Endo Cases Archit Singhal - PowerPoint Presentation

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Endo Cases

Archit SinghalAAS418@ic.ac.uk

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Contents to Cover

ThyroidDiabetes

AdrenalBone and Calcium

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Disclaimer

Slides may contain errors but oh well…SBAs best way to learn clinical medicine

Each SBA tests you on a different part of a condition, so if you do loads, you’ll cover all the aspects of the conditions Some of these SBAs are realistic, others are simply knowledge recallPost any questions in the chat

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Thyroid

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A 66-year-old woman is admitted to the emergency department with acute confusion. She is alone and unable to articulate any of her past medical history. On examination, she is overweight, there is non-pitting oedema affecting the eyes and legs, and she has dry skin and coarse hair. Her observations are a heart rate of 50 beats/min, blood pressure of 90/60mmHg, respiratory rate of 10 breaths/min, temperature of 30°C, and oxygen saturation of 90% on air. What is the most appropriate initial step in her management?

Carbimazole

Levothyroxine

Octreotide

Propranolol

Thyrotropin Releasing Hormone

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Myoxydema

Coma

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Management

Oxygen

RewarmingRehydration/fluids - correct electrolyte disturbance and hypoglycaemia

IV T4/T3 (liothyronine)IV hydrocortisone (assume adrenal insufficiency until excluded)

Treat underlying cause (e.g. infection) - IV antibiotics 

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Caveats to Levothyroxine Treatment

Always check for adrenal insufficiency before commencing treatmentSide effects of treatment:

HyperthyroidismWorsening of anginaOsteoporosisAF

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A 31-year-old woman visits her general practitioner with a 3-week history of palpitations and hot flushes. She has not been keeping track of her weight but has noticed that her clothes are looser than before. She is worried that she is going through menopause. On examination, she is tremulous at rest. Her heart rate is 135bpm and irregularly irregular, with a blood pressure of 124/86mmHg. Chest sounds are clear and heart sounds are normal. Her abdomen is soft with no palpable masses. She has a diffuse thyroid

goitre

which is tender to touch. There is no associated cervical lymphadenopathy. What is the most likely diagnosis?

De

Quervain’s

thyroiditis

Grave’s disease

Hashimoto’s thyroiditis

Papillary thyroid cancer

Riedel’s thyroiditis

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A 32-year-old woman has unintentional weight loss associated with sweating. She has a diffuse goitre and mild exophthalmos.

Which is the most appropriate investigation to confirm diagnosis?

Anti-thyroglobulin antibody

Serum thyroglobulin

Serum thyroid stimulating hormone

Serum thyroxine

Thyroid microsomal antibody

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Antibodies to remember

Graves (hyper): anti TSH receptorHashimotos’s

(hypo) : anti-thyroid peroxidase

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A 45-year-old woman with a thyroid carcinoma undergoes a total thyroidectomy. The post operative histology report shows a final diagnosis of medullary type thyroid cancer. Which of the tests below is most likely to be of clinical use in screening for disease recurrence?

Serum CA 19-9 Levels

Serum thyroglobulin levels

Serum PTH levels

Serum calcitonin levels

Serum TSH levels

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Thyroid Cancers

Papillary

 - most commonEuthyroid status - thyroid works normallyYoung females (20-40yrs)

Excellent prognosisHistology: orphan Annie eyes, psammomma bodies (calcified rings) 

 

Follicular

 - 2nd most common

Need biopsy for diagnosis (can't rely on FNA)

Older female patients (40-50yrs)

Commonly metastasises to cervical lymph nodes

Histology:

hurthle

cells (large cells with eosinophilic cytoplasm

) 

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Thyroid Cancers

Medullary

Hypocalcaemia * high calcitoninAssociated with MEN2a and Men2b

Tumour derived from C cells (parafollicular cells) Anaplastic

Exclusively found in 

older patients

Very aggressive

Tends to cause compression of surrounding structures e.g. trachea

Terrible prognosis 

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Investigations

Bloods

TFTs - can be normal or derangedBone profile (e.g. Hypocalcaemia in medullary -> link to high calcitonin)

Tumour MarkersThyroglobulin - papillary and follicularCalcitonin - medullary

Fine-Needle Aspiration Cytology (FNA)

Allows histological diagnosis  -

dont

use for follicular thyroid cancer

Excision Lymph Node Biopsy

If there is cervical lymphadenopathy -> common in follicular thyroid cancer

Isotope Scan

If the cause of the thyroid lump is unclear

Shows up as cold nodules (cold nodules are cancerous, hot nodules are not cancerous)

CT/MRI

 - for staging

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Diabetes

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A 24-year-old woman is brought to the emergency department resuscitation department by ambulance after being found unconscious at home. On examination, she looks pale, clammy and is semi-unconscious. Her airway is clear. She is using accessory muscles of respiration with deep,

laboured

breathing, but her chest was clear. Apart from a tachycardia, her cardiovascular examination was normal. The abdominal examination was normal. Her Glasgow Coma Scale (GCS) is 9. On full systems examination, there are pinpoint marks over the sides of her fingertips. Her temperature is 36.3℃, pulse rate 124 bpm, BP 84/57 mmHg and respiratory rate 30 breaths per minute. Urine dip is positive for glucose and ketones. ABG demonstrates metabolic acidosis. Given this presentation, which of the following options is the single best immediate management to commence for this patient?

Actrapid

(insulin) intravenous infusion at 0.1 units/kilogram/hour

400mcg intravenous naloxone STAT

1

litre

0.9% saline over 1 hour

Slow intravenous injection of 8.4% sodium bicarbonate

Co-amoxiclav STAT

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Diagnostic Criteria

pH <7.3

Glucose >11

Ketones >3 or positive ketonuria on urine dip

Bicarb <15

TRIAD of:

hypergylcaemia

/glycosuria 

ketososis

/ketonuria 

metabolic acidosis 

Resolved when:

pH>7.3

Bicarb >15

Ketones <0.6

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Management

Fluid replacement with isotonic saline

Insulin infusion: 0.1units/kg/hrPotassium replacement

Continue long-acting insulin and stop short acting insulin

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A 36-year-old woman presents to her general practitioner with a three-day history of increased thirst, polyuria and weight loss. She has a body mass index of 28 kg/m² (previously 30 kg/m² ) and no past medical history. Her mother is known to have type 1 diabetes mellitus. Which of these investigations best distinguishes between the two most likely diagnoses?

Anti-glutamic acid decarboxylase antibodies

Blood glucose

HbA1c

Lipid Profile

Urinalysis

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A 40 year-old man was diagnosed with Type 2 Diabetes Mellitus and was commenced on lifestyle changes and metformin. After 3 months his HbA1c comes back at 7.6%. Which of the following changes in his treatment should be made?

Increase dose of metformin

No change

Replace metformin with another drug

Add another drug

Commence insulin

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T2D Treatment Pathway

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A 40 year-old obese man was diagnosed with Type 2 Diabetes Mellitus and was commenced on lifestyle changes and metformin. After 3 months his HbA1c comes back at 7.8%. Which of the following drugs should not be added onto the treatment regime?

Gliclazide

Dapagliflozin

Pioglitazone

Linagliptin

Exenatide

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T2D Drugs

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A 46-year-old man is admitted to the hospital after two months of polydipsia and polyuria. On examination and general appearance, he is evidently dehydrated. Among other tests, urine osmolality is measured after a water deprivation test. The results are as follows: Urine osmolality post-fluid deprivation 145mOsm/kg (50-1200) Urine osmolality post-desmopressin administration 150mOsm/kg (50-1200) Given the above, what is the most likely diagnosis?

Cranial diabetes insipidus

Further tests needed before making a diagnosis

Nephrogenic diabetes insipidus

Primary polydipsia

Syndrome of inappropriate anti-diuretic hormone (ADH) secretion

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Adrenal

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A 30-year-old woman has general malaise and lethargy for two years. She has a hyperpigmented V-shaped area on her neck and mouth.

Investigations:

Sodium 125mmol/L (135-146)

Potassium 5.6mmol/L (3.5-5.3)

Glucose 2.0mmol/L (3.0-6.0)

Which is the most likely diagnosis?

Adrenal Insufficiency (Addison’s Disease)

Coeliac disease

Haemochromatosis

Hypopituitarism

Insulinoma

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Which of the following investigations will best help to confirm the diagnosis?

9am Serum Cortisol

Random Cortisol

Short synATCHen

test

Long

synACTHen

test

CT scan

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Addison’s Investigations

3 ways to measure cortisol

Random cortisol

If low during acute presentation, it is diagnostic because would expect cortisol to be high during illnessShould be between: 140-690

9 am Serum Cortisol

Low (

< 100 nmol/L

 is diagnostic of adrenal insufficiency)

> 550 nmol/L makes adrenal insufficiency unlikely

Short

Synacthen

Test

IM 250 mg

tetrocosactrin

(synthetic ACTH)

Serum cortisol has less than doubled or is 

< 550 nmol/L at 30 mins

 indicates adrenal failure

 (in a normal test, basal cortisol should be >170mM)

Identify the level of defect

HIGH ACTH in primary disease (e.g. Addison's)

LOW ACTH in secondary (low cortisol secondary to low ACTH due to decreased pituitary production)

Long

Synacthen

Test

1 mg synthetic ACTH administered

Measure serum cortisol at 0, 30, 60, 90 and 120 minutes

Then measure again at 4, 6, 8, 12 and 24 hours

Patients with primary adrenal insufficiency show no increase after 6 hours

Identify the cause

Autoantibodies (against 21-hydroxylase)

Abdominal CT or MRI

Other tests (adrenal biopsy, culture, PCR)

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A 35-year-old man is found to have a blood pressure of 180/110 mmHg. He complains of feeling tired and weak. Routine bloods show

hypokalaemia

. Which is the most likely diagnosis?

InsulinomaType 2 diabetes mellitusPrimary hyperaldosteronism

Congenital hypothyroidism

Multiple endocrine neoplasia 2A

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Which of the following is the first line investigation for primary hyperaldosteronism?

CT Scan

Fludrocortisone suppression test

ABGPlasma aldosterone

Aldosterone: renin ratio

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Primary Hyperaldosteronism Investigations

Urine

High urine K+

BloodsU&Es - low Serum K+Reduced plasma renin

High aldosterone: renin activity ratio -> this is definitive

ABG 

- 

hypokalaemic

metabolic alkalosis

 (protons lost at DCT, systemic K+-H+ exchange)

Imaging

CT/MRI - to exclude carcinoma

Special Tests - discover the hyperaldosteronism

Fludrocortisone suppression test - excludes/diagnose PA

Give fludrocortisone, should supress aldosterone but in PA patients, aldosterone will remain high

Salt Loading

2L infusion of normal (0.9%) saline for 4hrs/oral sodium loading for a few days

Failure of aldosterone suppression following salt load confirms primary hyperaldosteronism

Special tests - distinguish between Conn's and bilateral adrenal hyperplasia

Postural Test

Measure plasma aldosterone, renin activity and cortisol when the patient is lying down at 8 am

Measure again after 4 hrs of the patient being upright

Aldosterone-producing adenoma (Conn's)

 - aldosterone secretion 

decreases

 between 8 am and noon and when standing upright

Bilateral adrenal hyperplasia

 - adrenals respond to standing posture and increase renin production leading to 

increased

 aldosterone secretion

Bilateral adrenal vein catheterisation

Measures adrenal vein aldosterone levels for each adrenal gland

Allows you to distinguish between Conn's syndrome (high aldosterone in one vein - unilateral adenoma) and bilateral adrenal hyperplasia (high aldosterone in both veins)

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The same man demonstrated bilateral adrenal hyperplasia on a CT scan and was started on medication after which he developed gynecomastia and impotence. Which drug was he likely started on?

Eplerenone

Amiloride

Propranolol

Steroids

Spironolactone

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Primary Hyperaldosteronism Treatment

Bilateral Adrenal Hyperplasia

Spironolactone (potassium-sparing diuretic - aldosterone antagonist)

SE: gynaecomastia, impotence, GI disturbance, menstrual irregularitiesEplerenone can be used if the spironolactone side-effects are intolerable

Amiloride

 (potassium-sparing diuretic - ENaC blocker)

Monitor serum K+, creatinine and BP

ACE inhibitors and CCBs may also be added to treat BP

Aldosterone Producing Adenomas (Conn's)

Laparoscopic unilateral adrenalectomy

Adrenal Carcinoma

Surgery

Post-operative mitotane (antineoplastic) 

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A

30-year-old woman presents with weight gain and irregular menstruation. Her blood pressure is elevated at 170/100 mmHg and there is evidence of proximal muscle weakness. A diagnosis of Cushing's syndrome is suspected. Which one of the following is the best investigation for Cushing's syndrome?

Random insulin-like growth factor 1 (IGF-1)Overnight dexamethasone suppression test Serum IGF-1 measurements

ACTH Stimulation test

24hr urinary collection of

metanephrines

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Cushing’s Investigations

STEP 1: Initial High-Sensitivity Tests - confirm hypercortisolism

24hr urine collection for Urinary free cortisol

Not ideal as patients often forget to take urine sampleLate-night salivary cortisol (normal = low, Cushing's = high)Overnight dexamethasone suppression test (1mg)

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Cushing’s Investigations

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The same woman undergoes treatment for this disease after which develops hyperpigmented skin. Which of the following treatment plans was implemented?

Trans-sphenoidal surgery

Unilateral adrenalectomy Radiotherapy

Metyrapone Bilateral adrenalectomy

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Calcium and Bone

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A 67-year-old man presents to your GP practice with significant bone pain. He claims that the pain has come on gradually and is now affecting most of his body. He has a past medical history of chronic kidney disease stage 4 for which he is taking a wide range of medications. His examination is unremarkable, however. You request some blood tests: Calcium 2.9 mmol/L (2.2-2.6) Phosphate 0.9 mmol/L (0.74-1.40) Parathyroid Hormone 29.8

pmol

/L (1.6-6.9) Alkaline Phosphatase 476 u/L (60-350)

What is the most likely cause of the abnormal blood results?

Bone metastases

Paget's disease of bone

Primary bone cancer

Primary hyperparathyroidism

Tertiary hyperparathyroidism

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A 51-year-old man has recently been diagnosed with a renal calculus following a CT scan after presenting to hospital with loin pain. His blood results are shown below:

Investigations:

Urea 6.2mmol/L (2.5-7.8) Creatinine 76

µ

mol/L (60-120)

Calcium

2.85

mmol/L (2.2-2.6)

Vitamin D 85 nmol/L (50-250)

Alkaline phosphatase 121 IU/L (25-115)

Parathyroid hormone 10.2pmol/L (1.6-8.5)

Phosphate 0.65 mmol/L (0.8-1.5)

Urinalysis: Blood 3+, nitrites negative, leucocytes negative

Which is the most likely diagnosis?

Adult polycystic kidney disease

Primary hyperparathyroidism

Renal cell carcinoma

Sarcoidosis

Tertiary hyperparathyroidism

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Hyperparathyroidism

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Misc

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A 45-year-old builder presents to his GP with episodes of tremor, sweating and blurred vision following exercise. He says he thinks they happen because he has pushed himself too hard exercising, however he is now getting these episodes early in the morning soon after waking up. These episodes go away once he has eaten some food. He has a small parathyroid adenoma but is normally fit and well. What diagnosis most fits with this man's presentation?

Alcoholism

Anxiety

Factitious hypoglycaemiaInsulinoma

Phaeochromocytoma

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A 22-year-old woman has increased facial hair and difficulty losing weight. Her temperature is 37.2

, pulse rate 84 bpm, BP 114/75 mmHg, respiratory rate 17 breaths per minute and oxygen saturation 98% breathing air.

Which other sign would suggest a diagnosis of polycystic ovary syndrome?

Acanthosis nigricans

Bitemporal hemianopia

Exophthalmos

Postural hypotension

Proximal muscle weakness

 

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A 34-year-old woman has a headache and is sweating more than usual. Investigations: Prolactin 1200U/L (100-500)

Luteinising hormone (LH) 5U/L (luteal) (1-11)

Follicle stimulating hormone (FSH) 3U/L (luteal) (2-8) Thyroid stimulating hormone (TSH) 0.7mU/L (0.3-4.2) Free T4 14pmol/L (9-25) Free T3 3.0pmol/L (4.0-7.2) Cortisol (9am) 250nmol/L (200-700) IGF-1

markedly raised Which is the most likely diagnosis?

Acromegaly

Macroprolactinoma

Panhypopituitary

failure

Premature ovarian failure

TSHoma

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