Endocrinology Flashcards
Congenital adrenal hyperplasia
A.R
Most commonoly 21-hydroxylase deficiency
Low cortisol –> High ACTH
ACTH – Adrenal androgen produciton –> virilization of females
3 Types of Hormone
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
Impaired fasting glucose and IGT
IFG:
- 6.1 - 7.0
IGT:
7.8 - 11.1
Pendred’s syndrome
A.R.
Sesnorineural deafness.
Mild hypothyroid
Goitre
SNL deafness = worse after trauma.
Tx - thyroid hormone
+ cochlear implants
Hormones that act at cell surface MOA
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
Hormones of appetite/WL
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
Hormones in pregnancy
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
Growth hormne
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
Prolactin
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
Gynaecomastia
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
Thyroid hormone metabolism
95% boung to TBG/TBPA
T4 –> aT3 via D1/D2
T4 –> rT2 –> inative T2 via D3
D1/D2 inhibited bu:
- Illness
- propanolol
- propolythiouracil
- Amiodarone
RAAS
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.
Pituitary tumours
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
Pituitary apoplexy
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
Diabetes Insipidus - Cranial
Deficiency
Hypothalamaus damaged in some way therefore doesnt produce ADH.
Causes
- Idiopathic
- post head injury
- Pit surgeyr
- craniiopharyngioma
- Histiocytosis X
- DIDMOAD
- Haemochromatosis
ADH
peoduced by hypothalamus
- stored in posteropr pituitary
- insertion of AQP-2 channels in collectign duct
Diabetes insipidus - NEphrogenic
Resistance to aD~H
CauseS:
- Genetics - ADH Receptor
- HyperCa or HypoK+
- Drugs: Demelocycline/Li
- Tubulo-interstitial dx - obstruction/SCD/pyelonephritis
Diabetes insipidus geeral
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
Acromegaly
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
Octeotride
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
Hypopituitary - order of deficiency
Occurs in order
GH –> LH –> FSH –> ACTH –> TSH
only corticosteroid + T4 necessary for life
Mx:
- Replace glucocrticod 1st (as replaxcing thyroid could –> hypoadrenal crisis).
Low GH - Adult px
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
Thiazolinediones
PPAR - gamma agonist
reduce periheral insulin resistance
adverse effects:
- WG
- liver impairment –> monitor LFTs
- fluid retenetion
- Bladder Ca
GRaves Ee Dx Risk factors
Smoking
Radio-iodine treatment –> Worsenign or triggering
Toxic multinodular goitre
Thyrotoxicosis
Technetium scan –> patchy uptake
Tx of choice = radioiodine
Metabollic syndrome
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
Corticosteroid side effects
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
Hyperthyroidism ft
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
hypothyroidism ft
Ammennorhea/mennorhagia/infertility
Constipation/diarrhoea
Cramps/Raised CK/ MSK chest pain
Deafness. Ataxia/ Confusion/coma
Periobital oedema
Macrocytic anaemia / microcytic (mennorhagia
Dry/orange skin
Thyrotoxicosis causes
increased production:
- GRaves
- toxic multinodular goitre
- Toxic nodule
Normal prod: - Xs thyroxine ingestion - thyroiditis - ectopic -
Hashimotos thyroiditis
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
De Quervains thyrpoiditis
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.
Other causes of hypothyroid
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.
Hypothyroidism - Mx -
levothyroxine
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.
Subclinical hypothyroid
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
Graves dx
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
Carbimazole MOA
Blocks TPO binding to thyroglobulin
Propolythiouracil MOA
Blocks TPO binding to thyroglobulin and inhibits T4 –> T3
Thyroid storm
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.
Urinary urge incontinence Mx
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
Urinary stress incontinence mx
- pelvic muscle rtraining - 8 contractions TDS for 3/12
Surgical procedures
Amiodarone and the thyroid gland
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
Thyroid Cancer
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.
Cushing’s syndrome causes
Exogenous = most common
ACTH independent:
- Exogenous
- Adrenal adenoma/carcinoma
- Micronodular adrenal dysplasia
- carney complex
ACTH dependent:
- Cushing’s dx
- Ectopic - Small cell lung Ca
Pseudo cushings
mimics cushings
- EtOH xs or sev depression
- False + on Dex suppression trest
- Use insulin stress test.
Cushing syndrome inx
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.
Cushing Mx
Surgical
Medical = metyrapone
RT
Addisons dx
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
Primary hyperaldosteronism
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.
Congenital adrenal hyperplasia
21 yr old college brow
17 year old nerd
11 -
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
Hypoadrenalism
Primary:
- Addisons
- TB
- HIV
- Waterhouse-Friederich - haemorrhage post meningococcus septicaemia
- Antiphospholipid
- Mets
Secondary:
- Low ACTH - pit lesion
- Withdrawl of LT steroids.
Addisonian crisis
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
Autoimmune polyendocrinopathy
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
M.E.N
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
Hirsuitism causes
Ovarian:
- PCOS
- Virilizing tumour
Adrenal:
- CAH
- Cushings
- Adrenal Carcinoma
Drugs:
- phenytoin
- corticosteroids
- ciclosporin
- minoxidil
Others:
- Obesity
Hirsuitism assement + mx
Asssesment:
- Ferriman - Gallway
Mx:
- WL
- Cosemetic
- COCP (do not use dianette as LT –> increase VTE )
- fx of COCP –> Topical Eflornithine.
PCOS
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
Phaeochromacytoma
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
Disorders of Sex hormones
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
Kleinfelters
“Felter”
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
Kallman’s
X linked recessive
low GnRH
Q stem:
- Young MALE with ANOSMIA and DELAYED PUBERTY
- low FSH/LH
- Low Testo
- Hypogonadism
Androgen insensitivity syndrome
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
Disorders of sexual develoopment
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
Disorders of delayed puberty AND SST
Turners
Noonans
Prader-willi
Diabetes types
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
DB Diagnosis - BGL
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
DB Diagnosis - HbA1c
> = 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
DB type 1 Mx
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
DB type 2 Mx:
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
Criteria for GLP-1 use
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
ANti-DB drugs MOA and S.e
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
DB + HTN
ARGETS:
- 140/80
- End organ damage
- ACEI
DB foot dx
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 + " " " "
DB anti - platelets or statins
only antiplatelet if CVD
Only statin if QRISK >10% –> Atorvastatin 20mg
MODY
DB <25 yrs w/ +FHx
MODY 3
- majority
- HNF-1alpha gene
- Increase risk of HCC
Mody 2:
- defect in glucokinase gene
DB + DVLA
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
DKA
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
HHS
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
Hypoglycaemia causes
Insulinoma - c-peptide EtOH Self admin LFx Addisons Child --> Nesidioblastosis = beta cell hyperplasia/
Indications for parathyroidectomy in primary hyperparathyroidism
<50 Ca >0.25 mmol above ULN Sx Osteoperosis eGFR <60 Renal stones in presence of nephrocalcinosis on US or CT
What feature is most indicative of Graves?
Pretibial myxoedema
First line management of DIABETES in ACS
Metformin
Ci in heart fx and renal fx
What causes amennorhea in addissons
Hyperprolactinaemia
Causes of hypoglycaemia
EXPLAIN
Exogenous Pit insufficiency Liver fx Adrenak fx Insulinoma Non-pancreatic neoplasm
Barter vs gitelmanss
GITELMANS = LOW URINARY CA
Thyroid effect on prolactin?
Hypothyroidism can cause slightly raised prolactin
Myxoedema coma - profoud hypothyroidisn
Very low T4
Hypothetmia.
Decreased gcs
Heart failure
Mx
NG/Iv T3 at 2.5-5mcg TDS
Thyroid lymphoma treatment
Chemo and extrenal beam radiotherapy
Insulin stress test
Used to identify pituitary insufficiency
Give insulin and measure cortisol/GH –> In normal fn —> GH/cortisol increase
Recurrent hypoglycaemia - Inx
Glucose, Insulin and C-peptide during an attack
Manageent of infertility in PCOS?
Clomfene first line
Metformin - second line
DB management in preg
Try diet and lifestyle
BGL <7 –> Metformin
BGL >7 –> Metformin +/- insulin
Type 1 DB when to offer statin treatment
> 40 yrs
DB >10 yrs
established nephropathy
CVD risk factors
Aim for TSH in hypothyroid
NORMALISATION
0.5 - 2.5
