Endocrinology Flashcards
How does Post Partum Thyroiditis present.
Thyrotoxic phase
Hypothyroid
Normal Thyoid phase
Is Post Partum Thyroiditis antibody positive?
90% are TPO positive
What is the management of post partum thyroiditis
Beta Blockers ( Propanolol ) then thyroxine
If someones fasting blood glucose is <6.1 what is I described as?
Normal
If someones fasting blood glucose is 6.1 - 6.9 what is I described as?
Impaired Fasting Glucose
In a Glucose Tolerance Test if someones Blood glucose comes back as >11.1 what is the diagnosis?
Diabetes Mellitus
In a Glucose Tolerance test someones blood glucose comes back as 7.8 - 11.1 what is the diagnosis?
Impaired Glucose Tolerance
What blood results can be used to immediately diagnose DM?
Fasting Glucose >7.0
Random blood glucose >11.0
What medication can interact with levothyroxine?
Iron or Calcium Carbonate if taken within four hours of the levothyroxine can reduce the uptake within the stomach.
Diagnoses of Hypersomolar Hyperglycaemic state
Hypovolaemic
Serum Osmolarity >320
Hyperglycaemic >30mmol
Presentation of Hypersomolar Hyperglycaemic state.
Fatigue N+V Pappiloedema Thrombosis T2DM
Management of HHS
NOT insulin
Slowly fix osmolarity - 0.9% NaCl if this doesn’t work use 0.45% Saline
Iron studies in Haemochromatosis
Increased Transferrin and Ferritin
Reduced TIBC
MEN type 1
Three Ps Parathyriod hyperplasia (Primary Hyperparathyroid) Pituitary Pancreas (Insulinoma etc) \+/- adrenal or thyroid glands
What is the commonest presenting complaint of MEN 1?
Hypercalcaemia
What gene is associated with MEN 1
MEN 1
MEN IIa
Medullary Thyroid cancer
Parathyroid
Phaechromocytoma
What gene is responsible for MEN IIa
RET oncogene
MEN IIb
Phaechromocytoma
Medullary Thyroid
Marfanoid and Neurofibromas
What gene is responsible for MEN IIb
RET oncogene
What drugs can be used in Steroid Induced Hyperglycaemia and how does it present?
Normal HB1Ac but high Blood glucose
Sulfonylureas - gliclazide
MODY
T2DM onset generally before 25 years old
What is the commonest MODY
MODY 3
HNF alpha gene
MODY 3 is associated with what?
Increased Hepatocellular carcinoma risk
What medication is extremely effective in most MODY but particularly 3.
Sulphonylurea
MODY 2
Glucokinase gene
MODY 5
Rarest
Renal cysts
HNF-1 beta gene
How do you recognised and treat a Myxoedemic Coma?
Hypothermia and confusion
Thyroxine + Fluids and Hydrocortisone
(once adrenal insufficiency is ruled out steroid can be stopped)
Klinefelters
47 XXY
Primary Hypogonadism
Increased FSH LH
Reduced Testosterone
Kallmans
Primary Hypogonadotrophic Hypogonadism
Anosmia
Cleft palate
Delayed puberty
Androgen Insensitivity
X linked - 46XY
Genetically Male - Phenotypically Female
No testosterone receptors
High Testosterone Low FSH LH
How does someone with Androgen Insensitivity Present?
Breast development - testosterone conversion to oestradiol
Lack of other secondary sexual characteristics
Cryptochordism - masses in groin
Amenorrhoe
Female Genitalia
What is congenital adrenal hyperplasia
Series of Autosomal Reccesive conditions characterised by.
Low Glucocorticoids
High ACTH
Increased Androgens
What are the three types of congenital adrenal hyperplasia?
21 Hydroxylase deficiency - 90%
11 Beta Hydroxylase Deficiency
17 Hydroxylase Deficiency - V.Rare
How does 21 hydroxylase deficiency present?
Virilised female genitalia
Precocious Puberty in Boys
Salt wasting crisis in first few weeks of life
How does 11 beta hydroxylase deficiency present?
Virilised female genitalia
precocious puberty in boys
Hypertension
Hyperkalaemia
How is androgen insensitivity diagnosed?
Bucal swab for chromosome observation demonstrating 46 XY - chromosomal male
How does 17 hydroxylase deficiency present?
Non Virilised females
Intersex boys
Hypertension
Liver Enzyme Inducers - BREAK THINGS DOWN
Carbamezapine St Johns Wart Rifampacin Smoking Phenytoin
Liver Enzyme Inhibitors
Erythromycin Ciprofloxacin Isoniazid Omeprazole Amiodarone SSRI Sodium Valproate Allopurinol
Is fludrocortisone indicated in an addisonian crisis?
No
If someone with Addisons is profusely vomiting what is recommended?
IM hydrocortisone until settled
What is first line management in a Thyroid Storm?
Propanolol Treat underlying cause Antithyroid drugs Lugols Iodine Dexamethasone
Insulin infusion rate in DKA
0.1 units/kg/hr
PTH and PO4- link
PTH causes increased PO4 excretion
Indications for surgery in hyperparathyroidism
Life threatening hypercalcaemia
Nephrolithiasis
<50 years old
T -Score
Signs of Alcoholic Ketacidosis
Alcoholic with a recent history of starvation.
Low or normal blood glucose
High ketones
Acidotic ABG
Management of a Alcoholic Ketoacidosis
IV saline + Thiamine
Bone Pain + Muscle Pain
Increased ALP
Normal Ca2+, PTH, Phosphate
Pagets disease
- give bisphosphonates
Low Vitamin D Low Calcium Low Phosphate High ALP High PTH Waddling gate proximal myopathy + bone pain
Osteomalcia
What sign may be seen on a xray in osteomalacia ?
Translucent bands (Looser zone) with sclerotic bands
What is the management of osteomalcia?
Vitamin D and Calcium
In order to diagnose someone with T2DM via Hb1Ac how many abnormal tests are required?
2
What can be used to permanently lower the patients K+ by removing it from the body?
Calcium Resonium Enema
Loop diuretics
Dialysis
What medication should be stopped in hyperkalaemia?
check for ACEi
When is hypertonic 3% saline used over 0.9% in hypovolaemic hyponatraemia?
If Na <120
Acute symptomatic hyponatraemia.
Hypovolaemic Hyponatraemia causes
Addisons
Loop diuretics
Renal failure
Euvolaemic Hyponatraemia cause
SIADH
Hypervolaemic hypernatramia causes
HF
Liver failure
Nephrotic syndrome
Jittery Dehydrated Increased muscle tone Hyper-reflexia Convulsions Coma
Hypernatraemic Dehydration
Management of Hypercalcaemia.
Rapid fluid resus - 4/6L in 24 hours Bisphosphonates - 2/3 days to work Calcitonin - works faster than bisphosphonates Steroids - only in sarcoidosis Loop - if unable to tolerate fluid resus
If a patient with T2DM is controlled with lifestyle alone +/- metformin what is their Hb1Ac target?
48mmol
If a patient with T2DM is on metformin plus another drug capable of causing a hypo what is their Hb1Ac target?
53mmol
What is the Hb1Ac target for adding a second drug onto metformin?
58mmol
Acute onset dementia dermatitis and diarrhoea.
Pellagra Niacin (Vitamin B3) deficiency
Causes of SIADH
SSRI Carbamezapine Sulfonylureas TCA Small Cell Lung Cancer Post SAH
reasons for giving growth hormone
Deficiency
Turners
Pader Willi
Chronic renal insufficiency
A Hb1Ac of 42-48 is diagnostic of what? and how should it be managed?
Prediabetes - lifestyle and dietary changes
Metformin can be used
When are calcimimetics used?
Cinacalcet is used when someone is unable to tolerate a parathyroidectomy
If someone develops and illness and they are suffering from Addisons what are their sick day rules in regards to medication?
Corticosteroid dose should be doubled.
Fludrocortisone dose stays the same
PCOS fertility management
Weight loss - only if appropriate
Clomifene
Clomifene + metformin
Gonadotrophins
PCOS acne management
COCP Topical eflurnithine Spironolactone - specialist advice \+ Normal acne management
Normal Serum Osmolarity
275 - 295
Differentiating SIADH from Psychogenic Polydipsia
Both react as expected healthy individual would to fluid deprivation and desmopressin.
Psychogenic - past history of mental health disorder
+ Urinary and Plasma osmolarity low
SIADH - Urinary osmolarity high + plasma osmolarity low
When can bisphosphonates be stopped?
After 5 years if…
<75
Femoral T scan shows > -2.5
Low risk FRAX score
What is used to monitor haemochromatosis
Transferrin saturation
Ferritin
Cushings Diagnosis
Hypokalaemic Metabolic Alkalosis
Low dose dexamethasone ‘overnight suppression test’ - diagnostic
High dose dexamethasone - determine if cushings or ectopic ACTh
Insulin stress test - differentiate pseudocushings
Management of Acromegaly
IGF-1 is screening
OGTT is diagnostic
1st line = Transphenoidal surgery
Medication - Somatostatin Analogues - Ocrtreotide
-Pegvisomant - GH receptor antagonist - reduces IGF-1 and end organ affect but doesn’t reduce size
- Dopamine Agonist - Bromocriptine - not very effective
Indications for parathyroid surgery
<50
End organ disease - renal calculi bone disease
Serum calcium >2.8
Hypoglycaemia on fasting and or exercise
Reversal of symptoms with glucose
Low blood sugars measured during symptoms
Insulinoma
Link with MEN1
Surgery is first line
Diazoxide and somatostatin if unfit for surgery
BP target for a T2DM patient
Clinic <140/90
Home <135/85
Complication of DKA and insulin therapy that can present with respiratory distress and weakness.
Hypophosphataemia
Continue insulin but add in phosphate supplements
Decreased Caeruloplasmin
Decreased total serum copper
Increased Serum free copper
Increased urinary copper
Wilsons
What is diagnostic of Wilsons?
Genetic testing
Total cholesterol >7.5
Familial Hypercholesterolaemia
Iron deficiency anaemia
Dysphagia
Glossitis
Oesophageal webs
Plumer vinson syndrome
If semen analysis comes back ad abnormal when is it retaken?
3 months
Describe Gonadotrophin Dependant or ‘central’ precocious puberty
FSH and LH raised
Due to premature activation of hyopothalmic pituitary gonadal axis.
Testes will be large for age
Describe gonadotropin independent or ‘pseudo’ precocious puberty.
LH and FSH low
Testosterone or oestrogen high
In boys testes will be small but other secondary sexual characteristics will have developed
What can the testicular size tell us about the cause of the precocious puberty?
Bilaterally large - central lesion releasing GnRH
Unilaterally large - gonadal tumour
Bilaterally small - adrenal cause. Bilateral hyperplasia or unilateral tumour.
In someone with hyperaldosteronism if the renin is also increased what does this indicate?
Secondary hyperaldosteronism - renal artery stenosis causing continuous release of renin.
If someone is on steroid for over 3 months how should they be managed?
Bone protection should start immediately.
Bisphosphonates.
If someone on metformin monotherapy with well controlled T2DM develops CDV what is the management?
Regardless of Hb1Ac start SGLT2i unless contraindicated
Initial insuline regime in T1DM
Basal Bolus + Twice daily Detemir
Iodine uptake in De Quervians
Reduced uptake
If someone is on triple therapy + inadequate Hb1Ac + >35 BMI or insulin intolerant what should be trialled?
Swapping one of the drugs for a GIP-1 mimetic
In amiodarone induced hypothyroidism what is the management?
Add in levothyroxine - don’t alter dose of amiodarone
When monitoring effectiveness of levothyroxine in hypothyroidism. What should be monitored?
TSH is indicator
In hypocalcaemia which is resistant to Vitamin D and calcium replacement what should you check?
Magnesium levels as hypo magnesium is a common cause of resistant hypocalcaemia
Metformin sick day rules
Withhold if D+V
Signs associated with hypocalcaemia
Chvostek sign - tapping on the parotid gland triggers facial twitch
Trousseaus sign - carpal spasm on BP cuff inflation
What is the advised glucose monitoring regime in diabetics
4x a day
Before each meal and before bed
Definition of malnutrition
Unplanned weight loss of over 10% in 3-6 months
If metformin is contraindicated what is first line?
Sitapliptin mono-therapy
or SGLT2i if CVD or Q-risk >10%
Before adding a second drug to metformin what must happen.
Ensure metformin is titrated up.
Prolactinoma - management
Medical is used first line even if they have neurological symptoms
Cabergoline is first line
Before doing a water deprivation test what other electrolyte should be checked?
Check Calcium and PTH
