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MRCP PART 1 > Endocrine > Flashcards

Endocrine Flashcards

1
Q

Androgen insensitivity syndrome, why do females often still develop breasts? Uterus / cervix? What is recommended?

A

Partial or complete lack of response to androgens. Have testis which produce Mullerian inhibing substance - inhibits grown of uterus and cervix -> BLIND ENDED VAGINA.
Fetus may not develop male external genitalia or secondary sexual characteristics at puberty.

Breasts often develop due to the peripheral conversion of circulating androgens to oestrogens

Reccomended orchiectomy due to risk of testis Ca

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2
Q

What is ashermans syndrome ?

A

Intrauterine adhesions from previous infection / scarring

[Think that dam surgeon Ash who made loads of scarring -> ASH-err-man

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3
Q

How to differentiate between androgen insensitivity syndrome and Mullerian agenesis?

A

Testosterone levels - RAISED in AIS [normal male levels]
Karyotype - XY in AIS

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4
Q

Who commonly gets secondary amenorrhoea

A

Endurance athletes

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5
Q

Breakdown some causes of amenorrhoea in women

A

Physiological - Constitutional delay, exercise/stress

GU malformations - imperforate hymen, transverse septum, absent vagina/uterus

Endocrine - HYPER/HYPOthyroid, PITUITARY (Hyperprolactinaemia, cranial irradiation, Sheehans, hypopituitarism Eg after TBI), Cushing, PCOS.

Genetic - Turners

Iatrogenic - chemo/radio

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6
Q

What is Sheehan’s syndrome?

A

Pituitary infarction after major obstetric haemorrhage

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7
Q

Seondary Amenorrhea + evidence of androgen excess eg hirsutism/acne. Differentials

A

PCOS
Cushing’s
Late-onset congenital adrenal hyperplasia
androgen-secreting tumours [RARE]

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8
Q

What might red/thin vaginal mucosa mean

A

Decreased oestrogen levels

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9
Q

Secondary Amenorrhea with high levels of FSH/LH? What would testosterone and prolactin levels be?

A

Indicates ovarian failure
NORMAL prolactin / tesoterone

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10
Q

When to refer girls with primary Amenorrhea

A

No secondary sexual characteristic - Age 13
With secondary characteristics - Age 15

Worries about anything else…

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11
Q

MEN 1 features? Genetic? Most common presenting factor

A

Pancreatic neuroendocrine tumours
Primary hyperparathyroidism
Pituitary adenomas

Dominant - chromosome 11

Usually present with HyperCalcium [due to hyperparathyroidism]

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12
Q

Familial hypocalciuric hypercalcaemia syndrome.
Inheritance? Abnormalities in blood?

A

Dominant
Raised serum Ca, raised PTH

[Obvs LOW ca urine]

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13
Q

MEN2a gene? features? differneces to MEN

A

RET gene - chromosome 10
Primary hyperparathyroidism - Usually due to an adenoma [MEN1 is usually generalised hyperplasia]

Often have pheochromocytoma +/- thyroid Ca

[DO NOT get pituitary adenomas or pancreatic neuroendocrine like in MEN1]

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14
Q

What is pseudohypoparathyroidism

A

caused by resistance to PTH
->Low PO4 and Ca levels [+raised PTH]

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15
Q

Important management in MEN2

A

Prophylactic thyroidectomy

GENETIC COUNCILING

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16
Q

Difference between MEN2 A and B

A

B - gets a marfanoid appearance and mucosal neuromas

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17
Q

Investigations for diagnosis of phaeo? Specific scan type?

A

24-hr urinary catecholamines
MRI
MIGB scan (metaiodobenzylguanidine)

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18
Q

Investigation for medullary thyroid Ca

A

Elevated calcitonin
US and fine needle aspiration

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19
Q

Ix for likely acromegaly? Why is it good

A

IGF-1 (then confirmed by glucose tolerance test + pituitary MRI, visual fields, cardiac assessment…)
Has a long half-life, and can be measured at any time of day
-> Can use for assessment of recurrence

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20
Q

A less common cause of acromegaly (not pituitary adenoma secreting GH)?

A

Carcinoid tumour elsewhere

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21
Q

What causes pseudo acromegaly? Drug?

A

Insulin resistance - associated with hyperinsulinaemia / minoxidil (antihypertensive and male pattern balding)

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22
Q

Non surgical options for acromegaly

A

Radiotherapy - may end up with panhypopituitarism

Drugs
Dopamine agonists: Bromocriptine and -goline / -golides
Somatostatin analogues: ocretide

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23
Q

Micro vs Macro prolactinoma

A

Smaller or bigger than 1cm …..

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24
Q

Management of macroprolactinomas

A

Usually a dopamine agonist (most common is CARBEGOLINE or bromocriptine)

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25
Q

3 most common causes of raised prolactin

A

Prolactinomas
hypothyroid
Drug-induced - eg antipsychotics / dopamine antagonists (metoclopramide)

[Pregnancy, stress, breast stimulation, head injury, Cushings, cirrhosis]

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26
Q

Diabetic who is high risk CV disease and on metformin should get

A

A -flozin (SLG2 inhibitor)
Eg canagliflozin

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27
Q

What is Acanthosis nigricans? what does it indicate?

A

dark, thick, velvety skin in body folds and creases. It often appears in the armpits, groin and back of the neck.

Insulin resistance - DIABETES

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28
Q

Metformin + what if patient is OBESE and HBa1c raised on monotherapy

A

DPP4 inhibitor
-gliptin - eg sitagliptin

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29
Q

Pseudohypoaldosteronism syndrome name? What happens

A

Gordon syndrome
Failure of response to aldosterone -> Aldosterone levels are RAISED
-> High blood pressure, HYPERKALAEMIA, raised aldosterone, hyperchloremic metabolic acidosis

[Usually have physical abnormalities / low IQ]

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30
Q

What is addisons? Usual symptoms if not in crisis

A

Primary adrenal insufficiency
->low cortisol / aldosterone

Vauge - hypotension, GI discomfort, Weight loss, skin pigmentation

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31
Q

Bartter syndrome basic? Seen on bloods?

A

Autosomal recessive Salt wasting tubulopathy

Hypokalaemia
raised renin and aldosterone
Raised urinary cA

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32
Q

Conns syndrome is? - bloods?

A

Primary hyperaldosteronism [excess]
Hypokalaemia, low renin
HYPERTENSION

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33
Q

Gitelman syndrome basics?

A

Autosomal recessive hypokalemic salt wasting tuberopathy

Hypokalemic metabolic alkalosis
HypoCa, hypoMg

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34
Q

Which cells secrete renin? What stimulates this?

A

Juxtaglomerular cells

Reduced perfusion pressure to kidney [detected by pressure receptors in afferent arteriole]

Reduced Na in distal convoluted tuble
[Detected by macula densa cells]

Sympathetic stimulation of B1-adrenic receptors

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35
Q

What does renin do?

A

Renin converts angiotensin (produced in liver) to angiotensin I

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36
Q

What converts angiotensin I to II? Where is it produced

A

ACE
Produced in vasculature of lungs and kidney

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37
Q

Angiotensin II effects on organ systems
Renal?
Vasculature?
Pit?
Neuro?

A

Vessels: Binds to G-coupled protein receptors
-> vasoconstriction

Kidneys:
-Proximal convoluted tuble -> Increase Na reabsorption
-Adrenal cortex -> stimulates aldosterone
-Efferent arteriole -> constricts and increases pressure (increases GFR)

Pituitary
-Releases ADH

Nervous system
-Sympathetic - increases noradrenaline formation
-Hypothalamus - increases thirst -> water intake

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38
Q

What does aldosterone do? Where?

A

Acts on distal convoluted tubules

Na reabsorption, K+ excretion
[Increases osmolarity in blood -> increased volume from extracellular]

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39
Q

Uptake on 99Tc Thyroid scintigraphy in Graves? adenoma? throiditis?

A

Increased GLOBALLY in graves
Increased FOCALLY in adeoma / toxic multinodular

DECREASED in thyroiditis
[stored thyroid hormone (t3/4) gets released which causes a decrease in TSH -> reduced uptake as TSH synthesis is decreased]

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40
Q

When are TPO thyroid antibodies positive

A

95% in Hashimotos
70% in graves
20% in normal population

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41
Q

The most common cause of secondary hypothyroidism

A

Tumour secreting TSH

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42
Q

What antibodies are found in graves

A

IgG autoantibodies - eg TSH-receptor antibody

[Anti thyroglobulin, anti microsomal]

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43
Q

Causes of normal t3/4 with low TSH

A

Thyroxine excess
Steroid therapy
Dopamine infusion
non-thyroidal illness

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44
Q

Drugs used in hyperthyroid? Side effects

A

Carbimazole, propylthiouracil

Common - rash, leukopenia
Rare - agranulocytosis, aplastic anaemia, hepatitis, vasculitis (propylthiouracil)

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45
Q

Rapid control of symptoms in hyperthyroid

A

B blockers / CCBs

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46
Q

What are the 2 types of DI and what happens?

A

Cranial - failure to secrete vasopressin from posterior pituitary or; Nephrogenic resistance to vasopressin within the kidney

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47
Q

Common electrolye causes of nephrogenic DI ? Drug? Management?

A

Electrolyte - HyperCa, HypoK
Lithium

Treat cause. Or try Bendroflumethazide

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48
Q

Where does ADH (vasopressin) work

A

Collecting ducts - increases water resorbsion

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49
Q

Pathogenesis of cranial DI

A

Need to damage hypothalamic nuclei (supraoptic and paraventricular).
Damage to the posterior pituitary doesn’t cause it as it can be secreted directly from the hypothalamus

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50
Q

Plasma / urine osmolalities in DI vs psychogenic polydipsia?
Differentiate cranial / nephrogenic DI?

A

DI - HIGH plasma, Low urine
PsychoP- Low plasma, low/normal urine

Cranial - low plasma levels of ADH
Nephrogenic - high plasma levels of ADH

Check osmolalities post DDAVP (Desmopressin)
Cranial DI -> High/normal urine osmolality
Nephrogenic DI - Stays the same

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51
Q

Management of nephrogenic vs cranial DI

A

Nephrogenic - treat cause. Then Bendroflumethazide

Cranial - desmopressin

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52
Q

Women with diabetes who become pregnant advised to take what?

A

5mg folic acid daily

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53
Q

Diagnosis of gestational diabetes?

A

Fasting glucose >5.6
two hour glucose of >7.8

Then confirmed with oral glucose tolerance test

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54
Q

Who would you test for gestational diabetes

A

Previous GDM
2+ glycosuria on 1 occasion, 1+ on 2 occasions
Any risk factor:
-BMI >30
-Previous macrosomic baby >4.5kg
-First degree relative with DM
-South asian / middle eastern / afrocaribean

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55
Q

Antihyperglycaemics for GDM

A

Diet and lifestyle first -OBVIOUSLY

1st line - Metformin
2nd - Glibenclamide - (sulfonylureas)
3rd - insulin

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56
Q

Why do babies with diabetec mums get macrosomic ?

A

hyperglycaemia -> B-cell hyperplasia in islets of langerhan pancreatic cells -> increased insulin

Insulin is a growth promoter

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57
Q

Why do babies of diabetic mothers get more respiratory distress syndrome?

A

Surfactant deficiency

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58
Q

Metformin (and Glibenclamide) are the only oral antihyperglycaemic medication that is safe in pregnancy. Which common meds need to be stopped?

A

ACEi
A2A inhibitors
statins

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59
Q

Delivery of baby with GDM should be planned for when?

A

37-38 weeks IF ON Treatment

otherwise 40+6 if diet controlled

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60
Q

When cord is cut in baby with GDM what do you need to ensure?
What extra risks are in babies who are small for gestational age?

A

Constant glucose infusion which can be weaned down

Low fat/gyclogen stores -> risk of hypothermia and high insulin levels as they are used up.

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61
Q

When is insulin used first line in GDM

A

Fasting glucose >7
Fasting glucose >6 with complications such as macrosomia / hydraminos

Or later in preganacy:
fetal abdo circumfrence >95th percentile
Pre prandial >6.5, post prandial >7.5

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62
Q

When to start a sliding scale in labour

A

if Glucose >6

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63
Q

Hypoglycaemia in neonate Rx?

A

Feeding bottle / tube
if innefective add buccal dextrose

If ineffective -> IV dextrose

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64
Q

Fasting glucose <7 with no fetal complications? 1st line Rx

A

diet and exercise

(review in 1-2 weeks)

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65
Q

Who gets aspirin in pregnancy

A

Those at risk of pre-eclampsia
Either 1 high risk, or 2 moderate risk factors

High:
CKD, Autoimmune diseases eg SLE/APS, Diabetes, Hypertension or previous gestational hypertension

Moderate :
First preganacy, preganacy interval >10years, >40 years old, BMI >35, Twin/multiple, FHx of pre-eclampsia

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66
Q

Raised urinary Ca
hypokalaemia
Metabolic alkalosis
raised renin / aldosterone
Normotensive/Low

A

Barttler syndome

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67
Q

Hypokalemic metabolic alkalosis
HypoCa, hypoMg
Hypocalsuria

A

Gitelman syndrome

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68
Q

Hypertension
Hypokalaemic metabolic acidosisĺ

A

Liddle syndrome

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69
Q

Hyperk ECG

A

Tall t waves
flattened / absent P waves
Prolonged QR

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70
Q

HypoK ecg

A

Flat / inverted T waves
Prolonged PR
ST depression
Tall U waves

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71
Q

Triad of phaeochromocytoma

A

Hedaches, palpitations, sweating

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72
Q

Who gets bilateral familal phaeochromocytomas

A

MEN syndrome (bilat phaeos in 70%)

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73
Q

Cafe-au-lait patches and phaeo

A

Neurofibromatosis

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74
Q

Definitive management of phaeochromocytoma is surgery. What do you use pre op? What do you need to be careful with?

A

A blocker Eg Phenoxybenzamine - gives blood volume explansion

Then can add in a B blocker - DONT give before a-blocker as risk of hypertensive crisis due to unrestricted alfa stimulation

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75
Q

Urine test to differentiate T1/T2 DM

A

Ketonsuria - indictive of insulinaemia

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76
Q

Hashimotos thyroiditis test

A

Anti TPO
Also raised in Graves

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77
Q

Hypokalaemia
Metabolic alkalosis
Resistant hypertension

A

Primary hyperaldosteronism (Conns)

Will have a raised aldosterone:renin level

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78
Q

Why does low body weight lead to ammenorrhoea

A

-> Reduced FSH/LH and sedondary ovarian failure

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79
Q

Management of sheehan syndrome

A

Steroids immediately

Then full endocrine assement and replacement of other pit dependent hormones Eg thyroxine….

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80
Q

Sheehan syndrome… Features of hormone deficiencies

A

Fatigue and low muscle mass - GH

Low BP, cold intollerance and weight gain - TSH

Hypotension, hypoglycaemia - ACTH

Galactorrhoea - Prolactin

Ammenohhroea - FSH / LH

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81
Q

How to seperate pituitary and adrenal cushings syndrome? NOT using an MRI ya cheeky bastah.

A

BOTH will have lowered cortisol levels if given dexamethasone

Only pituitary (cushings disease) will be affected by corticotropin releasing hormone (cortisol increases)

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82
Q

What is cushings disease

A

Bilat adrenal hyperplasia secondary to ACTH secreting pituitary adenoma

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83
Q

2 tumours which often cause ectopic cushings syndrome

A

Small cell lung
Carcinoid

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84
Q

ACTH levels in adrenal adenoma ?
In pituitary adenoma?

A

LOW due to negative feedback

High in pit - that’s the tumour dipshit

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85
Q

Steps for diagnosis / working out where cushings is from..

A

Step 1 - Dexamethasone supression test OR 24hr urinary cortisol test

Step 2 - High dose dex supression test [0.5mg QDS for 2 days] then measure cortisol
-In normal people this will suppress to <50nmol/L
-ACTH will be -Normal/raised in pituitary or ectopic ‘ACTH dependent’
-ACTH will be low or non detectable in Adrenal

Step 3 - Localisation
Low/no ACTH - CT/MRI adrenals

Has ACTH - to differentiate between pit and ectopic -> High dose dexamethasone test.
-Cortisol will be raised if pituitary -> MRI
-Cortisol unaffected -> CT TAP with contrast

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86
Q

Who might get a positive dex supression test (PSEUDO-cushings) - therefor you need the high dose one to confirm diagnosis?

A

Obese, depression, alcoholic, liver enzyme inducers

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87
Q

Drug to normalise cortisol levels if surgery for cusings not possible

A

Metyrapone

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88
Q

Bilat adrenalectomy has what risk? Presentation

A

Nelson syndrome

Bilat adrenalectomy -> pit enlarges as loss of legative feedback on ACTH
-> Skin pigmentation common
-> Supression of other pit hormones / features of mass effect

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89
Q

Weight loss, nausea, lethargy, hypoNa, HyperK, hyperCa, Raised TSH, Postural hypotension, skin pigmentation / vitiligo,

A

Addisions

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90
Q

Most common cause of hypoadrenalism

A

Long term steroid use
[Then addisions]

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91
Q

Addisons is? Antibodies? Associated with? Other diseases which cause primary hypoadrenalism?

A

Autoimmune destruction of adrenal glands
Adrenal autoantibodies
Vitiligo - commmon [Also in other automimmune tho]

TB/HIV/adrenal haemorrhage / Congenital hypoadrenalism (21 hydroxylase deficiency)

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92
Q

21-hydroxylase deficiency is often misdiagnosed as?

A

Primary hypoadrenalism
[Same same but different cause to addisons]

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93
Q

What does aldosterone do in the kidney? [Pathophysiology of addisons]

A

Sodium retention and excretion of potassium

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94
Q

Addisons bloods

A

hypoNa, HyperK, hyperCa, Raised TSH, hypoglycaemia, raised urea,

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95
Q

Gold standard test for addisons? Briefly explain it and what values you arelooking for

A

Short synacthen

Inject 250mcg ACTH -> Plasma cortisol >550 after 30-60mins
Or rise of >200

Is normal
In Addisons they unable to make it

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96
Q

What needs replaced in addisons Rx

A

Steroids
Both glucocorticoids and mineralcorticoids

Eg hydrocortisone + fludrocortisone

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97
Q

Who gets thyroid eye disease? Key risk factor? Can you have normal TFTs

A

Graves usually
SMOKERS
yes 10% euthyroid

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98
Q

Thyroid eye disease brief pathophysiology?
Ix?

A

Throid stimulating hormone receptor (TSHR) + IGF-IR are expressed in thyroid/adipocytes/fibroblasts
-> Get simulated by TSHR autoantibodies / activated lymphocytes
->Fibroblast proliferation + water retention + increased orbital muscles -> Thyroid eye disease

CT/MRI
TSHR antibodies

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99
Q

Treatment for thyroid eye disease? Which thyroid treatement to avoid?

A

Smoking cessation
High dose steroids
IF reduced vision / colour differentiation (optic nerve dysfunction) -> urgent decompression surgery

AVOID radioiodine treatment - can make worse

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100
Q

What Ca often leads to SIADH? Biochem + urine findings?
What else do these tumours often secrete?

A

Small cell

SIADH -> HypoNa
LOW plasma osmolarlity
HIGH urine osmolarity with HIGH urine Na

ACTH

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101
Q

Common tumour secreting what leads to Hyper Ca

A

Squamous cell secreting parathyroid hormone related protein

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102
Q

Prolactinoma -> Ammenorrheoa. WHY?

A

Prolactin inhibits GnRH though negative feedback.
-> Reduced secretion of FSH/LH from anterior pituitary

-> Hypothalamic hypogonadism + secondary ammenorrhoea

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103
Q

Dyslipidaemia
Hairloss , fat, dryskin
Need to check?

A

THYROID function.
90% of hypothyroid have dyslipidaemia - usually HIGH LDH + total cholesterol

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104
Q

2 key Drugs that cause hypothyroid

A

Amoiodarone
Lithium

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105
Q

Demeclocycline use?

A

Drive free water excretion in patients with SIADH

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106
Q

Wilson disease is serum caeruloplasmin low or high? Inheritance?
Drug for Rx

A

Low
Recessive [ATP7B gene]
Penicilliamine [BUT mostly jsut avoidance of copper containing foods]

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107
Q

When might you think a diabetes presentation is MODY

A

Strong family history

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108
Q

MODY - 2 most common types and gene

A

MODY 2 - Glucokinase gene
20% - Mild form with minimal complications

MODY 3 - HNF-1a
60% - Progressive beta cell failure. Very Sensitive to sulfonyureas Eg Gliclazide

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109
Q

What is De Quervain’s

A

subacute) thyroiditis usually triggered by a viral infection Eg mumps / flu

Usually PAINFUL and rapid swelling unlike autoimmune causes

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110
Q

Breifly on primary secondary and tertiary hyperparathyroidism? Levels of Ca? PTH? PO4?

A

1 - Adenoma, usually present with symptoms of HyperCa. [BONES STONES MOANS GROANS]
[seen in POST MENOPAUSAL WOMEN]
Ca - RAISED, PTH - High or inappropriately normal, PO4 LOW

2 - Parathy glands undergo hyperplasia due to longstanding HypoCa [Usually Caused by longstanding CKD. Or sometimes malabsorbtion / vit D deficiency]
Presents with CKD
Ca - LOW, PTH- Raised, PO4 High in renal disease, PO4 low in Vit D deficiency

3- After prolonged longstanding secondary HyperPTHism [CKD]. Glands lose negative feedback loop and keep secreting PTH despite Ca being normal / high
Ca - Raised, PTH - raised, PO4 usually raised
Presents with symptoms of hyperCa

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111
Q

Trigger for PTH secretion? What does it do?

A

Secreted in response to low Ca levels

a) Increases osteoclast activity -> Release Ca + PO4 from bones
b) Increases absobtion of Ca and REDUCED PO4 from kidney
c) Increases Vit D3 production

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112
Q

Bar hyperPTH, some other causes of HyperCa

A

1 - familial benign hypocalciuric hypercalcemia
Dominant inheritance. HyperCa and normal / mildly raised PTH
[Due to loss of gene which senses Ca levels in PTH -> more PTH and less urinary excretion]

2 - Drug induced. Lithium, thiazide

3 - Sarcoidois

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113
Q

Drugs causing hyperCa

A

Lithium
Thiazide

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114
Q

Osteolysis, bone tumours, pepper pot skull

A

Some parathyroid ca xray buzz words

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115
Q

Management of mild primary HyperPTH

A

Hydration
Avoid Thiazides / lithium / high VitD/Ca intake

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116
Q

When would you surg mananage primary-HyperPTH?
2 - KEY complications

A

ANYONE with complications or <50
[Raised Ca
Bone disease
Renal calculi
Imapaired renal function
<50 ]

Hypoparathyroidism
Recurrent laryngeal nerve damage

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117
Q

Rx of secondary hyperPTH

A

Correct VitD if low
CKD Rx
-PO4 restriction/binders
-Ca supplement

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118
Q

Tertiary HyperPTH Rx

A

Cinacalcet if crumbly
Subtotal/total parathyroidectomy is recommended

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119
Q

Indications for surgery for toxic multimodular goitre

A

> 80g
Symotoms of neck compression
Co-existing HyperPTH needing surgery
Need for rapid correction of hyperthyroid state

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120
Q

Antihypertensive classes which impair glucose tollerance?

A

Thiazides
Non cardioselective B blockers. [Bisoprolol/Carvedilol are fine. Propranolol less so]

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121
Q

Medication class to reduce progression of diabetic peripheral neuropathy?

A

ACEi - even if normotensive

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122
Q

What are thionamides?

A

Antithyroid drugs
Carbimazole, Propylthiouracil

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123
Q

What is more protective of osteoporosis? Being fat or being active?

A

Being FAT bmi 25-30 - [Without having diabetes]

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124
Q

Is having a baby beneficial or bad for osteoporosis in later life

A

BABY = good - 4x less osteoporosis in later life

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125
Q

Oral contraceptives - which protect against osteoporosis?

A

COCP

[POP - does not]

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126
Q

Medullary thyroid Ca is in which syndrome?
Other bits

A

MEN 2a

1-Medullary thyroid Ca
2- Phaeochromocytoma
3- HyperPTH

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127
Q

First step in DKA

A

Fluid and electrolytes - people die of hypovolemia + electrolyte derangements
[IV insulin can wait a moment]

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128
Q

What causes congential adrenal hyperplasia? Inheritance?

A

Recessive - Hydroxylase defiency [90% are 21-hydroxylase]

129
Q

What is 21-hydroxylase for? When you lack it? Common Biochem / examination

A

Synthesis of steroid hormones - eg cortisol / aldosterone

End up with CAH
[High amounts of intermediates in steroid formation Eg Androgenic hormones - testosterone / 17-hydroxyprogesterone -> virilisation / ambiguous genetalia

-> Risk of Addisonian crisis due to low aldosterone shortly after birth

130
Q

The gold standard test for diagnosing CAH [21-hydroxylase deficiency]?

A

Corticotropin stimulation test

131
Q

Pharmacological Rx of CAH? In utero?

A

Gluco/mineral corticoids

If salt losing -> NaCl therapy in infants

Preg - IV steroids can help with genital ambiguity

[BILAT adrenalectomy is sometimes required]

132
Q

When would you use GLP-1 analouges? Contr-indications? Eg?

A

FAT people with diabetes BMI >35 as good for weight loss

Can’t use in gastroparesis as delay gastric emptying

-glutides Eg Semaglutide, luraglutide, dulaglutide
Uusally once daily or even once weekly

133
Q

What does glucagonoma do

A

Cancer of pancreas -> secretes glucagon

-> Increases glucose levels by activating anabolic and catabolic processes such as gluconeogenesis and lipolysis

134
Q

How does metformin work

A

inhibits gluconeogenesis by liver
[biguanide]

135
Q

C peptide in an isulinoma

A

C peptide raised
(As is insulin)

136
Q

Euvolaemia, hyponatraemia, low serum osmolality
Normal K, normal renal function, raised urine Na

A

SIADH

137
Q

hyponatraemia caused by hyper or hypo thyroid

A

Hypothyroid [think low and slow]

138
Q

Management of SIADH with minimal symptoms

A

Fluid restict

139
Q

Management of severe hyponatraemia? Key risk of correction fast?
Drug to cause (partial) nephrogenic DI?

A

Hypertonic saline [or loop diuretics+ saline]
Central pontine myelinolysis

Demeclocycline - blocks ADH [induces partial nephrogenic DI]
Vasorpressin receptor antagonist - eg tolvaptin

140
Q

Diabetic complication is gastroperisis. What is drug therapy of choice?

A

Domperidone
[second line erythromycin]

METOCLOPRAMIDE IS NO LONGER RECOMMENDED

141
Q

Non-classical CAH. Drug Rx in adults with mild symptoms

A

Flutamide [antiandrogen]

DONT WORRY IF YOU CANT REMEBER THIS

142
Q

Lithium impact on thyroid + prolactin?
Alternative drug if patient wants to get pregnant

A

Hypothyroid [will have raised TSH]
Raised prolactin

Lamotragine

143
Q

Recurrent painful orogenital ulceration
Uveitis
Polyarthritis

What syndrome?
Rx?

A

Bechet
[Autoimmune disease (HLA- b12/51/52) No specific test - but can exclude other causes Eg SLE]

Topical steroids for mucocutaneous
Oral pred / azithromycin
[TNFa inhibitors in combination with pred are 3rd line or if there is GI/CNS/Vascular involvement Eg. Infliximab

144
Q

Rest card

A

High 5 to you

145
Q

Hypos with high insulin and low c peptide = ?
high c peptide?

A

insulin abuse

Insulinoma or sulphonylurea (gliclazide) abuse

146
Q

Adrenal mass with normal urinary catecholamines and HTN.
What is the best drug for HTN? What if it is a phaeo

A

Spironolactone - block aldosterone
(Conns)

Phaeo - Phenoxybenzamine [doxazosin second line]

147
Q

Angiotensin II and aldosterone work where

A

Angiotensin II - proximal convoluted tubule

Aldosterone - distal convoluted tubule

[Angiotensin comes first]

148
Q

Liddle vs cons on bloods

A

Liddle- acidosis
Cons - alkalosis

Both HTN, hypoK

149
Q

Thyroid antibodies while pregnant increase risk of

A

Premature and spontaneous miscarriage

150
Q

Rx of severe graves with relapses and eye disease

A

Total (not subtotal) thyroidectomy

151
Q

First line Ix in Conns

A

Aldosterone:renin ratio

152
Q

How do the -flozins work?

A

SLG2 inhibitors
[SLG2 is a transporter which is responsible for 90% glucose reabsorption]

-> increased renal excretion of glucose

153
Q

how do the -glutides work?

A

GLP-1 monoagonists (incretin mimetics)

Stimulate glucose-sensitive insulin release

Also, delay gastric emptying

154
Q

How do the -gliptins work

A

DPP4 inhibitors

Prevent breakdown of incretin
-> Stimulates insulin release

155
Q

Strong family Hx of diabtes - eg mum type 2 and brother type 1.
Otherwise normal shape no risk factors. What type of Diabetes? 1st line rx?

A

MODY
Gliclazide

156
Q

How does metformin work?class?

A

Reduces hepatic glucose output
biguanides

157
Q

Most common cause of secondary hypertension?

A

Conns

158
Q

IGF-1 raised - how to confirm Acromegaly

A

Oral GTT and GH measurement

159
Q

Blood gas of cushings

A

Excess glucocorticoids ->
-Potassium depletion
-Na and water retention
->Cl excretion

HypoCloraemic metabolic alkalosis

159
Q

Blood gas of cushings

A

Excess glucocorticoids ->
-Potassium depletion
-Na and water retention
->Cl excretion

160
Q

What is the short synacthen test for

A

Cortisol deficiency / adrenal failure

161
Q

No option for overnight dex supression test. Ie want to investigate as OP what test for cushings

A

2x 24hr urinary cortisol

162
Q

Incidental pit adenoma on CT. What is likely by 12 months

A

No change / Sx - 75% of incidental remain unchanged

163
Q

New diagnosis of hypothyroid. How long after starting thyroxine do you need to wait to check levels?

A

1 month

164
Q

Most common cause of Hypothyroid worldwide

A

iodine defiinecy

165
Q

Poor controlled diabetes -> burning / aching / proximal weakness = ? Rx?

A

Diabetic amyotrophy
(Proximal neuropathy, lumbosacral plexopathy)

Improve glycaemic control Eg insulin

166
Q

Diabetes, then develops yellow lesion (usual shin) that grow slowly over years -> may ulcerate =?

A

Necrobiosis lipoidica

167
Q

Breasts and no pubes

A

Androgen insensitivity syndrome

168
Q

Best drug class to protect kidneys with diabetes

A

ACEi

169
Q

Which diabetic drugs promote weight loss? If IBD which needs to be avoided

A

GLP-1 (Glutides)

Liraglutide contra indicated in IBD

170
Q

Gitelman blood gas? Differentiate from barter?

A

Hypokalaemic metabolic alkalosis

Gitelman has low urinary Ca

171
Q

Differentiate MEN and MEN 2 and MEN 2b

A

MEN - Pit

2a - phaeos

2b - marfan

172
Q

Diabetic on metformin
FAT, hypertensive, Prev MI. Which additional agent?

A

SLG-2 inhibitor
-gliflozins
(Good For heart)

then could add a GLP-1 (eg glutide) for weight loss after
GLUTide (glutinous)

173
Q

Obese on gliclazide with shite kidneys. hba1c still high

A

GLP-1
-Eg dulaglutide

174
Q

What is seen in 95% of MEN1 sufferers

A

HyperParathyroidism

175
Q

When to use Throid isotope uptake scanning?

A

Differentiate causes of hyperthyroidism

176
Q

What test to initially assess size of thyroid gland

A

US

CT is used to asses tracheal compression if required

177
Q

HHS what would you expect BM / Bicarb / ketones / pH / serum osmolality to be

A

BM high >30 but likely at least 50
Bicarb <15
Ketones - none / 1+
pH - >7.3
Osmolality high >320

178
Q

What causes thyroid eye disease

A

Glycosaminoglycan (GAG) deposition

[fibroblasts stimulated by anti-TSH antibodies and activated T cells.
->GAG deposits which are hydrophilic and therefore draw in oedema]

179
Q

Dyslipidaemia - what do you always need to exclude

A

Hypothyroidism

180
Q

Sarcoid on steroids. Presents with polyuria/dipsia =

A

Cranial DI
Sarcoid well known cause of cranial DI

181
Q

Why does weight loss cause amenorrhoea? What about low body weight?

A

Weight loss -> increased ghrelin
->Inhibits hypothalamic-pituitary-ovarian axis

Low body weight -> low levels of leptin (stored in fat cells)
Which then also inhibits the axis

182
Q

Skin finding specific to graves ? Pathophysiology?

A

Pre-tibial myxoedema

(due to accumulation of glycosaminoglycans (GAGs)

183
Q

Long term use of what drug may cause PCOS

A

Sodium valproate

184
Q

Diagnosis of PCOS

A

2 out of 3 of:
-US (Ideally transvaginal)
-Clinical/biochem features
-Oligo/ammenorrhea

185
Q

LH/FSH in PCOS

A

LH:FSH ratio is high

186
Q

Best drug for androgenic acne in PCOS

A

Co-cyprindiol
(cyproterone acetate and ethinylestradiol)

187
Q

Stimulate ovulation in PCOS

A

Clomifine

188
Q

Which drug causes euDKA

A

SGLT2 inhibitors
-gliflozins

189
Q

Chemical for pear drop smell in DKA?
Cause of lingering acidosis after 36hrs

A

Acetone

Lingering acidosis: beta-hydroxybutyrate

190
Q

The most important thing for fetal protection and mum with diabetes

A

Tight glucose control

191
Q

amiodarone induced thyrotoxicosis Rx

A

steroids and antithyroid drugs

192
Q

antithyroid drugs in preg

A

propylthiouracil for most

Then switch to carbimazole in late pregnancy to prevent material liver toxicity

[Often can just observe if only minor increase in t4]

193
Q

Squamous cell Ca, narrowed QT on ECG and drowsy

A

Hypercalcaemia (from PTH related peptide)

194
Q

PCOS Levels of:
LH
FSH
Testosterone
Oestradiol

A

LH - high
FSH - normal
Testosterone - high
Oestradiol - normal

195
Q

Normal/Raised TSH with raised t4/t3. Ix needed?

A

MRI pituitary

196
Q

What do you need to replace in turners syndrome

A

Oestrogen

197
Q

Weirdly what can worsen diabetic retinopathy?

A

Rapid improvement in BM control

198
Q

Postpartum thyroiditis antibodies

A

Anti-TPO (same as hashimotos)

199
Q

3 Main enzyme deficiencies in CAH? Which have high androgens? Which causes HTN? Low cortisol?

A

21-hydroxylase
-Raised androgens -> masculinisation and early pubity
-Salt wasting (similar to addisons)

11b-hydroxylase
-Raised androgens
-HTN

17a-hydroxylase
-Low androgens -> ambiguous genitalia / undescended testis
-HTN

ALL 3 get low cortisol

200
Q

When would you be concerned about normal PTH

A

Raised CA - may indicate PT cancer
Or tertiary hyper PTH

201
Q

How does tamoxifen work on oestrogen receptors ?

A

Mixed agonist and antagonist (depending where the receptor is)
it is a selective oestrogen receptor modulator (SERM)

202
Q

When can a diabetic on insulin drive HGV?

A

NO Hypos for 12 months
Or if just started need 3 months of regular BM monitoring

203
Q

What type of renal tubular acidosis do people with autoimmune conditions get?

A

Type 1
(hypokalaemic)

204
Q

Fat and poor controlled diabetes - when can they not get a glp-1 analogue?

A

EGFR <30
(Same for metformin and DPP4 inhibitors)

205
Q

Which is the only DPP4 inhibitor licensed for eGFR <30? [Remeber none of the GLP-1 are allowed either]

A

Linagliptin

206
Q

Fall in whcih hormone leads to endometrial shedding?

A

Progesterone

207
Q

Primary hypertriglyceridaemia has which raised which lipids? Key risk?

A

VDL -> CV risk
If not treated alos high risk of pancreatitis

208
Q

Shortening of 4th/5th metacarpals, short stature. Why seizures? Seen on CT head?

A

Pseudohypoparathyroidism
Low Ca -> seizures
Calcification of basal ganglia

[Will have raised PTH as defect in PTH receptor in bones rather than PTH production

209
Q

Menorrhagia, fat and mildly increased prolactin

A

Hypothyroid

210
Q

Differentiate PCOS and Non-/classical CAH?

A

Both have irregular mentrual cycles, and signs of androgenism with raised testosterone

nc-CAH - raised 17-OH Progesterone
Normal weight

PCOS - usually fat.

Classical CAH presents as salt wasting as a child

211
Q

Gold standard test (not MRI) for panhypopituitarism

A

Insulin stress test
(checks GH and ACTH)

212
Q

Hypokalaemic periodic paralysis defect in wha1?

A

voltage-gated calcium channel
(CACLN1A3)

213
Q

Where secretes melatonin

A

Pineal gland (converts it from serotonin)

214
Q

Sometimes adrenal adenoma can be too small to see on CT? What test can you do to localise it?

A

Bilat adrenal vein blood sampling [for 18-hydroxycoroticosterone]
Can see if levels are 10:1 on one side ->localises tumour

215
Q

Post partum thyroiditis Rx if symptomatic

A

Propranolol and wait it out

216
Q

Hard fibrous thyroid mass causing hypothyroidism

A

Reidels thyroiditis

217
Q

DeQuevirans thyroiditis Rx

A

Propranolol and NSAID

[steroids if above fails]

218
Q

Differentiate first presentation of DKA vs Adisons based on anion gap only

A

Addison has a normal anion gap
DKA has raised (ketones )

219
Q

Features of prolactinoma and acromegaly is what?

A

Acromegaly (30% have raised prolactin as it is a mixed tumour)

220
Q

hypothyroid and cardiac issues

A

Risk of cardiomegaly and effusions / Heart failure

221
Q

Hard rapidly enlarging thyroid mass with lymphadenopathy is likely?

A

Anaplastic thyroid carcinoma

222
Q

Female external genitalia, breasts but no pubs and hernia operation as an infant

A

AIS

223
Q

Most common thyroid Ca ? If the question mentions familial?

A

Papillary

Medullary if familial (MEN2a)

224
Q

Port-wine naevus on face with phaeo?

A

Sturge-weber syndrome

225
Q

Known MEN1 - now new diabetes.
What rash? Why?

A

Necrolytic migratory erythema
Due to glucagonoma

226
Q

How does metformin help in PCOS

A

Increases insulin sensitivity
Including to ovary -> increased chance of ovulation

227
Q

PCOS LH/FSH/prolactin

A

Raised LH:FSH Ratio
Prolactin often mildly raised

228
Q

Hypo with no IV access and reduced GCS? Mechanism and key enzyme?

A

IM Glucagon 1mg
Glycogenolysis in the liver by activating adenylate cyclase

229
Q

Convert 5mg pred to hydrocortisone

A

20mg
Multiple by 4

230
Q

Weight gain, poorly controlled hypertension., HypoK, impaired glucose tolerance 1st line Ix?

A

24hr urinary cortisol

[cushingoid features more prominent than simply conns]

231
Q

Secondary HyperPTH frist line Rx

A

Calcium and vit D
low PO4 diet

232
Q

Hereditary haemochromatosis. When would you use iron chelation?
Rx of erectile dysfunction?

A

Iron chelation if cant tollerate venesection (eg anaemia / cardiac disease)

Erectile dysfunction is due to endocrine dysfunction -> hypogonadotropic gonadism
-> Give testosterone

233
Q

thyrotoxicosis but not graves. What might you find on exam of the eyes

A

Lid retraction
[due to sympathetic hyperactivity]

234
Q

Headaches, collapse, hypotension, partial CNIII palsy

A

Pit apoplexy

[PICA aneurysm usually more unilateral CN III]

235
Q

When is impaired fasting glucose?

A

6-6.9mmol/l

236
Q

Black urine, discolour sclera and cartillage = ? Due to?

A

alkaptonuria
Homogentisic acid oxase deficiency

237
Q

Homocystinuria due to defect in

A

Cistathionine beta synthase

238
Q

BP target post MI? What if diabetes?

A

<140/90
<130/80 if diabetic / albuminuria

239
Q

Sex hormone binding globulin in PCOS?

A

Low due to insulin resistance

240
Q

Hypothyroid on thyroxine. Normal TSH, Low t4 and normal T3. what next

A

Nothing - adequate replacement given normal t3 NA Dtsh

241
Q

What would tertiary hypothyroid look like

A

Low TSH and low T3/4

242
Q

Started oral contraceptive -> rash on the body and some blistering. ANA positive dx?

A

Porphyria cutanea tarda

243
Q

TSH targets following thyroidectomy

A

Supress TSH <0.1 for 12 months

244
Q

Post radioactive iodine Rx women shouldnt get pregant for 6 months - but what else should they avoid

A

Avoid close contact with children or other pregnant women for 10 days

245
Q

MEN 1 parathyroid issue

A

Hyperplasia, not malignancy

246
Q

Hypertension with HypoK and supressed renin and aldosterone =

A

Liddle

247
Q

Which Hyper/hypothyroid for increased prolactin? Decreased Oestrogenisation?

A

Hypothyroid

Hyper

248
Q

Spotty skin pigmentation, Atrial Myexoma and endocrine tumours in?Genetic?

A

Carney complex
[AD chromosome 17]

249
Q

How does levonorgestrel work as morning after pill ?

A

Delays ovulation

250
Q

What is the best dopamine agonist for prolactinomas? What do you do if they become pregnant

A

Carbegoline
Stop it

251
Q

Renal stone, episodes of sweating and palpitations, thyroid nodule. What is next Ix?

A

24hr urinary metanephrines

252
Q

Conns renin aldosterone ratio?

A

Reduced renin. Riased aldosterone [Producing aldoserone

253
Q

Cause of hyperCa in sarcoid?

A

Increased hydroxylation of vit D

254
Q

Most common side effect of HRT

A

Breast tenderness

255
Q

Glucose tolerance test in acromegaly actually measures?

A

75g of glucose - then measure GH level (will remain >1ng/ml)

256
Q

Disseminated TB key endocrine issue

A

Adrenal insufficiency Eg HyperK, weaness, lethargy increased pigmentation…..

257
Q

penumococcal / pseudomonal Sepsis -> HyperK, hypoNa, Hypotension and acidosis?

A

Adrenal insufficiency

Probably due to DIC -> adrenal haemorrhage

258
Q

What haooens to 97% of insulin dependent diabtetsa after 15 years even if thier controll is excellent?

A

Retinopathy

259
Q

Lanreotide does what

A

Stimulates somatostatin receptor

260
Q

Raised TSH with Low end of normal t3/t4 =

A

Su clicnical hypothyroidsim

261
Q

Diabetes + HTN. Acute visual loss in right eye. Fundoscopy shows segmenetal flame haemorrhages in lower quadrant of eye = ?

A

Branch rentinal vein occlusion

-Segmental haemorrhages

262
Q

Rx of solitary papilliary thyroid Ca

A

Near toltal thyroidectomy + radioactive iodine
[then thyroid hormone replacement]

263
Q

Amiodarone induced thyroxicosis Initial Rx if increased uptake and positive antibodies?

What if absent uptake and negative antibodies with destructive thyroiditis?

A

Propylthiouracil
[then add steroids if needed]

Steroids

264
Q

Polyglandular syndrome type 1 what is the most common issue? What is difference with type 2?

A

HypoPTH -> HypoCa
[Adrenal insufficiency, Gonadal failure, Hypothyroid]

Type 2 - dont have HypoPTH
[Do get others above AND T1DM]

265
Q

Charcots foot key Rx

A

Immobilisation of foot

266
Q

Long-standing watery diarrhoea and acidosis. which endocrine issue could cause

A

VIPoma

267
Q

Low Ca, Low Po4, raised ALP =

A

Vit D deficiency

268
Q

Pharmacist with raised T4 and <0.01 TSH with low uptake on thyroid scanning =

A

Thyrotoxicosis fasciata
[She been scranning thyroxine]

269
Q

How long before check HBA1C after 5units blood

A

3 months

270
Q

Stange thing on blood gas of hyperthyroidism

A

Low PCO2

271
Q

Kallman first line Rx ? If wants to have kids?

A

Testosterone patches
Pulsed therapy wihth GnRH analouges

272
Q

1st line Rx of hyperthyroid with solitary nodule (not Ca)

A

Radioiodine if no contraindications
[Surg second line]

273
Q

Known hashimotos, slow incresing size of goitre - which Ca?

A

Lymphoma

274
Q

Thyroid lymphoma Rx

A

Cehmo radio

275
Q

New diabetes, iron deficiency anaemia, weird rash

A

Glucagonoma
[Rash is necrolytic migratory erythema]

276
Q

Bar being marfanoid what is other difference between MEN2a and 2B

A

2a Hyper PTH more likely
2b Phaeos even more common

277
Q

What do bisphosphonates do

A

inhibit osteoclasts

278
Q

Previous cerebellar haemorrhage, bilat renial angiomas

A

VHL
cerebral / retinal issues are presenting feature 40% of time

279
Q

Asthma with exacerbations. Orthostatic hypotension, HypoNa, HyperK, Low 0900 cortisol which rises following synACTH =?

A

Steroid-induced hypoadrenalism

280
Q

Why ammenorhheoa in addisons

A

Get hyperprolactin

281
Q

Surgical cure rate in acromegally if microadeoma / macroadenoma

A

80% micro
40% macro

282
Q

Why hyperprolactin in metoclopramide therapy

A

Binds to D2 receptors in pituitary lactotropes

283
Q

Bopsy of pagets is only way to 100% differentiates from other mixed lytic/slcerotic malignancy - what does it show?

A

Multinucleated osetoclasts

284
Q

HLA DR7

A

minimal change

285
Q

HLA B47

A

CAH

286
Q

HLA A28

A

Schitz

287
Q

What do most autoimmune HLAs start with

A

HLA DR or HLA DQ

288
Q

Turner genetics

A

45X

289
Q

Superior bitemporal quadrantanopia caused by

A

Pit tumour

290
Q

Which of the pyruvate enzymes is inhibited and which is stimulated by insulin?

A

Pyruvate carboxylase - inhibited

Pyruvate dehydrogenase-stimulated

[thing the other dehydrogenase enzymes tend to be stimulated by things being added Eg Adehyde / alcohol dehydrogenase]

291
Q

Which hormone signals epiphyseal fusion and cessation of growth

A

Oestrogen

292
Q

Why glucagon in BB overdose

A

Bypass B receptor and stimulates cAMP -> B stimulation on heart

293
Q

Lasy with reflux oesophagitis who doesn’t want regular injections for osteoporosis can get

A

Denosumab
[IV but only once every 6 months]

294
Q

Testicular feminisation is also called? Chromosomes?
When do they usually present?
What is it biochemically due to?

A

Androgen insensitivity syndrome
46XY but looks female

Usually present with primary ammenhorea in late teens

Due to lack of dihydrotestosterone receptors

295
Q

Addison’s - anti-adrenal antibodies are also called

A

21-hydroxylase antibodies

296
Q

Acromegaly get which Ca

A

Colon

297
Q

Which hormone drives male secondary characteristics

A

Dihydrotestosterone
[testosterone for development of genitalia and spermatogenesis]

298
Q

Test to confirm conns other than hypoK, raised aldosterone and low renin?

A

Saline suppression test

299
Q

Acromegaly first line Rx

A

Transsphenoidal surgery

300
Q

What is testosterone formed from? Oestrogen? Why feminisation in alcoholics and obese?

A

Testosterone formed from cholesterol

Testosterone is converted by aromatase to form oestrogen

Alcohol / obese -> increased aromatase activity = increased oestrogen

301
Q

Glucokinase mutation = MODY?
HNFa
HNFb

A

MODY 2
HNFa - MODY 3
HNFb - MODY 5

Gets worse as prime number increases
Minimal -> symptomatic -> bilat cysts

302
Q

Weight loss, worsening of T2DM control anaemia and rash over groin and lower legs

A

Glucagonoma

303
Q

Antidiabetic which increases risk of foot fractures

A

Canagliflozin
[Calcanius]

304
Q

Male with FSH deficiency and rasied testosterone but reduced sperm count has?

A

Deficiency of androgen binding proteins

305
Q

What type of bone loss in osteoperosis

A

Trabecular

306
Q

Low TSH and T4 key Ix?

A

Pit MRI

307
Q

Significant weight gain, HTN, Hirtuism, abdominal striae… What is most likely

A

Cushings

308
Q

Which drug abuse would mimic barter’s syndrome?
When would this be the answer rather than barter ?

A

Furosemide

if questions mention someone who is not presenting young Ie >25 and may be a pharmacist

309
Q

Which of the GLUT transporter for:
Glucose is taken up into muscle and adipose tissue following insulin stimulation

A

GLUT 4

310
Q

Which of the GLUT transporter for:
non-insulin stimulated uptake of glucose into adipose and muscle

A

GLUT -1

311
Q

Which of the GLUT transporter for:
Glucose uptake into beta-cells (glucose sensing)

A

GLUT - 2

312
Q

Which of the GLUT transporter for:
Non-insulin glucose uptake into neruones

A

Glut -3

313
Q

Exogenous GH does what to GH-deficient. Fat/lean mass? Lipids?

A

Increases lean mass decreases fat mass
No impact on cholesterol / triglycerides

314
Q

Post sub total thyroidectomy - how long is the HypoCa from HypoPTH expected

A

Transient - usually due to devascularisation of one/more of the PTH glands at the time of surgery and will recover
[Though still needs treated in the acute setting]

315
Q

Identical twins - one hasT1M - risk of the other?

A

50%

316
Q

What is the cut-off for urine osmolality for primary polydipsia following the deprivation test

A

> 300 mOsmol/Kg = Psychogenic polydipsia

317
Q

Why sweating in acromegally

A

Sweat gland hyperplasia

MRCP PART 1 (22 decks)

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