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Phase 4 Question Knowledge > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

Hormone axis phisiology

A

See notes

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2
Q

Hyperthyroidism

A

High thyroid hormone (T3/4)

Primary - thyroid gland pathology

Secondary - thyroid gland stimulated by excessive TSH in circulation - pathology in hypothalamus / pituitary

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3
Q

Hyperthyroidism causes

A

Graves
- TSH receptor ABs bind to TSH receptors in thyroid

Toxic multinodular goitre
- nodules develop + produce TH

Solitary toxic nodule
- usually benign adenoma

Thyroiditis
- inflammation - often initial hyperthyroid, then hypo
- DeQuervain’s - transient inflammation of thyroid after viral infection
- Hashimoto’s
- Post-partum
- Drug-induced - amiodarone, iodine, lithium

Secondary
- TSH-secreting pituitary adenomas
- TH-resistance syndrome
- hCG-secreting tumour
- Gestational thyrotoxicosis

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4
Q

Hyperthyroidism Px

A
  • anxiety, irritable, sweaty, heat intolerance, tachy, palpitations, wt loss, fatigue, insomnia, diarrhoea, sexual dysfunction, brisk reflexes, AF, high output HF in elderly
  • palmar erythema, lid lag, stare, lid retraction, thin hair, onycholysis, ?nodules
  • oligomenorrhoea +/- infertility

Graves
- diffuse goitre
- Graves ophthalmopathy - exophthalmos, ophthalmoplegia
- pretibial myxoedema
- thyroid acropachy

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5
Q

Hyperthyroidism Ix

A
  • TFTs - high T3/4, TSH low (high in 2ndary)
  • Thyroid ABs - TSHR-Ab, TPO-Ab, TgAb
  • CRP / ESR - thyroiditis
  • baseline FBC, U/E
  • US thyroid - if lump
  • thyroid isotope scan
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6
Q

Hyperthyroidism Mx

A
  • propranolol
  • oral carbimazole, start high, titrate down, block-replace (add levo)
  • propylthiouracil
  • radioactive iodine
  • subtotal / total thyroidectomy
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7
Q

Thyrotoxic crisis

A
  • rapid T4 increase / release
  • eg stress, infection, surgery, stopping anti-thyroid drugs

Px
- high temp, tachy, restless, delirium, coma, death

Mx
- IV fluids, corticosteroids, BBs, carbimazole / propylthiouracil
- potassium iodide (Lugol’s iodine)

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8
Q

Hypothyroidism

A

Low TH - T3/4

Primary - thyroid gland disease - T3/4 low, TSH high

Secondary - disease of hypothalamus / pituitary - T3/4 low, TSH low

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9
Q

Hypothyroidism causes

A
  • Hashimoto’s - autoimmune inflammation, anti-TPO / anti-Tg ABs - IDDM, Addisons, pernicious anaemia associations (goitre then atrophy)
  • Post-partum
  • iatrogenic
  • drug - carbimazole / PTU, lithium (goitre), amiodarone
  • iodine deficiency
  • congenital / infiltration
  • secondary - tumour, surgery, radio, Sheehan’s, trauma
  • Riedel’s - dense fibrous tissue (hard fixed painless goitre)
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10
Q

Hypothyroidism Px

A
  • wt gain, fatigue, cold intolerance
  • dry skin, coarse hair, hair loss
  • fluid retention - non-pitting oedema, pleural effusions, ascites
  • menorrhagia, oligomenorrhoea
  • goitre
  • decreased deep tendon reflexes, carpal tunnel syndrome, bradycardia, ataxia, hoarse voice, low mood
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11
Q

Hypothyroidism Ix

A
  • TFTs
  • thyroid ABs - anti-TPO, anti-Tg
  • FBC - anaemia
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12
Q

Hypothyroidism Mx

A
  • levothyroxine
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13
Q

Myxoedema coma

A
  • severe hypothyroidism

Px
- confusion, coma, hypothermia, hypoglycaemia, hyponatraemia

Mx
- T3/4 replacement (T3 causes arrhythmias)
- IV glucose
- hydrocortisone if needed
- fluids / supportive care

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14
Q

Cushing’s syndrome

A

excess cortisol

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15
Q

Cushing’s causes

A

ACTH dependent (high)
- Cushing’s disease - ACTH-secreting pituitary adenoma + bl adrenal hyperplasia
- Ectopic ACTH - sg SCLC - paraneoplastic

ACTH independent (low)
- Exogenous steroids
- adrenal adenoma

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16
Q

Cushing’s Px

A
  • round moon face, central obesity, proximal limb muscle wasting
  • abdo striae, buffalo hump, hirsutism, acne, bruising, poor skin healing, osteoporosis
  • hyperpigmentation - with high ACTH
  • metabolic - HTN, T2DM, lipids,
  • mental health - anxiety, depression, insomnia, psychosis rarely
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17
Q

Pseudo-cushing’s

A
  • mimics cushings
  • often from alcohol excess
  • false positive on dex suppression test / 24hr urinary free cortisol
  • insulin stress test to differentiate
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18
Q

Cushing’s Ix

A
  • Bloods - hypokalaemic metabolic alkalosis, impaired glucose tolerance

Dexamethasone suppression test
- high 9am cortisol after dex administration
- low dose test - high cortisol -> Cushing’s syndrome
- high dose test -> high cortisol - adrenal adenoma / ectopic ACTH

  • ACTH levels
  • 24hr urinary free cortisol
  • midnight + waking salivary cortisol
  • CT / MRI adrenals / pituitary / TAP
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19
Q

Cushing’s Mx

A
  • stop steroids
  • Cushing’s - transsphenoidal resection of adenoma
  • Adrenal adenoma - adrenalectomy
  • adrenal carcinoma - surgery / radio / mitotane
  • ectopic ACTH - surgery / metyrapone / ketoconazole
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20
Q

Nelson’s syndrome

A
  • increased skin pigmentation from high ACTH from enlarging pituitary tumour - after adrenalectomy - removes -ve feedback
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21
Q

Hyperaldosteronism

A

excess aldosterone

Primary
- excess aldosterone independent of RAAS, renin low

Secondary
- high renin levels -> high aldosterone

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22
Q

Hyperaldosteronism causes

A

Primary
- Adrenal adenoma - Conn’s syndrome
- bl adrenocortical hyperplasia (more common)

Secondary
- reduced renal perfusion - eg RAS, HTN, diuretics, CCF, liver cirrhosis, ascites

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23
Q

Hyperaldosteronism Px

A
  • asym
  • HTN, headaches, flushing
  • metabolic alkalosis - H secretion
  • hypokalaemia - weakness, cramps, paraesthesia, polyuria, polydipsia, constipation, arrhythmias
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24
Q

Hyperaldosteronism Ix

A
  • U/E - low K, high Na
  • Aldosterone to renin ratio - high aldosterone, low renin in primary- first line
  • ECG
  • CT / MRI adrenals
  • renal artery imaging - eg doppler, angiography
  • adrenal vein sampling - which adrenal gland is producing more aldosterone
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25
Q

Hyperaldosteronism Mx

A
  • oral spironolactone for bilateral adrenocortical hyperplasia
  • laparoscopic adrenalectomy for adrenal adenoma
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26
Q

Adrenal insufficiency (AI)

A

Primary - low cortisol + aldosterone from adrenal cortex impairment

Secondary - low cortisol from low ACTH - pituitary / hypothalamus damage

Tertiary - lack of CRH from hypothalamus - suppression of HPA axis from exogenous steroids

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27
Q

AI causes

A

Primary
- worldwide - TB
- UK - Addison’s disease - autoimmune destruction
- mets, trauma

Secondary
- long-term steroid use
- hypothalamic / pituitary disease - tumour, trauma, surgery, sheehans…

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28
Q

AI Px

A
  • tanned, toned, tired, tearful
  • fatigue, muscle weakness, cramps, dizziness, fainting, thirst, wt loss, abdo pain, N+V, depression, reduced libido, vitiligo, bronze hyperpigmentation, postural hypotension
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29
Q

AI Ix

A
  • bloods - low Na, high K, low glucose, high Ca, dehydration (raised urea / creatinine)
  • short synacthen test - failure of cortisol to rise after synacthen
  • ACTH levels
  • adrenal ABs - adrenal cortex ABs, 21-hydroxylase ABs
  • CT / MRI adrenals
  • MRI pituitary
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30
Q

AI Mx

A
  • hydrocortisone (double when ill)
  • fludrocortisone
  • steroid card, ID tag, IM hydrocortisone
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31
Q

Adrenal crisis

A
  • acute severe adrenal insufficiency - eg infection, trauma

Px
- low GCS, hypotension, low BMs, low Na, high K

Mx
- IM/IV hydrocortisone, IV fluids, IV dextrose

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32
Q

Acromegaly

A
  • excess GH - stimulates skeletal / soft tissue growth
  • pituitary adenoma
  • other tumours - lung / pancreas - paraneoplastic
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33
Q

Acromegaly Px

A
  • headache, bitemporal hemianopia
  • frontal bossing
  • coarse, sweaty skin
  • large nose, ears
  • macroglossia
  • widely spaced teeth
  • large hands, feet - acral enlargement
  • large jaw - prognathism
  • acroparaesthesia
  • decreased libido
  • fatigue
  • also - hypertrophic heart, HTN, T2DM, CTS, arthritis, colorectal cancer, OSA, galactorrhoea, amenorrhoea
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34
Q

Acromegaly Ix

A
  • IGF-1 - raised
  • OGTT - high GH after glucose
  • MRI pituitary
  • test visual fields, acuity
  • ECG, ECHO
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35
Q

Acromegaly Mx

A
  • transsphenoidal resection of adenoma
  • IM octreotide
  • SC pegvisomant
  • Bromocriptine
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36
Q

T1DM

A

Autoimmune destruction of beta cells in pancreas leading to lack of insulin production

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37
Q

T1DM Px

A
  • asym
  • DKA
  • polyuria
  • polydipsia
  • wt loss- asym
  • DKA
  • polyuria
  • polydipsia
  • wt loss
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38
Q

T1DM Ix

A
  • cap BMs
  • urine dip - glucose, ketones

Serum blood glucose
- fasting >7, IGT 6.1-6.9
- random >11.1, IGT 7.8-11
- if asym - meet criteria on 2 separate occasions

HbA1c (not helpful in T1DM)
- >6.5% (48) - rpt if asym
- IGT (42-48)

OGTT
- >11.1 2hrs after 75g glucose - diagnostic

  • consider c-peptide, auto-ABs
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39
Q

T1DM Mx

A
  • monitor HbA1c every 3-6mo
  • self-monitor BMs - before every meal / bed - 5-7 on waking, 4-7 before meals

S/C insulin
- basal-bolus regime

  • insulin pumps
  • pancreas transplant
  • FreeStyle libre
  • closed loop system
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40
Q

T1DM sick day rules

A
  • Don’t stop insulin
  • Check BMs more frequently
  • Consider checking ketones
  • Maintain normal meal pattern if possible - carb drinks if necessary
  • Drink plenty fluids
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41
Q

T1DM Cx

A
  • insulin - hypos, lipohypertrophy, wt gain

Macrovascular
- atherosclerosis, stroke, IHD, PVD

Microvascular
- diabetic retinopathy, nephropathy, neuropathy, infections

Acute
- DKA, HHS, hypos

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42
Q

VRIII / sliding scale

A
  • to control BMs
  • actrapid infusion in one arm
  • infusion 5% dextrose + KCl in other arm
  • stop OHAs, short acting insulins, pre-mixed insulins
  • continue long-acting insulins

Indications
- no oral intake
- vomiting
- NBM
- severe illness, eg sepsis

more details in notes….

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43
Q

Prescribing insulin

A

Who needs
- T1DM
- DKA
- OHAs not enough

Calculating TDD
- total no units over 24hrs on VRIII
- 0.5units/kg/24hrs
- start on small dose - 6-8 units long-acting / mixed, 4-6 units short acting with meals

How to split
- long acting only - extra boost
- mixed BD insulin - eg T2DM
- basal-bolus - eg T1DM

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44
Q

T2DM

A

increased insulin resistance and decreased production, leading to persistent hyperglycaemia

RFs
- non-modifiable - older age, Black / South Asian, FHx
- modifiable - obesity, sedentary lifestyle, high sugar diet

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45
Q

T2DM Px

A
  • asym
  • fatigue
  • polyuria, polydipsia
  • wt loss
  • opportunistic infections - eg oral thrush
  • slow wound healing
  • acanthosis nigricans
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46
Q

T2DM Ix

A
  • cap BM, urine dip

Serum blood glucose
- fasting >7, IGT 6.1-6.9
- random >11.1, IGT 7.8-11
- if asym - meet criteria on 2 separate occasions

HbA1c
- >6.5% (48) - rpt if asym
- IGT 42-48)
- measure every 3-6mo, aim for 48 in new dx, or 52 if on 1+ med that might cause hypoglycaemia (eg sulfonylurea)

OGTT
- >11.1 2hrs after 75g glucose - diagnostic

  • bloods, FBC, U/E, LFTs etc
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47
Q

T2DM Mx overall

A
  • diet (eg low glycaemic index), exercise, wt loss
  • HTN - ramipril (if black - ARB)
  • atorvastatin 20mg if QRISK >10%, 80mg if pre-existing disease
  • oral hypoglycaemic agents
  • insulin

OHAs
1st - metformin, add SGLT-2 if CVD / QRISK
2nd - add sulfonylurea / pioglitazone / DPP4 inhibitor / SGLT-2 inhibitor
3rd - triple therapy metformin + 2 second line drugs / insulin therapy / switch one drug to GLP-1 mimetic
…see notes for more details…

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48
Q

T2DM Mx 1st line

A
  • metformin - titrate up slowly, modified release if GI sx
  • if CVD / HF / QRISK>10% - add SGLT-2 inhibitor (add at any point if these develop)

if metformin CI’d

  • SGLT-2 (if CVD/HF/QRISK)
  • or DPP4/pioglitazone/sulfonylurea
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49
Q

T2DM Mx 2nd line

A
  • add 2nd drug if HbA1c rises to 58
  • continue metformin
  • add sulfonylurea / pioglitazone / DPP4 / SGLT-2 (criteria)
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50
Q

T2DM Mx 3rd line

A

Triple therapy

  • Metformin + DPP4 + sulfonylurea
  • Metformin + pioglitazone + sulfonylurea
  • Metformin + pioglitazone/sulfonylurea/DPP4 + SGLT-2 (if criteria met)

Insulin therapy

  • consider if HbA1c>58 after >3mo dual oral therapy - humulin 1, continue metformin
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51
Q

T2DM further mx

A

If triple therapy fails and BMI>35, or if BMI<35 and insulin not suitable:

  • Switch one drug to GLP-1 mimetic - only continue if reduction of >11 (1%) in HbA1c and weight loss >3% in 6mo
  • Only add to insulin under specialist care
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52
Q

T2DM sick day rules

A
  • Some OHAs may be stopped, restart once feeling better
  • Metformin - stop if risk of dehydration
  • Sulfonylureas - increase hypo risk
  • SGLT-2 - check ketones
  • GLP-1 - stop if dehydrated
  • Monitor BMs more
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53
Q

DVLA DM

A

Group 1
- insulin - can drive if has hypo awareness, <1 bad hypo in last 12mo, no visual impairment
- tablets - no need to notify DVLA
- diet controlled - no need to notify

Group 2 must meet
- no severe hypos <12mo
- control of condition, monitoring etc
- understand hypo risks
- no cx of DM

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54
Q

DM ramadam

A
  • Try to eat meal with long-acting carbs prior to sunrise (Suhoor)
  • Use BM monitor
  • If taking metformin - 1/3 dose before sunrise, 2/3 after sunset (Iftar)
  • Switch OD sulfonylureas to after sunset
  • If taking BD gliclazide - take larger proportion of dose after sunset
  • No adjustments for pioglitazone
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55
Q

Diabetic neuropathy

A
  • Glove + stocking sensory loss
  • If painful - neuropathic pain meds, pain clinic

Also GI autonomic neuropathy
- Gastroparesis - erratic blood control, bloating, vomiting, Mx with metoclopramide, domperidone, erythromycin
- Chronic diarrhoea
- GORD

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56
Q

Diabetic foot disease

A
  • from neuropathy / PAD
  • loss of sensation, absent foot pulses, reduced ABPI
  • calluses, ulcers, Charcot’s arthropathy, cellulitis, osteomyelitis,
  • screen annually - palpate pulses, 10g monofilament
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57
Q

Biguanides - metformin

A
  • reduce gluconeogenesis, increase insulin sensitivity

S/Es
- D+V
- lactic acidosis

When to stop
- not E+D
- AKI
- raised lactate
- before IV contrast

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58
Q

SGLT-2 inhibitors - cana/empa/dapa-gliflozin

A
  • inhibit glucose resorption, increase urinary glucose loss

S/Es
- genital candidiasis, Fournier’s gangrene, UTIs
- increased UO, freq
- wt loss, DKA / EKA (stop on admission to hospital)

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59
Q

Thiazolidinediones / glitazones - pioglitazone, rosiglitazone

A
  • increase insulin sensitivity, decrease liver glucose production

S/Es
- wt gain, fluid retention, HF, liver impairment
- bladder Ca risk
- fracture risk

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60
Q

Sulfonylureas - gliclazide, glimepiride

A
  • stimulate insulin secretion from pancreas

S/Es
- wt gain
- hypos
- hyponatremia

Meglitanides work the same

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61
Q

DPP4 inhibitors - sita/lina/saxa-gliptin

A
  • enhance incretin effect (increased insulin response to oral glucose) - increase insulin, lower glucagon

S/Es
- nausea, headaches
- pancreatitis

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62
Q

GLP-1 agonists - exanatide, liraglutide

A
  • injectable S/C - increase incretin effect

S/Es
- nausea, GI sx, reduced appetite
- pancreatitis, AKI, wt loss

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63
Q

DKA

A
  • diabetic emergency of high ketones, high BMs, acidosis
  • lack of insulin, no glucose uptake, body starved, converts lipids into ketones - dissolve into blood, dehydration from this (also vomiting, glucose secretion in kidneys)
  • eg first px of T1DM, missing insulin dose, stress (surgery / infection)
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64
Q

DKA Px

A
  • pear drop breath
  • Kussmaul’s respiration
  • reduced LOC
  • vomiting
  • abdo pain
  • dehydration - dry mucous membranes, slow CRT, tachycardia, hypotension
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65
Q

DKA Ix

A
  • bloods - BMs, ketones, VBG, FBC, U/E, CRP, LFTs, ?cultures, lab BM
  • Dx - BM>11, ketones>3, pH<7.3
  • urine dip ketones
  • look for infection source, eg CXR
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66
Q

DKA Mx

A
  • Fluids - IV 0.9% NaCl
  • insulin infusion - actrapid 0.1units/kg/hr
  • glucose - 10% dextrose 125ml/hr once BM<14
  • Potassium - 40mmol/L KCl if 3.5-5.5
  • infection - tx cause
  • chart fluid balance
  • ketones, pH, bicarb - monitoring
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67
Q

DKA Cx

A
  • cerebral oedema
  • pulmonary oedema
  • cardiac arrhythmias, hypokalaemia
  • ARDS, AKI etc
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68
Q

HHS

A
  • hyperglycaemia, hyperosmolality, no ketosis
  • results in osmotic diuresis, severe dehydration, electrolyte deficiencies
  • potential causes - illness, dementia, sedative drugs, MI, surgery
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69
Q

HHS Px

A
  • sx onset over days
  • dehydration
  • polyuria, polydipsia
  • lethargy
  • N+V
  • altered consciousness
  • focal neurology
  • hyperviscous blood -> MI, stroke, peripheral arterial thrombosis
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70
Q

HHS Ix

A

Bloods
- FBC, U/E, glucose, VBG, CRP, cultures etc
- high osmolarity >320 (2xNa + glucose + urea)
- high glucose >33
- no ketones, low K/Mg, hypo/hypernatraemia, normal anion gap, pH >7.3

  • ix cause, eg CXR

Dx criteria
- Serum osmolarity >320
- Serum glucose >33
- Profound dehydration (elevated urea:creatinine ratio)
- No ketoacidosis

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71
Q

HHS Mx

A
  • 0.9% NaCl - 0.5-1l/hr
  • correct electrolytes
  • insulin - give if BM stops falling with fluids
  • LMWH for VTE prophylaxis
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72
Q

Hypoglycaemia

A

BM <4

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73
Q

Hypoglycaemia causes

A

EXogenous drugs - insulin, OHAs, alcohol, quinine, quinolones
Pituitary insufficiency - no GH/cortisol
Liver failure - no glycogen stores
Adrenal failure - no cortisol
Insulinomas / immune hypoglycaemia
Non-pancreatic neoplasms

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74
Q

Hypoglycaemia Px

A

Adrenergic
- sweating, palpitations, tremor, anxiety/irritable, hunger, feel cold

Neuroglycopenic
- confusion, dizziness, tingling, blurred vision, slurred speech, headache, N+V, seizure, coma

  • fatigue, weakness
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75
Q

Hypoglycaemia Ix

A
  • CBG
  • ix for cause…

Insulin vs C-peptide level

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76
Q

Hypoglycaemia Mx

A
  • conscious, orientated - oral glucose
  • conscious, confused, IV access - 100mls 20% / 200mls 10% glucose
  • conscious, confused, no IV access - 1mg IM glucagon
  • unconscious / fitting - as above
  • give long-acting carb on recovery
  • review meds etc
77
Q

Hyperglycaemia

A
  • high BMs

Causes
- decompensated / undiagnosed DM
- stress - acute illness
- Cushing’s, pheochromocytoma, acromegaly, hyperthyroidism
- meds - eg steroids, BBs

78
Q

Hyperglycaemia Px

A
  • weakness, headache, blurred vision, polyuria, polydipsia, palpitations, N+V, abdo pain, drowsiness, seizure, coma
79
Q

Hyperglycaemia Ix

A
  • CBG, VBG, bloods, HbA1c
80
Q

Hyperglycaemia Mx

A
  • Novarapid if need to bring down BM
  • diabetic team review
  • meds review
  • tx cause
81
Q

Hyperparathyroidism

A

high PTH - raises blood Ca by
- resorbing Ca from bones
- reabsorbing Ca in kidneys
- absorb Ca in intestines - by increasing vit D activity

82
Q

Primary hyperparathyroidism

A
  • excess PTH production from parathyroid tumour -> hypercalcaemia
  • mostly solitary adenoma, also hyperplasia, multiple adenoma, carcinoma
83
Q

Primary hyperparathyroidism Px

A
  • asym
  • bones, stones, moans, groans
  • short QT
  • HTN, MEN1/2 associations
84
Q

Primary hyperparathyroidism Ix

A
  • ECG - short QT
  • Bloods - high PTH, high Ca, low phosph, raised ALP
  • technetium-MIBI subtraction scan
  • XR - pepperpot skills, osteitis fibrosa cystica
85
Q

Primary hyperparathyroidism Mx

A
  • total parathyroidectomy - risk of low Ca / recurrent laryngeal nerve injury
  • calcimimetic (cinacalcet)
  • bisphosphonate - alendronate
86
Q

Secondary hyperparathyroidism

A
  • high PTH in response to low Ca

causes
- vit D deficiency - eg dietary, Crohn’s
- CKD - lack of Ca resorption

87
Q

Secondary hyperparathyroidism Px

A
  • Sx of CKD / vit D deficiency
88
Q

Secondary hyperparathyroidism Ix

A
  • Bloods - low/normal Ca, high PTH, low vit D
89
Q

Secondary hyperparathyroidism Mx

A
  • Tx cause - vit D replacement, renal transplant
  • maybe cinacalcet
90
Q

Tertiary hyperparathyroidism

A
  • after long period of secondary, hyperplasia of PTH glands -> autonomously produce high PTH

Px
- as primary

Ix
- bloods - high PTH, high Ca

Mx
- total / subtotal parathyroidectomy
- cinacalcet

91
Q

Hypoparathyroidism

A

Low PTH, leading to low Ca

92
Q

Primary hypoparathyroidism

A

Low PTH due to PT gland failure

Causes
- DiGeorge syndrome
- Autoimmune cause
- Lack of PT gland at birth
- Genetic mutations

93
Q

Secondary hypoparathyroidism

A
  • low PTH after damage

Causes
- Parathyroidectomy / thyroidectomy (most common)
- Radiation
- Hypomagnesaemia - Mg required for PTH secretion

94
Q

Pseudohypoparathyroidism

A
  • End-organ resistance to PTH - failure of target cell response
95
Q

Pseudopseudohypoparathyroidism

A
  • Same phenotypic defects as pseudo- without abnormalities of Ca metabolism
96
Q

Hypoparathyroidism Px

A

Hypocalcaemia - SPASMODIC
- Spasms - Trousseau’s
- Perioral paraesthesia
- Anxious, irritable, irrational
- Seizures
- Muscle tone increase in smooth muscle - wheeze
- Orientation impaired and confused
- Dermatitis
- Impetigo herpetiformis - reduced Ca and pustules in pregnancy
- Chvostek’s sign, cataracts, cardiomyopathy (long QT)

may see papilloedema

Cutaneous signs
- dry scaly puffy skin, brittle nails, coarse hair

Pseudo / pseudopseudo
- short stature, short 4/5th metacarpals, subcut calcification, intellectual impairment

97
Q

Hypoparathyroidism Ix

A
  • bloods - low serum Ca, PTH low (high in pseudo), ALP, phops, U/E, parathyroid ABs
  • ECG

Pseudo
- measure urinary cAMP and phosph after PTH infusion - no increase in pseudo, increase in others

98
Q

Hypoparathyroidism blood results

A

Hypo - normal appearance, low PTH, low Ca, high phosph

Pseudo - skeletal defects, high PTH, low Ca, high phosph

Pseudopseudo - skeletal defects, normal PTH, normal Ca, normal phosph

99
Q

Hypoparathyroidism Mx

A
  • IV calcium if severely low
  • Ca supplements
  • calcitriol - active vit D
100
Q

SIADH

A
  • excess ADH secretion -> increased water reabsorption from CDs, dilutes plasma, hyponatraemia
101
Q

SIADH causes

A
  • SCLC, pancreas, prostate ca
  • stroke, SAH, SDH, meningitis, encephalitis, abscess
  • TB, pneumonia, HIV
  • sulfonylureas, SSRIs, TCAs, carbamazepine
  • PEEP, porphyrias, post-op, endurance sport
102
Q

SIADH Px

A
  • hyponatraemia sx
  • asym
  • headache, fatigue, muscle aches, cramps, confusion, seizures, low GCS
103
Q

Primary polydipsia (a DDx of SIADH)

A
  • excessive water consumption, no cause
  • euvolaemic hyponatraemia, but low urine Na/osmolality also
104
Q

SIADH Ix

A
  • euvolaemic
  • FBC, U/E - low Na, low serum osmolality
  • urine studies - high Na, high osmolality >100
  • Ix for cause - CXR, CT TAP, short synacthen test, TFTs, serum cortisol
105
Q

SIADH Mx

A
  • hypertonic saline if neuro sx
  • hyponatraemia tx
  • Tx cause, eg meds, infection
  • fluid restriction
  • tolvaptan - vasopressin receptor antagonist
  • demeclocycline - reduces CD response to ADH
  • correct Na slowly
106
Q

Diabetes insipidus (DI)

A
  • hyposecretion / insensitivity to ADH - impaired water reabsorption - pass large volumes of dilute urine

Cranial DI - reduced ADH secretion from post pit

Nephrogenic DI - impaired response of kidney to ADH

107
Q

DI causes

A

Cranial DI
- idiopathic, head injury, pituitary surgery, Wolfram’s syndrome, HHC, tumours, genetics

Nephrogenic DI
- meds (lithium), genetics, high Ca, low K, PKD, demeclocycline, sickle cell, CKD

108
Q

DI Px

A
  • polyuria
  • polydipsia, chronic thirst
  • nocturia
  • infants - irritable, failure to thrive, crying, fever, anorexia
  • dehydration
  • postural hypotension
109
Q

DI Ix

A
  • urine collection - >3L/24hrs
  • high/normal serum osmolality
  • low urine osmolality

water deprivation test
- 8hr fluid restrict -> low urine osmolality
- administer desmopressin -> high urine osmolality in cranial DI, low in nephrogenic

  • MRI head
110
Q

DI Mx

A

Cranial DI
- oral desmopressin

Nephrogenic DI
- tx cause
- low salt / protein diet
- thiazide diuretics
- NSAIDs - ibuprofen

111
Q

Pheochromocytoma

A
  • catecholamine secreting tumour of adrenal glands
  • secrete adrenaline in bursts -> intermittent sx
  • more common in MEN II, NFT1, von-Hippel-Lindau
  • 10% bl, 10% cancerous, 10% outside adrenal gland
  • 30-40% genetic
112
Q

Pheochromocytoma Px

A
  • periodic sx
  • anxiety, sweating, headache, tremor, palpitations, HTN, tachycardia
113
Q

Pheochromocytoma Ix

A
  • plasma free metanephrines
  • 24hr urine catecholamines
  • CT / MRI
  • genetic testing
114
Q

Pheochromocytoma Mx

A
  • alpha blockers - phenoxybenzamine, doxazosin
  • BBs
  • partial adrenalectomy
115
Q

Thyroid cancer

A
  • cancer of thyroid gland
  • papillary, follicular, anaplastic, lymphoma, medullary cell

RFs
- radiation exposure
- hx of goitre, nodule, thyroiditis, FHx, female, Asian

116
Q

Thyroid cancer Px

A
  • thyroid nodule
  • hard / irregular thyroid
  • cervical lymphadenopathy
  • mets to lungs, brain, hepatic, bone
  • hoarse voice
117
Q

Thyroid cancer Ix

A
  • fine needle aspiration biopsy / cytology
  • Bloods - TFTs
  • US thyroid
  • thyroglobulin
118
Q

Thyroid cancer Mx

A
  • papillary / follicular - total thyroidectomy / radioactive iodine
  • anaplastic / lymphomas - external radiotherapy
  • medullary - thyroidectomy, lymph node removal
  • levothyroxine - keep TSH reduced
  • chemotherapy
119
Q

Carcinoid tumour

A
  • neuroendocrine malignancies - produce serotonin, bradykinin, histamine, prostaglandins, others….
  • neuroendocrine tumour - neoplasm of NE cells
    Carcinoid syndrome - GI carcinoid tumour metastasises to liver
120
Q

Carcinoid tumour Px

A
  • asym
  • pain, wt loss, mass, vague R abdo discomfort
  • CCF, face/neck flushing, appendicitis, obstruction
  • RUQ pain
  • diarrhoea, hypotension
  • Cushing’s
121
Q

Carcinoid tumour DDx

A

GI stromal tumour (GIST)

122
Q

Carcinoid tumour Ix

A
  • Liver USS
  • 24hr urinary HIAA - raised (serotonin metabolite)
  • ECHO
  • CXR / CT / MRI
123
Q

Carcinoid tumour Mx

A
  • octreotide
  • surgical resection
  • antihistamines - cyproheptadine
124
Q

Carcinoid crisis

A
  • tumour outgrows blood supply / handled too much in surgery - mediators flow out
  • vasodilation, hypotension, tachycardia, bronchoconstriction, hyperglycaemia

Mx
- high dose octreotide

125
Q

Prolactinoma

A
  • benign tumour of pituitary gland that secretes prolactin

Pituitary adenomas classified by:
- size - micro<1cm, macroadenoma >1cm
- hormonal status - secretory/functioning, non-secretory/functioning

126
Q

Prolactinoma patho

A
  • leads to hyperprolactinaemia
  • women - raised prolactin, inhibits FSH/LH -> menstrual dysfunction, galactorrhoea
  • men - raised prolactin, secondary hypogonadism, reduced libido, erectile dysfunction
  • prolactin release inhibited by dopamine
127
Q

Hyperprolactinaemia causes

A
  • prolactinoma
  • pregnancy
  • acromegaly
  • PCOS
  • non-functioning pituitary tumour - compresses pituitary stalk
  • meds - antidopaminergics, antidepressants, metoclopramide, domperidone, haloperidol
  • head injury
  • primary hypothyroidism
128
Q

Prolactinoma Px

A
  • headache
  • bitemporal hemianopia

Women
- irregular menstruation, infertility, galactorrhoea, osteoporosis

Men
- impotence, loss of libido, galactorrhoea

129
Q

Prolactinoma Ix

A
  • pituitary blood profile - inc GH, prolactin, ACTH, FSH, LH, TFTs
  • visual fields testing
  • MRI head
130
Q

Prolactinoma Mx

A
  • dopamine agonist - cabergoline, bromocriptine
  • transsphenoidal pituitary resection
131
Q

Hyperkalaemia

A
  • high serum K

Classification
- Mild - 5.5-5.9
- Moderate - 6.0-6.4
- Severe - >6.5

132
Q

Hyperkalaemia causes

A

Renal
- AKI, CKD, Addison’s,
- drugs - spironolactone, ACEi, ARBs, NSAIDs, ciclosporin, heparin

Increased circulation of K
- exogenous - foods, blood transfusion
- endogenous - rhabdo, crush, burns, tumour lysis syndrome

IC->EC
- DKA, metabolic acidosis
- digoxin toxicity, BBs, sux, theophylline

Pseudo
- haemolysed sample

133
Q

Hyperkalaemia Px

A
  • asym
  • Palpitations
  • Chest pain
  • Dizzy
  • Muscle weakness
  • Stiffness
  • Fatigue
134
Q

Hyperkalaemia Ix

A
  • VBG, U/E, FBC, LFTs, BMs
  • serum cortisol / aldosterone if adrenal insufficiency suspected

ECG
- tall tented T waves
- flattened P waves
- PR prolongation
- broad QRS
- sine wave pattern
- then VF

135
Q

Hyperkalaemia Mx

A
  • ABCDE
  • remove cause
  • calcium gluconate / chloride (if >6.5 / ECG changes)
  • insulin + dextrose - 10-20 units in 500mls of 10% glucose
  • salbutamol
  • furosemide, calcium resonium (GI binder), sodium bicarb, dialysis
136
Q

Hypokalaemia

A

serum K<3.5

137
Q

Hypokalaemia causes

A
  • not enough K in fluids
  • GI losses - D+V, malabsorption, laxatives, high output stoma, poor oral intake / inadequate feed
  • Renal losses - genetic syndromes, Conn’s, Cushing’s, renal tubular acidosis, furosemide, thiazides
  • Intracellular shift - alkalosis, insulin, adrenaline, salbutamol
138
Q

Hypokalaemia Px

A
  • asym
  • Muscle weakness
  • Hypotonia
  • Hyporeflexia
  • Tetany
  • Constipation
  • Palpitations
  • Light-headed
139
Q

Hypokalaemia Ix

A
  • U/E

ECG
- small / inverted T waves
- Long PR
- prominent U waves
- ST depression
- long QT, Torsades de Pointes

140
Q

Hypokalaemia Mx

A
  • tx cause

Mild >3.1
- oral sando-K

Severe <3.1
- IV KCl - no quicker than 10mmol/hr
- lower - ITU discussion

141
Q

Hypercalcaemia

A
  • normal serum Ca 2.1-2.6

Classification
- mild 2.65-3 - asym
- moderate - 3.01-3.40 - asym/sx
- severe >3.40 - arrhythmias, coma

142
Q

Hypercalcaemia causes

A

High/normal PTH
- hyperparathyroidism

Low PTH
- malignancy - SCLC, bone mets, myeloma, ectopic
- sarcoidosis, TB
- Drugs - Ca/vit D, antacids, thiazides, lithium, theophylline
- rhabdo
- adrenal insufficiency, thyrotoxicosis, phaeo

143
Q

Hypercalcaemia Px

A

Bones
- bone pain, fractures, osteopenia, osteomalacia, osteoporosis

Stones
- renal / biliary stones

Groans
- abdo pain, pancreatitis, malaise, nausea, constipation, polydipsia, dehydration, confusion

Moans
- depression, anxiety, cognitive dysfunction, insomnia, coma

  • sx of malignancy etc
144
Q

Hypercalcaemia Ix

A
  • hydration
  • Bloods - bone profile, vit D, ALP, U/E
  • ECG - short QT, brady, 1st HB
  • CXR, isotope bone scan, CT / MRI
  • serum ACE (sarcoidosis)
145
Q

Hypercalcaemia Mx

A
  • 0.9% NaCl 4-6l/24hrs
  • IV bisphosphonates - zolendronate
  • dialysis
  • cinacalcet, denosumab, calcitonin, prednisolone
146
Q

Hypocalcaemia

A

Ca <2.1

147
Q

Hypocalcaemia causes

A
  • total thyroidectomy / parathyroidectomy / hypoparathyroid
  • vit D deficiency
  • CKD
  • low Mg (PPIs)
  • pancreatitis
  • rhabdo, tumour lysis syndrome
  • Loop diuretics, steroids, gent, phosphates, theophylline
  • massive transfusion
148
Q

Hypocalcaemia Px

A

SPASMODIC
- Spasms - Trousseau’s
- Perioral paraesthesia
- Anxious, irritable, irrational
- Seizures
- Muscle tone increase in smooth muscle - wheeze
- Orientation impaired and confused
- Dermatitis
- Impetigo herpetiformis - reduced Ca and pustules in pregnancy
- Chvostek’s sign, cataracts, cardiomyopathy (long QT)

may see papilloedema

149
Q

Hypocalcaemia Ix

A
  • Bloods - bone profile, U/E, Mg, vit D, PTH, amylase, CK
  • ECG - prolonged QT
150
Q

Hypocalcaemia Mx

A

Mild >1.9
- oral sandocal / adcal
- vit D - colecalciferol
- IV Mg if low
- may need calcitriol in para/thyroidectomy

Severe <1.9 / sx
- cardiac monitor
- calcium gluconate bolus / infusion
- tx cause

  • ?endo referral
151
Q

Hypophosphataemia

A

low serum phosph <0.8 (normal 0.8-1.5)

152
Q

Hypophosphataemia causes

A
  • redistribution into cells - resp alkalosis, insulin, adrenaline
  • increased urinary excretion - acidosis, DKA, hyperparathyroid
  • decreased intestinal absorption - antacids, vit D deficiency, D+V, malabsorption
  • refeeding syndrome
  • chronic alcohol
  • acute liver failure
153
Q

Hypophosphataemia Px

A
  • Asymptomatic
  • Myopathy, rhabdomyolysis, weakness
  • Resp failure
  • Arrhythmias, cardiomyopathy
  • Irritable, confused, hallucinations, lethargy, seizure, coma
  • Rickets / osteomalacia if chronic
154
Q

Hypophosphataemia Ix

A
  • bloods - bone profile, Ca, phosph, U/E
155
Q

Hypophosphataemia Mx

A
  • oral phosphate sandoz
  • IV phosphates polyfusor / sodium glycerophosphate
156
Q

Hypomagnesaemia

A
  • low serum Mg (normal 0.7-1.05)
157
Q

Hypomagnesaemia causes

A
  • refeeding syndrome
  • D+V, high output stoma
  • alcoholism
  • hypercalcaemia
  • SIADH, DKA, aldosteronism
  • renal losses
  • post-parathyroidectomy
  • drugs - diuretics, gent, PPIs
158
Q

Hypomagnesaemia Px

A
  • asym
  • irritable, lethargy
  • N+V
  • confusion, depression, psychosis
  • tremors, cramps, tetany, weakness, seizures
159
Q

Hypomagnesaemia Ix

A
  • ECG - PR prolongation, ST depression, altered T waves, ventricular arrhythmias, eg VF
  • Bloods - U/E, Ca, Mg
  • urinary Mg
160
Q

Hypomagnesaemia Mx

A

0.4-0.7

  • oral Mg salts

<0.4 / tetany, arrhythmias, seizures

  • IV Mg
161
Q

Hypernatraemia

A
  • serum Na >145
162
Q

Hypernatraemia causes

A

Hypovolaemic hypernatraemia - salt + water lost, but more water

  • D+V, sweating, burns, loop diuretics, osmotic diuresis

Normovolaemic hypernatraemia - loss of purely water

  • impaired thirst / water intake -> dehydration - dementia, decreased access to water
  • diabetes insipidus

Hypervolaemic hypernatraemia - rare, iatrogenic

  • hypertonic saline
  • hypertonic dialysis
  • hyperaldosteronism
163
Q

Hypernatraemia Px

A
  • Thirst, lethargy, weakness, nausea, loss of appetite
  • Severe - myoclonic jerks, intracranial haemorrhage, coma, death
164
Q

Hypernatraemia Ix

A
  • assess fluid status
  • bloods - U/E, glucose, Mg, Ca
  • urine / serum osmolalities
165
Q

Hypernatraemia Mx

A
  • tx cause
  • oral fluids
  • 0.9% NaCl (unless hypervolaemic)
  • correct <0.5mmol/L/hr (cerebral oedema risk)
166
Q

Hyponatraemia

A
  • low serum Na <135

Severity

  • Mild – 130-134
  • Moderate – 120-129
  • Severe – <120
167
Q

Hyponatraemia causes

A

Hypovolaemic hyponatraemia - loss of Na and water

  • diuretics, Addisonian crisis, D+V, MDMA, pancreatitis
  • exercise induced hyponatraemia (EAH)

Euvolaemic hyponatraemia - volume expansion, no oedema

  • SIADH
  • hypothyroidism
  • beer potomania
  • adrenal insufficiency

Hypervolaemic hyponatraemia - Na and water increase, more water

  • HF, liver failure, nephrotic syndrome, excessive water consumption

Also classified by urine osmolality / Na conc - see notes

168
Q

False hyponatraemia

A
  • lab results show low Na, but no hypotonicity
  • eg glucose - draws water into blood - appears like Na low
169
Q

Hyponatraemia Px

A
  • asym

early
- Headache
- Lethargy
- N+V
- Dizziness
- Confusion
- Muscle cramps

late
- seizures
- coma
- cardio-respiratory arrest

170
Q

Hyponatraemia Ix

A
  • fluid status
  • U/E
  • serum / urine osmolality
  • urinary sodium
  • if fluid overloaded - BNP, LFTs, urine dip, protein:creatinine ratio
  • TFTs, 9am cortisol
171
Q

Hyponatraemia Mx

A

Severe sx, Na <120

  • HDU / ITU
  • hypertonic saline - 3% NaCl

Hypovolaemic

  • 0.9% NaCl

Euvolaemic

  • fluid restrict 500-1000ml/d
  • tolvaptan / demeclocycline

Hypervolaemic

  • fluid restrict 500-1000ml/d
  • furosemide / tolvaptan
172
Q

Osmotic demyelination syndrome

A
  • from rapid over-correction of hyponatraemia
  • astrocyte/oligodendrocyte apoptosis -> demyelination

Px

  • irreversible sx
  • dysarthria, dysphagia, paralysis, seizures, confusion
  • coma - locked-in-syndrome

Mx

  • avoid - Na levels raised by 8mmol/L/24hrs
173
Q

Bartter’s syndrome

A
  • autosomal recessive disease of severe hypokalaemia
  • defective NKCC2 transporter - like lots of furosemide

Px

  • childhood - failure to thrive
  • polyuria, polydipsia
  • hypokalaemia
  • normotension
  • weakness
174
Q

Insulinoma

A
  • NE tumour derived from pancreatic Islets of Langerhans cells

Px

  • hypoglycaemia - early morning, just after meal
  • rapid weight gain

Ix

  • high insulin, raised proinsulin:insulin ratio
  • high c-peptide
  • supervised prolonged fasting
  • CT pancreas

Mx

  • surgery
  • diazoxide / somatostatin
175
Q

Liddle’s syndrome

A
  • autosomal dominant - disordered Na channels in distal tubules -> increased Na reabsorption
  • HTN, hypokalaemic alkalosis

Mx

amiloride / triamterene

176
Q

Maturity-Onset Diabetes of the Young (MODY)

A
  • monogenic diabetes, autosomal dominant inheritance
  • impaired insulin secretion

Px

  • mild, non-ketotic hyperglycaemia

Ix

  • genetic testing

Mx

  • Sulfonylurea / insulin / nothing depending on type
177
Q

Multiple endocrine neoplasia

A
  • overgrowth / tumour of endocrine glands - benign / malignant - autosomal dominant

MEN-1

  • parathyroid, pituitary, pancreas, adrenal, thyroid
  • commonly px with hypercalcaemia

MEN-2a

  • medullary thyroid cancer, parathyroid, phaeo

MEN-2b

  • medullary thyroid cancer, phaeo, marfanoid body habitus, neuromas
178
Q

Gynaecomastia

A
  • abnormal breast tissue in males - increase in oestrogen:androgen ratio

Causes

  • Physiological: normal in puberty
  • Syndromes with androgen deficiency: Kallman’s, Klinefelter’s
  • Testicular failure: e.g. mumps
  • Liver disease
  • Testicular cancer e.g. seminoma secreting hCG
  • Ectopic tumour secretion
  • Hyperthyroidism
  • Haemodialysis
  • Drugs - spironolactone, cimetidine, digoxin, cannabis, finasteride, GnRH agonists, oestrogens, anabolic steroids
179
Q

Obesity

A

BMI = kg/m^2

Mx

  • diet, exercise
  • oristat, liraglutide
  • surgical
180
Q

Sick euthyroid syndrome

A
  • low TSH, T3, T4 in pt who has non-thyroidal illness, but are actually euthyroid
  • reverses on recovery from systemic illness
181
Q

Subclinical hyperthyroidism

A
  • normal T3/4, TSH low
  • may lead to AF / osteoporosis, dementia

Causes

  • multinodular goitre
  • excessive thyroxine

Mx

  • TSH normalises alone
  • low dose anti-thyroid 6mo - induce remission
182
Q

Subclinical hypothyroidism

A
  • TSH raised, T3/4 normal
  • tends to be asym

Mx

  • levothyroxine
183
Q

Thyroid eye disease

A
  • affects 25-50% pts with graves
  • autoimmune response, retro-orbital inflammation, collagen deposition in muscles
184
Q

Thyroid eye disease Px

A
  • May be eu/hypo/hyperthyroid
  • Exophthalmos
  • Conjunctival oedema
  • Optic disc swelling
  • Ophthalmoplegia
  • Eyelid retraction
  • Inability to close eyelids -> sore, dry eyes
185
Q

Thyroid eye disease Mx

A
  • stop smoking
  • topical lubricants
  • steroids
  • radiotherapy
  • surgery

Urgent ophthal review if

  • Unexplained deterioration in vision
  • Change in colour vision
  • Hx of eye popping out – globe subluxation
  • Corneal opacity
  • Cornea visible when eyelids closed
  • Disc swelling
186
Q

Thyroid eye disease Cx

A

Exposure keratopathy

  • FB sensation, pain, photophobia
  • corneal scarring / ulcer

Optic neuropathy

  • enlarged extraocular muscles compress optic nerve

Strabismus / diplopia

  • fibrosis / enlargement of extraocular muscles
187
Q

Pregnancy - thyroid problems

A

Hyperthyroid

  • PTU

Hypothyroid

  • thyroxine - titrate to TFTs (may need to increase)
188
Q

Subacute thyroiditis (De Quervain’s thyroiditis)?

A

Subacute thyroiditis thought to occur following viral infection typically presents with hyperthyroidism

Typically 4 phases:
Phase 1- lasts 3-6 weeks- hyperthyroidism, painful goitre, raised ESR
Phase 2- 1-3 weeks- euthyroid
Phase 3- weeks-months- hypothyroidism
Phase 4- Thyroid structure and function back to normal

Investigations- thyroid scintigraphy- globaly reduced uptake of iodine-131

Management-
Usually self limiting
Thyroid pain may respond to aspirin or other NSAIDs
More severe cases- steroids particularly if hypothyroidism

Phase 4 Question Knowledge (30 decks)

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