Endocrinology Flashcards
What are features of Kallman syndrome?
- Delayed pubtery
- Hypogonadism
- Loss of smell
- Low sex hormones
- Normal/above average height
How is Kallman syndrome managed?
- Testosterone supplementation
- Sex hormones supplementation for fertility
What is vitamin D deficiency associated with?
Hypocalcaemia
Patients with high calcium, low PTH with cancer risk factors?
Think malignancy
What is the management of hypoglycaemia with impaired GCS?
IV Glucose if access
What characterises tertiary hyperparathyroidism?
- extremely high PTH
- moderately raised calcium
What is the management of new onset graves disease to control symptoms?
- Propranolol
- Carbimazole used to induce remission
Any change in vision for someone with thyroid eye disease needs what?
Urgent review by specialist
What is the target HBa1c for those on hypoglycaemic medications for T2DM?
53
What conditions make up MEN Type 2?
Medullary thyroid cancer, hypercalcaemia - parathyroid hyperplasia, phaeochromocytoma
What would you see on blood test results for hypercalcaemia secondary to malignancy?
- Raised calcium
- low PTH
- low phosphate
- raised PTHrP
What is the mode of action of orlistat?
inhibiting gastric and pancreatic lipase to reduce the digestion of fat
What should patients on long-term steroids do during intercurrent illness?
Double steroid doses
What adjunct can be used alongside orlistat for obese patients with one weight related co-mobidity?
Liraglutide
Subclinical hyperthyroidism is associated with what?
atrial fibrillation, osteoporosis and possibly dementia
What should be monitored to detect recurrence of medullary thyroid cancer?
Serum calcitonin
What is definitive management of primary hyperparathyroidism?
Total parathyroidectomy
Confusion, hypothermia, hyporeflexia, bradycardia, seizures and signs of hypothyroidism?
Myoxedema coma
Patients with type I diabetes and a BMI > 25 should be considered for what?
Metformin alongside insulin
Asymptomatic patients with abnormal HbA1c/fasting glucose need what?
Second abnormal reading
hypothyroidism + goitre + anti-TPO triad suggests what?
Hashimotos thyroiditis
Thyrotoxicosis with tender goitre?
Subacute thyroiditis / De Quervains
What are sick day rules for T1DM?
- Insulin should not be stopped
- Increased frequency of checking blood sugars
- Drink atleast 3L fluids
- Replace meals with carbohydrate drinks if appetite is reduced
What are sick day rules for T2DM?
- Stop oral hypoglycaemics and restart once eating and drinking is back to normal for 24-24 hours
- Do not stop insulin if using
- Monitor blood glucose more frequently as needed
Which drugs can cause galactorrhoea?
- Metoclopramide, domperidone
- Haloperidol
Who should diabetic foot problems be referred to?
Local diabetic foot centre
What does a patchy uptake on nuclear scintigraphy suggest?
Toxic multinodular goitre
Long term steroid use can lead to what?
Avascular necrosis
Steroids can cause what in the muscles?
Proximal myopathy
Which hormones are decreased in response to stress?
- Insulin
- Testosterone
- Oestrogen
What are the features of sick euthyroid syndrome?
Low T3/T4 with normal TSH during acute illness
What imaging should be done for those with suspected Cushings syndrome?
CT adrenal glands
2nd line medication for obese patient with T2DM?
DPP-4 inhibitors as least likely to cause weight gain
What would be seen on thyroid scintigraphy for someone with De Quervains thyroiditis?
Reduced iodine uptake
Peptic ulceration, galactorrhoea, hypercalcaemia all suggest what?
MEN type 1(pancreas, parathyroid, pituitary)
Glucocorticoid therapy can induce what?
Neutrophilia
What would be the urine osmolality for someone with primary polydipsia?
-Initially low
- After fluid deprivation: High
What features would be atypical for suspected T1DM?
- Age > 50
- BMI > 25
- Slow progression of hyperglycaemia
What tests should patients undergo if atypical presentation of T1DM?
- C peptide and diabetic autoantibodies
What is the treatment of a thyrotoxic storm?
- Beta blockers, IV fluids, propylthiouracil and steroids
What should women with hypothyroidism do when they are pregnant?
Increase thyroid hormone replacement by upto 50%
Presentation of HHS
1) Hypovolaemia
2) Hyperglycaemia
3) Significantly raised serum osmolarity
4) Absence of ketoacidosis.
What blood sugars suggest impaired fasting glycaemia?
Between 6.1 and 6.9
What are the target blood sugars for T1DM?
Waking - 5-7
Other times: 4-7
What can worsen thyroid eye disease in patients with Graves?
Radioiodine treatment
What does a raised C-peptide help to distinguish?
Raised - T2DM
Low = T1DM
Management of subclinical hypothyroidism?
Check TPO antibodies
If 3 diabetic drugs are not helping, what should be done?
Switch one of them for a GLP-1 e.g. exenatide
Side effect of piogliotazone
Peripheral oedema
Patient who have 2 hypoglycaemic episodes need what?
Surrender driving licence
How should steroid doses be altered during illness with Addisons?
Glucocorticoid e.g. hydrocortisone -> doubled
Fludrocortisone -> kept the same
What are the diabetic specific autoantibodies?
anti-GAD
Which diabetes med increases risk of bladder cancer?
Thiazolidinedione e.g Pioglitazone
Over replacement with thyroxine increases the risk of what?
Osteoporosis
Fluids resuscitation in DKA?
1L of IV 0.9% NaCl over 1 hour - if systemic BP >90
500ml of IV 0.9% NaCl over 5 mins if systemic BP <90
What would be the expected metabolite results in Cushings?
Hypokalaemia with metabolic alkalosis
Erratic blood glucose control, bloating and vomiting
Gastroparesis
What should every person with insulin be given for emergencies?
Glucagon kit
Headaches, amenorrhoea, visual field defects suggests what?
Prolactinoma
Thyrotoxicosis with tender goitre?
De Quervains thyroiditis
Elevated prolactin with secondary hypothyroidism and hypogonadism?
Non-functioning pituitary adenoma
increased TSH levels and normal T4 suggests what?
Poor compliance with thyroxine
What can mimic Cushings disease?
Excess alcohol consumption
Increased plasma 17-hydroxyprogesterone levels is suggestive of what?
Congenital adrenal hyperplasia
Primary vs secondary hyperaldosteronism?
If renin is high, secondary cause is likely i.e. renal artery stenosis
hyponatraemia, reduced plasma osmolality and increased urine osmolality suggests what?
SIADH
Symptoms of acromegaly?
- Spade like hands and feet
- Frontal bossing
- Macroglossia
- Headaches
- Bitemporal hemianopia
- Sleep disturbances
- Carpal tunnel
- HTN
What is the main cause of death in patients with acromegaly?
CVD
What are some signs of hypothyroidism?
- Dry hair/skin
- Goitre
- Mental slowness
- Ataxia
- Peripheral neuropathy
- Slow/relaxing reflexes
What are some signs of hyperthyroidism?
- Tachycardia
- AF
- Goitre
- Palmar erythema
- Brisk reflexes
Hashimotos vs Graves antibodies
Graves - anti TSH reception antibodies
Hashimotos - anti TPO antibodies
Where does thyroid gland originate from embryologically?
Foramen caecum
What are symptoms of neuroglycopenia?
- Coma
- Seizures
- Drowsiness
- Confusion
What are causes of hypoglycaemia in non-diabetic patients?
- Liver failure
- Addisons
- Alcohol binging
- Pituitary insufficiency
- Insulin secreting tumour
What happens to periods with hypo and hyperthyroidism?
Hypo - heavy periods
Hyper - irregular/no periods
Low serum calcium, low serum phosphate, raised ALP and raised PTH
Osteomalacia
What is latent autoimmune diabetes of adulthood and maturity onset diabetes of the young?
LADA - Late onset T1DM - usually aged 30-50
MODY - earl onset T2DM - usually under 25
What cardiac manifestations can occur with carcinoid syndrome?
- Pulmonary stenosis and tricuspid insufficiency
Management of an incidental pituitary mass?
Lab investigations to assess hormone hypersecretion/hypopituitarism
What is alcoholic ketoacidosis?
A euglycemic form of ketoacidosis occurring in alcoholics
- When they don’t eat and they become malnourished, they start breaking down ketones
- Presents with metabolic acidosis, elevated ketones and normal/low glucose
- Tx with IV saline and thiamine
Depression, nausea, constipation, bone pain
Primary hyperparathyroidism
What is an important complication of fluid resus in DKA in children?
Cerebral oedema
When to start dextrose infusion in DKA?
When blood glucose is <14
Vit D deficiency vs CKD as cause of hyperparathyroidism
Vit d - low calcium and phosphate
CKD - low calcium but raised phosphate
What differentials for SIADH must be considered
Severe hypothyroidism + adrenal insufficiency
What is Klinefelters syndrome?
- 47 XXY
- Tall and slender male with small testes and gynaecomastia
- Low testosterone with raised FSH:LH
- Managed with HRT + regular monitoring for polycythaemia and DEXA scans for bone mineral density
Microvascular vs macrovascular complications of diabetes?
Micro - nephropathy, neuropathy, retinopathy
Macro - CVD/Stroke, MI, PVD
What is the pathophysiology of DKA?
Insulin deficiency produces glucose production in the liver;
lipolysis also occurs; fatty acids are broken done to form ketone
bodies which produce a metabolic acidosis
What should patients taking steroids be made aware of?
- carry steroid card
- medic alert bracelet
- know how to change dose for sick days
- carry emergency IM hydrocortisone
What sensation will be affected first in diabetic neuropathy?
Vibration
What findings may be present with diabetic neuropathy on feet?
- Joint deformity
- Painless ulcer
- Diminished reflexes
Vomiting in poorly controlled diabetic patient?
Think gastroparesis
carpal tunnel syndrome can be associated with what?
Acromegaly
What is the most common complication of thyroid eye disease?
Exposure keratopathy
What is the management of de Quervains thyroitidits?
Conservative with analgesia
What is the most common cause of Cushings syndrome?
Pituitary tumour secreting ACTH (Cushings disease)
What can cause low HbA1c?
Sickle cell/G6PD
Hereditary spherocytosis
Haemodialysis
Splenectomy can cause what?
Raised Hba1c
What is the key parameter to monitor in HHS?
Serum osmolality
How to differentiate between unilateral and bilateral sources of aldosterone excess?
High res CT
If normal, adrenal venous sampling
Moderate-severe aortic stenosis is a C/I to what?
ACE inhibitors
hypertension, hypokalaemia, and metabolic alkalosis
Conn’s syndrome
Management of myoxedemic coma?
Thyroxine + Hydrocortisone
Management of thyroid storm?
Beta blockers, propylthiouracil and hydrocortisone
How should HHS fluids be given?
Slow infusion
What are signs of hypercalcaemia on ECG?
Short QT, J waves
Which diabetic medication is approved in CKD?
DPP inhibitors
What is the medical management for acromegaly?
- Somatostatin analogues e.g ocreotide
What is the diagnostic test for acromegaly?
Oral glucose tolerance test
What enzyme is deficient in congenital adrenal hyperplasia?
21-hydroxylase
What serum marker is raised in CAH?
17-OH progesterone
How does CAH present?
- Ambiguous genitalia
- Acne
- Hirsutism
- Delayed puberty
How is CAH managed?
- Glucocorticoid (hydrocortisone) and mineralocorticoid (fludrocortisone) replacement
If patients are asymptomatic for DM, what do you need?
2 abnormal readings
What are side effects of gliotazones?
- Weight gain
- Increased risk of fractures
- Fluid retention
Iron tablets/calcium carbonate tablets can have what effect?
Reduced absorption of levothyroxine -> give 4 hours apart
How does Cushing’s disease present on dex suppression test?
ACTH and cortisol suppressed
What time gap should be kept when titrating metformin doses?
1 week
Which cancer is Hashimotos thyroiditis associated with?
MALT lymphoma
Thyrotoxicosis can lead to what?
high output cardiac failure
When should treatment with statins be discontinued?
If serum transaminase concentrations rise to 3 times the upper limit of reference ranges
Why does Cushing’s cause tanned appearance?
ACTH has a stimulatory effect on the melanocytes due to affinity for the MSH receptor
Why does impaired hypoglycaemia awareness occur?
neuropathy of parts of the autonomous nervous system
Management of subclinical hypothyroidism
TSH > 10 - Consider thyroxine if this is present on 2 separate occasions atleast 3 months apart
TSH 5.5-10 - Consider 6 months of thyroxine if <65 and there are symptoms of hypothyroidism
If asymptomatic/older - watch and wait
What do each of the zones of the adrenals produce?
Zona glomerulosa - Mineralocorticoids - Aldosterone
Zona fasciculata - Glucocorticoids - Cortisol
Zona reticularis - Androgens
Medulla - Adrenaline/Noradrenaline
hyperkalaemic, hyponatraemic, hypoglycaemic metabolic acidosis
Adrenal Crisis - Addisons
How quickly should ketones fall in DKA?
Atleast 0.5 per hour
What are primary causes of hypogonadism?
- Trauma
- Mumps
- Iatrogenic
- Klinefelter’s syndrome
What is the most common thyroid cancer?
- Papillary
What is the management of non adrenal adenoma hyperaldosteronism?
Spironolactone
Which cells of pancreas are affected in diabetes?
Beta pancreatic islet cells
What genetic mutations might T1DM have?
HLA-DR3/4
What time should serum cortisol be taken?
9am
Treatment of choice for toxic multinodular goitre?
Radioactive iodine
Osteoporosis in a man?
Check testosterone
What is the management of Addisonian crisis?
- Hydrocortisone
- 1L Saline
How do DPP-4 inhibitors work?
Increase incretin levels by reducing their peripheral breakdown
How should the dose of hydrocortisone be taken in someone with Addisons?
Majority in first half of the day
What should be corrected before giving bisphosphonates?
Hypocalcaemia
Vit D deficiency
Patient >75 with fragility fracture?
Start bisphosphonate without needing to do DEXA
What dose of glucose gel should be given to a patient with a low blood sugar?
10-20g
Which HTN drug an cause sexual dysfunction?
Thiazide-like diuretics e.g indapamide
How long should metformin be discontinued for after CT with contrast?
48 hours
In primary prevention of CVD, what should the non-HDL cholesterol reduce by?
> 40% within the first 3 months
What should be done after treatment with bisphosphonates for 5 years?
Repeat DEXA and FRAX and stop if score <-2.5
Which diabetes medication is linked to Fournier’s gangrene (necrotising fasciitis of the genitals)?
SGLT-2 inhibitors
What is the investigation of choice for suspected insulinoma?
72 hour fast
Ferrous sulphate can interact with what?
Levothyroxine
Management of hyperglycaemia in someone who has started enteral feeding?
Insulin
Management of steroid induced diabetes?
Sulfonylureas e.g. gliclazide
