endocrine Flashcards
which T2DM drug can cause UTI?
SGLT-2 inhibitors
canagliflozin, dapagliflozin and empagliflozin.
inhibit Na - Glucose co-transporter 2 in the renal proximal convoluted tubule
increases urinary glucose excretion
can therefore increase UTI
other sfx of SGLT-2 inhibitors? eg?
lose weight
canagliflozin, dapagliflozin and empagliflozin.
DKA - initial tx - very first thing?
IV fluids
what does raised TSH, normal T3,4 mean?
subclinical hypothyroidism
does everyone need managing with subclinical hypothyroidism?
no - nice cks
if older than 80 or asymptomatic then repeat TFTs in 6/12
tx hypothyroidism:
levothyroxine
if hypothyroidism + pregnant - what to do about tx?
increase dose of levothyroxine to 150mg per day
if already on 150mcg then increase by 50%
‘unrecordable’ blood sugar measurement with confusion and abdominal pain could be?
DKA
unrecordable means high not low
mx of DKA: (5 things)
fluid replace with saline IV insulin 0.1u/kg/hr FIXED when glucose<15 -> 5% dextrose given correct hypokalaemia long acting insulin continue, short acting stop
cx of DKA?
gastric stasis VTE arrhythmia due to hyperkalaemia/iatrogenic hypokalaemia cerebral oedema ARDS AKI
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
stop metformin. also drink 3L fluid a day
Grave’s disease triad:
exopthalmos, opthalmoplegia
pretibial myxoedema
clubbing, swelling hands/feet, periosteal new bone formation
tx with propranolol
specific Abs ix for Grave’s?
TSH receptor stimulating antibodies (90%)
anti-thyroid peroxidase antibodies (75%)
commonest type of hypothyroidism?
hashimoto’s thyroiditis
chronic autoimmune thyroiditis
what is hashimoto’s thyroiditis commonly associated with?
other autoimmune conditions - eg T1DM, coeliac, vitiligo
also MALT lymphoma
presentation and ix of hashimoto’s thyroiditis?
CP - hypothyroid sx
goitre, firm, non-tender
ix - anti-thyroid peroxidase (TPO) and anti-thyroglobulin (Tg) Abs
woman with br ca has worsening headaches and seizure - sx control while awaiting imaging?
Dexamethasone to prevent cerebral oedema
what is characterised by extremely high serum PTH with moderately raised serum calcium?
tertiary hyperparathyroidism
who is affected by tertiary hyperparathyroidism?
CKD patients
what commonly causes primary hyperparathyroidism?
benign tumour of parathyroid gland - adenoma
PTH (Elevated)
Ca2+ (Elevated) - mild
Phosphate (Low)
Urine calcium : creatinine clearance ratio > 0.01
primary hyperparathyroidism
PTH (Elevated)
Ca2+ (Low or normal)
Phosphate (Elevated)
Vitamin D levels (Low)
secondary hyperparathyroidism
Ca2+ (Normal or high) PTH (Elevated) Phosphate levels (Decreased or Normal) Vitamin D (Normal or decreased) Alkaline phosphatase (Elevated)
tertiary hyperparathyroidism
what can mimic cushing’s disease?
chronic alcohol excess
how can differentiate between cushing’s and pseudo-cushings?
serum cortisol and dex suppression test both normal in pseudo
hypoglycaemia with impaired GCS mx:
IV glucose with impaired GCS
definitive mx of primary hyperparathyroidism:
total parathyroidectomy
hyperparathyroidism X-Ray changes show:
osteopenia
Asymptomatic patients with an abnormal HbA1c or fasting glucose :
repeat test to confirm dx of diabetes
what tx will a child with Turner’s syndrome receive ?
Growth Hormone tx
commonest cause of thyrotoxicosis in UK?
Grave’s disease
hyperthyroid
45-F -> GP BP 165/95 mmHg. Also reports that she has had some muscle weakness. Bloods show a high aldosterone : renin ratio. CT scan shows bilateral adrenocortical hyperplasia. tx?
What is the most appropriate management plan for this woman?
spironolactone
she has primary hyperaldosteronism (Conn’s)
in elderly lady, what can over correction with levothyroxine cause?
osteoporosis
-> increased bone turnover
AF
acropachy?
dermopathy associated with Graves’ disease. It is characterized by soft-tissue swelling of the hands and clubbing of the fingers.
periosteal new bone formation
most thyroid nodules/cancerous nodules lead to what effect of thyroid?
hypothyroid
lower risk if TSH is low (hyperthyroid)
commonest thyroid cancer?
papillary - best prognosis
follicular
medullary
anaplastic
these are the others
what symptom is a red flag for thyroid ca?
hoarseness
3 conditions which make up MEN 2a?
medullary thyroid ca
phaeo
parathyroid hyperplasia
tender goitre, hyperthyroidism and raised ESR. The globally reduced uptake on technetium thyroid scan is also typical
dx?
subacute thyroiditis
which syndrome causes high LH and low T?
Kleinfelters syndrome
what is the karyotype of Kleinfelters?
XXY
in T1DM what HbA1c target should be used?
48 or 6.5%
what HbA1c needed to consider a second T2DM drug?
58
what cx can thiazides cause?
hypercalcaemia
HHS (hyperosmolar hyperglycaemic state) characterised by 3 things:
severe hyperglycaemia
dehydration and renal failure
mild/absent ketonuria
HHS dx:
- Hypovolaemia
- Marked Hyperglycaemia (>30 mmol/L) without significant ketonaemia or acidosis
- Significantly raised serum osmolarity (> 320 mosmol/kg)
Long term steroid use can cause cushings syndrome, what would this look like on a VBG?
hypokalaemic metabolic alkalosis
due to excess aldosterone which increases acid and K excretion in kidney
addison’s VBG findings:
hyperkalaemic metabolic acidosis
insufficiency of aldosterone which decreases acid secretion in the kidney and leads to the retention of potassium.
first line ix in primary hyperaldosteronism:
plasma aldosterone:renin ratio
Conn’s
A middle-aged male presents to the endocrinology clinic after needing to buy larger shoes and noticing that his hands are enlarging. An MRI brain shows a brain tumour accounting for his symptoms. He is sent for visual field testing.
What is the classical visual field deficit seen in these patients?
bitemporal hemianopia
gliclazide sfx:
hypos
weight gain
presence of which sx differentiates primary and secondary adrenal failure?
skin hyperpigmentation - primary
68-year-old male presents with headache and double vision. On examination you note pigmentation of his skin and a right CN VI palsy. He has a past medical history of a bilateral adrenalectomy 1 year ago for Cushing’s disease. An urgent MRI demonstrates a pituitary tumour that is invading the right cavernous sinus. dx?
Nelson’s syndrome
what is nelsons syndrome?
rapid enlargement of a pituitary corticotroph adenoma (ACTH producing adenoma) that occurs after the removal of both adrenal glands (bilateral adrenalectomy) which is an operation used for Cushing’s syndrome.
3 P’s make up MEN type I?
Parathyroid (95%): hyperparathyroidism due to parathyroid hyperplasia
Pituitary (70%)
Pancreas (50%): e.g. insulinoma, gastrinoma (leading to recurrent peptic ulceration)
Also: adrenal and thyroid
insulinoma: whipple’s triad:
sx hypoglycaemia
BM<2.5
reversibility of sx on administration of glucose
differentiating between insulinoma and abuse of insulin use?
C-peptide production does not fall on exogenous insulin injection in pts with insulinoma
would fall with insulin abuse
how is latent AI diabetes of adulthood (LADA) dx?
Glutamic Acid Decarboxylase (GAD) Autoantibodies
usually evidence of other AI diseases
(T1DM also anti-islet cell, ZnT8)
C-pep low/normal
what happens to periods with either thyroid disease?
hyper - oligo
hypo - menorrhagia
HbA1c underestimates the glucose levels in which condition?
hereditary spherocytosis
also sickle cell, g6pd
what is used as a monitoring tool for levothyroxine tx in hashimotos?
TSH
what is a potentially fatal complication of longstanding undertreated hypothyroidism. It may be precipitated by illness, stress, and certain drugs.?
myxoedema coma
Apart from confusion and hypothermia, patients may have non-pitting periorbital and leg oedema, reduced respiratory drive, pericardial effusions, long QT, anaemia, seizures, and other symptoms of hypothyroidism.
sglt2 sfx:
normoglycaemic ketoacidosis
UTI
risk of LL amputation - skin ulcers
standard hba1c target in type 2?
48
what opthalmological finding in graves disease means severe eye problem?
corneal involvement
The severity of Grave’s eye disease can be graded using the mnemonic NOSPECS
No signs / symptoms
Only signs (e.g: upper lid retraction)
Signs & symptoms (including soft-tissue involvement)
Proptosis
Extra-ocular muscle involvement
Corneal involvement
Sight loss due to optic nerve involvement
how often should t1dm monitor their glucose?
4 - including before each meal and before bed
what 2 things cause 90% of hypercalcaemia cases?
primary hyperparathyroidism
malignancy
others: sarcoid, vit d intox, acromegaly, thyrotoxicosis
Hyponatraemia and hyperkalaemia in a patient with lethargy is highly suggestive of
addisons disease
best test to ix addisons?
short synacthen test
give synthetic ACTH and in Addison’s this doesn’t cause the adrenals to make cortisol cos they’re fucked
Impaired glucose tolerance (IGT) is defined as
fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l
usual first line tx for burning pain in soles of t2dm feet?
amitriptyline
in pt with burning sensation in soles of feet of t2dm and BPH pt, what drug?
pregabalin
amitriptyline will cause urinary retention
hypertension, hypernatraemia, and hypokalemia - indicates?
primary hyperaldosteronism
Trousseau’s sign:
carpal spasm on inflation of BP cuff to pressure above systolic
hypocalcaemia
metabolic alkalosis with high bicarb that also shows hypokalaemia in context of HTN- which syndrome?
conns - hyperaldosteronism
which oral steroid has lowest mineralcorticoid activity?
dexamethasone
can addisons cause collapse? if so why
yes
causes hypos
Pepperpot skull is a characteristic X-ray finding of??
hyperparathyroidism
Consider adding exenatide to metformin and a sulfonylurea if:
BMI >= 35 kg/m² and high weight
BMI<35 and insulin can’t be used
DKA fluids given, what is insulin dose??
0.1 unit/kg/hr
phaeochromocytoma: iX
24h collection metanephrines
phaeochromocytoma symptoms:
hypertension (around 90% of cases, may be sustained) headaches palpitations sweating anxiety
what DM drugs have been linked to necrotising fasciitis of the genitalia or perineum (Fournier’s Gangrene)??
SGLT2is
A 34-year-old female presents with a thyroid nodule. She has a family history of thyroid disease and both her sisters have undergone total thyroidectomies. Her past medical history includes hypertension which has been difficult to manage.
medullary carcinoma
A 52-year-old woman presents with a neck swelling. Her GP reports that her TSH value is low at 0.01 mu/l. A scintigraphy demonstrates a hot nodule.
toxic adenoma
An 18-year-old female presents with 3 nodules in the right lobe of the thyroid. Clinically she is euthyroid and there is associated cervical lymphadenopathy. She has no family history of thyroid disease.
papillary carcinoma
likely to spread to nodes
inheritance of MODY (maturity onset DM of young)?
autosomal dominant
which diuretic can cause gynaecomastia?
spironolactone
other causes - goserelin
commonest effect of radioiodine therapy?
causes hypothyroidism
Thyrotoxicosis with tender goitre =
subacute (De Quervain’s) thyroiditis
also reduced iodine uptake
addisons crisis: mx?
IV hydrocortisone only (not fludro…)
A 19-year-old lady is admitted to ITU with severe meningococcal sepsis. She is on maximal inotropic support and a CT scan of her chest and abdomen is performed. The adrenal glands show evidence of diffuse haemorrhage. dx???
Waterhouse- Friderichsen syndrome
pre-terminal event associated with sepsis and coagulopathy
34-year-old lady is admitted with recurrent episodes of non-specific abdominal pain. On each admission all blood investigations are normal, as are her observations. On this admission a CT scan was performed. This demonstrates a 1.5cm nodule in the right adrenal gland. This is associated with a lipid rich core. Urinary VMA is within normal limits. Other hormonal studies are normal
benign incidental adenoma
MOA orlistat?
pancreatic lipase inhibitor
reduces digestion of fat
should delay insulin tx in adults in DKA?
no - some evidence that in children, waiting 1 hour helps prevent cerebral oedema, no evidence for this in adults
what would acromegaly show on an ECHO?
cardiomyopathy
Left ventricular hypertrophy
what is the most appropriate investigation for patients with increased urinary cortisol and low plasma ACTH levels?
CT adrenals
newly dx T1Dm - first line insulin?
basal-bolus
twice‑daily insulin detemir
what BM measurement is hypoglycaemia?
<3, some say <4 ‘four is the floor’
non-dm causes of hypoglycaemia (EXPLAIN):
Exogenous drugs such alcohol, aspirin poisoning, pentamidine, quinine sulfate, ACE-inhibitor Pituitary insufficiency Liver failure Addison's disease Islet cell tumours eg insulinoma Non-pancreatic neoplasms
if unsure between t1 and t2 dm, what test can help differentiate?
c-peptide
low in t1, n or high in 2
fasting glucose for PRE-dm?
6-7
There is decreased secretion of which hormones in response to major surgery:
insulin
testosterone
oestrogen
DKA abg result?
metabolic acidosis with partial respiratory compensation (low co2) and an increased anion gap
which thyroid ca gives high calcitonin result?
medullary
which thyroid ca causes ‘orphan annie’ eyes on on light microscopy?
papillary
which thyroid ca is thyroglobulin used as a tumour marker?
follicular
when don’t you need a second test to dx DM?
when symptomatic
In toxic multinodular goitre, nuclear scintigraphy reveals??
patchy uptake
Hypothermia, hyporeflexia, bradycardia and seizures, - ??
myxoedemic coma
8 causes of secondary HTN:
phaeo hyperparathyroidism renal artery stenosis renin secreting tumour (secondary hyperaldosteronism) acromegaly cushings hyperaldosteronism CKD hyperthyroidism obstructive sleep apnoea polycystic kidney disease
what is conns syndrome?
primary hyperaldosteronism
renin will be low as suppressed by the high BP
caused by 1. bilateral idiopathic adrenal hyperplasia
2. adrenal adenoma
in tx of hyperaldosteronism what is first line?
surgery first depending on size of nodule
dopamine agonists second line if tiny nodules
symptoms of cushings?
thin skin bruising buffalo hump purple striae DM - resistant HTN - resistant osteoporosis in males menorrhagia prox myopathy moon face
Water deprivation test: primary polydipsia:
urine osmolality after fluid deprivation: high
urine osmolality after desmopressin: high
what is primary polydipsia?
a psychogenic disorder characterised by excessive drinking despite being properly hydrated, hence the patient’s symptoms of polyuria, nocturia and chronic dry mouth. The past medical history of depression is relevant as primary polydipsia is more common in patients with psychiatric disorders
Low urine osmolality after both fluid deprivation and desmopressin is typical of ?
nephrogenic DI
what is nephrogenic DI?
kidneys insensitive to ADH so unable to concentrate urine
caused by CKD, nephrotoxics, metabolic disorders, lithium
Low urine osmolality after fluid deprivation, but high after desmopressin is typical of ?
cranial DI
what is cranial DI?
insufficient ADH release. This lack of ADH results in an inability to concentrate urine even if a patient is hypovolaemic, therefore producing a low urine osmolality even during water deprivation. when ADH given synthetically can concentrate urine tho
which drug can cause neutrophilia?
pred - glucocorticoids
what is known to cause drug-thrombocytopaenia?
furosemide
gold
penicillin
drug causing renal impairment with blood results often showing a raised eosinophils and may show raised neutrophils?
inuprofen, nsaids
Kallman’s syndrome - sex hormones?
FSH, LH low,
testosterone low
no sense of smell late puberty
x-rays demonstrate generalised osteopenia, erosion of the terminal phalyngeal tufts (acro-osteolysis) and sub-periosteal resorption of bone particularly the radial aspects of the 2nd and 3rd middle phalanges. These changes are consistent with>
hyperparathyroidism
myxoedema coma tx?
IV thyroid tx
IVI
IV corticosteroids (HC)
obese T2DM maxed out on metformin - doesn’t want 2nd line DM drug to cause weight gain. HbA1c 59. which drug next?
DPP-4 inhibitor - weight neutral
which DM drugs cause weight gain?
sulfonylureas
pioglitazone
MODA DPP-4-inhibitors? (sitagliptin)
increase levels of incretins (GLP-1 and GIP) by decreasing their peripheral breakdown
thyrotoxicosis mx:
1st line: IV Propranolol
antithyroid therapy with propylthiouracil or carbimazole
then lugols solution 1-4h after
hydrocortisone if storm
difference between thyrotoxicosis and thyroid storm?
Thyroid storm represents the extreme manifestation of thyrotoxicosis as a true endocrine emergency
differentiating graves from other forms of hyperthyroid?
TSH receptor stimulating abs
which syndrome typically presents with proteinuria, hypoalbuminaemia, oedema, and hyperlipidaemia?
nephrotic syndrome
which syndrome typically presents with haematuria, hypertension, oliguria, and azotemia?
nephritic syndrome
what is azotemia?
high urea and high creatinine
high levels of nitrogen in blood due to failed excretion by kidneys
HHS mx:
- Normalise the osmolality (gradually)
- Replace fluid and electrolyte losses
- Normalise blood glucose (gradually)
72M on allopurinol and metformin. 6 months ago gave lifestyle advice re HTN. Now BP is 148>80. mx?
ACE-I
What is the best way that her risk of developing thyroid eye disease can be reduced?
stop smoking
62F comes in with low TSH and low T4 - what type of disease is this and what ix should you do?
secondary hypothyroidism
MRI pituitary gland
U&Es in cushings?
hypokalaemia and hypernatraemia
patient has hyponatraemia
A high urine osmolality and low serum osmolality is characteristic of:
SIADH
Erratic blood glucose control, bloating and vomiting think:
gastroparesis in T1DM
due to neuropathy of the vagus nerve
cardiac cx of thyrotoxicosis?
high output cardiac failure
AF
what should be used to assess for diabetic neuropathy in the feet?
10g monofilament
42F irritability and altered bowel habit. smooth enlargement of the thyroid gland. Low TSH, low T4, normal ESR. dx?
graves
TSH receptor stimulating Abs stim the thyroid to make T4. however, negative feedback loop means TSH low.
gastroparesis mx:
metoclopramide, domperidone, erythromycin - prokinetic agents to help gastric emptying
PHaeochromocytoma - give (tx):
phenozybenzamine (a-blocker) before BBs (propranolol or labetolol)
what is definitive mx of phaeochromocytoma and when?
surgery to remove tumour 10 days after starting alpha blockers
how to tell if poor compliance with levothyroxine?
high TSH normal T4
if take thyroxine again before the blood test then t4 will normalise but tsh takes longer to
primary hypothyroidism: TFTs:
high TSH low T4
acral overgrowth, prognathism and macroglossia on a background of difficulty driving - which condition and which visual field defect?
acromegaly
bitemporal hemianopia
acromegaly blood ix?
IGF-1 level
in addison’s what would you expect a serum ACTH to shhow?
ACTH would be high - PGs are fine. They are trying hard to stimulate the adrenals to make cortisol but adrenals are the problem so they don’t - no negative feedback so ACTH high
What is cushing’s syndrome?
prolonged abnormal elevation of cortisol.
in cushing disease this is due to Pituitary adenoma -> ACTH
which cancer has a paraneoplastic syndrome that causes cushing’s syndrome?
SCLC
cushing’s ix:
- low dose dexamethasone suppression test (1mg)
(positive if cortisol not suppressed) - high dose dex suppression test (8mg)
(low cortisol = cushing’s disease
norm/high cortisol, high ACTH = ectopic ACTH (SCLC)
norm/high cortisol, low ACTH = adrenal adenoma)
if ?cushing’s disease - what ix to confirm -
MRI brain
if cushing’s syndrome from ectopic ACTH - ix to cocnfirm?
chest CT for SCLC
if cushing’s syndrome from adrenal source - ix to confirm?
CT abdo for adrenal adenoma
differentiating between primary and secondary hyperaldosteronism?
renin low primary
renin high secondary
causes of secondary hyperaldosteronism:
Renal artery stenosis
Renal artery obstruction
Heart failure
renin secreting tumour rare
phaechromocytoma - what is it?
tumour of chromaffin cells in adrenals
secretes unregulated and excessive amounts of adrenaline
60-M incidental finding of a mass within the pituitary sella. Subsequent pituitary MRI shows a 1.2cm pituitary lesion that does not compress on the optic nerve and chiasm.Denies having headache or visual field defects. There are no symptoms of acromegaly, Cushing’s disease or hypopituitarism.
No stigmata of Cushing’s disease and acromegaly. He is clinically euthyroid.
What should be done for this patient?
laboratory investigation must be done to determine if it is functional or non-functional - hypersecretion or hypopituitarism
boy with DKA in ED tx with IVI and insulin goes on to have a seizure. why?
cerebral oedema
what is a risk factor for grave’s disease?
smoking
vit d deficiency
female
An 80-year-old woman has a hip fracture. Her calcium is normal. She has never been given a diagnosis of osteoporosis.
mx?
risedronate and calcium supplements
no need for a dexa as post-menopausal woman
A 60-year-old man presents with recurrent renal stones. He is found to have a calcium of 2.72 (elevated) and a PTH of 12 (elevated).
mx?
parathyroidectomy
An 82-year-old woman from a nursing home is admitted to the orthopaedic ward with a hip fracture. She is acutely confused and agitated. Her Calcium is 2.95 (elevated).
mx?
IV fluids
IV bisphosphonate needed if ca > 3
what overdose causes hyperinsulinemia and high C-peptide levels?
sulfonylurea - gliclazide
rare but recognised complication of corticosteroid therapy is -
psychosis
what should insulin-dependent DM’s have for emergencies?
glucagon kit
what can cause a falsely high HbA1c?
splenectomy - increases lifespan of RBCs
also, IDA and b12/folate deficiency
A 43-year-old woman with Addison’s disease presents to the Emergency Department with gastroenteritis. While admitting her to the medical ward, what should you do regarding her steroid replacement?
double hydrocortisone dose
same fludrocortisone dose
first line tx for diabetic neuropathy causing pain. Nil PMH:
duloxetine also amitryptiline, gabapentin, pregabalin 2. if one doesn't work try one of others 3. tramadol rescue tx pain clinic referral if resistant
addisons dosing throughout day?
10mg am 5mg noon 5mg early evening for a 20mg dose hydrocortisone
mimics normal cortisol
why is pioglitazone CI in CCF patients?
can cause fluid retention and is therefore contraindicated in patients with heart failure.
31-year-old woman has been referred to endocrinology complaining of lethargy, weight loss and anorexia. On examination you note patches of depigmented skin on her upper limbs and increased pigmentation in her palmar creases dx?
addison’s disease
Toxic multinodular goitre - tx of choice?
radioactive iodine
DKA resolution is defined as:
pH>7.3, ketones <0.3
PTH levels are raised or ‘inappropriately’ normal in?
primary hyperparathyroidism
myeloma would -> low PTH
74-F 6/12 hx worsening confusion, unintentional weight loss and low back pain. PMH hypothyroidism - levothyroxine. 2/12 ago, investigations under the surgeons due to normocytic anaemia, but no cause was found. Calcium 3.05 mmol/L (2.1-2.6) Phosphate 1.28 mmol/L (0.8-1.4) Vitamin D 53 mmol/L (50-250) PTH 0.8 pmol/L (1.6-6.9) Na+ 143 mmol/L (135 - 145) K+ 4.6 mmol/L (3.5 - 5.0) Urea 11.5 mmol/L (2.0 - 7.0) Creatinine 175 µmol/L (55 - 120) dx?
multiple myeloma
hx of weight loss and bone pain
anaemia+hypercalcaemia+RF
First line treatment for most patients with a pituitary tumour causing acromegaly:
trans-sphenoidal surgery
- somatostatin analogue - octreotide
- GHRA
- RT
serious sfx carbimazole?
agranulocytosis (FBC)
seek medical attention if sx of infection
autoantibodies are useful to distinguish between type 1 and type 2 diabetes?
c-peptide - low in T1
DM specific:
anti-glutamic acid decarboxylase
(80% T1DM have this)
A 25-year-old gentleman is found to have a fracture of the distal scaphoid and a plaster of Paris cast is applied. Which medications will increase the risk of osteonecrosis?
pred - steroids
results establishes a diagnosis of impaired fasting glucose?
fasting glucose 6.1-6.9 on 2 occasions
A 55-year-old man is on the intensive care unit for many months after open aortic surgery. He is maintained on total parenteral nutrition. Clinically he is euthyroid, but his thyroid function tests reveal a low TSH and low T4. dx?
sick euthyroid syndrome
mx: gp recheck tfts 6/52
The patient has been diagnosed with maturity onset diabetes of the young (MODY) - type Hepatic Nuclear Factor 1 Alpha (HNF1A). HNF1A accounts for 70% of MODY cases. tx?
sulfonylureas - gliclazide
A 14-year-old girl sees you in the outpatients department with a variety of troubling symptoms. She has suffered with bullying at school due to facial hair and large stature. She also reports menarche was at 10 years old. You organise some investigations which show; plasma 17-hydroxyprogesterone - 2 mg/l (0.2-1 mg/l) dx?
congenital adrenal hyperplasia
PCOS would cause amenorrhoea not early menarche
In 1ml of (most standard) insulin, how many units?
100
what can reduce the absorption of levothyroxine - ?
iron / calcium carbonate tablets
give 4 hours apart
t1DM and driving:
can drive if have hypo awareness
should inform the DVLA
pathology SIADH? (renals)
increased permeabiblity of collecting ducts to water -> ↑ water reasbsorption -> Dilutional hyponatraemia
DKA pathology?
excessive hyperglycaemia leads to increased lipolysis
3 OTHER causes of high BMs?
corticosteroids
Cushing’s
phaeo
also haemachromatosis, amyloid, CF
high anion gap (MUDPILES):
methanol uraemia DKA Paraldehyde Iron/isoniazid Lactic acidosis Ethylene glycol salicylates
normal anion gap (metabolic acidosis):
diarrhoea CKD, renal tubular acidosis adrenal insufficiency hypoaldosteronism spironolactone, trimethoprim
features of diabetes insipidus?
polydipsia, polyuria, no glycosuria
what is action of ADH?
aquaporins into DCT and leads to loss of sodium and water follows
Thyrotoxic storm is treated with?
BB, propylthiouracil and hydrocortisone
What is the single most useful test for determining the cause of her hypercalcaemia?
PTH - differentiates between HoM and Primary PTH
17-M -> GP not begun puberty. He reports that he has no growth of pubic, facial or underarm hair. He also reports that he has no sense of smell. Small testes and penis. His height is 6 foot 1 inch. dx?
kallman’s
43M -GP tiredness, low mood and unintentional weight gain of 13kg past 4 months. Prior to feeling like this he recalls having a flu-like illness following which he had a two-week period of feeling very anxious, shaky and energetic. He wonders if this is connected. HR 68, bp 147/83 temp 37.1ºC. No goitre or any palpable lymphadenopathy. dx? TSH 6.1 (mildly raised). T4 6 (low)
subacute thyroiditis (de quervain’s)
causes hyper- then hypothyroidism
mx hypercalcaemia:
rehydration 3-4L NS
bisphosphonates
DM drug are associated with an increased risk of bladder cancer?
thiazolidinediones
In type 1 diabetics, blood glucose targets:
5-7 mmol/l on waking and
4-7 mmol/l before meals at other times of the day
glitazone MOA? (pioglitazone)
agonists of PPAR-gamma receptors, reducing peripheral insulin resistance
The most common endogenous cause of Cushing’s syndrome is a ?
PG adenoma - cushings disease
low T3/T4 and normal TSH with acute illness???
sick euthyroid disease
42M -GP feeling generally unwell. 3/12 daily frontal headaches - not helped by paracetamol. Wedding ring no longer fitting, his shoe size increasing and a small amount of milky discharge from both nipples. BP 168/96 mmHg. What is the most likely diagnosis?
acromegaly
30F recent dx Graves, incision and drainage of a pilonidal abscess 3h ago. Agitated, confused and is noted to be jaundiced and sweaty. t 39 oC, hr 152, bp 95/60. ECG shows an irregular ventricular rate with absent p waves. After resuscitation what is the most appropriate next step in management?
BB and thionamides
what should be used first-line for black TD2M patients who are diagnosed with hypertension?
ARB
32M recently emigrated from Nepal. He attends his GP practice with regards to symptoms of weight gain, tiredness and hoarseness of voice. Following blood tests, including a thyroid function test, it is found that he has hypothyroidism. What is the most likely cause of hypothyroidism in this patient?
iodine deficiency
A 52-year-old man presents to his GP as he is concerned about a discharge from his nipples. Which one of the following drugs is most likely to be responsible?
chlorpromazine
What is the most likely explanation for this patient’s impaired hypoglycaemia awareness?
neuropathy in the ANS
long term steroid -bone?
OP, avascular necrosis
