Endo Ix Mx

Question 1

Acromegaly

Answer 1

Ix:
1st = serum-IGF

2nd = OGTT test with GH levels is recommended to confirm the diagnosis if IGF-1 levels are raised

3rd = Pituitary MRI may demonstrate a pituitary tumour.

OGTT
in normal patients GH is suppressed to < 2 mu/L with hyperglycaemia
in acromegaly there is no suppression of GH
(may also demonstrate impaired glucose tolerance which is associated with acromegaly)

Mx:

1st = Trans-sphenoidal surgery

If surgery is CI, then medications can be tried;

1. Somatostatin analogue (octreotide) =
   directly inhibits the release of growth hormone
2. GH receptor antagonist (pegvisomant) once daily s/c administration

Very effective - decreases IGF-1 levels in 90% of patients to normal but doesn’t reduce tumour volume

3. Dopamine agonists (bromocriptine)

External irradiation is sometimes used for older patients or following failed surgical/medical treatment

Question 2

Adrenal insufficiency

Longer-term systemic corticosteroids suppress the natural production of endogenous steroids. They should therefore not be withdrawn abruptly, as this may precipitate an Addisonian crisis

Corticosteroids may cause insomnia

Answer 2

Ix:

1st = short Synacthen test. Plasma cortisol is measured before and 30 minutes after giving Synacthen 250ug IM.

Adrenal autoantibodies such as anti-21-hydroxylase may also be demonstrated.

If an ACTH stimulation test is not readily available (e.g. in primary care) then sending a 9 am serum cortisol can be useful:
> 500 nmol/l makes Addison’s very unlikely
< 100 nmol/l is definitely abnormal
100-500 nmol/l should prompt a ACTH stimulation test to be performed

Mx = glucocorticoid and mineralocorticoid replacement therapy

Combination of hydrocortisone (fludrocortisone): usually given in 2 or 3 divided doses. 20-30 mg per day, with the majority given in the first half of the day

Pt education: Emphasise the importance of not missing glucocorticoid doses

sick day rule = double the glucocorticoids, keep fludrocortisone dose the same

Consider MedicAlert bracelets and steroid cards

Pt should be provided with hydrocortisone for injection with needles and syringes to treat an adrenal crisis

When the pt is ill = double the glucocorticoid dose

Question 3

Carcinoid syndrome (neuroendocrine tumors most often found in the gut releasing biologically active substances into the blood causing symptoms such as flushing and diarrhea, and less frequently, heart failure, vomiting and bronchoconstriction)

Answer 3

Ix = (urinary 5-HIAA) + (plasma chromogranin A)

Mx = somatostatin analogues (octreotide)

Also, diarrhoea mx = cyproheptadine

Question 4

Cushing’s syndrome

Answer 4

Ix:
1st = overnight dexamethasone suppression test measuring urinary cortisol (morning cortisol spike is not suppressed in Cushings syndrome)

2nd = 24 hr urinary free cortisol

Ectopic ACTH secretion = very low potassium levels

Localisation tests

1st = 9am and midnight plasma ACTH (and cortisol) levels.

(If ACTH is suppressed then a non-ACTH dependent cause is likely such as an adrenal adenoma)

High-dose dexamethasone suppression test

If both ACTH and cortisol are suppressed then its a pituitary cause

Petrosal sinus sampling of ACTH may be needed to differentiate between pituitary and ectopic ACTH secretion.

An insulin stress test is used to differentiate between true Cushing’s and pseudo-Cushing’s.

Mx = surgery

ectopic = ketoconazole, metyrapone, mifepristone (a cush-ion running mtyrs doing a keto-diet eating mifeins 🧁)

Question 5

Diabetes insipidus

Answer 5

Ix = high plasma osmolality, low urine osmolality (pissing lots of dilute urine)

A urine osmolality of >700 mOsm/kg excludes diabetes insipidus

water deprivation test

Mx:
Nephrogenic = thiazides + (low salt/protein diet)
Cranial = desmopressin (ADH replacement)

Question 6

Diabetes mellitus T1

Why should pts alternate site of injection ?

Remember that impaired hypoglycaemia awareness occurs due to neuropathy of parts of the autonomous nervous system

Answer 6

Ix:

1st = fasting + random blood glucose

HbA1c monitored once every 3-6months;

C-peptide is low

antibodies (GAD, islet cell and insulin ab’s)

Mx: Insulin

Rapid = novorapid/aspar
Long-acting = Lantus/Glargine
Glucagon kit for emergencies

Importantly, patients should be encouraged
to alternate injection sites between the thighs, abdomen and shoulder to prevent build up of adipose tissue creating smooth, firm lumps known as
lipohypertrophy

Question 7

T2DM

Can cause acanthosis nigricans

Diabetes sick day rules: when unwell, If a patient is on insulin, they must NOT stop it due to the risk of diabetic ketoacidosis. They should continue their normal insulin regime but ensure that they are checking their blood sugars frequently

Answer 7

Ix: HbA1c>42 (42-48 = prediabetes)
Fasting >7 mmol/L
Random >11.1mmol/L

Symptomatic = 1 reading
Asymptomatic = 2 readings

Mx: meds below, or bariatric surgery!

1. If HbA1c is 48-52, Target<48

1st = metformin

+CVD RF’s = aspirin 7mg od, atorvastatin, anti-HTN’s

If metformin isn’t tolerated due to gastro issues = modified release metformin

If metformin is CI = DPP4i (sitagliptin)/ piaglitizone*/ gliclazide

Sulphonylureas can be considered as 1st line medical treatment if the patient is not overweight or if their blood glucose levels are particularly elevated!?

2. If HbA1c > 58, Target < 53

1st = dual therapy (metformin + x)
x = DPP4i (sitagliptin)/ pioglitazone/ sulphonyurea (gliclazide)/ SGLT2i (empagliflozin)

If pt is overweight/has CKD= sitagliptin (fat people need to ‘sit’ a lot)
If pt has CVD = SGLT2i* (empaglizlozin) (heart is emp_hatically sgalty!! 💛🧂🧂🧂)

3. If dual therapy doesn’t work -> triple therapy
4. If triple doesn’t work -> substitute one for GLP-1analogue (exenatide) under supervision*

Glitazones are agonists of PPAR-gamma receptors, reducing peripheral insulin resistanceis. Pioglitazone is contraindicated in heart failure + bladder cancer and can cause fractures

SGLT2i are associated w UTI’s

*exenatide criteria;

BMI > 35 kg/m^2

Greater than 1.0 percentage point HbA1c reduction after 6 months

Has type 2 diabetes mellitus

Weight loss > 3% at 6 months

Question 8

(Diabetic) (keto)(acidosis) - FIVES!

Answer 8

Ix:

glucose > 11 mmol/l or known diabetes mellitus
pH < 7.3
bicarbonate < 15 mmol/l
ketones > 3 mmol/l or urine ketones ++ on dipstick

Mx = FIVES! (fluids, insulin, vte prophylaxis, electrolytes, sugar)
1. 500ml NaCl bolus over 15mins, then 1L/hr once SBP>90
2. Insulin 0.1 unit/kg/hour*
3. KCl
4. 10% dextrose (once blood glucose <14mmol)
5. VTE prophylaxis (due to dehydration)

*Insulin is only used in hyperosmolar hyperglycaemic state if the glucose stops falling while giving IV fluids

If the rate of potassium infusion is greater than 20 mmol/hour then cardiac monitoring may be required

If the ketonaemia and acidosis have not been resolved within 24 hours then the patient should be reviewed by a senior endocrinologist

long-acting insulin should be continued, short-acting insulin should be stopped

Question 9

Graves’ disease

Answer 9

Ix:

Features seen in Graves’ but not in other causes of thyrotoxicosis
eye signs (30% of patients)
exophthalmos
ophthalmoplegia
pretibial myxoedema

thyroid acropachy, a triad of:
digital clubbing
soft tissue swelling of the hands and feet
periosteal new bone formation

Autoantibodies = (TSH-r) + (anti-TPO ab’s)
(TSH-r) = 90% + (anti-TPO ab’s) = 75%

Thyroid scintigraphy
diffuse, homogenous, increased uptake of radioactive iodine

Mx:

1st = anti-thyroid drugs (carbimazole 40 mg then reduced when euthyroid for 12-18months)
2nd = PTU (if pregnant!)

sx control = Propranolol (blocks the adrenergic effects)

Carbimazole can cause agranulocytosis

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
However, this regime leads to more SE’s

Question 10

Hyperparathyroidism

The most common cause of hyperparathyroidism is an adenoma.

Lithium is also a common cause!

CKD + extremely high pth = tertiary

Answer 10

Ix = Bloods;

Raised Ca*, low P
PTH may be raised or inappropriately normal (given the raised Ca)

Technetium-MIBI subtraction scan

x-ray findings = (pepperpot skull) + (osteitis fibrosa cystica)

Mx = total parathyroidectomy

Conservative mx = cinacalcet, a calcimimetic

Conservative mx = (1+2+3)
1. Ca2+ < 0.25 mmol/L above the upper limit of normal
2. > 50 yo
3. No evidence of end-organ damage

a calcimimetic ‘mimics’ the action of calcium on tissues by allosteric activation of the calcium-sensing receptor

*Ix for hypercalcaemia = PTH

Question 11

Hypogonadism (male and female) (prader-willi, kallmans etc)

Question 12

Hypopituitarism (compression of the pituitary gland by non-secretory pituitary macroadenoma (most common)
pituitary apoplexy
Sheehan’s syndrome
hypothalamic tumours e.g. craniopharyngioma
trauma
iatrogenic irradiation
infiltrative e.g. hemochromatosis, sarcoidosis)

Answer 12

pituriary macroadenoma → bitemporal hemianopia
pituitary apoplexy → sudden, severe headache

Ix = hormone profile testing + imaging

Mx = surgery + replacement of deficient hormones

Question 13

Hypothyroidism and caveats for elderly, ihd, pregnant. And side effects

Most commoncause;

In developing countries = iodine deficiency

western world = hashimotos

Hypothyroidism can cause menorrhagia! Other sx include;

Skin
Dry (anhydrosis), cold, yellowish skin
Non-pitting oedema (e.g. hands, face)
Dry, coarse scalp hair, loss of lateral aspect of eyebrows

Neurological
Decreased deep tendon reflexes
Carpal tunnel syndrome

A hoarse voice is also occasionally noted.

Answer 13

Ix = TSH!

Mx: = levothyroxine* (50-100mcg od)

Lower dose for elderly patients + pts w IHD (25mg)

Following a change in thyroxine dose thyroid function tests should be checked after 8-12 weeks

The therapeutic goal is ‘normalisation’ of the thyroid stimulating hormone (TSH) level 0.5-2.5 mU/l

Pregnant = dose increased ‘by at least 25-50 mcg

Subclinical hypothyroidism (TSH = 5.5 - 10mU/L): offer patients < 65 years a 6-month trial of thyroxine if TSH remains at that level on 2 separate occasions 3 months apart and they have hypothyroidism symptoms

SE’s = hyperthyroidism,
reduced bone mineral density
worsening of angina
atrial fibrillation

Interactions
*iron, calcium carbonate reduce the absorption of levothyroxine so should therefore be given at least 4 hours apart

Question 14

Menopause

Answer 14

Sx =

menstrual:
Change in periods
change in length of menstrual cycles
dysfunctional uterine bleeding may occur

Vasomotor symptoms - affects around 80% of women. Usually occur daily and may continue for up to 5 years
hot flushes
night sweats

Urogenital changes - affects around 35% of women
vaginal dryness and atrophy
urinary frequency

Psychological
anxiety and depression may be seen - around 10% of women
short-term memory impairment

Longer term complications
osteoporosis
increased risk of ischaemic heart disease

Mx:

Life, hormonal, non-hormonal

Hot flushes = regular exercise, weight loss and reduce stress

Sleep disturbance = avoiding late evening exercise and maintaining good sleep hygiene

Mood = sleep, regular exercise and relaxation

Cognitive symptoms = regular exercise and good sleep hygiene

HRT;

Uterus = Combined (Oe+prog) oral or transdermal

No uterus = oestrogen orally or in a transdermal patch

Hormonal Contraindications:
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia

Non-hrt
Vasomotor symptoms = fluoxetine, citalopram or venlafaxine

Vaginal dryness = vaginal lubricant or moisturiser

Psychological symptoms = self-help groups, cognitive behaviour therapy or antidepressants

Urogenital symptoms
if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not

Question 15

Multiple endocrine neoplasia

Answer 15

Ix:

Men 1 = MEN1 gene = 3P’s parathyroid, pituitary, pancreas

Most common presentation = hypercalcaemia

Men2a = RET oncogene = 2 P’s Parathyroid (60%) and Phaeochromocytoma

Men 2b = 1 P (Phaeochromocytoma), Medullary thyroid cancer,

Marfanoid body habitus
Neuromas

Question 16

Obesity

Answer 16

Ix = BMI>30

Mx: diet, excercise -> Orlistat + Liraglutide -> surgical

Orlistat = a pancreatic lipase inhibitor used for <1 year

Criteria = BMI>30, BMI>28 + RF’s

Adverse effects include faecal urgency/incontinence and flatulence.

A lower dose version is now available without prescription (‘Alli’).

Liraglutide = GLP-1 mimetic used to manage T2D, which causes weight loss

sub-cut OD

Criteria = BMI>35 and prediabetic hyperglycaemia (e.g. HbA1c 42 - 47 mmol/mol)

Question 17

Osteomalacia (Bone pain + tenderness, fractures in femoral neck, proximal myopathy leading to waddling gait)

Answer 17

Ix = Bloods + X-Ray

Low vit D, Ca and P
Raised ALP

x-ray
translucent bands (Looser’s zones or pseudofractures)

Mx = vitamin D supplmentation

a loading dose is often needed initially

calcium supplementation if dietary calcium is inadequate

Question 18

Osteoporosis

Answer 18

Ix: FRAX/QF -> DEXA scan

clinical prediciton tools = FRAX or QFracture to assess a patients 10 year risk of developing a fracture

FRAX

valid for patients aged 40-90 years

assesses the following factors: age, sex, weight, height, previous fracture, parental fracture, current smoking, glucocorticoids, rheumatoid arthritis, secondary osteoporosis, alcohol intake

bone mineral density (BMD) is optional, but clearly improves the accuracy of the results.

NICE recommend arranging a DEXA scan if FRAX (without BMD) shows an intermediate result

QFracture = considers larger group of RF’s

Includes a larger group of risk factors e.g. cardiovascular disease, history of falls, chronic liver disease, rheumatoid arthritis, type 2 diabetes and tricyclic antidepressants

DEXA immediately groups =

• Before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer).
• In people <40yo who have a major RF (such as history of multiple fragility fracture, major osteoporotic fracture, or current or recent use of high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer))

FRAX categorises into one of the following:

low risk: reassure and give lifestyle advice
intermediate risk: offer BMD test
high risk: offer bone protection treatment

Intermediate = BMD DEXA scan
.

When should we reassess a patient’s risk?

NICE recommend that we recalculate a patient’s risk (i.e. repeat the FRAX/QFracture):

if the original calculated risk was in the region of the intervention threshold for a proposed treatment and only after a minimum of 2 years, or
when there has been a change in the person’s risk factors

Mx:

1st = Alendronate
2nd = risedronate or etidronate (+ca supplements)
3rd = strontium ranelate and raloxifene

“Osteoporotic Al rizzes edi who is strong and relaxed”

Mx is indicated following osteoporotic fragility fractures in postmenopausal women who are confirmed to have osteoporosis (a T-score of - 2.5 SD or below).

In women aged 75 years or older, a DEXA scan may not be required ‘if the responsible clinician considers it to be clinically inappropriate or unfeasible’

vitamin D and calcium supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D replete

Around 25% of patients cannot tolerate alendronate, usually due to upper gastrointestinal problems.

Question 19

Paget’s disease of bone (Hyperactive osteoclasts lead to cellular remodeling and deformity of bones)

Answer 19

Ix = Bloods, Urine tests, X-Rays

Raised ALP
calcium and phosphate are typically normal
Hypercalcaemia may occasionally occur with prolonged immobilisation

other markers of bone turnover include

procollagen type I N-terminal propeptide (PINP)
serum C-telopeptide (CTx)
urinary N-telopeptide (NTx)
urinary hydroxyproline

x-rays = osteolytic -> sclerotic lesions

skull x-ray: thickened vault

bone scintigraphy = increased uptake is seen focally at the sites of active bone lesions

Mx = Bisphosphonate (either oral risedronate or IV zoledronate)

indications formx = bone pain, skull or long bone deformity, fracture, periarticular Paget’s

Question 20

Phaeochromocytoma

Most of these tumours are sporadic in origin but about 10% are part of manifestation of a hereditary syndrome such as multiple endocrine
neoplasia type 2, Von Hippel–Lindau syndrome and neurofibromatosis

Answer 20

Ix = 24 hr urinary collection of metanephrines (sensitivity 97%*)

this has replaced a 24 hr urinary collection of catecholamines (sensitivity 86%)

Mx = alpha blocker*, followed by beta blocker -> Surgery

Surgery is definitive, but the patient must first however be stabilised with medical mx: alpha-blocker (e.g. phenoxybenzamine), given before a
beta-blocker (e.g. propranolol)

Question 21

Pituitary tumours (non-functioning)

Question 22

Polycystic ovary syndrome (PCOS)

Answer 22

Ix = 2 of these 3; anovulation, hyperandrogenism, polycystic ovaries

Pelvic ultrasound: multiple cysts on the ovaries

Baseline investigatons: FSH, LH, prolactin, TSH, testosterone, sex hormone-binding globulin (SHBG) are useful investigations

raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis

prolactin may be normal or mildly elevated
testosterone may be normal or mildly elevated - however, if markedly raised consider other causes

SHBG is normal to low in women with PCOS
check for impaired glucose tolerance

Mx:

General
weight reduction if appropriate
if a women requires contraception then COCP may help regulate her cycle and induce a monthly bleed (see below)

Hirsutism and acne
a COCP may be used help manage hirsutism. Risk of VTE

if doesn’t respond to COC then topical eflornithine may be tried

spironolactone, flutamide and finasteride may be used under specialist supervision

Infertility
weight reduction if appropriate
meds are debated

Question 23

Primary hyperaldosteronism

Answer 23

Ix: Pt criteria to be screened:

hypertension with hypokalemia
treatment-resistant hypertension

1. Aldosterone/renin ratio (high!)
2. high-resolution CT abdomen
3. Adrenal vein sampling (to differentiate uni/bilateral)

Mx:

adrenal adenoma = surgery (laparoscopic adrenalectomy)

bilateral adrenocortical hyperplasia = aldosterone antagonist e.g. spironolactone*

*can cause gynaecomastia

Question 24

Prolactinoma

Answer 24

Ix = MRI

Mx = dopamine agonists (e.g. cabergoline, bromocriptine)

trans-sphenoidal surgery is performed for patients who cannot tolerate or fail to respond to medical therapy

Question 25

SIADH

Answer 25

Ix: ADH is too high, has many different causes

Mx:
correction must be done slowly to avoid precipitating central pontine myelinolysis

1st = Fluid restriction

Demeclocycline = reduces the responsiveness of the collecting tubule cells to ADH

Tolvaptan = ADH (vasopressin) receptor antagonists

Question 26

Thyroid nodule(s)

Answer 26

Ix:
1st = USS

Primary aim is to exclude thyroid cancer

Question 27

Hashimoto’s Thyroiditis

is an autoimmune disorder of the thyroid gland.

It is typically associated with hypothyroidism although there may be a transient thyrotoxicosis in the acute phase.

It is 10 times more common in women

Answer 27

Features:
features of hypothyroidism
goitre: firm, non-tender
anti-thyroid peroxidase (TPO) and also anti-thyroglobulin (Tg) antibodies

Associations = other AI conditions e.g. coeliac disease, type 1 diabetes mellitus, vitiligo

Hashimoto’s thyroiditis is associated with the development of MALT lymphoma

Initially treat the hyperthyroid phase with propranolol for the symptoms

Question 28

Sub-Acute (De Quervains) Thyroiditis

Presents with recent viral illness and the presence of a tender/painful goitre

Answer 28

Ix:
Thyroid scintigraphy: globally reduced uptake of iodine-131

Mx:

usually self-limiting - most patients do not require treatment

thyroid pain may respond to aspirin or other NSAIDs

in more severe cases steroids are used, particularly if hypothyroidism develops

Question 29

Secondary hyperparathyroidism

Answer 29

Hyperphosphataemia can cause vascular calcification and should be treated
as soon as possible.

Mx = Sevelamer

Gut phosphate binders such as sevelamer binds to
ingested phosphate within the gut, thereby lowering serum phosphate levels.
It also lowers calcium and lowers cholesterol.

Question 30

How does McCune-Albright syndrome present?

Answer 30

McCune–Albright syndrome is a genetic disorder that causes the
uncontrolled secretion of a number of endocrine glands causing
abnormalities of the skin, bones and hormonal disturbances. It is usually
suspected when the following pathologies occur:

precocious puberty,
cushingoid features, hyperpituitarism (acromegaly, gigantism),
café-au-lait spots
and hypophasphataemia

Question 31

hyperglycaemic hyperosmolar state signs?

Answer 31

HGHOS = hyperglycemia with increased serum osmolarity and no ketosis (key differentiator from DKA)

Mx:

fluid replacement

fluid losses in HHS are estimated to be between 100 - 220 ml/kg

IV 0.9% sodium chloride solution

typically given at 0.5 - 1 L/hour depending on clinical assessment

potassium levels should be monitored and added to fluids depending on the level

Insulin should not be given unless blood glucose stops falling while giving IV fluids

Venous thromboembolism prophylaxis - patients are at risk of thrombosis due to hyperviscosity

Question 32

Hyperthyroidism

Associated with oligomennorhoea, or amennorhoea!

Subclinical hyperthyroidism is associated with atrial fibrillation, osteoporosis and possibly dementia

Answer 32

Ix can include;

Technetium-99 scintigraphy
Fine-needle aspiration
Thyroid function tests
TSH-receptor antibodies

Question 33

Subclinical hypothyroidism

Answer 33

TSH raised but T3, T4 normal
no obvious symptoms

Mx:

TSH is > 10mU/L and T4 is normal;

consider offering levothyroxine if the TSH level is > 10 mU/L on 2 separate occasions 3 months apart

TSH is between 5.5 - 10mU/L and T4 is normal;

if < 65 years consider offering a 6-month trial of levothyroxine if:
the TSH level is 5.5 - 10mU/L on 2 separate occasions 3 months apart,and
there are symptoms of hypothyroidism

in older people (especially those aged over 80 years) follow a ‘watch and wait’ strategy is often used

asymptomatic pt = observe and repeat thyroid function in 6 months

Question 34

Adrenal crisis

Answer 34

IV saline and hydrocortisone

No fludrocortisone is generally required as high cortisol exerts weak mineralocorticoid action. Since high doses of hydrocortisone are used, enough mineralocorticoid activity is exerted, therefore giving extra mineralocorticoid would be unnecessary.

Question 35

Prediabetes criteria?

Impaired fasting glucose

Answer 35

A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG)

Impaired glucose tolerance (IGT) = fasting plasma glucose less than 7.0 mmol/l + OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l

Diabetes UK suggests:

‘People with IFG should then be offered an oral glucose tolerance test to rule out a diagnosis of diabetes.

A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person doesn’t have diabetes but does have IGT.’

Question 36

LADA and MODY

Answer 36

Maturity onset diabetes of the young (MODY) = 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

Latent autoimmune diabetes of adults (LADA) = The majority of patients with autoimmune-related diabetes present younger in life. There are however a small group of patients who develop such problems later in life. These patients are often misdiagnosed as having T2DM. In contrast to T1DM, insulin is not usually required in the early stages of the disease

Ix = Glutamic Acid Decarboxylase (GAD) Autoantibodies test and evidence of other autoimmune diseases.

Question 37

What acid-base imbalance does cushings cause and why?

Answer 37

Increased cortisol acts on mineralocorticoid receptors

This causes an increase in water and sodium retention, increased potassium excretion, and increased hydrogen ions excretion. Lower levels of hydrogen ions cause alkalosis and less potassium causes hypokalemia.

Thus, hypokalaemic metabolic alkalosis

Question 38

Drugs which cause gynaecomastia?

Answer 38

Disco

Digoxin
Isoniazid
Spironolactone
Cimetidine
oestrogen

Question 39

Px of hypothyroidism myxodema coma? and mx

Answer 39

Extreme hypothermia and confusion are the most common presenting features of myxoedema crisis, also known as myxoedema coma.

The name is a misnomer as it very rarely causes coma or pre-tibial myxoedema (an uncommon manifestation of Graves disease).

Other features include bradycardia, hypotension and hypoventilation.

mx = IV thyroxine and hydrocortisone

Question 40

Toxic multinodular goitre

Answer 40

Ix = nuclear scintigraphy reveals patchy uptake

low TSH, high T4

mx = radioiodine therapy

Question 41

Hypoglycaemia

conscious, unconscious, no iv access

Answer 41

Pt is conscious and able to swallow = oral glucose liquids, tablets or gels

Pt is unconscious/unsafe swallow = 10% glucose IV at 200ml in 15 min

Pt is unconscious/unsafe swallow + NO IV access = 1 mg of IM glucagon

Question 42

sick euthyroid bloods?

Answer 42

TSH normal, low t4/t3

Question 43

what drug can cause hypo or hyperthyroidism?

Answer 43

Amiodarone!

Amiodarone has a chemical structure that is analogous to thyroxine and contains large amounts of iodine. Amiodarone has a cytotoxic effect on thyroid follicular cells and inhibits conversion of T4 to T3

As a result, either hypothyroidism (Wolff–Chaikoff effect) or hyperthyroidism (Jod–
Basedow effect) may occur.

Thyroid function tests should be done before
commencement of amiodarone and thyroid-stimulating hormone should be measured every 6 months whilst the patient is on treatment