!

Endocrine notes

Internal medicine:

. ‫ڡ‬, ‫اﻟﻌﺸﺮة ﻛﻮﻣﺎ‬

‫ٮﺎ ﻫﺪﻫﻮد‬,‫ٮور‬3‫ ﻣﻦ دﻛ‬DM complications ‫ى ال‬
Hypoglycemia-
DKA-
Lactic acidosis-
Hyperosmolar-
Cerebral edema-
Rhinocerebral mucormycosis-
Cerebral thrombosis on top of atherosclerosis-
Respiratory failure on top of TB-
Renal failure on top of diabetic nephropathy-
Hepatic coma on top of severe fatty liver but rare-
‫ڡ>ٮيﻦ ﻫﻤﺎ‬3‫ﻪ اﻟ?ٮﺎ‬3‫ٮﻼٮ‬3‫ واﻟ‬emergencies ١٣ ‫ ﻣﻦ ال‬١٠ ‫ٮ?ٮرو‬3‫وكﻠﻬﻢ ٮ >ﻌ‬
acute MI on top of coronary atherosclerosis -
blindness on top of DR -
Gangrene in top of diabetic foot -

Notes "DM"
. ‫ڡ‬, ‫?ٮيﺸﺎرك‬/‫ٮﺴﻖ اﻟﻤﻮدٮ >ول‬,‫ڡﺔ ﻣ‬,‫ﻋﺮ‬.‫)ﻣﺤﺎﺿﺮة د‬
(‫ٮﺤﺎن‬3‫ى وﺿﻊ اﻻﻣ‬
1- classification according to ADA 2023: ‫ٮﺎدي‬,‫ڡﺴﻪ اﻟﺴ‬,‫ٮ‬,‫ڡﻬﺎ ?ٮ‬,> ‫ﻣﻬﻤﺔ ﻟﺴﻪ ﺿﺎٮ‬
2- insulin resistance is the hallmark of DM type 2
3- DM type 1 Antibodies ‫ﻣﻬﻤﺔ‬
4- oral hypoglycemics
Ineffective (contraindicated) in DM type 1
. ‫ڡ‬, ‫ ?ٮيﺤ?ٮوا ٮ >ﺴﺄﻟوا‬classic symptoms of dm ‫ﻋﻦ‬
5- ‫ى‬
Pruritis vulvae = repeated/persistant vaginal infection, parasthesia....
6- weight loss is a symptom of:
*DM type 1
*catabolic (severe) DM type2
7- obesity is a presentation/risk factor of DM type 2 but NOT a symptom (manifestation)
of it
8- obesity/weight gain is a part of insulin resistance (metabolic) syndrome
9- criteria for diagnosis of DM: ‫ٮﺎدي‬,‫ڡﺴﻪ اﻟﺴ‬,‫ٮ‬,‫ڡﻬﺎ ?ٮ‬,> ‫ﻣﻬﻤﺔ ﻟﺴﻪ ﺿﺎٮ‬
10- A1c:
Normal: </= 5.5
Prediabetic: 5.7-6.4
Diabetic: >/= 6.5
11- when A1c can't be used
(As in cases of anemia, hemoglobinopathies, recently discovered DM type1, gestational
dm) we use fructosamine
12- investigation for the cause: ‫ٮﻬﺎ‬3‫ﺤ‬3‫ٮﻮب ٮ‬3‫زودوا ﻋﲆ اﻟﻤﻜ‬
*Auto ab: anti GAD & pancreatic ICA
*C-peptide level to differentiate endogenous from exogenous insulin
13- investigation for complications:
Urina analysis: ‫ٮ?ٮﻬﺎ‬,‫زودوا ?ﺣ‬
Urine albumin creatinine ratio to detect microalbuminuria

lactic ً ‫ا‬b‫ڡﻠﻬﻢ ﺣﺪوٮ‬3‫ و أ‬hypoglycemic coma ‫ى‬ . ‫ڡ‬, ‫ٮﺤﺼﻞ‬3‫■ أﺷﻬﺮ واﺣﺪة ?ٮ‬
. ‫ ه‬acute complication ‫ى‬
acidosis
, ‫ٮ‬3‫ڡﻀﻞ اﺳ‬,> ‫ ٮ‬comatose ‫■ﻟﻮ ﰷن اﻟﻌ>ٮﺎن‬
‫ﺣﻠﺶ‬,‫ ﻋﺸﺎن ﻣ>ٮﺪ‬slowly ‫ و ﻻزم ٮ >ﻜون‬dextrose 25%‫ﺤﺪام ﻣﺤﻠول‬
Hyperosmolar syndrome ‫ى‬ . ‫ڡ‬,
short ACTH stimualtion test ‫ ﺣﺎ?ﺣﺔ اﺳﻤﻬﺎ‬addison disease ‫ﺤﺺ‬ , ‫ﺸ‬3‫■أﻫﻢ ﺣﺎ?ﺣﺔ ٮ‬
‫ىك‬. ‫ى ﻋﻼج ادٮ >ﺴون ?ٮﻌط‬. ‫ڡ‬,■
G.C ‫ ال‬replacement therapy
Mineralocorticoids ‫ٮﻤﺮ ﻻزم اﺿ>ٮﻒ‬3‫ ﻣﺴ‬hypotension ‫ﻟﻮ ﺿﻞ‬
serum Ca ‫ڡﻠﻞ‬3‫ى ﺣﺎ?ﺣﺔ ?ٮ‬
. ‫ٮ‬,‫ﺎ‬3‫ ٮ‬replcement therapy ‫ٮﺎ ?ٮﻌﺎﻟﺞ اﻟﻤﺮض ك‬,‫ أ‬addison ‫ ﻟﻤﺮﴇ‬CS ‫ى‬
. ‫■ﻟﻤﺎ اﻋط‬
TB is the 2nd most common cause of addison disease■
Urea & creatinine is high d.t hypovolemia in addison disease■
most ‫ ﻫﻮ‬sudden withdrawal CS ‫ٮ?ٮﺮ‬3‫■ٮ >ﻌ‬
common cause for addison crisis

diarrhea is the most GIT symptom of addison disease■

‫ڡ>ٮﻪ‬, ‫ و ﻷ ﻋﺸﺎن ﻟﻮ ﰷن‬retinopathy ‫ى‬ . ‫ڡ‬, ‫ﺎﻛﺪ ﻟﻮ‬3‫ و اٮ‬fundus ‫ڡﺤﺺ ال‬,‫ ﻻزم ا‬D. Nephropathy ‫ى ﻋ>ٮﺎن‬
. ‫ڡ‬, ■
. ‫ڡ‬, ‫ڡﻰ‬3‫ڡ>ٮﺶ ٮ >?ٮ‬,‫ و ﻟﻮ ﻣ‬diabetes ‫ ﻫﻮ‬nephropathy ‫ڡﻰ اﻟﺴ?ٮﺐ اﻟﲇ ﻋﻤﻞ‬3‫ٮ >?ٮ‬
‫ٮ>ٮﺔ ﻋﻤﻠﺖ ده‬,‫ﺎ‬3‫ى ﺣﺎ?ﺣﺔ ٮ‬
. ‫ڡ‬, ■
micovascular complication is retinopathy ‫ ف‬diabetic ‫ٮﺤﺼﻞ ﻟﻠﻌ>ٮﺎن‬3‫ٮ>ٮﺔ أول ﺣﺎ?ﺣﺔ ?ٮ‬,‫ﺎ‬3‫ى ﺣﺎ?ﺣﺔ ٮ‬
nephropathy ‫ ?ٮﻌﺪ ﻛﺪه‬neuropathy ‫?ٮﻌﺪ ﻛﺪه‬
DM is the most common non traumatic lower limb amputation ■
NaHco3 is not given in HHNC ■
Total k is decresed in DKA ■
While serum K initailly normal or high normal then become decresed after ttt by insulin
. ‫ڡﻌﺶ اﻋط‬,‫ٮ‬,‫ٮور اﻟﻬواري ﻣ>ٮ‬3‫ڡول دﻛ‬3‫■ ﰷن ?ٮي‬
fetal ‫ﺣﺎٮ >ﻒ ﻣﻦ‬, ‫ ﻋﺸﺎن‬DN ‫ ﻣﻊ ?ٮﻌﺾ ﻟﻤﺮﴇ‬ARBs ‫ و‬ACEi ‫ى‬
ARF ‫ و‬hyperkalemia
‫ڡول‬3‫ ﰷن ?ٮي‬DM1 ‫ٮﺴ?ٮﺔ ﻟﻞ‬,‫?ٮﺎﻟ‬
 ACEis is superior to ARBs
DM2 ‫ٮﻤﺎ‬,‫?ٮي‬
ARBs is superior to ACEis
: ‫ڡول‬3‫■ﰷن ?ٮي‬
The eyes are the windows of the brain & kidney
You treat your foot as you treat your child

‫ڡوق‬, ‫ى‬
. ‫ڡﺔ ﻟﻠﻤﺴﺞ ال‬,‫?ٮﺎﻹﺿﺎ‬

. ‫ڡ‬, ‫اول ﺣﺎ?ﺣﻪ‬

good glycemic control ‫ ﻫﻰ‬complications ‫ى ﻋﻼج اى‬
cerebrovascular + coronary + peripheral artery disease ‫تﻀﻤﻦ ال‬3‫ ٮ‬macro ‫ذﻛﺮ ان ال‬
retinopathy +neuropathy + nephropathy ‫تﻀﻤﻦ ال‬3‫ ٮ‬micro ‫ڡﺎل ان ال‬3‫و‬
_____
. ‫ڡ‬,
‫ٮﻰ ?ٮﺪى اﻟﺴﻜﺮ ?ٮﺸكﻞ ?ٮﻄﺊ‬,‫ڡروض ا‬,‫ى ﻋﻼج اﻟﻬ>ٮ?ٮﻮ?ﺣﻼٮ >ﺴ>ٮﻤ>ٮﺎ اﻟﻤ‬
DKA & hypoglycemia‫ڡرق ?ٮيﻦ ال‬,‫رﻛﺰ ع اﻟ‬
_____
‫ﺪﻫﺮ‬3‫ٮﻼ ﺻﺪاع او ٮ‬b‫ﻄﻬﺮ ﻋﻠ>ٮﻪ اﻋراض ﻣ‬,> ‫ٮﺶ و?ٮﺪأ ٮ‬,‫ٮﺤﺴ‬3‫ٮﻪ ﻣ‬,‫ڡ>ٮﺖ ا‬3‫ٮﻪ ﻋﻼج وﻟ‬3> ‫ وادٮ‬hypothyroid ‫ٮﻪ‬,‫ڡﺮﺿﺎ ا‬, ‫ﻟﻮ ﻋ>ٮﺎن‬
polygland disease ‫ٮﺪه‬,‫ﻫﺸﻚ ان ﻋ‬
_____
‫ٮﺎﻋﺖ اﻻدٮ >ﺴون‬3‫ ?ٮ‬investigation ‫ى‬ . ‫ڡ‬,
‫ٮﺎت‬,‫ڡ>ٮﺲ اﻟﻬﺮﻣﻮ‬3‫ٮ‬,‫ اﻻول و?ٮﻌﺪ ﻛﺪا ﻫ‬Effect ‫ٮﺸﻮف ال‬,‫>ٮﺐ ﻫﻮ ﻫ‬3‫ٮﺮٮ‬3‫ڡﺎل اﻟ‬3
_
. ‫ڡ‬, ‫كﻠﻢ ﻋﻦ اﻟ?ﺤﺮﻋﺎت‬3‫اٮ‬
‫ى ﻋﻼج ال ادٮ >ﺴون‬

: ‫ٮﺎﻋﻪ‬3‫ڡﻪ ذﻛﺮ ف اﻟريﻜوردات ?ٮ‬,‫د ﻋﺮ‬

:Whipple triad
,episodic hypoglycaemia
central nervous system (CNS) dysfunction temporally related to hypoglycaemia
,(confusion, anxiety, stupor, paralysis, convulsions, coma)
dramatic reversal of CNS abnormalities by glucose administration
. ‫ڡ‬, ‫ٮﻬﺎ‬,‫ٮﻮه ﻋ‬, ‫ڡﺼ>ٮﻞ ?ٮﺲ‬,‫ٮ‬3‫ﻣﺬﻛﺮﻫﺎش ?ٮﺎﻟ‬
.hypoglycemia ‫ى ال‬

DM chronic complications ‫درس ال‬

.cardiac complications ‫رﻛﺰ ?ﺣﺪا ع‬
addison ‫درس ال‬
Hyperpigmentation
. ‫ڡ‬3‫ٮ?ٮ‬3‫?ٮ‬
primary type as result of increased ACTH ‫ى ﻣﻊ ال‬
While secondary type there's no pigmentation
 ‫‪Surgery:‬‬

‫?ٮ ‪,‬‬
‫ﺤﺼﻮص أﺳﺌﻠﺔ ال‪Thyroid‬‬
‫دا ‪ Flow chart‬ﻣﻦ ﻛ‪3‬ٮﺎب د‪ .‬اﻟﻤﻄري ﻣ‪,‬ڡ>ٮﺪ ?ﺣﺪا ‪,‬ڡ ‪.‬‬
‫ى ﺣﻞ ال‪? MCQ‬ٮ‪3‬ٮﺎﻋﻬﺎ ؛ ﻷ‪,‬ٮﻬﺎ ﻣﻌ‪3‬ٮﻤﺪة ?ٮﺸكﻞ أﺳﺎﳼ ﻋﲆ ٮ‪3‬ﺮٮ‪>3‬ٮﺐ‬
‫‪,‬ﺣﻄوات ﻣﻌ>ٮﻦ ﻻزم ‪,‬ٮﻤﴚ ﻋﻠ>ٮﻪ‪..‬‬

‫ى ال‪ ، Thyroid function & scan‬ﻋﺸﺎن ﻟﻮ ﻣﺤﺪش ‪,‬ﺣﺪ‬ ‫ى أول ﺣﺎ?ﺣﺔ ﻣﻜ‪3‬ٮو?ٮﺔ ‪,‬ڡوق ‪,‬ﺣﺎﻟﺺ اﻟﲇ ه ‪.‬‬ ‫أول ‪,‬ﺣﻄﻮة ه ‪.‬‬
‫?ٮﺎﻟﻪ ﻣ‪,‬ٮﻬﺎ‪) ..‬ﰷن ﻋﻠ>ٮهﺎ ﺳؤال اﻣﺴ>ٮﻜ>ٮﻮ ‪,‬ڡﻌﻼ ف اﻟﻤ>ٮﺪ أو ف اﻟ‪,‬ڡﺎٮ >‪,‬ٮﺎل اﻟﺴ‪,‬ٮﺔ اﻟﲇ ‪,‬ڡﺎٮ‪3‬ﺖ(‬

‫ﻣﺴﺄﻟﺔ اﻣﱴ أﻋﻤﻞ ‪thyroidectomy‬‬

‫واﻣﱴ أﻋﻤﻞ ‪lobectomy & frozen section‬‬

‫‪,‬ڡﻜﺮٮ‪3‬ﻬﺎ أ‪,‬ٮﻪ أ‪,‬ٮواع ال‪ Tumors‬اﻟﲇ ه ‪.‬‬

‫ى ‪ Medullary, Papillary, Anaplastic‬كﻠﻬﺎ ‪? Malignant‬ٮﺲ‬

‫ى أ‪,‬ٮﺎ ﻟﻮ ﻟ‪3‬ڡ>ٮ‪3‬ٮﻬﺎ ف ال‪ <-- Fine needle aspiration‬ﻫﻌﻤﻞ ‪ Thyroidectomy‬ع ﻃول ﻷ‪,‬ٮﻬﺎ اﻛ>ٮﺪ‬
‫و?ٮﺎﻟ‪3‬ٮﺎل ‪.‬‬
‫‪Malignant‬‬

‫إ‪,‬ٮﻤﺎ ال‪, ، Follicular‬ڡﺪا ‪,‬ڡ>ٮﻪ ﻣ‪,‬ٮﻪ ‪ Benign‬و ‪Malignant‬‬

‫واﻟ‪,‬ڡرق ?ٮي‪,‬ٮﻬﻢ ?ٮيﻜون ال‪Invasion‬‬
‫ى ﻣﺶ ﻫﻌﺮف ﻣ‪,‬ٮﻬﺎ ﻫﻞ ‪,‬ڡ>ٮﻪ ‪ Invasion‬وﻻ ﻷ‬
‫وﻣﺸكﻠﺔ ال‪ Fine needle‬أ‪,‬ٮ ‪.‬‬
 ‫واﻟ‪,‬ڡرق ?ٮي‪,‬ٮﻬﻢ ?ٮيﻜون ال‪Invasion‬‬
‫ى ﻣﺶ ﻫﻌﺮف ﻣ‪,‬ٮﻬﺎ ﻫﻞ ‪,‬ڡ>ٮﻪ ‪ Invasion‬وﻻ ﻷ‬
‫وﻣﺸكﻠﺔ ال‪ Fine needle‬أ‪,‬ٮ ‪.‬‬

‫‪,‬ڡ?ٮﻀﻄﺮ آ‪,‬ﺣﺪ ‪ Tissue biopsy‬اﻷول ‪ ،‬اﻟﲇ ه ‪.‬‬

‫ى ‪Lobectomy & frozen section‬‬
‫ﻋﺸﺎن أﻋﺮف ﻣ‪,‬ٮﻬﺎ ﻫﻞ ﻫﻮ ‪ Benign‬وﻻ ‪Malignant‬‬

‫د‪ .‬اﻟﻤﻄري ﻟﻪ ?ﺣﻤﻠﺔ ﺷﺎﻣﻠﺔ ?ٮ ‪,‬‬

‫ﺤﺼﻮص ال‪ Fine needle aspiration‬ف ﺷﺎ?ٮ‪3‬ٮﺮ ال‪Thyroid‬‬
‫ى أ‪,‬ٮﻬﺎ ٮ‪33‬ڡﺪر ٮ‪3‬ﺸ ‪,‬‬
‫ﺤﺺ كﻞ أﻣراض ال‪ Thyroid‬إﻻ ال‪? Follicular neoplasm‬ٮ‪3‬ٮﻜون ﻣﺤ‪3‬ٮﺎ?ﺣﺔ ‪Tissue biopsy‬‬ ‫وه ‪.‬‬

‫?ٮﺎﻟ‪,‬ٮﺴ?ٮﺔ ﻟﺴؤال ‪147‬‬

‫ﻛ‪,‬ٮﺖ ﺳﺄﻟﺖ د ?ﺣوزيﻒ ‪3‬ڡﺎل ‪b‬‬

‫ﻣﻦ زﻣ>ٮﻠﺔ ﻟ‪,‬ٮﺎ ‪,‬ڡ ‪.‬‬

‫ى اﻟﺪ‪,‬ڡﻌﺔ) ?ﺣزاﻫﺎ ﷲ ‪,‬ﺣ>ٮرا ً( ﺣﺎوﻟﺖ ٮ‪3‬ﻮﺿﺢ اﻟ‪,‬ڡﻜﺮة ﻟﻌﻠﻬﺎ ٮ‪,3‬ڡ>ٮﺪ أﺣﺪ‬

‫اوﻻ دي ﺣﺎﻟﺔ ‪ highly suspicious of malignancy‬ﻻن ‪,‬ڡ>ٮﻪ ﻫ>ٮﺴ‪3‬ٮوري ‪ of irradiation‬و ﻣﻌﺎﻫﺎ ‪cold‬‬
‫ى اﻋﻤﻞ ‪ total thyroidectomy‬ﻻن دا‬ ‫‪, nodule‬ڡﺄول ﺣﺎ?ﺣﺔ ﻫ‪3‬ٮ>ٮ?ح ‪.‬‬
‫ى ف ?ٮﺎﻟﻚ وا‪,‬ٮﺎ ?ٮﻌﻤﻞ ‪ management‬ا‪,‬ٮ ‪.‬‬
‫‪ cancer‬ﻟﻜﻦ ﻣ>ٮ‪,‬ٮ‪,‬ڡﻌﺶ ‪,‬ﺣﺎﻟﺺ اﻋﻤﻞ ﻛﺪا وا‪,‬ٮﺎ ﻣﺶ ﻣ‪3‬ٮﺎﻛﺪ ا‪,‬ٮﻬﺎ ‪ cancer‬ﺻﺤيﺢ اﻟﺤﺎ?ﺣﺎت اﻟﲇ ‪,‬ڡوق ٮ‪, 3‬‬
‫ﺤﻠ>ٮﲏ اﺷﻚ‬
‫ﻟﻜﻦ ﻣ‪3‬ٮ‪3‬ڡﻮﻟﺶ ‪ % 100‬ا‪,‬ٮﻪ ‪, cancer‬ڡﻼزم اﺣﻠﻒ ﻋﺎﻟﻤﺼﺤﻒ ا‪,‬ٮﻪ ‪ cancer‬اﻻول ﻋﻠﺸﺎن اﻋﻤﻞ ‪thyroidectomy‬‬
‫‪,‬ڡﻬﻌﻤﻞ ‪ fine needle aspiration‬ﻟﻮ ‪3‬ڡﺎﻟﺖ ا‪,‬ٮﻪ ‪ cancer‬ﻫروح اﻋﻤﻞ ‪, thyroidectomy‬ڡﺎﻟﺪﻛ‪3‬ٮور ﻫ‪,‬ٮﺎ ?ٮيﻠﻌﺐ ع‬
‫ﺣ‪3‬ٮﺔ ‪ steps‬ٮ >ﻌﲏ ﻣ>ٮﻦ ‪ step‬ٮ‪3‬تﻌﻤﻞ ‪3‬ڡ?ٮﻞ اﻟ‪3‬ٮﺎ‪,‬ٮ>ٮﺔ ال ‪ thyroidectomy‬ﺻﺢ ﻟﻜﻦ ﻣﺶ ‪3‬ڡ?ٮﻞ ﻣﺎ اٮ‪3‬ﺎﻛﺪ‬

‫ى ﻣﺤﻠﻮﻟﺔ ف اﻟﻜ‪3‬ٮﺎب ‪? lobectomy‬ٮﺲ ‪,‬ﻋﻠﻂ ‪,‬ﺣﺎﻟﺺ ﻻ‪,‬ٮﻬﺎ ﻛﻌﻤﻠ>ٮﺔ ﻣ?ٮ‪3‬ٮتﻌﻤﻠﺶ ف ﺣﺎﻟﺔ ‪ malignancy‬وﻟﻮ‬
‫ه ‪.‬‬
‫ﺤﺪﻣﻬﺎ ك ‪ diagnosis‬ﻻزم ٮ >‪3‬ڡول ‪ lobectomy with frozen section‬ﻻن ﻫﻌﻤﻞ اٮ >ﻪ ب ‪lobectomy‬‬ ‫ﻫﺴ‪3‬ٮ ‪,‬‬
‫ﺤﺺ اﻟﺤﺎﻟﺔ ‪,‬ڡﻠﻮ اﻻ‪,‬ﺣ‪3‬ٮ>ٮﺎرات ‪,‬ڡ>ٮهﺎ ‪lobectomy with frozen section‬‬ ‫ﺤﺪﻣﻬﺎ ا‪,‬ٮ ‪.‬‬
‫ى اﺷ ‪,‬‬ ‫ﻟﻮﺣﺪﻫﺎ ﻣﻦ ‪,‬ﻋ>ٮﺮ ﻣﺎ اﺳ‪3‬ٮ ‪,‬‬
‫ﻫ‪3‬ٮ?ٮ‪3‬ڡ ‪.‬‬
‫ى اﺣﺴﻦ ا‪,‬ﺣ‪3‬ٮ>ٮﺎر‬