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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
Give some causes of a raised wcc.
``` Infection Dka Allergy Steroids Leukaemia Rheumatoid arthritis UC/crohns ```
26
Which drug has a risk of lactic acidosis?
Metformin
27
What is the mechanism of HONK?
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.
28
What are the skin manifestations of diabetes?
1. Ulcers 2. Necrobiosis lipoidica (shiny yellowish area on shin with telangiectasia) 3. Acanthosis nigricans (pigmented thickened skin in folds eg neck axilla groin)
29
What are the risk factors for hypothyroidism?
High lipids Diabetes Addissons Radioactive iodine for thyroid cancer
30
What are the risk factors for hyperthyroidism?
``` AF Amiodarone Lithium Downs /Turners Pregnancy ```
31
What are the symptoms of hypothyroidism?
``` Tired Weight gain Cold Dry skin Depression Menorrhagia Cramps ```
32
What are the signs of hypothyroidism?
``` 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
33
What are the symptoms of hyperthyroidism?
``` Restless Weight loss Palpitations Sweating Amenorrhea Anxious Hot ```
34
What are the signs of hyperthyroidism?
``` Clubbing Palmar erythema Tremor AF / tachycardia Eye signs Brisk reflexes Proximal myopathy Pretibial myxoedema ```
35
What are the eye signs of hyperthyroidism?
Photophobia Diplopia Exopthalmos Proptosis Eyelid retraction Opthalmoplegia
36
What is the differential for a neck lump?
``` Goitre - hyper or hypothyroidism Thyroglossal cyst Branchial cyst Sebaceous cyst Lipoma Lymphadenopathy ```
37
How would you examine a neck lump?
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
What is the difference between t3 and t4?
T4 is thyroxine Les active Longer half life Direct release from thyroid T3 is mostly converted peripherally by deiodinase.
39
How is thyroxine synthesised?
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
What are the causes of a goitre?
Physiological (supply/demand) - iodine deficiency, pregnancy, puberty Subacute viral thyroiditis (painful) Nodular - benign or adenoma/carcinoma Autoimmune - graves or hashimotos
41
What is the diagnosis if thyroid function test results are as follows? Tsh high T4 low
Primary hypothyroidism The hypothalamic- pituitary is producing trh and tsh but the thyroid is not responding appropriately
42
What is the diagnosis if thyroid function test results are as follows? Tsh high T4 normal
Treated hypothyroidism
43
What is the diagnosis if thyroid function test results are as follows? Tsh low T4 high
Primary hyperthyroidism The thyroid is producing too much, and the hypothalamus/pituitary are responding appropriately via negative feedback.
44
What is the diagnosis if thyroid function test results are as follows? Tsh low T4 normal
Subclinical hyperthyroidism
45
What is the diagnosis if thyroid function test results are as follows? Tsh low T4 low
Problem with hypothalamus/pituitary because thyroid is responding appropriately Or sick euthyroid
46
Which antibodies are positive in Graves' disease?
Anti tsh receptor stimulating antibodies gRaveS - anti TRS
47
Which antibodies are positive in hashimotos?
Anti thyroid peroxidase antibodies hashimOtos - anti TPO
48
How does thyroxine act on cells?
Increases cell metabolism at the nuclear receptors | Increases effects of catecholamines
49
Which nerve might be damaged during thyroid surgery?
Recurrent laryngeal
52
Which hormones are produced by the anterior pituitary?
TSH ACTH GH FSH AND LH
53
Which hormones are produced by the posterior pituitary?
ADH | Oxytocin
54
Name the layers of the adrenal glands and the hormones produced there
Zona glomerulosa - aldosterone Zona fasiculata - cortisol Zona reticularis - androgens Medulla - catecholamines
55
What are the metabolic functions of cortisol?
Insulin resistance Gluconeogenesis Protein catabolism Increased bone turnover
56
What are the cvs functions of cortisol?
Increase bp Fluid retention Increase Na
57
What are the cns functions of cortisol?
Increase appetite | Increase gastric acid
58
What is the action of cortisol on skin?
Decrease collagen
59
What tests would you order if you suspected Cushings disease? What results would you expect for true cushings disease?
True cushings is a pituitary adenoma secreting excess ACTH. Blood cortisol at 11pm - high ACTH - high (ACTH dependent) Dexamethasone suppression - suppressed
60
What would be the diagnosis if - Blood cortisol high even at 11pm ACTH high Dexamethasone suppression- not suppressed
Ectopic ACTH secreting adenoma
61
What would be the diagnosis if - Blood cortisol high even at 11pm ACTH high Dexamethasone suppression- suppressed
Pituitary adenoma secreting ACTH | Cushings disease
62
What would be the diagnosis if - Blood cortisol high even at 11pm ACTH low
ACTH independent cushings So adrenal adenoma or steroids.
63
What are the causes of pseudo cushings? What would the blood cortisol result be?
Alcohol Depression Obesity Steroids Equivocal blood cortisol
64
What tests would you order if you suspected addisons disease? What results would you expect?
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
How would you treat a dka?
0.9% saline Then insulin 0.1u/kg/hr until Blood glucose , bicarbonate , ph and anion gap are back to normal.
66
What are the targets for hba1c on 1) Metformin 2) sulphonylurea When would you add a second drug?
1) 6.5% 2) 7% Add a second drug if they hit 7.5%
67
What is the first line hypertension drug in diabetes?
ACE inhibitor
68
What are the side effects of Metformin?
GI disturbance | Lactic acidosis
69
What are the side effects of sulphonylureas?
Risk of hypo Weight gain SIADH liver damage
70
What are the side effects of pioglitazone?
Fluid retention- contraindicated in heart failure Weight gain Liver damage Bladder cancer
71
What are the side effects of SGLT 2 inhibitors?
Uti | Thrush
72
What might cause a painful goitre?
De quervains subacute thyroiditis
73
What might cause sick euthyroid syndrome?
Low everything General illness/infection/surgery. Goes away on its own
74
What is the genetic profile of MODY?
Autosomal dominant | Hnf alpha Or glucokinase genes
75
What is the main criteria for prescribing exenatide?
BMI over 35
76
What is the blood pressure target for : 1. Primary hypertension 2. Diabetic no organ damage 3. Diabetic with evidence of end organ damage
1. 140/90 2. 140/80 3. 130/80
77
What is Sheehans syndrome?
Hypopituitary after blood loss inbirth
78
What are the signs of an addissonian crisis? What causes it?
``` Shock Low Na High k Low glucose High ca Acidosis ``` Caused by sudden stop of steroids
79
What is the first line treatment for diabetic neuropathy?
Duloxetine/amytriptilline Gastroparesis - metoclopramide, domperidone
80
What is the mechanism of action of carbimazole?
blocks thyroid peroxidase from coupling and iodinating the tyrosine residues on thyroglobulin → reducing thyroid hormone production
81
What are the side effects of carbimazole?
Rash and pruritis - treat with antihistamine Agranulocytosis and neutropenia Crosses the placenta, but may be used in low doses during pregnancy
82
What is the test for acromegaly?
Oral glucose tolerance test with GH measurement
83
Why does a goitre move up with a swallow?
Thyroid is attached to the larynx by the pretracheal fascia. (Thyroglossal cyst will also move up)
84
What are the options for management of hyperthyroidism?
Carbimazole (Block and replace) Propylthiouracil Radioiodine Thyroidectomy

Junior blocks (12 decks)

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