Endocrinology Flashcards
What causes hyperpigmentation in Addisons
HIGH ACTH
Preferred treatment hyperthyroidism during preconception,first trimester, postpartum
PTU- propylthiouracil
Which drug has risk of aplastic cutis and omphalocele in the foetus?
carbimazole
What is aplasia cutis?
Congenital absence of skin with or without absence of underlying structures such as bone
What risk does PTU have on the mother?
Hepatotoxicity
Next step of management if hyperthyroidism cannot be controlled by drugs?
Partial thyroidectomy in 2nd trimester
Secondary adrenal insufficiency
Cause?
Presentation?
Mostly iatrogenic
Cause: Long periods of steroids —> sudden cessation
Unexplained abdominal pain + nausea + vomiting
+/- postural hypotension ( dizziness/falls)
DKA
Presentation
DM type 1 mostly
Abd pain + vomiting + Kussmaul breathing (deep hyperventilation) + dehydration + glucose >11
Management DKA
- IV fluids
- IV insulin & measure ABG/VBG/capillary blood glucose
IV insulin infusion @ 0.1U/kg/hr
- *systolic BP >90
- IV fluids = 1 litre 0.9% NS over 1 hr
- *systolic BP <90
- IV fluids = 1 litre 0.9% NS over 10-15 mins
When blood glucose reaches below 12 - IV fluids to NS + dextrose 5% to avoid hypoglycemia
Correct hypokalemia with kcl after 1st litre of NS
Diagnosis DKA
pH < 7.3
Ketonemia >3 or Ketonuria ++
Glucose >11
Bicarbonate <15
Normal Ca + normal phosphate + normal ALP
Osteoporosis
Normal Ca + normal phosphate + HIGH ALP
Paget’s disease
LOW Ca + LOW phosphate + HIGH ALP
Osteomalacia
**stem may only mention high ALP and give hints to vit D deficiency
Muscle aches, proximal muscle weakness, poor sunlight exposure
Poor diet
ECG changes seen in Hyperkalemia
Tall tented T waves Prolonged QRS (QRS > .12s)
TX Hyperkalemia
1.Calcium gluconate/ carbonate
To protect cardiac membrane
2.reduce serum K+ with
- Insulin dextrose
OR
- Salbutamol inhalation
What is acromegaly
Excess growth hormone
In 95% of cases it is secondary to pituitary adenoma
Growth hormone normally suppressed by glucose
In acromegaly it is not.
What are the features of acromegaly
- Optic chasm compression —>
bitemporal hemianopia - Spade like hands
- Enlarged nose and jaw
Large tongue
Prognathism - protrusion of mandible
Interdental spaces
Initial screening test and F/U test acromegaly
IGF-1 (insulin like growth factors)
Confirmatory test / most definitive test of acromegaly
OGTT with serial growth hormone measurements
Bitemporal hemianopia
Loss of vision in outer half
Most importantly seen in
Acromegaly
Hyoerptolactinemia( pituitary macroadenoma)
Hypercalcemic manifestations in pt with prostate ca
Polyuria Polydipsia Confusion Depression/low mood Kidney stones Abdominal pain Constipation Bone pain
MOANS GROANS BONES STONES
Main causes of hypercalcemia
Primary hyperparathyroidism
Malignancy
Sarcoidosis
TB
Sarcoidosis
Inflammatory disease
Abnormal collection of inflammatory cells —> granulomata
Affects various parts of the body
Most commonly lung skin and lymph nodes
Management of hypercalcemia
1.REHYDRATION
IV fluid 0.9% NS
- Bisphosphonate
“Dronates”
Alendronate, Risendronate,Pamidronate”
Amenorrhoea + Hypothyroidism
Features of hypothyroid Weight gain inspire of decreased appetite Cold intolerance Myxoedema Bradycardia Dry coarse skin.constipation Hair loss Menorrhagia initially followed by oligomenorrhoea or amenorrhoea
Commonest cause of hypothyroidism in the Uk
Autoimmune hypothyroidism
Hashimoto thyroid it is
Commonest cause of hypothyroidism worldwide
Iodine deficiency
Hyperprolactinemia presentation
Milk discharge in non pregnant women + amenorrhoea
Amenorrhoea =low FSH/LH
Galactorrhoea = milk discharge
Main cause of hyperprolactinemia
Pituitary adenoma
Do MRI of brain
Visual defect in pituitary adenoma
Bitemporal hemianopia
Diabetic patient collapses and falls unconscious
What do you do first?
Random blood glucose
Blood glucose <4 hypoglycaemia
Features of hypoglycemia
Tachycardia
Sweating
Confusion
Altered mental state
Hypoglycaemia management
200 ml fruit if they’re conscious and can swallow
If they’re conscious but can’t swallow —> 200ml 10%glucose IV or 1mg glucagon IM or SC
If unconscious
IV 20% glucose 75ml
IV 10% glucose 50ml
1mg glucagon IM or SC
Causes of hypoglycaemia
Alcohol
Liver failure( impaired gluconeogenesis)
Excess paracetamol or aspirin
Sulphonylureas (glibenclamide, gliclazide)
Why is glycosuria normal after surgery?
Stress hyperglycaemia
Stress increases the cortisol secretion —> hyperglycaemia
Resolves on its own a few days post op
What cause hypercalcemia in Squamos cell carcinoma SCC
Paraneoplastic effect
SCC releases parathyroid like molecules causing hypercalcemia
What derangement does small cell lung ca cause?
High ADH -> SIADH -> dilution also hyponatremia and hypokalemia
High ACTH -> Cushing syndrome
What medication do you give T2DM with impaired renal function
Insulin
Or
Gliptins DDP4 inhibitors
What diabetic meds are CI in T2DM with obesity and impaired renal function
Metformin (Biguanides)
- first line for T2DM however CI in GFR< 30
If GFR <45 dose should be reduced
Sulfonylureas (Glibenclamide)
- increases risk of hypoglycemia in impaired renal fn + increases weight
Glitazones ( Pioglitazone) increases weight
SG.T2 inhibitors CI in GFR< 60
WITH BAD KIDNEYS AVOID MS
(secondary amenorrhoea)
Cessation of menstruation >6 months after it has been established
Hypothalamic amenorrhoea
Occurs with stress, exercise, significantly low BMI
Due to hypothalamic failure
HIGH PROLACTIN seen
Dec. GnRH —> dec. FSH LH —> subsequent dec in oestrogen
Pheochromocytoma
Adrenal tumour
Secretes catecholamines - epinephrine , norepinephrine
EPISODIC
Features - HTN, headache , sweating, tremors, palpitations, anxiety
Known case of small cell lung ca presents with frequent falls and confusion
Diagnosis?
SIADH
High ADH - dilutional hyponatremia due to fluid retention
Small cell ca = high ACTH - Cushing
Treatment of choice - pheochromocytoma
Surgical resection
7-10 days before, stabilise HTN with, to prevent intraoperative HTN crisis
alpha blockers - PHENOXYBENZAMINE
Followed by Beta blockers - PROPANOLOL
T2DM + Microalbuminuria + mild HTN + Hypercholestrolemia
What do you give?
Metformin - control BG
ACEi - reduce BP, slow progression of kidney damage
(Kidney damage - microalbuminuria +T2DM)
Statins for the cholesterol
** T2DM + HTN - ALWAYS ACEi unless there is severe renal impairment
They are Reno-protective
DM poses risk of nephropathy, so ACEi slow the progression
Case - 54 year DM HTN on metformin ramipril bisoprolol
HBA1C 52
Management?
On metformin, HBA1C <58 — lifestyle modifications
New onset T2DM, first advice
Lifestyle modification
New onset T2DM, after lifestyle modification HBA1C high, but >48
Management?
Start 1 hypoglycaemic
51 year old T2DM on metformin, HBA1C >/= 58
Management?
Add another hypoglycaemic agent
When do you advise lifestyle changes in T2DM
New onset DM
Or
Already on metformin, HBA1C <58
When do you consider adding another hypoglycaemic agent
If already on one but HBA1C >= 58
Case of
Uncontrolled DM2 despite lifestyle Despite lifestyle changes + EGFR <30 and there is a history of heart failure and BMI> 30
What do you give?
Insulin
EGFR 30- Metformin contraindicated
Sulphonylureas- contraindicated obese + impaired GFR
Gliptins (DDP4) inhibitors contra indicated heart failure
Glitazones - CI in obesity, HF, bladder ca
When is metformin CI
GFR < 30
If <45 - reduce dose
When are sulphonylureas CI
Obesity
Impaired GFR
When are Gliptins(DDP4) CI
Heart failure
Diagnosis of pheochromocytoma
24 hour urine collection of metanephrines
If not available as option pick
24 hrs catecholamine
MRI to confirm
When is Pioglitazone CI
Obesity
Heart failure
Bladder ca
What is Addison’s disease?
What are the features?
Primary adrenal insufficiency
Most common cause UK - autoimmune
Worldwide - TB
LOW cortisol & aldosterone
Postural hypotension (dizziness & vertigo)
Weakness and fatigue
Nausea, vomiting, abdominal pain
Hyperpigmentation of skin and mucous membranes
What causes hyponatremia & Hyperkalemia in Addisons
LOW aldosterone
Most common causes of addisons in developed and developing world?
Developed - Autoimmune
Developing- TB (infection)
What causes postural hypotension and dizziness in Addisons
LOW Cortisol
What investigations are done for Addison’s?
DEFINITE investigation in suspected Addison’s - short ACTH stimulation test (short Synacthen test)
What is the Synacthen test?
Plasma cortisol measured before, and 30 mins after giving Synacthen 250ug IM
Adrenal autoantibodies e.g. anti-21-hydroxylase may also be demonstrated
If ACTH stimulation test not available , what do you do?
9 am serum cortisol
> 500 nmol/l - unlikely
<100 nmol/l definitely abnormal
100-500 nmol/l - ACTH stimulation should be performed
Management of addisons
Glucocorticoid and Mineralocorticoid replacement therapy
Hydrocortisone - 2-3 divided doses
20-30 mg per day - majority given in the morning
Fludrocortisone
***patient education
Importance of not missing doses
Consider medi alert bracelets & steroid cards
Management of inter current illness in Addisons
Double dose of glucocorticoid
What is Addisonian crisis
Adrenal crisis
Life threatening
Acute insufficiency of adrenal hormones (gluco/mineralo-corticoids)
Addison’s disease has more gradual course - adrenals don’t produce enough steroids over several months
Illness or acute stress can ppt adrenal crisis
Features of Addisonian crisis
Severe weakness / excessive tiredness Confusion Lower back or leg pain Severe abdominal pain vomiting diarrhoea —-> dehydration Reduced consciousness or delirium
HypoNA hyperK Hypoglcemia
Causes of addisonian crisis
Sepsis/surgery
- acute exacerbation of chronic insufficiency (addisons, hypopituitarism)
Adrenal haemorrhage - Waterhouse- Friedrichsen syndrome ( fulminant meningococcaemia)
Steroid withdrawal
Tx of Addisonian crises
Hydrocortisone 100mg IM/IV
1L NS - infuse over 30-60 mins + dextrose if hypoglycaemic
- continue to give 6 hourly until stable
-Oral replacement after 24 hours - maintenance over 3-4 days
ECG monitor
Antibiotics if there’s infection
Iv hydrocortisone in 5% dextrose
Congenital Hypothyroidism
What are the complications ?
JAUNDICE - prolonged physiological jaundice, starts 24hrs of birth, lasts a long time)
FTT
Short stature
Impaired mental development
Broad flat nose, wide set eyes, protruding tongue
T1DM with DKA, came unwell , with altered LOC + tachycardia + signs of dehydration
What investigations are done?
- CBG
2. ABG
Young male found outside local pub semi-conscious profusely sweating with diaphoretic skin GCS 12/15 tachycardic and hypotensive
What is the likely diagnosis
Hypoglycemia
Alcohol is most commonest cause of hypoglycemia in adults
What is Whipples triad?
Diagnosis of hypoglycaemia
1. Low plasma glucose <4 usually
2. Manifestations of hypoglycaemia
sweating confusion tachycardia hypotension altered mentation
3.If blood glucose is corrected rapid resolution of symptoms occur
What is Conn’s syndrome?
What features are seen?
What is the most common cause?
Primary hyperaldosteronism - excess aldosterone
Adrenal adenoma
Hypokalaemia)and hypertension
bilateral idiopathic adrenal hyperplasia is the cause in up to 70% of cases
Think Conn’s syndrome if …
Hypertension and hypokalaemia or refractory hypertension despite three or more antihypertensive drugs or hypertension before the age of 30
other possible manifestations - weakness lethargy headache
What investigations should be done in Conn’s syndrome?
Plasma aldosterone/renin ratio - first line investigation
= high aldosterone + low renin - negative feedback due to Na retention from aldosterone
high resolution CT abdomen and adrenal vein sampling
= to differentiate b/w unilateral & bilateral sources of aldosterone excess
What is the most suitable hormone to order in a patient with Hypertension + Hyperkalemia +/- headaches, weakness , lethargy
Aldosterone
Treatment of Conn’s syndrome (primary hyperaldosteronism)
Aldosterone antagonist - Spironolactone
Before you consider adrenalectomy
Conn’s syndrome
Excess aldosterone —-> Hypertension Hypokalemia, can be normokalemia Normal Na+ or upper normal Headache, weakness \+/- METABOLIC ALKALOSIS \+/- Polyuria ( due to aldosterone escape)
Addisons VS Conn’s VS Pheochromocytoma
Addisons - low cortisol, low aldosterone
HypERkalemia, hyPOtension, metabolic ACIDOSIS
Conn’s - high aldosterone
HyPOkalemia, hyPERtension, metabolic ALKALOSIS
Pheochromocytoma - high catecholamines
PHE + F - palpitations, headache, hypERtension, flushing/sweating , episodic
DM2 - preoperative management
Minor surgery - stop oral hypoglycaemic NIGHT B4
Major - continue same routine
Alternative
Minor procedure e.g upper gi endoscopy and pt on oral hypoglycaemic e.g glicazide - omit morning dose and restart once they are eating/drinking
DM1 - pre-op management
Minor surgery - omit insulin on day of surgery
Major - sliding scale IV insulin before surgery and continue until diet per mouth re-established
Diagnostic criteria of DM
DM symptoms + 1 abnormal value
Or
2 abnormal values w/o symptoms
Abnormal value = FBG >/= 7 nmol or HBA1C >/= 48 (>= 6.5%)
Prediabetes - impaired glucose tolerance
Fasting 5.5-6.9
2 hr PP - 7.8 - 11
HBA1C - 42-47
What is the diagnostic test for DM in pregnancy
OGTT
32 year old female presents with polyuria polydipsia and positive glucose in urine
what investigation would you do?
Measure fasting blood glucose
(NOT RANDOM)
FBG is cheaper
HBA1C is more expensive usually used if there is uncertainty
Causes of hypoglycaemia
Drugs: sulfonylureas, paracetamol, aspirin
Alcohol intoxication,liver failure (impaired gluconeogensis)
Addison’s disease (low cortisol —> hypoglycemia)
What is MODY( maturity onset diabetes in the young)??
What treatment is used?
DM < 25 years old
Strong family history (two generations)
mild hyperglycaemia
Respond to sulfonylureas , no need for insulin initially
Cushing’s disease vs Cushing’s syndrome
Both are due to excess cortisol levels, but the causes are different
Cushings disease =
- tumour on pituitary gland that produces excess ACTH —> incr cortisol
- ACTH responsible for production of cortisol via adrenal glands
ACTH suppressed by low (overnight) or high dose dexamethasone
Cushing’s syndrome =
- causes OUTSIDE the body that increase cortisol levels
E.g. meds, corticosteroids
Features of cushings
Hypertension that requires two or more antihypertensive agents Truncal obesity Hypoglycaemia Moon face Striae Cardiac hypertrophy Osteoporosis Weight gain Proximal muscle weakness Easy bruising Liability to infections Hypernatraemia and hypokalaemia Enlarged supraclavicular fat pads
Cushing syndrome investigations for diagnosis
Best initial ?
Outpatient?
Best initial - overnight dexa suppression test - 1mg low dose
Outpatient - 24 hr urinary free cortisol
To localise lesion HIGH dose dexa supression test
Excess cortisol, low ACTH - next step?
Low ACTH rules out ectopic cause —
So it could be adrenal tumour — adrenal ct
Excess cortisol intake
Excess cortisol, ACTH high - what do you do?
High dose dexa suppression to localise lesion If suppressed (low cortisol) — pituitary adenoma — pituitary MRI Not suppressed - cortisol still high —> ectopic cause - CT chest & abdomen
How is the dexa suppression test done?
Low dose test:
1mg dexa
Low cortisol —> normal
High/normal cortisol — Cushing’s syndrome
High dose test:
8mg dexa
Low cortisol - cushings disease
High/normal - ACTH low - adrenal cushings
- ACTH high - ectopic ACTH
What metabolic imbalance does vomiting cause?
Metabolic alkalosis
Due to loss of H+, body keeps CO2 to compensate via hypoventilation
High pH, High pCO2
What metabolic imbalance can occur secondary to acute kidney injury what ECG changes will you see
What is the initial step in management
Hyperkalemia
Tall tented T waves
Protect cardiac membrane —> IV Ca gluconate or Ca carbonate + ECG monitor
A 60 year old patient comes with a deep 4x3 cm ulcer on her left heel, it is painless.
She also mentions she has frequent urination, weight loss, and fatigue?
What investigations will you request?
BLOOD SUGAR
DM diagnosis
What situations does stress hyperglycaemia occur?
How do you manage it?
Pneumonia
MI
Stroke
Post-operatively.
= resolves spontanteously
A 43 year old man has just undergone a surgery, post op labs showed K+ >6.4 and on examination there are crackles over the lungs, and he has sacral oedema
What do you do?
Acute kidney injury secondary to HF
2 things
Calcium gluconate to protect heart
We want to push the K+ intracellularly to prevent life threatening arrythmia
= IV insulin + glucose
Crackles/ sacral oedema - think HF
IV insulin w/ glucose moves K+ into cells TEMPORARILY so give IV NS unless the patient is overloaded (HF!!)
If well hydrated or overloaded - start diuretics - lasiks (furosemide) or Calcium resonium
Acute renal failure
+ Anuria
+ severe hypokalemia
What do you do?
Hemodialysis especially if K+ >/= 7.5
A 53 year old woman comes with complaints of drowsiness and feeling thirsty all the time
She is a known case of breast cancer
What metabolic abnormality do you suspect?
Hypercalcemia - bone mets
A 43 year old male camels with a lump on the front of his neck that moves open swallowing. He also complains of weight loss even though he has a good appetite, palpitations, heat intolerance and restlessness.
What is the diagnosis?
Toxin nodular goitre
A 35 year old woman comes with complaints of panic attacks, headaches, palpitations, excess sweating and tremors. Her BP 140/100 What is your diagnosis? What investigations? Treatment?
Pheochromocytoma - rare catecholamine secreting tumour
PHE +F
24 hr urine collection of METANEPHRINES
Treatment -
Stabilise HTN with alpha blockers + beta blockers - phenoxybenzamine
Then propanolol
Surgical removal of adrenal tumour
What is the rule of 10 in pheochromocytoma?
Rule of 10 - 10% bilateral 10% malignant 10% extra- adrenal 10% familial 10% without HTN
A 23 year old woman came with complaints of tender and painful thyroid, the pain radiates to her lower jaw. She had a cold 1 week ago. And also compaints of palpitions and tachycardia.
On examination her thyroid is not enlarged.
Lab investigations:
Negative thyroid auto antio bodies
Decreased radioactive iodine uptake
What is your diagnosis?
Subacute thyroiditis DE QUERVAINS THYROIDITIS - painful !!!* Initially hyperthyroidism followed by hypothyroidism Follows URTI usually
Treatment - it is self limited
Pain and inflammation - give NSAIDS
Beta blockers to control arrhythmia*** IMP
*note - its not graves or hashimito as the antibodies are negative
Graves’ disease has INcreased uptake of iodine
What is a thyroid storm?
How do you manage it?
Thyroid crisis precipitated by infection
Sick patients - low GCS, palpitations, tremors, tachycardia, feeling warm
(Thyrotoxicosis)
AFIB can be seen secondary to the thyrotoxicosis
Propanolol - oral or IV
PTU* (if there is no storm, no pregnancy - carbimazole is 1st line)
Treat infection - broad spec antibiotic
Hypoglycaemic episode in a diabetic patient who presents with: drowsiness confusion fatigue, tremors, blood vision and sweating.
What investigation should be done?
Immediately check random blood glucose there is no time to check fasting.
A 45 year old man has undergone a thyroidectomy, he now complains on tingling, numbness and parenthesis. He also mentions he has random spasms in his upper arms.
What is your diagnosis?
Hypocalcemia
Due to hypoparathyroidism after thyroidectomy
Dec parathormone (PTH) - dec serum calcium
Cause of hypocalcemia
Osteomalacia - vit D deficiency
Chronic renal failure
Hypoparathyroidism - esp post thyroidectomy
Hyomagnesemia
HypERphosphatemia
Panic attacks - hyperventilation - transient hypoCA
Calcium and phosphate have an inverse relationship.
**Hypocalcaemia can occur in diabetic patients because of chronic renal failure which causes hypocalcaemia (diabetic nephropathy)
Features of hypocalcemia.
What are the signs seen?
Treatment
SPASMODIC Spasms Perioral parenthesia Anxious Seizures Muscle tones increase in smooth muscle Orientation impaired / confusion Dermatitis Impetigo herpetiform Cardiomyopathy - prolonged QT on ECG
Trousseaus’s sign- after occlusion of brachial artery —> wrist flex ion
Chvostek’s sign —> tapping over parotid - facial muscles twitch
Treatment - 10ml of 10% ca gluconate - initially
What is SIADH?
What is seen?
What is the management?
What is the 2nd line if first treatment fails?
Syndrome of inappropriate ADH
Can happen secondary to SMALL CELL CA — water retention
And 2nd to meningitis
Dilutional hyPOnatremia - patient is overloaded
Mainstay tx - fluid restriction
If failed —> Tolvaptan or Demeclocycline
Associated autoimmune diseases in Hashimotos
Vitiligo
Addison’s disease
Pernicious anemia
DM type 1
Case - 9 year old child, obese, short, with abdominal striae and history of renal transplant
Cushing syndrome
High cortisol- high glucose - low growth hormone
Steroids are anti vit D
Classification of pituitary adenoma
They are a type of pituitary adenoma - benign tumour
Can be classified according to:
size - <1 cm micro >1cm macro-adenoma
Hormonal status
- secretory/functioning = excess hormone
-non-secretory/non functional = no hormone
Prolactinomas** - most common
Excess prolactin
.
What effects does excess prolactin have?
Men: impotence, loss of libido, galactorrhoea
Women: amenorrhoea, infertility, galactorrhoea, osteoporosis
Diagnosis of prolactinoma
Confirmatory test?
Serum prolactin
= normally <400
If >= 5000 - suspect macroadenoma
If > 200 keep prolactinoma in mind
FSH LH oestradiol - LOW
MRI brain - confirmatory test
Management of prolactinoma
- 1st line = dopamine agonist
- Cabergoline, Bromocriptine
Inhibit prolactin from pituitary gland
Cabergoline more effective in micro prolactinoma - Second line ( if no response from first)
Transphenoidal surgery to remove prolactinoma
Manifestations of hyperprolactinemia
Galactorrhoea Amenorrhoea or oligomenorrhoea Headaches Infertility Visual disturbances Bitemporal hemianopia
Diabetic neuropathy
Glove and stocking - loss of fine touch and pain
Starts in toes and ascends
Loss of ankle jerk bilaterally
Mechanism - micro vascular injury - nerve damage
What drugs can cause Hyperkalemia
Levels of hyper K
Treatment
ACEi (-pril)
K+ sparing diuretics - spironolactone
Mild = 5.5-5.9 Moderate = 6-6.4 Severe = >6.5
Mild - stop meds
Mod/severe or ECG changes - ca gluconate
Insulin + dextrose
Isolated high ALP
BBP
Bones - osteomalacia, paget’s disease, hyperparathyroidism, donuts bone metastasis
Biliary tract : Cholestasis (Obstructive jaundice)
Pregnancy: (physiological finding)
Diabetes insipidus
Cranial vs nephrogenic
Diabetes Insipidus
= passage of large volumes (>3L/24hrs) of dilute urine <300mOsm/kg
Cranial or nephrogenic
Low urine osmolality
Give a vasopressin —> urine osmolality will increase
= diagnosis of central (cranial) DI
If no change after vasopressin - large volumes of urine high serum osmolality, low urine osmolality
= nephrogenic
SIADH vs Diabetes inspidus
SIADH = hypOnatremia
Low S - serum sodium , low serum osmolality, high urine osmolality
Cerebrum/cerebellum
DI= hypِERnatremia
Low urine osmolality, high serum osmolality
Urine osmolality increases after vasopressin
DIencephalon
How to differentiate DI and SIADH
Urine osmolality
If < 800 - likely DI (low urine osmolality)
SIADH has high urine osmolality
DI - is it central or nephrogenic?
= fluid deprivation test and then give desmopressin/vasopressin
**if urine osmalilty not given and you suspect DI
Choose fluid deprivation and response to vasopressin
High prolactin >2000 + hypogonadism + amenorrhoea + infertility
What are differentials?
Prolactinoma
Ddx:
PCOS - LH : FSH >2 LH is double FSH if not more
Premature ovarian failure - before age of 40
FSH is HIGH >25 on 2 occasions, 4 weeks apart
Hypercalcemia
Give causes and presentation
the treatment
Cause : SCC of the lung - hypERcalcemia Primary hyperPTH Multiple myeloma Sarcoidosis Metastasis - breast, prostate
Presentation: Neuro - lethargy, confusion, depression GIT - constipation Renal - polyuria, polydipsia CVS - short QT
Tx: Initial step - IV NS 0.9%
Then bisphosphonates - pamidronate, zolendronate infusion
Thyroid nodule >= 1cm
Initial step?
Most appropriate step?
Initially - US thyroid
FNAC - most appropriate
What drugs cause hepatitis?
Augmentin (co-amoxiclav) - especially in ppl with deteriorated liver fn e.g alcoholics
Clavulanic acid - highly toxic
If already at risk for hepatic impairment - chronic alcoholism
Hepatic excretion will be impaired -> CHOLESTASIS (dark urine, jaundice), high bilirubin and drug induced hepatitis (high ALP AST ALT)
Alcoholic hepatitis - AST>ALT
Drugs that cause hepatic cholestasis
Co-amoxiclav
Flucoxaxillin
Steroids
Sulphonylureas
Side effects of ACEi
Angioedema
Cough
Electrolyte - Hyperkalemia
Increased potassium
Side effects of spironolactone and thiazides diuretics
Spirononlactone - Hyperkalemia
Thiazides - hypOkalemia, hypOnatremia, hypERglycemia, hypERuricemia= GOUT high Uric acid
Metabolic alkalosis
DOC for Hyperthyroidism in pregnancy 2/3rd trimester and in non pregnant women
Carbimazole
What are the causes of autonomic nephropathy?
What are the manifestations?
Diabetes
Alcohol
Aging
Sweating, incontinence, diarrhoea/constipation, impotence, postural hypotension
**suspect it in DM pt with diarrhoea
Metformin can also cause diarrhoea
Pseudo gout
Where is the commonest site?
What is its pathognomonic feature?
What disease is it associated with??
Knee
On aspiration of synovial fluid - +ve Birefringent crystals
Hypothyroidism
What can hypothyroidism be associated with?
Pseudo gout
Amennorrhoea / oligomenorrhoea
Hyperprolactinemia
Autoimmune disease. - Addison’s, pernicious anemia, vitiligo, DM1
Gout vs Pseudogout
Gout - small joints, intense pain , inflamed joint, hypERuricemia, synovial fluid has uric acid crystals (-ve birefringent crystals)
Pseudo - large joints, moderate pain, swollen joints, chondrocalcinosis, calcium pyrophosphate crystals +ve birefringent.
He of SCC if lung + hypercalcemia
What is the NEXT step?
Check serum PTH level
In malignancy PTH is low
After that -
Check ALP, if high - suspect bone mets
SO
In lung ca - if ALP and Ca and high - bone metastasis
High corrected calcium + high ALP
What could it be?
Bone mets
Thyrotoxicosis
Sarcoidosis
High corrected Ca + high albumin + high urea = ??
Dehydration
High corrected Ca + High serum calcitonin =??
B cell lymphoma
Elderly woman comes with multiple fractures a T score of -2.5 or lower
What is your diagnosis?
What is your 1st line of management?
Osteoporosis
1st line - bisphosphonates
Side effects of HRT (hormone replacement)
VTE
Stroke
Breast ca
Coronary diseases
What are t-scores
Assessed by DEXA scan , they reflect bone mineral density (BMD)
- 1 or higher = normal
- 1 —> -2.5 - osteopenia
- 2.5 or lower - osteoporosis
Antipsychotic agent that causes dizziness and erectile dysfunction in men?
Haloperidol
It blocks dopamine 2 receptors and causes hyperprolactinemia => erectile dysfunction
First line treatment of thyrotoxicosis
Carbimazole
Except ***
Thyroid storm - PTU
Preconception or 1st trimester pregnant woman or postpartum
Carbimazole is used 1/day
PTU 2-3/day - higher risk of liver injury
Never use iodine in graves ophthalmopathy or in pregnancy
Best management of hypoglycemia in unconscious pt
IM 1mg glucagon
Others
75ml of 20% glucose IV 10-15mins
50 ml 10% glucose over 1-2 mins
Glucose gel useful in drowsy pts not in unconscious.
Causes of hypokalemia
Symptoms
ECG
Vomiting - loss of H+ - metabolic alkalosis- less K+
Chronic alcoholism
2 C’s - cushing, conn
Renal - bartter’s syndrome ( neonates/children, AR)
Sx- tiredness, FAINTING, weakness, leg cramps,
K+ <2.5 or <3+ Uwave = IV KCL 40mmol in 1L NS
K+ >= 2.5 no ecg changes - oral supplement K+
Remember to order Mg+ and ABG to exclude metabolic alkalosis
Postpartum thyroiditis
Management?
What antibodies are positive?
Usually resolves in 1 year after delivery so anti thyroid meds not needed
However in hypothyroid phase, you can give level thyroxine
Thyroid peroxidase antibodies - +ve in 80% cases
Treatment of SIADH
- Fluid restriction
If that fails - Tolvaptan or Demeclocycline
Hyperparathyroidism
Classification
Primary - N/H PTH, High Ca, Low Phosphate
Cause - parathyroid adenoma
Imp ddx is familial hypocalciuric hypercalcemia
Secondary - high PTH, low/N Ca, H/N phosphate
Causes - vit D deficiency. Chronic renal failure, prolonged hypocalcemia
Tetiary - ESRD
Congenital adrenal hyperplasia
Presentation
What test do you order?
Most commenest for>?
Autosomal recessive 1:4 if parents are carriers
11 beta hydroxylase deficiency
Neonates/ children -
Female - ambiguous genitalia
Males - penile enlargement, hyperpigmentation
Infant males - salt wasting ( aldosterone deficiency)
Order aldosterone
In adults
Males - no sign, maybe hyperpigmentation
Females - hirsute Sam, early pubarche, oligomenorrhoea, acne
Order 17-hydroxyprogesterone
Most commonest form - 21 alpha hydroxylase deficiency
Bartter’s syndrome
Cause?
Presentation?
Treatment?
usually AR
Severe hypokalemia
NKCC2 in ascending loop of Henle - defective chloride absorption
Presents as FTT Or polyhydramnios in week 24-30 Excessive polyuria/polydipsia after birth Normotension Weakness
Treatment -
Na K Cl replacement
Spironolactone to reduce K+ loss
Water access
NSAIDS if supplementation alone doesn’t work - reduces glomerular filtration
Should be given with acid suppression therapy to protect stomach
ACEi to reduce GFR
Renal US to monitor development of nephrocalcinosis
Side effects of loop diuretics
Furosemide, bumetanide
Hyponatremia
Hypokalemia
Gout
Side effects of thiazides
Indapamide, bendroflumethiazide
Hyponatremia Hypokalemia Gout (hypERuricemia) Postural hypotension Hyperglycaemia
Side effects of K+ sparing diuretics
Spironolactone
Eplerenone
Hyponatremia
HypERkalemia
Gynecomastia
Side effects of ACEi
Angioedema
Dry cough
Hyperkalemia
Test to differentiate DM1 from DM2
GAD - glutamic acid decarboxylase antibodies test
Test to diagnose insulinoma
C-peptide test
Insulinoma - causes pancreas to release too much insulin
What hypoglycaemic meds does MODY respond to?
And what else should be done
Sulphonylureas
Referral for genetic counselling
*** if patient is SYMPTOMATIC + HAS 1 ABNORMAL DM TEST - no need to repeat test
What is LADA?
What test should be done if you suspect it?
When is it usually diagnosed?
Treatment
Latent autoimmune diabetes of adulthood
Presence of any B cell antibody
If suspected = GAD antibodies (glutamic acid decarboxylayse Abs)
Tx= like DM 2 - however need for insulin occurs earlier
What is Sheehans syndrome?
Postpartum hypopituitarism
Symptoms of Sheehan
Severe hypotension = due to severe postpartum haemorrhage
== pituitary ischemia and necrosis == hypopituitarism
+ decrease in pituitary gland hormones - GH TSH prolactin LH FSH ACTH
Earliest and most important features of Sheehan
Agalactorrhoea - low prolactin = low milk prod
Amenorrhoea
Hypothyroid symptoms - cold intolerance weight gain etc
Best initial test Sheehan
Provocative hormonal testing
Most accurate test
MRI of pituitary gland + hypothalamus to r/o tumour or other pathology
Treatment - sheehan
Life long hormone replacement
High/normal PTH + high ca + low phosphate
Dx
1ry hyperparathyroidism
ESRD + high PTH + high calcium + high phosphate
Dx
Tertiary hyperparathyroidism
