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Year 3 > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

What is FHH and how is it diagnosed?

A

Familial Hypocalciuric Hypercalcemia

Investigations:

  • 24h urine Ca2+ level is LOW
  • DEXA scan

Results:

  • Mild increase in Ca2+
  • Increase in PTH

Surgery not appropriate in these patients!

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2
Q

What are the blood results like in primary hyperparathyroidism?

A

Increased PTH + increased Ca2+ + NO decrease in Ca2+ in the urine

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3
Q

What are the blood results like in secondary hyperparathyroidism?

A

Increased PTH + normal Ca2+

  • Renal dysfunction -> check serum creatinine
  • Vitamin D deficiency -> check 25-hydroxycholecalciferol levels
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4
Q

What are the blood results like in tertiary hyperparathyroidism?

A

Hypertrophy due to prolonged secondary hyperparathyroidism

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5
Q

What end organ damage can result from hypercalcemia?

A
  • osteoporosis

- kidney stones

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6
Q

What investigations are done for hyperparathyrodisim?

A
  1. Serum Ca2+
  2. Albumin
  3. PTH
  4. Phosphate
  5. Creatinine
  6. 25-hydroxy vitamin D
  7. 25h urine Ca2+ and creatinine
  8. DEXA bone scan
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7
Q

What are non-parathyroid related problems that can cause elevated Ca2+?

A
  • Familial hypocalciuric hypercalcemia (elevated serum Ca2+, elevated PTH)
  • Multiple endocrine neoplasia
  • Multiple myeloma (increased Ca2+, normal PTH)
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8
Q

What is the treatment for hyperparathyroidism?

A

Parathyroidectomy is the only curative treatment

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9
Q

What is the most common underlying cause of primary hyperparathyroidism?

A

A single adenoma

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10
Q

What is the investigation of choice to determine the localization of a parathyroid adenoma?

A
  1. Nuclear medicine parathyroid scan
    - Sestamibi scan injecting Tc99 + imaging with gamma camera
  2. Ultrasound
  3. MRI/CT
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11
Q

What hormones are released from the anterior pituitary?

A
  1. LH/FSH
  2. GH
  3. TSH
  4. Prolactin
  5. ACTH
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12
Q

What hormones are released from the posterior pituitary?

A
  1. Oxytocin

2. ADH/vasopressin

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13
Q

What are the microvascular and macrovascular complications of diabetes?

A

Microvascular:

  1. Retinopathy
  2. Nephropathy
  3. Neuropathy

Macrovascular:

  1. Stroke
  2. MI
  3. Renovascular disease
  4. Limb ischemia
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14
Q

What is the cause of type 1 diabetes?

A

Insulin deficiency from autoimmune destruction of insulin-producing pancreatic B-cells

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15
Q

What is the cause of type 2 diabetes?

A

Decreased insulin secretion ± increased insulin resistance

Associated with obesity, lack of exercise, calorie and alcohol excess

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16
Q

What is the glucose level cut off for impaired glucose tolerance?

A

Fasting glucose < 7mmol/L and OGTT 2h glucose ≥ 7.8mmol/L but less than 11.1mmol/L

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17
Q

What is the glucose level cut off for impaired fasting glucose?

A

Fasting glucose ≥ 6.1mmol/L but less than 7mmol/L

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18
Q

What are other causes of diabetes?

A
  1. Steroids, anti-HIV drugs, newer antipsychotics
  2. Pancreatic: pancreatitis, surgery (when pancreas is removed), trauma
  3. Cushing’s disease
  4. Acromegaly
  5. Phaeochromocytoma
  6. Hyperthyroidism
  7. Pregnancy
  8. Others: congenital lipodystrophy, glycogen storage diseases
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19
Q

What are the symptoms of hyperglycemia?

A
  1. Polyuria
  2. Polydipsia
  3. Unexplained weight loss
  4. Visual blurring
  5. Genital thrush
  6. Lethargy
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20
Q

How is diabetes diagnosed?

A
  1. Symptoms of hyperglycemia
  2. Raised glucose detected once - fasting ≥ 7mmol/L OR random glucose ≥ 11.1mmol/L

OR

  1. Raised glucose on TWO separate occasions - fasting ≥ 7mmol/L, random/OGTT 2h ≥ 11.1mmol/L
  2. HbA1c ≥ 48mmol/mol. Avoid in pregnancy, children, type 1 DM, and hemoglobinopathies
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21
Q

How is diabetes treated?

A
  1. Lifestyle changes (exercise, healthy eating)
  2. Start on statin (atorvastatin 20mg)
  3. Review every 3-6mo
  4. Start on metformin
  5. If HbA1c ≥ 58mmol/mol consider dual therapy:
    - Metformin + sitagliptan (DPP4 inhibitor)
    - Metformin + pioglitazone
    - Metformin + sulphonylurea
    - Metformin + glifazon (SGLT2 inhibitor)
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22
Q

What are the side effects of metformin?

A
  1. Lactic acidosis
  2. Abdo pain
  3. Nausea
  4. Diarrhea
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23
Q

What are side effects of glitazone (SGLT2 inhibitor)

A
  1. Hypoglycemia
  2. Fluid retention
  3. Fractures
  4. Elevated LFTs (do LFT every 8wk for 1yr)

Contraindicated in HF, osteoporosis

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24
Q

What are side effects of solfonylurea?

A
  1. Weight gain

2. Hypoglycemia

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25
If on insulin what should you do if you get sick?
Continue taking insulin | - Take BM ≥ 4x/day and look for ketonuria
26
What are the signs of diabetic retinopathy?
Background retinopathy: - Microaneurysms (dots) - Hemorrhages (blots) - Hard exudates (lipid deposits) Pre-proliferative (signs of retinal ischemia): - Cotton-wool spots (infarcts) - Hemorrhages - Venous beading Proliferative: - New vessels form Maculopathy: - Decreased visual acuity - Prompt laser, intravitreal steroids, anti-angiogenic agents needed in macular oedema
27
What should the BP control be for type 1 diabetics?
Treat BP if > 135/85mmHg unless albuminuria or 2+ features of metabolic syndrome in which case it should be 130/80mmHg - ACE inhibitor/ARB (1st line)
28
What should the BP control be for type 2 diabetics?
Target BP < 140/80mmHg or < 130/80mmHg if kidney, eye or CVD - ACE/ARB (1st line) - If pregnant = Ca2+ channel blocker
29
What do diabetic foot ulcers look like?
- Painless - Punched out - Thick callus ± superadded infection Causes: - Cellulitis - Abscess ± osteomyelitis
30
What are common organisms that cause cellulitis?
1. Staphs 2. Streps 3. Anaerobes
31
What medication is given for cellulitis?
1. Benzylpenicillin 2. Flucloxacillin 3. Metronidazole (4. IV insulin may help healing)
32
What is the pattern of diabetic neuropathy?
Symmetrical sensory polyneuropathy - Glove and stocking numbness, tingling, pain - Worse at night
33
What is the treatment of diabetic neuropathy?
- Paracetamol - Tricyclic (amitriptyline) - Duloxetine - Gabapentin - Pregabalin - Opiates
34
What are signs of autonomic neuropathy?
1. Postural hypotension (fludrocortisone/midodrine) 2. Decreased cerebrovascular autoregulation 3. Loss of respiratory sinus arrhythmia (vagal neuropathy) 4. Gastroparesis 5. Urine retention 6. Erectile dysfunction 7. Gustatory sweating 8. Diarrhea
35
In pregnancy what diabetic meds should be stopped?
All but metformin
36
What is the definition of hypoglycaemia and what are its symptoms/signs?
Blood glucose ≤ 3mmol/L Autonomic symptoms: - Sweating - Anxiety - Hunger - Tremor - Palpitations - Dizziness Neurogenic symptoms: - Confusion - Drowsiness - Visual trouble - Seizures - Coma
37
Which diabetic drugs can cause hypoglycaemia?
1. Insulin | 2. Sulphonylurea
38
What are the causes of hypoglycaemia in non-diabetics?
EXPLAIN Ex: exogenous drugs (alcohol, ACE-i, B-blockers, insulin-like growth factor) P: pituitary insufficiency L: liver failure (+ rare inherited enzyme defects) A: Addison's disease I: Islet cell tumours (insulinoma) and immune hypoglycaemia (anti-insulin receptor antibodies in Hodgkin's disease) N: non-pancreatic neoplasms (fibrosarcomas, hemangiopericytomas)
39
What is an insulinoma?
- Often benign pancreatic islet cell tumour - Sporadic OR with MEN-1 - Presents as fasting hypoglycaemia with Whipple's triad: 1. Symptoms associated with fasting/exercise 2. Recorded hypoglycaemia with symptoms 3. Symptoms relieved with glucose - Treat with excision of tumour
40
What are the TFTs like for sick euthyroidism?
Low TSH, Low T3/T4
41
What are the TFTs like for 1º hyperthyroidism? 1º hypothyroidism?
1º hyperthyroidism: TSH: low T3/T4: high 1º hypothyroidism: TSH: high T3/T4: low
42
What thyroid autoantibodies are increased in Hashimoto's and Grave's disease?
Antithyroid peroxidase antibodies (TPO) Antithyroglobulin antibodies TSH receptor antibodies -> Grave's disease
43
What investigations can be used to investigate thyroid problems?
1. Ultrasound 2. Isotope scan (iodine) -> useful for determining the cause of hyperthyroidism and to detect retrosternal goitre, thyroid mets
44
Which conditions are more likely to have abnormalities in thyroid functions?
1. AF 2. Hyperlipidemia (hypothyroidism) 3. DM 4. Women with type 1 diabetes during 1st trimester + post delivery (3x rise in incidence of postpartum thyroid dysfunction) 5. Lithium/amiodarone treatment for > 6mo 6. Down's syndrome, Turner's syndrome, Addison's disease (yearly monitoring)
45
What is the hormone profile for someone with subclinical hypothyroidism? TSH-secreting tumour? 2º hypothyroidism?
Subclinical hypothyroidism: Low TSH, normal T3/T4 TSH-secreting tumour: High TSH, high T4 2º hypothyroidism: Low TSH, low T3/T4
46
What are the symptoms of thyrotoxicosis?
1. Diarrhea 2. Weight loss 3. Increased appetite 4. Over-active 5. Sweats 6. Heat intolerance 7. Palpitations 8. Tremor 9. Irritability 10. Labile emotions 11. Oligomenorrhea ± infertility
47
What are signs of thyrotoxicosis?
1. Fast/irregular pulse 2. Warm, moist skin 3. Fine tremor 4. Palmar erythema 5. Thin hair 6. Lid lag 7. Lid retraction 8. Goitre 9. Proximal myopathy 10. Osteoporosis 11. Decreased libido/irregular menses
48
What are the signs of Grave's disease?
1. Eye disease (exophthalmos, ophthalmoplegia) 2. Pretibial myxoedema (oedematous swelling above lateral malleoli) 3. Thyroid acropachy
49
What are the causes of thyrotoxicosis?
1. Graves' disease (associated with vitiligo, DM1, Addison's) 2. Toxic multinodular goitre (iodine deficient areas) 3. Toxic adenoma 4. Ectopic thyroid tissue (metastatic follicular thyroid cancer) 5. Exogenous (iodine excess, levothyroxine excess, amiodarone/lithium)
50
What is the treatment for thyrotoxicosis?
1. B-blockers (propranolol) - rapid control of symptoms 2. Carbimazole - TITRATION: 20-40mg/d PO for 4wks then reduce according to TFTs every 1-2mo - BLOCK: give high-dose carbimazole + levothyroxine simultaneously - Maintain on either regimen for 12-18mo then withdraw (50% will relapse) 3. Radioiodine - Most become hypothyroid post-treatment - Caution in active hyperthyroidism as risk of thyroid storm - CI: pregnancy + lactation 4. Thyroidectomy (total) - Damage to recurrent laryngeal nerve (hoarse voice) - Hypoparathyroidism - Patients will become hypothyroid thus require thyroid replacement
51
What are the side effects of carbimazole?
Agranulocytosis (neutropenic sepsis) | - Warn to stop and get urgent FBC if signs of infection (fever, sore throat/mouth ulcers)
52
What is thyroid storm?
Uncontrolled hyperthyroidism - elevated heart rate - High BP - High body temperature Without prompt treatment is fatal
53
What is the most common ophthalmoplegia that occurs in thyroid eye disease?
Upward gaze due to muscle swelling + fibrosis
54
What are the causes of a diffuse goitre?
1. Physiological 2. Graves' disease 3. Hashimoto's thyroiditis 4. Subacute thyroiditis (painful!)
55
What are the causes of a nodular goitre?
1. Multinodular goitre 2. Adenoma 3. Carcinoma
56
What are the symptoms of hypothyroidism?
- Tiredness - Sleepy - Lethargic - Low mood - Cold intolerant - Increased weight - Constipation - Menorrhagia - Hoarse voice - Decreased memory/cognition - Dementia - Myalgia/cramps/weakness
57
What are the signs of hypothyroidism?
1. Bradycardic 2. Reflexes relax slowly 3. Ataxia (cerebellar) 4. Dry thin hair/skin 5. Yawning/drowsy/coma 6. Cold hands ± low temperature 7. Ascites ± non-pitting oedema (hands, feet, lids) 8. Pericardial/pleural effusion 9. Round puffy face 10. Defeated demeanour 11. Constipation 12. Neuropathy/myopathy/goitre
58
What are the causes of hypothyroidism?
1. Primary atrophic hypothyroidism (diffuse infiltration of the thyroid, leading to atrophy, so no goitre) 2. Hashimoto's thyroiditis (goitre) 3. Iodine deficiency 4. Post-thyroidectomy/radioiodine treatment 5. Drug-induced (antithyroid, amiodarone, lithium, iodine) 6. Subacute thyroiditis (temporary hypothyroidism after hyperthyroid phase)
59
What's the cause of secondary hypothyroidism?
Not enough TSH (due to hypopituitarism) - very rare
60
What is hypothyroidism associated with?
- Type 1 diabetes - Addison's - Turner's + Down's syndrome - Cystic fibrosis - Primary biliary cholangitis - Ovarian hyperstimulation
61
What is the treatment of hypothyroidism
Levothyroxine, OD, PO - Review at 12wks - Adjust 6 weekly by clinical state and to normalize but not suppress TSH - Wait 4wks before checking TSH levels - Once normalized check every 12mo
62
What is the starting dose of levothyroxine in someone with ischemic heart disease/elderly?
25mcg/24h increased dose by 25mcg/4wks according to TSH **Levothyroxine may precipitate angina/MI**
63
What is myxoedema coma?
Severe state of hypothyroidism - Decreased mental status - Hypothermia - Slowing of function in multiple organs Life-threatening - the ultimate hypothyroid state before death

Year 3 (7 decks)

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