Endocrinology: top- decile quiz SBA Quiz Quiz Dr Shuaib Siddiqui, - - PowerPoint PPT Presentation

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Endocrinology: top- decile quiz SBA Quiz Quiz Dr Shuaib Siddiqui, - - PowerPoint PPT Presentation

Nov 15, 2023 38 likes •472 views

Endocrinology: top- decile quiz SBA Quiz Quiz Dr Shuaib Siddiqui, MB BChir MRCP FY3 doctor Endocrinology series Content reviewed on the 05/05/2020. SBA Quiz Interactive SBA quiz competition Some answers are scored based on speed as

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Endocrinology series

Dr Shuaib Siddiqui, MB BChir MRCP FY3 doctor

Content reviewed on the 05/05/2020.

Quiz

Endocrinology: top- decile quiz

SBA Quiz

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SBA Quiz

  • Interactive SBA quiz competition
  • Some answers are scored based on speed as well as accuracy
  • Topics covered: endocrinology
  • Total 14 questions
  • All answers to the SBAs will be uploaded after the webinar

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Acromegaly: pathophysiology

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Acromegaly: investigations

Beside

  • ECG: acromegaly can cause cardiomyopathy and heart failure

Bloods

  • Insulin-like growth factor 1: first line investigation and raised in disease
  • Oral glucose tolerance test: a glucose load should cause suppression of GH
  • normally. In acromegaly, there is failure of GH suppression

Imaging

  • Pituitary MRI: visualisation of pituitary adenoma
  • CT chest, abdomen and pelvis: very rarely can be due to an ectopic source

Special tests

  • Visual field testing
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Prolactinoma: pathophysiology

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Prolactinoma: management

Medical

  • Dopamine agonist: cabergoline is preferred; dose increased for larger tumours

Surgical

  • Trans-sphenoidal surgery: if unresponsive or unable to tolerate medical therapy

Pregnancy

  • Discontinue dopamine agonist as soon as possible (most patients)
  • Selected patients with macroadenomas may continue medical therapy
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Hyperthyroidism: aetiology

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Primary hyperthyroidism: aetiology

Graves’ disease

  • Anti-TSH receptor antibodies
  • Most common cause of hyperthyroidism

(75%)

  • Diffuse goitre and thyroid eye signs

Toxic multinodular goitre

  • Iodine deficiency
  • Compensatory TSH secretion
  • Nodular goitre formation
  • Nodules become TSH-independent and

thyroid hormones

(1)

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Secondary hyperthyroidism: aetiology

Pituitary adenoma Ectopic tumour Hypothalamic tumour

  • TSH-secreting pituitary

adenoma

  • T4 secreting tumour (struma
  • varii)
  • hCG-secreting tumours (e.g.

choriocarcinoma)

  • Excessive TRH secretion
  • Rare cause of

hyperthyroidism

Choriocarcinoma (2)

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Thyroid disease: autoantibodies

Thyroid autoantibodies Autoantibody Condition Prevalence Anti-TSH receptor Graves’ disease 90-100% Hashimoto’s thyroiditis 0-5% Anti-TPO Graves’ disease 70-80% Hashimoto’s thyroiditis 90-95% Anti-thyroglobulin Graves’ disease 20-40% Hashimoto’s thyroiditis 30-50%

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Graves’ disease: management

Antithyroid medication:

  • Carbimazole: usually first-line
  • Propylthiouracil: first-line pre-pregnancy or in the first trimester
  • Titration: titrate down to lowest effective dose
  • Block and replace: levothyroxine is added as needed

Radioiodine:

  • First-line definitive management in Graves' and toxic multinodular goitre
  • Contraindicated in pregnancy, breastfeeding, and thyroid eye disease
  • Offer patient advice

Surgery: total or hemithyroidectomy

  • Requires pre-operative optimisation
  • Be aware of the risks

Other: consider propranolol for symptomatic relief

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Hypothyroidism: aetiology

TSH Free T4 Overt hypothyroidism ↑ ↓ Subclinical hypothyroidism ↑ ↔

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Hypothyroidism: management

Overt hypothyroidism:

  • Levothyroxine (T4): offer levothyroxine with regular review of symptoms and TSH

every 3 months

  • Pregnancy: increase dose
  • Ischaemic heart disease: reduce dose
  • Iron supplementation: reduces absorption so take 4 hours apart

Subclinical hypothyroidism:

  • The below must be measured on 2 separate occasions 3 months apart:
  • TSH > 10 mU/L and normal T4: consider levothyroxine if TSH persistently > 10mU/L
  • TSH < 10 mU/L and normal T4: consider levothyroxine if symptomatic and < 65 years
  • ld
  • In all other cases observation is indicated
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T1DM: management

Urgent referral to diabetes specialist team Lifestyle

  • Diet high in fibre and low in fat, sugar, and salt
  • Educate regarding carbohydrate counting; allows insulin dose to be matched to intake

Insulin therapy

  • Basal-bolus: first-line, long-acting regularly (basal) with rapid-acting insulin before meals

(bolus)

  • Basal: Levemir (Detemir) given BD. Lantus (Glargine) is an alternative
  • Bolus: Novorapid (Aspart)
  • Mixed insulin regimen: mixed insulin comprises a short or rapid-acting and intermediate-

acting insulin BD

  • Used when unable to tolerate basal-bolus regime
  • Continuous insulin infusion: disabling hypoglycaemia or persist hyperglycaemia (HbA1c

>69mmol/mol)

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T1DM: insulin

Type Onset Duration Examples Rapid 15 mins 2-5 hours Novorapid Humalog Short 30 mins 5-9 hours Actrapid Humulin S Intermediate 2 hours 12-24 hours Humulin I Insulatard Long 2-4 hours 16-42 hours Levemir Lantus

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DKA: diagnostic criteria

Joint British Diabetes Societies (2013) Glucose > 11 mmol/L

  • r

known DM HCO3 < 15 mmol/L and/or venous pH < 7.30 Ketonaemia (>3 mmol/l)

  • r

2+ ketonuria Triad: hyperglycaemia, acidosis and ketonaemia

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DKA: management

Treatment Further information IV fluid SBP < 90 mmHg

  • 1 litre 0.9% NaCl over 15 mins
  • Call for senior help as required

SBP > 90 mmHg: typical regimen

  • 1 litre 0.9% NaCl over 1 hour
  • 1 litre 0.9% NaCl with KCl over next 2 hours
  • 1 litre 0.9% NaCl with KCl over next 2 hours
  • 1 litre 0.9% NaCl with KCl over next 4 hours
  • 1 litre 0.9% NaCl with KCl over next 4 hours
  • 1 litre 0.9% NaCl with KCl over next 6 hours

Insulin Fixed-rate insulin infusion:

  • Commence at 0.1 U/kg/h
  • Add in 10% dextrose once glucose levels drop below 14.0 mmol/L
  • Do not stop long-acting insulin
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DKA: management

Serum potassium concentration (mmol/L) Potassium replacement > 5.5 None 3.5-5.5 40 mmol/L < 3.5 Consider HDU/ITU for replacement via central line

  • Potassium replacement: commence as per the table below
  • Total body potassium is low and correction of acidosis causes further reduction in

potassium

  • Anticoagulation: patients are at increased risk of VTE
  • Glucose, pH, bicarbonate, ketone levels, and electrolytes should be closely monitored

throughout, 1-2 hourly

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Please note, upon reviewing this question it has been retracted as the HbA1c in the question should have been > 58 mmol/mol

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T2DM

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T2DM: medication

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T2DM: medication

Drug class Side effects Biguanides GI upset AKI Sulfonylureas Hypoglycaemia Weight gain SGLT-2 inhibitor UTI Thiazolidinediones Weight gain Fluid retention DPP-4 inhibitor GI upset GLP-1 inhibitor GI upset Loss of appetite

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Diabetes: monitoring

Glucose

  • HbA1c: measured every 3-6 months
  • Self-monitoring: only advised if on insulin

Retinopathy

  • Immediate ophthalmology referral upon diagnosis and annually thereafter
  • Arrange urgent review thereafter if:
  • Acute reduction in acuity
  • Pre proliferative or proliferative retinopathy
  • Diabetic maculopathy

Diabetic foot

  • Should be assessed at least annually; refer urgently to foot protection service if at risk (e.g. ulceration)

Diabetic nephropathy

  • Annual measurement of eGFR and urinary albumin:creatinine ratio
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Cushing’s syndrome: investigations

Step 1 – confirm hypercortisolism

  • 24-hour free urinary cortisol
  • Late-night salivary cortisol
  • Overnight dexamethasone suppression test
  • Low dose dexamethasone suppression test

Step 2 – localise the source of the hypercortisolism

  • 9am ACTH
  • High dose dexamethasone suppression test
  • CT adrenals
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Cushing’s syndrome: investigations

Low dose DST High dose DST Pituitary tumour Not suppressed Suppressed Ectopic source Not suppressed Not suppressed

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Please note, upon reviewing this question it has been retracted as Nelson’s syndrome is usually seen in patients with Cushing’s disease who have a bilateral adrenalectomy

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Nelson’s syndrome

(3)

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Nelson’s syndrome

(4)

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Further information

We need your feedback and support! Release new lecture schedules every Saturday New, interactive website coming very soon Want to get involved? Contact us at opportunities@bitemedicine.com to get your information pack Stay up-to-date!

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  • Email: admin@bitemedicine.com
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References

(1) Blausen.com staff (2014). Medical gallery of Blausen Medical 2014;. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. / CC BY (https://creativecommons.org/licenses/by/3.0) (2) Nephron / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0) (3) FlatOut / CC0 (4) Klaus Hoffmeier / Public domain