Endocrine/Metabolic

Question 1

T score values for osteoporosis?

5 answers

Answer 1

-1 and over = normal

-1 to -2.5 = osteopenia

-2.5 or lower = osteoporosis

if aged >50 + Min.Trauma# (not vertebra or hip) + T score <-1.5 then = osteoporosis

If age >50 and min.trauma# at vertebra or hip = osteoporosis

Question 2

Pros/Cons of bisphosphonates

Answer 2

Pros
Low Cost,
Oral Dose,
Longer half life (so can be stopped and still have effect)

Cons
GI upset
absorption affected by food
Can’t be used in severe CKD
Short lasting myalgia

Question 3

Denusomab dose?

Answer 3

Denosumab 60mg SubCut 6 monthly

Question 4

Pros/Cons of Denusomab?

3 pros and 5 cons

Answer 4

Pros
Avoids GI upset
No renal adjustment
6 Monthly

Cons
STRICTLY 6 monthly
Therapy is indefinite
Withdrawal > 4 weeks can lead to spontaneous vertebral fractures
MAY cause hypocalcemia with CKD
Osteonecrosis of the jaw

Question 5

When do you stop bisphosphonate therapy

Answer 5

5 years after oral versions
-continue for 10 years however in those at high risk of MT#

3 years after IV bisphosphonate
- continue for 6 if high MT# risk

Question 6

When do you start assessing for osteoporosis?

And when do you start scanning (rebatable)?

Answer 6

Assess women > 45 and men > 55
For MT# or other conditions that effect BMD

Scan when
If W>45 or M>50 has a Minimal trauma fracture then scan

If W> 45 or M> 50 with any of the following: RA, premature menopause, hypogonadism, hyperthyrodism, hyperparathyroidsim, CKD, coeliac/malabsorption, taking glucocorticoids (>3 months dosed over 7.5mg), anti androgen therapy, then also scan and qualify for rebate.

If M or W over 70 years old then scan (DXA)

Question 7

What are the TSH targets in thyroxine replacement?

Answer 7

< 60 years old TSH target is between 0.5-2.5 milliunits/L

Between 60-80 years old TSH target is 1-5 milliunits/L

Over 80 years old TSG target is 4-6 milliunits/L

Question 8

General advice to give patients taking thyroxine replacement?

4 answers

Answer 8

1. To take thyroxine on an empty stomach, 30-60 minutes before breakfast OR 3 hours after evening meal
2. To avoid taking it with supplements that reduce absorption: iron, calcium
3. Patient will need long term bloods done to allow for dose titration
4. Warn of symptoms of hyperthyroidism as this indicates a dose reduction may be needed

Question 9

Simple Steps to investigate Hyperthyroidism?

Answer 9

1. TSH
2. Symptomatic treatment with betablocker
3. Retest TSH in 6-8 weeks
4. If still hyperthyroid test for TSH-R
5. Refer
6. Treat

Question 10

Treatment for severe symptoms of PRIMARY hyperthyroidism

list 3 symptoms

Give 1 example of dosing instructions

Answer 10

Symptoms include weight loss, AF, myopathy, heart failure

Carbimazole 30-45mg, orally, daily but divided into two or three doses.
Review with bloods and adjust every 4-6 weeks

or
propylthiouracil 300-450mg daily in 2-3 divided doses. Also adjust 4-6 weekly

Question 11

Treatment for milder symptoms in PRIMARY hyperthyroidism?

Answer 11

Carbimazole 10-20mg, orally, daily in 2-3 divided doses. Adjust 4-6 weekly

PTU 100-200mg PO daily in 2-3 divided doses. Adjust 4-6 weekly

Question 12

After remission of thyrotoxicosis with hyperthyroidism, what is the recommended follow up?

Answer 12

testing should be done every 3-4 months for the first year then annually for 5 years.

(If lifelong antithyroid medication is needed, 3-4 monthly testing is needed initially then 6 monthly thereafter)

Question 13

During a thyroid storm, what are the management priorities and what may you use to address these ?

5 answers

Answer 13

1. stopping thyroid hormone synthesis (with carbimazole)
2. decreasing t4–>t3 conversion (with IV dexamethasone)
3. Restoring hydration (IV fluids)
4. Controlling tachycardia (beta blocker)
5. Sedation if needed

Question 14

What to check for on examination of a Goitre?

4 answers

Answer 14

1. Size/shape and consistency of the goitre
2. Presence and amount of nodules
3. Enlarged lymph nodes
4. Pemberton’s sign

Question 15

If there is a Goitre with a Low TSH, which Imaging should be considered?

Answer 15

Radionucleotide scan and U/S. irrespective of remaining serology.

Question 16

What are signs and symptoms of Hereditary Haemochromatosis?

(7)

Answer 16

1. Loss of libido
2. Joint Aches
3. Abdominal pain
4. Weight loss
5. Tiredness/lethargy
6. Polyuria, polydipsia
7. Chest pain, SOB, palpitations

Question 17

Name three pieces of advise with regards to management of HH?

Answer 17

1. Will require therapeutic venesections if iron overloaded
2. Will require regular Iron studies. Depends on ferritin level how often this is.
3. Will need a specialist referral if ferritin is over 1000ul/L
4. If found to have haemochromatosis, should offer to test family members

Question 18

What tests should you order for an INCIDENTAL adrenal lesion?

Answer 18

1mg overnight dexamethasone suppression test

Aldosterone: Renin ratio

Plasma metanephrines

(Non Contrast Adrenal CT, if for some reason lesion found on a CTPA)

Question 19

Signs and Symptoms of pheochromacytoma?

Answer 19

Flushing
Sweating
Palpitations
Sense of doom
Tremor
Headache
Anxiety
Constipation
Weight loss

Question 20

Common causes of HYPOphoshpataemia ?

4 broad groups

Answer 20

1. Redistribution form extracellular fluid to intracellular.
   (glucose IV infusions, diabetic ketoacidosis, acute respiratory alkalosis, refeeding syndrome)
2. Poor intestinal absorption
   usually from phosphate binders. E.g. antacids.
3. Increased kidney excretion
   (primary hyperparathyroid, PTH related protein dependent hypercalcaemia of malignancy, Intrinsic renal disease -Fanconi syndrome, Drugs: alcohol, heavy metals)
4. Extra-renal removal
   Haemodialysis.
5. Also from IV iron transfusion with carboxymaltose
6. Alcoholism via multiple mechanisms: poor intake, increased GIT losses, magnesium depletion.

Question 21

Why does an iron infusion cause low phosphate?

Which formulation is worst?

Answer 21

Occurs mainly with iron carboxymaltose.

There is inhibition of a fibroblast growth factor- a hormone that regulates phosphate metabolism, and is produced by osteoblasts/casts.
Inhibition of it reduced PCT reabsorption.

Somehow iron infusions also inhibit 1-a-hydrolyase –> low vitamin D and then low intestinal absorption of phosphate

Question 22

What investigations to order for hypophospatemia?

(5)

Answer 22

1. fractional excretion of phosphate (Figure 1)
2. parathyroid hormone
3. serum corrected calcium
4. 1,25-dihydroxyvitamin D3
5. 25-hydroxyvitamin D.

Question 23

What does phosphate do in the body?
What are the symptoms of LOW phosphate?

Answer 23

Plays a key role in energy storage, metabolism and signalling within the cell through phosphorylation.

So it ends up affected multiple organ systems:
mild irritability, paraesthesia and muscle weakness, to more severe manifestations such as haemolytic anaemia, severe infection, delirium, generalised seizures, cardiac arrythmias, cardiomyopathy, respiratory failure and coma.

Question 24

Replacement of phosphate can occur simply by oral replacement if levels > 0.3.
If severe <0.3 then IV replacement should be used,

What are the things to watch for with IV phosphate replacement?

Answer 24

1. Hypocalcemia and the resultant cardiac arrhythmia that could occur.
2. Kidney injury - heterotopic calcification - bone growing where it shouldn’t! like in the kidney!
3. Vitamin D deficiency- replace as needed as this can help with phosphate levels. Can have cholecalciferol or calcitriol.

Question 25

What are the causes for HYPERcalcemia? What is the main cause?

Answer 25

1. the main cause is hyperparathyroidism 2. Cancer (from PTHrP related cancers) 3. Medications 4. Taking too much calcium in supplements 5. Too much vitamin D 6. Hyperthyroidism

Question 26

What is the process of investigation once you find a raised Calcium?

Answer 26

Usually start by checking serum albumin or serum ionised calcium Next is PTH If that is high well.. you have an answer If PTH is Low, test PTH-related protein in the plasma (PTHrP) --> if PTH related protein high then indicates cancers like Renal carcinomas, leukemias, lymphomas, and rhabdomyosarcoma. --> if PTHrP is low then test for Vitamin D (see flow chart)

Question 27

Primary hyperparathyroidism is usually caused by a single parathyroid adenoma. When is non-surgical, expectant management appropriate?

Answer 27

In patients aged 50 and older a watch and wait approach can be appropriate IF all the following are met: 1. serum calcium corrected for albumin remains lower than 2.9 2. There is normal renal function 3. there is no nephrolithiasis or nephrocalcinosis 4. BMD higher than -2.5 5. no symptoms Monitor every 6-12 months with serum calcium and renal function BMD every 2 years

Question 28

What should people with primary hyperparathyroidism be doing / not doing? (3)

Answer 28

1. avoid high calcium intake (from diet or supps) 2. limit vitamin D intake as this can cause increased calcium levels . no more than the normal 1000IU/day 3. Drink plenty of water- high water intake of 2.5 L a day, unless contraindicated for other reasons

Question 29

What does a high PTH do to calcium and phosphate?

Answer 29

Increases Calcium resorption from bone This also increases phosphate resorption from bone PTH will increase Calcium reabsorption from the kidneys BUT promotes Phosphate excretion hence this can all lead to hypercalcemia and hypophosphatemia

Question 30

What are the three clinical types of hyponatramia worth classifying into?

Answer 30

Hypovolemic- usually due to GI losses Euvolemic- SIADH, medications, hypothyroidism, primary polydipsia Hypervolemic - usually cardiac or renal, maybe liver failure

Question 31

What are medications that can cause hyponatraemia?

Answer 31

CAR DISH Chemo ANTI drugs (antidepressants, antipsychotics, anti-inflammatories exp COX2) Recreational drugs like ecstasy Diuretics Inhibitors (SSRIs, ACEi) Sulfonylureas Hormones (desmopressin) and Hyponotics (temazepam)

Question 32

what is the definition of SIADH? (5)

Answer 32

Serum osmolality < 275 Urine osmolality > 100 Euvolemia increased urine sodium > 20mmol/L no other cause of hyponatraemia (medications, hypothyroidism, cortisol deficiency, marked hyperproteinaemia, hyperlipidemia)

Question 33

How to you assess someone as being euvolemic when working up for SIADH? (5)

Answer 33

Make sure these are normal to conclude euvolemia -Pulse -Blood pressure -Hydration status -no Peripheral oedema -no Pulmonary crackles

Question 34

When suspecting SIADH what investigations might you order?

Answer 34

obvious biochem serum osmolality urine osmolality TFTs Cortisol level, renin or ACTH or Short synacthen (if addison disease) CT brain for neurological disease causes of SIADH Chest XRAY for pulmonary causes

Question 35

when should someone be sent to hospital for SIADH?

Answer 35

1. if symptoms < 48 hours 2. If severe symptoms 3. if serum sodium < 120mmol/L and symptomatic

Question 36

For an asymptomatic person with a sodium level of 125mmol/L what can be done?

Answer 36

patient does not need E.D Order investigations: CT/CXR Place on fluid restriction 800/1200ml / day

Question 37

What components make up the AUSDRISK score?

Answer 37

Age Gender Vegetabe intake Waist Circumference Hypertension Smoking Physical activity Ethnicity (indigenous) Previous high glucose reading Place of birth

Question 38

Which people are immediately at high risk of T2DM, without the need for the AUSDRISK calculation?

Answer 38

if over 40 AND diabetic anyone with IFG and IGT first degree relative with Diabetes all patients with a history of a Cardiovascular event High risk ethnic backgrounds (PI, indian subcontinent) History of Gestational Diabetes PCOS Taking anti-psychotics ABTSI

Question 39

Who do you and how do you screen for T2DM?

Answer 39

EVERYONE from age 40 ABTSI from age 18. Using the AUSDRISK score. A score of 12 or more is considered high risk- start testing.

Question 40

What lab values would be very much straight away give you a diagnosis of T2DM? Do you need to repeat the test?

Answer 40

Fasting BGL > 7.0mmol/L Random BGL > 11.1mmol/L HBA1c > 6.5 mmol/L (to confirm, repeat test, but use the same test and the same lab. Except if you used a random blood glucose, repeat with a FASTING BGL) If patient is symptomatic and has abnormal result there is no need to repeat the test.

Question 41

Symptoms that suggest diabetes?

Answer 41

Tiredness Polyuria Polydipsia Poor wound healing Frequent bacterial or fungal infections Blurred visions Loss of sensation Malaise Sexual dysfunction

Question 42

What are key steps in addressing management for effective diabetes care?

Answer 42

1. Patient education. provide initial information and resources such as NDSS, Diabetes Australia 2. Patient centred care. Holistic approach that takes into account patient values and socioeconomic factors 3. Emphasis on self management 4. Involvement of other care providers/multi disciplinary approach: pharmacy, podiatry, optometry, endocrinologist if needed. 5. Managing other cardiovascular risks: smoking, BP, cholesterol, diet, exercise

Question 43

What should be done at least every 6 months of a Diabetes cycle of care?

Answer 43

BP Height, weight BMI Feet check

Question 44

What should be done every 12 months as part of a diabetes Cycle of care?

Answer 44

Medication check Diet, physical activity, smoking check Assess control with HBA1c Cholesterol check Assess for albuminuria Review and discuss complications

Question 45

What should be done at least every 2 years on a Diabetes TCA?

Answer 45

eye check, more frequent if extensive diabetic retinopathy

Question 46

How often should BGL/HBA1c be checked initially?

Answer 46

every 3 months, then eventually annually.

Question 47

What can cause an abnormally low HBA1c?

Answer 47

Anaemia Chronic Blood loss Haemoglobulinopathies Chronic renal failure (variable) Recovery from acute blood loss Haemolytic anaemia

Question 48

What are non insulin medication options for T2DM?

Answer 48

Metformin Sulfonylureas SGLT2i GLP1-RA DDP4i

Question 49

If starting insulin what is the TOTAL insulin that should be needed?

Answer 49

0.6mg/kg (basal and bolus or any combination)

Question 50

When should you consider endocrinology referral for a person with t2DM?

Answer 50

If early onset (<40) No adequate response with medication Multiple co-morbidities especially CKD

Question 51

What are the main conditions that can affect the adrenal gland? (5)

Answer 51

Addison Disease - Adrenal Insufficiency Cushing Syndrome - Too much corticosteroids (not always due to a disease) Conn Syndrome - HYPERaldosteronism Pheochromocytoma Pituitary tumours

Question 52

What are corticosteroids?

Answer 52

This is either aldosterone (a mineralocorticoid) or Cortisol (glucocorticoid). Androgens are not usually classed as corticosteroids.

Question 53

__a____ affects __b__ to ___% of people with hypertension. With this condition you will see a high __c___ and a low __d___ on serology. However a normal __d___ does not rule out ____a____

Answer 53

a. Primary Hyperaldosteronism b. 5-10% c. high Sodium d. (low) potassium

Question 53

Sympathetic (catecholaminergic) mechanisms provide short-term, rapid changes in response to perturbations in __a__, whereas the HPA axis (via elevations in cortisol) provides a __b__ mechanism that allows continued resistance to homeostatic perturbations.

Answer 53

a. homeostasis b. longer term

Question 54

investigations for CONN syndrome to diagnose. how can you remember what Conn syndrome does to the sodium and potassium?

Answer 54

this is Primary Hyperaldosteronism Aldosterone-renin ratio Conn- cons you off potassium. so low potassium and high sodium.

Question 55

Why do you order a renin level when suspecting Addison's disease/Adrenal insufficiency?

Answer 55

Because there isn't enough hormonal signalling by the adrenal to raise the blood pressure, the renin system is trying to activate aldosterone to retain salt and therefore water and by extension pressure. Expect the renin level to be raised

Question 56

What are features of Addison's Disease?

Answer 56

Fatigue, anorexia and weight loss, postural hypotension, and skin and mucosal hyperpigmentation

Question 57

What do you expect to happen with sodium and potassium in primary hyperaldosteronism vs. primary adrenal insufficiency?

Answer 57

In primary hyperaldosteronism (Conn's syndrome). there is a decreased K+ and increased Na+ expected. Get conned of your potassium. In primary adrenal insufficiency you can expect Higher potassium and low Sodium. Addison's ADDS potassium

Question 58

The symptoms of 1.sweating 2. episodic headache and 3. tachycardia make up the triad for which adrenal disease. Despite it being present only 25% of the time.

Answer 58

Pheochromocytoma

Question 59

How do you investigate pheochromocytoma initially?

Answer 59

Plasma metanephrines or 24 hour urine metanephrine

Question 60

When administered a synacthen test and the subsequent level is raised, what does this indicate? And what is the name of the chemical we are measuring?

Answer 60

Indicates normal result. We are measuring the cortisol response to synacthen (which is essentially ACTH) IF there was NO response to synacthen, i.e. cortisol level DID NOT rise, it would indicate adrenal insufficiency.

Question 61

What is the difference between Cushing disease and Cushing Syndrome?

Answer 61

Both end points are a raised/too much cortisol Cushing Disease is specifically a pituitary adenoma Cushing syndrome is anything else that causes a raised cortisol exogenous drugs ACTH pituitary tumour ACTH ectopic tumour Adrenal specific cortisol producing tumour

Question 62

What investigation would you use to help diagnose Cushing Syndrome?

Answer 62

1mg overnight Dexamethasone suppression test or Midnight salivary cortisol measured twice or 24 hour urinary free cortisol collection

Question 63

Characteristics of cushing syndrome?

Answer 63

Question 64

What do you expect of Na and K+ in Cushing syndrome?

Answer 64

The coritsol takes over the aldosterone. Causes sodium retention and potassium excretion (hypokalemia)

Question 65

6 main causes for hyperkalemia?

Answer 65

Psuedohyperkalemia (e.g. haemolysed RBC) Acute renal failure Rhabdomyolysis or crush injury Diabetes Mellitus Drugs; ACEi, spironolactone, ARBs, NSAIDs Adrenal insufficiency (Addison's Disease)

Question 66

What is the test for Addison's disease or Adrenal insufficiency?

Answer 66

Short Synacthen test - this is ACTH, so should produce a rise in cortisol, but if it doesn't then it's addison's disease. Renin level - should be raised. trying to get aldosterone going.

Question 67

Causes for hyperphosphatemia? List 4

Answer 67

Artefact HypoPARAthyroidism Vitamin D excess Cell leakage e.g. tumour lysis syndrome Renal failure (though rare) Medications: phosphate containing laxatives

Question 68

What main investigation should you order when suspected hypercalcemia?

Answer 68

PTH as that is the most common cause

Question 69

What does hyperparathyroidism do to calcium and phosphate?

Answer 69

Increases serum calcium but decreases serum phosphate. Even though there is more phosphate released from bones, there is much less getting reabsorbed from the kidneys

Question 70

Main causes for HYPOcalcemia? (5)

Answer 70

Low albumin (check corrected calcium) Renal failure Hypoparathyroidism (?post surgery, also causing hypomagnesiemia) Vitamin D deficiency Acute pancreatitis

Question 71

Main causes for hypokalemia? (4)

Answer 71

Acute GI losses:diarrhoea, laxative use, vomiting Renal tubular acidosis Mineralocorticoid excess syndromes Inadequate intake: anorexia, alcoholism

Question 72

The main cause of hypernatraemia would be a ___(a)___ _______ or ____(b)____ excess or diabetes ___(c)____

Answer 72

a. renal disease b. mineralocorticoid c. diabetes insipidus

Question 73

In hyponatraemia, with a: -decreased serum osmolarity and -a normal to increased urine sodium and - a HYPOvolaemic state, what are the causes you are suspecting? (2)

Answer 73

Diruectics Addison's disease (also salt losing nephritis)

Question 74

When assessing hyponatraemia suspected to be due to cardiac failure or liver failure, what features of the hyponatraemia work up do you expect to find (3)

Answer 74

decreased serum osmolality decreased urinary sodium hypervolaemic state