ENDOCRINOLOGY by Dr Cinitia

Question 1

Hypothyroidism (Hashimoto Thyroiditis) CLINICAL FEATURES

Answer 1

Bilateral, firm, rubbery goitre

Question 2

Hypothyroidism (Hashimoto Thyroiditis) FIRST INVESTIGATION (3):

Answer 2

1. TSH
2. US If nodule
3. CT Scan if goitre is causing compression

Question 3

Hypothyroidism (Hashimoto Thyroiditis) BEST INVESTIGATION (3):

Answer 3

1.Antithyroglobulin (TgAb)
2.Antithyroid peroxidase Ab (TPO)
3.Biopsy: Chronic lymphocytic thyroiditis

Question 4

Hypothyroidism (Hashimoto Thyroiditis) TREATMENT

Answer 4

1. Tx if TSH>7.
   Monitor tx at 3m, 6m, 1y. You start with low dose and you increase it progressively.

Question 5

Myxedema coma CLINICAL FEATURES

Answer 5

Hypotension, hypoventilation, hypoglycaemia, hyponatraemia

Question 6

Myxedema coma TREATMENT

Answer 6

IV Levothyroxine + IV hydrocortisone

Question 7

Congenital hypothyroidism CLINICAL FEATURES

Answer 7

Macroglossia, harsh cry, dry skin, umbilical hernia

Question 8

Congenital hypothyroidism FIRST INVESTIGATION

Answer 8

Neonatal Heel prick TSH is (NEXT) if hypotonic kid with large open ant fontanelle

Question 9

Congenital hypothyroidism TREATMENT

Answer 9

Start thyroxine before 2 weeks of age

Question 10

Subclinical hypothyroidism CLINICAL FEATURES

Answer 10

High TSH and normal T3, T4

Question 11

Subclinical hypothyroidism FIRST INVESTIGATION

Answer 11

TSH

Question 12

Subclinical hypothyroidism TREATMENT

Answer 12

• TSH 5-10: Review TSH in 3 months
• TSH>10: Levothyroxine

Question 13

Sick Euthyroid Syndrome CLINICAL FEATURES

Answer 13

Decrease conversion from T4 to T3 so T3 will be low and T4, TSH, and reverse T3 could be normal or even high

Question 14

Hyperthyroidism CLINICAL FEATURES

Answer 14

Fine tremor, proximal myopathy, frozen shoulder

Question 15

Hyperthyroidism FIRST INVESTIGATION

Answer 15

1. TSH
2. Radioactive iodine uptake: -
   Low uptake: Thyroiditis -
   High uptake:
   Homogeneous (Graves), heterogenous (multiple- toxic multinodular goitre, single area-toxic adenoma)

Question 16

Hyperthyroidism TREATMENT (4)

Answer 16

1.Carbimazole (Agranulocytosis)
2.Propylthiouracil (Risk of liver dx)
3.Surgery
4.Radioactive iodine (If CIs to surgery)

Question 17

Graves Disease FIRST INVESTIGATION

Answer 17

TSH

Question 18

Graves Disease BEST INVESTIGATION

Answer 18

TSH receptor antibody, anti- TPO

Question 19

Graves Disease TREATMENT

Answer 19

The management of Graves’ disease according to RACGP guidelines involves three primary treatments:

1. Antithyroid Medications:
   
   • Drugs: Carbimazole (preferred) and Propylthiouracil (PTU).
   • Duration: 12-18 months.
   • Side Effects: Rash, gastrointestinal discomfort, agranulocytosis, hepatotoxicity.
2. Radioactive Iodine Therapy:
   
   • Procedure: Oral administration of I-131.
   • Advantages: Permanent resolution of hyperthyroidism.
   • Disadvantages: Permanent hypothyroidism, potential exacerbation of Graves’ orbitopathy, concerns about fertility and small increased risk of malignancy.
3. Thyroidectomy:
   
   • Indications: Severe Graves’ orbitopathy, large goitres, rapid control needed.
   • Advantages: Permanent resolution, may improve orbitopathy.
   • Risks: Surgical risks including hypoparathyroidism and nerve injury.

Symptomatic Treatment: Beta-blockers for initial symptom control.

These options should be discussed with patients to tailor treatment based on individual preferences and clinical features oai_citation:1,RACGP - Thyroid disease Long term management of hyperthyroidism and hypothyroidism oai_citation:2,RACGP - Evaluating and managing patients with thyrotoxicosis oai_citation:3,RACGP - Hyperthyroidism in a hypothyroid patient.

Same than above + Tx of vision threatened:
1. IV Methylprednisolone
2. Oral high dose prednisolone

Question 20

Hyperthyroidism in pregnancy TREATMENT

Answer 20

1. Propylthiouracil in 1st trimester
2. Carbimazole in 2nd/3rd trimester

Question 21

Subacute thyroiditis (De Quervains) CLINICAL FEATURES

Answer 21

Pain/Tenderness, fever

Question 22

Subacute thyroiditis (De Quervains) FIRST INVESTIGATION

Answer 22

1. TSH

Question 23

Subacute thyroiditis (De Quervains) BEST INVESTIGATION

Answer 23

1. ESR>50mm/Hr

The best investigation for subacute thyroiditis (De Quervain’s thyroiditis) as per the RACGP guidelines is the measurement of C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR). Elevated levels of these markers indicate inflammation, which is characteristic of subacute thyroiditis. Additionally, thyroid function tests typically show suppressed TSH levels with elevated free T4 and free T3 during the hyperthyroid phase, and reduced or absent uptake on a radionuclide thyroid scan supports the diagnosis.

For more detailed information, you can refer to the RACGP article on managing thyrotoxicosis here oai_citation:1,RACGP - Evaluating and managing patients with thyrotoxicosis oai_citation:2,RACGP - Thyroid disease Long term management of hyperthyroidism and hypothyroidism.

Question 24

Subacute thyroiditis (De Quervains) TREATMENT

Answer 24

1. Analgesia: NSAIDs
2. Severe: Oral prednisolone.
3. If constitutional symptoms: BB
   NOT antithyroid medication

Question 25

Thyroid Storm CLINICAL FEATURES

Answer 25

Anxiety, weight loss, hyperpyrexia, tachycardia

Question 26

Thyroid Storm TREATMENT

Answer 26

Hospital admission: IV saline, IV steroids

Question 27

Thyroid Nodule CLINICAL FEATURES

Answer 27

Moves with swallowing, can cause compression.

Question 28

Thyroid Nodule FIRST INVESTIGATION

Answer 28

1. TSH - TSH Normal or High: Next: US. Next: FNA - TSH Low: Next T3 & T4. Next: Radioisotope scan and US. If cold nodule: FNA

Question 29

Thyroid Nodule BEST INVESTIGATION

Answer 29

1. FNAC

Question 30

Retrosternal Goitre CLINICAL FEATURES

Answer 30

Compression

Question 31

Retrosternal Goitre FIRST INVESTIGATION

Answer 31

1. X-ray ### Why Use X-Ray for Retrosternal Goitre as the First Investigation According to RACGP Guidelines **Retrosternal goitre** refers to an enlarged thyroid gland that extends into the chest cavity behind the sternum. Using an X-ray as the first investigation is recommended for several reasons: 1. **Initial Assessment of Size and Position**: - **Overview of Goitre**: An X-ray provides a quick and initial assessment of the size and position of the goitre. This helps in understanding how much of the thyroid has extended into the chest cavity. - **Tracheal Deviation or Compression**: X-rays can show if the goitre is causing any displacement or compression of the trachea, which is critical for assessing potential breathing issues. 2. **Accessibility and Simplicity**: - **Widely Available**: X-rays are widely available in most medical settings and can be performed quickly, making them an accessible first step in investigation. - **Non-Invasive**: The procedure is non-invasive, straightforward, and doesn't require special preparation, making it easy to perform on most patients. 3. **Guidance for Further Imaging**: - **Determining Need for Advanced Imaging**: Based on X-ray results, clinicians can determine if further imaging studies like CT scans or MRIs are necessary. These advanced imaging techniques are more detailed but also more resource-intensive and less readily available. 4. **Identifying Complications**: - **Secondary Findings**: An X-ray can also help identify other potential issues, such as the presence of calcifications within the goitre or signs of compression of nearby structures, guiding the urgency and nature of subsequent investigations. ### Summary Using an X-ray as the first investigation for retrosternal goitre is recommended due to its ability to provide an initial overview of the goitre's size, position, and effect on surrounding structures. It is a widely available, non-invasive, and simple tool that helps guide further diagnostic steps if needed. For more detailed guidelines, you can refer to the RACGP website: - [RACGP - Goitre](https://www.racgp.org.au)

Question 32

Retrosternal Goitre BEST INVESTIGATION

Answer 32

CT of neck and upper chest

Question 33

Retrosternal Goitre TREATMENT

Answer 33

Total thyroidectomy

Question 34

Thyroid Cancer CLINICAL FEATURES (4)

Answer 34

- Hoarseness - Psammoma bodies: PapillaryThyroid Ca - Follicular cells: always do excisional biopsy bc it’s hard to diff between non and carcinoma. - Parafollicular C cells (secrete calcitonin): Medullary thyroid Ca. MEN2. - Rapidly growing: Anaplastic

Question 35

Thyroid Cancer FIRST INVESTIGATION

Answer 35

1. TFT

Question 36

Thyroid Cancer BEST INVESTIGATION

Answer 36

1. FNAB

Question 37

Hyperparathyroidism CLINICAL FEATURES

Answer 37

HyperCalcaemia (Stones, polyuria, hypoPh, constipation, psych disturbance)

Question 38

Hyperparathyroidism FIRST INVESTIGATION

Answer 38

1. Ca The first investigation for suspected hyperparathyroidism, according to the RACGP guidelines, is: **Serum calcium levels.** If the serum calcium is elevated, the next step would typically be to measure **parathyroid hormone (PTH)** levels to confirm the diagnosis of primary hyperparathyroidism. Elevated calcium levels in conjunction with elevated or inappropriately normal PTH levels would suggest primary hyperparathyroidism.

Question 39

Hyperparathyroidism BEST INVESTIGATION

Answer 39

1. PTH

Question 40

Hyperparathyroidism TREATMENT

Answer 40

Qx for Ca<0.25, nephrolithiasis, bone erosions, reduction in bone mass, reduction of Cr clearance.

Question 41

Diabetes Mellitus Type 1 FIRST INVESTIGATION (2)

Answer 41

Urine Dipstick for sugar. Other: Abs against Hashimoto

Question 42

Diabetes Mellitus Type 1 BEST INVESTIGATION

Answer 42

FSB

Question 43

Diabetes Mellitus Type 1 TREATMENT (4)

Answer 43

1.  Admission 2.  Insulin 3.  Follow up w/ HbA1c e/3m (<7%) 4.  Vaccine for Pneumococcal, Influenza, and dTPa

Question 44

Diabetes Mellitus Type 2 FIRST INVESTIGATION

Answer 44

RBG≥11.1

Question 45

Diabetes Mellitus Type 2 BEST INVESTIGATION

Answer 45

FBG: -  If ≥7: DM -  If 5.5-6.9->OGTT. If OGTT≥11.1: DM, if 7.8-11 Retest in a year, if <7.8 with FBG 6.1-6.9 retest in a year, OGTT≤7.7 Retest in 3 years - HbA1c: ≥6.5: DM, 6-6.4: retest in 1y, ≤5.9 retest in 3 years Here’s a more organized version of your notes: ### Fasting Blood Glucose (FBG) Testing: - **FBG ≥ 7.0 mmol/L:** Diagnosis of Diabetes Mellitus (DM). - **FBG 5.5-6.9 mmol/L:** Requires an Oral Glucose Tolerance Test (OGTT). - **OGTT ≥ 11.1 mmol/L:** Diagnosis of Diabetes Mellitus (DM). - **OGTT 7.8-11.0 mmol/L:** Retest in 1 year. - **OGTT < 7.8 mmol/L:** - If FBG is 6.1-6.9 mmol/L: Retest in 1 year. - If OGTT ≤ 7.7 mmol/L: Retest in 3 years. ### HbA1c Testing: - **HbA1c ≥ 6.5%:** Diagnosis of Diabetes Mellitus (DM). - **HbA1c 6.0-6.4%:** Retest in 1 year. - **HbA1c ≤ 5.9%:** Retest in 3 years.

Question 46

Diabetes Mellitus Type 2 TREATMENT (5):

Answer 46

1. Lifestyle modifications for 3-6m 2. Metformin 3. Metformin+Sulfonilurias or acarbose 4. Insulin (If HbA1c>9%) 5. Follow-up with HbA1c e/3m (<7) except in risk of hypoglycaemia (7-8) -  Pioglitazone - bladder Ca -  Rosiglitazone-HF

Question 47

Diabetic Nephropathy TREATMENT (2)

Answer 47

Annual screening for albuminuria Photocoagulation

Question 48

Diabetic Retinopathy FIRST INVESTIGATION

Answer 48

Screening e/2y. -  If nonproliferative dx: e/1y -  If proliferative dx: Urgent referral -  If vitreous hemorrhage: Same day referral

Question 49

Diabetic Retinopathy TREATMENT

Answer 49

Photocoagulation

Question 50

Diabetic Neuropathy FIRST INVESTIGATION

Answer 50

1. Check Vitamin B12 levels (Metformin can decrease them)

Question 51

Diabetic Neuropathy TREATMENT

Answer 51

1.  Amitriptyline 2.  Gabapentin/Pregabalin

Question 52

Diabetic Ketoacidosis CLINICAL FEATURES

Answer 52

MCC: Infections, HypoK, HypoNa, ketones

Question 53

Diabetic Ketoacidosis FIRST INVESTIGATION

Answer 53

MCC: Infections, HypoK, HypoNa, ketones

Question 54

Diabetic Ketoacidosis BEST INVESTIGATION

Answer 54

Ketones in serum or urine

Question 55

Diabetic Ketoacidosis TREATMENT (2)

Answer 55

1.  Rehydration (NS IV 15-20mL/kg) 2.  Short acting insulin IV

Question 56

Hypoglycaemia CLINICAL FEATURES

Answer 56

Early dumping: 30 mins-1hr: Tx diet Late dumping:1-3 hrs after meals

Question 57

Hypoglycaemia TREATMENT

Answer 57

Conscious: -    <1yr: Milk, >1yr something sweet Unconscious: If Glucose<3 -    Children: 10% dextrose -    Adults: 50% Dextrose Next: IM Glucagon

Question 58

Hyperglycaemic hyperosmolar nonketotic Coma CLINICAL FEATURES

Answer 58

Glucose >33 with normal ketones

Question 59

Hyperglycaemic hyperosmolar nonketotic Coma TREATMENT (2)

Answer 59

1.  Rehydration (NS 0.45%) 2.  Insulin with caution ### Treatment of Hyperglycaemic Hyperosmolar Nonketotic Coma (HHNC) - Simplified **1. **Fluid Replacement**: - **Goal**: Correct dehydration, which is the main problem in HHNC. - **Method**: Large amounts of IV fluids are given, usually starting with saline. This helps restore the fluid balance and lower blood sugar levels gradually. **2. **Insulin Therapy**: - **Goal**: Reduce high blood glucose levels. - **Method**: Insulin is given, usually at a low dose, through an IV. This helps to bring down the blood sugar levels without causing a rapid shift in electrolytes. **Note**: Monitoring and managing electrolytes (like potassium) and addressing the underlying cause (like infection) are also crucial parts of treatment. 2)

Question 60

Addison's dx CLINICAL FEATURES

Answer 60

Hypotension, weakness, fatigue, HypoNa, HyperK

Question 61

Addison's dx FIRST INVESTIGATION

Answer 61

Cortisol level

Question 62

Addison's dx BEST INVESTIGATION

Answer 62

Short synacthen stimulation test The **best investigation** for diagnosing Addison's disease, according to RACGP guidelines, is the **Short Synacthen Stimulation Test (SST)**. ### Why? - **SST** assesses the adrenal glands' ability to produce cortisol in response to synthetic ACTH (Synacthen). In Addison's disease (primary adrenal insufficiency), the adrenal glands are damaged and cannot produce adequate cortisol, leading to a poor or absent response to Synacthen. ### Procedure: - A baseline cortisol level is measured. - Synthetic ACTH (Synacthen) is administered. - Cortisol levels are measured again 30 and 60 minutes later. - A low cortisol response confirms the diagnosis of Addison's disease. This test is preferred because it is specific, reliable, and directly assesses adrenal function [oai_citation:1,Islamic Prayer Times Today, Salat Time, Namaz Timings | IslamicFinder](https://www.islamicfinder.org/prayer-times/) [oai_citation:2,Pakistan Prayer Times, Salah (Salat), Azan Time & Namaz TimeTable | IslamicFinder](https://www.islamicfinder.org/world/pakistan/).

Question 63

Addison's dx TREATMENT

Answer 63

1. IV line with fluids -  Dx made: Hydrocortisone -  No Dx: Dexamethasone

Question 64

Hyperaldosteronism CLINICAL FEATURES

Answer 64

Hypertension, HyperNa, HypoK. Renin low if primary. Renin high if secondary ### Hyperaldosteronism Lab Features - Simplified - **High Aldosterone**: Too much aldosterone hormone. - **Low Potassium**: Aldosterone causes potassium loss, leading to low levels. - **High Sodium**: Sodium may be high due to retention by aldosterone. - **Low Renin**: In primary hyperaldosteronism, renin (a hormone that regulates aldosterone) is low. These changes help the body retain sodium and water, but at the cost of losing potassium.

Question 65

Hyperaldosteronism FIRST INVESTIGATION

Answer 65

Plasma aldosterone and renin. - Next: Adrenal CT if primary

Question 66

Hyperaldosteronism TREATMENT (2)

Answer 66

1.  Spironolactone/Amiloride 2.  Surgery to remove adenoma

Question 67

Cushing Syndrome CLINICAL FEATURES

Answer 67

Hyperglycaemia, Hypertension, amenorrhoea, weakness, obesity, HyperNa, HypoK

Question 68

Cushing Syndrome FIRST INVESTIGATION (3)

Answer 68

1.               24-hour cortisol 2.               Early morning cortisol levels following a low dose dexamethasone suppression test 3.               ATCH

Question 69

Cushing Syndrome BEST INVESTIGATION

Answer 69

1. High dose dexamethasone suppression test. 2. Cranial CT/MRI

Question 70

Cushing Syndrome TREATMENT

Answer 70

Surgery. Give steroids if ACTH is supressed The treatment of Cushing syndrome, according to RACGP guidelines, depends on the underlying cause of the excess cortisol production. Here’s a simplified overview: ### 1. **Surgical Treatment**: - **First-line treatment** for Cushing syndrome caused by an adrenal tumor, pituitary adenoma (Cushing's disease), or ectopic ACTH-secreting tumor. - **Adrenalectomy**: Surgical removal of the adrenal tumor. - **Transsphenoidal Surgery**: For pituitary adenomas, this surgery involves removing the tumor through the nasal passages. - **Resection of Ectopic Tumors**: If the source of excess ACTH is outside the pituitary (like in the lungs), the tumor is surgically removed. ### 2. **Medical Management**: - If surgery is not an option or as a pre-surgical treatment, medications can be used to lower cortisol levels: - **Ketoconazole, Metyrapone, or Mitotane**: These drugs inhibit cortisol production. - **Pasireotide**: A drug used particularly for Cushing's disease that inhibits ACTH release from the pituitary. ### 3. **Radiation Therapy**: - Used when surgery is not completely effective or if the tumor cannot be removed. This is more commonly applied in cases of pituitary adenomas. ### 4. **Management of Symptoms**: - **Hypertension, diabetes, and osteoporosis** should be managed according to standard treatment guidelines, as these are common complications of Cushing syndrome. ### 5. **Post-Surgical Monitoring**: - Regular monitoring of cortisol levels is essential after surgery to ensure that the treatment is effective and to manage potential adrenal insufficiency. In summary, the approach to treating Cushing syndrome involves addressing the root cause (often through surgery), managing cortisol levels with medication if necessary, and treating any associated conditions. Regular follow-up is crucial to monitor the effectiveness of treatment and manage any complications [oai_citation:1,Islamic Prayer Times Today, Salat Time, Namaz Timings | IslamicFinder](https://www.islamicfinder.org/prayer-times/) [oai_citation:2,United States: Prayer Times | Muslim Pro](https://www.muslimpro.com/Prayer-times-United-States-US).

Question 71

Pheochromocytoma CLINICAL FEATURES

Answer 71

Headache, palpitations, diaphoresis

Question 72

Pheochromocytoma FIRST INVESTIGATION

Answer 72

1. 24-hour free catecholamines (increased VMA)

Question 73

Pheochromocytoma BEST INVESTIGATION

Answer 73

1. Plasma metanephrines +MRI

Question 74

Pheochromocytoma TREATMENT (3)

Answer 74

1.  Alpha Blockers (Phenoxybenzamine) 2.  BB 3.  Qx

Question 75

Adrenal Tumours TREATMENT

Answer 75

- <4cm and benign: Follow up in 3-6m - ≥4cm and suspicious: Adrenalectomy

Question 76

Pituitary Tumour FIRST INVESTIGATION (2)

Answer 76

1.  TFT 2.  CT The first-line investigation for diagnosing a pituitary tumor, according to RACGP guidelines, is **Magnetic Resonance Imaging (MRI) of the brain**. MRI is the gold standard for visualizing the pituitary gland and identifying any tumors, including their size, location, and impact on surrounding structures. Alongside MRI, **hormonal blood tests** are crucial to assess the tumor's functional status by measuring hormone levels such as prolactin, growth hormone, ACTH, and others, depending on the clinical presentation. For more details, you can visit the RACGP site [here](https://www.racgp.org.au).

Question 77

Pituitary Tumour BEST INVESTIGATION

Answer 77

1. MRI

Question 78

Pituitary Tumour TREATMENT

Answer 78

-    If <1cm: Review in 1y -    If ≥1cm: with visual field symptoms: Transphenoidal resection

Question 79

Hyperprolactinaemia CLINICAL FEATURES

Answer 79

Reduced libido, amenorrhoea, erectile dysfunction

Question 80

Hyperprolactinaemia FIRST INVESTIGATION

Answer 80

1. Prolactin: -  >5000: Prolactinoma -  <5000: other causes

Question 81

Hyperprolactinaemia BEST INVESTIGATION

Answer 81

1. MRI

Question 82

Hyperprolactinaemia TREATMENT (2)

Answer 82

1. Dopamine agonist (Cabergoline, bromocriptine) 2. Surgery

Question 83

Acromegaly CLINICAL FEATURES

Answer 83

Spade like hands, frontal bossing, greasy skin, thickened palms, increased shoe size, heteronymous hemianopia

Question 84

Acromegaly FIRST INVESTIGATION

Answer 84

1.               IGF-1. 2.               Measurement of GH following OGTT. If GH is no supressed by glucose, acromegaly

Question 85

Acromegaly BEST INVESTIGATION

Answer 85

Pituitary MRI

Question 86

Diabetes Insipidus CLINICAL FEATURES

Answer 86

Low ADH, HyperNa, HypoK

Question 87

Diabetes Insipidus FIRST INVESTIGATION

Answer 87

1. Plasma Na and osmolality

Question 88

Diabetes Insipidus BEST INVESTIGATION

Answer 88

Water deprivation test: - In primary polydipsia osmolarity will go back to normal. Desmopressin administration to see if its central (Osm increases) or nephrogenic

Question 89

Diabetes Insipidus TREATMENT

Answer 89

1. Central: Desmopressin 2. Nephrogenic: Solute restriction and thiazides

Question 90

SIADH CLINICAL FEATURES

Answer 90

High ADH, HypoNa, concentrated urine. Caused by SSRI, morphine, surgery, etc

Question 91

SIADH FIRST INVESTIGATION

Answer 91

1. Plasma Na and osmolality

Question 92

SIADH TREATMENT (3)

Answer 92

1. Water restriction 2. Hypertonic saline if pt is severely symptomatic. 3. Demeclocycline