Endocrinology Flashcards
A 12-year-old white girl is brought to the emergency department by her parents due to 12 hours of rapidly worsening nausea, vomiting, abdominal pain, and lethargy. Over the last week she has felt excessively thirsty and has been urinating a lot. Physical examination reveals a lean, dehydrated girl with deep rapid respirations, tachycardia, and no response to verbal commands.
Type 1 Diabetes Mellitus
Investigations: Random plasma glucose greater than 11.1 mmol/L or Fasting plasma glucose greater than 7 or HBA1c greater than 6.5% or 48mmol
Treatment: 1st line is basal bolus insulin and 2nd line is metformin
A 20-year-old man is brought to the accident and emergency department with abdominal pain, nausea, and vomiting with increasing polyuria, polydipsia, and drowsiness since the previous day. He was diagnosed with type 1 diabetes 2 years previously. He mentions that he ran out of insulin 2 days ago. Vital signs at admission are: BP 106/67 mmHg, heart rate 123 beats per minute, respiratory rate 32 breaths per minute, temperature 37.1°C (98.8°F). On mental status examination, he is drowsy. Physical examination reveals Kussmaul’s breathing (deep and rapid respiration due to ketoacidosis) with acetone odour and mild generalised abdominal tenderness without guarding and rebound tenderness. Initial laboratory data are: blood glucose 25.0 mmol/L (450 mg/dL), arterial pH 7.24, PCO2 25 mmHg, bicarbonate 12 mmol/L (12 mEq/L), WBC count 18.5 × 10⁹/L (18,500/microlitre), sodium 128 mmol/L (128 mEq/L), potassium 5.2 mmol/L (5.2 mEq/L), chloride 97 mmol/L (97 mEq/L), serum urea 11.4 mmol/L (32 mg/dL), creatinine 150.3 micromol/L (1.7 mg/dL), serum ketones strongly positive.
Diabetic Ketoacidosis
Investigations: Venous blood gas, blood ketones, glucose U and Es and FBC
Treatment: 1st line is IV fluids 0.9 saline +- Potassium replacement then supportive care, referral and insulin IV ar 0.1 unit per kilogram and restore electrolytes
An overweight 55-year-old woman presents for preventative care. She notes that her mother died of diabetes, but reports no polyuria, polydipsia, or weight loss. BP is 144/92 mmHg, fasting blood sugar 8.2 mmol/L (148 mg/dL), HbA1c 65 mmol/mol (8.1%), LDL-cholesterol 5.18 mmol/L (200 mg/dL), HDL-cholesterol 0.8 mmol/L (30 mg/dL), and triglycerides 6.53 mmol/L (252 mg/dL).
Type 2 diabetes mellitus in adults
Investigations: Fasting plasma glucose greater than 7, HBA1C greater than 48,OGTT greater than 11, random greater than 11.1
Treatment: 1st Line is lifestyle and metformin then add a sulphonylurea or a DP44 inhibitor or pioglitazone or SGLT2 inhibitor then triple therapy then insulin
Notes: P - weight gain, fluid retention, HF and anaemia, S- weight gain, hypo, CVD and Mi
DPP4 -GI upset, resp, pancreatitis
GLP-1 : Weight loss, GI upset, dizziness and hypo
SGLT2: Risk UTI, weight loss, DKA? but decreases CVD risk
Case history #1
A 72-year-old man is brought to hospital from a nursing home for progressive lethargy. The patient has a history of hypertension complicated by a stroke 3 years previously. This has impaired his speech and rendered him wheelchair-bound. He also has schizophrenia for which he was started recently on clozapine. On presentation, he is disoriented to time and place and febrile, with a temperature of 38.3°C (101°F). Vital signs include a BP of 106/67 mmHg, heart rate of 106 beats per minute, and a respiratory rate of 32 breaths per minute. Initial laboratory work-up reveals a serum glucose of 52.7 mmol/L (950 mg/dL), a serum sodium of 127 mmol/L (127 mEq/L), a serum urea of 21.1 mmol/L (59 mg/dL), and a serum creatinine of 200 micromol/L (2.3 mg/dL). Serum osmolality is calculated as 338 mOsm/kg (338 mmol/kg). Urinalysis reveals numerous white blood cells and bacteria. Urine is positive for nitrates but negative for ketones. Serum is negative for beta-hydroxybutyrate.
Case history #2
A 45-year-old man with a history of type 2 diabetes is admitted directly from clinic for a serum glucose of 53.8 mmol/L (970 mg/dL). He was started recently on basal bolus insulin therapy after several years of treatment with oral antiglycaemic agents. However, he reports not having followed his insulin prescription because he struggles to inject himself. For the past 2 weeks he has had polyuria and polydipsia, and has lost 5 kg in weight. He has also noted a progressively worsening cough for approximately 3 weeks that is productive of greenish-brown sputum. On examination, he is febrile, with a temperature of 38.5°C (101.3°F), tachypnoeic (respiratory rate of 24 breaths per minute), and normotensive. Urinalysis reveals trace ketones, but serum beta-hydroxybutyrate is not elevated. Serum bicarbonate is 17 mmol/L (17 mEq/L), and venous pH is 7.32.
Hyperosmolar Hyperglycaemic state
Investigations: Blood glucose, ketones, blood gas, serum osmolality, U and E and creatinine, FBC, ECG - Cardiac failure that brought tit on or potassium changes
Low potassium overall but high serum potassium
Treatment: Replace fluid with IV saline Insulin at low infusion rate Restore electorlytes LMWH
A 38-year-old woman, who in the past had tried to lose weight without success, is happy to see that in the last 2 months she has lost about 11 kg (25 pounds). She also has difficulty sleeping at night. Her husband complains that she is keeping the house very cool. She recently consulted her ophthalmologist because of redness and watering of the eyes. Eye drops were not helpful. She consults her doctor for fatigue and anxiety, palpitations, and easy fatigability. On physical examination, her pulse rate is 100 bpm and her thyroid is slightly enlarged. Conjunctivae are red and she has a stare.
Graves Disease
Investigate: Thyroid function tests in primary hyperthyroidism high free T4 and T3 and a low TSH in primary and high
TSH in secondary
Thyroid autoantibodies: Anti TSHR- Ab
Treatment: 1st line is carbimazole , 2 line is propylthiouracil , 3 is radioactive iodine and 4 is thyroidectomy
Thyroid storm requires: High dose antithyroid drugs, corticosteroids, beta blockers and iodine potentially with lithium
A 45-year-old white woman presents with symptoms of fatigue, depression, and mild weight gain. Physical examination demonstrates heart rate of 58 beats per minute, coarse dry skin, and bi-lateral eyelid oedema. Serum thyroid-stimulating hormone (TSH) is 40 mIU/L (normal range, subject to laboratory standards, 0.35 to 6.20 mIU/L), and free T4 is 6.44 picomol/L (0.5 nanograms/dL) (usual normal range, subject to laboratory standards, 9.00 to 23.12 picomol/L [0.8 to 1.8 nanograms/dL]). Therapy is begun with levothyroxine 100 micrograms daily and the patient’s symptoms improve. Repeat testing 6 weeks later reveals a normal TSH (5 mIU/L). The patient is maintained on this dose and repeat TSH testing is planned yearly or if symptoms recur.
Hypothyroidism
Investigations:
TFTS: Low T4 and T3 but in primary high TSH and low TSH in secondary
Autoantibodies :Antithyroid peroxidase
Treatment: Levothyroxine
Case history #1
A 34-year-old woman presents with complaints of weight gain and irregular menses for the last several years. She has gained 20 kg over the past 3 years and feels that most of the weight gain is in her abdomen and face. She notes bruising without significant trauma, difficulty rising from a chair, and proximal muscle wasting. She was diagnosed with type 2 diabetes and hypertension 1 year ago.
Case history #2
A 54-year-old man presents for evaluation of an incidentally discovered adrenal nodule. He underwent a computed tomography scan of the abdomen for evaluation of abdominal pain, which was negative except for a 2 cm well-circumscribed, low-density (2 Hounsfield units) nodule in the right adrenal gland. He reports weight gain of 15 kg over the past 4 years. He has difficult-to-control type 2 diabetes and hypertension. He has had 2 episodes of renal colic in the last 5 years.
Cushing’s syndrome
Investigations: 1st line is overnight dexamethasone suppression test , 2nd line is 48 hour dexamethasone, 3 is urinary free cortisol and if these are positive do a plasma ACTH and if its undetectable suspect a adrenal tumour.
If ACTH is Detectable do a CRH test and if cortisol rises its a pituitary tumour and if it doesnt its an ectopic tumour
Case history
Case history #1
A 47-year-old man presents with arthritic pain of the knees and hips, soft-tissue swelling, and excessive sweating. He also noticed progressive enlargement of the hands and feet. He has been taking antihypertensive medicine for the past 3 years. On physical examination, he has coarse facial features with prognathism and prominent supra-orbital ridges. The tongue is enlarged and the fingers are thickened. His wife says that he frequently snores. Laboratory work-up reveals an elevated plasma insulin-like growth factor 1 (IGF-1) concentration of 73 nanomols/L (560 micrograms/L or 560 nanograms/mL) (normal for age, 16 to 31 nanomols/L [120 to 235 micrograms/L or 120 to 235 nanograms/mL]) and a basal plasma growth hormone level of 15 micrograms/L (15 nanograms/mL). MRI examination of the sella turcica region shows a 14 mm pituitary mass with right cavernous sinus invasion.
Case history #2
A 15-year-old girl presents with primary amenorrhoea and accelerated growth. On physical examination, her height is above the 90th percentile, her pubertal development is evaluated at Tanner stage 2, and she has soft-tissue swelling. Laboratory work-up reveals a moderately elevated serum prolactin concentration of 1913 picomol/L (44 micrograms/L) (normal, <870 picomol/L [<20 micrograms/L]) and an elevated IGF-1 level of 200 nanomols/L (1525 micrograms/L or 1525 nanograms/mL) (normal for age, 26 to 72 nanomols/L [198 to 551 micrograms/L or 198 to 551 nanograms/mL]). Pituitary MRI shows a 15 mm pituitary mass without parasellar extension.
Acromegaly
Investigations: 1st line is a IGF-1 test but gold standard is OGTT with acromegaly is greater than 1
Treatment: 1st line is Tran sphenoidal resection of pituitary tumour
2nd line is somatostatin analogue’s e.g. octerotide
3 is GH receptor antagonist e.g. Pegvisamont
4 is Dopamine agonist e.g. cabergoline
5 is radiotherapy if surgery isn’t an option
Case history #1
A 54-year-old man presents with a 10-year history of hypertension that has been difficult to control with antihypertensive medicines. His symptoms include frequent headaches, nocturia (3-4 times per night), and lethargy. He has no other medical conditions or past medical history. Apart from a blood pressure (BP) of 160/96 mmHg, findings on physical examination are unremarkable. Plasma electrolytes are normal.
Case history #2
A 28-year-old woman presents with a 2-year history of hypertension, associated with nocturia (4-5 times per night), polyuria, palpitations, limb paraesthesias, lethargy, and generalised muscle weakness. There is no other past medical history. Physical examination is unremarkable apart from a BP of 160/100 mmHg, global hyporeflexia, and weak muscles. Plasma potassium is 2.2 mmol/L (2.2 mEq/L), bicarbonate is 34 mmol/L (34 mEq/L), and serum creatinine is normal.
Hyperaldosteronism / Conn’s
Investigations: Blood U and Es Renin and aldosterone ratio in primary high aldosteronism and low renin but both are high in secondary
Low or normal potassium !!
CT/MRI for tumour or renal doppler or angiogram to look for renal artery stenosis
Case history #1
A 36-year-old woman presents with increasing fatigue especially in the afternoon, 7 kg weight loss, decreased appetite, diminished libido, and decreased axillary and pubic hair over a 10-month period. Her skin seems more tanned despite lack of sun exposure. She is craving salty food and feels dizzy when standing up suddenly. She has been dying her hair as she started having grey hair when she was 17 years old. Her mother has Hashimoto’s thyroiditis and one of her sisters has type 1 diabetes. Her blood pressure is 102/66 mmHg with a heart rate of 86 beats/minute (supine) and 78/56 mmHg with a heart rate of 116 beats/minute (sitting). Hyperpigmentation is noted in the oral mucosa and also over a previous appendectomy scar.
Case history #2
A 63-year-old woman with severe degenerative osteoarthritis of the knees underwent total right knee replacement without immediate complications. She had a history of atrial fibrillation for several years and was on oral anticoagulant therapy and beta blockers. The oral anticoagulant therapy was discontinued before surgery and she was placed on intravenous heparin postoperatively. Two days after starting heparin therapy, she became fatigued and nauseated. Her supine blood pressure decreased from its preoperative value of 122/78 mmHg to 90/60 mmHg.
Primary Adrenal Insufficiency:
Investigations: 1st line is U and E ( hyponatremia an hyperkalaemia ) and maybe early morning cortisol
Gold standard is short synACTHEN test - failure of cortisol to rise is Addison’s
ACTH is high in primary and low in secondary
