Endocrinology Flashcards
1
Q
What is most common cause of hypopituitarism
A
Non secretory pituitary macroadenoma
2
Q
What do if multiple painkillers have not worked for neuropathic pain from diabetic neuropathy
A
Refer to pain clinic
3
Q
What is management first line of acromegaly
A
Transsphenoidal surgery
4
Q
Medication options for treating acromegaly if surgery fails
A
Somatostatin analogues- octreotide
Pegvisomat- GH receptor antagonist
Dopamine agonist- bromocriptine
5
Q
What is pegvisomat
A
GH receptor antagonist
6
Q
Blood findings in cushings
A
Blood gas
- hypokalaemia metabolic alkalosis
- hypernatraemia
High glucose
7
Q
Causes of cushings
A
Iatrogenic steroid use
ACTH dependant
- pituitary tumour (cushings disease)
- ectopic ACTH
ACTH independant
- adrenal adenoma
8
Q
First line tests- gold standard+what else can be used for cushings
A
Gold standard first line- low dexamethasone test
Can use 24 hr urinary cortisol and evening salivary cortisol
9
Q
How investigate cause of cushings
A
Inferior petrosal sinus sampling is preferred
Can also use high dose dexamethasone test
10
Q
Management of hypokalaemia
A
Above 2.5 and asymptomatic= sando k tablets
Below 2.5 or symptomatic= cardiac monitoring and IV potassium chloride
11
Q
What is maxium infusion rate for saline with potassium chloride
A
Should not exceed 20mmol/hour as irritant to veins
Have to do rates above 10mmol on ITU
12
Q
What should every person on insulin be given
A
Glucagon emergency kit if swallow impaired
13
Q
What is risk of continuous inuslin injections in the same place
A
Lipodystrophy which presents as lumps or atrophy of fat
14
Q
Education points for patients on insulin
A
Advise about rotation of sites to avoid lipodystrophy
Safety net about signs of hypoglycaemia
- anxiety
- confusion
- sweating
- blurred vision
If swallow intact-> glass of lucozade or 15-20g glucose gel
If swallow impaired-> glucagon emergency kit
15
Q
MOA of sulphonylureas
A
Increase pancreatic insulin production
16
Q
Common side effects of sulphonylureas
A
Hypos
Weight gain
17
Q
Rarer side effects of sulphonylureas
A
SIADH
BM suppression
Hepatotoxic
Peripheral neuropathy
18
Q
When avoid sulphonylreas
A
Breastfeeding and pregnancy
19
Q
Investigating de quervains
A
Globally reduced iodine uptake on thyroid scintigraphy
Raised ESR in initial stage
20
Q
Painful goitre and hyperthyroid
A
De quervains
21
Q
How long do phases to de quervains last
A
weeks
22
Q
What can cause a ketoacidosis that isnt diabetic
A
Alcohol
23
Q
Blood findings of alcoholic ketoacidosis
A
Metabolic acidosis
Elevated anion gap
Elevated serum ketone levels
Normal or low glucose concentration
24
Q
Management of alcoholic ketoacidosis
A
Saline and thimaine infusion
25
Risk factors for small bowel bacterial overgrowth syndrome
DM
Scleroderma
26
Presentation of small bowel bacterial overgrowth syndrome
Chronic diarrhoea
Bloating, flatulence
Abdominal pain
27
Management of Small bowel bacterial overgrowth syndrome
Correct underlying DM
Antibiotic therapy- rifamixin
28
How is T2DM diagnosed
1 reading of if symptomatic
2 readings of if asymptomatic
- Fasting glucose >7
- Random glucose >11.1
- HbA1c > 48
29
What is defined as impaired glucose tolerance
Fasting glucose under 7 but OGTT 2 hour= 7.8-11.0
30
What is defined as impaired fasting glucose
Fasting glucose 6.0-6.9
31
Complication of hashimotos
MALT lymphoma
32
What can lower HbA1c levels
Haemodialysis
Haemolysis
- Hereditary spherocytosis
- G6PD
- SCD
33
What is glucagon like peptide
Hormone secreted by small intestine in response to glucose load which increases insulin release
34
MOA of GLP 1 mimetics
Increase insulin release
Reduce appetite
Suppress glucagon
35
What is GLP broken down by
Dipetidyl-peptidase-4
36
Advantage of liraglutide over exenatide
Liraglutide has to be taken once a day whereas exenatide is taken within 1 hour before morning and evening meal as a subcut injection
37
What are gliptins
DPP 4 inhibitors which decrease peripheral breakdown of GLP1
38
What is main advantage of gliptins compared to other anti-diabetic agents
Cause weight loss
39
Drug causes of gynaecomastia
spironolactone (most common drug cause)
cimetidine
digoxin
cannabis
finasteride
GnRH agonists e.g. goserelin, buserelin
oestrogens, anabolic steroids
40
Poor thyroxine adherance TSH and T4 results
Elevated TSH
Can be normal T4
41
If have addisons and an intercurrent illness, what do with steroids
Mineralcorticoid dose remains same
Glucocorticoid doubles
42
What use to treat addisons
Both glucocorticoid and mineralcorticoid
43
Dose of hydrocortisone required/day in addisons
20-30mg
44
How is hydrocortisone dose given in a day
Majority of dose given in the first half of day
For example if on 30mg
- 20mg in morning
- 10mg in afternoon
45
What do people with addisons needs to be given
Steroid card and medicalert bracelet
Hydorcortison injection kits for addisonian emergency
46
Patchy uptake on iodine scintigraphy
Toxic multinodular goitre
47
Management of Toxic multinodular goitre
Radioiodine unless compression sx then would do surgery
48
What is sick euthyroid
In patients who are ill they can have reduced thyroid function
Seen in elderly
49
Management of sick euthyroid
Ask GP to review TFTs in 6 weeks post illness
Do not need thyroxine replacement unless severe
50
What tends to happen to TFTs in sick euthyroid
TSH normal
T3 and T4 tend to be low
51
Common causes of polyuria
Diuretics
Alcohol and caffeine
Lithium
HF
52
Can you drive a HGV if on insulin
Yes if meet strict DVLA criteria
53
Definitive test for addisons
Short Synacthen test
54
If short synacthen test is not available what do instead
Morning cortisol 9am
55
What antibodies may be seen in addisons
Anti 21 hydroxylase
56
Eye signs of graves
Opthalmoplegia
Exopthalmos
57
What are blood findings of tertiary hyperparathyoidism
Ca elevated
PTH very elevated
ALP up
Phosphate high
58
When add 10% dextrose infusion in DKA
When glucose is less than 14
59
What is insulin infusion rate in DKA management
0.1 units/kg/hour
60
Fluids used for DKA
Isotonic saline
61
BP aimed for in T2DM
Under 80 ABPM= 135/85
Over 80 ABPM= 145/85
62
What is nesidioblastosis
Beta cell hyperplasia
63
Causes of hypoglycaemia
Insulinoma
Insulin/sulphonylureas OD
Liver failure
Addisons
Alcohol
Nesidioblastosis
64
What do if someone on insulin becomes unwell
Keep taking insulin as normal but check levels more frequently
65
What is most common cause of primary hyperaldosteronism
Bilateral idiopathic adrenal hyperplasia
66
When start to get symptoms with carcinoid tumours
When get metastases to liver which release serotonin to systemic circulation
67
Carcinoid syndrome presentation
Flushing (earliest)
Diarrhoea
Arrythmias
Bronchospasm
68
How investigate carcinoid tumours
Urinary 5-HIAA
69
What drug can be used for carcinoid syndrome
Octreotide
70
How differentiate conns from bilateral renal artery stenosis
Renin levels are high in renal artery stenosis
71
What is main danger of HHS compared to DKA
Onset slower so volume depletion and metabolic abnormalities more pronounced
72
Presentation of HHS
Volume loss sx
- polyuria
- polydipsia
Lethargy
Nausea and vomiting
LOC
Hyperviscosity complications
- MI
- stroke
- peripheral arterial disease
73
Diagnostic criteria for HHS
Hyperglycaemia in range over 30
Raised serum osmolality
No ketonaemia
74
Management of HHS
Aggressive fluid resus
Insulin if glucose not dropping
VTE prophylaxis
75
When give insulin in HHS
If glucose not responding to IV fluids
76
Complications of HHS
Hyperviscosity problems
- MI
- CVA
- PAD
- VTE
77
If driving and on insulin, when check blood glucose
Before and every 2 hours
78
What is pseudocushings
Mimic of cushings
Get all signs and biochemical results of cushings but no malignant cause
79
Causes of pseudo-cushings
Alcohol excess
Depression
80
What initial fluids regime give to someone in DKA
Haem stable
- 1L saline over 1 hour
Haem unstable
- 500ml STAT
81
What is most important test for determining response to thyroxine
TSH
82
Insulinoma presentation
Whipples triad
1- hypoglycaemia post exercise
2- quick reversal with food
3- low BMs at time of symptoms
Rapid weight gain
83
What is in whipples triad
1- hypoglycaemia post exercise
2- quick reversal with food
3- low BMs at time of symptoms
84
Management of insulinoma
Surgery
If not candidate then somatostatin
85
What can be used for insulinoma if not candidate for surgery
Somatostatin
86
If T1DM, what do about driving
Must inform DVLA but can drive if adequate hypoglycaemia awareness
87
How long should acidosis and ketonaemia take to resolve in DKA
24 hours if not then needs to be reviewd by senior endocrinologist
88
What do if acidosis and ketonaemia in DKA have not resolved after 24 hours
Get review by a senior endocrinologist
89
When is DKA defined as being resolved
pH>7.3
Ketones< 0.6
Bicarbonate >15
90
When can switch to subcut insulin in DKA
Once eating and drinking again
DKA resolution criteria met
- pH>7.3
- ketones< 0.6
- bicarbonate >15
91
Whats in MEN 1
3 Ps
- parathyroid adenoma
- pituitary tumour
- pancreatic tumour
92
What are examples of pancreatic tumours in MEN 1
Insulinoma
Gatrinoma
Somatostatinoma
Glucagonoma
93
How do gastrinomas present
Zollinger Ellison disease
- severe peptic ulceration
- diarrhoea
94
Whats in MEN2a
2 Ps
Parathyroid disease
Phaeochromocytoma
Medullary thyroid cancer
95
Whats in MEN 2b
Phaeochromocytoma
Marfanoid habitus
Neuromas
96
Test for phaeochromocytoma
Urinary metanephrines 24 hr collection
This has superceded urinary catecholamines
97
Management of phaeochromocytoma
Blood pressure mangement intially
- phenoxybenzamine
- beta blocker (propanolol)
Then surgery is definitive
98
Patient on steroids has illness then develops abdo pain and low grade fever
Addisons
99
Addisonian crisis presentation
Abdo pain
Fever
Lightheaded
Hyperkalaemia metabolic acidosis
100
What is first line investigation for acromegaly
Serum IGF-1
101
What test confirms acromegaly post IGF 1
OGTT with serial GH measurements then MRI
102
What is subclinical hypothyroidism
TSH raised but T3 and T4 normal
No symptoms
103
When treat subclinical hypothyroidism
TSH>10 with normal thyroxine
This recorded twice 3 months apart
ALSO TREAT if under 65 with TSH 5.5-10 twice 3 months apart and there are symptoms of hypothyroidism
104
What do if identify subclinical hypothyroidism on 1 blood test
If see TSH up with normal T4 then repeat in 3 months
If this still high then may consider thyroxine
105
Cause of arrythmia post starting DKA treatment
Hypokalaemia
106
What is subacute thyroiditis
De quervains
107
What is pepper pot skull seen in
Primary hyperparathyroidism
108
Myxoedema features
Hyporeflexia
Hypothermia
Seizures
Bradycardia
Drowsy
109
Precipitating features of thyrotoxic storms
Typically in people with established hyperthyroidism and isnt usually first presentation
Triggers
- trauma
- infection
- surgery
- pregnancy
110
Presentation of thyroid storm
fever > 38.5ºC
tachycardia
confusion and agitation
nausea and vomiting
hypertension
heart failure
abnormal liver function test - jaundice may be seen clinically
111
Management of thyroid storm
Hydrocortisone
IV propanolol
Anti thyroid drugs- propylthiouracil
112
Which thyroid cancer spreads early to lymph nodes
Papillary
113
Which thyroid cancer secretes calcitonin
Medullary
114
Which thyroid cancer is most likely to cause pressure symptoms
Anaplastic
115
What thyroid cancer is hashimotos associated with
MALT Lymphoma
116
What is plasma osmolality in psychogenic, nephrogenic and central diabetes insipidus
Psychogenic is low
Cranial and nephrogenic is high
117
Features of klinefelters
Tall
Gynaecomastia
Small testes
Lack of pubic hair
118
Gonadotrophin and testosterone levels in klinefelters
Low testosterone
High gonadotrophin
119
How is klinefelters diagnosed
Karyotyping- 47 XXY
120
Metabolic cases of polyuria
Diabetes
Hypokalaemia
Hypercalcaemia
121
Hypoglycaemia management in hospital
Conscious- oral glucose gel
Unconscious or combative- IM glucagon
122
How do pituitary adenomas present
Functional
- excess of a hormone
Non-functional
- panhypoituitarism
All can present with bitemporal hemianopia and headache
123
What can cause dyspepsia symptoms in diabetic
Gastroparesis
124
Presentation of gastroparesis in diabetic
Dyspepsia- bloating, etc
Erratic glucose measurements
125
How manage gastroparesis in diabetic
Prokinetic agents like metoclopramide
126
If on insulin and have DKA, what do with everyday insulin during admission
Stop short acting
Continue long acting
127
Investigation of choice for small bowel overgrowth syndrome
Hydrogen breath test
128
What does vitamin B2 (riboflavin) deficiency lead to
Angular cheilitis
129
How is diabetic neuropathy screened for
10g monofiliment
130
What is an adrenal mass with a rich lipid core, asymptomatic patient too
Benign adenoma
131
What is waterhouse friederichsen syndrome
In meningococcal sepsis get an adrenal haemorrhage
132
Metabolic alkalosis with hypokalaemia
Excess vomiting (or cushings)
133
If develop gynaecomastia on spironolactone, what switch to
Epleronone
134
Hormone profile of kallmans
Low testosterone and low gonadotrophins as hypothalamic problem
135
Management in primary care of graves
generally managed by secondary care but carbimazole may sometimes be started for troublesome symptoms whilst waiting
136
First line investigation for thyroid nodules/lumps
USS
137
What do with levothyroxine dose if become pregant
Increase dose by up to 50%
138
Presentation of conns
HTN
Muscle weakness in exams as a symptoms of hypokalaemia
139
If get given 9am cortisol and ACTH and shows;
high cortisol
low ACTH
What is next investigation
CT adrenal glands
140
MSK side effects of corticosteroids
Osteoprosis
Proximal mopathy
Avascular necrosis of femoral head
141
When do you test for T1DM with C peptide and autoantibodies
Diagnostic uncertainty where atypical features
- 50 or older
- BMI over 25
- slow evolution of symptoms
- long prodrome
142
How test for T1DM when diagnostic uncertainty
C peptide levels
Diabetes autoantibodies
143
What happens to thyroid levels during pregnancy
Total levels rise however free T3 and T4 remain the same
The increase is due to increased thyroid binding globulin which increases during pregnancy
144
Management of hypoglycaemia if impaired swallow
If IV access then IV 20% glucose
If not then IM glucagon
145
What is risk of giving insulin in HHS
Get massive compartment shift of fluid which may lead to central pontine myelinolysis
146
Causes of primary hyperaldosteronism
Bilateral adrenal hyperplasia
Adrenal adenoma
147
How determine cause of conns
CT scan of abdomen after RA ratio
148
If CT scan normal when determining cause of conns, what do
Venous sampling from both adrenals
149
How manage Conns
Depends on cause
If bilateral adrenal hyperplasia spironolactone
If unilateral adenoma then surgical removal
150
How manage thyrotoxicosis in pregnancy
First trimester- PTU
Second and third- carbimazole
Keep it PC
151
What use to control symptoms of a graves patient awaiting secondary care attention
Propanolol
152
What do if on long term steroids for PMR and becomes unwell
Double the dose
153
What give first line anti HTN if black and diabetes
ARB
154
What interacts with and affects efficacy of levothyroxine
Oral iron tablets due to preventing its absorption
155
What is nelsons syndrome
When have bilateral adrenectomy, can get growth of corticotrophs in the pituitary gland due to unchecked inhibition
156
How does nelsons syndrome present
Post bilateral adrenectomy
Pituitary tumour compressive symptoms
Increased skin pigmentation due to increased MSH production
157
What is pretibial myxoedema and what seen in
Erythematous and oedematous lesions seen on the lower leg in graves disease
158
What is thyroid acropachy
Triad of
- clubbing
- new bone formation
- soft tissue swellings
159
What can stop a diabetic from being able to drive
- More than 2 episodes of hypoglycaemia which required help
- not having hypoglycaemic awareness
- the mcdonalds drive thru queue
160
How screen for diabetic nephropathy
Early morning ACR urine sample
161
Management of de quervains
NSAIDs- Naproxen specifically
162
What does blood glucose being "unrecordable" indicate
That it is very high not low
163
How monitor response to treatment in HHS
Serum osmolality
164
First line antibiotic for small bowel overgrowth syndrome
Rifamixin
165
Drug causes of galactorrhoea from raised prolactin
metoclopramide, domperidone
phenothiazines- prochlorperazine
haloperidol
SSRIs, opioids
166
Side effects of thyroxine therapy
Osteoporosis
AF
Worsening angina
Hyperthyroidism
167
How manage a diabetic ulcer
Check for gangrene
If not provide education about foot care and arrange an appt with diabetic foot clinic
168
How does alcohol cause polyuria
Suppresses ADH suppression therefore like a cranial diabetes insipidus
169
How does alcohol causing polyuria present with
- urine osmolality
- serum osmolality
- water deprivation test
Urine osmolality = low
Serum osmolality= high
Water deprivation= like cranial
170
How differentiate between primary and secondary hypoadrenalism symptomatically
Skin hyperpigmentation in primary
In primary there will be increased ACTH release which increases MSH
171
How treat cranial DI
Desmopressin
172
How treat nephrogenic DI
Thiazide diuretics
173
How long need to treat graves with carbimazole for
Only 12-18 months
No need for lifelong as carbimazole induces remission
174
What do if addisons patient on long term steroids starts vomiting illness
Give IM glucocorticoid until resolves
175
Causes of cranial DI
Idiopathic
Head injury
Pituitary tumours/surgery
Sarcoidosis
Haemochromatosis
176
Complications of acromegaly
Cardiomyopathy
HTN
DM
Colorectal cancer
177
How diagnose osteoporosis
DEXA scan T score over -2.5
OR
Post menopausal woman has fracture
178
What do if patient on metformin having a scan with contrast
Withold for 2 days afterwards
179
Mental side effects of steroids
Insomnia
Psychosis
Depression
Mani(l)a 🇵🇭
180
First line medication for acromegaly
Octreotide
181
How manage if change in vision in TED patient
Urgently refer to opthalmology ED
182
Menstrual problems associated with hyperthyroidism vs hypothyroidism
Hyperthyroidism- Oligomenorrhoea or amenorrhoea
Hypothyroidism- menorrhagia
183
If someone recently migrated to the UK and has hypothyroidism, what is likely cause
Iodine deficiency
184
With pituitary tumours, what quadrantopia is seen
Superior
185
What tests to confirm T1DM
Random glucose
186
What are C peptide levels in T1DM
Low
187
How can carcinoid syndrome affect the heart
Pulmonary stenosis and tricuspid insufficiency
188
What do if ACR raised on spot urine sample
Repeat with first pass morning specimen
189
HbA1c target if on metformin
48
190
HbA1c target if taking a drug which can cause hypos (sulphonylureas)
53
191
HbA1c target if on 2 drugs and HbA1c has reached 58
53
192
When does HbA1c target become 53
Taking an antidiabetic which causes hypos
Taking 2 antidiabetics and have gone above 58
193
When add SGLT2i to diabetes regime
Develop at any time or history of CVD or HF
Q-risk >10%
194
What is important thing to do when prescribing metformin and SGLT2i
Make sure metformin is fully titrated up
195
When add a second antidiabetic
If HbA1c rises above 58
196
Dietary advice for DM
Low glycaemic food
Oily fish
Discourage food aimed at people with DM
197
What weightloss aim for in T2DM
5-10%
198
2nd line options for T2DM after metformin
Sulphonylureas
Pioglitazone
DPP4 inhibitors
199
When is pioglitazone CI
Heart failure or CVD
Bladder Ca history
200
MOA of pioglitazone
PPAR gamma agonist which increases insulin sensitivity peripherally
201
When is only time can offer GLP1 agonists
If triple therapy unsuccessful therefore switch one of them to GLP1 if overweight or
Low BMI but insulin lowering therapy would be inappropriate due to occupation or weight loss would be key for controlling rfx for other diseases like CVD
202
After triple therapy what are options
Insulin therapy or GLP1 mimetics
- use GLP1 if BMI over 35
- under 35 but insulin not appropriate for occupation or would want weight loss for controlling other diseases
203
Triple therapy options for T2DM
Metformin+sulphonylurea+pioglitazone
Metformin+ sulphonylurea+DPP4i
Metformin+ (DPP4i or sulphonylurea or pioglitazone) + SGLT2i
204
Third line options for T2DM
Metformin+sulphonylurea+pioglitazone
Metformin+ sulphonylurea+DPP4i
Metformin+ (DPP4i or sulphonylurea or pioglitazone) + SGLT2i
Insulin therapy
205
How start insulin for T2DM
Use human insulin
Taken at bedtime or BD
206
What is function of DPP4i
Increases levels of incretins- GLP1 etc
207
What is most likely cause of impaired hypo awareness in long term T1DM
Neuropathy in ANS
208
What antidiabetic avoid in severe renal impairment
Sulphonylureas
209
What is exenatide
GLP1 agonist
210
What is a long acting sulphonylurea
Glibenclamide
211
Inheritance of MODY
AD
212
What happens when TED patients are not able to close eyelids
Exposure keratopathy from dry eyes
213
What thyroid treatment can worsen TED
Radioiodine
214
How does MODY typically present
Non ketotic hyperglycaemia detected incidentally
Not overweight nor signs of insulin resistance
215
Key differentiators of MODY from T1DM and T2DM
T1DM- no ketosis with hyperglycaemia
T2DM- normal weight, aged under 25
216
Indications for orlistat in obesity
BMI over 28 with CVD rfx or BMI over 30
217
When can give liraglutide for obesity
BMI over 35
Prediabetic hyperglycaemia 42-47
218
When must diabetics give up their license
Over 2 hypoglycaemic episodes where assistance needed
219
Which antidiabetics causes weight gain
Sulphonylureas
Pioglitazone
220
Which is best 2nd line antidiabetic to give if want to avoid weight gain
DPP4i
221
What is max metformin dose
500mg QDS
222
When determining 3rd choice antidiabetic, what consider if overweight
SGLT2i
DPP4i
223
Which antidiabetics are best for weight
SGLT2i
DPP4i
GLP1 agonists
224
Which drugs impair levothyroxine absorption
Iron and calcium replacements
225
It taking gliclazide when can add another antidiabetic
If HbA1c goes above 53
226
Presentation of latent autoimmune diabetes of adults
T1DM but when adult
227
SEs of SGLT2i
Increased risk of amputation
Recurrent UTI
Euglycaemic ketoacidosis
228
Treatment of MODY with HNF1 mutation
Sulphonylureas
229
What can use to treat T1DM on top of insulin
Metformin if BMI over 25
230
What do with antidiabetics in T2DM if ill
Metformin- stop if dehydration risk
Sulphonylureas- stop if acutely unwell or at risk of dehydration
GLP-1- stop if dehydration
231
How many units of insulin in 1ml
100
232
What use to draw up insulin
Do not use a standard syringe- use an insulin syringe
233
Examples of each type of insulin
Rapid- Insulin aspart (NovoRapid), Insulin lispro (Humalog)
Short- Actrapid (soluble)
Intermediate- isophane insulin
Long- insulin determir (Levemir), insulin glargine (Lantus)
234
What insulin start in DKA
Fixed rate insulin while continuing long acting insulin but stop short acting
235
Blood glucose target on waking in T1DM
5-7
236
Blood glucose target before meals in T1DM
4-7
237
When need to measure glucose more regularly
Illness
Sport
Pregnancy
Breastfeeding
238
How often measure HbA1c in T1DM
3-6 months
239
How often measure glucose/ day in T1DM
4 times a day including before each meal and before bed
240
In adults what is recommended regime for T1DM adults
Injection of basal bolus insulin
Twice daily detemir
Rapid acting insulin before meals
241
Basal options for T1DM
Twice daily detemir first line
Alternative include- OD glargine or detemir
242
How take metformin perioperatively
Day before= take
Day of surgery= only ever stop it take TDS where omit lunchtime dose
Consider stopping if risk of AKI
243
How take sulponylureas perioperatively
Day before= take as normal
Day of surgery= if once daily omit, if BD omit morning if morning op and omit both if pm operation
244
How take SGLT2i perioperatively
Day before= take as normal
Day of operation= omit dose
245
What do with once daily insulins perioperatively
Day before= reduce dose by 20%
Day of operation= reduce dose by 20%
246
When would you stop metformin for a surgery
High risk of AKI
247
If taking insulin, what will determine operative period management
Minor procedure
- If good glycaemic control (less than 69 HbA1c) then can adjust normal regime (reduce by 20%)
- poorly controlled then variable rate
Major (missing 1 or more meal)
- variable rate insulin infusion
248
Side effects of pioglitazone
Fracture risk
Fluid retention
Weight gain
Liver dysfunction
249
Side effects of sulphonylureas
Hypoglycaemic episodes
Increased appetite and weight gain
SIADH
Liver dysfunction (cholestatic)
250
What antidiabetic drug can cause pancreatitis
Gliptins
251
Main problems if subclinical hyperthyroidism
Osteoporosis
AF
252
Main cause of subclinical hyperthyroidism
Multinodular goitre in elderly women
253
Management of subclinical hyperthyroid
Review in 6 mths as often revert to normal
Can consider treatment if persistent due to risk of osteoporosis and AF
254
Causes of hypothyroidism
Primary
- hashimotos
- iodine defic
- thyroiditis
- drugs- lithium and amiodarone
Secondary
- panhypopituitarism
- trauma to thyroid (eg surgical)
255
Myxoedema coma management
IV fluids
IV thyroid replacement
IV steroids until adrenal failure been ruled out
256
Management of papillary and follicular thyroid cancer
Thyroidectomy
Treat with radioiodine afterwards
Follow up with annual thyroglobulin
257
Management of single thyroid nodule
Surgical removement (benign adenoma)
258
Where is hypothyroidism treated
Provided no indication of secondary aetiology or cocontaminant adrenal disease then do so at GP
259
Main side effects of carbimazole and PTU
Carbimazole
- pancreatitis
- agranulocytosis
PTU
- agranulocytosis too
260
Investigations for thyroid cancer
USS then guided FNA
261
Addisonian crisis management
IV hydrocortisone
IV fluids
Correct hypoglycaemia and hyperkalaemia if necessary
262
If have addisons from stopping long term steroids, what type of adrenal insufficiency is it
Tertiary
If take for over 3 weeks then lose endogenous hypothalamic CRH production
263
Investigations for addisons
Short synacthen- 9am cortisol if not available
Anti 21 alpha hydroxylase antibodies
264
Cushings presentation
Centripetal obesity
Moon face
Striae
Acne
HTN
Myopathy
Osteoporosis and AVN
Psychiatric complications
265
Management of cushings
Treat cause
- first line normally surgery
For reducing cortisol
- metyrapone
- ketoconazole
266
What does skin pigmentation in cushings indicate about cause
If hyperpigmentation is cushings disease
267
Causes of secondary hyperaldosteronism
Liver failure
Heart failure
RAS
268
Rfx for phaeo
MEN2
Von hippel lindau
NF
269
Acromegaly presentation
HTN and DM
Prognathism
Coarse facial features
Big hands and feet
Oily sweaty skin
Compressive sx- prolactin signs, headache and bitemp
270
Panhypopituitarism causes
Non-functioning adenomas- most common
Prolactinomas
Infiltrative diseases- sarcoid, haemochromatosis
Craniopharyngioma
Sheehans
Trauma
271
Investigations for panhypopituitarism
MRI
Combined pituitary testing
272
What skin lesion can precipitate T1DM diagnosis
Necrobiosis lipoidica- waxy, yellow lesions in pretibial distribution with telengiectasia present
273
If someone has suspected T1DM diagnosis in GP what do
Refer for same day endo referral
274
How diagnose T1DM in GP
Random glucose >11 with 1 of following
- Ketosis
- Rapid weight loss
- Age of onset younger than 50 years
- Body mass index (BMI) below 25 kg/m2
- Personal and/or family history of autoimmune disease
275
What do if discover someone as prediabetic
Refer for local lifestyle change programme
276
What are options to monitor blood glucose in T1DM
Standard use is capillary blood glucose
Can use libre which is circular device on arms which continuously monitor however 5 minute lag so if suspect hypo then use CBG and also need to replace every 2 weeks
277
When can refer T1DM for islet cell/pancreatic transplant
Recurrent severe hypos refractory to medical treatment
278
When consider continuous insulin pump
Poorly controlled HbA1c- above 69 despite daily injections
Attempts to achieve target HbA1c levels with insulin result in the person experiencing disabling hypoglycaemia
