Endocrinology

Question 1

Define Diabetes Mellitus

Answer 1

Endocrine disorder characterised by lack of insulin or the increased resistance to insulin

Question 2

Define Type 1 and Type 2 Diabetes.

Answer 2

Type 1 (age <30): Autoimmune disease characterised by the destruction of islet cells responsible for the production of insulin

Type 2 (Age >65):
Progressive disease resulting from reduced insulin secretion AND increased insulin resistance.

Question 3

Which type of diabetes is associated with weight loss?

Answer 3

1

Question 4

Which type of diabetes is associated with Diabetic ketoacidosis?

Answer 4

1

Question 5

What is metabolic syndrome?

What are the features of metabolic syndrome?

Answer 5

Metabolic syndrome is a cluster of features that occur together increasing the risk of heart disease, stroke, and T2DM
1) Abdominal obesity (<40inch male, <35 inch female)
2) BP >130/85 or on BP meds
3) Fasting glucose >5.6
4) High TGs
5) Low HDL

Question 6

Which type of diabetes is associated with LADA - Latent autoimmune disease in adulthood?

Define LADA
When should you suspect LADA?

Answer 6

Type 2 DM (6-10% of patients with T2DM develop this)

LADA is a latent autoimmune disease characterised by Anti-GAD antibodies and is associated with increased risk of insulin dependence and ketoacidosis (basically think of them becoming type 1)

Suspect if either:
1) T2DM
2) Absence of metabolic syndrome features
3) Uncontrolled hyperglycemia despite oral medical management.
4) other autoimmune diseases (Thyroid, pernicious anaemia)

Question 7

What is MODY?
When should you suspect?
How is it diagnosed?

Answer 7

Maturity-Onset Diabetes of the Young
Patients <25yo with family hx of diabetes.

Diagnosed via genetic testing of HNF1-alpha (main one). (also HNF1beta, HNF4alpha, glucokinase)

Question 8

Give 5 RF for T2DM

Answer 8

1) Age >65
2) Obesity
3) Past medical hx of GDM or macrosomia (7x)
4) Pancreatic Disease (Pancreatic Ca, surgery, pancreatitis, CF, Haemochromatosis)
5) Endocrine: Cushing’s thyrotoxicosis, phaechromocytoma, acromegaly.
6) Drugs: Steroids
7) Anti-glutamic acid decarboxylase (LADA)
HNF1alpha (MODY)
8) Fam Hx of diabetes
9) Ethnic (south asians/afrocarribean)

Question 9

Why is HbA1c superior?

Answer 9

Blood glucose may be temporarily raised during acute illness, steroid use, after trauma etc.. HbA1c tests the % of hemoglobin that is glycated due to exposure to glucose in the blood.

Question 10

Give 3 tests used in the diagnosis of diabetes.

Give the ranges of each test for Normal, pre-diabetes, and diabetes

Answer 10

Fasting glucose:
Normal <6
Pre-diabetic 6-7
Diabetes: 7+

OGTT - 1hr post-prandial
Normal <7.8
Pre-diabetic 7.8-11
Diabetes >11

HbA1c
Normal <42%
Pre-diabetic 42-48%
Diabetes >48

Question 11

Explain the diagnostic algorithm for Diabetes

Answer 11

Question 12

What is the diagnostic definition of pre-diabetes?

How would you manage a patient with pre-diabetes? (not in depth)

Answer 12

Fasting Glucose 6-7
OGTT 7.8-11
HbA1c 42-48%

These people are at risk of developing full-blown diabetes => should begin lifestyle changes now to prevent diabetes.

=> Management is followup w/annual Fasting glucose/HbA1c + Lifestyle modifications

Question 13

How can diabetes present?

Answer 13

Acute: Ketoacidosis (mostly Type 1 and LADA Type 2) or hyperosmolar non-ketotic coma

Subacute: Weight changes, polydipsia, polyuria, lethargy, recurrent infections, visual disturbances, paraesthesia

Chronic: Complications of diabetes (nephropathy, neuropathy, eye disease, skin changes, diabetic foot)

Question 14

State the 9 complications of Diabetes

Answer 14

1) Hypoglycemia
2) Recurrent UTIs
3) Diabetic Nephropathy
4) Cardiovascular
5) Skin changes
6) Eye disease (retinopathy)
7) Diabetic neuropathy
8) Diabetic Foot
9) Depression

Question 15

What are the symptoms of hyperglycemia

What are the symptoms of hypoglycemia

Answer 15

Hyper: Polydispsia, Polyuria, urinary frequency, weight changes, lethargy

Hypo: Polyphagia, sweating, tremor, lightheadedness, fits/seizures, altered GCS/coma, tachycardia

Question 16

How would you manage a hypoglycaemic episode?

Answer 16

3x oral glucose tablets/sugar drink/glucogel (babies) followed by complex carbs

If cannot because unconscious, IM 1mg glucagon followed by IV 10% glucose/dextrose followed by complex carbs

Question 17

There are 2 scenarios whereby IM glucagon would be much less effective. What are they?

Answer 17

Patient is drunk
Patient is starved

Question 18

A patient has just been diagnosed with diabetes requiring insulin. What would you tell them with regards to hypoglycaemic episodes and their prevention (Give 5)

Answer 18

Prevention:
1) Advise on pattern of checking before exercise and after meals
2) Importance of adherence to insulin/meds and alter insulin to match needs
3) Explain the signs of hypoglycaemia to look out for them: Polyphagia, sweating, tremor, lightheadedness, fits/seizures, altered GCS/coma, tachycardia
4) Reduce alcohol intake as that may induce “starvation: and hence reduced effectiveness of IM glucagon
5) Blood sugar diary: Assess frequency of testing and control of sugar levels
6) Glucagon kit. Advise family members of signs of hypoglycemia and how to safely administer IM glucagon injection

Question 19

Why do diabetics get recurrent UTIs?

Answer 19

Weakened immunity + Diabetic nephropathy exacerbates renal failure and causing scarring especially in uncontrolled cases. This leads to papillary necrosis and hence increased risk of UTIs

Question 20

Diabetes is the most common cause of end-stage renal failure. Diabetes causes the progressive loss of renal function. How does this affect
GFR
BUN
Protein
BP

Answer 20

Progressive loss of renal function (reduced GFR, increased BUN, proteinuria and BP)

Question 21

What investigations would you conduct to rule out or screen for evidence of diabetic nephropathy?

Answer 21

1) ACR/PCR (albumin-creatinine ratio) (>70-refer)
2) eGFR (<30-refer)
Conduct these annually and refer to renal physician for Renal US if CKD grade 4/5 (eGFR<30) or ACR > 70
3) Folic acid/B12 (pernicious anaemia)

Question 22

How is ACR (albumin-creatinine ratio obtained)?

Answer 22

Urine

Question 23

How would you specifically manage a patient with diabetic nephropathy in GP practive?

Answer 23

1) Optimise blood glucose control: adherence, adjust dose, consider insulin pump
2) Prevent renal damage: Reduce dosages and avoid nephrotoxic drugs. Adjust doses of medication dependent on renal elimination
3) Treat BP: ACE inhibitor/ARD, Atorvastatin
4) Supplements: Vitamin B12 and Folic acid

Question 24

What are the cardiovascular complications of Diabetes?

Answer 24

Remember metabolic syndrome with the increased risk of T2DM (this), stroke MI, PVD (atherosclerosis)

Question 25

How would you medically manage atherosclerosis?

Answer 25

Plaques => lipid and platelets => Statin therapy and antiplatelet therapy

Question 26

What is Vitiligo?

Answer 26

Patches of skin losing pigment

Question 27

State 5 skin complications of Diabetes

Answer 27

1) Vitiligo 2)Predisposition to infection (candidiasis) => Neuropathic and ischaemic ulcers 3) Xanthoma/Xanthalasma 4) Necrobiosis Lipoilica (small dusky-red nodule on shin that become yellow-brown in colour before ulcerating) 5) Acanthosis Nigricans 6) Diabetic Cheiroarthropathy (Skin thickening ver dorsum of hand causing restricted mobility) 7) Diabetic Dermopathy (pigmented scars over shins)

Question 28

State the 3 main eye complications of diabetes

Answer 28

Blurred vision Cataract Retinopathy Others include: optic neuropathy, retinal vein occlusion and ocular nerve palsies

Question 29

Poor control in diabetes is the main cause of eye complications such as blurred vision and Cataracts. What are the 2 types of cataracts that are a result of poorly controlled diabetes. How would you manage it?

Answer 29

Juvenile Cataracts (more common) which can develop over days Senile cataracts can occur very early (on average 10 years earlier than juvenile) Cataract surgery

Question 30

95% of T1DM and 60% of T2DM will have retinopathy. 20-40% of T2DM will have retinopathy at diagnosis, 5-10% of which are sight-threatening. What is the pathophysiology of Retinopathy?

Answer 30

Small retinal vessels become blocked (atherosclerosis) or swollen (aneurysm) => ischaemia => Inflammation => leaky exudate formation, oedema, haemorrhages, and angiogenesis (new immature vessels quickly to regain supply)

Question 31

Diabetic retinopathy is the most common cause of blindness in people of working age (18-65). How is diabetic retinopathy classified/staged?

Answer 31

Non-proliferative: Microaneurysms, haemorrhages, venous bleeding (graded by number of microaneurysms) Proliferative: + angiogenesis/new vessel formation (graded by how close they are to optic disc) Maculopathy: + Involvement of macula => macular oedema Retinal detachment: Severe complication due to haemorrhages of abnormal vessel formation => scarring and fibrosis

Question 32

How would you assess for diabetic neuropathy

Answer 32

Neuropathic ulcers Paraesthesia Pain Erectile dysfunction

Question 33

What are the 2 main causes of diabetic foot ulcers?

Answer 33

Peripheral vascular disease: Atherosclerosis causing reduced flow => increased pain (ischemic) and predisposition to infection and ucleration Peripheral neuropathy: Reduced sensation -> increased risk of unknown breach (and reduced sensation of pain from ischaemia) => ulceration and goes longer unnoticed.

Question 34

What is Charcot's arthropathy and give the 2 defining features on exam

Answer 34

AKA Charcot's foot Neuropathic foot damages due to trauma secondary to loss of pain sensation Abnormal foot shape/foot deformity Joint deformity and rigidity

Question 35

What is this? What is it used for?

Answer 35

Monofilament Tests for peripheral neuropathy by assessing sensation

Question 36

Briefly go over the history and examination of a patient presenting for their annual diabetic foot check.

Answer 36

Incorporate this to any hx and exam concerning diabetes Hx: Assess 1) Foot problems since last review 2) Knowledge of foot care and self-care behaviours 3) Visual or mobility problems affecting self-care 4) Hx of numbness, paraesthesia, burning Examination: 1) Foot shape, deformity, joint rigidity (Charcot's Arthropathy/foot) 2) Skin condition: fragility, cracking, ulceration, shiny skin, absence of hair (vascular component so same as PVD) 3) Monofilament sensitivity: Testing for sensation + ABPI

Question 37

How would you differentiate between Vascular and Neuropathic ulcers

Answer 37

Vascular: Cool foot, absent pulses, reduced ABPI, located in webspaces, painful, and clearly defined (punched out) Neuropathic: Warm, pounding pulses, normal ABPI, located at pressure points!!, painless, irregular/less delienated

Question 38

You perform ABPI on a diabetic patient and notice that there are absent pulses but a normal ABPI. What does this indicate?

Answer 38

Calcifications are present which make the artery stiffer. The calcifications are retaining BP but the weakened or absent pulses from atherosclerosis remain

Question 39

How would you educate a patient about footcare in diabetes

Answer 39

Ensure that 1) Daily examination of the feet for problems including sensation, swelling, colour change, breaks in skin!! and to seek medical attention if any occur 2) Wear well-fitting shoes and avoid walking bearfoot 3) Hoisery (if ABPI >0.8) 4) Daily washing and careful drying for hygeine 5) Observe lesion if healing properly, otherwise seek medical attention

Question 40

How would you manage a diabetic patient presenting with skin changes associated with PVD and paraesthesia of the foot?

Answer 40

Conservative: 1) Supervised exercise program (>2h/week for 3 months) with advice to exercise to the point of maximal pain 2) Foot care via regular chiropody/podiatry 3) Educate about foot care: a) Daily examination of the feet for problems including sensation, swelling, colour change, breaks in skin!! and to seek medical attention if any occur b) Wear well-fitting shoes and avoid walking bearfoot c) Hoisery (if ABPI >0.8) d) Daily washing and careful drying for hygeine e) Observe lesion if healing properly, otherwise seek medical attention 4) Optimize diabetic control 5) Optimise vascular RF via RF reduction: - Reduce intake of fats. avoid saturated fats, low cholesterol diet + - Smoking cessation - Reduce weight (5-10%) - Regular exercise (150 moderate, 75 high) - Reduce alcohol intake (<14) - Reduce salt intake (<6g/day) - Mediterranean diet: Increase fruit and veg intake (>5/day), fish >2/week - Reduce caffeine

Question 41

A patient has just been diagnosed with T2DM. How often will they need to be reviewed? What is included in that review?

Answer 41

6-monthly review: 1) Update on recent life events, new sx, and difficulties with management 2) Review a) Blood sugar diary b) Labs: HbA1c, lipid profile, BP, U&E, eGFR, ACR c) LIfestyle - Dietary behaviours, physical activity, smoking d) Adherence and injection technique e) Complications (incl examination) => Hypoglycemic episodes, any infections, skin changes, visual problems + Fundoscopy, Neuropathy (tingling), Foot care, Depression screening

Question 42

A diabetic diet does not need to include expensive diabetic products. A diabetic diet is just a healthy diet. What dietary advice would you give a patient?

Answer 42

Aim for 5-10% weight loss >50% of calories need to be a fibre-rich diet with minimum saturated fat and refined carbs by avoiding ready-made foods etc... Spread food intake throughout the day to prevent hypoglycemia Avoid alcohol

Question 43

Diabetes is a chronic condition that requires self-care no matter how well controlled it is in clinic. A patient has just been diagnosed with T2DM. What education would you provide to this patient including lifestyle advice

Answer 43

1) General knowledge about a) The complications of diabetes and how to access diabetic service. b) Equipment information and administration of medications c) Problems with pregnancy (miscarriage, Preterm labour, IUGR, macrosomia, NTD, heart...) 2) Diet: Aim for 5-10% weight loss >50% of calories need to be a fibre-rich diet with minimum saturated fat and refined carbs by avoiding ready-made foods etc... Spread food intake throughout the day to prevent hypoglycemia Avoid alcohol 3) Exercise: Exercise increases insulin sensitivity and reduces BP => reduces most complications. Aim for 150 minutes of moderate exercise/week or 75 high intensity. (or 30 minutes 5/week) 4) Immunisation with annual influenza vaccine and pneumococcal 5) Psychological support, counselling services 6) Smoking and alcohol cessation

Question 44

The medical management of diabetes involves lifestyle changes, hypoglycemic meds, non-hypoglycemic meds, and insulin. Give 3 examples of medications that are non-hypoglycemic used in the treatment of diabetes and 3 hypoglycemic

Answer 44

Non-hypoglycemics: Metformin DPP4i (Linagliptin) Pioglitazone Hypoglycemics: Sulfonylureas (Glicazine) SGLT2i (only introduced in triple therapy) GLP-1 mimetics (Exenatide)

Question 45

What is the indication for GLP-1 mimetics in the management of diabetes? When it is indicated, what 2 other drugs are prescribed with it?

Answer 45

T2DM that has HbA1c >58 despite being on triple therapy AND patient does not wish to go on insulin Triple therapy with Metformin + Sulfonylurea + GLP1-mimetic

Question 46

What is the aim of diabetic management (in terms of HbA1c) What is the threshold to begin medical management of diabetes? What is the threshold to escalate medical management

Answer 46

<48 if lifestyle controlled or 1 non-hypoglycemic medication (metformin, DPP4i/linagliptin, pioglitazone <53 if Hypoglycemic meds or any combination Medical management begins once the individual is diabetic (HbA1c >48) and is escalated if HbA1c >58 despite current therapy (same at every step)

Question 47

Metformin is not associated with hypoglycemia and is only effective if some endogenous insulin is produced. Its side effects include GI disturbances and impaired B12 absorption with long-term use => Pernicious anemia. What is the typical starting dose? What is the regimen? What is it's mechanism of action? When should it be stopped? What is 2nd line to it? Give an example

Answer 47

Metformin 500mg TDS. This is then increased monthly until control achieved (<48) It suppresses gluconeogenesis and increases peripheral glucose utilisation. As metformin relies on renal excretion, it must be stopped/avoided if eGFR<30. Go for DPP4i (Linagliptin)

Question 48

DPP4i, or dipeptidyl peptidase 4 inhibitor is a non-hypoglycemic medication used in the treatment of T2DM. Give an example What is it's mechanism of action?

Answer 48

Linagliptin Inhibits breakdown of GLP-1 (which promotes insulin secretion by giving negative feedback to glucagon - glucagon-like peptide) => reduces serum glucose.

Question 49

Pioglitazone is a non-hypoglycemic medication used in the treatment of T2DM by reducing peripheral insulin resistance. In the case that these non-hypoglycemic drugs are not sufficient, Hypoglycaemic drugs such as Sulfonylureas and GLP-1 mimetics may be used. Give an example of each and their mechanism of action

Answer 49

Sulfonylureas: Glicazine Augments insulin secretion GLP-1 Mimetic: Exenatide Promotes insulin secretion by giving negative feedback to glucagon - glucagon-like peptide) => reduces serum glucose. (same as DPP4i as that just inhibits the breakdown of GLP1 => effect lasts longer)

Question 50

Give an example of a long-acting insulin

Answer 50

Insulin Detemir or Glargine

Question 51

Give an example of rapid acting insulin When should these be taken

Answer 51

Lispro taken before meals

Question 52

What is an intermediate-acting insulin?

Answer 52

NPH (type containing protamine) Neutral Protamine Hagedorn Answer: Isophane (which is an example of an NPH)

Question 53

How is insulin administered? What are the risks of insulin administration (4)?

Answer 53

Deep Subcutaneous injections into upper arm, thigh, buttocks, or abdomen Risks: Hypoglycemia Lipodystrophy: Ecchymosis Infection Needle-stick injury (additional info) It is advised to teach the patient the technique and allow them to demonstrate it back. Advise monitoring via blood sugar diary Provide contact telephone Teach glucagon kit. Advise adjustments of dose when starting to achieve acceptable levels. Fasting >10 => increase by 6-8 units Fasting 8-10 => increase by 4-6 6-8 => increase by 2-4

Question 54

What is Lipodystrophy?

Answer 54

Fat atrophy and hypertrophy with repeat injections in same place => keep changing location of injection

Question 55

What is the first line medical management of T1DM?

Answer 55

Insulin with multiple daily injection boluses 1) Basal insulin therapy is long-acting insulin => Insulin Detemir or Glargine 2) Before meals, Rapid acting insuling => Insulin Lispro Those with BMI >25, + Metformin

Question 56

What is the Full medical management of Type 2 diabetes with its escalations?

Answer 56

Refer to goals of HbA1c <48 vs <53 and escalation if HbA1c >58 despite current therapy (same at every step) 1) If pre-diabetic (<48) => lifestyle advice only 2) Once diabetic (48+) => Monotherapy with Metformin or other non-hypoglycemic drugs (DPP4i, Pioglitazone) 3) Dual Therapy: Metformin + any other medication 4) Triple therapy: Metformin + any 2 other medications (here including SGLT2i) 5) Insulin OR Metformin + Sulfonylurea + GLP-1 mimetic Note that if metformin is not tolerated or eGFR <30, replace with DPPi4 (Linagliptin)

Question 57

What is the Insulin Regimen for T2DM

Answer 57

Once triple therapy has failed (>58 despite), Metformin is continued and either: a) Intermediate-acting insulin => Isophane (NPH) OD/BD b) Long-acting insulin => Insulin Detemir/glargine

Question 58

What is the indication for an insulin pump

Answer 58

T1 or T2DM on insulin >12yo with poor adherence leading to unpredictable shifts in glucose levels + HbA1c >69 mmol/mol

Question 59

What is your advise to a newly diagnosed patient with diabetes with regards to exercise

Answer 59

Exercise increases insulin sensitivity (reduces resistance) Reduce your insulin dose before exercise to prevent a hyperglycemic episode Or take 1-2 glucose tablets before exercise and check levels after

Question 60

What is your advice to a diabetic patient currently suffering from an intercurrent illness e.g. diarrhoea

Answer 60

Continue insulin as usual but check more frequently. Monitoring is crucial with an intercurrent illness. If Type 1 diabetic, ensure regular checks of ketone levels and to attend hospital if feeling unwell

Question 61

Give the Full management plan for a T1DM patient

Answer 61

Conservative: 1) General knowledge about a) The complications of diabetes and how to access diabetic service. b) Equipment information and administration of medications c) Problems with pregnancy (miscarriage, Preterm labour, IUGR, macrosomia, NTD, heart...) 2) Diet: Aim for 5-10% weight loss >50% of calories need to be a fibre-rich diet with minimum saturated fat and refined carbs by avoiding ready-made foods etc... Spread food intake throughout the day to prevent hypoglycemia Avoid alcohol 3) Exercise: Exercise increases insulin sensitivity and reduces BP => reduces most complications. Aim for 150 minutes of moderate exercise/week or 75 high intensity. (or 30 minutes 5/week) 4) Immunisation with annual influenza vaccine and pneumococcal 5) Psychological support, counselling services 6) Smoking and alcohol cessation Medical: Insulin with multiple daily injection boluses 1) Basal insulin therapy is long-acting insulin => Insulin Detemir or Glargine 2) Before meals, Rapid acting insuling => Insulin Lispro Those with BMI >25, + Metformin

Question 62

Give the full management plan for a T2DM patient

Answer 62

Conservative: 1) General knowledge about a) The complications of diabetes and how to access diabetic service. b) Equipment information and administration of medications c) Problems with pregnancy (miscarriage, Preterm labour, IUGR, macrosomia, NTD, heart...) 2) Diet: Aim for 5-10% weight loss >50% of calories need to be a fibre-rich diet with minimum saturated fat and refined carbs by avoiding ready-made foods etc... Spread food intake throughout the day to prevent hypoglycemia Avoid alcohol 3) Exercise: Exercise increases insulin sensitivity and reduces BP => reduces most complications. Aim for 150 minutes of moderate exercise/week or 75 high intensity. (or 30 minutes 5/week) 4) Immunisation with annual influenza vaccine and pneumococcal 5) Psychological support, counselling services 6) Smoking and alcohol cessation Medical: Refer to goals of HbA1c <48 vs <53 and escalation if HbA1c >58 despite current therapy (same at every step) 1) If pre-diabetic (<48) => lifestyle advice only 2) Once diabetic (48+) => Monotherapy with Metformin or other non-hypoglycemic drugs (DPP4i, Pioglitazone) 3) Dual Therapy: Metformin + any other medication 4) Triple therapy: Metformin + any 2 other medications (here including SGLT2i) 5) Insulin OR Metformin + Sulfonylurea + GLP-1 mimetic

Question 63

A diabetic patient presents with uncontrolled diabetes. What factors may lead to this?

Answer 63

Exclude any intercurrent illness Check blood sugar diary Consider diet Check insulin administration, ensuring sites are not scarred or hypertrophic Consider psychosocial factors If all fails, there may be an underlying change in insulin resistance/sensitivity

Question 64

You conduct TFTs on a patient. What are the typical results of a patient with hyperthyroidism? Hypothyroidism?

Answer 64

Hyperthyroidism: reduced TSH and raised T4 Hypothyroidism: increased TSH, reduced T4

Question 65

What is meant by subclinical Hypothyroidism? (answer based on TFTs)

Answer 65

Raised TSH but normal T4

Question 66

What would it mean if TSH and T4 are both low?

Answer 66

Pituitary failure

Question 67

You conduct TFTs on a patient and results show low TSH and raised T4. Give the causes What are the features of hyperthyroidism?

Answer 67

Causes: 1) Grave's disease 2) Toxic nodular goitre 3) Thyroiditis 4) Amiodarone Features: Increased metabolism: Heat insensitivity, increased sweating, increased appetite despite weight loss, diarrhoea, palpitations, Brittle/fine hair Bonus: HTN with widened pulse pressure, tachycardia, atrial fibrillation. Increased movement: Tremulousness (hand tremor), excessive sweating (warm clammy skin) Increased mentation: Increased anxiety, insomnia, depression Women: Hypomenorrhoea Elderly: Confusion, Eyes: Exompthalmos, lid lag, double vision Syncope

Question 68

What is the management of Hyperthyroidism as a GP?

Answer 68

Refer to endocrinology

Question 69

How is syncope a feature of hypo and hyperthyroidism

Answer 69

A.fib from hyper Hypotension from Hypo

Question 70

What is the role of beta blockers in the management of thyroid disease

Answer 70

Used in hyperthyroidism for symptom control until anti-thyroid therapy takes effect

Question 71

What is the surgical management of hyperthyroidism? What are the indications? What are specific risks associated with this surgery?

Answer 71

Partial or Total thyroidectomy. Reserved for patients with large goitres or who decline radioactive iodine or in patients that have had unsuccessful previous treatment Recurrent laryngeal nerve injury (hoarse voice) Damage to parathyroid glands => Hypercalcaemia (trousseau and Chvostek's sign

Question 72

How would you manage a patient presenting with Hyperthyroidism

Answer 72

1) Give patient education and refer to endocrinology at presentation 2) Carbimazole 3) Radioactive Iodine 4) Surgery (partial/total thyroidectomy) + Beta blocker for symptom control until anti-thyroid therapy takes effect

Question 73

What is the mechanism of action of Carbimazole? What must you warn patients about when prescribing this medication

Answer 73

Inhibits synthesis of thyroid hormone Agranulocytosis is the major risk factor. Patients should be warned to stop medication and seek urgent help if they develop sore throat or signs of infection

Question 74

A patient is on Carbimazole with uncontrolled thyroid disease. What is the next step?

Answer 74

Radioactive Iodine or Surgery (partial/total thyroidectomy) if they refuse

Question 75

A patient is on Carbimazole with uncontrolled thyroid disease. They opt for radioactive iodine therapy. What should the patient be warned about before starting radioactive iodine therapy? What are the long term risks?

Answer 75

Patients should be warned that it takes 3-4 months for the effects to become apparent. + Stop Carbimazole 4 days prior and 3 days after iodine therapy. + Advise against pregnancy with 4 months after treatment Most patients end up hypothyroid years later.

Question 76

What is the most common cause of Hyperthyroidism?

Answer 76

Grave's Disease

Question 77

Grave's disease is the most common cause of hyperthyroidism. It is associated with smoking. What is the pathophysiology behind it? What are the clinical features of Grave's disease (including exam findings)

Answer 77

Autoimmune antibodies (LT) to TSH receptors prevent their down-regulation Clinical features: Signs and sx of hyperthyroidism - Increased metabolism: Heat insensitivity, increased sweating, increased appetite despite weight loss, diarrhoea, palpitations Bonus: HTN with widened pulse pressure, tachycardia, atrial fibrillation. Increased movement: Tremulousness (hand tremor), excessive sweating (warm clammy skin) Increased mentation: Increased anxiety, insomnia, depression Women: Hypomenorrhoea Elderly: Confusion, Eyes: Exompthalmos, lid lag, double vision Syncope Exam: Diffuse goitre Grave's opthalmopathy Pretibial Myxoedema Thyroid acropachy (swelling of finger + Clubbing) Retrosternal expansion Thyroid bruit

Question 78

What is thyroid acropachy

Answer 78

rare (0.3%) Thickening of the extremities associated with hyperthyroidism with the characteristic triad of 1) Clubbing 2) Digital and feet swelling 3) New bone formation

Question 79

What is Pre-tibial Myxoedema? Is the oedema pitting or non-pitting?

Answer 79

Thickening and welling of skin over tibia. It is waxy and shiny + colour ranges from pink to brown. It is non-pitting oedema

Question 80

A patient presents with a large goitre on examination. You conduct blood tests showing raised TSH but low T4. What is the most likely diagnosis?

Answer 80

Hashimoto's thyroiditis

Question 81

Give the top 3 causes of hypothyroidism

Answer 81

1) Post- Radioactive Iodine therapy 2) Post- Thyroidectomy 3) Hashimoto's thyroiditis (Anti-TPO)

Question 82

What are the signs and symptoms of hypothyroidism?

Answer 82

Signs: 1) Goitre (Hashimoto's) 2) Slow reflexes 3) Non-pitting oedema => Myxoedema of the face. eyelids...systemic Symptoms: (just opposite of hyper) Depression fatigue, lethargy General malasie Increased weight Constipation Cold intolerance Hair loss Anhydrosis (dry skin and hair) Hoarse voice (a/w thyroidectomy)

Question 83

Myxoedema is a feature of both hypo and hyperthyroidism. Define myxoedema How would you differentiate

Answer 83

Myxoedema is the widespread thickening and non-pitting swelling of the skin as a result of thyroid dysfunction In both they are non-pitting oedema (definition of myxoedema). In pre-tibial myxoedema (from Grave's disease), it is localized to the shin => Pre-tibial. In hypothyroidism it is systemic => widespread mostly to the face, eyelids, and feet

Question 84

When someone presents as always being tired what tests will you always order?

Answer 84

FBC (anemia) and TFTs (hypothyroidism)

Question 85

What is the management of Hypothyroidism including followup

Answer 85

Patient education <65 and healthy: 50-100mcg Levothyroxine OD >65 or heart disease: Start at 25mcg levothyroxine (Consider beta blocker propanalol if heart disease) For both, followup every 4 weeks to adjust dose until Euthyroid, then checks annually

Question 86

What genotype is associated with T1DM?

Answer 86

HLADR3/4

Question 87

What is meant by widened pulse pressure? Where is it seen?

Answer 87

widened difference between systolic and diastolic pressure Seen in hyperthyroidism. Hypo would have normal or narrow Think of asian guy who takes tablets for thyroid and he had a very wide pulse pressure as well as very anxious

Question 88

What is the treatment of subclinical hypothyroidism?

Answer 88

Raised TSH but normal T4 It is not treated unless patient is symptomatic or infertile Then start Etroxin 25mg