Endocrinology

Question 1

Causes of osteoporosis

Answer 1

Primary:
- idiopathic
- post menopausal

Secondary: (ME DR G)
- malignancy = myeloma, metastatic cancer
- endocrine = cushing’s disease, thyrotoxicosis, primary hyperPTH, hypogonadism
- drugs = steroids, heparin
- rheum = RA, AS
- gastro = malabsorption (e.g. coeliac, partial gastrectomy), liver disease (e.g. PBC), anorexia

Question 2

Osteoporosis risk factors (SHATTERED)

Answer 2

Steroid use of >5m/g prednisolone
Hyperthyroidism
Hyperparathyroidism
Hypercalciuria
Alcohol and tobacco use
Thin (<BMI<22)
Testosterone low
Early menopause/late menarche
Renal or liver failure
Erosive/inflammatory bone disease, e.g. RA
Dietary calcium low/malabsorption/DMT1

Question 3

Management of post-menopausal woman with hip fracture and normal Ca and no diagnosis of osteoporosis

Answer 3

Bisphosphonates (e.g. ALENDRONATE, Risedronate) and calcium supplements

Osteoporosis guidelines state if a postmenopausal woman has a fracture she should be put on bisphosphonates (there is no need for a DEXA scan)

Question 4

What is the FRAX tool?

Answer 4

An online tool that combines risk factors and femoral neck T-score to estimate 10-year fracture risk

Question 5

Conservative measures for osteoporosis

Answer 5

o Smoking cessation
o Reduce alcohol intake
o Weight-bearing and muscle-strengthening exercise: 20 mins 3x per week
o Diet with optimal calcium and vit D: 1g calcium and 800-1000 units vit D daily
o Maintain BMI > 19
o Falls prevention - elderly care fall clinics, fall physiotherapy

Question 6

What monoclonal antibody can be used in osteoporosis to inhibit bone resorption?

Answer 6

Denosumab

SC 6 monthly

Question 7

What agents can increase bone formation in osteoporosis?

Answer 7

Teriparatide
* Recombinant human PTH  inc activation of osteoblasts
* Daily SC injection
* Prescribed by specialists in severe cases

Abaloparatide
* Stimulates PTH type 1 receptor

Question 8

What surgery can be done in vertebral osteoporotic fractures?

Answer 8

Kyphoplasty

Question 9

Triad of thyroid acropachy

Answer 9

Digital clubbing
Soft tissue swelling of hands/feet
Periosteal new bone formation

Question 10

What familial syndromes put patients at risk of phaeochromocytoma?

Answer 10

Men 2a and 2b
Von Hippel Lindau Syndrome
Neurofibromatosis type 1

Question 11

What do you use in hypertensive crisis for phaeochromocytoma?

Answer 11

Short-acting IV alpha blocker phentolamine

Question 12

What are some complications of phaeochromocytoma?

Answer 12

Malignant hypertension
Hypertensive encephalopathy
Post-operative complications (hypoglycaemia, hypotension, arrhythmia)

Question 13

What is pioglitazone shown to increase the risk of?

Answer 13

Risk of bladder cancer

Question 14

What can cause lower than expected Hb1Ac levels?

Answer 14

Sickle-cell anaemia
G6PD deficiency
Haemodialysis
Hereditary spherocytosis

Question 15

What can cause higher than expected Hb1Ac levels?

Answer 15

IDA
Vit B12/folic acid deficiency
Splenectomy

Question 16

What anti-diabetic drug is contraindicated in heart failure?

Answer 16

Pioglitazone (thiazolidinediones)

Question 17

Sulphonylurea side effects?

Answer 17

Hypoglycaemia
Weight gain

Example - gliclazide

Question 18

What is the therapy for toxic multinodular goitre?

Answer 18

Radioiodine therapy

Question 19

Three signs of disease activity in Grave’s disease

Answer 19

Tremor
Tachycardia
Lid lag

Question 20

What is Lofgren’s syndrome?

Answer 20

Specific type of sarcoidosis

Triad of:
- erythema nodosum
- bilateral hilar lymphadenopathy
- polyarthralgia

Question 21

What are differentials for sarcoidosis?

Answer 21

TB
Lymphoma
HIV
Hypersensitivity pneumonitis
Toxoplasmosis
Histoplasmosis

Question 22

Management of sarcoidosis

Answer 22

1. Usually no treatment (no/mild symptoms) - majority resolve themselves
2. Oral steroids for 6-24 months (given with bisphosphonates to protect bones)
3. Immunosuppressants (e.g. methotrexate, azathioprine)

Severe pulmonary disease –> lung transplant

Question 23

Management of sarcoidosis

Answer 23

1. Usually no treatment (no/mild symptoms) - majority resolve themselves
2. Oral steroids for 6-24 months (given with bisphosphonates to protect bones)
3. Immunosuppressants (e.g. methotrexate, azathioprine)

Severe pulmonary disease –> lung transplant

Question 24

Best indicator of hypovolaemia in hyponatraemia?

Answer 24

Low Urine Na+

Question 25

How to treat Addisonian crisis?

Answer 25

Hydrocortisone 100 mg im or iv
1L normal saline infused over 30-60 mins or with dextrose if hypoglycaemic
Continue hydrocortisone 6 hourly until the patient is stable. No fludrocortisone is required because high cortisol exerts weak mineralocorticoid action
Oral replacement may begin after 24 hours and be reduced to maintenance over 3-4 days

Question 26

How to treat subclinical hypothyroidism:
- T4 normal, TSH > 10
- TSH 5-10, TPO +ve
- TSH 5-10, TPO -ve

Answer 26

• T4 normal, TSH > 10 = treat
• TSH 5-10, TPO +ve = repeat annually & commence thyroxine when TSH > 10
• TSH 5-10, TPO -ve = check every 3-5 years

Question 27

Common causes of hypocalcaemia

Answer 27

Vitamin D deficiency
Hypoparathyroidism (neck surgery/radiation, chronic renal failure)
Hypomagnesaemia (diarrhoea, IBD, PPIs)
Pancreatitis

Question 28

How do you know when hypocalcaemia is an emergency?

Answer 28

QT prolongation
Signs of tetany

Question 29

Causes of gynaecomastia

Answer 29

• Most idiopathic
• Causes include renal failure, cirrhosis, testicular tumours (b-hCG), drugs (spironolactone, cannabis, oestrogen, steroids)
• Check for endocrine causes e.g. Klinefelter’s, hypogonadism, Cushing’s, CAH