Endocrinology - Thyroid and Diabetes Flashcards
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
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
Plummer’s Disease
A single toxic nodule (adenoma) which is present on a background of a suppressed multi-nodular goitre.
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.
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
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
Hypothyroidism late clinical manifestations
Subnormal temp Bradycardia Wt gain LOC Thickened skin Cardiac complications
Hashimoto’s Thyroiditis
Presentation
Autoimmune disease of the thyroid.
Antibodies against thyroid peroxidase (TPO).
Presentation:
Hypothyroidism
Swelling of the thyroid - firm/large
Common causes of hypothyroidism
Hashimoto’s Thyroiditis
Iodine deficiency
Post-thyroidectomy
Drug-induced - Amiodarone, Lithium, Iodine
Thyroid cancer types
Papillary - Most common [80%]
Follicular [15%]
Medullary [5%]
Anaplastic - V rare
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
Follicular Carcinoma
Presentation
Tend to metastasize to lung and bone
Presentation with Hurthle cells
Middle age
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
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
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
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
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
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
Diabetic investigations
Fasting plasma glucose
Random plasma glucose
Oral Glucose Tolerance Test
HBA1c
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
