Consultation

Turner syndrome

・karyotype : 45, X

・short stature

・webbed neck

・streak ovaries → primary amenorrhea.

Klinefelter syndrome

・karyotype : 47,XXY

・tall stature

・gynecomastia

・small testes, infertility.

Polycystic ovary syndrome (PCOS)

・oligomenorrhea

・hirsutism, acne

・polycystic ovaries on ultrasound

・insulin resistance.

Gout — Acute management

・Colchicine

・NSAIDs

・corticosteroids

(Allopurinol or Febuxostat only for long-term prevention, not during an acute attack.)

Tophi

Deposits of uric acid crystals in soft tissues, typically around joints, ears, or tendons in chronic gout

Wilson's vs Hemochromatosis — Key difference

Wilson's = copper accumulation

Hemochromatosis = iron accumulation.

Acute pancreatitis — Diagnostic criteria

(1) Characteristic abdominal pain

(2) Serum amylase/lipase >3× normal

(3) Imaging findings consistent with pancreatitis

(need 2 of 3)

Antibiotics in pancreatitis

Only indicated in cases of sepsis or biliary tract infection, not routinely

Biliary tract infection — Imaging/Treatment

ERCP or MRCP used for diagnosis & management

Hepatitis B — Key serologic markers

HBsAg = current infection

Anti-HBs = immunity

Anti-HBc IgM = acute infection

Anti-HBc IgG = past infection

Hepatitis C — Diagnosis

Anti-HCV antibodies

HCV RNA PCR

Drug-induced liver injury — Causes

Commonly from:

・Acetaminophen

・Amiodarone

・Isoniazid

・Methotrexate

Wilson's disease

Copper accumulation due to ATP7B mutation

・low ceruloplasmin

・high urinary copper

・Kayser-Fleischer rings

Hemochromatosis

Iron overload

・high ferritin

・high transferrin saturation

・normal CRP

(to exclude acute phase elevation)

FIB-4 score

Non-invasive score to assess liver fibrosis using:

・age

・AST, ALT

・platelet count.

Ascitic fluid — Exudate vs Transudate

Transudate : low protein, low WBC, low LDH

Exudate: high protein, high LDH, often malignancy/infection

Spontaneous bacterial peritonitis

Ascitic fluid WBC >0.25 × 10⁹/L (250 cells/µL), mainly neutrophils

Hepatocellular carcinoma — Marker

Alpha-fetoprotein (AFP) — used mainly for follow-up, not screening

Acute liver failure — Causes

・viral hepatitis

・drug-induced (acetaminophen)

・ischemic

・autoimmune.

Pituitary adenoma

Benign tumor of the pituitary gland that can cause endocrine hyperfunction (e.g., prolactinoma, acromegaly, Cushing's disease) or local compression effects

Acromegaly — Classic symptoms

・Organ enalrgement : macroglossia, cardiomegaly

・Development of insulin resistance

・Headache on top of head

・Excessice sweating due to hypertrophy of glands

Acromegaly — Screening test

Measure IGF-1 levels (insulin-like growth factor 1)

→ if elevated, confirms GH hypersecretion suspicion

Acromegaly — Confirmatory test

Oral Glucose Tolerance Test (OGTT) with GH measurement (measured every 30 mins)

→ failure of GH to suppress after glucose load confirms diagnosis

Acromegaly — Alternative in diabetic patients

Avoid OGTT

→ 24-hour GH or IGF-1 monitoring (check 5/day)

Prolactinoma — Endocrine symptoms in women

・amenorrhea

・galactorrhea

・infertility

Prolactinoma — Endocrine symptoms in men

・decreased libido

・erectile dysfunction

・infertility

Prolactinoma — Mass effect symptoms

・bitemporal hemianopia (optic chiasm compression)

・headache

Diabetes insipidus — Central

Deficiency of ADH due to hypothalamic / pituitary damage

→ polyuria and polydipsia.

Diabetes insipidus — Nephrogenic

Renal insensitivity to ADH

→ may be :

・genetic (V2 receptor or AQP2 mutation)

・acquired (eg. lithium, hypokalemia).

Acquired nephrogenic DI — Causes

・Lithium therapy

・prolonged hypokalemia

Cushing's disease vs. Cushing's syndrome

Cushing's disease = pituitary ACTH-secreting adenoma

Cushing's syndrome = excess cortisol from any cause (pituitary, adrenal, or exogenous)

Addison's disease — Diagnosis

・low cortisol levels & inadequate rise after ACTH (Synacthen) stimulation test

・autoimmune antibodies : may confirm etiology

Addisons Disease — Treatment + Dosage

Replacement therapy

Primary : Hydrocortisone & fludroortisone (both cortisol & mineralocorticoid must be replaced)

Secondary : Hydrocortisone (don’t give methyprednisone doesn't have MR effect)

Dosage : 2/day morning & noon (mimics bodies endogenous production)

Addisons disease - Dosing during illness

Must be increased to mimic the bodies natural response to stress situation

Addisons disease- Most Common Cause

Autoimmune adreanalitis

WBC

4-10 G/L

neu

45-70%

hgb

135-170 g/L in males, 120-150 g/L in females

hct

0.4-0.5 in males, 0.35-0.45 in females

MCV

80-100 fL

PLT

150-400 G/L

Na

135-145 mmol/L

K

3.5-5.1 mmol/L

Ca

2.25-2.65 mmol/L

PO4

0.8-1.45 mmol/L

creat

60-100 umol/L (2 digit number)

BUN

3-7 mmol/L (1 digit number)

Urate

200-430 umol/L

Glucose

4.1-5.9 mmol/L

Cholesterol

2.0-5.2 mmol/l

Triglyceride

< 1.7 mmol/l

Total bilirubin

5-20 umol/L

GOT

< 50 U/L

GPT

< 50 U/L

GGT

< 55 U/L

ALP

LDH

< 250 U/L

Total protein

65-80 g/L

Albumin

35-50 g/L

CRP

< 5 mg/L - < 20-30 means basically normal, 30-100 should be followed in 3-4 days

INR

0.85-1.2

Urine SG

1005-1030 (1010-1012 = isostenuria)

Urine pH

5-8

TSH

0.35-4.9 mU/L

What HbA1c level indicates that insulin is needed along with oral antidiabetic medications?

HbA1c > 10%

Why is insulin needed when HbA1c is greater than 10%?

Oral medications alone are not effective enough to lower HbA1c below 7%.

What is the main difference between human insulin & insulin analogs?

Absorption properties : analogs absorb faster & mimic physiological insulin better

Why are snacks required throughout the day with human insulin?

To prevent hypoglycemia due to slower & longer-lasting insulin activity

Which type of insulin typically causes more weight gain?

Human insulin

Which insulin type causes less weight gain?

Insulin analogues

What is the insulin dosing regimen for elderly patients?

Twice a day using premixed insulin (intermediate + short acting), usually administered with family help

What is a once-a-day insulin regimen used for?

For patients with high HbA1c not controlled with oral meds

What is the 4/day insulin dosing regimen called?

Intensive conservative treatment

What is included in the 4/day intensive regimen?

3 rapid-acting doses before meals + 1 intermediate-acting dose

Who receives intensive insulin treatment (4/day)?

Type 1 & Type 2 diabetics with uncontrolled HbA1c despite oral therapy

What is a hospital-based insulin dosing strategy?

High initial doses monitored 5 times a day : 3 before meals, 1 at 10 PM, 1 at 3 AM (both rapid acting)

Why do Type 1 diabetics usually need less insulin than Type 2 diabetics?

Type 2 diabetics have insulin resistance

What is the insulin dosing approach for pancreatogenic diabetes?

Very small doses 4 times a day : doses should not be merged

What is the contraindication for Metformin?

Renal failure (GFR < 30 mL/min) and before contrast agent administration

What patients benefit most from SGLT2 inhibitors?

Heart failure patients & those with proteinuria

What are the benefits of DPP-4 inhibitors?

Fewer side effects : best for elderly patients, but expensive

What is the advantage of Sulfonylureas?

Cheap (good for low-income patients)

Who should avoid Sulfonylureas & why?

Elderly patients

→ risk of hypoglycemia

Which antidiabetic drug is best for obese patients?

GLP-1 receptor agonists

Diabetic Ketoacidosis Mangment

1. IV Fluids : give isotonic solution (0.9% saline) for the 1st hour

2. IV human insulin : In the 2nd hour insulin administration can begin give 8U then an in the 3rd hr another 8U

3. IV KCl : Must be given before insulin to prevent hypokalemia in (K+ will begin to move inside cells)

4. Constant monitoring of blood glucose and K+ : once in between 10-14mmol/L can switch to S.C. insulin If pH is below 7 give bicarbonate

Diabetic ketoacidosis — First step in management

IV fluids (normal saline) :correct dehydration before insulin

DKA — Potassium management

If K⁺ is normal, start replacement with fluids before insulin

→ insulin shifts K⁺ into cells

DKA — Insulin regimen

IV bolus 0.1 U/kg only in 2nd hour, then continuous infusion

→ switch to subcutaneous insulin once glucose 10-15 mmol/L

Pseudohyponatremia in DKA

Caused by hyperglycemia drawing water into extracellular space

→ sodium corrects after insulin therapy

Chronic diabetes — Types of insulin

Human insulins : Regular, NPH

Analogs : short-acting (lispro, aspart), long-acting (glargine, detemir)

→ easier to use due to stable profiles

How to measure eGFR based on endogenous & exogenous values?

Endogenously : creatinine & cystatin C

Exogenously : Inulin, but invasive

Benefits of measuring Cystatin C opposed to creatinine

・Cystatin C is independent of muscle mass

・higher levels can show up faster on lab tests

Which endogenous substance should be used to evaluate eGFR in case of acute renal damage?

Cystatin C : increased level faster

RBC cast + dimorphic RBCs indicate

Glomerularnephritis

WBC cast indicates

Tubular interstitial nephritis (pyelonephritis)

WBC cast indicates

Tubular interstitial nephritis (pyelonephritis)

Hyalinic cast indicates

It can be seen in healthy patients, but a higher level can be indicative of a prerenal issue

What is the composition of hyaline casts?

Tamm-Horsfall protein (= uromodulin)

CKDEpi equation. Why is it beneficial, and when can we not use it?

The way to calculate eGFR most accurately takes into account age, gender, and creatinine

Cannot be used in case of Pregnant women Anuria: zero urine output = zero GFR Not to be used

AKI — Common causes

Prerenal : hypoperfusion

Intrinsic : ATN

Postrenal : obstruction