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Clinical - Rosie > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

What is the difference between a functioning and non-functioning tumor?

A 
Non-functioning = the tumor doesn't produce any hormones
Functioning = the tumor produces hormones.
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2
Q

What is a prolactinoma? What are the symptoms

A

Prolactin-producing tumor.

Women : absent periods, infertility, galactorrhoea.

Men - breasts, erectile dysfunction.

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3
Q

What causes acromegaly?

A

Excess growth hormone usually due to a benign tumor.

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4
Q

What is the clinical presentation of acromegaly?

A

Interdental separation, large nose, large lips, hands and feet get bigger.
Very slow presentation - occurs over months and years.
In children get gigantism
In adults, the bones are fixed and will not grow more.

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5
Q

How is acromegaly treated?

A

The first line treatment is usually surgical removal of the tumor.
If surgery is not possible can use somatostatin analogs - this stops all hormones being produced, this causes a lot of problems is very expensive!

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6
Q

What is one of the biggest issues with somatostatin analogs?

A

Can cause diabetes as stops insulin production.

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7
Q

What signs are associated with cushings DISEASE?

A

Bruising, thin skin, central obesity, peripheral wasting and myopathy, hypertension, diabetes, low potassium, moon face and buffalo hump, gastric ulcers, psychological illness.

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8
Q

How is cushings DISEASE (not syndrome) treated?

A

Metyrapone - stops hydrocortisone synthesis. Goal is to achieve a normal(ish) cortisol prior to surgery to aid tissue healing and reduce chances of infection from surgery.

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9
Q

What are the side effects of testosterone replacement?

A

Polycythaemia (red blood stimulation, leads to raised hematocrit and Hb)
Prostatism/prostate cancer
Mood swings - aggression

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10
Q

What monitoring is required with testosterone replacement therapy?

A

LFTs, Hb, PSA, and testosterone levels.

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11
Q

Why isn’t hydrocortisone given late a night?

A

Can disrupt the sleep cycle - want to closely mimic the natural diurnal rhythm.

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12
Q

What patients do we see taking hydrocortisone?

A

Addisons

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13
Q

Why is it important patients are properly counselled on ‘sick day rules’ with hydrocortisone?

A

Can go into adrenal crisis

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14
Q

How should the hydrocortisone dose be adjusted if a patient has gastroenteritis?

A

Double dose

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15
Q

How should the hydrocortisone dose be adjusted if a patient goes on a long haul flight?

A

Double dose

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16
Q

In addition to their regular hydrocortisone, what else should patients with addisons be supplied with?

A

IM hydrocortisone for emergencies

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17
Q

What is ADHD? what happens if you dont have a enough of it?

A

Lack of ADHD causes diabetes insipidius - means you cant concentrate your urine. Patient has to drink lots to avoid dehydration

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18
Q

What is desmopressin?

A

Acts on kidney collecting ducts and tubules (ADH) to allow water resorption into the blood stream. Used to treat diabetes insipidus

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19
Q

How is desmopressin dosed?

A

Managed according to symptoms and what is acceptable for that patient e.g. ask them how often they are going to the toilet.

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20
Q

What thyroid function tests would be indicative with hyperthryoidism?

A

High T3 and T4

Low TSH

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21
Q

What is the active thyroid hormone?

A

T3

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22
Q

How is hyperthyroidism managed?

A

Carbimazole and a BB may be given to quickly relieve symptoms/control tremors. Once thyroid levels are undercontrol can gradually reduce the BB

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23
Q

What important counselling must be given with carbimazole?

A

Patients should be informed to look out for sore throat or fever, flu like symptoms or mouth ulcers and report this to the doctor immediatley

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24
Q

What are the two ways carbimazole can be given?

A

Titration regimen or block and replace

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25
Q

What is meant by titrating carbimazole?

A

Carbimazole can be given in reducing doses, starting with a dose of 15-40mg daily. Serum T4 and TSH are monitored every 4-6 weeks and doses reduced accordingly. Maintenance doses of 5-15mg per day and monitoring every 12 weeks.

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26
Q

What is meant by carbimazole block and replace regimen?

A

Use high doses 40-60mg to completely shut down the thyroid and block hormone production. Then replace with around 150mcg of levothyroxine per day.

27
Q

What are the advantages of the carbimazole block and replace regimen?

A

under/over treatment is avoided
tends to work quicker
generally preferred by patients and doctors

28
Q

Name two drugs that can induce thyroid disease

A

Amiodarone - can cause both hypo and hyper

Lithium - hypothyroidism by unknown mechanism

29
Q

Who should we be thyroid screening?

A

Patients taking amiodarone or lithium
Patients with diabetes
Patients with AF - AF is a symptom of hyper and so might be causing it
Patients with hyperlipidaemia - hypothyroidism can raise cholesterol
Patients with downs syndrome, addisons disease

30
Q

How can hypothyroidism alter cholesterol levels?

A

Can raise cholesterol

31
Q

What is a common differential diagnosis for abnormal thryoid function

A

Cardiovascular disease

32
Q

What is adrenal insufficiency?

A

Is the clinical manifestation of deficient production or action of glucocorticoids, with or without deficiency also in mineralocorticoids and adrenal androgens.

33
Q

What is addisons disease?

A

Lack of cortico and mineralocortico steroids, mainly due to an autoimmune response.

34
Q

What are the signs and symptoms of addisons disease?

A

Anorexia, weight loss, weakness, dizziniess, low BP, arthralgia, low Na, high K. Salt loss leads to salt cravings. Nausea and vomiting and diarrhoea common.

Hyperpigmentation of skin and mucous membranes is a characteristic feature of addisons (due to increased ACTH)

35
Q

How can we treat addisons?

A

Mineral corticoid replacement - fludrocortisone

Glucocorticoid replacement - hydrocortisone

36
Q

What is a synacthen test?

A

During the synacthen test you are given a chemical called tetrcosactide (chemical copy of ACTH) IM/IV. Then measure the level of cortisol @30mins and 60 mins. A serum level of >500 is normal, if levels are low then suggests a problem with the adrenal glands.

37
Q

What is the management of an acute adrenal crisis?

A

Dial 999
Parental hydrocortisone
IV fluids

38
Q

How should patients with adrenal insufficiency at risk of osetoporosis be managed?

A

Calcium and vitamin D intake should be optimized, non-weight bearing exercises, well balanced diet encouraged.

39
Q

How are thyroid hormones produced and regulated?

A

Hypothalamus produces TRH
Anterior pituitary produces thyroid stimulating hormone (TSH)
The thyroid gland produces thyroid hormones T3 and T4

Negative feedback onto the the anterior pituitary and hypothalamus.

40
Q

How can correcting hypothyoridism impact on a patients antidiabetic medicines?

A

Correction of hypothyroidism can increase insulin or oral antidiabetic requirements.

41
Q

How can correcting hypothyroidism impact on a patients oral anticoagulant therapy?

A

Hypothyroidism decreases the metabolism of clotting factors. Therefore, patients taking an anticoagulant may have been taking a higher dose than normally required to achieve their target INR. If such a patient starts treatmetn for hypothyroidism his/her dose of anticoagulant may need to be reduced.

42
Q

What is levothyroxine?

A

Synthetic form of thyroxine T4

43
Q

How are levothyroxine doses initiated and titrated?

A

Dosing depends on weight, age and sex. Men generally require 25-50ug more leveothyroxine than women pe r day, and requirements fall during the 7th and 8th decades of life.

Patients are usually started on 50-100ug daily and most patients will require upward titration in steps of 25-50ug until a maintenance dose is reached.

44
Q

How should patients taking levothyroxine be monitored?

A

4-6 weeks after starting treatment or changing dose, serum TSH levels should be assessed to monitor the need for further dose alteration. Patients should then have their thyroid function monitored annually once their treatment is stabilised.

45
Q

How do we know if a patient is taking the correct leveothyroxine dose? (I.e. so they are euthyroid)

A

If the dose is too high the pituitary gland reduces TSH secretion and low TSH level will be seen; conversely, a dose that is too low will result in a high TSH level.

46
Q

How does carbimazole and propylthiouracil work?

A

Impair binding of iodide to thyroglobulin and therefore, reduce synthesis of thyroid hormones.

Unlike carbimazole, propyluracil also inhibits conversion of T4 to T3

47
Q

How it the dose of thioamides decided?

A

The optimal dose depends upon factors such as the size of goitre (if present) and the degree of hyperthyroidism.

48
Q

Why is carbimazole the treatment of choice for hyperthyroidism?

A

Compared with propylthiouracil it reverses hyperthyroidism more quickly, has fewer side effects and is more likely to result in sucessful radioactive iodine treatment.

49
Q

What thioaminde should be used in pregnancy?

A

Thionamides carry a small risk of birth defects when given to pregnant women but the risk is lower wiht propylthiouracil, so this is the preferred drug for women who are pregnant.

50
Q

How is cushings syndrome diagnosed?

A

Diagnosis is usually based on medical history, lab tests and scans.

Tests may include the dexamethasone suppression test.

51
Q

What is the dexamethasone suppression test?

A

Dexamethasone suppresion tests are based on the ability of synthetic glucocorticoid to suppress ACTH and cortisol production. An overnight test is useful where there is low clinical suspicion of cushings syndrome. Oral dexamethasone 1mg is given at 11 pm and the cortisol levels measured at 9 am the next morning.

Levels below 50nnol/L indicate suppression and would be expected in healthy subjects. Higher levels indicate supression failure and cushings syndrome.

52
Q

How is cushings syndrome treated?

A

Cushings syndrome is usually reversible on reduction or withdrawal of steroid therpay . Treatment cessation must be graduaal in order to avoid adrenal crisis.

53
Q

Outline how you would counsel a patient taking steroids

A

Take your tablets as recommended - the first tablet of the day should be taken immediately on waking (before getting out of bed) and the evening dose no later than 6pm.

Carry a steroid card giving details of your current dose of steroid tablets.

Never stop taking your medicines suddenly.

Sick day rules - you we need to take twice the number of normal tablets.

54
Q

What is the main cause of cushings syndrome?

A

Excess exposure to exogenous glucocorticoids

55
Q

What are the three main hormones excreted by the thyroid?

A

T4, T3 and calcitonin

56
Q

How can amiodarone cause hypothyroidism?

A

It inhibits the conversion of T4 to T3 and can also directly inhibit thyroid gland function.

57
Q

How can amiodarone cause hyperthyroidism?

A

Can cause an inflammatory process that leads to increased release of thyroid hormones

58
Q

When should levothyroxine be taken?

A

Taken on an empty stomach - usually, advise to take it 30 mins before breakfast.

59
Q

How should levothyroxine doses be adjusted in patients with cardiac disease?

A

Use half the normal dose initially.

60
Q

How should constipation be managed in hypothyrodism patients?

A

Hypothyrodism may be causing the constipation so we would want to get this under control.

1st line is dietary and lifestyle advice. However, if this doesn’t help or if patient already follows this then we need a laxative:
1st line bulk forming laxtive such as laxido
2nd line osmotic or stimulant such as senna

61
Q

Low TSH levels is indicative of what?

A

Hyperthyroidism

62
Q

What BB might you use for symptom control in a patient with hyperthyroidism? What doses?

A

Propronolol will help control the symptomatic tachycardia and tremor.

10-40mg tds/qds (see thyrotoxicosis in BNF)
Doses adjusted according to patients symptoms and should be continued until the symptoms go away.

63
Q

Why might a DOAC be a preferred anticoagulant in patients taking levothyroxine?

A

Warfarin and levothyroxine interact - thyroid status will affect the response to wafarin. Weekly monitoring of iNR required until patient is euthyroid.

64
Q

How do we assess the severity of a CAP infection?

A

CURB65 score

Clinical - Rosie (16 decks)

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