Endocrine

Question 1

3 causes of osteomalacia

Answer 1

1. Unavailability of vitamin D - malabsorption (coeliac disease, pancreatic insufficiency, cirrhosis), abnormal metabolism (CKD, pseudohypoparathyroidism), decreased vit D bioavailability (inadequate sunlight, nephrotic syndrome, PD)
2. Phosphate unavailability caused by phosphate binding antacids, tumour induced osteomalacia, hereditary hypophosphotaemia
3. NAGMA eg distal RTA

Question 2

Indications for BMD assay

Answer 2

1. Fracture following minimal trauma
2. All women >65, men >70
3. Monitoring of bone loss after prolonged steroid use or as a result of hypogonadism
4. Monitoring of bone loss in primary hyperthyroidism, cirrhosis, CKD, crohns disease, known malabsorption, RA
5. Measurement of BMD 12 months after change in treatment for osteoporosis
6. Monitoring of known low BMD after at least 1 year

Question 3

Treatment of osteoporosis

Answer 3

1. Consumption of 1.2-1.5g calcium/day in adults above age 65 (calcium bsorption decreases with age)
2. Vitamin D supplementation
3. Cease smoking, avoid excess alcohol consumption
4. Regular weight bearing exercise, consider hip protector
5. Bisphosphonates - reduces risk of fracture for post menopausal women with osteoporosis by 50%
6. SERM such as raloxifene reduces risk of spine fractures and breast Ca but increases the risk of DVT
7. Teriparatide
8. Denosumab - RANKL mab

Also, consider androgen replacement in men with osteoporosis and androgen deficiency

Question 4

How would you manage this patient’s osteoporosis?

Answer 4

Firstly, I would like to explore for any underlying reversible causes:

1. Hyperthyroidism
2. Hyperparathyroidism (sx of hypercalcaemia)
3. Hypogonadism
4. Drug intake (steroids, methotrexate, azathioprine, carbamazepine etc)
5. Myeloma (ask about CRAB)

Then I would like to explore the exacerbating causes:

1. Calcium intake
2. Sun exposure
3. Assessment of falls risk - visual acuity, home situation, rugs, bathroom etc

Then finally, possible therapeutic interventions

1. Reflux disease?
2. Dental health
3. IV vs oral bisphosphonates?
4. Vit D?
5. Balance/strength exercises

Question 5

How are you going to manage this patient’s diabetic foot?

Answer 5

First of all, I would like to assess its risk by checking for:

1. Peripheral neuropathy
2. PVD
3. History of previous ulcerations
4. Presence of foot deformity
5. Glycaemic control to date
6. Low SES
7. ?previous foot care education

If low risk - annual review using monofilament and general foot care adn advice

At risk foot (neuropathy, PVD etc):

1. Daily inspection
2. Adequate daily moisturizing
3. Well fitted shoes
4. Regular podiatry care
5. Avoid barefoot walking
6. Avoid stepping into bath without testing temperature
7. Cotton loose fitting socks

If ulcers are already present:

1. Debridement/local wound care/relief of pressure
2. Check for bone involvement (bone seen or easily probed?)
3. MRI or bone scan (only really good if negative)