Endocrinology Flashcards
Type 1 DM | Diagnosis & Management
Monitoring
Insulin deficiency, hyperglycaemia
Autoimmune destruction of beta-cells
Onset before puberty
Polyuria, polydipsia, glycosuria, ketonuria, weight loss, fatigue
Random glucose >11 mmol/L
HbA1c > 58
[Monitoring] Target 4-7 mmol/L HbA1c < 48 BG monitoring QDS Annual retinopathy screening Annual nephropathy screening; U&Es, A:Cr Annual diabetic foot screening CVD risk; HTN, lipids, BMI, smoking, diet
Manage concurrent illness; causes hyperglycaemia
Sick day rules
[Management]
Lifestyle; carbohydrate-counting, weight, alcohol hypo awareness, exercise, smoking cessation
Insulin regimen; BD/QDS SC injections
Continuous SC insulin pump
Variable rate (sliding scale)
DKA | Clinical features & Management
Hyperglycaemia, acidosis, ketonaemia, ketonuria
Symptoms; polyuria, polydipsia, D&V, abdominal pain, lethargy, confusion
Signs; ketotic breath, dehydration, Kussmaul breathing, shock, reduced GCS, oliguria
[Management]
- IV 0.9% saline 500mL over < 15mins +/- KCl 40mmol (resus)
- IV insulin 50u in 50mL saline at 0.1u/kg/hr
- IV glucose 10%; once BG <14 to prevent rebound hyperglycaemia
- Reassess BG, ketones, bicarb hourly
- Reassess fluid and K requirements
- Consider catheter if anuric
- Consider NG tube if persistent vomiting
Hypoglycaemia | Clinical features & Management
Diagnosis
Reduced GCS
Aggression, sweating, tachycardic, seizures
BG < 3.5 mmol/L
[Management]
If conscious;
1. Quick-acting carb snack, sugar lumps, lucozade
2. Glucose gel, glucose syrup
If unconscious;
- IV glucagon
- IV glucose 20%
Type 2 DM | Epidemiology & Demographics
Older patients
Insulin resistance
Asymptomatic but may present with complications such as MI
[Management]
- Lifestyle modification; diet, exercise, weight loss
- Metformin; biguanide, does not cause hypoglycaemia
- Gliclazide; sulfonylurea
DKA | Complications
Hyperkalaemia; K will fall with insulin, monitor and do not replace in the first bag
Hypokalaemia; monitor and replace with 40ml KCl if between 3.5-5.5
Do not replace if > 5.5
Senior advice for additional replacement if < 3.5
Hypoglycaemia; once BG < 14, + IV glucose 10% to 0.9% saline
Through large vein/large-guage needle
Cerebral oedema; consider slower fluid replacement over 48hrs
Caution in children/young people
Pulmonary oedema; check SpO2, CXR
Caution fluid overload in the elderly or renally impaired
HHS | Clinical features & Management
Hyperglycaemic hyperosmolar state
Hypovolaemia; severe dehydration
Hyperglycaemia without hyperketonaemia/acidosis
Hyperosmolarity
[Management]
- IV 0.9% saline 1-2L over 1hr
- Continue slow fluid replacement 50% of loss in first 12hrs
- If BG not falling or significant ketonaemia, give IV insulin infusion at 0.05u/kg/hr
- Assess K requirements
- Investigate and treat source; sepsis, MI, metformin, bowel infarct
- Prophylactic LMWH for hypercoagulable state
HHS | Complications
Cerebral oedema/seizures; slow correction of fluid deficit
Arterial/venous thrombosis; MI, stroke, peripheral arterial thrombosis, VTE
Fluid overload; renally impaired, HF, comorbidities
Central pontine myelinosis; reduced GCS, assess hourly for complications
Foot ulceration; daily foot check
Metformin-associated Lactic Acidosis (MALA) | RFs, Investigations & Management
RFs; high dose, elderly, renal impairment (AKI/CKD), sepsis, dehydration (D&V), shock (renal hypoperfusion), acidosis
Inv; high anion gap metabolic acidosis, raised lactate
R/o other causes of lactic acidosis; sepsis, cardiogenic shock, hypoperfusion, ischaemic bowel
[Management]
- Stop metformin
- IV fluid rehydration
- Correct acidosis; bicarbonate
- RRT; haemodialysis
DM | Complications
[Macrovascular]
Atherosclerosis
Combined RFs; HTN, smoking, hyperlipidaemia, DM
Tx; target BP <130/80, ACEi, statin, aspirin
[Microvascular]
Diabetic retinopathy, cataracts, CN3/6 palsy
Diabetic nephropathy, UTIs
Diabetic neuropathy; sensory glove/stocking distribution, painful ‘burning’ sensation, mononeuritis multiplex (Carpal tunnel syndrome, CN 3/6 palsies)
Autonomic neuropathy; resting tachycardia, postural hypotension, arrhythmias, peripheral vasodilation, D&V, gastroparesis, incomplete bladder emptying, erectile dysfunction
Diabetic foot; infection, ischaemia, neuropathy producing tissue necrosis, Charcot arthropathy, PVD
Immunodeficiency and infections
Hyperthyroidism |
Clinical features & Differentials
Symptoms
Signs
Symptoms; SOB, tiredness, heat intolerance, sweating, weight loss, menorrhagia
Signs; tremor, agitation, warm moist skin, palmar erythema, tachycardia, AF, dependent oedema
[Differentials]
Grave’s disease; enlarged soft symmetrical gland, bruit (+ thyroid acropachy, pretibial myxoedema, eye disease, ophthalmoplegia/exophthalmos)
Toxic multinodular goitre; non-tender thyroid nodules >1x
Toxic adenoma/carcinoma; unilateral non-tender nodular mass, hot nodule
De Quervain’s thyroiditis; subacute, hyperT then hypoT
(tender, enlarged, firm, irregular gland, diffuse, asymmetrical (+ fever, malaise))
Amiodarone-induced thyroiditis; small goitre
Thyroid storm; tachycardia, fever, AF, HF, fever, D&V, dehydration, jaundice, agitation, delirium, coma
Hyperthyroidism | Investigations & Management
Pharmacological
Surgical
Inv; low TSH, high T3/4
USS thyroid, FNAC
[Management]
2WWR if ?malignancy
- Beta-blocker, propranolol
- Carbimazole (PTU in pregnancy)
- Radioiodine treatment; TMG
- Thyroidectomy
Hypothyroidism | Clinical features & Differentials
Symptoms; fatigue, cold intolerance, weight gain constipation, amenorrhoea, depression, impaired concentration/memory
Signs; coarse dry hair, dry skin, hair loss, periorbital oedema, goitre, bradycardia
[Differentials]
SOL; headache, diplopia, reduced peripheral vision
Pituitary adenoma; skin depigmentation, amenorrhoea, erectile dysfunction, Cushing’s syndrome, acromegaly, atrophic breasts
Postpartum thyroiditis; ~6/12 postpartum
Myxoedema coma; hypothermia, coma, seizures
Sick euthyroid; low T4, normal TSH, + acute illness
Hypothyroidism | Investigations & Management
Inv; normal/high TSH, low T3/4, anti-TPO
USS thyroid, FNAC
[Management]
Levothyroxine; for life
Monitor TFTs
Hyperparathyroidism | Clinical features, Investigations & Management
Complications
[Clinical features]
Stones, bones, abdominal groans, psychic moans
Hypercalcaemia
[Complications]
Osteopenia/porosis
Renal stones, PUD, HTN, pancreatitis, arrhythmias, muscle spasm
Commonly caused by adenoma
Inv; high PTH, high Ca, low phosphorus
DEXA scan; to detect bone loss/softening
PXR/USS kidney/CT KUB; Ca stones
[Management]
- Lifestyle; avoid high-Ca diet, drink plenty of fluids, avoid thiazide diuretics
- Fluid rehydration
- Bisphosphonates + Vit D
- Parathyroidectomy
- Cinacalcet; if surgery unsuitable
Hypoparathyroidism | Clinical features & Management
[Clinical features] Muscle cramps, tiredness Paraesthesia in fingertips, toes, lips Facial muscle twitch Mood disturbance Dry skin, coarse hair
Inv; low PTH, low Ca, high phosphorus
Hypocalcaemia, hyperphosphataemia
Caused by gland failure
[Management]
- Lifestyle; high-Ca, low phosphorus diet
- Calcium carbonate + Vit D supplements; calcitriol/alfacalcidol, taken for life
- Regular monitoring of PTH, Ca, phosphorus
Multiple endocrine neoplasia (MEN) | Types
Functioning hormone-producing tumours in multiple organs
AD inheritance
MEN-1; parathyroid hyperplasia/adenoma, pancreatic tumours, pituitary prolactinoma
MEN-2a; medullary thyroid carcinoma, phaeochromocytoma, parathyroid hyperplasia
Cushing’s syndrome | Clinical features & Aetiology
ACTH-dependent causes
ACTH-independent causes
Symptoms; weight gain, mood change, proximal weakness, amenorrhoea, hirsutism, erectile dysfunction
Signs; central obesity, plethoric moon face, buffalo hump, skin/muscle atrophy, bruises, purple abdominal striae, osteoporosis, HTN, hyperglycaemia, recurrent infections, poor healing
Exogenous causes; oral steroids
Endogenous causes; commonly excess ACTH usually from pituitary adenoma ‘Cushing’s disease’
[ACTH-dependent]
Cushing’s disease
Ectopic ACTH; SCLC, lung carcinoid tumours
[ACTH-independent]
Steroid medication
Adrenal tumours
Cushing’s syndrome | Investigations & Management
[Investigations]
1. Overnight dexamethasone suppression test + morning plasma cortisol; NO suppression
Alt: 24hr urinary free cortisol
2. 48hr dexamethasone suppression test; + midnight cortisol
MR brain; pituitary adenoma
CT abdo; adrenal tumours
CXR; lung carcinoid tumours, SCLC
[Management] Iatrogenic; stop steroid medication Surgical removal of pituitary adenoma Bilateral adrenalectomy Radiotherapy to tumour Medication to block ACTH production
Endocrine | History taking
Generalised, diffuse, non-specific features
Tiredness, weakness, lack of energy, lack of drive Changes in appetite, thirst Changes in appearance, body shape/size Changes in skin/hair Libido, impotency Menstrual cycle, sexual development
PMH; previous surgery, radiation to glands, menstrual history, pregnancy, growth/development in childhood
DA; to exclude iatrogenic/exogenous causes
FH; autoimmune disease, endocrine disease, DM, CVD
Family’s height, weight, hair growth, age of sexual development
Addison’s disease | Clinical features, Aetiology & Investigations
[Aetiology]
Autoimmune adrenal gland destruction (Zg, Zf) and hence gland failure
Sx manifest at 90% destruction
TB main cause in developing countries
[Clinical features] Hyperpigmentation Weight loss, loss of appetite Weakness, fatigue Loss of body hair Postural hypotension, syncope Back pain, abdo pain Dehydration, salt craving N&V, muscle/joint pain
[investigations]
Serum cortisol, U&Es
Short synACTHen stimulation test; low cortisol, low aldosterone
Addison’s disease | Management
Addisonian crisis
[Acute]
- IV hydrocortisone 100mg given with IV 0.9% saline 1L over 30-60mins
- Continue fluid resus to correct hypotension over 24hrs
[Ongoing] Lifelong
GC replacement; hydrocortisone, prednisolone
MC replacement; fludrocortisone
(Androgen replacement)
IM hydrocortisone injection for emergencies
Steroid treatment card
Safety net for impending signs of adrenal crisis
Primary hyperaldosteronism | Aeitology, Investigations & Management
Clinical features
‘Conn’s syndrome’ = adrenal adenoma
[Aetiology]
Primary; idiopathic, familial, adrenal adenoma
Secondary; CCF/cirrhosis causing high renin
Hypokalaemia, hypernatraemia, HTN, metabolic alkalosis
[Investigations]
U&Es, ECG
Plasma aldosterone:renin ratio
CT abdo; adrenal enlargement
[Management]
Aldosterone antagonists; spironolactone
Unilateral adrenalectomy
Tx underlying CCF/cirrhosis
Phaeochromocytoma | Clinical features, Investigations & Management
SNS tumour
Adrenal medulla tumour, usually benign
1 in 3 may be genetic
May present as hypertensive crisis
[Clinical features]
Headaches, sweating, palpitations, tachycardia, HTN, tremor
Nausea, anxiety, panicky
[Investigations] Plasma catecholamines Urinary catecholamines CT abdo; adrenal tumour Genetic testing
[Management]
Beta-blockers
Laparoscopic removal
Thyrotoxic storm | Clinical
Pyrexia, confusion, tachycardia, hypotension
Precipitated by stress, infection, trauma, surgery
[Management]
Carbimazole + hydrocortisone + beta-blocker
