Dermatology and Endocrine Flashcards
1
Q
Describe the progression from melanocytic naevi (mole) to nodular melanoma.
A
Melanocytic naevi -> dysplastic melanocytic naevi -> in situ melanoma -> superficial spreading melanoma -> nodular melanoma.
2
Q
What is the main cause of all skin cancer?
A
SUN EXPOSURE - UV light.
3
Q
What is the treatment for malignant melanoma?
A
Surgical excision.
4
Q
Give 5 causes of generalised pruritus but no rash.
A
- AGEING.
- Chronic renal failure.
- Cholestasis e.g. PBC.
- Iron deficiency.
- Lymphoma.
- Polycythaemia.
- Hypothyroid.
- Drugs.
5
Q
Give 3 causes of generalised pruritus with rash.
A
- Urticaria.
- Atopic eczema.
- Psoriasis.
- Scabies.
- Lichen planus.
6
Q
What investigations might you do in someone with pruritus?
A
- FBC.
- Ferritin levels.
- U+E.
- LFT’s.
- TFT’s.
7
Q
What cytokines are commonly targeted in the treatment of pruritus?
A
IL-4 and IL-13.
8
Q
Why do transdermal drugs need to be lipophilic?
A
They need to be lipophilic in order to get through the lipid rich stratum corneum.
9
Q
Give 2 essential properties of transdermal drugs.
A
- Lipophilic.
- High affinity for their targets.
10
Q
Give 3 advantages of transdermal drug delivery.
A
- Avoids first pass effect, hardly metabolised.
- No pain.
- Controlled dosing.
11
Q
What are emollients used for?
A
They hydrate the skin and reduce itching.
12
Q
In what diseases would the use of emollients be indicated?
A
Dry skin, eczema.
13
Q
What receptors do glucocorticoids target?
A
Cytoplasmic receptors.
14
Q
How does hydrocortisone work?
A
Hydrocortisone targets cytoplasmic receptors. It leads to a reduction in pro-inflammatory cytokines and an increase in anti-inflammatories.
15
Q
In what diseases would the use of hydrocortisone be indicated?
A
Eczema and contact dermatitis.
16
Q
Give 3 potential side effects of glucocorticoids.
A
- Skin thinning.
- Oral candidiasis.
- Acne.
- Striae.
- Bruising.
17
Q
What receptors do vitamin A analogues target?
A
Nuclear retinoic acid receptors.
18
Q
Name a Vitamin D analogue.
A
Calcipotriol.
19
Q
How does calcipotriol work in the treatment of psoriasis?
A
Calcipotriol is a vitamin D analogue. It has anti-proliferative and anti-inflammatory effects.
20
Q
In what diseases would the use of calcipotriol be indicated?
A
Psoriasis.
Calcipotriol is a vitamin D analogue.
21
Q
What receptors does tazarotene bind to?
A
Tazarotene is a Vitamin A analogue. It binds to nuclear retinoic acid receptors.
22
Q
How does tazarotene work in the treatment of acne and psoriasis?
A
Tazarotene is a Vitamin A analogue. It binds to nuclear retinoic acid receptors and modifies gene expression and inhibits cell proliferation.
23
Q
In what diseases would the use of tazarotene be indicated?
A
Psoriasis and acne.
24
Q
Would you prescribe tazarotene to a pregnant lady?
A
NO! Tazarotene is highly teratogenic.
25
What class of drug is tacrolimus?
Calcineurin inhibitor.
26
When might you prescribe someone tacrolimus?
Tacrolimus is often used as a second line treatment for eczema.
(1st line = glucocorticoids e.g. hydrocortisone).
27
Name 3 drug induced dermatological reactions.
1. Exanthematous reactions.
2. Urticaria.
3. Stephen Johnson syndrome.
28
Give 5 signs of eczema.
1. Superficial skin redness/inflammation.
2. Oozing.
3. Scaling.
4. Pruritus.
5. Flexors typically affected e.g. at elbows.
29
Describe the aetiology of eczema.
1. Genetic predisposition - loss of function mutations in filaggrin.
2. Environmental triggers and irritants.
30
Describe the treatment for eczema.
1. Avoid irritants and allergens.
2. Use emollients liberally and frequently.
3. First line - hydrocortisone.
4. Second line - tacrolimus.
5. Third line - sedative anti-histamines.
31
Briefly describe the pathophysiology of acne.
Seborrhea (increased sebum production) -> narrowed follicle blocks sebum, comedo formation -> sebum stagnates and p.acne colonises -> inflammation of pilosebaceous unit.
32
Describe the treatment for acne.
Treatment is important to avoid scarring and psychological distress:
- Regular washing with acne soaps to remove grease.
- Benzoyl peroxide and topical clindamycin.
- 2nd line - topical retinoids e.g. tazarotene.
- 3rd line - low dose oral antibiotics e.g. doxycycline.
- Hormone treatment can also be used.
33
What is psoriasis?
A chronic hypo-proliferative disorder characterised by well demarcated silvery grey, scaly plaques over extensor surfaces such as elbows and knees and in the scalp.
34
What environmental factors can cause psoriasis in a genetically susceptible individual?
1. Group A streptococcal infection.
2. Lithium.
3. UV light.
4. Alcohol.
5. Stress.
35
Describe the treatment for psoriasis.
1. Emollients and reassurance.
2. Vitamin D and A analogues e.g. calcipotriol and tazarotene.
3. Phototherapy.
36
What is necrotising fasciitis?
Deep spreading infection of all layers of the skin -> necrosis.
37
Give 3 risk factors for necrotising fasciitis.
1. IVDU.
2. Diabetes mellitus.
3. Homeless.
4. Recent surgery.
38
What bacteria can cause necrotising fasciitis?
1. Type 1: aerobic and anaerobic.
2. Type 2: group A strep e.g. s.pyogenes.
39
What is the treatment for necrotising fasciitis?
1. Surgical debridement.
2. Aggressive IV benzylpenicillin and clindamycin.
40
What is cellulitis?
Inflammation of the SC layer of the skin.
41
What bacteria is the commonest causal organism of cellulitis?
S.pyogenes.
42
Give 5 signs of cellulitis.
1. Inflammation.
2. Swelling.
3. Redness.
4. Warmth.
5. Pain.
6. Unilateral.
43
What is the differential diagnosis in someone with the signs and symptoms of cellulitis?
DVT!
44
What is the treatment for cellulitis?
Penicillin and flucloxacillin.
45
Give an example of a water soluble hormone.
Peptides e.g. TRH, LH, FSH.
46
Are water soluble hormones stored in vesicles or synthesised on demand?
Water soluble hormones e.g. peptides are stored in vesicles.
47
How do water soluble hormones e.g. peptides get into a cell?
They bind to cell surface receptors.
48
Give an example of a fat soluble hormone.
Steroids e.g. cortisol.
49
Are fat soluble hormones stored in vesicles or synthesised on demand?
Fat soluble hormones e.g. steroids are synthesised on demand.
50
Give an example of an amine hormone.
Noradrenaline and adrenaline.
51
Describe the pathway for noradrenaline synthesis.
Phenylalanine -> L-tyrosine -> L-dopa -> dopamine -> NAd and Ad.
52
Name 2 enzymes that break down catecholamines.
MAO and COMT.
53
What are noradrenaline and adrenaline broken down into?
Normetadrenaline and metadrenaline.
54
Where in a cell are peptide cell receptors located?
Peptide cell receptors are located on the cell membrane.
55
Where in a cell are steroid cell receptors located?
Steroid cell receptors are located in the cytoplasm.
56
Where in a cell are thyroid/vitamin A and D cell receptors located?
Thyroid, vitamin A and D and oestrogen act on nuclear receptors.
57
Give 5 ways in which hormone action is controlled.
1. Hormone metabolism.
2. Hormone receptor induction.
3. Hormone receptor down-regulation.
4. Synergism e.g. glucagon and adrenaline.
5. Antagonism e.g. glucagon and insulin.
58
What layer of the trilaminar disc is the anterior pituitary derived from?
Ectoderm (Rathke's pouch).
59
Name 6 hormones that the anterior pituitary produces.
1. TSH.
2. FSH.
3. LH.
4. ACTH.
5. Prolactin.
6. GH.
60
What is the posterior pituitary derived form?
The floor of the ventricles.
61
Where are posterior pituitary hormones synthesised?
They are synthesised in the para-ventricular and supra-optic nuclei.
62
Name 2 hormones secreted from the posterior pituitary.
Oxytocin and ADH.
63
What is the function of ADH?
It acts on the collecting ducts of the nephron and increases insertion of aquaporin 2 channels -> there is H2O retention.
64
Give 2 functions of oxytocin.
1. Milk secretion.
2. Uterine contraction.
65
Which has a longer half life, triiodothyronine or thyroxine?
Thyroxine has a half life of 5-7 days whereas triiodothyronine has a half life of only 1 day.
66
Describe the thyroid axis.
Hypothalamus -> TRH -> AP -> TSH -> thyroid -> T3 and T4.
T3/4 have a negative feedback effect on the hypothalamus and the anterior pituitary.
67
What would be the effect on TSH if you had an under-active thyroid?
TSH would be raised as you have less T3/4 being produced and so no negative feedback.
68
What would a low TSH tell you about the action of the thyroid?
A low TSH indicates an over-active thyroid.
Lots of T4 and T3 is being produced and so there is more negative feedback on the pituitary and less TSH.
69
Describe the mechanism of ACTH.
Hypothalamus -> CRH -> AP -> ACTH -> adrenal cortex (zona fasciculata) -> glucocorticoid synthesis e.g. cortisol.
Cortisol has a negative feedback effect on the hypothalamus and the anterior pituitary.
70
Give 3 functions of thyroid hormones (T3/4).
1. Food metabolism.
2. Protein synthesis.
3. Increased sympathetic action e.g. CO and HR.
4. Heat production.
5. Needed for growth and development.
71
Give 3 functions of cortisol in response to stress.
1. Mobilises energy sources -> lipolysis, gluconeogenesis and protein break down.
2. Vasoconstriction.
3. Suppresses inflammatory and immune repsonses.
4. Inhibits non-essential functions e.g. growth and reproduction.
72
Briefly describe the mechanism of LH and FSH.
Hypothalamus -> GnRH -> AP -> FSH/LH -> ovaries/testes.
FSH acts on granulosa cells to produce oestrogen and sertoli cells to stimulate spermatogenesis.
LH acts on theca cells to produce androgens or leydig cells to produce testosterone.
73
What cells does FSH act on?
- In the ovaries: granulosa cells.
- In the testes: sertoli cells.
74
What cells does LH act on?
- In the ovaries: theca cells.
- In the testes: leydig cells.
75
What is the function of theca cells?
Theca cells are stimulated by LH to produce androgens that diffuse into granulosa cells to be converted into oestrogen.
76
What is the function of granulosa cells?
Granulosa cells are stimulated by FSH to convert androgens into oestrogen using aromatase.
77
What is the function of sertoli cells?
Sertoli cells produce MIF (mullerian inhibiting factor) and inhibin and activin which acts on the pituitary gland to regulate FSH.
78
What is the function of leydig cells?
Leydig cells are stimulated by LH to produce testosterone.
79
Describe the GH/IGF-1 axis.
Hypothalamus -> GHRH (+) or SMS (-) -> AP -> GH -> Liver -> IGF-1.
80
What is the function of IGF-1?
It induces cell division, cartilage and skeletal growth and protein synthesis.
81
Briefly describe the mechanism of prolactin.
Hypothalamus -> dopamine (-) -> AP -> prolactin.
Prolactin acts on the mammary glands to produce milk.
82
What would happen to serum prolactin levels if something was to impact on the pituitary stalk and block dopamine release?
Prolactin levels would increase.
83
Give 3 potential consequences of a pituitary tumour.
1. Pressure on local structures e.g. optic chiasm.
2. Hypo-pituitary.
3. Functioning tumour e.g. Cushing's, gigantism, prolactinoma.
84
Give 2 causes of prolactinoma.
1. Pituitary adenoma.
2. Anti-dopaminergic drugs.
85
Give 5 signs of prolactinoma.
1. Infertility.
2. Golactorrhoea.
3. Amenorrhoea.
4. Loss of libido.
5. Visual field defects and headaches due to local effect of tumour.
86
What investigation would you do on someone presenting with difficulty getting pregnant, golactorrhoea, amenorrhoea, loss of libido and headaches?
You would measure serum prolactin.
These are symptoms of prolactinoma.
87
Describe the treatment for prolactinoma.
Dopamine agonist e.g. cabergoline.
88
Describe growth hormone secretion from the anterior pituitary.
It is secreted in a pulsatile fashion and increases during deep sleep.
89
What can cause acromegaly?
A benign pituitary adenoma producing excess GH.
90
Give 5 symptoms of acromegaly.
1. Change in appearance.
2. Increase in size of hands and feet.
3. Excessive sweating.
4. Headache.
5. Tiredness.
6. Weight gain.
7. Amenorrhoea.
8. Deep voice.
9. Goitre.
91
Give 5 signs of acromegaly.
1. Prognathism - jaw protrusion.
2. Interdental separation.
3. Large tongue.
4. Spade like hands and feet.
5. Tight rings.
6. Bi-temporal hemianopia.
92
What co-morbidities are associated with acromegaly?
1. Arthritis.
2. Cerebrovascular events.
3. Hypertension and heart disease.
4. Sleep apnea.
5. T2 DM.
93
What investigations might you do on someone who you suspect has acromegaly?
1. Plasma GH levels can exclude acromegaly - not diagnostic!
2. Serum IGF-1 levels raised.
3. Oral glucose tolerance test - diagnostic!
4. MRI of pituitary.
94
What test is diagnostic for acromegaly?
Oral glucose tolerance test - failure of glucose to suppress serum GH.
95
Describe the treatment for acromegaly.
1. Trans-sphenoidal surgical resection.
2. Radiotherapy.
3. Medical therapy: somatostatin analogues, dopamine agonists e.g. cabergoline.
96
Give 3 potential complications of trans-sphenoidal surgical resection for the treatment of acromegaly.
1. Hypopituitarism.
2. Diabetes insipidus.
3. Haemorrhage.
4. CNS injury.
5. Meningitis.
97
Give 3 advantages of using dopamine agonists in the treatment of acromegaly.
1. No hypopituitarism.
2. Oral administration.
3. Rapid onset.
98
Give 2 disadvantages of using dopamine agonists in the treatment of acromegaly.
1. Can be ineffective.
2. Risk of side effects.
99
Name a dopamine agonist that can be used in the treatment of acromegaly.
Cabergoline.
100
Give 5 causes of hypothyroidism.
1. Autoimmune thyroiditis e.g. Hashimoto's and atrophic thyroiditis.
2. Post-partum thyroiditis.
3. Iatrogenic - thyroidectomy.
4. Drug induced e.g. carbimazole, amiodarone, lithium.
5. Iodine deficiency.
101
Hypothyroidism: name 3 anti-bodies that may be present in the serum in someone with autoimmune thyroiditis.
1. TPO (thyroid peroxidase).
2. Thyroglobulin.
3. TSH receptor.
102
Give an example of a transient cause of hypothyroidism.
Post-partum thyroiditis.
103
Give 2 examples of iatrogenic causes of hypothyroidism.
1. Thyroidectomy.
2. Radioiodine therapy.
104
Name 3 drugs that can cause hypothyroidism.
1. Carbimazole (used to treat hyperthyroidism).
2. Amiodarone.
3. Lithium.
105
Why can amiodarone cause hypo/hyperthyroidism?
Because it is iodine rich.
106
Give 5 symptoms of hypothyroidism.
1. Menorrhagia – heavy bleeding.
2. Obesity/weight gain.
3. Malar flush.
4. Tiredness.
5. Intolerance to cold.
6. Energy levels fall/eyebrow loss.
7. Depression/dry skin and hair.
8. GOITRE!
107
Give 5 signs of hypothyroidism.
1. Mental slowness.
2. Dry thin hair.
3. Bradycardia.
4. Anaemia.
5. Hypertension.
6. Loss of eyebrows.
7. Cold peripheries.
8. Carpal tunnel syndrome.
108
What investigations might you do in someone who you suspect has hypothyroidism?
- TFT's - serum TSH will be raised and T3/T4 will be low.
- Thyroid antibodies.
109
Describe the management for hypothyroidism.
Levothyroxine.
110
Give 5 causes of thyrotoxicosis.
Thyrotoxicosis - excess thyroid hormone due to any cause:
1. Increased production e.g. Grave's, toxic adenoma.
2. Leakage of T3/4 due to follicular damage.
3. Ingestion.
4. Thyroiditis.
5. Drug induced.
111
Give 3 causes of hyperthyroidism.
1. Grave's disease.
2. Toxic adenoma.
3. Toxic Multinodular Goitre (TMG)
112
Briefly describe the pathophysiology of Grave's disease.
Autoimmune disease. TSH receptor antibodies stimulate thyroid hormone production -> hyperthyroidism.
113
Give 5 symptoms of Grave's disease that don't include opthalmopathy signs.
1. Weight loss.
2. Increased appetite.
3. Irritable.
4. Tremor.
5. Palpitations.
6. Goitre.
7. Diarrhoea.
8. Heat intolerance.
9. Malaise.
10. Vomiting.
114
Give 5 signs of Grave's disease that don't include opthalmopathy signs.
1. Tachycardia.
2. Arrhythmias e.g. AF.
3. Warm peripheries.
4. Muscle spasm.
5. Pre-tibial myxoedema (raised purple lesions over the shins).
6. Thyroid acropachy (clubbing and swollen fingers).
115
With what disease would you associated pre-tibial myxoedema and thyroid acropachy?
Grave's disease.
116
Give 5 Grave's opthlmopathy signs.
1. Exophthalmos (bulging eyes).
2. Lid lag stare.
3. Redness.
4. Conjuctivitis.
5. Pre-orbital oedema.
6. Bilateral.
7. Extra-ocular muscle swelling.
117
What investigations might you do in someone who you suspect has hypothyroidism?
TFT's - serum TSH is suppressed and T3/4 are elevated.
118
What would you see histologically in someone with Grave's disease?
Lymphocyte infiltration and thyroid follicle destruction.
119
Describe the treatment for Grave's disease.
1. Anti-thyroid drugs e.g. carbimazole.
2. Radioiodine drugs.
3. Surgery - partial thyroidectomy.
120
How does carbimazole work in treating Grave's disease?
It targets thyroid peroxidase and so prevents the formation of T3/4.
121
Give a potential serious side effect of taking carbimazole to treat Grave's disease.
Agranulocytosis.
Patient's are advised to seek medical attention if they develop an unexplained sore throat or fever.
122
How do radioiodine drugs work in treating Grave's disease?
Radioiodine drugs emit beta particles that destroy thyroid follicles and so thyroid hormone production is decreased.
123
Give 3 potential complications of a partial thyroidectomy.
1. Bleeding.
2. Hypocalcaemia.
3. Hypothyroidism.
4. Recurrent laryngeal nerve palsy.
124
What disease would you treat with Carbimazole?
Grave's disease.
125
What disease would you treat with levothyroxine?
Hypothyroidism.
126
Give 5 metabolic changes that occur in pregnancy.
1. Increased EPO, cortisol and NAd.
2. High CO.
3. High cholesterol and triglycerides.
4. Pro thrombotic and inflammatory state.
5. Insulin resistance.
127
Give 5 gestational syndromes.
1. Pre-eclampsia.
2. Gestational diabetes.
3. Obstetric cholestasis.
4. Gestational thyrotoxicosis.
5. Postnatal depression.
6. Post partum thyroiditis.
128
At what week are foetal thyroid follicles and T4 synthesised?
Week 10.
129
Why can hCG activate TSH receptors and cause hyperthyroidism?
HCG and TSH are glycoprotein hormones with very similar structures. HCG can therefore activate TSH receptors.
130
Is hypothyroidism or thyrotoxicosis more common in pregnancy?
Hypothyroidism is more common in pregnancy.
131
How can you differentiate between Grave's disease and gestational thyrotoxicosis?
- Grave's: symptoms predate pregnancy; symptoms are severe during pregnancy; goitre and TSH-R antibodies present.
- Gestational thyrotoxicosis: symptoms do not predate pregnancy; lots of N/V - hyperemesis gravidarum associated. No goitre or TSH-R antibodies.
132
Give 3 potential consequences of untreated hypothyroidism in pregnancy.
1. Gestational hypertension.
2. Placental abruption.
3. Post partum haemorrhage,
4. Low birth weight.
5. Neonatal goitre.
133
Give 3 potential consequences of untreated hyperthyroidism in pregnancy.
1. Intra-uterine growth restriction.
2. Low birth weight.
3. Pre-eclampsia.
4. Risk of still birth/miscarriage.
134
What disease is described as being a 'disorder of carbohydrate metabolism characterised by hyperglycaemia'?
Diabetes mellitus.
135
What are the 4 cells to make up the islets of langerhans?
1. Beta cells (70%).
2. Alpha cells (20%).
3. Delta cells (8%).
4. Polypeptide secreting cells.
136
What do beta cells produce?
Insulin.
137
What do alpha cells produce?
Glucagon.
138
What do delta cells produce?
Somatostatin.
139
What is the importance of the alpha and beta cells being located next to each other in the islets of langerhans?
This enables them to 'cross talk' - insulin and glucagon show reciprocal action.
140
Describe the mechanism of insulin secretion from beta cells.
Glucose binds to beta cells -> glucose-6-phosphate -> ADP -> ATP -> K+ channels close -> membrane depolarisation -> Ca2+ channels open, influx -> insulin release.
141
Describe the physiological processes that occur in the fasting state in response to low blood glucose.
Low blood glucose = high glucagon and low insulin.
- Glycogenolysis and gluconeogenesis.
- Reduced peripheral glucose uptake.
- Stimulates the release of gluconeogenic precursors.
- Lipolysis and muscle breakdown.
142
Describe the effect on insulin and glucagon secretion in the fasting state.
Fasting state = low blood glucose.
Raised glucagon and low insulin.
143
How many carbon precursors are needed for gluconeogenesis?
3.
144
Describe the physiological processes that occur after feeding in response to high blood glucose.
High blood glucose = high insulin and low glucagon.
- Glycogenolysis and gluconeogenesis are suppressed.
- Glucose is taken up by peripheral muscle and fat cells.
- Lipolysis and muscle breakdown suppressed.
145
Describe the effect on insulin and glucagon secretion after feeding.
Insulin is high and glucagon is low.
146
A diagnosis of diabetes can be made by measuring plasma glucose levels. What would a persons fasting plasma glucose be if they were diabetic?
Fasting plasma glucose >7mmol/L.
147
A diagnosis of diabetes can be made by measuring plasma glucose levels. What would a persons random plasma glucose be if they were diabetic?
Random plasma glucose >11mmol/L.
148
A diagnosis of diabetes can be made by measuring plasma glucose levels. What would the results of the oral glucose tolerance test be if someone was diabetic?
Fasting plasma glucose >7mmol/L and 2-hour value >11mmol/L.
149
What might someone's HbA1c be if they have diabetes?
>48mmol/mol.
150
What is the affect of cortisol on insulin and glucagon?
Cortisol inhibits insulin and activates glucagon.
151
Describe the aetiology of type 1 diabetes mellitus.
Beta cells express HLA antigens (HLA DR3/DR4). Autoimmune destruction -> beta cell loss -> impaired insulin secretion.
152
Is type 1 diabetes characterised by a problem with insulin secretion, insulin resistance or both?
Type 1 diabetes is characterised by impaired insulin secretion - there is severe insulin deficiency.
153
At what age do people with T1DM present?
Often people with Type 1 diabetes will present in childhood.
154
Give 2 potential consequences of T1DM.
1. Hyperglycaemia.
2. Raised plasma ketones -> ketoacidosis.
155
Describe the natural history of T1DM.
Genetic predisposition + trigger -> insulitis, beta cell injury -> pre-diabetes -> diabetes.
156
T1DM is characterised by impaired insulin secretion. Describe the pathophysiological consequence of this.
Severe insulin deficiency -> glycogenolysis/gluconeogensis/lipolysis all not suppressed AND reduced peripheral glucose uptake -> hyperglycaemia and glycosuria.
Perceived stress -> cortisol and Ad secretion -> catabolic state -> increased plasma ketones.
157
Give 3 symptoms of T1DM.
1. Weight loss.
2. Thirst (fluid and electrolyte losses).
3. Polyuria (due to osmotic diuresis).
158
Would you associate ketoacidosis with T1 or T2 DM?
TYPE 1.
Occurs due to the absence of insulin.
159
Describe the pathophysiology of diabetic ketoacidosis.
No insulin -> lipolysis -> FFA's -> oxidised in liver -> ketone bodies -> ketoacidosis.
160
Name 3 ketone bodies.
- acetoacetate.
- acetone.
- beta hydroxybutyrate.
161
Where does ketogenesis occur?
In the liver.
162
Give 4 signs of diabetic ketoacidosis.
1. Hypotension.
2. Tachycardia.
3. Kussmaul’s respiration.
4. Breath smells of ketones.
5. Dehydration.
163
Describe the treatment for T1DM.
1. EDUCATION - make sure the patient understands the benefits of good glycaemic control.
2. Healthy diet - low in sugar, high in carbohydrates.
3. Regular activity, healthy BMI.
4. BP and hyperlipidaemia control.
5. Insulin.
164
How is insulin administered in someone with T1DM?
Injected into SC fat.
165
Other than SC injections, how else can insulin be administered?
Insulin pump.
166
Give 4 potential complications of insulin therapy.
1. Hypoglycaemia.
2. Lipohypertrophy at ejection site.
3. Insulin resistance.
4. Weight gain.
5. Interference with life style.
167
Is type 2 diabetes characterised by a problem with insulin secretion, insulin resistance or both?
Type 2 DM is characterised by impaired insulin secretion AND insulin resistance.
168
Describe the aetiology of T2DM.
Genetic predisposition and environmental factors e.g. obesity and lack of exercise.
169
Why is insulin secretion impaired in T2DM?
Impaired insulin secretion is thought to be due to lipid deposition in the pancreatic islets.
170
Describe the pathophysiology of T2DM.
Impaired insulin secretion and resistance -> IGT -> T2DM -> hyperglycaemia and high FFA's.
171
Is insulin secretion or insulin resistance the driving force of hyperglycaemia in T2DM?
Hepatic insulin resistance is the driving force of hyperglycaemia.
172
Give 3 risk factors for insulin resistance in T2DM.
1. Obesity.
2. Physical inactivity.
3. Family history.
173
What happens to insulin resistance, insulin secretion and glucose levels in T2DM?
- Insulin resistance increases.
- Insulin secretion decreases.
- Fasting and post-prandial glucose increase.
174
Why do you rarely see diabetic ketoacidosis in T2DM?
Insulin secretion is impaired but there are still low levels of plasma insulin. Even low levels of insulin can prevent muscle catabolism and ketogenesis.
175
Describe the treatment pathway for T2DM.
1. Lifestyle changes: lose weight, exercise, healthy diet.
2. Metformin.
3. Metformin + sulfonylurea.
4. Metformin + sulfonylurea + insulin.
5. Increase insulin dose as required.
176
How does metformin work in treating T2DM?
Metformin increases insulin sensitivity and inhibits glucose production.
177
How does sulfonylurea work in treating T2DM?
Sulfonylurea stimulates insulin release.
178
Give a potential consequence of taking Sulfonylurea for the treatment of T2DM.
Hypoglycaemia.
(Sulfonylurea stimulates insulin release).
179
Give 3 microvascular complications of diabetes mellitus.
1. Diabetic retinopathy.
2. Diabetic nephropathy.
3. Diabetic peripheral neuropathy.
180
Give a macrovascular complication of diabetes mellitus.
CV disease and stroke.
181
What is the main risk factor for diabetic complications?
Poor glycaemic control!
182
Give a potential consequence of acute hyperglycaemia?
Diabetic ketoacidosis and hyperosmolar coma.
183
Give a potential consequence of chronic hyperglycaemia?
Micro/macrovascular tissue complications e.g. diabetic reinopathy, nephropathy, neuropathy, CV disease etc.
184
What is the commonest form of diabetic neuropathy?
Distal symmetrical polyneuropathy.
185
Give 3 major clinical consequences of diabetic neuropathy.
1. Pain.
2. Autonomic neuropathy.
3. Insensitivity.
186
Describe the pain associated with diabetic neuropathy.
- Burning.
- Paraesthesia.
- Nocturnal exacerbation.
187
Diabetic neuropathy clinical consequences: what is autonomic neuropathy?
Autonomic neuropathy - damage to the nerves that supply body structures that regulate functions such as BP, HR, bowel/bladder emptying.
188
Diabetic neuropathy: give 5 signs of autonomic neuropathy.
1. Hypotension.
2. HR affected.
3. Diarrhoea/constipation.
4. Incontinence.
5. Erectile dysfunction.
6. Dry skin.
189
What are the consequences of insensitivity as a result of diabetic neuropathy?
Insensitivity -> foot ulceration -> infection -> amputation.
190
Describe the distribution of insensitivity as a result of diabetic neuropathy?
Insensitivity starts in the toes and moves proximally. Glove and stocking distribution.
191
Give 5 risk factors for diabetic neuropathy.
1. POOR GLYCAEMIC CONTROL.
2. Hypertension.
3. Smoking.
4. HbA1c.
5. Overweight.
6. Long duration of DM.
192
Describe the treatments for diabetic neuropathy.
1. Improve glycaemic control.
2. Antidepressants.
3. Pain relief.
193
PVD is a potential complication of Diabetes. Give 6 signs of acute ischaemia.
1. Pulseless.
2. Pale.
3. Perishing cold.
4. Pain.
5. Paralysis.
6. Paraesthesia.
194
Give 5 ways in which amputation can be prevented in someone with diabetic neuropathy.
1. Screening for insensitivity.
2. Education.
3. MDT foot clinics.
4. Pressure relieving footwear.
5. Podiatry.
6. Revascularisation and abx.
195
Would there be increased or decreased pulses in a diabetic neuropathic foot?
There would be increased foot pulses.
196
Give 5 risk factors for diabetic retinopathy.
1. Long duration DM.
2. Poor glycaemic control.
3. Hypertension.
4. Insulin treatment.
5. Pregnancy.
6. High HbA1c.
197
Describe the pathophysiology of diabetic retinopathy.
Micro-aneurysms -> pericyte loss and protein leakage -> occlusion -> ischaemia.
198
How can diabetic retinopathy be sub-divided?
Diabetic retinopathy is divided into:
- Proliferative - evidence of neovascularisation in retina.
- Non-proliferative.
199
What would you see in someone with an R1 retinopathy grade?
R1 - non-proliferative/background.
- Micro-aneurysms.
- Intraretinal haemorrhages.
- Exudates.
200
What would you see in someone with an R2 retinopathy grade?
R2 - pre-proliferative.
- Venous beading.
- Growth of new vessels.
201
What would you see in someone with an R3 retinopathy grade?
R3 - proliferative.
- New blood vessel on disc.
202
What is the treatment for diabetic retinopathy?
People with diabetes are offered regular screening to assess visual acuity.
- Laser therapy treats neovascularisation.
203
What is the hallmark of diabetic nephropathy?
Development of proteinuria and progressive decline in renal function.
204
What happens to the glomerular basement membrane in someone with diabetic nephropathy?
On microscopy there is thickening of the glomerular basement membrane.
205
Give one way in which the presentation of diabetic nephropathy differs between T1 and T2DM.
T1 DM: microalbuminuria develops 5-10 years after diagnosis.
T2 DM: microalbuminuria is often present at diagnosis.
206
Describe the treatment for diabetic nephropathy.
1. Glycaemic and BP control.
2. ARB/ACEi.
3. Proteinuria and cholesterol control.
207
Name 3 types of skin cancer.
1. BCC (75%) - in situ, grows slowly.
2. SCC (20%) - can metastasise, grows rapidly.
3. Melanoma (5%).
208
What is Keratoacanthoma?
A benign variant of SCC. It is unlikely to metastasise.
209
What is Bowen's disease?
Bowen's disease is also known as SCC in situ. It is characterised by red and scaly patches.
210
Give 5 early signs of melanoma.
MAJOR
1. Enlargement.
2. Colour change (almost always darkening).
MINOR
3. Irregular shape.
4. Bleeding.
5. Itching.
211
What is Hutchinson's sign?
Pigmentation of the nail and proximal nail fold. It is an important sign of subungual melanoma.
212
What is the ABCDE of melanoma?
Asymmetrical.
Border irregularity.
Colour variability.
Diameter >5mm.
Elevation irregularity.
213
Give 4 risk factors for melanoma.
1. High density freckles.
2. Red hair.
3. >100 moles.
4. >5 atypical moles.
5. Family history.
214
Give 3 factors that can be used to determine the prognosis of melanoma?
1. Breslow's thickness - the thinner (<1mm) the better.
2. Younger = better prognosis.
3. Female = better prognosis.
215
Give 4 differential diagnoses for melanoma.
1. Melanocytic neavi.
2. Seborrhoeic wart.
3. Freckle.
4. BCC.
5. Pyogenic granuloma.
216
Describe the distribution and characteristics of infantile eczema.
Infantile eczema is generalised. The cheeks and foreheads are commonly affected.
Scaly, dry and red patches.
217
Describe the distribution and characteristics of childhood eczema.
There is a shift from extensor surfaces being affected to flexural surfaces.
Lichenification.
218
Describe the distribution and characteristics of adult eczema.
There is increasing dryness and lichenification.
S.aureus infections may be common.
219
Describe the diagnostic criteria of eczema.
The patient must have had an itchy skin condition in the past 6 months and >3 or more of:
- History of involvement of skin creases.
- Personal history of asthma or hay-fever.
- History of generally dry skin.
- Visible flexural dermatitis.
220
Briefly describe the natural history of eczema.
Sub-clinical skin barrier defect -> sub-clinical inflammation -> AD phase 1 (non-atopic) -> AD phase 2 (true atopic, extrinsic), high IgE.
221
Where does Seborrhoeic dermatitis usually affect?
The scalp and face, there is thickened and scaly skin.
222
What can trigger Seborrhoeic dermatitis?
Yeast infection.
223
What is cradle cap an example of?
Seborrhoeic dermatitis.
224
Describe the treatment for Seborrhoeic dermatitis?
1. Anti-fungal treatment.
2. Keratolytic agents to reduce thickening.
225
Describe the signs of acne.
1. Open comedones (black heads).
2. Closed comedones (white heads).
3. Papules and pustules.
226
When might biological agents be indicated in the treatment of psoriasis?
In someone with a PASI score > 10 - severe psoriasis.
227
What type of psoriasis might you associate with streptococcal infections?
Guttate psoriasis.
228
Give 3 signs of Rosacea?
1. Flushing.
2. Erythema.
3. Papules and pustules.
NO comedones!
229
How does Rosacea differ from Acne?
Rosacea tends to affect older people and isn't associated with comedone formation.
Acne affects adolescents and often the presenting feature is open and closed comedones.
230
Describe the treatment for rosacea.
Metronidazole.
231
Briefly describe the pathophysiology of urticaria.
Mast cell and basophil activation, with resultant histamine release.
232
Give 2 clinical features of urticaria.
1. Wheals (hives) - superficial redness and swelling. Itching/burning.
2. Angio-oedema - more severe swelling. Painful.
233
Describe the sub-types of chronic urticaria.
Chronic - recurrent or continous signs:
1. Chronic spontaneous: idiopathic or associated with infection.
2. Chronic inducible: physical (triggered by temperature or pressure) OR contact (triggered by allergens).
234
What is the treatment for urticaria?
Anti-histamines and manage triggers.
235
Name the suprasellar neoplasm that can result from benign cysts and calcification of Rathke's pouch?
Craniopharyngioma.
236
Give 4 signs of Craniopharyngioma.
1. Raised ICP.
2. Vision affected.
3. Growth failure.
4. Puberty affected.
237
Give 4 local effects of pituitary adenoma.
1. Headaches.
2. Visual field defects - bitemporal hemianopia.
3. Cn palsy and temporal lobe epilepsy.
4. CSF rhinorrhoea.
238
What is the affect of hypothyroidism on TSH and T4 levels?
- TSH will be high.
- T4 will be low.
239
What is the affect of hyperthyroidism on TSH and T4 levels?
- TSH will be low.
- T4 will be high.
240
What is the affect of hypopituitarism on TSH and T4 levels?
- TSH will be low.
- T4 will be low.
241
What is the treatment for thyroid hypopituitarism?
Levothyroxine.
242
Give a cause of primary hypogonadism.
Klinefelter's syndrome - extra X chromosome.
243
What is the affect of primary hypogonadism on testosterone and FSH/LH levels?
- Testosterone will be low.
- FSH/LH will be high.
244
What is the affect of hypopituitarism on testosterone and FSH/LH levels?
- Testosterone will be low.
- FSH/LH will be low.
245
When should serum testosterone be measured?
At 9am due to circadian rhythm.
246
Give 5 consequences of androgen deficiency in a male.
1. Loss of libido.
2. High pitched voice.
3. Loss of facial, axillary, limb and pubic hair.
4. Loss of erections.
5. Poorly developed scrotum and penis.
247
What is the treatment for hypogonadism?
Testosterone gel/injection.
- Can improve BMD, QOL and libido etc.
248
What syndrome is characterised by a congenital deficiency of GnRH?
Kallmann's syndrome.
249
Are the levels of oestradiol and FSH/LH low or high before puberty?
Before puberty there are very low levels of these hormones in the serum.
250
What is the affect of primary ovarian failure on oestradiol and FSH/LH levels?
- FSH/LH is high.
- Oestradiol is low.
251
What is the affect of hypopituitarism on oestradiol and FSH/LH levels?
- FSH/LH are low.
- Oestradiol is low.
252
What is the affect of primary adrenal insufficiency on cortisol and ACTH levels?
- Cortisol is low.
- ACTH is high.
253
What is the affect of hypopituitarism on cortisol and ACTH levels?
- Cortisol is low.
- ACTH is low.
254
What can lead to elevated levels of prolactin?
1. Stress.
2. Drugs.
3. Pressure on the pituitary stalk.
255
What stimulates the posterior pituitary to release ADH?
Osmoreceptors in the hypothalamus detect raised plasma osmolarity -> posterior pituitary is signalled to release ADH.
256
Give 5 signs of diabetes insipidus.
1. Excessive urine production (>3L/24h).
2. Very dilute urine - <300 mOsmol/Kg.
3. Severe thirst.
4. Hypernatraemia.
5. Dehydration.
257
What investigations might you do to determine whether someone has diabetes insipidus?
1. Measure 24-hour urine volume - >3L/24h = suggests DI.
2. Plasma biochemisty - hypernatraemia.
3. Water deprivation test - urine will not concentrate when asked not to drink.
258
What is the treatment for neurological diabetes insipidus?
Desmopression.
259
Give 4 causes of polyuria.
1. Hypokalaemia.
2. Hypercalcaemia.
3. Hyperglycaemia.
4. Diabetes insipidus.
260
Would TSH and T4 be high or low in someone with sub-clinical hypothyroidism?
TSH would be high but T4 would be normal. These patients are often asymptomatic and well.
(Hypothyroidism: high TSH and low T4).
261
What is Cushing's syndrome?
A set of signs/symptoms resulting from chronic glucocorticoid excess with a loss of normal feedback mechanisms.
262
What can cause Cushing's syndrome?
1. Adrenal Tumour (adenoma or carcinoma).
2. Pituitary tumour (Cushing's disease).
3. Exogenous steroids.
4. Ectopic ACTH syndrome.
263
What is Cushing's disease?
Hypercortisolaemia specifically due to a pituitary adenoma releasing increased ACTH
ATCH dependent.
264
Give 7 signs/symptoms of Cushing's disease.
1. Central obesity.
2. Moon face.
3. Hypertension.
4. Skin thinning.
5. Abdominal striae.
6. Mood change.
7. Osteoporosis.
8. Muscle thinning.
9. Weight gain.
265
What investigations might you do in someone with Cushing's syndrome?
1. Overnight dexamethasone suppression test - failure to suppress cortisol.
2. Late night salivary cortisol - loss of circadian rhythm.
3. Urinary free cortisol is raised.
4. Loss of circadian rhythm.
266
What is the treatment for Cushing's syndrome?
1. Surgical removal of pituitary tumours.
2. Drugs to inhibit cortisol synthesis e.g. metyrapone, ketoconazole.
267
What is SIADH?
Syndrome of inappropriate ADH secretion.
Too much ADH = very concentrated urine and hyponatreamia.
268
Give 3 symptoms of SIADH.
1. Anorexia.
2. Nausea.
3. Malaise.
4. Headache.
5. Confusion.
269
Give 3 causes of SIADH.
1. Malignancy.
2. CNS disorders e.g. meningitis, brain tumour, cerebral haemorrhage.
3. TB.
4. Pneumonia.
5. Drugs.
270
Describe the treatment for SIADH.
1. Restrict fluid!
2. Give salt.
3. Loop diuretics e.g. furosemide.
4. ADH-R antagonists e.g. vaptans - can be used when people find fluid restriction challenging.
271
What is Conn's syndrome?
Primary hyperaldosteronism - high aldosterone levels independent of RAAS activation -> H2O and sodium retention and potassium excretion.
272
What are the 2 main signs of Conn's syndrome?
1. Hypertension.
2. Hypokalaemia.
Sodium will be normal or slightly raised.
273
Give 3 symptoms of Conn's syndrome. A deficiency in which electrolyte causes these symptoms?
1. Muscle weakness.
2. Tiredness.
3. Polyuria.
Due to potassium deficiency - hypokalaemia.
274
What can cause Conn's syndrome?
Adrenal adenoma.
275
What hormone is raised in Conn's syndrome and what hormone is reduced? Where are these hormones synthesised?
1. Aldosterone is raised - synthesised in the zona glomerulosa.
2. Renin is reduced - synthesised by the juxta-glomerular cells.
276
What investigations might you do in someone to confirm a diagnosis of Conn's syndrome?
1. Bloods - U+E, renin (low) and aldosterone (high).
2. Plasma aldosterone renin ratio can be used as an initial screening test - raised ratio indicates the need for further tests.
277
Give 4 ECG changes that you might see in someone with Conn's syndrome.
1. Increased amplitude and width of P waves.
2. Flat T waves.
3. ST depression.
4. Prolonged QT interval.
5. U waves.
278
What is the treatment for Conn's syndrome?
1. Laparoscopic adrenalectomy.
2. Spironolactone (aldosterone antagonist).
279
What does the parathyroid control?
Serum calcium levels.
A low serum calcium triggers the release of PTH and a high serum calcium triggers c-cells to release calcitonin.
280
What hormone does the parathyroid secrete and what is its function?
PTH - secreted in response to low serum calcium.
PTH increases bone resorption; increases calcium reabsorption at the kidney and activates vitamin D which then acts on the intestine to increase calcium absorption.
281
What is released by c-cells in the parathyroid in response ot high serum calcium?
Calcitonin.
282
What is the affect of hyperparathyroidism on serum calcium levels?
Hyperparathyroidism -> hypercalcaemia.
283
Give 5 symptoms of hyperparathryoidism.
Hyperparathyroidism -> hypercalcaemia:
1. Renal/biliary stones.
2. Bone pain.
3. Abdominal pain.
4. Polyuria.
5. Depression, anxiety, malaise.
Stones,bones, groans, thrones, moans.
284
Give 3 causes of hyperparathyroidism.
1. Primary: parathyroid adenoma - ↑PTH ↑Calcium ↓Phosphate.
2. Secondary: physiological hypertrophy in an attempt to correct low calcium.
3. Prolonged uncorrected hypertrophy.
285
Describe the treatment for hyperparathyroidism.
1. High fluid intake, low calcium diet.
2. Excision of adenoma.
3. Correct underlying cause.
4. Parathyroidectomy.
286
What is the affect of hypoparathyroidism on serum calcium levels?
Hypoparathyroidism -> hypocalcaemia.
287
Give 5 symptoms of hypoparathryoidism.
Hypoparathyroidism -> hypocalcaemia:
1. Spasm.
2. Paraesthesia around mouth and lips.
3. Anxious/irritable.
4. Seizures.
5. Increased muscle tone.
6. Confusion.
7. Dermatitis.
8. Impetigo herpetiformis.
9. QT prolongation.
288
What is the treatment for hypoparathyroidism?
Calcium supplements.
289
Give 5 causes of hypocalcaemia.
1. Dietary insufficiency.
2. Anticonvulsant therapy.
3. CKD.
4. Vitamin D deficiency.
5. Osteomalacia.
6. Hypoparathyroidism.
290
Give 2 ECG changes that you might see in someone with hyperparathyroidism.
Hyperparathyroidism -> hypercalcaemia and so:
1. Tall T waves.
2. Shorted QT interval.
291
Give 2 ECG changes that you might see in someone with hyoparathyroidism.
Hyoparathyroidism -> hypocalcaemia and so:
1. Small T waves.
2. Long QT interval.
292
What is phaeochromocytoma?
A rare catecholamine secreting tumour in the adrenal medulla.
293
Give 5 symptoms of phaeochromocytoma.
Classic triad of:
1. Headache.
2. Sweating.
3. Tachycardia.
Also:
4. Hypertension.
5. Palpitations.
6. Tremor.
7. Arrhythmia.
8. Confusion.
294
What investigations might you do in order to diagnose someone with having a phaeochromocytoma?
Bloods - raised WCC, increased plasma metadrenaline and normetadrenaline.
295
What is the treatment for phaeochromocytoma?
1. Alpha blocker e.g. phenoxybenzamine.
2. Beta blockers.
3. Surgical resection of tumour.
296
What is the major concern in someone with phaeochromocytoma?
Phaeochromocytomare are a dangerous but treatable cause of hypertension.
297
Describe the different types of subcutaneous insulins that can be given to people with T1DM.
1. Ultra-fast acting e.g. Humalog - taken before eating in conjunction with a long-acting insulin at night.
2. Long-acting insulin e.g. insulin glargine - taken before going to bed.
3. Pre-mixed insulin e.g. NovoMix - taken twice daily.
298
What is adrenal insufficiency?
Adrenocortical insufficiency resulting in a reduction of mineralocorticoids, glucocorticoids and androgens.
299
Give 6 symptoms of adrenal insufficiency.
1. Tanned - pigmentation.
2. Tired.
3. Tearful.
4. Thin - weight loss.
5. Headaches.
6. Abdominal cramps.
7. Myalgia.
8. Throwing up.
9. Weakness.
300
Give 5 primary causes of adrenal insufficiency?
1. Addison's disease (autoimmune destruction of the adrenal cortex).
2. Congenital adrenal hyperplasia (CAH).
3. TB.
4. Adrenal metastases.
5. Drugs.
6. Haemorrhage.
7. Infection.
301
What investigations might you do in someone who you suspect has adrenal insufficiency?
1. Bloods - FBC, U+E (↓Na+ and ↑K+ - due to ↓ aldosterone - ↑Ca2+, ↑Urea).
2. ↓ Glucose.
3. ACTH stimulation test - Addison's will not respond.
302
What is the treatment for adrenal insufficiency?
Hormone replacement - any steroids e.g. hydrocortisone.
In addison's disease replace aldosterone with fludrocortisone.
303
Give 3 causes of hypokalaemia.
1. Diuretics.
2. D+V.
3. Conn's syndrome.
4. Insulin.
304
Give 5 symptoms of hypokalaemia.
1. Muscle weakness.
2. Hypotonia.
3. Hyporeflexia.
4. Palpitations.
5. Arrhythmia.
6. Nausea and vomiting.
7. Cramps.
305
What ECG changes might you see in someone with hypokalaemia?
1. Increased amplitude and width of P waves.
2. ST depression.
3. Flat T waves.
4. U waves.
5. QT prolongation.
306
Give 3 causes of hyperkalaemia.
1. AKI.
2. NSAIDs.
3. Metabolic acidosis.
4. K+ sparing diuretics.
307
Give 3 symptoms of hyperkalaemia.
1. Weakness.
2. Palpitations.
3. Tachycardia.
4. Chest pain.
308
What ECG changes might you see in someone with hyperkalaemia?
1. Tall tented T waves.
2. Wide QRS.
3. Small P waves.
309
Give 3 causes of hypercalcaemia.
1. Hyperparathyroidism.
2. Hypercalcaemia of malignancy.
3. Vitamin D toxicity.
4. Myeloma.
310
What biochemical test might you want to do to establish the cause of hypercalcaemia?
PTH measurement.
311
How can hypercalcaemia be treated?
1. IV normal saline.
2. IV furosemide.
3. IV calcitonin.
312
A man presents with a history of weight loss, polyuria and nocturia. He is very unwell. The GP performs a capillary blood glucose which is found to be 17.2mmol/l. What is the most likely diagnosis of this mans symptoms?
Type 1 Diabetes Mellitus.
313
What is the treatment for someone presenting with ketoacidosis?
1. ABCDE.
2. IV normal saline.
3. IV soluble insulin via syringe driver and sliding scale.
4. Restore potassium levels.
5. Look for underlying cause.
314
pH 7.1; pCO2 1.2 kPa; pO2 11.1 kPa; Bicarbonate 4mmol/l.
Interpret this blood gas result.
Severe metabolic acidosis.
315
Give 3 causes of severe metabolic acidosis.
1. Diabetic ketoacidosis.
2. Severe sepsis.
3. Uraemia.
4. Lactic acidosis.
316
What is hirsutism?
Excess hair growth in women in a male pattern.
317
What is the cause of hirsutism?
Hirsutism indicates increased androgen production by the ovaries or adrenal glands, most commonly polycystic ovary syndrome.
318
What diseases are associated with polycystic ovary syndrome?
1. Insulin resistance and so T2DM.
2. Hypertension.
3. Hyperlipidaemia.
4. CV disease.
319
Give 5 symptoms of polycystic ovary syndrome.
1. Amenorrhoea.
2. Oligomenorrhoea.
3. Hirsutism.
4. Acne.
5. Overweight.
6. Infertility.
320
What criteria can be used to make a diagnosis of polycystic ovary syndrome?
Rotterdam diagnostic criteria:
1. Menstrual irregularity.
2. Clinical or biochemical evidence of hyperandrogenism.
3. Polycystic ovaries on USS.
321
Describe the treatment for polycystic ovary syndrome?
1. Hirsutism therapy: shaving/waxing excess hair OR oestrogens e.g. OCP.
2. Menstrual disturbance therapy: cyclic oestrogen/progesterone.
3. Metformin can improve hyperinsulinaemia and regulates the menstrual cycle.
322
A 27-year- old woman comes to see you because she is having infrequent periods (oligomenorrhoea). You note, on examination, that she has facial acne and is overweight. What is the most likely diagnosis? Give 3 other signs you might see in this patient.
Polycystic ovary syndrome.
Other signs:
1. Hirsutism.
2. Amenorrhoea.
3. Infertility.
323
Describe insulin action at muscle and fat cells.
Insulin binds to membrane receptors -> intracellular signalling cascade stimulated -> GLUT-4 mobilisation to plasma membrane -> GLUT-4 integrates into plasma membrane -> glucose enters cell via GLUT-4.
324
Which bacteria is responsible for causing impetigo?
Staphylococcus aureus.
325
What is the treatment for impetigo?
Flucloxacillin.
326
Give 5 symptoms of DKA.
1. Polyuria.
2. Polydipsia.
3. Weight loss.
4. Nausea/vomiting.
5. Confusion.
6. Weakness.
327
Give 3 causes of DKA.
1. Unknown.
2. Infections.
3. Treatment errors - not administering enough insulin.
4. Having undiagnosed T1DM.
328
Describe the triad of DKA.
1. Acidaemia – blood pH < 7.3
2. Hyperglycaemia – blood glucose > 11mmol/L.
3. Ketonaemia.
329
Give 4 potential complications of untreated DKA.
1. Oedema.
2. Adult respiratory distress syndrome.
3. Aspiration pneumonia.
4. Thromboembolism.
5. Death.
330
Give 5 symptoms of hypoglycaemia.
1. Hunger.
2. Sweating.
3. Tachycardia.
4. Anxious.
5. Shaking.
331
Give 3 endocrine diseases that can cause diabetes.
1. Cushing's.
2. Acromegaly.
3. Phaeochromocytoma.
332
What class of drugs can cause diabetes?
1. Steroids.
2. Thiazides.
3. Anti-psychotics.
333
Give 3 secondary causes of adrenal insufficiency.
1. Hypopituitarism.
2. Withdrawal from long term steroids.
3. Infiltration.
4. Infection.
5. Radiotherapy.
334
An adrenal crisis is a common presentation of adrenal insufficiency. Give 3 features of an adrenal crisis.
1. Hypotension.
2. Fatigue.
3. Fever.
4. Hypoglycaemia.
5. Hyponatraemia.
6. Hyperkalaemia.
335
How would you treat an adrenal crisis?
Hydrocortisone and IV saline.
336
State whether sodium and potassium levels would be high or low in someone with adrenal insufficiency.
- Hyponatraemia.
- Hyperkalaemia.
Lack of aldosterone and so less sodium is reabsorbed and less potassium is excreted.
337
17 year old man presents with intermittent headaches and anxiety. He is sweating and vomiting. His BP is 223/159 and his pulse is 115. What is the likely cause?
Phaeochromocytoma crisis!
Hypertension and tachycardia = phaeochromocytoma until proved otherwise; especially in younger patients.
338
What is the management of a phaeochromocytoma crisis?
Non-competitive alpha-blocker e.g. phenoxybenzamine.
Excision of paraganglioma.
Biochemistry: measure plasma and serum metanephrines.
339
Give 3 causes of hyponatraemia.
1. SIADH.
2. Sodium deficiency.
3. Renal failure.
4. Malignancy.
340
Define hyponatraemia.
Serum sodium <135mmol/L.
341
Give 3 signs of hyponatraemia.
1. Anorexia.
2. Confusion.
3. Headache.
4. Lethargy.
5. Weakness.
342
What is the treatment for acute hyponatraemia?
Give a bolus dose of saline.
343
What are the units for osmolality?
mOsmol/Kg.
344
What is the primary cation in ICF?
K+.
345
What is the primary cation in the ECF?
Na+.
346
what are the primary anions in the ECF?
Cl- and HCO3-.
347
What is the effect of water excess on thirst and ADH secretion?
Decreased thirst and decreased ADH -> reduced intake and increased excretion.
348
What is the effect of water deficit on thirst and ADH secretion?
Increased thirst and increased ADH -> increased water intake and reduced secretion.
349
What GPCR does ADH bind to on renal tubules?
V2.
350
Do you have hypernatraemia or hyponatraemia in diabetes insipidus?
Hypernatraemia.
351
Give 3 causes of cranial diabetes insipidus.
1. Tumours.
2. Trauma.
3. Infections.
4. Idiopathic.
5. Genetic - AR.
352
Give 3 causes of nephrogenic diabetes insipidus.
1. Osmotic diuresis - diabetes mellitus.
2. Drugs.
3. CKD.
4. Metabolic e.g. hypercalcaemia and hypokalaemia.
353
In what class of drugs does metformin belong?
Biguanide.
354
Give an example of a sulfonylurea.
Tolazamide and gliclazide.
355
Give a sign of Cushing's syndrome that is due to impairments in carbohydrate metabolism.
Diabetes mellitus.
356
Give a sign of Cushing's syndrome that is due to electrolyte disturbances.
1. Sodium retention.
2. Hypertension.
357
People with Cushing's syndrome may have immune dysfunction. Give a consequence of this.
Increased susceptibility to infection.
358
Why is it important to take a drug history when speaking to someone with potential Cushing's?
To exclude exogenous glucocorticoid exposure as a potential cause.
359
Name 2 drugs that suppress cortisol synthesis and so can be used in the treatment of Cushing's disease.
1. Metyrapone.
2. Ketoconazole.
360
When might you see signs of hypercortisolism without Cushing’s disease?
1. Pregnancy.
2. Depression.
3. Alcohol dependence.
4. Obesity.
361
Would you expect a patient with SIADH to be hypovolaemic, euvolaemic or hypervolaemic?
Euvolaemic.
362
Describe 5 features of the essential criteria for SIADH.
1. Hyponatreamia (<135mmol/L).
2. Plasma hypo-osmolality.
3. High urine osmolality.
4. Clinical euvolaemia.
5. Increased urinary sodium excretion with normal salt and water intake.
363
Name 3 diseases that you must exclude in someone who you suspect could have SIADH.
1. Renal disease.
2. Hypothyroidism.
3. Hypocortism.
4. Recent diuretic use.
364
Would you associate SIADH with hyponatraemia or hypernatraemia?
Hyponatraemia <135mmol/L.
365
Would you associate SIADH with plasma hypo-osmolality or hyper-osmolality?
Plasma hypo-osmolality <275mOsm/Kg.
366
Would you associate SIADH with a high or low urine osmolality?
High urine osmolality.
367
Give 2 clinical signs of hypervolaemia.
1. Ascites.
2. Oedema.
368
Give 3 clinical signs of hypovolaemia.
1. Hypotension.
2. Tachycardia.
3. Decreased skin turgor.
4. Dry mucus membranes.
369
Define puberty.
Puberty describes the physiological, morphological and behavioural changes as the gonads switch from infantile to adult forms.
370
What is the first sign of puberty in girls?
Menarche.
371
What hormone is responsible for regulating the growth of the breasts and female genitalia?
Ovarian oestrogen.
372
Which hormones are responsible for controlling the growth of pubic and axillary hair in females?
Ovarian and adrenal androgens.
373
What is the first sign of puberty in boys?
First ejaculation, often nocturnal.
374
What are the roles of testicular androgens in male puberty?
1. Development of external genitalia.
2. Growth of pubic and axillary hair.
3. Deepening of voice.
375
What scale is used to describe physical development based on external sex characteristics?
Tanner scale.
376
What is thelarche?
Breast development.
- Takes about 3 years and is controlled by oestrogen.
377
Describe the 3 stages of thelarche.
1. Ductal proliferation.
2. Adipose deposition.
3. Enlargement of areola and nipple.
378
What is adrenarche?
Maturation of the adrenal gland - the development of the zona reticularis cells.
Peri-pubertal adrenal androgen production -> body odour and mild acne.
379
Give 2 signs of adrenarche.
1. Body odour.
2. Mild acne.
380
What is pubarche?
Growth of pubic hair.
381
What term is used to describe the onset of secondary sexual characteristics before 8/9 y/o?
Precocious puberty.
382
What must you rule out as a cause of precocious puberty in boys?
Brain tumour!
383
What is the treatment for precocious puberty?
GnRH super agonist to suppress pulsatility of GnRH secretion.
384
What is delayed puberty?
The absence of secondary sexual characteristics by 14y/o or 16y/o.
385
What is precocious puberty?
The onset of secondary sexual characteristics before 8/9 y/o.
386
What is the most likely cause of delayed puberty in boys?
Constitutional delay - runs in the family; late menarche in mum or delayed growth spurt in father.
387
Give 3 consequences of delayed puberty.
1. Psychological problems.
2. Reproduction defects.
3. Reduced bone mass.
388
What must you rule out in girls with delayed puberty and short stature?
Turner Syndrome (45X)!
They might also have recurrent ear infections.
389
Give 5 functional causes of delayed puberty.
1. Anorexia.
2. Bulimia.
3. Over exercising.
4. CKD.
5. Drugs.
6. Stress.
7. Sickle cell.
390
What investigations might you do in someone with delayed puberty?
1. FBC - red cell count especially.
2. U+E.
3. LH/FSH measurements.
4. TFT's.
5. Karyotyping for Turners.
391
What is hypergonadotropic hypogonadism?
Primary gonadal failure!
- Testes or ovarian failure.
392
What is the affect of hypergonadotropic hypogonadism on FSH/LH and oestrogen/testosterone?
High FSH/LH low oestrogen/testosterone.
393
Give 2 examples of hypergonadotropic hypogonadism.
1. Turner Syndrome (45X).
2. Klinefelter's syndrome (47XXY).
394
What is hypogonadotropic hypogonadism?
Secondary gonadal failure!
- Hypopituitary or problems with the hypothalamus.
395
What is the affect of hypogonadotropic hypogonadism on FSH/LH and oestrogen/testosterone?
Low FSH/LH and low testosterone/oestrogen.
396
Give an example of hypogonadotropic hypogonadism.
Kallman syndrome.
397
What is Turner syndrome?
In Turner syndrome the patient is missing an X chromosome - 45X. It is an example of primary gonadal failure (hypergonadotropic hypogonadism).
398
Give 3 signs of Turner syndrome.
1. Short stature.
2. Delayed puberty.
3. CV and renal malformations.
4. Recurrent otitis media.
399
What is Klienfelter's syndrome?
In Klinefelter's syndrome the patient has an extra X chromosome - 47XXY. It is an example of primary gonadal failure (hypergonadotropic hypogonadism).
400
Give 2 signs of Klinefelter's syndrome.
1. Azoospermia.
2. Gynaecomastia (enlargement of male breast tissue).
3. Increased risk of breast cancer.
4. Testicular size <5ml.
401
Why might someone with Klinefelter's syndrome have fertility problems?
Azoospermia - semen contains no sperm.
402
Give 4 symptoms of Klinefelter's syndrome.
1. Reduced pubic hair.
2. Tall stature.
3. Reduced IQ.
4. Small testicles (<5ml).
403
What cancer is someone with Klinefelter's at an increased risk of developing?
Breast cancer.
404
What is Kallman syndrome?
Congenital deficiency of GnRH. It is an example of secondary gonadal failure -
hypogonadotropic hypogonadism.
405
What must you test in a person who you suspect has Kallman syndrome?
Smell! 75% are ansomia.
406
How is Kallman syndrome inherited?
X linked recessive or dominant.
407
How do you treat asymptomatic SIADH?
Fluid restriction.
408
How do you treat symptomatic SIADH of acute onset?
Give 3% saline.
409
Name 2 drugs that can be used to treat acromegaly. What class of drugs do they belong to?
1. Cabergoline - dopamine agonist.
2. Octreotide - somatostatin analogue.
410
What is T1DM?
T4 hypersensitivity Rxn
Auto immune destruction of pancreatic beta cells
Causes absolute insulin deficiency
411
What is the cause of T1DM?
Triggered by environmental event (eg. virus)
Leads to autoimmune antibodies against beta cells
(HLA DR3 and HLA DR4)
412
What is the pathogenesis of T1DM?
Autoimmune Beta cell islet destruction - leads to absolute decrease in insulin
Therefore causes Hyperglycaemia
Low cellular glucose - Increased lipolysis and gluconeogenesis
Hyperkalaemia
413
What are the symptoms of T1DM?
Lean
Young Px
Polydipsia
Polyuria
Polyphagia
Weight loss
Glycosuria
Signs of DKA (ketoacidosis)
414
Why do patients with T1DM experience polyuria, Polydipsia and Glycosuria?
Increase glucose in blood
Increase glucose filtered in the kidney
Glucose in the kidney draws water into the kidney
Causes increased urination - polyuria
Causes Glycosuria - glucose in urine
Due to increased urination, the blood is hyperosmolar (high glucose)
detected by the hypothalamus and so stimulates thirst centres (causes polydipsia)
415
Why do patients with T1DM experience Polyphagia and weight loss?
Decreased glucose in the cells (no GLUT4)
Therefore cells need energy from Lipolysis and Gluconeogenesis
Increased Lipolysis and Increase proteolysis leads to weight loss
Leads to increased hunger - causes Polyphagia
416
How is T1DM diagnosed?
Random Plasma Glucose (RPG) = > 11.1 mmol/L
Fasting Plasma Glucose (FPG) = > 7.0 mmol/L
HbA1C = 48mmol/mol (6.5%)
417
Is there Pre-diabetes for T1DM and can this be altered with Lifestyle modification?
No - lifestyle modification will not prevent T1DM
418
What is the Treatment for T1DM?
Basal Bolus Insulin
Basal - longer acting to maintain stable insulin levels through out the day
Bolus - Faster acting - 30mins preprandial
419
What is the main acute complication in T1DM?
Diabetic Ketoacidosis (DKA)
From poorly managed T1DM
Absolute insulin deficiency - unrestricted lipolysis and gluconeogenesis
Not all glucose is usable so some is converted to ketone bodies
There are acid and their increased concentration leads to ketoacidosis
420
What are the symptoms of DKA in T1DM?
T1DM Sx +:
Kussmaul Breathing - Deep laboured breaths to blow off CO2 as compensation
Pear drop breath - ketones have a pear drop smell
Reduced tissue turgor - hypotension and tachycardia
421
What is the Diagnosis of DKA?
Ketones (blood) >3mmol/L
Hyperglycaemia > 11.1mmol/L - RPG
Acidosis (metabolic) - <7.3pH or <15mmol HCO3
+ Ketonuria, Glycosuria and Hyperkalaemia
422
What is the treatment for DKA?
ABCDE emergency
1st line is ALWAYS FLUID - Px die from dehydration
Then insulin + glucose + K+
423
What is T2DM?
Peripheral insulin resistance With partial insulin deficiency that tends to present later in life (30+)
424
What are the risk factors for T2DM?
Genetic link - FHx very strong
Smoking
Obesity
HTN
Sedentary lifestyle
425
What is T2DM a big risk factor for?
HTN
Silent MI
Nephrotic Syndrome
CKD
426
What is the pathogenesis of T2DM?
Peripheral insulin resistance (malfunctioned insulin intracellular activation pathway)
Decreased GLUT4 expression due to lower insulin
Some destruction of pancreatic beta cells
Causes hyperglycaemia with an increased insulin demand from a depleted Beta cell population
427
What are the Symptoms of T2DM?
Obese
Hypertensive
Older Px
Polydipsia
Polyuria
Nocturia
Glycosuria
Acanthosis Nigracans - dark pigmented skin folds
428
How is T2DM diagnosed?
Same as T1DM:
Random Plasma Glucose (RPG) = > 11.1 mmol/L
Fasting Plasma Glucose (FPG) = > 7.0 mmol/L
HbA1C = 48mmol/mol (6.5%)
429
What is Pre-diabetes?
Prediabetes is a condition in which your blood sugar or A1C levels are higher than normal but not high enough for a diagnosis of type 2 diabetes.
430
How is pre-diabetes diagnosed?
OGTT (oral glucose tolerance test) = 7.8-11
FPG = 6-6.9mmol/L
431
What advice should be given to a Px who is Pre-diabetic?
Lifestyle advice:
Diet
exercise
modify RFs
432
What is the Treatment for T2DM?
Metformin - Increase peripheral sensitivity to Insulin
If HbA1c >58mmol/mol then add sulfonylurea
If persistently high then consider 3rd drug - DPP4-i/ SGLT2 inhibitor
Then as a last resort give insulin.
433
What is the main acute complication of T2DM?
Hyperosmolar - Hyperglycaemic State (HHS)
Excessive hepatic gluconeogenesis (when not completely insulin deficient) leads to increased glucose in the blood
therefore become hyperosmolar and hyperglycaemic.
(don't get ketogenesis so no DKA)
434
What are the symptoms of HHS in T2DM?
Severe T2DM
Decreased Consciousness - related to plasma osmolarity
435
How is HHS diagnosed in T2DM?
High Glycosuria
High plasma osmolarity (>300mol/L)
Hyperglycaemia
No ketonuria/hyperketonaemia
436
What is the treatment for HHS?
First give Insulin
Then give IV fluid
LWMH (Low molecular weight heparin) - anticoagulant as patients have thicker blood due to the glucose.
437
What are some common chronic T1DM and T2DM complications?
Macrovascular - Cardiovascular, cerebrovascular, peripheral vascular Disease
Microvascular - retinopathy, neuropathy, nephropathy
438
How does chronic diabetes lead to Macro/microvascular complications?
Hyperglycaemia can lead to glucose conjugating with proteins and lipids to create proinflammatory molecules.
These can lead to inflammation and LDL deposition leading to atherosclerosis
This will lead to Macrovascular complications
439
What is Hypoglycaemia?
Abnormally low blood glucose levels
440
What are the different Types of Diabetes?
T1DM
T2DM
MODY (Maturity Onset Diabetes of Youth)
Pancreatic Diabetes
Endocrine Diabetes
Malnutrition related Diabetes
441
What are the Causes of Hypoglycaemia?
Diabetes drugs:
Sulfonylureas - Stimulate insulin
Insulin
442
What are the symptoms of Hypoglycaemia?
Reduced consciousness
Dizziness
Sometimes may faint
443
What is the treatment for Hypoglycaemia?
IV glucose
(if no IV access then IM Glucagon)
444
Where is the Thyroid located anatomically?
Between C5-T1
2 lobes connected via an isthmus
445
What is the blood supply to the thyroid?
Inferior thyroid artery - branch of thyrocervical trunk (subclavian)
Superior Thyroid artery - branch of external carotid
446
How is T3/T4 synthesised?
Iodine is trapped and diffuses into the colloid
It binds to tyrosine residues on Thyroglobulin molecules using Thyroid peroxidase enzyme to produce T1/T2
TSH bind to TSH-R to stimulate the production of T3/T4 from T1/T2.
T3/T4 are released into the circulation.
447
Who is more likely to get hyperthyroidism?
Women
448
What is the main causes of hyperthyroidism?
Graves disease (75-80%)
Toxic multinodular Goitre (TMG) - nodules secrete thyroid hormone
Toxic Adenoma
449
What are the causes for DKA / HHS?
The 6 I
Decreased insulin supply: low insulin
Increased insulin demand (via stress):
Infections
Inflammation
Intoxication
Infarction
Iatrogenic
450
What is the Main complication found in T1DM and T2DM respectively?
T1DM - DKA
T2DM - HHS (may also get DKA in severe chronic T2DM)
451
Define Hyperthyroidism and its possible mechanisms?
Excess of thyroid hormones in the blood
Overproduction of thyroid hormone
Leakage of preformed hormone from thyroid
Ingestion of excess thyroid hormone
452
What is the function of T3 (active thyroid hormone)?
Increase glycogenolysis
Increase glycolysis
Increase lipolysis
453
What is the characteristic triad of symptoms in Graves disease?
Ophthalmopathy
Pretibial Myxoedema
Acropachy (characteristic rash)
Also diffuse goitre and thyroid eye disease
454
What is Graves Disease?
Autoimmune disease characterised by the presence of TSH receptor autoantibodies.
These stimulate the TSH-R
Leading to the over production of T3/T4
455
What are the Signs and Symptoms of Hyperthyroidism?
Symptoms:
Heat intolerance
Diarrhoea
Weight loss + Hyperphagia
Anxiety
Oligomenorrhoea
Signs (everything FAST):
Goitre
Tachycardia
exophthalmos - Protruding eyeball (graves specific)
Pretibial Myxoedema
Muscle wasting
Fine Tremor
456
What is the Diagnosis of Hyperthyroidism?
TSH-R Abs - In graves disease
Clinical Hx
Thyroid Function Tests (TFTs)
457
What do the results for Thyroid Function Tests (TFTs) signify
1' Hyperthyroidism - Decrease TSH, Increase T4
2' Hyperthyroidism - Increase TSH, Increased T4
Subclinical Hypothyroid - Increased TSH, = T4
Subclinical Hyperthyroid - Decreased TSH, = T4
458
What drugs can cause Hyperthyroidism?
Amiodarone
Iodine
Lithium
459
What investigation is done to distinguish between Graves disease and TMG?
Thyroid Ultrasound or RAIU (Radioiodine uptake test)
Presence of multinodular goitres in TMG
460
What is the treatment for Hyperthyroidism?
1st Line = Carbimazole - inhibits T3 to T4 conversion
(if contraindicated such as in pregnancy = use Propylthiouracil
+ Propranolol alongside - targets symptomatic effects
Can also use radioactive iodine - destroys thyroid tissue
Last resort is surgery
461
What are the complications of hyperthyroidism?
Thyroid storm - where large amounts of Thyroid hormone is released very quickly (A MEDICAL EMERGENCY)
Rapid deterioration of thyrotoxicosis
leads to systemic compensation causing AF, HTN and coma
462
What is the treatment for Thyroid storm?
Propylthiouracil + KI
463
What are some Graves specific signs and symptoms?
Diffuse goitre
Thyroid Eye disease
Pretibial Myxoedema
Acropachy
464
What are some Graves specific signs and symptoms?
Diffuse goitre
Thyroid Eye disease
Pretibial Myxoedema
Acropachy
465
What are some consequences of Hyperthyroidism during pregnancy if left untreated?
Low birth Weight
Pre eclampsia
Preterm delivery
Risk of still birth
Risk of Miscarriage
466
what is a transient hyperthyroidism?
Where the thyroid overproduces thyroid hormone for a short period of time before then it may lead to hypothyroidism.
This usually occurs due to destruction of the thyroid gland and therefore T3/T4 hormones are leaked/released but then greater destruction leads to less T3/T4 being produced causing hypothyroidism
467
What is a side effect of carbimazole?
Agranulocytosis
Presents as a sore throat
468
What is hypothyroidism?
Where there is too little thyroid hormone
469
What are the main causes of hypothyroidism?
Hashimoto's Thyroiditis - more common in developed world
Iodine Deficiency - more common in developing world
Post partum Thyroiditis
470
What is Hashimoto's Thyroiditis?
Hypothyroidism due to aggressive destruction of thyroid cells.
Autoimmune condition where there are Anti-TPO (thyroid peroxidase) Abs that leads to less production of T3 and T4.
471
What are the symptoms of hypothyroidism?
(everything slow)
Symptoms:
Cold intolerance
Constipation
Weight gain
lethargy
menorrhagia
Signs:
Bradycardia
Slow reflexes
Cold hands
Goitre - in hashimoto's and I2 deficiency
Pretibial Myxoedema
472
What are the different potential causes of Hypothyroidism at each level?
Primary:
Hashimoto's Thyroiditis
Drugs - Lithium, Amiodarone
Iodine Deficiency
Transient:
Post Partum Thyroiditis
Secondary:
Hypopituitarism
473
Who is more at risk of developing Hypothyroidism?
Women
Elderly
Post partum
474
What is the Epidemiology of T1DM?
Younger onset (<30yrs)
Usually lean
North European
475
What is the Epidemiology of T2DM?
Older onset (>30yrs)
Usually overweight
More common in african/asian
