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AKT > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

In what conditions can you not use HbA1C to diagnose T2DM?

A

Haemoglobinopathies

Haemolytic anaemia

Untreated iron deficiency anaemia

Gestational diabetes

Children

HIV

CKD

Medications causing hyperglycaemia

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2
Q

Alterations to metformin dose during ramadan

A

split dose to 1/3rd before sunrise and 2/3rds after sunset

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3
Q

Alteration to sulfonyulrea dose during ramadan

A

OD - take after sunset

BD - take large proportion after sunset

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4
Q

Dietary advice for T2DM during ramadan

A

Meal containing long acting carbohydrates prior to sunrise

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5
Q

Sick day rules for diabetes

A

Four hourly BMs

3 litres of fluid

May need sugary fluids if can’t drink

Continue normal insulin

Stop metformin if dehydrated

Continue oral hypoglycaemic meds

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6
Q

Conditions that need to be met to hold HGV licence if diabetic

A

No severe hypo in 12 months

Full hypo awareness

Adequate control shown by regular BMs

Understands risks of hypos

No other debarring conditions from diabetes

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7
Q

Conditions that need to be met to hold group 1 license if diabetic on insulin

A

Hypoglycaemic awareness

No hypo needing help in last 12 months

No relevant visual impairment

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8
Q

What is the target when treating hyperlipidaemia?

A

40% reduction in non-HDL cholesterol

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9
Q

Pre-diabetes range for HbA1c in mmol/mol

A

42-47

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10
Q

Non-drug causes of gynaecomastia

A

Physiological - normal in puberty

Androgen deficiency syndromes (Kallman, Klinefelters)

Testicular failure

Liver disease

Testicular cancer

Ectopic tumour secretion

Hyperthyroidism

Haemodialysis

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11
Q

Drug causes of gynaecomastia

A

Spironolactone

Cimetidine

Digoxin

Cannabis

Finasteride

GnRH agonists - goserelin, buserelin

Oestrogens, anabolic steroids

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12
Q

Orlistat - mechanism of action

A

Pancreatic lipase inhibitor

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13
Q

Orlistat - side effects

A

Faecal urgency
Incontinence
Flatulence

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14
Q

Criteria for starting orlistat

A

BMI over 28 with associated risk factors

BMI over 30

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15
Q

Criteria for continuing orlistat

A

Continued weight loss - 5% at 3 months

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16
Q

How long is orlistat used for?

A

1 year

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17
Q

TFTs in secondary hypothyroidism

A

Low TSH

Low T4

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18
Q

Investigations for secondary hypothyroidism

A

MRI pituitary

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19
Q

Cause of secondary hypothyroidism

A

Pituitary insufficiency

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20
Q

First line insulin regime for new T1DM

A

Basal bolus with twice daily insulin detemir

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21
Q

Pre-diabetes range for HbA1c in %

A

6.0-6.4%

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22
Q

Possible consequences of untreated subclinical hyperthyroidism

A

Supraventricular arrhythmias and osteoporosis

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23
Q

When do patients require a gradual withdrawal of systemic corticosteroids?

A

> 40mg pred daily for >1 week

> 3 weeks treatment

Recently received repeated courses

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24
Q

What ketones should prompt admission to hospital in T1DM?

A

3

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25
Q

Medication that interacts with orlistat

A

Contraception and anti-epileptics

due to GI side effects affecting absorption

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26
Q

At what renal function should you review metformin?

At what renal function should you stop stop metformin?

A

Review at creat >130 or eGFR <45

Stop if creat >150 or eGFR <30

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27
Q

Should you ever start metformin in prediabetes?

A

Yes if HbA1c going up despite lifestyle measures

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28
Q

Extra investigations for new T2DM diagnosed over age 60 or weight loss

A

CT abdomen to exclude pancreatic ca

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29
Q

Blood glucose targets in T1DM - on waking

A

5-7 mmol/l

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30
Q

Blood glucose targets in T1DM - before meals during the day

A

4-7 mmol/l

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31
Q

Which group of patients taking insulin do not need to inform DVLA?

A

Taking insulin for less than 3 months

Taking for gestational diabetes up to 3 months post partum

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32
Q

Which type of drugs reduced hypoglycaemia awareness?

A

Beta blockers

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33
Q

TSH goal in treating hypothyroidism

A

0.5 to 2.5 mU/l

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34
Q

Instructions to patients on how to take levothyroxine

A

30 minutes before breakfast or caffeine or other medication

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35
Q

Blood pressure target in T1DM with no end organ damage

A

135/85

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36
Q

Blood pressure target in T1Dm if albuminuria or 2 or more features of metabolic syndrome

A

130/80

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37
Q

Criteria for diagnosing T1DM

A

Fasting glucose ≥ 7
Random glucose ≥ 11.1

If not symptomatic needs to be on two occasions

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38
Q

Target HbA1c in T1DM

A

≤48

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39
Q

T1DM investigations

A

Urine dip

Fasting + random glucose

C-peptide

Anti-glutamic acid antibodies (anti-GAD)

Islet cell antibodies

Insulin autoantibodies

Insulinoma-associated-2 autoantibodies

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40
Q

Tests to do when differentiating between T1 and T2 diabetes

A

C-peptide

Insulin antibodies

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41
Q

What are the insulin antibodies to test for?

A

Anti-glutamic acid antibodies

Islet cell antibodies

Insulin autoantibodies

Insulinoma-associated-2 autoantibodies

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42
Q

HbA1c target for T2DM being managed with lifestyle measures

A

48

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43
Q

HbA1c target for T2DM being managed with lifestyle measures and metformin

A

48

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44
Q

HbA1c target for T2DM being managed with any drug that can cause hypoglycaemia

A

53

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45
Q

At what HbA1c do you add a second medication to metformin?

A

58

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46
Q

At what HbA1c do you start metformin?

A

48

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47
Q

2nd line medication options to add to metformin in the management of T2DM

A

Sulfonylurea

Gliptin

Pioglitazone

SGLT2 inhibitor

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48
Q

3rd line medication options to add to metformin in managmeent of T2DM

A

Sulfonylurea
Gliptin
Pioglitazone
SGLT2 inhibitor

OR consider insulin

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49
Q

Which medication should you continue when starting insulin in T2DM?

A

Metformin only

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50
Q

Medication options for T2DM who can’t tolerate metformin

A

Sulfonylurea
Gliptin
Pioglitazone

Start with 1, add 2nd if HbA1c ≥ 58

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51
Q

When to consider insulin in T2DM who can’t tolerate metformin?

A

After 2 drugs started and HbA1c rising to ≥ 58 or remains high

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52
Q

Dietary advice in T2DM

A

High fibre low GI carbs

Low fat dairy products

Oily fish

Reduce saturated fats + trans fats

Discourage diabetic foods

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53
Q

Target weight loss in T2DM

A

5-10%

Even if normal weight

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54
Q

When to start cholesterol medication in T2DM?

A

If 10 year cardiovascular risk score is >10% using QRISK 2

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55
Q

Primary prevention statin

A

Atorvastatin 20mg

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56
Q

Secondary prevention statin

A

Atorvastatin 80mg

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57
Q

BP targets in T2DM if age <80

A

clinic 140/90

ABPM 135/85

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58
Q

BP targets in T2DM if age >80

A

clinic 150/90

ABPM 145/85

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59
Q

First line treatment for hypertension in T2DM

A

ACEI or ARB

Use ARB if black/Caribbean

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60
Q

What will cause a lower than expected HbA1c?

A

Reduced red cell lifespan due to

  • sickle cell anaemia
  • GP6D deficiency
  • hereditary spherocytosis
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61
Q

What will cause a higher than expected HbA1c?

A

Increased red cell lifespan due to

  • Vit B12/folate acid deficiency
  • iron deficiency anaemia
  • splenectomy
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62
Q

Examples of SGLT-2 inhibitors

A

Canagliflozin

Dapagliflozin

Empagliflozin

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63
Q

What type of drug is canagliflozin?

A

SGLT2 inhibitor

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64
Q

What type of drug is dapagliflozin?

A

SGLT2 inhibitor

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65
Q

What type of drug is empagliflozin?

A

SGLT2 inhibitor

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66
Q

Mechanism of action of SGLT-2 inhibitors

A

Reversibly inhibit sodium-glucose cotransporter 2 in the renal PCT

to reduce glucose reabsorption and increase urinary glucose excretion

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67
Q

Side effects of SGLT-2 inhibitors

A

Urinary and genital infections

Fournier’s gangrene

Normoglycaemic ketoacidosis

Increased risk of lower limb amputation so need to monitor feet carefully

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68
Q

Examples of sulfonylureas

A

Gliclazide

Tolbutamide

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69
Q

What type of drug is gliclazide?

A

Sulfonylurea

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70
Q

What type of drug is tolbutamide?

A

Sulfonyulrea

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71
Q

Effect of SGLT-2 inhibitors on weight

A

Weight loss

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72
Q

Do SGLT-2 inhibitors cause hypoglycaemia?

A

Not by themselves

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73
Q

Mechanism of action of sulfonylureas

A

Increase pancreatic insulin secretion

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74
Q

Where in the pancreas do sulfonylureas work?

A

ATP dependent K+ channels on the cell membrane of pancreatic beta cells

to increase pancreatic insulin secretion

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75
Q

Side effects of sulfonylureas

A

Hypoglycaemia

Weight gain

SIADH

Bone marrow suppression

Cholestatic liver damage

Peripheral neuropathy

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76
Q

Effect of sulfonylureas on weight

A

Weight gain

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77
Q

Do sulfonylureas cause hypoglycaemia?

A

Yes

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78
Q

Which T2DM medication can cause liver damage?

A

Sulfonylureas cause cholestatic liver damage

Pioglitazone causes liver impairment, need to monitor LFTs

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79
Q

Example of thiazolidinediones

A

Pioglitazone

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80
Q

What type of drug is pioglitazone?

A

Thiazolidinedione

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81
Q

Mechanism of action of pioglitazone

A

Reduces peripheral insulin resistance

by agonising the PPAR-gamma receptor

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82
Q

Which T2DM medication reduces peripheral insulin resistance?

A

Pioglitazone

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83
Q

Side effects of pioglitazone

A

Weight gain

Liver impairment

Fluid retention so C/I in heart failure

Increased risk of fractures

Increased risk of bladder ca

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84
Q

Effect of pioglitazone on weight

A

Weight gain

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85
Q

Can pioglitazone cause hypoglycaemia?

A

Not when taken in isolation

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86
Q

Examples of meglitinides

A

Repaglinide

Nateglinide

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87
Q

What type of medication is repaglinide?

A

meglitinide, used in T2DM

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88
Q

What type of medication is nateglinide?

A

Meglitinide, used in T2DM

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89
Q

For which group of patients are meglitinides helpful?

A

Those with erratic lifestyles

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90
Q

Mechanism of action of meglitinides

A

Increase pancreatic insulin secretion

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91
Q

Side effects of meglitinides

A

Weight gain

Hypoglycaemia

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92
Q

Examples of rapid acting insulins

A

Aspart (novorapid)

Lispro (humalog)

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93
Q

Examples of short acting insulins

A

Actrapid

Humulin S

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94
Q

Examples of intermediate acting insulins

A

Isophane

Aspart protamine

lispro protamine

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95
Q

Examples of long acting insulins

A

Detemir (levemir)

Glargine (lantus)

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96
Q

Examples of GLP-1 mimics

A

Exenatide

Liraglutide

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97
Q

What type of drug is exenatide?

A

GLP-1 mimic

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98
Q

How is exenatide taken?

A

sub cut 60 minutes before morning and evening meal

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99
Q

How is liraglutide taken?

A

sub cut once daily

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100
Q

What type of drug is liraglutide?

A

GLP-1 mimic

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101
Q

Mechanism of action of GLP-1 mimics

A

Increase insulin secretion and inhibit glucagon secretion

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102
Q

Side effects of GLP-1 mimics

A

Nausea and vomiting

Renal impairment

Severe pancreatitis

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103
Q

Criteria for starting GLP-1 mimics

A

Triple therapy not effective AND one of:

BMI ≥ 35 + obesity related health problems
BMI <35 + insulin would cause occupational problems + weight related health conditions

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104
Q

Criteria for continuing GLP-1 mimics

A

Drop of 11 mmol/mol (1%) in HbA1c AND weight loss of 3% in 6 months

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105
Q

Effect of GLP-1 mimics on weight

A

Weight loss

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106
Q

Do GLP-1 mimics cause hypoglycaemia?

A

Not in isolation

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107
Q

Examples of DPP-4 inhibitors

A

Vildagliptin

Sitagliptin

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108
Q

What type of drug is vildagliptin?

A

DPP-4 inhibitor

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109
Q

What type of drug is sitagliptin?

A

DPP-4 inhibitor

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110
Q

What drug classification is generally referred to as gliptins?

A

DPP-4 inhibitors

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111
Q

Examples of gliptins

A

Vildagliptin

Sitagliptin

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112
Q

Mechanism of action of DPP-4 inhibitors/gliptins

A

Increase levels of incretins (GLP1 and GIP) by decreasing their peripheral breakdown

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113
Q

How are DPP-4 inhibitors/gliptins taken?

A

Orally

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114
Q

Impact of DPP-4 inhibitors/gliptins on weight

A

Weight neutral

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115
Q

Do DPP-4 inhibitors cause hypoglycaemia?

A

No

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116
Q

Two key causes of diabetic foot disease

A

Neuropathy

Peripheral artery disease

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117
Q

Screening for diabetic foot disease

A

Every year
Check for ischaemia by palpating pulses
Check for neuropathy using a 10g monofilament

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118
Q

Presentation of diabetic foot disease

A

Neuropathy

Ischaemia - absent foot pulses, intermittent claudication

Calluses

Ulceration

Charcot’s arthropathy

Cellulitis

Osteomyelitis

Gangrene

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119
Q

Diabetic foot disease - low risk

A

No risk factors except callus

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120
Q

Diabetic foot disease - moderate risk

A

1 of:

Deformity
Neuropathy
Non-critical limb ischaemia

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121
Q

Diabetic foot disease - high risk

A

Previous ulceration or amputation
on RRT

2 of: deformity, neuropathy, non-critical limb ischaemia

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122
Q

Inheritance of MODY

A

Autosomal dominance

123
Q

Presentation of MODY

A

T2DM in patients <25y
FH of early onset diabetes
no ketosis at presentation

124
Q

What does MODY stand for?

A

Maturity onset diabetes of the young

125
Q

Where is prolacin secreted from?

A

Anterior pituitary gland

126
Q

What is the primary prolactin releasing inhibitory factor?

A

Dopamine

127
Q

Features of excess prolactin in men

A

Impotence

Loss of libido

Galactorrhoea

128
Q

Features of excess prolactin in women

A

Amenorrhoea

Galactorrhoea

129
Q

Causes of raised prolactin

A

Prolactinoma

Pregnancy

Physiological - stress, exercise, sleep

Acromegaly

PCOS

Primary hypothyroidism

Drugs

130
Q

Drug causes of raised prolactin

A

Metoclopramide

Domperidone

Pheothiazines

Haloperidol

131
Q

Which medication can be used to control galactorrhoea?

A

Bromocriptine

132
Q

Features of metabolic syndrome

A 
Elevated waist circumference
Elevated triglycerides
Reduced HDL
Raised BP or on treatment for HTN
Raised fasting glucose or T2DM

Raised uric acid
NAFLD
PCOS

133
Q

Causes of thyrotoxicosis

A

Grave’s disease

Toxic multinodular goitre

Amiodarone

Acute phase of subacute thyroiditis, post partum thyroiditis or Hashimotos

134
Q

Investigations of thyrotoxicosis

A

Low TSH
High T4

TSH receptor antibodies in Grave’s disease

135
Q

Management of thyrotoxicosis

A

Propranolol

Carbimazole

Radioiodine treatment

136
Q

Carbimazole mechanism of action

A

Reduces thyroid hormone production

137
Q

Carbimazole side effects

A

Agranulocytosis

138
Q

Can carbimazole be used in pregnancy?

A

in 2nd and 3rd trimester

139
Q

Two regimes for using carbimazole

A

“antithyroid drug titration” start at 40mg then reduce till euthyroid

“block and replacement” carbimazole 40mg then add thyroxine when euthyroid

140
Q

Side effects of radioiodine

A

May make thyroid eye disease worse

Majority will become hypothyroid requiring thyroxine within 5 years

141
Q

Antibodies in Grave’s disease

A

TSH receptor stimulating antibodies in 90%

Anti-thyroid peroxidase antibodies in 75%

142
Q

Grave’s specific findings

A

Thyroid eye disease
Pretibial myxodemea
Thyroid acropachy

143
Q

What is thyroid acropachy?

A

Digital clubbing
Soft tissue swelling in hands and feet
Periosteal new bone formation

144
Q

How many with Grave’s disease get thyroid eye disease?

A

25-50%

145
Q

Risk factors for thyroid eye disease

A

Smoking

Radioiodine

146
Q

Features of thyroid eye disease

A 
Exophthalmos
Conjunctival oedema
Optic disc swelling
Ophthalmoplegia
Risk of exposure keratopathy
147
Q

Management of thyroid eye disease

A

Topical lubricants to prevent corneal inflammation
Steroids
Radiotherapy
Surgery

148
Q

What is toxic multinodular goitre?

A

Autonomously functioning thyroid nodules that secrete excess thyroid hormone

149
Q

Causes of hypothyroidism

A

Hashimoto’s thyroiditis

Subacute thyroiditis (de Quervian’s)

Iodine deficiency

Post partum thyroiditis

Reidel thyroiditis

Drugs - lithium, amiodarone, carbimazole

150
Q

When to have a lower starting dose for levothyroxine?

A

Age >50

History of ischaemic heart disease

151
Q

Goal of levothyroxine treatment

A

Normal TSH

152
Q

Side effects of levothyroxine

A

Hyperthyroidism

Reduced bone mineral density

Angina

AF

153
Q

Interactions to levothyroxine

A

Iron, calcium carbonate

Reduce absorption therefore give 4 hours apart

154
Q

TFTs in primary hypothyroidism

A

Raised TSH, Low T4

155
Q

TFTs in secondary hypothyroidism

A

Low TSH, Low T4

156
Q

TFTs in sick euthyroid syndrome

A

Low TSH, Low T4

157
Q

Cause of low TSH and low T4

A

Secondary hypothyroidism

Sick euthyroid syndrome

158
Q

TFTs in subclinical hypothyroidism

A

Raised TSH, normal T4

159
Q

TFTs in poor thyroxine compliance

A

Raised TSH, normal T4

160
Q

Cause of raised TSH and normal T4

A

Subclinical hypothyroidism

Poor thyroxine compliance

161
Q

Cause of raised TSH and low T4

A

Primary hypothyroidism

162
Q

What is Reidel thyroiditis?

A

Fibrous tissue replacing normal thyroid parenchyma

163
Q

Features of Reidel thyroiditis

A

Painless goitre, hard, fixed
Middle aged women
Associated with retroperitoneal fibrosis

164
Q

Drug causes of hypothyroidism

A

Lithium
Amiodarone
Antithyroid drugs e.g. carbimazole

165
Q

What is Hashimoto’s thyroiditis?

A

Chronic autoimmune thyroiditis causing hypothyroidism

May have a transient thyrotoxicosis

166
Q

Is there a goitre in Hashimoto’s thyroiditis?

A

Firm, non-tender goitre

167
Q

Associations with Hashimoto’s thyroiditis

A

Coeliac

T1DM

Vitiligo

MALT lymphoma

168
Q

Investigations for Hashimoto’s thyroidits

A

Raised TSH low T4

Anti-thyroid peroxidase antibodies

Anti-thyroglobulin antibodies

169
Q

Is there a goitre in Subacute thyroidits?

A

Painful goitre

170
Q

Presentation of subacute thyroidits

A

After viral infection

Initially hyperthyroid, then euthyroid, then hypothyroid

171
Q

Management of subacute thyroidits

A

Self limiting
Asprin and NSAIDs for thyroid pain
Steroids in severe cases

172
Q

Changes to thyroxine dose in pregnancy

A

Increase up to 50% by 4-6 weeks

173
Q

Is thyroxine safe in pregnancy and breastfeeding?

A

Yes

174
Q

Thyrotoxicosis management in 1st trimester

A

Propylthiouracil

175
Q

Thyrotoxicosis management in 2nd and 3rd trimester

A

carbimazole

176
Q

What level do you maintain maternal thyroxine levels at during pregnancy?

A

Upper 3rd of normal to avoid fetal hypothyroidism

177
Q

Why do we change thyrotoxicosis management during pregnancy?

A

Carbimazole increases risk of congenital abnormality

Propylthiouracil has increased risk of hepatic injury

178
Q

Causes of thyrotoxicosis during pregnancy

A

Grave’s disease

Transient gestation hyperthyroidism - activation of TSH receptor by HCG

179
Q

What complications can thyrotoxicosis cause during pregnancy?

A

Increased risk of fetal loss
Maternal heart failure
Premature labour

180
Q

Causes of primary hypoadrenalism

A

Addison’s disease

TB

Metastases e.g. bronchial carcinoma

Waterhouse-Friderichsen syndrome

HIV

181
Q

Causes of secondary hypoadrenalism

A

Pituitary disorders e.g. tumours, irradiation, infiltration

182
Q

What is Bartter’s syndrome?

A

Inherited cause of hypokalaemaia

due to defective chloride absorption at the Na/K/Cl cotransporter in the ascending LoH

183
Q

Inheritance of Bartter’s syndrome

A

Autosomal recessive

184
Q

Features of Bartter’s syndrome

A

Normotension
Hypokalaemia
FTT
Polyuria, polydipsia

185
Q

Drugs causing gynaecomastia

A 
Spironolactone
Cimetidine
Digoxin
Cannabis
Finasteride
GnRH agonists - goserelin
Oestrogen, steroids
186
Q

Two key causes of hypercalcaemia

A

Primary hyperparathyroidism

Malignancy - bone mets, myeloma, squamous cell lung ca

187
Q

Causes of hypercalcaemia

A 
Primary hyperparathyroidism
Malignancy
Sarcoidosis
Vit D toxicity
Acromegaly
Milk-alkali syndrome
Addison's
188
Q

Drugs causing hypercalcaemia

A

Thiazides

Calcium containing antacids

189
Q

Causes of hypoglycaemia

A 
Insulinoma
Insulin/Sulphonylureas
liver failure
Addison's
Alcohol
Nesidioblastosis - beta cell hyperplasia
190
Q

Treatment of hypoglycaemia

A

10-20g oral glucose
Glucogel
Glucagon

191
Q

Investigations to confirm Cushing’s syndrome

A

Overnight dexamethasone suppression test

24 hour urinary free cortisol

192
Q

Management of pheochromocytoma

A

Stabilise medically then surgery

Alpha blocker first - phenoxybenzamine

Then beta blocker - propranolol

193
Q

What is a pheochromocytoma?

A

Rare catecholamine secreting tumour

194
Q

Features of phaeochromocytoma

A 
Episodic
HTN
Headaches
Palpitations
Sweating
Anxiety
195
Q

Investigations for phaeochromocytoma

A

24 hour urinary collection of metanephrines

196
Q

What is carcinoid syndrome?

A

When metastases present in the liver and release serotonin into systemic circulation

Can also occur with lung carcinoid

197
Q

Investigations for carcinoid tumours

A

Urinary 5-HIAA

Plasma chromogranin A Y

198
Q

Management of carcinoid tumours

A

Somtatostatin analogues - ocreotide

Cyproheptadine may help with diarrhoea

199
Q

What is pituitary apoplexy?

A

Sudden enlargement of pituitary tumour secondary to haemorrhage or infarction

200
Q

Criteria for diagnosing DKA

A

Glucose >11 or known diabetic
pH <7.3
Bicarb <15
Ketones >3

201
Q

What is neuroblastoma?

A

Common childhood malignancy arising from the neural crest tissue of adrenal medulla and sympathetic nervous system

202
Q

Symptoms of neuroblastoma

A 
Abdo mass
Pallor
Weight loss
Bone pain, limp
Hepatomegaly
Paraplegia
Proptosis
203
Q

Investigations for neuroblastoma

A

Raised urinary VMA and HVA levels
Calcification on abdo xray
Biopsy

204
Q

Phaeochromocytoma associations

A

MEN type II
Neurofibromatosis
Von Hippel-Lindau syndrome

205
Q

What is a prolactinoma?

A

Pituitary adenoma which produces an excess of prolactin

206
Q

Management of prolactinoma

A

Medically - dopamine agonists (cabergoline bromocriptine)

Surgery if meds not tolerated

207
Q

Examples of dopamine agonists

A

Bromocriptine

Cabergoline

208
Q

What type of drug is bromocriptine?

A

Dopamine agonist

209
Q

What type of drug is cabergoline?

A

Dopamine agonist

210
Q

Features of hypoparathyroidism

A 
Paraesthesia
Oral numbness
Facial twitching
Muscle spasm
Bone pain
Depression, confusion
Cataracts
Seizures
211
Q

Signs of hypoparathyroidism

A

Chvostek’s sign

Trousseau’s sign

212
Q

ECG in hypoparathyroidism

A

Prolonged QTc

213
Q

Management of hypoparathyroidism

A 
Severe = IV calcium
Mild/mod = oral calcium + vit D
214
Q

Primary hypoparathyroidism causes

A

Reduced PTH secretion e.g. secondary to thyroid surgery

215
Q

Primary hypoparathyroidism - investigations

A

Low calcium
High phosphate
Low/inappropriately normal PTH

216
Q

Primary hypoparathyroidism - management

A

Alfacalcidol

217
Q

Pseudohypoparathyroidism - investigations

A

Low calcium
High phosphate
High PTH

218
Q

Pseudohypoparathyroidim - features

A

Low IQ
Short stature
Shortened 4/5th metatarsals

219
Q

What is pseudohypoparathyroidism?

A

Inadequate response to PTH, normal amount of PTH

220
Q

What is pseudopseudohypoparathyroidism?

A

Same phenotype as pseudohypoparathyroidism but normal biochemistry

221
Q

Primary hyperparathryoidism - causes

A

Solitary adenoma (80%)
Hyperplasia
Multiple adenoma
Carcinoma

222
Q

Primary hyperparathryoidism - who is typically affected?

A

Elderly women
Thirsty
With normal or raised PTH

223
Q

Primary hyperparathryoidism - associations

A

Hypertension

MEN I and MEN II

224
Q

Primary hyperparathryoidism - investigations

A

Raised calcium
Low phosphate
PTH raised or inappropriately normal
Xray: pepperpot skull

225
Q

Primary hyperparathryoidism - features

A 
Polydipsia, polyuria
Peptic ulcer
Constipation
Pancreatitis
Bone pain or fractures
Renal stones
Depression
Hypertension
226
Q

Secondary hyperparathyroidism - causes

A

Any disorder causing hypocalcaemia will elevate PTH and cause secondary hyperparathyroidism

CKD
Malabsorption e.g. crohns, coeliac, chronic pancreatitis
Chronic inadequate sunlight

227
Q

Secondary hyperparathyroidism - investigations

A

Raised calcium

Raised PTH

228
Q

Secondary hyperparathyroidism - management

A

Reduce serum phosphate

Boost dietary calcium

229
Q

What is tertiary hyperparathyroidism?

A

Parathyroid glands develop autonomous function in patients with long standing secondary hyperparathyroidism

Management = subtotal parathyroidectomy

230
Q

Features of MEN I

A

Hyperparathyroid secondary to hyperplasia

Pituitary tumour

Insulinoma

Gastrinoma causing recurrent peptic ulcer

231
Q

Most common presentation of MEN I

A

Hypercalcaemia

232
Q

Features of MEN IIa

A

Medullary thyroid cancer

Parathyroid tumours

Phaeochromocytoma

233
Q

Features of MEN IIb

A

Medullary and thyroid cancer

Phaeochromocytoma

Marfanoid body habitus

Neuromas

234
Q

Key features of Kallman’s syndrome

A

Ansomnia

Delayed puberty

Hypogonadism

Cleft lip/palate

235
Q

Key features of Klinefelter’s syndrome

A 
Tall
Infertile
Small testes
Lack secondary sexual characteristics
Gynaecomastia
236
Q

Key features of androgen insensitivity syndrome

A

Primary amenorrhoea

Groin swellings from undescended testes

237
Q

Hormones in testosterone secreting tumour

A

LH low

Testosterone high

238
Q

Hormones in androgen insensitivity syndrome

A

LH high
Oestrogen high
Testosterone high

239
Q

Inheritance of androgen insensitivity syndrome

A

X linked recessive

240
Q

Key features of 5-alpha reductase deficiency

A

Males unable to convert testosterone
Ambiguous genitalia at birth
Hypospadias
Virilisation at puberty

241
Q

Hormones in Kallman’s syndrome

A

LH low
FSH low
Testosterone low

242
Q

Inheritance of Kallman’s syndrome

A

X linked recessive

243
Q

Hormones in Klinefelter’s syndrome

A

LH high
FSH high
Testosterone low

244
Q

What is primary hyperaldosteronism?

A

Excess production of aldosterone

245
Q

Primary hyperaldosteronism - causes

A

Bilateral idiopathic adrenal hyperplasia

Adrenal adenoma (Conn’s syndrome)

Adrenal carcinoma

246
Q

Primary hyperaldosteronism - features

A 
HTN
Hypokalaemia
Muscle weakness
Polyuria, polydipsia
Alkalosis
247
Q

Primary hyperaldosteronism - investigations

A 
Low potassium
Low renin, high aldosterone
Aldosterone: renin ratio high
CT abdomen
Adrenal vein sampling - if one side has high aldosterone then adenoma likely
248
Q

When to consider Conn’s syndrome?

A

Hypertension with hypokalaemia
Refractory hypertension
Hypertension <40 years

249
Q

Primary hyperaldosteronism - management of bilateral idiopathic adrenal hyperplasia

A

Aldosterone antagonist e.g. spironolactone

250
Q

Example of an aldosterone antagonist

A

Spironolactone

251
Q

What type of drug is spironolactone?

A

Aldosterone antagonist

252
Q

Management of Conn’s syndrome

A

surgical excision

253
Q

Causes of primary adrenal insufficiency

A

Addison’s
Congenital adrenal hyperplasia
Waterhouse-Friederichsen syndrome

254
Q

Causes of secondary adrenal insufficiency

A

Exogenous steroids

Sheehan’s syndrome

255
Q

Features of adrenal insufficiency

A 
Fatigue
Dehydration
N+V 
Salt craving
Hyperpigmentation
Postural hypotension
256
Q

Features of adrenal crisis

A

Collapse
Shock
Pyrexia

257
Q

Investigations of adrenal insufficiency

A

Low sodium High potassium
Low aldosterone High renin
Hypoglycaemia

ACTH - high in primary, low in secondary
ACTH stimulation test

CT adrenals

258
Q

Causes of acute adrenal insufficiency

A 
Infection
Trauma
Surgery
Missed medication
Waterhouse-Friderichsen syndrome
259
Q

Management of acute adrenal insufficiency

A

IV fluids
100mg IV hydrocortisone
Dextrose if hypoglycaemic

260
Q

What is Addison’s disease?

A

Autoimmune destruction of the adrenal glands

Causes primary adrenal insufficiency

261
Q

Investigations for Addison’s disease

A

Low sodium High potassium
ACTH stimulation test
Random cortisol at 9am

262
Q

Management of Addison’s disease

A

Hydrocortisone - in 2 or 3 divided doses

Fludrocortisone

263
Q

Addison’s disease - sick day rules

A

Double hydrocortisone

Keep fludrocortisone the same

264
Q

Causes of Cushing’s syndrome

A

ACTH dependent:

  • Cushing’s disease
  • Ectopic ACTH secreting tumours

ACTH independent:

  • exogenous steroids
  • adrenal adenoma
  • adrenal carcinoma
265
Q

What is Cushing’s diseaes?

A

Pituitary tumour secreting ACTH causing adrenal hyperplasia

266
Q

What is pseudocushings?

A

Cushings caused by alcohol, depression, HIV, diabetes

Insulin stress test to differentiate from Cushing’s

267
Q

Investigations to confirm Cushing’s

A

24h urinary free cortisol >3x upper limit of normal
1mg overnight dexamethasone suppression test
Late night cortisol

268
Q

What is acromegaly?

A

Excess growth hormone secretion

269
Q

Causes of acromegaly

A

Pituitary adenoma in 95%
Ectopic GHRH
GH production by tumours e.g. pancreatic

270
Q

Acromegaly - investigations

A

Raised glucose, phosphate, calcium, TAG
IGF-1
Oral glucose tolerance test to confirm raised IGF-1
MRI pituitary + hypothalamus

271
Q

Management of acromegaly

A

Trans-sphenoidal surgery
Somatostatin analogues - ocreotide
Dopamine agonists - cabergoline

272
Q

Complications of acromegaly

A

HTN
Diabetes
Cardiomegaly
Colorectal cancer

273
Q

Who should get primary prevention with statins?

A

High risk of cardiovascular disease with 10 year risk >10%

274
Q

How do we calculate cardiovascular risk?

A

QRISK2

275
Q

Which patient groups can we not use QRISK2 on?

A

T1DM
eGFR <60 or albuminuria
History of familial hyperlipidaemia

276
Q

When to investigate for familial hypercholesterolaemia

A

Total cholesterol >7.5
Family history of premature coronary heart disease

Refer if total cholesterol >9.0 or LDL >7.5 even with no family history

277
Q

When to offer statins to T1DM?

A

Older 40
Diabetes for >10 years
Nephropathy
Other CVD risk factors

278
Q

Prescribing statins to CKD patients

A

All CKD patients should get atorvastatin 20mg

Increase dose if greater than 40% reduction in non-HDL cholesterol not achieved and eGFR >30

279
Q

When to follow up patients who have been started on a statin?

A

3 months

280
Q

Goal of statin therapy

A

Reduce non-HDL cholesterol by 40%

If hasn’t met this then increase atorvastatin to 80mg

281
Q

Goal for physical activity

A

150 minutes moderate intensity aerobic activity or 75 minutes vigorous intensity

Muscle strengthening activities on 2 days

282
Q

Who should get atorvastatin for primary prevention?

A

QRISK2 >10%
most T1DM
CKD if eGFR <60

283
Q

Consequence of vitamin A deficiency

A

Night blindness

284
Q

Consequence of vitamin B1 deficiency

A

‘Beriberi’
Polyneuropathy
Wernicke-Korsakoff
Heart failure

285
Q

Consequence of vitamin B3 deficiency

A

‘Pellagra’
Dermatitis
Diarrhoea
Deficiency

286
Q

Which vitamin is folic acid?

A

B9

287
Q

Which vitamin is niacin?

A

B3

288
Q

Which vitamin is thiamine?

A

B1

289
Q

Consequence of vitamin C deficiency

A

Scurvy
Gingivitis
Bleeding

290
Q

Which vitamin is ascorbic acid?

A

C

291
Q

Which vitamin is cyanocobalamin?

A

B12

292
Q

Consequence of vitamin K deficiency

A

Haemorrhagic disease of the newborn

293
Q

Inheritance of familial hypercholesterolaemia

A

Autosomal dominant

294
Q

Statins and pregnancy

A

Discontinue 3 months before conception due to risk of congenital defects

295
Q

For which patient groups does QRISK2 underestimate cardiovascular risk?

A

HIV
Serious mental health problems
Drugs causing dyslipidaemia e.g. antipsychogics, steroids, immunosupressants
Autoimmune or inflammatory disorders

296
Q

Foods high in potassium

A 
Salt substitutes
Bananas
Oranges
Kiwi
Avocado
Spinach
Tomatoes
297
Q

Causes of hypokalaemia with hypertension

A

Cushing’s syndrome
Conn’s syndrome
Liddle’s syndrome

298
Q

Causes of hypokalaemia without hypertension

A 
Diuretics
GI loss
Renal tubular acidosis
Bartter's syndrome
Gitelman syndrome
299
Q

Hyperkalaemia - ECG changes

A

tall tented T waves
small P waves
Widened QRS

300
Q

Causes of predominantly hypercholesterolaemia

A

Nephrotic syndrome
Cholestatis
Hypothyroidism

301
Q

How does ezetimibe work?

A

Decreases cholesterol absorption in the small intestine

302
Q

Management of SIADH

A

Fluid restrict

Demeclocycline

303
Q

First line management for diabetic neuropathy

A

Amitriptyline
Duloxetine
Gabapentin
Pregabalin

304
Q

Management gastroparesis in diabetics

A

Metoclopramide
Domperidone
Erythromycin

AKT (20 decks)

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