Endocrinological Conditions Flashcards

Question

Diabetes and screening of complications (timeframe)

Answer 1

1. Diabetic retinopathy/Vision - At time of diagnosis - Optometry yearly - Ophthalmologist 1-2 yearly or early as indicated * * Add fenofibrate if signs of diabetic retinopathy 2. Diabetic neuropathy - At time of diagnosis - Annually * * 10g monofilament, 128Hz tuning fork 3. Foot care - Podiatry if at risk (6 monthly) 4. Nephropathy - Urine ACR and eGFR annually

Answer 2

Key words: weakness + polyuria + polydipsia Pathophysiology: impaired secretion of vasopressin Causes: postoperative (transient), cranial tumours/infections/infiltrations, anorexia nervosa Differentials: psychogenic Presentation: polyuria, nocturia and compensatory polydipsia (3-20L of urine per day) Treatment: desmopressin (intranasally BD)

Answer 3

Clinical features: distal symmetric sensory polyneuropathy, ‘stocking-glove’ sensory loss Signs and symptoms: ● Negative symptoms (nerve fiber loss or dysfunction) - numbness and weakness ● Positive symptoms (abnormal function of the surviving nerve fibers) - tingling and pain Examination: pinprick sensation, 10g monofilament, 128Kh tuning fork, ankle reflexes Differentials: ** consider if asymmetry, non-length dependence, predominant motor involvement, rapid onset ● B12 deficiency ● Alcohol use ● Cardiovascular ○ Suspect if resting HR > 100 bpm or orthostatic reduction in BP (>20mmHg) ● CKD ● Hypothyroidism ● Chemotherapy ● Idiopathic ** consider in absence of atypical features ● Peripheral artery disease Recommendations: ● Screen for at diagnosis and annually thereafter ● Assess with 10 g monofilament or tuning fork at dorsum of great toe Management: Difficult. Refer to the options below with evidence. ● Tricyclic medications (first-line) ● Gabapentin (⅓ of people) ● Pregabalin 300-600mg (high levels of benefit)

Answer 4

``` Alcoholic Risk factor: malnourished patients with chronic alcoholism with history of binge alcohol ingestion Clinical manifestations: ● N&V, abdominal pain ● Generalised abdominal tenderness , hepatomegaly, alcoholic hepatitis/pancreatitis ● Hypovolaemia/K+ depletion ● Tachycardia/hypertension ● Increased respiratory rate ``` Fasting Timeframe: ● 12-14 hours ● Peaks at 20-30 hours

Answer 5

Summary Group: postmenopausal women and men > 50 yrs - Minimal hip/vertebral trauma = initiate anti-osteoporosis medication - Minimal trauma at any other site = DEXA = T-score -1.5 refer to specialist - No history of minimal trauma = assess for risk factors ** Refer to page 217-218 of GP Study Notes

Answer 6

Non-modifiable - Parental history of fracture Modifiable - Premature menopause - Multiple falls - Low physical activity - Low body weight - Low muscle mass - Poor balance - Smoking - Alcohol >2 drinks/day - Vitamin D insufficiency Disease or conditions - Rheumatoid arthritis - Hyperthyroidism - Chronic kidney disease - Chronic liver disease - Diabetes - Myeloma - HIV infection - Depression Medications - Prednisolone - SSRI - Anti-psychotics

Answer 7

``` Non-pharmacological management ● Adequate dietary calcium intake 1300 mg a day ● Weight bearing exercises ● Maintain vitamin D level above 75 ● Smoking cessation advice ● Implement falls reduction strategies ``` Calcium supplementation - Total intake should not exceed 2000mg/day - Additional supplementation should only be considered if dietary intake is insufficient (max daily dose 500-600mg)

Answer 8

Bisphosphonates Tip: Must be taken on an empty stomach, at least 2 hours before calcium/iron/magnesium/ antacids Duration: Beneficial effects can persist for several years after ceasing. Consider ceasing after 5 years of oral therapy or 3 year of IV therapy. Can be continued for up to 10 years for oral therapy or 6 years for IV therapy. Management after cessation: Measure bone mineral density after 2-3 years. Therapy can be restarted if needed. Denosumab Considerations: ● Need to adhere for 6 months ● Life-long therapy or be replaced with bisphosphonate on cessation ● Risk of multiple spontaneous vertebral fractures if delayed for more than 4 weeks Parameters for prolia: Vit D > 50, corrected calcium normal, CrCl > 30 Dosing: denosumab 60mg subcut every 6 months Osteonecrosis of jaw ● Rare complication of bisphosphonates and denosumab. ● Benefit of therapy in preventing fractures often outweighs the low risk of osteonecrosis of the jaw. ● Risk is highest after dental extractions or dental implant insertion.

Answer 9

Raloxifene (60mg PO daily) - Reduced postmenopausal bone loss - Protects from vertebral fractures but not non-vertebral - Most appropriate in <60 years and women with high risk of breast cancer Tibolone (2.5mg PO daily) - Has oestrogenic and progestogenic effects. - Generally used for <60 years Oestrogen - Less harm is started in women at a younger age - Required in women with premature ovarian insufficiency until typical age of menopause (regardless of BMD status)

Answer 10

Teriparatide (synthetic PTH) 20 microg subcut once daily Second line treatment Strict eligibility criteria ● Must be started by a specialist ● T score -3 or less ● >2 minimal-trauma fractures (including a fracture at least 1 year of antiresorptive therapy) Contraindications: <25 years, known/suspected Paget disease, previous radiotherapy of bone, pre-existing hypercalcaemia/malignancy/severe kidney disease/primary hyperthyroidism

Answer 11

``` Non-pharmacological management ● Adequate dietary calcium intake 1300 mg a day ● Weight bearing exercises ● Maintain vitamin D level above 75 ● Smoking cessation advice ● Implement falls reduction strategies ``` ``` You decide to start the patient on Alendronate. What are 4 appropriate investigations? ● Dual-energy XR absorptiometry ● UEC ● Vit D ● Calcium ```

Answer 12

Aim: relieve symptoms and prevent complications. ● Lesions do not always normalise by symptom relief and normalisation of ALP occurs when the lesions become inactive. ``` Bisphosphonates ● E.g. zoledronic acid 5 mg IV over 15 minutes ● Requirements for infusion: ○ Vitamin D >50 ○ Corrected calcium in normal range ○ eGFR > 35 ○ Patient well hydrated ● Asymptomatic disease does not need treatment ``` Analgesia (commonly NSAIDS)

Answer 13

Pathophysiology: adrenomedullary tumor that produces catecholamines Presentation: paroxysmal hypertension, headaches, palpitations and sweating Screening test: plasma free metanephrines and normetanephrines, or urine total metanephrines

Answer 14

Key points ● Underdiagnosed cause of hypertension ● Classic presenting signs are hypertension and hypokalaemia Common causes: Aldosterone-producing adenomas (Conn syndrome) and bilateral adrenal hyperplasia Consider testing for in: ● Hypertension with diuretic-induced hypokalaemia ● Severe hypertension or drug-resistant hypertension ● Hypertension with adrenal incidentaloma ● Hypertension with sleep apnoea ● Hypertension with family history of early-onset of HTN or CVA (<40 yrs) ● All hypertensive first-degree relatives of patients with primary aldosteronism ● Hypertension and AF Initial evaluation: morning blood sample in seated patient = plasma renin activity or plasma renin concentration AND plasma aldosterone concentration

Answer 15

``` Work up ● Urinary calcium excretion ● Vitamin D level ● Serum creatinine and eGFR ● Bone density ``` Management ● Asymptomatic - work up as above and decide based on findings ● Symptomatic - work up with likely surgery

Answer 16

Pathophysiology: Inability to suppress the secretion of ADH Causes: Cancer, pulmonary disorders, intracranial lesions, drugs (carbamazepine, antipsychotics). Presentation: hyponatraemia (from ADH-induced water retention and secondary solute loss), hypoosmolality, and urine osmolality above 100 mosmol/kg Management: Treat underlying cause, fluid restriction (<800ml/day)

Answer 17

``` Hyperthyroidism: Graves disease Toxic adenoma Toxic multinodular goitre Postpartum thyroiditis Painful subacute thyroiditis Amiodarone Factitious ingestion ``` ``` Hypothyroidism: Hasimoto’s thyroiditis Iodine deficiency Amiodarone Lithium ```

Answer 18

TSH - Symptoms suggestive of imbalance - Goitre/nodules present - Thyroxine replacement - Preconception and during first trimester in patients with history F3, F4 - If TSH abnormal - Suspected pituitary or hypothalamic disease - Rapidly changing thyroid function - Thyroxine replacement for central hypothyroidism Ultrasound - Structural thyroid abnormality (nodule or goitre) - Prior to neck surgery for thyroid cancer - Following thyroid cancer surgery Antibodies - Thyroglobulin - Hashimoto’s or Graves, malignancy - Thyroid peroxidase - Hashimoto’s - TSH receptor - Graves Radionuclide thyroid scan - Aetiology of thyrotoxicosis not evident from pathology ** contraindicated in pregnancy, cease breastfeeding for 2-3 days post.

Answer 19

Signs and symptoms - constipation - menorrhagia - fatigue - weight gain Starting treatment ● Thyroxine 25 to 50 microg PO daily ● Adjust dose every 4-8 week as required ** Start at lower end for patient with cardiovascular disease *** Aim for TSH 0.5-2.5 for patients younger than 60, TSH 1-5 for > 60 years (requirement decreases with age) ``` When to refer ● Patients < 18 years ● Unresponsive to treatment ● Pregnant patients ● Cardiac patients ● Presence of goitre, nodule or other structural changes ```

Answer 20

Graves - TSH receptor antibodies - Asymmetrical goitre, proptosis - Elevated diffuse uptake pattern Toxic multi-nodular - Nodular goitre - Multifocal or focal uptake Painless postpartum - Autoimmune destruction - 1-6 month postpartum, followed by hypothyroidism - Near absent uptake Exogenous - No goitre - Near absent uptake Painful subacute - Viral, destruction of follicles - Tender goitre, thyrotoxicosis for 1-2 months following by hypothyroidism for 4-5 months Amiodarone induced ** Refer to pages 284-285 of GP Study Notes

Answer 21

Initial First line: Carbimazole 30 to 45 mg oral daily, BD or TDS. Adjust 4-6 weekly as required. Second line: Propylthiouracil (can cause severe liver disease; use if first-line not tolerated or before conception/first trimester or thyroid storm). Dose titration ● Consider down titrating every 4-6 weeks ● Base initial dose adjustment on FT3 and FT4 (TSH can take months to correct) **Do not stop treatment abruptly once thyroid hormones have normalised Adverse effects ● Agranulocytosis (rare, first months of treatment) ** Advise to stop medication and seek medical assessment if have acute malaise, fever or infection Symptoms ● Propranolol 10mg oral BD (can increase up to 40mg) ** do not add a second beta blocker if one ineffective

Answer 22

Findings: Elevated ESR, near absent uptake on nuclear thyroid scan Differentials: acute infectious thyroiditis, haemorrhage into thyroid nodule, Hashimoto's thyroiditis (rarer), Grave’s hyperthyroidism (rarer) Treatment: ** no role for antithyroid drugs during thyrotoxic stage ● Symptoms: propranolol 10mg oral BD ● Pain: Aspirin/ibuprofen (mild), prednisolone 40mg daily (severe)

Answer 23

** Refer to page 287 of GP Study Notes

Answer 24

Classification - Mild: 30-49 - moderate: 12.5-29 - severe: <12.5 ``` When to measure ● People at increased risk of vitamin D deficiency: ○ Institutionalised or housebound ○ Clothing that covers most of the skin ○ Dark skin (Fitzpatrick V and VI) ○ Medical condition (CLD, CKD) ○ Fat malabsorption (CF, coeliac, IBD) ○ Pregnant women (antenatal screen) ``` Supplementation Indication: ● Uncomplicated moderate to severe Vit D deficiency (<30) ● If starting drug therapy for osteoporosis (<50) ● Osteomalacia or rickets Treatment regimes: ● Mild: colecalciferol 25-50 mcg PO daily or 175-350 mcg PO weekly ● Moderate to severe: 75-125 mcg PO daily for 6 weeks, then 25-50 mcg daily