endocrinology Flashcards
addisons disease mx in illness
double hydrocortisone dose and keep fludrocortisone the same
dequervains thyroidirtis iodine uptake scane
globally reduced
painful goitre
Men1 3 ps
men2a 2 ps
men 2b 1 p
parathyroid pituitary pancreas men 1 gene
parathyroid phaeo ret oncogene
phaeo
mx of DKA
fluid replacement: most patients with DKA are deplete around 5-8 litres. Isotonic saline is used initially. Please see an example fluid regime below.
insulin: an intravenous infusion should be started at 0.1 unit/kg/hour. Once blood glucose is < 15 mmol/l an infusion of 5% dextrose should be started
correction of hypokalaemia
long-acting insulin should be continued, short-acting insulin should be stopped
whipples triad of insulinom
Symptoms and signs of hypoglycemia
Plasma glucose < 2.5 mmol/L
Reversibility of symptoms on the administration of glucose
pioglitazone c/i
Pioglitazone can cause fluid retention and is therefore contraindicated in patients with heart failure.
and c/i in history of bladder cancer
drug causes of gynaecomastia
C: cirrhosis. O: obesity. D: digoxin. E: estrogen. S: spironolactone.
sick euthyroid syndrome
In sick euthyroid syndrome (now referred to as non-thyroidal illness) it is often said that everything (TSH, thyroxine and T3) is low. In the majority of cases however the TSH level is within the >normal range (inappropriately normal given the low thyroxine and T3).
waterhouse friderichsen syndrome
adrenal gland failure due to bleeding into the adrenal glands, commonly caused by severe bacterial infection. Typically, it is caused by Neisseria meningitidis
t1dm bm targets
Blood glucose targets
5-7 mmol/l on waking and
4-7 mmol/l before meals at other times of the day
when to give bisphosphonate in high calcium low bone density
ca above 3 iv bisphos
cause
neuropathy of nervous system
when to add drug 2 in t2dm mx
HbA1c more than 58 on metformin
thyroid storm
Precipitating events: thyroid or non-thyroidal surgery trauma infection acute iodine load e.g. CT contrast media
Clinical features include: fever > 38.5ºC tachycardia confusion and agitation nausea and vomiting hypertension heart failure abnormal liver function test - jaundice may be seen clinically
Management:
symptomatic treatment e.g. paracetamol
treatment of underlying precipitating event
beta-blockers: typically IV propranolol
anti-thyroid drugs: e.g. methimazole or propylthiouracil
Lugol’s iodine
dexamethasone - e.g. 4mg IV qds - blocks the conversion of T4 to T3
mody fx
MODY 3
60% of cases
due to a defect in the HNF-1 alpha gene
is associated with an increased risk of HCC
Features of MODY
typically develops in patients < 25 years
a family history of early onset diabetes is often present
ketosis is not a feature at presentation
patients with the most common form are very sensitive to sulfonylureas, insulin is not usually necessary
kallmans syndrome
secondary hypogonadism
characteristically suffer from anosmia and would not exhibit gynaecomastia.
criteria for glp-1 mimetic
BMI >= 35 kg/m² in people of European descent and there are problems associated with high weight, or
BMI < 35 kg/m² and insulin is unacceptable because of occupational implications or weight loss would benefit other comorbidities.
impaired fasting glucose and impaired glucose tolerance definitions
A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG)
Impaired glucose tolerance (IGT) is defined as fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l
drug causes of raised prolactin
Drug causes of raised prolactin metoclopramide, domperidone phenothiazines haloperidol very rare: SSRIs, opioids
pseudo cushings
mimics Cushing’s
often due to alcohol excess or severe depression
causes false positive dexamethasone suppression test or 24 hr urinary free cortisol
insulin stress test may be used to differentiate
hhs vs DKA on bloods
HHS is characterised by: a higher blood glucose (>30 mmol/L), much milder hyperketonaemia (ketones <3 mmol/l) and a higher pH (>7.3).
hba1c overestimates glucose levels in
splenectomy
Thiazolidinediones are associated with
pioglitazone
an increased risk of bladder cancer
weight gain
liver impairment: monitor LFTs
fluid retention - therefore contraindicated in heart failure. The risk of fluid retention is increased if the patient also takes insulin
recent studies have indicated an increased risk of fractures
Nelson’s syndrome
rapid enlargement of a pituitary corticotroph adenoma (ACTH producing adenoma) that occurs after the removal of both adrenal glands (bilateral adrenalectomy) which is an operation used for Cushing’s syndrome
pregabalin c/i
BPH- urinary retention risk
sulfonylurea adverse effects
gliclazide
Common adverse effects
hypoglycaemic episodes (more common with long-acting preparations such as chlorpropamide)
weight gain
Rarer adverse effects hyponatraemia secondary to syndrome of inappropriate ADH secretion bone marrow suppression hepatotoxicity (typically cholestatic) peripheral neuropathy
max dose metformin
1g bd
types of thyroid cancer
1) Papillary - 65%, generally young females. Metastasis to cervical lymph nodes. Thyroglobulin can be used as a tumour marker. Characteristic Orphan Annie eyes on light microscopy. Good prognosis
2) Follicular - 20%, generally women >50 years old. Metastasis to lung and bones. Thyroglobulin can be used as a tumour marker. Moderate prognosis
3) Medullary - 5%, sporadic or part of MEN2 syndrome. It originates from the parafollicular cells which produce calcitonin - can be used as a tumour marker.
4) Anaplastic - very rare. Elderly patient. Very poor prognosis
complications of acromegaly
hypertension
diabetes (>10%)
cardiomyopathy
colorectal cancer
Features
coarse facial appearance, spade-like hands, increase in shoe size
large tongue, prognathism, interdental spaces
excessive sweating and oily skin: caused by sweat gland hypertrophy
features of pituitary tumour: hypopituitarism, headaches, bitemporal hemianopia
raised prolactin in 1/3 of cases → galactorrhoea
6% of patients have MEN-1
thiazides can cause
hyper calcaemia
klinefelters
often taller than average
lack of secondary sexual characteristics
small, firm testes
infertile
gynaecomastia - increased incidence of breast cancer
elevated gonadotrophin levels but low testosterone
acromegaly ix
Serum IGF-1 levels have now overtaken the oral glucose tolerance test (OGTT) with serial GH measurements as the first-line test. The OGTT test is recommended to confirm the diagnosis if IGF-1 levels are raised.
bp targets in diabetes
Type 2 diabetes blood pressure target
no organ damage: < 140 / 80
end-organ damage: < 130 / 80
Endocrine parameters reduced in stress response:
insulin
testosterone
oestrogen
corticosteroids in glycaemic control
Corticosteroids oppose the action of insulin and stimulate hepatic gluconeogenesis. Even a short course of corticosteroids can adversely affect glycaemic control.
carbimazole s/e
agranulocytosis
crosses the placenta, but may be used in low doses during pregnancy
The severity of Grave’s eye disease can be graded using the mnemonic NOSPECS
No signs / symptoms
Only signs (e.g: upper lid retraction)
Signs & symptoms (including soft-tissue involvement)
Proptosis
Extra-ocular muscle involvement
Corneal involvement
Sight loss due to optic nerve involvement
glucose monitoring in t1dm
recommend testing at least 4 times a day, including before each meal and before bed
more frequent monitoring is recommended if frequency of hypoglycaemic episodes increases; during periods of illness; before, during and after sport; when planning pregnancy, during pregnancy and while breastfeeding
neuroblastoma fx and ix
Features abdominal mass pallor, weight loss bone pain, limp hepatomegaly paraplegia proptosis
Investigation
raised urinary vanillylmandelic acid (VMA) and homovanillic acid (HVA) levels
calcification may be seen on abdominal x-ray
biopsy
types of insulin
offer multiple daily injection basal–bolus insulin regimens, rather than twice‑daily mixed insulin regimens, as the insulin injection regimen of choice for all adults
twice‑daily insulin detemir is the regime of choice. Once-daily insulin glargine or insulin detemir is an alternative
offer rapid‑acting insulin analogues injected before meals, rather than rapid‑acting soluble human or animal insulins, for mealtime insulin replacement for adults with type 1 diabetes
Iron reduces the absorption
of thyroxine
role of mg
Magnesium is required for both PTH secretion and its action on target tissues. Hypomagnesaemia may both cause hypocalcaemia and render patients unresponsive to treatment with calcium and vitamin D supplementation.
sick day diabetes rules
Increase frequency of blood glucose monitoring to four hourly or more frequently
Encourage fluid intake aiming for at least 3 litres in 24hrs
If unable to take struggling to eat may need sugary drinks to maintain carbohydrate intake
It is useful to educate patients so that they have a box of ‘sick day supplies’ that they can access if they become unwell
Access to a mobile phone has been shown to reduce progression of ketosis to diabetic ketoacidosis
