Endocrine and general

Question 1

Facial Features of Acromegaly

Answer 1

Prominent supraorbital ridges 
Large nose 
Protrusion of lower jaw (Prognathism)
Deep voice 
Thick lips, Macroglossia
Bitemporal hemianopia

Question 2

Body features of acromegaly

Answer 2

Neck goitre (visceromegaly leading to hyperthyroidism)
Large hands with broad palms
Large feet
Organomegaly

Question 3

Systemic features of acromegaly

Answer 3

Hypertension

DM - glycosuria

Question 4

Most common cause of acromegaly

Answer 4

Growth hormone secreting pituitary adenoma

Question 5

Investigations for acromegaly

Answer 5

Basal IGF1 elevation
Oral glucose tolerance test
MRI pituitary
Other anterior pituitary hormones: any hypothyroidism or secretion of prolactin by adenoma

Question 6

Complications of acromegaly

Answer 6

Disfigurement 
Obstructive sleep apnea (macroglossia)
Hypopitutarism 
Carpal tunnel syndrome 
HT with LVH, DM

Question 7

Management of acromegaly

Answer 7

Transphenoidal surgery to remove pituitary tumor

Dopamine agonist (carbergoline) or HG hormone receptor antagonist (Octreotide)

Question 8

Difference between Acromegaly and Paget’s disease

Answer 8

Acromegaly has soft tissue involvement but Paget only affects bones

Question 9

Features of Atopic eczema

Answer 9

• Dry skin, symmetrical, lichenification and excoriations
• Neck: post-inflammatory hyperpigmentation at sides
• Trunk: patches/ papules with lichenification, excoriation, crusting
• Hand and feet: lichenified papules with pigmentation over finger knuckles, ankles, dorsa of feet and hands
• Painful fissuring and cracking of fingers and palm

Question 10

Causes of Atopic eczema

Answer 10

• Genetic predisposition to hypersensitivity response/ Atopy

Question 11

Ddx of atopic eczema

Answer 11

Contact dermatitis: only at site of irritant contact

Drug eruption: trunk and proximal limbs

Seborrhoeic dermatitis: hairline, eye brows, nasolabial folds, axilla, groin

Psoriasis: well-defined, silver scaling erythematous papules, always at extensor surfaces

Dermatophytosis: annular scaly rash with central clearing

Question 12

Investigations for atopic eczema

Answer 12

Skin patch/ prick test
Skin swab for bacterial culture
Serum IgE

Question 13

Features of Cushing’s syndrome

Cause

Ddx

Answer 13

Moon face, acne, hirsutism
Pigmentation 
Truncal obesity, Buffalo hump, purple striae 
Limb muscle wasting 
Bruising 

Cause: excessive glucocorticoids

Ddx

• Iatrogenic
• ACTH dependent: pituitary adenoma, ectopic ACTH production (e.g. cancer)
• ACTH independent: Adrenal tumors

Question 14

Investigations for Cushing’s syndrome

Answer 14

24 hour urinary free cortisol

Dexamethasone suppression test: Low dose for confirmation of Cushing’s syndrome, high dose for ACTH-dependent Cushing’s syndrome (suppress cortisol and ACTH)

ACTH levels

Corticotrophin releasing factor stimulation test: Pituitary-dependent Cushing’s disease

MRI pituitary and adrenals

Question 15

Complications of Cushing’s syndrome

Answer 15

Hypertension, Diabetes mellitus, Osteoporosis, Immune suppression, Proximal muscle wasting, frequent bruising, Avascular necrosis of hip joint (iatrogenic cause)

Question 16

Management of Cushing’s syndrome

Answer 16

Transphenoidal surgery for pituitary lesion
Control hypercortisolism with Metyrapone and Ketoconazole
Suppress pituitary ACTH secretion with cabergoline and pasireotide

Question 17

Ddx of diabetic retinopathy

Answer 17

Hypertensive retinopathy

Central retinal vein thrombosis:

• Venous dilatation and tortuosity
• Flame-shaped hemorrhage
• Cotton wool spots
• Papilloedema
• Neovascularization

Question 18

Investigations for diabetic retinopathy

Answer 18

Blood glucose, HbA1c
Dipstick for proteinuria
Screen for other diabetic complications

Question 19

Management of diabetic retinopathy

Answer 19

Glucose and BP control

Laser photocoagulation

Vitrectomy

Anti-VEGF against proliferative neovascularization

Question 20

Features of Erythema nodosum

Answer 20

Bilateral, multiple, tender, erythematous subcutaneous nodules
ANTERIOR aspects of legs and knees
Bruise-like, brown patches
+/- Arthalgia at ankle joint

Question 21

Causes of erythema nodosum

Answer 21

TB
Streptococcal infection
Drugs: sulphonamide, oral contraceptives
Sarcoidosis, IBD

Question 22

Ddx of erythema nodosum

Answer 22

Other panniculitis e.g. erythema induratum
Vasculitis e.g. polyarteritis nodosa
Pre-tibial myxedema of Grave’s disease
Superficial thrombophlebitis

Question 23

Features of Grave’s disease

Answer 23

Eyes: Proptosis, lid lag and retraction, periorbital edema, opthalmoplegia

Hands: sweaty, action tremor, palmar erythema

Neck: thyroidectomy scar, goiter moves with swallowing

Limb: Pre-tibial myxedema, proximal myopathy

Heart failure

Question 24

Causes of neck swelling and thyrotoxicosis symptoms

Answer 24

Grave’s disease
Toxic multinodular goiter
Toxic thyroid adenoma
Subacute thyroiditis

Question 25

Investigations for Grave’s disease

Answer 25

Thyroid function test

TSH receptor autoantibodies
Anti-thyroglobulin antibodies
Anti-thyroperoxidase antibodies

Radionucleotide scans

Ultrasound

Question 26

4 stages of hypertensive retinopathy

Answer 26

1: Silver wiring
2: + Arteriovenous nipping
3: + cotton wool spots, flame shaped hemorrhages
4: + papilloedema

Question 27

Causes of secondary hypertension

Answer 27

Renal: chronic renal failure, renal artery stenosis, IgA nephropathy
Vascular: Coarctation of aorta
Metabolic: Cushing’s syndrome, pheochromocytoma
Drugs: mineralocorticoids and glucocorticoids

Question 28

Causes of neck goiter with euthyroid presentation

Answer 28

Controlled Grave’s
Hashimoto’s thyroiditis
Euthyroid goiter