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General Medicine > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

Type 1 DM | Diagnosis & Management

Monitoring

A

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&amp;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)

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2
Q

DKA | Clinical features & Management

A

Hyperglycaemia, acidosis, ketonaemia, ketonuria

Symptoms; polyuria, polydipsia, D&V, abdominal pain, lethargy, confusion

Signs; ketotic breath, dehydration, Kussmaul breathing, shock, reduced GCS, oliguria

[Management]

  1. IV 0.9% saline 500mL over < 15mins +/- KCl 40mmol (resus)
  2. IV insulin 50u in 50mL saline at 0.1u/kg/hr
  3. IV glucose 10%; once BG <14 to prevent rebound hyperglycaemia
  4. Reassess BG, ketones, bicarb hourly
  5. Reassess fluid and K requirements
  6. Consider catheter if anuric
  7. Consider NG tube if persistent vomiting
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3
Q

Hypoglycaemia | Clinical features & Management

Diagnosis

A

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;

  1. IV glucagon
  2. IV glucose 20%
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4
Q

Type 2 DM | Epidemiology & Demographics

A

Older patients
Insulin resistance
Asymptomatic but may present with complications such as MI

[Management]

  1. Lifestyle modification; diet, exercise, weight loss
  2. Metformin; biguanide, does not cause hypoglycaemia
    • Gliclazide; sulfonylurea
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5
Q

DKA | Complications

A

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

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6
Q

HHS | Clinical features & Management

Hyperglycaemic hyperosmolar state

A

Hypovolaemia; severe dehydration
Hyperglycaemia without hyperketonaemia/acidosis
Hyperosmolarity

[Management]

  1. IV 0.9% saline 1-2L over 1hr
  2. Continue slow fluid replacement 50% of loss in first 12hrs
  3. If BG not falling or significant ketonaemia, give IV insulin infusion at 0.05u/kg/hr
  4. Assess K requirements
  5. Investigate and treat source; sepsis, MI, metformin, bowel infarct
  6. Prophylactic LMWH for hypercoagulable state
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7
Q

HHS | Complications

A

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

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8
Q

Metformin-associated Lactic Acidosis (MALA) | RFs, Investigations & Management

A

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]

  1. Stop metformin
  2. IV fluid rehydration
  3. Correct acidosis; bicarbonate
  4. RRT; haemodialysis
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9
Q

DM | Complications

A

[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

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10
Q

Hyperthyroidism |
Clinical features & Differentials

Symptoms
Signs

A

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

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11
Q

Hyperthyroidism | Investigations & Management

Pharmacological
Surgical

A

Inv; low TSH, high T3/4
USS thyroid, FNAC

[Management]
2WWR if ?malignancy

  1. Beta-blocker, propranolol
  2. Carbimazole (PTU in pregnancy)
  3. Radioiodine treatment; TMG
  4. Thyroidectomy
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12
Q

Hypothyroidism | Clinical features & Differentials

A

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

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13
Q

Hypothyroidism | Investigations & Management

A

Inv; normal/high TSH, low T3/4, anti-TPO
USS thyroid, FNAC

[Management]
Levothyroxine; for life
Monitor TFTs

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14
Q

Hyperparathyroidism | Clinical features, Investigations & Management

Complications

A

[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]

  1. Lifestyle; avoid high-Ca diet, drink plenty of fluids, avoid thiazide diuretics
  2. Fluid rehydration
  3. Bisphosphonates + Vit D
  4. Parathyroidectomy
  5. Cinacalcet; if surgery unsuitable
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15
Q

Hypoparathyroidism | Clinical features & Management

A 
[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]

  1. Lifestyle; high-Ca, low phosphorus diet
  2. Calcium carbonate + Vit D supplements; calcitriol/alfacalcidol, taken for life
  3. Regular monitoring of PTH, Ca, phosphorus
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16
Q

Multiple endocrine neoplasia (MEN) | Types

Functioning hormone-producing tumours in multiple organs

AD inheritance

A

MEN-1; parathyroid hyperplasia/adenoma, pancreatic tumours, pituitary prolactinoma

MEN-2a; medullary thyroid carcinoma, phaeochromocytoma, parathyroid hyperplasia

17
Q

Cushing’s syndrome | Clinical features & Aetiology

ACTH-dependent causes
ACTH-independent causes

A

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

18
Q

Cushing’s syndrome | Investigations & Management

A

[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
19
Q

Endocrine | History taking

A

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

20
Q

Addison’s disease | Clinical features, Aetiology & Investigations

A

[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&amp;V, muscle/joint pain

[investigations]
Serum cortisol, U&Es
Short synACTHen stimulation test; low cortisol, low aldosterone

21
Q

Addison’s disease | Management

Addisonian crisis

A

[Acute]

  1. IV hydrocortisone 100mg given with IV 0.9% saline 1L over 30-60mins
  2. 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

22
Q

Primary hyperaldosteronism | Aeitology, Investigations & Management

Clinical features

‘Conn’s syndrome’ = adrenal adenoma

A

[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

23
Q

Phaeochromocytoma | Clinical features, Investigations & Management

SNS tumour

A

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

24
Q

Thyrotoxic storm | Clinical

A

Pyrexia, confusion, tachycardia, hypotension

Precipitated by stress, infection, trauma, surgery

[Management]
Carbimazole + hydrocortisone + beta-blocker

25
Q

Pituitary tumours

A

Cushing’s disease
Acromegaly
Hyperprolactinaemia

26
Q

Hypopituitarism | Aetiology

But causes hyperprolactinaemia rather than hypo

Syndromes

A

Commonly pituitary/hypothalamic tumours, surgical, radiotherapy tx

Many causes including congenital, infective, trauma, autoimmune, neoplastic, functional (anorexia nervosa)

Progressive loss of ant. pituitary hormones
Multiple deficiencies seen in pituitary tumours where growth causes localised destruction

[Aetiology]
Kallmann’s syndrome; anosmia + GnRH deficiency
Sheehan’s syndrome; pituitary infarction from PPH

27
Q

Acromegaly/Gigantism | Clinical features, Investigations & Management

A

Children; gigantism
Adults; acromegaly (hands, face, feet)

[Clinical features]
Sweating, headaches, soft tissue swelling
Bitemporal hemianopia
Impaired glucose tolerance
(Hypopituitarism + hyperprolactinaemia)

Inv; OGTT, (GH, IGF-1), MR brain, pituitary function, visual fields

[Management]
Significant increased CV and cancer risk

  1. Trans-sphenoidal surgical removal
  2. Radiotherapy
  3. Somatostatin analogues; octreotide (inhibits GH release)
  4. Dopamine agonists; cabergoline, bromocriptine
  5. GH antagonists
28
Q

Hyperprolactinaemia | Clinical features, Investigations & Management

Aetiology

A

Pregnancy, prolactinomas, 1° hypothyroidism, dopamine antagonists (antiemetics, antipsychotics)

[Clinical features]
Galactorrhoea, headaches, visual field defect
Low oestrogen/testosterone; reduced libido, subfertility, delayed/arrested puberty, gynaecomastia, hypogonadism, amenorrhoea, osteoporosis

Inv; prolactin, TFTs, pituitary function, MR brain, visual fields

[Management]

  1. Dopamine agonists; cabergoline, bromocriptine
  2. Surgical removal; trans-sphenoidal
  3. Radiotherapy
29
Q

PCOS | Clinical features, Investigations & Management

Differentials; CAH, Cushing’s syndrome, ovarian/adrenal tumours, medication

A

Rotterdam criteria triad of:

  1. Hirsutism, virilisation
  2. Amenorrhoea, anovulation
  3. Polycystic ovaries on USS

Acne, subfertility, DM, endometrial cancer risk

[Diagnosis]
Testosterone, androgens, prolactin, OGTT
Pelvic USS
17-hydroxyprogesterone; to r/o CAH

[Management]
Weight loss 5%
Hair removal; mechanical, topical

  1. Oestrogens/contraceptives; amenorrhoea, hirsutism
  2. Metformin; DM, subfertility, amenorrhoea
  3. Clomifene; subfertility
  4. Antiandrogens; spironolactone
30
Q

Subfertility | Aetiology, Investigations & Management

A

Inability to conceive after 1yr of regular unprotected sex

[Aetiology]

  1. Ovulatory disorders; PCOS
  2. Tubal disorders; PID, chlamydia
  3. Uterine disorders; fibroids, endometriosis, intrabdominal adhesions
  4. Cervical disorders; gonorrhoea/chlamydia cervicitis
  5. Male potency
[Investigations]
Day 21 mid-luteal progesterone
Gonadotrophins; FSH, LH
Prolactin, TFTs
STI screen; cervical swabs
Semen analysis

[Management]
Referral to specialist (if F < 36yrs)
IVF

31
Q

Thyroid carcinoma | Aetiology

A
  1. Papillary, most common

Medullary; phaochromocytoma
Toxic adenoma; hot solitary nodule, thyrotoxicosis (low TSH)

General Medicine (7 decks)

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