Endocrine Prep

Question 1

What are the (i) investigations and (ii) management for someone with suspected SIADH?

Answer 1

(i) Fluid status, serum sodium low, plasma osmolality reduced, urine osmolality high, urine sodium raised, TFTs (hypothyroid), serum cortisol (low if Addisons), imaging for SCLC
(ii) Fluid restriction (1-1.5L/day), replace sodium (oral or IV), treat the underlying cause

Question 2

What are the (i) investigations and (ii) management for someone with suspected type 1 diabetes?

Answer 2

(i) random plasma glucose
fasting plasma glucose, 2h plasma glucose, plasma/urine ketones, HbA1c
(ii) INSULIN regimen planned to suit the patients lifestyle
- have HbA1c checked every 3 months + then 6 months when regular
- if pts smoke, advised to quit, dr should check BP, cholesterol + U+E yearly
- give foot care + refer for diabetic food and eye review
- screen yearly for peripheral neuropathy and ensure up to date vaccines

Question 3

What are the (i) investigations and (ii) management for someone with suspected T2DM?

Answer 3

(i) HbA1c, fasting+ random plasma glucose, 2h plasma glucose
(ii) LIFESTYLE = weight loss, alcohol reduction, physical activity, smoking cessation
1. METFORMIN = avoid if GFR less than 30
2. SULFONYLUREA (glicazide) or SGLT2 inhib (empagliflozin) or GLP1 agonist (exenatide) or DPP-4 inhib (sitagliptin) or basal insulin

Question 4

What are the (i) investigations and (ii) management for someone with suspected thyrotoxicosis?

Answer 4

(i) low TSH, high T3 and 4, may be mild anaemia, mild neutropenia (Graves), raised ESR, Ca and LFT. Check thyroid autoantibodies
(ii) Propranolol for rapid control of symptoms plus carbimazole for 12-18months (PTU if pregnant)
Radioiodine 131
Thyroidectomy

Question 5

What is the criteria for diagnosing diabetes mellitus?

Answer 5

1. Symptoms of hyperglycaemia and fasting of over 7mmol or random over 11.1mmol/L
2. Fasting (x2) over 7mmol/L, random over 11.1mmol/L or OGTT-2h value over 11.1mmol/L
3. HbA1c over 48mmol/L

Question 6

What are the (i) investigations and (ii) management for someone with suspected hypothyroidism?

Answer 6

(i) high TSH, low T4, TPO antibodies, macrocytosis, raised cholesterol + triglyceride
(ii) healthy + young = levothyroxine 50-100 micrograms. Review in 12 weeks, adjust 6 weekly
elderly or IHD = 25 micrograms and increase at 4 week intervals

Question 7

What are the (i) investigations and (ii) management for someone with suspected cushings?

Answer 7

(i) confirm diagnosis with raised plasma cortisol then localise the source
1st-line = overnight dexamethasone suppression test (no suppression in cushings) and 24h urinary free cortisol
2nd-line = 48h high dose DST pituiary will suppress and other causes wont
midnight cortisol
(ii) depends on the cause
1. Iatrogenic - stop meds if possible
2. Cushing’s = selective removal of adenoma or bilateral adrenalectomy if unlocalised
3. Adrenal adenoma/carcinoma = adrenalectomy

Question 8

What are the (i) investigations and (ii) management for someone with suspected Addison’s Disease?

Answer 8

(i) hyperkalaemia, hyponatraemia, hypoglycaemia and hypotension. Also: uraemia, increased calcium, eosinophilia, anaemia. Short synacthen test (ACTH stimulation), plasma renin + aldosterone, CXR (prev TB)
(ii) REPLACE STEROIDS: hydrocortisone and fludrocortisone.
Important to make patients aware of risk of stopping steroids abruptly and to double dose when febrile illness, injury or stress

Question 9

How do you treat an Addisonian Crisis?

Answer 9

1. Bloods - cortisol + ACTH, U+E (raised K and low Na)
2. Hydrocortisone 100mg IV
3. IV fluid bolus to support BP
4. Monitor blood glucose - danger of hypoglycaemia so glucose IV may be required
   Switch to oral steroids after 72h

Question 10

What are the (i) investigations and (ii) management for someone with suspected hyperaldosteronism?

Answer 10

(i) U+E (low sodium, high potassium), renin + aldosteronism
(ii) 1. CONN’S = laparoscopic adrenalectomy - spironolactone for 4wks pre-op controls hypokalaemia
2. HYPERPLASIA = spironolactone and elperenone (ARB)

Question 11

What are the differences between primary, secondary and tertiary hyperparathyroidism?

Answer 11

Primary = low phosphate and raised ALP from bone activity, increased calcium (weak/tired/thirsty/depressed) and PTH (pain/fractures/OP)
Secondary = low calcium and high PTH. Low vit D intake or chronic renal failure
Tertiary = increased calcium and PTH - after prolonged secondary hyperparathyroidism