Endocrinology

Question 1

What are the findings, investigation and management for Addison’s Disease?

Answer 1

Fatigue
Anorexia, weight loss 
Hyperpigmentation - present in mucosa and sun-exposed areas, palmar creases 
Nausea, vomiting,hypotension 
Uncommonly: salt craving 

Hyponatremia and hyperkalemia in a patient with lethargy is highly suggestive of Addison’s disease

Morning serum cortisol - decreased
Short synACTHen test - elevated (will be decreased in secondary or tertiary adrenal insufficiency) - better test to do

Adrenal crisis = hydrocortisone sodium succinate
Glucocorticoid + mineralocorticoid = pred/ cortisone/hydrocortisone

Question 2

What are the investigations for cushings syndrome?

Answer 2

late-night salivary cortisol
1 mg overnight low-dose dexamethasone suppression testing
24-hour urinary free cortisol
48-hour 2 mg dexamethasone suppression testing).

Question 3

What are the findings, investigation and management for diabetic ketoacidosis

Answer 3

Occurs in T1 diabetics

Nausea/vomiting 
Abdominal pain 
Dehydration 
Hyperventilation 
Reduced consciousness - coma/delerium 

VENOUS blood gas - metabolic acidosis
Blood ketones

1L of saline (0.9% sodium chloride)
Add potassium to SECOND IV fluids if potassium is low.

Serious Complication of DKA is cerebral oedema - headache, nausea/vomiting, seizures

Question 4

What are the findings in hypercalcemia of malignancy? How do you treat it?

Answer 4

Stones thrones bones groans and psychiatric overtones
Nausea, loss of appetite, CONSTIPATION
Bone pain
Fatigue, confusion, coma
POLYURIA (induces nephrogenic diabetes insipidus), polydipsia
Muscle weakness

Moderate to severe = IV saline + IV bisphosphonates/ denosumab + treat malignancy

Question 5

What is hyperosmolar hyperglycemic state? How do you manage it?

Answer 5

profound hyperglycaemia (glucose >30 mmol/L), HYPEROSMOLARITY (>320 mOsm/kg), and VOLUME DEPLETION in the absence of significant ketoacidosis (pH >7.3 and bicarbonate >15 mmol/L)

Occurs in T2DM

IV saline - mixed with potassium if necessary
Then insulin
Treat precipitating illness, thromboprophylaxis(LMWH)

Question 6

What are the findings, investigation and management for primary hyperparathyroidism

Answer 6

Hypercalcemia symptoms, especially myalgia, fatigue, confusion, memory loss, kidney stone
RFs - lithium treatment, MEN syndrome

Serum calcium and PTH - elevated

Parathyroidectomy
Acute hypercalcemia = IV Fluids, followed by bisphosphonates if calcium remains high

Question 7

What are the examination and investigation findings is secondary hyperparathyroidism?

Answer 7

Features of CKD or malabsorption syndromes
Muscle cramps/bone pain due to osteomalcia
Hypocalcemia signs - perioral tingling or paresthesias in toes/fingers, chvostek’s sign, trousseau’s sign,

Low calcium, high PTH, high phosphate

Question 8

What causes tertiary hyperparathyroidism? What are the examination findings?

Answer 8

Refractory autonomous hyperparathyroidism resulting from chronic kidney disease. PTH and Ca are both high. Phosphate high

Parathyroid surgery indicated

Question 9

What is the treatment for graves disease?

Answer 9

Antithyroid drug - carbimazole
Radioactive iodine + prednisolone
Thyroid surgery
Thyroid storm is treated with - antithyroid drugs(e.g. Carbimazole, PTU), corticosteroids, beta blockers, iodine solution

Question 10

What are the different causes of thyrotoxicosis?

Answer 10

graves, thyroid nodules(thyroid adenoma, toxic multinodular goitre), early thyroiditis, amiodarone, iodine load

Question 11

How do you investigate a toxic thyroid adenoma?

Answer 11

Thyroid ultrasound - shows nodule = a single hyperfunctioning area with suppression of contralateral gland

radioactive iodine therapy I-131. Antithyroid drugs if pregnant

Question 12

How do you investigate and manage toxic multinodular goitre?

Answer 12

Serum testing to confirm hyperthyroid
I-123 thyroid scan - multiple hot and cold areas.

radioactive iodine therapy I-131. Antithyroid drugs if pregnant

Question 13

Summarise the examination findings, investigations and management for Subacute granulomatous thyroiditis

Answer 13

Inflammation of the thyroid characterised by a triphasic course of transient thyrotoxicosis, followed by hypothyroidism, followed by a return to euthyroidism.

History and Examination
Thyroid pain and tenderness. Often following flu-like illness e.g. fever
Enlarged thyroid

Investigation
Serum thyroid hormones
Radioactive iodine uptake = low

Management - self limiting = NSAIDs

Question 14

What are the findings, investigation and management for thyroid cancer?

Answer 14

asymptomatic thyroid nodule detected by palpation or ultrasound.
Uncommonly: voice hoarseness, difficulty swallowing

PAPILLARY THYROID CANCER most common- TSH normal/ euthyroid
- use thyroglobulin as tumour marker

Follicular thyroid cancer 2nd most common
- use thyroglobulin as tumour marker

Medullary thyroid cancer

• hypocalcemia due to high calcitonin
• associated with MEN2a and MEN2b
• use calcitonin as tumour marker

anaplastic thyroid cancer
- very aggressive

Ultrasound - nodules
Fine needle aspiration

Total thyroidectomy followed by radioactive iodine ablation and TSH suppression.

Question 15

What is the management for T1DM?

What test distinguishes from type 2?

Answer 15

Basal insulin - detemir, glargine
Bolus insulin = “LAG” = lispro, aspart, glulisine

Anti GAD-65

Question 16

What is the first line management for T2DM?

what if patients diabetes is uncontrolled and they have atherosclerotic cardiovascular disease?

Answer 16

First line = lifestyle changes to reach HBA1C goal
If still above this = metformin

with cardiovascular disease and persistently high HBA1C give:

1. empagliflozin (SGLT2) or
2. Liraglutide (GLP-1)

Question 17

Define hypothermia

Answer 17

a core body temperature <35°C (<95°F).

Question 18

Define heat stroke

Answer 18

Core body temp >40 degrees celsius

Question 19

State some symptoms of hypoglyceamia

Causes?

Treatment of hypoglycaemia with impaired consciousness?

Answer 19

1. Sweating
2. Tremor
3. Confusion
4. Blurred vision

• excess insulin
• insulinoma (MEN 1 & 2 = RFs)

IM Glucagon

Question 20

What are the symptoms of hypothyroidism? How do you manage it?

Answer 20

weakness, lethargy, depression, and mild weight gain.
dry skin, thick tongue, eyelid oedema, bradycardia, constipation may occur
Macrocytic anemia

Levothyroxine

Question 21

What are the causes of hypothyroidism?

Answer 21

hashimotos(anti-thyroid peroxidase antibodies)

post-partum, cretinism, SG thyroiditis

Question 22

Define obesity

Answer 22

defined as a BMI ≥30 kg/m²)

Question 23

Causes and symptoms of hypoparathyroidism?

Investigation and management?

Answer 23

Leads to hypocalcemia:
neuromuscular irritability(tingling of fingers, toes, mouth)
intermittent muscle spasms(tetany) - trousseau’s sign, Chvostek’s sign 

Causes include:
Surgical excision of parathyroid gland - often incidental
Systemic diseases - hemochromatosis, wilson’s disease, metastatic cancer
APS-1 - triad of candidiasis, autoimmune hypoparathyroidism, addisons disease
Thymic aplasia/ Di George syndrome

Investigation
Low PTH and Low Ca

Management
Calcium and calcitriol

Question 24

What are the findings, investigation and management for osteomalacia?

Answer 24

diffuse bony pain usually with a history of limited sunlight exposure.
Proximal muscle weakness, spinal tenderness to percussion, pseudofractures, and skeletal deformities are found commonly.

Investigation
Serum vitamin D = low
Serum calcium = low/normal
Serum PTH - high

Management
Calcium + vitamin D

Question 25

What is the most common cause of hypercalcemia?

Answer 25

Primary hyperparathyroidism