Endocrine and metabolic disorders

Question 1

Hashimoto’s thyroiditis: 3 top clinical signs/findings

Answer 1

Hashimoto’s thyroiditis = hypothyroidism + goitre + anti-TPO

Question 2

The main ECG abnormality seen with hypercalcaemia is

Answer 2

The main ECG abnormality seen with hypercalcaemia is shortening of the QT interval

Question 3

If the blood pressure is >= 180/120 mmHg:
admit for specialist assessment if:

Answer 3

• signs of retinal haemorrhage or papilloedema (accelerated hypertension) or
• life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury

Question 4

Pretibial myxoedema is an uncommon but specific feature in

Answer 4

Pretibial myxoedema is an uncommon but specific feature in Grave’s disease that is not seen in hyperthyroidism secondary to other causes

Question 5

subclinical hypothyrodism definition and management

Answer 5

• subclinical hypothyroidism (very mildly raised TSH but normal T3 and T4)
• watch and wait

Question 6

when do you give IV glucose in hypos?

Answer 6

hospital setting: reduced GCS and already has IV access
100ml of IV glucose 20% STAT

Question 7

clinical picture of hypothyroidism with what appears to be a brief period of hyperthyroidism prior to this. diagnosis ?

Answer 7

most common cause of this is De Quervain’s thyroiditis

Question 8

biochemical abnormality in cushing’s

Answer 8

hypokalaemic metabolic alkalosis

Question 9

Primary hyperaldosteronism: manage with

Answer 9

Primary hyperaldosteronism: manage with spironolactone

Question 10

The Hba1c target for patients on a drug which may cause hypoglycaemia

Answer 10

The Hba1c target for patients on a drug which may cause hypoglycaemia (eg sulfonylurea) is 53 mmol/mol

Question 11

T1DM sick days rules

Answer 11

• if a patient is on insulin, they must not stop it due to the risk of diabetic ketoacidosis
  check blood glucose more frequently, for example, every 1-2 hours including through the night
• consider checking blood or urine ketone levels regularly
  maintain normal meal pattern if possible
• if appetite is reduced meals could be replaced with carbohydrate-containing drinks (such as milk, milkshakes, fruit juices, and sugary drinks)
• aim to drink at least 3 L of fluid (5 pints) a day to prevent dehydration

Question 12

T2DM sick day rules

Answer 12

advise the patient to temporarily stop some oral hypoglycaemics during an acute illness

medication may be restarted once the person is feeling better and eating and drinking for 24-48 hours
* metformin: stop treatment if there is a risk of dehydration, to reduce the risk of lactic acidosis.
* sulfonylureas: may increase the risk of hypoglycaemia
* SGLT-2 inhibitors: check for ketones and stop treatment if acutely unwell and/or at risk of dehydration, due to the risk of euglycaemic DKA
* GLP-1 receptor agonists: stop treatment if there is a risk of dehydration, to reduce the risk of AKI

if on insulin therapy, do not stop treatment
monitor blood glucose more frequently as necessary

Question 13

In the primary prevention of CVD using statins aim for a reduction in non-HDL cholesterol of…

Answer 13

In the primary prevention of CVD using statins aim for a reduction in non-HDL cholesterol of > 40%
(4.2 value usually)

Question 14

A 72-year-old female known to have osteoporosis is started on alendronate. Which one of the following side-effects is it most important to warn her about?

Answer 14

Heartburn
Bisphosphonates can cause a variety of oesophageal problems

Question 15

Diabetic ketoacidosis: the IV insulin infusion should be started at which rate?

Answer 15

0.1 unit/kg/hour

Question 16

Use of 0.9% Sodium Chloride for fluid therapy in patients requiring large volumes = risk of

Answer 16

Use of 0.9% Sodium Chloride for fluid therapy in patients requiring large volumes = risk of hyperchloraemic metabolic acidosis

Question 17

patient taking prednisolone for over 3 months, what is the most appropriate action regarding the increased risk of developing osteoporosis?

Answer 17

Bone protection for patients who are going to take long-term steroids should start immediately
Alendronate first line

Question 19

subclinical hyperthyrodism definition

Answer 19

• normal serum free thyroxine and triiodothyronine levels
• with a thyroid stimulating hormone (TSH) below normal range (usually < 0.1 mu/l)

Question 20

subclinical hyperthyroidism causes

Answer 20

• multinodular goitre, particularly in elderly females
• excessive thyroxine may give a similar biochemical picture

Question 21

subclinical hyperthyroidism complications

Answer 21

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

Question 22

subclinical hyperthyroidism management

Answer 22

• TSH levels often revert to normal - therefore levels must be persistently low to warrant intervention
• a reasonable treatment option is a therapeutic trial of low-dose antithyroid agents for approximately 6 months in an effort to induce a remission

Question 23

Addison’s: how is the hydrocortisone split

Answer 23

Addison’s: the hydrocortisone dose is split with the majority given in the first half of the day

Question 24

Features of an addisonian crisis:

Answer 24

Features of an addisonian crisis:
Hyponatraemia
Hyperkalaemia
Hypoglycaemia

scenario where they forgot to double steroid dose pre/post-op

Question 25

Primary hyperaldosteronism can present with

Answer 25

Primary hyperaldosteronism can present with hypertension, hypernatraemia, and hypokalemia

Question 26

osteoporosis risk factors

Answer 26

Question 27

It is important to look for precipitants of HHS. Precipitants include:

Answer 27

New diagnosis of type 2 diabetes
Infection
High dose steroids
Myocardial infarction
Vomiting
Stroke
Thromboembolism
Poor treatment compliance

Question 28

The mortality of HHS occurs from complications of the hyperosmolar state:

Answer 28

rhabdomyolysis
venous thromboembolism
lactic acidosis hypertriglyceridaemia
renal failure
stroke
cerebral oedema.

Question 29

HHS is characterised by: (3 top features)

Answer 29

1.) Severe hyperglycaemia
2.) Dehydration and renal failure
3.) Mild/absent ketonuria

Question 30

Osteoporosis in a man - check

Answer 30

Osteoporosis in a man - check testosterone

Question 31

osteoporosis blood test results

Answer 31

Osteoporosis is commonly associated with normal blood test values (e.g. normal ALP, normal calcium, normal phosphate, normal PTH)

Question 32

first-line management in patients with hypercalcaemia

Answer 32

IV fluid therapy is the first-line management in patients with hypercalcaemia

Question 33

Non-functioning pituitary tumours present with

Answer 33

Pituitary adenomas are a type of brain tumour that commonly occurs in people aged 30-50. 15% are non-functioning, and thus present with hypopituitarism and mass effect symptoms, such as postural headache and visual loss.

Question 34

Metabolic alkalosis + hypokalaemia →

Answer 34

Metabolic alkalosis + hypokalaemia → ?prolonged vomiting