Endocrinology

E-1 Pathogenetic classification of diabetes mellitus

DM type 1: autoimmune response, destruction of insulin-producing beta-cells of pancreas,

DM type 2: Insulin resistance or impaired insulin secretion due to progressive destruction and dysfunction of B-cells. Obesity and a sedentary lifestyle.

Gestational Diabetes: Impaired Glucose Tolerance during pregnancy

Specific types:
Genetic (B-cell function or insulin action)
pancreatic conditions
Endocrine conditions
Drug induced
infections

E-2 Diabetes diagnostic and metabolic compensation criteria

Diabetes Diagnostic Criteria

Hemoglobin A1c (HbA1c) ≥ 6,5%
Fasting plasma Glucose 7> mmol/L
Oral glucose tolerance test: ≥11.1 mmol/L
Random blood glucose level ≥ 200 mg/dL
symptoms: polyuria, polydipsia, weight loss

Metabolic compensation criteria (all in normal range)
TAG, Cholesterol, BMI, BP, lipid profile
fasting glycemia target < 6.1
post meal 2h <7.8
HbA1C < 6.5%

E-3 Type 1 and type 2 DM differences

Pathogenesis

DM1: Genetic & environmental factors → Progressive autoimmune destruction of pancreatic beta cells → Absolute insulin deficiency → Hyperglycemia
DM2:Genetic & environmental factors: Obesity, Aging with glucotoxicity & lipotoxicity → Insulin Resistance & Secretion deficit. (increased insulin production maintain blood glucose levels initally)

Clinical picture:
General: Polyuria, Polydypsia, Unexplained Weight loss, Poor Wound Healing, Visual Disturbances
DM1: sudden onset <20y, ketoacidosis, thin body type
DM2: gradual onset >30y, initally asymptomatic, obese

Therapy:
DMI1: Lifelong (long or short) insulin injection/pump, Regular meals & glucose monitoring, Healhy diet and lifestyle
DM2: lifestyle changes & loose weight, metformin, insulin

E-4 Late complications of diabetes mellitus: pathogenesis, types, therapy principles.

Pathogenesis:Chronic hyperglycemia → glycation of proteins & lipids, sorbitol accumulation, PKC acitivation,oxidative stress → thickend Basal mem brane & endothelial dysfunction → microvascular & macrovascular damage

Types:

Macrovascular (atherosclerosis)
Coronary Artery Disease
Cerebrovascular Disease: Stroke, stenosis, vascular
Peripheral Artery Disease
malformation

Microvascular
Eyes, ears, kidney
retinopathy
nephropathy
neruopathy
Diabetic foot

Therapy:
glycemic control
BP control (ACE inhibitor)
lipid control (Statins)
lifestyle (smoking, exercise, diet, weight)
regular screening
pain medication (asprin)

E-5 Diabetic sensorimotor polyneuropathy symptoms, diagnosis, and therapy principles

symptoms:

Numbness & tingeling, Burning pain (feet & hands)
hypersensitivity
muscle weakness
foot  ulcers

diagnosis:

Clinical diagnosis & history
Vibration sensation & pressure test

Therapy principles:
Glucose/diabetes control
Foot carePain management
Treat risk factors/ healhty lifestyele (BP, smoking, dyslipedemia)
Education
pain management

E-6 Diabetic macroangiopathy symptoms and diagnostic principles

symptoms

Coronary Artery Disease (CAD): Angina, Shortness of breath & Fatigue
Cerebrovascular disease: Stroke symptoms — Weakness, One-sided Paralysis, Slurred speech.
Peripheral artery disease: Coldness or numbness in the legs or feet

diagnostic principles
Clinical history
Physical examination
Blood test: blood glucose, HbA1C,renal function, lipid profile
Imaging studies: ECG, Echocardiography, Carotid ultrasound, Ankle-brachial index (ABI), Coronary angiography, CT, MRI

E-7 Basic groups of insulin preparations (with examples and pharmacokinetic differences)

Rapid acting: insulin lispro & aspart.
onset: 10min, Duration: 4h
Before meals to manage blood sugar spikes

short acting: Humulin & regualar human.
onset: 1-4h, Duration: 8-16h
Before meals to manage blood sugar spikes, IV emergencies

Intermediate: NPH.
onset: 30min, Duration: 6h
basal coverage

long acting: glargine & detemir.
onset: 1-4h, Duration: 24h
basal coverage

Mixed: short or rapid with intermediate.

E-8 Oral antidiabetic drug groups (Preparations & mechanism of action)

Biguandines: Metformin
Increases Insulin sensitivity in skeletal muscles , Decrease hepatic  glucose absorption

Thiazolidinediones: Pioglitazone
activate/increase PPAR-γ & insulin sensitivity (adipose tissue, muscle, and liver)

DPP-4 inhibitor: Sitagliptin
increases GLP-1 & insulin secretion

SGLT-2 inhibitor: Empagliflozin
Reduce glucose reabsorption in kidneys

GLP-1 agonist: Semaglutide / Liraglutide
increase insulin secretion, inhibit glucagon secretion. Slowing down gastric system

Sulfonylureas: Sulfonylureas
Stimulates Pancreatic B-cell insulin secretion

Meglinitides:Repaglinide
Stimulates Pancreatic B-cell insulin secretion (Short duration)

alpha gluconisade inhibitor: Miglitol
reduce Miglitolintestinal carbohydrate breakdown

E-9 Dietary principles of diabetes patients (Treated with insulin and oral antidiabetics)

DM1: match caloric intake with insulin amount

DM2: Weight loss, cardiovascular risk prevention

Patient education, 5 small meals a day witout snacking. proper sleep, Healthy lifestyle
Carbohydrates: fruit and grain. Avoid fast carbs
Protein: Lean meat, fish , egg
Fats: avoid saturated and trans fats,
avoid, salt, alcohol, smoking

E-10 Intensive insulin therapy principles (first 2)

Goal: mimic natural insul secretion form pancreas

Basal bolus regime: (intensive) Basal insulin 1-2 times daily+ Bolus insulin injection before meals

Insulin pump: Continuous subcutaneous insulin infusion

Education

Intensive short term: Supplimental

Blood glucose monitoring: Monitor blood glucose levels typically at least 4 times a day

Carbohydrate counting:

Insulin adjustment: Based on physical activity, stress, and changes in diet.

Prevention of hypoglycemia

E-11 Insulin therapy strategies

Intensive Insulin Therapy: Basal-Bolus or Insulin Pum. To keep normal glucose level

Conventional Insulin Therapy: 2 injections/day of mixed (regular & intermidiate) insulin. Simple but must follow strict diet

Basal only

supliment insulin therapy: short term

E-12 Hypoglycemia etiology, symptoms & treatment

Etiology:
Diabetic patient: insulin excess, insulin sensativity, renal failure,
Beta blockers, insulinoma, glycogen storage diseases, missed meals, exercise, sepsis, oragan failure, trauma, alcohol use

Symptoms:
Increased Sympathetic/parasympathetic activity: Increased Heart rate, Palpitations, Tremor, Sweating, Pallor, Hunger, Nausea, Vomiting
Behavioral changes, Agitation, Confusion, Fatigue, Seizures , Somnolence, Coma, Death

Treatment: Oral glucose, fast carbs, IV Dextrose, glucagon,

E-13 Thyroid gland physiology, reflex axis (norm & physiology)

physiology: produces T4 (thyroxine), T3 (triiodothyronine) from follicular cells & calcitonin. essential for metabolism and growth

Effect of Thyroid hormone:
metabolic intensity, regulate heart rate, increase body temperature, growth and development, organ maintenance

reflex axis: The thyroid functions are regulated by the hypothalamic-pituitary-thyroid (HPT) axis
Hypothalamus releases TRH (Thyrotropin-releasing hormone) → Stimulates release of 1.       TSH (thyroid-stimulating hormone) from anterior pituitary → stimulates T3 & T4 produciton

E-14 Hyperthyroidism (symptoms, laboratory indicators, therapy principles)

symptoms:
Heat intolerance, weight loss (increased apetite),anxiety
interstianl hypermotility, taxhycardia, protruding eye, tachycardia, hypertension, muscle tremor, , weakness, Decreased libido

laboratory indicators:
Decreased TSH
Elevated T4, T3

therapy principles:
Propranolol (symptomatic BB)
Methiamazole
Radioactive iodine ablation
thyroid surgery

E-15 Grave’s disease (diagnostic criteria, therapy principles)

diagnostic criteria
thyroid function test: Decreased TSH, increased T4,T3
thyroid antibodies: Increased TSH receptor antibodies
thyroid Scintigraphy: Diffuse uptake of radioactive iodine if low TSH antibodies.
Thyroid Doppler ultrasound: enlarged, hyper vascular thyroid
(CT neck/chest,MRI neck,FNA)

therapy principles:
Propranolol (symptomatic BB)
Methiamazole
Sterioids
Radioactive iodine ablation
thyroid surgery

E-16 Toxic nodular struma diagnostic criteria, therapy principles

Hyperthyroidism caused by thyroid nodules within a multinodular goiter

diagnostic criteria
thyroid function test: Decreased TSH, increased T4,T3
thyroid Scintigraphy: Increased Radioactive iodine uptake in nodules
Thyroid Doppler ultrasound: enlarged, hyper vascular thyroid
(CT neck/chest,MRI neck,FNA)

Fine needle aspiration biopsy
Symptoms: Tachycardia, heat intolerace, 

therapy principles:
Propranolol (symptomatic BB)
Methiamazole
Radioactive iodine ablation
thyroid surgery

E-17 Hypocalcemia symptoms, differential diagnosis, therapy principles

Total Ca2+ < 8.5 mg/dL

Neurological: Seizures, Tetany, Trousseau sign, Pseudotumor cerebri
Cardiovascular: Congestive heart failure, Hypotension, Arrhythmia
Psychiatric: E.g., Emotional instability, Anxiety, Depression
Ophthalmologic: Papilloedema, Cataracts, Corneal calcification
Osteomalacia and growth plate abnormalities

Differential diagnosis

Vitamin D deficiency
CKD 3. Acute Pancreatitis
Hypoparathyroidism
Hypomagnesemia

therapy principles:
calcium suplements, Vitamin D

E-18 Hypothyroidism symptoms, laboratory indicators, and therapy principles

Symptoms: Fatigue & Weakness, Weight gain & Constipation, Cold intolerance, Muscle & Joint pain, Bradycardia

laboratory indicators:
Increased TSH, Decreased T4,T3
Thyroid antiboidies,
Decreased radioactive iodine uptake

therapy principles:
Lifelong: Levothyroxine, Liothyronine

19. Hashimoto's thyroiditis (diagnostic criteria, therapeutic and effect principles of control)

diagnostic criteria:
thyroid function test:
thyroid antibodies: Increased TSH receptor antibodies
Thyroid Doppler ultrasound: enlarged, hyper vascular thyroid
(CT neck/chest,MRI neck,FNA)

therapeutic:
Lifelong: Levothyroxine, Liothyronine (+ propranolol)

effect principles of control:
To ensure effective thyroid hormone replacement therapy with regular TSH testing 4-6 weeks after starting or adjusting therapy until stable, then every 6 months. Once stable, annual monitoring of TSH levels.

E-20 Subacute (de Quervain’s) thyroiditis(diagnostic criteria and therapy principles)

diagnostic criteria:
thyroid function test:
Thyrotoxic phase: Decrease TSH, Increase T3,T4
Hypothyroid phase: incrase TSH, Decrease T3,T4
thyroid Scintigraphy: Diffuse uptake of radioactive iodine if low TSH antibodies.
Thyroid Doppler ultrasound: enlarged, hyper vascular thyroid
(CT neck/chest,MRI neck,FNA)

therapy principles:
Thyrotoxit phase: Propranolol, NSAID
Hyothyroid phase:  Levothyroxine, Liothyronine

E-21 Hypercalcemia (clinical picture and pathogenetic classification)

clinical picture
Nephrolithiasis & Polyuria
Arrhythmias
Bone & Joint pain
Abdominal pain, Constipation, Nausea & Vomiting
Anxiety, Depression, Fatigue & Cognitive Dysfunction

pathogenetic classification
PTH - Hypercalcemia: primary hyperparathyroidism
non PTH Hypercalcemia:Malignancy, vitamin D intoxication, granulomatous diseases, drugs, endocrine

E-22 Cushing’s syndrome (clinical features, classification and investigation, diagnostic criteria)

diagnostic criteria
Cushing's syndrome: an endocrine disorder characterized with hypercortisolism.

clinical features: purple stretch marks, cetral obesity, depression, hypertension, diabetes, osteoporosis, hypokalemia, isulin resistance,hump

classification:
Exogenous: overdose/prolonged glucocorticoid medicine (most common)
Endogenous: ACTH-dependent (from pituitary,) or ACTH-independent (adrenal gland problem)

investigation:
medical history & physical examination of clinical features
24-h urinary free cortisol: elevated
ACTH Analysis: Differentiate ACTH-dependent or ACTH-independent
1. ↓ACTH → Primary Hypercortisolism → Adrenal MRI/CT
2. ↑ACTH → Secondary Hypercortisolism → MRI or PET-Scan

23. Primary hyperaldosteronism: clinical picture, diagnostic criteria

clinical picture:
Hypertension, Hypernatremia, Hypokalemia (weakness), Metabolic acidosis, drug restsistant hypertension

diagnostic criteria:
Clinical picute
Aldosterone to renin ratio (increased aldosterone renin ratio)
Oral sodium loading test
Adrenal CT

E-24 Pheochromocytoma Diagnostic criteria and clinical features

clinical features:
Headache, sweating, tachycardia, hypertension, weightloss, hyperglycemia

Diagnostic criteria:
Free plasma metanephrines test
24h urine metanephrines and carecholamine test
CT/MRI/scintigraphy
Genetic testing

Diagnostic criteria and clinical features of Addison's disease

hypocortisolism, adrenal insufficiency by adrenal gland dysfunction or decreased ACTH

Diagnostic criteria
Low Na & glucose, morning cortisol, adrenal insufficiency,
high: morning ACTH,
ACTH stimulation test,
Hypoaldosteronism & Hypoandrogenism

clinical features
Fatigue, weight loss, nausea, hypotension, salt craving,

26. Diagnostic and therapy principles of osteoporosis

Diagnostic
Bone mineral density
T-Score
History of bone fragility
X ray for fracutres
Hypercalcemia

therapy
Healhy lifestyle
Calcium rich food & Vitamin D
Biphosphonates
RANKL inhibitor
Calcionin
SERM

27. Hyperprolactinemia - clinical features and investigation

Clinical features
Increased Prolactin
Lower: LH, FSH, testosterone, Estrogen, hypogonadism
loss of libido, infertility, osteoporosis,

investigation
Prolactin stimulation test
rule out: ,hypothyroidism,pregnancytest, MRI for adenomas.

E-28 Acromegaly & gigantism Diagnostic criteria and clinical features

Acromegaly: benign pituitary adenoma → ↑GH & ↑IGF-1
Gigantism: Acromegaly before epithelial plate closure in children

Diagnostic criteria:
IGF-1 elevated
Pituitary MRI to confirm mass
oral glucose test: no GH supression


clinical features
Tumor mass, loss of vision, headache, enlarged nose/jaw/hand/feet, atrophy, t

29. Diagnostic criteria and therapy principles of diabetes insipidus

Kidneys are unable to concentrate urine —> Hypotonic Polyuria

Diagnostic criteria
Polyuria, polydipsia, nocturia,
high urine volume
low urine osmolarity (high serum)
hypernatremia
ADH



Therapy
adequate fluid intake
Discontinue casative agent (Desmopressin)
Desmopressin
Thiazide diuretic

E-30 Hyperparathyroidism Diagnostic criteria and therapy principles

Diagnostic criteria
high serum calcium, PTH, Aklaline phosphate
Neck ultrasound
Vitamin D levels

therapy principles
Parathyroidectoms/tumor resectionCinacalcet
Biphosponates
Calcitrol/vitamin D supliment
Underlying cause/symtomatic: Hyperphosphatemia, Hypercalcemia

E-31 Hypoparathyroidism Diagnostic criteria and therapy principles

Diagnostic criteria
Clinical symptoms: Muscle cramps/spasm, arrythmia, Chvostek & Trousseau signs
Hypocalcemia, low PTH, hyperphosphatemia

therapy principles
Calcitriol (vitamin D)
Calcium citrate
Monitor calcium & phosphate levels
Magnesium supliments

E-32 Thyroid nodules, physicians action tactic

1. Anamnesis, Family history & Physical examination

2. Thyroid Function Tests of TSH, T3 & T4,
(TSH low → scintigraphy, TSH high → imaging)

3. Thyroid Ultrasound to Check size, location, characteristics according to TI-RADS.
Start fine needle aspiration

4. Manage benign or malignant

5. Long term monitoring

E-33 Secondary osteoporosis cause and diagnostic investigation

cause
Druig induced: Corticosteroids
Endocrine/metabolic: Hypercortisolism
multiple myeloma
Risk factors: Smoking, Malabsorption, Vitamin D deficiency, immobilization, Family history

diagnostic investigation
Fracture despite lack of appropriate trauma

Bone mineral density test

Blood test of Calcium, Phosphate, PTH, Vitamin D, TSH, FT4