ENDOCRINOLOGY
WORKBOOK
By
Dr. Priyansh Jain
RISE WITH ARISE
ARISE MEDICAL ACADEMY
https://instagram.com/arisemedicalacademy
www.arisemedicalacademy.com
INDEX
1. Pathogenesis of diabetes
2. Diabetes - presentation, diagnosis & complication
3. DKA & HHS
4. Thyroid physiology
5. Interpretation of thyroid profile test
6. Hypothyroidism & Hyperthyroidism
7. Thyroid disorders
8. Adrenal gland physiology
9. Hyperaldosteronism
10. Cushing sundrome
11. Pheochromocytoma
12 . Adrenal insufficiency
13. Parathyroid gland - physiology
14 parathyroid gland - pathology
15. Pituitory glamd - physiology
16. Pituitory disorders
17. Endocrine neoplasia
Chapter 1
Pathogenesis of Diabetes mellitus
PATHOGENESIS OF TYPE 1 DM
Relation of Insulin with body weight
Occur at Age-
B- cell mass at the time of diagnosis-
Concordance in identical twins -
body wt
PATHOGENESIS OF TYPE 2 DM
B-cell
Glut-2
Blood
S.muscle
Body wt
PATHOGENESIS OF TYPE 1.5 DM
LADA -LATENT AUTOIMMUNE DIABETES OF ADULTS
PATHOGENESIS OF Maturity onset of diabetes (MODY)
M
GLUT 2
HNF-1-ALPHA
Endoplasic reticulum
B-cell
CaLcium channel
Inheritance pattern -
So
Types. Of MODY
Age of onset -
B-cell mass-
Rx-
BRONZE DIABETES
Caused by -
Iron deposition - skin
- liver
- pancreas
So manifest as
Type 3 Diabetes
Summary
Type Of DM Pathogenesis
1
1.5
2
Mody
Bronze
Overall M/C type of DM -
Overall most rare type of DM-
Also know
Gene associated with insulin production - CTL4A
chromosome for MODY type 3- chromosome 12
Chapter 2
Diabetes Presentation , diagnosis and Complications
C/f
Diagnosis
Pre-diabetes
Normal Impaired glucose Diabete
tolerance
Fasting
Post prandial
HbA1C
Random
Post prandial means -
Best test for
HbA1C
Sugar level Sugar level
95 mg/dl 95 mg/dl
Hb - 15 gm/dl Hb - 5 gm/dl
Glycated albumin ( s. Fructosamine ) -
Shows average blood sugar of -
Oral glucose tolerance test (OGTT)
4pm 6pm
Extra point
Healthy So
4pm 6pm
DM So
4pm 6pm
Mechanism for Fasting hyperglycemia
healthy Meal
Fasting sugar at 8am
DM
Fasting sugar at 8am
7pm
Mechanism for Post prandial hyperglycemia.
healthy Meal
DM
Meal
Complication of DM
Myocardium
Brain
Earliest change Earliest change
Most specific change Most specific change
So retinal examination in type 1 DM.........................
and type 2 DM .............
Managment of DM
1- BIGUANIDES
MOA
Effect on Hb1aC
S/E -
C/I
2 - sulfonylurea - 1st generation
2nd generation
MOA
S/E
MOST POTENT
3- SGLT -2 inhibitors
SGLT2
Eg-
S/E
Preferred in
4 thiazolidinediones
MOA
S/E
5.Incretins
GLP(glucagon like peptide -1 ) analogue -
MOA
S/E-
DPP-4 INHIBITOR-
Most renal safe DPP-4 #-
6. Alpha- glucosidase inhibitor
Complex carbohydrate
Glucose
Other
Carbohydrate
Glucosidase
7. Amylin analogue
Gastric emptying
8.insulin
Basal insulin
Prandial insulin
Complication of insulin therapy
DAWN phenomenon
Gloucose
Level
Somogyi phenomenon
So in
Type 1 DM
Type 1.5 DM
Type 2 -
MODY
Summary
*Hb1ac shows average of - ........................weeks
2. Anemia leads to fasle ............ HB1ac
3. FALSE + OGTT --
4. FALSE - ve OGTT -
5. Fasting hyperglycemia in DM is due to ........
6.anti - diabetic to avoid
If -- DM + HF
-- DM + medullary ca of thyroid
-- DM + uti
-- DM +MI
7. Maximum Hb1AC reduction -
8. Longest acting insulin -
9. Dawn phenomenon - fasting .................................. Rx-
10. Somogyi phenomenon - fasting ........................... Rx-
Chapter 3
Diabetic keto acidosis (DKA) &
Hyperglycemic Hyperosmolar State (HHS)
DIABETIC KETO ACIDOSIS
Pathogensis
B- cell
Fatty acid
Blood
glucose
Tissue
C/f-
Investigation - blood glucose level-
- urine keton
- ABG - pH-
- S. Na+
Rx-
Complication
Initially Later
Hyperglycemic hyperosmolor state
Commonly seen with -
Age -
Pathogenesis
Blood osmolarity
Blood
C/f
Treatment
Summary
1. DKA commonly seen with type ...... DM and trigger is ......................../,..........,.....
2. M/C keton body synthesized in liver is -
3. Keton body having fruity smell-
4. Keton body can be detected by -
5. Main stay of rx in DKA-
6. ............................... insulin used in DKA managment .
7. MCC of death in DKA is .............
8. HHS seen with type .... DM in ..................... age group .
9. C/f of HHS - commonly - ...................................t manifestation .
10 . prognosis of HHS
Chapter 4
Thyroid Physiology
Thyroid gland
Cancer of parafollicular c cell is called
Pituitary
T4 v/s T3
Production
Activity
Half life
Convertion of T4 To T3
Brain
Effect of thyroxine
On α recpetor
On B- receptor
Metabolism
Bone
Testosteron
Thyroid FeedbBack system
Hypothalamus
Pituitary
Chapter 5
Interpretation of thyroid profile test
Hypothalamus
Pituitary
Hypothalamus
Pituitary
Hypothalamus
Pituitary
Hypothalamus
Pituitary
Hypothalamus
Pituitary
Lets practice
T4 TSH Diagnosis
Primary hyperthyroidism
Sick euthyroid syn
Chapter 6
Hypothyroidism & Hyperthyroidism
Hypothyroidism
Etiology
C/f. - Metabolism
Lipid level
Hair
Eyebrow
Skin-
Deep tendon reflex
Heart (ECG)-
GIT -
body temprature-
Menstrual bleed-
Rx-
Hyperthyroidism
Etiology
C/f. - Metabolism-
Skin-
Deep tendon reflex -
Heart - HR ........./ SBP ......../ ......CMP/.......... .............. murmur
Hands-
GIT -
body temprature-
Menstrual bleed-
Upper eye lid sign of hyperthyroidism
Managment of hyperthyroidism
Follicular cell Colloid
So
1. Thyroid peroxidase inhibitor -
2. Harmone release inhibitor -
3. Peripheral convertion inhibitor-
Chapter 7
RAIU & Thyroid disorders
Radioactive iodine uptake test (RAIU)
For RAIU - ................... ...... is used.
Mechanism of RAIU -
Thyroid Pathology
Hashimoto thyroiditis
Pathogenesis
Thyroglobin (TG)
Thyroid peroxidase (TPO)
Associated with -
C/f - initially -
- later. Stage (main) -
Increased risk of -
Biopsy -
Rx-
Subacute thyroiditis or dequervein thyroiditis
Pathogenesis
C/F - initially
- later
Rx-
Reidel thyroiditis
Pathogenesis
C/f-
Associated with -
Rx - for hypothyroidism
- to decrease fibrosis-
Grave disease
Pathogenesis
Immune
Pituitary system
TSH receptor
Associated with-
Rx
Toxic multinodular goiter
Pathogenesis
C/f
Rx
Thyroid storm
Pathogensis
C/f - HR -
BP -
Body temp. - Sensorium -
Rx-
Myxedema coma
Pathogenesis
Poe
C/f - HR -
BP-
Body temp.-
Sensorium - S.glucose............. S.Na +..............
Rx-
Extra point - Wolf- chaikoff effect
Jod basedow effect
Summary
1. More active .......... form .
2.more production of .............. form.
3. Calcitonin is secreted by ..................................................cell.
4.MCC of hypothyroidism .........
5. DTR - In hypothyroidism ..........
- in hyperthyroidism..........
6.upper rim of sclera is visible is called as .................................. sign.
7.thyroid peroxidase inhibitor drugs ........
8.most safe anti thyroid medication in pregnancy ................
9.RAIU in a) thyroiditis..............................
b) Grave disease ........./
10.hashimoto thyroiditis - HLA .................. // Anti ........... Ab
-Bx
11.viral illness f/b pain in neck (tender thyroid) - .......................
12.fibrosis of thyroid gland ............................. thyroiditis .
13. Excess Iodine leading to hypothyroidism -c/a- .............. ............. effect
14. Delibrate ingestion of thyroxine to loose wait c/a ............. ................
On raising the arm
Goiter
Svc
SVC
RA
RA
Chapter 8
Basics of Adrenal Gland
Medulla
Increase in Aldosteron -
Increase in Cortisol -
Increase in NE/E -
Slow (Gradual) decrease in all adrenal haromones -
Rapid (acute) decrease in all adrenal harmones -
RASS system (Renin - Angiotensin - Aldosteron-System)
Angiotensinogen
ENaC
Gain of ............ & .........
Blood
So loss of ........... & ...........
in urine
ALDOSTERON - leads to S.Na+ .........
S.K+........
S.H+........
Chapter 9
Hyperaldosteronism
Definition Aldosteron so - S.Na + ......... / S.K+............./ S.H+................
From zona ..................................... of adrenal gland.
Etiology
Definition -
1 hyperaldosteronism
2 hyperaldosteronism
Summary
1 hyperaldosteronism 2 hyperaldosteronism
Aldosterone
S.Na+
S.K+
Metabolic
HTN
Renin
Pedel edema
Rx
Chapter 10
Cushing Syndrome
DEFINITION - increase in ........
Pituitary
Cortisol
Level
Cortisol
Time
Etiopathogenesis
Pituitary
Iatrogenic Pituitary tumor Lung cancer
Cortisol
ACTH
Pigmentation
Headache
Hemoptysis
C/f
Blood sugar -
BP -
Work up Cushing suspected
1.Screening test of choice
2. IOC
To differentiate between iatrogenic v/s pitutory tumor / lung cancer
Managment-
1. Cortisol receptor antagonist-
2. Cortisol synthesis inhibitor -
3 .In Cushing Disease to decrease release of ACTH from pituitary
tumor -
Summary of cushing syndrome
1. M/C/C of cushing syndrom -
2. 2nd MCC of Cushing syndrome ............................. ..............c/a .......... ...............
3. earliest pathological change of cushing syndrome -
4. MC C/F -
5. Blood sugar ........................and BP.........................
6. pigmentation of skin is seen if cause of cushing syn is .........................
........................
7. Screening test of choice
8 IOC
9 To differentiate between pituitary adenoma v/s lung cancer -
Chapter 11
Pheochromocytoma
Definition- Tumor of .........................................found in ............
Etiopathogenesis
AORTA
........... % Pheochromocytoma are extra adrenal.
........... % Pheochromocytoma are Malignant .
........... % Pheochromocytoma are bilateral.
C/f - .............. activity of sympathetic system
...rec
....rec
....... metabolism so wt ......
Investigation -
screening test of choice
IOC-
For localization -
Rx
RxOC-
Summary of PCC
A/C/A -
RULE of 10
Rule of 5o -
Rule of 9-
M/C extra-adrenal site
M/C- c/f -
Screening test -
IOC -
RX - ......... blocker f/b .......... blocker .
Chapter 12
Adrenal Insufficiency
1 adrenal insufficiency
Etiopathogenesis
Z.glomerulosa
Z.fasiculata
Z.reticularis
M/C/C- worldwide-
- India
- HIV patients -
C/f - due to decrease in aldosterone - S.Na+......./ S.K+......../S.H+....
-due to decrease in cortisol -
-due to decrease in sex harmone -
-due to increase in ACTH -
IOC -
Rx. -DOC -
- For salt craving-
ACUTE ADRENAL INSUFFICIENCY
Pathogenesis
DOC
Chapter 13
Physiology of parathyroid gland
Secretes
Activation of
Bone
Blood
Blood
Urine
Net effect of PTH - S.Ca+.........../ S.po4 ........../ ALP.............
Chapter 14
Parathyroid Pathology
1 hyperparathyroidism Etiopathogenesis
Definition - increase in PTH due to
Parathyroid gland
Excess ........
Excess activation of ...................
.................................................
Urine
Investigation - PTH........ / S.Ca+........ / S.PO4........ / ALP.......
For localization of tumor -
DOC
RxOC-
2 Hyperparathyroidism
Definition ..............in PTH due to ........
Etiopathogenesis
Absorption of
Parathyroid gland
Blood
Investigation - PTH........ / Vit D........ / S.PO4........ / ALP.......
S.Creatinine........ / S. Ca+2.......
Rx-
Hypoparathyroidism
Etiopathogenesis- .......................... in PTH
Due to .................................
C/f
Chvostek sign. Trosseau sign
ECG
S Ca+2
Rx -
Extra point
Pesudo-hypoparathyroidism Pseudo-Pesudo-hypoparathyroidism
Bone. Kideny Bone. Kideny
Summary
1.effect of PTH ---S.Ca+2 .........and S.PO4..........
2. 1 hyperParathyroidism - MCC -
- Xray skull-
-PTH ........ S.Ca+2 ...... S.PO4.......
3. 2 hyperParathyroidism - MCC -
- Bone defect c/a-
- PTH ........ S.Ca+2 ...... S.PO4.......
4.Hypoparathyroidism - PTH ........ S.Ca+2 ...... S.PO4.......
Carpo -pedal spasm with BP Cuff c/a - ......................... sign.
* Troisier sign---
5.PTH - Both bone and kidney resistant -
- only bone resistant
- associated with .................... gene mutation.
Chapter 15
Basics of pituitary Gland
Hypothalamus Periventricular nucleus
Supraoptic nucleus
Pituitary stalk
Adenohypophysis Neurohypophysis
Prolactin
GH
Antidiuretic harmone (ADH)
TSH
ACTH Oxytocin
FSH/LH
Control of ant. Pituitary
Hypothalamus GHRH Dopamin TRH CRH GnRH
Ant.Pituitary GH Prolactin TSH ACTH FSH/LH
Pituitary injury v/s pituitary stalk injury
Hypothalamus Hypothalamus
Pituitary
Pituitary harmone level - ................ Pituitary harmone level - ................
Prolaction level ........................ Prolaction level ........................
Extra points for pituitary injury
1. Pituitary injury if due to obstetric cuase
2. Pituitary injury if due to obstetric cuase
1 st harmonen to decrease -
Last harmone to decrease -
1st harmone to be replaced via treatment-
Chapter 17
Pituitary disorders
Hyperprolactinemia
Definition - ............................... level of prolactin
Etiopathogenesis-
1. 2. 3
Hypothalamus Hypothalamus
Pituitary Pituitary
Prolactin
C/f- increased prolactin - 1.
2.
3.
screening test -
IOC -
Rx- 1.
2. In pregenancy
3. If compression symptom-
Acromegaly
Definition -
Increase in GH before puberty is called as -
Clinicopathogenesis
Increased GH - ............................ Somatomedins -
Facial feature
Voice
Hand and ring size
Hands looks like .............
GH
1981 1982 1983 1984
Screening test of choice -
Confirmatory test-
For size of tumor
Rx- if resectable tumor -
If non-resectable - initial treatment -
Best drug -
Extra point GH receptor anomaly
Xray foot
SIADH Syndrome of inappropriate secretion of
antidiuretic harmone (ADH)
Etiology - H
E
L
D
Physiology fact
* ADH is secreted from ........ ............ acts on ........receptor
in collecting tubles of nephron and opens .................................
channels which leads to...................................water absorption
from.................
Pathogenesis
SIADH
ADH
V2 receptor
Bloodvolume
Heart
Gain of
.........
Loss of ......... &........
ANP- atrial natriuretic peptide
BNP- brain natriuretic peptide
C/f -
Investigation - IOC -
urine osmolarity ...
Plasma osmolarity ... DOC
Diabetes Insipidus
Post. Post.
Pituitary Pituitary
V2 rep V2 rep
Urine amount Urine amount
Urine osmolarity Urine osmolarity
Plasma osmolarity Plasma osmolarity
ADH level ADH level
IOC
DOC DOC
Extra point
Polyuria ( 3lit./day or >40ml/kg/day)
Urine volume .... Urine volume ....
Urine osmolarity .... Urine osmolarity ....
Plasma osmolarity.. Plasma osmolarity..
Extra point
DM + DI + Optic atrophy -
Endocrine neoplasia
Insulinoma - tumor of ........ cell so .............. insulin
C/f-
Ioc -
For localizing tumor -
Rx-
B-cell hyperplasia is called as-
VIPOMA -
(VIP - vaso active intestinal peptide )
A/c/a -
C/f -
Glucagunoma - tumor of ......cell so ...................
C/f - blood sugar
- skin -
Gastrinoma/ zollinger elison syndome
Tumor or ...... cell. M/c site-
C/f-
Doc-
Multiple endocrine neoplasia (MEN)
MEN 1 MEN 4
overall mc enteropancreatic tumor
M/C pancreatic tumor
MEN 2A MEN 2B (MEN 3)
Summary -
1.Pituitary gland injury - prolactin level .......-
2.Pituitary stalk injury - prolactin level ....
3. Prolactinoma - mcc -
-DOC
-DOC in pregnancy
4.ACROMEGALY - voice
- MC cancer
Screening test
IOC
Xray foot -
Rx- initial
- BEST-
5.SIADH
MCC -
PATHOgenesis -.................................. ....................natremia.
Urine osmolarity - .........
IOC -
DOC
6. Diabetes insipidus
Central - ADH level -
Nephrogenic - ADH level -
Urine osmolarity ...
IOC
rx - central
- nephrogenic -
7. Insulinoma
C/f - ................... triad
IOC -
FOR localization --
8. Glucagunoma - skin finding
9 VIPOMA- c/f - ...........................................
K+. ........ / cl-.........
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