Endocrinology - Disorders Flashcards
A man with poorly controlled hypertension, despite the use of 3 anti- hypertensives, is found to have a low potassium. Please select the most likely diagnosis.
A. Cushing’s syndrome B. Cushing’s disease C. Phaeochromocytoma D. Conn’s syndrome E. Addison’sdisease
a) Conn’s Syndrome
Poorly controlled HTN
Low K
Addisions also has low K, but would have low BP
A 50 year old woman, who recently moved to the UK from India, presents with myalgia and lethargy. You see that she aIended the GP surgery previously reques5ng an5-depressants. Blood tests reveal a low sodium and high potassium. From the list below, please pick the most likely diagnosis. A. Cushing’ssyndrome B. Cushing’sdisease C. Phaeochromocytoma D. Conn’s syndrome E. Addison’s disease
E) Addisons
Addisons = reduced mineralocorticoid and glucocorticoid activity
Therefore low Na, High K
Symptoms = myalgia, lethargy and mood disturbances
Low BP
Low weight
Most common cause worldwide = TB (India)
During a GP consultation, you notice a 65 year old man has coarse facial features and widely spaced teeth. He also complains of headaches and has recently noticed that his rings are feeling tight on his fingers. Please select the best investigation from the following. A. Oralglucosetolerancetest B. Randomgrowthhormonelevel C. High dose dexamethasone test D. Plasma catecholamines E. Short synacthen test
a) OGTT
Features of acromegaly
A middle-aged man presents to his GP with recent weight gain. On examination, his blood pressure is mildly raised and you notice several bruises on both his arms. Please select the best investigation from the following. A. Plasmaaldosterone:reninratio B. Prolactinlevels C. Random plasma cortisol level D. Low dose dexamethasone test E. High dose dexamethasone test
b) Low sode dexamethasone test
= Cushings
A 30 year old lady presents to her GP with generalised weakness and paraesthesia. She has severe hypertension on examina5on and her blood tests show hypernatraemia and hypokalaemia. Please select the best inves5ga5on from the list below.
A. Plasma catecholamines B. Plasma aldosterone:renin ra5o C. Short synacthen test D. Thyroid func5on tests E. Lowdosedexamethasonetest
a) Plasma Aldo:Renin ratio
Conn’s syndrome investigation
High cortisol but low ACTH denotes what?
Primary Hypercortisolism eg adrenal cortisol producing tumour
High ACTH and high cortisol (not supressed even by high dose dexamethasone test) =
Ectopic ACTH production
Normal/high ACTH and high cortisol, (but low cortisol after dexamethasone administration test) =
Cushing’s disease (=due to pituitary problem)
What is the investigation for Conn’s syndrome?
Aldosterone:renin ratio
Findings:
Aldosterone high
Renin low
What are the Na and K levels in Conn’s?
Low K (excreted) High Na (reabsorbed) – causes HTN
Investigation for Phaeochromocytoma?
24hr urinary catecholamines
also plasma catecholamines, MRI/CT
What is the gold standard investigation for Addison’s disease?
Short synACTHen test:
• Cortisol and ACTH levels measured at the start
• IM injection 250 micrograms synthetic ACTH administered
• Cortisol measured 30 and 60 minutes post-injection
• In Addison’s disease, cortisol will NOT rise
Investigations Acromegaly
Oral Glucose Tolerance Test (OGTT)
Normal = Glucose supresses GH
Acromegaly = no suppression GH
(IGF-1 Levels)
(MRI Pituitary)
Investigations Prolactinoma/Hyperprolactinaemia
Prolactin levels (>6000 confirms diagnosis)
Urinary HCG – rule out pregnancy!
TFTs
Pituitary MRI
A 30 year old lady comes in to her GP complaining of worsening constipation. These are some of your blood results: high calcium, low phosphate, normal PTH, normal vitamin D, normal ALP. Please select the most likely diagnosis.
A. Renal bone disease B. Primary hyperparathyroidism C. Small cell lung cancer D. Multiple myeloma E. Ricket’s
B) Primary Hyperparathyroidism
High Ca
Low Phosphate
NORMAL PTH
High Ca = either malignancy or prim. Hyperpara.
PTH = always supressed in malignancy, therefore cannot be malignancy here as it is normal
A 65 year old lady has presented to A&E with a wrist fracture. These are some of your blood results: normal calcium, normal phosphate, normal PTH, normal vitamin D, normal ALP. She has an abnormal T score on a DEXA scan. Please select the most likely diagnosis.
A. Osteomalacia B. Osteoporosis C. Paget’s disease D. Multiple myeloma E. Renalbonedisease
b) Osteoporosis
Normal bloods
Abnormal DEXA scan
Fractures
Bone and Calcium Disorders: Hypercalcaemia =
Primary Hyperparathyroidism = PTH up
Malignancy
(Sarcoidosis, Multiple myeloma) = PTH down
Bone and Calcium Disorders:
Hypocalcaemia =
Osteomalacia
Renal disease
Bone and Calcium Disorders:
Normal Calcium
Osteoporosis
Paget’s Disease
Symtoms Hypercalcaemia =
STONES: renal stones
BONES: bone pain
GROANS: abdominal pain, nausea and vomiting
THRONES: constipation, polyuria MOANS: confusion, psychosis, depression
(Fatigue )
Symptoms hypocalcaemia
a) Muscle twitching/spasms
b) Tingling
c) Numbness
d) Hyper-reflexia
e) Chvostek’s sign (tapping on the cheek causes facial twitching)
f) Trousseau’s sign (applying a blood pressure cuff causes carpal
spasm)
Causes hypocalcaemia
Non-PTH driven: vitamin D deficiency, chronic kidney disease, PTH resistance (pseudohypoparathyroidism)
Due to low PTH: iatrogenic (post-thyroidectomy), autoimmune hypoparathyroidism, congenital absence of parathyroid glands (DiGeorge syndrome)
Management acromegaly
Trans-sphenoidal surgery to remove tumour
Somatostatin analogues (octreotide) - which stop GH production
Radiotherapy
What is addison’s disease
Primary adrenalocortical insufficiency leading to reduced Mineralocorticoid and Glucocorticoid acttivity
Commonest causes addisons UK and worldwide
UK = Autoimmine Worldwide = TB
Symptoms Addison’s
Non-specific: Malaise, Myalgia
Weight Loss, Fatigue, weakness
GI: Abdo Pain, Vomiting, diarrhoea, constipation
Mood: Depression, psychosis
Vague so not usually picked up until present with crisis.
Postural Hypotension (2Ps) Low Na, High K (can still produce aldosterone) Vitiligo
Pigmentation (buccal and palmar crease)
Negative feedback on pituitary = more POMC -> more MSH
Symptoms Addisonian crisis
Addisonian Crisis = salt-losing crisis
• Vomiting
• Abdominal pain
• Weakness
• Hypoglycaemia
- due to increased insulin sensitivity
• Hypovolaemic shock – Low BP due to loss Na
Cushings symptoms
Easy bruising, purple striae, thin skin, poor wound healing
Fat redistribution = Increased weight Central obesity (lemon on sticks), Moon face, Interscapular fat pad
Plethoric face (red cheeks)
Acne
Osteoporosis
Diabetes
(cortisol excess = gluconeogenesis, + extra fat = insulin resistance)
Mood changes eg depression, lethargy
Androgen effect eg irregular menses, erectile dysfunction
Proximal myopathy
Management Cushings
Conservative
Iatrogenic: decrease steroid dose Surgical
Radiotherapy
If tumour can’t be removed eg. adrenal carcinoma
Pre-op to reduce size
Surgically
Cushing’s disease: remove tumour trans-sphenoidally
Ectopic ACTH prod: removal of tumour/bilateral adrenalectomy if spread
Adrenal adenoma: unilateral adrenalectomy
Pharmacologically
Inhibit cortisol synthesis (ketoconazole)
Management Osteoporosis
Conservative: smoking cessation,
reduce alcohol intake, weight
bearing exercise
Medical: calcium/vitamin D supplements, bisphosphonates, teriparatide (recombinant PTH), HRT (replace protective oestrogen)
What is osteoporosis
Decreased bone density leading to loss of bone mass and fractures
What is osteomalacia
Defective bone mineralisation due to
vitamin D deficiency (called rickets in
children)
Paget’s disease is
Disorder of bone turnover resulting in
‘pockets’ of disorganised bone
metabolism.
Unlike osteoporosis which effects all bones in the body.
Symptoms Pagets
Warmth over affected bone (due to increased vascularity)
Bone pain
Fractures
What is a Phaeochromocytoma
Rare catecholamine producing tumour
Symptoms phaeo
Triad of PHEochromocytoma
Palpitations (episodic tachycardia)
Headache
Episodic sweating (diaphoresis)
HIGH BP
Treatment phaeo
Alpha and beta blockade TOGETHER
Sugery to remove.
What is Conn’s syndrome
Hyperaldosteronism caused by screting adenoma
Conn’s signs
Hypertension – increased resorption Na and therefore water
Hypokalaemia or alkalosis – secretion of K in kidneys
Hypernatremia (but can be normal)
Management Conn’s
Medical
Spironolactone for 4 weeks pre-op to control BP and K
Androgen receptor antagonist and a K-sparing diuretic
Side effects: gynaecomastia, menstrual disturbances
Surgical
Laparascopic adrenalectomy
Management hyperprolactinaemia
Dopamine agonist – bromacriptine, cabergoline
as dopamine produced in hypothalamus inhibits prolactin production
