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MRCP 2 > Endo > Flashcards

Endo Flashcards

1
Q

Pregnant patient - TFTs

A

TSH can be mildly suppressed in up to 13% of pregnancy in first trim. T3 and T4 can slightly increased too due to HCG stimulation

T-binding globulin has twofold increase due to reduced hepatic clearance and increased synthesis due to oestrogen

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2
Q

Best management for hirtuism in PCOS

A

weight loss
5% weight loss has 40% improvement of hirtuism

Crypterone acetate& ethinyloestradiol or COCP can be used

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3
Q

Patient collapses. Raised c peptide, hypoglycemic

A

Could be sulphonylurea abuse, esp if family member has T2DM
Could be insulinoma, but rare
Could be Addisonian crisis - low BP, hyperkal hyponat

Insulin abuse would have suppressed c peptide

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4
Q

Management of prolactinoma

A

Cabergoline, very effective, unlikely to need surgery

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5
Q

Management for acromegaly

A

Treat with Somatostatin Analogues (Octreotide) then transphenoidal surgery

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6
Q

Patient with hyperthyroidism on amiodarone due to paroxysmal VT. On Doppler USS blood flow is increased

Management

A

Start carbimazole 40mg OD

Amiodarone should ideally be stopped but given the VT this is difficult

USS with increased blood flow is Type 1 amiodarone hyperthy, treat with carbimazole
decreased blood flow is Type 2, corticosteroids

Type 2 is usually with no underlying disease

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7
Q

Thyrotoxicosis in pregnancy…management

A

propylthiouracil in first trim, then carbimazole

If painful goitre, raised ESR could be subacute so NSAIDs

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8
Q

Bartter Vs gittelman

A

Bartter is usually in childhood with failure to thrive

Also has elevated urinary calcium excretion

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9
Q

77 with Colles wrist fracture. Management

A

Start alendronate in patients >= 75 years following a fragility fracture, without waiting for a DEXA scan

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10
Q

Cause of adrenal insufficiency in developing world

A

TB is most common cause

Remember can get transient low T4 , but corrects with steroid replacement

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11
Q

Management of patient that presents with hypoglycemia. BG of T2DM, on metformin and gliclazide

Not responsive to 10% dextrose

What is management

A

Octreotide in sulphonylurea OD
- blocks insulin secretion

(aka Sandostatin - synthetic somatostatin)

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12
Q

Most likely cause of Low TSH levels in hospitalised patients

A

Sick thyroid syndrome 3x more likely than hyperthyroidism

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13
Q

Management of gestational diabetes

A

Fasting >=5.6
2hr glucose >= 7.8

Fasting glucose 5.6 - 7 then diet,+/- Metformin after 1-2/52

6-6.9 with complications -macrosomia or hydramnios, then offer insulin

Fasting >7 then start insulin

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14
Q

Management of subclinical hypothyroidism

A

Treat if TSH above 10 (if younger than 70)

TSH 4-10 then treat if symptomatic

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15
Q

Hyponatremia with normal osmolarity

A

Pseudohyponatraemia

… serum Na is measured as a ratio of Na to plasma volume. If the patients plasma has high amounts of proteins or lipids, the plasma volume will be increased resulting in a measured hyponatraemia. This is not a true hyponatraemia as the actual ratio of sodium to plasma fluid will be normal.

So look out for hyperproteinaemia (e.g. TPN, IVIG) and hyperlipidaemia (in particular hypertriglyceridemia)

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16
Q

Management for patient with familial hypercholesterolemia

A

First line: high dose statins.

Second line: Ezetimibe (inhibits the intestinal absorption of cholesterol)

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17
Q

Calcium in adrenal Insufficiency

A

hypercalcemia—
combination of increased calcium input into the extracellular space and reduced calcium removal by the kidney

hyponatraemia in 85–90%
hyperkalaemia in 60–65%,
“hypercalcaemia is a rare occurrence”

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18
Q

familial benign hypocalciuric hypercalcaemia Vs primary hyperparathyroidism

A

Both may have high calcium with high or (inappropriately) normal PTH

But FHH has low urinary calcium
High calcium should lead to high urinary calcium

FHH is auto dom asymp hypercal - defect in the calcium-sensing receptor

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19
Q

What is familial benign hypocalciuric hypercalcaemia

A

FHH is auto dom asymp hypercal - defect in the calcium-sensing receptor

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20
Q

macroadenoma with high prolactin management

A

If prolactin extremely high (>6000) then prolactinoma, so treat with bromocriptine or cabergoline (dopamine-R agonist)

In macroadenoma, other may be reduced and prolactin can be raised ( 600–3000 mU/L) secondary to pit stalk blockage w prevention of dopamine reaching the pituitary
Mx Trans-sphenoidal surgery

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21
Q

Management of insulinoma

A

CT scan - 10% are malignant 10% are multiple
50% are MEN1
Refer to surgery
Diazoxide and somatostatin are tx options if not surgery

22
Q

52y w galactorrhoea. Generally fatigued. Prolactin 440, what is next test?

A

Pregnancy, TFTs (hypothy common cause)

MRI if these ruled out

23
Q

Management of hyperparathyroidism

A

Total parathyroidectomy

Conservative if calcium less than 0.25 above AND under 50y AND not symptomatic (fragility#, renal stones) AND eGFR over 60

Can use calcimemetics like cinacalcet

24
Q

Hypokal differentials

A

CCL (Cushing’s Conn’s liddle) hypertension
Gitelman gentleman (older but still only 20s), decreased Ca urine
Bart has a Cat (bart is also child)
Liddle you get when you’re little

25
Q

Diagnosis of growth hormone deficiency

A

First line: IGF-1 may be raised (but N in 30-40%)

If unsure: oral glucose tolerance test (OGTT) with serial GH measurements
(normally would get suppressed to <2 in hypergly)

Contraindicated w IHD or seizures so use arginine-GHRH simulation test

26
Q

Management of acute thyrotoxicosis

A

IV propranolol
Propylthiouracil or Methimazole
Lugol’s iodine
Dexamethasone (blocks T4 to T3 conversion

Stop aspirin as it can worsen storm by displacing T4 from thyroid binding globulin

27
Q

Markers of severe DKA

A 
pH <7
Blood ketones >6
Bicarb <5
Anon gap >16
K <3.5 on admission
Tachy or Bradycardia
Sys BP <90
O2<92
GCS<12
28
Q

Myxedema coma management

A

Combo of levo and liothyronine
Fluid resus

Not great evidence for T3 because of lack of RCT but T3 has faster onset

29
Q

Pregnant woman with history of Graves

A

thyrotrophin (TSH) receptor stimulating antibodies should be checked at 30-36 weeks gestation - helps to determine the risk of neonatal thyroid problems

30
Q

Management of papillary thyroid cancer

A

Thyroidectomy and radio iodide therapy

31
Q

Progression of Subacute (De Quervain’s) thyroiditis

A

4 phases
1) lasts 3-6/52, hyperthy, painful goitre, raised ESR, decreased uptake

2) 1-3/52 euthy
3) weeks-months hypothy
4) goes back to normal

32
Q

Incidental 3mm thyroid mass found on CT. Asymptomatic

A

non-palpable nodule found on imaging that are < 1cm don’t need biopsy, managed in primary care

33
Q

Signs of congenital adrenal deficiency pneumonic

A

2 1 def- Low mineralocorticoids - Increased androgens (normal BP - virilizing)
1 7 def- Increased mineralocoticoids- Low androgens (HTN - non virilizing)
1 1 def- Increased mineralocorticoids- Increased androgens (HTN - virilizing)

34
Q

Electrolytes suggestive of laxative abuse

A

Hypokal with reduced k urinary excretion

Kidneys trying to hold on to it
May have calluses on hand from vomiting

35
Q

CK and thyroid disease

A

CK is modestly elevated (<10x upper limit) in up to 90% of untreated hypothy, and up to 79% complain of muscle symptoms

Polymyositis unlikely if <1000

36
Q

Pt has hx of phaeochromocytoma and presents w thyroid swelling. What is the most appropriate next test to confirm the diagnosis?

A

Calcitonin levels

  • as could be MEN 2a or b, with a Medullary thyroid cancer parafollicular (C) cells, which secrete calcitonin)
37
Q

classic hx of pseudo-cushings

A 
severe psychotic depression or alcohol use 
mildly raised 24-h urinary free cortisol (unlike 3x upper limit in Cushing's)
low dose (1mg) dex ... cortisol 55 nmol/L (<50)
38
Q

interpretation of raised dehydroepiandrosterone sulphate in PCOS investigations

A

DHEA is produced by adrenal cortex

If raised it points to an adrenal rather than an ovarian source, making ovarian tumour unlikely

39
Q

urinary sodium in vol depletion

A

low urinary sodium (appropriate response to volume depletion)

40
Q

hyperthyroid in pregnancy

A

propylthiouracil in first trimester then carbimazole

41
Q

post-partum thyroiditis

A 
usually hyper (don't treat, maybe propanolol
then hypothy (can treat)
then euthyroid
42
Q 
severe psychotic depression  
mildly raised 24-h urinary free cortisol 
low dose (1mg) dex ... cortisol 55 nmol/L (<50)
A

classic hx of pseudo-cushings

often due to alcohol excess or severe depression

43
Q

cause of amenorrhoea in low BMI

A

hypothalamic amenorrhoea

44
Q

The history of T1DM and coeliac, with a new likely diagnosis of Hashimotos….. probable diagnosis and what test?

A

Very suggestive of Autoimmune polyendocrinopathy syndrome type 2, which Addisons is strongly linked to

treating for Hashmitos which could result in an Addisonian crisis

short synacthen test

45
Q

low calcium, high phosphate, high PTH

A

could be secondary hyperparathyroidism
in context of CKD
- CKD leads to high phosphate, and low Vit D… causing osteomalacia

or pseudohypoparathyroidism, where there is receptor insensitivity to PTH due to G-protein mutation... 
audo dom
short fourth and fifth metacarpals
cognitive impairment 
obesity 
round face
46
Q

pseudohypoparathyroidism types

A

1a Has a characteristic phenotypic appearance (Albright’s hereditary osteodystrophy)
Type 1b and 2 no phenotype but has biochem
but 2 has normal cAMP response to PTH stimulation

47
Q

pt w low Ca, Mg, and PTH

A

Magnesium deficiency causes hypocalcaemia
Without sufficient levels of magnesium, PTH cannot function properly

e.g. due to PPI

48
Q

Secondary hyperparathyroidism vs vit d deficiency/osteomalacia

A

both low calcium high PTH

vit d def usually has low Phosphate too, whereas that’s high in secondary hyperpara
(CKD leads to low Vit D and high phosphate -reduced excretion)

Vit D def /Osteomalacia has raised ALP

49
Q

Low Calcium, Raised ALP

A

could be osteomalacia - check Vit D

esp if phenytoin, Coeliacs, cirrhosis, Type 2 RTA (hypokal)

50
Q

hx of weight loss

Low TSH and T4. Management?

A

In approximately 5% of patients with clinical and biochemical hyperthyroidism, T3 may be elevated prior to T4. This is known as T3 toxicosis.

If TSH and T4 T3 are low then its subclinical thyrotoxicosis

51
Q

Management of secondary hyperparathyroidism

A

Reduce phosphate in diet
- reduction in foods like chocolate, nuts, shellfish and cola

Next step is a phosphate binder like Sevelamer or Lanthanum carbonate
Vit D replacement alfacalcidol
Can have parathyroidectomy

52
Q

Common consequences of acromegaly

A

T2DM
Hypertension
LVH, doesn’t improve after treatment
33% have sleep apnoea, but tends to improve after treatment
30% have premalig colononic polyps, and 5% develop cancer

colonoscopic screening, starting at the age of 40 years

MRCP 2 (13 decks)

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