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Hark and Paul's clinical review > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

Goitre

What is the differential diagnosis of a neck mass?

A

Mnemonic SLC VN (Slick V Neck)

  • Salivary: Sialadenitis, Salivary gland tumour
  • Lymphadenopathy: Infectious, Malignant, Granuomatous (sarcoidosis, tuberculosis)
  • Congenital: Thyroglossal cyst, Branchial anomalies
  • Vascular: Carotid artery aneurysm, Carotid body tumour, Jugular vein thrombosis
  • Neurogenic: Neural crest derivatives e.g. Schwannoma, Neurofibroma, Malignant peripheral nerve sheath tumours
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2
Q

Goitre

What is the differential diagnosis of a retrosternal mass?

A
  • Goitre
  • Thymoma
  • Lymphoma
  • Germ cell tumours e.g. teratomas, seminoma
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3
Q

Goitre

What are the causes of a goitre?

A
  • Simple goitre (iodine deficiency)
  • Physiological goitre (puberty, pregnancy)
  • Grave’s disease
  • Thyroiditis e.g. Hashimoto’s, De Quervain’s, Infectious, Radiation, Post-partum
  • Thyroid cyst
  • Thyroid cancer
  • Toxic adenoma
  • Single palpable nodule in multinodular goitre
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4
Q

Assessment of Thyroid State

What are the causes of hyperthyroidism?

A
  • Grave’s disease
  • Toxic adenoma
  • Toxic multinodular goitre
  • Thyroiditis
  • Drugs e.g. iodine, amiodarone, lithium
  • TSH secreting pituitary tumour (TSHoma)
  • Trophoblastic disease & Germ cell tumours
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5
Q

Assessment of Thyroid State

What are the causes of hypothyroidism?

A
  • Hashimoto’s thyroiditis
  • Idiopathic atrophy
  • Iatrogenic: Radioiodine treatment, Thyroidectomy
  • Iodine deficiency
  • Antithyroid drugs; lithium, amiodarone
  • Thyroiditis (all can cause transient hypothyroidism)
  • Hypothalamic or Pituitary disease
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6
Q

Cushing’s Syndrome

What are the causes of Cushing’s Syndrome?

A 
>ACTH dependent Cushing's syndrome:
-Cushing's disease (pituitary adenoma)
-Ectopic ACTH secretion (SCLC, carcinoid tumour)
>ACTH independent CUshing's syndrome:
-Exogenous steroid administration
-Adrenocortical adenomas/carcinomas
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7
Q

Acromegaly

What are the complications of acromegaly?

A
  • Hypertension
  • Impaired glucose tolerance (diabetes)
  • Cardiomegaly
  • Visual field defects
  • Tumours e.g. colonic polyps, uterine leiomyomata
  • Entrapment neuropathies e.g. carpal tunnel syndrome
  • Arthritis
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8
Q

Addison’s Disease

What are the causes of primary adrenal failure?

A
  • Autoimmune adrenalitis
  • Tuberculosis
  • Bilateral adrenalectomy
  • Haemorrhagic infarction e.g. Waterhouse-Friedrichsen syndrome (meningococcal sepsis), Bacterial sepsis, Thromboembolism disease, Thrombophilia, Antiphospholipid syndrome, Anticoagulation
  • Adrenal metastases
  • Infections e.g. HIV (CMV adrenalitis), Disseminated fungal infection
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9
Q

Hypopituitarism

What are the causes of pituitary failure?

A
  • adenoma, craniopharyngioma, cyst, metastases
  • Iatrogenic e.g. Pituitary surgery or radiotherapy
  • Empty sella syndrome (surgery, radiotherapy, infarction)
  • Pituitary Infarction e.g. Sheehan’s syndrome following postpartum haemorrhage
  • Pituitary apoplexy (sudden haemorrhage into pituitary gland)
  • Infiltrative disease e.g. sarcoidosis, haemochromatosis
  • Trauma, Subarachnoid haemorrhage
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10
Q

Addison’s Disease

What are the differential diagnoses of skin pigmentation?

A
  • Addison’s disease
  • Nelson’s syndrome
  • Ectopic ACTH syndromes
  • Haemochromatosis
  • Jaundice
  • Uraemia
  • Porphyria cutanea tarda
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11
Q

Gynaecomastia

What are the causes of gynaecomastia?

A
  • Cirrhosis
  • Hypogonadism (primary or secondary)
  • Androgen insensitivity syndromes (testicular feminization syndrome)
  • Tumours (testicular, adrenocortical ectopic HCG secreting)
  • Drugs (digoxin, spironolactone, cyproterone)
  • Chronic renal failure
  • Thyrotoxicosis
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12
Q

Neurofibromatosis

What are the clinical features of neurofibromatosis?

Name three causes of hypertension associated with neurofi bromatosis?

(pocketbook)

A

> Clinical Features:
-NF-1 (peripheral): Cafe-au-lait spots, Neurofibromata, Axillary/Inguinal freckling, LIsch nodules, Pulmonary fibrosis, Restrictive cardiomyopathy
-NF-2 (central): Acoustic neuroma (affecting CN 5-8), Meningioma, Ependymoma, Optic glioma (which also occur in 15% of NF-1).
Diagnostic Criteria:
-NF-1: 2 or more of >6 cafe-au-lait spots, >2 neurofibromata, >2 lisch nodules, axillary/inguinal freckling, first degree relative
-NF-2: bilateral VIII nerve involvement, first degree relative
————-
• Renal artery stenosis
• Phaeochromocytoma
• Coarctation of the aorta.

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13
Q

In hypopituitarism, in what order does hormone loss progress?

A

1) GH and FSH/LH
2) TSH
3) ACTH

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14
Q

How would you investigate a goitre / hyperthyroidism?

A 
>TSH; Free T3, T4
>TRAb (or TSI)
- TSH receptor TRAb's (TSI thyroid stimulating immunoglobulin in graves; sometimes in TMNG; sometimes a blocking TRAb in Hashimotos)
>Thyroid U/S
>Thyroid uptake scan
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15
Q

How would you investigate hypothyroidism?

A

> TSH (high); Free T4/T3
Anti TPO (thyroid peroxidase) and Anti thyroglobulin
-Thyroid peroxidase TPOAb (involved in Hashimotos and post-partum thyroiditis; some overlap in Graves)
-Thyroglobulin TgAb (released in both destruction Hashimoto and disordered growth of Graves)

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16
Q

Features of acromegaly?

A
  • hand shape: spade
  • axilla acanthosis nigricans
  • facies: frontal bossing
  • macroglossia
  • visual field defects
  • CCF, Organomegaly
  • signs of hypothyroidism
17
Q

What investigations for acromegaly?

A

IGF1 (increased)
OGTT (should suppress GH level)
MRI

18
Q

How to diagnose diabetes?

A

Fasting BSL > 7
Or
OGTT > 11

IGT: OGTT BSL 7-11

19
Q 
What class of OHG is metformin?
How does it work?
What are the side effects?
A
  • biguanide
  • increases insulin sensitivity, decrease hepatic glucose production; bonus wt loss
  • SE: lactic acidosis, B12 malabsorption

Don’t use in renal failure
eGFR

20
Q 
What are some sulfonylurea class OHG?
How do they work?
What are the side effects?
A
  1. Gliplizide, gliclazide (good for fat people)
  2. Increase insulin secretion from pancreatic B cells
  3. Hypoglycaemia, wt gain

Avoid in elderly or renal failure

21
Q
  1. What are examples of thiazolidenidiones?
  2. How do they work?
  3. What are the side effects?
A
  1. Pioglitazone
  2. Activates PPAR-gamma -> increases periph gluc uptake
  3. Fluid retention/CCF, increase bladder CA, Rosiglitazone increases CVD events, pio might be ok
22
Q
  1. What are some DPP4 inhibitors?
  2. How do they work?
  3. What are the side effects?
A
  1. The gliptins: sitagliptin, saxagliptin
  2. Inhibits DPP4, which breaks down GLP1: Slows gastric emptying, suppress glucagon
  3. Hypoglycaemia with sulfonylureas, N/V
23
Q
  1. Name one GLP-1 mimetic
  2. How does it work?
  3. What are the side effects?
A
  1. Exenatide
  2. Slows gastric emptying, suppressed glucagon
  3. Hypoglycaemia when used with sulfonylureas, N/V
24
Q

What does dapaglifozin do?

What are the side effects?

A

Inhibits glucose transport in the kidneys, leading to excretion
Side effects: UTI risk, euglycaemic ketoacidosis (withhold perioperatively or if fasting)

25
Q

How would you commence insulin therapy?

A

0.5 units/kg/day
With 40% being long acting
Aim BSL 4 - 7

26
Q

What are factors that contribute to hypoglycaemic episodes?

A
  • altered diet
  • injection errors
  • renal disease
  • exercise
27
Q

What is the Somogyi effect and how is it treated?

A

Rebound hyperglycaemia after nocturnal hypoglycaemia

Mx: reduce note Insulin dose

28
Q

What is the dawn phenomenon?

A

Morning hyperglycaemia without nocturnal hypo

Treat: increase Nocte insulin

29
Q

What are the criteria for micro, macro and nephrotic range proteinuria?

A

Micro: 30-300mg/day
Macro: >300mg/day
Nephrotic: >3g/day

30
Q

What are the investigations for diabetic nephropathy?

A
  • Urine ACR
  • 24hr urine collection for protein
  • EUC
  • renal ultrasound: look for small kidneys
  • hba1c
31
Q

How do you manage diabetic nephropathy?

A
  • control BP (Aim 125/75
32
Q

What are signs of diabetic retinopathy on fundoscopy?

A
  • dot and blot haemorrhages
  • hard and soft exudates (soft: cotton wool spots)
  • neovascularisatiom
33
Q

What is the usual order of progression of microvascular complications?

A
  • retinopathy
  • nephropathy
  • neuropathy
34
Q

What are the features of diabetic neuropathy?

A
  • sensory neuropathy/parasthesia
  • ulcers
  • Charcot foot
  • autonomic neuropathy: impotence, postural hypotension, delayed gastric emptying, bladder dysfunction
35
Q

How do you manage diabetic neuropathy?

A 
>Non pharm:
- podiatrist, orthotics, footwear
>Pharm:
- BSL control
- analgesia, adjuncts (pregabalin, TCA)
36
Q

How would you manage autonomic neuropathy in diabetes?

A
  • Postural hypotension: med review, stockings, fludrocortisone
  • Impotence: med review, exclude other causes, sildafenil, implant
  • Gastroparesis: promotility agents, such as metoclopramide
  • Large bowel: (constipation or diarrhea) loperamide, codeine, aperients
  • Bladder: self cath, regular toileting
37
Q

What investigations for osteoporosis?

A
  • BMD (-2.5 or -1.5 on steroids)
  • Ca and Vit D
  • PTH
  • LFT/ALP
  • TFT
  • EUC
  • EPG/IEPG
  • testosterone in males
38
Q

What are the management options for osteoporosis?

=========================

A

> Non pharm: prevent falls and fracture
Pharm:
- Ca and Vit D replacement
- bisphosphonates
- denosumab (use if CKD)
- raloxifene: SERM - reduces postmenopausal bone loss; decreased risk of breast Ca, higher risk of DVT - use if high risk of breast ca
- teriparatide: synthetic PTH - increases bone formation; side effect of sarcoma risk. (2nd line)

Hark and Paul's clinical review (12 decks)

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