Medicine Notes Medicine and Surgery Notes
Theses are my latest set of notes for my first year as a clinical medic, complementing the 3rd year curriculum perfectly. Each topic is briefly but thoroughly covered with clear headings and colour co-ordination.
The notes use a great mix of words and diagrams in an eye-pleasing layout making revision easier for you with plenty of space to annotate.
Each system is clearly marked and most of the core diseases are covered and broken down into prevalence, aetiology, clinical features, managemen...
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Causes of Pituitary Disorders
Hypersecretion – functioning tumours or drugs
Symptoms | Deficient Hormone |
---|---|
Growth retardation in children, excessive tiredness, muscle weakness | GH |
Hypogonadism – reduced body hair, low libido, impotence in men, amenorrhoea, dyspareunia and hot flushes in women | FSH/LH |
Weight gain, decreased energy, sensitivity to cold, constipation, dry | TSH |
Pale appearance, weight loss, low BP, dizziness, tiredness | ACTH |
Thirst and polyuria | VP |
Hyposecretion – craniopharyngeoma, non-functioning pituitary tumours, radiotherapy, trauma, empty sella syndrome
Deficiency of hypothalamic releasing hormones
Isolated deficiency of GH, LH, ACTH, TSH & vasopressin
Thyroid function test – hypothyroidism
GH status
IGF-1 – GH undersecretion
Assessment of bone age
Karyotyping female – turner’s syndrome
Treatment
Hypothyroidism – levothyroxine
GH insufficiency – somatrophin injections
GH excess due to a pituitary tumour
Changes in appearance
Visual fields defects/headaches
Sweating
Investigations
GH levels
Glucose tolerance test – diagnostic if there is no suppression of GH
IGF-1 – almost always raised
Visual field exam – bitemporal hemianopia
MRI scan – pituitary adenoma
Prolactinaemia
Management & Treatment
Surgery - trans-sphenoidal
Pituitary radiotherapy after surgery
Medical therapy
Somatostatin receptor agonist – octreotide
Dopamine agonists
GH antagonists – normalises IGF-1 levels
Caused by a small prolactin producing tumour , PCOS, primary hypothyroidism
Applies pressure on the optic nerve resulting in bitemporal hemianopia
Amenorrhea, breast milk production, loss of libido, headaches, oesteoporosis due to hypoestrogenism
Investigations
Visual fields
Hypothyroidism must be excluded
Anterior pituitary function – tumours
MRI scan of pituitary
Treatment
Must be treated to avoid the long term effects of oestrogen deficiency
Medical
Dopamine agonist – cabergoline/bromocriptine
Trans-sphenoidal surgery
Radiotherapy
Controls the growth but is slow in effect
Produces thyroxine, T4 and triiodothyronine, T3
These regulate the rate of metabolism and affect growth and rate of function of many systems
Iodine and tyrosine are both used to for T3 and T4
T4 is converted to T3 and reverse T3 by de-iodination
T3 is rapidly excreted due to poor binding and further de-iodination
Regulation
Regulated by TRH from the hypothalamus
TSH stimulates the enlargement of follicular cells and increases all steps in hormone production: iodine uptake, formation of reactive iodine, production of thyroglobulin colloid, endocytosis of colloid and liberation of T4 & T3
TSH is stimulated by TRH
Negative feedback of T4 and T3 on the pituitary switch of TSH production
Actions
T4 & T3 operate through nuclear receptors regulating gene transcription
Genes concerned with cell differentiation and metabolism
Most tissues respond to T3/T4 and require thyroid hormones for normal development
Main effects:
Respiratory – maintains normal hypoxic & hypercapnic drive
Metabolism of proteins, carbohydrates, lipids – increases
Cardiovascular effects – heart rate & cardiac output
Neuromuscular effects – increases speed of muscle contraction, relaxation & protein turnover
Function of sympathetic nervous system – increases sensitivity
Higher functions of CNS
GI tract – motility
Skeletal – increased turnover & resorption
Growth and development
Primary hypothyroidism -1% prevalence in women 0.1% in men
Causes
AUTOIMMUNE
Atrophic (autoimmune) hypothyroidism
Antithyroid antibodies
Lead to lymphoid infiltration and atrophy/fibrosis
Hashimoto’s thyroiditis
Autoimmune
Atrophy with regeneration leading to goitre formation
Levothyroxine may shrink the goitre
Postpartum thyroiditis
Due to modifications of the immune system in pregnancy
DEFECTS OF HORMONE SYNTHESIS
Iodine deficiency
Dyshormonogenesis
Genetic defects
Goitre
Clinical features
Slow, dry-haired, thick-skinned, deep-voiced, weight gain, cold intolerance
Children: slow growth velocity
Investigations
Serum TSH
Normocytic anaemia
Increased serum creatinine kinase
Hypercholesterolaemia
Hyponatraemia
Treatment
Replacement therapy
Levothyroxine for life
Monitoring
Up to 6 months for full resolution of Sx
2-5% of all females affected
Autoimmune process
IgG antibodies bind to TSH receptors in the thyroid, stimulating thyroid production
These antibodies can be measured in serum TSHR-Ab
Thyroid eye disease accompanies Grave’s
Relapse & remission is common
Only 40% will experience one episode
Toxic multinodular goitre
Amiodarone-indiuced toxicosis
Clinical features
Eye signs
Pretibial myxoedema
Thyroid acropachy
Atrial fibrillation in the elderly
Children: excessive height, hyperactivity
Weight loss
Increased appetite
Irritability
Heat intolerance
Tremor
Goitre
Investigations
Serum TSH is suppressed in hyperthyroidism
Raised T4/T3
Treatment
Antithyroid drugs
Carbimazole – inhibit formation of thyroid hormones
Beta-blockers provide rapid relief
50% will relapse within 2 years
Radioactive iodine
Not during pregnancy
Destroys the gland by radiation
May take months
Subtotal thyroidectomy
Risks: laryngeal nerve palsy, hypoparathyroidism, hypothyroidism
CRH ACTH Cortisol
Negative feedback control
DEXAMETHASONE | Measure | Normal test result | Use & explanation |
---|---|---|---|
Overnight | 0900 | Cortisol<100nmol/L | Outpatient screening test |
Low-dose | 0900 +2 days | Cortisol <50nmol/L | Diagnosis of Cushing’s syndrome |
High-dose | 0900 +2 days | Cortisol on day 2 <50% of day 0 suggests pituitary dependent disease | Differential of Cushing’s syndrome |
Destruction of the adrenal cortex
Glucocorticoid, mineralocorticoid and sex steroid production are all reduced
Reduced...
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Theses are my latest set of notes for my first year as a clinical medic, complementing the 3rd year curriculum perfectly. Each topic is briefly but thoroughly covered with clear headings and colour co-ordination.
The notes use a great mix of words and diagrams in an eye-pleasing layout making revision easier for you with plenty of space to annotate.
Each system is clearly marked and most of the core diseases are covered and broken down into prevalence, aetiology, clinical features, managemen...
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