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Dr Shivani Kalair (FY1) Shivani.kalair2@nhs.net Endocrinology and Diabetes A MedED LECTURESESSION STRUCTURE GLUCOSE CALCIUM & PTH OTHERS • T1DM & T2DM • Hyperparathyroidism • Diabetes insipidus • DKA • Hypoparathyroidism • Diabetic nephropathy • HHS • Hypercalcaemia • Hyperlipidaemia • Hypoglycaemia • Osteomalacia • Diabetes in pregnancy (gestational and pre- existing) THYROID PITUITARY • Obesity • Osteoporosis • Hyperthyroidism • Pituitary tumours • Hypothyroidism • Thyrotoxicosis CORTISOL • Thyroid eye disease • Addison’s disease • Thyroid nodules • Cushings syndrome Finals PACES • Simulated patients with common problems • 4 Domains as per Mark Scheme: • Focussed history (5mins) • Summarise key findings + review relevant data (1min) • Investigations and Management (3-4mins) • Professionalism *get familiar with the official Year 6 PACES mark scheme CASE 1 You are a junior doctor seeing 60M referred by GP for polyuria and polydipsia in the endocrine clinic. • Please take a focused history. • Suggest key investigations you’d like to perform • Discuss management with the examiner Differentials T1DM T2DM Diabetes insipidus Hypercalcaemia Investigations Bedside: urinalysis Blood tests: FBC, U&Es, LFTs, blood glucose, Hba1c, PTH, plasma calcium, urine and plasma osmolalities Persistent hyperglycaemia defined as: Random plasma glucose >11mmol/L Fasting plasma glucose > 7mmol/L Hba1c >48mmol/mol *If person is asymptomatic, do not diagnose diabetes on the basis of a single abnormal repeat test result is normal, arrange to monitor the person for the development of diabetes Management (part 1) • Referral to diabetes specialist for individualised care plan • Provide advice and support on the diagnosis E.g Diabetes UK • Provide advice on lifestyle measures such as weight loss, exercise and diet where appropriate • Offer immunization against influenza and pneumococcal infection • Advise that HbA1c should be measured at 3–6 monthly intervals initially until stable on unchanging antidiabetic treatment, and then every 6 months to ensure adequate blood glucose control Management (part 2) T1DM Insulin therapy Education on self monitoring of glucose and optimal targets T2DM Offer standard release metformin initially, unless contraindicated (E.g. low eGFR) If patient has CVS/HF, offer SGLT-2 inhibitor (E.g.dapagliflozin) + metformin pioglitazone, SGLT-2 inhibitor or sulfonylureaonsider DPP-4 inhibitor, Complications of diabetes Diabetic ketoacidosis Hyperosmolar hyperglycaemic Presentation: abdominal pain, state vomiting, nausea, lethargy Presentation: confusion, polyuria, Signs: Kussmaul breathing, polydipsia, nausea tachycardic, SOB, hypotensive, fruity acetone breath Signs: dehydration and Investigations: urinalysis (2+ hypovolaemic ketones), blood glucose (can be Investigations: urinalysis (normal normal) ketones), blood glucose >30mmol/L Management:ADMIT , IV fluids, IV Management:ADMIT , IV fluids, IV insulin + potassium replacement insulin + potassium replacementDKA treatment summary CASE 2 You are a junior doctor seeing 30F for fatigue at the GP . • Please take a focused history. • Suggest key investigations you’d like to perform. • Discuss the management with the examiner. CASE 2 – fatigue hx • Timeline • Weakness • Sleep • Mood (Beck’s triad) + any recent stressors. • FLAWS: Constitutional symptoms rule out malignancy early on in the hx! • Systemic: SOB, Bowel habits, recent illness/trauma/surgery, hot/cold intolerance, Skin changes (palmar crease hyperpigmentation), Hair loss, salt- craving. • Meds hx: steroid use (?missed dose or forgetting to double dose while sick). • FHx of autoimmune conditions • ICE CASE 2 • Tired all the time, sleep is good • Noticed her skin looks darker, but not had a tan • My partner noticed I’m adding salt to everything • Dropped a few kg past few months. • Lost some hair down below unexpectedly. • PMHx: pernicious anaemia in her mid 20s. Differentials • Addison’s disease • Hypothyroidism • Hypopituitarism • IDA • Chronic fatigue syndrome • Vit B12 deficiency Investigations • Bedside: Thyroid + Abdo Exam • Blood tests: ABG, FBC, U&Es, LFTs, TFTs, CRP, Bone profile, blood glucose, serum ACTH, AM Cortisol, Iron Studies, Short SynACTHen test, anti-21- hydroxylase Ab. • Imaging: CXR ?lung pathology Plasma Cortisol B4. SynACTHen 250 μg IM. Plasma Cortisol 30mins post -> This should increase in response to ACTH normally to >500nanomol/L OR 9AM cortisol: If > 500 nmol/l = Addison's unlikely < 100 nmol/l abnormal. 100-500 nmol/l = do SynACTHen test. VIVA • Which O/E findings can help distinguish Primary vs Secondary Adrenal insufficiency? • - Hyperpigmentation in primary (POMC → ACTH + alpha MSH) • Steroid induced vs Primary Addison’s? • - Paradoxically appear Cushingoid from chronic exogenous steroid exposure. • - Lack hyperpigmentation, HyperK+ and salt cravings • - Preserved MR activity (Aldosterone) secretion in GC induced Addisons. So no hyperK+. • How would you manage this patient? • - Sick day rules if steroids, steroid emergency card, medic-alert bracelet, involve seniors/ICU early. • - If Addisonian crisis: IV fluids, hydrocortisone 100mg IM/IV STAT then 200mg continuous IV for 24hrs. (± fludrocortisone ± glucose). • - If Stable: PO Hydrocortisone / Prednisolone + Fludrocortisone.Steroid emergency card Case 3 You are a junior doctor seeing 30F for weight counselling at the GP . • Please take a focused history. • Suggest key investigations you’d like to perform. • Discuss the management with the examiner. Weight gain • Timeline • Site / Distribution • Exercise • QoL impact • Striae +/- Plethora • Easy bruising +/- Thin skin • Cold intolerance • FLAWS: Constitutional symptoms rule out malignancy early on in the hx! • Systemic: Mood, SOB, vision changes, bowel habits. Recent illness? • Menstrual hx. • Meds hx: steroid use? • ETOH excess • FHx: thyroid? • ICE Case 3 • “gained so much weight around my tummy that I've got these horrible vertical red stretch marks. • I’m struggling to wear my usual size of clothes, there’s more weight on the back of my neck too. “dorsocervical fat” • I bruise from the tiniest injuries that I don’t recall. And they take ages to go away. • I used to take steroids for my rheumatoid, had a lot of flares when I was first diagnosed but not been on steroids for past 10 years. • I haven't noticed any hair loss or changes to my vision. My periods are regular, last one was 1/52 ago” Differentials • Cushing’s Syndrome • Cushing’s Disease • HypothyroidismCauses of Cushings syndrome Investigations • Confirm Cushing’s Syndrome: 1mg 11PM Dexa Suppression test > 24hr Urinary Cortisol • - 8AM Cortisol spike = Cushing’s syndrome. • Localisation: High Dose Dexa Suppression test • Pituitary MRI • IPSS (inferior petrosal sinus sampling) : angiographic procedure in which catheters are passed from the femoral veins up to the base of petrosal sinuses bilaterally. Used to differentiate between ACTH inducing pituitary diagnostic oCushing's disease.ortisolemia. A central-to-peripheral ratio of serum ACTH values greater than 2:1 isManagement Case 4 You are a junior doctor seeing 23F medical student at the GP for diarrhoea. • Please take a focused history. • Suggest key investigations you’d like to perform. • Discuss the management with the examiner. Diarrhoea • Timeline, Freq, Onset, Trigger, Recent travel • N&V / PR bleed • Appetite • Weight • Tremor • Heat intolerance • Sleep/restlessness/irritability • Palpitations • Systemic: Mood, Menstrual hx. Sexual hx (?libido), vision changes • PMHx: IBD, IBS. ?Autoimmune, ?recent viral illness* • Meds: thyroxine / amiodarone / laxatives • ICE Case 4 • “Started 3/12 ago, before I had normal bowel openings. Denies blood / no new takeaways/ N&V. • No changes to my diet. I’m always feeling hot and impatient for things. • At night I find myself that I lie awake for ages tossing & turning feeling anxious. • I go to the gym twice a week – no changes to my routine but I noticed I haven't had as many gains recently. • I take the COCP so haven’t really had proper periods. I smoke socially. Case 4 • Bedside: Cardio, Abdo, Thyroid + neuro exams. ECG, Stool MC&S, parasitic screen. • Blood tests: FBC, U&Es, LFTs, TFTs, TSH receptor antibodies (TRAb). Imaging: Radioactive Iodine / Technetium Tc99 / Thyroid Isotope scan • Which other autoAbs? • - anti-thyroid-peroxidase (anti-TPO) • - anti-thyroglobulin (anti-Tg). non-specific: autoimmune BOTH hyper (Grave’s) AND hypo thyroidism (Hashimoto’s). Differentials • Graves' disease • Toxic nodular goitre (Plummer’s) • Acute phase of de Quervain’s thyroiditis • Acute phase of Hashimoto’s thyroiditis • TSH producing pituitary adenoma • Iatrogenic hyperthyroidism (if relevant Meds Hx).Scintigraphy Management • Thyroid Storm: ABCDE + ICU HDU support High dose ATD (antithyroid drugs), corticosteroids, βBs, iodine solution + cooling. βB contraindicated in asthma/brady/HB. • If stable: Counsel on smoking (modifiable RF for thyroid eye disease!) • Medical: ATD (Carbimazole) + Symptomatic βB. • Carbimazole 40mg start then taper until euthyroid + cont for 12-18 months. • Radioactive Iodine for TMG: takes time to work. Surgical: subtotal thyroidectomy (euthyroid 1st +/- iodine to minimise hypervascularity / blood loss intraop). Viva • How to differentiate Graves’ vs other causes of Thyrotoxicosis? Complications • AF • Grave’s SIGHT THREATENING orbitopathy (within 1st yr) • Bone loss • CCF • Dermopathy Hypothyroidism management • Ix: Mx: • Bedside: Cardio, Abdo, Thyroid + neuro exams. ECG. • Bloods: FBC, U&Es, LFTs, TFTs, Anti-TPO, Anti-thyroglobulin. • Schmidt syndrome screen (blood glucose, short SynACTHen+cortisol). • Imaging: CXR ?effusions. Goal is to normalise TSH. - Elderly: Initiate 25mcg. - Under 50s: Initiate 50mcg. - Repeat TFTs 8-12 weeks after dose titration. - If pregnant: UP the dose. - No evidence to support combo T3 + T4 replacement. - Counsel Thyroxine side effects: Hyperthyroid due to overcorrection, low bone density, AF/Angina Schmidt syndrome = Addison’s + autoimmune hypothyroidism + T1DM. Case 5 You are a junior doctor seeing 35M for review of bloods. • Please take a focused history. • Suggest key investigations you’d like to perform. • Discuss the management with the examiner. FINDINGS All NAD except K+ 2.6 • Pt reports: "I’ve been on all sorts of -pils and other BP tablets but the other day at home, I still had a really high reading! It was 178/112 mmHg!” • occasional headaches. Differentials • Hyperaldosteronism • Phaeochromocytoma • Renal disease CKD • Cushing’s syndrome • Poor medication compliance Investigations and mx • plasma aldosterone/renin ratio (high Ald: low Renin due to –ve feedback). • CT abdo If CT NAD, adrenal vein sampling (unilateral vs bilateral) à Adrenal adenoma: XS aldosterone in only one adrenal vein. Bilateral: raised in both adrenal veins. Management • adrenal adenoma -> Laparoscopic adrenalectomy • Bilteral hyperplasia -> aldosterone antagonist (spironolactone) What if: What if their potassium was normal PC: hypertension + sweating? DDx? Phaeochromocytoma Ix: 24hr urinary metanephrines > catecholamines. More sensitive. • 10 – 10 – 10 % Bilateral – Malignant – Extra-adrenal (@ Zuckerkandl organ). • 10% Familial (MEN 2A+B, neurofibromatosis, von Hippel-Lindau) Surgery is definitive Mx. To plan for surgery: • “A before B” • PHaeochromocytoma - give PHenoxybenzamine before beta-blockers. 1. Alpha block first preop for weeks. 2. Beta (to avoid unopposed alpha stimulation i.e. avoid hypotensive emergency, cardiac arrest intraop). Case 6 Endocrine Clinic.doctor seeing 59F referred by GP for bone pain in the • Please take a focused history. • Suggest key investigations you’d like to perform. • Discuss the management with the examiner. Case 6 • Constant lower back pain since 6/52 ago. 7/10 in severity. • Occasionally in hips too. Impacting ADLs. • Initially, ibuprofen gel and paracetamol helped with pain, now I feel it’s getting worse. • Assoc. w (main carer for husband not coping with the pain), been drinking lots of water and goes to toilet x8/day, napping all the time. • Post-menopause 5 yrs ago • Known hx of renal calculi. Differentials • test results)parathyroidism ~ most likely (bone pain, kidney stones, post-menopause, blood • ? Multiple myeloma (causing HyperCa) • Diabetes Insipidus • Diabetes Mellitus Hypercalcaemia: Mild: 2.6–3.00 mmol/L Moderate: 3.01–3.40 mmol/L Severe: > 3.40 mmol/L Investigations • Bedside: Urinalysis, 24 hour urine calcium, ECG • Blood tests: FBC, U&Es, LFTs, Bone profile, PTH, HbA1c, blood glucose, Paired Osmolalities, protein electrophoresis. • Imaging: Bone density scan, XR Her results: PTH ↑ Calcium ↑. DEXA: T-score < -2.5 = osteoporosis Hypercalcaemia hx • “Stones, bones, abdo groans, psychic moans” § Polydipsia + polyuria § Renal: stones, polyuria, dehydration. § Bone resorption effects of PTH: ask about pain, fractures and osteopaenia/osteoporosis. § Abdo pain (constipation, pancreatitis, peptic ulcers (duodenal:gastric ≈ 7:1). § changes in mood/concentration / confusion § Palpitations/ chest pain/ arrhythmia • Screening Qs: § HTN effects § Constitutional symptoms (myeloma, haem) § SOB, breast lump (SCLC, Breast Ca) § Rule out LUTS § Meds Hx: thiazides / lithium, OTC supplements. § FHx: familial hypocalciuric hypercalcaemia / MEN1 Hypercalcaemia management • - If mild: advise fluid intake. To avoid thiazides + vit D intake; review again in 6 months. • - Admit if moderate/severe hyperCa. • - FLUIDS FLUIDS FLUIDS • - IV 0.9% NaCl typically 4-5 L / 24 hrs. • - Post rehydration if hyperCa persists: IV bisphosphonates on senior advice (Zolendronic acid/ pamidronate). • Loop diuretics: reserved for those who cannot tolerate aggressive fluid rehydration. Be aware that they may worsen electrolyte disturbances. Hypocalcaemia hx Fatigue, weakness, Perioral/digital paraesthesia Tetany/seizures Meds hx: PPIs, bisphosphonates, chemo, radiotherapy, anticonvulsants. Prev surgical hx: thyroidectomy? Parathyroidectomy? FHx of hypoCa, Congenital DiGeorge syndrome. O/E: - Trousseau’s sign: carpopedal spasm - Chvostek’s sign: tapping over parotid causes twitch of facial muscles (↓sensitivity). - Shortened 4th metacarpal brachydactyly (pseudohypoPTH). - Dry, coarse, puffy skin (chronic HypoPTH). - Nail dystrophy Hypocalcaemia ix & mx Ix: Initial Mx: • Bedside: ECG (?arrhythmia / prolonged QT). - IV 10% Ca2+ gluconate 10ml over 10mins. • Bloods: Bone profile (aCa, phosphate, Mg2+, - (with telemetry or ECG monitoring). PTH, U&Es, Vit D, LFTs (ALP). - Consider PO Ca2+ supplements. • Imaging: XR consider if fractures / osteomalacia. - Senior advice: calcitriol/ synthetic PTH. VIVA • Life-threatening complications of severe hypoparathyroidism? Laryngeal spasm, seizures, tetany, hypoCa -> Arrhythmia. • Common surgical procedure that could cause hypoparathyroidism? Thyroid/Laryngeal/Parathyroid surgery – temporary vs permanent dysfunction (if compromised vascular supply). • Relevance of ↑Ca2+ and MRI finding of pituitary adenoma? MEN Type 1 = 3Ps. Autosomal dominant. Parathyroid (95%), Pituitary (70%), Pancreatic (50%) insulinoma / gastrinoma.THANKYOU FOR COMING! PLEASE FILL IN THE FEEDBACK FORM!