Endocrinology 2 Flashcards
What is sick euthyroid?
Management?
incidental finding of low fT4 with normal TSH on a background of an acute infection
Repeat thyroid function test in 6 weeks
Subclinical hyperthyroidism is associated with (3)
Causes (2)
see what in tests?
- atrial fibrillation
- osteoporosis
- and possibly dementia
- multinodular goitre, particularly in elderly females
- excessive thyroxine
normal serum free thyroxine and triiodothyronine levels
with a thyroid stimulating hormone (TSH) below normal range (usually < 0.1 mu/l)
How do youmanage asymptomatic patient with fasting glucose > 7.0 or random glucose/ OGGT > 11.0?
MUST demonstrate on two seperate occasions before giving diag and giving med.
Freebee- PTH can be inappropriatley normal in primary hyperparathyroidism
Diabetic Neuropathy management
- first-line- 4 options
- Use 1 of the other 3
- Breakthrough pain-
- Localised neurpathic pain use—
- Finally
- first-line treatment: amitriptyline, duloxetine, gabapentin or pregabalin
- Doesn’t work, try one of the other
- tramadol as rescue thrapy
- topical capsaicin
- pain management clinics if tx. resistant
Gastroparesis
symptoms (3)
management (3 options)
Chronic diarrhoea
often occurs at night
Gastro-oesophageal reflux disease
caused by decreased lower esophageal sphincter (LES) pressure
erratic blood glucose control, bloating and vomiting
metoclopramide, domperidone or erythromycin (prokinetic agents)
Investigations for acromegaly
- First line = (if raised)
- Diagnostic-
- First line = IGF-1 levels, (if raised)
- Diagnostic- oral glucose tolerance test (OGTT) with serial GH measurements is suggested to confirm the diagnosis
Kallman’s syndrome - bloods
LH & FSH low-normal and testosterone is low
absence of GnRH producing cells.
Further, failure of olfactory nerve development causes a reduced or absent sense of smell, which is characteristic
The presence of an elevated prolactin level along with secondary hypothyroidism and hypogonadism is indicative of stalk compression is consistent with a non-functioning pituitary adenoma
The presence of an elevated prolactin level along with secondary hypothyroidism and hypogonadism is indicative of stalk compression is consistent with a non-functioning pituitary adenoma
What should you do if ketonaemia and acidosis have not been resolved within 24 hours?
Endocrinology review- patient should be reviewed by a senior endocrinologist
educe blood ketones by around 1mmol/hr and glucose by around 3mmol/hr.
patient is expected to be eating and drinking normally by 24hrs- at this point can be switched to subcutaneous insulin.
which anti-diabetic drug is associated with an increased risk of bladder cancer
Thiazolidinediones- pioglitazone
What medication can reduce the absorption of levothyroxine?
should be taken how long apart form each other?
Iron / calcium carbonate tablets
- should be given 4 hours apart
HHS or DKA how do you tell the difference?
diagnostic criteria for hyperosmolar hyperglycaemic state (HHS): (3)
HHS
- over days
- No ketonaemia
- no acidosis
- obvs have hyperglycaemia and stupidly high Na+ (serum osmolality > 320)
DKA
- over hours
- obvs ketonaemia
- obvs acidosis
- hyperglycaemia (same)
- hypovolaemia
- hyperglycaemia (blood sugar > 30mmol/L)
- serum osmolality > 320mosmol/kg.
Presentation includes hypovolaemia, fatigue, lethargy, altered consciousness, hypotension and tachycardia.
HHS management
1.
- rate?
2. DONT GIVE….. UNLESS
3. WHy?
Complications of the disorder? (2)
- fluid replacement
(estimated to be between 100 - 220 ml/kg)
- IV 0.9% sodium chloride solution
- typically given at 0.5 - 1 L/hour depending on clinical assessment
- potassium levels should be monitored and added to fluids depending on the level - insulin
should not be given unless blood glucose stops falling while giving IV fluids - VTE prophylaxis
patients are at risk of thrombosis due to hyperviscosity
Due to increase blood viscosity:
1. MI
2. Stroke
Phaeochromocytoma typically presents with a triad of:
Risk factors (2)
Investigations
- first-line
- second-line
- sweating
- headaches
- palpitations in association with severe hypertension
- MEN 2
- Neurofibromatosis type 1
Investigations
- first-line = urinary metanephrines
- second-line = Clonidine suppression tests
WHat do you see on Cushings ABG? + why? (2)
hypokalaemic metabolic alkalosis
- High aldosterone- lose K+ (opposite of K+ sparing sprinolcatone)
- High aldosterone - also lose H+ in the renal tubules, with bicarbonate being retained, leading to metabolic alkalosis.
Factors which artificially RAISE HbA1c are due to SHORTENING of RBC life span- these include: (4)
(all the weird ones)
Factors which articially LOWER HbA1c are due to RBC life-span LENGTHENING, this includes: (3)
SHORTENING RBC LIFE:
- Sickle cell
- GP6D deficiency
- Hereditary spherocytosis
- Haemodialysis
LENGTHEN RBC LIFE:
- Splenectomy (don’t remove them)
- Vit B12/ folic acid deficiency
- Iron def anaemia
SGLT -2 Inhibitor CI
- Foot ulcer disease (increase risk of amputation)
Management of acromegaly
- First-line =
- If 1 CI or unsuccessful then give… class=
- 2 other drugs and classes
- First-line = Transphenoidal surgery
- If 1 CI or unsuccessful then give Ocreotide, class= Somatostatin analogue whih diretly inhibits GH
- 2 other drugs and classes
- Pegvisomant, GH rec anatgonist, decrease IGF-1
- Bromcriptine, D2 Agonist
External irradiation is sometimes used for older patients or following failed surgical/medical treatment
Diagnositc criteria of sublinicial hypothyroidism:
what do you give and what age?
- Raised TSH, normal T4, T3
- Two +ve readings 3 months apart
- Give < 65 yo a 6-month trial of thyroxine
Steroid use not only causes osteoperosis but also…. (2)
think of a particular fracture this could affect
Osteonecrosis/ Avascular necrosis
- Scaphoid fractures
- And proximal myopathy (not too relevant here)
Addison’s: the hydrocortisone doses given how much and at what times?
- Standard release corticosteroid
- two doses
hydrocortisone dose is split with the majority given in the first half of the day, don’t need late on as it will prevent them sleeping
if 30mg = ‘hydrocortisone 20mg at 8am and 10mg at 5pm.
What is the max dos metformin can be titrated up to before adding the next med
1g BD
Orlistat
MOA
Criteria to receive it
1. oe 2.
3.
4 used for a max time of…
Another drug that can be give
Class GLP-1 mimetic
Name =
Criteria
1
2
MOA- Pancreatic and gastric lipase blocker, reduce fat digestion
Criteria
- BMI > 28 with comorbidities attributed/Risk factors
- BMI > 30
- ongoing weight loss 5% 3 month?
- Max 1yr use
Liroglutide
1. person has a BMI of at least 35 kg/m²
2. prediabetic hyperglycaemia (e.g. HbA1c 42 - 47 mmol/mol)
Definitions
Diabetic diagnosis criteria
sympatomatic =
asymp =
Impaired fasting glucose
Impaired glucose tolerance
Diabetic diagnosis criteria
sympatomatic =
Fasting > 7.0
OGGT > 11.1 (after 75g of glucose)
asymp =
2 +ve results on 2 separate occasions
Impaired fasting glucose
Fasting 6.1-6.9
Impaired glucose tolerance
OGGT 7.8-11.1
T1DM daignostic criteria
Symp =
Asmp =
Aiding diagnosis:
- C peptide low or high?
name 2/4 auto-antibodies
sympatomatic =
Fasting > 7.0
OGGT > 11.1 (after 75g of glucose)
asymp =
2 +ve results on 2 separate occasions
Aiding diagnosis:
- C peptide LOW
name 2/4 auto-antibodies
1. Anti GAD (most common)
2. Anti- Islet antibody
3. Insulin autoantibodies (IAA) (KIDS)
4. Insulinoma-associated-2 autoantibodies (IA-2A)
Thyroid Cancer
Papillary- most common
1. Solitary or multifocal?
2. encap or not?
3. Spreads how?
Follicular
1. Solitary or multifocal?
2. encap or not?
3. Spreads how?
Medullary
1. From what cells?
2. KEY FACT
3. KEY FACT
4. Increase release in
thyrotoxicosis (low TSH) and a hot solitary nodule indicates…
Papillary- most common
1. multifocal
2. not encap
3. Spreads lymph nodes
Follicular
1. Solitary
2. yes encap
3. Spreads how haematogenous
Medullary
1. From C- cells
2. KEY FACT- big FAMILIAL link 20%
3. KEY FACT- Assoc woth pheochromocytoma and MEN II
4. Increase release in calcitonin
Toxic adenoma
radioactive iodine uptake test what do you see in Graves?
Increased, homogenous uptake
Myxoedema coma typically presents with (2)
confusion and hypothermia.
Gastric adenocarcinoma feature on histology
signet ring cells
