Endocrinology Flashcards
1
Q
what is the function of insulin?
A
reduces hepatic glucose production
increases skeletal muscle and adipose tissue glucose uptake
reduces glycogenolysis and gluconeogenesis
direct inhibition of glucagon secretion
inhibition of glucagon gene in pancreatic alpha cells
2
Q
what are the most serious complications of diabetes?
A
diabetic ketoacidosis
hyperosmolar hyperglycaemic syndrome
3
Q
what are the investigations and results required to diagnose DKA?
A
existing diabetes
or
new presentation with BM >11.1mmol/L
urinary ketones >++
or
capillary ketones >3.0mmol/L
venous pH <7.30
and/or
bicarbonate <15mmol/L
4
Q
name some hyperglycaemic states
A
DM
HHS
stress hyperglycaemia
impaired glucose tolerance
5
Q
name some ketotic states
A
ketotic hyperglycaemia
alcoholic ketosis
starvation ketosis
(not always harmful)
6
Q
name some metabolic acidotic states
A
lactic acidosis hyperchloraemic acidosis salicylism uraemic acidosis drug-induced acidosis
7
Q
what are the signs of insulin reduction?
A
total body K depletion PO4 decrease Cr increase renal failure ketoacidosis hyperlipidaemia glycogenolysis gluconeogenesis hyperglycaemia hyperosmolarity glucosuria
8
Q
what is the pathogenesis of DKA?
A
absolute insulin deficiency gluconeogenesis, glucogenolysis and hyperglycaemia -> osmotic diuresis electrolyte abnormalities dehydration hormone sensitive lipase production increased FFA to liver increased ketogenesis acidosis
9
Q
what is the pathogenesis of HHS?
A
relative insulin deficiency gluconeogenesis, glucogenolysis and hyperglycaemia -> osmotic diuresis electrolyte abnormalities dehydration hyperosmolarity increased hormone sensitive lipase absent or minimal ketogenesis
10
Q
what are the precipitants of a DKA?
A
newly diagnosed diabetes non-compliance omission pump failure infection inflammation iatrogenic infarction intoxication
11
Q
what are the symptoms of DKA?
A
deep, rapid breathing (dyspnoea) fruity-smelling breath dry mouth nausea vomiting abdominal pain lethargy polyuria polydipsia new diagnosis/symptoms of T1DM develops over <1 day
12
Q
what are the symptoms of HHS?
A
polyuria +/- polydipsia weight loss confusion lethargy develops over >1 day
13
Q
what is the management of DKA?
A
ABC IV fluids (1L 0.9% NaCl over 1 hour) insulin potassium treat cause reassess prevention of future DKA
14
Q
what are the differences in managing DKA <18yrs?
A
fluid prescription based on estimated weight and estimated deficit
insulin not started until IV fluids running for 1 hour
use 0.9% NaCl with 5% glucose
15
Q
describe the insulin infusion in a DKA
A
0.1 units/kg/hour (7 units in 70kg)
draw up 50 units Actrapid
add to 49.5ml 0.9% NaCl in a 50ml syringe
concentration 1 unit/ml
continue long-acting insulin (lantis, levemir)
16
Q
what is the management of hyper/hypokalaemia post DKA?
A
> 5.5mmol/L nil
3.5-5.5mmol/L requires 40mmol/L replacement of infusion solution
<3.5mmol/L requires senior review
17
Q
what are the causes of a DKA?
A
gastroenteritis UTI pneumonia MI stroke pancreatitis non-compliance cocaine first presentation
18
Q
what is involved in the reassessment of a DKA?
A
GCS
clinical observations
hourly CBG and ketones
once CBG <14mmol/L start 10% dextrose alongside 0.9% NaCl
high rate insulin infusion until ketones are clear
once ketones <0.6mmol/L, resume s/c insulin if able to eat and drink, fasting protocol with variable rate insulin if not
19
Q
what are the complications of DKA?
A
infection shock vascular thrombosis pulmonary oedema cerebral oedema (mannitol)
20
Q
what is the treatment of HHS?
A
hydration treat underlying cause insulin drip after aggressive hydration switch to s/c regimen once glucose <11mmol/L and patient eating K replacement
21
Q
describe the effects of SGLT2 inhibitors
A
glucosuria free fatty acid release pancreatic glucagon secretion hepatic glucose production and ketogenesis renal ketone resorption
22
Q
what is the definition and causes of gluconeogenesis?
A
delivery of precursors to liver from breakdown of fat and muscle
insulin deficiency
glucagon excess
23
Q
define hypoglycaemia
A
blood glucose <3.9mmol/L
24
Q
what are the symptoms of hypoglycaemia?
A
sweating palpitations agitation shaking hunger confusion drowsiness speech difficulty odd behaviour incoordination
25
what are the risk factors for hypoglycaemia?
```
intensive treatment
missed meal
PMHx severe hypo
hypo unawareness
duration of diabetes
increased age
exercise
pregnancy
lipoatrophy/hypertrophy
reduced clearance (renal failure, SUs, ACEis, ARBs)
```
26
what is the management of mild hypoglycaemia?
15-20g quick-acting carbohydrate
or
150-200ml pure fruit juice
test glucose level 15 minutes later and if <4.0mmol/L repeat up to 3 times
27
what is the management of moderate hypoglycaemia?
1.5-2 tubes of 40% glucose gel
or
1mg glucagon IM
test glucose level 15 minutes later and if <4.0mmol/L repeat up to 3 times
28
what is the management of severe hypoglycaemia?
```
ABC
stop IV insulin
75ml 20% IV glucose over 15 minutes
or
1mg glucagon IM
check glucose after 10 minutes and repeat if <4.0mmol/L
```
29
in what conditions will glucagon not be effective?
malnourishment
severe liver disease
repeated hypoglycaemia
30
describe the hypothalamic-pituitary-thyroid axis
hypothalamus produces TRH which acts on the pituitary
pituitary produces TSH which acts on the thyroid
thyroid produces T3 and T4 which acts on the heart, liver, bone and CNS
31
what are the TFT results for primary hypo/hyperthyroidism?
hypo - FT4 low, TSH high
| hyper - FT4 high, TSH low
32
what are the TFT results for secondary hypo/hyperthyroidism?
hypo - FT4 low, TSH low/normal
| hyper - FT4 high, TSH high/normal
33
what are the symptoms and signs of hypothyroidism?
```
tiredness
weight gain
cold intolerance, cold peripheries, hypothermia
goitre (deep voice)
depression
poor memory
dry hair and skin
myalgia, myotonia
constipation
periorbital oedema
deafness
hypertension
HF
bradycardia
pericardial effusion
anaemia
```
34
what are the causes of hypothyroidism?
```
agenesis
Hashimoto's disease (autoimmune)
thyroiditis
iodine deficiency
antithyroid drugs
lithium
amiodarone
monoclonal antibody therapy
pituitary adenoma
following pituitary surgery
```
35
what is the treatment of hypothyroidism and what adjustments does this require in special situations?
thyroxine
1.6 mcg/kg
reduced dose with cardiac history, elderly
assess response after 6-8 weeks
36
what are the symptoms and signs of hyperthyroidism?
```
weight loss
irritability
itching
heat intolerance
tremor
thirst
vomiting
diarrhoea
oligomenorrhoea
hyperkinese
tachycardia or AF
full pulse
warm vasodilated peripheries
exophthalmos
lid lag
goitre
bruit
```
37
what are the causes of hyperthyroidism?
```
grave's disease (autoimmune)
toxic multi nodular goitre
toxic nodule (solitary)
thyroiditis (viral, autoimmune, postpartum)
gestational thyrotoxicosis
exogenous iodine
amiodarone
monoclonal antibody therapy
excess T4
TSH secreting pituitary adenoma
HCG producing tumours
```
38
describe the pathology and symptoms of Grave's disease
autoimmune
presence of stimulating TSH receptor antibodies
thyroid eye disease (specific to Grave's)
swelling and inflammation of retro-orbital tissues and extra ocular muscles; proptosis
gritty sensation in eye
lid lag
periorbital oedema
optic nerve compression (severe disease)
39
what is the treatment of hyperthyroidism?
anti-thyroid drugs (carbimazole)
radioactive iodine therapy
surgery
40
what are the side effects of carbimazole and prophythiouracil (PTU)?
rash
agranulocytosis (stop if develop a sore throat or fever and require surgery WCC measurement)
liver dysfunction (PTU)
41
describe the 2 regimens of anti-thyroid treatment and why/when they are used
titration - high dose anti-thyroid and titrate down as TFT improve, used in women planning pregnancy
block and replace - high dose carbimazole and replace with thyroxine, requires less monitoring
42
what are the causes of goitres/nodules?
```
puberty
pregnancy
grave's
hashimoto's
thyroiditis
iodine deficiency
multi nodular goitre
solitary nodular
cysts
tumours
```
43
what are the types of thyroid cancer?
```
papillary
follicular
medullary cell
anaplastic
lymphoma
```
44
what investigations should be performed on a thyroid lump?
```
TFT
thyroid antibodies
US thyroid
FNA
CT thoracic inlet
```
45
what is the treatment of thyroid cancer?
```
surgery (lobectomy or total thyroidectomy)
ablative radioactive iodine
high dose thyroxine (suppress TSH)
radiotherapy
chemotherapy
```
46
what hormones are produced by the different regions of the adrenal cortex and medulla?
zona glomerulosa - aldosterone
zona fasciculata - cortisol
zona reticularis - adrenal androgens
medulla - catecholamines
47
how do ACTH and RAAS affect the adrenal cortex?
cause the production of cortisol and aldosterone (glucocorticoids and mineralocorticoids)
48
what are the symptoms and signs of Cushing's syndrome?
```
weight gain
slow healing of cuts
increased infection risk
fatigue
glucose intolerance
sweating
moon face
buffalo hump
skin thinning
depression, irritability
hypertension
oligomenorrhoea/erectile dysfunction
```
49
what are the causes of Cushing's syndrome?
ACTH dependent;
pituitary adenoma
ectopic ACTH
ACTH independent;
exogenous steroids
adrenal adenoma/hyperplasia
50
what investigations are required to diagnose Cushing's syndrome?
24hr urinary free cortisol
| 48hr low dose dexamethasone suppression test
51
what is the treatment of Cushing's syndrome?
treat the cause
transsphenoidal resection of pituitary tumour
surgical resection of adrenal tumour
weaning and discontinuation of exogenous steroid
in pituitary or adrenal surgery require steroid cover (IM then oral)
52
define Addison's disease
an absolute or relative lack of adrenal (endocrine) function
53
what are the symptoms and signs of Addison's disease?
```
fatigue
weakness
weight loss
nausea
vomiting
abdominal pain
diarrhoea
constipation
myalgia
decreased libido
amenorrhoea
hyperpigmentation
hypotension
axillary and pubic hair thinning
vitiligo
```
54
what are the causes of primary adrenal insufficiency?
```
autoimmune
TB
metastatic disease
trauma
opportunistic infection
bilateral adrenal haemorrhage/infarction
anticoagulant therapy
coagulopathy
postoperative state
severe sepsis
```
55
what are the causes of secondary/tertiary adrenal insufficiency?
panhypopituitarism
isolated ACTH deficiency
traumatic brain injury
high dose glucocorticoids
56
what is the treatment of adrenal insufficiency?
hydrocortisone 15mg morning and 5mg afternoon (glucocorticoid)
rarely prednisolone 5mg or dexamethasone 0.5mg
fludrocortisone 100mcg daily (mineralocorticoid), only required in primary disease
57
what are the rules for taking steroids?
double dose on sick days
never stop steroid replacement
attend GP/ED if vomiting/diarrhoea as hydrocortisone absorption will be impaired, will require IV or IM
58
what are the symptoms and signs of an adrenal crisis?
```
hypotension/shock
hypoglycaemia
hyperkalaemia
hyponatraemia
extreme fatigue
abdominal pain
nausea
vomiting
diarrhoea
```
59
what is the treatment of an adrenal crisis?
fluid replacement
hydrocortisone 100mg IV stat then 6hrly
glucose replacement occasionally
treatment of underlying cause
60
define primary aldosteronism
a group of disorders in which aldosterone production is
inappropriately high
relatively independent from RAAS
non-suppressible by sodium loading
61
what are the causes of primary aldosteronism/Conn's syndrome?
```
aldosterone producing adenoma
bilateral adrenal hyperplasia
unilateral adrenal hyperplasia
aldosterone producing adrenocortical carcinoma
FH
```
62
what are the signs and investigations required to diagnose primary aldosteronism?
```
(resistant) hypertension
hypokalaemia
adrenal nodule
FHx of HTN or CVD <40yr
FHx of primary aldosteronism in first degree relative
```
aldosterone:renin ratio
saline suppression test
CT adrenals
adrenal venous sampling
63
what is the management of unilateral and bilateral primary aldosteronism?
adrenalectomy
spironolactone
eplerenone
amiloride
64
define a pheochromocytoma
a tumour arising from adrenomedullary chromaffin cells that commonly produces one or more catecholamines
65
what are the symptoms and signs of a pheochromocytoma?
```
headache
sweating
palpitations
postural hypotension
cardiomyopathy
end organ damage
hyperglycaemia
retinal haemangioblastoma
cutaneous neurofibromata
cafe-au-lait spots
```
66
what investigations are required for the diagnosis of a pheochromocytoma?
```
24hr urinary metanephrines
plasma metanephrines
clonidine suppression test
CT abdomen
MIBG
```
67
what is the treatment of a pheochromocytoma?
```
phenoxybenzamine (alpha-1 adrenoceptor blocker, controls BP, expands plasma volume and avoid a hypertensive crisis)
once alpha blockade is complete
beta blockade
laparoscopic adrenalectomy
genetic testing
```
68
how does insulin dosing correct for hyperglycaemic episodes?
1 unit of insulin to reduce blood glucose by 2-3 mmol/L
69
what are the considerations when prescribing insulin?
what insulin is the patient taking
what is the usual home dose of insulin
what is control usually like and why has it changed
what is the pattern of glucose monitoring
are adjustments needed
which insulin needs adjusted
how much does insulin need adjusted
70
what rules must be adhered to in insulin adjustment?
10% adjustment - on regular insulin (basal bolus or BD mixed insulin)
correction for hyperglycaemia - on diet alone, oral agents or OD insulin
71
what are the general principles of peri-operative diabetes care
continue long-acting insulin
take rapid and mixed insulin and oral hypoglycaemic agents the day before surgery and hold on day of surgery
IV variable insulin infusion started on day of surgery
ensure patient does not become dehydrated; 0.45% NaCl with 5% glucose and 10mmol/L K
72
what structures are adjacent to the pituitary?
superior; optic chiasm
lateral; cavernous sinus (CN III, IV, VI, V1)
inferior; sphenoidal sinus
73
what is the function of the pituitary?
anterior produces GH, prolactin, LH, FSH, ACTH, TSH
| posterior produces ADH, oxytocin
74
describe dynamic tests
in overproductive diseases we do a "suppression" test to try and suppress it to normal and vice versa
if a patient has the disease the hormones will not suppress/stimulate with dynamic testing
75
what investigation results will confirm pituitary acromegaly?
elevated IGF1 and GH
| oral glucose tolerance test; GH will remain high despite glucose load
76
what is the treatment of pituitary acromegaly?
transsphenoidal surgery to resect tumour
risk of hypopituitarism so given cortisol until confirmed normal in post-op
radiotherapy
prolactinoma - dopamine agonists (bromocriptine/cabergoline)
acromegaly - dopamine agonists, somatostatin analogues, GH receptor antagonists
77
what are the direct complications of hyperglycaemia?
```
blood flow abnormalities
vascular permeability
angiogenesis
capillary occlusion
vascular occlusion
pro-inflammatory gene expression
```
78
describe the findings of non-proliferative retinopathy
lipid deposits
haemorrhage
cotton wool spot due to ischaemia
79
describe the findings of proliferative retinopathy
new vessel formation which can result in haemorrhage or retinal detachment
80
define normal, micro and macroalbuminuria
normal <3
microalbuminuria ACR 3-30
macroabluminuria ACR>30
81
what are the 3 ways of managing diabetic eye disease?
prevention (good blood sugar control)
early detection (eye screening)
treatment (laser, anti-VEGF)
82
what are the 3 ways of managing diabetic renal disease?
prevention (good blood sugar and pressure control)
early detection (urinary ACR monitoring)
treatment (ACEi/ARBs)
83
describe how ulcers occurs in diabetic patients
neuropathy increases injury risk
| PVD impedes healing
84
what are the 3 ways of managing diabetic neuropathy?
```
prevention (good blood sugar control)
early detection (monofilament)
treatment (good foot care, podiatry)
```
85
how is macrovascular disease (stroke) prevented in diabetes?
A1c 7%
blood pressure 130/80
LDL <2
86
describe the immunological defects associated with diabetes
neutrophil function impaired
lymphocyte response impaired
production of IL-2 impaired
manifest as delayed/impaired response to injury and increased wound infections
87
what are the aspects of diabetes that play a significant role in the impairment of healing?
peripheral vascular disease (ischaemia)
immunological defects
neuropathy (decreased pain and proprioception, dry skin, small muscle wasting)
88
what are the risk factors for a neuropathic foot?
```
age
poor blood sugar control
diabetes duration
HTN
renal failure (proteinuria, microalbuminuria)
neuropathy
ischaemia
inappropriate footwear
limited joint mobility
Hx of amputation or foot ulceration
dry skin
infection
```
89
what are the signs of a neuropathic foot?
```
well perfused
bounding pulses (absence of pulses doubles amputation risk)
distended dorsal veins
high arch
plantar callus, ulceration
lacks protective pain sensation
does not perceive trauma or infection
```
neuroischaemic - cool, pulseless, hairless
90
what are the complications of a neuropathic foot?
plantar ulceration
gangrene
Charcot's osteoarthropathy
neuropathic oedema
91
define ankle brachial pressure index (ABPI)
highest pedal pulse pressure / highest brachial pulse
| normal range 0.8-1.2
92
describe the neurological assessment of a diabetic foot
autonomic and motor - observation
sensory - pressure, sharp touch, vibration
sensory - neurotip, 10g monofilament, neurothesiometer
93
what are the reasons for debridement of a callous?
reduced plantar pressure
discover true dimensions of the ulcer
establish drainage
granulation of wound edge
94
what is the treatment methods of a diabetic foot ulcer?
wound control (debridement, dressings, larvae therapy)
mechanical control (appropriate footwear, casts)
microbiological control
lifestyle (smoking cessation, exercise, alcohol, eating habits)
education
95
what is the diabetic foot triad?
neuropathy
ischaemia
infection
96
describe the rapid-acting insulins
novorapid/aspart, humalog/lispro, apidra
onset at 5-10 minutes
peak at 1-2 hours
duration of 3-5 hours
97
describe the quick-acting insulins
actrapid, humulin S
onset at 30 minutes
peak at 3 hours
duration of 6 hours
98
describe the intermediate-acting insulins
insulatard, humulin I
onset at 2 hours
peak at 5-8 hours
duration of 20 hours
99
describe the long-acting insulins
levemir/detemir, lantus/glargine
immediate onset
duration of 20-24 hours
100
what is the target blood sugar?
5-9 mmol
101
describe insulin regimens
4x daily - greater flexibility, better control
2/3x daily - more common and suitable to lifestyle
1x daily - commonly in combination with OHAs
102
what are the essential components of a regular diabetes check-up?
```
any new health problems
BP
peripheral pulses
sensation in feet
foot ulceration
urinalysis (ACR)
visual acuity
glycemic control
lipid profile
```
103
describe glomerular hypertension in diabetes
thickened by leaky GBM
| filtrate includes a small amount of albumin
104
which hormones are produced by the anterior pituitary and on which organs do they act?
```
GH; bones, muscles, organs
prolactin; breast
LH and FSH; ovaries and testes
ACTH; adrenal cortex
TSH; thyroid gland
```
105
which hormones are produced by the posterior pituitary and on which organs do they act?
ADH; kidneys
| oxytocin; breasts and uterus
106
what are the local signs and symptoms of pituitary problems?
headache
| visual acuity, fields, movement
107
what are the signs and symptoms of pituitary under function?
fatigue
reduced sexual function; gonadotrophin loss
delayed growth
thirst/polyuria; DI due to loss of ADH
108
what are the signs and symptoms of pituitary over function?
```
prolactin;
galactorrhea
amenorrhoea
reduced sexual function
reduced facial hair growth
gynaecomastia
```
GH;
overgrowth
metabolic features
gigantism in children (long bone growth)
ACTH;
Cushing's disease
109
what are the signs and symptoms of acromegaly?
```
interdental separation
hirsutism
thick greasy skin
spade-like hands and feet
weight gain
headaches
visual deterioration
deep voice
carpal tunnel syndrome
prognathism
frontal bossing
large tonsils and tongue
GI and gallbladder polyps
hepatosplenomegaly
goitre
hypogonadism
hypothyroidism
hypoadrenalism
```
110
what are the signs of prolactinoma?
```
galactorrhoea
amenorrhoea
hypogonadism
erectile dysfunction
infertility
gynaecomastia
```
111
what investigations are required to diagnose pituitary disease?
```
prolactin
GH
IGF1; marker of GH production, screening test for acromegaly
cortisol/synacthen test
TFT
FSH
LH
oestrogen/testosterone
U&E
dynamic tests
MRI
genetic testing
```
112
describe the dynamic tests used in pituitary disease
overproduction;
dexamethasone suppression test
oral glucose tolerance test
underproduction;
water deprivation test
insulin tolerance test
113
what is the medical treatment of prolactinoma?
```
1st line (not surgery)
dopamine agonists; bromocriptine, cabergoline
```
114
what is the medical treatment of acromegaly?
dopamine agonists
somatostatin analogues
GH receptor antagonists
used in residual disease following surgery
115
what is the medical treatment of Cushing's disease?
dopamine agonists; metyrapone mitotane
| somatostatin analogues
116
what are the features of SIADH?
```
hyponatraemia
hypotonic plasma
inappropriate urine osmolality
excessive renal Na loss
normal renal, adrenal and thyroid function
```
117
what are the causes of SIADH?
tumours; small cell lung ca, thymoma, lymphoma, mesothelioma
respiratory; pneumonia, TB, aspergillosis, pulmonary abscess
CNS; meningitis, encephalitis, abscess, injury, Guillain barre, SAH, stroke
drugs; chemotherapy, antidepressants, antipsychotics, carbamazepine, PPIs, opiates
metabolic; hypothyroidism, glucocorticoid deficiency
idiopathic
118
what are the actions of PTH?
bone; releases calcium and phosphorus
| kidney; increases calcitriol formation, decreases calcium excretion, increases phosphorus excretion
119
what are the actions of calcitriol?
bone; releases calcium and phosphorus
| small intestines; increases absorption of dietary calcium and phosphorus
120
what are the symptoms of hypercalcaemia?
renal; polyuria, polydipsia
GI; abdominal pain, vomiting, constipation, anorexia
CNS; depression, fatigue, weakness, confusion
121
what are the causes of hypercalcaemia?
```
hyperparathyroidism; primary or tertiary
malignancy; multiple myeloma, bone metastases
vitamin D or A intoxication
sarcoidosis
familial hypocalciuric hypercalcaemia (FHH)
thiazide diuretics
lithium
immobilisation
thyrotoxicosis
renal disease
Addisons disease
```
122
describe the presentation of chronic hypercalcaemia
mild-moderate
often asymptomatic
mostly caused by primary hyperparathyroidism
surgical vs conservative management
123
describe the presentation of acute hypercalcaemia
```
severe
symptomatic
mostly caused by malignancy
treatment hypercalcaemia
find and treat cause
```
124
define corrected calcium
measured Ca + 0.02 x (40 - albumin)
| normal range 2.10-2.60 mmol/L
125
how do you determine the mechanism of hypercalcaemia?
PTH elevated; primary or tertiary hyperparathyroidism
| PTH suppressed; non-parathyroid cause
126
what investigations should be performed to diagnose hypercalcaemia?
```
history and examination
CXR
Bence-jones protein
plasma protein electrophoresis
biochemical profile; U&E, LFTs, TFTs, FBC, ESR
vitamin D
serum cortisol/short synacthen test
serum ACE
```
127
what are the signs and causes of primary hyperparathyroidism?
raised Ca, raised/normal PTH
adenoma (90%)
multiple gland enlargement; MEN1, MEN2A, familial hyperparathyroidism
parathyroid carcinoma
128
what are the signs and causes of secondary hyperparathyroidism?
low Ca, raised PTH
| vitamin D deficiency
129
what are the signs and causes of tertiary hyperparathyroidism?
raised Ca, very raised PTH
| renal failure
130
what are the clinical features of primary hyperparathyroidism?
```
f>m
usually >50yrs
asymptomatic
renal stones
decreased bone density
hypercalcaemia symptoms
```
131
what is the management of primary hyperparathyroidism?
```
ensure adequate hydration
review medications; Ca and vitamin D supplements, thiazide diuretics
conservative management
medical; bisphosphonates, cinacalcet
surgical; parathyroidectomy
referral to genetics
```
132
what are the indications for a parathyroidectomy?
```
symptomatic hypercalcaemia
renal calculi/impairment
osteoporosis
correct calcium >2.85mmol/L
age <50
pancreatitis
```
133
describe hypercalcaemia of malignancy
```
late manifestation
poor prognostic sign
untreatable tumour
raised Ca, suppressed PTH
acute onset
very symptomatic
```
134
which tumours metastasise to bone?
```
kidney
prostate
breast
lung
thyroid
colon
ovary
```
135
what is the treatment of hypercalcaemia?
```
rehydration;
4-6L IVF / 24hrs
monitor for fluid overload
caution in elderly
loop diuretics if required
```
IV bisphosphonate therapy;
4mg zolendronic acid or 30-90mg pamidronate
can take up to 72hrs to reach full effect
2nd line; steroids, calcitonin
136
what are the causes of hypocalcaemia?
vitamin D deficiency resulting in osteomalacia
hypoparathyroidism; surgical/radiation, autoimmune, Mg deficiency
renal failure
tumour lysis syndrome
pancreatitis
PPIs
137
what are the signs and symptoms of hypocalcaemia?
```
perioral parasthesia
cramps
depression
tetany
carpo-pedal spasm; trousseau's sign
chovstek's sign
prolonged QT interval
cardiac arrhythmia
seizures
```
138
what are the signs of pseudohypoparathyroidism?
Albright's hereditary osteodystrophy
short metacarpals
short stature
round face
139
what investigations are required to diagnose hypocalcaemia?
```
corrected Ca
PTH
vitamin C
magnesium
phosphate
ALP
```
140
what is the treatment of mild, asymptomatic hypocalcaemia?
Ca >1.90mmol/L
oral Ca supplements; sandocal, adcal, calcichew
caused by vitamin D deficiency; cholecalciferol
caused by hypomagnesaemia; stop offending drugs, replace with IV magnesium
141
what is the treatment of severe, symptomatic hypocalcaemia?
Ca <1.90mmol/L
medical emergency
10-20ml calcium gluconate / 10-20mins with cardiac monitoring
100ml calcium gluconate infused / 10hrs
treat underlying cause
consider vitamin D analogues; alfacalcidol or calcitriol
