT HbA1c U+E, eGFR TFTs Lipid profile
Treatment for Type II DM?
Lifestyle changes Metformin Gliclazide Glitaxones Gliptins GLP-1 agonists Arcabose Nateglinide Repglidine Insulin (final step)
Who gets hypothyroidism?
F»M
Mean age at diagnosis is 60
2.5% of pregnant women affected
Autoimmune hypothyroidism is more common in Japan
Causes of hypothyroidism?
Usually primary disease of thyroid (can be secondary to hypothalamic pituitary disease) Autoimmune (Hashimotos) Iodine deficiency Dyshormonogenesis Antithyroid drugs Other drugs (lithium, amiodarone, interferon) Congenital (no thyroid) Post infection sub acute thyroiditis Post surgery/irradiation Tumour infiltration
Risk factors of hypothyroidism?
Female >60 y/o Other autoimmune diseases FHx of autoimmune disease Radioactive iodine treatment Anti-thyroid medications Partial thyroidectomy Pregnancy or <6months post partum
Symptoms of hypothyroidism?
Tired Cold Constipation Weight gain Hair thinning Dry skin Intellectual slowing Decreased appetite Deep hoarse voice Changes in period (heavy/painful) Impaired hearing Decreased libido Myxodema Bradycardia Delayed reflexes Carpal tunnel Serous cavity effusions
Differentials for hypothyroid?
Addison's Sleep apnoea Autoimmune thyroid disease Pregnancy Cardiac tamponade Chronic fatigue Depression Dysmenorrhoea Fibromyalgia Familial hypercholesterolaemia Mediastinal tumours Menopause Ovarian insufficiency Prolactin deficiency
Investigations for hypothyroidism?
TFTs Anti-TPO Abs Antithyroglobulin Abs in 90-95% of autoimmune thyroiditis Raides CK Raised cholesterol/triglycerides Anaemia One sided goitre (imaging)
Treatment for hypothyroidism?
Levothyroxine and liothyronine
How common is hyperthyroidism?
400 per 100,000
Who gets hyperthyroidism?
20-50 year olds
Causes of hyperthyroidism?
60-80% due to Grave’s
Toxic multinodular goitre
Solitary toxic nodule
Uncommon acute thyroiditis, pregnancy, neonatal thyrotoxicosis, drugs (amiodarone, exogenous iodine)
Risk factors for hyperthyroidism?
FHx High iodine intake Smoking TRauma Toxic multinodular goitre Contrast agents Childbirth HAART
Symptoms of hyperthyroidism?
Weight loss Heat intolerance Palpitations Tremor Agitated Decreased appetite Weakness Fatigue Diarrhoea Lowered libido Reduced periods Palmar erythema Tachycardia AF/HF Hair thinning Diffuse alopecia Urticaria Pruritus Brisk reflexes Goitre Lid lag Gynaecomastia
Differentials for hyperthyroidism?
Goitre Grave's Plummer-Winson syndrome Malignancy Anxiety
Investigations for hyperthyroidism?
TFTs
TPO and thyroglobulin present in Grave’s
TSH receptor Abs
Thyroid US
Treatment for hyperthyroidism?
Anti-thyroid drugs (carbimazole, methimaxole, propylthiouracil)
Radio-iodine
Thyroidectomy
Which sex is more likely to develop a goitre?
Females
Causes of goitre?
Diffuse smooth goitre may be physiological (puberty, pregnancy) Autoimmune (Grave's, Hashimoto's) Acute thyroiditis Iodine deficiency Dyshormonogenesis Goitrogens (sulphonylureas) Reidel's thyroiditis Cysts Adenomas Cancer TB/sarcoidosis
Risk factors for goitre?
Pregnancy Menopause Lithium Eating too much iodine Exposure to radiation Lack of dietary iodine Female Increasing age FHx
Symptoms of goitre?
Neck swelling Painless (unless inflamed) Dyspnoea Dysphagia Coughing Tight feeling in throat Hoarse/vocal changes Bruit (thyrotoxicosis) Retrosternal extension if inferior border cannot be palpated
Investigations for goitre?
Exam
TFTs
Thyroid Abs
USS
CXR for tracheal compression
If there is 1 nodule (or 1 dominant) fine needle aspiration
Radioactive thyroid scan (hot v cold nodules - cold = 10% chance of malignancy)
Treatment for goitre?
Depends on cause
Treat underlying cause
What % of thyroid nodules are benign?
95%
Who gets thyroid nodules?
F>M
Uncommon in children and adolescents
Causes of thyroid nodules?
Iodine deficiency Pregnancy Female Lithium Menopause Malignancy Benign thyroid disease FHx
Symptoms of thyroid nodules?
Asymptomatic Pain/compression of trachea Swallow water whilst palpating Note movement, asymmetry Check for regional lymphadenopathy
Differentials for thyroid nodules?
Non-toxic goitre Grave's/Hashimoto's Solitary thyroid nodule Carcinoma Thyroid lymphoma Acute suppurative thyroiditis
Investigations for thyroid nodules?
Physical exam TFTs Thyroid Abs USS CXR Fine needle aspiration Radioactive thyroid scan
Treatment for thyroid nodules?
Based on cause
Benign + asymp = no treatment needed
Who is more likely to develop Cushing’s?
Obese DM HTN Osteoporosis F>M 25-40 y/o
ACTH dependent causes of Cushing’s?
Pituitary dependent
Ectopic ACTH producing tumours
ACTH administration
Non ACTH dependent Cushing’s?
Adrenal adenomas
Adrenal carcinomas
Glucocorticoid administration
Alcohol induced pseudo-Cushing’s
Risk factors for Cushing’s?
Female Lung cancer (ectopic ACTH) Prolonged use of corticosteroids in asthma/RhA
Symptoms of Cushing’s?
Central weight gain Depression Psychosis/insomnia Low libido Thin skin, easy bruising Poor wound healing Purple/red striae Kyphosis Back pain Polyuria Growth arrest in children Muscle weakness Hair growth Acne Amenorrhoea Moon face Plethora Frontal balding HTN Glycosuria
Differentials for Cushing’s?
Chronic anxiety/depression Prolonged excess alcohol Obesity Poorly controlled DM HIV
Investigations for Cushing’s?
24 hour urinary free cortisol 48 hour low dose dexamethasone suppression test and late night salivatory cortisol FBC, U+E Adrenal CT/MRI Hypokalaemia with ectopic ACTH Plasma ACTH CRH test for pituitary dependent Cushing's CXR for lung malignancy
Treatment for Cushing’s?
Surgical treatment for adrenal tumours
Drugs (metyapone, ketoconazole, mitotane)
Pit radiotherapy
Complications of surgery: Nelson’s, loss of hormonal function
