ENDOCRINE END OF BLOCK TEACHING ROOM TUTORIAL

Question 1

What hormone is known as anti-diuretic hormone? Where is ADH produced and stored?

Answer 1

Vasopressin Produced in the hypothalamus and stored in the posterior pituitary gland

Question 2

Name of a hypothalamic hormone also known as prolactin inhibiting factor?

Answer 2

Dopamine

Question 3

A hormone stored in the posterior pituitary whose target organs are the breast and uterus? What does it cause in the breast and uterus?

Answer 3

Oxytocin - rpdocued in hypothalamus and stored in posterior pituitary Stimulates prolactin release causing nipple stimulation Also causes uterine contractions

Question 4

Along with FSH, which other hormone from the anterior pituitary targets the ovaries or testes?

Answer 4

LH

Question 5

What hormone is produced to excess in acromegaly? Which hormone is used in the short synacthen test in Addison’s?

Answer 5

Growth hormone is produced Synthetic ACTH

Question 6

What two bone conditions are associated with increase alkaline phosphatase?

Answer 6

Osteomalacia and paget’s disease

Question 7

What are two common complications of thyroid surgery?

Answer 7

Recurrent laryngeal nerve palsy Hypoparathyroidism

Question 8

Patient with normal calcium, phosphate and alk phos, presents with a Colle’s fracture What is the cause? What direction is the angulation?

Answer 8

Osteoporosis Dorsal angulation

Question 9

60 year old man has back pain, elevated calcium levels and lytic lesions on X-ray What is this?

Answer 9

Multiple myeloma

Question 10

Bitemporal hemianopia is caused by a lesion in the optic chiasm What is the difference in the way in which pituitary adenomas and craniopharyngiomas typically cause a bitemporal hemianiopia?

Answer 10

upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma

Question 11

A 41 year old man presents with headache and visual loss. Your history elicits symptoms of lethargy, loss of libido and impotence. On examination you find a bitemporal hemianopia and galactorrhea. What do you suspect this to be?

Answer 11

Prolactinoma

Question 12

Why does prolactinoma cause a decreased production of gonadotrphins?

Answer 12

Prolactin has an inhibitory effect on the GnRH causing a decrease in the gonadotrophic hormone production leading to the loss of libido and impotence in the patient

Question 13

A 50 year old women presents with lethargy and weakness. Her past medical history includes type 1 diabetes mellitus and pernicious anaemia. On examination you find she is hypotensive, with hyperpigmentation of her palmar creases and buccal mucosa? What is the likely cause of her findings? What causes the hypotensive and hyperpigmentation?

Answer 13

Addison’s disease Hypotensive due to lack of the mineralocorticoid hormone aldosterone which causes low sodium resorption into blood and therefore low water resorption into the blood causing a low blood volume - hypotension Hyperpigmenation due to excess ACTH being produced due to the lack of aldosterone and cortisol - ACTH contains the sequence for MSH and therefore when broken down this cause the pigmentation

Question 14

What is pernicious anaemia?

Answer 14

Autoimmune disorder where the body doesnt produce enough intrinsic factor (Pernicious anaemia causes your immune system to attack the cells in your stomach that produce the intrinsic factor) which is a protein produced by the stomach which combines with vitamin B12 which is required for the formation of healthy red blood cells Therefore you become anaemic

Question 15

A 28 year old female develops polyuria, with a urine output greater than 400ml/hour. She suffered a subarachnoid haemorrage two days previously, and underwent surgery to clip an aneurysm in the anterior communicating artery. What is the most likely cause of the clinical findings?

Answer 15

Cranial diabetes insipidus

Question 16

A 49 year old man complains of tightening of his shoes and visual loss. On examination you note macroglossia, plus spade like hands and feet What is the most likely cause of the clinical findings?

Answer 16

Acromegaly due to a growth hormone producing pituitary adenoma

Question 17

What drug is used for the treatment of cranial diabetes insipidus?

Answer 17

Desmopressin aka vasopressin

Question 18

What anti-thyroid drug can cause agranulocytosis?

Answer 18

Carbimazole Sore throat, ulcers, cough means stop taking drug and go to doctors

Question 19

Which drug can be used to control the symptoms of cushings syndrome?

Answer 19

Metyrapone and ketaconazole - inhibit steroid genesis (inhibit cortisol synthesis)

Question 20

What drug should be the first-line short term treatment of a pheochromocytoma?

Answer 20

Alpha blocker Phenoxybenzamine - non selective alpha blocker to lower BP given before beta blocker

Question 21

Which drug may be used in the treatment of hyperprolactinaemia?

Answer 21

Cabergoline or bromocryptine

Question 22

An 18 year old man comes to see you, his GP, complaining of a 3month history of polydipsia, polyuria, nocturia and unexplained weight loss What endocrine disorder do you believe could be the cause? List two other potential causes?

Answer 22

Type 1 diabetes mellitus or diabetes insipdus or hypercalcaemia

Question 23

Explain how the underlying pathophysiology of diabetes mellitus relates to the symptoms polyuria and polydipsia?

Answer 23

Autoimmune disorder reacting against islet cells of pancreas Causes insulin not to be be produced therefore glucose does not get taken up by tissue Hyperglycaemia causes high urine output which will cause an osmotic drift leading to poluria This will cause thirst

Question 24

What are the criteria for diagnosing type 1 diabetes?

Answer 24

Random glucose over 2 occasions - 11.1mmol/L Fasting - greater than 7mmol/L HbA1c - greater than 48mmol/L (6.5%)

Question 25

What advice would be given for treating type 1 diabetes?

Answer 25

Diet treatment Basal bolus insulin regime - basal is long lasting and bolus is short acting for each meal

Question 26

What is the type 2 diet diabetes treatment? (pharmacogical steps)

Answer 26

Diet and exercise 1. Metformin - a biguanide increases insulin sensitivity 2. Sulphonylurea - increases insulin secretion 3. SGLT2 inhibtors or DPP4 inibitors - DPP-4 inhibitors slow the inactivation and degradation of GLP-1, a hormone involved in glucose removal from the gut. 4. TZDs (thiazolidinediones eg the glitazones) - activate PPARy (causes weight gain, osteoporosis and heart failure)

Question 27

What are the long term microvascular and macrovascular complications?

Answer 27

Macrovascular - stroke and MI Microvascular - Retinopathy, neuropathy and nephropathy Severe complication can be limb ischaemia

Question 28

How is diabetes insipidus diagnosed?

Answer 28

To diagnose give water deprivation test - deprive of water for 8 hours and see if * The body’s normal response to dehydration is to conserve water by concentrating the urine. Those with DI continue to urinate large amounts of dilute urine in spite of water deprivation * Therefore urine osmolality does not increase to above a certain level (>600mOsmol/kg) after 8 hours

Question 29

How is diabetes insipidus differentiated between cranial and nephrogenic?

Answer 29

Give patient desmorpressin (vasopressin analogue): * In nephro - will not resorb water and therefore serum osmalility will remain high * In cranial (Central) - will cause a decrease in serum osmolalilty as increased water resoprtion

Question 30

Six months, the 18 year old man presents to A&E with a 12-hour history of nausea, vomiting and abdominal pain. On examination, his respirations are deep and sighing with a respiratory rate of 22, a heart rate of 110beats/min, a blood pressure of 100/70mmHg, and he appears to be confused. BM glucose taken by the nurse is 24. What diagnosis do you suspect?

Answer 30

Diabetic ketoacidosis (DKA)

Question 31

Explain how the underlying pathophysiology of your answer for DKA relates to his hyperventilation? What is the name for this type of hyperventilation?

Answer 31

Known as Kaussmaul breathing Basically, not enough insulin to convert glucose to glucagon for energy therefore body needs energy and breaks down fat to fatty acids insteads, excess fatty acid causes ketones which causes acidosis Metabollically acidotic and therefore body tries to blow of CO2

Question 32

What are the diagnostic criteria for diabetic ketoacidosis?

Answer 32

2 out of 3 of Ketones - urine ketones positive Bicarb 14

Question 33

What is the treatment process of diabetic ketoacidosis?

Answer 33

After ABC Give IV fluids within 30minutes IV insulin in first hour and potassium after first hour

Question 34

Should the person stop insulin diabetic ketoacidosis?

Answer 34

No as no insulin will continue to cause ketones to be produced

Question 35

A 55-year old woman presents with symptoms of palpitations, diarrhoea and feeling warm and sweaty. She has lost two stone in the last 6 weeks What is the probable diagnoses?

Answer 35

Hyperthyroidism Could be pheochromocytoma

Question 36

What is the building blocks of T4?

Answer 36

Iodine and tyrosine residues

Question 37

What blood test results would you expect to see in hyperthyroidism?

Answer 37

High T4 Low TSH TSH receptor antibody (TRab)

Question 38

What are the pharmacological and non-pharmacologcial management options for hyperthyroidism?

Answer 38

For symptomatic relief - beta blockers Carbimazole, propylthiouracil if carbimazole contraindicated Surgery + ablation and radio iodine to detect metastases

Question 39

When is carbimzole contraindicated as treatment for hyperthyroidism?

Answer 39

When pregnant Give propylthiouracil for first trimester instead

Question 40

Failure of medical management meant that this patient underwent surgery. One year after surgery the patient presents to her GP complaining of weight gain, lethargy and a dislike for cold. What is your new diagnosis?

Answer 40

Hypothyroidism

Question 41

What are other symptoms of hypothyroidism? What test results would you expect to support your answer for the diagnosis?

Answer 41

Myxoedema, heavy periods, decreased appetite, greasy hair Low T3,4 High TSH

Question 42

What treatment would you initiate in hypothyroidism? How long for and how would you assess this? What are possible complications specific to the surgery? (how long to notice hypoparathyroidism)

Answer 42

Give T4 (levothyroxine) 50-100mg, lifelong and assess by measuring TSH levels Recurrent laryngeal nerve palsy Hypoparathyrodism - usually within a day or two Hypocalcaemia - Troussea or Chovstek sign

Question 43

A 70 year old woman is admitted with nausea, polyuria and drowsiness. Her serum calcium is 4.2mmol/L (normal is 2.25 - 2.5) What is she suffering from?

Answer 43

Hypercalcaemia

Question 44

How would you manage hypercalcaemia? List 6 diseases associated with hypercalcaemia

Answer 44

Could give calcitonin or biphosphonates Non small cell lung cancer, bones cancers Hyperparathyrodiism, hyperthyrodiism Sarcoidosis, MENs syndromes, vit D failure

Question 45

Name 4 causes of adrenal insufficiency?

Answer 45

Addison’s disease Hypopituitarism Congenital 21-OH deficiency Trauma to hypothalamus

Question 46

What is the difference between primary and secondary addisons? What is the treatment of Addisons and addisonian crisis?

Answer 46

Primary addison - adrenal origin therefore high ACTH and hyperpigmentation Secondary - low ACTH and no pigmentation Treatment - hydrocortisone for corticosteroid replacement - cortisol fludrocortisone for mineralocorticoid replacement - aldosterone