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3B General Care > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

Disease by organ

pituitary and hypothalamus

A
  • hyperprolactinaemia
  • hypopituitarism
  • pituitary tumours
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2
Q

Disease by organ

parathyroid glands

A

hyperparathyroidism

hypoparathyroidism

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3
Q

Disease by organ

breast

A

hyper prolactinaemia

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4
Q

Disease by organ

Adrenals

A

addison’s disease
cushing’s syndrome
conn’s syndrome
phaeochromocytoma

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5
Q

Disease by organ

Ovaries

A

PCOS
Menopause
Subfertility

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6
Q

Disease by organ

Bone

A

Osteoporosis

Osteomalacia

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7
Q

Disease by organ

Testes

A

Sub-fertility

Testicular failure

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8
Q

Disease by organ

Kidneys

A

renin-dependent hypertension

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9
Q

Disease by organ

Pancreas

A

Type 1 DM

Type 2 DM

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10
Q

Disease by organ

Thyroid

A

Hyperthyroidism
hypothydroidism
Goitre
Carcinoma thyroid

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11
Q

Hormones produced by the anterior pituitary

  • stimulate peripheral glands and tissues
A
  • GnRH (LHRH) (Gonadotrophin releasing hormone/ Lutenising hormone releasing hormone)
  • GHRH (Growth hormone releasing hormone)
  • Dopamine
  • TRH (thyrotrophin-releasing hormone)
  • CRH

(Somatostatin- depresses secretion of GHRH, dopamine, TRH)

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12
Q

Hormones secreted by the posterior pituitary

  • storage organ
A

Vasopressin (renal tubules)
Oxytocin (breasts/uterus)

(produced in supraoptic and paraventricular nuclei of hypothalamus

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13
Q

GnRH pathway

A

GnRH (LHRH) (anterior pituitary)

–> LH + FSH

–> Ovaries + testes

–> Androgen/ Sperm, Oestrogens/Ovaries

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14
Q

GHRH pathway

A

Secreted by anterior pituitary

–> GH

-> Liver

–> Growth (via IGF)

suppressed by somatostatin

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15
Q

Dopamine pathway

A

Secreted by anterior pituitary

–> Prolactin

–> Breasts/Gonads

–> Lactation

suppressed by somatostatin

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16
Q

TRH Pathway

A

secreted by anterior pituitary

–> TSH

–> Thyroid

–> Thryoxine

Suppressed by somatostatin

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17
Q

CRH pathway

A

Secreted by anterior pituitary

–> ACTH

–> Adrenals

–> Steroids

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18
Q

Pituitary space occupying lesions and tumours

A

most commonly benign adenomas

symptoms arise from inadequate hormone production, excess hormone secretion or from local tumour effects

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19
Q

Under production in pituitary SOL

A

disease at hypothalamic or putuitary level

results in clinical features of hypopituitarism

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20
Q

Overproduction in pituitary SOL

A
  • Growth Hormone excess –> acromegaly in adults/ gigantism in children
  • prolactin excess - causing galactorrhoea or clinically silent
  • excess ACTH secretion - Cushing’s disease or Nelson’s syndrome
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21
Q

Local effects in pituitary SOL

A
  • optic chiasm –> bitemporal hemianopia
  • cavernous sinus with III, IV and VI cranial nerve lesions
  • bony structures and the meninges causing headache
  • hypothalamic structures - obesity, altered appetite and thirst, precocious puberty
  • ventricles- interruption of CSF flow and hydrocephalus
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22
Q

Hypopituitarism

A

Multiple deficiences = tumour growth or destructive lesion
- progressive loss of function with GH and gonadotrophins being affected first and TSH & ACTH last

  • hyperprolactinaemia occurs early becuase of loss of tonic inhibitory control by dopamine
  • pan hypopituitarism is a deficiency of all anterior pituitary hormones
  • vassopressin and oxytocin secretion is only affected if the hypothalamus is involoved
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23
Q

Aeitology of Hypopituitarism

A

Neoplastic - primary/secondary/lymphoma
Infective - basal meningitis (TB)/encephalitis/syphilis
Vascular - pituitary apoplexy/ Sheehan’s syndrome/ carotid artery aneurysm
Immunological - pituitary antibodies
Congenital - kallmann’s syndrome
Traumatic- skull fracture/ surgery
Infiltrations- sarcoidosis/haemochromatosis
Others- radiation/chemo/empty sella syndrome
Functional - anorexia/ starvation/ emotional deprivation

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24
Q

Clinical features of hypopituitarism

A

Gonadotrophin deficiency - loss of libido/amenorrhea/ erectile dysfunction

Hyperprolactinaemia - galactorhhoea & hypogonadism

GH deficiency - short strature, clinically silent in adults

Secondary hypothyroidism & adrenal failure –> tiredness, slowness of thought and action, mild hypotension

long standing hypopituitarism - hairlessness

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25
Q

Congenital deficiency of gonadotrophin-releasing hormone
(GnRH)

Kallmann’s syndrome

A
  • anosmia
  • colour blindness
  • cleft palate
  • renal abnormalities
  • male hypogonadism
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26
Q

Sheehan’s syndrome

A

pituitary infarction following severe post partum haemorrhage

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27
Q

pituitary apoplexy

A

rapid enlargement of a pituitary tumour due to infarction of haemorrhage

  • severe headache and sudden severe visual loss
  • sometimes followed by acute life threatening hypopituitarism
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28
Q

Empty sella syndrome

A

sella turcia (bony shell around pituitary
appears empty on imaging
pituitary may be placed eccentrically - function normal
or
pituitary atrophy - after injury/ surgery/radiotherapy
and associated hypopituitarism

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29
Q

INvestigating hypopituitarism

A
  • each axis
  • normal gonadal function suggests multiple defects of anterior pituitary is unlikely
  • measure basal hormone levels and stiumlatory test
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30
Q

Management of hypopituitarism

A
  • steroid and thyroid hormones are essential
  • androgens and oestrogens are replaced for symptomatic control
  • LH & FSH given if fertility is desirable
  • GH given to growing children
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31
Q

Warnings in management of hypopituitarism

A
  • thyroid replacement should not commence until normal gluccorticoid function has been demonstrated/ replacement steroids have started –> otherwise may cause adrenal crisis
  • glucocorticoid deficiency masks impaired urine concentrating ability
  • diabetes insipidus is apparent after steroid replacement
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32
Q

Pituitary hypersecretion syndromes

pituitary growth hormone

A
  • secreted in a pulsatile fashion- also stimulated by Ghrelin (Secreted by the stomach)
  • acts indirectly by inducing insulin-like growth factor (liver)
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33
Q

CLinical features of pituitary growth hormone

acromegaly/ gigantism

A
  • tumour expansion- headache/visual field loss/ hypopituitarism
  • changes in physical features and appearance - compare to old pictures- growth of liver, muscle, bone or fat
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34
Q

INvestigations in pituitary hypersecretion syndromes

A
  • plasma GH
  • serum IGF-1
  • Glucose tolerance test- if positive failure of normal suppression of serum GH
  • MRI
  • plot visual field defects
  • serum prolactin
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35
Q

Symptoms of acromegaly

A

changes in appearance

  • increased size of hands/feet
  • headaches/ visual field changes/
  • excessive sweating
  • tiredness
  • weight gain
  • amenorrhoea/oligomenorrhea
  • galactorrhoea
  • impotence/ loss of libido
  • goitre
  • deep voice
  • breathlessness
  • pain/tingling in hands
  • polyuria/ polydipsia
  • muscular weakness
  • joint pain
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36
Q

Signs of acromegaly

A
  • prominent supraorbital ridge
  • prognathism
  • interdental separation
  • macroglossitis
  • hirsuitism
  • thick greasy skin
  • spade like hands or feet- tight rings
  • carpal tunnel syndrome
  • visual field defects
  • galactorrhoea
  • hypertension
  • oedema
  • heart failure
  • arthropathy
  • proxmial myopathy
  • glycosuria
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37
Q

Management of acromegaly

A

reduce serum IGF-1

  • transsphenoidal surgical resection - complications = hypopituitarism, diabetes insipidius, CSF rhinorrhoea and infection)
  • medical therapy when surgery has failed
    • somatostatin analogues - pcterotide and lanreotide
    • dopamine agonists - bromocriptine or cabergoline
  • pegvisomant
  • external radiotherapy
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38
Q

Hyper prolactinaemia

A

normally under tonic inhibition by dopamine from the hypothalamus
- physiological increase in serum prolactin during pregnancy, lactation and severe stress

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39
Q

Aetiology of prolactinaemia

A
  • prolactinoma
  • pituitary/hypothalamic tymours (interfering with dopamine inhibition of prolactin release)
  • primary hypothroidism (high TRH stimulate prolactin)
  • drugs - metoclopramide, phenothiazides, oestrogens, cimetidine,
  • PCOS
  • acromegaly
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40
Q

Clincial features of hyperprolactinaemia

A
  • galactorrhoea
  • oligo or a mennorrhoea
  • decreased libido, subfertility or erectile dysfunction
  • if pituitary tumour- headache and visual field defects
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41
Q

investigations of hyperprolactinaemia

A
  • serum prolactin level (at least 3)
  • thyroid function tests
  • MRI of pituitary
  • pituitary function tests and visual fields
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42
Q

Management of hyperprolactinaemia

A
  • withdraw any drugs that could be causing (metoclopramide, phenothiazides, oestrogens, cimetidine)
  • dopamine agonist - cabergoline/ bromocriptine
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43
Q

Hypothyroidism

A

primary from thyroid gland disease

secondary to hypothalamic or pituitary disease

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44
Q

Aetiology of hypothyroidism

A
  • more common in women
  • incidence increases with age
  • most commonly autotimmune thryoiditis in places with enough iodine
  • iatrogenic
  • drug induced
  • iodine deficiency
  • congential hypothyroidism
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45
Q

Thyroid function tests in thyrotoxicosis

A
  • low TSH
  • high free T4
  • high free T 3
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46
Q

Thyroid function tests in primary hypothyroidism

A
  • high TSH
  • low or low-normal free T4
  • low or normal free T3
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47
Q

Thyroid function tests in TSH deficiency

A
  • low or low-normal TSH
  • low or low-normal free t4
  • low or normal free T3
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48
Q

Thyroid function tests in T3 toxicosis

A
  • low TSH
  • normal free T4
  • high free T3
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49
Q

Thyroid function tests in borderline hypothyroidism

A
  • slightly elevated TSH
  • normal free T4
  • normal free T3
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50
Q

Autoimmune thyroiditis

A
  • may be associated with goitre (Hashimoto;s) or thryoid atrophy
  • cell and anti-body mediated destruction of thyroid tissue
  • serum antibodies to thyroglobulin, thyroid peroxidase enzyme (thyroid microsomal antibodies) and anti-bodies that block binding to TSH receptors
  • associated with other autoimmune conditions. can be transient post-partum = hypo-hyperthyroidism
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51
Q

Iatrogenic hypothyroidism

A

thyroidectomy
radioactive iodenine treatment
external neck irradiation for head and neck cancer

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52
Q

Drug induced hypothyroidism

A

carbimazole
lithium
amiodarone
interferon

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53
Q

Iodine deficiency hypothyroidism

A

particularly moutainous regions - alps, himalayas, south america

  • goitre is common
  • iodine excess can also cause hypothyroidism in patients with pre-existing thyroid disease
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54
Q

Congenital hypothyroidism

A

thyroid aplasia
thyroid dysplasia
defective synthesis of thryoid hormones

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55
Q

Symptoms of hypothyroidism

A 
Tiredness/ malaise
weight gain 
anorexia 
cold intolerance
poor memory 
change in appearance
depression 
poor libido 
goitre
puffy eyes 
dry/brittle/unmanageable hair 
dry/coarse skin 
arthralgia 
myalgia
muscle weakness/stiffness
constipation 
menorrhagia/oligomenorrhoea
psychosis
coma 
deafness
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56
Q

Signs of hypothyroidism

A 
BRADYCARDIC
B= bradycardia
R= reflexes relax slowly
A= ataxia 
D= dry, thin hair/skin
Y= yawning/drowsy/coma
C= cold hands ± low temp
A= ascite ± non-pitting oedema ± pericardial/pulmonary effusion
R= round puffy face/double chin/obese
D = defeated demeanour
I = Immobile ± ileus 
C = CCF
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57
Q

Diagnosis of hypothyroid

A

Low free T4 and low TSH
raised cholesterol and triglyceride
macrocytosis
normocytic anaemia

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58
Q

Associations with hypothyroidism

A 
Other autoimmune diseases 
Turner's & Down's syndrome 
Cystic fibrosis 
primary biliary cirrhosis 
ovarian hyperstimulation 
POEMS - polyneuropathy, organomegaly, endocrinopathy, m-protein band + skin tethering/pigmentation
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59
Q

Pregnancy problems with hypothyroidism

A 
Eclampsia
anaemia
prematurity 
low birth weight 
still birth 
PPH
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60
Q

Treatment of hypothyroidism

Young and healthy

A

Levothryoxine 50-100 micrograms w/ regular reviews

once normal review annually

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61
Q

Treatment of hypothyroidism

elderly/ ischaemic heart disease

A

start with 25 micrograms/24hrs

increase dose by 25 micrograms / 4 weeks according to TSH

62
Q

Amiodarone and hypothyroidism

A

iodine rich drug
2% of will get significant thryoid problems from it
–> thyroxicosis
thyroidectomy may be necessary if amiodarone cannot be discontinued
half life of amiodarone is 80 days so symptoms may continue after withdrawal

63
Q

Subclinical hypothryoidism

A

low TSH with normal T4 &T3

  • low threshold for treatment (if THS >10, +ve thyroid autoantibodies, past Graves or other organ specific autoimmunity)
  • risks from well-monitored treatment of subclincial hypothyroidism are small but increased risk of AF and osteoporosis
64
Q

Subclincial hyperthyroidism

A

low TSH with T4 and T3
41% increase in mortality from all causes vs euthyroid
- confirm suppressed TSH
- check for non-thryoidal cause
-treat on an individual basis
- carbimazole or propylthiouracil or radioiodine

65
Q

Parathyroid hormone

A

secreted in response to low ionised Ca2+ levels
controlled by negative feedback via Ca2+
Increases osteoclast activity - releasing calcium and phosphate from the bones
increases calcium and reduces phosphate reabsorption in the kidney
active 1,25 vit D3 production increased

overall - increases calcium and decreases phosphate

66
Q

Causes of primary hyperparathryoidism

A 
solitary adenoma (80%)
hyperplasia of all glands (2-%)
parathyroid cancer (<0.5%)
67
Q

Presentation of Hyperparathyroidism

A

raised Ca2+ on routine tests
1. weak, tired, depressed, thirsty, dehydrated byt polyuric, renal stones, abdo pain, pancreatitis and ulcers

  1. Bone resorption effects - pain, fractures, osteoporosis/osteopenia
  2. raised BP
68
Q

Hyperparathyroidism

Investigations

A 
raised Ca2+ and PTH 
low phosphate 
raised alk phos
24 urinary Ca2+ elevated 
ostetitis fibrosa cystica on imaging - subperiosteal erosions, cysts or brown tumours of phalanges ± acrosteolysis ± pepper pot skull
69
Q

Treatment of hyperparathyroidism

A
  • mild - increase fluid intake
  • avoid thiazides and high Ca2+ and vit D intake
  • excision of adenoma or all 4 hyperplastic glands - prevents fractures and peptic ulcers
70
Q

Complications of hyperparathyroidism treatments

A

hypoparathyroidism
recurrent laryngeal nerve damage - hoarse voice
symptomatic low calcium - hungry bone syndrome (check Ca2+ daily for 14/7 post op)

71
Q

Indications to treat hyperparathyroidism

A

high serum/urine calcium,
bone disease, osteoporosis,
renal caliculi,
low renal function

72
Q

Secondary hyperparathryoidism

A

low Ca2+, appropriately elevated PTH
causes - low vit D intake, chronic renal failure
Rx- correct causes, phosphate binders, vit D, cinacelet

73
Q

tertiary hyperparathyroidism

A

elevated Ca2+, very elevated PTH (inappropriate)
occurs after significantly prolonged secondary hyperparathyroidism
glands act autonomously - hyperplastic or adenomatous changes
Ca2+ increases from elevated secretion of PTH unlimited by feedback control

Seen in chronic renal failure

74
Q

Malignant hyperparathyroidism

A

parathyroid related protein (PTHrP) produced by some squamous cell lung cancers, breast and renal cell carcinomas
mimics PTH causes Ca2+ to rise
PTH is low- PTHrP not detected on normal assay

75
Q

Primary hypoparathyroidism

A

low PTH secretion due to gland failure
low Ca2+, high or normal phosphate, normal alk phos

Signs of hypocalcaemia ± autoimmune comorbidities

Causes- autoimmune, confenital

treat with calcium supplements + calcitriol or synthetic PTH

76
Q

Secondary hypoparathyroidism

A

radiation, surgery hypomagnesaemia

77
Q

psuedohypoparathyroidism

A

failure of target cell response to PTH

Signs- short metacarpals, round face, short stature, calcified basal ganglia, low IQ
low Ca2+, raised PTH, normal alk phos,

78
Q

psuedopsuedohypoparathyroidism

A

morpholoical features of pseudohypoparathyroidism
normal biochem
cause is genetic

79
Q

MEN

multiple endocrine neoplasia

A

Functioning hormone producing tumours in multiple organs
MEN-1 = neurofibromatosis, Von Hippel-Lindau and peutz-jeghers syndrome, carney complex and endocrine tumours

MEN-1 is a tumour suppressing gene- menin alters transcription activation. presents 3rd-5th decade

MEN-2 associated with ret - receptor tyrosine kinase

80
Q

Adrenal cortex

Physiology

A
  1. Glucocorticoids (cortisol) affect carbohydrate, lipid and protein metabolism
  2. Mineralocorticoids - control sodium and potassium balance (aldosterone)
  3. Androgens - sex hormones

corticotropin releasing factor from hypothalamus –> stimulates ACTH from pituitary–> cortisol and androgens from adrenal cortex

81
Q

Cushings syndrome

A

clinical state produced by chronic glucocorticoid excess + loss of normal feedback mechanisms of hypothalamo-pituitary-adrenal axis
loss of circadian rhythm of cortisol secretion
chief cause - oral steroids
endogenous causes - 80% due to elevated ACTH usually caused by a pituitary adenoma (Cushing’s disease)

82
Q

ACTH dependent causes of Cushing’s Syndrome

Cushing’s disease

A

bilateral adrenal hyperplasia from an ACTH secreting pituitary adenoma (usually microadenoma)
30-50yrs
low dose dexamethasone test leads to no change in plasma cortisol

83
Q

ACTH dependent causes of Cushing’s Syndrome

Cushing’s disease

Tests

A

1st - Overnight dexamethasone suppression test 1mg overnight, 8am cortisol- normally would be half (24hr urinary free cortisol is the alternative)

2nd - 48hr dexamethasone suppression/ high dose 48hr dexamethasone suppression test/ midnight cortisol

84
Q

ACTH dependent causes of Cushing’s Syndrome

Ectopic ACTH production

A

small cell lung cancer
carcinoid tumours
pigmentation, hypokalaemic metabolic acidosis (high cortisol –> mineralocorticoid activity), weight loss, hyperglycaemia
classical features of cushing’s are normally absent
even high dose Dexamethasone (8mg) fails to suppress cortisol production

85
Q

ACTH dependent causes of Cushing’s Syndrome

Rarely ectopic CRF production

A

some thyroid (medullary) and prostate cancers

corticotrophin releasing hormone

86
Q

ACTH independent causes of Cushing’s Syndrome

  • low ACTH due to -ve feedback
A
  • adrenal adencoma/cancer
  • adrenal nodular hyperplasia
  • iatrogenic - pharmacological doses of steroids
  • rarely - Carney complex, McCune-Albright syndrome
87
Q

Symptoms of Cushing’s

A
  • increasing weight
  • mood change- lethargy, depression, irritablility, psychosis
  • proximal weakness
  • gonadal dysfunction- irregular periods, hirsuitism, ED
  • acne
  • recurrent Achilles tendon rupture
  • occasional virilisation if female
88
Q

Signs of Cushing’s

A
  • central obesity
  • plethoric (full of fluid)
  • moon face
  • buffalo neck hump
  • supraclavicular fat distribution
  • skin and muscle atrophy
  • bruises
  • purple abdominal striae
  • osteoporosis
  • high BP
  • high glucose
  • infection prone
  • poor healing
89
Q

Cushing’s Treatments

A
  • iatrogenic -> stop medicines if possible
  • cushing’s disease -> remove pituitary adenoma or bilateral adrenalectomy if source unlocatable or recurrence
  • adrenal adenoma or carcinoma - adrenalectomy - cures adenomas but rarely cures cancer. Radiotherapy & adrenolytic drugs (mitotane)
  • ectopic ACTH - surgery if tumour located 1
90
Q

Prognosis of Cushing’s

A

Untreated- high vascular mortality
treated - good prognosis, but myopathy, obesity, menstrual irregularity, high BP, osteoporosis, subtle mood changes and DM often remain

91
Q

Adrenal insufficiency

A

adrenal insufficiency

  • exogenous steroid suppression of pituitary adrenal axis
  • overwhelming sepsis
  • metastatic cancer
  • addison’s disease
92
Q

Primary adrenocortical insufficiency

Addison’s disease

A

rare but may be fatal

  • destruction of adrenal cortex leads to glucocorticoid (cortisol) and mineralocorticoid (aldosterone) deficiency
  • signs are capricious
93
Q

Causes of adrenal insufficiency

A 
Autoimmunit 
TB 
adrenal metastases
lymphoma 
opportunistic infections in HIV (CMV, mycobacterium avium)
adrenal haemorrhage
congenital
94
Q

SYmptoms of adrenal insufficiency

A
  • lean
  • tanned
  • tired
  • tearful ± weakness
  • anorexia
  • dizzy
  • faints
  • flu- like myalgia/arthralgias

Mood- depression, psychosis, low-self esteem
GI - N&V, abdominal pain, diarrhoea/constipation
Pigmented palmar creases and buccal mucosa
postural hypotension
vitiligo

95
Q

Signs of critical deterioration in adrenal insufficiency

A

Shock ( high pulse, vasoconstriction, postural hypotension, oliguria, weak, confused, comatose

  • manage with IV glucose, IV fluids, correct electrolytes, IV/IM hydrocortisone,
96
Q

Tests for adrenal insufficiency

A 
low sodium, high potassium
low glucose 
uraemia, high calcium, eosinophilia, anaemia 
Synacthen (short ACTH stimulation)
plasma renin and aldosterone
97
Q

Treatment of adrenal insufficiency

A

replace steroids ~15-25mg/day in 2-3 doses
mineralocorticoids to correct postural hypotension
tell drs/dentists/surgeons of steroid use
add extra hydrocortisode before strenuous exercise, double in febrile illness, injury or stress

98
Q

Secondary adrenal insufficiency

A

most commonly iatrogenic from long term steroids

99
Q

Primary hyperaldosteronism

A

excess production of aldosterone
independent of the renin-angiotensin system causing increases in sodium and water retention
low renin release

  • hypertension, hypokalaemia or alkalosis in someone not on diuretics
100
Q

Symptoms of hyperaldosteronism

A

asymptomatic
signs of hypokalaemia (muscle weakness, hypotonia, hyporeflexia, cramps, tetany, palpitations, light-headedness (arrhythmias), constipation)
parasthesia, polyuria, polydipsia, high BP

101
Q

Causes of hyperaldosteronism

A

2/3 solitary aldosterone producing adenoma
(Conn’s syndrome)

1/3 bilateral adrenocortical hyperplasia

Rarely- adrenal carcinoma, glucocortioid-remedial aldosteronism

102
Q

Tests for hyperaldosteronism

A

U&E, renin and aldosterone

103
Q

Treatment of hyperaldosteronism

A

Conn’s –> Laproscopic adrenalectomy
spironolactone

Hyperplasia - spironalactone, amiloride oR eplernone

Glucocorticoid-remedial aldosteronism - dexamethasone

Adrenal carcinoma - surgery ± post-operative adrenolytic therapy (mitotane)

104
Q

Secondary hyperaldosteronism

A

high renin from reduced renal perfusion e.g. renal artery stenosis, accelerated hypertension, diuretics, CCF or hepatic failure

105
Q

Bartter’s syndrome

A

congenital salt wasting - sodium/chloride leak in the loop of Henle
failure to thrive, polyuria and polydipsia
BP normal
sodium loss leads to volume depletion, increases renin and aldosterone production

–> hypokalaemia, metabolic acidosis, high urinary potassium and chloride

Rx- K+ replacment, NSAIDs and ACE-i

106
Q

Phaeochromocytoma

A

Rare catecholamine producing tumours
arise from sympathetic paraganglia
usually found in the adrenal medulla

episodic headache, sweating, tachycardia

Raised WCC, plasma and urinary metadrenaline and normetadrenaline ±clonidine suppression test

Rx- surgery w/ alpha blockade pre-op

107
Q

Hyperaldosteronism

solitary aldosterone-producing adenoma Conn’s syndrome

A

tumour in the zona Glomerulosa, zona Fasiculata or zona Reticularis with syndromes of raised MINERalocorticoids, Glucocorticoids, Androgens respectively

GFR= miner GA

108
Q

Gynaecomastia

A

abnormal breast tissue in men
may occur in normal puberty
oestrogen/androgen ratio raised

Causes- hypogonadism, liver cirrhosis, hyperthyroidism, tumours, drugs (oestrogens, spironolactone, digoxin, testosterone, marijuana)

109
Q

Erectile Dysfunction causes

A

Psychological
Big 3: smoking, alcohol, diabetes
endocrine: hypogonadism, hyperthyroidism, raised prolactin
cord lesions, MS< autonomic neuropathy,
pelvic surgery, radiotherapy, artheroma, renal or hepatic failure, prostatic hyperplasia, penile anaomalies, drugs (digoxin, beta-blockers, diuretics, antipsychotics, antidepressants, oestrogens, finasteride, narcotics)

110
Q

Male hypogonadism

A

failure of testes to produce testosterone, sperm or both

small testes, low libido, erectile dysfunction, loss of pubic hair, loss of muscle bulk, increased fat, gynaecomastia, osteoporosis low mood

if pre-pubescet - decreased virilisation, incomplete puberty, eunuchoid body, reduced secondary sex characterists

111
Q

Causes of primary hypogonadism (male)

A

testicular failure

  • local trauma, torsion, chemotherapy/irradiation
  • post-orchitis e.g. mumps, HIV, brucellosis, leprosy
  • renal failure, liver cirrhosis or alcohol excess
  • Chromosomal abnormalities
112
Q

Causes of secondary hypogonadism (male)

A

low gonadotrophins from

  • hypopituitarism
  • prolactinoma
  • Kallmann’s syndrome - isolated gonadotrophin releasing hormone deficiency
  • systemic illness
  • Laurence-Moon-Biedl and PRader Willi syndromes
  • Age
113
Q

Diabetes insipidus

A

passage of large volumes (3L+/day) of dilute urine
due to impaired water resorption from the kidney
reduced ADH secretion from posterior pituitary (cranial)
impaired response of kindey to ADH (nephrogenic)

114
Q

Symptoms of diabetes insipidus

A

polyuria
polydipsia
dehydration
symptoms of hypernatraemia (lethargy, thirst, weakness, irritability, confusion, coma)

115
Q

Causes of cranial diabetes insipidus

A 
idiopathic 
congenital 
tumour- craniopharyngioma, metastases, pituitary tumour 
trauma 
hypophysectomy 
autoimmune hypophysitis
infiltration - histiocytosis/ sarcoidosis 
vascular- haemorrhage
infection - meningioencephalitis
116
Q

Causes of nephrogenic diabetes insipidus

A
  • inherited
  • metabolic - low potassium, high calcium
  • drugs - lithium, demeclocycline
  • chronic renal disease
  • post- obstructive uropathy
117
Q

Tests for diabetes insipidus

A 
U&amp;E
glucose (exclude DM)
calcium 
serum and urinen osmolalities
water deprivation test
118
Q

SIADH

syndrome of inappropriate ADH secretion

A

important but over diagnosed cause of hyponatraemia
concentrated urine in the presence of hyponatraemia and low plasma osmolality in the abscence of hypovolaemia, oedema or diuretics

119
Q

Causes of SIADH

A

Malignancy - small cell lung, pancreas, prostate, thymus or lymphoma
CNS - meningoencephalitis, abscess, stroke, SAH/SDH, head injury, neurosurgery, Guillan-Barre, vasculitis or SLE
Resp- TB, pneumonia, abscess, aspergillosis
Endo- hypothyroidism
Drugs - opiates, psychotropics, SSRIs or cytotoxics
Other - acute intermittent porphyria, trauma, major abdominal/ thoracic surgery, symptomatic HIV

120
Q

Treatment of SIADH

A

treat cause
fluid restriction
consider salt ± loop diuretics if severe

121
Q

Symptoms of hyperthyroidism (thyrotoxicosis)

A 
diarrhoea
weight loss
appeitie increase 
overactive 
sweats
heat intolerance 
palpitations
tremor
irritability
labile emotions
oligomenorrhoea ± infertility

Rarely: psychosis, chorea, panic, itch, alopecia, urticaria

122
Q

Signs of hyperthyroidism (thyrotoxicosis)

A 
pulse - fast/ irregular 
warm, moist skin
fine tremor
palmar erythema
thin hair
lid lag/retraction
goitre

thyroid nodules or bruit

123
Q

Signs of Graves Disease

A
  1. Eye disease - exopthalmos, ophthalmoplegia,
  2. Pre-tibial myxoedema - oedematous swelling above lateral malleoli
  3. thyroid acropachy - extreme manifestation with clubbing painful finger and toe swelling and periosteal reaction in limb bones
124
Q

Tests in thyrotoxicosis

A 
suppressed (low) TSH
elevated T4 and T3
mild normocytic anaemia, mild neutropenia (Graves)
raised ESR, calcium, LFTs 
Check thyroid autoantibodies
125
Q

Graves disease

A

2/3 of hyperthyroidism
circulating IgG autoantibodies binding to and activating G-protein coupled thyrotropin receptors
causes smooth thyroid enlargement and increased hormone production (esp T3) and reaction with orbital autoantigens
- triggers: stress, infection, childbirth

associated with other autoimmune disease

126
Q

Toxic multinodular goitre

A

seen in elderly and iodine deficient areas
nodules that secrete thyroid hormones
surgery indicated for compressive symptoms from enlarged thyroid (dysphagia or dyspnoea)

127
Q

toxic adenoma

hyperthyroidism

A

solitary nodule producing T3 and T4

nodule ‘hot’ on isotope scan, rest of the gland is suppressed

128
Q

Ectopic thyroid tissue

hyperthyroidism

A

metastatic follicular thyroid cancer or struma ovarii

ovarian teratoma with thyroid tissue

129
Q

Exogenous causes of hyperthyroidism

A

iodine excess - food contamination , contrast media

levothyroxine

130
Q

Other causes of hyperthyroidism

A
  1. Sub acute de Quervain’s thryoiditis
  2. Drugs - amiodarone, lithium
  3. Post-partum
  4. TB (rare)
131
Q

Treatment of hyperthyroidism

A
  1. Drugs –>beta blockers and anti-thyroid medication - carbimazole (titration or block and replace)
  2. Radioiodine
  3. Thyroidectomy
132
Q

Complications of hyperthyroidism

A 
heart failure (thyrotoxic cardiomyopathy)
angina
AF
osteoporosis 
ophthalmopathy
gynaecomastia
133
Q

Thyroid eye disease

symptoms

A 
eye discomfort 
grittiness 
increased tear production
photophobia
diplopia decreased acuity 
afferent pupillary defect
134
Q

Thyroid eye disease

signs

A 
exophthalmos
proptosis 
conjunctival oedeam 
corneal ulceration 
papilloedema
loss of colour vision 
ophthalmoplegia
135
Q

Signs and symptoms of thyrotoxic storm (hyperthyroid crisis)

A 
severe hyperthyroidism 
high temp
agitation
confusion 
coma 
tachycardia 
AF
D&amp;V
goitre
thyroid bruit
acute abdomen 
heart failure
cardiovascular collapse
136
Q

Precipitants of hyperthyroid crisis

A 
recent thyroid surgery 
radioiodine 
infection 
MI
trauma
137
Q

Treatment of hyperthyroid crisis

Grand strategy

A
  1. Counteract peripheral effects of thyroid hormones
  2. Inhibit thyroid hormone synthesis
  3. Treat systemic complications
138
Q

Step by step management of hyperthyroid crisis

A 
IV access, fluids, NG tube if vomiting 
take blood
sedate if necessary 
propanolol/ ultra-short acting B-Blockers/ diltiazem
High dose digoxin 
antithyroid drugs - carbimazole 
hydrocortisone/IV dexamthasone
co-amox if suspected infection
139
Q

PCOS

A

most common hormonal disorder affecting women
multiple small cysts within the ovary - arrested follicular development
excess androgen production from the ovaries (and adrenals)
associated with hyperinsulinaemia, insulin resistance, T@DM, HTN, hyperlipidaemia and increased CVD

140
Q

Clinical features of PCOS

A

amenorrhoea/ oligomenorhoea
hirsuitism
acne
usually beginning shortly after menarche
associated with obesity
mild virilisation (clitoromegaly, recent onset frontal balding, deepening of voice and loss of female body shape) in severe cases

141
Q

Criteria for PCOS diagnosis

A
  • menstrual irregularity
  • clinical or biochemical evidence of hyperandrogenism
  • Polycystic ovaries on USS
142
Q

Investigations of PCOS

A
  • sex hormones- raised free androgen index, total testosterone raised
  • serum prolactin slightly elevated in PCOS
  • serum 17-hydroxyprogesterone elevated in non-classice adrenal hyperplasia
143
Q

Management of PCOS

A
  • local therapy for hirsuitism - waxing/ bleaching etc
  • systemic - oestrogens, cyproterone acetate, spironolactone, finasteride
  • cyclical oestroen/ progesterone
  • treat infertility - anti-oestrogen clomifene for induction of ovulation
144
Q

Hypothalamic causes of amenorrhoea

A

GnRH deficiency - Kallmann’s syndrome or isolated
weight loss, physical exercise, stress
post oral contraceptive therapy

145
Q

Pituitary causes of amenorrhoea

A

hyperprolactinaemia

hypopituitarism

146
Q

Gonadal causes of amenorrhoea

A

PCOS
premature ovarian failure - autoimmune basis
defective ovarian development (dysgenesis)
androgen-secreting ovarian tumours
radiotherapy

147
Q

Other diseases causing amenorrhoea

A

thyroid dysfunction
Cushing’s syndrome
adrenal tumours
severe illness

148
Q

Uterine/ vaginal abnormalities causing amenorrhoea

A

imperforate hymen

absent uterus

149
Q

Investigating amenorrhoea

A
  • basal serum FSH/LH, oestrogren and prolactin
  • USS ovaries
  • laproscopy and ovarian biopsy
  • pituitary MRI
  • serum testosterone
150
Q

Management of amenorrhoea

A

treat cause
cyclical oestrogens
human LH/FSH in isolated GnRH deficiency or hypopituitarism

3B General Care (8 decks)

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