Endocrinology - Thyroid and Diabetes Flashcards by Guy Kirkpatrick

Hyperthyroid Signs and Symptoms

Diarrhoea
Loss of weight
Increase in appetite
Sweating
Heat intolerance
Tremors
Irratibility
Oligomenorrhoea
Amenorrhoea
Fine, Straight hair
Bulging eyes
Enlarged thyroid
Breast enlargement
Localised oedema
Finger clubbing

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Grave’s Disease

Presentation, Treatment

Autoimmune disorder, TSH receptor activating antibodies

Hyperthyroid picture:
Exopthalmos
Pretibial myxoedema
Acropachy

Grave’s is the commonest cause of a smooth diffuse goitre.

Rx:
Carbimazole
Propylthiouracil

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Plummer’s Disease

A single toxic nodule (adenoma) which is present on a background of a suppressed multi-nodular goitre.

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Thyroglossal cyst

A fibrous cyst that is a persistent remnant of the thyroglossal duct.
No hyperthyroid, benign and painless.
Moves upwards on protrusion of the tongue.

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De Quervain’s Thyroiditis

Presentation and Treatment

Acute viral infection of the thyroid gland

Presentation:
Viral prodrome
Thyroid tenderness
Hyperthyroid, THEN Hypothyroid.

Treatment:
NSAID
Corticosteroids

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Hypothyroidism Symptoms and Signs

Constipation
Gain of weight
Tired/Sleepy
Memory/Cognition slowness
Cold intolerance
Cramps
Menstrual disturbance

Receding hairline
Facial and eyelid oedema
Dull-blank expression
Slow speech
Anorexia
Brittle nails and hair
Muscle aches and weakness
Dry skin - coarse and scaly
Apathy

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Hypothyroidism late clinical manifestations

Subnormal temp
Bradycardia
Wt gain
LOC
Thickened skin
Cardiac complications

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Hashimoto’s Thyroiditis

Presentation

Autoimmune disease of the thyroid.
Antibodies against thyroid peroxidase (TPO).

Presentation:
Hypothyroidism
Swelling of the thyroid - firm/large

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Common causes of hypothyroidism

Hashimoto’s Thyroiditis
Iodine deficiency
Post-thyroidectomy
Drug-induced - Amiodarone, Lithium, Iodine

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Thyroid cancer types

Papillary - Most common [80%]
Follicular [15%]
Medullary [5%]
Anaplastic - V rare

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Papillary carcinoma

RF, Prognosis

RF - Radiation Exposure
Most common in young people - presents in 20-55 age group.

Excellent prognosis

Papillary pattern
Calcified rings - Psamomma bodies
Clear nuclei - Orphan Annie Eye nuclei

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Follicular Carcinoma

Presentation

Tend to metastasize to lung and bone
Presentation with Hurthle cells
Middle age

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Medullary Carcinoma

Inheritance, Association, Pathogenesis

Familial pattern of inheritances

Associated with MEN 2A:
Parathyroid hyperplasia
Medullary thyroid carcinoma
Phaeochromocytoma

Arises from parafollicular cells - C cells
–> Increased secretion of calcitonin

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Multiple Endocrine Neoplasias

MEN 1 - Pituitary adenoma, parathyroid hyperplasia, pancreatic tumours/insulinomas/gastrinomas, facial angiofibromas and collagenomas

MEN 2A - Parathyroid hyperplasia, Medullary thyroid carcinoma, Phaeochromocytoma

Men 2B - Mucosal neuromas, Marfanoid body habitus, Medullary thyroid carcinoma, phaeochromocytoma

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A 42-year-old woman presents with visual disturbances. She reports having double vision which was intermittent initially but has now become much more frequent. In addition, she becomes breathless very easily and experiences palpitations. On examination, raised, painless lesions are observed on the front of her shins and finger clubbing.

De Quervain’s thyroiditis
Thyroid storm
Phaeochromocytoma
Graves’ disease
Plummer’s disease

Graves’ Disease

Visual disturbances
Double vision
Intermittent initially
Breathless easily
Palpitations
Raised painless lesions
Finger clubbing

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A 16-year-old girl presents to her GP complaining of a swelling in her neck which she has noticed in the last 2 weeks. She has felt more irritable although this is often transient. On examination, a diffuse swelling is palpated with no bruit on auscultation. The most likely diagnosis is:

Hyperthyroidism
Simple goitre
Riedel’s thyroiditis
Thyroid carcinoma
Thyroid cyst

Simple goitre

16 yr old girl
Swelling in neck
Last two weeks
Irritable
Transient
Diffuse swelling
No bruit

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A 58-year-old woman presents with an acutely painful neck, the patient has a fever, blood pressure is 135/85 mmHg and heart rate 102 bpm. The patient explains the pain started 2 weeks ago and has gradually become worse. She also notes palpitations particularly and believes she has lost weight. The symptoms subside and the patient presents again complaining of intolerance to the cold temperatures.

Thyroid Papillary Carcinoma
Plummer’s Disease
De Quervain’s Thyroiditis
Hyperthyroidism
Thyroid Follicular Carcinoma

De Quervain’s Thyroiditis

Acutely painful neck
Fever, BP high
HR high
2 weeks ago
Palpitatoins
Lost weight
Subside
Intolerance to cold

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A 35 year old female presents with amenorrhoea, galactorrhoea and visual disturbance. A prolactin level was noted as being very high. On further questioning, her mother had problems with recurrent renal stones and an operation on her neck. A relative has recently suffered with Pancreatic Cancer.

Multiple Endocrine Neoplasia 1 (MEN 1)
MEN 2a
MEN 2b
MEN 3
Von Hippel Lindau Disease

MEN 1

Amenorrhoea
Galactorrhoea
Visual disturbances
Recurrent renal stones
Operation on neck
Pancreatic cancer

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Diabetic investigations

Fasting plasma glucose
Random plasma glucose
Oral Glucose Tolerance Test
HBA1c

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Fasting plasma glucose

After 8hr fast
Diagnostic cut off > 6.9mmol/L
Impaired fasting glucose is between 6.1-6.9mmol/L

Random plasma glucose

Non-fasting test
Convenient but less accurate
> 11.1mmol/L
used if symptoms of polyuria/polydipsia/wt loss present

Oral Glucose Tolerance Test

2 hrs after an oral load of 75g glucose
Diagnostic cut off is >11.1mmol/L

Impaired OGTT:
Fasting plasma glucose is <7.0mmol/L
With OGTT of 7.8 - 11.0mmol/L

HBA1c

Diagnostic is > 48mmol/mol (6.5%)

A form of haemoglobin which identifies 3 month average plasma glucose
Higher amounts of ABA1c in T2DM
Higher value represents poor control

Change of units:
Remember two values - 6% = 42mmol/mol and 7% = 53 mmol/mol

Type 2 Diabetes Diagnosis

Symptomatic (e.g. poyuria/polydipsea/unexplained wt loss)
A single fasting plasma glucose >/= 7 mmol/L
OR
A single random plasma glucose >/= 11.1mmol/L

Asymptomatic:
A fasting glucose >/= 7 on tow separate occasions
OR
A random glucose >/= 11.1 on two separate occasions
OR
An HBA1c >/= 6.5% (48mmol/mol) on two separate occasions
OR
An HBA1c >/= 6.5% AND a single elevated plasma glucose (fasting > 7 or random > 11)

Impaired fasting glucose diagnosis

Fasting plasma glucose 6.1-6.9mmol/L

Pre-Diabetes diagnosis

HBA1c 6-6.4% (42-47 mmol/mol) [NICE] HBA1c 5.7-6.4% (39-47mmol/mol) [American Diabetes Association]

Impaired glucose tolerance diagnosis

Fasting plasma glucose <7.0mmol/L AND OGTT 7.8-11mmol/L

Which of these fulfills the diagnostic criteria of Type 2 Diabetes Polyuria and polydipsia, no further investigations necessary Asymptomatic patient, single fasting plasma glucose >6.9 mmol/L Asymptomatic patient, single reading of elevated HbA1c Symptomatic patient, single reading, fasting plasma glucose> 6.9 mmol/L Symptomatic patient, single reading, random plasma glucose <11.1 mmol/L

Symptomatic patient, single reading, fasting plasma glucose > 6.9mmol/L

Which of these is used in the long term management of Type 2 Diabetes ``` HBA1c Fasting Plasma Glucose Random Plasma Glucose 2 hr OGTT 3 Day Fasting Glucose ```

HBA1c

Impaired Fasting Glucose is Fasting Plasma Glucose less than 7.0mmol/L Fasting Plasma Glucose between 6.1 – 6.9mmol/L Fasting Plasma Glucose between 7.0– 7.8mmol/L Fasting Plasma Glucose between 7.8 – 11.0mmol/L Fasting Plasma Glucose between 5.5-6.5mmol/L

Fasting plasma glucose between 6.1-6.9mmol/L

What must a HBA1c be in excess of to diagnose Type 2 Diabetes ``` 59mmol/mol 52mmol/mol 48mmol/mol 42mmol/mol 38mmol/mol ```

48mmol/mol

Insulin effects

``` Reduces: Glucogenesis Glycogenolysis Lipolysis Ketogenesis Proteolysis ``` Increases: Glucose uptake in muscle and adipose tisue Glycolysis Glycogen synthesis Protein synthesis Uptake of ions (especially K+ and PO4 3-)

Type 1 Diabetes

Autoimmune condition where beta cells are destroyed Patients present when beta cells have been severely depleted No insulin producing cells Chronic and lifelong disease.

Type 1 Diabetes Management Rationale

Insulin is an anabolic hormone Anabolism builds Without insulin there is: Glycogenolysis Gluconeogenesis Ketogenesis Break down of muscle Increase in circulating glucose Increase in circulating ketones Ketones are acidotic Hyperglycaemia Acidosis cause by ketones ...Therefore management is with Insulin

Diabetic Ketoacidosis Management Rationale

Progression to a point where there is an impairment of normal function... Hyperglycaemia Acidotic Hyperglycaemia leads to an osmotic diuresis; this can potentiate dehydration. Acidity may cause vomiting, diarrhoea which worsens dehydration. ...Treat dehydration and glucose level Dehydration provides greatest risk so treat this with fluid management

Type 2 Diabetes

A long term metabolic disorder Characterised by high blood sugar Management is a stepwise method 1st Step is Diet and Exercise

Metformin

Main method of action is to sensitise cells to insulin, allowing greater uptake of glucose. 1st line, particularly in obese patients. ``` Reduces hepatic gluconeogenesis Reduces hepatic glycogenolysis Increases skeletal muscle glucose uptake Increases anaerobic glucose metabolism Reduces fatty acid oxidation Increases glycogenesis --> In turn reducing hyperglycaemia. ```

Sulphonylurea

Mechanism of action relates to increased secretion of insulin e.g. Glibenclamide, Chlorpropamide, Tolbutamide. Often in those with uncontrolled T2DM who are not obese.

Alpha Glucosidase Inhibitors

Acarbose Act as competitive inhibitors in the digestion of carbohydrates, preventing it. Reduce amount of glucose entering blood. Particularly used in those not tolerating other medication and those suffering with post-prandial hyperglycaemia.

Diabetes Management Algorithm

Diet and Exercise Metformin Sulfonylurea Basal insulin/Pre-mix Insulin OR a-glucosidase inhibitor/DPP-4 inhibitor/Thiazolidinedione Basal + meal-time insulin

A 19 year old male presented to A&E with abdominal pain, nausea and vomiting. He reports nocturia and examination reveals Kussmaul breathing ``` Insulin Oral Glucose Diet and Exercise Fluid Replacement Glibenclamide ```

Fluid and replacement

A 40 year old women waiting in a diabetic clinic looks pale and complains of being tired and weak ``` Oral Glucose Metformin Diet and Exercise Insulin Sliding Scale Fluid Bolus ```

Oral Glucose

A 55 Year Old obese diabetic man controls his diabetes with diet and exercise. On his review his HBA1c is 70mmol/mol and his fasting glucose is 10mmol/L ``` Stop Treatment Start Metformin Glucagon Injection Continue Current Treatment Fluid Bolus ```

Star Metformin

A 17yr old boy presents to his GP with increased urinary frequency and increased thirst ``` Insulin Metformin Diet and Exercise No Treatment Required Fluid Replacement ```

Insulin

Hypoglycaemia Symptoms

``` Autonomic: Sweating Palpitations Shaking Hunger ``` ``` Neuroglycopenic: Confusion Drowsiness Odd behaviour Speech difficulty Incoordination ``` General Malaise: Headache Nausea

Hypoglycaemia Management | Group 1 – Adults who are conscious and orientated

Give 15-20g of Quick Acting Carbohydrate such as Fruit Juice, Lucozade or sugar in water Repeat Capillary Blood Glucose and repeat until it reaches 4.0mmol/L or more If remains below 4mmol/L – Get Help! Consider 1mg Glucagon IM or IV 10% Glucose at 100ml/Hr Once above 4.0mmmol/L give a long acting Carbohydrate such as biscuits, slice of toast or 200-300mL milk

Hypoglycaemia Management | Group 2- Adults who are Conscious but confused, disorientated, unable to cooperate, aggressive but able to swallow

If possible, follow Group 1 If uncooperative but able to swallow give 1.5 – 2 tubes of glucogel squeezed onto the gums If unable to do this consider 1mg Glucogon IM If does not raise CBG to 4mmol/L consider IV 10% Glucose infusion at 100ml/hr and call for help Once above 4.0mmol/L give a long acting carbohydrate

Hypoglycaemia Management | Group 3 - Adults who are unconscious or experiencing seizures

Must take an ABC approach first Stop any current insulin infusion Consider 1 of the following 3 based on local guidelines: 1mg Glucagon IM 75-80mL 20% Glucose IV over 10-15mins 150-160 10% Glucose IV Raise CBG to over 4.0mmol/L and regaining consciousness give a long acting carbohydrate meal