ENDOCRINOLOGY
~ >
V V
2 D
~ L
L 3
~ -
~ -
Keywords
History s/o acromegaly
MRI pituitary macroadenoma
GH normal does not rule out
acromegaly as it has pulsatile
-
secretion so not reliable
Investigation in Acromegaly
Confirmatory
Screening OGTT- Glucose
SERUM IGF-1 LEVELS cannot suppress GH
Keywords
• History suggestive of
acromegaly
• Drug treatment
Acromegaly Treatment of choice
Surgery
-
~
If contraindicated
SLR - Lanreotide
- / octreotide
86 no response
~
Pegvisomant
8f no response
~
Pasireotide
Features suggestive of
acromegaly
Confirmation
Screening
~
IGF-1 OGTT
Keywords
• Postpartum haemorrhage
• Hypoglycaemia
• Hypotension
• Hyponatremia
• No lactation
• Hormones low
Suggestive of pituitary apoplexy /
- Sheehan’s
Urgent treatment iv
hydrocortisone
-
Cabergoline/Bromocriptine
Cabergoline -1st choice
Bromocriptine- pregnancy
Diagnosis of prolactinoma easy
from question
Management
Treatment of choice
Medication in both
Micro/ Macro
(cabergoline)
Repeat prolactin Repeat MRI after
High 4 months
no size shrinkage /
Change the dopamine
persistent
agonist
hyperprolactinemia
Surgery
Physiology of Vasopressin (ADH)
Supra optic and paraventricular nucleus of
Hypothalamus
Secreted from pituitary
Acts on AVP receptor(V2) basal side of
principal cell in collecting duct of kidney
Insertion of Aquaporin(AQP) into
apical part of cell
Water reabsorption
Excess Deficit
SIADH Diabetes Insipidus
I
Urine
osm
Plasma
osm
Meningitis , encephalitis , tumour
Saline
SIADH
Inability to suppress ADH
More activity of ADH
Re absorbs water > salt from kidney
Dilution of blood
• Hyponatremia
• Euvolemia
• Concentrated urine ( increase osmolality)
Relatively increased
plasma volume
reduced RAS
Increased Atrial natriuretic peptide
Natriuresis ( urinary sodium high )
-
Keywords : Polyuria + High serum osmolarity
Loss of free water( absence of ADH/AVP)
S/P pituitary tumour surgery
Reduced AVP transcient
and recovers
Supplementation for 2 weeks
Other options
VAPTANS - SIADH
THIAZIDES- Nephrogenic DI
-
Keywords
• Lithium usage
• Low urine osmolality ( large
amount of urine passed )
• No improvement with
Desmopressin
Diabetes Inspidus
Desmopressin
Response No response
Central DI Nephrogenic DI
Keywords
1. Palpitation
-
2. Weight loss
3. Tremors
4. Sweating
5. Diarrhoea
Suggestive of
hyperthyroidism
Primary
hypothyroidism
~
Involvement of
Thyroid gland
Keywords
• History suggestive
of hypothyroidism
• Non compliant on
medication
• Altered mentation
- • Bradycardia
Myxedema coma
Other options
Heart failure Ketoacodosis Hashimoto
• Non pitting edema • No acidotic breathing • doesn’t present
• No breathlesness • No ABG with
• No Tachycardia bradycardia and
encephalopathy
-
Keywords:
Long standing MNG
exposed to iodine and
develops Thyrotoxicosis
( LOW TSH)
-
JOD BASEDOW
PHENOMENON ( Jumping
of thyroid hormones )
Other options
-
Thyroid storm
Hashimotos Subacute thyroiditis
Patient in
Thyroid is going to be question has
Causes hypothyroidism
painful and tender thyrotoxicosis
and no
symptoms
suggestive of
storm
Keywords
1. Untreated Graves
2. Symptoms of storm -
CNS symptom
3. Drugs blocking
peripheral conversion
PTU
Methimazole -
inhibits TPO
PROPRANOLOL -
symptom
management
Lugol iodine - wolf
chaikoff effect
-
Symptoms suggestive of hypothyroidism
TSH FT4
Sub clinical
Hypothyroidism
Central hypothyroidism
Primary hypothyroidism
Sick euthyroid
A. Anti TPO abs -
Hashimotos ( causes
hypothyroidism )
-
Keywords
• Low serum osmolality
• High urine osmolality
- That is excess ADH is
concentrating urine , by
excessive reabsorption of water
and diluting blood
Low serum osmolality
High urine osmolality
SIADH
treatment
Mild Moderate to
severe
Hypertonic
Fluid
saline / Vaptan
Restriction
Serum osmolality high
Urine osmolality low
Blood is concentrated
~ because more water is lost
in urine
diabetes insipidus
Water deprivation
Urine concentrates No concentration of urine
Psychogenic polydipsia Desmopressin -
Urine
Urine
osmolality
osmolality
doesn’t
improves
improve
Central DI Nephrogenic DI
>
Cabergoline/Bromocriptine
Cabergoline -1st choice
-
Bromocriptine- to induce
pregnancy
-- al
~
Steps
1. Diagnose DKA in
both by using
definition
2. Decide management
mbolusnatient
20
has shock
Blood sugar - > 200 mg/dl
Blood sugar > 200 mg/dl
+ urine ketones 4+
+ urine ketones positive
DKA
DKA
SINCE Patient sodium is high and
Management will be IVF
Glucose less than 250 combination
+ Insulin
Of 1/2NS and 5% Dextrose are apt
CHILD DKA ADULT DKA
• IV Fluid for 1 hour • IV fluid + insulin
followed by insulin
• No bolus insulin • no bolus but consider if
insulin infusion delayed
• Bicarbonate • Bicarbonate if pH <7
if pH <6.9
[Injectable -
Type 2]
screening
↓
34
-
Palpitation
perspiration
Pain (Headache
Syndrome Manifestation Gene
Il
MEN 3/ RET gene
MEN2B
Chromoso
En
me 10
/ --
M M M
Mucosal
Medullary Medullarya Neuroma
thyroidenoma adrenal
pheochromo
cytoma
Triaes 3 MEN
with Marfan's
3M
standing
on
.MEN 4 Mnemonic CDKN1B
RARE MEN 1 without pancreas
Chromoso
Reproductive organ tumor me -12
Adrenal tumor (RARe)
Renal tumor
tumour
<
MEN2
without
Pituitary adenoma 3'p'
Parathyroid adenoma pancreatic
involvement)
Harrison’s principle of internal medicine page 2984
MEN SYNDROME
-
Parathud
a
Tparathyroid
noma
↑
Peritory Pancreaa Fur carcinoma
pheochromocy
MEN-I MEN-2 tora
- -
Marjan's
Fanta
carcinoma
Tedua
adrenal-
I
neuroma .
pheochromocyt
- oma
MEN-3
-
Keywords
ACR -150mg/g
Microalbuminuria
AER Diabetic Nephropathy
· omglg
30-300 mglg
Microalbuminuria
First line
Macroalbuminuria 300mglg
>
SGLT 2 inhibitor
+ Metformin
Keywords
Dizziness on standing -
postural hypotension
Early satiety - Diabetic
Gastropathy
Erectile dysfunction
BP > 20 mm Hg fall in systolic
and 10 mmHg fall in diastolic -
Postural hypotension
Autonomic neuropathy
Diabetes history -
Diabetic autonomic
neuropathy
-
Drug beneficial in IHD and
~
Diabetic Nephropathy
SGLT-2 inhibitor
(Dapagliflozin)
-
Options
Basal insulin MDI- basal insulin
CSII - allows
given as once is for continuous
adjustments
daily dosage coverage and short
irrespective acting insulin is for
of meals post prandial
glucose spikes
Glargine is long acting
Keywords
Triad of Pheochromocytoma
• Sweating
• Palpitation
• Headache
Pheochromocytoma
Screening test confirmatory test
24 hour urinary fractionated Plasma free metanephrines
Metanephrines
Pheochromocytoma
Alpha+ Beta activity
by catecholamines
On giving beta blocker
Uninhibited Alpha activity
Accelerated hypertension
Hence alpha blocker
( phenoxybenzamine)
followed by beta blocker
~ BP ↑ > - Pheo
painless nodule
-
S Mucosal neuroma
-
~ Marjan's
Thyroid
-
-
MIC
-
of Cushing's
Screening
↓
cortisol
① ahhe urinary free
& Denamethasone
overnight
cortisol
salivary
③ Midnight
↓
Confirmat
Low dose dena
- ↓+ ve
ACTH
---
↑
pituitary + Adrenal
-
MRI ↓
dos adrenal
-
High 77
deva
x-
0
⑦
Ectopic
Pituitary
~
Resistant hypertension +
hypokalemia
↓
Hyperaldosteronism
-
↓
-
Screening: aldosterone -
renin ratio
U
↓
Confirmation: saline infusion
test
↓
CT adrenal
History if missing steroid dose
Vomiting , abdominal pain ,
hypotension
-
Hypotension
Addisons disease
Iv fluids and iv
hydrocortisone
↑
- Benzathine penicillin
prophylaxis every 3-4
weeks
Secondary prophylaxis in Rheumatic fever depends on cardiac
involvement
Condition Duration of prophylaxis
RF without carditis 5 years after last attack / 21
years whichever is longer
10 years after attack / 21 years
RF with carditis but
whichever is longer
no residual heart defect
RF with carditis 10 years after attack /
and residual 40 years whichever is
Heart defect longer , sometimes
lifelong
↑
↑ ↓ ↑ ↓
↑
↓
↓
↑
↑
↑
Elevated PTH
Sestamibi scan showing
parathyroid Adenoma
-
Hyperparathyroidism
surgery- 1st line
treatment
Hypocalcemia
Hyperphosphatemia
Low PTH
History of thyroid
-
surgery
Hypoparathyroidism
Hypocalcemia
+ Hyperphosphatemia+ PTH
elevated
Resistant hypoparathyroidusm
Round face and short 4th
-
metacarpals
Albright hereditary
osteodystrophy
Pseudohypoparathyroidism
Fatigue, constipation,
polyuria and
hypercalcemia
Suppressed PTH + elevated
-
PTHrP
Malignancy
secreting PTHrP
Resistant hypertension +
hypokalemia
↓
Hyperaldosteronism
-
↓
-
Screening: aldosterone -
renin ratio
U
-
↓
Confirmation: saline infusion
test
↓
CT adrenal
Keywords
History s/o acromegaly
Random GH is not reliable
IGF-1 - screening test elevated
Question is about confirmation
-
-
Investigation in Acromegaly
Screening
SERUM IGF-1 LEVELS Confirmatory
OGTT- Glucose
cannot suppress GH
Diagnosis of prolactinoma easy
from question
Management
Treatment of choice
Medication in both
Micro/ Macro
(cabergoline)
Repeat prolactin Repeat MRI after
High 4 months
no size shrinkage /
Change the dopamine
persistent
agonist
hyperprolactinemia
Surgery
-
Keywords
• low urine osmolality
• polyuria
• Dehydration
• No improvement with
- Desmopressin
Diabetes Inspidus
Desmopressin
Response No response
Central DI Nephrogenic DI
Hyponatremia
No edema - euvolemic
hyponatremia
-
Natriuresis+ Concentrated
urine ( inappropriate ADH
activity )
Treatment
Mild Symptomatic
( confusion)
Fluid restriction
Hypertonic
saline +_
vaptans
Hyperglyemia + acidosis+
ketosis
DKA
(p1 < 7)
-
(Not inDKA) Children Adults Iv fluids
(Not in DKA) +insulin infusion
Iv fluids ' simultaneously
After one hour insulin
infusion
No bolus
-
Drug beneficial in IHD and
~
Diabetic Nephropathy
SGLT-2 inhibitor
(Dapagliflozin)
Calcium Ne Parathyroid
adenoma
Father pituitary
pituitary
surgery
-
-
adenoma
Screening test
1. 24 hour urinary free cortisol
2. Dexamethasone overnight
test
3. Midnight salivary cortisol
-
Confirmation
Low dose dexamethasone
suppression
Differentiation between
ectopic and pituitary
ACTH
High dose
dexamethasone
suppression test
-
sno hyperpigmentation)
-
Screening test in
hypothyroidism - TSH
Screening test in
hyperthyroidism - TSH and
Free T4
-
.'
-
Keywords
• polyuria+
polydipsia+hypernatremia
• Low urine osmolality
( large amount of urine
passed )
improvement with
Desmopressin
Diabetes Inspidus
Desmopressin
Response No response
Central DI Nephrogenic DI
