Endocrinology 💊 Flashcards
Metabolic syndrome aspects and diagnosis
WEIGHHT
waist size, impaired glucose tolerance, hypertension, HDL, TG
> =3/5 of above
Best initial Tx for metabolic syndrome
Lifestyle
If patient has impaired fasting glucose in metabolic syndrome, can give what??
Metformin
Main treatments for diabetic retinopathy
Anti VEGF agents and laser photocoagulopathy
Main Tx for diabetic nephropathy
ACEi
Which CN is most seen in diabetic neuropathy
CN3
Neuropathic pain in DM can be Mx with
TCA or SNRI or gabapentin
Gastroparesis Tx
Metoclopromide or erythromycin
How to Dx micro albuminuria in DM
Spot urine ACR (30-300). Otherwise cannot see in routine UA
Dx for DM
Random glucose at >=200 with symptoms.
Or fasting glucose >=126
Or >=200 after OGTT
Or HbA1c > 6.5%
Screening for T2 DM in age > 45
Check HbA1c every 3 years. If 5.7-6.4 then do yearly recheck. Do yearly check up on high glucose generally/positive OGTT, if they didn’t quite make Dx
Excserize advice to DM patient
Moderate intensity for 30-60 mins, 5 days a week
When to give statin your DM patient
All aged 40-75 regardless of lipid level
Aside from routine, which Vx’s should be given to DM patients
Pneumococcal (above 19)
If patient on insulin struggling with intermittent dosing… can give what?
Insulin infusion pump
Out of Metformin and sulfonylureas, which decreases microvasc events and which decreases CVD
Metformin decreases CVD and sulfons reduce microvasc
Goal HbA1c for adults and children
Adults - <7%
Children - <7.5%
Does tight glycemic control reduce risk more for macro or micro vasc complications
More for microvasc complications
DKA vs HHS
Glucose-
Acidosis-
Ketones-
Anion gap-
Osmolality-
Glucose- >250 DKA. >600 HHS
Acidosis- only in DKA
Ketones- only in DKA
Anion gap- raised in DKA
Osmolality- raised in HHS
Mx for DKA
-consider K+ being low to start
-consider if glucose goes down but AG remains
NS, insulin (check for low K+) until AG closes. If K+ <3.3 then give K+ before starting insulin. If glucose goes below 200, but acidosis remains, give dextrose with the Insulin
Mx of HHS
NS first, insulin (check for low K+).. DVT prophlx
When to further evaluate patients with hypoglycemia
If Whipple triad is present only!
Hypoglycemia after meals only… consider what disease
Consider dumping syndrome
If patient has hypoglycemia after fasting, then what should we do to Invx
Do a fast, then take glucose, Insulin, c peptide.
Patient conscious and has hypoglycemia. Mx?
Oral sugar/drink
Patient with altered mental state and has hypoglycemia. Mx?
IV dextrose. Or IM glucagon if no IV access
Best initial test to screen for thyroid disease
TSH
Best initial tests to screen for pituitary-based thyroid disease
TSH and T4
Euthyroid sick syndrome findings (TFTs)
Low T3, but high rT3 (T4 converted to rT3)
Thyroid bruits can be a sign of what disease
Graves
Which kind of thyroid nodules need biopsy and further workup for CA
Non functioning nodules
Dx
Hyperthyroid signs, low thyroglobulin, low uptake on RAI scan.
⬆️ Exogenous thyroid hormone
DDx
Hyperthyroid signs, high thyroglobulin, low uptake on RAI scan.
Acute thyroiditis, iodine exposure, extra glandular exposure
Graves opthalmopathy Tx
Steroids
Definitive Tx for hyperthyroidism. When is this CI’d
I 131. Not if large and obstructive goiter, or graves (worsens ophthalmopathy). Do thyroidectomy for these cases
Mainstay symptomatic treatment for hyperthyroidism
Bb
First line agent to tackle the high TH in hyperthyroidism
Methimazole (recall 1st trim rule)
Thyroid storm Tx
Bb, then anti thyroid meds (PTU due to rapid action), GCs, then KI
(+-) cholestyramine
Most common cause of congenital hypothyroidism
Thyroid dysgenesis
High CK seen in hypo or hyper thyroidism
Hypo
Mx of myxedema coma
ICU admission. IV levo and IV hydrocortisone (unless excluded adrenal crisis)
De quervain thyroiditis Mx
Self limited, but give NSAID for pain
Thyroiditis Mx (generally)
Anti thyroid meds if hyperT, and levo if hypoT. Anti thyroid meds not indicated
Why does levo dose need to be increased in pregnancy
Because E. increases, increasing TBG, decreasing free T3/T4
Appreciate diagnostic workup for thyroid nodule
Thyroid nodule:
Next two things to do
TSH and neck US
Thyroid nodule:
TSH low. Do what?
Scintigraphy
Thyroid nodule:
TSH low. And RAI shows hot nodule. How to Mx
I131, or Sx excision
Thyroid nodule:
TSH low. And RAI shows cold nodule. How to Mx
Check if needs FNA criteria on US. Then proceed to FNA
Thyroid nodule:
TSH high/normal.
How to Mx
See if meets FNA criteria on US. Then do FNA
Tx for malignant thyroid CA
Hemi or total thyroidectomy. +- RAI
Tx for indeterminate thyroid nodule (risk of CA)…. FNA not 100%
Balance watch and wait with hemithyroidectomy
Mx for patient with confirmed benign thyroid nodule
Exam and US follow up
Diagnostic test for osteoporosis.
When should this be done
DEXA scan. This should be done for all women above 65 and older men above 70. And in patients with signs and symptoms or risk factors
When and what to treat osteoporosis
Treat all osteoporosis patients. Do you lifestyle modifications and bisphosphonates are first line.
Supposed cause of Padgetts disease
Latent viral infection in susceptible patience
Best initial test for Paget’s disease
Plain x-ray, to see the lytic and sclerotic lesions
Aside from plain x-ray, what to other tests can be done in Paget’s disease
Radionucleotide bone scan is needed to characterise the extent of the disease. And bloods (LP, calcium, phosphate)
Treatment for PAgets
Usually no treatment. But may need to reduce pain. Is phosphonate our first line pharmacologically, calcitonin second line.
Bone pain and hearing loss, think what disease
Paget’s disease
General hypercalcaemia treatment. Consider if secondary to malignancy
IV fluids and calcitonin. If secondary to malignancy, add bisphosphonate
Treatment of solitary parathyroid adenoma, and parathyroid hyperplasia
If adenoma can remove. If hyperplasia remove 3.5 of the glands
Management of hyperPTH in the setting of chronic kidney disease
Oral phosphate binders and diet phosphate restriction. Consider cinacalcet
What is the diagnosis. Profound hypocalcaemia following a parathyroidectomy in a patient who had hyper parathyroidism
Hungry bone syndrome
What inhibits GnRH
Prolactin
What is the main inhibition and stimulation for prolactin secretion
Dopamine inhibits and TRH stimulates
Dopamine inhibit secretion of which two anterior pituitary hormones
Prolactin and TSH
What is panhypopituitarism
Where are the anterior and posterior pituitary are affected
Diagnose this. Asymptomatic patient, has high calcium, PTH as normal, urinary calcium is low.
Most likely FHH
Which hormones are most affected in pituitary diseases
Gonadotropins and growth hormone. So children often have growth retardation an adult often have hypogonadism
What are the routine hypopituitarism testings
8 am cortisol (on two occasions), three T4, testosterone and oestrogen, urine and plasma osmolality. Once that is established do an MRI of the brain
Watery diarrhoea, low potassium and hypochlorhydria. What is the diagnosis
VIPoma 
What are the 4 Ss Of adrenal crisis management
Salt (0.9% saline), steroids (IV hydrocortisone), support (resus and 50% dextrose), and search for underlying illness
Do you have a concern for adrenal insufficiency, what is the first investigation
8 am cortisol
Do you have a patient where you are suspicious for Adrenal insufficiency. The cortisol results are indeterminate. How do you manage next
Do a cosyntropin stimulation test
In an adrenal insufficiency suspicion. Cosyntropin test shows minimal cortisol response. What do you do
Measure ACTH. At this rate adrenal insufficiency is confirmed. Now we just want to know where the secondary or primary
If you have a concern for adrenal insufficiency, you do an 8 am cortisol test.
It comes back with low cortisol levels. Is this diagnostic
Yes and you can now measure ACTH
When do you do a cosyntropin stimulation test
When you suspect adrenal insufficiency, and your 8 am quarts or test shows indeterminate results. If the 8 am cortisol tests show low cortisol, adrenal insufficiency is confirmed
Hi suspicion of adrenal insufficiency, what takes precedent giving steroids or diagnostic testing
Giving steroids
Best initial test for pheochromocytoma
24 hour urine metanephrines and catecholamines
When do you do imaging for pheochromocytoma
After labs. Can do CT or MRI of the adrenals, and nuclear MIBG scam to localise extra adrenal lesions
Talk to me about the treatment of pheochromocytoma
Surgical resection. However you must give phenoxybenzamine prior. Beta blockers never given first due to unopposed alpha vasoconstriction
3 diagnostic tests for Cushing’s syndrome
24 hour urine 3/4 or or low-dose dexamethasone suppression test or late night salivary cortisol
Once diagnosed Cushing’s syndrome what do you do next
Measure ACTH to know whether it is adrenal or extra adrenal
Patient diagnosed with Cushing syndrome, ACTH is suppressed. Next investigation?
Adrenal CT
Patient diagnosed with Cushing’s syndrome and has elevated ACTH. How did we manage the patient
MRI of pituitary. If more than 6 mm Adenoma than this is Cushing’s disease. Note that the US Emily algorithm does not include high-dose dexamethasone suppression test
Patient diagnosed with Cushing’s syndrome, has high ACTH, and no adenoma (or less than 6 mm adenoma) is seen on MRI. How to investigate next
Do Petros or sinus sampling with CRH. If there is a central to peripheral ACTH gradient it is Cushing’s disease, if there is no gradient is likely ectopic ACTH
Why do some patients with hyperaldosteronism get muscle weakness and Ileus
Due to hypokalaemia
Main way to diagnose primary hyperaldosteronism
 I give sodium load and measure urine aldosterone. Failure to suppress aldosterone indicates diagnosis. Can also do plasma renin activity to calculate the aldosterone to plasma renin activity ratio
Went to do imaging for primary hyperaldosteronism
Only after labs. And a CT/MRI usually is used
Management of con syndrome. What about management of bilateral hyperplasia (Hyperaldosteronism)
For constant room you can do surgical resection (done after correction of potassium and blood pressure).
Hyperplasia is usually treated with spironolactone
Diagnostic marker for 21 hydroxylase deficiency
17 hydroxyprogesterone elevation 
General management for congenital adrenal hyperplasia
Fluid resource and salt repletion. Cortisol to decrease the ACTH.
An antigen is. Fludrocortisone can be given in severe 21 hydroxylase deficiency cases. Consider surgery for ambiguous genitalia
Main way to differentiate between CAH and aromatase defficiency
They present very similarly in females. But CAH will have blood pressure and electrolyte problems
Initial lab test for diabetes insipidus
Serum osmolality, urine osmolality, serum sodium, urine sodium
Confirmation test for diabetes insipidus, and how to differentiate them (Central and nephrogenic)
Water deprivation test. Then give desmopressin
Treatment for central diabetes insipidus
Desmopressin IV or intranasally or orally
Treatment regime for nephrogenic diabetes insipidus
Salt restriction, thiazide, amiloride, low protein diet
You clinically suspect acromegaly, what is the first test to do. Interpret what are the results with mean
IGF – 1 levels. If normal rules out acromegaly, if elevated must do further testing
Patient had a suspicion for acromegaly, IGF levels were elevated. What must be done next
Oral glucose suppression test. If there is adequate growth hormone suppression this rules out acromegaly. If inadequate must do MRI
Patient had suspicion for acromegaly. IGF-I was elevated and oral glucose suppression test was inadequate (i.e. positive). What must be done next
MRI of the brain.
What is the surgical and medical therapy for acromegaly
Surgery is transphenoidal surgical resection. Medical therapy is ocreotide or pegvisomant
What diagnostic tests must be done in suspected hyperprolactinaemia
Serum prolactin. MRI of the brain. And a pregnancy test
Best initial treatment for hyperprolactinaemia
Dopamine agonists (cabergoline or bromocriptine)
If Prolactinoma is resistant to medication. Or has compressive effects. How can we manage
Transphenoidal surgery
Mainstay treatment for SIADH
Restriction of fluids
Patient with SIADH. You have restricted fluids. But it is persistent and symptomatic. How do you manage
Try IV hypertonic saline therapy
Aside from restriction of fluids and IV hypertonic saline. What to therapies can be given for either severe SIADH or chronic SIADH
Severe can be given tolvaptan. Chronic can be given Demeclocycline
Initial test for pheochromocytoma suspicion. And then the diagnostic test
Initial test is plasma metanephrines. If they are high do a CT.
Why might glucose be elevated in pheochromocytoma
Because epinephrine and norepinephrine inhibit insulin
Diagnosis of nonclassic congenital Adrenal hyperplasia. What’s the treatment
Diagnosed by doing And ACTH stimulation test, which will see an increase in 17 0HPROG. Treat with Hydro Cortizone believe it or not
Why estrogen will recquire more levothyroixine
Because increase estrogen means more TBG. Usually in normal people this will equilibrate, but since a hypothyroidism patient cannot increase TH when TSH increases, it doesn’t. So that’s why more Levo needed.
Babies with CAH… do they have electrolyte abnormalities at birth?
No. 2-3 weeks after, since maternal adrenal hormones are still present
Hyperparathyroid like symptoms… high urine Ca excretion vs low? DDx
Low = FHH. High = HyperPTH (so much Ca that even though PTH increases reab, there is net excretion)
Precocious puberty, one of the best things to do first
Bone age test
Precocious puberty, if bone scan shows same bone age as chronological age
Benign pubertal variant
Precocious puberty, if bone scan shows higher bone age as chronological age, measure what?
LH, to see if the precoc is central or peripheral
How does the location of the diabetes inspires impact the Na levels
If the hypothalamus or pituitary are effected, then The thirst centre is kinda fucked, so Na levels can go up more. If it’s nephrogenic then the thirst centre is intact and Na is ok often
Neuropathic pain Tx…. Say if patient is old and has MI Hx
Preg abalone or gabapentin. Avoid TCA here
Patient who is young and has HTN. Given thiazide and suddenly gets low K. What’s occurring here and what to do next
Likely hyper aldosterone. These patients are very susceptible to low K. Do Aldo:PRA to Dx.
Values of Na and K in central adrenal insuff
Na is low, since cortisol usually inhibits ADH. K is normal
Why might CF patient (or other chronic pancreatitis cases) with pancreatic insuff and DM, be as risk for hypos
Since alpha cells are usually damaged too, we get lack of glucagon…. Causing hypos
Myopathy of hyperthyroidism
Weakness, can be distil but more likely proximal, muscle atrophy, reflexes often normal, no pain, other signs of hyperthyroidism. Usually resp and bulbar muscles normal
Neonatal hyperthyroidism cause . TX?
Mums graves antibodies cross placenta. Cannot be from mums levothyroxine since it cannot cross placenta. Give methimazole and a BB, will resolve in 3 mo.
What changes in TSH, and total T3/T4 do we see in pregnancy and why
Due to high TBG, we see increase in total T3/T4. Because of hCG being high, it stimulates TSHr and negatively feeds back on TSH (lowering it).
Findings of TFTs in euthyroid sick syndrome
Low total and free T3. Normal TSH and T4
Neuroblastoma facts
Usually in adrenal medulla or sympathetic plexus. Usually young young child. If in Cervicle plexus then can cause horners. Can mets to orbit and cause periorbital bruising. Can cause opsiclonus myoclonus syndrome. Small blue cells and schwaaniana stroma . N myc amplification
Harlequin sign
when a child cries, they flush only on one side of the face. Due to horners in a child
How to monitor for recurrence after papillae, follulcar and medullary thyroid cancer
TG for the first two. And calcitonin for the last
What is postpartum thyroiditis in relation to Hashimoto
Postpartum firelighters is a type of Hashimoto, that is not chronic. And of course after pregnancy
Galactosaemia, mention signs and symptoms, genetic defect, management
GALT mutation. Patient will have vomiting, low glucose, Portone, hepatomegaly, bilateral cataracts, jaundice. Will be part of newborn screening, we’ll see reducing sugars in the urine, GALT activity in red blood cells will be low. Managed bye reducing milk, going to soy diet
What is subclinical hypothyroidism
High TSH, yet normal T4
What is euthyroid sick syndrome. How do you manage
In ill patients are cytokines cause a decrease in T4 to T3 conversion. This means we will have normal TSH, normal T4, low T3. rT3 struggles to get degraded to, so is elevated. For treatment thyroid hormone does not work, so we just observe. Later on TSH may decrease, and then near the end of the disease it starts to increase (which can appear like hypothyroidism). So wait a bit before retesting
What is the equation to calculate the calcium corrected for albumin
Ca + (0.8 * (4 - alb))
What is pseudo gynaecomastia
Essentially lipomastia. Fat accumulates in the chest, and does not have clear define borders like normal mammary glands. The man will have no hypogonadal problems or cancer signs. It’s benign so just advise weight loss
If diagnose somebody with high blood pressure what other tests should be done initially
ECG, UandEs, urinanalysis, complete blood count, diabetes testing, cholesterol testing. Essentially checking for comorbidities and complications
What’s the definition of resistant hypertension
Blood pressure that persists even with three classes of antihypertensives
What is the diagnostic/investigation steps for pheochromocytoma
Plasma metanephrines, then ct or pet to confirm and locate tumour
Why do we see gynaecomastia more in primary gonad issues, rather than central courses.
Because in primary gonadal issues, we get increased LH and FSH, which increase the aromatisation of testosterone to oestrogen.
In central cause as we don’t have this so gynaecomastia is less prominent
Can opioids cause hypogonadism
Yes! They can suppressed secretion of GnRH and LH
Name a couple of key differences between symptoms in polymyositis and thyroid myopathy
Polymyositis usually has reserved the tendon reflexes, where is thyroid problems will show varying signs. Polymyositis have weak muscles not myalgia.
A patient with diabetes and persistent albumuria Is said to have diabetic nephropathy when what is present (two potential things)
Had type one for five or more years, or type two for a significant time
Has proliferative diabetic retinopathy
How to diagnose premature adrenarche or premature thelarche
Patient will have signs of high androgen (pubic hair and acne) or the patient will have breast development respectively. Both of these will have normal bone age, versus precocious puberty which has advanced bone age 
How to diagnose central versus peripheral precocious puberty
Patient has advanced bone age, to distinguish between the two must do GnRH stimulation test. If LH is low it’s preferable if LH is high its central
Describe the relationship between calcium and. Albumin
Albumin will bind calcium (free), And lower it.
So maybe you will have hypocalcaemia on labs, but the actual calcium might be normal. Or you may have normal on labs, but may have a slightly high calcium in reality
Treatment for hypercalcaemia due to immobilisation
Bisphosphonate (make sense)
Constitutional delay of growth and puberty versus familial short stature, in terms of bone age
Bone age will be less than actual age in the prior, And bone age will be the same as actual age in the latter. Also there’s usually a fam history in the latter
Talk to me a bit about constitutional delay of growth of puberty
Patient would have had normal-ish growth around six months to 3 years, then it will have come down to around the second percentile (but it will be on the same trajectory for a very long time).
Bone age less than actual age. Tanner will be one. Maybe a family history of delayed puberty. Manage with watch and wait
Went to do partial lobectomy versus total thyroidectomy.
And when do we give radioactive iodine
If the cancer is less than one to 2 cm and there is no lymph node or local invasion, we can do partial lobectomy. If it’s greater than 2 cm old is lymph nodes all this invasion we do total thyroidectomy. Radioactive iodine is given after. Third hormone is required (to replace the hormone but also to inhibit TSH). TSH is our market of choice for follicular carcinoma
If a woman has increased hair and acne on the face. Also has temporal balding, enlarged clitoris, muscular build.
What does this tell us about the aetiology
Since it’s virilisation, It’s most likely a testosterone or DHE a producing tumour
DHEAS versus DHEA versus testosterone producing Tumour in women
DHEAS (sulphated = partially metabolised), DHEA, T from adrenal,
T and DHEA from ovary
Presentation of CAH in newborns do not have salt changes, why
Mothers hormones are present. So salt wasting only seen in 1-2 weeks
Why does secondary adrenal insufficiency cause low sodium
Loss of cortisol can prevent its natural inhibition on ADH. So we can an SIADH. Lowering sodium
What are some of the things that can trigger Phae attack
Surgery, anaesthetics, abdominal pressure, BB
Graves Tx details
If mild can do remission with methimazole. If severe do thyroidectomy or RAI (give GCs with it to stop opthalmopathy)
Overview of invx and Dx of primary hyperaldo
Basic labs, then plasma aldo to renin ratio (almost Dx’ic). Urine aldo after Na loading is Dx’ic. Abdominal CT or adrenal venous sampling to determine bilateral or unilateral
Patient in PTU or methimazole, and gets sore throat, what to do?
Stop med, and take WBC count. If less than 1000, stop indefinitely. No need to do WBC screening however
Hooklike osteophytes are seen where
Hemochromatosis (in fingers )
How to adjust insulin for long and short excserize
If short burst, can reduce short acting dose of insulin. If long duration, reduce both long and short acting
Why is sodium
Low in HHS
Osmolality will draw water into vessels causing diltional low Na
Risks for HHS
CSs, thiazide, skipping insulin, MI, infx
Does aggressive DM medical management and HBA1C refutation improve micro or macro vasc complications
Micro, macro not so much. And it can even increase all cause cardiac mortality. Aim for 7
Pathophys and cause of milk alkali syndrome
Intake of calcium and absorbable alkali. Can even be just CaCO4 as a whole. Causes renal Vasoconstriction and reab of bicarbonate. Causing high Ca signs. And met alk. Give ISOtonic fluid and then furosemide
When to do statins for primary prevention
LDL >190, age > 40 and DM,
What effect does E therapy have on hypothyroid patients on Levo
As we know, TBH increases, free T4 decreases, TSH increases… but hypoT patients cannot increase the TH, so they need bigger dose of Levo
Decrease libido and pubic hair in primary adrenal insufficiency are seen in men or women? Why?
Women. Men have testes still
Central Precocious puberty treatment
If ideopathic give GnRH ag therapy. Surgery if adenoma
Osteomyelitis and patient has foot puncture wound. Bacteria cause?
Pseudomonas
Osteomyelitis in diabetes patients. What are the causes bacterial level
Polymicrobial. Gram-positive and anaerobic coverage needed
Is first trimester thyroid hormone changes
Thyroid finding population increases which increases total thyroid hormone. Also the increase in HCG (due to close alpha subunit mimicry) can decrease TSH via negative feedback and further increase forward hormone production
When do you do adrenal Veena sampling for high aldosterone
Do either when the CT comes back normal, and you need to know whether it’s bilateral adrenal hyperplasia or Conns syndrome. Or if the patient about 40 years old
Pro insulin level percentage compared to insulin. What is the significance of this value when comparing hypoglycaemia due to sulphonylurea versus insulinoma
In insulinoma pro insulin is more than 20% of the total insulin level. Where is it usually less than 20% in sulphonylurea. However you do need to take sulphonylurea levels to diagnose
Quick contrast between metoclopramide and erythromycins for diabetic gastroparesis
Metoclopramide obviously has extra promote effects. Erythromycins exhibits tachyphylaxis, and it’s only really used for less than a month
Is chronic GC then withdrawal a secondary or primary AI. and why does the Na decrease
Secondary, and Na decreases due to increase ADH… Aldo is normal
If you have low T. Or E. And the LH and FSH are normal…. Is this primary or secondary
Secondary apparently
HHS mainstay Tx
IV insulin. aggressive fluids, do NS regardless of Na, then 0.45 NS if sodium high. Give K if it’s less than 5.3
DKA Tx overview
Thyroid storm vs phae… which has fever
Thyroid storm (sometimes 40°c plus)
Causes of hypoglycaemia without DM
Drugs: quinolones, quinine, beta blockers
Alcohol (usually with prolonged starvation)
Sepsis/critical illness
Adrenal insufficiency
Insulinoma
Surreptitious insulin, sulfonylurea, or meglitinide use
Depleted glycogen stores (anorexia nervosa)
Severe hepatic failure
HB A1c levels above 45 years old. When and how often to recheck the levels
If below 5.7 recheck every three years. If between 5.7 and 6.4 recheck yearly
On top of giving levothyroxine treatment to a myxedema coma patient, what else do we have to give him why
Give hydrocortisone. Unless you have ruled out adrenal crisis, as they present similarly
In what circumstances do we give levothyroxine, even if the patient is subclinically presenting
If the TSH is above 10, or if the patient has Hashimoto (treat anyway)
In the work up for Cushing’s, if the ACTH is high and you’ve done the MRI, what millimetre adenoma cut off would signify Cushing’s disease
6 mm. Bigger than 6 mm adenoma is Cushing’s disease. Less than 6 mm, must do petrosal sinus CRH sampling
Milk alkali syndrome Tx
IV fluids then loops. and stop offending cause
Milk alkali symptoms
High Ca, alkalosis, AKI
Meds that worsen milk alkali
Mainly thiazides. Makes sense
Why might celiacs patient have bone pain
Vit D deficiency. Got Q wrong based on this…
Infant with low low BP and signs of hypovolemia. Na very low, K very high. Dx?
Most likely CAH salt wasting
Long standing CKD patient. Calcium starts to rise. po4 still high, PTH very very high.
Maybe 3° hyperPTH
3° hyperPTH usual Tx
Parathyroidectomy
Causes of acute hypocalcemia
Citrate chelation, EDTA, surgical PTectomy, major resp alkalosis, sepsis, pancreatitis, TLS
Diagnostic tests for PKU. Consider if the newborn screening, versus suspected later on.
Newborn screening is with mass spectrometry. Later on you can do amino acid analysis.
TFT results in preg
Increase Estrogen, and thus TBG. This will increase the total T3 and T4. Because the HCG is high, this mimics TSH, so TSH often is decreased. So increase thyroxine if they are hypothyroidism patient
Diagnosed this condition. Pancytopenia, bone pain, delayed puberty, hepatic splenic Meg.. 14-year-old.
G A,UCHER 
Before doing plasma, rennin and aldosterone testing, what medications need to be withdrawn?
All of the thiazide, spironolactone diuretics. And they should be withdrawn one month before testing.
What Aldo:renin suggests 1° hyperaldo
20
What is the rough schedule for medical therapy prior to surgical reception of the phaechromocytoma? 
Roughly 2 weeks before start irreversible, non-selective, alpha blocker therapy. Then roughly a couple of days before the operation can initiate beta-blockade as well.
Why might a diabetic gastroparesis patient have increased hypoglycaemic episodes when taking insulin
Because there is delayed transit into the duodenum, the patient may misstime the insulin doses 
Compare and contrast the benefits and drawbacks to erythromycin versus metoclopramide
metoclopramide can cause extra pyradimal side-effects. Erythromycin has tachyphylaxis, and can diminish effect overtime. 
Tx of these prolactinomas
Micro (<1cm) and no symptoms
2cm and no symptoms
0.5cm and symptoms
Above 3cm
Failed cabergoline
No Tx
DA ag
DA ag
Sx
Sx
For how long can someone be on GC before withdrawal Adrenal insuff is a risk
3 weeks only!
Polyuria is how many L in 24 hr
3hr
Why are pregnant women at risk of D.I.
Placenta produces vasopressinase. Which breaks down ADH. It can either unmask DI or cause transient DI
Once established polyuria… what do I want to know next
Is it osmotic or non osmotic.
Osmotic: DM, urea
Non osmotic: DI, psychogenic polydyp
Best way to look at whether something is primary or secondary (axis wise)
Primary disorders will always cause major feedback to the central system. So primary hypogonadism will need high LH and FSH. If we have primary hypergonadism, we will see very low FSH and LH. If the FSH or LH are normal, it’s usually central
What two things do I give to a patient in myxedema, and why?
IV. Thyroid hormone replacement. An IV hydrocortisone (unless you have excluded adrenal insufficiency)
What is cinacelet
 PTH analog. It’s a calcium and can be used in hyperparathyroidism to decrease the PTH.
Exercise recommendation for diabetics
Moderate intensity exercise for 30 to 60 minutes, five times per week
What is the statin rule for diabetics
40 to 75-year-olds year olds should be placed on a statin
Three contraindications for Met Forman
Heart failure, renal failure, hepatic failure
Do DKA and HHS both have high serum osmolality
No, only HHS
Some rules about potassium and DKA treatment
If potassium is low (less than 3.3) don’t give insulin, replete potassium first. If potassium is in normal range, often give potassium with insulin. If potassium hi give insulin, and monitor potassium
When you reach around 250 to 300 glucose levels when treating DKA with insulin. What should we do
Consider adding 5% dextrose, just to avoid hypoglycaemia
What is mixed meal testing for dumping syndrome
Consume nonliquid meal, and then do glucose, C-peptide, insulin.
Best initial test if suspect thyroid disease, versus if suspect hypothalamic/pituitary thyroid disease
TSH
TSH and free T4
Not sure how important is it
In essence what is euthyroid sick syndrome
A physiological adaptation, where T4 is not shunted T3, but rather a rT3. this avoids excess catabolism. So do not supplement thyroid hormone
In essence what is subclinical hypothyroidism
Beginning stages/compensated hypothyroidism. TSH is elevated and can compensate (T3 and T4 are normal).
Thyroid bruit is specific for what disease
Graves disease
If a patient has large obstructive goitre, or Graves ophthalmopathy. Can we do radioactive iodine
No.
What is the role of bile acid finding resins for thyroid storm
Because the right hormone is excreted in bile, BABR can prevent its reabsorption

Delayed relaxation of deep tendon reflexes are seen in which disease
Hypothyroidism
LDL triglycerides CK and sodium levels in hypothyroidism
Hi, hi, hi, low
In subclinical hypothyroidism when do we give levothyroxine
When the TSH goes above 10
De quervain thyro
Lymphocytic or granulomatous
TX?
Granulomatous
NSAID or CS for pain
How to manage an indeterminate FNA of a thyroid nodule
Watch and wait versus hemithyroidectomy
Vertebral compression fractures in osteoporotic patient presentation
Usually asymptomatic, often shows lots of height and progressive thoracic kyphosis
Osteoporosis patients, who get bis phosphonate. Osteopenic patients who gets bisphosphonate
All osteoporosis patients. Osteopenic patients with high calculated fracture risk based on FRAX
Where is consequence of osteoporosis
Hip fracture. Carries the highest mortality in a
If intolerant to bisphosphonates, what is the second line treatment for Paget’s disease
Calcitonin, and of course analgesia for the pain
Recall the general criteria for parathyroidectomy, given that the patient is asymptomatic (every symptomatic patient gets a parathyroidectomy)
Very high calcium, high creatinine, low bone mineral density, less than 50
Two circumstances that cinacalcet is used 
Hyper parathyroidism secondary to renal disease or when no Sx can be done on PT gland
Which two hormones are primarily affected in panhypopituitarism
Growth hormone and gonadotropins
Why do we give levothyroxine and cortisol in Myxoedema coma?
We must do this unless we have ruled out adrenal insufficiency. Because levothyroxine can increase cortisol clearance and worsen the adrenal crisis
Most common cause of death in acromegaly
Left ventricle hypertrophy and thus diastolic heart failure
Some other random complications of acromegaly
Type two diabetes, diverticulosis, colon cancer
Dopamine and TRH control of prolactin
Dopamine inhibits, TRH stimulates
MEN2A has which of the Ps??
Parathyroid stuff
Acid-base disorder that adrenal insufficiency causes
None annoying gap metabolic acidosis (due to low aldosterone)
Morning plasma cortisol level of what value is considered low (Low enough to skip the synacthen test)
Less than three. In this case go straight to ACTH levels to see if primary or secondary
If you have low 8 am cortisol level, but not lower than three. What investigation do you do
Synacthen test
Hi suspicion of adrenal insufficiency. What comes first diagnostic testing or steroids
Steroids
What’s more common, pituitary or adrenal Cushing’s
Pituitary
K levels in cushings
Low
My three diagnostic tests for Cushing syndrome
Low dose dexa surp , late nights delivery cortisol, 24 hour urine cortisol
Cushing’s disease adenoma less than 6 mm (or can’t see on MRI) what investigation do we do
Petros will sign a sampling with CRH. Central peripheral gradient indicates crushing disease. Takes the place of high dose Dexa surp
High dose dexamethasone suppression test will suppress cortisol in Cushing’s disease or ectopic ACTH production
Cushing’s disease
Why is it extra important to screen for pheochromocytoma (urine VMA) prior to surgery for medullary thyroid cancer
Obviously to check for con commitment pheochromocytoma, but also to avoid risk of hypertensive crisis during surgery
If have severe salt wasting in 21 hydroxylase deficiency, aside from fluid resource, salt repression, cortisol what can we add
Fludrocortisone. Remember this is the only CAH associated with low mineralocorticoid
Remember the side effect that Savvas mentioned about SGL T2 inhibitors
Eug lycaemic ketoacidosis
Out of pheochromocytoma and thyroid storm which has an elevated temperature
Thyroid storm
We all know that in the euthyroid state sick syndrome, T3 is low, T4 and TSH is normal. What happens in severe cases
All of them can become low, but T3 come become very low
Why would a patient with severe pancreatic damage have specifically bad diabetes, in terms of risk of hypoglycaemia
Alpha cells are damaged, glucagon cannot be made. Causing unopposed insulin one treated
Woman with acne, increase hair growth on face, secondary aminuria. You also find that they are muscular and build and have a large clitoris
Most likely a testosterone or DHE a tumour. PCOS does not cause rapid visualisation
In C8H when do we get salt wasting, in assault wasting type
One to 2 weeks after birth. Don’t expect in a couple of days-year-old infant. Really tough question we had on ambiguous genitalia XX.
Had high testosterone, but sodium and potassium are normal. This is not a Leydig cell tumour this is CAH
How can I use DHEAS levels to know a androgen producing tumour and a woman is in the adrenal or the gonad
DHEA and testosterone are produced in both the ovary and the adrenal. DHEAS is only produced in the adrenal.
As we know patients with PT you can get a granulocytosis. We don’t need to do regular monitoring, however what do we do if a patient get a sore throat or signs of infection
Immediately come off the medication. If the white blood cells are less than 1000 we never go back onto it
General rules for diabetics on insulin, wanting to do exercise. Mention just the insulin dose changes. Consider if short or long distance
If short: just decrease the short acting
If long: decrease the long and the short acting
HHS, why can we see sodium being low
 hi osmolality can cause a shift of sodium into cell
Which osteoporotic medication can cause milk alkaline
Calcium carbonate
Cance previous severe chronic hypoglycaemic episode cause eventual unawareness
Yes
Which medications are risk factors for milk alkaline
Thiazides especially, anything else that decreases intravascular volume
You see low LA, low TSH, high prolactin. What are you thinking
Non-functioning adenoma in the pituitary
What is considered a low urine specific gravity
Less than 1.006
What changes to systemic vascular resistance and heart contraction does thyroid hormone make
Drops systemic vascular resistance increases contraction. Increasing pulse pressure
When discussing albumin to creatinine ratio. What is an okay milligram per gram
Less than 30
Man with osteoarthritis, hepato-megaly, history of diabetes, loss of libido
Haemochromatosis
Site induces can have affect on what vitamin di
It can induce vitamin di breakdown
Is gynaecomastia more of a primary or central problem in men
Peripheral. Because then the increase subsequent LH will stimulate testosterone and oestrogen
For deficiencies. Mothers milk is low in what, cows milk is low in what
Mums milk is low and a lot of things commonly seems to be low in vitamin D. And can cause Ricketts. Cows milk is low in iron
Treatment for hypercalcaemia secondary to immobilisation
Bisphosphonate
Galactosaemia patients are at increased risk for infection
E. coli sepsis
Calcium levels in chronic pancreatitis
Usually normal
General centimetres for when you would do a total thyroidectomy for thyroid cancer
1 to 2 cm or less you do parcel. More than two you do total
General cut off to do oral versus IV calcium in hypocalcaemia
7.5
Very rarely mentioned, but bear in mind somebody with primary adrenal insufficiency can also have androgen deficiency, so decrease the decrease libido
Mayway to tell between constitutional Grace delay and family or short stature
Burnage. Burnage will be less than actual age in constitutional.
Burnage will equal actual age and family.
Is HbA1c reliable in pregnancy
No, that is increase red blood cell turnover
The link usually between coeliac’s and endocrine in terms of vitamins
Vitamin di deficiency. Causing an osteomalacia
Remember diabetes insipidus 300 room (for remembering osmolality
 Serum osmolality above 300, urine osmolality below 300
Recall some of my calcium chelating things that’s causing hypocalcaemia
EDT A, for Scarlett, lactate, blood transfusion i.e. citrate
If I have established precocious puberty. Is it when my LH is high or low that I would continue to do the GnRH stimulation test
If LH is low. Give GnRH see whether I can increase it, which would mean it central
