Endocrine Medicine and Surgery Final Year Medical Students

1. Endocrine Medicine and Surgery Final Year Medical Students Dr Neil Clough F2

2. What are we going to cover? Common and important topics Finals Focused – MCQs/OSCE discussion Diabetes Calcium and parathyroid Thyroid function tests Pituitary - adrenal Axis

3. Important Points I will ask you questions - Have a go at answering You’re not expected to know everything – if you did you wouldn’t be here. Ask me questions

4. Type 1 Diabetes Lifelong Multisystem Disease Complications: • Macrovascular • IHD • Cerebrovascular Disease • Peripheral Vascular Disease • Microvascular • Retinopathy • Neuropathy – what are the common problems? • Nephropathy – what are the consequences of this? • Diabetic Foot Disease

5. Diabetic Retinopathy • What are the stages? • Background • Pre-proliferative • Proliferative • End-Stage

7. Background DR: Microaneurisms Hard Exudates Blot Haemorrhages

8. Pre-Proliferative: • CWS • Venous Beading/Looping • IRMA

9. IRMA

10. Diabetic MaculopathyLocation, location, locationWill affect visual acuity significantly

11. Proliferative DR:NVDNVERubeosis Iridies

12. End Stage DR:Vitreous HaemorrhageTractional retinal detachment

13. ? Laser Burns!

14. How do Type 1 Diabetics Present? Most Type 1s present to GP with just: • Malaise • Thirst • Polyuria Young adults, usually not obese Presentation in DKA is unusual as patients seek help much earlier- so often start insulin as an outpatient

15. How do Type 1 Diabetics Present? Most DKAs already known to have T1DM and present with: Tachy and hypotensive High resp rate (Kussmaul Breathing) Ketone Smell Vomiting/Abdo Pain Look for precipitant factors – most common are non-compliance and intercurrent illness

16. How do Type 1 Diabetics Present? Ketoacidosis Diagnostic Triad: Capillary blood glucose above 11 mmol/L Capillary ketones above 3 mmol/L or urine ketones ++ or more (May not even have ketones in blood - clinical diagnosis) Venous pH less than 7.3 and/or bicarbonate less than 15 mmol/L

17. Kussmaul Respiration Ketone Smell Negative Ionotropism Ketoacidosis FATS Increased stress Hormones Lipolysis Lack of Insulin Hyperglycaemia Osmotic Diuresis SUGAR Dehydration Potassium Depletion Renal Impairment

18. Diabetic Ketoacidosis • What are the things you need to get worried about? • Acidosis • Dehydration • Potassium • ? What’s the precipitant? Eg sepsis, MI Know diabetes well. Its important

19. How do you treat DKA? General Concepts • Rehydrate: • 1L NaCl 1hr, 1L 2hr, 1L 2hr, 1L 4hr • Insulin: • (0.1unit/kg/hr based on estimate of weight) 50 units acrapid made up to 50ml with 0.9% sodium chloride solution. • Replace Potassium: – total body K+ is low: why? • Monitor Closely: see guidelines LINK TO DIABETES UK GUIDELINES…..

20. Type 2 Diabetes Diagnosis Symptoms and one of: Random plasma glucose > 11.1 mmol/l 
or Fasting plasma glucose  > 7.0 mmol/l 
or OGTT: plasma glucose > 11.1 mmol/l two hours after 75g anhydrous glucose No Symptoms and above x2 NICE 2011: ‘An HbA1c of 48 mmol/mol (6.5%) is recommended as the cut point for diagnosing diabetes’

21. Mrs Dawes has blurred vision, is feeling tired, thirsty and peeing a lot. Fasting plasma glucose=11.2 What are key areas you need to discuss with her?

22. Discussing Type 2 Diabetes with a Patient • Check understanding of disease • Managing Modifiable Cardiovascular Risk Factors • Lifestyle/Diet • Blood Pressure • Blood glucose control • Diet/exercise • Medications/Insulin • Minimizing/managing Complications • Screening • Regular health checks

23. Antidiabetic Medications • Biguanides:eg. metformin Reduce glucose production in liver, increase peripheral sens to insulin. First line overweight. BEWARE:Lactic acidosis.NO HYPOS • Sulphonylureas: eg. gliclazide, glibenclamide. Promote insulin secretion. BEWARE:HYPOS • Alpha-glucosidase inhibitors: acarbose Reduce carbohydrate absorbtion. GI side effects

24. Antidiabetic Medications • DPP-4 inhibitors/gliptins e.g Sitagliptin Increase insulin secretion • Incretin mimetics e.g. Exenatide - Byetta Increase insulin secretion • Thiazolidinediones: eg pioglitazone Increase insulin sensitivity • Insulin: eg. lantus, actrapid Know how to prescribe safely – incorrect insulin prescibing can kill

25. Hypoglycaemia – how to treat?

26. Calcium Regulation

27. Hyperparathyroidism • Primary • Raised Ca, raised/normal PTH • Usually solitary adenoma. • Secondary • Low Ca, raised PTH • Chronic renal failure, low vit D intake • Tertiary • Raised Ca, Very raised PTH • Autonomous production of PTH following chronic secondary. • Malignant • PTHrP produced by some cancers (eg. small cell lung, breast, renal)

28. Hypercalcaemia • Symptoms? • Thirst/polyuria • Nausea/vomiting • Confusion/coma • Abdo pain/constipation Causes? • Malignant Disease – how? • Primary Hyperparathyroidism • Medications – eg Thiazide Diuretics

29. Hypercalcaemia • Correct fluid status: • Often volume deplete: IV fluids +/- furosemide(will improve UO and calcinuria) • Aim for euvolaemia + urine output of 200ml/hr • Pamindronate? If still hypercalcaemic after 24hrs consider – How long does this take to work? • ? Due to hyperparathyroidism/renal impairment – speak to renal team. ? Cinacalcet

30. Hypocalcaemia • Symptoms: • Spasms/increased muscle tone • Perioral parasthesia • Anxious/irritable • Seizures • Confusion • Common Causes: • CKD • Hypoparathyroidism eg post surgery • Resp alkalosis – how?

31. Hypocalcaemia • Treatment: • Mild – PO replacement • Severe – 10ml of 10% calcium gluconate IV 30 min

32. EMQ Thyroid funcion Tests A: Raised Thyroglobulin B: Low T4 C: Raised T3 D: Raised T4 E: Raised TSH F: Low TSH Tumour recurrence following previous thyroid surgery? A Most common test to diagnose hypothyroidism? E Can be used to diagnose Graves disease or hypopituitarism? F Most sensitive test for hyperthyroidism? c Suggestive of hypothyroidism but affected by thyroxine-binding globulin levels? B

33. MCQ time A 45 year old Asian Man is diagnosed with cushings disease in India. He undergoes a bilateral adrenalectomy and recovers well from the operation. On his return to the UK 1 year later, he complains of a constant dull headache, peripheral visual disturbances and increasing pigmentation of the skin creases on both hands. The most likely diagnosis is: • Ectopic ACTH secreting tumour • Prolactinoma • Nelson syndrome • Addisons disease • Side effects from steroid intake

35. MCQ A 45 year old Asian Man is diagnosed with cushings disease in India. He undergoes a bilateral adrenalectomy and recovers well from the operation. On his return to the UK 1 year later, he complains of a constant dull headache, peripheral visual disturbances and increasing pigmentation of the skin creases on both hands. The most likely diagnosis is: • Ectopic ACTH secreting tumour: Could be(SCLC), but expect weight loss. • Prolactinoma: Some similar sympt due to compression, expect loss of libido, impotence + gynaecomastia • Nelson syndrome • Addisons disease: Similar sympt, no periph vision loss, we also have a more likely explanation • Side effects from steroid intake: Expect striae, bruising, weight gain

36. MCQ A 45 year old Asian Man is diagnosed with cushings disease in India. He undergoes a bilateral adrenalectomy and recovers well from the operation. On his return to the UK 1 year later, he complains of a constant dull headache, peripheral visual disturbances and increasing pigmentation of the skin creases on both hands. The most likely diagnosis is: • Ectopic ACTH secreting tumour: Could be(SCLC), but expect weight loss. • Prolactinoma: Some similar sympt due to compression, expect loss of libido, impotence + gynaecomastia • Nelson syndrome: Post bilateral adrenalectomies. Loss of negative feedback mean a pituitary microadenoma forms which secretes ACTH and can impede producion of other pituitary hormones • Addisons disease: Similar sympt, no periph vision loss, we also have a more likely explanation • Side effects from steroid intake: Expect striae, bruising, weight gain

39. MCQ 52 Yr old male presents to A+E after collapsing at home. He appears pale with cold extremities. BP 97/73, HR 110, temp 36.9, ECG normal. Blood and urine culture are negative. He was on holiday with his wife in wales but did not take his Crohns disease medication. Most likely diagnosis is: • Addisonian Crisis • Sepsis • MI • AAA rupture • Nelsons syndrome

40. 52 Yr old male presents to A+E after collapsing at home. He appears pale with cold extremities. BP 97/73, HR 110, temp 36.9, ECG normal. Blood and urine culture are negative. He was on holiday with his wife in wales but did not take his Crohns disease medication. Most likely diagnosis is: • Addisonian Crisis • Sepsis • MI • AAA rupture • Nelsons syndrome

41. Addisonian crisis • Important • What investigations would you do and why?

42. Addisonian crisis

44. THANK YOU