Endocrinology Flashcards
Thyrotoxicosis (signs)
Easy fatigability = Fine tremor
Heat intolerance = Warm, sweaty extremities
Excessive sweating = Proximal myopathy/atrophy
Palpitations = Tachy/ arrythmias
Weight loss, increased appetite = Dyspneoa
Diarrhoea
Target organs =heart, muscle etc)
Thyrotoxicosis (Atypical)
weight loss, slow AF, severe depression
Primary presentation with heart involvement
Tachy-arrythmias (resistant AF)
Young women: infertility, menstrual abnormalities
Thyrotoxicosis (Typical)
Elderly: Apathetic thyrotoxicosis: small goitre
Severe muscle weakness, Associated HPP
(> older patient > 60yrs)
High output failure
Thyrotoxicosis (common causes)
- Grave’s disease (Diffuse, smooth, vascular)
Toxic multinodular goitre (multi nodular)
Toxic adenoma (single nodule)
Subacute thyroiditis (de Quervain’s) (extremely tender to touch)
Drugs: Amiodarone, Thyroid hormone replacement
Grave’s disease
Common form of thyrotoxicosis
F>M, 20-40 yrs
Auto-immune dx
stimulate antibodies against TSH receptor
Thyroidal (bruit), Extrathyroidal
Graves:
Ophthalmopathy = Inflammation vs Infiltration (Proptosis, muscle, vision)
Dermopathy = anterior aspect of shin (Fibrosis), itchy
Acropachy
Grave’s (more info)
Suspected hyperthyroidism
TSH + free T4
High TSH and low T4/T3 = Primary hyperthyroidism
Ultrasound (Anat)
(Functional) = Thyroid uptake scan, NIS
Treatment:
-Neomercazole (Relapse graves)
-Radio-active iodine (very effective, contra = grave’s eye dx, pregnancy)
-Surgery (refuse RAI, large goitre, pregnancy, failed medical px, single adenoma, very young, comsetic eye dx)
-Supportive / anti-inflammatory therapy : Thyroiditi
When to request TSH-R antibodies?
To confirm Grave’s disease if no extrathyroidal signs and patient keen to be treated medically
When to do free T3?
Free T4 normal, TSH suppressed
Free T3:
High “T3 toxicosis” = Grave’s, Toxic nodular goitre
Normal = Subclinical toxicosis
Low = Euthyroid sick syndrome, Non-thyroidal illness
Primary hypofunction
Low T4 and T3
High TSH level
Clinically hypo
Hypo-thyroidism (COMMONEST CAUSES)
HASHIMOTO’S disease (Most common)
Iatrogenic damage to thyroid gland
Drugs: Amiodarone, Lithium
Hypothyroidism (symptoms and signs)
Face, puffy
Skin cold, dry, rough, yellow discoloration
Voice hoarse
Bradycardia
Slow mentation
Concentration difficulties
Slow reflexes
Elderly
Macrocytic anaemia
Depression
Infertility, menstrual abnormalities
Apathy and withdrawal in elderly
HASHIMOTO’S disease
(Most common cause of hypothyroidism)
F>M, any age
Auto-immune dx
Lymphocytic/chronic thyroiditis
Antibodies: TPO/microsomal
High TSH and low T4/T3 = Primary hyperthyroidism =>Iatrogenic damage to thyroid 9Prev surge./radio-active iodine, Hashimoto’s thyroiditis
What should you do if there is a strong clinical suspicion of hypo-thyroidism?
But TSH is normal
Do free T4
If low – then secondary hypothyroidism (pituitary hypofunction)
Patient should be referred to endocrinologist for further evaluation
Hypothyroidism treatment
-Levo-Thyroxine (Eltroxin, Euthyrox) T4
-replacement dose 50– 200ug/d (age, weight)
-TSH only stabilize on therapy after 4 – 6 weeks
-once daily (long half-life) - Give in morning on empty stomach.
-Absorption may be affected by concomitant use of calcium / Fe-supplements / estrogen / anti-acids / proton pump inhibitors
-Primary care level; Life-long replacement = T4 converted to T3, no need to give T3
-Carefully and slowly in the elderly and in patients with known heart disease
- Thyroxine in elderly / heart disease ( Start low & go slow!!!) ( 25ug daily, incr. 25ug 2-4 weeks, continue on 50-75ug for 6weeks) Only increase dose = if TSH still elevated
Subclinical hypothyroidism
- Elevated TSH ; normal free T3 and T4 levels in a clinically euthyroid patient
- If TSH level above 10mIU/l, consider treatment as for overt hypothyroidism
- If TSH level less than 10mIU/l, repeat functions after 3-6 months - see proposed algorithm
DM type 1
Young with normal BMI
Fatigue, weight loss, polyuria and polydipsia, blurry vision, slow healing of cuts or wounds, more frequent infections
Present in DKA
DM Type 2
Frequently Asymptomatic
Middle age and older
Metabolic phenotype
Gestational diabetes
Any insulin resistance during pregnancy
Due to diabetogenic effect of placental hormones
Many potential complications for mother and baby.
Diabetes (Other)
MODYs
LADAs
Secondary to pancreas insufficiency
DM (Clinical signs)
Associated conditions: Obesity, Hypertension
Insulin resistance: Acanthosis Nigrans, Skin tags, Folliculitis or fungal skin infections
Signs of complications: Decreased light touch and vibration sense due to neuropathy, Retinal changes, Absent peripheral pulses
In case of DKA: Acidotic breathing
Diabetes complications (Microvascular)
Nephropathy
Retinopathy
Neuropathy
Autonomic Neuropathy
Gastroparesis
Diabetes complications (Microvascular)
CVA
IHD
PVD
ED
Diabetes complications (Metabolic)
DKA
Hyperosmolar state
Hypoglycaemia
Diabetes complications (less common)
Diabetic Amyotrophy
Charcot joint
Diabetes Dx
Glucose tolerance test
HbA1C
(Random glucose > 11)
Glucose on Dipstick
Monitoring (HbA1C & Diabetic Diary)
DM Treatment
Non-pharmacological: Education (Risk and reasons for control, Use of diabetic diary, Diet), Life style modification (Weight loss, Exercise)
1) Metphormin
2) add Sulponurea (su)
3) long-acting insulin at night (stop SU)
4) Twice-daily insulin (Only stop metformin if poor renal fx)
DM type 1 treatment
Regimes
-Twice daily insulin = Use combination of short and long acting insulin (70/30 – Actrophane) 2x/day
-Basal bolus regime = Long-acting at night covering 24hrs. With short-acting 30min before meals (3x/day)
-SC insulin pump
DKA (Presentation)
Acutely unwell
Abdominal pain and vomiting
Acidotic breathing
Confused or depressed level of consciousness
DKA Dx
Combination of raised serum glucose, metabolic acidosis on blood-gas and ketones confirms Dx
DKA management
Fluids, fluids, fluids
IVI insulin
Replace potassium
If glucose drop to below 12, while still acidotic, replace glucose
* Look for secondary cause, Presenting as a DKA per definition mean you are insulin-dependant – pt should be discharged on insulin
Hypoglycaemia (presenation)
Sympathetic symptoms: Tachycardia, sweating, tremor
Neuroglycopenic symptoms: Confusion go towards coma
Hypoglycaemia (causes)
-Diabetic nephropathy = leading to accumulation of medication
-Not eating but still using medication
-Reduced basal needs due to weight loss, but not adjusting medication
Hypoglycaemia (Management)
Glucose
Monitor glu. = When monitoring, always ask about hypo’s as well. Older pts with autonomic dysfunction and Beta-blocker use may not have sympathetic symptoms
Address cause: Adjust dose
Hypoglycaemia (outside of a Diabetic)
-⟪Severe sepsis and organ failure⟫: Acute severe sepsis, Liver failure , Renal failure
-⟪(Adison’s)⟫Counter regulating hormone failure: If glucose low, cortisol and adrenalin must push it up
When adrenals fail, this do not happen.
-⟪Paraneoplastic⟫: Solid tumors (sarcoma) most common, Insulinoma (of pancreas), Can be any other
