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Endocrinology Flashcards

1
Q

What is type 1 diabetes?

A

Autoimmune destruction of pancreatic beta-cells causes reduced insulin production, resulting in hyperglycaemia

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2
Q

List aetiology/risk factors for type 1 diabetes

A

Autoimmunity
Genetics (HLA DR3/4)
Latent autoimmune diabetes of adulthood

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3
Q

List clinical features of type 1 diabetes

A 
Polyuria
Polydipsia
Weight loss
Fatigue
Malaise
Blurred vision (retinopathy)
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4
Q

What investigations would you do for type 1 diabetes?

A

Bloods: FBC, U+E, LFT’s, eGFR
Antibodies: anti- islet cell, GAD
Screening for retinopathy/nephropathy/neuropathy

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5
Q

What are the parameters for impaired glucose tolerance testing in diabetes?

A

Fasting: less than 7 mmol/l

2h oral glucose level: greater than 7.8, less than 11.1 mmol/l

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6
Q

What are the parameters for impaired fasting glucose testing in diabetes?

A

Fasting: greater than 6.1, less than 7 mmol/l

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7
Q

What are the WHO diagnostic criteria for diabetes?

A

Fasting glucose greater than 7 mmol/l
Random glucose greater than 11.1 mmol/l
HbA1C greater than 48
Either symptomatic + 1 positive lab test or asymptomatic + 2 positive lab tests

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8
Q

List two rapid-acting insulins

A

Humalog

Novorapid

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9
Q

List two short-acting insulins

A

Actrapid

Humulin S

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10
Q

List two intermediate-acting insulins

A

Insulatard

Humulin I

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11
Q

List two long-acting insulins

A

Lantus

Levemir

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12
Q

Novomix 30 insulin has how much short and how much long -acting insulin?

A

30% short-acting

70% long-acting

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13
Q

List the main insulin regimens that patients may be on

A

Once-daily: long-acting before bed
Twice-daily: short-acting pre-breakfast and pre-dinner
Basal-bolus: long-acting before bed, short-acting before meal

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14
Q

What is type 2 diabetes?

A

Relative insulin deficiency caused by insulin resistance/reduced sensitivity, resulting in hyperglycaemia

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15
Q

List aetiology/risk factors for type 2 diabetes

A 
Asians
Obesity
Low level of exercise
Cardiovascular disease
Monogenic twins
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16
Q

List clinical features of type 2 diabetes

A 
Polyuria
Polydipsia
Obesity
Fatigue
Malaise
Blurred vision
Recurrent infections
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17
Q

List the main drug classes (and examples) used in type 2 diabetes

A 
Biguanides (metformin)
Sulfonylureas (gliclazide, glibenclamide)
TZD's (pioglitazone)
DPP-IV inhibitors (sitagliptin)
GLP-1 analogue (exenatide)
Alpha-glucosidase inhibitors (acarbose)
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18
Q

What does metformin do? List side effects

A

Reduces hepatic gluconeogenesis, increases insulin sensitivity
No weight gain or hypo risk
SE: lactic acidosis, GI upset, avoid if eGFR less than 35

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19
Q

What does gliclazide do? List side effects

A

Increases insulin secretion from pancreatic B-cell

SE: weight gain, hypoglycaemia

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20
Q

What does pioglitazone do? List side effects

A

Enhances PPAR-alpha to increase insulin gene transcription, also reduces hepatic gluconeogenesis
SE: fluid overload, weight gain, osteoporosis

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21
Q

What does sitagliptin do?

A

Increases incretin effect of GLP-1 and GDP (delays gastric emptying, reduces appetite)

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22
Q

What are the components of metabolic syndrome?

A

Central obesity
Hypertension
Hyperglycaemia
Dyslipidaemia

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23
Q

Outline management of metabolic syndrome

A

Exercise (Tai Chi)
Weight reduction, orlistat
Statin, anti-hypertensive, metformin +/- pioglitazone

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24
Q

What is the pathophysiology of diabetic ketoacidosis?

A

Reduced insulin results in reduced cellular uptake of glucose, causing less pyruvate and more acetyl-coA
Acetyl-coA is converted to ketone bodies and acetate

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25
List aetiology/risk factors for diabetic ketoacidosis
``` Non-compliance Missed dose, missed meal Infection (esp UTI) MI Steroid use Pancreatitis Surgery Alcohol-induced ```
26
List clinical features of diabetic ketoacidosis
``` Drowsiness Vomiting Dehydration Polyuria, polydipsia Ketotic "pear-drop" breath Kussmaul (deep) breathing ```
27
What investigations would you do for diabetic ketoacidosis?
Glucose usually greater than 11 Bloods: FBC, U+E, osmolarity, ABG CXR Urinary ketones, culture
28
Outline management of diabetic ketoacidosis
NG tube if vomiting/unconscious IV insulin 6u per hour, increase if poor response IM insulin 20u if no infusion pump Monitor U+E ever hour, aim for glucose to drop by 5mmol/l IV fluids
29
What is hyperosmolar hyperglycaemic state (HHS)?
Hyperosmolar state caused by uncontrolled hyperglycaemia, usually in type 2 diabetics
30
List clinical features of HHS
Dehydration Stupor, coma Impaired consciousness
31
Outline management of HHS
9L saline over 48h (slower rate than DKA) Replace K May or may not need insulin
32
List aetiology/risk factors of hypoglycaemia
``` Insulin/sulfonylurea use Increased activity Missed meal Alcohol binge Drugs (aspirin, ACEi, B-blocker, quinine) Pituitary insufficiency Liver failure Addison's disease Islet cell tumour ```
33
List clinical features of hypoglycaemia
``` Sweaty Anxious Tremor Confusion, coma Dizziness Vision trouble Seizure ```
34
What investigations would you do for hypoglycaemia?
Blood glucose Prolonged OGTT, fasting tests Blood insulin/c-peptide/ketones if symptomatic
35
Outline management of hypoglycaemia
Oral sugar + long-acting starch | IV dextrose/IM glucagon
36
List aetiology/risk factors for hyperthyroidism
``` Autoimmunity (Grave's disease, associated conditions such as vitiligo, T1DM, Addison's) Toxic multinodular goitre (elderly, iodine-deficient) TSH-secreting tumour Acute thyroiditis (De Quervain's) Amiodarone, lithium Ectopic thyroid tissue Iodine excess Radiation exposure ```
37
List clinical features of hyperthyroidism
``` Irritability, anxiety Heat intolerance Sweating, warm skin Tremor Increased sympathetic drive Weight loss, diarrhoea Labile emotions Oligomenorrhoea Thin hair Goitre/nodule, bruit Eye disease Pretibial myxoedema in Grave's ```
38
List typical eye signs seen in Grave's disease
``` Lid lag Lid retraction Exophthalmus Ophthalmoplegia Proptosis ```
39
What investigations would you do for hyperthyroidism?
``` TSH (low), T4 (high), T3 (high) Anti-TPO antibody Anti-TSH receptor antibody IgG Isotope scan for nodule/goitre shows smooth symmetrical butterfly-shape ```
40
Outline management of hyperthyroidism
Carbimazole, propylthiouracil in pregnancy B-blocker for symptoms Radioiodine Thyroidectomy
41
What is thyroid storm?
Rapid deterioration of hyperthyroidism
42
List clinical features of thyroid storm
``` Hyperthyroid signs and symptoms Fever Confusion, coma Diarrhoea and vomiting Goitre AF/tachycardia Heart failure ```
43
Outline management of thyroid storm
``` Counteract peripheral effects and treat complications Propranolol, osmolol in asthmatic Carbimazole Steroid Digoxin if heart is fast ```
44
List aetiology/risk factors for hypothyroidism
``` Autoimmunity (Hashimoto's) Primary atrophy (diffuse lymphocytic infiltration) Thyroidectomy Radioiodine Postpartum Amiodarone, lithium, iodine Turner's, Down's syndrome ```
45
List clinical features of hypothyroidism
``` Tired, slow, sleepy Low mood Cold intolerance Bradycardia Sparse hair, dry skin, cold hands Constipation Menorrhagia Weakness Goitre Weight gain, puffy face Memory change/loss ```
46
What investigations would you do for hypothyroidism?
TSH (high), T4 (low), T3 (low) Anti-TPO antibody Anti-TBG antibody FBC for anaemia
47
Outline management of hypothyroidism
Levothyroxine (T4) | Restore and monitor metabolic rate
48
What is myxoedema coma?
Severe hypothyroid state
49
List clinical features of myxoedema coma
``` Hypothyroidism signs and symptoms Often over 65yo Hypothermia Hyper-reflexia Coma, seizures Goitre Hypotension Cyanosis ```
50
Outline management of myxoedema coma
Liothyronine (T3) intravenously Hydrocortisone IV fluids Treat complications and heart failure
51
List aetiology/risk factors for goitre
``` Pregnancy Puberty Autoimmunity Thyroiditis Iodine deficiency Radiation exposure Malignancy, cysts Tuberculosis ```
52
What are the typical types of goitre?
Smooth non-toxic Toxic (Grave's, De Quervain's) Multinodular non-toxic Toxic multinodular
53
List clinical features of thyroid cancer
``` Palpable nodule in neck, goitre Dysphagia Hoarseness Weight loss Signs of hyper/hypo thyroidism ```
54
What investigations would you do for thyroid cancer?
USS-guided FNA LN biopsy Iodine scan
55
What are the different subtypes of thyroid cancer?
Papillary Follicular Medullary Anaplastic
56
What is the most common subtype of thyroid cancer and how does it spread?
Papillary | Lymphatic spread to nodes, lung
57
How does follicular thyroid cancer spread?
Haematogenous spread to bone, lung
58
Which thyroid cancer may be part of MEN2 syndrome? From which cells does it arise and what does it produce?
Medullary Derived from para-follicular C cells Produces calcitonin
59
Which thyroid cancer has the poorest prognosis?
Anaplastic
60
List causes/pathophysiology of primary, secondary and tertiary hyperparathyroidism
Primary: adenoma, gland hyperplasia, cancer Secondary: low vit D, chronic renal failure Tertiary: prolonged secondary causes autonomous gland hyperplasia, causing unchecked PTH release
61
Which lung cancer may produce PTH?
Squamous cell lung cancer
62
List clinical features of hyperparathyroidism
``` Weakness Fatigue Low mood Thirst, dehydration Polyuria Renal stones Abdo pain Pancreatitis Ulcers Osteopenia/porosis, fractures ```
63
Describe PTH and Ca levels in primary, secondary and tertiary hyperparathyroidism
Primary: increased PTH, increased Ca Secondary: increased PTH, decreased Ca Tertiary: very increased PTH, increased Ca
64
Which scan would be used to detect PTH-related adenoma?
Sestamibi scan
65
List causes/pathophysiology of primary, secondary, pseudo and pseudopseudo hypoparathyroidism
Primary: gland failure, autoimmunity, DiGeorge syndrome Secondary: radiation, surgery, hypomagnesium Pseudo: end-organ resistance to PTH due to GNAS1 mutation Pseudopseudo: pseudo with normal biochemistry
66
List clinical features of hypoparathyroidism
``` Cramps Numbness Parasthesiae Spasms Trousseau sign Rovstek sign ```
67
Outline management of hypoparathyroidism
Ca supplements Calcitriol Synthetic PTH
68
What are multiple endocrine neoplasia syndromes?
Inherited autosomal dominant disorders involving functioning hormone-producing tumours in multiple organs
69
MEN1 syndrome involves altered tumour-suppressor/ret proco-oncogene gene (delete as appropriate)
MEN1 syndrome involves altered tumour-suppressor gene
70
MEN2 syndrome involves altered tumour-suppressor/ret proco-oncogene gene (delete as appropriate)
MEN1 syndrome involves altered ret proco-oncogene
71
Which tumours typically occur as part of MEN1 syndrome?
``` Parathyroid hyperplasia/adenoma (95%) Pancreatic tumours (gastrinoma, insulinoma, glucagonoma) Pituitary adenoma Adrenal tumour Carcinoid tumour ```
72
Which tumours typically occur as part of MEN2 syndrome?
Thyroid (medullary) carcinoma Adrenal (phaeochromocytoma) Parathyroid adenoma Mucosal neuroma
73
What is Von-Hippel Lindau syndrome?
Germ-line mutation of tumour suppressor on c3p
74
Which tumours typically occur as part of Von-Hippel Lindau syndrome?
Bilateral renal cell cancer Retinal and cerebellar hemangioblastoma Phaeochromocytoma
75
What is Addison's disease?
Primary adrenal insufficiency | Destruction of adrenal cortex results in reduced aldosterone, cortisol and androgen release
76
List aetiology/risk factors for Addison's disease
``` Autoimmunity Tuberculosis Adrenal mets (lung, breast, kidney) Lymphoma Opportunistic infections in HIV Adrenal haemorrhage, adrenalectomy ```
77
List clinical features of Addison's disease
``` Pigmented skin/palmar creases Amenorrhoea Tiredness Weakness Dizziness Weight loss Abdo pain Vomiting Postural hypotension ```
78
What would you find on investigations for Addison's disease?
``` Bloods: hyponatraemia, hypokalaemia Low glucose Raised 9am ACTH Short synACTHen test fails to increase cortisol Plasma renin + aldosterone ```
79
Outline management of Addison's disease
Hydrocortisone Fludricortisone if reduced aldosterone Double dose in illness/injury
80
List aetiology/risk factors for secondary adrenal insufficiency
Long-term steroid use | HP axis disease (reduced ACTH production)
81
Skin pigmentation occurs in secondary adrenal insufficiency. True/False?
False | No ACTH produced so would not cross-react
82
What are the 2 main causes of hyperaldosteronism?
Conn's syndrome (adenoma) | Bilateral adrenal hyperplasia
83
List clinical features of hyperaldosteronism
Asymptomatic Hypertension Hypokalaemia (weakness, tetany, cramps, numbness)
84
What would you find on investigations for hyperaldosteronism?
Aldosterone : renin ratio (raised aldosterone, reduced renin) Saline suppression test if APR increased (would fail to suppress aldosterone) CT/MRI adrenals Adrenal vein sampling
85
Outline management of hyperaldosteronism
Adrenalectomy if unilateral adenoma | Spironolactone/amiloride if bilateral adrenal hyperplasia
86
What is phaeochromocytoma?
Rare catecholamine-producing tumour arising from chromaffin cells in adrenal medulla (sympathetic ganglion cells)
87
List aetiology/risk factors for phaeochromocytoma
``` 10% malignant 10% bilateral 10% extra-adrenal 10% familial MEN2 Neurofibromatosis Von-Hippel Lindau syndrome ```
88
List clinical features of phaeochromocytoma
Episodic headache Sweating Tachycardia Hypertension
89
What investigations would you do for phaeochromocytoma?
Urinary catecholamines Clonidine suppression test if borderline Abdo CT/MRI, PET scan MIBG scan
90
Outline management of phaeochromocytoma
Alpha-blocker (phenoxybenzamine) then beta-blocker (propranolol) Surgical excision
91
What is Cushing's syndrome?
Chronic glucocorticoid (cortisol) excess
92
List ACTH-dependent causes of Cushing's syndrome
Cushing's disease (bilateral adrenal hyperplasia, ACTH-producing pituitary adenoma) Ectopic ACTH production (small cell lung cancer) Ectopic CRF (thyroid, medullary, prostate cancers)
93
List ACTH-independent causes of Cushing's syndrome
Adrenal adenoma Steroid use Adrenal nodular hyperplasia
94
List clinical features of Cushing's syndrome
``` Weight gain Mood change Proximal weakness Gonadal dysfunction Central obesity Moon-face Achilles tendon rupture Buffalo neck lump Abdominal striae ```
95
What would you find on investigations for Cushing's syndrome?
Dexametasone suppression test in ACTH-dependent causes fails to suppress cortisol
96
Outline management of Cushing's syndrome
Trans-sphenoidal excision of adenoma Adrenalectomy Ectopic ACTH (metyrapone)
97
List hypothalamic causes of hypopituitarism
``` Kallman's syndrome Tumour Inflammation Infection (meningitis, TB) Ischaemia ```
98
List pituitary causes of hypopituitarism
``` Trauma Surgery Irradiation Inflammation Autoimmunity Ischaemia (apoplexy, DIC, Sheehan syndrome) ```
99
List clinical features of hypopituitarism (split up into hormone deficient features)
GH: central obesity, dry wrinkly skin, reduced strength and balance FSH/LH: oligo/amenorrhoea, reduced fertility, low libido, hypogonadism (reduced pubic hair, small testes, low volume ejaculate) TSH: hypothyroidism features ACTH: adrenal insufficiency features Alabaster skin in panhypopituitarism
100
What investigations would you do for hypopituitarism?
Basal tests (hormone levels) Dynamic tests (stress tests) Insulin stress test for GH/ACTH (would induce hypoglycaemia to raise GH and cortisol normally) Prolonged glucagon test if insulin test contraindicated Water deprivation test for ADH (would induce ADH release normally) SynACTHen test for ACTH (would induce cortisol release normally)
101
List the common pituitary adenomas
``` Usually benign adenomas Prolactinoma GH-secreting PRL + GH -secreting ACTH-secreting LH/FSH/TSH - secreting ```
102
List clinical features of pituitary tumours
``` Headaches Bitemporal hemianopia Altered appetite Precocious puberty CN III, IV, VI palsy CSF rhinorrhoea Effect of hormone release ```
103
Outline management of pituitary tumours
Hormone replacement Trans-sphenoidal surgery for macroadenomas Radiotherapy if resistant/recurrent Dopamine agonist for prolactinoma (cabergoline)
104
Where do craniopharyngiomas develop?
Arise from Rathke's pouch, located between pituitary and floor of 3rd ventricle
105
How does hyperprolactinaemia typically arise?
Loss of tonic inhibition of prolactin release by dopamine
106
List aetiology/risk factors for hyperprolactinaemia
``` Prolactinoma Disinhibition by compression of pituitary stalk Dopamine antagonists (metoclopramide) Oestrogen therapy (OCP) Antipsychotics Alpha-methyldopa Pregnancy Breastfeeding Stress ```
107
List clinical features of hyperprolactinaemia
``` Oligo/amenorrhoea Infertility Galactorrhoea Weight loss Dry vagina Sexual dysfunction Reduced pubic/facial hair Osteoporosis ```
108
Outline management of hyperprolactinaemia
``` Dopamine agonist (cabergoline) Trans-sphenoidal surgery for adenoma ```
109
List clinical features of acromegaly
``` Thickened skin and soft tissues Change in appearance Headache, vision disturbance Big hands/feet Coarse face, wide nose, big supraorbital ridge, big tongue Weight gain Amenorrhoea Impotence, low libido Acanthosis nigricans Goitre Proximal weakness Carpal tunnel syndrome ```
110
What investigations would you do for acromegaly?
``` Glucose tolerance test (normally would suppress GH) IGF-1 levels MRI pituitary Visual fields Lipids, glucose ```
111
Outline management of acromegaly
``` Trans-sphenoidal surgery for adenoma Somatostatin analogue (octreotide) Dopamine agonist (cabergoline) GH antagonist (pegvisomant) ```
112
What is diabetes insipidus?
Deficiency (cranial) or insensitivity (nephrogenic) to ADH
113
List aetiology/risk factors for cranial diabetes insipidus
``` Idiopathic Congenital defect Tumour, craniopharyngioma, mets Trauma Hypophysectomy Histiocytosis Sarcoidosis Haemorrhae Encephalitis ```
114
List aetiology/risk factors for nephrogenic diabetes insipidus
Inherited Metabolic (hypokalaemia hypercalcaemia) Chronic kidney disease Drugs (lithoum, demeclocycline)
115
List clinical features of diabetes insipidus
``` Polyuria Polydipsia Dehydration Nocturia "tasteless" urine ```
116
What would you find on investigations for diabetes insipidus?
Increased plasma osmolality Decreased urine osmolality Dilute urine Water deprivation test would fail to concentrate urine
117
Outline management of diabetes insipidus
Desmopressin for cranial DI | Thiazide for nephrogenic DI
118
What is SIADH?
Inappropriately high ADH levels
119
List aetiology/risk factors for SIADH
``` Malignancy (SCLC, pancreas, prostate, thymus, lymphoma) Pneumonia, TB Meningitis Vasculitis Hypothyroidism Alcohol withdrawal Drugs (opiates, SSRI, psychotropics) Trauma ```
120
List clinical features of SIADH
``` Confusion Irritability Fits Coma Nausea ```
121
What would you find on investigations for SIADH?
Hyponatraemia (urine hypernatraemia) | Decreased plasma osmolality
122
Outline management of SIADH
``` Treat cause Fluid restrict Salt +/- loop diuretic if severe Demeclocycline (ADH inhibitor) Vaptans may be trialled ```

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