Endocrinology Flashcards
1
Q
define endocrine and exocrine
A
endocrine put inngs into teh blood
exocine purs yjomgs inot the sight o action - for example into the stomach
2
Q
what are teh differences between water and fat soluble hormones
A
water:
half life - short
clerance - fast
3
Q
what are peptide hormones
A
tey vary in amino acid lengths
they may bind t a carbohydrate
released in pulses or bursts
stored in secretory granules
cleared by tissues and circulating enzymes
4
Q
how are peptide hormones stored
A
preprohorme
prehormone
stored as a horone
secreted as a hormone
5
Q
what are the 4 catogries of hormones
A
peptides
Amines
iodothyronines - not water soluble
sterioid - not water soluble
6
Q
how are iodothyronins made
A
Secretory cells release thyroglobulin into colloid – acts as base for thyroid hormone synthesis
Incorporation of iodine on tyrosine molecules to form iodothyrosines
Conjugation of iodothyrosines gives rise to T3 and T4 and stored in colloid bound to thyroglobulin
TSH stimulates the movement of colloid into secretory cell, T4 and T3 cleaved from thyroglobulin
7
Q
which hormoes are in teh nucluer receptro family
A
oestrogen, thyroid hormone, vit D
8
Q
how does vitamin D work inside the cell when it gets t teh recepotr
A
Fat soluble
Enters cells directly to nucleus to stimulate mRNA production
Transported by Vitamin D binding protein
9
Q
what is the rhythem of cortisol called
A
diruinal rhythems
10
Q
what are the functions of thyrid hormones
A
Accelerates food metabolism
Increases protein synthesis
Stimulation of carbohydrate metabolism
Enhances fat metabolism
Increase in ventilation rate
Increase in cardiac output and heart rate
Brain development during foetal life and postnatal development
Growth rate accelerated
11
Q
what are teh three layers of teh adrenals and what do they produce
A
Zona glomerulosa - mineralcorticoids (Aldosterone)
Zona fasicilata - glucocorticoids (cortisol)
Zona reticularis - androgens (sex hormones - dihydroepiandrosterone)
12
Q
what are the BMI weight catogries
A
<18.5 underweight
18.5 - 24.9 normal
25.0 - 29.9 overweight
30.0 - 39.9 obese
>40 morbidly obese
13
Q
what are teh risks caused by obesity
A
Type II diabetes
Hypertension
Coronary artery disease
Stroke
Osteoarthritis
Obstructive sleep apnoea
Carcinoma:
Breast
Endometrium
Prostate
Colon
14
Q
what hormone inhibits hunger and another ne
A
leptin - it is expressed in white fat
it is immunostimulatory
Insulin as well
15
Q
what is an additional hormone that inhibits appetite
A
cholecystokinin - CCK
receptors in teh pyloric sphincyer and delayes gastjc empyting
it is an enterogastrone
16
Q
what is teh main appitite stimulator and another one
A
ghrelin
agouti releated peptide
17
Q
what is PYY
A
binds to NPY receptrs, and is secred by ilium, pancrse and colon
it inhibits gastic motility and reduced appetite
18
Q
what is release when teh stomach is full stimulate satiety
A
CCK
GLP1 (glucagon like peptide)
Insulin
PYY (peptide YY)
Leptin is tehn produced longer term
19
Q
what are teh hormones produced by teh anteriro pituitry
A
FLAT PIG
1.Follicle-stimulating hormone (FSH):
- Produced in gonadotrophs
2. Lutenizing hormone (LH):
- Prodcued in gonadotrophs
3. Adrenocorticotropic hormone (ACTH - also known as corticotropin):
- Produced in corticotrophs
4. Thyroid-stimulating hormone (TSH - also known as thyrotropin):
- Produced in thyrotrophs
5. Prolactin:
- Produced in lactotrophs
6. IGNORE
7. Growth hormone (GH - also known as somatotropin):
- Produced in somatotrophs
20
Q
What are the three things ot think about when it comes to pituitry tumours
A
-pressure on local structure for example the optci nerve or 4th ventricle
-pressure on the normal pituitry
-functioninf tumour - it releases hormones
-
21
Q
- How to differentiate between CSF and snot
A
CSF has glucose in it
22
Q
what are the three types of functioning pituitry tumour
A
prolatinoma
acromegally and giganism
cushings diseas
23
Q
why does acromegally cuase suhc large growth when just givign growth homone doesnt have such an effect
A
gigantism growth hormone also surpresses the rest of the pituitry gland beause there is a tumour, so the children dont go through puberty and the long bones arent inhibited from growing
24
Q
what is the test to do if someone if infertile and how can it be treated
A
you can do a prolacin test bevause prolacin surpresses other things and make you more infertile
Give a dopamine agonist! this will also cause teh tumour to shrink
25
what are the signs of cushings in children
fat and short
26
what does thelarche mean
breast development
27
what does thelarche mean
breast development
28
what starts thelarchy
induced by estrogne and it happens over three years
Ductal proliferation
Site specific adipose deposition`
Enlargement of the areola & nipple
29
what is teh shap diffence in a prepubertal and post pubertal uterus
pre is tube shap, post is pear shap
30
diabeteis type 1 defornition
Metabolic Disorder characterised by hyperglycaemia due to absolute immunodeficiency. Develops due to destruction og pancreatic beta cells, immune mediated.
31
diabeties type 1: Epidemiology
Aetiology
Risk Factors
5-10% of all diabetes, normally diagnosed between 5-15 years
Autoimmune condition causing destruction of the pancreas, HLA-DR and HLA-DQ provide protection from or increase suspetability to the disease. Enviromental facots trigger destrction of beta cels such as viruses.
Genetic predisposition, geographical region (european), nfection agents, diatry factors
32
diabeties type 1 pathophysioology
Destruction of the pancreas by antibodies, when 80-90% of beta cells have been destroyed, hyperglycemia develops,
33
Diabeties 1, key signs, signs and symptoms
Polyuria, polydipsia, fatuigue
Young age, weight loss, low BMI, Automimmine disease, ketoacidosis
Thirst, dry mouth, blurred vision, hunger, weightloss
34
diabeties 1 tests
Random glucose tolerance test >11.1
Fasting plasma glucose
Glycerated heamogobin A1C test (this measure the glucose attatched t the Hb
>6.5% is diabetes
Low CC peptide (releaed from insulin)
35
diabeties 1 treatment and monitering
Basal blous insulin there is short and long acting which are used
Check BP and treat with a goal of <140/90
When not on statins, check the lipis profile at the initial check and then every 5 years
36
what are teh macrovascular complication of diabeties 1
Macrovascular - CAD (coronary artery dsease), cerebrovascular disease, PAD
37
what are teh microvascualer complications of diabeties
Microvascular - retinopathy, neurophathy, nephropathy, diabetic foot
38
diabeies 2 defornition, epidemiology, aetiology, risk factors
Progressive disorder defined by deficits in insulin secretion and increased insulin resistance that leads to abnormal glucose metabolism
Older age adults
Genetic susceptibility
Diet, obesity, older age, gestational diabetes
39
whate are the tests for type 2 diabeties
Random glucose test in urine
HBA1C test - prediabetes is 42-47, diabetes is 48mmol/l
Oral glucose tolerance test - performed in the morning before any food, there is a fasting plasma glucose taken, then 75g drink, then measuring of glucose 2 hours later . Diabeties is a fastig glucose of >7, prediabeties is a fasting glucose of >6.1-6.9
Random glucose test - if higher than 11mmol/l its diabetes
40
differential diagosis for type 2 diabeties
Type 1, pre diabetes hyperglycaemia, latent autoimmune disease, Cushing's disease
41
what is teh treatment and manegment for tpe 2 diabeties
Diet and exercise changes
Metformin and gliclazide (this is a sulfonylurea and works by increased the amount of insulin released form the pancreas)
Insulin
Regular HBA1C tests
42
what are complication of type 2 diabeties
Hyperosmolar hyperglyceamic state, diabetic nephropathy, diabetic neuropathy (-> lack of sensation in feet -> occult foot ulcers), diabetic retinopathy, Hyperosmolar hyperglycaemic nonketotic coma (mostly in type 2s)
Increased risk of cardiovascular disease
43
define ketoacidosis
An acute metabolic complication, where the production of ketones causes an acidic pH which can be fatal. Ketones are produced when the body breaks down excessive amounts of fat.
44
ketoacidosis epidemiology and risk factors
Diabeties 1 (nearly always), low carbohydrate diet
inadequate or inappropriate insulin therapy
infection
myocardial infarction
Pancreatitis
having an infection, such as flu or a urinary tract infection (UTI)
not following your treatment plan, such as missing doses of insulin
an injury or surgery
taking certain medicines, such as steroids
binge drinking
using illegal drugs
pregnancy
having your period
45
ketoacidosis key presintation, signs and symptoms
Diabetes, N+V, abdominal pain. Dehydration
Acetone smell on breath
needing to pee more than usual
feeling very thirsty
being sick
tummy pain
breath that smells fruity (like pear drop sweets, or nail varnish)
deep or fast breathing
feeling very tired or sleepy
confusion
passing out
46
ketoacidosis
47
ketoacidosis tests
venous blood gas
blood ketones - lower than 0.6mmol is normal 3 mol is critical
blood glucose
urea and electrolytes
Blood ketone test
urinalysis
ECG
pregnancy test
amylase and lipase
48
ketoacidosis treatment
insulin, usually given into a vein (intravenously)
fluids given into a vein to rehydrate your body
nutrients given into a vein to replace any you've lost
Moniter blood glcose and ketones carefully
49
Hyperosmolar hyperglycaemic state defortion
profound hyperglycaemia (glucose ≥30 mmol/L [≥540 mg/dL]), hyperosmolality (effective serum osmolality usually ≥320 mOsm/kg [≥320 mmol/kg]), and volume depletion in the absence of significant ketoacidosis (pH ≥7.3 and bicarbonate ≥15 mmol/L [≥15 mEq/L]), and is a serious complication of diabetes
50
Hyperosmolar hyperglycaemic state epidemiology and risk factors
Type 2 diabetes
infection
inadequate insulin or oral antidiabetic therapy
acute illness in a known patient with diabetes
nursing home residents
It can be the first time someone presents with diabetes and is a form of diabetic crisis, can go alongside diabetic ketoacidosis
51
Hyperosmolar hyperglycaemic state signs and symptoms
acute cognitive impairment
presence of risk factors
polyuria
polydipsia
weight loss
nausea and vomiting
52
Hyperosmolar hyperglycaemic state tests
* blood glucose (high)
* blood ketones (low)
* venous blood gas
* serum osmolality (high)
* urinalysis
* cardiac enzymes
* chest x-ray
* liver function tests
53
Hyperosmolar hyperglycaemic state differential diagnosis
Conditions which causes impaired mental state - CNS infection, hypernatremia
54
Hyperosmolar hyperglycaemic state manegment and moitering
intravenous fluids and potassium replacement
PLUS – supportive care and referral to critical care
PLUS – insulin
PLUS – identify and treat any precipitating acute illness
Assess for cerebral oedema and if GCS is low order a head CT scan
Keep under close obstervation
55
Hypoglycaemia defornition
Hypoglycaemia is a clinical syndrome present when the blood glucose concentration falls below the normal fasting glucose range, generally <3.3 mmol/L (<60 mg/dL)
56
Hypoglycaemia risk factors
middle age
female sex
ethanol consumption
bariatric surgery - not absorbing enough?
diabeties
57
Hypoglycaemia causes
It can be diagnosed by wipples trangle which is: symptoms of hypoglycaemia, low blood plasma glucose concentration, and relief of symptoms when plasma glucose concentration is increased
It can also be caused by an insulinoma, which is a insulin secreting tumour.
58
Hypoglycaemia key, signs, symptoms
Diaphoresis (excessive sweating)
anxiety
tremor
hunger
Hypotension, hyperpigmentation, weightloss or gain
Nausea, confusion, tremor, sweating, palpitations, or hunger.
59
Hypoglycaemia tests
serum glucose
liver function testing
renal function testing
serum insulin
48- to 72-hour fast under observation
oral glucose tolerance test
serum insulin-like growth factor (IGF)-II
serum adrenocorticotropic hormone
60
Hypoglycaemia differential diagnosis
Cardiac dysrhythmia. Endocrine disorders (eg, pheochromocytoma, Addison disease, glucagon deficiency, carcinomas, extrahepatic tumors) Substance abuse (eg, cocaine, ethanol, salicylates, beta-blockers, pentamidine) Hypoglycaemic agents (eg, insulin, oral hypoglycemic agents
61
hypogluceamia manegment and monitering
In emergancy, intramuscular glucagon administered to raise BG
Quick acting carhohydrate
Long term:
Dietary changes such as more protien
Psychaitric assessment if due to overdose/toxin/ethanol
Nutrition councelling
Medication chnages that moght be causing it
Tumour removal
62
hyperthyroid epidemiology and risk factors
Affects more females than males, mainly between 20-40 years
Female, family history, stress, smoking, amiodarone
63
hyperthyroid aitiology
* Graves' disease - autoimmune disease attacking the thyroid gland causing an excess production
* Associated with other autoimmune disease - T1DM toxic multilocularities - older women,
* Toxic multinodular goitre - an engorged thyroid, causing too much hormone to be produced (antithyroid medication radioactive iodine, surgery)
* Toxic thyroid adenoma
* Pituitary adenoma
* De Quervains thyroiditis - swelling of the thyroid gland due to viral infection such as mumps or flu
64
pathophysiology of graves disease
* Graves’ Disease
○ Serum IgG antibodies called TSH receptor stimulating antibodies (TRAb) bind to TSH receptors on the thyroid and stimulate T3/4 production
This results in excess secretion, hyperplasia of the thyroid follicular cells, hyperthyroidism and goitre
65
hyperthyroid key, signs and symptoms
Heat intolerance, irritability and weight loss
* Tachycardia/AF
* Goitre
* Tremor
* Hyperkinesia – increase in muscle activity
* Lid lag
* Lid retraction
* Thin hair and hair loss
* Onycholysis – painless separation of the nail from the nail bed
* Exophthalmos – bulging of the eye out of the orbit
Insomnia, sialorrhea, Palpitations, fatigue, tremor, anxiety, weight loss, menstrual disturbances
66
hyperthyroid tests
Thyroid function test, (if it is primary disease, it will be low TSH and high T3/T4) if secondary high TSH and high T3/T4
Thyroid ultrasound, radioactive iodine isotope uptake scan
67
hyperthyroid manegemtn and monitering
Beta blockers for heart rate control
Carbimazole - antithyroid drug, which also has immunosuppressive effects, this has two mechanisms, block and replace with thyroxine to get it more tightly controlled, or a strong doe at first which is then reduced in accordance to the tests
Radioiodine therapy (not in pregnancy and breast feeding)
Thyroidectomy - removal of part of the gland
Dose of carbimizol is adjusted in accordance to thyroid tests
68
hyperthyroid complications
Congestive heart failure, atrial fibrillation, osteoporosis, graves dermopathy (elephantiasis) and graves ophthalmopathy complications
69
what is a thyroid crisis (hyper) and how is it treated
There is a rapid deteriorsion of thyrotoxicosis which hyperpyrexia (increased body temp), tachycardia, restlessness, coma and death
Its normally caused by surgery, stress or infection
It can be treated by a large dose of carbimizole, propranolol and hydrocortisone to prevent the conversion of T4-T3
Also potassium iodide to block the release of thyroid hormone form the gland
70
hypothyroidism defornition
Underactivity of the thyroid gland. May be primary (from disease of the thyroid gland) or secondary (pituitary/hypothalamic disease)
71
hypothyroidism epidemiology
Females more than males
Only 0.1-2% of the population
Family history of autoimmune disease
72
hypothyroidism causes
* Autoimmune thyroiditis - anti thyroid hormones are made and so there is lymphatic infiltration of the gland and eventual atrophy (so no goitre)
Almost all patients have serum antibodies to thyroglobulin and thyroid peroxidase (TPO)
Associated with other autoimmune conditions e.g. pernicious anaemia and Addison’s disease
CD8 mediated
* Hashimoto thyroiditis - caused by autoimmune, associated with goitre
* Amiodarone - contains hight levels of iodine and can cause hyperactive thyroid. It is a drug taken for irregular heartbeats and slows the nerve impulses in the heart
* lithium toxicity - it collects in the thyroid and prevents it from being able to uptake more iodine
* post-partum thyroiditis
* Iodine deficiency - common in mountainous areas
Congenital hypothyroidism
73
hypothyroidism signs (mneumonic)
BRADYCARDIC
* Bradycardia
* Reflexes relax slowly
* Ataxia
* Dry thin hair/skin
* Yawning
* Cold hands
* Ascites
* Round puffy face
* Defeated demeanour
* Immobile – ileus (temporary arrest of intestinal peristalsis)
* Congestive HF
74
hypothyroidism symptoms
* Hoarse voice
* Goitre
* Weight gain
* Constipation
* Cold intolerance
* Menorrhagia – heavy periods
* Tiredness
* Lethargy
* Poor memory
* Puffy eyes
Arthralgia/myalgia
75
hypothyroidism tests
Thyroid function test
Thyroid antibodies in Hashimoto's
FBC - anaemia
76
hypothyroidism differential diagnosis
Primary adrenal insufficiency, anaemia,
§ Hyperlipidaemia
§ Hyponatraemia (due to increased ADH and impaired clearance of free water)
Increased serum creatine kinase levels with associated myopath
77
hypothyroidism treatmetn
Levothyroxine T4 started at 25mcg and increased every 4-6 weeks
§ Primary – titrate dose until TSH normalises
§ Secondary – TSH will always be low, T4 monitored
78
hypothyrpisism complications
heart disease, goitre, pregnancy problems and a life-threatening condition called myxoedema coma
79
thyroid cancer types
Papillary - young people
Follicular - middle age
Medullary - familial
Lymphoma - variable
Anaplastic - aggressive
80
thyroid cancer signs and symptoms
Lumps in neck, swollen glands, horarsness, sore throat
Lymph node metastasis, lung or bone metastasis, thyroid nodule which history of growth, hard and irregular nodes, enlarged lymph nodes
Thyroid nodules, dysphagia (difficulty swallowing), hoarse voice
81
thyroid cancer tests
* Fine needle aspiration cytology biopsy best for distinguishing between benign and malignant thyroid nodules
* Thyroid ultrasound
* TFTs – hyper/hypothyroidism needs to be treated before surgery
82
thyroid cancer treatment for follicular and papillery
* Follicular and papillary cancers
○ Total thyroidectomy with neck dissection for local nodal spread
○ Ablative radioiodine subsequently given – taken up by remaining thyroid tissue or metastatic lesions
83
thyroid cancer treatment for anaplastic and lymphoma
* Anaplastic and lymphoma
○ External radiotherapy may produce brief respite
○ Otherwise treatment is largely palliative
84
thyroid cancer monitering
Long term monitoring o repeat ultrasound examinations, radioactive scanning, measuring thyroglobin level in the blood
85
cushings syndrome and cushings disease differnces
The clinical state of free circulating glucocorticoids
Cushing's syndrome is the symptoms caused by too much cortisol in the body.
Cushing's disease is caused specifically by a tumour in the pituitary causing too much ACTH, it is lie the secondary disease version essentially.
86
cushings syndrome causes
Most common cause is oral steroids, increased ACTH, and increased cortisol itself being made randomly by teh adrenals (for example an adenoma)
87
cushings syndrome signs and symptoms
Truncal obesity, moon face, red face, buffalo hump on back, acne, hirsutism (male pattern hair growth in women), this skin and easy bruising, osteoporosis
Cateracts, ulcers, purple striae on skin, hypertention, hyper-glycemua, increased risk of infection, necrosis, glucosuria,
88
cushings syndrome tests
Random cortisol - misleading test though as diurinal rhythem
24 hour urinary free cortisol measurment - not elevated levels make it unlikely to be cushings
overnight dexamethasone test
If plasma ACTH is low, adrenal imading using CT or MRI to detect neoplams
If ACTH is high, if there is suppression by high dose its probably a pituitry adenoma so look for one with an MRI, if there is no surpressio its probl do to ectopic, this involves CT scant of abdo, chest and pelvis, MRI of neck and thorx, chest x ray to look fr lung tumours
Do the corticotrophin releasing hormone test - if cortisol increases it’s a pituitry prblem
89
cushings syndrome differential diagnosis
Diabetes type 2, pseudo Cushing's - caused by alcohol excess which resloves within 1-3 weeks of abstinence
90
cushings syndrome treatment and management
* If iantrogenic - stop the steroids
* If Cushing's disease - transsphenoidal removal of pituitary
* Adrenal adenoma - adrenalectomy, radiotherapy
* Adrenal carcinoma - adrenalectomy and radiotherapy and adrenolytic drugs (mitotane)
* Ectopic ACTH - surgery to remove tumour if possible
Essentially, remove the tumours and rebalance the hormone levels, its kind of obvious.
If there is an adrenal adenectomy it might causes nelsons disease where the pituitary continues to release ACTH in large amounts which causes bronze pigmentation, visual disturbances, and headaches
Long term steroids if adrenalectomy so measuring the levels of it
91
cushings syndrome how does teh dexamethasone surpression test work
Dexamethasone suppression test - there is the low dose and the high dose, the low dose confirms that its Cushing's and the high dose says if its caused by excess ACTH or excess cortisol from the adrenal
Low dose: you give 1mg of dexamethasone the night before and if it suppresses it when measured on a blood testt at 9am, then its not Cushing's, as in Cushing's its used to the levels being so ight all the time that a little more wont make any difference
High dose: 8mg is given - if this is suppressed the Cushing's is caused by the ACTH from the pituitary, if it is not suppressed and the ACTH is still very high it is caused by an ectopic tumour, and if it's not suppressed by eth ACTH is low then it is caused by an adenoma.
92
acromegally defornition
Acromegaly- excessive production of growth hormones occurring in adults after fusion of the epiphyseal plates
93
gigantism defornition
Gigantism - excessive production of growth hormone occurring in children before the fusion for the epiphysis of long bones which causes extra growth
94
aetiology and risk factors for gigantism/acromegally
Benign GH producing pituitary adenomas - very slow onsey over many years
Ectopic- GH releasing hormone form a carcinoid tumour
Multiple endocrine neoplasia
95
signs and symptoms of acromegally
* Acral enlargement (growth in the hands, feet, jaw)
* Big tongue
* Prominent supraorbital ridg
* Thick skin
* Sleep apnoea
* Hypertension
* Puffy lips eyelids and skin
* Headache
* Bitemporal hemianopia
* Acro paraesthesia
* Sweating
* Arthralgia
* Decreased libido
* Amenorrhea
* Galactorrhoea (random milk production)
96
tests for acromegallly
Oral glucose test - a rise in blood glucose should suppress GH levels. If they remain high it is diagnostic for acromegaly
IGF1 level - should be raised in acromegally
MRI - of pituitry fossa
Visual field defects - betemporal hemianopia
Serum prolacteremia - can be raised in the case of an adenoma
ECG and ecocardiogram
97
treatment for acromegally
1 - Transsphenoidal pituitry surgery to remove an adeoma, can causes diabetes insipidus, infection, hypopituitrism
2- Somato statin analougen inhibit GH secretion
3- Dopamine agonist inhibit GH secretion
4- GH antagonist
5- External radiotherapy
98
who is prolacteremia most commen in
young women
99
what is the aetiology of prolacteremai
The most commen cuase is a prolactin secreating pituityr adenoma
Other tuours couls also cuase it by inhibiting dopamine and reducing its inhibitory capabilities
Also primary hyperthyroidism (high TSH stimulates it)
Drugs such as oestrogens and metoclopramide (ant sickness drug)
100
symptoms of prolacteremia
Loss of libido
Galactorrhoea
Reduced fertility
Decreased libido
amenhorrhea
101
test and treatment for prolactermia
* Serum prolactin level (at least 3 measurements)
* Thyroid function tests
* MRI of the pituitary
* Dopamine agonist – CABERGOLINE or BROMOCRIPTINE
102
what is a carcinoid tumour
Release of serotonin and other vasoactive peptides from a carcinoid tumour
They can be found in the midgut, bronchus and pancreas
They are a subset of neuroendocrine tumour on a whole and usually benign in the digestive tract or lungs
103
risk factors and pathophysiology of carcinoid tu ours
Having genetic multiple endocrine neoplasia type 1
Random tumours that secrete hormones such as serotonin
104
signs of carcinoid tumours
palpitations
abdominal cramps
Telangiectasia (spider veins)
signs of right heart failure
105
carconoid tumour test
serum chromogranin A/B
urinary 5-hydroxyindoleacetic acid
metabolic panel
liver function tests
106
carcinoid tumour treatment
Neuroendocrine tumour can be treated with octreotide which is a somatostatin analogue
107
aitiology of hyperaldosternoism - primary and secondary
There is two catogries: primary and secondary
hyperaldosteronism causes an increased sodium and decreasde potassium
Primary
* Idiopathic - xona glomerulosa increases number of aldosterone secreting cells
* Conns - tumour in the ZGlom
* Famelial - aldosteone cells start reponsing to adrenocorticotrophic hormone as well as angiotensin 2
Secondary -
* Renin producting tumour
* Heart faliure
Chronic low blood pressure
108
risk factors and pathophysiolohy of hyperaldosteronism
Hypertension, electrolyte imbalance
Excess production of aldosterone
K+ loss, Na incrase, higher blood pressure
109
signs and symptoms of hyperaldosteronism
Hypertension
Increased risk of cardiac arrhythmias
Usually asymptomatic
Hypokalaemia - constipation, muscle weakness and cramps, polyuria, polydipsia, paraesthesia
Sweating attacks
110
tests for hyperaldosteronism
U and Es - decreased Renin, increased aldosterone
ECG - Rhyme – U have no Pot (K+) and no Tea but a Long PR and a Long QT
There is a long PR nad long QT wave but a flattened T wave on an ECG
This is for CONNS disease!
111
differential diagnosis for hyperaldosteronism
Renal artery stenosis
Accelerated hypertension
Diuretics
Congestive HF
Hepatic failure
(these are all causeso fteh secondary type)
112
management for hyperaldosteronism
Potaissium s[aring diuretic - spiralactone!
Laproscpoic adrelanectomy to treat cones disease -
113
complications of hyperaldosteronism
Chronic high blood pressure
114
what is addisons disease
Addisons is an autoimmune condition where there is destrctuion of the adrena cortex leading to deficancies
115
causes of addisons disease, primary and secondary
* Primary
○ Addison’s - autoimmune adrenalitis (90% of cases)
○ Adrenal TB
○ Surgical removal of adrenal glands
○ Adrenal haemorrhage/infarction (in meningococcal septicaemia)
○ Malignant infiltration – from lung, breast or renal cancer
* Secondary
○ Steroids
○ Congenital
○ CRH deficiency
○ Trauma
○ Radiotherapy
116
risk factors for addisons disease
Other autoimmune condition ssuch as ovarian faliure, pernicous aneamia, and thyroid disease
117
pathophysiology of addisons disease
Autoimmune destructio resulting in reducd to no glucocorticoid and mineral corticoid production
This leads to increase ACTH and CRH
ACTH is what is responsible fo the hyperpigmentation
118
what are the key presintations of addisons
TANNED TIRED TONED TEARFUL
119
signs and symptoms of addisosn
Postural hypertension
Hyperpigmentation
Virtiligo
Hypoglycaemia
Nausea and vomiting
Abdominal pain
Weight loss
Legarthy
Depression
120
test or addisons
ACTH stimulation test - take baseline cortisol, give ACTH (synATCHen) and then remeasure cortisol levels.
Failure of exogenous ACTH to increase plasma cortisol
In Addisons - cortisol remais low after giving ACTH
Plasma ACTH level - high ACTH and low cortisol is primary, low both is secondary
Adrenals CXR
Look for adrenal antibodies
U and Es - high plasma renin and rasied urea shows aldosterone mysfunctions
121
manegment for addisons disease
Glucocorticoids - oral hydrocortisone/prednisolone
Mineral corticoids - fludruocortisone to replase aldosterone
Double does of sterioids is needed when unwell, trauma, sugeru and hightwhift work
They should also be given emergancy injection hydrocortisone for adrenal crisis times
122
complications of addisons disease
Can present as an emergency (Addisonian crisis) – sudden need for aldosterone and cortisol
* Vomiting + nausea
* Abdominal and back pain
* Muscle cramps
* Confusion
* Hypotension
* Hypoglycaemia
* Hypovolaemic shock
Treat with fluids and IV Hydrocortisone
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wha are teh commentest causes f addiosns disease bth worldwisde and in teh uk
Worldwide = TB
In UK = Addison’s (autoimmune adrenalitis)
124
what is the deforntiiotn of SIADH
Continued secretion of ADH despite plasma being very dilute, this causes water retention, excess blood volume and hyponatremia
125
what are teh causes of SIADH
alignancy
* Small cell lung carcinoma
* Prostate
* Thymus
* Pancreas
Drugs
* Opiates
* Chlorpropamide
* Carbamexepine
Brian issues:
* Meningitis
* Cerebral abscess
* Head injury
* Tumour
Lung -
* Pneumonia
* TB
* Abscesses
* Asthma
* CF
Metabolic
* Porphyria - body cant process haem
Alcohol withdrawal
126
risk factors for SIADH
age >50 years
pulmonary conditions (e.g., pneumonia)
nursing home residence
postoperative state
127
what os teh pathpphysiology of SIADH
Excess ADH - causes an insertion of aquaporin 2 and so more water retention
It also decreases the RAAS as there is enough water in the plasma, which means that less aldosterone is release. This means that there is more Na+ secreted which causes hyponatremia!
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what are teh keypresintation of SIADH
Prescence of risk factors
Abscenece of hypovolemia
Absence of hypervolemia
prescence or signs of adreanl insurciacncy ot hypothyroidism
129
what are the signs and symptoms of siadh
Concentrated Urine
Hyponatremia
Reduced GCS
Irritability
Headaches
Anorexia
Nausea
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what are teh first line test for SIADH
It needs to be distinguished from hyponatremia, diagnostic criteria:
- Low serum sodium
- Low plasma osmolality
- Inappropriate urine osmolality
- Continued urinary sodium excretion
- Absence of hypokalaemia
- Normal renal, adrenal and thyroid function
* Test with 1-2L of 0.9% saline – sodium depletion WILL respond, SIADH will NOT
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what are teh differential diagnoses for SIADH
Pseudohyponatraemia due to hyperglycaemia, hyperlipidaemia, or hyperproteinaemia should be ruled out first
Renal failure, adrenal insufficiency, and appropriate release of AVP secondary to extracellular volume depletion (hypovolaemia, due to gastrointestinal or renal loss) or intravascular volume depletion (hypervolaemia due to congestive heart failure, cirrhosis of the liver, or nephrotic syndrome) must be ruled out in order to diagnose SIADH.
132
what is the treatment for SIADH
Treat the cause
* Restrict fluid to increase the Na
* Demecocycline - inhibts vasopression on the kidneys - cuase nephrogenic DI
* Tolvaptan - treatment og hyponatremai secondary to SIDAH as prmotes water excretion with no loss of electrolytes
Furosemide - salt and loop diruetics help prevent overload
133
what is diabeties insipidus
a lack of ADH
134
what is a risk factor for diabeties insipidus
sickle cell disease
135
what is teh pathophysiologyy of teh two types of diabeties insipidus
Cranial - too little ADH released form the pituitary gland
* Neurosurgery
* Head trauma
* Pituitry disease
* Infiltrative disease
* Idiopathic
* Congenital defect in ADH making gene
Nephrogenic - kidney just not responding to it
* Drugs
* Hypokalemia
* Hypercalceamia
* Sickle cell disease
Familelia - ADH receptor mutation
136
what are teh sympotms of diabeties insipidus
Polyuria
Polydipsia
Dehydration
137
what are teh first line tests for diabeties insipidus
Water deprivation test - aims to see if the kidneys will still dilute water even if dehydrates
Normal response would be for urine to become concentrated
Desmopressin (ADH analogue) can then be given to see if it is kidney or brain related, if the urine osmolarity remains the same it is nephrogenic, if it changes it is cranial
138
what are teh otehr tests for diabeties insipidus
* MRI of hypothalamous
* Plasma biochemistry - high or normal Na+
* Bloog glucose, serum K and Ca2+ should be measured to exclude oyeh causs of polyuria
* Urine volume ot confirm polyuria
139
differenctial diagnosis for diabeties insipidus
Primary polydipsia - drinking too much water
140
what is teh treatment for diabeties insipidus
Cranial DI - demopressin
Nephrogenic DI -
○ Bendroflumethiazide (diuretic) – causes more Na+ secretion in DCT 🡪 increased water lost makes body respond by reducing GFR
○ NSAIDs – reduce GFR by inhibiting prostaglandin synthase (prostaglandins locally inhibit ADH action)
Drink a certain amount of water each day
look out for hypnatremia!
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what are teh three types of hyperpartnyroidism
Primary - excessive PTH secretion
Secondary - physiological compensatory hypertrophy of all the glands in response to hypocalcaemia (vit D deficiency, chronic kidney disease)
Tertiary - autonomous parathyroid hyperplasia after long standing secondary hyperparathyroidism, plasma calcium and PTH are raised
142
what are eth risk factors for hyperparathyroidism
Genetics, women after menapause, radiation therapy in the neck
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whatare ethe signs and symptoms of hyperparathyroidms
Fractures and osteoporosis hypertension
* Painful bones,
* Renal stones,
* psychiatric moans(legarthy, memory loss, depression, psychciss, insomnia, these are caused by the excess calcium)
* Abdominal groans - nausea, vomiting, constipation
* Thirst and polyuria
144
what is the tests for hyperparathyrpidism
Blood test for parathyroid horone -
○ Primary - ↑PTH, ↑Ca, ↓Phosphate
○ Secondary - ↑ PTH, ↓ Ca, ↑ Phosphate (due to renal disease)
○ Tertiary - ↑ everything (progression of secondary)
* Increaaaaaed urinary caliucm excretion
* Bone scan for density
* Abdominal xray
* Radioisotope scanning for detecting adeanomas in the body
145
what is teh treatment for promary hyperparathyroidism
Primary
* Parathyroid adenoma- surgical removal
* Remove the parathyroid glands, causes hypocalceamia
* Give calcimeitic (cinacalet) that increases senstitivity of parathyroid cells to Ca2
* Avoid thiazide diuretics and high calcium and vitamin d intake
146
what is teh treatment for secondary and tertary hyperparathyroidm and for emergacnsys?
Secondary and tertiary - treat the cause (renal problems)
Emergancy
* rehydrate with 0.9% NaCl
* give biphosphne to preovent bone reabsorbtion y inhibiting the osteoblastasts after rehydration
* Measure serum U and Es daily
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what are teh causes of hypoparathyroidism
Syndromes
Genetic
Surgical
Radiation
Autoimmune
Infiltration
Magnesium deficancy
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what is teh pathophysiology of hypoparathyroidism
* Autoimmune destruction of parathyroid cland
* Vitamin D defiecancy causing less Ca2+ can lead to autoimmune destruction?
149
key symptoms of hypoparathyroidism
SPASMODICT
Spasms – carpopedal spasms = trousseau’s sign
Perioral paraesthesia (around mouth)
Anxious, irritable, irritational
Seizures
Muscle tone increases
Orientation impaired and confusion
Dermatitis
Impetigo herpetiformis – psoriatic pustules
Chvostek’s sign, cataracts, cardiomyopathy
Trousseaus sign
150
signs and symptoms of hypoparathyroidism
* Chvostek’s sign - involutary twithng of facial misces when the cheek is gently tapped infrot of the ear
* Convulsiotn
* Arrhymthia
* Tetany
* Trousseau’s sign – carpopedal spasm induced by inflation of the sphygmomanometer cuff to ~20 mmHg above systolic BP
* Spasms (hands and feet, larynx, premature labour)
* Periheral paraesthesia
* Anxiety
* Seizures
* Muscle tone increase
151
hypoparathyrpidmsm teste
Blood test to measure parathyroid and calcium levels,
phosphate levels will be high,
152
differenctia diagnosis for hypoparathyroidism
Type 1 diabetes, Addison's diseas, ceaoliac disease
153
management for hypoparathyrpidms
* Calcium supplement
* Calcitriol (active vitamin D)
Synthetic PTH
154
what is pseudohypoparathyroidism
* There is also pseudohypoparathyroidism!
* Resistance to PTH hormone due to mutaiton on subunit
* Bloodworks show low calcium and high PTH
* Treated as nomeal hypoparathyroidism
* Associated with short stature, short metacarpals (especially 4th and 5th), subcutaneous calcification and sometimes intellectual impairment
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what is a pheocrocytoma
A tumour in the adrenal gland causing too much adrenaline to be released
156
what is teh aetiology of a pheocromacytoma
* Tumour in the adrenal medulla which cause the release of catecholamines (85% of cases)
* The other 15% us causes by paragangliomas on the spinal cord which can be due to hereditary syndromes
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what are the risk factors of pheocromacytoma
Having the heredity syndromes endocrine neoplasia type 2 or Von Hippel-Lindau syndrome
Succiate dehydrogenase subunit b c and d gene mutation
158
what are teh key presintations of pheocromacytoma
Headache
Palpitations
Diaphoresis - excessive sweating
159
what are teh signs and symptoms of pheocromacytoma
Orthostatic hypotension (postureal hypotention)
Hypercalceamia
Cushigns sundrom
Abdminal masses
Diahorrhea
Fever
Tremors
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what are teh tests for pheocromacytoma
24 hour urine collection for catchelocamies, normetaphrrines and creatine
Genetic testing
Palsma catcholocamines
* serum free metanephrines and normetanephrines
FBC
serum calcium
serum potassium
chromogranin A
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what are teh differenctial diagnosis for a pheocromacytoma
Anxiety, carcinoid syndrome
Hyperthyroidism
162
what is teh treatment for a pheocromacytoma
Beta blockers to reduce the effect
Surgery to remove the tumour
163
what are the risk factros for hypercalceamia
* Non metastatic malignancy
* Metastatic skeletal involvement
* Lymphoma
History of malignancy
older age lady
164
causes of hypercalceamia
90% of causea are caused by either
* Malignancy
- bone mets, myeloma, PTHrP, lymphoma
* Primary hyperparathyroidism
Other factors:
* Thiazides
* Thyrotoxicosis
* Sarcoidosis
* Familial hypocalciuric / benign hypercalcaemia
* Immobilisation
* Milk-alkali
* Adrenal insufficiency
* Phaeochromocytoma
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what is teh mneumonic for teh causes of hyercalceamia
CHIMPANZEES:
* Calcium supplementation
* Hyperparathyroidism
* Iatrogenic drugs (thiazides)
* Milk alkali syndrome
* Pagets disease
* Acromegaly and Addison's
* Zolinger-ellison syndrome
* Excess vitamin d
* Excess vitamin a
* Sarcoidosis
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what is teh pathophysiology f hypercalceamia in cancer patients
It's common for cancer patients as it can cause metastasis in kidneys or in bone which causes breakdown and so increased calcium release. This is called hymoural hypercalceamia of malignancy
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signs and symptoms of hypercalceamia
Short QT segment on ECG
Dry mucus membranes
Poor skin turgour
Painful bones-
Renal stones
Psychiatry moans - le
legarthy fatigue, memory loss, psychosis, depression
Abdominal groans - GI symptoms (nausea, constipation, indigestions)
Cardiac arrest!
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what are the tests for hypercalceamia
ECG - tented T, short QT interval
CXR to rule of myeloma and non Hodgkin's lymphoma
24 hour calcium
Bloods - undetectable PTH excludes primary hyperparathyroidism and requires further investigation
X ray
DEXA bone scan
Hight resolution CT
TSH test to write out hyperthyroidism
synACTHen test for Addison's - small dose of ACTH is given to test if it will cause a spike in cortisol
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differential diagnosis for hyperalceamia
Adrenal insufficiency, hyperthyroidism, hyperparathyroidism, pheocromcacytoma, pulmonary tuberculosus
Tuberculosis can cause hypercalceamia becuas of the granulomas have lts of macrophages which are able to change the vitamin d inot its active form.
170
managemtn of hypercalceamia
Lowering calcium levels and treating the underlyign cause
Primary hyperparthyrpidism - surgical removla of adenoma
IV saline - dilute levels of calium in eh blood
Biphosphenates - encourage osteoclasts to apoptose so there is less bone breakdown (risdronate)
171
complicait of hypercalceaima
Acute kidney injury, coma, acute pancreatitis.
172
in hypocalceamia, what three cuases and what are the calcium levels, PTH leves, phosophate levels and id teh PTF appropriate or inaprotriate
Disorder PTH Calcium Phosphate PFH
Vit D deficiency Hight low low Appropriate
Hypoparathyroidism low low high Innapropriate
Pseudohypoparathyroidism High low High Appropriae
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what are the cuases of hypocalceamia
* Vitamin d deficiency - poor calcium uptake and also decreased absorption leads to osteomalacia
* Acute pancreastitus - the sepsis causes more catchelocomines to be release hihc causes a shift in circulating calcium
* Osteomalacia - there is less calcium in the bones meaning that there is less to be reabsored which its low
* Chronic kidney disease - high phosphate levels as well because there is poor uptake of calcium as well and tehre is inadequate vitamin d nd so there is renal phosphate retetntion
* Pseudohypoparathyroidism- resistance to PTH due to a mutation in the parathyroid gland
* Drugs - calcitonin, biphsophates reduce the osteoclast activity resulting in reduced Ca2+
Hypoparathyroidism
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what are teh signs of hypocalceamia
* It will cause the QT interval on an (ECG) to become longer if there is less calcium in the body
* Convulsions
* arrhythmias
* Chvosteks sign (tapping on the facial nerve causes twitching of face)
* Trousseaus sign - carpopedal spasm induced by inflated sphygmomanometer cuff
There are the same symptoms as with hypoparathyroidism
Remember the main ones by -
SPASMODICT
* Spasms
* Paraesthesia
* Anxiety
* Seizures
* Muscle tonicity increased
* Orientation impaired and confused
* Impetigo herpeformis
* Chvostek's sign (face)
* Trousseaus sign (arm)
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what are teh symptoms of hypocalcaemia
Spasms (hands and feet, larynx, premature labour)
Peripheral paraesthesia
Anxiety
Seizures
Muscle tone increase
176
what are the tests for hypocalceamia
ECG - long QT interval
Bloods -there will be low calcium and potentially an abnormal phosphate as well
177
what is teh differencial diagnosis for hypocalceamia
Iantrogenic postsurgical hypoparathyroidism
Vit d deficiency
Hypo magnesia
Hyperventilation
178
what is teh treatment for hypocalceamia
Sever:
* Calcium gluconate - this is calcium salt which increases levels of calcium in the blood and also binds to excess potassium and magnesium in the blood
Mild:
* Adcal supplement (calcium carbonate ) or cholecalciferol (vit d in inactive form)
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what are teh causes of hyperkaleamia
Cramping of smooth muscle, weakness of skeletal and arrhythmias and arrest of cardiac.
Exxessive consumption (IV fluids)
Low levels of aldoseteron n the kidneys causes more to be kept
Drugs - potassium sparing diruetics, nsaids, heparin, ace inhibirots as the block the binding of aldosterone to the receptors
Acute kidney injury - decrased filtration rate
Metanloic acidosis - ketoacidosis,
180
what is teh pathophyisology of hyperkaleamia
K levels are controlled by uptake of k into cells, renal excretion and extrarena losses such as GI
The amount in reh blood helps deterine the excitability og the nerve and muscles cells
When levels rise it creates a reduced electrical potentail between cardiac mycocyte and so the action potentail secreases causing arrhythemias and cardiac arrest
In metabolci acidodsis the body tries to compensae by moevinh h+ ions into cells in exchange for K+ into the bloocd which can cause ther hyperkalemia
181
signs and symptoms of hyperkaleamia
Metaboicl acidosis causesin kussmauls respiration
Tachycardia
* Often asymptomatic until high enough to cause cardiac arrets
* Muscle weakness
* Impaired neuromuscular transmission
* Flaccid paralysis
* Chest pain
* Light headedness
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tests for hyperkaleamia
U and e - if it is over 6.6mmol/l its hyperkalemia and if its over 6.5mmol/litre it’s a medical emergancy
ECG - small t waves, small p, wide qrs complex
183
manegemnt for hyperkaleamia
Moderate - treat underlysing cause, dietry potassium restriction, change of drugs if theyre causing ti, loop diuretic furosemide to increase urinary K+ excretion
Severe -
○ Calcium gluconate – decreases VF risk in the heart and protects myocardium by reducing excitability of cardiac myocytes
○ Insulin and dextrose – drives K+ into the cells
○ Polystyrene sulphonate resin – binds K+ in the gut decreasing uptake
184
what is pseudohyperkalemia
It could be pseudohyperkalemia where the blood test causes tehre to be excess levels of k in te hblood due to thke clentching their fist to get the blood, or heamolysis
185
defornition of hypokalemia
Low potassium level in the body below serum <3.5mmol, severe is <2.5mmol
186
causes of hypokaleamia
Fasting, anorexia,
high levels of aldosterone n the kidneys ( Cushing's and conns) increased renal excretion (loop diuretics and thiazide diuretics), GI losses
GI causes - Vomiting, severe diahorhea, laxative abuse
187
pathophysiology of hypokaleamia
Low k+ in the serum causes a water concentration gradient out of the cell
Increased leakage from the ICF causing hyperpolarisation of the monocyte membrane decreasing the excitability which causes
188
symptoms of hypokaleamia
Usually asymptomatic - muscle weakness, cramps, tetany (muscle spasms), palpitation, constipation
189
test for hypokaelamia
U and E's - <3.5 is hypokalaemia <2.5 is a medical emergency!!!
ECG :
* U waves
* Depressed ST segment
* Small or inverted T
* Lond PR
* Long QT
There is a rhyme - 'have no POT (K+), have no Tea, but a long PR and a long QT
190
differencial diagnosis for hypokaleamia
Vomiting
Severe diarrhoea
Laxative and bowel cleansing agent use
Bulimia nervosa
191
treatment for hypokaleamia
Mild - oral K+ and spironolactone - K+ sparing diuretic
Severe - IV K+
192
defien hypernatreamia
Plasma sodium >145mmol
193
pidemiology and risk factors for hypernatreaima
Those at either extremes of age and those physically or cognitively debilitated, mortality rates can be quite high for those of greater age
Diabetes (insipidus or mellitus)
Kidney disease
194
causes of hypernatreamia
Normally form water loss
Hyperosmolar hyperglycaemic state caused by badly managed diabetes
sodium gain
Mineralocorticoid excess
Diabetes insipidus
195
pathophysiology for hypernatreimia
The patient will often present hypovolemic state if its due to osmotic diuresis. If its due to diabetes insipidus it will most likely be due to
Because of the high salt in the blood, water from the cells will move into the blood, which can cause lots of neural problems.
If they are hypovolemic
196
mnemumonic for hypernatreiam causes
MODEL:
Medication
Osmotic diuresis
Diabetes insipidus
Excessive water loss
Low water intake
197
symptoms of hypernatreiamia
Muscle weakness
Restlessness
Thirst
Confusion
Legarthy
Confusion
Seizures
Unconsciousness
Changes in urination
Muscel twitching
198
test for hypernatreiama
U and E- Na of >145mmol/l is hypernatremia
Urine osmolarity may help determine the causes - normal respons is highly concentrated very little urine, hypertonic urine suggests extra reanl fluid loss (vomiting diharrohea, burns) isotonic sugests osmotic diuresis, diuretic use and hypotonic suggests diabetes insipidus
Head CT looking for intercranial haemorrhage and brain syrinkage
199
differenital diagnosis dor hypernateriamia
Diabetes insipidus
Hyperosmolar hyperglycaemic state
Nephrogenic diabetes insipidus
Severe diahorrhea
200
treatemtn of hypernatreiamia
Replace water defect SLOWLY!!!!!!
Wit NaCL 0.9% and glucose 5%
If its given too fast cerebreral oedema will occur
Treat the underlying causes despressin for diabetes insipidus
201
complications of hypernatreeamia
Moderate to severe hypernatraemia can cause acute brain shrinkage with vascular rupture, haemorrhage, demyelination and permanent neurological injury
Infants and small children are more vulnerable to hypernatraemia due to greater insensible losses and inability to communicate their need for fluids or access fluids independently
202
define hyponatreamia
A serum sodium concentration of less than 135mmol/l, it is the most common electrolyte disorder encountered
203
reik factors for hyponatreiama
Old age
Hospitalisation
SSRI use
Thiazide diuretic use
204
causes of hyponatreamia
Normally caused by an increase in renal water intake due to ADH (SIADH) the most common causes is hypo-osmolar hyponatraemia.
Hypovolemic:
-GI fluid loss
-Mineralocorticoid deficiency
Hypervolemic:
- Kidney injury and disease
- Congestive heart failure
- Cirrhosis
Euvolemic:
- Medications
- SIADH
- High fluid intake
- Medical testing (cardiac catheterisation)
205
key presintation of hyponatriam
presence of risk factors
high fluid intake
fluid losses
history of diabetes mellitus
206
signs and symptoms of hyponatreima
Odema, weight changes, absence of auxillery sweat, poor skin turgour
Confusion, headache, balance problems, altered metal stare, low urine output, weught changes,
207
tests for hyponatreamia
Serum sodium concentration
serum electrolytes, urea, creatinine, and glucose
serum osmolality
urine sodium concentration
Urine osmolality
CT of the brain, tests to find the underlying cause
208
differential diagnosis for hyponatreamia
Chirrosis, heart faliure, kidney faliure, primary polydipsia
209
treatent for hyponatreamia
Hypertonic solution of 3% saline over 24 hours
Restrict the fluid intake if euvolemic or hypervolemic
Tolvaptan - (competitive ADH receptor)
210
what is teh synacten test
synactes in artifical ACTH
it can help tell if teh adran insurficanc of cortisol is due to teh pituitry or adrenals
if its given and cortisol increases its probably due to the pituitry not working properly
211
what is the Essential criteria for the diagnosis of SIADH
Hyponatraemia < 135 mmol/L
Plasma hypo-osmolality < 275 mOsm/Kg
Urine osmolality > 100 mOsm/Kg
Clinical euvolaemia
No clinical signs of hypovolaemia (orthostatic decreases in blood pressure, tachycardia, decreased skin turgor, dry mucous membranes)
No clinical signs of hypervolaemia (oedema, ascites)
Increased urinary sodium excretion > 30 mmol/L with normal salt and water intake
Exclude recent diuretic use, renal disease, hypothyroidism, and hypocortisolism
212
what are the 4 main causes of SIADH
central nevous system (head inury, brain lesion, infection)
tumours
respiratory causes (pnumonia, TB, asthma, pnumothorx)
drugs - ssris, carbamazapine, vasopressin, demopressin, chloroproramide.
213
where is leptin secreted from
white adipose tissue
214
what is teh treatment for hyponatramia
mild or asymptomatic - fluid restriction
severe - 3% saline
215
if a patient with addisons presents with a chest infection what should you do
double teh steroid dose as teh body normally produces more steroid whne under stress
216
where is grenlin released from
the stomach
217
what is teh gold standard test for acromegally
* Oral glucose tolerance test
○ Normally a rise in blood glucose will suppress GH levels
Give glucose and then test GH levels – if they remain high this is diagnostic for acromegaly
218
why do you not do GH test or acromegally
GH is released in pulses and so isnt very accurate.
219
who should you not give carbimazole to and what should they be give instead
pregnant ladies
propylthiouracil
220
what is a dangerous side effects of carbimazole you need to tell teh patient about
221
what is a dangerous side effects of carbimazole you need to tell teh patient about
antigranulosis - a deficany of granulocytes in teh blood, causing inceased vunrability to infection as it depresses teh bone marrow
tell teh patiensts tat if they get any signs of infection they need to stop taking it e.g a sore throat
222
why does alchholism causes hypoparathyroidism
alcohol is a magnesuim diuretic and cuases teh magnesium to leave the body. This leads to low Mg levels. Mg is needed to make parathyroid hormone, so this leads to hypoparathyroidism and hypocalceamia
223
what are two effects of insulin on cells whihc doesnt include glucose
drived [otassium into teh cells
surpresses growth hormone
224
what medication would uou give to some who is pregncnt with graves hyperthyroidism
PROPYLTHIOURACIL - carbimazole is teatrogenic
