Endocrine Long Case

Question 1

Osteoporosis

Answer 1

1. Diagnosis
2. Risk factors
   - menopause
   - steroids
   - malnutrition
   - endocrine dx (hypogonadism, hyperthyroidism, Cushing’s)
   - bone marrow dx
   - connective tissue dx (RA, Marfans)
3. Presentation
   - history of fractures (fragility)
   - complications of fractures
   - falls risk
4. Investigations
   - vitamin D
   - UEC
   - calcium, phosphate
   - ALP
   - PTH
   - XRAY lumbar spine
   - Bone density
   - secondary causes - CKD, TSH, myeloma, coeliac
   - bone turnover markers
5. Management
   - correct contributing factors
   - lifestyle
   - weight bearing exercise
   - falls prevention
   - vitamin D
   - calcium
   - bisphosphonates
   - denosumab
   - teriparatide
6. Complications
   - side effects of therapy - atypical femoral fractures, ONJ, hypocalcaemia, GORD
7. Outlook
   - function

Question 2

Hypercalcaemia

Answer 2

1. Risk factors/aetiology
   - hyperparathyroidism
   - malignancy
   - immobility
   - medication - thiazides/lithium
   - hyperthyroidism
   - CKD
   - family history of FHH/MEN
2. Presentation
   - constipation, polydipsia, polyuria, confusion, renal calculi, pseudogout
3. Investigations
   - PTH
   - low PTH - SPEP, PTHrP, CXR, 1,25-OH Vit D, bone scan
4. Management
   - treat cause - PTHectomy
   - hydration
   - IV zoledronic acid
   - IV calcitonin (transient)

Question 3

Paget’s disease

Answer 3

1. Risk factors
2. Presentation
   - bony pain
   - hypercalcaemia
   - pathological fractures
   - neurological
   - heart failure
3. Investigations
   - raised ALP, bone turnover
   - Calcium
   - Bone scan
4. Management
   - pain management
   - bisphosphonates
   - calcitonin
   - surgery
5. Complications
6. Outlook
   - function

Question 4

Acromegaly

Answer 4

1. Risk factors
   - MEN1
2. Presentation
   - acral enlargement
   - OSA
   - cardiac failure
   - diabetes mellitus
   - pituitary macro adenoma
   - sweating
   - hypogonadism
   - peripheral neuropathy
3. Investigations
   - IGF-1
   - OGTT
   - pituitary profile (cortisol, testosterone, LH/FSH, prolactin, TSH)
   - MRI pituitary
4. Management
   - transphenoidal pituitary surgery
   - radiotherapy
   - octreotide
   - cabergoline
5. Complications
   - cardiovascular - TTE
   - CRC - colonoscopy
   - thyroid - TSH
   - metabolic - HbA1c, lipids, BP
   - carpal tunnel/arthropathy
6. Outlook

Question 5

Diabetes Mellitus

Answer 5

1. Diagnosis
   - type 1 or 2
   - IAA, IA-2, ZnT8, GAD
2. Risk factors
   - MODY
   - Chronic pancreatitis
   - Haemochromatosis
   - Steroids, tacrolimus
   - Olanzapine
   - Pregnancy
   - Acromegaly
   - Cushing’s
   - Phaeochromocytoma
   - family history
   - metabolic syndrome
3. Presentation
   - progress of disease
   - control adequacy
   - hyperglycaemic episodes
   - hypoglycaemic episodes
   - action plan
4. Investigations
   - HbA1c
5. Management
   - diet
   - weight
   - carbohydrate counting
   - oral hypoglycaemics
   - insulin + technique
6. Complications
   - microvascular
   - microvascular
7. Outlook