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eureka Endocrinology eureka Endocrinology Thomas Fox MBBS BSc MRCP Bijay Vaidya MBBS PhD FRCP (Lon & (Endo) PGCert Med Ed Edin) Consultant Endocrinologist Consultant Endocrinologist The Royal Devon and Exeter NHS The Royal Devon and Exeter NHS Foundation Trust Foundation Trust Exeter, UK Exeter, UK Antonia Brooke MBBS MD MA MRCP Consultant Endocrinologist The Royal Devon and Exeter NHS Foundation Trust Exeter, UK Series Editors Janine Henderson MRCPsych Stephen Parker BSc MS DipMedEd MClinEd FRCS MB BS Programme Director Consultant Breast and General Hull York Medical School Paediatric Surgeon York, UK St Mary’s Hospital Newport, UK David Oliveira PhD FRCP Professor of Renal Medicine St George’s, University of London London, UK London • Philadelphia • New Delhi • Panama City © 2015 JP Medical Ltd. Published by JP Medical Ltd, 83 Victoria Street, London, SW1H 0HW, UK Tel: +44 (0)20 3170 8910 Fax: +44 (0)20 3008 6180 Email: [email protected] Web: www.jpmedpub.com The rights of Thomas Fox, Antonia Brooke and Bijay Vaidya to be identified as authors of this work have been asserted by them in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission in writing of the publishers. Permissions may be sought directly from JP Medical Ltd at the address printed above. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the authors assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought. Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. ISBN: 978-1-907816-71-0 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Publisher: Richard Furn Development Editors: Thomas Fletcher, Paul Mayhew, Alison Whitehouse Editorial Assistants: Sophie Woolven, Katie Pattullo Copy Editor: Kim Howell Graphic narratives: James Pollitt Cover design: Forbes Design Page design: Designers Collective Ltd v eureka Series Editors’ Foreword Today’s medical students need to know a great deal to be effective as tomorrow’s doctors. This knowledge includes core science and clinical skills, from understanding biochemical pathways to communicating with patients. Modern medical school curricula integrate this teaching, thereby emphasising how learning in one area can support and reinforce another. At the same time students must acquire sound clinical reasoning skills, working with complex information to understand each individual’s unique medical problems. The Eureka series is designed to cover all aspects of today’s medical curricula and reinforce this integrated approach. Each book can be used from first year through to qualification. Core biomedical principles are introduced but given relevant clinical context: the authors have always asked themselves, ‘why does the aspiring clinician need to know this’? Each clinical title in the series is grounded in the relevant core science, which is introduced at the start of each book. Each core science title integrates and emphasises clinical relevance throughout. Medical and surgical approaches are included to provide a complete and integrated view of the patient management options available to the clinician. Clinical insights highlight key facts and principles drawn from medical practice. Cases featuring unique graphic narratives are presented with clear explanations that show how experienced clinicians think, enabling students to develop their own clinical reasoning and decision making. Clinical SBAs help with exam revision while starter questions are a unique learning tool designed to stimulate interest in the subject. Having biomedical principles and clinical applications together in one book will make their connections more explicit and easier to remember. Alongside repeated exposure to patients and practice of clinical and communication skills, we hope Eureka will equip medical students for a lifetime of successful clinical practice. Janine Henderson, David Oliveira, Stephen Parker About the Series Editors Janine Henderson is the MB BS undergraduate Programme Director at Hull York Medical School (HYMS). After medical school at the University of Oxford and clinical training in psychiatry, she combined her work as a consultant with postgraduate teaching roles, moving to the new Hull York Medical School in 2004. She has a particular interest in modern educational methods, curriculum design and clinical reasoning. David Oliveira is Professor of Renal Medicine at St George’s, University of London (SGUL), where he served as the MBBS Course Director between 2007 and 2013. Having trained at Cambridge University and the Westminster Hospital he obtained a PhD in cellular immunology and worked as a renal physician before being appointed as Foundation Chair of Renal Medicine at SGUL. Stephen Parker is a Consultant Breast and General Paediatric Surgeon at St Mary’s Hospital, Isle of Wight. He trained at St George’s, University of London, and after service in the Royal Navy was appointed as Consultant Surgeon at University Hospital Coventry. He has a particular interest in e-learning and the use of multimedia platforms in medical education. vii Preface Endocrine disorders are common and becoming more prevalent, not just in the United Kingdom but worldwide. The complications of endocrine disease cause significant morbidity and mortality, so a sound understanding of their diagnosis and management is of vital importance to all clinicians. Our goal in writing Eureka Endocrinology is to set out this knowledge in the clearest manner possible. The endocrine system is integral to the functioning of the human body. Chapter 1 of Eureka Endocrinology therefore provides the reader with a detailed overview of normal endocrine anatomy and physiology. Throughout the chapter, we have included correlating clinical information to help students understand the relevance of the anatomy, physiology and pathology to everyday practice. In chapter 2 we explain how to take a history and examine the patient, exploring and illustrating key symptoms and clinical signs, before discussing the most important investigations and management options. In the subsequent chapters each endocrine disease is described in depth, using illustrated cases to give the student a unique insight into how patients present and how we manage their medical problems in real life. The starter questions at the beginning of each chapter will help students consolidate and apply their learning, and the clinical SBAs at the end of the book will provide them with an invaluable revision aid. We hope you enjoy reading and learning from Eureka Endocrinology. Thomas Fox, Antonia Brooke, Bijay Vaidya March 2015 About the Authors Thomas Fox is lead for curriculum development in endocrinology at the University of Exeter Medical School (UEMS). He has played an active role in teaching endocrinology and clinical skills at UEMS both during specialist training and as a Consultant Endocrinologist. He delivers a special study module in metabolic medicine. Antonia Brooke is the clinical lead for endocrinology at the Royal Devon and Exeter Hospital. She is Endocrinology Training Programme Director for the South West Peninsula, supporting registrars as they work towards becoming consultants. In her role as tutor for undergraduates and junior doctors she enjoys encouraging students into a career in endocrinology. Bijay Vaidya is a Consultant Physician and Honorary Associate Professor of Endocrinology. As well as playing an active role in teaching endocrinology at UEMS, he has co-authored clinical reviews and learning modules on endocrine disorders for several journals, including The BMJ and BMJ Learning. viii Contents Series Editors’ Foreword v Case 2 Recurrent thrush 148 About the Series Editors v Type 1 diabetes mellitus 150 Preface vii Type 2 diabetes mellitus 158 About the Authors vii Monogenic diabetes mellitus 163 Glossary xi Gestational diabetes 164 Acknowledgements xii Obesity 165 Lipid disorders 168 Chapter 1 First principles Overview of the endocrine system 1 Chapter 4 Complications of diabetes The thyroid gland 8 The parathyroid glands 15 Introduction 173 The hypothalamus 20 Case 3 Red swollen foot 174 The pituitary gland 27 Macrovascular complications 176 The adrenal glands 36 Microvascular disease 180 The pancreas 44 Diabetic foot disease 189 The gut 49 The male reproductive system 51 The female reproductive system 56 Chapter 5 Thyroid disease The pineal gland 61 Introduction 193 Case 4 Tremor and irritability 194 Chapter 2 Clinical essentials Hyperthyroidism 196 Introduction 67 Thyroid eye disease 202 Common symptoms and how to take a Hypothyroidism 204 history 67 Thyroiditis 207 Common signs and how to examine a Goitre 208 patient 80 Thyroid nodule 211 Investigations 98 Thyroid cancer 211 Management options 116 Chapter 6 Pituitary disease Chapter 3 Diabetes mellitus, Introduction 215 obesity and lipid disorders Case 5 H eadaches and change in facial appearance 216 Introduction 145 Case 6 Weight gain and easy bruising 217 Case 1 W eight loss, thirst and excessive amounts of urine 146 Acromegaly 219 ix Contents Prolactinoma 223 Disorders of sex development 287 Cushing’s syndrome 226 Hypogonadism in men 288 Hypopituitarism 230 Klinefelter’s syndrome 290 Non-functioning pituitary tumours 233 Diabetes insipidus 234 Chapter 10 Other endocrine disorders Chapter 7 Adrenal disease Introduction 293 Introduction 239 Case 12 Worsening vision and headache 294 Case 7 Headaches and profuse sweating 240 Multiple endocrine neoplasia syndromes 295 Addison’s disease 242 Autoimmune polyglandular syndromes 298 Conn’s syndrome 246 Ectopic hormone syndromes 299 Phaeochromocytoma 248 Carcinoid tumours and carcinoid syndrome 300 Congenital adrenal hyperplasia 250 Insulinomas 301 Cushing’s syndrome 252 Other neuroendocrine tumours: Adrenal adenomas 252 gastrinoma, glucagonoma, vipoma and somatostatinoma 302 Chapter 8 Calcium homeostasis and metabolic bone Chapter 11 Endocrine disease emergencies Introduction 255 Introduction 305 Case 8 Sharp pain in the back and tiredness 256 Case 13 D iarrhoea, vomiting and lethargy after a meal out 306 Case 9 Leg pain while walking 258 Diabetic ketoacidosis 307 Hypercalcaemia 259 Hyperosmolar hyperglycaemic state 308 Hyperparathyroidism 260 Severe hypoglycaemia 309 Hypocalcaemia 264 Case 14 Collapse and agitation 310 Hypoparathyroidism 265 Hyponatraemia 311 Osteoporosis 266 Paget’s disease 268 Case 15 A bdominal pain, vomiting and Vitamin D deficiency 269 drowsiness 313 Addisonian crisis 315 Chapter 9 Reproductive system Case 16 Weight loss and anxiety 315 disorders Thyroid storm 316 Introduction 273 Myxoedema coma 317 Case 10 C omplete absence of menstrual Case 17 W orsening palpitations, periods in a 16-year-old 274 headaches and tremor 317 Case 11 Excessive hair growth 277 Hypertensive crisis 320 Polycystic ovary syndrome 279 Case 18 S evere headache and double Primary ovarian insufficiency 282 vision 320 Turner’s syndrome 284 Pituitary apoplexy 321 Functional hypothalamic amenorrhoea 285