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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 11 • 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? 18 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