Endocrinology Flashcards
Diagnosis of T1DM
Requires 2 lab tests, or one and symptomatic.
FBG >/ 7
Non fasting >/11.1
2h 75g GTT >/ 11.1
HbA1c >/ 6.5
HbA1c goals per group
<7: most adults, most children
<7.5: children and adolescents <18
7.1-8: functionally dependent
7.1-8.5: recurrent severe hypoglycemias, decreased life expectancy, frail, elderly
Annal investigations for diabetics
Fasting lipid q1-3 years (1 year in kids)
Optometry
ACR
Foot exam
EKG
What BMs must be reported to the licensing body?
Any severe hypo while driving in past 12 months
>1 severe hypo while awake but not driving in past 6 months
When to refer for T1DM
ACR >60mg/mmol
eGFR <30
Pets with albumineria
>30% Cr in 3 month of starting ACEi/ARB
Retinopathy/vitreous hemp/macular edema
What to start if symptomatic hyperglycemia +/- metabolic decompensation in T2DM
Insulin +/- Metformin
Second line for T2DM if ASCVD, HF or >60 with 2 CV risk factors
SGLT2i - Empagliglozin, Dapagliflozin
GLP-RA - Semaglutide, Liraglutide
Second line for T2DM if no cardiac hx or risk factors but wanting cardiorenal benefit and weight loss
SGLT2i - Empagliglozin, Dapagliflozin
GLP-RA - Semaglutide, Liraglutide
Second line for T2DM if no cardiac hx or risk factors but wanting weight neutral and CV neutral
DPP4i - sitagliptin
Second line for T2DM if no cardiac hx or risk factors but increased hypoglycemias
Sulfonylureas - glicazide
What T2DM meds should be held in acute illness
Metformin, insulin secretagogues and SGLT2i
Diagnosis of DKA in peds
BG >11, venous ph < 7.3 or bicard <15, ketonemia or mod-large ketonuria
What to monitor in DKA
q1-2h glucose, lytes, urea, calcium, magnesium, phosphate, hematocrit, blood glasses, ECG (t-waves), fluid input/output, neuro
DKA rehydration in peds
- 0.9% NS 10ml/kg over 60 min, may repeat
- Replace remaining fluid deficit over 24-48 hours with 0.9% NS at 4-6.5mL/kg/hr with 40mmol/L of KCl
- When glucose < 16 or down by 5 then change to 0.45 or 0.9 % NS and add glucose to fluids
1-2h after IV fluid start IV insulin at rate of 0.05-0.1 units/kg/hr
DKA rehydration in adults
- Rehydrate
- Once euvolemic check correct sodium (Na + (3/10 x glucose) - 5). If corrected sodium low or low osmolality > 3mmol/kg/hr then continue NS. If normal or high and osmolality < 3mmol/kg/hr then switch to 0.45% NS.
- when glucose <14 do D5W or D10W to maintain glucose 12-14
- When K <5.5 and patient urinating, add KCl.W
What is the normal function of parathyroid
Decrease serum ionised calcium
Secrete PTH
Increase calcium reabsorption in disral renal tubular cells
Osteoclastic bone resorption
Conversion to D3
Increase calcium reabsorption from the gut
What is hyperparathyroidism associated with
Multiple endocrine neoplasia type 1 and 2a
Familial hypocalciuric hypercalcemia
Familial hyperparathyroidism
What are the signs of symptoms of hyperparathyroidism
bones, groans, stones, and psychiatric understones
What are the investigations for hyperparathyroidism
- Likely increased calcium +/- PTH
- If normal PTH that is abnormal in setting on high calcium - repeat 3 times to confirm
- Low phosphate and high ALP
- Decreased BMD
- Albumin (corrected ca)
- R/o vitamin d deficiency
- R/o chronic renal insufficiency
- R/o TSSH, malignancy, adrenal insufficiency
How can you differentiate between FHH and HPT
Replace vitamin D
- In HPT this increases urinary calcium
- In FHH this does not
What is the management of hyperparathyroidism
Primary:
Parathyroidectomy
Hypercalcaemia - hydration, loop diuretics, pamidronate or zolendronate
FHH - no parathyroidectomy
Screen family members
What medications can cause hyperthyroidism
Lithium
Amiodarone
Iodide
What is the etiology of Graves
Hyperthyroidism
Autoimmune
Antibodies against TSH receptor
What is the etiology of toxic multinodular goiter
Hyperthyroidism
Higher risk in iodine deficit area
Insidious onset
What is the etiology of toxic adenoma
Hyperthyroidism
Younger patients in iodine deficit area
What is the etiology of thyroiditis
Hyperthyroidism
Subacute - hormones leak from inflamed gland, usually resolves in 8 months, can be recurrent
Lymphocytic + postpartum
Which tumours can cause hyperthyroidism
Metastatic thyroid ca
Ovarian ca
Secrete TSH
Signs and symptoms of hyperthyroidism
General: weight loss, heat intolerance
HEENT: lid lag, proptosis, periorbital edema, hair loss, goiter, thyroid tenderness, nodularity, bruit
CVS: palpitations, tachycardia, afib, widened pulse pressure, HTN
MSK: tremor, edema, pretibial myxoedema, muscle weakness
GU: amenorrhea
What should you consider if TSH and T4 are high
MRI - suspect TSH secreting pituitary adenoma
Treatment of primary hyperthyroidism
- Beta blocker
- Methimazole - for 12-18 months then taper and d/c if asymptomatic and normal TSH
(3. Propylthiouracil. Risk of hepatic failure)
Radioactive iodine - high cure rate
Subtotal thyroidectomy treatment of choice in pregnancy and less than 40 y/o
Signs and symptoms of thyroid storm
Fever***
CNS agitation
Tachycardia
CHF
GI
?Precipitant
Investigations for thyroid storm
Low TSH
High fT4
Low Hb
High WCC
High glucose
High calcium
High LFTs
Treatment for thyroid storm
Can be fatal
- Decrease thyroid synthesis - methimazole
- Inhibit hormone release - potassium iodide 5 drops
- Decrease HR - BB
- Support circulation - glucocorticoids, fluids, O2, cooling
Causes of primary hypothyroidism
Chronic autoimmune thyroiditis
Postpartum thyroiditis (Hashimotos)
Thyroid sx
Iodine deficiency
Cancer
Drugs - amiodarone, lithium, iodine
Agenesis/dysgenesis of the thyroid
Causes of central hypothyroidism
Pituitary adenoma
Pituitary damage
Infiltrative
Signs and symptoms of hypothyroidism
General: Fatigue, weakness, coled intolerance, increased weight
Cognitive: depression, decreased memory, sleep dissturbance
HEENT: enlargement of tongue, hoarseness, goitre
CVS: bradycardia, pericardial effusion, HTN, CHF and angina
Resp: Decreased exercise capacity, muscle weakness, sleep apnea
GI: Constipation
Neuro: Parasthesia, muscle cramps, delayed relaxation of deep tendon reflexes, carpal tunnel
GU: menorrhagia, amenorrhea, impotence
Derm: perioribital edema, cool pale dry skin, hair loss, thinning lateral eyebrow, brittle nails
Investigations for hypothyroidism
TSH
T4
Trab
TPOab
Thyroglobulin
When not to treat subclinical hypothyroidism
If TSH <10, asymptomatic, not pregnant
When to treat hypothyroidism
Elevated TPO antibodies
Goitre
Strong FH autoimmune disease
Pregnancy
What to treat subacute granulomatous thyroiditis with
NSAIDs
How often to monitor TSH in hypothyroid
6-8 weeks after starting dose and q6-8 weeks until in target
