Transcript Endocrine for Finals

Endocrine for Finals
Daniel Watkin
1
Core cases
• Diabetes (type 1, 2)
• Thyroid disorders
• Parathyroid disorders
• MEN
• Phaeo
• Hyperaldosteronism
• Zollinger-Ellison
• Cushing’s
• Conn’s
• Addison's
2
Components of MEN
• MEN Type 1
•
•
•
•
PPP
Parathyroid
Pituitary
Pancreatic (ZE)
• MEN Type 2
•
•
•
•
TAP
Thyroid
Adrenal (phaeo)
Parathyroid
• Type 2B
• Marfanoid appearance
• Neuromas (buccal)
3
+ Phosphate
+ Phosphate
↓ Phosphate!
4
Parathyroid disorders
• Primary hyperparathyroidism
• Secondary hyperparathyroidism
• Tertiary hyperparathyroidism
• 1*
• PTH ↑↑
• Calcium ↑
• Phosphate ↓
• Cause? Adenoma
5
• 2*
• 3*
• PTH ↑↑
• Calcium ↓
• Phosphate ↑
• PTH ↑↑↑!
• Calcium ↑
• Phosphate ↓ or normal
• Cause?
• CKD!!!
• So test U+Es!
• Essentially long-standing CKD 
Parathyroid gland becomes
autonomous and pumps out +++
PTH
• U+E (differentiate from 1*)
6
Symptoms + Signs
• Hypercalcaemia
• Bones, stones, groans, psychic
moans
• Polydipsia, polyuria
• Hypocalcaemia
• CATS go numb
• Chovstek’s, Convulsions
• Arrhythmia
• Tetany
• Trousseau’s
• Perioral paraesthesia
7
Zollinger-Ellinson syndrome
• Gastrinoma
• (i.e.) it secretes gastrin
• Symptoms?
• +++ ulcers
• Bleeding PR
• Weight loss, fatigue, malaise…
8
A 28 year old Welsh woman
attends her GP with a month
history of fatigue and depression.
Her blood pressure is 124/80
mmHg lying and 92/58 mmHg
standing. Blood tests reveal a mild
hyponatraemia and mild
hyperkalaemia. The GP arranges a
short synacthen test and the
results are as follows: (expected
30 minute level >580 nmol/l)
Baseline cortisol
30 minute cortisol
300 nmol/l
350 nmol/L
1. Waterhouse-Friderichsen
Syndrome
2. Tuberculosis
3. Metastatic disease
4. Autoimmune adrenalitis
5. Amyloidosis
9
A 28 year old Welsh woman
attends her GP with a month
history of fatigue and depression.
Her blood pressure is 124/80
mmHg lying and 92/58 mmHg
standing. Blood tests reveal a mild
hyponatraemia and mild
hyperkalaemia. The GP arranges a
short synacthen test and the
results are as follows: (expected
30 minute level >580 nmol/l)
Baseline cortisol
30 minute cortisol
300 nmol/l
350 nmol/L
1. Waterhouse-Friderichsen
Syndrome
2. Tuberculosis
3. Metastatic disease
4. Autoimmune adrenalitis
5. Amyloidosis
10
• Which of the following results
establishes a diagnosis of
diabetes mellitus?
1.Symptomatic patient with random
glucose 12.0 mmol/L on one occasion
2.Asymptomatic patient with random
glucose 22.0 mmol/L on one occasion
3.Glycosuria +++
4.Symptomatic patient with fasting
glucose 6.8 mmol/L on two occasions
5.Asymptomatic patient with fasting
glucose 7.9 mmol/L on one occasion
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• Which of the following results
establishes a diagnosis of
diabetes mellitus?
1.Symptomatic patient with random
glucose 12.0 mmol/L on one
occasion
2.Asymptomatic patient with random
glucose 22.0 mmol/L on one occasion
3.Glycosuria +++
4.Symptomatic patient with fasting
glucose 6.8 mmol/L on two occasions
5.Asymptomatic patient with fasting
glucose 7.9 mmol/L on one occasion
12
• A 36-year-old woman presents
with feeling tired and cold all
the time. On examination a firm,
non-tender goitre is noted.
Blood tests reveal the following:
TSH
Free T4
1.
2.
3.
4.
5.
34.2 mU/l
5.4 pmol/l
Primary atrophic hypothyroidism
Pituitary failure
De Quervain’s thyroiditis
Iodine deficiency
Hashimoto’s thyroiditis
13
• A 36-year-old woman presents
with feeling tired and cold all
the time. On examination a firm,
non-tender goitre is noted.
Blood tests reveal the following:
TSH
Free T4
1.
2.
3.
4.
5.
34.2 mU/l
5.4 pmol/l
Primary atrophic hypothyroidism
Pituitary failure
De Quervain’s thyroiditis
Iodine deficiency
Hashimoto’s thyroiditis
14
• Hashimoto's thyroiditis =
hypothyroidism + goitre + antiTPO
• Lithium?
• Amiodarone?
• Iodine deficiency?
15
Diabetes: Management
• You review a 61-year-old
woman who has type 2 diabetes
mellitus. She is currently taking
metformin therapy but her
HbA1c is 54 mmol/mol (7.1%).
You are considering prescribing
a DPP-4 inhibitor. Which one of
the following best describes the
side-effect profile?
1.Weight gain + hypoglycaemia
2.Weight gain + no hypoglycaemia
3.Weight neutral + no hypoglycaemia
4.Weight neutral + hypoglycaemia
5.Weight neutral + hypoglycaemia +
fluid retention
16
Diabetes: Management
• You review a 61-year-old
woman who has type 2 diabetes
mellitus. She is currently taking
metformin therapy but her
HbA1c is 54 mmol/mol (7.1%).
You are considering prescribing
a DPP-4 inhibitor. Which one of
the following best describes the
side-effect profile?
1.Weight gain + hypoglycaemia
2.Weight gain + no hypoglycaemia
3.Weight neutral + no hypoglycaemia
4.Weight neutral + hypoglycaemia
5.Weight neutral + hypoglycaemia +
fluid retention
17
Diabetes
• Important values in diabetes:
•
•
•
•
IGT?
Diabetes?
When to add a second drug?
Risk with Pioglitazone?
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19
• A 43-year-old man presents to
surgery with lethargy.
Examination is unremarkable
apart from a blood pressure of
192/112 mmHg. Routine blood
tests reveal:
Na+
K+
Bicarbonate
Urea
Creatinine
1.
2.
3.
4.
5.
146 mmol/l
2.4 mmol/l
34 mmol/l
5.3 mmol/l
75 µmol/l
Phaeochromocytoma
Renal artery stenosis
Diabetes mellitus
Bartter's syndrome
Primary hyperaldosteronism
20
• A 43-year-old man presents to
surgery with lethargy.
Examination is unremarkable
apart from a blood pressure of
192/112 mmHg. Routine blood
tests reveal:
Na+
K+
Bicarbonate
Urea
Creatinine
1.
2.
3.
4.
5.
146 mmol/l
2.4 mmol/l
34 mmol/l
5.3 mmol/l
75 µmol/l
Phaeochromocytoma
Renal artery stenosis
Diabetes mellitus
Bartter's syndrome
Primary hyperaldosteronism
21
• A 62 year old woman attends
her GP complaining of weight
gain, lethargy and hair loss. She
denies any intercurrent illness.
Thyroid function tests are
performed and the results are
as follows:
Thyroid stimulating
hormone (TSH)
Free T4
0.3 mu/l
8 pmol/l
1. Thyroid ultrasound
2. Radio-iodine uptake scan
3. Anti-thyroid peroxidase (TPO)
antibodies
4. Fine-needle aspiration of thyroid
5. MRI pituitary gland
22
• A 62 year old woman attends
her GP complaining of weight
gain, lethargy and hair loss. She
denies any intercurrent illness.
Thyroid function tests are
performed and the results are
as follows:
Thyroid stimulating
hormone (TSH)
Free T4
0.3 mu/l
8 pmol/l
1. Thyroid ultrasound
2. Radio-iodine uptake scan
3. Anti-thyroid peroxidase (TPO)
antibodies
4. Fine-needle aspiration of thyroid
5. MRI pituitary gland
23
24
• A 45-year-old man presents
with bitemporal hemianopia
and spade-like hands. What is
the definite test to confirm the
diagnosis?
1.
Early morning growth hormone
2.
Insulin tolerance test
3.
Oral glucose tolerance test with
growth hormone measurements
4.
Random insulin-like growth factor
1 (IGF-1)
5.
Short ACTH test
25
• A 45-year-old man presents
with bitemporal hemianopia
and spade-like hands. What is
the definite test to confirm the
diagnosis?
1.
Early morning growth hormone
2.
Insulin tolerance test
3.
Oral glucose tolerance test with
growth hormone measurements
4.
Random insulin-like growth factor
1 (IGF-1)
5.
Short ACTH test
26
• A 38-year-old lady presents with
a recent episode of renal colic.
As part of her investigations the
following results are obtained:
Corrected Calcium
PTH
3.84 mmol/l
88pg/ml (increased)
1. Carcinoma of the bronchus
2. Secondary
hyperparathyroidism
3. Primary hyperparathyroidism
4. Tertiary hyperparathyroidism
5. Carcinoma of the breast
27
• A 38-year-old lady presents with
a recent episode of renal colic.
As part of her investigations the
following results are obtained:
Corrected Calcium
PTH
3.84 mmol/l
88pg/ml (increased)
1. Carcinoma of the bronchus
2. Secondary
hyperparathyroidism
3. Primary
hyperparathyroidism
4. Tertiary hyperparathyroidism
5. Carcinoma of the breast
28
• A 23-year-old woman presents
with sweating and tremor. Her
thyroid function tests are as
follows:
TSH
Free T4
1.
2.
3.
4.
5.
<0.05 mU/l
25 pmol/l (9-18 pmol/l)
Hashimoto's thyroiditis
Graves' disease
Toxic nodular goitre
De Quervain's thyroiditis
Toxic adenoma
29
• A 23-year-old woman presents
with sweating and tremor. Her
thyroid function tests are as
follows:
TSH
Free T4
1.
2.
3.
4.
5.
<0.05 mU/l
25 pmol/l (9-18 pmol/l)
Hashimoto's thyroiditis
Graves' disease
Toxic nodular goitre
De Quervain's thyroiditis
Toxic adenoma
30
• Samantha, 30, is brought into
the emergency department due
to onset of confusion one week
after returning from holiday in a
developing country. Her family
report her having vomiting and
diarrhoea that developed within
the past day. On examination
Samantha is found to have a low
blood pressure, and inspection
of her hands reveals
hyperpigmentation of the skin.
Samantha's U&Es show the
following:
Na+
K+
124 mmol/l
6.6 mmol/l
1.
2.
3.
4.
5.
Cushing's disease
Addison's disease
Conn's syndrome
Cholera
Rotavirus
31
• Samantha, 30, is brought into
the emergency department due
to onset of confusion one week
after returning from holiday in a
developing country. Her family
report her having vomiting and
diarrhoea that developed within
the past day. On examination
Samantha is found to have a low
blood pressure, and inspection
of her hands reveals
hyperpigmentation of the skin.
Samantha's U&Es show the
following:
Na+
K+
124 mmol/l
6.6 mmol/l
1.
2.
3.
4.
5.
Cushing's disease
Addison's disease
Conn's syndrome
Cholera
Rotavirus
32
• Management of an Addisonian
crisis?
33
• Hydrocortisone
• Saline
• Dextrose
34
• A 19 year old with type 1
diabetes presents to the
Emergency Department feeling
unwell. She states she has had
vomiting and diarrhoea for 2
days and has not been taking
her full insulin doses as she has
been off her food. Her capillary
glucose is 37 mmol/l and there
are 4+ ketones on urinalysis.
An arterial blood gas is
performed and the results are
as follows:
pH
pO2
pCO2
HCO3
Na
K
7.12
13 kPa
3.5 kPa
13
129 mmol/l
6.1 mmol/l
1. IV 0.9% NaCl bolus
2. IV 10 units actrapid + 50ml
50% dextrose
3. IV 8.4% sodium bicarbonate
4. Empirical IV antibiotics
5. Insulin sliding scale
35
• A 19 year old with type 1
diabetes presents to the
Emergency Department feeling
unwell. She states she has had
vomiting and diarrhoea for 2
days and has not been taking
her full insulin doses as she has
been off her food. Her capillary
glucose is 37 mmol/l and there
are 4+ ketones on urinalysis.
An arterial blood gas is
performed and the results are
as follows:
pH
pO2
pCO2
HCO3
Na
K
7.12
13 kPa
3.5 kPa
13
129 mmol/l
6.1 mmol/l
1. IV 0.9% NaCl bolus
2. IV 10 units actrapid + 50ml
50% dextrose
3. IV 8.4% sodium bicarbonate
4. Empirical IV antibiotics
5. Insulin sliding scale
36
• Managements of DKA?
37
• Fluid first!
• Insulin (0.1U/kg/hr)
• Glucose (If glucose <15)
• Potassium – why?
• And one other..?
38
• A 46-year-old woman is referred
to endocrine with a tender neck
swelling. Blood results are as
follows:
TSH
T4
<0.1 mU/l
188 nmol/l
Hb
Plt
WBC
14.2 g/dl
377 * 109/l
6.4 * 109/l
ESR
65 mm/hr
1.
2.
3.
4.
5.
Sick thyroid syndrome
Acute bacterial thyroiditis
Hashimoto's thyroiditis
Subacute thyroiditis
Toxic multinodular goitre
39
• A 46-year-old woman is referred
to endocrine with a tender neck
swelling. Blood results are as
follows:
TSH
T4
<0.1 mU/l
188 nmol/l
Hb
Plt
WBC
14.2 g/dl
377 * 109/l
6.4 * 109/l
ESR
65 mm/hr
1.
2.
3.
4.
5.
Sick thyroid syndrome
Acute bacterial thyroiditis
Hashimoto's thyroiditis
Subacute thyroiditis
Toxic multinodular goitre
40
• De Quervain’s thryoiditis
41
Components of MEN
• MEN Type 1
•
•
•
•
PPP
Parathyroid
Pituitary
Pancreatic (ZE)
• MEN Type 2
•
•
•
•
TAP
Thyroid
Adrenal
Parathyroid
• Type 2B
• Marfanoid appearance
42
+ Phosphate
+ Phosphate
↓ Phosphate!
43
Parathyroid disorders
• Primary hyperparathyroidism
• Secondary hyperparathyroidism
• Tertiary hyperparathyroidism
• 1*
• PTH ↑↑
• Calcium ↑
• Phosphate ↓
• Cause? Adenoma
44
• 2*
• 3*
• PTH ↑↑
• Calcium ↓
• Phosphate ↑
• PTH ↑↑↑!
• Calcium ↑
• Phosphate ↓ or normal
• Cause?
• CKD!!!
• So test U+Es!
• Essentially long-standing CKD 
Parathyroid gland becomes
autonomous and pumps out +++
PTH
45
Symptoms + Signs
• Hypercalcaemia
• Bones, stones, groans, psychic
moans
• Polydipsia, polyuria
• Hypocalcaemia
• CATS go numb
• Chovstek’s, Convulsions
• Arrhythmia
• Tetany
• Trousseau’s
• Perioral paraesthesia
46
Zollinger-Ellinson syndrome
• Gastrinoma
• (i.e.) it secretes gastrin
• Symptoms?
• +++ ulcers
• Bleeding PR
• Weight loss, fatigue, malaise…
47