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Revision > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

What causes hyperpigmentation in Addisons

A

HIGH ACTH

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2
Q

Preferred treatment hyperthyroidism during preconception,first trimester, postpartum

A

PTU- propylthiouracil

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2
Q

Which drug has risk of aplastic cutis and omphalocele in the foetus?

A

carbimazole

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3
Q

What is aplasia cutis?

A

Congenital absence of skin with or without absence of underlying structures such as bone

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4
Q

What risk does PTU have on the mother?

A

Hepatotoxicity

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5
Q

Next step of management if hyperthyroidism cannot be controlled by drugs?

A

Partial thyroidectomy in 2nd trimester

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6
Q

Secondary adrenal insufficiency
Cause?
Presentation?

A

Mostly iatrogenic
Cause: Long periods of steroids —> sudden cessation

Unexplained abdominal pain + nausea + vomiting

+/- postural hypotension ( dizziness/falls)

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7
Q

DKA

Presentation

A

DM type 1 mostly

Abd pain + vomiting + Kussmaul breathing (deep hyperventilation) + dehydration + glucose >11

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8
Q

Management DKA

A
  1. IV fluids
  2. IV insulin & measure ABG/VBG/capillary blood glucose
    IV insulin infusion @ 0.1U/kg/hr
  • *systolic BP >90
  • IV fluids = 1 litre 0.9% NS over 1 hr
  • *systolic BP <90
  • IV fluids = 1 litre 0.9% NS over 10-15 mins

When blood glucose reaches below 12 - IV fluids to NS + dextrose 5% to avoid hypoglycemia

Correct hypokalemia with kcl after 1st litre of NS

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9
Q

Diagnosis DKA

A

pH < 7.3
Ketonemia >3 or Ketonuria ++
Glucose >11
Bicarbonate <15

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10
Q

Normal Ca + normal phosphate + normal ALP

A

Osteoporosis

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11
Q

Normal Ca + normal phosphate + HIGH ALP

A

Paget’s disease

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12
Q

LOW Ca + LOW phosphate + HIGH ALP

A

Osteomalacia

**stem may only mention high ALP and give hints to vit D deficiency
Muscle aches, proximal muscle weakness, poor sunlight exposure
Poor diet

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13
Q

ECG changes seen in Hyperkalemia

A 
Tall tented T waves 
Prolonged QRS (QRS > .12s)
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14
Q

TX Hyperkalemia

A

1.Calcium gluconate/ carbonate
To protect cardiac membrane

2.reduce serum K+ with
- Insulin dextrose
OR
- Salbutamol inhalation

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15
Q

What is acromegaly

A

Excess growth hormone

In 95% of cases it is secondary to pituitary adenoma

Growth hormone normally suppressed by glucose
In acromegaly it is not.

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16
Q

What are the features of acromegaly

A
  1. Optic chasm compression —>
    bitemporal hemianopia
  2. Spade like hands
  3. Enlarged nose and jaw

Large tongue

Prognathism - protrusion of mandible

Interdental spaces

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17
Q

Initial screening test and F/U test acromegaly

A

IGF-1 (insulin like growth factors)

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18
Q

Confirmatory test / most definitive test of acromegaly

A

OGTT with serial growth hormone measurements

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19
Q

Bitemporal hemianopia

A

Loss of vision in outer half

Most importantly seen in
Acromegaly
Hyoerptolactinemia( pituitary macroadenoma)

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20
Q

Hypercalcemic manifestations in pt with prostate ca

A 
Polyuria
Polydipsia 
Confusion 
Depression/low mood
Kidney stones
Abdominal pain
Constipation 
Bone pain

MOANS GROANS BONES STONES

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21
Q

Main causes of hypercalcemia

A

Primary hyperparathyroidism
Malignancy
Sarcoidosis
TB

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22
Q

Sarcoidosis

A

Inflammatory disease
Abnormal collection of inflammatory cells —> granulomata
Affects various parts of the body
Most commonly lung skin and lymph nodes

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23
Q

Management of hypercalcemia

A

1.REHYDRATION
IV fluid 0.9% NS

  1. Bisphosphonate
    “Dronates”
    Alendronate, Risendronate,Pamidronate”
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24
Q

Amenorrhoea + Hypothyroidism

A 
Features of hypothyroid
Weight gain inspire of decreased appetite
Cold intolerance 
Myxoedema
Bradycardia
Dry coarse skin.constipation
Hair loss
Menorrhagia initially followed by oligomenorrhoea or amenorrhoea
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25
Q

Commonest cause of hypothyroidism in the Uk

A

Autoimmune hypothyroidism

Hashimoto thyroid it is

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26
Q

Commonest cause of hypothyroidism worldwide

A

Iodine deficiency

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27
Q

Hyperprolactinemia presentation

A

Milk discharge in non pregnant women + amenorrhoea

Amenorrhoea =low FSH/LH
Galactorrhoea = milk discharge

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28
Q

Main cause of hyperprolactinemia

A

Pituitary adenoma

Do MRI of brain

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29
Q

Visual defect in pituitary adenoma

A

Bitemporal hemianopia

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30
Q

Diabetic patient collapses and falls unconscious

What do you do first?

A

Random blood glucose

Blood glucose <4 hypoglycaemia

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31
Q

Features of hypoglycemia

A

Tachycardia
Sweating
Confusion
Altered mental state

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32
Q

Hypoglycaemia management

A

200 ml fruit if they’re conscious and can swallow

If they’re conscious but can’t swallow —> 200ml 10%glucose IV or 1mg glucagon IM or SC

If unconscious
IV 20% glucose 75ml

IV 10% glucose 50ml

1mg glucagon IM or SC

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33
Q

Causes of hypoglycaemia

A

Alcohol
Liver failure( impaired gluconeogenesis)
Excess paracetamol or aspirin
Sulphonylureas (glibenclamide, gliclazide)

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34
Q

Why is glycosuria normal after surgery?

A

Stress hyperglycaemia
Stress increases the cortisol secretion —> hyperglycaemia

Resolves on its own a few days post op

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35
Q

What cause hypercalcemia in Squamos cell carcinoma SCC

A

Paraneoplastic effect

SCC releases parathyroid like molecules causing hypercalcemia

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36
Q

What derangement does small cell lung ca cause?

A

High ADH -> SIADH -> dilution also hyponatremia and hypokalemia

High ACTH -> Cushing syndrome

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37
Q

What medication do you give T2DM with impaired renal function

A

Insulin
Or
Gliptins DDP4 inhibitors

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38
Q

What diabetic meds are CI in T2DM with obesity and impaired renal function

A

Metformin (Biguanides)
- first line for T2DM however CI in GFR< 30
If GFR <45 dose should be reduced

Sulfonylureas (Glibenclamide)
- increases risk of hypoglycemia in impaired renal fn + increases weight

Glitazones ( Pioglitazone) increases weight

SG.T2 inhibitors CI in GFR< 60

WITH BAD KIDNEYS AVOID MS

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39
Q

(secondary amenorrhoea)

A

Cessation of menstruation >6 months after it has been established

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40
Q

Hypothalamic amenorrhoea

A

Occurs with stress, exercise, significantly low BMI
Due to hypothalamic failure
HIGH PROLACTIN seen
Dec. GnRH —> dec. FSH LH —> subsequent dec in oestrogen

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41
Q

Pheochromocytoma

A

Adrenal tumour
Secretes catecholamines - epinephrine , norepinephrine
EPISODIC
Features - HTN, headache , sweating, tremors, palpitations, anxiety

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43
Q

Known case of small cell lung ca presents with frequent falls and confusion
Diagnosis?

A

SIADH
High ADH - dilutional hyponatremia due to fluid retention

Small cell ca = high ACTH - Cushing

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44
Q

Treatment of choice - pheochromocytoma

A

Surgical resection
7-10 days before, stabilise HTN with, to prevent intraoperative HTN crisis
alpha blockers - PHENOXYBENZAMINE
Followed by Beta blockers - PROPANOLOL

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44
Q

T2DM + Microalbuminuria + mild HTN + Hypercholestrolemia

What do you give?

A

Metformin - control BG
ACEi - reduce BP, slow progression of kidney damage
(Kidney damage - microalbuminuria +T2DM)
Statins for the cholesterol

** T2DM + HTN - ALWAYS ACEi unless there is severe renal impairment
They are Reno-protective
DM poses risk of nephropathy, so ACEi slow the progression

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45
Q

Case - 54 year DM HTN on metformin ramipril bisoprolol
HBA1C 52
Management?

A

On metformin, HBA1C <58 — lifestyle modifications

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46
Q

New onset T2DM, first advice

A

Lifestyle modification

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47
Q

New onset T2DM, after lifestyle modification HBA1C high, but >48
Management?

A

Start 1 hypoglycaemic

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48
Q

51 year old T2DM on metformin, HBA1C >/= 58

Management?

A

Add another hypoglycaemic agent

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49
Q

When do you advise lifestyle changes in T2DM

A

New onset DM
Or
Already on metformin, HBA1C <58

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50
Q

When do you consider adding another hypoglycaemic agent

A

If already on one but HBA1C >= 58

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51
Q

Case of
Uncontrolled DM2 despite lifestyle Despite lifestyle changes + EGFR <30 and there is a history of heart failure and BMI> 30

What do you give?

A

Insulin

EGFR 30- Metformin contraindicated
Sulphonylureas- contraindicated obese + impaired GFR
Gliptins (DDP4) inhibitors contra indicated heart failure
Glitazones - CI in obesity, HF, bladder ca

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52
Q

When is metformin CI

A

GFR < 30

If <45 - reduce dose

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53
Q

When are sulphonylureas CI

A

Obesity

Impaired GFR

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54
Q

When are Gliptins(DDP4) CI

A

Heart failure

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57
Q

Diagnosis of pheochromocytoma

A

24 hour urine collection of metanephrines

If not available as option pick
24 hrs catecholamine

MRI to confirm

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58
Q

When is Pioglitazone CI

A

Obesity
Heart failure
Bladder ca

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59
Q

What is Addison’s disease?

What are the features?

A

Primary adrenal insufficiency
Most common cause UK - autoimmune
Worldwide - TB

LOW cortisol & aldosterone

Postural hypotension (dizziness & vertigo)
Weakness and fatigue
Nausea, vomiting, abdominal pain
Hyperpigmentation of skin and mucous membranes

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59
Q

What causes hyponatremia & Hyperkalemia in Addisons

A

LOW aldosterone

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60
Q

Most common causes of addisons in developed and developing world?

A

Developed - Autoimmune

Developing- TB (infection)

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61
Q

What causes postural hypotension and dizziness in Addisons

A

LOW Cortisol

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62
Q

What investigations are done for Addison’s?

A

DEFINITE investigation in suspected Addison’s - short ACTH stimulation test (short Synacthen test)

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63
Q

What is the Synacthen test?

A

Plasma cortisol measured before, and 30 mins after giving Synacthen 250ug IM
Adrenal autoantibodies e.g. anti-21-hydroxylase may also be demonstrated

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64
Q

If ACTH stimulation test not available , what do you do?

A

9 am serum cortisol

> 500 nmol/l - unlikely
<100 nmol/l definitely abnormal
100-500 nmol/l - ACTH stimulation should be performed

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65
Q

Management of addisons

A

Glucocorticoid and Mineralocorticoid replacement therapy

Hydrocortisone - 2-3 divided doses
20-30 mg per day - majority given in the morning

Fludrocortisone

***patient education
Importance of not missing doses
Consider medi alert bracelets & steroid cards

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66
Q

Management of inter current illness in Addisons

A

Double dose of glucocorticoid

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67
Q

What is Addisonian crisis

A

Adrenal crisis
Life threatening
Acute insufficiency of adrenal hormones (gluco/mineralo-corticoids)

Addison’s disease has more gradual course - adrenals don’t produce enough steroids over several months
Illness or acute stress can ppt adrenal crisis

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68
Q

Features of Addisonian crisis

A 
Severe weakness / excessive tiredness
Confusion
Lower back or leg pain
Severe abdominal pain vomiting diarrhoea —-> dehydration
Reduced consciousness or delirium

HypoNA hyperK Hypoglcemia

69
Q

Causes of addisonian crisis

A

Sepsis/surgery
- acute exacerbation of chronic insufficiency (addisons, hypopituitarism)

Adrenal haemorrhage - Waterhouse- Friedrichsen syndrome ( fulminant meningococcaemia)

Steroid withdrawal

70
Q

Tx of Addisonian crises

A

Hydrocortisone 100mg IM/IV
1L NS - infuse over 30-60 mins + dextrose if hypoglycaemic
- continue to give 6 hourly until stable
-Oral replacement after 24 hours - maintenance over 3-4 days

ECG monitor
Antibiotics if there’s infection
Iv hydrocortisone in 5% dextrose

71
Q

Congenital Hypothyroidism

What are the complications ?

A

JAUNDICE - prolonged physiological jaundice, starts 24hrs of birth, lasts a long time)

FTT
Short stature
Impaired mental development
Broad flat nose, wide set eyes, protruding tongue

72
Q

T1DM with DKA, came unwell , with altered LOC + tachycardia + signs of dehydration
What investigations are done?

A
  1. CBG

2. ABG

73
Q

Young male found outside local pub semi-conscious profusely sweating with diaphoretic skin GCS 12/15 tachycardic and hypotensive

What is the likely diagnosis

A

Hypoglycemia

Alcohol is most commonest cause of hypoglycemia in adults

74
Q

What is Whipples triad?

A

Diagnosis of hypoglycaemia
1. Low plasma glucose <4 usually
2. Manifestations of hypoglycaemia
sweating confusion tachycardia hypotension altered mentation
3.If blood glucose is corrected rapid resolution of symptoms occur

75
Q

What is Conn’s syndrome?
What features are seen?
What is the most common cause?

A

Primary hyperaldosteronism - excess aldosterone
Adrenal adenoma
Hypokalaemia)and hypertension

bilateral idiopathic adrenal hyperplasia is the cause in up to 70% of cases

76
Q

Think Conn’s syndrome if …

A 
Hypertension and hypokalaemia 
or 
refractory hypertension despite three or more antihypertensive drugs 
or 
hypertension before the age of 30

other possible manifestations - weakness lethargy headache

77
Q

What investigations should be done in Conn’s syndrome?

A

Plasma aldosterone/renin ratio - first line investigation
= high aldosterone + low renin - negative feedback due to Na retention from aldosterone

high resolution CT abdomen and adrenal vein sampling
= to differentiate b/w unilateral & bilateral sources of aldosterone excess

78
Q

What is the most suitable hormone to order in a patient with Hypertension + Hyperkalemia +/- headaches, weakness , lethargy

A

Aldosterone

79
Q

Treatment of Conn’s syndrome (primary hyperaldosteronism)

A

Aldosterone antagonist - Spironolactone

Before you consider adrenalectomy

80
Q

Conn’s syndrome

A 
Excess aldosterone 
—-> 
Hypertension
Hypokalemia, can be normokalemia
Normal Na+ or upper normal
Headache, weakness
\+/- METABOLIC ALKALOSIS
\+/- Polyuria ( due to aldosterone escape)
81
Q

Addisons VS Conn’s VS Pheochromocytoma

A

Addisons - low cortisol, low aldosterone
HypERkalemia, hyPOtension, metabolic ACIDOSIS

Conn’s - high aldosterone
HyPOkalemia, hyPERtension, metabolic ALKALOSIS

Pheochromocytoma - high catecholamines
PHE + F - palpitations, headache, hypERtension, flushing/sweating , episodic

82
Q

DM2 - preoperative management

A

Minor surgery - stop oral hypoglycaemic NIGHT B4
Major - continue same routine

Alternative
Minor procedure e.g upper gi endoscopy and pt on oral hypoglycaemic e.g glicazide - omit morning dose and restart once they are eating/drinking

83
Q

DM1 - pre-op management

A

Minor surgery - omit insulin on day of surgery

Major - sliding scale IV insulin before surgery and continue until diet per mouth re-established

84
Q

Diagnostic criteria of DM

A

DM symptoms + 1 abnormal value

Or

2 abnormal values w/o symptoms

Abnormal value = FBG >/= 7 nmol or HBA1C >/= 48 (>= 6.5%)

Prediabetes - impaired glucose tolerance
Fasting 5.5-6.9
2 hr PP - 7.8 - 11
HBA1C - 42-47

85
Q

What is the diagnostic test for DM in pregnancy

A

OGTT

86
Q

32 year old female presents with polyuria polydipsia and positive glucose in urine
what investigation would you do?

A

Measure fasting blood glucose
(NOT RANDOM)

FBG is cheaper
HBA1C is more expensive usually used if there is uncertainty

87
Q

Causes of hypoglycaemia

A

Drugs: sulfonylureas, paracetamol, aspirin

Alcohol intoxication,liver failure (impaired gluconeogensis)

Addison’s disease (low cortisol —> hypoglycemia)

88
Q

What is MODY( maturity onset diabetes in the young)??

What treatment is used?

A

DM < 25 years old
Strong family history (two generations)
mild hyperglycaemia

Respond to sulfonylureas , no need for insulin initially

89
Q

Cushing’s disease vs Cushing’s syndrome

A

Both are due to excess cortisol levels, but the causes are different

Cushings disease =
- tumour on pituitary gland that produces excess ACTH —> incr cortisol
- ACTH responsible for production of cortisol via adrenal glands
ACTH suppressed by low (overnight) or high dose dexamethasone

Cushing’s syndrome =
- causes OUTSIDE the body that increase cortisol levels
E.g. meds, corticosteroids

90
Q

Features of cushings

A 
Hypertension that requires two or more antihypertensive agents
Truncal obesity
Hypoglycaemia
Moon face
Striae
Cardiac hypertrophy
Osteoporosis
Weight gain
Proximal muscle weakness
Easy bruising
Liability to infections
Hypernatraemia and hypokalaemia
Enlarged supraclavicular fat pads
91
Q

Cushing syndrome investigations for diagnosis
Best initial ?
Outpatient?

A

Best initial - overnight dexa suppression test - 1mg low dose
Outpatient - 24 hr urinary free cortisol
To localise lesion HIGH dose dexa supression test

92
Q

Excess cortisol, low ACTH - next step?

A

Low ACTH rules out ectopic cause —
So it could be adrenal tumour — adrenal ct
Excess cortisol intake

93
Q

Excess cortisol, ACTH high - what do you do?

A 
High dose dexa suppression to localise lesion
If suppressed (low cortisol) — pituitary adenoma — pituitary MRI
Not suppressed - cortisol still high —> ectopic cause - CT chest & abdomen
94
Q

How is the dexa suppression test done?

A

Low dose test:
1mg dexa
Low cortisol —> normal
High/normal cortisol — Cushing’s syndrome

High dose test:
8mg dexa
Low cortisol - cushings disease
High/normal - ACTH low - adrenal cushings
- ACTH high - ectopic ACTH

95
Q

What metabolic imbalance does vomiting cause?

A

Metabolic alkalosis
Due to loss of H+, body keeps CO2 to compensate via hypoventilation
High pH, High pCO2

96
Q

What metabolic imbalance can occur secondary to acute kidney injury what ECG changes will you see
What is the initial step in management

A

Hyperkalemia
Tall tented T waves
Protect cardiac membrane —> IV Ca gluconate or Ca carbonate + ECG monitor

97
Q

A 60 year old patient comes with a deep 4x3 cm ulcer on her left heel, it is painless.
She also mentions she has frequent urination, weight loss, and fatigue?
What investigations will you request?

A

BLOOD SUGAR

DM diagnosis

98
Q

What situations does stress hyperglycaemia occur?

How do you manage it?

A

Pneumonia
MI
Stroke
Post-operatively.

= resolves spontanteously

99
Q

A 43 year old man has just undergone a surgery, post op labs showed K+ >6.4 and on examination there are crackles over the lungs, and he has sacral oedema
What do you do?

A

Acute kidney injury secondary to HF

2 things
Calcium gluconate to protect heart
We want to push the K+ intracellularly to prevent life threatening arrythmia
= IV insulin + glucose

Crackles/ sacral oedema - think HF
IV insulin w/ glucose moves K+ into cells TEMPORARILY so give IV NS unless the patient is overloaded (HF!!)

If well hydrated or overloaded - start diuretics - lasiks (furosemide) or Calcium resonium

100
Q

Acute renal failure
+ Anuria
+ severe hypokalemia

What do you do?

A

Hemodialysis especially if K+ >/= 7.5

101
Q

A 53 year old woman comes with complaints of drowsiness and feeling thirsty all the time
She is a known case of breast cancer
What metabolic abnormality do you suspect?

A

Hypercalcemia - bone mets

102
Q

A 43 year old male camels with a lump on the front of his neck that moves open swallowing. He also complains of weight loss even though he has a good appetite, palpitations, heat intolerance and restlessness.

What is the diagnosis?

A

Toxin nodular goitre

103
Q 
A 35 year old woman comes with complaints of panic attacks, headaches, palpitations,  excess sweating and tremors.
Her BP 140/100
What is your diagnosis?
What investigations?
Treatment?
A

Pheochromocytoma - rare catecholamine secreting tumour
PHE +F

24 hr urine collection of METANEPHRINES

Treatment -
Stabilise HTN with alpha blockers + beta blockers - phenoxybenzamine
Then propanolol
Surgical removal of adrenal tumour

104
Q

What is the rule of 10 in pheochromocytoma?

A 
Rule of 10 -
10% bilateral
10% malignant
10% extra- adrenal
10% familial
10% without HTN
105
Q

A 23 year old woman came with complaints of tender and painful thyroid, the pain radiates to her lower jaw. She had a cold 1 week ago. And also compaints of palpitions and tachycardia.
On examination her thyroid is not enlarged.
Lab investigations:
Negative thyroid auto antio bodies
Decreased radioactive iodine uptake
What is your diagnosis?

A 
Subacute thyroiditis
DE QUERVAINS THYROIDITIS
- painful !!!*
Initially hyperthyroidism followed by hypothyroidism
Follows URTI usually

Treatment - it is self limited
Pain and inflammation - give NSAIDS
Beta blockers to control arrhythmia*** IMP

*note - its not graves or hashimito as the antibodies are negative
Graves’ disease has INcreased uptake of iodine

106
Q

What is a thyroid storm?

How do you manage it?

A

Thyroid crisis precipitated by infection

Sick patients - low GCS, palpitations, tremors, tachycardia, feeling warm
(Thyrotoxicosis)
AFIB can be seen secondary to the thyrotoxicosis

Propanolol - oral or IV
PTU* (if there is no storm, no pregnancy - carbimazole is 1st line)
Treat infection - broad spec antibiotic

107
Q

Hypoglycaemic episode in a diabetic patient who presents with: drowsiness confusion fatigue, tremors, blood vision and sweating.
What investigation should be done?

A

Immediately check random blood glucose there is no time to check fasting.

108
Q

A 45 year old man has undergone a thyroidectomy, he now complains on tingling, numbness and parenthesis. He also mentions he has random spasms in his upper arms.

What is your diagnosis?

A

Hypocalcemia

Due to hypoparathyroidism after thyroidectomy

Dec parathormone (PTH) - dec serum calcium

109
Q

Cause of hypocalcemia

A

Osteomalacia - vit D deficiency
Chronic renal failure
Hypoparathyroidism - esp post thyroidectomy
Hyomagnesemia
HypERphosphatemia
Panic attacks - hyperventilation - transient hypoCA
Calcium and phosphate have an inverse relationship.

**Hypocalcaemia can occur in diabetic patients because of chronic renal failure which causes hypocalcaemia (diabetic nephropathy)

110
Q

Features of hypocalcemia.
What are the signs seen?
Treatment

A 
SPASMODIC
Spasms
Perioral parenthesia
Anxious
Seizures 
Muscle tones increase in smooth muscle
Orientation impaired / confusion
Dermatitis
Impetigo herpetiform
Cardiomyopathy - prolonged QT on ECG

Trousseaus’s sign- after occlusion of brachial artery —> wrist flex ion
Chvostek’s sign —> tapping over parotid - facial muscles twitch

Treatment - 10ml of 10% ca gluconate - initially

111
Q

What is SIADH?
What is seen?
What is the management?
What is the 2nd line if first treatment fails?

A

Syndrome of inappropriate ADH
Can happen secondary to SMALL CELL CA — water retention
And 2nd to meningitis
Dilutional hyPOnatremia - patient is overloaded

Mainstay tx - fluid restriction
If failed —> Tolvaptan or Demeclocycline

112
Q

Associated autoimmune diseases in Hashimotos

A

Vitiligo
Addison’s disease
Pernicious anemia
DM type 1

113
Q

Case - 9 year old child, obese, short, with abdominal striae and history of renal transplant

A

Cushing syndrome
High cortisol- high glucose - low growth hormone
Steroids are anti vit D

114
Q

Classification of pituitary adenoma

A

They are a type of pituitary adenoma - benign tumour
Can be classified according to:
size - <1 cm micro >1cm macro-adenoma
Hormonal status
- secretory/functioning = excess hormone
-non-secretory/non functional = no hormone

Prolactinomas** - most common
Excess prolactin

.

115
Q

What effects does excess prolactin have?

A

Men: impotence, loss of libido, galactorrhoea
Women: amenorrhoea, infertility, galactorrhoea, osteoporosis

116
Q

Diagnosis of prolactinoma

Confirmatory test?

A

Serum prolactin
= normally <400
If >= 5000 - suspect macroadenoma

If > 200 keep prolactinoma in mind

FSH LH oestradiol - LOW

MRI brain - confirmatory test

117
Q

Management of prolactinoma

A
  1. 1st line = dopamine agonist
    - Cabergoline, Bromocriptine
    Inhibit prolactin from pituitary gland
    Cabergoline more effective in micro prolactinoma
  2. Second line ( if no response from first)
    Transphenoidal surgery to remove prolactinoma
118
Q

Manifestations of hyperprolactinemia

A 
Galactorrhoea 
Amenorrhoea or oligomenorrhoea
Headaches
Infertility
Visual disturbances
Bitemporal hemianopia
119
Q

Diabetic neuropathy

A

Glove and stocking - loss of fine touch and pain
Starts in toes and ascends
Loss of ankle jerk bilaterally

Mechanism - micro vascular injury - nerve damage

120
Q

What drugs can cause Hyperkalemia
Levels of hyper K
Treatment

A

ACEi (-pril)
K+ sparing diuretics - spironolactone

Mild = 5.5-5.9
Moderate = 6-6.4
Severe = >6.5

Mild - stop meds
Mod/severe or ECG changes - ca gluconate
Insulin + dextrose

121
Q

Isolated high ALP

A

BBP
Bones - osteomalacia, paget’s disease, hyperparathyroidism, donuts bone metastasis
Biliary tract : Cholestasis (Obstructive jaundice)
Pregnancy: (physiological finding)

122
Q

Diabetes insipidus

Cranial vs nephrogenic

A

Diabetes Insipidus
= passage of large volumes (>3L/24hrs) of dilute urine <300mOsm/kg

Cranial or nephrogenic

Low urine osmolality
Give a vasopressin —> urine osmolality will increase
= diagnosis of central (cranial) DI

If no change after vasopressin - large volumes of urine high serum osmolality, low urine osmolality
= nephrogenic

123
Q

SIADH vs Diabetes inspidus

A

SIADH = hypOnatremia
Low S - serum sodium , low serum osmolality, high urine osmolality
Cerebrum/cerebellum

DI= hypِERnatremia
Low urine osmolality, high serum osmolality
Urine osmolality increases after vasopressin
DIencephalon

124
Q

How to differentiate DI and SIADH

A

Urine osmolality
If < 800 - likely DI (low urine osmolality)
SIADH has high urine osmolality

DI - is it central or nephrogenic?
= fluid deprivation test and then give desmopressin/vasopressin

**if urine osmalilty not given and you suspect DI
Choose fluid deprivation and response to vasopressin

125
Q

High prolactin >2000 + hypogonadism + amenorrhoea + infertility
What are differentials?

A

Prolactinoma

Ddx:
PCOS - LH : FSH >2 LH is double FSH if not more
Premature ovarian failure - before age of 40
FSH is HIGH >25 on 2 occasions, 4 weeks apart

126
Q

Hypercalcemia
Give causes and presentation
the treatment

A 
Cause :
SCC of the lung - hypERcalcemia 
Primary hyperPTH
Multiple myeloma
Sarcoidosis 
Metastasis - breast, prostate
Presentation:
Neuro - lethargy, confusion, depression
GIT - constipation
Renal - polyuria, polydipsia
CVS - short QT

Tx: Initial step - IV NS 0.9%
Then bisphosphonates - pamidronate, zolendronate infusion

127
Q

Thyroid nodule >= 1cm
Initial step?
Most appropriate step?

A

Initially - US thyroid

FNAC - most appropriate

128
Q

What drugs cause hepatitis?

A

Augmentin (co-amoxiclav) - especially in ppl with deteriorated liver fn e.g alcoholics

Clavulanic acid - highly toxic
If already at risk for hepatic impairment - chronic alcoholism
Hepatic excretion will be impaired -> CHOLESTASIS (dark urine, jaundice), high bilirubin and drug induced hepatitis (high ALP AST ALT)

Alcoholic hepatitis - AST>ALT

129
Q

Drugs that cause hepatic cholestasis

A

Co-amoxiclav
Flucoxaxillin
Steroids
Sulphonylureas

130
Q

Side effects of ACEi

A

Angioedema
Cough
Electrolyte - Hyperkalemia
Increased potassium

131
Q

Side effects of spironolactone and thiazides diuretics

A

Spirononlactone - Hyperkalemia
Thiazides - hypOkalemia, hypOnatremia, hypERglycemia, hypERuricemia= GOUT high Uric acid
Metabolic alkalosis

132
Q

DOC for Hyperthyroidism in pregnancy 2/3rd trimester and in non pregnant women

A

Carbimazole

133
Q

What are the causes of autonomic nephropathy?

What are the manifestations?

A

Diabetes
Alcohol
Aging

Sweating, incontinence, diarrhoea/constipation, impotence, postural hypotension

**suspect it in DM pt with diarrhoea

Metformin can also cause diarrhoea

134
Q

Pseudo gout
Where is the commonest site?
What is its pathognomonic feature?
What disease is it associated with??

A

Knee

On aspiration of synovial fluid - +ve Birefringent crystals

Hypothyroidism

135
Q

What can hypothyroidism be associated with?

A

Pseudo gout
Amennorrhoea / oligomenorrhoea
Hyperprolactinemia
Autoimmune disease. - Addison’s, pernicious anemia, vitiligo, DM1

136
Q

Gout vs Pseudogout

A

Gout - small joints, intense pain , inflamed joint, hypERuricemia, synovial fluid has uric acid crystals (-ve birefringent crystals)

Pseudo - large joints, moderate pain, swollen joints, chondrocalcinosis, calcium pyrophosphate crystals +ve birefringent.

137
Q

He of SCC if lung + hypercalcemia

What is the NEXT step?

A

Check serum PTH level
In malignancy PTH is low

After that -
Check ALP, if high - suspect bone mets

SO
In lung ca - if ALP and Ca and high - bone metastasis

138
Q

High corrected calcium + high ALP

What could it be?

A

Bone mets
Thyrotoxicosis
Sarcoidosis

139
Q

High corrected Ca + high albumin + high urea = ??

A

Dehydration

140
Q

High corrected Ca + High serum calcitonin =??

A

B cell lymphoma

141
Q

Elderly woman comes with multiple fractures a T score of -2.5 or lower
What is your diagnosis?
What is your 1st line of management?

A

Osteoporosis

1st line - bisphosphonates

142
Q

Side effects of HRT (hormone replacement)

A

VTE
Stroke
Breast ca
Coronary diseases

143
Q

What are t-scores

A

Assessed by DEXA scan , they reflect bone mineral density (BMD)

  • 1 or higher = normal
  • 1 —> -2.5 - osteopenia
  • 2.5 or lower - osteoporosis
144
Q

Antipsychotic agent that causes dizziness and erectile dysfunction in men?

A

Haloperidol

It blocks dopamine 2 receptors and causes hyperprolactinemia => erectile dysfunction

145
Q

First line treatment of thyrotoxicosis

A

Carbimazole

Except ***

Thyroid storm - PTU
Preconception or 1st trimester pregnant woman or postpartum

Carbimazole is used 1/day
PTU 2-3/day - higher risk of liver injury

Never use iodine in graves ophthalmopathy or in pregnancy

146
Q

Best management of hypoglycemia in unconscious pt

A

IM 1mg glucagon

Others
75ml of 20% glucose IV 10-15mins
50 ml 10% glucose over 1-2 mins

Glucose gel useful in drowsy pts not in unconscious.

147
Q

Causes of hypokalemia
Symptoms
ECG

A

Vomiting - loss of H+ - metabolic alkalosis- less K+
Chronic alcoholism
2 C’s - cushing, conn
Renal - bartter’s syndrome ( neonates/children, AR)

Sx- tiredness, FAINTING, weakness, leg cramps,

K+ <2.5 or <3+ Uwave = IV KCL 40mmol in 1L NS
K+ >= 2.5 no ecg changes - oral supplement K+

Remember to order Mg+ and ABG to exclude metabolic alkalosis

148
Q

Postpartum thyroiditis
Management?
What antibodies are positive?

A

Usually resolves in 1 year after delivery so anti thyroid meds not needed
However in hypothyroid phase, you can give level thyroxine

Thyroid peroxidase antibodies - +ve in 80% cases

149
Q

Treatment of SIADH

A
  1. Fluid restriction

If that fails - Tolvaptan or Demeclocycline

150
Q

Hyperparathyroidism

Classification

A

Primary - N/H PTH, High Ca, Low Phosphate
Cause - parathyroid adenoma
Imp ddx is familial hypocalciuric hypercalcemia

Secondary - high PTH, low/N Ca, H/N phosphate
Causes - vit D deficiency. Chronic renal failure, prolonged hypocalcemia

Tetiary - ESRD

151
Q

Congenital adrenal hyperplasia
Presentation
What test do you order?
Most commenest for>?

A

Autosomal recessive 1:4 if parents are carriers

11 beta hydroxylase deficiency

Neonates/ children -
Female - ambiguous genitalia
Males - penile enlargement, hyperpigmentation
Infant males - salt wasting ( aldosterone deficiency)

Order aldosterone

In adults
Males - no sign, maybe hyperpigmentation
Females - hirsute Sam, early pubarche, oligomenorrhoea, acne
Order 17-hydroxyprogesterone

Most commonest form - 21 alpha hydroxylase deficiency

152
Q

Bartter’s syndrome
Cause?
Presentation?
Treatment?

A

usually AR
Severe hypokalemia
NKCC2 in ascending loop of Henle - defective chloride absorption

Presents as 
FTT
Or polyhydramnios in week 24-30
Excessive polyuria/polydipsia after birth
Normotension
Weakness

Treatment -
Na K Cl replacement
Spironolactone to reduce K+ loss
Water access
NSAIDS if supplementation alone doesn’t work - reduces glomerular filtration
Should be given with acid suppression therapy to protect stomach
ACEi to reduce GFR
Renal US to monitor development of nephrocalcinosis

153
Q

Side effects of loop diuretics

A

Furosemide, bumetanide

Hyponatremia
Hypokalemia
Gout

154
Q

Side effects of thiazides

A

Indapamide, bendroflumethiazide

Hyponatremia
Hypokalemia 
Gout (hypERuricemia)
Postural hypotension
Hyperglycaemia
155
Q

Side effects of K+ sparing diuretics

A

Spironolactone
Eplerenone

Hyponatremia
HypERkalemia
Gynecomastia

156
Q

Side effects of ACEi

A

Angioedema
Dry cough
Hyperkalemia

157
Q

Test to differentiate DM1 from DM2

A

GAD - glutamic acid decarboxylase antibodies test

158
Q

Test to diagnose insulinoma

A

C-peptide test

Insulinoma - causes pancreas to release too much insulin

159
Q

What hypoglycaemic meds does MODY respond to?

And what else should be done

A

Sulphonylureas
Referral for genetic counselling

*** if patient is SYMPTOMATIC + HAS 1 ABNORMAL DM TEST - no need to repeat test

160
Q

What is LADA?
What test should be done if you suspect it?
When is it usually diagnosed?
Treatment

A

Latent autoimmune diabetes of adulthood
Presence of any B cell antibody
If suspected = GAD antibodies (glutamic acid decarboxylayse Abs)

Tx= like DM 2 - however need for insulin occurs earlier

161
Q

What is Sheehans syndrome?

A

Postpartum hypopituitarism

162
Q

Symptoms of Sheehan

A

Severe hypotension = due to severe postpartum haemorrhage
== pituitary ischemia and necrosis == hypopituitarism
+ decrease in pituitary gland hormones - GH TSH prolactin LH FSH ACTH

163
Q

Earliest and most important features of Sheehan

A

Agalactorrhoea - low prolactin = low milk prod
Amenorrhoea

Hypothyroid symptoms - cold intolerance weight gain etc

164
Q

Best initial test Sheehan

A

Provocative hormonal testing

165
Q

Most accurate test

A

MRI of pituitary gland + hypothalamus to r/o tumour or other pathology

166
Q

Treatment - sheehan

A

Life long hormone replacement

167
Q

High/normal PTH + high ca + low phosphate

Dx

A

1ry hyperparathyroidism

168
Q

ESRD + high PTH + high calcium + high phosphate

Dx

A

Tertiary hyperparathyroidism

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