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MRCP > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

Congenital adrenal hyperplasia

A

A.R

Most commonoly 21-hydroxylase deficiency

Low cortisol –> High ACTH

ACTH – Adrenal androgen produciton –> virilization of females

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2
Q

3 Types of Hormone

A

Amine

  • chatecholamine, serotonin, thyroxine
  • Acts on cell surface –> 2nd messenger
  • Short half life

Peptdes:

  • Lots of hormones
  • Same MOA as Amne

Steroids
- Intracellular = lipid soluble –> bind to hromone receptor in cytoplasm –> Complex –> DNA
- Acts at DNA
0 Sald/sweet/sex

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3
Q

Impaired fasting glucose and IGT

A

IFG:
- 6.1 - 7.0

IGT:
7.8 - 11.1

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4
Q

Pendred’s syndrome

A

A.R.

Sesnorineural deafness.
Mild hypothyroid
Goitre

SNL deafness = worse after trauma.

Tx - thyroid hormone
+ cochlear implants

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5
Q

Hormones that act at cell surface MOA

A

cAMP

  • Hormone receptor = 7 domain trnasmembrane
  • Binding –> Gs or Gi –> inc/dec cAMP –> Adenyl cyclase
  • Ad (Beta)/ all pituitary except GH/PRL/Glucagon/ stomatostatin

Intracellular Ca release

  • Binding to Gq protein -> cytoplasmic PLC –> IP3–> Ca release from ER
  • Ad (alpha)/GnRH.TRH

Recepto TK

  • Receptor acts as enxyme itself –> phosphorylation cascade
  • Insulin/GH/PR:/ IGF
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6
Q

Hormones of appetite/WL

A

LEptin:

  • Decreases appetite
  • secreted from hypothalamus
  • Obesity leptin resistance

Peptde YY

  • Released from L cells of SI/LI
  • Decreases appetite

GLP-1

  • L cells
  • decreases appetite + insulin secretion

Oxyntomodulin:

  • L cells
  • Same action as GLP-1

Neuropeptide - Y:

  • Hypothalamus
  • Increases appetite

Ghrelin:

  • Released from stomach
  • trigers appetite
  • Decreased in gastric bypass
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7
Q

Hormones in pregnancy

A

PRL:

  • Increases w/ pregnanacy
  • Combines with oestrogen –> Lactation
  • Post partum –> surges of PRL + Oxytocin from nipple stimulation –> Lactation
  • PRL returnes to N weeks after borth despite breastfeeding

LH/FSH:
- Decrease during preg

Thyroid:

  • Increase in TBG –> Increase T3/T4 after 1st trimester
  • HCG = same alpha unit as TSH –> therefore can get thyrotoxicosis asso with HCG
  • T4 can X placenta
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8
Q

Growth hormne

A

secreted by somatotrophs of ant pituitary gland

Anabolic hormine

pulsatile secretion

Fn:

  • Acts on transmembran receptors - Repceptoor TK
  • Directly and ndirectly (IGF)

Increased secretion:

  • Excercise
  • Sleep
  • GnRH
  • Fastibg

Decrease secretion:

  • Glucose
  • Somatostatin
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9
Q

Prolactin

A

secreted by anterior pituitary
inhibited by Dopamine

Fn:

  • Stim Breast development
  • milk production
  • Decreases GnRH secretion
  • Stop action of LH/FSH on testes

Increased secretion caused by:

  • Prolactinoma
  • TRH
  • Prenancy
  • Oestrogens
  • Breast feeding
  • Sleep
  • MEtoclop/antipsychotics.phenothiazines
  • Stress/Ex
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10
Q

Gynaecomastia

A

increased oestrogen:Androgen

Causes:

  • Puberty
  • androgen deficiency - Kallmans/Kleinfelters
  • Testis fx
  • LFx
  • Testicular Ca –> Seminoma secretes HCG
  • Ectopic tumour
  • Hyperthyroid
  • HAemodialysis

Drugs causes:

  • Spironolactone
  • Cimetidine
  • Digoxin
  • Cannabis
  • Finasteride
  • Gosrellin
  • Oestrogen/Anabolic steroids
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11
Q

Thyroid hormone metabolism

A

95% boung to TBG/TBPA

T4 –> aT3 via D1/D2

T4 –> rT2 –> inative T2 via D3

D1/D2 inhibited bu:

  • Illness
  • propanolol
  • propolythiouracil
  • Amiodarone
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12
Q

RAAS

A

Out –> in of Adrenal cortex = G –> F —> R

Renin:

  • Stimulated by: decreased renal perf/low Na/ Beta-adrnoreceptors
  • Secreted by Juxtagomerular apparatus
  • Converts AT –> AT1

AT 1 –> AT2 by ACE in Lungs - note ACE also BD bradykinin
therefore ACEI –> bradykinin increase –> cough

AT2 actions:

  • VC
  • Increase aldosterone
  • Increase thirst.
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13
Q

Pituitary tumours

A

defined by size:

  • microadenoma <1cm
  • Macroadenoma >1cm

Defined by Fn:
- Secretory vs on-secretory

Prolactinoma = most common 
others:
- non-secreting adenoma
- GH adenoma
- ACTH secreting adenom a
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14
Q

Pituitary apoplexy

A

Sudden enlargement of pituitary following infarction or haemorrhage.

Ft:

  • SAH like headache
  • Vomitting
  • NEck stiffness (w/o meningitis sgns)
  • Bitemp superior hemianopia
  • Extra-occular nerve palsy
  • Pituitary insufficiency - e.g. hypotension - secondary to hypoadrenalism
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15
Q

Diabetes Insipidus - Cranial

A

Deficiency

Hypothalamaus damaged in some way therefore doesnt produce ADH.

Causes

  • Idiopathic
  • post head injury
  • Pit surgeyr
  • craniiopharyngioma
  • Histiocytosis X
  • DIDMOAD
  • Haemochromatosis
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16
Q

ADH

A

peoduced by hypothalamus

  • stored in posteropr pituitary
  • insertion of AQP-2 channels in collectign duct
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17
Q

Diabetes insipidus - NEphrogenic

A

Resistance to aD~H

CauseS:

  • Genetics - ADH Receptor
  • HyperCa or HypoK+
  • Drugs: Demelocycline/Li
  • Tubulo-interstitial dx - obstruction/SCD/pyelonephritis
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18
Q

Diabetes insipidus geeral

A

Ft - polyuria/polydipsia

inx:
- Plasma OSM increased + Urinary osm decreased

  • Urinary OSM >700 - XCLUDES di
  • Water deprivation test

Mx:

  • NEohrogenic: Thiazides and low NA/protein diet
  • Cranial: Desmopressin
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19
Q

Acromegaly

A

95% due to xs GH - secondary to pit tumour

OThers:
- Ectopic - pancreatinc Ca

6% assoc with MEN 1

Complications:

  • HTN
  • DB
  • Cardiomyopathy
  • colorectal Ca

Inx:

  • IGF-1 now 1st line –> if raised–> confirm with OGTT
  • OGTT - if >2 = positive
  • after this –> PITUITARY MRI = cause

Mx:

  • 1st line = transphenoidal surgery
  • 2nd line = octeotride = somatostatin analogue

others:

  • Bromocriptine - DA agonist
  • Pegvisomant = GH Receptor antag = OD S/c admin - howevere doesn’t decrease size
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20
Q

Octeotride

A

LA somatostatin anaologue
- Somatostatin secreted by D cells of pancreas

  • Inhibits GH/Glucagon.Insulin

S.E = Gall stones

uses:

  • Carcinoid
  • Acromegalu
  • Acute variceal bleead
  • Pancreatic surgery
  • refractory diarrhoea
  • VIPOMA
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21
Q

Hypopituitary - order of deficiency

A

Occurs in order

GH –> LH –> FSH –> ACTH –> TSH

only corticosteroid + T4 necessary for life

Mx:
- Replace glucocrticod 1st (as replaxcing thyroid could –> hypoadrenal crisis).

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22
Q

Low GH - Adult px

A 
loss of muscle mass/power
Increased fat 
Fatigueability/decreas ex tolerance 
poor mood/ conc / memory 
Osteoperosis 
Increased CV risk

MX:
- Replace if poor QOL + GH <9

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23
Q

Thiazolinediones

A

PPAR - gamma agonist

reduce periheral insulin resistance

adverse effects:

  • WG
  • liver impairment –> monitor LFTs
  • fluid retenetion
  • Bladder Ca
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24
Q

GRaves Ee Dx Risk factors

A

Smoking

Radio-iodine treatment –> Worsenign or triggering

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25
Q

Toxic multinodular goitre

A

Thyrotoxicosis

Technetium scan –> patchy uptake

Tx of choice = radioiodine

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26
Q

Metabollic syndrome

A

Increased waist circumference
TGs >1.7
HDL <1.03 M and <1.29 F

BP >130/85
DB os fasting >5.6

Raised uric acid
NAFLD
PCOS

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27
Q

Corticosteroid side effects

A

GLUCOCORTICOID - S.E:

IGT, increased appetite, WG
Cushings

osteoperosis, proximal myopathy, AVN of femoral head

immunosupression

insomina, mania, depression, psychosis

PUD, acute pancreatitis

Growth supression in child

ICH

Neutrophillia

MINERALCORTICOID SIDE EFFECT:

Fluid retention

HTN

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28
Q

Hyperthyroidism ft

A

Gynae - increase SHBG

GI - Vomitting/raised ALP

Muscle - proximal myopathy/periodic paralysis

Bone - osteoporosis

Neuro = Apathetic thyrotoxicosis

Eyes- thyroid eye dx

blood - leukopaeni/ microcytic anaemia

skin 0- urticarial

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29
Q

hypothyroidism ft

A

Ammennorhea/mennorhagia/infertility

Constipation/diarrhoea

Cramps/Raised CK/ MSK chest pain

Deafness. Ataxia/ Confusion/coma

Periobital oedema

Macrocytic anaemia / microcytic (mennorhagia

Dry/orange skin

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30
Q

Thyrotoxicosis causes

A

increased production:

  • GRaves
  • toxic multinodular goitre
  • Toxic nodule
Normal prod:
- Xs thyroxine ingestion 
- thyroiditis 
- ectopic 
-
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31
Q

Hashimotos thyroiditis

A

most common cause of hypothyroid in developed world

AI - associated with other AI Dx - anti-TPO ab
- also anti- Tg

in acute setting can cause hyperthyroid

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32
Q

De Quervains thyrpoiditis

A

PAINFUL goitre w/ RAISED ESR

follows viral infection

stages:

1) 3-6/52 hyperthyroid + raised ESR + painful goitre
2) 1-2/52 of euthyroid
3) wks - mnths of Hypothyroid
4) normal

Inx:
- Thyroud Scintography - globally decreased uptake

Mx:

  • self limiting
  • Thyroid pain –> ASA/NSAIDS
  • if sev –> steroid/I.S.
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33
Q

Other causes of hypothyroid

A

Iodine deficiency - most common in developing world

Reidels - PAINLESS goitre

Post-partum thyroiditis

Drugs:

  • Li
  • Amiodarone

Sick euthyroid - transient - everything low except TSH = inapprop. normal

Congenital hypothyroid:
- note T4 can X placenta - may not present till after births
Ft - prolonged neonatal jaundice/poor development/puffy face/SST
- Inx = Guthrie’s test.

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34
Q

Hypothyroidism - Mx -

levothyroxine

A

N ddose = 50-100 (reduce in elderly)

Afetr thyroxine dose change –. recheck at 8-12weeks.

Increase dose in pregnanct

S.e:

  • hyperthyroid
  • AF
  • decreasd bone mineral density
  • angina

Interaction:
- Fe –>decreased absorption.

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35
Q

Subclinical hypothyroid

A

TSH raised but T3/.T4 normal

Mx - TSH 4 - 10

  • <65 + sx –> levo
  • > 65 –> WW
  • Asx - rpt TFT 6/23

Mx TSH <4:

  • <70 –> tx
  • > 70 WW
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36
Q

Graves dx

A

most common thyrotoxicosis
30-40 yrs

Inx:

  • TSH antibody 90%
  • anti-TPO 75%

Mxx:
- propanolo initially for Sx control
- Carbimazole
(+/- replace) - note that just carbimazole is assoc with less side effects

Carbimazole –> AGRANULOCYTOSIS

  • Radio-iodine tx - is contraindicatioed if:
  • thyroid eye dx
  • Pregnanc - avoid 6/12 post tx
  • <16yrs
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37
Q

Carbimazole MOA

A

Blocks TPO binding to thyroglobulin

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38
Q

Propolythiouracil MOA

A

Blocks TPO binding to thyroglobulin and inhibits T4 –> T3

39
Q

Thyroid storm

A

precipitating events:

  • Surgeyr
  • infection
  • Trauma
  • high iodine load (e.g.CT)

Ft:

  • T = >38.5
  • Tachy
  • High BP
  • Confusion/agitated
  • HFx
  • Jaundice + Abnormal LFT

Mx:

  • Paracetamol
  • Tx precipitant
  • IV propranolol + propolythiouraxil
  • Dex

lugols iodine.

40
Q

Urinary urge incontinence Mx

A

First line

  • bladder retraining
  • diaries
  • 6 weeks

Second line:

  • anti muscarininc
  • Oxybutinin,, tolterodine or darifenacin
  • If CI/cannot tolerat antimuscarinic side effects - Elderly - Mirabegron = beta-3 agonist
41
Q

Urinary stress incontinence mx

A
  • pelvic muscle rtraining - 8 contractions TDS for 3/12

Surgical procedures

42
Q

Amiodarone and the thyroid gland

A

Hypothyroidism:

  • Wofl - chaikoff effect
  • high iodine content –> low thyroxine
  • Cont amiodarone
Hyperthyroid:
- 2 types - AIT1 and AIT2 
- AIT 1 has goitre, AIT 2 doesn't 
Mx:
- AIT1 = carbimaxzole 
- AIT 2 - steroids. 
- STOP AMIODARONE
43
Q

Thyroid Cancer

A

Papillary - 70%

  • young female
  • multiple follicles
  • good prognosi s
  • histology: papillary follicles _ pale nucleus

Follicular - 20%

  • Adenoma or Carcinoma
  • Histology = capsular invasion

Medulalry - 5%

  • MEN2 assoc
  • Produced by C cells –> Increased calcitonin

Anaplastic - 1%

  • Elderly female
  • Doesn’t respond to tx
  • local pressure sx –> Surgical tx.

Lymphoma:
- asssopc. with hashimotos.

44
Q

Cushing’s syndrome causes

A

Exogenous = most common

ACTH independent:

  • Exogenous
  • Adrenal adenoma/carcinoma
  • Micronodular adrenal dysplasia
  • carney complex

ACTH dependent:

  • Cushing’s dx
  • Ectopic - Small cell lung Ca
45
Q

Pseudo cushings

A

mimics cushings

  • EtOH xs or sev depression
  • False + on Dex suppression trest
  • Use insulin stress test.
46
Q

Cushing syndrome inx

A

Confirmatory tests:

  • overnight dex supress test
  • 24hr urinary cortisol

Localising test:
1) 09:00 & 00:00 ACTH level

2) low or high dose DST
- not supressed at LD = exogenous
- not supressed by LD but supressed by HD = cushing’s dx
- not supressed by either = ectopic

3) CRH stim test:
- pit sours - increase in cortisol
- if ectopic/adrenal - cortisol normal

4) Petrosal sinus sample.

47
Q

Cushing Mx

A

Surgical

Medical = metyrapone

RT

48
Q

Addisons dx

A

Hypotension with hyperkalaemia and hyponatraemia

Metabolic acidosis

Letheargy/weakness.salt craving

  • hyperpigmentat

Vitiligo

  • Femal –> loss of libido/pubic hair loss = DHEA deficiency as secreted by adnrelas in Female

Inx:

  • SST
  • if unavail 09:00 cortisol
  • > 500 unlikely adison
  • 100-500 - SST
  • <100 = def abnormal

Blods:
- High K+
Low NA - metab acidosis

Mx:
- steroid replace

Sick Day rules –> dbl hydrocortisone when sick

49
Q

Primary hyperaldosteronism

A

most commonly secodbary to B/L adrenal hyperplasia

Other causes:
- Adrenal hyperplasia/carcinoma

Ft:

  • HTN
  • High Na
  • Low K+

Inx:
- Aldosterone:Renin ratio

  • after CT/Adrenal vein sampling

x:
- Surgery - adrenal adenoma
MEdical = Spironolactone - if bilat/not for surg.

50
Q

Congenital adrenal hyperplasia

21 yr old college brow

17 year old nerd

11 -

A

21-hyrdroxylase deficiency:

  • 21yr old colledge bro
  • not slaty as gets what he wants –> low aldost
  • High testosterone –> + manly

17 Hydroxyalse deficiency

  • 17 yr old nerdy kid
  • not mascukine - low testosterone
  • salty as lives with parents - high aldosterone

11 hydroxylase deficiency:

  • 11 inch penis
  • Sa11ty - despite low alodost as body produces substance that is chemically similar
  • LOW ALDOST
51
Q

Hypoadrenalism

A

Primary:

  • Addisons
  • TB
  • HIV
  • Waterhouse-Friederich - haemorrhage post meningococcus septicaemia
  • Antiphospholipid
  • Mets

Secondary:

  • Low ACTH - pit lesion
  • Withdrawl of LT steroids.
52
Q

Addisonian crisis

A

Collapse/ Shock/pyrexia

Low BP/ Low Na/ High K+/ Low BGL

Causes:

  • Sepsi
  • surgery
  • Waterhouse-Freiderichsen
  • Steroid withdrwal

Mx:

  • 100 mch hydrocortisone
  • IVI - Resus - 1L NS 30-60’ –> 6 htl hydrocortisone until stable –> Cont PO replacement –> after 24 hr reduce to maintenance over 3-4/7
53
Q

Autoimmune polyendocrinopathy

A

Those with addissons dx assoc with other endocrine prob

APS type 1:

  • AR
  • rare
  • AIRE-1 gene
  • Chronic mucocutaneous candidiasis
  • Primary HypoPTH

ARS Type 2:
- more common
- HLA DR3/4
Addisonse + Thyroid DX or DB 1

54
Q

M.E.N

A

MEn 1 - 3 Ps

  • PArathryoid high –> high Ca - measure serum Ca
  • Pituitary lesions
  • Pancreas (insulinoma)
  • MEN 1 gene

MEN 2 - 2Ps

  • PTH
  • Phaeochromacytoma
  • RET oncogene

MEN 3 - 1 P

  • Phaeochromacutoma
  • RET oncogene
  • assoc with medullary thyroid Ca
55
Q

Hirsuitism causes

A

Ovarian:

  • PCOS
  • Virilizing tumour

Adrenal:

  • CAH
  • Cushings
  • Adrenal Carcinoma

Drugs:

  • phenytoin
  • corticosteroids
  • ciclosporin
  • minoxidil

Others:
- Obesity

56
Q

Hirsuitism assement + mx

A

Asssesment:
- Ferriman - Gallway

Mx:

  • WL
  • Cosemetic
  • COCP (do not use dianette as LT –> increase VTE )
  • fx of COCP –> Topical Eflornithine.
57
Q

PCOS

A 
Ft:
- hirsuitism
- decreased fertility 
0 menstrual change 
- obesity 
-  acanthosis nigricans

Inx:

  • Pelvic US
  • Bloods –> Raised LH:FSH Ratio
  • Check gor IGTT

Mx:

  • WL
  • COCP - regulate periods

1) COCP (co-cyprinidiol - high anti-androgen)
2) Topical Eflornithine
3) Spironolactone/Finasteride/F;umateride

Mx - infertility:

1) WL
2) CLOMIFENE +/- metformin
3) Gondotrophins

58
Q

Phaeochromacytoma

A

nb

Assoc w/ VHGL and MEN 2/3

Ft - Episodic:

  • Headache
  • flushing
  • HTN
  • Sweating
  • Anxiety

Inx:
- 24hr urinary METANEPHRINE

Mx - Medically optimise first:

  • ALPHA BLOCK 1st - phenylbenzamine
  • then beta block with propranolol

Mx definitive - Surgery !

10% BL
10% malignant
#10% extra-adrenal

59
Q

Disorders of Sex hormones

A

Kleinfelters - Primar hypogonadism:

  • LH up
  • Testo down

Kallmans - low GnRH

  • LH down
  • Testo down

Androgen insensitivity

  • LH up
  • Tetso N or up

Testo secreting tumour:

  • LH down
  • Testo up
60
Q

Kleinfelters

“Felter”

A

primary hypogonadism

47XXY

F - Fc of secondary sexual characteristics - facial hair small testes

E - Estradiol up

L - Long limbs

T - Testo low, tall/slim

E - Elevated LH/FSH

R - RAGE

61
Q

Kallman’s

A

X linked recessive

low GnRH

Q stem:
- Young MALE with ANOSMIA and DELAYED PUBERTY

  • low FSH/LH
  • Low Testo
  • Hypogonadism
62
Q

Androgen insensitivity syndrome

A

X linked recessive

End organ insensitivity

genetically male - with a female phenotype

Px - Phenotype female w/:

  • Primary amennorhea
  • Undescended testes
  • Breast development ]

Inx:
- Buccal smar or chromosome analysis

Mx:

  • Counselling –> raise a sfemale
  • b/l Orchidectomy
  • Oestrogen therapy
63
Q

Disorders of sexual develoopment

A

Androgen insensitivity:
- see othe rcard

5-alpha reductase deficiency:

  • 46 XY
  • Male that cant convert T –> DHT
  • ambiguous genitalia
  • Hypospadia
  • Virilization at puberty

Male Pseudohermaphrodite:

  • 46 XY
  • Testes present
  • Ext genital afemale or ambiguous
  • secondary to andogen insensitivity

Female pseudohermaphrodite:

  • 46 XX
  • OVaries present
  • Ext genitalia male or ambiguous.
  • Secondary to CAH

True hermaphrodite:

  • 46 XX or 47 XXY
  • Both ovaries and testes
64
Q

Disorders of delayed puberty AND SST

A

Turners

Noonans

Prader-willi

65
Q

Diabetes types

A

Type1:

  • Known
  • AI - Ab vs B cells
  • HLA DR4>DR3
  • if GAD/IAA Ab present – high risk of developing

Type 2 known

MODY:

  • Type 2 DB in young
  • px more sev –> e.g. DKA

LADA:
- DB1 px in adult

66
Q

DB Diagnosis - BGL

A

DB:

  • Fasting- =>7.0
  • Post prandial - => 11.1

IFG:

  • Fasting 6.1 –> 7.0
  • PP <7.8

IGT:

  • Fasting - <6.1
  • PP 7.8 –> 11.1

If Asx –> need 2x positive test
Sx –> 1x

67
Q

DB Diagnosis - HbA1c

A

> = 48

PRe diabetes = 41–> 47 or IFG
- Mx = WL/diet –> yrl bloods

Do not HbA1c in:

  • Pregnancy
  • haemoglobinopathies
  • IDA
  • Haemolytic anaemia
  • HIV
  • Children
  • CKD
  • On steroids
68
Q

DB type 1 Mx

A

HbA1c monitoring - every 6/12:
- aim <48

Self monitor BGL - >=4x daiy
- increased freq in illness/stress/preg/breastfed

BGL Targets:

  • waking: 5-7
  • premeal/other times 4-7

Mainstay = basal bolus - LA= glargine of determir
if BD - use Determir

If BMI =>25 –> + Metformin

69
Q

DB type 2 Mx:

A

Diet + WL

Metformin

add second if HbA1c =>58

Tatgets - based onTx:

  • Lifestyle - 48
  • Lifestyle + metformin - 48
  • On drug that has hypo s.e. - 53
  • Already on 1st line but needs second - 53

Tx algorithim - can take Metformin

Metformin –> >58 –> Metformin _ second agent –> >58 —> either insulin or triple therapy

If triple not effective and BMI >35 –> GLP-1

Tx Algorithim if Metformin CI/not tolerated:

glitazone/glitin/SU –> >58 –> dual therapy –> >58 –> insulin

70
Q

Criteria for GLP-1 use

A

Exanatide or Liraglutide

Triple therapy Fx and one of:
- BMI= >35
or
- BMI <=35 but occupation means insulin not tolerated

Cont Exenatide if:

    • =>11 mmol decrease in HbA1c
  • WL3% in 6/12
71
Q

ANti-DB drugs MOA and S.e

A

MEtfromin:

  • aAMPH
  • Increase Insulin sensitivity
  • decrease gluconeogenesis
  • Gastric upset –> decrease with MR
  • Lactic acidosis at eGFR <30
  • B12 deficiency
  • eGFR<30 = CI

Sulphonylurease:

  • ATP-K+ Channels
  • Inc Insulin secretion
  • Decrease gluconeogenesis
  • Hypoglycaemia
  • WG!!!
  • SIADH
  • Cholestasis –> liver Dysfn
Glitazones (Thiazolidenedione)
- PPAR-gamma agonist 
- Decreas einsulin resistance 
- Increase glucose metab 
- WG !!!!!
- Fluid oberload 
Liver dysfn 
- Bone #

DPP 4 inhiubitor - Gliptins:

  • Stops BD of GLP-1
  • Increase insulin secretion
  • inhibits glucagon
  • PANCREATITIS
  • weight neutral/loss

GLP-1 mimetic:

  • Criteria discussed in other slide
  • MOA - as per DPP4 inhib
  • HYPO!!!
  • WL !!!!
  • N/v
  • Exenatide –> sev pancreatitis/

SGLT - 2 inhibitor:

  • decrease glucose reabsorb
  • inc glucse urinary excretion
  • Recurrent UTI/genital infection
  • WL!!!!
  • normoglycaemic ketoacidosis
  • Increased amputation risk
  • Rise in cholesterol

Acarbose:

  • Alpha glucosidaswe inhibitor
  • stop BD carb
  • Flatulence
72
Q

DB + HTN

A

ARGETS:

  • 140/80
  • End organ damage
  • ACEI
73
Q

DB foot dx

A

NEuropathy or PAD

Screen annually:

  • pulses
  • 10g monofilament

Risk stratify:

Low risk:

  • NO RF
  • Only callous
Med:
- Deformity 
or 
- neuropathy 
or 
- non-CLI 
High:
- PRec ulcer
- prev amp 
- on RRT
NEuropasthy + non-CLI
- Neuropathy + callus or deformity 
- Non -SLI +    "          "         "       "
74
Q

DB anti - platelets or statins

A

only antiplatelet if CVD

Only statin if QRISK >10% –> Atorvastatin 20mg

75
Q

MODY

A

DB <25 yrs w/ +FHx

MODY 3

  • majority
  • HNF-1alpha gene
  • Increase risk of HCC

Mody 2:
- defect in glucokinase gene

76
Q

DB + DVLA

A

Can have HGV if on insulin or oral hypoclycaemics if meet strict criteria:

  • no sev hypo in 12/12
  • good hypo awareness
  • understands risks
  • good monitoring
  • no debilitating complications

Group 1 driver:

  • On insulin
  • =<1 Ep of hyppo req assisytance in 12/12
  • no visual impairment

On PO - if hypoglycaemic same as above

77
Q

DKA

A

Diagnosis:

  • BGL >11
  • pH<7.3
  • Urinary KEtones ++ or Keton >3mmol

Mx:

  • IVI (1 hr, 2,2,4,4,6
  • Replace K_ if <5.5 (3.5 –>5.5 40 mmol/L, <3.5 –> senior)
  • Insuline 0.1 units/kg/hr –> give 5% dex once BGL <15
  • cont LA insulin

Complicstions:

  • VTE/gastric stasis/arrhythmias
  • ARDS/AKI

Cerebral oedema = incorrect IVI

  • n+V/headaches/visual change/irritable
  • seen more in child
  • CT HEAD
78
Q

HHS

A

Hypovolaemia
BM>30
Osm>320

Mortality > DKA

Mx - IVI
- 0.9% NS hypotonic therefore good to correct Osm
- Can correct BGL by itself
aim for +ve 3-6L/12 hr (50% replace)
- if Achieve + fluid balance but osm doesn’t fall 0–> 0.45% NaCL

Monitoring:

  • Monitor OSM
  • Osm = 2xNA + Glucose + Urea
  • If OSm decrease too quick –> Cerebral pontine myelinosis.
  • N.B. Fall in OSM –> H2O moves intracellular –> rise in Na
  • allow for rise of Na of 2.4 with evere fall in BGL of 5.5
  • if Na rise >2.4 –> ?under fluid replace.

Aim BGL fall of 4-6mmol/ht

aim fall on Na of =<10mmol/hr

Insulin:

  • Wait as if give too early –> CV collapse
  • These pt = v insulin sensitive + IVI can cause BGL fall
  • only start at Px if sig ketonuria = 0.05 units/kg/hr
79
Q

Hypoglycaemia causes

A 
Insulinoma  - c-peptide
EtOH
Self admin 
LFx
Addisons
Child --> Nesidioblastosis = beta cell hyperplasia/
80
Q

Indications for parathyroidectomy in primary hyperparathyroidism

A 
<50
Ca >0.25 mmol above ULN 
Sx
Osteoperosis
eGFR <60
Renal stones in presence of nephrocalcinosis on US or CT
81
Q

What feature is most indicative of Graves?

A

Pretibial myxoedema

82
Q

First line management of DIABETES in ACS

A

Metformin

Ci in heart fx and renal fx

83
Q

What causes amennorhea in addissons

A

Hyperprolactinaemia

84
Q

Causes of hypoglycaemia

A

EXPLAIN

Exogenous
Pit insufficiency
Liver fx
Adrenak fx
Insulinoma
Non-pancreatic neoplasm
85
Q

Barter vs gitelmanss

A

GITELMANS = LOW URINARY CA

86
Q

Thyroid effect on prolactin?

A

Hypothyroidism can cause slightly raised prolactin

87
Q

Myxoedema coma - profoud hypothyroidisn

A

Very low T4
Hypothetmia.
Decreased gcs
Heart failure

Mx
NG/Iv T3 at 2.5-5mcg TDS

88
Q

Thyroid lymphoma treatment

A

Chemo and extrenal beam radiotherapy

89
Q

Insulin stress test

A

Used to identify pituitary insufficiency

Give insulin and measure cortisol/GH –> In normal fn —> GH/cortisol increase

90
Q

Recurrent hypoglycaemia - Inx

A

Glucose, Insulin and C-peptide during an attack

91
Q

Manageent of infertility in PCOS?

A

Clomfene first line

Metformin - second line

92
Q

DB management in preg

A

Try diet and lifestyle

BGL <7 –> Metformin
BGL >7 –> Metformin +/- insulin

93
Q

Type 1 DB when to offer statin treatment

A

> 40 yrs
DB >10 yrs
established nephropathy
CVD risk factors

94
Q

Aim for TSH in hypothyroid

A

NORMALISATION

0.5 - 2.5

MRCP (20 decks)

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