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Endocrine RevisionA 28-years-old woman with a history of type 1 diabetes was brought in to the emergency department due to palpitations, diaphoresis and tremors. On examination, her vital signs show a heart rate of 120 bpm and respiratory rate of 24 per min. It is noted that she has tremors of her hands, unusually bulging eyeballs and a diffuse swelling in her neck and shins. Her blood tests show: TSH 0.1 mU/l (low) Free T4 32.5 pmol/l (high) FreeT3 12.5 pmol/l (high) What is the most likely underlying pathophysiology in this patient?Treatment Hypothyroid: replace with levothyroxine Hyperthyroid: control symptoms with propranolol; antithyroid drugs like PTU, carbimazole, radioiodine treatment, and surgeryA 67 year old patient is recovering from a thyroidectomy on the ward. The nurse comes to get you as the patient starts to complain of tingling and numbness in the face, toes, and fingers. What is the differential and pathophysiology of this condition?A 60 year old post menopausal woman is complaining of fatigue, memory loss, increased anxiety, and general aches. She claims it may just be her “feeling old”. What do you think the differential could be?Calcium regulation The two hormones which primarily control calcium metabolism are: ● parathyroid hormone (PTH) ● 1,25-dihydroxycholecalciferol (calcitriol, the active form of vitamin D) What are the actions of PTH? What are the actions of calcitriol?DKA Question An 10-year-old boy with no past medical history presents to the emergency department with diarrhoea and vomiting. He complains of abdominal pain. A venous blood gas was on the previous slide. He had a blood glucose finger-prick test which read Glucose = 24. What is his most likely diagnosis?DiabetesDKA - Diabetic ketoacidosis ▶ Uncontrolled LIPOLYSIS not proteolysis ▶ excess fatty acids get converted to ketone bodies ▶ Causes ▶ infection, missed doses, MI ▶ Features ▶ “DKA is Deadly” ▶ Delirium/psychosis ▶ Kussmaul respirations ▶ Abdominal pain/nausea/vomiting ▶ Dehydration ▶ Fruity breath ▶ Bloods: Hyperglycemia, depleted intracellular potassium ▶ Main management: Insulin, correct electrolyte disturbances, FLUIDSA 70-year-old woman presents to her GP complaining of weight gain over the past few months. Her friends have been commenting on her face appears rounder and developed some stretch marks on her abdomen. On examination, she is noted to have a heart rate of 99 beats per minute, a respiratory rate of 17 breaths per minute and blood pressure of 162/74 mmHg. She has a waist circumference of 41 inches and a body mass index of 31 kg/m2. Which of the following correctly describes one of the effects of the main hormone implicated in this patient's condition?Cushings Too little Endocrine HTN (5-10%) 🡪 Hypotension ⇡ ALDOSTERONE Hyperaldosteronism ⇡ CORTISOL Cushing’s ⇡ CATECHOLAMINES Phaeochromocytoma Adrenaline, Noradrenaline G SALT Mineralocorticoids F SUGAR Glucocorticoids R SEX AndrogensAddison’s Disease Primary Adrenal Insufficiency Autoimmune (Hx / FH) ⇣ Aldosterone 🡪 Hyponatraemia, Hypotension (postural) ⇣ Cortisol 🡪 Hypoglycaemia, ⇡ ACTH - Skin Pigmentation *SICK DAY RULES Early am Cortisol (Low / not v useful) ACTH (HIGH) HYDROCORTISONE Short SynACTHen (< Double baseline) Glucocorticoid Adrenal cortex / 21-hydroxylase Abs (80%) Fludrocortisone Mineralocorticoid Decreased Libido 🡪 Androgen replacement (DHEA)A 49-year-old woman attends an appointment with her GP, she complains of night sweats, hot flashes and vaginal dryness which causes sexual intercourse to be painful. What would be the possible differentials and what would the blood tests show?Menstrual cycleMenopause Main symptoms: ▶ Periods ▶ change in length ▶ irregular ▶ Vasomotor ▶ hot flushes ▶ sweats ▶ Genital changes ▶ dryness ▶ frequency ▶ psychological ▶ memory ▶ “fog”Menopause physiology ▶ Decrease in estrogen production due to age linked decline in the number of ovarian follicles ▶ Average age is around 51 years ▶ An increase in FSH is usually diagnostic for menopause - can anyone tell me why?A 52-year-old female presents to the GP concerned she has passed through the menopause following no periods for 1 year. What is the cause of the end of the menstrual cycle? A. The decline in ovarian follicles B. Reduced production of GnRH C. Reduced production of FSH D. Reduced production of oestrogen E. Endometrial atrophyA 52-year-old female presents to the GP concerned she has passed through the menopause following no periods for 1 year. What is the cause of the end of the menstrual cycle? A. The decline in ovarian follicles B. Reduced production of GnRH C. Reduced production of FSH D. Reduced production of oestrogen E. Endometrial atrophyA perimenopausal patient is given hormone replacement therapy (HRT) to alleviate their symptoms, including both an oestrogen and progesterone component. Their GP warns that HRT is associated with several complications. Which complication is this patient at an increased risk of developing? A. Atheroma formation B. Endometrial cancer C. Stroke D. Vaginal atrophyA perimenopausal patient is given hormone replacement therapy (HRT) to alleviate their symptoms, including both an oestrogen and progesterone component. Their GP warns that HRT is associated with several complications. Which complication is this patient at an increased risk of developing? A. Atheroma formation B. Endometrial cancer C. Stroke D. Vaginal atrophyMarge is a 52-year-old patient, presenting to you, her GP, with unpleasant menopausal symptoms lasting for over a year. These symptoms include hot flushes, headaches and fatigue. Her last period was 14 months ago, she has 3 grown-up children and has no surgical history. She demands to be prescribed an oestrogen-only HRT regimen as she has read on the internet that combined HRT is poorly tolerated. What is the appropriate thing to do here? A. Advice her to first try making lifestyle changes like reducing vasovagal triggers B. Tell her all patients get prescribed combined HRT C. Explain to her that oestrogen-only HRT should not be prescribed to patients with a uterus D. Explain to her that oestrogen-only HRT should not be prescribed to patients with a headache E. Advice her not to take HRT as cancer is its side effectMarge is a 52-year-old patient, presenting to you, her GP, with unpleasant menopausal symptoms lasting for over a year. These symptoms include hot flushes, headaches and fatigue. Her last period was 14 months ago, she has 3 grown-up children and has no surgical history. She demands to be prescribed an oestrogen-only HRT regimen as she has read on the internet that combined HRT is poorly tolerated. What is the appropriate thing to do here? A. Advice her to first try making lifestyle changes like reducing vasovagal triggers B. Tell her all patients get prescribed combined HRT C. Explain to her that oestrogen-only HRT should not be prescribed to patients with a uterus D. Explain to her that oestrogen-only HRT should not be prescribed to patients with a headache E. Advice her not to take HRT as cancer is its side effectA 13-year-old girl is brought to the GP by her mother who is concerned about her lack of development. She is shorter than her peers, has no sign of breast growth, has no axillary or pubic hair, and has not started her periods. The girl's mother and grandmother both started their periods at age 14. The patient is otherwise healthy and takes no regular medications. How should this patient be managed? A. She requires investigation for primary amenorrhoea B. She should return to clinic if she has no sign of menstruation by age 15 C. She requires investigation for secondary amenorrhoeaA 13-year-old girl is brought to the GP by her mother who is concerned about her lack of development. She is shorter than her peers, has no sign of breast growth, has no axillary or pubic hair, and has not started her periods. The girl's mother and grandmother both started their periods at age 14. The patient is otherwise healthy and takes no regular medications. How should this patient be managed? A. She requires investigation for primary amenorrhoea B. She should return to clinic if she has no sign of menstruation by age 15 C. She requires investigation for secondary amenorrhoea6 year old girl, with 6 months history of pubic hair growth associated with fine axillary hair as well as adult odor to sweat. No breast development with no acceleration of growth. Otherwise normal history and examinations. What is the most likely diagnosis? A. Precocious puberty B. Premature adrenarche C. Premature thelarche6 year old girl, with 6 months history of pubic hair growth associated with fine axillary hair as well as adult odor to sweat. No breast development with no acceleration of growth. Otherwise normal history and examinations. What is the most likely diagnosis? A. Precocious puberty B. Premature adrenarche C. Premature thelarchePubertyNeuroscience RevisionKey areas- Neuro • Motor pathways – UMN and LMN • Sensory pathways • Epilepsy • Movement disorders (Parkinson’s disease) • Neuroinflammatory disorders (MS, meningitis) • Stroke and blood supply of the brain • Headache types • DementiaThinking about localising pathology… ❖ THINK - WHERE, WHEN, WHY WHERE? - MOTOR- UMN, LMN, NMJ, MUSCLE - SENSORY- BRAIN, CORD, NERVE ROOT, NERVE - SYMPATHETIC/PARASYMPATHETIC  WHEN? ❖ INSTANTANEOUS - VASCULAR, EPILEPTIC ❖ MINUTES- MIGRAINE ❖ HOURS/DAYS - INFECTIVE, INFLAMMATORY ❖ YEARS- NEURODEGENERATIVEA 73 y/o man presents to A&E with a left-sided facial droop and slurred speech. His cranial nerves are assessed- * Unable to smile on left side * Can close both eyes Can raise both eyebrows symmetrically and wrinkle his forehead Where is the lesion located? A. Left UMN B. Temporal branch of the facial nerve (CN7) C. Right UMN D. Right LMN E. Left LMNA 73 y/o man presents to A&E with a left-sided facial droop and slurred speech. His cranial nerves are assessed- * Unable to smile on left side * Can close both eyes Can raise both eyebrows symmetrically and wrinkle his forehead Where is the lesion located? A. Left UMN B. Temporal branch of the facial nerve (CN7) C. Right UMN D. Right LMN E. Left LMNA 43 y/o female patient comes in to ward complaining of muscle weakness. On investigation you find that her reflexes are greater and have increased tone (spasticity). What is a likely diagnosis? A. Motor neurone disease affecting both UMN and LMN B. LMN disorder C. Guillain-Barre syndrome D. Carpal tunnel syndrome E. UMN disorderA 43 y/o female patient comes in to ward complaining of muscle weakness. On investigation you find that her reflexes are greater and have increased tone (spasticity). What is a likely diagnosis? A. Motor neurone disease affecting both UMN and LMN B. LMN disorder C. Guillain-Barre syndrome D. Carpal tunnel syndrome E. UMN disorderDistinguishing between UMN and LMN lesionsWhat type of lesion does this represent? A. Occlusion of the right anterior cerebral artery B. Right-sided hemisection of the spinal cord C. Peripheral neuropathy D. Parkinson's disease E. Complete transection of the spinal cordWhat type of lesion does this represent? A. Occlusion of the right anterior cerebral artery B. Right-sided hemisection of the spinal cord C. Peripheral neuropathy D. Parkinson's disease E. Complete transection of the spinal cordSensory pathways/ ascending tracts • 3 neurones • Dorsal column pathway - Proprioception, vibration, fine touch - Decussate in the medulla • Spinothalamic pathway - Pain, temperature - Decussate immediately in the spinal columnA patient presents with a 4 month history of progressive muscle weakness and numbness in the lower limbs. Investigations showed the presence of anaemia and vit B12 deficiency. The results of their neurological exam are given. Which area of the spinal cord is most likely to be affected? A. Dorsal column B. Ventral horn C. Anterior and lateral columns D. Anterior and dorsal columnsA patient presents with a 4 month history of progressive muscle weakness and numbness in the lower limbs. Investigations showed the presence of anaemia and vit B12 deficiency. The results of their neurological exam are given. Which area of the spinal cord is most likely to be affected? A. Dorsal column B. Ventral horn C. Anterior and lateral columns D. Anterior and dorsal columnsA cyclist falls off their bike during an accident. They come into clinic post the incident complaining of pain and paraesthesia in their outer thigh (lateral). Which spinal nerve root is likely to be affected? A. C5-C6 B. S4-S5 C. L2-L3 D. T12A cyclist falls off their bike during an accident. They come into clinic post the incident complaining of pain in their outer thigh (lateral). Which spinal nerve root is likely to be affected? A. C5-C6 B. S4-S5 C. L2-L3 D. T12A 45-year-old woman presents with worsening diplopia throughout the day. She has been suffering from this double vision for several weeks, and always feels that it is worse in the evenings and never present in the morning. On further questioning the patient reveals she believes her double vision improves after 'resting her eyes’. What is the most likely diagnosis? A. Migraine B. Diabetic neuropathy C. Myasthenia gravis D. Multiple sclerosis E. Guillain-Barre syndromeA 45-year-old woman presents with worsening diplopia throughout the day. She has been suffering from this double vision for several weeks, and always feels that it is worse in the evenings and never present in the morning. On further questioning the patient reveals she believes her double vision improves after 'resting her eyes’. What is the most likely diagno is? A. Migraine B. Diabetic neuropathy C. Myasthenia gravis D. Multiple sclerosis E. Guillain-Barre syndromeA 27 y/o male presents with visual impairment, headaches and unexplained tiredness. His MRI shows a pituitary tumour compressing the optic chiasm. Which image would best represent the likely visual impairment this patient has?A 27 y/o male presents with visual impairment, headaches and unexplained tiredness. His MRI shows a pituitary tumour compressing the optic chiasm. Which image would best represent the likely visual impairment this patient has? Bitemporal hemianopiaA 27 y/o female involved in a car accident sustains a head injury. Her CT scan demonstrates a haemorrhage which is likely to be caused by damage to the bridging veins between the cortex and cavernous sinuses. What type of haemorrhage is this? A. Subarachnoid haemorrhage B. Extradural haemorrhage C. Intraparenchymal haemorrhage D. Subdural haemorrhage E. Intracerebellar haemorrhageA 27 y/o female involved in a car accident sustains a head injury. Her CT scan demonstrates a haemorrhage which is likely to be caused by damage to the bridging veins between the cortex and cavernous sinuses. What type of haemorrhage is this? A. Subarachnoid haemorrhage B. Extradural haemorrhage C. Intraparenchymal haemorrhage D. Subdural haemorrhage E. Intracerebellar haemorrhageAn elderly patient presents with unilateral tremor. They are found to be unable to look upwards on examination. Which other signs are characteristic of their most likely diagnosis? A. Rigidity, memory loss and hypereflexia B. Flaccid paralysis and absent Babinski sign C. Decreased muscle tone and facial asymmetry D. Rigidity, bradykinesia and postural instabilityAn elderly patient presents with unilateral tremor. They are found to be unable to look upwards on examination. Which other signs are characteristic of their most likely diagnosis? A. Rigidity, memory loss and hypereflexia B. Flaccid paralysis and absent Babinski sign C. Decreased muscle tone and facial asymmetry D. Rigidity, bradykinesia and postural instability Parkinson’s Disease • Progressive neurodegenerative disorder due to degeneration of dopaminergic neurons in the substantia nigra. • 2x more common in males • Later onset • abnormal accumulation and aggregation of α-Syn in the form of Lewy bodiesYou are on placement in intensive care. A 31 y/o man is admitted with closed head injuries after a road accident. His GCS is 14/15 with no focal neurological deficit. HR, BP and ICP are normal. He is is administered maintenance IV fluids. Few hours later- he becomes agitated and confused and his GCS is 11/15. HR= 101 bpm, BP= 161/89 mmHg and ICP is 18mmHg (normal: 7–15 mm Hg). Which of the following pathophysiological changes explain his clinical deterioration? A. Rise in ICP causing fall in cerebral perfusion pressure B. Fall in ICP causing rise in cerebral perfusion pressure C. Fall in cardiac output causing cerebral hypoxia D. Fall in blood volume causing a fall in cardiac outputYou are on placement in intensive care. A 31 y/o man is admitted with closed head injuries after a road accident. His GCS is 14/15 with no focal neurological deficit. HR, BP and ICP are normal. He is is administered maintenance IV fluids. Few hours later- he becomes agitated and confused and his GCS is 11/15. HR= 101 bpm, BP= 161/89 mmHg and ICP is 18mmHg (normal: 7–15 mm Hg). Which of the following pathophysiological changes explain his clinical deterioration? A. Rise in ICP causing fall in cerebral perfusion pressure B. Fall in ICP causing rise in cerebral perfusion pressure C. Fall in cardiac output causing cerebral hypoxia D. Fall in blood volume causing a fall in cardiac outputA middle-aged man presents with pain and numbness in the thumb, index finger and middle finger of his right hand. Which nerve roots are likely to be affected? A. C8-T1 B. C5-T1 C. T11-L4 D. C3-C5 E. T1-T6A middle-aged man presents with pain and numbness in the thumb, index finger and middle finger of his right hand. Which nerve roots are likely to be affected? A. C8-T1 B. C5-T1 C. T11-L4 D. C3-C5 E. T1-T6A 7 y/o girl is brought to the GP by her father after a few recurrent episodes of sudden loss of awareness. The father says that she “suddenly went blank and did not respond for a period of 10-15 seconds and then went back to normal.” She does not recall this and things nothing has happened. Her father also recalls light lip-smacking during these episodes. What is the most likely diagnosis? A. Juvenile myoclonic epilepsy B. Occipital lobe epilepsy C. Frontal lobe epilepsy D. Childhood absence epilepsyA 7 y/o girl is brought to the GP by her father after a few recurrent episodes of sudden loss of awareness. The father says that she “suddenly went blank and did not respond for a period of 10-15 seconds and then went back to normal.” She does not recall this and things nothing has happened. Her father also recalls light lip-smacking during these episodes. What is the most likely diagnosis? A. Juvenile myoclonic epilepsy B. Occipital lobe epilepsy C. Frontal lobe epilepsy D. Childhood absence epilepsyEpilepsy • Recurrent and spontaneous seizures • Seizure = abnormal firing of neurones in part(s) of the brain • Diagnosis: By history and eyewitness account. - pre-ictal signs (aura), post-ictal signs - Triggers - Risk factors: FHx, meningitis etc. • EEGs are useful to spot genetic epilepsies • Treatment: AEDs, surgery to remove a small part of the brain that's causing the seizures etc. • Common types of AED include (NHS): - sodium valproate - Carbamazepine - LamotrigineA 17 y/o boy has been in status epilepticus for 45 mins. He is given IV lorazepam before which is a benzodiazepine. His seizures stop and he regains consciousness. How does this class of drugs work in seizure treatment? A. Increasing acetylcholine binding to muscarinic receptors B. Facilitating binding of GABA at its receptors in the CNS C. Blocks reabsorption of serotonin into neurons D. inhibition of neurotransmitter release from the primary afferent terminals in the spinal cordA 17 y/o boy has been in status epilepticus for 45 mins. He is given IV lorazepam before which is a benzodiazepine. His seizures stop and he regains consciousness. How does this class of drugs work in seizure treatment? A. Prevent breakdown of acetylcholine B. Facilitating binding of GABA at its receptors in the CNS C. Blocks reabsorption of serotonin into neurons D. inhibition of neurotransmitter release from the primary afferent terminals in the spinal cordVery short answer question: A 78 y/o woman presents with 12 hr Hx of severe, persistent headache. She describes this as the worst headache she has had and says it is worst at the back of her head. She has no history of trauma and her no other signs and symptoms. She has PMH of hypertension for which she is taking amlodipine. What is the most like diagnosis?Very short answer question: A 78 y/o woman presents with 12 hr Hx of severe, persistent headache. She describes this as the worst headache she has had and says it is worst at the back of her head. She has no history of trauma and her no other signs and symptoms. She has PMH of hypertension for which she is taking amlodipine. What is the most like diagnosis? Subarachnoid haemorrhageA 25 y/o woman comes to the GP complaining of a headache occurring once every few weeks for the past 6 months. She describes seeing flashing lights and needs to lie down in a dark room for it to pass. She also mentions that it normally occur on the RHS. What is the most likely diagnosis? A. Tension headache B. Focal epilepsy C. Cluster headache D. Subarachnoid haemorrhage E. MigraineA 25 y/o woman comes to the GP complaining of a headache occurring once every few weeks for the past 6 months. She describes seeing flashing lights and needs to lie down in a dark room for it to pass. She also mentions that it normally occur on the RHS. What is the most likely diagnosis? A. Tension headache B. Focal epilepsy C. Cluster headache D. Subarachnoid haemorrhage E. MigraineAn 81 y/o man presents to A&E with sudden onset weakness in his left leg. On examination there is hyperreflexia in the ankles. Which artery is most likely to be occluded? A. R anterior cerebral artery B. L middle cerebral artery C. L carotid artery D. R middle cerebral artery E. Left posterior cerebral arteryAn 81 y/o man presents to A&E with sudden onset weakness in his left leg. On examination there is hyperreflexia in the ankles. Which artery is most likely to be occluded? A. R anterior cerebral artery B. L middle cerebral artery C. L carotid artery D. R middle cerebral artery E. Left posterior cerebral arteryWhich of these statements is false? A. Cranial nerves IX-XII arise from the medulla B. The facial nerve controls lacrimation C. Cranial nerve IV has purely motor functions D. Cranial nerve I is responsible for pupillary contraction E. All of the aboveWhich of these statements is false? A. Cranial nerves IX-XII arise from the medulla B. The facial nerve controls lacrimation C. Cranial nerve IV has purely motor functions D. Cranial nerve I is responsible for pupillary contraction E. All of the aboveA young woman presents after multiple episodes of optic neuritis, during which she develops unilateral eye pain. Upon examination, she is found to have decreased visual acuity and colour saturation on her affected eye. Her doctor suspects multiple sclerosis. Which features would be expected on a T2-weighted MRI? A. Single hyperintense lesion B. Midline shift C. Many hyperintense lesions D. Cortical atrophyA young woman presents after multiple episodes of optic neuritis, during which she develops unilateral eye pain. Upon examination, she is found to have decreased visual acuity and colour saturation on her affected eye. Her doctor suspects multiple sclerosis. Which features would be expected on a T2-weighted MRI? A. Single hyperintense lesion B. Midline shift C. Many hyperintense lesions D. Cortical atrophyMultiple sclerosis • Chronic inflammatory and degenerative disease of the central nervous system • Inflammation, demyelination, neuronal injury and loss, scarring • Can be relapsing-remitting, primary progressive or secondary progressive • Diagnosis: dissemination in SPACE and TIME; McDonalds criteria - MRI and lumbar puncture • Relapses treated with immunomodulatory and immunosuppressive therapiesA young man presents with the inability to produce coherent sentences after a right middle cerebral artery infarct. He puts in a lot of effort to finish his sentences but struggles to do so. His understanding of spoken language is intact. The GP suspects neurological damage from the infarct. Which part of the brain has likely been affected? A. Wernicke’s area B. Frontal and occipital lobes of the left hemisphere C. Right superior temporal gyrus D. Occipital lobe of the right hemisphere E. Broca’s areaA young man presents with the inability to produce coherent sentences after a right middle cerebral artery infarct. He puts in a lot of effort to finish his sentences but struggles to do so. His understanding of spoken language is intact. The GP suspects neurological damage from the infarct. Which part of the brain has likely been affected? A. Wernicke’s area B. Frontal and occipital lobes of the left hemisphere C. Right superior temporal gyrus D. Occipital lobe of the right hemisphere E. Broca’s areaA 6 year old girl presents with a non-blanching rash and neck stiffness over the last 6 hours. She describes headache that is worsened in bright rooms and has a fever of 38.1C. Give the likely diagnosis and the best diagnostic test?A 6 year old girl presents with a non-blanching rash and neck stiffness over the last 6 hours. She describes headache that is worsened in bright rooms and has a fever of 38.1C. Give the likely diagnosis and the best diagnostic test? Bacterial meningitis Lumbar puncture NeutrophilsFurther resources ▶ https://geekymedics.com/endocrinology-quiz/ ▶ PASSMED!! ▶ http://www.edinburghdiabetes.com/managementprotocols ▶ Zero to finals ▶ Use what work for you:)Feedback Please take a minute now before you leave to fill in a quick feedback form: Individual links will be provided for you: https://app.medall.org/training/feedback/anonymous?organisation=accessibilit y-in-medicine&keyword=02518c339e46a7154b5e4916 AIM Facebook Page ▶ Give our Facebook page a like for updates and opportunities,just search @AIMEdinburgh Thank you for coming! ▶ If you have any more questions, feel free to email me at s2134684@ed.ac.uk, S1908775@ed.ac.uk or email accessibilityinmedicine@gmail.com