Endocrine Revision:
A 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)
Free T3 12.5 pmol/l (high)
What is the most likely underlying pathophysiology in this patient?
A 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 (exophthalmos) and a diffuse swelling (pretibial myxoedema) in her neck and shins. Her blood tests show:
TSH 0.1 mU/l (low)
Free T4 32.5 pmol/l (high)
Free T3 12.5 pmol/l (high)
What is the most likely underlying pathophysiology in this patient?
What are the appropriate treatment options?
What are the appropriate first-line treatment options for Graves Disease?
Control symptoms with propranolol; antithyroid drugs like carbimazole, propylthiouracil
A 42-year-old woman presents with a 2-week history of fever and malaise. On examination, the patient reports a dull, aching pain in the front of her neck that is painful on palpation. She has felt increasingly fatigued and noted mild palpitations and heat intolerance. She denies significant weight changes but admits to occasional sweating and irritability. Two weeks ago, she had a sore throat and mild fever, which resolved after a few days.�
TSH 0.2 mU/l (low)
Free T4 33.4 pmol/l (high)
Free T3 12.7 pmol/l (high)
�What is the most likely underlying pathophysiology in this patient?
A 42-year-old woman presents with a 2-week history of fever and malaise. On examination, the patient reports a dull, aching pain in the front of her neck that is painful on palpation. She has felt increasingly fatigued and noted mild palpitations and heat intolerance. She denies significant weight changes but admits to occasional sweating and irritability. Two weeks ago, she had a sore throat and mild fever, which resolved after a few days.�
TSH 0.2 mU/l (low)
Free T4 33.4 pmol/l (high)
Free T3 12.7 pmol/l (high)
�What is the most likely underlying pathophysiology in this patient?
What are the appropriate treatment options?
What are the appropriate treatment options for Subacute Thyroiditis (De Quervain’s Thyroiditis)?
Early Stage: Control symptoms with propranolol; pain control (NSAIDs/Corticosteroids)
The hyperthyroid phase is due to the release of preformed thyroid hormones from damaged thyroid follicles; it is a temporary phase that is followed by a longer hypothyroid phase
Later stage: Monitor thyroid function, possible levothyroxine replacement
A 35-year-old woman presents with a 6-month history of fatigue, weight gain, and cold intolerance. She reports feeling unusually tired despite adequate sleep, and she has gained approximately 5 kg over the past few months despite no significant changes in her diet. She mentions that she has noticed her skin becoming dry and hair thinning. Upon examination, the patient has pale skin, bradycardia (52 bpm), and a symmetrical, smooth non-tender goiter in her neck. She recently immigrated to Scotland from a mountainous region in South Asia. Her blood tests show:
TSH (high)
Free T4 (low)
Anti-TPO Negative
What is the most likely underlying pathophysiology in this patient?
A 35-year-old woman presents with a 6-month history of fatigue, weight gain, and cold intolerance. She reports feeling unusually tired despite adequate sleep, and she has gained approximately 5 kg over the past few months despite no significant changes in her diet. She mentions that she has noticed her skin becoming dry and hair thinning. Upon examination, the patient has pale skin, bradycardia (52 bpm), and a symmetrical, smooth non-tender goiter in her neck. She recently immigrated to Scotland from a mountainous region in South Asia. Her blood tests show:
TSH 0.1 mU/l (low)
Free T4 32.5 pmol/l (high)
Anti-TPO Negative
What is the most likely underlying pathophysiology in this patient?
Treatment
Hyperthyroid:
Propranolol (dampens sympathetic nervous system), Propylthiouracil/carbimazole (blocks synthesis of thyroid hormones), radioiodine treatment(destroys overactive thyroid tissue), and surgery (remove overactive thyroid tissue)
Hypoparathyroidism Treatment:
Replace with levothyroxine (exogenous thyroid hormones substitute)
Calcium regulation
The two hormones which primarily control calcium metabolism are:
What are the actions of PTH?
What are the actions of calcitriol?
Calcium regulation
The two hormones which primarily control calcium metabolism are:
What are the actions of PTH?
What are the actions of calcitriol?
A 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 most likely underlying cause?
A 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 most likely underlying cause?
Hypocalcemia, as a result of hypoparathyroidism from damaged parathyroid glands during thyroidectomy
What is the treatment?
A 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 most likely underlying cause?
Hypocalcemia, as a result of hypoparathyroidism from damaged parathyroid glands during thyroidectomy
What is the treatment?
Calcium supplementation, vitamin D might be added
Magnesium deficiency must be corrected before calcium supplementation because magnesium is essential for the proper secretion and function of PTH, and for the activation of vitamin D to enhance calcium absorption.
A 60-year-old postmenopausal woman presents with fatigue, joint pain, and increased anxiety over the past few months. She reports recurrent kidney stones in the last 2 years. Her memory is worsening, and she feels more irritable. She has mild swelling in her knees. The patient has no history of chronic kidney disease or vitamin D deficiency. What lab value is most likely to be decreased?
A 60-year-old postmenopausal woman presents with fatigue, joint pain, and increased anxiety over the past few months. She reports recurrent kidney stones in the last 2 years. Her memory is worsening, and she feels more irritable. She has mild swelling in her knees. The patient has no history of chronic kidney disease or vitamin D deficiency. What lab value is most likely to be decreased?
The patient most likely has primary hyperparathyroidism
What do these arterial blood gas values indicate?
What do these arterial blood gas values indicate?
Acidotic
Not due to excess
CO2
Is due to insufficient HCO3
Possibly raised anion gap?
An 10-year-old boy with no past medical history presents to the emergency department with diarrhoea and vomiting. He complains of abdominal pain. He had a blood glucose finger-prick test which read Glucose = 24. An arterial blood gas was performed (as listed on the previous slide). The anion gap is confirmed to be elevated. What is his most likely diagnosis?
An 10-year-old boy with no past medical history presents to the emergency department with diarrhoea and vomiting. He complains of abdominal pain. He had a blood glucose finger-prick test which read Glucose = 24. An arterial blood gas was performed (as listed on the previous slide). The anion gap is confirmed to be elevated. What is his most likely diagnosis?
Diabetes
DKA - Diabetic ketoacidosis
A 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?
A 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?
The most likely diagnosis is Cushing’s disease which is characterised by high cortisol
Cushings
Endocrine HTN (5-10%)
⇡ ALDOSTERONE
⇡ CORTISOL
⇡ CATECHOLAMINES
Too little
🡪 Hypotension
Adrenaline, Noradrenaline
Hyperaldosteronism
Cushing’s
Phaeochromocytoma
SALT
SUGAR
SEX
G
F
R
Mineralocorticoids
Glucocorticoids
Androgens
Addison’s Disease
Primary Adrenal Insufficiency
⇣ Aldosterone 🡪 Hyponatraemia, Hypotension (postural)
⇣ Cortisol 🡪 Hypoglycaemia, ⇡ ACTH
- Skin Pigmentation
Autoimmune (Hx / FH)
Early am Cortisol (Low / not v useful)
Short SynACTHen (< Double baseline)
ACTH (HIGH)
Adrenal cortex / 21-hydroxylase Abs (80%)
HYDROCORTISONE
Fludrocortisone
Glucocorticoid
Mineralocorticoid
Decreased Libido
🡪 Androgen replacement (DHEA)
*SICK DAY RULES
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 lab test would be used to confirm the most likely diagnosis?
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 lab test would be used to confirm the most likely diagnosis?
Follicle-Stimulating Hormone
FSH increases due to the loss of negative feedback on FSH from lack of estrogen. It is usually diagnostic for menopause.
Menstrual cycle
Menopause
Main symptoms:
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 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 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 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?
Marge 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?
Marge 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 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 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?�
6 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?
6 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?
Milestone | Definition | Typical Age Range |
Adrenarche | Activation of adrenal glands, leading to androgen production | 6–8 years |
Thelarche | Breast development due to estrogen | 8–13 years (average 10-11) |
Pubarche | Development of pubic and axillary hair due to androgens | 8–14 years (often after adrenarche) |
Menarche | First menstrual period | 11–14 years (average 12-13) |
Puberty | General development of secondary sexual characteristics and growth spurts | 8–14 years (typically earlier in girls) |
Testicular Enlargement (in boys) | Increase in testicle size due to testosterone production | 9–14 years |
Puberty
Neuroscience Revision
Key areas- Neuro
Thinking about localising pathology…
WHERE?
WHEN?
�
A 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 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 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 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?
Distinguishing between UMN and LMN lesions
What type of lesion does this represent?
What type of lesion does this represent?
Sensory pathways/ ascending tracts
A 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 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 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 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 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 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?
Bonus Q! How could you treat?
A 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?
Bonus Q! How could you treat?
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?���
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 hemianopia
A 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 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 70-year-old man presents to the clinic with a one-year history of progressive difficulty walking and occasional trembling in his hands. He reports feeling stiff, especially in the morning, and notes that he struggles to keep up with his grandchildren when walking. His wife mentions that his handwriting has become smaller and less legible. On physical examination, the patient demonstrates mild rigidity in the upper limbs, reduced arm swing while walking, and slowness in rapid alternating hand movements. His reflexes are normal, and there is no muscle weakness.
Which of the following findings is most consistent with the likely underlying condition?
A 70-year-old man presents to the clinic with a one-year history of progressive difficulty walking and occasional trembling in his hands. He reports feeling stiff, especially in the morning, and notes that he struggles to keep up with his grandchildren when walking. His wife mentions that his handwriting has become smaller and less legible. On physical examination, the patient demonstrates mild rigidity in the upper limbs, reduced arm swing while walking, and slowness in rapid alternating hand movements. His reflexes are normal, and there is no muscle weakness.
Which of the following findings is most consistent with the likely underlying condition?
Parkinson’s Disease
You 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 18 mmHg (normal: 7–15 mm Hg). ��Which of the following pathophysiological changes explain his clinical deterioration?�
You 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 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 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 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 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?
Epilepsy
A 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 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?
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?
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 haemorrhage
A 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 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?
An 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?
An 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?
Which of these statements is false?�
Which of these statements is false?�
A 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 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?�
Multiple sclerosis
A 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 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 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
Neutrophils
Further resources
Feedback
Please take a minute now before you leave to fill in a quick feedback form:
Thank you for coming!