Endo

Question 1

What is the most common cause of increased cortisol?

Answer 1

Iatrogenic (meds). 70% of non-iatrogenic cortisol is pituitary.

Question 2

If the increased cortisol is due to pituitary then what else will you see?

Answer 2

Increased ACTH

Question 3

What is Conn’s syndrome?

Answer 3

Adrenal Adenoma - that leads to increased Aldosterone production

Question 4

What is secondary hyperaldosteronism?

Answer 4

Overactive RAAS system - due to increased renin secreting tumour or renal artery stenosis

Question 5

What is Cushing’s disease

Answer 5

Primary hyper-cortisol production.Generally due to basophils with microadenoma and no leading to bitemporal hemianopia

Question 6

What is Cushing syndrome?

Answer 6

Range of symptoms due to ectopic ACTH production or adrenal adenoma/adrenal hyperplasia

Question 7

Cushingoid features:

Bam Cushingoid

Answer 7

BAM CUSHINGOID

Buffalo Hump
Amenorrhea
Moon facies

Central/truncal obesity  - proximal myopathy
Ulcers
Skin changes - Easy bruising, Hirsutism, Acne, Plethora, Striae, pigmentation
Hypertension, Hypercholestrolaemia
Infection
Necrosis of femoral head
Glaucoma
Osteoporosis
Immunosuppression
Diabetes - Hyeprglycaemia

Question 8

What would you see on bloods for Hyperaldosterone?

Answer 8

Hypertension, Hypokalaemia

The low K+ levels may cause muscle weakness, N/V, and alkalosis due to H+ secretion

Question 9

How does the dexamethasone test work?

What is a positive finding?

Answer 9

Dexamethasone provides negative feedback to the pituitary gland to suppress the secretion of ACTH by the pituitary.

A normal result is a decrease in cortisol levels on admisitration of a low dose dexa(2mg)

results indicative of Cushing’s disease involve o change in cortisol on low dose dexa but inhibition of cortisol on high dose dexa (8mg)

If cortisol levels are unchanged after both low and high dose then it may be indicative of primary adenoma (undetectable or levels of ACTH) or Ectopic ACTH syndrome (Elevated ACTH)

Question 10

How do you investigate for Hyper-aldo?

Answer 10

Serum aldosterone:renin ratio

Aldo:renin ratio is increased in Primary hyperaldo, normal in secondary hyperaldo (as renin is high there)

Question 11

Ix for Hyper-cortisol / Hyper-aldo?

Answer 11

Dexa suppression, ACTH levels, Abdo +chest CT, pituitary MRI, Serum aldosterone:Renin ration

Question 12

Differentials for increased aldosterone levels?

Answer 12

Primary aldosteone - Idiopathic adrenocortical hyperplasia (most common), Conn’s syndrome (Adrenal adenoma), Familial hyperaldosteronism, Congenital adrenal hyperplasia

Liddle syndrome, Renal artery stenosis, RAAS dysfunction

Question 13

What is Liddle Syndrome?

Answer 13

pseudohyperaldosteronism - Involves abnormal kidney function with excess reabsorption of sodium and loss of potassium from the renal tubule.

Question 14

How to differentiate from Conn’s Syndrome and Idiopathic adrenal hyperplasia?

Answer 14

CT?

Question 15

How do you manage pituitary adenoma?

Answer 15

Pituitary adrenal mass resection with post-op glucocorticoid replacement, at least in the short term (temporary suppression of ACTH post op)

Question 16

What is Nelson’s Syndrome?

Answer 16

In extreme circumstances of hyper-cortisol you do a bilateral adrenalectomy - which can lead to Nelsons Syndrome:
Sudden removal of cortisol and negative feedback on AP allows pre-existing pituitary tumours to grow rapidly and produce increased amount so ACTH and MSH. Since no cortisol can be produced there is hyperpigmentation from MSH and muscle weakness

Question 17

Mx of hyper-aldo?

Answer 17

If Primary adrenal adenoma - laprascopic surgical resection
If bilateral adrenal hyperplasia then risky to operate - hence use aldosterone anattagonist (spironlactone)

In both regularly assess Serum K for 4-6 weeks after

Question 18

Does increased cortisol lead to increased or decreased osteoblastic function.

Answer 18

Decreased osteoblastic function and hence osteoporosis

Question 19

3 common AIDS defining illnesses?

Answer 19

PCP, Kaposi’s Sarcoma, Oesophageal Candida

Question 20

Diagnosis of HIV?

Answer 20

ELIZA test confirmed by Western Blot

Question 21

Signs of Haemachromatosis?

Answer 21

Bronzed, joint pain,

Question 22

Managing Haemachromatosis?

Answer 22

Screen (gene analysis), Transferrin saturation, Consider liver biopsy (if symptomatic)

Question 23

Does transferrin saturation and serum transferrin go up/down in Fe deficiency?

Answer 23

Serum transferrin would go up (since we try to move more iron) and Saturation would be down (Because not enough iron)

Question 24

A patient with Dm. Start with Metformin and if more drugs need to be added you add..

Answer 24

Sulfonylurea, Gliptin, Poiglitazone, SGLT2 inhibitor

Question 25

If FBG or RBG less than 5.5 then...

Answer 25

diabetes unlikely

Question 26

Cut off to diagnose DM - for FBG, RBG or HbA1C

Answer 26

FBG > 7 RBG > 11 (OGTT 2hr > 11) HbA1c >6.5% - Each on 2 separate occasions

Question 27

OGTT normal results for Fasting and 2hr?

Answer 27

FBG

Question 28

What are the four phases of De Quervian's thyroiditis (Subacute thyroiditis)

Answer 28

``` Phase 1 (3-6 weeks): Hyperthyroidism, painful goitre, raised ESR Phase 2 (1-3 weeks): Euthyroid Phase 3 (weeks-months): Hypothyroidism Phase 4: Thyroid structure and function goes back to normal ```

Question 29

How does Subacute Thyroiditis present?

Answer 29

Its presents after a viral infection with a tender goitre, hyperthyroidism and raised ESR

Question 30

Common problems with poiglitazone?

Answer 30

Weight gain, Liver impairment | Fluid retention, Some studies show Bladder on 2 separate occasions)

Question 31

How to Mx Addison's disease?

Answer 31

Glucocorticoid and Mineralcorticoid= | Hydrocortisone + Fludrocortisone

Question 32

What are the causes of Addisonian Crisis (3):

Answer 32

- Sepsis or surgery causing an acute exacerbation of chronic insufficiency (addison's, hypopituitarism) - Adrenal Haemorrhage e.g. Waterhouse-Friderichsen syndrome - Steroid withdrawl

Question 33

How to manage Addisonian crisis?

Answer 33

High dose hydrocortisone with Normal Saline fluids. (No fludrocortisone required because high dose hydrocortisone accommodates for it

Question 34

What are the 3 causes of malignany associated hypercalcaemia?

Answer 34

Lytic Bone disease metastasis Myeloma PTH like tumour

Question 35

Test to diagnose Addison's disease?

Answer 35

Short ACTH test: Short synacthen test

Question 36

4 features of hypercalcaemia?

Answer 36

Bones, stone, abdominal groans and psychic moans

Question 37

3 features seen on Graves disease but not other Thyroiditis?

Answer 37

1. Eye signs - exopthalmos, opthalmoplegia 2. Pretibial Myxedema 3. Thyroid Acropachy

Question 38

Prediabetes is defined y HbA1c between ______

Answer 38

6.0 and 6.5%

Question 39

How to manage Hyperthyroidism medically?

Answer 39

Carbimazole

Question 40

How to manage Hypothyroidism?

Answer 40

Levothyroxine

Question 41

How to diagnose Acromegaly?

Answer 41

OGTT with serial GH measurements In normal patients GH is suppressed to

Question 42

Hypokalaemia with hypertension points towards a diagnosis of __________

Answer 42

primary hyperaldosteronism. Barteter's Syndrome is associated with normotension.

Question 43

Which diabetic medication acts to increase insulin sensitivity:

Answer 43

Pioglitazone

Question 44

__________ is caused by systemic illness. With this, the patient may have an apparently low total and free T4 and T3, with a normal or low TSH. Note that the levels are only mildly below normal.

Answer 44

Sick Euthyroid

Question 45

What is the most common thyroid cancer?

Answer 45

Papillary carcinoma

Question 46

Psammoma bodies and so called "orphan Annie nuclei"

Answer 46

Papillary carcinoma

Question 47

This type of thyroid cancer tends to spread haematogenously. This translates into a higher mortality rate.

Answer 47

Follicular thyroid carcinoma

Question 48

Papillary or follicular - which are more accurately diagnosed on fine needle aspiration?

Answer 48

Papillary carcinoma -

Question 49

Typically metastasise via the lymphatics and thus laterally located apparently ectopic thyroid tissue is usually a metastasis from a well differentiated __________

Answer 49

Papillary carcinoma

Question 50

__________ thyroid carcinoma tend to occur in elderly female. The disease usually at advanced presentation and often only palliative decompression and radiotherapy can be offered.

Answer 50

Anaplastic

Question 51

________ thyroid tumours are of the Parafollicular cells (C-Cells) and are of neural crest origin

Answer 51

Medullary

Question 52

In _______ carcinoma, the serum calcitonin may be elevated and hence used when monitoring for recurrence

Answer 52

Medullary carcinoma

Question 53

Spread of this thyroid cancer can be haematogenous or lymphatic and these tumours are not derived primarily from thyroid cells and are not responsive to radioiodine

Answer 53

Medullary

Question 54

TSH: high, T4: Normal

Answer 54

Poor compliance with Thyroxine

Question 55

Sick Euthyroid presents with TSH and T4 as?

Answer 55

TSH low, T4 low

Question 56

Nuclear scintigraphy reveals patchy uptake with thyroid

Answer 56

Toxic Multinodular goitre

Question 57

_______ work by stimulating the pancreatic beta cells to secrete insulin

Answer 57

Sulfonylureas

Question 58

_____ have an increased risk of pancreatitis and side effects include n/v

Answer 58

GLP-1 agonists (-tides)

Question 59

A group of inherited genetic disorders affecting the production of insulin. Results in younger patients developing symptoms similar to those with T2DM, i.e. asymptomatic hyperglycaemia with progression to more severe complications such as diabetic ketoacidosis

Answer 59

Maturity onset diabetes of the young - MODY

Question 60

Hypothyroid with a painful goitre and raised ESR

Answer 60

De Quervain's - Subacute hypothyroiditis

Question 61

Is Post partum thyroiditis Hyper- or Hypo?

Answer 61

Initially brief hyperthyroid phase followed by longer hypothyroid phase

Question 62

Two most common causes of hyperthyroidism?

Answer 62

Grave's disease and Toxic multinodular goitre

Question 63

Two disease which cause an initial brief phase of hyperthyroidism and then prolonged hypo

Answer 63

Subacute thyroditis (De Quervain's) and Post-partum thyroiditis

Question 64

gliclazide and glimepiride are _____

Answer 64

Sulphonylurea

Question 65

anti-TPO antibodies are seen in

Answer 65

Hashimoto's thyroiditis

Question 66

works by increasing insulin sensitivity and decreasing hepatic gluconeogenesis Notes

Answer 66

Metformin

Question 67

Side effects of Sulphonylureas?

Answer 67

Hypoglycaemia, weight gain and hyponaetraemia