Endocrinology Flashcards
What is most common cause of hypopituitarism
Non secretory pituitary macroadenoma
What do if multiple painkillers have not worked for neuropathic pain from diabetic neuropathy
Refer to pain clinic
What is management first line of acromegaly
Transsphenoidal surgery
Medication options for treating acromegaly if surgery fails
Somatostatin analogues- octreotide
Pegvisomat- GH receptor antagonist
Dopamine agonist- bromocriptine
What is pegvisomat
GH receptor antagonist
Blood findings in cushings
Blood gas
- hypokalaemia metabolic alkalosis
- hypernatraemia
High glucose
Causes of cushings
Iatrogenic steroid use
ACTH dependant
- pituitary tumour (cushings disease)
- ectopic ACTH
ACTH independant
- adrenal adenoma
First line tests- gold standard+what else can be used for cushings
Gold standard first line- low dexamethasone test
Can use 24 hr urinary cortisol and evening salivary cortisol
How investigate cause of cushings
Inferior petrosal sinus sampling is preferred
Can also use high dose dexamethasone test
Management of hypokalaemia
Above 2.5 and asymptomatic= sando k tablets
Below 2.5 or symptomatic= cardiac monitoring and IV potassium chloride
What is maxium infusion rate for saline with potassium chloride
Should not exceed 20mmol/hour as irritant to veins
Have to do rates above 10mmol on ITU
What should every person on insulin be given
Glucagon emergency kit if swallow impaired
What is risk of continuous inuslin injections in the same place
Lipodystrophy which presents as lumps or atrophy of fat
Education points for patients on insulin
Advise about rotation of sites to avoid lipodystrophy
Safety net about signs of hypoglycaemia
- anxiety
- confusion
- sweating
- blurred vision
If swallow intact-> glass of lucozade or 15-20g glucose gel
If swallow impaired-> glucagon emergency kit
MOA of sulphonylureas
Increase pancreatic insulin production
Common side effects of sulphonylureas
Hypos
Weight gain
Rarer side effects of sulphonylureas
SIADH
BM suppression
Hepatotoxic
Peripheral neuropathy
When avoid sulphonylreas
Breastfeeding and pregnancy
Investigating de quervains
Globally reduced iodine uptake on thyroid scintigraphy
Raised ESR in initial stage
Painful goitre and hyperthyroid
De quervains
How long do phases to de quervains last
weeks
What can cause a ketoacidosis that isnt diabetic
Alcohol
Blood findings of alcoholic ketoacidosis
Metabolic acidosis
Elevated anion gap
Elevated serum ketone levels
Normal or low glucose concentration
Management of alcoholic ketoacidosis
Saline and thimaine infusion
Risk factors for small bowel bacterial overgrowth syndrome
DM
Scleroderma
Presentation of small bowel bacterial overgrowth syndrome
Chronic diarrhoea
Bloating, flatulence
Abdominal pain
Management of Small bowel bacterial overgrowth syndrome
Correct underlying DM
Antibiotic therapy- rifamixin
How is T2DM diagnosed
1 reading of if symptomatic
2 readings of if asymptomatic
- Fasting glucose >7
- Random glucose >11.1
- HbA1c > 48
What is defined as impaired glucose tolerance
Fasting glucose under 7 but OGTT 2 hour= 7.8-11.0
What is defined as impaired fasting glucose
Fasting glucose 6.0-6.9
Complication of hashimotos
MALT lymphoma
What can lower HbA1c levels
Haemodialysis
Haemolysis
- Hereditary spherocytosis
- G6PD
- SCD
What is glucagon like peptide
Hormone secreted by small intestine in response to glucose load which increases insulin release
MOA of GLP 1 mimetics
Increase insulin release
Reduce appetite
Suppress glucagon
What is GLP broken down by
Dipetidyl-peptidase-4
Advantage of liraglutide over exenatide
Liraglutide has to be taken once a day whereas exenatide is taken within 1 hour before morning and evening meal as a subcut injection
What are gliptins
DPP 4 inhibitors which decrease peripheral breakdown of GLP1
What is main advantage of gliptins compared to other anti-diabetic agents
Cause weight loss
Drug causes of gynaecomastia
spironolactone (most common drug cause)
cimetidine
digoxin
cannabis
finasteride
GnRH agonists e.g. goserelin, buserelin
oestrogens, anabolic steroids
Poor thyroxine adherance TSH and T4 results
Elevated TSH
Can be normal T4
If have addisons and an intercurrent illness, what do with steroids
Mineralcorticoid dose remains same
Glucocorticoid doubles
What use to treat addisons
Both glucocorticoid and mineralcorticoid
Dose of hydrocortisone required/day in addisons
20-30mg
How is hydrocortisone dose given in a day
Majority of dose given in the first half of day
For example if on 30mg
- 20mg in morning
- 10mg in afternoon
What do people with addisons needs to be given
Steroid card and medicalert bracelet
Hydorcortison injection kits for addisonian emergency
Patchy uptake on iodine scintigraphy
Toxic multinodular goitre
Management of Toxic multinodular goitre
Radioiodine unless compression sx then would do surgery
What is sick euthyroid
In patients who are ill they can have reduced thyroid function
Seen in elderly
Management of sick euthyroid
Ask GP to review TFTs in 6 weeks post illness
Do not need thyroxine replacement unless severe
What tends to happen to TFTs in sick euthyroid
TSH normal
T3 and T4 tend to be low
Common causes of polyuria
Diuretics
Alcohol and caffeine
Lithium
HF
Can you drive a HGV if on insulin
Yes if meet strict DVLA criteria
Definitive test for addisons
Short Synacthen test
If short synacthen test is not available what do instead
Morning cortisol 9am
What antibodies may be seen in addisons
Anti 21 hydroxylase
Eye signs of graves
Opthalmoplegia
Exopthalmos
What are blood findings of tertiary hyperparathyoidism
Ca elevated
PTH very elevated
ALP up
Phosphate high
When add 10% dextrose infusion in DKA
When glucose is less than 14
What is insulin infusion rate in DKA management
0.1 units/kg/hour
Fluids used for DKA
Isotonic saline
BP aimed for in T2DM
Under 80 ABPM= 135/85
Over 80 ABPM= 145/85
What is nesidioblastosis
Beta cell hyperplasia
Causes of hypoglycaemia
Insulinoma
Insulin/sulphonylureas OD
Liver failure
Addisons
Alcohol
Nesidioblastosis
What do if someone on insulin becomes unwell
Keep taking insulin as normal but check levels more frequently
What is most common cause of primary hyperaldosteronism
Bilateral idiopathic adrenal hyperplasia
When start to get symptoms with carcinoid tumours
When get metastases to liver which release serotonin to systemic circulation
Carcinoid syndrome presentation
Flushing (earliest)
Diarrhoea
Arrythmias
Bronchospasm
How investigate carcinoid tumours
Urinary 5-HIAA
What drug can be used for carcinoid syndrome
Octreotide
How differentiate conns from bilateral renal artery stenosis
Renin levels are high in renal artery stenosis
What is main danger of HHS compared to DKA
Onset slower so volume depletion and metabolic abnormalities more pronounced
Presentation of HHS
Volume loss sx
- polyuria
- polydipsia
Lethargy
Nausea and vomiting
LOC
Hyperviscosity complications
- MI
- stroke
- peripheral arterial disease
Diagnostic criteria for HHS
Hyperglycaemia in range over 30
Raised serum osmolality
No ketonaemia
Management of HHS
Aggressive fluid resus
Insulin if glucose not dropping
VTE prophylaxis
When give insulin in HHS
If glucose not responding to IV fluids
Complications of HHS
Hyperviscosity problems
- MI
- CVA
- PAD
- VTE
If driving and on insulin, when check blood glucose
Before and every 2 hours
What is pseudocushings
Mimic of cushings
Get all signs and biochemical results of cushings but no malignant cause
Causes of pseudo-cushings
Alcohol excess
Depression
What initial fluids regime give to someone in DKA
Haem stable
- 1L saline over 1 hour
Haem unstable
- 500ml STAT
What is most important test for determining response to thyroxine
TSH
Insulinoma presentation
Whipples triad
1- hypoglycaemia post exercise
2- quick reversal with food
3- low BMs at time of symptoms
Rapid weight gain
What is in whipples triad
1- hypoglycaemia post exercise
2- quick reversal with food
3- low BMs at time of symptoms
Management of insulinoma
Surgery
If not candidate then somatostatin
What can be used for insulinoma if not candidate for surgery
Somatostatin
If T1DM, what do about driving
Must inform DVLA but can drive if adequate hypoglycaemia awareness
How long should acidosis and ketonaemia take to resolve in DKA
24 hours if not then needs to be reviewd by senior endocrinologist
What do if acidosis and ketonaemia in DKA have not resolved after 24 hours
Get review by a senior endocrinologist
When is DKA defined as being resolved
pH>7.3
Ketones< 0.6
Bicarbonate >15
When can switch to subcut insulin in DKA
Once eating and drinking again
DKA resolution criteria met
- pH>7.3
- ketones< 0.6
- bicarbonate >15
Whats in MEN 1
3 Ps
- parathyroid adenoma
- pituitary tumour
- pancreatic tumour
What are examples of pancreatic tumours in MEN 1
Insulinoma
Gatrinoma
Somatostatinoma
Glucagonoma
How do gastrinomas present
Zollinger Ellison disease
- severe peptic ulceration
- diarrhoea
Whats in MEN2a
2 Ps
Parathyroid disease
Phaeochromocytoma
Medullary thyroid cancer
Whats in MEN 2b
Phaeochromocytoma
Marfanoid habitus
Neuromas
Test for phaeochromocytoma
Urinary metanephrines 24 hr collection
This has superceded urinary catecholamines
Management of phaeochromocytoma
Blood pressure mangement intially
- phenoxybenzamine
- beta blocker (propanolol)
Then surgery is definitive
Patient on steroids has illness then develops abdo pain and low grade fever
Addisons
Addisonian crisis presentation
Abdo pain
Fever
Lightheaded
Hyperkalaemia metabolic acidosis
What is first line investigation for acromegaly
Serum IGF-1
What test confirms acromegaly post IGF 1
OGTT with serial GH measurements then MRI
What is subclinical hypothyroidism
TSH raised but T3 and T4 normal
No symptoms
When treat subclinical hypothyroidism
TSH>10 with normal thyroxine
This recorded twice 3 months apart
ALSO TREAT if under 65 with TSH 5.5-10 twice 3 months apart and there are symptoms of hypothyroidism
What do if identify subclinical hypothyroidism on 1 blood test
If see TSH up with normal T4 then repeat in 3 months
If this still high then may consider thyroxine
Cause of arrythmia post starting DKA treatment
Hypokalaemia
What is subacute thyroiditis
De quervains
What is pepper pot skull seen in
Primary hyperparathyroidism
Myxoedema features
Hyporeflexia
Hypothermia
Seizures
Bradycardia
Drowsy
Precipitating features of thyrotoxic storms
Typically in people with established hyperthyroidism and isnt usually first presentation
Triggers
- trauma
- infection
- surgery
- pregnancy
Presentation of thyroid storm
fever > 38.5ºC
tachycardia
confusion and agitation
nausea and vomiting
hypertension
heart failure
abnormal liver function test - jaundice may be seen clinically
Management of thyroid storm
Hydrocortisone
IV propanolol
Anti thyroid drugs- propylthiouracil
Which thyroid cancer spreads early to lymph nodes
Papillary
Which thyroid cancer secretes calcitonin
Medullary
Which thyroid cancer is most likely to cause pressure symptoms
Anaplastic
What thyroid cancer is hashimotos associated with
MALT Lymphoma
What is plasma osmolality in psychogenic, nephrogenic and central diabetes insipidus
Psychogenic is low
Cranial and nephrogenic is high
Features of klinefelters
Tall
Gynaecomastia
Small testes
Lack of pubic hair
Gonadotrophin and testosterone levels in klinefelters
Low testosterone
High gonadotrophin
How is klinefelters diagnosed
Karyotyping- 47 XXY
Metabolic cases of polyuria
Diabetes
Hypokalaemia
Hypercalcaemia
Hypoglycaemia management in hospital
Conscious- oral glucose gel
Unconscious or combative- IM glucagon
How do pituitary adenomas present
Functional
- excess of a hormone
Non-functional
- panhypoituitarism
All can present with bitemporal hemianopia and headache
What can cause dyspepsia symptoms in diabetic
Gastroparesis
Presentation of gastroparesis in diabetic
Dyspepsia- bloating, etc
Erratic glucose measurements
How manage gastroparesis in diabetic
Prokinetic agents like metoclopramide
If on insulin and have DKA, what do with everyday insulin during admission
Stop short acting
Continue long acting
Investigation of choice for small bowel overgrowth syndrome
Hydrogen breath test
What does vitamin B2 (riboflavin) deficiency lead to
Angular cheilitis
How is diabetic neuropathy screened for
10g monofiliment
What is an adrenal mass with a rich lipid core, asymptomatic patient too
Benign adenoma
What is waterhouse friederichsen syndrome
In meningococcal sepsis get an adrenal haemorrhage
Metabolic alkalosis with hypokalaemia
Excess vomiting (or cushings)
If develop gynaecomastia on spironolactone, what switch to
Epleronone
Hormone profile of kallmans
Low testosterone and low gonadotrophins as hypothalamic problem
Management in primary care of graves
generally managed by secondary care but carbimazole may sometimes be started for troublesome symptoms whilst waiting
First line investigation for thyroid nodules/lumps
USS
What do with levothyroxine dose if become pregant
Increase dose by up to 50%
Presentation of conns
HTN
Muscle weakness in exams as a symptoms of hypokalaemia
If get given 9am cortisol and ACTH and shows;
high cortisol
low ACTH
What is next investigation
CT adrenal glands
MSK side effects of corticosteroids
Osteoprosis
Proximal mopathy
Avascular necrosis of femoral head
When do you test for T1DM with C peptide and autoantibodies
Diagnostic uncertainty where atypical features
- 50 or older
- BMI over 25
- slow evolution of symptoms
- long prodrome
How test for T1DM when diagnostic uncertainty
C peptide levels
Diabetes autoantibodies
What happens to thyroid levels during pregnancy
Total levels rise however free T3 and T4 remain the same
The increase is due to increased thyroid binding globulin which increases during pregnancy
Management of hypoglycaemia if impaired swallow
If IV access then IV 20% glucose
If not then IM glucagon
What is risk of giving insulin in HHS
Get massive compartment shift of fluid which may lead to central pontine myelinolysis
Causes of primary hyperaldosteronism
Bilateral adrenal hyperplasia
Adrenal adenoma
How determine cause of conns
CT scan of abdomen after RA ratio
If CT scan normal when determining cause of conns, what do
Venous sampling from both adrenals
How manage Conns
Depends on cause
If bilateral adrenal hyperplasia spironolactone
If unilateral adenoma then surgical removal
How manage thyrotoxicosis in pregnancy
First trimester- PTU
Second and third- carbimazole
Keep it PC
What use to control symptoms of a graves patient awaiting secondary care attention
Propanolol
What do if on long term steroids for PMR and becomes unwell
Double the dose
What give first line anti HTN if black and diabetes
ARB
What interacts with and affects efficacy of levothyroxine
Oral iron tablets due to preventing its absorption
What is nelsons syndrome
When have bilateral adrenectomy, can get growth of corticotrophs in the pituitary gland due to unchecked inhibition
How does nelsons syndrome present
Post bilateral adrenectomy
Pituitary tumour compressive symptoms
Increased skin pigmentation due to increased MSH production
What is pretibial myxoedema and what seen in
Erythematous and oedematous lesions seen on the lower leg in graves disease
What is thyroid acropachy
Triad of
- clubbing
- new bone formation
- soft tissue swellings
What can stop a diabetic from being able to drive
- More than 2 episodes of hypoglycaemia which required help
- not having hypoglycaemic awareness
- the mcdonalds drive thru queue
How screen for diabetic nephropathy
Early morning ACR urine sample
Management of de quervains
NSAIDs- Naproxen specifically
What does blood glucose being “unrecordable” indicate
That it is very high not low
How monitor response to treatment in HHS
Serum osmolality
First line antibiotic for small bowel overgrowth syndrome
Rifamixin
Drug causes of galactorrhoea from raised prolactin
metoclopramide, domperidone
phenothiazines- prochlorperazine
haloperidol
SSRIs, opioids
Side effects of thyroxine therapy
Osteoporosis
AF
Worsening angina
Hyperthyroidism
How manage a diabetic ulcer
Check for gangrene
If not provide education about foot care and arrange an appt with diabetic foot clinic
How does alcohol cause polyuria
Suppresses ADH suppression therefore like a cranial diabetes insipidus
How does alcohol causing polyuria present with
- urine osmolality
- serum osmolality
- water deprivation test
Urine osmolality = low
Serum osmolality= high
Water deprivation= like cranial
How differentiate between primary and secondary hypoadrenalism symptomatically
Skin hyperpigmentation in primary
In primary there will be increased ACTH release which increases MSH
How treat cranial DI
Desmopressin
How treat nephrogenic DI
Thiazide diuretics
How long need to treat graves with carbimazole for
Only 12-18 months
No need for lifelong as carbimazole induces remission
What do if addisons patient on long term steroids starts vomiting illness
Give IM glucocorticoid until resolves
Causes of cranial DI
Idiopathic
Head injury
Pituitary tumours/surgery
Sarcoidosis
Haemochromatosis
Complications of acromegaly
Cardiomyopathy
HTN
DM
Colorectal cancer
How diagnose osteoporosis
DEXA scan T score over -2.5
OR
Post menopausal woman has fracture
What do if patient on metformin having a scan with contrast
Withold for 2 days afterwards
Mental side effects of steroids
Insomnia
Psychosis
Depression
Mani(l)a 🇵🇭
First line medication for acromegaly
Octreotide
How manage if change in vision in TED patient
Urgently refer to opthalmology ED
Menstrual problems associated with hyperthyroidism vs hypothyroidism
Hyperthyroidism- Oligomenorrhoea or amenorrhoea
Hypothyroidism- menorrhagia
If someone recently migrated to the UK and has hypothyroidism, what is likely cause
Iodine deficiency
With pituitary tumours, what quadrantopia is seen
Superior
What tests to confirm T1DM
Random glucose
What are C peptide levels in T1DM
Low
How can carcinoid syndrome affect the heart
Pulmonary stenosis and tricuspid insufficiency
What do if ACR raised on spot urine sample
Repeat with first pass morning specimen
HbA1c target if on metformin
48
HbA1c target if taking a drug which can cause hypos (sulphonylureas)
53
HbA1c target if on 2 drugs and HbA1c has reached 58
53
When does HbA1c target become 53
Taking an antidiabetic which causes hypos
Taking 2 antidiabetics and have gone above 58
When add SGLT2i to diabetes regime
Develop at any time or history of CVD or HF
Q-risk >10%
What is important thing to do when prescribing metformin and SGLT2i
Make sure metformin is fully titrated up
When add a second antidiabetic
If HbA1c rises above 58
Dietary advice for DM
Low glycaemic food
Oily fish
Discourage food aimed at people with DM
What weightloss aim for in T2DM
5-10%
2nd line options for T2DM after metformin
Sulphonylureas
Pioglitazone
DPP4 inhibitors
When is pioglitazone CI
Heart failure or CVD
Bladder Ca history
MOA of pioglitazone
PPAR gamma agonist which increases insulin sensitivity peripherally
When is only time can offer GLP1 agonists
If triple therapy unsuccessful therefore switch one of them to GLP1 if overweight or
Low BMI but insulin lowering therapy would be inappropriate due to occupation or weight loss would be key for controlling rfx for other diseases like CVD
After triple therapy what are options
Insulin therapy or GLP1 mimetics
- use GLP1 if BMI over 35
- under 35 but insulin not appropriate for occupation or would want weight loss for controlling other diseases
Triple therapy options for T2DM
Metformin+sulphonylurea+pioglitazone
Metformin+ sulphonylurea+DPP4i
Metformin+ (DPP4i or sulphonylurea or pioglitazone) + SGLT2i
Third line options for T2DM
Metformin+sulphonylurea+pioglitazone
Metformin+ sulphonylurea+DPP4i
Metformin+ (DPP4i or sulphonylurea or pioglitazone) + SGLT2i
Insulin therapy
How start insulin for T2DM
Use human insulin
Taken at bedtime or BD
What is function of DPP4i
Increases levels of incretins- GLP1 etc
What is most likely cause of impaired hypo awareness in long term T1DM
Neuropathy in ANS
What antidiabetic avoid in severe renal impairment
Sulphonylureas
What is exenatide
GLP1 agonist
What is a long acting sulphonylurea
Glibenclamide
Inheritance of MODY
AD
What happens when TED patients are not able to close eyelids
Exposure keratopathy from dry eyes
What thyroid treatment can worsen TED
Radioiodine
How does MODY typically present
Non ketotic hyperglycaemia detected incidentally
Not overweight nor signs of insulin resistance
Key differentiators of MODY from T1DM and T2DM
T1DM- no ketosis with hyperglycaemia
T2DM- normal weight, aged under 25
Indications for orlistat in obesity
BMI over 28 with CVD rfx or BMI over 30
When can give liraglutide for obesity
BMI over 35
Prediabetic hyperglycaemia 42-47
When must diabetics give up their license
Over 2 hypoglycaemic episodes where assistance needed
Which antidiabetics causes weight gain
Sulphonylureas
Pioglitazone
Which is best 2nd line antidiabetic to give if want to avoid weight gain
DPP4i
What is max metformin dose
500mg QDS
When determining 3rd choice antidiabetic, what consider if overweight
SGLT2i
DPP4i
Which antidiabetics are best for weight
SGLT2i
DPP4i
GLP1 agonists
Which drugs impair levothyroxine absorption
Iron and calcium replacements
It taking gliclazide when can add another antidiabetic
If HbA1c goes above 53
Presentation of latent autoimmune diabetes of adults
T1DM but when adult
SEs of SGLT2i
Increased risk of amputation
Recurrent UTI
Euglycaemic ketoacidosis
Treatment of MODY with HNF1 mutation
Sulphonylureas
What can use to treat T1DM on top of insulin
Metformin if BMI over 25
What do with antidiabetics in T2DM if ill
Metformin- stop if dehydration risk
Sulphonylureas- stop if acutely unwell or at risk of dehydration
GLP-1- stop if dehydration
How many units of insulin in 1ml
100
What use to draw up insulin
Do not use a standard syringe- use an insulin syringe
Examples of each type of insulin
Rapid- Insulin aspart (NovoRapid), Insulin lispro (Humalog)
Short- Actrapid (soluble)
Intermediate- isophane insulin
Long- insulin determir (Levemir), insulin glargine (Lantus)
What insulin start in DKA
Fixed rate insulin while continuing long acting insulin but stop short acting
Blood glucose target on waking in T1DM
5-7
Blood glucose target before meals in T1DM
4-7
When need to measure glucose more regularly
Illness
Sport
Pregnancy
Breastfeeding
How often measure HbA1c in T1DM
3-6 months
How often measure glucose/ day in T1DM
4 times a day including before each meal and before bed
In adults what is recommended regime for T1DM adults
Injection of basal bolus insulin
Twice daily detemir
Rapid acting insulin before meals
Basal options for T1DM
Twice daily detemir first line
Alternative include- OD glargine or detemir
How take metformin perioperatively
Day before= take
Day of surgery= only ever stop it take TDS where omit lunchtime dose
Consider stopping if risk of AKI
How take sulponylureas perioperatively
Day before= take as normal
Day of surgery= if once daily omit, if BD omit morning if morning op and omit both if pm operation
How take SGLT2i perioperatively
Day before= take as normal
Day of operation= omit dose
What do with once daily insulins perioperatively
Day before= reduce dose by 20%
Day of operation= reduce dose by 20%
When would you stop metformin for a surgery
High risk of AKI
If taking insulin, what will determine operative period management
Minor procedure
- If good glycaemic control (less than 69 HbA1c) then can adjust normal regime (reduce by 20%)
- poorly controlled then variable rate
Major (missing 1 or more meal)
- variable rate insulin infusion
Side effects of pioglitazone
Fracture risk
Fluid retention
Weight gain
Liver dysfunction
Side effects of sulphonylureas
Hypoglycaemic episodes
Increased appetite and weight gain
SIADH
Liver dysfunction (cholestatic)
What antidiabetic drug can cause pancreatitis
Gliptins
Main problems if subclinical hyperthyroidism
Osteoporosis
AF
Main cause of subclinical hyperthyroidism
Multinodular goitre in elderly women
Management of subclinical hyperthyroid
Review in 6 mths as often revert to normal
Can consider treatment if persistent due to risk of osteoporosis and AF
Causes of hypothyroidism
Primary
- hashimotos
- iodine defic
- thyroiditis
- drugs- lithium and amiodarone
Secondary
- panhypopituitarism
- trauma to thyroid (eg surgical)
Myxoedema coma management
IV fluids
IV thyroid replacement
IV steroids until adrenal failure been ruled out
Management of papillary and follicular thyroid cancer
Thyroidectomy
Treat with radioiodine afterwards
Follow up with annual thyroglobulin
Management of single thyroid nodule
Surgical removement (benign adenoma)
Where is hypothyroidism treated
Provided no indication of secondary aetiology or cocontaminant adrenal disease then do so at GP
Main side effects of carbimazole and PTU
Carbimazole
- pancreatitis
- agranulocytosis
PTU
- agranulocytosis too
Investigations for thyroid cancer
USS then guided FNA
Addisonian crisis management
IV hydrocortisone
IV fluids
Correct hypoglycaemia and hyperkalaemia if necessary
If have addisons from stopping long term steroids, what type of adrenal insufficiency is it
Tertiary
If take for over 3 weeks then lose endogenous hypothalamic CRH production
Investigations for addisons
Short synacthen- 9am cortisol if not available
Anti 21 alpha hydroxylase antibodies
Cushings presentation
Centripetal obesity
Moon face
Striae
Acne
HTN
Myopathy
Osteoporosis and AVN
Psychiatric complications
Management of cushings
Treat cause
- first line normally surgery
For reducing cortisol
- metyrapone
- ketoconazole
What does skin pigmentation in cushings indicate about cause
If hyperpigmentation is cushings disease
Causes of secondary hyperaldosteronism
Liver failure
Heart failure
RAS
Rfx for phaeo
MEN2
Von hippel lindau
NF
Acromegaly presentation
HTN and DM
Prognathism
Coarse facial features
Big hands and feet
Oily sweaty skin
Compressive sx- prolactin signs, headache and bitemp
Panhypopituitarism causes
Non-functioning adenomas- most common
Prolactinomas
Infiltrative diseases- sarcoid, haemochromatosis
Craniopharyngioma
Sheehans
Trauma
Investigations for panhypopituitarism
MRI
Combined pituitary testing
What skin lesion can precipitate T1DM diagnosis
Necrobiosis lipoidica- waxy, yellow lesions in pretibial distribution with telengiectasia present
If someone has suspected T1DM diagnosis in GP what do
Refer for same day endo referral
How diagnose T1DM in GP
Random glucose >11 with 1 of following
- Ketosis
- Rapid weight loss
- Age of onset younger than 50 years
- Body mass index (BMI) below 25 kg/m2
- Personal and/or family history of autoimmune disease
What do if discover someone as prediabetic
Refer for local lifestyle change programme
What are options to monitor blood glucose in T1DM
Standard use is capillary blood glucose
Can use libre which is circular device on arms which continuously monitor however 5 minute lag so if suspect hypo then use CBG and also need to replace every 2 weeks
When can refer T1DM for islet cell/pancreatic transplant
Recurrent severe hypos refractory to medical treatment
When consider continuous insulin pump
Poorly controlled HbA1c- above 69 despite daily injections
Attempts to achieve target HbA1c levels with insulin result in the person experiencing disabling hypoglycaemia
