Emq - Endocrine

Front 1

40 years old female

Hyperpigmentation of skin

After hx of bilateral Adrenalectomy

Back 1

Nelson's Syndrome

( Removal of physiological feedback inhibition of ACTH production => ^^ACTH =>^^ Pigmentaion )

* ^= increased

Front 2

21 y female:

Amenorrhea, vaginal dryness, galactorrhea

Examination: Bilateral Hemianopia

Back 2

Hyperprolactinaemia

MX: Transphenoidal resection

PS: Anti-dopaminergic drugs may cause Hyperplocatemaemia

Front 3

26 years old female,

Weight gain, menustrual irregular, Hirsuitism

Proximal muscle weakness

BP 150/100

Back 3

Cushing's Syndrome

( ^ glucocortisol due to ^^ ACTH secondary to Pituitary tumor )

Front 4

Moon-shaped face

Buffalo lump at neck

Centripetal Obestiy ( Trunkal Obesity )

Thin Skin

Bruises easily

Purple Straia

Back 4

Cushing 's Disease

( Extra Sx )

Front 5

Cushing's Investigation :

& Managment

Back 5

Plasma ACTH

( If low - Adrenal Tumor )

If detectable , then do , High dose Dexamethasone

( differentiate b/n Ectopic ACTH & Pituitary origin)

Mx:

Coritison Suppresion

( Good with pituitary origin , poor with ectopic ACTH)

Front 6

28 years old female, chest tightness & Anxiety Attack

Hx of HTN , ECG : suggest Left ventricular Hypertrophy

Back 6

Phaechromocytoma

( Sympathic Nervous System Tumor occurs in Adrenals in 90% - & 10 % Malignant )

Possible Extra Sx: Palpitaion , Paraxysmal high BP

Front 7

Phaechromocytoma Investigation / Diagnosis

Management

Back 7

Urine test:

VMA : (Vanillylmandellic Acid)

HVA: (Homovanillalic Acid)

CT / MRI ( b/c its a tumor) of Abd

Mx: Before Surgical excision ( treatment of chip ice ) Stabelise HTN w/ alpha blocker ( Phenoxybenzamine )

Front 8

40 years old female,

changing appearance , Deepening of Voice

Examination :

Coarse oily skin, Enlarged Tongue

Proximal Muscle weakness

Parasethia in both hands

Back 8

Acromegaly

( Over secretion of Growth Hormone, from a pituitary gland)

Extra Sx: Marcroglossia , spade like hands, headache , visual field defect

Assx with DM, Cardiomyopathy

Front 9

Acromegaly Inv & Mx:

Back 9

Oral Glucose, ^ Growth Factor ' paradoxical '

Increased Somatsomedin- C ( a.k.a. Insulin Like Growth factor / IGF-1 )

Test:

Give glucose 70 g Per Oral wait 90 min , then test GH ( Normal person GH will be suppressed ) in Acromegaly = GH ^increased

MX:

GH Suppresion : Somatostain

Transsphenoidal surgical excision

Front 10

30 y woman with poor diet complains of bleeding gums

Deficiency of :

Back 10

Vitamin C

It is involved in hydroxylation of proline to hydroxyproline, which is necessary for normal formation of collagen.

In this case Vit C deficicy lead to SCURVY

Front 11

A 55 y with alcohol problems presents with

Nystagmus + Opthalmoplegia + ataxia , triad =

Deficiencies of

Back 11

Thiamin

Dx: Wernicke's Encephalopathy

MX: urgent thiamin required to prevent progression to Korsakoff's Syndrome ( an irreversible condition characterized by anterograde and retrograde amnesia => resulting in 'Confabulation' (which means: fabricating imaginary experience to compensate for memory loss )

Front 12

A 35 y pt recently diagnosed with coeliac disease complains of prolonged bleeding after a small cut. The prothrombin time is increased

Deficiency of :

Back 12

Vitamin K

Coeliac disease results in malabsorpotion of Fat soluble (ADEK) . And there are multiple Vit k dependent clotting factors ( 1972 -II, VII,IX,X)

Front 13

A 25 y African man presents with symmetrical dermatitis on sun-exposed skin, diarrhea and depression.

He has recently been on anti -TB Treatment

Deficiency of :

Back 13

Nicotonic acid ( B6)

Dx: Pellagra

Causes : Isoniazid therapy (TB med)

Mechanism: ther is a predisposition to Pellagra in pt with carcinoid syndrome b/c TRYPTOPHAN (an aminoacid )metabolism is diverted away from nicotinamide produciton to produce amines

Front 14

A 12 y boy presents with night-blindness

Deficiency of :

Back 14

Vitamin A

Also can cause Xerophthamlmia ( dryness of conjunctiva and cornea of eye)

Signs: Bitot Spots ( white areas of keartinized epithelial cells seen in the conjunctiva of young children with Vit A Deficiency)

Front 15

40 y woman treated with Spironolactone and Lisinopril for Heart Failure presents with BRADYCARDIA .

ECG: Tall tended T waves

Back 15

Hyperkalemia

Spironolactone( Aldosterone antagonist ) +Lisiinopril ( ACE Inhibitor =Risk of Hyperkalemia

But it is combined anyways due to improve survival

Front 16

30 y woman presents with

tetany , perioral paraesthesia, Carpopedal spasm

After thyroid surgery

Back 16

Hypocalcaemia

Due to inadvertent removal of Parathyroid gland

Front 17

30 y man treated for systemic fungal infection presents with

muscle weakness, arrhythmia s, tetany

ECG: prolonged P-R interval, prominent U waves

Back 17

Hypokalemia

S/E of Amphotericin (antifungal) mx secondary to increased renal loss.

Other ECG signs: Flattened T waves

Front 18

50 y woman on TPN presents with

Red crusted lesions around the nostrils and corner of mouth

Back 18

Zinc Deficiency

Due to TPN for long period

Front 19

45 year old woman presents with

Thirst , abdominal pain, History of renal stones

Back 19

Hypercalcaemia

Causes: malignancy , 1ry hyper-parathyroidism, sarcoidosis, thyrotoxicosis

Initial Mx: aggressive rehydration w/ IV fluids. Further therapy through treating underlying cause.

Biphophonates are useful if the cause was malignancy . The inhibit osteoclasts resorption of bone hence lower serum calcium levels.

Front 20

55 y smoker presents with

wt loss, haemoptysis , Confusion

Urine osmolaltiy : 520 mosmol/kg, Serum sodium : 112 mold/l

Back 20

SIADH : Syndrome of inappropriate ADH secretion

Is assx with malignancy, esp SCC of lung.

Or tumors of CNS, prostate, pancreas , thymus , lymphomas.

Other causes: Head injury, CNS disorders : i.e. meningioencephalitis, Metabolic disease: i.e. Porphyria

To Dx: pt need to be euvolmic, normal thyroid and adrenal function, low plasma osmolality , inappropriate high Urine osmolality.

Drugs that can cause it: Carbamepine( Anticonvulsant /analgesic ), Chloropromiode (mx DMII), Cyclophosphamide ( mx. Leukemia / lymphoma immune suppressing )

Front 21

30 y man presents with Sx:

Polyuria, polydipsea.

Plasma sodium: 165 moll/l, plasma osmolality 310mosmol/kg, urine osmolality 190 mosmol/kg

Back 21

Diabetes Insipidu

( Impaired water resorption by kidney as a result of lack of ADH secretion by Post Pituitary -' Cranial DI' or reduced sensitivity of kidneys to the action of ADH - 'Nephrogenic DI' )

High plasma osmolality + low Urine usmolality

Sx of each

(Feel thirty & need to replace ) + ( produciton of large amounts of very dilute urine )

Front 22

45 y man with DM II presents with

Drowsiness and Dehydration .

Plasma sodium is 158 mmol/l

Glucose : 40 mmol/l

Back 22

Hyperosmolar non-ketotic coma ( HONK)

A complication of DM II. Hx of uncontrolled DM / undiagnosed before presentation.

No acidosis.

Mx: IV fluid replacement with 0.9 % saline.

Insulin used with care. If glucose fall too rapid => rapid change in osmolality => cerebral oedema

Anticoagulant , due to risk of thrombosis

Front 23

50 y with DM 1 , and hyperlipediam :

Mild hyponatremia . Plasma sodium : 125 mmol/l

Back 23

Pseudohyponatraemia

False low plasma Na concentration due to hyperlipidaemia/ hyperprotenaemia

Front 24

HypoNa assx with heavy proteinuria in a 55 y woman on long term Pencillamine treatment for Rheumatoid arthritis

Back 24

Nephrotic Syndrome

=> hyperVolaemia with clinical evidence of Oedema i.e. Pedal edema .

Immuno complex glomerulonephritis is common with penicillamine and causes mild proteinuria .

Mx: drug must be stopped but can be resumed at a lower dose once problem is resolved

IF HeaVy proteinuria then its more serious and PERMANT withdrawal of treatment is needed

Front 25

Disorder of sodium balance Investigations:

Normal range

Serum Sodium :

Plasma Osmolality :

Urine Osmolality :

Glucose :

Back 25

S. Na: 135-145 mmol/l

P.Osm: 275-295 mosm/kg

U.Osm:

-24-hr : 500-800 mosm/kg

-Random: 300-900 mosm/kg

-12 hr after fluid restriction : Above 850 mosm/kg

G: 70-100 mg/dL

Front 26

80 y woman presents with

Wt loss, Back Pain

Inv: elevated ESR, marked excretion of immunoglobulin chains in the urine

Cause of hypercalcaemia ?

Back 26

Myeloma

(Bone marrow tumor)

More than 1 g light chain excreted in the urine per day is a MAJOR criterion for Dx of myeloma.

Red flags: Wt loss, Elevated ESR

Mx: Biphosphonates may be used to treat the hyeprCa assx with Myeoloma.

Radiotherapy for bone pain relieve

Front 27

35 y man presents with dry cough and SOB

CXR Bilateral hilar lymphadenopathy

Cause of hypercalcaemia ?

Back 27

Sarcoidosis

The hx is usually the initial presentation in up to 50% of sarcoidosis pt.

Other cause of CXR finding : TB, malignancy, silicosis, , extrenisic allergic alviolitis

Higher incidence of sarcoidosis in Afreican -Carribbeans

Front 28

35 y woman with Breast cancer complains of

Pain and tenderness over the upper lumbar region

Alkaline phosphatase 400 U/I

Cause of hypercalcaemia ?

Back 28

Bone metastasis

Mx: NSAIDs i.e. Ibuprofen are good mx for pain of bone metastasis

Front 29

55y smoker has recently been Dx with squamous cell lung cancer .

Bone scan unremarkable

Cause of hypercalcaemia ?

Back 29

(Ectopic ) PTH-like hormone secretion

By Sq CC is relativiley rare cause of hypercalcaemia

Front 30

Hypercalcaemia in a 45 y man after renal transplantation

Cause of hypercalcaemia ?

Back 30

Tertiary hyperparathyroidism

Involves the development of autonomous parathyroid hyperplasia that occurs after long-standing secondary hyperparathyroidism.

Both plasma PH & Ca are raised

2ry hyperparathyroidism is physiological hypertrophy of parathyroid glands in response to hypOCa

Vit D def & choric Renal Failure are cause of 2ry hyperparathyroidism

Front 31

DM: 50 y man with diabetes complains of impotence

Back 31

L

Front 32

DM: 65 y man presents with loss of sensation in a stocking distribution

Back 32

Peripheral Neuropathy

Starts dismally thus = 'glove and stocking' distribution term

Front 33

45 y woman with DM presents with Shiny areas on her skin with yelllowish color and overlying Tenalgiectasia

Back 33

Necrobiosis Lipoidica

most common over the shins

PS: Pyoderma gangrenous is not a diabetic Complicaiton and involves the presence of nodulopustular ulcers. Assx with inflammatory bowel disease

Front 34

50 y with DM presents with

Swollen joint with abnormal painless movement

Back 34

'Charcot's joint'

It is a severe neuropathic arthropathy.

Also seen in Syringomelia ( Cervical spine have longitudinal cavities) and Tabes Dorsalis ( degenearation of neural tract n the dorsal column , syphilitic infection )

Front 35

85 y old person with DM :

Painful wasting of quadriceps muscles of the right leg with absent knee reflex. Area is very tender

Back 35

Diabetic Amyotrophy

Due to untreated diabetes in elderly pt

Sx: painful proximal motor neuropathy of lower limbs , then weakness and wasting of thigh muscles.

Improve on glycaemic control

Front 36

A 45 y man with DM II presents with hyperglycaemic, hyperosmolar, non-Ketotic Coma.

Blood glucose: 40 mmol/l

Mx:

Back 36

0.9 % saline + Insulin + Heparin

Initial mx involves treating the severe hyperglycaemia & dehydration that has occured.

Assx wth high risk of thrombosis and hence Heparin

Front 37

First-line Mx of a 19 y with diabetes and metabolic ketoacidosis

Back 37

0.9%saline + IV insulin + Metformin

Medical emergency : Fluid replacement ( 0.9 % saline)

IV infusion Insulin ( for hyperglycaemia )

Continued until ketones are absent from urine .

IF bl. Gl fall below 12 mmol => 10% glucose solution

Regular K supplements due to rapid fall of K as soon as Insulin therapy stopped.

Front 38

A 25 y athlete with type 1 diabetes is brought to A & E. he is unconscious with blood glucose level of 1.0n mmol/I

MX

Back 38

IV 50 % glucose

Immediate glucose. Oral is difficult due to risk of aspiration , if outside of hospital substitute IV with Glucagon SC/IM

Front 39

A 21 y man with type 1 diabetes presents with dizziness. On ex: alert and no abnormalities are detected

Glucose 1 mmol/l

Mx

Back 39

Oral glucose

( cause he is conscious )

Front 40

50 y man with sx of tiredness. Fasting glucose 6.8 mmol/l which rises to 10.7 after oral glucose tolerance test

Mx

Back 40

Lifestyle

Impaired glucose tolerance rather than frank diabetes.

Lifestyle measure is important witherways