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Junior blocks > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

What is the pathophysiology of diabetes type 1?

A

Autoimmune destruction of pancreatic beta islet cells. Therefore insulin deficient/absent.

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2
Q

What is significant about the immunology of patients with type 1 diabetes?

A

90% Associated with HLA DR3/4 which means a high risk of other autoimmune diseases

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3
Q

What is the pathophysiology of diabetes type 2?

A

Progressive reduced relative insulin production due to high demand for insulin - From high levels of adipose tissue or prolonged exposure to high blood glucose.

Then reduced insulin insensitivity as prolonged exposure causes Insulin receptors to upregulate the threshold for response.

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4
Q

What are the risk factors for diabetes type 2? 3x unmodifiable and and 3x modifiable

A

Asian
Male
Age

Obesity
Diet - calories and sugar
Alcohol

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5
Q

What are the criteria for diagnosis of diabetes?

A
  1. Symptoms (polyuria, polydipsia, lethargy, weight loss, thrush, vision changes) plus 1 raised glucose (fasting over 7 and random over 11)
  2. 2 separate raised glucose
  3. Hba1c over 6.5%
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6
Q

What is the difference between impaired glucose tolerance and impaired fasting glucose? Which is more predictive of developing into full blown diabetes?

A

Both demonstrate pre diabetes.
Fasting - over 6 but not quite 7
Tolerance - (after 2hrs) over 7.8 but not quite 11

Tolerance more predictive but both useful

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7
Q

What are some non lifestyle causes of diabetes?

A

Pregnancy

Steroids
Cushings
Acromegaly
Hyperthyroidism

Pancreatitis
Pancreatic surgery
CF

Antipsychotics
Thiazides

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8
Q

What are the differences between type 1 and type 2 diabetes?

A

Cause - autoimmune versus progressive insensitivity
Age - pre-puberty versus older
Genetics - HLA d3/4 versus no HLA link
Presentation - weight loss/DKa versus complications e.g. MI

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9
Q

What is included in a prediabetic/metabolic syndrome care plan?

A 
Group education programs 
Smoking cessation
Dietary advice 
Statin
Bp control
Foot care
Retinal screening
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10
Q

What is the treatment for type 1 diabetes?

A 
Insulin
Dafne course to help adjustment 
Monitor hba1c
Specialist nurse
Dietician 
Foot care
Retinal screening 
Bp 
Statin
Smoking cessation
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11
Q

What is the treatment for type 2 diabetes?

A

Metformin
Then add gliclazide (sulphonylurea)
Then swap one for sitagliptin (DPP-4) or exenatide (GLP analogue)
Then consider insulin

Dietician
Specialist nurse
Foot care
Retinal screening
Bp 
Statin
Smoking cessation
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12
Q

What should be checked in a patient with established diabetes?

A

Injection sites - infection/lipohypertrophy
Vascular - pulses, diet, smoking, hypertension
Nephropathy- urine dip for microalbuminuria (-ve protein but increased albumin:creatinine)
Fundoscopy
Feet - ulcers, pulses, sensation
Episodes of hypos

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13
Q

What would you see on fundoscopy in progressive diabetic retinopathy?

A
  1. Micro aneurysms and hard exudates
  2. Pre proliferative - haemorrhages, venous beading and cotton wool spots (infarcts)
  3. Proliferative - haemorrhages and new vessel formation. These can can bleed and fibrose and detach the retina
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14
Q

What are the signs of diabetic ischaemia in the feet?

A

Absent dorsalis pedis and posterior tibialis pulse

Leads to punched out painless arterial ulcer (+- infection)

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15
Q

What are the signs of diabetic neuropathy in the feet?

A

Glove and stocking loss of sensation
Absent ankle jerks
Deformity - pes cavus, claw toes, loss of transverse arch, rocker bottom sole

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16
Q

How would you manage a diabetic foot?

A

Assess

  1. Sensation loss
  2. Ischaemia via pulses and Doppler
  3. Bony deformity- Charcot may require X-ray
  4. Infection- swabs
  5. Regular chiropodist, therapeutic shoes
  6. Consider surgery
  7. IV abx for cellulitis
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17
Q

What are the indications for surgery in a diabetic foot?

A 
Abcess - drain
Spreading anaerobic infection
Wet Gangrene 
Rest pain 
Septic arthritis
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18
Q

What is the difference between wet and dry gangrene?

A

Gangrene is visible necrosis

Wet is caused by venous occlusion, packed with blood, oedematous, has undefined borders, full of bacteria, backs up and spreads.

Dry is caused by arterial occlusion and very little blood, shrunken, defined edges, not too much bacteria, autoamputates.

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19
Q

What types of neuropathy are associated with diabetes?

A

Autonomic - eg gastroparesis, postural hypotension, erectile dysfunction

Symmetric sensory peripheral neuropathy- glove and stocking

Mononeuritis multiplex- e.g. Single cranial nerve

Amyotrophy - wasting of quads

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20
Q

What is the mechanism of DKA?

A

Acute increase in demand for glucose by the cells leads to an acute deficiency in insulin
Cells resort to using ketones for energy. This is inefficient and produces acetone as a byproduct.
Acetone is acidic which causes acidosis with an anion gap
Hyperglycaemia causes water to be drawn out of cells - dehydration and dilutional hyponatraemia

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21
Q

What are the signs of dka?

A 
Vomiting and abdo pain
Drowsy
Dehydration 
Ketotic breath
Kussmaul breathing
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22
Q

What might trigger a dka?

A 
Infection
Surgery
MI
Pancreatitis
Chemo
Antipsychotics
Insulin non compliance
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23
Q

Why is there hyponatraemia in dka?

A

Osmolar pressure from hyperglycaemia draws water out of cells and dilutes the Na

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24
Q

Why is there hyperkalaemia in dka?

A

Acute loss of insulin relative to demand. Less k going into cells. May need to replace as insulin is given.

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25
Q

Give some causes of a raised wcc.

A 
Infection
Dka
Allergy
Steroids
Leukaemia
Rheumatoid arthritis
UC/crohns
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26
Q

Which drug has a risk of lactic acidosis?

A

Metformin

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27
Q

What is the mechanism of HONK?

A

Hyperglycaemic osmolar non ketotic coma
Type 2 acutely high glucose (above 35)
No ketones so no acidosis, but huge dehydration and dilution of salts. Very Thrombotic state.

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28
Q

What are the skin manifestations of diabetes?

A
  1. Ulcers
  2. Necrobiosis lipoidica (shiny yellowish area on shin with telangiectasia)
  3. Acanthosis nigricans (pigmented thickened skin in folds eg neck axilla groin)
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29
Q

What are the risk factors for hypothyroidism?

A

High lipids
Diabetes
Addissons
Radioactive iodine for thyroid cancer

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30
Q

What are the risk factors for hyperthyroidism?

A 
AF
Amiodarone
Lithium
Downs /Turners
Pregnancy
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31
Q

What are the symptoms of hypothyroidism?

A 
Tired
Weight gain
Cold
Dry skin
Depression
Menorrhagia 
Cramps
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32
Q

What are the signs of hypothyroidism?

A 
Bradycardia
Reflexes slow
Ataxia - cerebellar
Dry skin and hair
Yawning
Cold 
Ascites and non pitting oedema
Round 
Defeated
Ileus
Congestive heart failure

Goitre
Pleural effusions

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33
Q

What are the symptoms of hyperthyroidism?

A 
Restless 
Weight loss
Palpitations 
Sweating
Amenorrhea
Anxious
Hot
34
Q

What are the signs of hyperthyroidism?

A 
Clubbing
Palmar erythema
Tremor
AF / tachycardia 
Eye signs 
Brisk reflexes
Proximal myopathy
Pretibial myxoedema
35
Q

What are the eye signs of hyperthyroidism?

A

Photophobia
Diplopia

Exopthalmos
Proptosis
Eyelid retraction
Opthalmoplegia

36
Q

What is the differential for a neck lump?

A 
Goitre - hyper or hypothyroidism 
Thyroglossal cyst
Branchial cyst
Sebaceous cyst
Lipoma
Lymphadenopathy
37
Q

How would you examine a neck lump?

A

Inspect
Swallow - goitre moves up
Stick out tongue - thyroglossal cyst moves up

Palpation
Nodular or diffuse
Fluctuance - lipoma
Feel below - if not retrosternal extension

Auscultation
Bruit - graves

38
Q

What is the difference between t3 and t4?

A

T4 is thyroxine
Les active
Longer half life
Direct release from thyroid

T3 is mostly converted peripherally by deiodinase.

39
Q

How is thyroxine synthesised?

A
  1. Iodine uptake into follicle cell by channel sensitive to tsh
  2. Activated and bound to tyrosine on thyroglobulin by thyroid peroxidase
  3. Stored as colloid in the middle of follicle
  4. Endocytosis back into cell
  5. Lysozyme release from thyroglobulin which is recycled
  6. Diffusion into blood
  7. Circulates bound to thyroid binding globulins (tbgs)
  8. Some is peripherally converted to t3 by deiodinase
40
Q

What are the causes of a goitre?

A

Physiological (supply/demand) - iodine deficiency, pregnancy, puberty
Subacute viral thyroiditis (painful)
Nodular - benign or adenoma/carcinoma
Autoimmune - graves or hashimotos

41
Q

What is the diagnosis if thyroid function test results are as follows?
Tsh high
T4 low

A

Primary hypothyroidism

The hypothalamic- pituitary is producing trh and tsh but the thyroid is not responding appropriately

42
Q

What is the diagnosis if thyroid function test results are as follows?

Tsh high
T4 normal

A

Treated hypothyroidism

43
Q

What is the diagnosis if thyroid function test results are as follows?

Tsh low
T4 high

A

Primary hyperthyroidism

The thyroid is producing too much, and the hypothalamus/pituitary are responding appropriately via negative feedback.

44
Q

What is the diagnosis if thyroid function test results are as follows?

Tsh low
T4 normal

A

Subclinical hyperthyroidism

45
Q

What is the diagnosis if thyroid function test results are as follows?

Tsh low
T4 low

A

Problem with hypothalamus/pituitary because thyroid is responding appropriately

Or sick euthyroid

46
Q

Which antibodies are positive in Graves’ disease?

A

Anti tsh receptor stimulating antibodies

gRaveS - anti TRS

47
Q

Which antibodies are positive in hashimotos?

A

Anti thyroid peroxidase antibodies

hashimOtos - anti TPO

48
Q

How does thyroxine act on cells?

A

Increases cell metabolism at the nuclear receptors

Increases effects of catecholamines

49
Q

Which nerve might be damaged during thyroid surgery?

A

Recurrent laryngeal

52
Q

Which hormones are produced by the anterior pituitary?

A

TSH
ACTH
GH
FSH AND LH

53
Q

Which hormones are produced by the posterior pituitary?

A

ADH

Oxytocin

54
Q

Name the layers of the adrenal glands and the hormones produced there

A

Zona glomerulosa - aldosterone
Zona fasiculata - cortisol
Zona reticularis - androgens
Medulla - catecholamines

55
Q

What are the metabolic functions of cortisol?

A

Insulin resistance
Gluconeogenesis
Protein catabolism
Increased bone turnover

56
Q

What are the cvs functions of cortisol?

A

Increase bp
Fluid retention
Increase Na

57
Q

What are the cns functions of cortisol?

A

Increase appetite

Increase gastric acid

58
Q

What is the action of cortisol on skin?

A

Decrease collagen

59
Q

What tests would you order if you suspected Cushings disease? What results would you expect for true cushings disease?

A

True cushings is a pituitary adenoma secreting excess ACTH.

Blood cortisol at 11pm - high
ACTH - high (ACTH dependent)

Dexamethasone suppression - suppressed

60
Q

What would be the diagnosis if -

Blood cortisol high even at 11pm
ACTH high

Dexamethasone suppression- not suppressed

A

Ectopic ACTH secreting adenoma

61
Q

What would be the diagnosis if -

Blood cortisol high even at 11pm
ACTH high

Dexamethasone suppression- suppressed

A

Pituitary adenoma secreting ACTH

Cushings disease

62
Q

What would be the diagnosis if -

Blood cortisol high even at 11pm
ACTH low

A

ACTH independent cushings

So adrenal adenoma or steroids.

63
Q

What are the causes of pseudo cushings? What would the blood cortisol result be?

A

Alcohol
Depression
Obesity
Steroids

Equivocal blood cortisol

64
Q

What tests would you order if you suspected addisons disease? What results would you expect?

A

Primary adrenal failure

Blood cortisol - low even at 8am
U and e - low Na high k (mineralocorticoid aldosterone from zona glomerulosa also effected)
Glucose - low

Short synacthen - cortisol doesn’t rise after 30 mins.

65
Q

How would you treat a dka?

A

0.9% saline
Then insulin 0.1u/kg/hr until
Blood glucose , bicarbonate , ph and anion gap are back to normal.

66
Q

What are the targets for hba1c on 1) Metformin 2) sulphonylurea

When would you add a second drug?

A

1) 6.5%
2) 7%

Add a second drug if they hit 7.5%

67
Q

What is the first line hypertension drug in diabetes?

A

ACE inhibitor

68
Q

What are the side effects of Metformin?

A

GI disturbance

Lactic acidosis

69
Q

What are the side effects of sulphonylureas?

A

Risk of hypo
Weight gain
SIADH
liver damage

70
Q

What are the side effects of pioglitazone?

A

Fluid retention- contraindicated in heart failure
Weight gain
Liver damage
Bladder cancer

71
Q

What are the side effects of SGLT 2 inhibitors?

A

Uti

Thrush

72
Q

What might cause a painful goitre?

A

De quervains subacute thyroiditis

73
Q

What might cause sick euthyroid syndrome?

A

Low everything
General illness/infection/surgery.
Goes away on its own

74
Q

What is the genetic profile of MODY?

A

Autosomal dominant

Hnf alpha Or glucokinase genes

75
Q

What is the main criteria for prescribing exenatide?

A

BMI over 35

76
Q

What is the blood pressure target for :

  1. Primary hypertension
  2. Diabetic no organ damage
  3. Diabetic with evidence of end organ damage
A
  1. 140/90
  2. 140/80
  3. 130/80
77
Q

What is Sheehans syndrome?

A

Hypopituitary after blood loss inbirth

78
Q

What are the signs of an addissonian crisis? What causes it?

A 
Shock 
Low Na
High k
Low glucose
High ca
Acidosis

Caused by sudden stop of steroids

79
Q

What is the first line treatment for diabetic neuropathy?

A

Duloxetine/amytriptilline

Gastroparesis - metoclopramide, domperidone

80
Q

What is the mechanism of action of carbimazole?

A

blocks thyroid peroxidase from coupling and iodinating the tyrosine residues on thyroglobulin → reducing thyroid hormone production

81
Q

What are the side effects of carbimazole?

A

Rash and pruritis - treat with antihistamine
Agranulocytosis and neutropenia

Crosses the placenta, but may be used in low doses during pregnancy

82
Q

What is the test for acromegaly?

A

Oral glucose tolerance test with GH measurement

83
Q

Why does a goitre move up with a swallow?

A

Thyroid is attached to the larynx by the pretracheal fascia.
(Thyroglossal cyst will also move up)

84
Q

What are the options for management of hyperthyroidism?

A

Carbimazole (Block and replace)
Propylthiouracil

Radioiodine
Thyroidectomy

Junior blocks (12 decks)

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