Endocrinology Flashcards
1
Q
What are the diagnostic criteria for T2DM based on plasma glucose in a symptomatic patient?
A
- Fasting glucose greater than or equal to 7.0 mmol/l
- Random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)
2
Q
What are the diagnostic criteria for T2DM based on plasma glucose in an asymptomatic patient?
A
- Fasting glucose greater than or equal to 7.0 mmol/l
- Random glucose greater than or equal to 11.1 mmol/l (or after 75g oral glucose tolerance test)
- Must be demonstrated on two separate occasions
3
Q
What are the diagnostic criteria for T2DM based on HBA1c?
A
A HbA1c of greater than or equal to 48 mmol/mol (6.5%) is diagnostic of diabetes mellitus
4
Q
What are the minimum recommended times of day for a patient with T1DM to routinely self-monitor their capillary blood glucose levels?
A
At least 4 times a day, including before each meal and before bed
5
Q
What conditions are associated with MEN-1?
A
Hyperparathyroidism (+ hypercalcaemia), pituitary disease and pancreatic disease such as insulinomas or gastrinomas
6
Q
What conditions are assocaited with MEN-2a?
A
- Medullary thyroid cancer (70%)
- Parathyroid (60%)
- Phaeochromocytoma
7
Q
What conditions are assocaited with MEN-2b?
A
- Medullary thyroid cancer
- Phaeochromocytoma
- Marfanoid body habitus
- Neuromas
8
Q
What advice should be given to patients on metformin who are participating in Ramadan?
A
During Ramadan, one-third of the normal metformin dose should be taken before sunrise and two-thirds should be taken after sunset
9
Q
T2DM. Metformin not tolerated. What next?
A
Next option should be either a DPP4 inhibitor, SGLT2 inhibitor, sulfonylurea, or thiazolidinedione
10
Q
Which type of oral steroid has the least amount of mineralocorticoid activity?
A
Dexamethasone
11
Q
What blood results are associated with hypercalcaemia secondary to malignancy?
A
PTH is low, although PTHrP may be raised
12
Q
What is the preferred investigation for T1DM?
A
Random plasma glucose (HbA1c not recommended)
13
Q
What anti-diabetic drug is contraindicated with a history of bladder cancer?
A
Pioglitazone
14
Q
What is the best test to diagnose Addison’s disease?
A
The short synacthen test
15
Q
List the drug causes of raised prolactin
A
- Metoclopramide, domperidone
- Phenothiazines
- Haloperidol
- Very rare: SSRIs, opioids
16
Q
In patients with T2DM, what drug should be introduced if they develop CVD, a high risk of CVD or chronic heart failure?
A
SGLT-2 inhibitor (e.g. dapagloflozin)
17
Q
Management of patients with type I diabetes and a BMI > 25
A
Should be considered for metformin in addition to insulin
18
Q
What water deprivation test results are associated with primary polydipsia?
A
- Urine osmolality after fluid deprivation: high
- Urine osmolality after desmopressin: high
19
Q
Patient commenced on vitamin D. Blood tests show mild hypercalcaemia, low phosphate and raised PTH.
What is the most likely diagnosis?
A
Primary hyperparathyroidism (unmasked by vitamin D replacement)
20
Q
What dexamethasone suppression test results are associated with Cushing’s?
A
Cortisol is not suppressed by low-dose dexamethasone but is suppressed by high-dose dexamethasone
21
Q
TD2M already on 2 drugs - if HbA1c > 58 mmol/mol then what should be offered?
A
- Metformin + DPP-4 inhibitor + sulfonylurea
- Metformin + pioglitazone + sulfonylurea
- Metformin + (pioglitazone or sulfonylurea or DPP-4 inhibitor) + SGLT-2 if certain NICE criteria are met
- Insulin-based treatment
22
Q
What is the commonest cause of Addison’s disease in the U.K?
A
Autoimmunity
23
Q
What visual field defect is associated with a prolactinoma?
A
Bi-temporal superior quadrantanopia
24
Q
What brain MRI results would indicate a prolactinoma?
A
An abnormally enlarged pituitary gland that is sitting within the sella turcica
25
What blood results are associated with tertiary hyperparathyroidism?
* Extremely high serum PTH
* Moderately raised serum calcium
* Low-normal phosphate
26
What blood results are associated with Addison's?
Hyponatraemia, hyperkalamia, hypoglycaemia
27
What is the most common type of thyroid cancer?
Papillary
28
What can be used as a tumour marker in papillary and follicular thyroid cancer?
Thyroglobulin
29
What findings on light microscopy are associated with papillary thyroid carcioma?
Orphan Annie eyes
30
What can be used as a tumour marker in medullary thyroid carcinoma?
Calcitonin
31
What investigation can be used to distinguish between unilateral adenoma and bilateral hyperplasia in primary hyperaldosteronism?
Adrenal venous sampling
32
What is the confirmatory test for Addison's disease?
Synthactin (ACTH) stimulation test
33
How do thyroid disorders affect periods?
Hyperthyroidism is associated with oligomennorhoea, or amennorhoea, whereas hypothyroidism is associated with menorrhagia
34
What advise should be given to patients on long-term steroids during intercurrent illness?
Double the dose
35
What is the first line management for control of blood pressure while awaiting definitive management of pheochromocytoma?
* Alpha (e.g. phenoxybenzamine) and beta blockade (e.g. propranolol, labetalol)
* Alpha blocker should be given BEFORE beta blocker
36
What hormone test results are associated with Klinefelter's syndrome?
Hypergonadotrophic hypogonadism - FSH and LH concentrations are elevated and serum testosterone concentrations are low
37
Describe the presentation of Klinefelter's syndrome
* Often taller than average
* Lack of secondary sexual characteristics
* Small, firm testes
* Infertile
* Gynaecomastia - increased incidence of breast cancer
38
What is the first line tretment for a hypoglycaemic conscious patient who is able to swallow?
* Fast-acting carbohydrate by mouth i.e.. glucose liquids, tablets or gels
* e.g. 30g glucose gel
39
Wha drugs can reduce the absorption of levothyroxine?
Iron/calcium carbonate - should be given 4 hours apart
40
What complications are associated with subclinical hyperthyroidism?
Atrial fibrillation, osteoporosis and possibly dementia
41
What is the key parameter to monitor in patients with hyperosmolar hyperglycaemic state?
Serum osmolality
42
In TD2M, if a triple combination of drugs has failed to reduce HbA1c you should switch one of the drugs for what type of drug?
GLP-1 mimetic e.g. liraglutide
43
What is the first line investigation for primary hyperaldosteronism?
Plasma aldosterone/renin ratio
44
A 27-year-old female develops eye pain and reduced visual acuity following the initiation of treatment for her recently diagnosed Grave's disease.
Which one of the following treatments is likely to have been started?
Radioiodine treatment
45
What are the target blood pressure readings for a patient with T2DM?
The same as for non-T2DM:
* Clinic reading: < 140 / 90
* ABPM / HBPM: < 135 / 85
46
Describe the presentation of Addison's disease
* Confusion
* Hyperpigmentation
* Low blood pressure
47
What blood test results are associated with primary hyperparathyroidism?
* Hypercalcaemia and increased PTH
* Normal urea and electrolytes
48
What are the sick day rules for T1DM?
* If a patient is on insulin, they must not stop it due to the risk of diabetic ketoacidosis
* Check blood glucose more frequently, for example, every 1-2 hours including through the night
* Consider checking blood or urine ketone levels regularly
* Maintain normal meal pattern if possible
* Aim to drink at least 3 L of fluid (5 pints) a day to prevent dehydration
49
What blood test and thyroid scintigraphy scan results are associated with De Quervain's thyroiditis?
Initial hyperthyroidism (raised TSH, T3 and T4), eventually resulting in hypothyroidism
* Globally reduced uptake of iodine-131
50
What autoantibodies are associated Graves disease?
TSH receptor stimulating autoantibodies
51
A 34-year-old woman was found to have persistently raised thyroid stimulating hormone (TSH) and normal thyroxine (T4) levels on routine blood tests.
What is the most appropriate next investigation test for her?
Thyroid peroxidase antibodies
## Footnote
Check thyroid peroxidase antibodies in patients who have subclinical hypothyroidism as this can indicate patients who are more likely to progress to overt hypothyroidism
52
Hypoglycaemia with impaired GCS. IV access is present.
What is the most appropriate next step in management?
IV glucose
53
What type of drug is gliclazide?
Sulfonylurea
54
What are the important adverse effects of sulfonylreas?
* Hypoglycaemic episodes
* Weight gain
* Hyponatramia
* Hepatoxicity (typically cholestatic)
55
How do sulfonylureas cause weight gain?
They directly increase the amount of insulin secreted by the pancreas via binding to ATP-K+ channels on the beta cells, which in turn stimulates cells to store glucose in the form of fat
56
What drug should be used in new cases of new Graves' disease to help control symptoms?
Propranolol
57
Describe the presentation of primary hyperparathyroidism
Depression, nausea, constipation, bone pain
58
The presence of an elevated prolactin level along with secondary hypothyroidism and hypogonadism is indicative of?
Non-functioning pituitary adenoma
59
Describe the presentation of gliclazide overdose?
Hyperinsulinemia and high C-peptide levels
60
Name a drug which can cause hypercalcaemia
Thiazides
61
DKA: ketonaemia and acidosis have not been resolved within 24 hours
What is the next step in management?
Patient should be reviewed by a senior endocrinologist
62
Medullary thyroid cancer is associated with what oncogene?
RET oncogene
63
Patient with Addison's has persistent vomiting. What advise should be given?
IM hydrocortisone
64
A 34-year-old female presents with a thyroid nodule. She has a family history of thyroid disease and both her sisters have undergone total thyroidectomies. Her past medical history includes hypertension which has been difficult to manage.
What is the most likely diagnosis?
Medullary carcinoma
65
An 18-year-old female presents with 3 nodules in the right lobe of the thyroid. Clinically she is euthyroid and there is associated cervical lymphadenopathy. She has no family history of thyroid disease.
What is the most likely diagnosis?
Papillary carcinoma
66
List the conditions which are associated with lower-than-expected HBA1c
* Sickle-cell anaemia
* GP6D deficiency
* Hereditary spherocytosis
* Haemodialysis
67
List the conditions which are associated with higher-than-expected HBA1c
* Vitamin B12/folic acid deficiency
* Iron-deficiency anaemia
* Splenectomy
68
Describe the presentation of phaeochromocytoma
Sweating, headaches, and palpitations in association with severe hypertension
69
What is the most important blood test to monitor for treatment response Hashimoto's thyroiditis?
TSH
70
Why is insulin only used in hyperosmolar hyperglycaemic state if the glucose stops falling while giving IV fluids?
Risk of cerebral pontine myelinolysis
71
What is the most common cause of hypothyroidism in the UK?
Hashimoto's (autoimmune)
72
What advice should be given to women with hypothyroidism regarding levothyroxine dose in therapy?
Women with hypothyroidism may need to increase their thyroid hormone replacement dose by up to 50% as early as 4-6 weeks of pregnancy
73
When should you treat subclinical hypothyroidism?
If the TSH level is > 10 mU/L on 2 separate occasions 3 months apart
74
What is the first step in investigating hypercalcaemia?
Measuring PTH level
75
What is the standard HbA1c target in type 2 diabetes mellitus?
48 mmol/mol
76
When might the Hb1c target in T2DM be higher than 48mmol/mol?
The target may change to 53 mmol/mol if the patient is started on a second agent, or if they are receiving a medication that carries the risk of hypoglycaemia (e.g. sulphonylurea)
77
When should a second drug should be added in type 2 diabetes mellitus?
If the HbA1c is > 58 mmol/mol
78
What is the management of a thyrotoxic storm?
* Beta-blockers: typically IV propranolol
anti-thyroid drugs: e.g. methimazole or
* Propylthiouracil
* Lugol's iodine
* Dexamethasone
79
What blood results are associated with primary hyperaldosteronism?
Hypokalaemic metabolic acidosis
80
What is the mechanism of action of glitazones
* Glitazones e.g. pioglitazone are thiazolidinediones
* Increase insulin sensitivity in peripheral tissues such as adipose tissue, skeletal muscle, and the liver by binding to PPAR-γ nuclear receptor
* This results in decreased insulin resistance and improved glycaemic control
81
What is the first-line treatment for prolactinomas?
Dopamine agonists e.g. cabergoline
82
True or false: the PTH level in primary hyperparathyroidism may be normal
True
83
Name a contraindication for pioglitazone
Heart failure
84
What is the first line investigation for pheochromocytoma?
Urinary metanephrines
85
What standards must be met in order for a person with diabetes mellitus to drive?
* There has not been any severe hypoglycaemic event in the previous 12 months
* The driver has full hypoglycaemic awareness
* The driver must show adequate control of the condition by regular blood glucose monitoring (at least twice daily and at times relevant to driving
the driver must demonstrate an understanding of the risks of hypoglycaemia)
* There are no other debarring complications of diabetes
86
Pepperpot skull is a characteristic X-ray finding of what condition?
Hyperparathyroidism
87
Increased, homogenous uptake on a radioactive iodine uptake test suggests what?
Grave's disease
88
How many units are in 1ml of most standard insulin?
100
89
In the investigation of acromegaly, if a patient is shown to have raised IGF-1 levels, what investigation is diagnostic?
An oral glucose tolerance test (OGTT) with serial GH measurements is suggested to confirm the diagnosis
90
What is the mode of action of orlistat?
Orlistat works by inhibiting gastric and pancreatic lipase to reduce the digestion of fat
91
Clubbing (acropachy) + hyperthryoidism indicates which disease?
Grave's
92
Thyrotoxicosis with tender goitre indicates what condition?
Subacute (De Quervain's) thyroiditis
93
What is the most common cause of primary hyperparathyroidism?
Solitary adenoma
94
What blood results are associated with secondary hyperparathyroidism?
* High PTH
* Low or normal calcium
95
What drugs can cause gynaecomastia?
* Spironolactone (most common drug cause)
* Cimetidine
* Digoxin
* Cannabis
* Finasteride
* GnRH agonists e.g. goserelin, buserelin
oestrogens, anabolic steroids
96
True or false: steroids can cause psychosis
True
97
What blood results are associated with primary hyperaldosteronism?
* High sodium
* Low potassium
98
99
Suspected Addison's disease. 9 am cortisol between 100-500nmol/l.
What is the next step?
9 am cortisol between 100-500nmol/l is inconclusive and requires further investigation with a short synacthen test
100
Hashimoto's thyroiditis is associated with the development of what malignancy?
MALT lymphoma
101
What is the inheritance pattern for MODY?
Autosomal dominant
102
What is the treatment of choice for a toxic multinodular goitre?
Radioactive iodine
103
What are the clinical features of Kallmann's syndrome?
* 'Delayed puberty'
* hypogonadism, cryptorchidism
* Anosmia
* Patients are typically of normal or above-average height
104
What blood test results are associated with Kallman's syndrome?
LH & FSH low-normal and testosterone is low
105
What is the most suitable oral treatment for an obese patient with T2DM if metformin fails to control diabetes?
DPP-4 inhibitor e.g. sitagliptin
## Footnote
Do not cause weight gain
106
What is the most common endogenous cause of Cushing's syndrome?
Pituitary adenoma
107
An 80-year-old woman has a hip fracture. Her calcium is normal. She has never been given a diagnosis of osteoporosis.
What is the most appropriate management?
Risedronate and calcium supplements
108
A child presents with a palpable abdominal mass or unexplained enlarged abdominal organ.
What is the next step in management?
Refer very urgently (<48hr) for specialist assessment for neuroblastoma and Wilms' tumour
109
What is the most common cause of primary hyperaldosteronism?
Bilateral idiopathic adrenal hyperplasia
110
What is the most appropriate treatment of gastroparesis caused by T1DM?
Metoclopramide
111
Over-replacement with thyroxine in patients with hypothyroidism increases the risk of what condition?
Osteoporosis
112
What is the first line treatment for an adrenal crisis?
IV hydrocortisone
113
Describe the presentation of hypercalcaemia
* Stones (renal)
* Bones (bone pain)
* Groans (abdominal pain, nausea and vomiting)
* Thrones (polyuria)
* Psychiatric overtones (confusion and cognitive dysfunction, depression, anxiety, insomnia, coma)
114
What type of goitre is associated with Hashimoto's thyroiditis?
Diffuse and painless goitre
115
What is the first line treatment for prolactinomas?
Dopamine agonists (e.g. cabergoline, bromocriptine) are first-line treatment for prolactinomas, even if there are significant neurological complications
116
In DKA, once blood glucose is < 14 mmol/l, what should be started?
An infusion of 10% dextrose should be started at 125 mls/hr in addition to the saline regime
117
What is the definitive management of primary hyperparathyroidism?
Total parathyroidectomy
118
What atypical factors would prompt further tests in suspected T1DM?
Age 50 years or above, BMI of 25 kg/m² or above, slow evolution of hyperglycaemia or long prodrome
119
What is the first line insulin regime for newly diagnosed adults with T1DM?
Basal-bolus using twice-daily insulin detemir
120
What should patients with Addison's should be given for adrenal crises?
Hydrocortisone injection kit
121
What gene mutation is associated with MODY?
Hepatic Nuclear Factor 1 Alpha (HNF1A)
122
What is a possible explanation for increased TSH levels and normal T4?
Poor compliance with thyroxine medication
123
How should you manage a patient with subclinical hypothyroidism with TSH level of level is 5.5 - 10mU/?
Offer patients < 65 years a 6-month trial of thyroxine if TSH remains at that level on 2 separate occasions 3 months apart and they have hypothyroidism symptoms
124
What fasting plasma glucose implies impaired fasting glucose?
Greater than or equal to 6.1 but less than 7.0 mmol/l
125
What is the definition of impaired glucose tolerance?
Fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l
126
What is the first line treatment for most patients with a pitiutary tymour causing acromegaly?
Trans-sphenoidal surgery
127
What is the most appropriate investigation for patients with increased urinary cortisol and low plasma ACTH levels?
CT adrenal glands
128
What are the blood glucose targets for T1DM?
* 5-7 mmol/l on waking and
* 4-7 mmol/l before meals at other times of the day
129
At what point should a second drug (in combination with metformin) be added in T2DM?
If the HbA1c is > 58 mmol/mol
130
What venous blood gas results are associated with Cushing's?
Hypokalaemic metabolic alkalosis
131
Name the genetic syndrome associated with insulinomas
MEN-1
132
If starting an SGLT-2 as initial therapy for T2DM, what should you do?
Ensure metformin is titrated up first
133
C-peptide levels are typically (high/low) in patients with T1DM
Low
134
What is the single most useful test initial for determining hypercalcaemia?
PTH
135
Describe the administration of insulin in DKA
Insulin should be fixed rate whilst continuing regular injected long-acting insulin but stopping short actin injected insulin
136
What is the first line treatment for Grave's disease?
Carbimazole (12-18 months)
137
What is the major complication of carbimazole therapy?
Agranulocytosis
138
What is the prognosis of papillary thyroid cancer?
Shows excellent prognosis, despite the tendency to spread to cervical lymph nodes early
139
What is pretibial myoedema?
Incommon but specific feature in Grave's disease that is not seen in hyperthyroidism secondary to other causes
140
Name two invesigations which can be used to differentiate between T1 and T2DM
C-peptide levels and diabetes-specific autoantibodies
