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PACES Revision Cards > Endocrinology Flashcards > Flashcards

Endocrinology Flashcards

1
Q

How would you diagnose Diabetes Mellitus?

A

Random glucose >11.1 or Fasting glucose > 7

HbA1c >48

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2
Q

Which diabetes drugs can cause hypoglycaemia?

A

Insulin

Sulphonylureas e.g. gliclazide (esp if alongside metformin)

Glinides

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3
Q

Causes of Diabetes

A

Type 1 = autoimmune destruction of beta cells = reduced insulin secretion

Type 2 = insulin resistance

Steroid use
Chronic pancreatitis
Cystic fibrosis
Haemachromatosis
Acromegaly
Cushing’s
Glucagonoma

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4
Q

Diabetes & DVLA

Group 1 drivers on insulin can still drive if….

A

1) Hypoglycaemic awareness

2) <1 hypo episode requiring assistance in last year

3) No visual impairment

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5
Q

True or False:

Group 2 (e.g. HGV) drivers do NOT need to inform DLVA if on oral anti-diabetic agents

A

FALSE

Group 2 drivers must stop driving HGVs and tell the DVLA if they are diabetic and taking insulin AND/OR oral anti-diabetic agents

They do not need to inform the DVLA if their diabetes is diet controlled

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6
Q

Grave’s Disease

A

70% of all hyperthryoidism

Autoimmune disorder
- antibodies to TSH receptor

Features of hyperthyroidism
- Tachycardic/AF
- Dry skin
- Tremor

PLUS
- Thyroid eye disease
- Lid lag

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7
Q

Thyroid Eye Disease

A

NO SPECS

N - nil
O - Only signs, no symptoms e.g. eye lid retraction

S - Swelling of periorbital soft tissue e.g. eyelid swelling
P - Proptosis
E - Extra-ocular muscle involvement (ophthalmoplegia)
C - Corneal involvement
S - Sight loss (suggests compression of CN II)

URGENT referral to ophthalmology if any loss of visual acuity/colour vision

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8
Q

How would you manage a patient with Grave’s Disease?

A

CONSERVATIVE
- Eye care
- STOP smoking! (v. important)

MEDICAL
- Carbimazole titration or carbimazole + levo (“Block and replace”)
—— risk of agranulocytosis
- Beta blockers (can help with symptom control)
- Radioiodine
—- Contraindicated in thryoid eye disease

SURGICAL
- Thyroidectomy (risk of parathyroid damage)

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9
Q

Toxic Multinodular Goitre (TMG)

A

2nd most common cause of hyperthyroidism

Features of hyperthyroidism PLUS
- Goitre (can be painful/painless)

NO thyroid eye disease present!

Negative for thyroid autoantibodies

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10
Q

How would you investigate a patient in whom you suspect hyperthyroidism?

A

ECG

Bloods
- FBC, baseline renal function
- TFTs
- Thyroid autoantibodies

USS thyroid +/- CT neck or thorax (if suspicious of extension into mediastinum ?compression issues)

Thyroid Scintigraphy
- Diffuse uptake = Grave’s
- Focal/patchy uptake = TMG/thyroid adenoma

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11
Q

How would you manage a patient with Toxic Multinodular Goitre?

A

Indications for Rx =
- Cosmetic
- Compression/obstructive issues e.g. horner’s syndrome secondary to goitre
- Marked intra-thoracic extension

Management
- Radio-iodine
- Surgical resection of goitre

Antithryoid drugs not particularly helpful as thyrotoxicosis recures once Rx stops

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12
Q

Hypothyroidism

A

Most common endocrine condition
(approx 5-10% of UK)

CAUSES
- Hashimoto’s thyroiditis
- Iodine deficiency
- Iatrogenic (thyroidectomy/iodine)
- Post illness (De Quervain’s thyroiditis)
- Post partum thyroiditis
- Drugs e.g. amiodarone & lithium

Features of hypothyroidism
- Dry skin
- ?goitre
- ?macroglossia (secondary to myxoedema)
- NO eye disease
- Pleural effusions/ascites (RARE!)

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13
Q

Hashimoto’s Thyroiditis

A

Autoimmune condition

Thyroid peroxidase antibodies

F > M

Associated with:
- Coeliac disease
- T1DM
- Vitiligo
- ADDISON’S!!

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14
Q

How would you investigate a patient in whom you suspect hypothyroidism?

A

Bloods
- FBC, renal function
- TFTs
- Thyroid peroxidase antibodies

USS neck ?goitre

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15
Q

How would you manage a patient with hypothyroidism?

A

Levothyroxine
- 50-100mcg OD (starting dose)
- 25-50mcg OD if elderly or history of IHD

Check TFTs every 8-12 weeks after a dose change

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16
Q

True or false

In pregnant women with hypothyroidism, you should reduce their usual levothyroxine dose

A

FALSE

Increase their levothyroxine dose by 25-50% (esp in 1st 12 weeks)

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17
Q

Risks of levothyroxine

A

Hyperthyroidism

AF

Worsening of IHD/angina

Lowers bone mineral density –> OP

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18
Q

What is a Myxoedema Coma?

A

Severe hypothyroidism

Endocrinological emergency!

Usually precipitated by infection/MI/surgery

Features
- Bradycardic
- Hypotensive
- Hypothermic
- Hyponatraemia
- Confused

Rx = IV liothyronine and IV hydrocortisone (in case of concurrent Addison’s)

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19
Q

What is Acromegaly?

A

Condition of increased production and secretion of Growth Hormone

CAUSES
- Pituitary macroadenoma
- Pituitary hyperplasia
- Carcinoid tumour (ectopic GH release)

5% associated with MEN-1

20
Q

What symptoms may a patient with Acromegaly notice?

A

Increase hand/foot size - ?noticed a change in shoe size
Weight gain

Changes in vision (bitemporal hemanopia)
Headaches

Sweating

Drowsiness/somnolence (?OSA)

Proximal muscle weakness
Arthralgia

Change in bowel habit

21
Q

What are the 4 signs of active disease in Acromegaly?

A

1) Sweating

2) Skin tags

3) HTN

4) Peripheral oedema

22
Q

Associations/Complications of Acromegaly

A

Diabetes

HTN
LVF –> CCF (60% of deaths are due to CVD)
Cardiomyopathy
Arrhythmias

Carpal Tunnel Syndrome

OSA

Increased risk of IHD and stroke

Increased risk of colorectal cancer

23
Q

How would you investigate a patient in whom you suspect Acromegaly?

A

Bedside
- BP
- BM
- Urine dip
- ECG

Bloods
- FBC, baseline renal function
- Calcium profile (MEN1 is also associated with hyperparathyroidism)
- Oral Glucose Tolerance Test (OGTT)
—- If fails to suppress GH to <2 = diagnostic
- IGF-1 (monitoring)

Imaging
- MRI pituitary
- Echocardiogram (CVD risk)

Special
- Visual fields and perimetry

24
Q

How would you manage a patient with Acromegaly?

A

Surgery is first line!
- Usually transphenoidal surgery

Radiotherapy can be used as an adjunct or sole Rx in those who are unfit for surgery

MEDICAL
- Pegvisomont = GH antagonist (subcut)
- Bromocriptine = dopamine agonist (only works in <20%)
-Ocreotide = somatostatin analogue (negative feedback)

CVD risk factor management

?CPAP if OSA
?Surgery if CTS

FOLLOW UP
- Annual follow up with GH/IGF1 levels, visual fields and CVD assessment
- Low threshold for colonoscopy

25
Q

What are the MEN syndromes?

A

Multiple Endocrine Neoplasia syndromes

Autosomal dominant

Associated with NF1, vHL and peutz jeger’s

26
Q

Outline the components of MEN1

A

3Ps

Primary hyperparathyroidism
Pancreatic tumours e.g. insulinoma
Pituitary tumours e.g. prolactinoma, macroadenoma

27
Q

Outline the components of MEN2a

A

2 Ps, 1M

Primary hyperparathyroidism
Phaeochromocytoma

Medullary thyroid cancer

28
Q

Outline the components of MEN2b

A

1P, 2 Ms

Phaeochromocytoma

Medullary thyroid cancer
Marfanoid habitus

29
Q

Causes of Hypoadrenalism?

A

DISORDERS OF THE ADRENAL GLANDS
Addison’s disease (autoimmune)

Congenital adrenal hyperplasia (= excess ACTH and androgens, but low cortisol/mineralocorticoids)

Infiltration of adrenal glands
- Metastases
- Haemochromatosis
- Sarcoidosis
- TB
- Amyloidosis

Damage to adrenal glands
- Adrenal haemorrhage
- Adrenalectomy

DISORDERS OF THE PITUITARY
- Hypopituitarism (low ACTH levels)

30
Q

What is Addison’s disease?

A

Autoimmune condition of the adrenal glands = reduced adrenal cortex hormones

Associated with other AI disorders e.g.
- T1DM
- Thyroid disease
- Coeliac disease
- Pernicious anaemia

31
Q

Outline features of Addison’s disease

A

GLUCOCORTICOID LOSS
- Weight loss
- Anorexia
- Malaise/fatigue
- Postural hypotension
- CIBH/vomiting

MINERALOCORTICOID LOSS
- Hypotension
- Hyponatraemia
- Hyperkalaemia

ACTH EXCESS (due to feedback loop)
- Pigmentation of sun exposed/pressure areas and mucosa = BRONZE skin
- Amenorrhoea
- Body hair loss

32
Q

How would you investigate a patient in whom you suspect Addison’s disease or hypoadrenalism?

A

Bedside
- L+S BP
- BM
- Urine dip

Bloods
- FBC, U&Es
- Glucose, HbA1c
- TFTs
- Morning cortisol
- Short synacthen test (does cortisol level rise appropriately with synthetic ACTH?)

Imaging
- ?CT adrenals
- ?CXR (?TB)
- ?MRI pituitary

33
Q

How would you manage a patient in whom you suspect has Addison’s disease?

A

Education regarding steroids, sick day rules and Addisonian crises

Hydrocortisone +/- fludrocortisone

Monitor HbA1c

34
Q

Outline Autoimmune Polyglandular Syndrome 1

A

Chronic mucocutaneous candidiasis
(immunodeficiency)

Hypoparathyroidism

Addison’s disease

35
Q

Outline Autoimmune Polyglandular Syndrome 2

A

Addison’s disease

T1DM

Hypo OR hyperthyroidism

36
Q

What is Nelson’s Syndrome? What clinical features may you see on examination?

A

Occurs following bilateral adrenalectomy (e.g. for Cushing’s disease)

Reduced cortisol = loss of negative feedback loop back to anterior pituitary = +++ ACTH production and secretion

= Pituitary adenoma
= Activates melanocytes = hyperpigmentation

SIGNS
- Abdominal rooftop incision
- Bronze skin

37
Q

What is Cushing’s Syndrome?

A

= any condition which causes increased cortisol production (hypercortisolism)

EXOGENOUS CUSHING’S
- Steroid use (most common cause)

ENDOGENOUS CUSHING’S
ACTH DEPENDENT
- Pituitary adenoma = increase ACTH production and then cortisol = Cushing’s DISEASE!
- Ectopic ACTH e.g. SCLC

ENDOGENOUS CUSHING’S
ACTH INDEPENDENT
- Adrenal adenoma = increased cortisol

PSEUDOCUSHING’S
- Alcoholism
- Severe depression

38
Q

What is Cushing’s Disease?

A

Pituitary adenoma resulting in increased ACTH production –> hypercortisolism

39
Q

Features of Cushing’s Syndrome

A

Weight gain
Adipose tissue deposition on abdomen and back of neck
Abdominal striae
Typical cushing facies (“moon”)

Thin skin
Easy bruising

Mood disturbance

Fluid retention
HTN

Gynaecomastia
Amenorrhoea, hirsutism
Acne

Hyperglycaemia –> Diabetes
Osteoporosis
CVD risk
Cataracts

40
Q

How would you investigate someone in whom you suspect Cushing’s syndrome?

A

Bedside
- BP
- BM
- Urine dip
- ECG

Bloods
- FBC
- Renal function (can cause hypokalaemic metabolic acidosis)
- Overnight dexamethasone suppression test (give dex at 00:00 then test cortisol level in morning)
— If ODST is positive = ACTH levels and High Dose Dex Suppression Test (identifies pituitary vs adrenal/ectopic cause)

Imaging
- CT adrenals or MRI pituitary
- ?HRCT if suspect ectopic ACTH

41
Q

How would you manage a patient with Cushing’s syndrome?

A

Depends on underlying cause e.g. if on steroids, consider whether able to reduce/stop (risk vs benefits)

Metyrapone (cortisol inhibitor) whilst awaiting results

If PITUITARY cause = surgery/radiotherapy

If ADRENAL cause = adrenalectomy

Management of CVD RFs e.g. antihypertensives

42
Q

Clinical Features of Hypopituitarism

A

ANTERIOR PITUITARY
Growth hormone
- Lethargy
- FTT/growth failure
FSH/LH
- Reduced libido
- Hair loss
- Amenorrhoea
- Infertility
TSH
- Features of hypothyroidism
ACTH
- Lethargy
- Postural hypotension
- Hypoadrenalism

POSTERIOR PITUITARY
ADH
- Diabetes insipidus = polyuria & thirst

43
Q

Causes of Hypopituitarism

A

Large compressive pituitary tumour
Removal of a pituitary macroadenoma

Pituitary haemorrhage/infarct

Severe head injury
Cranial radiotherapy

Sarcoidosis
Haemochromatosis

44
Q

How would you investigate a patient in whom you suspect Hypopituitarism?

A

Bedside = L+S BP, urine dip

Bloods
- Baseline FBC, U&Es
- Pituitary Screen =
– GH / LH & FSH / TFTs / ACTH
- Synacthen test

Imaging
- MRI pituitary

45
Q

How would you manage a patient with hypopituitarism?

A

Treat underlying cause if possible e.g. surgery if large compressive tumour

Low GH = daily subcut GH

Low FSH/LH = intramuscular testosterone or COCP
- Refer to fertility specialists

Low TFTs = levothyroxine

Low ACTH = hydrocortisone (prevent addisonian crises)

PACES Revision Cards (9 decks)

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