WSREVMED25 Valid until 31 August 2020 Only at wwwworldscientificcom RevMED 300 SBAs in Medicine and Surgery By Lasith Ranasinghe amp Oliver Clements Imperial College London UK ID: 935035
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Slide1
25% off
with the online code
WSREVMED25
Valid until 31 August 2020
Only at www.worldscientific.com
RevMED: 300 SBAs in Medicine and Surgery
By Lasith Ranasinghe & Oliver Clements
(
Imperial College London, UK
)
Slide2Silvia MuttoniEndocrinology Part 1
Slide3Disclaimer“MedED does not represent the ICSM Faculty or Student Union. This lecture series has been designed and produced by students. We have made every effort to ensure that the information contained is accurate and in line with Learning Objectives featured on SOFIA, however, this guide should not be used to replace formal ICSM teaching and educational materials.”
Slide4Outline DiabetesSodium imbalance
Pituitary diseaseThyroid disorders
AcromegalyMEN
Carcinoid syndrome
Slide5Diabetes insipidus Inadequate secretion of or insensitivity to vasopressin (ADH) hypotonic polyuria
Slide6Slide7Diabetes insipidus Inadequate secretion of or insensitivity to vasopressin (ADH) hypotonic polyuria
2 types:Cranial/central (posterior pituitary fails to secrete ADH) Nephrogenic
(collecting ducts insensitive to ADH)
Causes: Cranial: pituitary tumour, infection (meningitis), sarcoidosisNephrogenic: ↑ Ca, ↓ K, lithium, inherited (AVPV2 gene), idiopathic
Slide8Diabetes insipidus Presentation: Polyuria (including nocturia) – UO often >3L
Polydipsia Symptoms of hypernatremia: lethargy, irritability, confusion Investigations:
General: U&Es (Ca, Na, K), glucose (to exclude DM) Diagnostic: water deprivation test
Slide9Diabetes insipidus – water deprivation test Water is restricted for 8 hours
Plasma and urine osmolality are measured every hour After 8 hours, give desmopressin and measure urine osmolality
Water restriction causes…
Desmopressin causes… NormalRise in ADH ↑ plasma osm Urine osm >600 (concentrated)DI – cranial
DI – nephrogenic
Slide10Diabetes insipidus – water deprivation test Water is restricted for 8 hours
Plasma and urine osmolality are measured every hour After 8 hours, give desmopressin and measure urine osmolality
Water restriction causes…
Desmopressin administration causes… NormalRise in ADH ↑ plasma osm Urine osm >600 (concentrated)DI – cranial
Lack of ADH urine is unable to concentrateUrine osm <400
Urine osm ↑ by >50% after desmopressin DI – nephrogenic Lack of ADH urine is unable to concentrateUrine osm <400
Urine
osm
↑ by <45% after desmopressin
Slide11Diabetes insipidus Management:Treat the cause
Cranial: intranasal desmopressin Nephrogenic: thiazide diuretic or NSAIDs
Slide12Diabetes mellitus
Type 1 DM
Type 2 DMPathophysiology
Hyperglycaemia due to deficiency of insulin production (autoimmune destruction of beta cells in 90%)Hyperglycaemia due to ↑ peripheral resistance to insulin actionPresentationRisk factors Diagnosis
Management
Slide13Diabetes mellitus
Type 1 DM
Type 2 DMPathophysiology
Hyperglycaemia due to deficiency of insulin production (autoimmune destruction of beta cells in 90%)Hyperglycaemia due to ↑ peripheral resistance to insulin actionPresentationPolyuria + polydipsia Tiredness & weight loss DKA: N&V, abdo pain, Kussmaul breathing, sweet breath
Polyuria + polydipsia Risk factors
Diagnosis Management
Slide14Diabetes mellitus
Type 1 DM
Type 2 DMPathophysiology
Hyperglycaemia due to deficiency of insulin production (autoimmune destruction of beta cells in 90%)Hyperglycaemia due to ↑ peripheral resistance to insulin actionPresentationPolyuria + polydipsia Tiredness & weight loss DKA: N&V, abdo pain, Kussmaul breathing, sweet breath
Polyuria + polydipsia Risk factors Susceptibility genes:
HLA DR3/4Other autoimmune conditionsObesity, FH, ethnicity, endocrine, drugs Diagnosis
Management
Slide15Diabetes mellitus
Type 1 DM
Type 2 DMPathophysiology
Hyperglycaemia due to deficiency of insulin production (autoimmune destruction of beta cells in 90%)Hyperglycaemia due to ↑ peripheral resistance to insulin actionPresentationPolyuria + polydipsia Tiredness & weight loss DKA: N&V, abdo pain, Kussmaul breathing, sweet breath
Polyuria + polydipsia Risk factors HLA DR3/4
Other autoimmune conditionsObesity, FH, ethnicity, drugsDiagnosis Blood glucose measurement
Fasting ≥7 mmol/L
Random >11.1 mmol/L
Management
Slide16Diabetes mellitus
Type 1 DM
Type 2 DMPathophysiology
Hyperglycaemia due to deficiency of insulin production (autoimmune destruction of beta cells in 90%)Hyperglycaemia due to ↑ peripheral resistance to insulin actionPresentationPolyuria + polydipsia Tiredness & weight loss DKA: N&V, abdo pain, Kussmaul breathing, sweet breath
Polyuria + polydipsia Risk factors HLA DR3/4
Other autoimmune conditionsObesity, FH, ethnicity, drugs Diagnosis Blood glucose measurement
Fasting ≥7 mmol/L
Random >11.1 mmol/L
Management
Insulin
Patient education
In DKA 1
st
line treatment is fluids
1
st
line =
diet and lifestyle
2
nd
line = metformin
+/-
sulphonylurea
+/- insulin
Slide17Outline DiabetesSodium imbalance
Pituitary diseaseThyroid disorders
AcromegalyMEN
Carcinoid syndrome
Slide18Sodium imbalanceNormal range of Na: 135-145 mmol/L Na can be ↑ or ↓
Slide19HYPOnatraemia ↓
Na (<135) is a WATER PROBLEM
caused by
too much ADH: physiological or inappropriate secretion When you see ↓ Na 1. Think volume status
Dry pt postural hypotension, dry mucous membranes, tachycardic
Wet pt peripheral oedema, raised JVP
If neither are mentioned, you can assume the patient is
euvolaemic
Slide20Hypovolaemia
Euvolaemia
= ENDOCRINEHypervolaemia Drop in BP detected by hypothalamus → more ADH secreted in order to absorb more water.
Causes
Diarrhea
Vomiting
Diuretics
Hypothyroidism,
Hypoadrenalism,
SIADH (pneumonia/cancer)
HF
Cirrhosis
Nephrotic syndrome
Signs
Reduced turgor, postural hypotension, dry mucous membrane.
Oedematous
, high JVP
Ix
- Clinically
hypovolaemic
- Low urine sodium
kidneys will detect
volume and hang on to salt
(
measure off diuretics
)
TFTs
Short
synACTHen
: ACTH injection (cortisol will not rise)
Drug review, breast examination, CXR, brain MRI
Fluid overloaded
Low urine sodium
aldosterone secretion --> retention of Na
If very severe hyponatremia (seizures/↓ consciousness), can give slow hypertonic saline but change in [Na+]
must not exceed 10mmol/L
in the first 24 hours
risk of
central pontine myelinolysis
Slide21HYPERnatramia ↑ Na (>145)Causes: vomiting, diarrhea, diabetes insipidus, primary aldosteronism
Presentation: lethargy, irritability, thirst, signs of dehydration, confusion, coma, fits Management: replace water
Slide22Outline DiabetesSodium imbalance
Pituitary diseaseThyroid disorders
AcromegalyMEN
Carcinoid syndrome
Slide23Syndrome of inappropriate ADHSIADH = too much ADH secretion = too much water is reabsorbed
So serum Na ↓, urine Osm ↑, urine Na ↑
SIADH is not a final diagnosis – need to find the
cause (clues in the hx!) Causes of SIADH: CNS pathologyLung pathologyDrugs: SSRI, TCA, opiates, PPIs, carbamazepineTumours (do not forget breast cancer!)Management: 1. Treat underlying cause 2. Fluid restrict to 0.5-1L3. If ineffective give demeclocycline or vasopressin receptor antagonist e.g. tolvaptan
Slide24Hypovolaemia
Euvolaemia
= ENDOCRINEHypervolaemia Drop in BP detected by hypothalamus → more ADH secreted in order to absorb more water.
Causes
Diarrhea
Vomiting
Diuretics
Hypothyroidism,
Hypoadrenalism,
SIADH (pneumonia/cancer)
Causes of SIADH:
CNS pathology
Lung pathology
Drugs: SSRI, TCA, opiates, PPIs, carbamazepine
Tumours (do not forget breast cancer!)
HF
Cirrhosis
Nephrotic syndrome
Signs
Reduced turgor, postural hypotension, dry mucous membrane.
SIADH
: reabsorbing lots of water so serum Na low, urine
Osm
high, urine Na high.
Oedematous
, high JVP
Ix
- Clinically
hypovolaemic
- Low urine sodium
kidneys will detect
volume and hang on to salt
(
measure off diuretics
)
TFT
Short
synACTHen
: ACTH injection (cortisol will not rise)
Drug review, breast examination, CXR, brain MRI
Fluid overloaded
Low urine sodium
aldosterone secretion --> retention of Na
Mx
Saline (this abolishes the stimulus for ADH secretion)
Treat the cause
Fluid restrict
Treat the cause
Fluid restrict
Slide25HyperprolactinaemiaExcess circulating prolactin
Slide26Slide27Hyperprolactinaemia Causes:
Pituitary prolactinoma (commonest)Hypothyroidism Drugs e.g. metoclopramide, antipsychotics (DA antagonists) Physiological! Pregnancy, breast feeding
Presentation: Women: galactorrhoea,
amenorrhoea, infertility, loss of libido Men: loss of libido, infertility, galactorrhoea uncommon Mass effects of tumour: headache, loss of visual fields Investigations:ProlactinTFTsPituitary MRI
Slide28Hyperprolactinaemia Management:1st line = DA agonist e.g. bromocriptine and carbergoline
2nd line = surgery
Slide29Outline DiabetesSodium imbalance
Pituitary diseaseThyroid disorders
AcromegalyMEN
Carcinoid syndrome
Slide30Thyroid
Slide31Thyroid disorders
Hyperthyroidism
Hypothyroidism Heat intolerance, sweating
Cold intolerancePalpitations, irregular pulseBradycardia Irritable LethargyWeight loss but good appetite Weight gainDiarrhoeaConstipation Menstrual irregularities in females, impotence in men
Menstrual disturbance in females Tremor Dry skin, cold hands
↓ TSH, ↑ T3/4 ↑TSH, ↓T3/4
Slide32Hyperthyroidism Excess circulating T4/T3 Due to:Increase thyroid hormone
synthesis: hyperthyroidism Increased release of stores thyroid hormones: thyroiditis
Slide33Hyperthyroidism
Cause of hyperthyroidismFeatures
Grave’s disease (80%)Autoantibodies to TSH receptor. Associated with other AI diseases e.g. Addison’s, vitiligo, T1DM
Grave’s triad = exophthalmos, pretibial myxedema and thyroid acropachy
Slide34Hyperthyroidism
Cause of hyperthyroidismFeatures
Grave’s disease (80%)Autoantibodies to TSH receptor. Associated with other AI diseases e.g. Addison’s, vitiligo, T1DM
Grave’s triad = exophthalmos, pretibial myxedema and thyroid acropachyDe Quervain’s thyroiditis Post-viral, fever, high ESR. Causes painful goitre. Self-limiting (treat with NSAIDs)
Slide35Hyperthyroidism
Cause of hyperthyroidismFeatures
Grave’s disease (80%)Autoantibodies to TSH receptor. Associated with other AI diseases e.g. Addison’s, vitiligo, T1DM
Grave’s triad = exophthalmos, pretibial myxedema and thyroid acropachyDe Quervain’s thyroiditis Post-viral, fever, high ESR. Causes painful goitre. Self-limiting (treat with NSAIDs)Toxic multinodular goitre In elderly and iodine deficient areas
Slide36Hyperthyroidism
Cause of hyperthyroidismFeaturesGrave’s disease
(80%)Autoantibodies to TSH receptor. Associated with other AI diseases e.g. Addison’s, vitiligo, T1DM
Grave’s triad = exophthalmos, pretibial myxedema and thyroid acropachyDe Quervain’s thyroiditis Post-viral, fever, high ESR. Causes painful goitre. Self-limiting (treat with NSAIDs)Toxic multinodular goitre In elderly and iodine deficient areas Adenoma Solitary nodule producing T3/4
Slide37Hyperthyroidism – radioisotope scan
Cause of hyperthyroidismRadioisotope scan findings
Grave’s diseaseDiffuse increased uptake (smooth diffuse goitre)
De Quervain’s thyroiditis NO uptake Toxic multinodular goitre Multiple areas of increased uptake Adenoma Single area of increased uptake
Slide38Slide39Hypothyroidism Causes: Autoimmune Hashimoto’s thyroiditis (commonest cause in the West)
Iodine deficiency (commonest cause worldwide)Iatrogenic: post-surgery, radioiodine, amiodarone De Quervain’s thyroiditis
hyperthyroidism then hypothyroidism. Usually self resolving but may need thyroxine replacement for a few weeks Congenital thyroid dysgenesis
↑ TSH, ↓ T3/4 Management = levothyroxine 25-200 micrograms/day (monitor TFTs at 6 weeks and adjust dose accordingly)
Slide40Thyroid cancer
TypeFeaturesPapillary
Most common. Affects younger patients RF: radiation exposureBuzzwords: Psammoma bodies, Orphan Anne nuclei
FollicularAffects middle aged women especially Buzzwords: Hurthle cells MedullaryAssociated with MEN2 (?FHx)Lymphoma More common in females. Generally occurs after pre-existing Hashimoto’s thyroiditis Anaplastic Elderly femalesBuzzwords: giant cells, pleomorphic hyperchromatic nuclei
Slide41Outline DiabetesSodium imbalance
Pituitary diseaseThyroid disorders
AcromegalyMEN
Carcinoid syndrome
Slide42AcromegalyHypersecretion of growth hormone in adults Same condition in children is known as gigantism.
Usually caused by a GH secreting adenoma in the pituitary.GH stimulates release of IGF-1 growth of bones and soft tissues
Presentation: rings and shoes become right, ↑ sweating, coarse facial features, sleep apnoea
, weight gain, headaches/visual disturbance, carpal tunnel syndrome, hypertension, insulin resistance
Slide43Acromegaly Investigations: Screening: serum IGF-1
Diagnostic: OGTT acromegalics fail to suppress GH after 75g glucose load
MRI brain to visualise the pituitary tumour
Management: 1st line = transphenoidal hypophysectomy 2nd line = somatostatin analogue e.g. ocreotide
Slide44Outline DiabetesSodium imbalance
Pituitary diseaseThyroid disorders
AcromegalyMEN
Carcinoid syndrome
Slide45MENHormone producing tumours in multiple organs Autosomal dominant
Slide46MEN
TypeFeaturesMEN 1
(mutation in menin gene chr 11)
Parathyroid adenoma/hyperplasia hyperparathyroidism, high Ca Pancreas: insulinoma, gastrinomaPituitary: prolactinoma, acromegaly, adrenal, carcinoid tumours MEN 2(mutation in RET gene chr 10) Thyroid: medullary thyroid cancer (in ALL)Adrenal: phaeochromocytoma (in 50%)
Parathyroid hyperplasiaMEN 3 aka 2B Med thyroid carcinoma +
phaeo (as in MEN 2) + Mucosal neuromas: bumps on lips/cheeks/tongue/eyelids+ Marfanoid appearance NO hyperparathyroidism
Slide47Outline DiabetesSodium imbalance
Pituitary diseaseThyroid disorders
AcromegalyMEN
Carcinoid syndrome
Slide48Carcinoid syndromeConstellation of symptoms caused by systemic release of humoral factors from carcinoid tumours They produce secretory products such as serotonin, histamine, tachykinins and prostaglandin Common sites for carcinoid tumours are appendix and rectum
Presentation: paroxysmal flushing, diarrhea, crampy abdominal pain, wheeze, sweating, palpitations Investigations: 24 hour urine collection:
↑ 5-HIAA levels (serotonin metabolite)CT/MRI to localize tumour. Also consider looking for underlying MEN 1
Slide49Questions
Slide50SBAA 49 year old woman presents with 4kg weight loss over 2 months. She complains of feeling hot all the time and her partner mentions that she’s been more irritable recently. On examination she has a smooth goitre, and you also notice proptosis and a rash on her shins. What is the most likely diagnosis?
De Quervain’s thyroiditis Toxic multinodular goitre
Grave’s diseaseMenopause
Medullary thyroid cancer
Slide51SBAA 49 year old woman presents with 4kg weight loss over 2 months. She complains of feeling hot all the time and her partner mentions that she’s been more irritable recently. On examination she has a smooth goitre, and you also notice proptosis and a rash on her shins. What is the most likely diagnosis?
De Quervain’s thyroiditis Toxic multinodular goitre
Grave’s diseaseMenopause
Medullary thyroid cancer
Slide52SBA A 16 year old boy presents to the GP with polyuria and polydipsia. He is diagnosed with diabetes insipidus. This condition is characterized by overproduction of which of the following? Antibodies against insulin-producing beta cells of the pancreas
Anti-diuretic hormone Brain natriuretic peptide
Oxytocin
Aldosterone
Slide53SBA A 16 year old boy presents to the GP with polyuria and polydipsia. He is diagnosed with diabetes insipidus. This condition is characterized by overproduction of which of the following? Antibodies against insulin-producing beta cells of the pancreas
Anti-diuretic hormone
Brain naturetic peptideOxytocin
Aldosterone
Slide54SBA A 35 year old female presents with 4 month history of amenorrhoea. On examination, she is noted to have loss of peripheral vision. What is the most likely underlying problem?
Second cranial nerve palsyStroke Hyperparathyroidism Prolactinoma
Pregnancy
Slide55SBA A 35 year old female presents with 4 month history of amenorrhoea. On examination, she is noted to have loss of peripheral vision. What is the most likely underlying problem?
Second cranial nerve palsyStroke Hyperparathyroidism
Prolactinoma Pregnancy
Slide56SBA A 49 year-old man presents with a history of difficulty sleeping. He reports feeling increasingly tired and general weakness which he attributes to his poor sleep pattern. Additionally, the patient has noticed he has gained weight and sweats more easily. On examination, the patient has coarse facial features. What is the most likely diagnosis?
Hyperthyroidism Cushing’s diseaseAcromegaly Hypothyroidism
Diabetes
Slide57SBA A 49 year-old man presents with a history of difficulty sleeping. He reports feeling increasingly tired and general weakness which he attributes to his poor sleep pattern. Additionally, the patient has noticed he has gained weight and sweats more easily. On examination, the patient has coarse facial features. What is the most likely diagnosis?
Hyperthyroidism Cushing’s diseaseAcromegaly Hypothyroidism
Diabetes
Slide58SBA A 50 year old Asian man is referred to diabetes clinic after presenting with polyuria and polydipsia. He has a BMI of 30, a blood pressure measurement of 137/88 and a fasting plasma glucose of 7.7mmol/L. The most appropriate first-line treatment is:Dietary advice and exercise
Sulphonylurea Exenatide Thiazolidinediones
Metformin
Slide59SBA A 50 year old Asian man is referred to diabetes clinic after presenting with polyuria and polydipsia. He has a BMI of 30, a blood pressure measurement of 137/88 and a fasting plasma glucose of 7.7mmol/L. The most appropriate first-line treatment is:
Dietary advice and exercise Sulphonylurea Exenatide
Thiazolidinediones Metformin
Slide60SBA A 15 year old girl complains of headaches which started 6 weeks ago. The headaches initially occurred 1-2 times a week but now occur up to five times a week, they are not associated with any neurological problems, visual disturbances, nausea or vomiting. The girls also reports a white discharge from both of her nipples. She has not started menstruating. The most appropriate investigation is:
Lateral skull X ray CT scanMRI scanThyroid function tests
Serum prolactin measurement
Slide61SBA A 15 year old girl complains of headaches which started 6 weeks ago. The headaches initially occurred 1-2 times a week but now occur up to five times a week, they are not associated with any neurological problems, visual disturbances, nausea or vomiting. The girls also reports a white discharge from both of her nipples. She has not started menstruating. The most appropriate investigation is:
Lateral skull X ray CT scanMRI scanThyroid function tests
Serum prolactin measurement
Slide62SBA A 58 year old woman presents with an acutely painful neck, the patient has a fever, blood pressure is 135/85, and heart rate is 102 bpm. The patient explains the pain started 2 weeks ago and has gradually become worse. She also experiences palpitations and believes she has lost weight. She presents one week later complaining of intolerance to cold temperatures. What would you see if you performed a radioisotope scan on her?
Single area of increased uptake Multiple areas of increased uptake Diffuse increased uptake No uptake
She does not need a radioisotope scan
Slide63SBA A 58 year old woman presents with an acutely painful neck, the patient has a fever, blood pressure is 135/85, and heart rate is 102 bpm. The patient explains the pain started 2 weeks ago and has gradually become worse. She also experiences palpitations and believes she has lost weight. She presents one week later complaining of intolerance to cold temperatures. What would you see if you performed a radioisotope scan on her?
Single area of increased uptake Multiple areas of increased uptake Diffuse increased uptake
No uptake She does not need a radioisotope scan
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