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Endocrinology: Thyroid, Adrenal & HomeostasisThyroidHypothalamic-pituitary-thyroid Axis • Hypothalamic–pituitary–thyroid axis controls the levels of circulating thyroid hormone • The thyroid synthesises two hormones in response to thyroid- stimulating hormone (TSH) : • Triiodothyronine (T3) (active) • Thyroxine (T4) (inactive) • This works in a negative feedback loopThyroid Hormone TransportT3Thyroid Dysfunction Thyroid disorders are common (2-5%) and occur in F > MCauses of Hyperthyroidism • Grave’s Diseases • Most common, responsible for 75% of cases of Hyperthyroidism • Toxic multinodular goitre (TMNG) (15%) • Toxic nodule • Thyroiditis • Drug-induced thyrotoxicosis • Caused by drugs such as Amiodarone (arrhythmias), iodinated contrast (imaging), Interferon alpha (HCV) and Lithium (BPD)Thyroid Hormone TransportHHHHHHHHHHHHHHHMCQ You see a 24-year-old female in the endocrinology clinic. She has been diagnosed with Grave's disease. The diagnosis was based on the elevated levels of the thyroid hormones T3 and T4 and he symptoms of heat intolerance, weight loss and tremors. Where are the thyroid hormone receptors typically found? a) Mitochondria b) Membrane c) Rough endoplasmic reticulum d) Nucleus e) GolgiMCQ You see a 24-year-old female in the endocrinology clinic. She has been diagnosed with Grave's disease. The diagnosis was based on the elevated levels of the thyroid hormones T3 and T4 and he symptoms of heat intolerance, weight loss and tremors. Where are the thyroid hormone receptors typically found? a) Mitochondria b) Membrane c) Rough endoplasmic reticulum d) Nucleus e) GolgiMCQ A 45-year-old women 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? a) Serum CA 19-9 Levels b) Serum Thyroglobulin levels c) Serum PTH levels d) Serum Calcitonin levels e) Serum TSH levelsMCQ A 45-year-old women 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? a) Serum CA 19-9 Levels b) Serum Thyroglobulin levels c) Serum PTH levels d) Serum Calcitonin levels e) Serum TSH levelsParathyroidParathyroid Gland • Pea-sized glands just behind the thyroid gland • Most people have four parathyroid glands • Responsible for Ca2+ homeostasisPHypercalcaemiaHypercalcaemia - causesHypercalcaemiaHypercalcaemiaHypercalcaemiaHypercalcaemiaHypercalcaemiaHypercalcaemiaHypercalcaemiaHypercalcaemiaHypercalcaemiaMCQ Which of the following events is least likely to involve hypercalcaemia? a) An elderly patient hospitalised at the end-stage of metastatic breast cancer b) A patient with a parathyroid carcinoma c) A patient taking calcium supplements who has taken too many antacids d) A malnourished patient admitted to hospital, where they report paraesthesia and experience muscle spasms in their hands e) A patient’s X-ray results show multiple diffuse radiolucent bony lesionsMCQ Which of the following events is least likely to involve hypercalcaemia? a) An elderly patient hospitalised at the end-stage of metastatic breast cancer b) A patient with a parathyroid carcinoma c) A patient taking calcium supplements who has taken too many antacids d) A malnourished patient admitted to hospital, where they report paraesthesia and experience muscle spasms in their hands e) A patient’s X-ray results show multiple diffuse radiolucent bony lesionsMCQ A 72-year-old woman with back pain and chronic renal failure has the following blood test results: Ca2+ 2.03 mmol/l (2.15-2.55) Parathyroid hormone 10.4 pmol/l (1-6.5) Phosphate 0.80 mmol/l (0.6-1.25) What is the most likely diagnosis? a) Hypoparathyroidism b) Primary hyperparathyroidism c) Secondary hyperparathyroidism d) Tertiary hyperparathyroidism e) PseudohypoparathyroidismMCQ A 72-year-old woman with back pain and chronic renal failure has the following blood test results: Ca2+ 2.03 mmol/l (2.15-2.55) Parathyroid hormone 10.4 pmol/l (1-6.5) Phosphate 0.80 mmol/l (0.6-1.25) What is the most likely diagnosis? a) Hypoparathyroidism b) Primary hyperparathyroidism c) Secondary hyperparathyroidism d) Tertiary hyperparathyroidism e) PseudohypoparathyroidismMCQMCQ A 63-year-old man presents to his GP. He has a history of thyroid cancer that was treated with surgical removal. What might you expect to see in his biochemistry results? a) High calcium, high phosphate, low PTH b) Low calcium, high phosphate, low PTH c) Low calcium, high phosphate, high PTH d) Low calcium, low phosphate, high PTH e) Low calcium, low phosphate, low PTHMCQ A 63-year-old man presents to his GP. He has a history of thyroid cancer that was treated with surgical removal. What might you expect to see in his biochemistry results? a) High calcium, high phosphate, low PTH b) Low calcium, high phosphate, low PTH c) Low calcium, high phosphate, high PTH d) Low calcium, low phosphate, high PTH e) Low calcium, low phosphate, low PTHAdrenal Basic Anatomy Adrenal cortex (85% of gland) 3 layers (synthesising different steroids) • Zona glomerulosa (mineralocorticoids) • Zona fasciculata (glucocorticoids) • Zona reticularis (adrenal androgens) Adrenal medulla (15% of gland) Produces catecholaminesBasic AnatomyAldosterone FunctionBasic AnatomyBasic AnatomyBasic AnatomyBasic AnatomyBasic AnatomyBasic AnatomyBasic AnatomyBasic AnatomyBasic AnatomyBasic AnatomyBasic AnatomyBasic AnatomyMCQ Which region of the adrenal glands produces cortisol? a) Adrenal medulla b) Zona fasciculata c) Zona pellucida d) Zona glomerulosa e) Zona reticularisMCQ Which region of the adrenal glands produces cortisol? a) Adrenal medulla b) Zona fasciculata c) Zona pellucida d) Zona glomerulosa e) Zona reticularisMCQ Which enzyme controls the rate limiting step in aldosterone synthesis? a) Aldosterone synthase b) 11β-hydroxylase c) 11β-HSD2 d) StAR e) 21-hydroxylaseMCQ Which enzyme controls the rate limiting step in aldosterone synthesis? a) Aldosterone synthase b) 11β-hydroxylase c) 11β-HSD2 d) StAR e) 21-hydroxylaseMCQ Which of the following stimulate the release of renin from juxtaglomerular cells? a) Parasympathetic innervation from the carotid arch baroreceptors detecting low systemic blood pressure b) Sympathetic innervation from the hypothalamus detecting physiological stresses c) Innervation from enteric nervous system detecting high salt levels in the lumen of the colon d) Parasympathetic innervation from the pelvic splenic nerves after voiding of the bladder e) Sympathetic innervation from macula densa cells detecting low sodium in the efferent arterioleMCQ Which of the following stimulate the release of renin from juxtaglomerular cells? a) Parasympathetic innervation from the carotid arch baroreceptors detecting low systemic blood pressure b) Sympathetic innervation from the hypothalamus detecting physiological stresses c) Innervation from enteric nervous system detecting high salt levels in the lumen of the colon d) Parasympathetic innervation from the pelvic splenic nerves after voiding of the bladder e) Sympathetic innervation from macula densa cells detecting low sodium in the efferent arterioleMCQ A 65M presents with increasingly worse thirst and polyuria. He is very hypertensive and blood test show he is hypokalaemic and has elevated renin and aldosterone. He is a heavy smoker and has a history of angina which he manages with a GTN spray. What is the most likely cause of his hyperaldosteronism? a) Renin-secreting JC cell tumour b) Conn’s Syndrome c) Renal artery stenosis d) Bilateral adrenal hyperplasia e) PheochromocytomaMCQ A 65M presents with increasingly worse thirst and polyuria. He is very hypertensive and blood test show he is hypokalaemic and has elevated renin and aldosterone. He is a heavy smoker and has a history of angina which he manages with a GTN spray. What is the most likely cause of his hyperaldosteronism? a) Renin-secreting JC cell tumour b) Conn’s Syndrome c) Renal artery stenosis d) Bilateral adrenal hyperplasia e) PheochromocytomaMCQ A 24M has a history of severe hypertension which has been unresponsive to treatment (ACEi, β-blocker, thiazide diuretic). Blood tests show hypernatraemia, high aldosterone/renin ratio, and imaging showed no adrenal lesions or hyperplasia. The patient doesn’t think there is a family history for any adrenal diseases, but his father did die at an early age (43) from a ruptured aortic aneurysm. What would be the appropriate treatment? a) Bilateral adrenalectomy b) Hydrocortisone c) Bisoprolol d) Dexamethasone e) FludrocortisoneMCQ A 24M has a history of severe hypertension which has been unresponsive to treatment (ACEi, β-blocker, thiazide diuretic). Blood tests show hypernatraemia, high aldosterone/renin ratio, and imaging showed no adrenal lesions or hyperplasia. The patient doesn’t think there is a family history for any adrenal diseases, but his father did die at an early age (43) from a ruptured aortic aneurysm. What would be the appropriate treatment? a) Bilateral adrenalectomy b) Hydrocortisone c) Bisoprolol d) Dexamethasone e) FludrocortisoneMCQ A 30F (pictured) presents to you, the GP complaining of low mood. She has been struggling to lose weight but she has been feeling increasingly lethargic. During the history, you find that menstrual cycle has been a bit irregular for the past few months. On examination, you find she is hypertensive. You suspect this patient has a particular adrenal disease and you take a 24-hour urinary cortisol to confirm your clinical diagnosis (it is very elevated). What would be the next appropriate step? a) Dexamethasone suppression test b) Short Synacthen test c) Pituitary MRI d) Adrenal CT e) Surgical removal of the pituitaryMCQ A 30F (pictured) presents to you, the GP complaining of low mood. She has been struggling to lose weight but she has been feeling increasingly lethargic. During the history, you find that menstrual cycle has been a bit irregular for the past few months. On examination, you find she is hypertensive. You suspect this patient has a particular adrenal disease and you take a 24-hour urinary cortisol to confirm your clinical diagnosis (it is very elevated). What would be the next appropriate step? a) Dexamethasone suppression test b) Short Synacthen test c) Pituitary MRI d) Adrenal CT e) Surgical removal of the pituitaryMCQ A 34F presents to you, the GP, with weight loss. She has gone down from 58 kg to 51 kg in the past few months. She is worried that it might be cancer since her mother she has recently diagnosed with breast cancer, and she has heard that unexplained weight loss can be an early symptom. The patient also has T1DM, but she doesn’t think it is linked to her weight loss since its well managed. Upon further inquiry, you find that she hasn’t had much of an appetite lately which the patient attributes to stress from her mother’s diagnosis. On examination, you find she has a postural drop of 15 mmHg, and you notice some dark patches on the skin on the inside of her elbow. Which is the most appropriate investigation? a) CT CAP b) Dexamethasone suppression test c) Renal MR angiography d) Short Synacthen test e) Adrenal venous samplingMCQ A 34F presents to you, the GP, with weight loss. She has gone down from 58 kg to 51 kg in the past few months. She is worried that it might be cancer since her mother she has recently diagnosed with breast cancer, and she has heard that unexplained weight loss can be an early symptom. The patient also has T1DM, but she doesn’t think it is linked to her weight loss since its well managed. Upon further inquiry, you find that she hasn’t had much of an appetite lately which the patient attributes to stress from her mother’s diagnosis. On examination, you find she has a postural drop of 15 mmHg, and you notice some dark patches on the skin on the inside of her elbow. Which is the most appropriate investigation? a) CT CAP b) Dexamethasone suppression test c) Renal MR angiography d) Short Synacthen test e) Adrenal venous samplingMCQ A 79M is rushed into A&E after having a collapse in his garden. The patient has a GSC of 11 and you struggle to get any history from him, but you take a collateral history from the neighbour who witnessed the fall and came in with the patient. He says the patient is normally lives independently by himself, with his daughter visiting often to help with some chores and medication for his rheumatoid arthritis but she has been in hospital for the past week after a car accident. You find is blood glucose is 3.4 mmol/l and you have already sent blood samples to the lab. During your examination find signs of circulatory failure and the patient had vomited since he arrived in A&E . What is the most appropriate initial treatment? a) IV fluids + glucose b) IV hydrocortisone and IV fluids c) Oral hydrocortisone and oral fludrocortisone d) IV fludrocortisone e) IV hydrocortisoneMCQ A 79M is rushed into A&E after having a collapse in his garden. The patient has a GSC of 11 and you struggle to get any history from him, but you take a collateral history from the neighbour who witnessed the fall and came in with the patient. He says the patient is normally lives independently by himself, with his daughter visiting often to help with some chores and medication for his rheumatoid arthritis but she has been in hospital for the past week after a car accident. You find is blood glucose is 3.4 mmol/l and you have already sent blood samples to the lab. During your examination find signs of circulatory failure and the patient had vomited since he arrived in A&E . What is the most appropriate initial treatment? a) IV fluids + glucose b) IV hydrocortisone and IV fluids c) Oral hydrocortisone and oral fludrocortisone d) IV fludrocortisone e) IV hydrocortisoneQUESTIONS?Feedback Please take a minute now before you leave to fill in a quick feedback form!Thank you for coming! If you have any more questions, feel free to email me at s2144937@ed.ac.uk or email accessibilityinmedicine@gmail.com Give our Facebook page a like for updates and opportunities, just search @AIMEdinburghThank you to our sponsors