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Medicine > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

When would TBG be raised?

A

Pregnancy, oestrogen therapy (HRT, oral contraceptives), hepatitis

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2
Q

When would TBG be lowered?

A

Nephrotic syndrome, malnutrition (protein loss), drugs (androgens, corticosteroids, phenytoin), chronic liver disease, acromegaly

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3
Q

What thyroid function test results would you see is sick euthyroidism?

A

Everything is low

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4
Q

What would be a worrying result on an isotope scan of a thyroid?

A

A ‘cold’ nodule (decreased uptake of isotope) as 20% of these are malignant

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5
Q

What are the signs of someone with Hashimoto’s thyroiditis? Which demographic is most commonly affected?

A

Goitre
May be hypo or euthyroid
Commoner in women 60-70 y/o

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6
Q

Which antibodies are associated with Hashimoto’s thyroiditis?

A

Anti-TPO abs

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7
Q

If a patient is on amiodarone how often must you check their TFTs and why?

A

Every 6 months as amiodarone is like T4 so can cause hypothyroidism due to toxicity from iodine release (T4 release is inhibited)

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8
Q

What is the most common cause of hyperthyroidism?

A

Graves’

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9
Q

What is the pathophysiology behind Graves’ disease?

A

IgG autoAbs binding to and activating g-protein-coupled TSH (AKA thyrotropin) receptors
Can also react w/ orbital autoantigens

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10
Q

What effect does levothyroxine have on…

  • T4
  • T3
  • Thyro-globulin
A

Increases T4
Decreases T3
Decreases Thyroglobulin

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11
Q

Subacute de Quervain’s thyroiditis:

a) What tends to precede it?
b) How would you describe the goitre?
c) Would the patient have a temperature?
d) What would be the results on an isotope scan?
e) What is the treatment?

A

a) A viral infection
b) Painful and diffuse
c) Yes and a raised ESR
d) Low isotope uptake on scan
e) NSAIDs

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12
Q

What is a major side effect of carbimazole? What advice would you give to patients on it?

A

Agranulocytosis (decreased neutrophils - at risk of sepsis). Warn patient to get an urgent FBC if signs of infection

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13
Q

Why must you not give radioiodine in a patient with active hyperthyroidism?

A

Risk of thyroid storm

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14
Q

Name 3 causes of a diffuse goitre

A
  • Graves’
  • Hashimoto’s thyroiditis
  • Subacute (de Quervain’s) thyroiditis
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15
Q

Name 3 causes of a nodular goitre

A
  • Multinodular goitre
  • Adenoma
  • Carcinoma
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16
Q

How would poor compliance with thyroxine show on blood tests?

A

High TSH and normal T4

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17
Q

Name the 3 autoantibodies in thyroid disease

A
  • Anti-thyroid peroxidase (anti-TPO)
  • TSH receptor abs
  • Thyroglobulin abs
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18
Q

What is the other name for primary adrenocortical insufficiency?

A

Addison’s disease

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19
Q

What is the pathophysiology of Addison’s disease?

A

There is destruction of the adrenal cortex leading to glucocorticoid (cortisol) and mineralocorticoid (aldosterone) deficiency. Auto immunity is most common cause in the UK.

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20
Q

What is a cause of secondary adrenal insufficiency?
What happens to mineralocorticoid production?
Would the patient have hyperpigmentation and why?

A

Iatrogenic - due to long-term steroid therapy which suppresses the pituitary-adrenal axis

  • Mineralocorticoid production remains intact.
  • There is NO hyperpigmentation as ACTH is decreased
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21
Q

What happens to the following in Addison’s disease…

Potassium 
Sodium 
Glucose 
Calcium 
Urea
Eosinophils 
Red blood cells
A 
Raised potassium 
Decreased sodium 
Decreased glucose 
Raised calcium 
Raised urea 
Raised urea (uraemia)
Raised eosinophils (Eosinophilia)
Decreased red blood cells (anaemia)
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22
Q

Which autoantibody is found in 90% of patients with Hashimoto’s thyroiditis?

A

Anti-thyroid peroxidase (anti-TPO)

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23
Q

Which autoantibody is found in nearly all Grave’s disease patients?

A

TSH receptor antibodies

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24
Q

Which is the main test used to diagnose Addison’s disease?

A

Short ACTH stimulation test

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25
Q

What does the short ACTH stimulation test entail?

How do you interpret results?

A

Do plasma cortisol before and 30 minutes after Synacthen (synthetic ACTH) IM.
Cortisol would rise (>550 nmol/L) in normal individuals, but would not rise in people with Addison’s

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26
Q

Other than the short ACTH stimulation test, what other tests can you do in Addison’s disease?

A
  • ACTH 9am
  • 21- Hydroxylase adrenal autoantibodies in autoimmune disease
  • Plasma renin and aldosterone to assess mineralocorticoid status
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27
Q

What would 9am ACTH in someone with Addison’s disease be compared to someone in a secondary cause of adrenal insufficiency?

A

ACTH 9am is inappropriately high in Addison’s but is low in secondary causes of adrenal insufficiency.

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28
Q

What 2 treatments should be given to those with Addison’s disease?

A 
Replace steroids (hydrocortisone daily): avoid giving late as can cause insomnia. 
Give mineralocorticoids to correct postural hypotension, low sodium and high potassium E.G. Fludrocortisone
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29
Q

What happens to a patient is Addisonian crisis?

A

They go into SHOCK! - High HR; vasoconstriction; postural hypotension; oliguria; weak; confused; coma.

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30
Q

Give 3 causes of Addisonian crisis?

A
  • Steroids not being increased to cover stress
  • Forgotten tablets
  • Bilateral adrenal haemorrhage
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31
Q

What 3 biochemical tests should be ordered in Addisonian crisis?

A

Bloods for cortisol, ACTH & U+Es

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32
Q

What treatment should be given to patients who are experiencing an Addisonian crisis?

A

Hydrocortisone IV and an IV bolus (increases BP).

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33
Q

If you suspect an infection as the underlying cause in Addisonian crisis, what 2 samples should you send for culture?

A

Blood and urine samples.

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34
Q

When should you switch to oral steroids in someone being treated for an Addisonian crisis?

A

After 72 hours if the patient’s condition is good

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35
Q

What should you advise someone with Addison’s disease to do with their steroid intake if they plan to do strenuous exercise?

A

They should add 5-10 mg of hydrocortisone to their daily intake

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36
Q

What should you advise someone with Addison’s disease to do with their steroid intake if they have febrile illness, injury or stress?

A

They should double their steroid intake

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37
Q

What metabolic disturbance can Cushing’s syndrome cause?

A

Hypokalaemic metabolic alkalosis

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38
Q

Define Cushing’s syndrome

A

Chronic glucocorticoid XS and loss of circadian rhythms of cortisol secretion.

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39
Q

What is the main cause of Cushing’s syndrome?

A

Oral steroids

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40
Q

What is the most common cause of Cushing’s disease?

A

XS glucocorticoid due to a pituitary adenoma

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41
Q

How can an ACTH-secreting pituitary adenoma affect the adrenals in Cushing’s disease?

A

Bilateral adrenal hyperplasia

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42
Q

What 2 malignancies that commonly cause ectopic ACTH production?

A

Small cell lung cancer and carcinoid tumours

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43
Q

What would change in the skin of someone who has ectopic ACTH production?

A

Pigmentation!!

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44
Q

What happens to ACTH levels in ACTH-independent causes of Cushing’s syndrome?

A

ACTH decreases due to negative feedback.

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45
Q

Is McCune Albright syndrome a ACTH dependent or independent cause of Cushing’s syndrome?

A

ACTH-independent

46
Q

List as many symptoms of Cushing’s syndrome as you can

A
  • Increased weight
  • Mood change
  • Proximal weakness
  • Irregular menses
  • Hirsutism
  • ED
  • Acne
  • Recurrent Achilles tendon rupture
  • Central obesity
  • Moon face
  • Buffalo hump
  • Striae
  • Osteoporosis
  • Increased BP
  • Increased glucose
  • Infection prone
47
Q

What is the treatment for Cushing’s disease?

A

Trans-sphenoidal removal of pituitary adenoma in Cushing’s disease.

48
Q

What are the 3 treatments for adrenal carcinoma?

A
  • Adrenalectomy
  • Radiotherapy
  • Adrenolytic drugs (mitotane)
49
Q

What is the overnight dexamethasone suppression test used for?

A

To diagnose Cushing’s syndrome.

50
Q

How do you conduct the overnight dexamethasone suppression test and how do you interpret the results?

A

The patient has 1mg PO of dexamethasone then serum cortisol at 8am - there is no suppression in Cushing’s.

51
Q

In which 4 circumstances may you get a false positive overnight dexamethasone suppression test?

A

Pseudocushing’s…

1) Depression
2) Obesity
3) Alcohol XS
4) Inducers of liver enzymes

52
Q

The overnight dexamethasone suppression test has come back positive - what tests do you do next in this patient with suspected Cushing’s syndrome?

A

48 hr dexamethasone suppression test and midnight cortisol.

53
Q

Localisation tests…
A patient with suspected Cushing’s syndrome has their plasma ACTH measured. It comes back as being undetectable - what is the next investigation you should do?
If this investigation comes back negative, what should you do next?

A

CT/MRI to look for an adrenal tumour.

If no mass is found, do adrenal vein sampling.

54
Q

Localisation tests…
A patient with suspected Cushing’s syndrome has their plasma ACTH measured. It comes back as being detectable - what is the next test you should do?

How do you carry this test out? How can you interpret this result?

A

High dose suppression test/ CRH test - measure cortisol at 2 hours - cortisol is increased in pituitary disease but NOT with ectopic ACTH production.

55
Q

Generally, if cortisol responds to manipulation in tests for Cushing’s syndrome/disease, which diagnosis does it point towards? Which 2 investigations should you do to investigate?

A

Suggests Cushing’s disease - should then do an MRI of the pituitary and consider bilateral inferior petrosal sinus blood sampling

56
Q

Which investigation can you use to hunt for an ectopic source of ACTH?

A

IV contrast CT of chest, abdo and pelvis.

57
Q

Name 5 causes of hypocalcaemia that would present with increased phosphate levels?

A
  • CKD
  • Hypoparathyroidism
  • Pseudohypoparathyroidism
  • Acute rhabdomyolysis
  • Hypomagnesaemia
58
Q

What is the treatment of mild hypocalcaemia?

A

Give calcium

59
Q

What is the treatment of hypocalcaemia in CKD?

A

Alfacalcidol (a vitamin D analogue)

60
Q

How do you treat severe hypocalcaemia?

A

Calcium gluconate IV

61
Q

What are the features of hypocalcaemia?

A

S: Spasms
P: Perioral paraesthesia
A: Anxious, irritable, irrational
S: Seizures
M: Muscle tone increases in smooth muscle
O: Orientation impaired and confusion
D: Dermatitis
I: Impetigo herpetiformis (reduced Ca2+ and pustules in pregnancy - rare and serious)
C: Chvostek’s sign; choreoathetosis (chorea and twisting); cataract (if chronic); Cardiomyopathy (long QTi on ECG)

62
Q

What is Trousseau’s sign?

A

On inflating the cuff, the wrist and fingers flex and draw together (carpopedal spasm)

63
Q

What is Chvostek’s sign?

A

Tapping over parotid (facial nerve) causing facial muscles to twitch

64
Q

Name as many features as you can of hypercalcaemia

A

Bones, stones, groans, psychic moans.

Constipation, polyuria, weight loss.

65
Q

What may you see on ECG of someone with hypercalcaemia?

A

Decreased QT interval

66
Q

A patient is found to have hypercalcaemia with normal urea levels. What is the likely cause?

A

Cuffed specimen

67
Q

A patient’s Ca2+ is >3.5 mmol/L and they are symptomatic. What treatment do you give if they are…

a) Dehydrated
b) You want something to prevent bone resorption
c) Have cancer
d) Have sarcoidosis

A

a) Give IV saline 0.9%
b) Bisphosphonates e.g. Zoledronic acid inhibits osteoclasts
c) Chemo
d) Steroids

68
Q

Name 5 things that can affect the hypothalamus and consequently cause hypopituitarism

A
  • Kallman’s syndrome
  • Meningitis
  • TB
  • Tumour
  • Ischaemia
69
Q

Name 2 things that can affect the pituitary stalk and consequently cause hypopituitarism?

A

Craniopharyngioma, carotid artery aneurysm

70
Q

Name 2 things that can affect the pituitary and consequently cause hypopituitarism

A

Pituitary apoplexy, irradiation

71
Q

Name 5 effects of low growth hormone secondary to hypopituitarism

A
  • Central obesity
  • Atherosclerosis
  • Decreased strength
  • Osteoporosis
  • Decreased glucose
72
Q

Name 4 effects of low FSH/ LH secondary to hypopituitarism

A

Oligomenorrhoea, osteoporosis, ED, Hypogonadism

73
Q

What may happen to prolactin levels in hypopituitarism?

A

They may be raised due to low dopamine levels

74
Q

What type of anaemia may you see in someone with hypopituitarism?

A

Normochromic, normocytic anaemia

75
Q

Name 1 test that can be used to investigate suspected hypopituitarism
How is this test conducted? What do you have to tell the patient beforehand?

A

Insulin tolerance test
IV insulin is given to patient which causes hypoglycaemia. This stress should increase cortisol and GH secretion in a normal person. The patient must be fasted.

76
Q

What medication can you give someone experiencing low GH?

A

Somatotrophin (mimics GH)

77
Q

Name 2 treatment options for someone who has chronic hyponatraemia and is asymptomatic?

A

Fluid restriction and sometimes a ADH antagonist (demeclocycline) may be needed

78
Q

What treatment should you give to someone who has acute/ symptomatic/ dehydrated hyponatraemia?

A

Rehydrate them with 0.9% saline.

79
Q

Why must you not correct hyponatraemia rapidly?

A

Risk of central pontine myelinolysis

80
Q

What are ‘vaptans’? What do they do? Name 2 types of hyponatraemia they may be used for?

A

They are vasopressor (ADH) receptor antagonists which promote water excretion without loss of electrolytes.
Can be used to treat hypervolaemic and euvolaemic hyponatraemia.

81
Q

What 4 criteria must be met to diagnose SIADH?

A
  • Concentrated urine (high sodium and high osmolality)
  • Hyponatraemia
  • Low plasma osmolality
  • Without hypovolaemia, oedema or diuretics
82
Q

What is a malignant cause of SIADH?

A

Small cell lung cancer

83
Q

What are the 4 treatment options for SIADH?

A
  • Restrict fluid
  • Salt
    +/- loop diuretics if severe
  • Vaptans
84
Q

What electrolyte abnormality can diabetes insipidus lead to? When should you suspect it? Name 2 causes of it.

A

Can lead to hyponatraemia
Suspect if large urine volume
May follow head injury or CNS surgery

85
Q

Name 2 treatments for hypernatraemia.

Which other treatment would you give if the patient is hypovolaemic?

A

H2O orally.
If this doesn’t work, give glucose 5% IV slowly (guided by urine output and plasma Na+)
Use 0.9% saline IV if hypovolaemic

86
Q

What would you expect to happen to the following in hyperaldosteronism…

  • Sodium
  • Water
  • Renin release
A
  • Increased Sodium
  • Water retention
  • Decreased Renin release
87
Q

When should you consider hyperaldosteronism in a patient?

A

If they are hypertensive (not always!), hypokalaemic (not always!) or alkalotic but not on diuretics.

88
Q

What is the most common cause of hyperaldosteronism? What is another name for this?
What is the 2nd most common cause?

A

Solitary aldosterone-producing adenoma AKA Conn’s syndrome

Bilateral adrenocortical hyperplasia

89
Q

In which 3 cases should you consider Conn’s syndrome?

A

1) HTN w/ low potassium
2) Refractory hypertension
3) Hypertension before 40 years old

90
Q

What must you be wary of if you are doing an MRI to find a cause for hyperaldosteronism?

A

You might find adrenal incidentalomas that are common but not the actual cause

91
Q

What should you do if you find a unilateral adenoma of the adrenals on MRI? What is a positive result? What is the treatment?

A

Do adrenal vein sampling. If 1 side reveals increased aldosterone production then it is an adenoma and it should be surgically excised.

92
Q

Name a differential diagnoses other than adenoma and bilateral adrenal hyperplasia that could cause hyperaldosteronism with no nodules found on MRI?

A

Renal artery stenosis

93
Q

What are the treatment options for adrenal hyperplasia?

A

Spironolactone, amiloride or eplerenone (new selective aldosterone receptor antagonist that does NOT cause gynaecomastia

94
Q

What surgery is used in the treatment of Conn’s? What treatment must you give to the patient beforehand and why?

A

Laparoscopic adrenalectomy

Give spironolactone for 4 weeks pre-op to control BP and potassium.

95
Q

What are the 4 ‘10%’ rules in phaechromocytoma?

A
  • 10% malignant
  • 10% bilateral
  • 10% familial
  • 10% extra-adrenal
96
Q

What is the triad in phaechromocytoma?

A

Sweating
Episodic headache
Tachycardia

97
Q

Where do phaechromocytomas arise from normally?

A

Arise from sympathetic paraganglia cells found within the adrenal medulla.

98
Q

Name 5 things that can lead to acute hypertensive crisis in someone with a phaechromocytoma?

A
  • Stress
  • Abdo palpation
  • Parturition
  • GA
  • Contrast media
99
Q

Name 5 symptoms of an acute hypertensive crisis in someone with a phaechromocytoma?

A
  • Pallor
  • Pulsating headache
  • HTN
  • Feels ‘about to die’
  • Pyrexia
100
Q

List 4 things you may see on the ECG of someone with phaechromocytoma

A

1) Signs of LVF
2) Increased ST elevation
3) VT
4) Cardiogenic shock

101
Q

What medications must you give to someone prior to the surgery needed to treat their phaechromocytoma and why?

A

a blocker THEN b blocker to avoid crisis from unopposed a-adrenergic blockade.

102
Q

What 2 things must you monitor post-op in someone with phaechromocytoma? How long must you follow up these patients?

A

1) 24 hr urine metadrenalines 2 weeks post-op
2) Monitor BP as there is a risk of this dropping
Life-long follow up as malignant recurrence may present late.

103
Q

What tests should you do in someone with a phaechromocytoma?

A

Plasma + x3 24 hour urines for free metadrenaline and normetadrenaline +/- clonidine suppression test if borderline.

104
Q

List 5 symptoms of PCOS

A
  • Secondary oligo- or amenorrhoea
  • Infertility
  • Obesity
  • Acne
  • Hirsutism
105
Q

What imaging would you do in someone with suspected PCOS? What may you find?

A

An ultrasound scan - bilateral polycystic ovaries.

106
Q

What would happen to the following in someone with PCOS…

  • Testosterone
  • Sex hormone binding globulin
  • LH : FSH ratio
  • TSH
  • Lipids
A
  • High Testosterone
  • Low Sex hormone binding globulin
  • High LH : FSH ratio
  • TSH: could be low as hypothyroidism is common in PCOS
  • Dyslipidaemia
107
Q

What 4 medications can be used for PCOS and why?

A
  • Metformin: may restore cycles and fertility and helps insulin resistance
  • COCP: can cause ovarian androgen suppression
  • Can add spironolactone if not working: An androgen receptor blocker
  • Co-cyprindicol can be used to treat hirsutism and acne (combo of oestrogen and anti-androgen)
108
Q

What is pituitary apoplexy?

A

Sudden endocrine crisis due to haemorrhage/ ischaemic infarction of gland.

109
Q

Name 4 potential symptoms of pituitary apoplexy

A
  • Sudden, severe headache
  • Visual field defects
  • III/ IV/ VI CN palsies
  • +/- meningeal irritation
110
Q

What treatment is necessary for pituitary apoplexy and which treatment may be required?

A

IV hydrocortisone ASAP

May need decompressive surgery

111
Q

What is the criteria for diagnosing PCOS? How many of the criteria needs to be met?

A

2/3 needed for diagnosis:

  • Oligo/ amenorrhea
  • Hyperandrogenism (clinical or biochemical)
  • Polycystic ovaries on US + exclusion of other disorders

Medicine (15 decks)

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