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Grace Phase 2 > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

how do beta 2 agonists work?

A

bind beta 2 receptors, mimicking action of catecholamines

relax smooth muscle in bronchial tree [broncho-dilation]

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2
Q

why can a pituitary tumour cause vision problems?

A

optic chiasm lies adjacent to pituitary gland/pituitary

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3
Q

which types of drugs can cause medication induced diabetes?

A 
corticosteroids
thiazide diuretics
beta blockers
antipsychotics
statins
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4
Q

examples of diseases that cause “endocrine diabetes”

A

acromegaly

cushings

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5
Q

Fasted state hormone in glucose regulation

A

Glucagon

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6
Q

Fed state hormone in glucose regulation

A

Insulin

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7
Q

Alpha cells of pancreas produce..

A

Glucagon

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8
Q

Beta cells pancreas produce..

A

Insulin

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9
Q

Where do glycogen conversion to glucose + gluconeogenesis occur

A

Liver

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10
Q

how do cortisol levels vary during the day?

A

high in the morning

decrease during the day

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11
Q

what hormones [produced by the hypothalamus] are secreted by the posterior pituitary

A

oxytocin

ADH [vasopressin]

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12
Q

describe action of ADH

A

distal tubule H2O reabsorption [water retention]

to dilute the circulation/^blood vol

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13
Q

actions of oxytocin

A

breast milk production

labour contractions

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14
Q

ACTH acts on the..

A

adrenal cortex

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15
Q

which hormone continuously inhibits prolactin?

A

dopamine

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16
Q

what is Grave’s disease + its cause

A

autoimmune thyroid disorder > hyperthyroidism

IgG antibodies bind to TSH receptor + stimulate thyroid hormone production + cause diffuse smooth enlargement

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17
Q

2 types of autoimmune thyroiditis

A

Hashimoto’s [goitre]

atrophic [shrunken]

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18
Q

treatment of thyroid malignancy

A

thyroidectomy
neck dissection for lymph nodes
radioactive iodine

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19
Q

asymptomatic thyroid nodules that increase in size, become hard and irregular may suggest what pathology?

A

carcinoma

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20
Q

treatment of primary hypothyroidism

A

levothyroxine

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21
Q

describe thyroid hormone axis

A

hypothalamus > TRH (thyrotropin-releasing)
pituitary > TSH (thyroid-stimulating)
thyroid > T4 [+some T3]
in circulation, T4-> more active T3

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22
Q

describe the hormone axis that leads to testosterone or progesterone/oestrogen release

A

hypothalamus > GnRH (gonadotropin-releasing)
pituitary > LH, FSH
testes > testosterone
ovaries > progesterone, oestrogen

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23
Q

hormone axis that leads to cortisol release

A

hypothalamus > CRH (corticotropin-releasing)
pituitary > ACTH (adrenocorticotropic)
adrenal cortex > cortisol

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24
Q

growth hormone hormone axis

A

hypothalamus > GHRH (growth-hormone releasing)
pituitary > GH
liver > IGF1 (insulin-like growth factor)

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25
Q

describe the pathway that leads to prolactin inhibition

A

hypothalalmus > dopamine (-ve action on pituitary)

pituitary inhibited from producing prolactin

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26
Q

action of somatostatin on pituitary

A

negative action preventing release of growth hormone

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27
Q

what would levels of TSH and T4 look like in hypothyroid disease?

A

low T4

high TSH

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28
Q

what would levels of TSH and T4 look like in hypopituitary disease?

A

low/norm TSH

low T4

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29
Q

what would levels of TSH and T4 look like in Grave’s disease?

A

high T4

low TSH [negative feedback]

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30
Q

what would TSH and T4 levels look like in patients with genetic hormone resistance [where pituitary doesn’t respond to -ve feedback]?

A

high TSH

high T4

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31
Q

describe levels of LH/FSH and testosterone in a male patient with primary hypogonadism

A

low testosterone

high LH/FSH

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32
Q

describe levels of LH/FSH and testosterone in a male pateint with hypopituitary

A

low testosterone

norm/low FSH/LH

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33
Q

describe levels of LH/FSH and testosterone in a male pateint with anabolic steroid use

A

low testosterone
suppressed LH/FSH
(steroids inhibit pathway)

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34
Q

describe levels of LH/FSH and oestradiol in female patient with hypopituitary.
& periods?

A

norm/low LH/FSH
low oestradiol
+ amenorrhoea

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35
Q

describe levels of LH/FSH and oestradiol in female patient with primary ovarian failure [or menopause]

A

high LH/FSH

low oestradiol

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36
Q

describe levels of ACTH and cortisol in patient with primary adrenal insufficiency

A

low cortisol

high ACTH

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37
Q

how does patient with primary adrenal insufficiency respond to synacthen test

A

poor response

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38
Q

what is the synacthen test?

A

patient given synacthen [ACTH]

test for cortisol response

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39
Q

describe levels of ACTH and cortisol in patient with hypopituitary.

A

low cortisol

low/norm ACTH

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40
Q

what hormone do you measure to investigate growth hormone pathway problems & why?

A

IGF-1
GH is pulsatile/ fluctuates so not useful
[also GH stimulation test used]
and OGTT for acromeg

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41
Q

how is prolactin measured?

A

phlebotomy
BUT stress hormone! so may be raised [white coat]
so can use cannula and take blood over 1 hr [should decrease if raised due to stress]

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42
Q

a benign pituitary adenoma may put pressure on what in the cavernous sinus??

A

cranial nerves 3,4,5

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43
Q

main symptom of benign pituitary adenoma causing raised intracranial pressure

A

headache

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44
Q

a benign pituitary adenoma can erode the sphenoid bone causing leakage of what?

A

CSF

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45
Q

what sort of visual field loss is caused by benign pituitary tumour pressing on optic chiasm?

A

bitemporal hemianopia

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46
Q

physical features of hypopituitarism

A

pale
no body hair
central obesity

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47
Q

reproductive related problems in women with hypopituitarism

A

infertility

amenorrhoea

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48
Q

what causes cushings DISEASE?

A

pituitary adenoma > excess cortisol

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49
Q

symptoms of a prolactin microadenoma [of lactotroph cells]

A 
unovulation > infertility
galactorrhoea (men&women)
amenorrhoea
decreased libido
possible visual field defect
low testosterone in men
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50
Q

growth hormone disorders of increased GH production before and after epiphysial growth plate fusion?

A

before: gigantism
after: acromegaly

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51
Q

diagnosis of cushing’s syndrome

A

dexamethasone suppression test to confirm raised cortisol

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52
Q

causes of cushing’s syndrome other than pituitary adenoma

A

exogenous steroids e.g. for asthma
ectopic neuroendocrine cell tumours > ACTH
adrenal tumour > cortisol

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53
Q

is ACTH measurement in cushing’s syndrome is +ve, what further diagnostic test would you carry out?

A

CT/MRI pituitary

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54
Q

is ACTH measurement in cushing’s syndrome is -ve, what further diagnostic test would you carry out?

A

CT/MRI adrenal

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55
Q

diagnostic test for agromegaly

A

glucose tolerance test

GH not supressed as it should be

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56
Q

difference between suppression and stimulation tests (when you’d use them)

A

suppression: for suspected over-production
stimulation: for suspected deficiency

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57
Q

when would you do transphenoidal surgery for non-functioning pituitary tumour?

A

if threatening eye sight

or progressively increasing in size

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58
Q

diagnosis of prolactinoma

A

prolactin test

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59
Q

prolactinoma treatment

A

dopamine agonist

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60
Q

2 types of pituitary adenoma that lead to ^ed prolactin and must be distinguished

A

prolactinoma > prolactin

adenoma pressing on pituitary stalk & inhibiting dopamine

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61
Q

hyperandrogenism in females, physical features

A

hirsutism
temporal balding
acne

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62
Q

what types of regulation is the hypothalamus responsible for?

A 
appetite/thirst
menstrual
thermal regulation
sleep
stress
 mood
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63
Q

where are vasopressin + oxytocin produced stored and released from

A

produced in hypothalamus

stored + reelased from posterior pituitary

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64
Q

name the 5 hormones relased from the anterior pituitary + where they act

A 
LH/FSH > ovaries/testes
GH > many tissues
TSH > thyroid
prolactin > breasts/gonads
ACTH > adrenals
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65
Q

DM causes serious micro and macrovascular problems. Give e.g.s of each

A

micro: nephropathy, neuropathy, retinopathy
macro: stroke, MI, renovascular disease, limb ishaemia

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66
Q

what causes type 1 DM

A

autoimmune destruction of insulin-secreting pancreatic B cells, leading to insulin deficiency

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67
Q

risk factors for type 2 DM

A 
asian
male
elderly
obesity
reduced exercise
calorie excess
alcohol excess
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68
Q

which had higher genetic influence, type 1 or type 2 DM

A

type 2

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69
Q

other causes of DM [other than type 1 or 2]

A

drugs: steroids, anti-HIV, newer antipsychotics
Pancreas: -itis, surgery, CA, trauma, destruction [CF, haemochromatosis].
cushings/acromeg/phaeochromocytoma/^thyroid/pregnancy

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70
Q

Sx of hyperglycaemia

A 
polyuria
polydipsia
unexplained weight loss
visual blurring
genital thrush
lethargy
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71
Q

general principles of type 2 DM Mx

A

weight loss, diet, exercise
tablets (mono>dual>triple therapy)
insulin

statin, BP control
footcare
bariatric surgery
DVLA

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72
Q

DVLA w/ regards DM?

A

patient must inform

don’t drive if they have hypos

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73
Q

describe drugs used in type 2 DM algorithm

A 
monotherapy - metformin
dual therapy - metformin + sitagliptin/sulfonylurea/pioglitazone
triple therapy
GLP analogues
insulin
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74
Q

S.E.s of metformin and how you might overcome?

A

nausea
diarrhoea
abdo pain

change to modified release

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75
Q

what is the risk of binge drinking in DM

A

delayed hypoglycaemia
[alcohol prevents liver releasing glucose, drinks contain sugar so effect of liver damage not noticed til later when drinks have been digested/metabolised]

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76
Q

what advice do you give to insulin-dependent DM patients during acute illness e.g. flu

A 
don't stop insulin
illness can ^ insulin requirement despite reduced food intake
maintain calorie intake
check BM 4X/day
safety net
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77
Q

what can happen at DM insulin injection sites?

A

infection

lipohypertrophy

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78
Q

how can you manage microalbuminuria in DM

A

ACE-inhibitor
ARB [sartan]
spironalactone

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79
Q

what 2 DM complication s affect the feet

A

neuropathy

ischaemia/vascular disease

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80
Q

examination findings in DM neuropathy and in ischaemia

A 
neuropathy:
reduced sensation (stockings)
absent ankle jerk
deformity - [charcot joint, pes cavus, claw toes, rocker bottom sole]
swelling

ischaemia: absent pulses, cold, ulcers

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81
Q

DM foot Ix and Mx

A

xray, Doppler

patient regular examination
podiatry/chiropodist
shoe advice

treat infections e.g. fungal
vascular surgery

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82
Q

main hormonle released from the thyroid gland

A

T4

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83
Q

which hormone is more active t3 or t4

and how are they formed

A

t3

t4 from thyroid gland
t3 from t4 conversion

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84
Q

Investigations when hyperthyroid is suspected

A

T3, T4, TSH

thyroid autoantibodies

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85
Q

what would happen to TSH in hyperthyroidism

A

low

unless pituitary adenoma [^TSH]

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86
Q

what can happen to TFTs in systemic illness

A

sick euthyroidism

deranged TFTs - usually everything low

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87
Q

Pt.s who need thyroid fn screening

A 
DM
type 1 in 1st trimester + postpartum
amiodarone/ lithium
downs/ turners/ addisons
AF
hyperlipidaemia
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88
Q

what imaging can be used for the thyroid?

A

US

isotope scan

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89
Q 
60 yr old male
lump on L side of neck
wife noticed hoarse voice
no weight loss
visible thyroid mass w/ no lymph nodes
normal TFT
Most likely diagnosis?
a)graves
b)CA
c)multinodular goitre
d)benign thyroid adenoma
A

b)CA

[recurrent laryngeal nerve palsy, Pt age]

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90
Q

commonest type of thyroid CA

A

papillary

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91
Q

Mx of thyroid CA

A

surgical excision
radioiodine
suppression of TSH using thyroxine

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92
Q

what is the diagnostic significance of positive peroxidase antibodies

A

autoimmune thyroid disease

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93
Q

how does amiodarone affect thyroid fn

A

hypo or hyper [hypo is more common]

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94
Q

graves disease - thyroid uptake scan shows what

A

diffusely ‘hot’ gland due to increased uptake

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95
Q

a single ‘hot’ spot on a thyroid uptake scan suggests what

A

adenoma

carcinoma

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96
Q

Mx of graves

A

carbimazole or propylthiouracil

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97
Q

60 yr old into A+E
confusion, weight loss, agitation, sweating.
HR 140, AF
CXR: enlarged heart w/ bibasal pleural effusions. Diffuse shadow in upper mediastinum + neck scar.

Likely diagnosis?

A

thyroid storm [complicated by hyperthyroid-induced HF]

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98
Q

what do you test for in urine for phaeochromocytoma

A

24 hr for metanephrines/ metadrenaline

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99
Q

where in the adrenals are phaeochromocytomas found

A

medulla

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100
Q

phaeochormocytoma age and gender commonest

A

equal sex incidence

30-50

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101
Q

MEN-2 [multiple endocrine neoplasia] consists of :

A

phaeo
hyperparathyroidism
medullary thyroid ca

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102
Q

MEN-1 [multiple endocrine neoplasia] consists of :

A

hyperparathyroidism
pituitary tumour
pancreatic tumour

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103
Q

Mx of phaeo

A

alpha blockade [phenoxybenzamine] followed by beta blockage [propranolol] to avoid massive catecholamine release during surgery

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104
Q

classic triad of phaeochromocytoma

A

episodic headache
sweating
tachycardia

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105
Q

2 examples of catecholamines

A

dopamine
noradrenaline
adrenaline

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106
Q

most common cause of addisons in the developed and worldwide

A

uk - autoimmunek adrenalitis

worldwide - TB

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107
Q

3 layers of the adrenal cortex from outer to inner and what they produce

A

glomerulosa - aldosterone
fasciculata - cortisol
reticulata - testosterone

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108
Q

why do addisons patients have hyperkalaemia

A

no production of glucocorticoids OR mineralocorticoids e.g. aldosterone.
Aldosterone increases K+ secretion

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109
Q

diagnostic investigation for addisons

A

short synacthen test

110
Q

describe synacthen test

A

give ACTH
measure cortisol before and 30 min after
cortisol not raised in addisons

111
Q

mx of addisons

A

glucocorticoid and mineralocorticoid replacement [thrice daily hydrocortisone + od fludrocortisone]

112
Q

what Ix.s might you do for an ulcer in DM foot

A

xray [osteomyelitis]
cultures
swabs

113
Q

Sx of symmetric sensory polyneuropathy [DM]

A

numbness
tingling
pain
worse at night

114
Q

Mx of symmetric sensory polyneuropathy [DM]

A

PCM > amitriptyline > duloxetine/ gabapentin/ pregab > opiates
avoid weight bearing

115
Q

clinical features of autonomic neuropathy

A 
BP postural drop
gastroparesis
loss of sinus arrhythmia [vagal neuropathy]
reduced cerebrovascular autoregulation
urine retention
ED
gustatory sweating
diarrhoea
116
Q

if hypoglycaemia is severe/ prolonged, what severe outcome can it cause…

A

death, brain damage

117
Q

Sx of hypoglycaemia [autonomic and neuroglycopaenia]

A

autonomic: sweating, anxiety, hunger, tremo;;r, palpitations, dizzy
neuroglycopaenia: confusion, drowsy, vision, coma, seizure

118
Q

chief causes of hypoglycaemia in DM

A

insulin/sulfonylureas
^activity/missed meal
accidental/non-accidental overdose

119
Q

causes of hypoglycaemia in non-DM [EXPLAIN]

A

EXogenous drugs [diabetic relative, body builder, alcohol, aspirin, ACEi, BB etc.]
Pituitary insufficiency
Liver failure
Addisons
Islet cell tumour/ Insulinoma/ Immune antibodies
Non-pancreatic tumour e.g. fibrosarcoma

120
Q

describe the relationship between cortisol and glucose

A

cortisol increases gluconeogenesis + glycogenesis
counteracts insulin
inhibits peripheral glucose use > hyperglycaemia

121
Q

hypo Mx

A

15-20g quick acting carb e.g. 200ml OJ
/glycogel in gums/ IV glucose/ IV/IM glucagon if reduced level of consciousness

after - long acting carb e.g. toast

122
Q

Sx of thyrotoxicosis

A 
diarrhoea
weight loss
increased appetite
over-active
sweats
heat intolerance
palpitations
tremor
irritable
oligomenorrhoea/infertility
123
Q

clinical signs of thyrotoxicosis

A 
fast irregular pulse [AF/SVT]
warm moist skin
fine tremor
palmar erythema
thin hair/ hair loss
lid lag, lid retraction [stare], exopthalmus/proptosis
goitre, thyroid nodules, bruit
pretibial myxoedema
onycholysis [nail separates from nailbed]
124
Q

clinical signs of graves disease

A
  1. eyes - exopthalmus, opthalmoplegia
  2. pretibial myxoedema
  3. thyroid acropachy/ clubbing
125
Q

what happens to the calcium in thyrotoxicosis

A

hypercalcaemia

126
Q

causes of thyrotoxicosis

A 
grave's
toxic multinodular goitre [nodules secrete T3/T4]
toxic adenoma [solitary nodule]
ectopic thyroid tissue
iodine [contaminated food, contrast]
thyroiditis [post-infection]
amiodarone, lithium
postpartum
127
Q

typical age and gender for graves

A

female 40-60

128
Q

triggers of graves disease

A

stress
infection
childbirth

129
Q

what other autoimmune diseases can grave’s be associated with

A

vitiligo
type 2 dm
addisons

130
Q

treatment of thyrotoxicosis

A 
propanolol
carbimazole [titration]
OR carbimazole + levothyroxine ['block-replace']
radioiodine
thyroidectomy
131
Q

rare but dangerous side effect of carbimazole.

how do you warn patients

A

agranulocytosis (low neutrophils) [can lead to sepsis]

warn to stop and get urgent FBC if signs of infection e.g. sore throat, fever, mouth ulcers

132
Q

risks and consequences of thyroidectomy

A

risk of damage to recurrent laryngeal nerve
risk of damage to parathyroid gland
will become hypothyroid and need replacement therapy

133
Q

complications of thyrotoxicosis

A 
HF
angina
AF
osteoporosis
opthalmopathy
gynaecomastia
thyroid storm
134
Q

what is a myxoedema coma +clinical features of myxoedema coma

A

severe hypothyroid state

hypothermia
hyporeflexia
bradycardia
coma
seizures
135
Q

precipitants of myxoedema coma

A

infection
mi
stroke
trauma

136
Q

Tx of myxoedema coma

A 
O2
may need ventilation
glucose
T3 [liothyronine]/levothyroxine
hydrocortisone
if infection is suspected cause > ABx
fluid/inotropes
active warming
137
Q

signs and Sx of thyrotoxic storm

A 
pyrexia
agitation
confusion
coma
tachycardia
AF
D+V 
goitre/bruit
acute abdo
HF
138
Q

precipitants of thyrotoxic storm

A 
recent thyroid surgery
radioiodine
infection
MI
trauma
139
Q

thyrotoxic storm Mx

A 
fluids
NGT if vomiting
chlorpromazine [sedate]
propanolol, digoxin [HR]
carbimazole
Lugol's solution [iodine blocks thyroid]
hydrocortisone [prevents T4 >T3]
infection > co-amox
140
Q

when would you not use propanolol in thyrotoxic storm?

A

asthma/ poor cardiac output -> cardiac arrest

141
Q

Mx of thyroid eye disease other than correcting the hyper/hypothyroidism

A

STOP SMOKING
IV methypred
surgical decompression
drops/glasses

142
Q

causes of goitre. Diffuse, and nodular

A

diffuse: Grave’s, hashimoto’s thyroiditis, post infection, physiological
nodular: multinodular goitre, adenoma, carcinoma

143
Q

Sx of hypothyroidism

A 
lethargy
low mood
weight gain
constipation
menorrhagia
hoarse voice
reduced cognition/dementia
myalgia/cramps/weakness
144
Q

what is an insulinoma?

and Mx?

A

usually benign pancreatic islet cell tumour. Causes hypoglycaemia

excision

145
Q

tests in insulinoma

A

serum glucose
plasma insulin

supressive test: give IV insulin + measure C-peptide {insulin should suppress but wont]

CT/MRI, endoscopic pancreatic ultrasound

146
Q

Sx of DKA

A 
drowsy
vomiting
abdo pain
polyuria
polydipsia
lethargy
anorexia
ketotic breath
coma
deep breathing
147
Q

triggers for DKA

A 
poor compliance/wrong dose
infection
surgery
MI
pancreatitis
chemo
antipsychotics
148
Q

3 criteria needed for a diagnosis of DKA

A
  1. acidaemia [ph]
  2. hyperglyc OR known DM
  3. ketonaemia or ^^^ketonuria
149
Q

Ix in DKA

A 
glucose [cap+lab]
VBG/ABG for pH
ketones
U+Es [K+]
ECG
CXR [signs of infection]
urine dip+MSU
FBC
culture
osmolality
150
Q

DKA Mx

A 
ABCDE
fluids [bolus or bag NS]
insulin 50U in 50ml NS
check BM + ketone hrly
when glucose <14, start IV 10% glucose
K+
LMWH
consider catheter
consider NGT
151
Q

other causes of ketonuria [than DKA]

A

anyone after overnight fast

alcohol

152
Q

complications of DKA

A

cerebral odema
thromboembolism
aspiration pneumonia
low K+/Mg/phos

153
Q

actions of aldosterone on serum Na+, water, K+, bicarb

A

^ serum Na+ and water

reduced K+ and bicarb [loss in urine]

154
Q

Mx of newly diagnosed addisons

A

hydrocortisone
fluid resus NaCl 0.9%
dextrose for hypoglyc

155
Q

what effect does cortisol have on glycaemic state + how

A

hyperglycaemia

counter acts insulin
turns glycogen from muscles into glucose

156
Q

what does secondary adrenal insufficiency mean?

A

pituitary dysfunction

157
Q

what can cause chronic hyponatraemia

A

DIURETICS

e.g. bendroflumethiazide

158
Q

in a patient with a pituitary prolactinoma, what specifically would causes a sudden severe headache?

A

apoplexy [haemorrhage]

159
Q

what effect would a pituitary prolactinoma have on Na+, cortisol, and periods

A

Na+ low
cortisol low
amenorrhoea

160
Q

causes of hypercalcaemia

A 
hyperparathyroidism
myeloma
bone mets
PTH secreting tumour
excess vit D supplements
sarcoidosis
161
Q

give 4 Sx of hypercalcaemia

A 
bone pain 
fractures
renal stones
depression
abdo pain
vomiting
constipation
weakness
tired
thirst
polyuria
weight loss
confusion
162
Q

Ix for hypercalc

A 
PTH
FBC
U+E
Mg2+, Ca2+, PO43-
ALP [LFTs]
ECG! 
CXR
bone scan
163
Q

ECG findings in hypercalcaemia

A

short QT

arrhythmias

164
Q

Mx of hypercalcaemia

A

fluids
furosemide
IV bisphosphonates

165
Q

complications of hypercalcaemia

A 
pancreatitis
renal stones
arrhythmias
renal failure
osteopenia
peptic ulcers
166
Q

what is primary hyperparathyroidism and what would you see in PTH and Ca2+

A

^PTH from parathyroid

^PTH, ^Ca2+

167
Q

what is secondary hyperparathyroidism and what would you see in PTH and Ca2+

A

^PTH caused by low Ca2+

168
Q

Mx of primary hyperparathyroidism

A

correct hyperCa2+

parathyroidectomy

169
Q

what is tertiary hyperparathyroidism and what disease is it commonly seen alongside

A

parathyroid adenoma due to prolonged hypoCa2+

end stage renal failure

170
Q

5 cancers that metastasise to bone?

A 
breast
lung
thyroid
kidney
prostate
171
Q

why is growth hormone test not useful in acromegaly?

what diagnostic test would you use instead?

A

normal individuals secrete pulses of growth hormone throughout the day, which is difficult to differentiate from acromegaly.
Also GH is released in stress, puberty, sleep, preg.

OGTT - lack of normal suppression of GH with glucose load

172
Q

most common cause of acromegaly

A

pituitary tumour secreting GH

[>95% of cases]

173
Q

Pt with oligo or amenorrhoea, and ^testosterone. Likely diagnosis?

174
Q

differentials for ^prolactin

A

prolactinoma
pituitary stalk compression
dopamine antagonists, antipsychotics, oestrogens
hypothyroid

physiological: stress, pregnancy, breastfeeding

175
Q

Sx of raised levels of prolactin

A 
oligo/amenorrhoea
infertility
galactorrhoea
weight gain
low libido
vaginal dryness
ED
pressure effects from prolactinoma
osteoporosis [fracture]
176
Q

Ix in high prolactin

A

pregnancy test
TFT
U+E [reduced excretion]
MRI pituitary if other causes ruled out

177
Q

Mx of hyperprolactinaemia

A

bromocriptine [dopamine agonist]

178
Q

drugs that cause hypercalcaemia

A

lithium
thiazide diuretics
vit D

179
Q

commonest cause of hypercalc in an asymptomatic Pt?

A

hyperparathyroidism

180
Q

is hypercalc an early or late sign in CA

181
Q

common tumours ass. w/ hypercalc

A

multiple myeloma
breast
SCC

182
Q

commonest cause of hirsutism

183
Q

female Pt with deepening of the voice, frontal balding, cliteromegaly suggests what diagnosis?

A

androgen secreting tumour

184
Q

what blood result might contraindicate metformin

185
Q

how do insulin and sulfonylurea affect patient’s weight?

186
Q

give 5 signs of hypothyroidism

A 
weight gain
cold peripheries
bradycardia
dry skin
thin hair
slow reflexes
ascites + oedema
depression
ataxia
goitre
neuropathy
187
Q

causes of primary hypothyroidism

A 
primary atrophic hypothyroidsim [autoimm]
hashimoto's thyroiditis
iodine deficiency [worldwide]
post-thyroidectomy
radioiodine Tx
antithyroid drugs/ lithium/ amiod
188
Q

what is primary atrophic hypothyroidism and which gender is more susceptible

A

Autoimmune. Lymphocytic infiltration. Atrophy. Female.

189
Q

what is hashimoto’s thyroiditis and which gender is more susceptible

A

autoimmune. lymphocytic and plasma cell infiltration. goitre. female.

190
Q

what is secondary hypothyroidism?

A

hypopituitarism [pituitary not producing enough TSH]

191
Q

other diseases associated with hypothyroidsim

A 
autoimmune: PA, T1DM, addisons
turners/ downs
CF
primary biliary cholangitis
ovarian hyperstimulation
192
Q

pregnancy problems associated with hypothyroidism

A 
eclampsia
anaemia
prem
low birthweight
stillbirth
PPH
193
Q

Mx hypothyroidism

A

levothyroxine

194
Q

how does amiodarone affect the thyroid

A

hypo or hyper
iodine rich drug
iodine excess can toxicity > hypo
or hyper from destructive thyroiditis which releases ^hormones

195
Q

what stimulates PTH release?

196
Q

what are the actions of PTH

A

^osteoclast activity = release Ca2+ and phosphate from bones
^ calcium and less phosphate reabsorption in the kidney
increased production of active 1,25 dihydroxy-vitamin D

overall increases calcium and reduces phosphate

197
Q

causes of primary hyperparathyroidism

A

adenoma
hyperplasia of glands
parathyroid CA [<0.5%]

198
Q

presentation of hyperparathyroidism

A

high calcium Sx: thirst, polyuria, tired, depressed, weakness, kidney stones, ulcers, pancreatitis, abdo pain

bone resorption Sx: pain, osteoporosis, fracture

HTN

199
Q

Ix in hyperparathyroidism

A 
Ca2+
phosphate
PTH
urine free calcium
Alk phos
XR, DEXA
200
Q

advice for patient with mild hyperparathyroidsim and a type of drug to avoid prescribing

A

reduced calcium and vit D in the diet
drink plenty of fluids to avoid kidney stones
avoid thiazide diuretic

201
Q

complications of removal of parathyroid adenoma or hyperplastic glands?

A

damage to recurrent laryngeal nerve = hoarseness
hypoparathyroidism
hypocalc - cramps, parasthesia, anxiety, seizure, wheeze, confusion, long QT

202
Q

Mx of parathyroid adenoma or hyperplastic glands

A

excision

cinacalcet - increases PT cell sensitivity to Ca2+ which reduces PTH secretion

203
Q

what is malignant hyperparathyroidism

A

some cancers produce parathyroid-related protein. [breast, squamous cell lung CA, renal cell carcinoma].
mimics PTH -> high calcium

204
Q

causes of primary hypoparathyroidism

A

autoimmune gland failure

congenital [DiGeorge]

205
Q

actions of vitamin D in relation to calcium

A

increases the level of calcium in the blood
BY…
increasing the uptake of calcium from the gut
increasing reabsorption of calcium by the kidneys

206
Q

Mx of hypoparathyroidism

A

Calcium and cacitriol supplements or synthetic PTH subcut

207
Q

causes of secondary hypoparathyroidism

A

radiation
surgery
hypomagnesaemia [need Mg to secrete PTH]

208
Q

what are MEN syndromes?

A

multiple endocrine neoplasia

hormone producing tumours in multiple organs

209
Q

outline the hypothalamo-pituitary-adrenal axis for steroid secretion

A

hypothalamus > CRF [corticotrophin-releasing factor]
pituitary > ACTH [adrenocorticotrophic hormone]
adrenal > cortisol + androgens (steroids)

210
Q

what is cushings syndrome and what is the main cause

A

too much cortisol, lack of hypothalamo-pituitary-adrenal feedback mechanism, loss of circadian rhythm or cortisol release.
Exogenous steroids.

211
Q

other causes of cushings sydrome, other than exogenous steroids

A

^ACTH due to…..
pituitary adenoma [cushings disease]
ectopic ACTH production
rarely ectopic CRF production

adrenal CA/adenoma
adrenal nodular hyperplasia

212
Q

describe cushings DISEASE

A

Pituitary adenoma secretes ACTH. Leads to bilateral adrenal hyperplasia. Leads to high cortisol.

213
Q

where does ectopic ACTH secretion usually come form?

A

small cell lung cancers

carcinoid tumours

214
Q

cushings Sx

A 
weight gain
depression
lethargy
proximal weakness
irregular periods
hirsutism
ED
acne
achilles tendon rupture
215
Q

signs in cushings syndrome

A 
central obesity
moon face
wasted limbs
buffalo hump
supraclavicular fat pads
striae
skin atrophy
bruising
HTN
216
Q

Tx of cushings syndrome

A

stop exogenous steroids
cushings disease: pituitary adenoma excision + bilateral adrenalectomy
Cancer: adrenalactomy + radio + mitotane
ectopic: surgery / metyrapone

217
Q

what is the risk of untreated cushings?

A

vascular mortality - incerased risk of arterial and venous clots

218
Q

investigations in suspected cushings syndrome

A

dexamethasone suppression test
24h urinary free cortisol

Localization:
serum ACTH
adrenal MRI
adrenal vein sampling
CRH test [give CRH, measure cortisol]
MRI pituitary
219
Q

most common cause of addisons?

give 2 other causes

A

autoimmune

TB, adrenal mets, lymphoma, adrenal haemorrhage

220
Q

what is the commonest cause of secondary adrenal insufficiency?

A

iatrogenic [long term steroids suppress pituitary, then withdrawn]

221
Q

Sx of addisons

and signs of a critical deterioration

A

famously non-specific

lean
tanned/ pigmented creases and oral mucosa
tired
tearful
weakness
anorexia
dizzy
myalgia/arthralgia
abdo pain
N, V + D/constipation

Critical: shock - low BP, tachycardia. Pyrexia, coma.

222
Q

Ix in addisons

A 
U+E, glucose, FBC
short synacthen test [give ACTH, measure cortisol]
ACTH
autoantibodies (21-hydroxylase)
renin + aldosterone
CXR [TB]
adrenla CT for cause
223
Q

how does aldosterone affect Na+ and K+

A

Na+ sparing and K+ loss

so aldosterone increases plasma Na+ and reduces plasma K+

224
Q

precipitants to addisonian crisis

A

infection
trauma
surgery
missed meds

225
Q

Mx of addisonian crisis

A

check ECG, calcium gluconate for ^K+
fluid bolus
hydrocort

ABx if suspected infection
glucose if hypo
fludrocortisone
treat the cause

226
Q

longterm Mx of addisons disease including non-medical

A 
hydrocort
fludrocort
steroid bracelet/ steroid card
double dose in febrile illness
IM hydrocort for emergency
227
Q

what is the commonest cause for hyperaldosteronism?

give 2 other causes

A

conn’s syndrome (aldosterone-secreting adenoma)

bilateral adrenocortical hyperplasia
adrenal carcinoma

(POOR RENAL PERFUSION > HIGH RENIN)
renal artery stenosis
CCF
diuretics
liver failure
228
Q

Mx of conn’s

A

spironalactone pre-op

adrenalectomy

229
Q

what is a phaeochromocytoma and where are they usually found

A

catecholamine-producing tumour

adrenal medulla

230
Q

what is the classic triad of phaeochromocytoma

A

episodic headache
sweating
tachycardia
[+/- normal/high/low BP]

231
Q

tests in phaeochromocytoma

A

24 hr urine metanephrines/metadrenaline
FBC [^WCC]
abdo CT/MRI
chromaffin-seeking isotope scan

232
Q

phaeochromocytoma Tx

A

alpha blockade with phenoxybenzamine, then B blocker

then surgery

233
Q

precipitants for hypertensive crisis in phaeochromocytoma

A 
stress
abdo palpation
childbirth
GA
contrast
234
Q

Sx, signs and ECG findings for hypertensive crisis in phaeochromocytoma

A

Sx: pulsing heachache, feels “about to die”

signs: pallor, HTN, pyrexia

ECG: signs of LVF, ST elevation, VT

235
Q

Mx of for hypertensive crisis in phaeochromocytoma

A

alpha then beta blockade

236
Q

Ix in hyperaldosteronism

A 
U+E - low K+
low renin
high aldosterone
CT/MRI adrenal to localise cause
adrenal vein sampling
237
Q

causes of hirsutism

A 
familial
idiopathic
PCOS
ovarian CA
adrenal hyperplasia
cushings
adrenal CA
drugs [steroids]
238
Q

Ix in hirsutism

A

US ovaries

bloods: testosterone, sex hormone binding globulin, LH/FSH, TSH, lipids

239
Q

Mx of hirsutism

A 
weight loss
shaving/waxing/electorlysis/bleach
eflornithine cream
COCP
metformin
spironalactone
clomifene (ovulation)
240
Q

causes of gynaecomastia

A 
hypogonadism
liver cirrhosis
hyperthyroid
oestrogen secreting tumour [testicular]
drugs: e.g. spironalactone, digoxin
241
Q

male hypogonadism features

A 
small testes 
low libido
ED
pubic hair loss
loss of muscle bulk
^fat
gynaecomastia
osteoporosis
low mood
242
Q

Mx of gynaecomastia if unable to remove or stop the cause

A

consider testosterone and tamoxifen (oestrogen blocker)

243
Q

causes of primary hypogonadism

A 
trauma/torsion
chemo/radio
orchitis e.g. mumps
renal failure
liver cirrhosis
excess alcohol
Klinefelters syndrome [XXY]
244
Q

causes of secondary hypogonadism

A 
hypopituitarism [low FSH/LH]
prolactinoma
kallmans syndome
systemic disease (DM, COPD, HIV)
age
245
Q

contraindications to giving hypogonadism pt testosterone. And what test might you want to monitor due to risk of giving testosterone?

A

previous prostate, liver or breast CA
hypercalcaemia
nephrosis
polycythaemia

monitor PSA

246
Q

what are the levels of causes of hypopituitarism?

A

hypothalamus
pituitary stalk
pituitary

247
Q

what tests might you do for hypopituitarism

A

LH, FSH, testosterone, oestradiol, TSH, T4, prolactin, IGF-1, Cortisol
U+E, Hb
synacthen test
MRI hypothalamus/ pituitary

248
Q

Mx of hypopituitarism

A 
hydrocort 1st
then replace the other hormones:
thyroxine
oestrogen/testosterone
somatotrophin [mimics GH]
gonadotrophin therapy for fertility

treat the cause

249
Q

features of local pressure of a pituitary tumour

A

headache
visual field defects [bilat temp hem]
cranial nerve palsy
diabetes insipidus

250
Q

ix.s in pituitary tumour

A 
MRI
hormone levels
assessment of visual fields
short synacthen test
GTT [acromeg]
251
Q

Mx of pituitary tumour including post-Mx considerations

A

surgery
hormone replacement
radiotherapy
discuss fertility

252
Q

acute onset headache, meningism, low GCS, visual field defect, opthalmoplegia, differentials?

A

pituitary apoplexy

SAH

253
Q

Mx of pituitary apoplexy

A

hydrocortisone
cabergoline if prolactinoma
surgery

254
Q

Sx of acromegaly

A 
peripheral neuropathy
low libido
headache
^sweating
snoring
arthralgia
backache
rings/shoes don't fit
change in facial appearance
obstructive sleep apnoea
255
Q

signs of acromegaly

A 
hand and feet growth
coarsening of facial features
nose enlargement
big supraorbital ridges
macroglossia
spaced teeth
thick oily skin, skin tags
puffy lips, eyelids, skin
carpal tunnel signs 
skin darkening
macrognathia/prognathism
(acral [distal] + soft tissue overgrowth)
256
Q

complications/ co-morbidities of acromegaly

A 
HTN
LVH/ CCF
cardiomyopathy
arrhythmias
IHD
stroke
impaired glucose tolerance/ DM/ DKA
colon CA
sleep apnoea
athritis
257
Q

tests in acromegaly

A 
high glucose
high Ca2+ and phosphate
OGTT
MRI pituitary
visual fields/acuity
ECG/echo
old photos
258
Q

when is GH increased physiologically

A

stress
pregnancy
puberty
sleep

259
Q

Mx of acromegaly

A 
transsphenoidal surgery excision
octreotide [somatostain analogue]
pegvisomant [GH antagonist]
bromocriptine [dopamine agonists]
radiotherapy
260
Q

what causes diabetes insipidus

A

reduced ADH secretion from post. pituitary (CRANIAL)
OR
impaired response of the kidneys to ADH (NEPHROTIC)

261
Q

Sx of diabetes insipidus

A

POLYURIA
polydipsia
dehydration
hypernat Sx: lethargy, weakness, confusion, coma, fits, irritable

262
Q

causes of cranial diabetes insipidus

A 
idiopathic
tumour
congenital
trauma
surgical removal of pituitary
autoimmune
sarcoid
haemorrhage
meningoencephalitis
263
Q

cause of nephrotic diabetes insipidus

A 
inherited
metabolic: low K+, high Ca2+
lithium
CKD
post-obstructive uropathy
264
Q

tests in diabetes insipidus

A 
U+E, Ca2+
glucose to exclude DM
serum and urine osmolality
water deprivation test
MRI pituitary
test anterior pituitary Fn. e.g. hormones, synacthen
265
Q

differntials for diabetes insipidus

A

DM
lithium
diuretics

266
Q

Tx of cranial diabetes insipidus

A

IV fluids to keep up with losses

desmopressin [synthetic ADH]

267
Q

Tx of nephrogenic diabetes insipidus

A

IV fluids to keep up with losses
treat cause
bendroflumethiazide
NSAIDs

268
Q

what factors are needed for a diagnisis of SIADH?

in the abscence of what factors?

A

concentrated urine [^Na+ and osmolality]
hyponatraemia
low plasma osmolality

in the absence of diuretics, oedema, hypovolaemia

269
Q

name 4 causes of SIADH

A 
malignancy e.g. SCLC
CNS e.g. stroke
Chest e.g. pneumonia
drugs e.g.opiates
trauma
major abdo/thoracic surgery
270
Q

Tx of SIADH

A

treat cause
fluid restrict
salt
loop diuretic

Grace Phase 2 (9 decks)

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