Endo

Question 1

Diabetic foot disease occurs secondary to which two main factors?

Answer 1

1. neuropathy: resulting in loss of protective sensation (e.g. not noticing a stone in the shoe), Charcot’s arthropathy, dry skin
2. peripheral arterial disease:

Question 2

Presentation of Diab foot dis

Answer 2

neuropathy: loss of sensation

PAD; ischaemia: absent foot pulses, reduced ankle-brachial pressure index (ABPI), intermittent claudication

complications: calluses, ulceration, Charcot’s arthropathy, cellulitis, osteomyelitis, gangrene

Question 3

screening for ischaemia in Diab pt

Answer 3

palpating for both the dorsalis pedis pulse and posterial tibial artery pulse

Question 4

MOA of Metformin and Gliclazide(Sulfonylurea)

Answer 4

Metformin reduces the amount of glucose produced in the liver, and also makes muscle tissue absorb more glucose

gliclazide increases the amount of insulin produced by the pancreas(closing the ATP-dependent K+(KATP) channel when it binds to its receptor, decreasing the potassium efflux from the cell leading to depolarisation)

Question 5

S/E of Sulfonylurea(Gliclazide)

Answer 5

Common adverse effects
1. hypoglycaemic episodes (more common with long-acting preparations such as chlorpropamide)

SO SU ARE CI FOR HEAVY GOODS DRIVER(DUE TO HYPOGLYCEMIA)

2. weight gain

Rarer adverse effects

1. hyponatraemia secondary to syndrome of inappropriate ADH secretion
2. bone marrow suppression
3. cholestatis
4. peripheral neuropathy

Question 6

CI of Sulfonylurea (Gliclazide)

Answer 6

breastfeeding and pregnancy.

Question 7

Graves dis;
marked thyrotoxicosis and the patient is elderly/has underlying CVD
eyes feel dry and look wider in comparison with photographs from a few years ago(stigmata of graves dis/ophthalmopathy)
Tx?

Answer 7

1. Carbimazole
   sp in elderley and pt with hx of CVD

at 40mg and reduced gradually to maintain euthyroidism
typically continued for 12-18 months

2. an alternative regime is termed ‘block-and-replace’
   carbimazole is started at 40mg
   thyroxine is added when the patient is euthyroid
   treatment typically lasts for 6-9 months

patients following an ATD titration regime have been shown to suffer fewer side-effects than those on a block-and-replace regime

3. Radioiodine treatment for people who relapse;
   SE of it; a. Hypothyroidism (need thyroxine replacement)
   b. precipitate thyroid eye disease

Question 8

TX of pheochromocytoma

Answer 8

Adrenelectomy

Question 9

Tx of Cushings

Answer 9

Ketconazole can be used to control excess cortisol production

Question 10

the major complication of carbimazole therapy

Answer 10

agranulocytosis

Question 11

44-year-old woman
recurrent thrush and fatigue. She was worried that it may be due to a sexually transmitted infection, however, a recent sexual health screen including syphilis, HIV, Chlamydia and Gonorrhoea are negative.
Her urine show ketones + and glucose +.
A random glucose is 13.

Tx?

Answer 11

Metformin because she has Diabetes type 2.

symptomatic and has a random blood glucose of greater than 11.1.

Insulin is the first line management of type 1 diabetes.

Gliclazide is often given as the second line medication for the treatment of type 2 diabetes.

Pioglitazone and glibenclamide are also used in type 2 diabetes but would not usually be started as a first line treatment.

Question 12

What is HBA1C dependant on?

Answer 12

HbA1c is produced by the glycosylation of haemoglobin at a rate proportional to the glucose concentration. The level of HbA1c therefore is dependant on

1. red blood cell lifespan
2. average blood glucose concentration

Question 13

conditions that can interfere with accurate HbA1c interpretation?

Answer 13

Lower than expected hba1c(whereas the fasting blood glucose if more);

1. Sickle-cell anaemia
2. GP6D deficiency
3. Hereditary spherocytosis

Higher than expected hba1c;

1. Vitamin B12/folic acid deficiency
2. Iron-deficiency anaemia
3. Splenectomy

Question 14

what dose of levothyroxine should patients of hypothyroidism be started on?

Answer 14

dose of 50-100mcg od

Levothyroxine must be taken 30 minutes before food as it’s absorption may be affected by food, caffeine or other medications.

Question 15

what dose of levothyroxine should patients of hypothyroidism be started on who have severe hypothyroidism/more than 50 years of age/have cardiac dis?

Answer 15

should be started on 25mcg od

Question 16

following a change in thyroxine dose when should TFTS be checked?

Answer 16

8 to 12 weeks

Question 17

women with established hypothyroidism who become pregnant should have their dose increased ‘by at least ?

Answer 17

25-50 micrograms levothyroxine’* due to the increased demands of pregnancy.

Question 18

absorption of levothyroxine is reduced by which meds?/

SO LOW FREE T4 AND HIGH TSH IS CAUSED BY?

Answer 18

iron, calcium carbonate

so these should be taken 4 hrs apart from levothyroxine

Question 19

63-year woman
past medical history includes hypothyroidism
takes levothyroxine 100mcg.
currently well and has no symptoms of note. Her last thyroid function tests (TFTs) 12 months ago on this dose were normal.

New TFTS;
Free T4 18.5 pmol/l
TSH 0.1 mu/l

How should the dose change?

Answer 19

Decrease the dose to 75mcg OD(titrate to decrease slowly by 25mcd OD)

as scenario shows suppressed TSH indicating over replacement. Even though she is asymptomatic the dose should be decreased to reduce the risk of osteoporosis and atrial fibrillation.

Question 20

Difference between Cushings syndrome and Cushings Disease

Answer 20

Cushing syndrome(Cushing's syndrome is a collection of signs and symptoms due to prolonged exposure to cortisol)
excess cortisol can come from outside or inside the body. For example, it can come from using corticosteroid medications, such as prednisone. Or it can come from a pituitary or adrenal tumor causing the body to make too much cortisol.

Cushing disease occurs when a pituitary tumor causes the body to make too much cortisol.

Question 21

Cushing’s Triad

Answer 21

Cushing’s triad refers to a set of signs that are indicative of increased intracranial pressure (ICP), or increased pressure in the brain. Cushing’s triad consists of bradycardia (also known as a low heart rate), irregular respirations, and a widened pulse pressure.

Question 22

Types of Cushing’s syndrome;
ACTH Dependant
ACTH indépendant
Pseudo Cushing’s

Answer 22

ACTH dependent causes

1. Cushing’s disease (80%): pituitary tumour secreting ACTH
2. ectopic ACTH production (5-10%): e.g. small cell lung cancer is the most common causes

ACTH independent causes
1. steroids

Pseudo-Cushing’s/mimics Cushing’s
alcohol excess
severe depression
causes false positive dexamethasone suppression test or 24 hr urinary free cortisol
insulin stress test may be used to differentiate

Question 23

All patients with diabetes should be screened for diabetic foot disease how often?

Answer 23

on at least an annual basis

Question 24

what is done in diab foot clinic?like how is screening done?

Answer 24

screening for ischaemia: done by palpating for both the dorsalis pedis pulse and posterial tibial artery pulse

screening for neuropathy: a 10 g monofilament is used on various parts of the sole of the foot

Question 25

Difference between impaired fasting glucose and impaired glucose tolerance

Answer 25

Impaired glucose tolerance is defined as two-hour glucose levels of (7.8 to 11.0 mmol) on the 75-g oral glucose tolerance test,
and impaired fasting glucose is defined as glucose levels of (6-7 mmol per L) in fasting patients.

Question 26

what is the criteria of DM in symptomatic patients

Answer 26

fasting glucose greater than or equal to 7.0 mmol/l

random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)

Question 27

criteria of DM in non symptomatic its

Answer 27

fasting glucose=(n)<6__(Pre diab)____>7(DM)

hba1c=(n)<41_(Pre Diab)___>48(DM)

Question 28

Conditions where HbA1c may not be used for diagnosis:

Answer 28

H3USC2=HUSC

H haemoglobinopathies
H haemolytic anaemia
H HIV
U untreated iron deficiency anaemia
S suspected gestational diabetes

C chronic kidney disease
people taking medication that may cause hyperglycaemia C (for example corticosteroids)

Question 29

Side-effects of thyroxine therapy

Answer 29

1) Hyperthyroidism due to over tx
2) reduced bone mineral density because it increase the activity of osteoclasts
3) worsening angina
4) AFib

Question 30

thyroxine interacts with?

Answer 30

iron and calcium carb

give atlas 4 hrs apart

Question 31

following a change in thyroxine dose thyroid function tests should be checked after

Answer 31

8-12 weeks

Question 32

SE of hypothyroidism

Answer 32

1) Hyperlipidemia( because thyroid hormones are required for the metabolism of lipids. An underactive thyroid means that lipids are metabolised more slowly and so build up in the serum.)
2) Insulin resistance
3) 1st degree AV block/sinus Brady