passmed year 5 Flashcards
If IV access if available in an unresponsive pt - hypoG
IV glucose
If pt with acromegaly has raised IGF-1 how do you confirm
OGTT and GH levels
what is primary adrenal failure
problem is located in the adrenal gland
secreting a smaller amount of cortisol
pituitary gland responding to this drop in cortisol by secreting more ACTH
ACTH is derived from a larger precursor called pro-opiomelanocortin (POMC), which also happens to be a precursor for beta-endorphin and melanocyte stimulating hormone (MST)
this gives hyperpigmentation
what is secondary adrenal insuffiency
secondary adrenal insufficiency, as the underlying mechanism of this is hypopituitarism. This means that, as opposed to a lack of cortisol production as in primary disease, the problem is from a lack of ACTH. A lack of ACTH production means that there is also a lack of POMC, and hence a lack of MST.
function of beta endorphin
Beta-endorphin is a neuropeptide and hormone that is produced in the brain and nervous system, and is known for its role in pain management and stress relief
cannot tolerate metformin what next
MR metformin
elevated prolactin level with secondary hypothyrpidism and hypogonadism indicates what leading to what
stalk compression is consistent with a non-functioning pituitary adenoma
4 symptoms cause by pituitary adenomas
excess of a hormone -eg cushings due to excess ACTH
depletion of hormones - compression of normal functioning pituitary gand
stretching of dura causing headaches
compression of the optic chiasm (bitemporal heminaopia)
ix if suspected pituitary adenoma
a pituitary blood profile (including GH, prolactin, ACTH, FSH, LSH and TFTs)
formal visual field testing
MRI brain with contrast
hypoG commonly mistaken for
being drunk so check BM
what does the dexamethasone do in congential
difference between cushing syndrome and congenital adrenal hyperplasia
would have an elevated 8am cortisol as body does not respond to the dexamthesone
low dex in congential
fatigue and dizziness , increase pig in creaes and hypopig on forearm
addisons causes hypoglycaemia
africa and asia most common cause of hypoT
iodine deficiency
Suppressed ACTH but unsuppressed cortisol on high-dose dexamethasone suppression
cushing syndrome due to adrenal adenoma
Suppressed ACTH and cortisol on high-dose dexamethasone suppression
pituitary adenoma
Unsuppressed ACTH and cortisol on high-dose dexamethasone suppression
ectopic ACTH syndrome
acropachy seen in graves - what is it
clubbing
thyrotoxic storm treated with
beta blockers, propylthiouracil and hydrocortisone
features of thyroxic storm
fever > 38.5ºC
tachycardia
confusion and agitation
nausea and vomiting
hypertension
heart failure
abnormal liver function test
post aldosterone/renin ratio ix for primary aldosteronism (which would show high aldosterone alongside low renin- as aldosterone causes sodium retention) what should follow
high res CT abdomen and adrenal vein sampling
what is sublcinial hypoT
TSH elevated and T4 normal and asx
when do you treat subclinical hypoT with levy
if TSH level above 10 on 2 seperate occasions 3 months apart
preg hyperT tx
propylthiouracil
how do distinguish between T1DM and T2DM
C-peptide levels and diabetes-specific autoantibodies (GAD) are useful to distinguish between type 1 and type 2 diabetes
Diabetes meliitus diagnosis: fasting > 7.0, random > 11.1 - if asymptomatic what do you need
need 2 readings
6 causes of raised prolactin
pregnancy
prolactinoma
physiological
polycystic ovarian syndrome
primary hypothyroidism
phenothiazines, metoclopramide, domperidone
cardiac drug that can cause gynaecomastia
digoxin
subclinical hyperthyrodism can lead to what complications
low TSH and normal T4
osteoporosis and AF and dementia
offer tx for 6 months to induce remission
Graves disease how long on carbimazole
12-18m
Hyponatraemia, hyperkalaemia and weight loss can indicate
treated with
addisons
IV hydrocortisone
compare malignancy to pirmary hyperparathyroidism
In hypercalcaemia secondary to malignancy, PTH is low, although PTHrP may be raised
primary hyperpara - PTH high
Increased, homogenous uptake on a radioactive iodine uptake test suggests
graves
what thyroid cancer is assoicated with phaechromocytoma ( difficult HTN to control) and requires prophylactic thyroidectomy
medullay thyroid cancer
hot noduel
toxic adenoma
what thyroid cancer is most likely to have lymphatic spread - most common in females
papillary
in 1lm of inuslin how many units
1000 units
the normal target for blood glyocse level is 48 if on diet and lifestyle or one anitidiabti drug - if they are on a drug which can cause hypos what is the target
53
subacute thyroiditis is same as
de gervain thyrodisits
what is de quervains thyrodisits
Subacute thyroiditis (also known as De Quervain’s thyroiditis and subacute granulomatous thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism.
on thyroid scintigraphy testing with iodine what will you see in a pt with subacute thyroiditis and how manage
In De Quervain’s thyroiditis there is globally reduced uptake of iodine-131 during thyroid scintigraphy
self limits - if painful can give aspirin of NSAID
thryotoxic storm treated with what three things
beta blockers, propylthiouracil and hydrocortisone
why do we get an increase in hba1c after a splectomy
Conditions that prolong the life of erythrocytes (e.g., aplastic anemia, iron deficiency anemia and after splenectomy) may lead to increased (prolonged) exposure of cells to glucose and to falsely high HbA1c results.
hasimoto also known as
autoimmune thyroiditis
temporal arteritis rarely seen below age of 60
true
so more likely to be a migraine
pt with bloating and distention after eating in T1DM - how it metaclopramide useful
Metoclopramide is used to treat the symptoms of slow stomach emptying (gastroparesis) in patients with diabetes. It works by increasing the movements or contractions of the stomach and intestines
sick euthryoid findings
Sick euthyroid syndrome = low T3/T4 and normal TSH with acute illness
gastroparesis characterised by
irratic glucose control
bloated
early satiety
chronic nausea
Gastroparesis
occurs secondary to autonomic neuropathy
symptoms include erratic blood glucose control, bloating and vomiting
management options include
metoclopramide, domperidone or erythromycin (prokinetic agents)
two other autonomic problems with diabtes
Chronic diarrhoea
often occurs at night
Gastro-oesophageal reflux disease
caused by decreased lower esophageal sphincter (LES) pressure
hypokalaemia and hypertension
thirsty raise suspicion of
primary aldosteronism
how do differentiate between HHS or DKA and how would you treat HHS
HHS or DKA? - HHS has no acidosis/significant ketosis, the history is longer and the glucose is often significantly raised eg >30mmol/L
HHS - IV crystalloid fluid and montior blood glucose after 1 hour
in preg what should you do with levothyroxine dose
Women with hypothyroidism may need to increase their thyroid hormone replacement dose by up to 50% as early as 4-6 weeks of pregnancy
what is whipples triad for an insulinoma
Whipple’s triad of symptoms of 1) hypoglycaemia with fasting or exercise, 2) reversal of symptoms with glucose, and 3) recorded low BMs at the time of symptoms is hallmark for an insulinoma
Phaeochromocytoma, alcoholism and anxiety are reasonable diagnoses to consider, however the episodes do not typically go away with food.
insulinoma related to what MEN
men 1
The release of PTHrP in malignancy suppresses PTH secretion and the result is a low PTH with an elevated calcium.
true
why is hydrocortiosne dosage in addisons given majority in monring and remainder in evening
This dosing regimen is done to mimic the normal physiological pattern of cortisol secretion, which follows the circadian rhythm: it is highest in the morning upon waking, and then slowly starts to decline throughout the day reaching its lowest levels before we sleep, it then slowly starts to rise again during sleep and peaks on waking.
difference between dka and HHS
the history is longer and the glucose is often significantly raised eg >30mmol/L
difference of pth levels in hyperparathyroidism and malignancy
In hypercalcaemia secondary to malignancy, PTH is low, although PTHrP may be raised
. At what Hba1c should you consider adding a second agent for diabetes T2?
58
non functioning pituitary adenoma blood results
(3)
The presence of an elevated prolactin level
Secondary hypothyroidism
hypogonadism
all indicative of stalk compression for tumour
suspected t1dm what are atypical factors
Diagnose type 2 diabetes mellitus
20%
Suspected T1DM: atypical factors that would prompt further tests include: age 50 years or above, BMI of 25 kg/m² or above, slow evolution of hyperglycaemia or long prodrome
C-peptide levels (which are low in T1DM and normal/high in T2DM)
dka can presetn with high potassium
yes
A 52-year-old woman who was diagnosed as having primary atrophic hypothyroidism 12 months ago is reviewed following recent thyroid function tests (TFTs):
TSH 12.5 mU/l
Free T4 14 pmol/l
She is currently taking 75mcg of levothyroxine once a day. How should these results be interpreted?
poor compliance
The TSH level is high. This implies that over recent days/weeks her body is thyroxine deficient. However, her free T4 is within normal range. The most likely explanation is that she started taking the thyroxine properly just before the blood test. This would correct the thyroxine level but the TSH takes longer to normalise.
what do you need to check in patients with subclinical hypothyroidism
Check thyroid peroxidase antibodies in patients who have subclinical hypothyroidism as this can indicate patients who are more likely to progress to overt hypothyroidism
The water deprivation test is designed to help evaluate patients who have polydipsia.
what conditons are we looking at in this
psychogenic polydipisia - both reduced with low starting plasma osmo
and diabetes insipidus
with urine post ddavp low in nephrogenic
