Diabetes and Pituitary

Question 1

Cause of T1DDM?

Answer 1

pancreatic islet beta-cells desstroyed by autoimmmune

ABSOLUTE insulin sinsufficiency -> lipolysis and ketogenesis

Associated with HLADR3/4

Question 2

Cause of T2DM?

Answer 2

Obesity, HTN, inactivity, and disturbed lipids

Reduced peripheral sensitivty to insulin and reduced insulin production over time

Question 3

T1DM presentation?

Answer 3

5-15YO
Polyuria and polydipsia (osmotic diuresis)
Weight loss from muscle and fat breakdown

DKA: abdo pain, N&V, tachypnoea (kussmaul), coma

Question 4

T2DM presentation?

Answer 4

Asymptomatic
RFs present, obesity, Fhx, south asian, black, age,

Fatigue, poludipsia, polyria, infections e.g. fungal, cellulitis
Acanthosis nigricans

Question 5

Which patients should HbA1c not be used in?

Answer 5

All children/young, high risk of acutely ill, medication that can rise glucose e.g. steroids, antipsychotis, acute pancreatic damage patients

Question 6

T1DM management?

Answer 6

Basal bolus insulin

Long = glargine subcut OD)
Short = lispro/aspart subcut pre meal

Question 7

T2DM glycaemic Mx?

Answer 7

1) Metformin if HbA1c >48
2) Add another drug (Dpp4i, pioglitazone, SU, SGLT-2i)
3) Add further drug

Question 8

T2DM lipid Mx?

Answer 8

Atorvastatin 20mg OD if 10year CV>10%

80mg if IHD/CVD/peripheral arter disease

Question 9

T2DM BP Mx?

Answer 9

1)ACEi or ARB
2) Add CCB or thiazide
3) Add ccb or thiazide
4) if K+>4,5, spironolactone
if less then alpha blocker/beta blocker

Question 10

Example of each glycaemic medication?

Answer 10

DPP4i = sitagliptin
Pioglitazone
Sulfonylurea = glicazide
SGLT = dapaglifozin

Question 11

Platelet Mx for T2DM?

Answer 11

Aspiring 75mg for patients with IHD/CVD/perpheral artery disease

Question 12

what are the micro/macro complications of DM?

Answer 12

Micro = retinopathy, nephropathy, neuropathy

Macro = IHD, Cerebrovascular disease, peripheral artery disease

Question 13

Causes of hypoglycaemia?

Answer 13

Missed meals, inadequate snacks, unaccustomed exercise, alcohol, some drugs e.g. SU, SGLT2, inappropriate insulin regime

Question 14

Signs of hypoglycaemia?

Answer 14

Palpitations, tremor, seating, pallor, anxiety, drowsiness, confusion, altered behaviour, coma

Question 15

Tx for hypoglycaemia?

Answer 15

Conscious = oral glucose and complex carborhydrates

Impaired = PArenteral 1mgglucagon IM
2nd line = IV dextrose (10% glucosie infusion)

Question 16

DKA triad?

Answer 16

Hyperglyaemia, ketonaemia and metabolic acidosis

Also dehydration

Question 17

S+S and Ix DKA?

Answer 17

Collapse and confusion, dehyrated, kussmaul breathing, abdo pain, N+V

Ketones >3mmol?l, pH <7.3 (high anion gap metabolic acidosis, plasma glucose >11

Question 18

Mx of DKA?

Answer 18

Fluids started (normal saline unless K+ <5.5. then potassium chloride)
IV insulin after fluids
Include dextrose
Treat underlying cause

Question 19

Breakdown of diabetic retinopathy?

Answer 19

Background = blot and dot haemorrhages/hard exudates

Pre-proliferative = background + cotton wool spots

Proliferative = pre-proliferative + new vessels on disk (neovascularization)

maculopathy = Previous + hard exudates near macula

Question 20

Mx of diabetic retinopathy?

Answer 20

background = improve glycaemic control

Pre and proliferative = pan-retinal photocagulation

Maculopathy = grid of photocoagulation

Question 21

What is neovascularization associated with?

Answer 21

Retinal detachment and vitreous haemorrhage -> visual loss

Question 22

Diabetic nephropathy features and Ix?

Answer 22

Albuminuria, reduction of eGFR, associated with retinopathy

1) urinarlysis and eGFR
Biopsy gold standard and show Kimmelstiel-wilson nodules (mesangiel expansion)

Question 23

Mx for diabetic nephropathy?

Answer 23

Improve glycaemic control and ACEi/ARB

Question 24

Breakdown of diabetic neuropathy?

Answer 24

Caused by blockage of vasa nervorum

Perpheral neuropathy = loss of sensation (feet) and may not sense injury. Monofilament exam and loss of anklejerk/vibration/fractures (charcots joint)

Mononeuropathy = sudden motor loss usually e.g. wrist drp, foot drop, 3rd nerve palsy (down and out)

Autonomic neuropathy = dysphagia, delayed gastric empyting, bladder dysfunction, postural hypotension and cardiac autonomic supply

Question 25

Mx of diabetic neuropathy?

Answer 25

Glycaemic control, if painful then neuropathic pain agent e.g. duloxetine, pregabalin or gabapentin

Question 26

Causes of cranial DI?

Answer 26

pituitary tumour/surgery, TBI, infection e.g. meningitis, sarcoidosis, SAH

Question 27

Causes of nephrogenic DI?

Answer 27

Lithium therapy, electrolyte imbalance e.g. Increase ca, decreased K, idiopahic, ureteric obstruction , Inherited AVPV2 gene

Question 28

DI presentation?

Answer 28

polyuria and nocturia, polydipsia, dehydration so tachycardia, reduced tissue turgor, dry mucous membranes Cause e.g. bitemporal hemianopia

Question 29

IX for DI?

Answer 29

General = U&Es, Na but increased urea, glucose to exclude DM Water deprivation test with desmopressin is diagnostic

Question 30

Mx for DI?

Answer 30

1) treat the cause 2) Crnial = intranasal desmopressin (less water) 3) nephrogenic = thiazide diurteic or NSAIDs (these inhibit prostaglandin and prostaglandin inhibits AHD)

Question 31

Causes of SIADH?

Answer 31

``` CNS = SAH, stroke, tumour, TBI Pulmonary = pneumonia, bronchietasis Malignancy = Small cell lung cancer Drugs = carbamazepine, SSRI Idiopathic ```

Question 32

Features of SIADH?

Answer 32

expansion of ECF volume, decreased plasma osmolality and hyponatraemia, concentrated urine and increased Na excretion

Question 33

Mx for SIADH?

Answer 33

Treat the cause Immediate fluid resus for hyponatraemia oral demeclocyline or IV vaptans

Question 34

Features of volume statuses with hyponatraemia?

Answer 34

Hypovolaemic = tachy, reduced skin turgor, dry, low bp, postural hypotension and urine sodium low Euvolaemic = normal or cause Hypervolaemia = peripheral oedema, bibasal crackles and raised JVP

Question 35

Causes of each volume status with hyponatraemia?

Answer 35

Hypo = vomiting/diarrhoea + diuretics ``` Eu = Hypothrypid (TFTs) Adrenal insufficiency (short synacthen)or SIADH (decreased plasma and increased urine osmolality ``` hyper = heart failure, cirrhosis of nephrotic syndrome

Question 36

Mx for volume statues>

Answer 36

Hypo = volume replacement with 0.9% saline Other two si fluid restriction and treat underlying cause

Question 37

What do rapid Na+ changes cause?

Answer 37

if seizing/reduced GCS + hyponatraemic = give hypertonic 3% saline Usually slow changes to prevent central pontine myelinlysis = quadriplegia, pseudobulbar palsy, seizures, coma and death

Question 38

Causes of hypernatraemia?

Answer 38

GI losses and sweat loss, rena losses such as osmotic diuresis (HHS) or DKI Sodium Overload in Cushings, primary aldosteronism, iatrogenic

Question 39

Mx of hypernatraemia?

Answer 39

Correct water deficit - 5% dectrose Correct ECF volume - 0.9% saline Measure Na every 4-6 hours

Question 40

Examples of pituitary adenomas?

Answer 40

Acromegaly (GH secreting) Prolactinoma Cusings

Question 41

Causes of hyperprolactinaemia?

Answer 41

Pregnancy and breast feeding Prolactinoma or other pituitary adenoma (stalk compression), oprimary hypothyroidism High prolactin suppresses GnRH pulsatility

Question 42

S+S of hyperprolactinaemia?

Answer 42

Men = libido loss, erectile dysfunction, infertility, rare galactorrhoea Women = galactorrhoea, secondary amenorrhoea/oligomenorrhoea, libido loss, infertilyi Mass effect = heachache/visual field deficit

Question 43

Ix for hyperprolactinaemia>

Answer 43

Pregancy test TFTs Basal serum prolactin (if >60000mU/L) = prolactinma MRI

Question 44

Prolactinoma Mx.

Answer 44

Dopamine agonists e.g. oral bromocriptine and cabergoline

Question 45

what is a hyperosmolar hyperglycaemic state (HHS)

Answer 45

hyperglycaemia but no ketonaemia so same presentation as DKA bar abdo pain as no ketonaemia