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200 Cards in this Set
- Front
- Back
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How to calculate BMI? |
Weight (kg) / (height)^2 |
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Give me the range of underweight healthy over weight obese severely obese |
underweight <18 healthy 18-24 overweight 25- 29 obese 30-39 severely obese >40 |
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what is the range of low blood pressure? |
< 90/60mmHg |
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what is the normal blood pressure range? |
90/60 mmHg to 120/80 mmHg |
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what is the pre high blood pressure range? |
120/80 mmHg to 140/90 mmHg |
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what is the high blood pressure stage 1 range? |
Systolic 140-159 mmHg diastolic 90-99 mmHg |
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What is the hypertension stage 2 range? |
systolic 160-179 mmHg diastolic 100- 109 mmHg |
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what is the hypertension stage 3 range? |
systolic >180 mmHg diastolic > 110 mmHg |
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What is prostatectomy? |
removal of prostate |
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What is Grave's disease? |
autoimmune disorder that leads to over-activity of they thyroid gland. This condition occurs when the immune system mistakenly attacks the healthy tissue, antibodies stimulate TSH (thyroid stimulating hormone) by binding to TSH receptors. |
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What is euthyroid? |
condition of stabilized normal thyroid level |
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what is exophthalmos? |
bulging eye balls red and painful eye tearful sensitive to light double vision |
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What is thyroid crisis? |
the toxic reactions towards too high thyroid level |
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what are the symptoms of Grave's disease? |
- increased sweating - weight loss - fatigue associated with loss of muscle tissue - arrhythmia - irregular menstrual cycle in female - breast enlargement in male - difficulty in concentrating - anxiety |
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What is goitre? |
enlarged thyroid gland |
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Goitre occurs in both hypo- and hyper-thyroidism. Why? |
Hyper: due to the inflammation of thyroid gland, attacked by antibodies. Hypo: The body is trying to get sufficient amount of iodine by increasing the surface area. |
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What are the diagnostic tests for Grave's disease? |
- Thyroid function test - Radioactive iodine uptake test - Physical test measuring the size of goitre |
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What is thyroid function test? |
Thyroid function test is a blood test measuring TSH, T3 and T4 level. |
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What is a normal TSH, free T4 and free T3 level? |
TSH: 0.4-4.2 μU/ml free T4: 10-26 pmol/l free T3: 4.0-30.8 pmol/l |
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What happen to TSH level if you are hyperthyroidism? |
TSH should be lower than normal <0.4μU/ml due to the negative feedback system TSH should be lower because T4 and T3 levels are too high |
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What is radioactive iodine uptake test? How does it carry out? |
Swallow a small amount of radioactive iodine (liquid or capsule) and a scan is used to measure how much of isotope has been absorbed by a thyroid gland. |
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What do the results of radioactive iodine uptake tell us? Higher than normal: Lower than normal: |
Higher than normal: Grave's disease Lower than normal: inflammation of thyroid gland (thyroiditis) caused by immune system attacking thyroid tissue having too much iodine in diet rarely, thyroid cancer |
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What are the possible triggers for thyroid crisis? |
- infections (especially in lungs) - Thyroid surgery (therefore you must be euthyroid before surgery) - stopping medication for hyperthyroidism - too high dose of thyroid replacement therapy - treatment with radioactive iodine - pregnancy - heart attack |
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What are the symptoms of thyroid crisis? |
- palpitation - great increased body temperature >40℃ - chest pain - shortness of breath - increased sweating - weakness - anxiety |
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What are the medications available to treat Grave's disease? |
- Thionamides (carbimazol and propylthiouracil) - Beta blockers (propranolol and atenolol) |
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How do thionamides work? |
Thionamide decreases the uptake and concentration of inorganic iodine by thyroid, it also reduces the formation of di-iodotyrosine and thyroxine. It also prevents the thyroid peroxidase enzyme from coupling and iodinating the tyrosine residues on thyroglobulin, hence reducing the production of the thyroid hormones T3 and T4. |
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what is the onset of thionamides? |
slow onset 4-8 weeks to notice improvement. |
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why do thionamides have slow onset of action? |
because thyroid gland has a store called thyroidglobuline and a lot of thyroid hormones are already synthesized |
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Carbimazol What is the recommended dose for normal adults? maintenance dose? |
15-40mg once daily for 4-8 weeks then reduce gradually to maintenance dose of 5-15mg. Therapy is usually given for 12 - 18 months. higher doses should be prescribed under specialist only. |
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what are the possible side effects of carbimazole and propylthiouracil? How can you overcome these side effects? |
rashes and pruritus they can be treated with antihistamines without discontinuing therapy other side effects, GI disturbance, taste disturbance, headache |
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what is pruritus? |
itching |
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what are normal dose and maintenance dose for propylthiouracil PTU? |
200-400mg daily in divided doses (3 times daily) maintenance dose 50-150mg in divided dose |
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what is the referral point for carbimazol? |
report any infection like symptoms (especially sore throat but also fever, cough, mouth ulcer)immediately because of rare complication of agranulocytosis |
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what is agranulocytosis? |
a condition when granulocytes (major class of infection-fighting white blood cells) decreased, very high risk of serious infections due to their suppressed immune system. |
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what is the referral point of PTU? |
high risk of liver damage, patients should report if symptoms such as anorexia, nausea, vomiting, fatigue, jaundice, dark urine |
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what is jaundice? |
yellowed skin and eyes |
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what are the other drugs used for hyperthyroidism apart from thionamides? |
beta blockers (propranolol or atenolol ) beta blockers can be used as an adjunct to antithyroid drugs or radioactive iodine. They can suppress tremor, palpitation and tachycardia, often used until thioamides bring the thyroid gland under control. |
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what are the side effects of beta blockers? |
fatigue, cold hands and feet, difficulty in sleeping (nightmare) |
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how does radioiodine therapy carry out? |
small amount of radioactive iodine solution (131 I) is ingested. It will accumulate around thyroid gland at high concentration and shrink the gland, reducing the amount of thyroid hormones produced. only single dose is usually required, may need follow up dose after 6-12 months. |
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what are the potential risks of radioiodine therapy? |
It is very difficult to titrate the correct dose, therefore it may induce hypothyroidism and possible worsening of exopthalmos . |
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Who are not suitable for radioiodine therapy? |
pregnant women and patients having eye problems |
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How is surgery carried out for hyperthyroidism? what are the potential risks? |
remove part of thyroid gland, useful for patients having a severe Grave's ophthalmopathy. Risk of damage of nerves around the gland (especially affecting voice) and damage to parathyroid which is responsible for Ca ion rising. |
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what is Grave's ophthalmopathy? |
eye problems caused by grave's disease |
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what is the recommended monitoring for treatment of hypothyroid? |
measure free T4 and TSH during and after the treatment, every 4-6 weeks. Before thionamide therapy, measure a full blood count for white blood cells and liver function tests. |
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What is the aim of thyroid therapy during pregnancy? |
radioiodine therapy and surgery are contraindicated during pregnancy. Target is making the pregnant woman slightly high thyroid level. |
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Is there any possible change to the pharmacokinatics of the antithyroid drugs in pregnancy? |
there is no big pharmacokinatic changes. |
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Which one is the suitable antithyroid drug during pregnancy? CMZ or PTU? |
both CMZ and PTU can cross placental barrier, therefore lowest dose that will control the hyperthyroidism is required. PTU is suitable in first trimester because PTU has less free drug available to cross placenta due to the stronger protein binding. However, switch to CMS in second trimester (13-28 weeks) due to the potential risk of hepatoxicity with PTU. |
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How to treat Thyrotoxic crisis? |
emergency treatment with IV propranolol 5mg hydrocortisone (100mg/ 6hrs as sodium succinate) oral iodine solution (not to pregnancy) CMZ or PTU by nasogastric tube |
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what happen if hyperthyroidism is not treated during pregnancy? What happen if hypothyroidism is not treated? |
hyper: increase the fetal rate of fetus hypo: baby develops cretinism |
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what is cretinism? |
severely stunted physical and mental growth - dwarfed infants - coarse and scanty hair dry, yellowish skin - protruding tongue and abdomen |
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What is the underlying cause of exophthalmos? |
immune system mistakenly attacks the muscles and fatty tissue around and behind eye, cause them to inflamed |
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what are the treatments available for exophthalmos? |
no direct treatment available: corticosteroid by mouth/ IV to reduce inflammation antithyroid drugs to prevent further damage corrective surgery possible artificial tear special glasses for double vision |
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what is Cushing's disease? |
a disease in a serious condition of an excess of the steroid hormone cortisol in the blood level caused by a pituitary tumor secreting ACTH. |
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what is Cushing's syndrome? |
hypercortisolism, a collection of symptoms caused by very high level of cortisol in the body |
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what are the symptoms of cushing's syndrome? |
- muscle weakness especially arms and legs - thinning of skin leading to bruise easily - reddish/ purple stretch marks - redistribution of fat tissue - weight gain - loss of libido - glaucoma - osteoporosis - hypertension - diabetes - pigmentation of skin (gums, fingers, elbows) |
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what the characteristics of cushing's syndrome in terms of fat redistribution? |
moon face buffalo humps
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what are the differences between cushion's disease and syndrome? |
Cushing's disease caused by a tumor develop in the pituitary - High ACTH - High Cortisol Cushing's syndrome caused by the long term use of corticosteroid or a tumor at adrenal gland/ lungs - Low ACTH (negative feedback) - High Cortisol |
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what is the mechanism of regulating cortisol secretion in the body? |
[Triggers] stress (pain, fear, hypoglyceamia] ↓ [ hypothalamus] CRH ↓ [anterior pituitary] ACTH ↓ [ adrenal gland] sex hormone and cortisol |
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what are the negative feedback systems in cortisol regulation? |
ACTH suppressing CRH in hypothalamus Cortisol supressing ACTH in anterior pituitary (direct negative feedback) Cortisol suppressing CRH in hypothalamus ( indirect negative feedback) |
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how does hypercortisolism cause hypertension? |
cortisol enhances the activity of noradrenaline for vasoconstriction |
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how does hypercotisolism cause glaucoma? |
- more like steroid induced due to the permanent change of trabecular meshwork for draining aqueous humor. This drainage creates intraocular pressure |
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what other conditions might a patient develop because of the cushing's disease? |
-osteoporosis resulting in unusual bone fractures such as rib and feet - frequent unusual infection - curved spine (kyphosis) - hirsutism in women (excessive face hair growth) due to androgen from adrenal gland - acne |
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how does plasma cortisol test carry out? what are the normal ranges? what do the results tell you? |
blood sample or saliva taken in the morning (9:00) and midnight normal range: 200-690 mmol/l in the morning 80-220 mmol/l at midnight the results can tell you whether the patient has hypercortisol or not. (cannot distinguish the cause) |
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how does insulin hypoglycaemia test carry out? |
insulin induced hypoglycemia by administering soluble insulin 0.15U/kg. this test is to assess pituitary function and adrenal function. In response, ACTH and GH are released as a part of the stress mechanism, therefore should increase the cortisol level. |
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What is low dose of dexamethasone suppression test? |
1mg of dexamethasone is ingested at 11pm and blood cortisol is measured at 8 am in the morning. Dexamethasone is an exogenous steroid that provides negative feedback to the pituitary gland to suppress the secretion of ACTH. |
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what can you tell from the results of high dose dexamethasone test? |
if cortisol respond (suppression) -- cushing's disease from pituitary dysfunction if not respond --- ectopic lung tumor |
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what is pituitary microadenoma? |
a tumor less than 10 mm in diameter in pituitary |
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what is cortisol diurnal rhythm? |
blood samples are taken throughout the day to see if the cortisol level follows the circadian rhythm. Cortisol level should be the highest just before waking up and decreased during awake time and gradually increase once a patient is asleep. |
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what is CRH test? |
human or ovine (sheep) CRH is given to test pituitary ACTH deficiency. CRH usually stimulates ACTH which then stimulate cortisol secretion. This test can distinguish between cushing's syndrome and pseudo-cushing |
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what is pseudo cushing's syndrome? |
a medical condition in which patients display the signs of cushing's syndrome, but caused by idiopathic conditions. (not known cause) |
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what is the treatment if cushing's disease is caused by the long term use of corticosteroid? |
Reducing the corticosteroid use gradually. It is contraindicated to stop the use suddenly because of the risk of side effects induced by sudden hypocortisolism. possible side effects) fatigue, vomiting, diarrhoea |
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what are the medicines used to treat cushing's disease? |
ketoconazole (anti-fungal metyrapone |
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How does ketoconazole work? |
Ketoconazole acts as a potent inhibitor of cortisol and aldosterone synthesis by inhibiting the activity of 17α-hydroxylase, 11-hydroxylation steps and at higher doses the cholesterol side-chain cleavage enzyme. It also inhibits the activity of adrenal C17-20 lyase enzymes resulting in androgen synthesis inhibition, may have a direct effect on corticotropic tumor cells in patients with cushing's disease |
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what is the normal dose of ketoconazole? |
Adult and child over 12 years, initially 400–600 mg daily in 2–3 divided doses, increased to 0.8–1.2 g daily usual maintenance dose 400–800 mg daily in 2–3 divided doses (max. 1.2 g daily) |
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How does metyrapone work? |
metyrapone is a competitive inhibitor of 11β-hydroxylation in the adrenal cortex the resulting inhibition of cortisol production leads to an increase synthesis and release of cortisol precursors. |
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what is the normal dose of metyrapone? |
Management of Cushing's syndrome, range 0.25–6 g daily |
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what are the cautions of taking ketoconazole? |
the high risk of hepatotoxicity and this medicine may cause dizziness; caution for driving w |
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what are the side effects of ketoconazole? |
nausea, abdominal pain, itching, rash |
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what are the side effects of metyrapone? |
occasional nausea, vomiting, dizziness, headache, sedation, hypotension |
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what kind of surgery might be involved for the treatment of cushing's disease? |
part or all of; - pituitary gland removal - adrenal gland removal - lung tumor |
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what other type of treatment available for cushing's disease? |
Radiotherapy; it may be recommended if pituitary gland surgery is not successful/ suitable. This involves using high every xrays to shrink the tumor and stop it producing exessive ACTH. The therapy is operated for 5 weeks |
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what is the term of removing a tumor in the pituitary gland? |
transsphenoidal adenoectomy |
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what is the main problem of treating cushing's disease with medicines? |
medications do not cure the tumor itself, and they may actually increase the tumor size. However, this might be beneficial; the tumor can be seen then able to remove by surgery |
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what are the characteristics of type 1 diabetes? |
- weight loss - polydipsia - polyuria - polyphagia - itchiness around the genital area - low BP due to dehydration - hyperglycemia - fatigue |
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what is polyuria? |
frequent passing urine |
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what is polydipsia |
extreme thirst |
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what is polyphagia? |
excessive hunger |
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what is the underline cause of type 1 diabetes? |
Type 1 diabetes is an autoimmune disease, that the body cannot produce insulin sufficiently, leading to the high blood sugar level. The antibodies attack the islet beta cells in the pancreas which are responsible for producing insulin. |
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what is ketoacidosis? |
ketoacidosis is a potentially life-threatening complication when the body breaks down fat as an alternative source of fuel and the blood ketone body level goes too high. ketone is acidic substance |
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what are the possible causes of ketoacidosis? |
- infections such as UTI, pneumonia and gastroenteritis - missed insulin treatment - uncontrolled or undiagnosed diabetes (usually type 1 diabetes) - medications (corticosteroids, illegal drugs, binge drinking) |
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what is the HLA genotype that has higher risk of developing type 1 diabetes with islet beta cell antibodies? |
DR3/DR4 |
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what are treatments in hospital for type 1 diabetes with ketoacidosis? |
- Glycaemic control - Insulin therapy - fluid replacement for dehydration and dilute blood glucose level - Electrolyte replacement for ketoacidosis - antibiotics for infection |
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What is the insulin infusion procedure in hospital for ketoacidosis? dose and route of administration |
1. started with IV normal saline with soluble insulin (short acting) infusion by 0.2 unit/ kg until glucose level stablized at 7.8 mmol/l (around 14 hrs) 2. continue the infusion until next morning until no ketoacidosis is seen 3. switch to subcutaneous insulin twice daily with home blood glucose monitoring method
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what are the treatments on discharge? after having ketoacidosis |
- insulin injection pens with titrated dose and formulation - antibiotics for infections |
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What are the long term goals for treating diabetes? |
There is no complete cure for type 1 diabetes, you have to get along with your life - education (how to inject insulin properly, how to manage hypoglycemia) - controlled diet ( do not miss a meal, alcohol intake) - close monitor of glucose level (at home and in hospital) - adjust the correct insulin dose for the whole life (teenage, adult, elderly) |
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what are the normal ranges for blood constituents? Na+ K+ Cl- HCO3- glucose pH |
Na+ 135-145 mmol/l K- 3.5-5.0 mmol/l Cl- 98-108 mmol/l HCO3- 22-26 mmol/l glucose 3.6-6.5 mmol/l or 65-115 mg/dl pH 7.42-7.38 |
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what is glycosylated heamoglobin test? |
glycosylated haemoglobin test, also called HbA1c test shows how well your diabetes is being controlled. when the glyceamic controll is not sufficient, sugar builds up in your blood and combines with haemoglobin (glycated). Thus, if the glucose level has been high over weeks, higher the glycated hemoglobin level |
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what is the normal range for HbA1c test? how often should it be measured? |
normal range; 3.9-6.8% of total blood Hb people with diabetes should have this test every 3 months until glucose level is well controlled. After controlled, at least 2 times a year. |
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what is the normal range of new born baby weight? |
normal baby 6-7 ibs |
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what is ibs in unit? |
pounds |
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How is a birth weight more than 4kg called? |
macrosomic weight more than 4kg or 8.8ibs |
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What is gestational diabetes? |
a type of diabetes that affect during pregnancy where the there is too much glucose in the blood |
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what are the managements for gestational diabetes? |
similar to type 2 diabetes 1st line treatment: changing lifestyle including diet and moderate exercise such as maternity yoga medications: insulin (unlicensed) Glibenclamide (unlicensed) from 11 weeks need to be discontinued after giving birth |
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what are the risk factors of having gestational diabetes? |
- women with BMI more than 30 - previously had a baby who weighed more than 4.5 kg (10 ibs) - family history of diabetes - ethnicity (south asian, black caribbean, middle eastern) |
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What test is used to diagnose the gestational diabetes? |
Oral glucose tolerance test |
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how is oral glucose tolerance test carried out? |
- fasting before the test 8 hours - drink glucose liquid (75g) - blood samples are taken before the test, after 1,2 and 3 hours |
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what are the results for oral glucose tolerance test? normal people: |
Normal (75g glucose) fasting: less than 100mg/dl 1hr: less than 184mg/dl 2hrs: less than 140mg/dl |
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what are the results for oral glucose tolerance test? Gestational diabetes: |
Gestational diabetes (75g glucose) fasting: more than 92mg/dl or more than 7.8 mmol/l 1hr: more than 180 mg/dl 2hrs: more than 153 mg/dl more prolonged peak glucose level is observed |
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what are the implication of uncontrolled gestational diabetes? |
- premature birth - miscarriage - macrosomia leading to birth problems such as low blood sugar - shoulder dystocia - developing type 2 after giving birth - still birth - increased risk of having gestational diabetes for future pregnancy |
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how likely is to resolve gestational diabetes after giving birth? |
- the likelihood of gestational diabetes resolving after delivery is very high (>90%) - the risk of recurrence during a subsequent pregnancy or developing type 1 diabetes at future date remain high (>50%) |
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when is the usual onset of developing gestational diabetes? |
usually develops in the third trimester (after 28weeks) and usually disappears after the baby is born |
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what is the underline cause of gestational diabetes? |
during pregnancy, your body produces a number of hormones such as oestrogen, progesterone, and human placental lactogen (HPL). these hormones make your body insulin resistant, which means the cells become less sensitive to insulin and the level of glucose in the blood remains high. The purpose of this hormonal effect is to allow extra glucose and nutrients to the fetus. To cope with the increased amount of glucose in the blood, the body should produce more insulin. However, some women either fail to produce more insulin or body cells are more resistant to insulin. |
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what is Glibenclamide and normal dose? |
antidiabetic drug under sulfonylureas used for type 2 diabetes normal dose: initially 5mg daily with or just after breakfast dose should be adjusted for pregnancy |
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what are the possible side effects for glibenclamide? |
generally mild GI disturbances such as nausea, diarrhoea and constipation Glibenclamide can occasionally cause a disturbance in liver function |
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what is the mechanism of action of glibenclamide? |
Glibenclamide (sulfonylureas) bind to ATP sensitive potassium channels on the pancreatic cell surface, reducing potassium conductance and causing depolarization of the membrane. This depolarization stimulate the calcium ion influx through voltage gated calcium channels which induces the exocytosis of insulin |
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what is the cause of developing type 2 diabetes? |
deficiency or less sensitive to insulin |
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what are the risk factors of type 2 diabetes? |
- high cholesterol level - obesity -smoking - environmental factors such as diet, stress and lifestyle - there is strong genetic link exist in developing NIDDM - age (over 40s and over 25 for south Asian) - ethnicity (south Asian, chinese, African caribbean or black african) |
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what is NIDDM? |
non insulin dependent diabetes mellitus |
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what are the symptoms of type 2 diabetes? |
- polyurea - nocturea - polydipsia - unexplained weight loss - itching around the genital area, thruth - blurred vision caused by the lens becoming dry |
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How common to develop ischemic hear disease with diabetes? |
2-4 times higher risk than without diabetes |
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How common to develop cerebrovascular disease with diabetes? |
2-4 times higher risk of stroke |
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how common to develop hypertension with diabetes? |
2 times higher risk than without diabetes |
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why poorly controlled diabetes are more prone to have heart disease and stroke? |
Prolonged high glucose level causes blood to be thick and viscous, thus the blood vessels become clogged up and narrowed by fatty substances |
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why poorly controlled diabetes cause peripheral neuropathy? |
Peripheral neuropathy (nerve damage) high blood glucose level can damage the blood vessels and capillaries in the nerves. This can cause a tingling or burning pain or numbness which can lead to ulceration of the feet. |
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what is the diabetic retinopathy and how it should be monitored? |
diabetic retinopathy is when the retina becomes damaged, this prevent light from fully passing through to the retina. annual eye checks are recommended |
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what other complications might be caused by type 2 diabetes? |
kidney damage (kidney failure) foot problems (ulceration) sexual dysfunction |
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what are the treatment of type 2 diabetes on discharge? |
- lifestyle change: diet (especially cutting down fat and salt), exercise, stop smoking and alcohol - sulphonylureas (1st line treatment) - hypoglycemic drug - Acarbose - insulin (if the patient cannot improve after lifestyle attempt and antidiabetic drugs) Patients may need to take several medications due to the different mechanism of actions and side effects. |
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what is sulphonylrea and give examples of the drugs. what are the potential side effects? |
Gliclazide, glibenclamide skin rashes, blood disorder, fever and jaundice |
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give example of biguanide. |
metformin |
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how does biguanide work? |
- it is a hypoglycemic drug by stimulate muscle glucose uptake and inhibit gluconeogenesis and glucose absorption from the gut - improving insulin sensitivity by increasing peripheral glucose uptake and utilization - also suppress appetite |
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what are the side effects of biguanide? |
GI disorders hypoglycemia taste disturbance (metalic taste) possible lactic acidosis |
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give example of acarbose |
glucobay |
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what is the mechanism of action of acarbose? |
It reversibly binds to alpha amylase and membrane bound intestinal alpha glucose hydrolase that convert complex dietary carbohydrate. Thus delays the digestion of ingested carbohydrate (slower rise of glucose level) |
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what are the side effects of acarbose? |
flatulence, abdominal disturbance, diarrhoea |
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what is male hypogonadism? |
male hypogonadism is a condition in which the body doesn't produce enough testosterone |
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what are differences between primary and secondary hypogonadism? |
primary: testicular dyfunction secondary: pituitary or hypothalamic dysfunction |
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what are the clinical suspicious of hypogonadism? |
- hemochromatosis - frailty - obstructive sleep apnea - type 2 diabetes - insulin resistance - metabolic syndrome -treatment with opioids/ glucocorticoids/ ketoconazole - chronic alcohol or heroin abuse - liver damage - osteoporosis - end stage of renal disease - COPD |
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what is hemochromatosis? |
excess level of iron |
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what is frailty? |
physical weakness |
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what is COPD? |
chronic obstructive pulmonary disease |
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what is the diagnose pathway of hypogonadism? |
[clinical suspicious] ↓ [measure testosterone in the morning] ↓ [if low testosterone, conduct comprehensive evaluation] - FSH and LH - SHBG - TSH - ferrintin (or iron saturation) - PRL - CBC - PSA ↓ if low testosterone but high LH/FSH then primary hypoginadism if low testosterone and normal LH/FSH then secondary hypogonadism |
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what is CBC? |
complete blood count |
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what is SHBG? |
sex hormone binding globulin |
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what is PSA test? |
test for prostate cancer, the amount of prostate specific antigen is counted This protein is produced by normal cells in prostate and also by prostate cancer cells. The amount increases as get older but high level suggests the cancer. |
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The patient has a kid and he shows clinical symptoms of hypogonadism. Which type is he most probably having? |
if he had primary hypogonadism, it is associated with infertility therefore, most probably he is having secondary. However, it is possible to develop primary hypogonadism after having kids |
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what are the underlying causes of hypogonadism? |
- kallmann syndrome - pituitary disorders - inflammatory disease - HIV/ AIDs - medications especially opioids - obesity - normal aging - concurrent illness - diabetes - sickle cell disease - high prolactin level |
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what is kallmann syndrome? |
abnormal development of hypothalamus associated with anosmia (impaired smell ability) and red-green colour blindness |
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what are the symptoms of hypogonadism? |
- ED - infertility - decrease in beard and body hair growth - decrease in mucle mass - development of breast tissue - loss of bone mass - fatigue - increased sweating - difficulty concentrating |
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what are the most common delivery modes for testosterone replacement therapy (TRT)? |
gel injection buccal tablets patch implantable pallet |
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what is testosterone gel? what is the dose? adv and disadv? |
testosterone gel: rubbing onto the shoulder, chest or back once daily. It dies up within a few mins Adv) stable blood levels of testosterone throughout the day no operation Disadv) skin irritation (rare) testosterone may be transmitted to partner by touch (especially cautious to pregnant woman) Not be able to shower for few hours |
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what is testosterone injection? what is the dose? adv and disadv? |
Testosterone injection by intramuscular in the buttocks every 3 months Adv) steady level of testosterone for 3 months dis adv) local pain |
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what is testosterone buccal tablets? dose? adv and disadv? |
A tablet applied to the outside the gum. Testosterone is absorbed through the gum tissue. Not recommended for children and adolescent twice daily adv) - stable level throughout the day - no operation - low risk of being dislodged during eating, drinking or intimate contact disadv) - has to be applied every 12 hours - local irritation (rare) - may be dislodged while brushing teeth |
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what is testosterone patches? dose? adv and disadv? |
A patch is applied each night to the back, abdomen, upper arm or tights adv) no operation low risk of intimate contact disadv) the site needs to be rotated skin irritation |
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what is testosterone implantable pallets? dose? adv and disadv? |
implanted under the skin adv) stable level for 3-6 months disadv) surgery required local pain |
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what are the general side effects of testosterone replacement therapy? |
side effects are occasional but... - spots, usually on the back or chest - prolonged painful erection - thickening of blood by over production of red blood cells - disturbed liver function especially oral - aggression especially oral - acne especially oral - prostate cancer risk - infertility |
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what is the referral condition of TRT? |
Polycythaemia red blood cell concentration higher than 52% stop medication or change delivery |
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what might be the possible causes of having high PSA level? |
- age - inflammation or infection of prostate (prostatitis) - enlarged prostate - urine infection - prostate cancer |
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who shouldn't take testosterone replacement therapy? |
- men who have prostate cancer or at risk - breast cancer or at risk (such as family history) - severe urinary tract problem |
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what kinds of monitoring are required for TRT? |
- monitor prostate and PSA in men over 45 years - monitor haemotocrit and harmoglobin before treatment, every 3 months for the 1st year and yearly thereafter - bone density every 1-2 years - testosterone and free testosterone every 1-2 months |
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which alternative therapies may be offered to men who wish to retain their fertility? what is the disadv? |
If second hypogonadism coincides with fertility issues, HCG treatment should be considered especially in men with low gonadtrophins HCG treatment with standard dose 1500-500 IU intramuscular or subcutaneous twice a week + FSH treatment (150 IU 3 times weekly IM or SC) very expensive |
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why TRT causes infertility? |
TRT will cause the reduction of spermatogenocis |
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What is endometriosis? |
Tissues like the lining of the womb are found outside the womb, commonly around pelvis and uterus |
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what are the symptoms of endometriosis? |
symptoms are usually chronic, -painful heavy periods - pain in the lower abdomen, pelvis or lower back - pain during/after sexual intercourse - bleeding between periods - difficulty getting pregnant - fatigue - blood in cough, stool (if tissues are in the lungs or rectum) - depression |
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How does endometriosis cause pain? |
thickening of endometriosis due to the increase of oestrogen before ovulation. As following the menstrual cycle, the tissues become shedding. However, unlike the normal womb lining, the shed tissues cannot be excreted so they will deposit around the area and cause swelling. (often such tissues will eventually get excreted but takes time) |
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How is the diagnosis of endometriosis confirmed? |
It is diagnosed by a gynaecologist - pelvic exam (a doctor palpates pelvis for abnormalities such as cysts) - ultrasounds (device called a transducer either pressed against abdominal skin or inserted into vagina) - laparoscopy |
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what is gynaecologist? |
婦人科医 |
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what is laparoscopy? |
It is a surgical examination under general anesthetic. A thin tube with a light is passes into the body to look at the outside the uterus. Also, a small tissue sample is collected for laboratory testing |
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What is the cure for endometriosis? |
There is no cure for endometriosis, the different treatments are to reduce the severity of symptoms. Becoming pregnancy or hysterectomy are not cure for endometriosis |
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what us hysterectomy? |
removing uterus womb |
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what are the treatments available? |
- surgery - hormone replacement - pain management - nutrition - complementary therapies - emotional support |
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what is the disadvantage of having surgery for endometriosis? |
50% of chance of having endometriosis within 5 years again, even if all the tissues are removed. |
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What kind of analgesics are used for endometriosis? |
acute pain: paracetamol, ibuprofen chronic pain: combination with painkiller (such as opiates) and anti-depressant (amitriptyline) anti-epileptics (gabapentin and pregabalin) |
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what is amitriptyline? mechanism of action? |
Tricyclic antidepressant Amitriptyline is metabolised to nortriptyline which inhibits the membrane pump mechanism responsible for uptake of noradrenaline and serotonin in adrenergic and serotonergic neurons. |
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what are the side effects of amitriptyline? |
dry mouth constipation drowsiness weight gain heart rhythm problems such as palpation or tachycardia |
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why is gabapentin used for endometriosis? mechanism of action? |
Gabapentin is effective for the treatment of neuropathic pain Gabapentin increases the synaptic concentration of GABA to enhance GABA renponses at non-synaptic sites in neuronal tissues. This leads to reductions of the axon excitability of neurons including pain. |
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what are the side effects of gabapentin? |
nausea, GI problems, dry mouth, weight gain |
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what are the hormonal therapies for endometriosis? |
- pseudo-pregnancy (combined oral contraceptives, progestogens, mirena coil) - pseudo-menopause (GnRH analogue) - male hormone analogue (testosterone derivatives) |
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What is the theory behind for pseudo-pregnancy treatment? |
during pregnancy, the endometrium is thin and inactive |
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What is the combined oral contraceptive? How does it work? |
The pill contains both oestrogen and progesterone and works by suppressing the ovulation and affect the production of female hormones by negative feedback. |
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What are the side effects of COC? |
nausea, vomiting, diarrhoea, abdominal pain, liver damage |
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what is progestogen and how does it work? formulations? |
Progestogen only formulations; oral, intra-uterine and injection Progestogen will send weak negative feedback to LH, therefore suppressing the growth of endometriosis and inflammation |
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What are the side effects of progestogens? |
menstrual irregularities, nausea, vomiting, headache, dizziness |
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what is Mirena coil and how does it work? |
Mirena coil is intrauterine progestogen only device. It release levonogestrel directly into the uterine cavity over a period of 5 years. It is responsible for thinning of lining, irregular bleeding, acne and mood swings |
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what are the side effects of Mirena coil? |
- change in menstrual cycle and duration - abdominal or pelvic pain - peripheral oedema - headache |
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What is GnRH analogue? how does it work? |
GnRH analogues produce an initial phase of stimulation. continued administration over 2 weeks will down regulate the GnRH receptors, therefore reducing the release of gonadtrophins (LH and FSH). This will decrease androgen and oestrogen production. The ovaries switches off and temporary stop producing eggs and oestrogen. |
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what are the examples of GnRH analogues? formulations? |
Buserelin by intranasally Goserelin by subcuteneous injection Leuprorelin acetate by intramuscular injection nafarelin by nasal spray triptorein by intramuscular injection |
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what are the side effects of GnRH analogues? How to overcome these side effects? |
manopausal like symptoms; such as hot flushes, increased sweating, vaginal dryness, loss of libido, joint stiffness headache, rash risk of osteoporosis using HRT (low dose of estrogen and progesterone ) as addback to combat symptoms |
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what are testosterone derivatives? how does it work? |
It decreases the synthesis of oestrogen and progesterone as a gonadotrophin releasing inhibitor and anti-oestrogenic activities |
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what are the examples of testosterone derivatives? formulation? |
Danazol (both testosterone derivatives and gonadotripin releasing inhibitor) f and Gestrinone capsules |
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what are the side effects of testosterone derivatives? |
nausea, dizziness, skin reactions including rashes danazol is contraindicated for pregnant patients |
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is endometriosis life long disease? |
no symptoms will disappear at menopause due to lack of estrogen |
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what are the risks of not treating endometriosis? |
- cancer induced with dead endometriosis tissues - lupus - sjogren syndrome - rheumatoid arthritis - multiple sclerosis - chronic fatigue syndrome - fibromyalgia - hypothyroidism - infertility |
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what is lupus? |
rashes appeared everywhere especially on the face, wrist and hands |
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what is sjogren syndrome? |
autoimmune disorders associated with dry mouth and dry eyes |
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what is fibromyalgia? |
long term conditions that causes pain all over the body |
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what are the symptoms of ketoacidosis? |
early stages: - frequent urination - polydispia - fatigue - feeling sick - shortness of breath - abdominal pain late stages: - tachycardia - vomiting - fruity odor on the breath - confusion - dizziness |
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who are at risk of ketoacidosis? |
it is common in people with type 1 diabetes but can occasionally affect type 2 diabetes. children and young adults are most at risk |
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what is the target of glucose level with diabetic patients? |
glucose 4-9 mmol/l |
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what are the symptoms of hypoglycemia ? |
- hunger - sweating - confusion - palpitation - light headed - nausea |
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what are the treatments of hypoglycemia? |
Ingest sugary drink and sweets (15-20g) avoid fizzy, diet drinks if unconscious, glucagon injection |
