endocrinology Flashcards
1
Q
acromegaly: epidemiology
A
male:female 1:1
5% associated with MEN-1
2
Q
acromegaly: causes
A
excess growth hormone from pituitary tumour (99%) or hyperplasia
if occurs before epiphyses fuse- gigantism
3
Q
acromegaly: symptoms
A
resp: snoring GI: wonky bite- malocclusion MSK: arthralgia, backache neuro: headache, acroparaethesia increase in sweating and weight decrease in libido
4
Q
acromegaly: signs
A
skin darkening big supraorbital ridge interdental separation macroglossia progathism laryngeal dyspnoea OSA spade like hands and feet carpal tunnel syndrome
5
Q
acromegaly: complications
A
impaired glucose tolerance- 40%
diabetes mellitus- 15%
arrhythmias, cardiomyopathy, stroke
colon cancer
6
Q
acromegaly: investigations
A
IGF-1 and OGTT test
don’t rely on GH as pulsatile secretion
MRI pituitary fossa
look at old photos
7
Q
acromegaly: treatment
A
trans-sphenoidal surgery to remove tumour
somatostatin analogue
radiotherapy
pegvisomant
8
Q
acromegaly: acroparaethesia
A
a condition of burning, tingling or prickling sensations in the extremities
9
Q
endocrine tumours: epidemiology
A
incidence 10/100,000/year
women effected more than men
prevalence 90/100,000
10
Q
endocrine tumours: symptoms caused by
A
pressure on local structures pressure on normal pituitary functioning tumours local effect of tumour effect of hyperprolactinaemia
11
Q
endocrine tumours: pressure on normal pituitary
A
hypopituitarism
12
Q
endocrine tumours: functioning tumours examples
A
prolactinoma
acromegaly
cushing’s disease
13
Q
endocrine tumours: local effect of tumours
A
headache
visual field defect
CSF leak
14
Q
endocrine tumours: effect of hyperprolactinaemia
A
menstrual irregularity infertility galactorrhoea low libido low testosterone in men
15
Q
endocrine tumours: causes of hyperprolactinaemia
A
non-functioning pituitary tumour: compresses pituitary stalk
antidopaminergic drugs: don’t measure prolactin on these but a careful drug history needed
16
Q
endocrine tumours: management
A
dopamine agonists
shrinkage usual with macroadenoma- sight saving
17
Q
carcinoid tumours
A
diverse group of tumours of enterochromaffin origin
produce serotonin
also secrete bradykinin, tachykinin, insulin etc.
appendix 45%, ileum 30%, rectum 20%
18
Q
prolactinoma
A
benign tumour of the pituitary gland that produces prolactin
19
Q
hypokalaemia levels
A
K+ <3.5mmol/L
severe= <2.5 mmol/L
20
Q
hypokalaemia: causes
A
diuretics cushing's conn's pyloric stenosis alkalosis
21
Q
hypokalaemia: symptoms
A
muscle weakness muscle cramps decrease in muscle tone and reflexes palpitations arrhythmias constipations
22
Q
hypokalaemia: investigations
A
Bloods
ECG: U have no Pot and no Tea BUT and long PR and a long QT
23
Q
mild hypokalaemia: treatment
A
oral K+ supplements
review K after 3 days
if taking thiazide diuretic and K>3mmol/L consider repeating and/or K+ sparing diuretic
24
Q
severe hypokalaemia: treatment
A
IV K+ cautiously
no more than 20mmol/Hour and not more concentrated than 40mmol/L
25
hyperkalaemia levels
K+ >5.5mmol/L
severe= >6.5mmol/L
26
hyperkalaemia: causes
```
oliguric renal failure
K-sparing diuretics
rhabsomyolysis
addisons
burns
metabolic acidosis
```
27
hyperkalaemia: symptoms
myocardial excitability- VF and cardiac arrest
concerning:
fast irregular pulse, chest pain, weakness, palpitations, light-headedness
28
hyperkalaemia: investigations
Bloods
ECG:
Tall tented T waves, small P waves, wide QRS
29
hyperkalaemia: non-urgent treatment
treat underlying cause
review meds
polystyrene sulfonate resin- binds K+ in gut
30
hyperkalaemia: emergency treatment
stabilise cardiac membrane with 10ml 10% calcium gluconate
drive K+ into cells with 10U actrapid (insulin) and 50ml 20% glucose
31
puberty
describes the physiological, morphological and behavioural changes as the gonads switch from infantile to adult
32
definitive signs of puberty in females
menarche- first menstrual bleeding
breast bud noted/palpable
secondary characteristics:
- oestrogen regulates growth of breast and female genitalia
- ovarian and adrenal androgens control pubic hair
33
definitive signs of puberty in males
first ejaculation, often nocturnal
testicular volume >3ml
secondary characteristics:
- testicular androgens
- external genitalia and pubic hair growth
- laryngeal muscles enlarge
34
early puberty
onset of secondary characteristics before 8 (girls), 9 (boys)
35
true precocious puberty
GnRH increase
idiopathic
CNS tumours or disorders
secondary central precocious puberty
36
precocious pseudo- puberty
```
autonomous production of oestrogen- GnRH independent
increased androgen secretion
secreting tumours
ovarian cyst
hypothyroidsism
```
37
early puberty investigations
GnRH stimulation test to see if dependent(stimulation) or independent (no stimulation)
bone age- advanced in precocious
38
early puberty treatment
precocious- GnRH super-agonist to suppress pulsatility of GnRH
psuedo- treat underlying cause
39
delayed puberty
absence of secondary sexual characteristics by 14 years for girls or 16 years for boys
40
types of delayed puberty
constitutional delay of growth and puberty
hypergonadotropic hypogonadism
hypogonadotropic hypogonadism
41
constitutional delay of growth and puberty
delayed activation of hypothalamic pulse generator
42
hypergonadotropic hypogonadism
primary hypogonadism:
- gonadal disorder
- hypergonadotropic as increase in GnRH, FSH and LH to increase gonadal sex hormone
43
hypogonadotropic hypogonadism
secondary/tertiary hypogonadism
| sexual infantilism related to gonadotrophin deficiency
44
constitutional delay of growth and puberty causes
inherited from multiple genes
45
hypergonadotropic hypogonadism causes
males= klinefelters, testicular failure, chemotherapy
females= turners
46
hypogonadotropic hypogonadism causes
CNS disorders such as tumours
isolated gonadotropin deficiency
Idiopathic and Genetic Forms of Multiple Pituitary Hormone Deficiencies
47
delayed puberty investigations
```
red blood count
LH, FSH
testosterone/ oestradial
thyroid function
karyotyping
bone age
```
48
delayed puberty treatment for females
ethinyl estradiol or oestrogen
| oral tablets
49
delayed puberty treatment for males
testosterone enanthate
| IM injection
50
delayed puberty treatment for fertility
GnRH-TX
| parental combination of gonadotropin TX
51
Cushing's syndrome
chronic glucocorticoid excess
| loss of normal feedback mechanisms and circadian rhythm
52
ACTH dependent causes of Cushing's syndrome
cushing's disease- bilateral adrenal hyperplasia from ACTH secreting adenoma
ectopic ACTH production
ectopic CRH production
53
ACTH independent causes of Cushing's syndrome
adrenal adenoma/carcinoma
adrenal nodular hyperplasia
iatrogenic- steroids
54
cushing's syndrome symptoms
```
acne
increased weight
gonadal dysfunction
proximal weakness
recurrent achilles tendon rupture
mood change- depression, lethargy, irritability
```
55
cushing's syndrome signs : fat distribution
central obesity
moon face
buffalo neck hump
supraclavicular fat distribution
56
cushing's syndrome signs: skin changes
skin and muscle atrophy
bruises
purple abdominal striae
57
other cushing's syndrome signs
```
osteoporosis
hypertension
hyperglycaemia
infection prone
poor healing
```
58
Cushings syndrome investigations
bloods- increased plasma cortisol
| overnight or 48 hour dexamethasone suppression test
59
treating iatrogenic causes for cushings
stop steroids
60
cushing's disease treatment
trans-sphenoidal surgery or bilateral adrenalectomy
61
adrenal adenoma treatment
adrenalectomy
62
adrenal carcinoma treatment
adrenalectomy, adrenolytics
63
ectopic ACTH treatment
surgery
64
adrenal insufficiency
adrenal glands do not produce adequate amounts of steroid hormones- primarily cortisol
65
types of adrenal insufficiency
primary
secondary
tertiary
66
primary adrenal insufficiency
adrenal gland disorder
aka addison's disease:
- primary adrenocortical insufficiency
- destruction of adrenal cortex
- decrease in glucocorticoids and mineralocorticoids
67
primary adrenal insufficiency: causes
autoimmune- 80%, most common in UK
TB= most common worldwide
adrenal metastases
lymphoma
opportunistic infections in HIV
adrenal haemorrhage
68
adrenal insufficiency: symptoms
- abdominal pain, constipation/diarrhoea
- tanned skin
- lean build
- MSK weakness, myalgia
- dizzy, fainting
- tired, tearful, anorexic, depressed
69
adrenal insufficiency: signs
pigmented palmar creases and buccal mucosa
vitiligo
postural hypotension
70
primary adrenal insufficiency: investigations
Bloods:
- FBC (anaemia, eosinophilia)
- U&E ( low Na, high K, Ca and urea)
- BM glucose (low)
short ACTH stimulation test (excluded if 30 min cortisol is >550nmol/L)
9am ACTH levels- will be high in addison's
71
primary adrenal insufficiency: treatment
replace steroids with 15-25mg hydrocortisone daily
replace mineralocorticoids (aldosterone) with fludocortisone
drug card and bracelet
72
secondary adrenal insufficiency
inadequate secretion of ACTH by the pituitary gland
73
secondary adrenal insufficiency: causes
most common cause is iatrogenic- long term steroid therapy suppresses HPA axis
pituitary disorders
74
secondary adrenal insufficiency: investigations
Bloods:
- FBC (anaemia and eosinophilia)
- U&E (high Ca)
- BM glucose (low)
short ACTH stimulation (>550nmol/L)
9am ACTH levels (low)
75
secondary adrenal insufficiency: treatment
replace steroids with 15-25mg of hydrocortisone daily
76
tertiary adrenal insufficiency
impaired hypothalamic release of corticotropin-releasing hormone- CRH
77
tertiary adrenal insufficiency: causes
hypothalamo-pituitary disease
suppression of HPA
78
tertiary adrenal insufficiency: investigations
Bloods:
- FBC (anaemia and eosinophilia)
- U&E (high Ca)
- BM glucose (low)
short ACTH stimulation (>550nmol/L)
9am ACTH levels (low)
79
tertiary adrenal insufficiency: treatment
replace steroids with 15-25mg of hydrocortisone daily
80
Adrenal crisis
constellation of symptoms caused by insufficient levels of cortisol
81
Adrenal crisis: causes
adrenal insufficiency
82
Adrenal crisis: symptoms
```
hypotension
fatigue
fever
hypoglycaemia
hyponatraemia
hyperkalaemia
```
83
Adrenal crisis: treatment
immediate IV hydrocortisone 100mg
fluid resuscitation- 1L N/Saline 1 hour
hydrocortisone 50-10mg 6 hourly
84
Conn's syndrome
excess aldosterone independent of RAAS
85
Conn's syndrome: causes
solitary aldosterone-producing adenoma
86
Conn's syndrome: symptoms
increased retention of sodium and water
may have signs of low potassium
often asymptomatic
87
Conn's syndrome: investigations
U&E
Renin
Aldosterone
88
Conn's syndrome: treatment
laparoscopic adrenalectomy
89
actions of ADH
vasoconstriction
| increased water reabsorption
90
Diabetes insipidus
when secretion of, or response to, vasopressin is impaired
91
Diabetes insipidus: types
Cranial
nephrogenic
other
92
Cranial diabetes insipidus:
lack of vasopression
93
nephrogenic diabetes insipidus
resistance to vasopressin
94
other forms of diabetes insipidus
gestational- excessive vasopressinase activity
dipsogenic- disordered thirst
95
Cranial diabetes insipidus: causes
```
tumour
lack of blood supply
impact/fracture
surgical
autoimmune
```
96
nephrogenic diabetes insipidus: causes
lithium toxicity
release of obstruction
hypercalcaemia
hypokalaemia
97
Diabetes insipidus: symptoms
polydipsia- excessive or abnormal thirst
polyuria- abnormally large volumes of dilute urine
dehydration
hypernatraemia
98
Diabetes insipidus: investigations
water deprivation test to diagnose DI
water deprivation with desmopressin (ADH agonist):
- cranial= urine output falls and osmolality increases
- nephrogenic= no change
99
Cranial diabetes insipidus: treatment
desmopressin
| treat underlying condition
100
Nephrogenic diabetes insipidus: treatment
thiazide diuretics and amiloride- encourages salt and water uptake
high dose of desmopressin
free access to water
101
syndrome of inappropriate ADH secretion: SIADH
excessive ADH production
102
SIADH: causes
CNS disorders- infection, bleed, MS
| pulmonary- infection, abscess, asthma, CF
103
SIADH: symptoms
```
small volumes of concentrated urine
hyponatraemia
anorexia
nausea
aches and weakness
```
104
SIADH: investigations
euvolaemic with hyponatraemia
urine osmolarity >100mOsm/Kg
urine sodium >40mEq/L
105
SIADH: treatment
fluid restriction- increases Na concentration
| tolvaptin- v2 vasopressin blocker
106
hyponatraemia
serum sodium <135mmol/L
107
hyponatraemia: causes
fluid overload
SIADH
dehydration
malignancy
108
hyponatraemia symptoms: Na 130-135mmol/L
asymptomatic
109
hyponatraemia symptoms: Na 125-130mmol/L
headache
lethargy
abdominal pain
weakness
110
hyponatraemia symptoms: Na<1255mmol/L
confusion
hallucinations
agitation
decreased consciousness
111
hyponatraemia symptoms: Na<115mmol/L
fitting
| coma
112
hyponatraemia: acute vs chronic
acute= 48 hours, rapid correction is safer
chronic= CNS has adapted so correction must be slow
113
hyponatraemia: investigations
```
plasma osmolality
urine osmolality
plasma glucose
urine sodium
urine dip test for protein
```
114
hyponatraemia: treatment
restrict fluids if fluid overload
saline replacement if dehydrated
115
thyroid disease epidemiology
```
most common endocrine disorders
female preponderance is 5-10 fold
hyperthyroidism, 2.5% prevalence
hypo= 5%
goitre=5-10%
```
116
autoimmune thyroid disease
2% of women will get grave's disease or autoimmune hypothyroidism
5% will have postpartum thyroiditis
20% will have positive thyroid antibodies
117
hypothyroidism
abnormally low activity of the thyroid gland
118
primary hypothyroidism: causes
(over 99% of cases, low T4 due to absence or dysfunction of thyroid gland)
hashimoto's thyroiditis
primary atrophic hypothyroidism
iodine deficiency
TH resistance
119
secondary hypothyroidism: causes
(low TSH due to pituitary/ hypothalamic dysfunction)
hypopituitarism
120
hypothyroidism: symptoms
```
hoarse voice
constipation
cold intolerance
weight gain
myalgia
tired
low mood
abnormally heavy bleeding at menstruation (menorrhagia)
```
121
hypothyroidism: signs
think BRADYCARDIC
```
Bradycardic
Reflexes relax slowly
Ataxia
Dry thin hair and skin
Yawning, drowsy
Cold hands
Ascites
Round puffy face
Defeated demeanour
Immobile
CCF
```
122
hypothyroidism: investigations
thyroid function tests
lipids/cholesterol
↓T3, ↓T4 = ↑TSH (secondary/tertiary TSH low)
123
hypothyroidism: inherited associations
turner's syndrome
down's syndrome
cystic fibrosis
124
hypothyroidism: autoimmune associations
type 1 diabetes
addison's
pernicious anaemia
125
hypothyroidism: treatment
levothyroxine (T4)
126
hyperthyroidism
excess of thyroid hormones in blood due to overactivity of the thyroid gland
127
hyperthyroidism: causes
graves' disease (75-80%)
toxic multinodular goitre
toxic adenoma
ectopic thyroid tissue
128
hyperthyroidism: symptoms
```
palpitations
diarrhoea
heat intolerance
weight loss
tremor
irritability
```
129
hyperthyroidism: signs
```
warm, moist skin
palmar erythema
tachycardia
thin hair
lid lag/retraction
goitre
```
130
hyperthyroidism: Graves' specific signs
diffuse goitre
thyroid eye disease
pretibial myxoedema
acropachy
131
hyperthyroidism: MNG specific signs
multinodular goitre
132
hyperthyroidism: adenoma specific signs
solitary nodule
133
hyperthyroidism: investigations
linked with liver failure
thyroid function tests
thyroid autoantibodies
isotope uptake scan
134
hyperthyroidism: treatment
beta-blockers
antithyroid medication
radioiodine
thyroidectomy
135
thyroid eye disease
autoimmune inflammatory disorder of the orbit and periorbital tissues
swelling of extraocular muscles
136
thyroid eye disease: causes
25-50% have graves' disease
main risk factor is smoking
eye and thyroid disease may not correlate
137
thyroid eye disease: symptoms
eye discomfort
grittiness
diplopia
138
thyroid eye disease: signs
exophthalmos
proptosis
ophthalmoplegia
139
thyroid eye disease: tests
clinical diagnosis
140
thyroid eye disease: management
```
stop smoking
sunglasses
IV methylprednisolone
surgical decompression
eyelid surgery
```
141
goitre
swelling of neck resulting from enlargement of the thyroid gland
142
goitre presentation:
palpable and visible thyroid enlargement
| endemic in iodine deficient areas
143
diffuse goitre causes:
physiological
graves' disease
hashimoto's thyroiditis
144
nodular goitre causes:
multinodular
adenoma
cyst
carcinoma
145
thyroid cancers
```
papillary- 60%
follicular- <25%
medullary- 5%
lymphoma- 5%
anaplastic
```
146
hyperparathyroidism
abnormally high concentration of parathyroid hormone in the blood
147
primary hyperparathyroidism
one or more of the parathyroid glands are overactive
148
primary hyperparathyroidism: causes
80% due to adenoma
| 15-20% due to four gland hyperplasia
149
primary hyperparathyroidism: symptoms
STONES- kidney
BONES- osteitis fibrosa cystica, osteoporosis
MOANS- abdominal, constipation, pancreatitis
GROANS- confusion
150
primary hyperparathyroidism: investigations
PTH high-> calcium is high
phosphate usually low
phosphatase usually high
151
primary hyperparathyroidism: treatment
treat underlying cause- usually surgical
152
secondary hyperparathyroidism
excessive secretion of PTH by the parathyroid glands in response to hypocalcaemia and associated hyperplasia of the glands
153
secondary hyperparathyroidism: causes
CKD and vitamin D deficiency is most common
| GI bypass and crohn's disease also possible causes
154
secondary hyperparathyroidism: symptoms
usually asymptomatic
symptoms are predominantly bony- joint pain, osteomalacia
155
secondary hyperparathyroidism: investigations
PTH high -> calcium low
phosphate high
phosphatase high
156
treating secondary hyperparathyroidism
treat underlying cause
| bisphosphonates to protect bones
157
tertiary hyperparathyroidism
a state of excessive secretion of PTH after a long period of secondary hyperparathyroidism
results in high blood calcium level
158
hypoparathyroidism
diminished concentration of parathyroid hormone in the blood
159
hypoparathyroidism: causes
```
surgical
autoimmune
DiGeorge
infiltration
familial forms
magnesium deficiency
```
160
hypoparathyroidism: symptoms
```
paraesthesia- abnormal sensation or prickles
convulsions
arrhythmia
tetany
numb
```
161
hypoparathyroidism: differential diagnosis
many other potential reasons calcium might be low
kidney disease, vit d malabsorption, drugs, CCB overdose
162
pseudohypoparathyroidism
resistance to PTH
| PTH levels okay, peripheral resistance
163
pseudopseudohypoparathyroidism
RARE
osteodystrophy without resistance of PTH
skeletal defects
164
hypoparathyroidism: treatment
calcium and vitamin D long term
165
hypocalcaemia
deficiency of calcium in the bloodstream
166
hypocalcaemia: causes
```
actual vitamin d deficiency
functional vitamin d deficiency
magnesium deficiency
hypoparathyroidism
pseudohypoparathyroidism
drug therapy
alkalosis
```
167
hypocalcaemia: due to actual vitamin D deficiency
dietary
lack of sunlight
malabsorption
168
hypocalcaemia: due to functional vitamin D deficiency
renal disease
| liver disease
169
hypocalcaemia: due to hypoparathyroidism
autoimmune
| post-surgery
170
hypocalcaemia: from drug therapy
bisphosphonates calcitonin
| anticonvulsant therapy
171
hypocalcaemia: by alkalosis
because albumin dissociates from hydrogen and picks up calcium
172
hypocalcaemia: symptoms
```
paraesthesia
convulsions
arrhythmia
tetany
numb
```
173
hypocalcaemia: signs
chvostek's sign:
-tap over facial nerve and look for spasm of facial muscles
trousseau's sign:
- inflate BP cuff to 20mmHg above systolic for 5 minutes
- hand will go into spasm
174
hypocalcaemia: treatment
admit if severe
| calcium replacement with calcium glucoronate
175
hypercalcaemia: main causes
90% are either malignancy- bone mets, myeloma, lymphoma
| or primary hyperparathyroidism
176
hypercalcaemia: other causes
```
thiazides
thyrotoxocosis
sarcoidosis
adrenal insufficiency
immobilisation
```
177
hypercalcaemia: symptoms
```
thirst
nausea
constipation
confusion
renal stones
ECG abnormalities- short QT
```
178
normal range of blood glucose
3.5-8mmol/L
179
diabetes mellitus
syndrome of chronic hyperglycaemia due to relative insulin deficiency or resistance
180
primary diabetes mellitus
type 1 or type 2 diabetes
181
secondary diabetes mellitus
pancreatic disease
endocrine disease
drug induced
maturity onset diabetes of youth
182
type 1 diabetes
beta cell destruction in islet of langerhans
insulin deficiency
183
type 1 diabetes: epidemiology
manifests in childhood
patient is usually lean
increased in those of northern european ancestry
184
type 1 diabetes: causes
autoimmune
185
type 1 diabetes: risk factors
family history
| associated with other autoimmune diseases
186
type 1 diabetes: pathophysiology
autoimmune destruction by autoantibodies of pancreatic insulin-secreting beta cells in the islets of langerhans
187
type 2 diabetes
combination of insulin resistance and less severe insulin deficiency
188
type 2 diabetes: epidemiology
- common in all populations of an affluent lifestyle
- usually diagnosed at an older age
- overweight around the abdomen
- prevalent in south asian, african and caribbean ancestry
189
type 2 diabetes: causes
decreased insulin secretion
increased insulin resistance
associated with obesity, lack of exercise, calorie and alcohol excess
polygenic disorder
190
type 2 diabetes: risk factors
family history
obesity
poor exercise
ethnicity
191
type 1 diabetes: presentations
leaner
| present with more marked polydipsia, polyuria, weight loss and ketosis
192
type 2 diabetes: presentations
overweight in abdominal area
193
type 2 diabetes: presentations
overweight in abdominal area
polydipsia, polyuria
weight loss and ketosis in advanced
194
type 2 diabetic retinopathy
microaneurysms are seen as tiny red dots:
- intramural pericyte death and thickening of basement membrane of small blood vessels
- reduction in junctional contact with endothelial cells
- fluid leakage
haemorrhages seen as blots:
- when there is a breach of the microaneurysms
- fluid is cleared into the retinal veins, leaving protein and lipid deposits
- these become hard exudates which are yellow/white
195
type 2 diabetic nephropathy
thickening of basement membrane causes glomerular damage
causes microalbuminuria
196
type 2 diabetic neuropathy
isolated mononeuropathies are thought to result from occlusion of vasa nervorum (arteries that supply peripheral nerves)
197
type 2 diabetes: infections
poorly controlled diabetes impairs the function of polymorphonuclear leucocytes and confers and increased susceptibility to infections
198
type 2 diabetes: investigations
HbA1c
random plasma glucose
fasting plasma glucose
oral glucose tolerance tests
199
type 2 diabetes: HbA1c
measured amount of glycated haemoglobin
pre-diabetes= 42-47 (6.1-6.4%)
diabetes= >48 (6.5%)
200
type 2 diabetes: random plasma glucose
>11.1mmol/L is diabetes
in symptomatic individuals- one abnormal result is needed
2 if they are asymptomatic
201
type 2 diabetes: fasting plasma glucose
>7mmol/L is diabetes
in symptomatic individuals- one abnormal result is needed
2 if they are asymptomatic
202
type 2 diabetes: oral glucose tolerance tests
diabetes diagnosis:
fasting >7mmol/L
2 hours after glucose >11.1mmol/L
203
type 2 diabetes: treatment
```
lifestyle and dietary changes
metformin
sulfonylurea
DPP-4 inhibitors
pioglitazone
triple therapy (sulfonylurea, DPP-4 inhibitors and pioglitazone)
insulin
secondary prevention
```
204
type 2 diabetes treatment: lifestyle and dietary changes
decreased carbs and sugar intake
nutrient load
BP control
hyperlipidaemia control
205
type 2 diabetes treatment: metformin
increases insulin sensitivity
helps lose weight
reduces rate of gluconeogenesis in the liver
reduces CVS risk
206
type 2 diabetes treatment: secondary prevention
```
eye screening
foot screening
kidney tests
BP checks
appropriate aggressive management
statins
```
207
ketoacidosis
biochemical triad of hyperglycaemia, ketonaemia and acidaemia
with rapid onset
208
ketoacidosis: causes
uncontrolled hyperglycaemia and catabolic state
undiagnosed diabetes
interruption of insulin therapy
stress of intercurrent illness
more likely in type 1
209
ketoacidosis: risk factors
```
stopping insulin
infection
surgery
MI
pancreatitis
undiagnosed diabetes
```
210
ketoacidosis: pathophysiology
- state of uncontrolled catabolism associated with insulin deficiency
- there is an increase in hepatic gluconeogenesis and reduced peripheral uptake by tissues
- ketones produced as body requires glucose in cells
- accumulation of ketone bodies produces metabolic acidosis
211
ketoacidosis: investigations
hyperglycaemia: blood glucose >11mmol/L
raised plasma ketones: >3mmol/L
acidaemia: pH <7.3
metabolic acidosis with bicarbonate: <15mmol/L
212
ketoacidosis: treatment
first priority= replace fluid loss and electrolytes:
- 0.9% saline, 500ml
- aim for fall in ketones of 0.5mmol/hr and rise in bicarb of 3mmol/hour
- when glucose hits 10-14, add glucose and insulin to prevent hypos
second priority= replace deficient insulin:
-actrapid 0.1u/kg/hr IV
213
hyperosmolar, hyperglycaemic state
life threatening emergency marked by hyperglycaemia, hyperosmolality and mild ketosis
uncontrolled type 2 diabetes
214
hyperosmolar, hyperglycaemic state: epidemiology
patients present in middle or later life
| undiagnosed diabetes
215
hyperosmolar, hyperglycaemic state: risk factors
infection- particularly pneumonia
consumption of glucose rich fluids
concurrent medication such as thiazide diuretics or steroids
216
hyperosmolar, hyperglycaemic state: pathophysiology
endogenous insulin levels are reduced but still sufficient to inhibit hepatic ketogenesis
but insufficient to inhibit hepatic glucose production
217
hyperosmolar, hyperglycaemic state: symptoms
```
dehydration
decreased level of consciousness
hyperglycaemia
hyperosmolality
no ketones
coma
bicarb is not lowered
```
218
hyperosmolar, hyperglycaemic state: diagnosis
blood glucose >11mmol/L
urine stick testing shows heavy glycosuria
high plasma osmolality
219
hyperosmolar, hyperglycaemic state: treatment
fluid replacement
low molecular weight heparin
restore electrolytes
220
hypoglycaemia
plasma glucose <3mmol/L
221
hypoglycaemia: diabetic causes
due to insulin or sulphonylurea treatment
increased activity, missing meals, accidental/nonaccidental overdose
222
hypoglycaemia: non-diabetic causes
EXPLAIN
```
EXogenous drugs (insulin, alcohol)
Pituitary insufficiency
Liver failure
Addison's disease
Islets cell tumour
Non-pancreatic neoplasm
```
223
hypoglycaemia: symptoms
autonomic= sweating, anxiety, hunger, tremor, dizziness
neuroglycopenic= confusion, drowsiness, visual trouble, seizures, coma
224
hypoglycaemia: diagnosis
fingerprick blood
drug history
general bloods
225
hypoglycaemia: treatment
oral sugar
long acting starch
if they cannot swallow- 50% glucose IV
IM glucagon if no IV access
226
ketoacidosis: symptoms
```
ketonuria
dehydration
drowsiness
vomiting
polyuria
confusion
abdo pain
coma
kussmaul breathing- deep and rapid to compensate (hyperventilating)
```
