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Endo Flashcards

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1
Q

Causes of hyperthyroidism

A

Single toxic adenoma
Toxic multinodular goitre
Grave’s disease
Viral thyroiditis - thyrotoxicosis without hyperthyroidism

Secondary Hyperthyroidism
- Pituitary tumours

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2
Q

Presentation of hyperthyroidism

A

Eye disease

Palpitations (AF)

Hands

  • Sweating
  • Tremor

Bowels/metabolism

  • Diarrhoea
  • Weight loss + increased appetite
  • Heat intolerance

Menstrual irregularities

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3
Q

Mx of hyperthyroidism

A

Medical

  • Propranolol
  • Carbimazole/PTU (either titrate to TSH, or block and replace)

Invasive

  • Radioiodine (if hyperfunctioning nodule - not if eye disease in GD)
  • Thyroidectomy (+ lifelong thyroid replacement)
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4
Q

Management of thyroid storm

A

Medical

- Propranolol + PTU + Hydrocortisone

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5
Q

Signs of hyperthyroidism

A

Graves

  • Smooth goitre (not lumpy as a multinodular goitre would be)
  • Pretibial myxoedema
  • Eye disease (exophthalmos, diplopia, gritty eyes w/ increased tear production)
  • Thyroid acropachy

General

  • Lid lag
  • Lid retraction
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6
Q

Causes of hypothyroidism

A

Autoimmune (Hashimoto’s)
Iodine deficiency
Viral thyroiditis
Post-thyroidectomy

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7
Q

Presentation of hypothyroidism

A 
Fatigue
Dry skin
Constipation
Menstrual irregularities
Weight gain + reduced appetite
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8
Q

Mx of hypothyroidism

A

Medical

- Thyroid replacement (levothyroxine, titrate to TSH, or to T4 if secondary)

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9
Q

Mx of myxoedema coma

A 
IV thyroxine
IV hydrocortisone
Fluids (with caution as possible cardiac dysfunction)
Antibiotics if infection suspected
Active warming if hypothermic
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10
Q

Differentials for thyroid lump

A 
Thyroid adenoma (asymptomatic)
Single toxic adenoma
Toxic Multinodular goitre
Thyroid malignancy
Thyroid cyst
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11
Q

Investigation of thyroid lump

A
  1. TFTs

If TSH low: Indicates probably hyperfunctioning nodule
- Thyroid scintigraphy
If high uptake, hyperfunctioning nodule: Tx with
propranolol/carbimazole/Radioactive
iodine/thyroidectomy

    If low uptake: do thyroid USS and FNA if 
    suspicious features present

If TSH high: do Thyroid USS
If suspicious features: do US-guided FNA
If no suspicious features: Monitor

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12
Q

Types of Thyroid malignancy

A

Hard irregular lump, normally non-functioning

Papillary (most common)
Medullary (associated with MEN2a - measure calcitonin)
Anaplastic
Follicular

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13
Q

MEN 1

A

Pituitary adenoma
Parathyroid hyperplasia
Pancreatic tumour

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14
Q

MEN 2

A

Medullary thyroid carcinoma
Phaeochromocytoma
Parathyroid hyperplasia

+ for MEN2b:
Mucosal neuromas
Marfanoid body habitus

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15
Q

Cushing’s syndrome presentation

A
  • Centripetal Obesity
  • Proximal myopathy
  • Hypertension

Cosmetic

  • Moon face
  • Thin skin
  • Purple abdominal striae
  • Buffalo hump

PCOS-like

  • Amenorrhoea
  • Acne
  • Hirsutism
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16
Q

Cushing’s causes

A

ACTH-dependent
Pituitary tumour secreting ACTH (Cushing’s disease)
Ectopic ACTH

ACTH-independent
Adrenal adenoma
Steroid excess

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17
Q

Secondary causes of hypertension

A

Renal

  • RAS
  • PKD

Endocrine

  • Acromegaly
  • Cushing’s
  • Hyperaldosteronism
  • Phaeo
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18
Q

Cushing’s Ix

A

Bloods

  • HbA1c/BM
  • U&E

Screening: 9am cortisol + Low dose dexamethasone suppression test

Inferior petrosal sinus sampling
Pituitary MRI

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19
Q

Cushing’s Tx

A

Cushing’s disease

  • Medical therapy (ketoconazole, metyrapone)
  • Transphenoidal hypophysectomy (1st-line)

Ectopic ACTH
- Tumour resection +/- chemotherapy/radiotherapy

Adrenal adenoma
- Adrenalectomy + lifelong steroid replacement

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20
Q

Acromegaly Presentation

A

Compressive effects
Headaches
Disconnection hyperprolactinaemia
Bitemporal hemianopia

Hormonal effects
Enlargement of hands and feet
Coarse facial features (prognathism, supraorbital ridging)
Carpal tunnel syndrome

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21
Q

Acromegaly Ix

A

Serum IGF-1
OGTT

Pituitary screen
MRI

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22
Q

Acromegaly Mx

A

Medical
Somatostatin analogues e.g, octreotide
Dopamine agonists e.g. cabergoline

Surgery (first-line)
Pituitary surgery
Radiotherapy

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23
Q

Addison’s causes

A 
Primary adrenal insufficiency
Autoimmune (most common UK)
Adrenal malignancy
Adrenal haemorrhage
TB (most common worldwide)

Secondary adrenal insufficiency
Pituitary tumours
Pituitary surgery
Hypopituitarism

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24
Q

Anterior pituitary hormones and pathologies

A 
GH: Acromegaly
TSH: Hyperthyroidism
LH/FSH: 
Prolactin: Hyperprolactinaemia
ACTH: Cushing's
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25
Addison's presentation
Every non-specific symptom under the sun: ``` Postural hypotension Abdominal pain Weight loss (best way to monitor) Dizziness Lethargy Weakness Anorexia ```
26
Addison's Ix
FBC U&E 9am cortisol + Short Synacthen test
27
Addison's + Addisonian crisis Mx
Addison's Hydrocortisone + Fludrocortisone replacement (replicate diurnal variation, + sick day rules) Addisonian crisis IV 100mg hydrocortisone STAT + Saline 500ml bolus + Hydrocortisone infusion Treat underlying cause
28
Phaeochromocytoma Presentation, Ix and Mx
PC: Episodic headaches, flushing, palpitations, dizziness Ix: FBC, U&E, serum and urine metanephrines Mx: Alpha blockade (phentolamine/phenoxybenzamine) + Beta blockade (for reflex tachycardia) + Surgery (open or laparoscopic adrenalectomy)
29
Carcinoid syndrome Presentation, Ix and Mx
30
Causes of gynaecomastia
Physiological - elderly - Puberty Endocrine (more oestrogen or less testosterone) - Pituitary tumours e.g. prolactinoma - Adrenal tumours - Testicular tumours - Androgen insensitivity Drugs - Spironolactone - Ketoconazole - Digoxin
31
Hyperprolactinaemia causes
Prolactinoma Pituitary stalk compression (disconnection hyperprolactinaemia) Drugs (antipsychotics)
32
Hyperprolactinaemia presentation
Headache Visual disturbance Gynaecomastia Galactorrhoea Decreased libido Sexual dysfunction (oligomenorrhoea, erectile dysfunction) - inhibits GnRH
33
Polyuria/Polydipsia differentials
Diabetes mellitus Diabetes insipidus Psychogenic polydipsia Hypercalcaemia
34
Hyperparathyroidism causes
Primary: - Parathyroid hyperplasia - Parathyroid adenoma (most common) Secondary: - Hypocalcaemia (Vit. D deficiency, CKD) Tertiary CKD
35
How is calcium homeostasis mediated
PTH causes: Calcium release from bones, increased intestinal calcium absorption and intestinal phosphate excretion, increased Vit. D activation Activated Vit. D causes: Increased calcium and phosphate reabsorption
36
Polyuria/Polydipsia Ix
Urine dip HbA1c Serum/urine osmolality Calcium + U&Es Water deprivation test MRI (if cranial DI suggested)
37
Mx of Diabetes Insipidus
Cranial: Give intranasal desmopressin Nephrogenic: Thiazide diuretics
38
Hypercalcaemia Ix
1. PTH If normal or high: Suspect Primary hyperparathyroidism If low: Likely to be hypercalcaemia of malignancy - Liberation of calcium from bone in bony metastases - PTHrp release
39
Hypercalcaemia Mx
Loads of fluids (0.9% normal saline) | Bisphosphonates (if hypercalcaemia of malignancy)
40
Hyponatraemia causes
Hypovolaemic - Diarrhoea - Vomiting - Diuretics (w/ raised urinary Na (>20) Euvolaemic - SIADH - Hypothyroidism - Addison's Hypervolaemic - Cirrhosis/hypoalbuminaemia - HF - Nephrotic syndrome -
41
Assessment of hyponatraemia
1. Assess fluid status, review drug chart 2. If not hypo or hypervolaemic, rule out thyroid disease and Addison's 3. If TFTs and synacthen test -ve, can make diagnosis of exclusion SIADH
42
Mx of hyponatraemia
Hypervolaemic/euvolaemic: fluid restrict + treat underlying cause Hypovolaemic: Fluid resuscitation
43
Causes of SIADH
CNS pathology: Trauma, SOL, stroke Lung pathology: malignancy, pneumonia Drugs: SSRIs, Carbamazepine Surgery
44
Mx of SIADH
Fluid restriction Demeclocycline (induces nephrogenic DI) Vaptans (V2 receptor antagonists)
45
Pseudocushing's causes
Depression Obesity Alcohol excess
46
Hyperaldosteronism causes
Primary hyperaldosteronism - Bilateral adrenal hyperplasia (most common) - Adrenal adenoma ``` Secondary hyperaldosteronism ( low aldosterone:renin ratio) - RAS ```
47
Hyponatraemia presentation
Confusion Anorexia Muscle weakness Seizures Nausea
48
Endo differentials for palpitations/tremor
Phaeo Hyperthyroidism Anxiety
49
Presentation of thyroid storm
Fever Tachycardia (possibly with AF) Agitation/confusion Diarrhoea, N+V, jaundice, abdo pain
50
Ix for thyroid storm
Find underlying cause - Bloods (TFTs, FBC, U&E, LFTs) - ECG - CXR - ABG
51
Complications of acromegaly (CHOD)
Cardiomegaly Hypertension/Hyperprolactinaemia OSA Depression
52
Presentation of myxoedema coma
``` Hypothermia Hypoglycaemia Hyporeflexia Bradycardia Seizures Coma ```
53
RFs for phaeo
MEN1 VHL NF1
54
Indications for Tx of stage 1 HTN
``` DM Renal disease Target organ damage Established CVD QRISK >10% ```
55
Hyperaldosteronism Ix
Bloods (FBC, U&E, hormone profile inc. plasma aldosterone/renin ratio) CT abdo Adrenal venous sampling
56
Levels of hyperkalaemia
5.5-5.9 = mild 6-6.5 = moderate >6.5 or symptomatic/ECG changes = severe Urgent treatment required if severe
57
Hyperkalaemia ECG features
Flattening of P waves PR prolongation Wide QRS Tented T waves
58
Hyperkalaemia Mx
Stop offending medications If <6.5 and asymptomatic, cardiac monitoring and repeat bloods 10mls 10% Ca gluconate 10U actrapid in 100mls 20% dextrose Salbutamol NEB Haemodialysis
59
Paget's disease of the bone - What is it? | what areas of the skeleton are most often affected
Disorder of increased, aberrant bone turnover Skull, Spine, long bones of extremities
60
Classical presentation of Paget's
Older man with bone pain Bowing of tibia, skull bossing (in untreated disease)
61
Paget's Ix
Isolated raised ALP (normal Ca and phosphate) XR: Osteolysis, progressing to mixed osteolytic/osteosclerotic lesions Bone scintigraphy: Increased uptake
62
Paget's Mx and indications for Tx
Bisphosphonates (oral or IV) Indications: - Bone pain - Fracture - Skull/long bone deformity - Periarticular Paget's
63
Causes of osteomalacia
Vitamin D deficiency - Malnutrition - Lack of sunlight - CKD - Liver disease - Drugs
64
Osteomalacia Presentation
Bone pain Bone/muscle tenderness Fractures
65
Osteomalacia Ix
Bloods Low Ca, Phosphate High PTH and ALP XR: Looser's zone pseudofractures
66
What are the 4 types of renal tubular acidosis
Type 1: Distal - unable to excrete H+ Type 2: Proximal - unable to reabsorb HCO3 (related to osteomalacia) Type 3: Caused by carbonic anhydrase deficiency, very rare Type 4: Related to lack of aldosterone, causing hyperkalaemic acidosis
67
Assessment of risk in osteoporosis
FRAX assessment: For asymptomatic patients (women >65, Men >75) DEXA scan: - If under 40 with major RF for osteoporosis - If going to be on steroids for at least 3 months and <65 - If <75 presenting with a fragility fracture
68
Complications of inappropriate correction of hyponatraemia and hypernatraemia
Hyponatraemia: Central pontine myelinolysis Hypernatraemia: Cerebral oedema
69
Hyperaldosteronism Mx
Bilat. adrenal hyperplasia: Spironolactone + SandoK Adrenal adenoma: Surgery Adrenal carcinoma: Surgery + radiotherapy
70
Hyperkalaemia causes
``` Release from cells (rhabdomyolysis, acidosis) RAAS system inhibition (ACEi, ARB, spironolactone) Low aldosterone (Addison's disease, RTA) ```
71
Hypokalaemia causes
``` GI loss (diarrhoea > vomiting) Renal loss (aldosterone excess) Redistribution into cells (insulin, beta-agonists, alkalosis) ```
72
Hypernatraemia causes
Increased sodium intake | Fluid loss
73
Hypokalaemia Mx
Mild/moderate (2.5-3.5) Oral SandoK ``` Severe (<2.5) or symptomatic IV KCl (IV saline + 40mmol KCl) ```
74
What is pseudohyponatraemia
hyponatraemia with a raised serum osmolality - indicating an artefact
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