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MRCP - Passmed > Endocrinology > Flashcards

Endocrinology Flashcards

1
Q

How is a myxoedemic coma treated? How can this present?

A

Thyroxine and hydrocortisone

Eg presentation - confusion, bradycardia, hypotension

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2
Q

What happens to thyroxine dose in pregnancy?

A

Safe to take during pregnancy and breastfeeding

Increase by to 50% as early as 4-6 weeks

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3
Q

Diagnosis for insulinomas?

A

Supervised fasting with abnormally high insulin

CT pancreas

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4
Q

Treatment of thyrotoxicosis in pregnancy?

A

Propylthiouracil in 1st trimester

Carbimazole afterwards

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5
Q

When to avoid radioiodine in management of graves disease (hyperthyroidism) ?

A

When thyroid eye disease is present!

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6
Q

Investigation of acromegaly?

A

1st line - serum IGF1

Confirmed with OGTT and serial GH levels

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7
Q

Medical mx of phaeochromocytoma?

A

1st a-blocker eg PHenoxybenazmine (like PHaeo)

then B-blockers

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8
Q

When to add SGLT2 inhibitor to inital therapy in T2DM mx when on Metformin?

A

the patient has a high risk of developing cardiovascular disease (CVD, e.g. QRISK ≥ 10%)

the patient has established CVD

the patient has chronic heart failure

SGLT-2 inhibitors should also be started at any point if a patient develops CVD (e.g. is diagnosed with ischaemic heart disease), a QRISK ≥ 10% or chronic heart failure

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9
Q

Which supplement to be careful of when on levothyroxine?

A

Iron or Calcium carbonate tablets can reduce absorption of levothyroxine hence should be given 4 hours apart

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10
Q

Side effects of thyroxine therapy?

A

hyperthyroidism: due to over treatment
reduced bone mineral density
worsening of angina
atrial fibrillation

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11
Q

Management of thyrotoxic storm?

A

BB

Anti thyroid drugs - Propylthiouracil > Carbimazole due to effects on peripheral conversion

Steroids - prevent conversion of T4 -> T3

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12
Q

Blood gas findings in renal tubular acidosis?

A

Hyperchloraemic metabolic acidosis (normal anion gap)

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13
Q

What are the different types of RTA?

A

Type 1 RTA - Distal
Type 2 RTA - Proximal
Type 3 RTA - Mixed
Type 4 RTA - Hyperkalaemic

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14
Q
A
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15
Q
A
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16
Q

MEN 1, 2a and 2b?

A

MEN 1 (3Ps)
Parathyroid - hyper due to hyperplasia of gland
Pituitary
Pancreas
(Also adrenal and thyroid)

MEN 2a (2Ps)
Medullary thyroid cancer
Parathyroid
Phaeochromocytoma

MEN 2b (1P)
Medullary thyroid cancer
Phaeochromocytoma
Marfanoid appearance
Neuromas

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17
Q

Gene involved in MEN 1 v 2a v 2b

A

MEN 1 = MEN1 gene

MEN 2a + 2b = RET

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18
Q

Describe the hormonal responde to hypoglycaemia

A

1st - decreased insulin secretion

2nd - glucagon secretion

3rd - GH and Cortisol release

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19
Q

Describe the symathoadrenal responde to hypoglycaemia

A

Increased catecholamine-mediated (adrenergic) and acetylcholine-mediated (cholinergic) neurotransmission in PANS and CNS

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20
Q

Definitive mx of primary hyperparathyroidism?

A

Total parathyroidectomy

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21
Q

What cancer is associated with Hashimoto’s thyroiditis?

A

Thyroid lymphoma

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22
Q

Carbimazole v Propylthiouracil MoA?

A

Carbimazole + Propylthiouracil:
blocks thyroid peroxidase from coupling and iodinating the tyrosine residues on thyroglobulin → reducing thyroid hormone production

Propylthiouracil:
Also inhibits peripheral conversion of T4 to T3 via inibition of 5-deiodinase

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23
Q

Delayed puberty + hypogonadism + anosmia
LH & FSH low-normal and testosterone is low

Diagnosis?

A

Kallman’s syndrome

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24
Q

What to do in T2DM if HbA1c not controlled with triple therapy?

A

If triple therapy is not effective or tolerated consider switching one of the drugs for a GLP-1 mimetic:

BMI ≥ 35 kg/m² and specific psychological or other medical problems associated with obesity or

BMI < 35 kg/m² and for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity-related comorbidities

only continue if there is a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months

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25
Q

Mx of infertility in PCOS?

A

Clomifene
Can also add metformin particularly if obese
Weight loss also important if appropriate

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26
Q

Drug causes of Gynaecomastia?

A

spironolactone (most common drug cause)
cimetidine
digoxin
cannabis
finasteride
GnRH agonists e.g. goserelin, buserelin - used in prostate ca
oestrogens, anabolic steroids

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27
Q

Mx of stress incontinence?

A

Pelvic floor exercises - 8x3 daily - 3 months min

Surgical - retropubic midrethral tape procedures

Duloxetine - Offered if decline surgical procedures

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28
Q

Inheritance of Familial Hypercholesteraemia?

A

Autosomally dominant

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29
Q

Adverse effects of thiazolidinediones (-glitazones) used in T2DM?

A

Weight gain

Liver impairment - monitor LFTs

Fluid retention - CI in HF (increased risk if taking insulin)

Increased # risk

Increased risk of bladder ca

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30
Q

What to do to doses of long-term steroids in illness?

A

Double the dose of long-term steroids

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31
Q

MoA of Sulphonureas? Can these cause weight gain and hypoglycaemia?

A

Binding of ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta - CLOSES THE CHANNELS

Yes causes weight gain and hypoglycaemia

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32
Q

Glucocorticoid eg Pred effect on WBC?

A

Neutrophillia

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33
Q

How to distinguish between renal artery stenosis v primary hyperaldosteronism?

A

Both has raised aldosterone

Renin = low in primary hyperaldosteronism as HTN -> excessive renal perfusion-> decreased renin production (negative feedback mechanism)

Renin = high in renal artery stenosis for opposing reasons

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34
Q

MODY mechanism of inheritance?

A

Autosomally dominant

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35
Q

Klinefelter karyotype?

A

47 XXY

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36
Q

Which drugs can cause hypercalcaemia?

A

Thiazides

Ca-containing antacids

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37
Q

Statins in established CVD (stroke, IHD or PVD)?S

A

High intensity (Atorvastatin 80mg)

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38
Q

Gliclazide type of drug? MoA description?

A

Sulfonyureas - increase stimulation of insulin secretion by pancreatic B-cells and decrease hepatic clearance of insulin

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39
Q

Blood gas findings in Cushings?

A

Hypokalaemic metabolic alkalosis

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40
Q

Which HPV increases risk of cervical cancer? what are some other RFs?

A

HPV 16, 18, 33

Smoking
HIV
Earky first intercourse / multiple partners
High parity
Lower socio-economic status
COCP

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41
Q

Which type of thyroid ca is associated with RET oncogene?

A

Medullary

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42
Q

Which diabetic medications cause weight gain?

A

Insulin
Sulfonylureas
Thiazolidiones

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43
Q

Which diabetic meds can cause hypoglycaemia?

A

Insulin
Sulfonylureas
SGLT2 inhibitors

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44
Q

Medical mx of urge incontinence?

A

Muscarinic antagonist eg tolterodine, oxybutinin or solifenacin

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45
Q

Target improvement when using statins?

A

NICE look for a 40% reduction in non-HDL cholesterol after 3 months

If not improving by this level to consider titrating to 80mg

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46
Q

High LH, Low Testosterone

Infertile

Dx?

A

Klinefelters

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47
Q

Effect of corticosteroids on WBC?

A

Neutrophilia

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48
Q

How should 9am cortisol levels be interpreted?

A

> 500 nmol/l makes Addison’s very unlikely
< 100 nmol/l is definitely abnormal
100-500 nmol/l should prompt a ACTH stimulation test to be performed

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49
Q

What is addisons disease?

A

Low cortisol and aldosterones

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50
Q

Blood sugar targets in gestational DM?

A

fasting: 5.3mmol/L
AND
1 hour postprandial: 7.8 mmol/L or
2 hours postprandial: 6.4 mmol/L

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51
Q

Causes of pseudohyponatraemia?

A

Hyperlipidaemia
Hyperproteinaemia
Blood taken from drip arm
Severe hyperglycaemia -> draws intracellular water into extracellular place

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52
Q

Cause of Bartters syndrome?

A

defective chloride absorption at the Na+ K+ 2Cl- cotransporter (NKCC2) in the ascending loop of Henle

Note- loop diuretics work by inhibiting this so think of bartters as taking large doses of furosemide

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53
Q

What is Hashimotos thyroiditis associated with?

A

MALToma

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54
Q

Why should slow infusion given to younger patients with DKA?

A

cerebral oedema

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55
Q

DKA insulin dose?

A

Diabetic ketoacidosis: the IV insulin infusion should be started at 0.1 unit/kg/hour

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56
Q

Which antibodies in hashimotos thyroiditis

A

anti-TPO

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57
Q

Important adverse effects of SGLT2 inhibitors?

A

Normoglycaemic ketoacidosis

Increased risk of lower limb amputation

Urinaru + genital infection secondary to glycosuria

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58
Q

How is a thyrotoxic storm managed?

A

counteracting the peripheral effects of thyroid hormone (using propranolol)

preventing peripheral conversion of T4 to active T3 (using steroids),

inhibiting further thyroid hormone synthesis (using antithyroid drugs and Lugol’s iodine).

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59
Q

When to refer for parathyroid surgery in primary hyperparathyroidism?

A

Symptoms of hypercalcaemia (e.g. thirst, polyuria, constipation)
End-organ disease (renal calculi, fragility fractures or osteoporosis)
Corrected serum calcium of 2.85 mmol/L or above

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60
Q

Which type of thyroid ca is associated with Hashimotos thyroiditis? (AI thyroiditis)

A

Lymphoma

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61
Q

What is anti-SS-A also known as? Which rheumatological condition is this associated with?

A

Also known as anti-ro and is associated with Sjogrens

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62
Q

Blood gas findings in Cushings?

A

Hypokalaemic metabolic acidosis -> excess cortisol prodcution leading to Na / water retention

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63
Q

Which type of RTA can show nephrocalcinosis?

A

Type 1 RTA

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64
Q

Which type of RTN is associated with osteomalacia?

A

Type 2 RTN

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65
Q

What is type 3 RTN caused by?

A

Carbonic anhydrase II deficiency

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66
Q

What are causes of type 4 RTN?

A

Hypoaldosteronism and diabetes

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67
Q

What are the causes of hypokalaemia with HTN?

A

Cushing’s syndrome
Conn’s syndrome (primary hyperaldosteronism)
Liddle’s syndrome
11-beta hydroxylase deficiency*

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68
Q

What are the causes of hypokalaemia without HTN?

A

diuretics
GI loss (e.g. Diarrhoea, vomiting)
renal tubular acidosis (type 1 and 2**)
Bartter’s syndrome
Gitelman syndrome

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69
Q

What happens to GLP-1 levels in T2DM?

A

There is decreased levels of GLP1
- released by small intestine in response to oral glucose load

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70
Q

Inheritance pattern of familial hypercholesteraemia?

A

Autosomally dominant

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71
Q

What is distal RTA (type 1) caused by?

A

Inability to secrete H+ in distal tubule

causes hypokalaemia

Can lead to nephrocalcinosis and renal stones (calcium phosphate)

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72
Q

What is distal (type 1) RTA linked to?

A

Idiopathic, rheumatoid arthritis, SLE, Sjogren’s, amphotericin B toxicity, analgesic nephropathy

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73
Q

What is proximal (type 2) RTA caused by?

A

decreased HCO3- reabsorption in proximal tubule

causes hypokalaemia also

Can lead to osteomalacia

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74
Q

What are the causes of proximal (type 2) RTA?

A

Idiopathic, as part of Fanconi syndrome, Wilson’s disease, cystinosis, outdated tetracyclines, carbonic anhydrase inhibitors (acetazolamide, topiramate)

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75
Q

What is mixed RTA (type 3) caused by?

A

extremely rare

caused by carbonic anhydrase II deficiency

results in hypokalaemia

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76
Q

What are the features and causes of hyperkalaemic RTA (type 4)?

A

reduction in aldosterone leads in turn to a reduction in proximal tubular ammonium excretion

causes hyperkalaemia

causes include hypoaldosteronism, diabetes

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77
Q

Describe the different BMI classes?

A

Underweight < 18.49
Normal 18.5 - 25
Overweight 25 - 30
Obese class 1 30 - 35
Obese class 2 35 - 40
Obese class 3 > 40

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78
Q

What are the management options for obesity?

A

conservative: diet, exercise

medical
> orlistat - pancreatic lipase inhibitor -> faecal urgency / incontinence + flatulence + oily / fatty stools
> liraglutide - GLP1 mimetic

surgical

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79
Q

What are the tx options for urge incontinence?

A

Bladder retraining min 6 weeks - increasing intervals between voiding

Bladder stabilising meds:
1st line = antimuscarinics (oxybutinin, tolterodine or darifenacin) - avoid IR oxybutinin in frail older women risk of confusion + delirium
2nd line (if worried in older women) = Mirabegron (b3 agonist)

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80
Q

When can SGLT2 inhibitors be added in T2DM mx with context of CVD?

A

SGLT-2 should be introduced at any point they develop CVD, a high risk of CVD or chronic heart failure

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81
Q

What is the most common cause of thyroiditis?

A

Graves

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82
Q

In the primary prevention of CVD using statins aim for a reduction of what?

A

In the primary prevention of CVD using statins aim for a reduction in non-HDL cholesterol of > 40%

If not consider titrating up to 80mg

83
Q

What are the adverse effects associated with fibrate use?

A

GI side effects

Increased risk of VTE

84
Q

What antibodies are seen in Graves?

A

TSH receptor stimulating antibodies - seen in 90%

anti-thyroid peroxidase antibodies (75%)

85
Q

Features of Bartters syndrome?

A

usually presents in childhood, e.g. Failure to thrive
polyuria, polydipsia
hypokalaemia
normotension
weakness

Loop diuretics work by inhibiting NKCC2 - think of Bartter’s syndrome as like taking large doses of furosemide

86
Q

Which hormone is under constant inhibition?

A

Prolactin

87
Q

What to do to Metformin dose during Ramadan?

A

for patients taking metformin the expert consensus is that the dose should be split one-third before sunrise (Suhoor) and two-thirds after sunset (Iftar)

88
Q

What to do to sulphonylureas during Ramadan?

A

expert consensus also recommends switching once-daily sulfonylureas to after sunset.

For patients taking twice-daily preparations such as gliclazide it is recommended that a larger proportion of the dose is taken after after sunset

89
Q

What to do to Pioglitazone during Ramadan?

A

no adjustment is needed for patients taking pioglitazone

90
Q

Complications associated with Acromegaly?

A

hypertension
diabetes (>10%)
cardiomyopathy
colorectal cancer

91
Q

What drugs can lead to SiADH?

A

sulfonylureas*
SSRIs, tricyclics
carbamazepine
vincristine
cyclophosphamide

92
Q

What is hungry bone syndrome and what causes it?

A

Post-parathyroidectomy -> rapid drop in PTH levels which previously provided stimulation to osteoclasts when this drops rapid remineralisation occurs leading to

This leads to low Ca and to XR changes similar to metastatic lytic leisons if untreated

93
Q

What is Pendred syndrome?

A

AR genetic disorder characterised by:
- Sensorineural deafness
- Mild hypothyroidism
- Goitre

Often head trauma worsens sensorineural hearing loss

94
Q

What do bloods show in pseudohypoparathyroidism?

A

↑ PTH
↓ calcium
↑ phosphate

> short fourth and fifth metacarpals, short stature
learning difficulties, obesity, round face

95
Q

What are meglitinides and who are they used for? what are possible adverse effects? suffix?

A

Meglitinides - increase pancreatic insulin secretion

Like sulphonylureas bind to ATP-dependent K+ channel on panc beta cells

Used in patients with erratic lifestyles

Adverse effects - weight gain + hypoglycaemia

Suffix = -glinide

96
Q

Which antithyroid tx can exacerbate Graves eye disease sx? how can you reduce this risk?

A

radioiodine treatment may increase the inflammatory symptoms seen in thyroid eye disease.

In a recent study of patients with Graves’ disease around 15% developed, or had worsening of, eye disease.

Prednisolone may help reduce the risk

97
Q

Why does metformin help boost fertility in those with PCOS?

A

Increases peripheral insulin sensitivity -> lead to complicated changes in the hypothalamic-pituitary-ovarian axis.

98
Q

Which thyroid ca is likely to cause pressure symptoms?

A

Anaplastic thyroid cancer - aggressive, difficult to treat and often causes pressure symptoms

99
Q

Stress incontinence mx?

A

pelvic floor muscle training- NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months

surgical procedures: e.g. retropubic mid-urethral tape procedures

duloxetine may be offered to women if they decline surgical procedures

100
Q

What causes Gitelmans syndrome? What are the features?

A

Gitelman’s syndrome is due to a defect in the thiazide-sensitive Na+ Cl- transporter in the DCT

Features:
> normotension
> hypokalaemia
> hypocalciuria
> hypomagnesaemia
> metabolic alkalosis

101
Q

What electrolyte abnormalities are seen in Addisons disease?

A

hyperkalaemia
hyponatraemia
hypoglycaemia
metabolic acidosis

102
Q

What is definitive ix for Addisons?

A

ACTH stimulation test (short Synacthen test)

Plasma cortisol is measured before and 30 minutes after giving Synacthen 250ug IM. Adrenal autoantibodies such as anti-21-hydroxylase may also be demonstrated.

103
Q

Describe how 9am serum cortisol can be interpreted in Addisions

A

> 500 nmol/l makes Addison’s very unlikely

< 100 nmol/l is definitely abnormal

100-500 nmol/l should prompt a ACTH stimulation test to be performed

104
Q

What is the limitation of the ACTH stimulation test (short synacthen)

A

Excludes only primary adrenal failure and does not exclude cortisol deficiency secondary to failure of the pituitary to produce ACTH

105
Q

When can you add metformin in T1DM?

A

NICE recommend considering adding metformin if the BMI >= 25 kg/m²

106
Q

Nuclear scintigraphy in toxic multinodular goitre?

A

Nuclear scintigraphy reveals patchy uptake

107
Q

tender goitre, hyperthyroidism and raised ESR is suggestive of ?

A

Subacute thyroiditis (De Quervains)

108
Q

What can cause pseudohyponatraemia?

A

pseudohyponatraemia include hyperlipidaemia (increase in serum volume) or a taking blood from a drip arm

109
Q

What are some causes hyponatraemia with urinary sodium <20mmol/L?

A

Sodium depletion, extra-renal loss
> diarrhoea, vomiting, sweating
> burns, adenoma of rectum

Water excess (patient often hypervolaemic and oedematous)
secondary hyperaldosteronism
> heart failure, liver cirrhosis
> nephrotic syndrome
> IV dextrose
> psychogenic polydipsia

110
Q

What are some causes hyponatraemia with urinary sodium >20mmol/L?

A

Sodium depletion, renal loss (patient often hypovolaemic)
diuretics: thiazides, loop diuretics
> Addison’s disease
> diuretic stage of renal failure

Patient often euvolaemic
> SIADH (urine osmolality > 500 mmol/kg)
> hypothyroidism

111
Q

What is diagnosis of gestational diabetes based on?

A

these have recently been updated by NICE, gestational diabetes is diagnosed if either:

fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L

112
Q

Mx of GDM?

A

if the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered

if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started

if glucose targets are still not met insulin should be added to diet/exercise/metformin
gestational diabetes is treated with short-acting, not long-acting, insulin

if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started

if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered

glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment

113
Q

Hyperthyroidism -> hypothyroidism +- viral infection preceeding is suggesive of?

A

De quervains thyroiditis (subacute)

114
Q

Main issue with oestrogen only HRT v combined oestrogen+progesterone?

A

Raised risk of endometrial ca

115
Q

What does FSH + LH do in menstrual cycle and which phase mainly?

A

A rise in FSH results in the development of follicles which in turn secrete oestradiol

When the egg has matured, it secretes enough oestradiol to trigger the acute release of LH. This in turn leads to ovulation

This both occurs in Follicular phase (proliferative)

116
Q

how to assess diabetic neuropathy in feet?

A

A 10 g monofilament

117
Q

Rules re HGV licence for those DM with insulin (+ other hypoglycaemic agents)?

A

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
here are no other debarring complications of diabetes

118
Q

Recent transsphenoidal pituitary surgery can lead to what endo issue?

A

Cranial DI

119
Q

How to distinguish between Gitelmans and Barters syndrome?

A

Levels of calcuria - high in Barters, low in Gitelmans

Low Ca + Mg in addition to low Na, K and Cl - Gitelmans

Metabolic alkalosis - both

120
Q

What are some signs of GI autonomic neuropathy that can occur in DM?

A

Gastroparesis - erratic BMs, bloating + voming

Chronic diarrhoea - often at night

GORD - decreased lower oesophageal sphincter pressure

121
Q

Mx of gastroparesis due to DM?

A

Prokinetic agents - metoclopramide, domperidone, erythromycin

122
Q

evolocumab moa and what is us used for?

A

Evolocumab prevents PCSK9-mediated LDL receptor degradation

used for hypercholesteramia in rare cases

123
Q

What can cause euglycaemic DKA? when to consider?

A

Can be seen with use of novel oral hypoglucaemic agents eg SGLT2 inhibitors

Consider if people with unexplained raised anion gap acidosis and normal blood sugar level who is on one of these medications

124
Q

What is a rare haematological complication of uterine fibroids and why?

A

Polycythaemia due to autonomous production of EPO

125
Q

Describe the hormonal and sympathoadrenal responses to hypoglycaemia?

A

hormonal response: the first response of the body is decreased insulin secretion. This is followed by increased glucagon secretion. Growth hormone and cortisol are also released but later

sympathoadrenal response: increased catecholamine-mediated (adrenergic) and acetylcholine-mediated (cholinergic) neurotransmission in the peripheral autonomic nervous system and in the central nervous system

126
Q

Often taller than average
lack of secondary sexual characteristics
small, firm testes
infertile
gynaecomastia - increased incidence of breast cancer
elevated gonadotrophin levels but low testosterone

Dx?

A

Klinefelters

127
Q

Triple therapy and adding a GLP 1 mimetic ?

A

You should switch a drug for the GLP 1 mimetic not add on a 4th

128
Q

What are the fasting glucose and 2 hours post glucose ingestion targets in GDM?

A

fasting blood glucose in gestational diabetes is <5.3 mmol/L. T

he target for blood glucose two hours after an oral glucose tolerance test is <6.4

129
Q

What hyperthyroidism features are unique to Graves disease?

A

1)Ex“opathalmo”s+“ Opthalmo”plegia [ NOT lid lag]
2) Pretibial myxedema
3) Thyroid acropachy (clubbing)

130
Q

Mx of subacute thyroiditis?

A

usually self-limiting - most patients do not require treatment

thyroid pain may respond to aspirin or other NSAIDs

in more severe cases steroids are used, particularly if hypothyroidism develops

131
Q

Main adverse effects of GLP 1 mimetics

A

N+V

Also risk of pancreatitis

132
Q

Radioiodine most common side effect + most problematic

A

Most common = hypothyroidism

Most problematic = exacerbation of thyroid eye disease

133
Q

Typical presentation of insulinoma?

A

of hypoglycaemia: typically early in morning or just before meal, e.g. diplopia, weakness, sweating etc

rapid weight gain may be seen

high insulin, raised proinsulin:insulin ratio

high C-peptide

134
Q

Advantage of Block+replace v block therapy in Graves mx?

A

Block and replace regimens are shorter duration than carbimazole titration

135
Q

Starting dose of carbimazole in Graves? main complication?

A

40mg and reduce gradually continued for 12-18m

Agranulocytosis = major complication

136
Q

What does clitoromegaly suggest?

A

High androgen levels -> if suspecting PCOS investigate further to exclude ovarian / adrenal androgen secreting tumour

137
Q

Most common causes of ACTH dependent and independent Cushings?

A

ACTH dependent causes
>Cushing’s disease (80%): pituitary tumour secreting ACTH producing adrenal hyperplasia
>ectopic ACTH production (5-10%): e.g. small cell lung cancer is the most common causes

ACTH independent causes
> iatrogenic: steroids
> adrenal adenoma (5-10%)
> adrenal carcinoma (rare)
> Carney complex: syndrome including cardiac myxoma
> micronodular adrenal dysplasia (very rare)

138
Q

What is pseudo-cushings? causes? and what are the investigations

A

mimics Cushing’s - often due to alcohol excess or severe depression

causes false positive dexamethasone suppression test or 24 hr urinary free cortisol

insulin stress test may be used to differentiate

139
Q

Causes of raised ALP?

A

liver: cholestasis, hepatitis, fatty liver, neoplasia

Paget’s
osteomalacia
bone metastases
hyperparathyroidism

renal failure

physiological: pregnancy, growing children, healing fractures

140
Q

Riedel’s thyroiditis - what is it? how does it present? what is it associated with?

A

Rare cause of hypothyroidism characterised by dense fibrous tissue replacing normal thyroid parenchyma

O/E - diffuse neck goitre that is hard on palpation, non-tender and fixed in position.

Associated with retroperitoneal fibrosis

141
Q

Hyperlipidaemia describe cases which are predominantly hypertriglycerides v hypercholesteraemia?

A

TRIGLYCERIDES
diabetes mellitus (types 1 and 2)
obesity
alcohol
chronic renal failure
drugs: thiazides, non-selective beta-blockers, unopposed oestrogen
liver disease

CHOLESTEROL
nephrotic syndrome
cholestasis
hypothyroidism

142
Q

Kallmans v Klinefelters?

A

Kallmans- hyPOgonadotropic hyPOgonadism
Kallman’s = 1 ball and tall, can’t smell at all, no hormones, balls may be undescended

Klinefelters- HyPERgonado. hyPOgonad.
Klinefelters = Tall, titties, tiny testes, high gonad hormones

143
Q

Which patients may not respond to glucagon in hypoglycaemia?

A

Those with alcoholic liver disease - give IV glucose 20% / oral if conscious

144
Q

Sick euthyroid syndrome bloods?

A

TSH is inappropriately normal / raised

Low T4 and T3

Usually reversible following recovery from systemic illness hence no tx needed

145
Q

Possible causes of sick euthyroid?

A

myocardial infarctions, starvation, burns, trauma, surgery, malignancy, diabetic ketoacidosis, any organ failure and inflammatory conditions.

146
Q

Causes of raised prolactin??

A

oestrogens
acromegaly: 1/3 of patients

Ps
pregnancy
prolactinoma
physiological - stress, exercise, sleep
polycystic ovarian syndrome
primary hypothyroidism (due to thyrotrophin releasing hormone (TRH) stimulating prolactin release)
phenothiazines, metoclopramide, domperidone

147
Q

Drug causes of raised prolactin?

A

metoclopramide, domperidone
phenothiazines
haloperidol
very rare: SSRIs, opioids

NB bromocriptine is used to counteract this

148
Q

Remnant hyperlipidaemia, also known as dysbetalipoproteinaemia or type III hyperlipoproteinaemia, is characterised by increased levels of remnant lipoproteins (chylomicron and VLDL remnants)

Mx?

A

Fibrates

work by activating peroxisome proliferator-activated receptors (PPARs), particularly PPAR-alpha, which leads to increased lipolysis and elimination of triglyceride-rich particles from plasma

149
Q

Complete androgen insensitivity syndrome (CAIS)

features? mx?

A

‘primary amenorrhoea’
little or no axillary and pubic hair
undescended testes causing groin swellings
breast development may occur as a result of the conversion of testosterone to oestradiol

MX:
counselling - raise the child as female
bilateral orchidectomy (increased risk of testicular cancer due to undescended testes)
oestrogen therapy

150
Q

Two types of IGR (impaired glucose regulation) + causes and differentiation?

A

impaired fasting glucose (IFG) - due to hepatic insulin resistance
impaired glucose tolerance (IGT) - due to muscle insulin resistance

a fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG)

impaired glucose tolerance (IGT) is defined as 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

You can buy lots of unhealthy snacks at a 7/11, which might give you diabetes.

7 = cutoff for fasting flucose
11 = cutoff for random or after glucose load

151
Q

Steroids mineralcorticoid v glucorticoid activity?

A

Mnemonic - From mineralcorticoid activity&raquo_space;> glucocorticoid activity: Free Hotels Provide Delicious Breakfasts

Fludrocortisone > Hydrocortisone > Prednisolone > Dexamethasone & Betmethasone

152
Q

T1DM when to provide 20mg atorvastatin?

A

older than 40 years, or
have had diabetes for more than 10 years or
have established nephropathy or
have other CVD risk factors

NB see point 3 - also offer in CKD

153
Q

Describe tertiary hyperparathyroidism

A

autonomous hypersecretion of PTH due to hypertrophied parathyroid glands

occurs after a period of long standing secondary hyperparathyroidism

treatment involves parathyroidectomy

154
Q

Causes of pseudohyperkalaemia?

A

haemolysis during venipuncture (excessive vacuum of blood drawing, prolonged tourniquet use or too fine a needle gauge)

delay in the processing of the blood specimen

abnormally high numbers of platelets, leukocytes, or erythrocytes (such as myeloproliferative disorders)

familial causes

155
Q

Causes of hypokalaemia with acidosis v alkalosis?

A

Hypokalaemia with alkalosis
1. vomiting
2. thiazide and loop diuretics
3. Cushing’s syndrome
4. Conn’s syndrome (primary hyperaldosteronism)

Hypokalaemia with acidosis
1. diarrhoea
2. renal tubular acidosis
3. acetazolamide
4. partially treated diabetic ketoacidosis

NB mg deficiency can also cause hypokalaemia

156
Q

Insulin stress test, when to use and findings?

When is it CI?

A

used in investigation of hypopituitarism

IV insulin given, GH and cortisol levels measured
with normal pituitary function GH and cortisol should rise

CI - Epilepsy, IHD and adrenal insufficiency

157
Q

Describe what happens in dynamic pituitary tests and what is measured with this?

A

Insulin, TRH and LHRH are given to the patient following which the serum glucose, cortisol, growth hormone, TSH, LH and FSH levels are recorded at regular intervals.

Prolactin levels are also sometimes measured*

Normal changes:
GH level rises > 20mu/l
cortisol level rises > 550 mmol/l
TSH level rises by > 2 mu/l from baseline level
LH and FSH should double

158
Q

Why should subclinical hyperthyroidism be managed?

A

Potential risk on cardiovascular system (atrial fibrillation) and bone metabolism (osteoporosis)

Impact on QoL + dementia risk

159
Q

Nesidioblastosis features?

A

diffuse proliferation of pancreatic β-cells, would show elevated C-peptide levels alongside the high insulin levels, as the insulin is being produced endogenously

Seen in neonates or post-bariatric surgery

160
Q

Features of sulphonylurea abuse?

A

Raised c peptide - stimulates endogenous insulin

161
Q

Glitazones cellular moa?

A

agonists of PPAR-gamma receptors, reducing peripheral insulin resistance

162
Q

Acute phase proteins? negative acute phase - increased liver degreation?

A

CRP*
procalcitonin
ferritin
fibrinogen
alpha-1 antitrypsin
caeruloplasmin
serum amyloid A
serum amyloid P component**
haptoglobin
complement

-ve acute phase:
albumin
transthyretin (formerly known as prealbumin)
transferrin
retinol binding protein
cortisol binding protein

163
Q

Features of metabolic syndrome?

A

WTH BestFriend?!!!

Waist Circumference - inc
Triglycerides - inc
HDL - low
BP - high
Fasting glucose - high

NB - LDLs are not involved

Other associated features include:
raised uric acid levels
non-alcoholic fatty liver disease
polycystic ovarian syndrome

164
Q

circumstances under which parathyroidectomy should be considered in primary hyperparathyroidism?

A

Age under 50 years.

Adjusted serum calcium concentration that is 0.25 mmol/L or more above the upper end of the reference range.

Estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2 although this threshold depends on other factors, such as age.

Renal stones or presence of nephrocalcinosis on ultrasound or CT.

Presence of osteoporosis or osteoporotic fracture.

Symptomatic disease

165
Q

Autoimmune polyendocrinopathy syndrome aka APS type 1 and type 2 features?

A

APS type 2 has a polygenic inheritance and is linked to HLA DR3/DR4. Patients have Addison’s disease plus either:
- type 1 diabetes mellitus
- autoimmune thyroid disease

NB type 2 is way more common

Features of APS type 1 (2 out of 3 needed)
- chronic mucocutaneous candidiasis (typically first feature as young child)
- Addison’s disease
- primary hypoparathyroidism

Can get vitiligo in both types

166
Q

What food are high in K and avoided in CKD?

A

salt substitutes (i.e. Contain potassium rather than sodium)

bananas, oranges, kiwi fruit, avocado, spinach, tomatoes

167
Q

What is the majority of hypercalcaemia of malignancy caused by?

A

PTHrp - even in non scc lung ca

168
Q

What increases risk of breast ca in HRT?

A

Progesterone

169
Q

Chovstek v Trousseau which is more sensitive / specific for hypocalcaemia?

A

Trousseau’s sign is more sensitive and specific than Chvostek’s sign

NB Chvostek’s sign, which involves twitching of the facial muscles in response to tapping over the area of the facial nerve, is less sensitive and specific for hypocalcaemia than Trousseau’s sign. Trousseau’s sign involves carpal spasm induced by inflating a blood pressure cuff above systolic pressure for 2-3 minutes; it has greater sensitivity and specificity for hypocalcaemia.

170
Q

Addison’s disease what may be seen in women?

A

Loss of pubic hair + axillary hair due reduced production of testosterones from the adrenal gland

171
Q

Describe results of high dose dex and interpretation

A

Cortisol suppressed, ACTH supressed - Cushings disease (Pituitary adenoma -> ACTH)

Cortisol not suppressed, ACTH supressed - Cushing’s syndrome due to other causes (e.g. adrenal adenomas)

Cortisol and ACTH not supressed - Ectopic ACTH

172
Q

Petrosal sinus sampling interpretation?

A

A central-to-peripheral gradient of ACTH (higher levels in the petrosal sinus compared to peripheral blood) indicates pituitary adenoma.

Conversely, similar ACTH levels in both sites suggest ectopic ACTH production

Do when Cushings syndrome picture but no clear adenoma on MRI H

173
Q

CRH stimulation interpretation?

A

if pituitary source then cortisol rises

if ectopic/adrenal then no change in cortisol

174
Q

Tests to confirm Cushing’s syndrome?

A

overnight (low-dose) dexamethasone suppression test- this is the most sensitive test and is now used first-line to test for Cushing’s syndrome

patients with Cushing’s syndrome do not have their morning cortisol spike suppressed

24 hr urinary free cortisol - two measurements are required

bedtime salivary cortisol - two measurements are required

175
Q

Bloods in hypothalamic amenorrhoea?

A

Gonadotrophins: Low levels of LH and FSH indicate a hypothalamic cause.

Oestradiol: Levels are usually low due to decreased gonadotrophin release.

176
Q

Causes of hypocalcaemia with different phosphate levels?

A
  1. Low Phosphate (Hypophosphataemia):
    - Vitamin D deficiency: Osteomalacia or rickets.
    - Chronic kidney disease: Early stages may present with low phosphate.
    - Malnutrition: Inadequate dietary intake of calcium and phosphate.
  2. Normal Phosphate:
    - Hypoparathyroidism: Post-surgical or autoimmune causes.
    - Pseudohypoparathyroidism: Genetic condition causing resistance to PTH.
    - Acute pancreatitis: Can lead to transient hypocalcaemia without significant phosphate changes.
  3. High Phosphate (Hyperphosphataemia):
    - Chronic kidney disease: Impaired renal excretion of phosphate.
    - Rhabdomyolysis: Release of intracellular phosphate during muscle breakdown.
    - Massive blood transfusion: Citrate anticoagulant can bind calcium and release phosphate.
177
Q

Causes of hyperuricaemia - increased synthesis?

A

Lesch-Nyhan disease
myeloproliferative disorders
diet rich in purines
exercise
psoriasis
cytotoxics

178
Q

Causes of hyperuricaemia - decreased excretion?

A

drugs: low-dose aspirin, diuretics, pyrazinamide
pre-eclampsia
alcohol
renal failure
lead

179
Q

Patchy uptake in nuclear scintigraphy is what condition? mx>

A

Toxic multinodular goitre

mx = radioiodine

180
Q

Concordance between identical twins is higher in type 2 diabetes mellitus than type 1 - true or false?

A

TRUE!

181
Q

Hyper or hypothyroidism which leads to gynaecomastia?

A

Hyper more often!!

182
Q

Different mutations in MODY?

A

The most common types are MODY2 (GCK mutation) - mild often asymptomatic / mildy not associated with T2DM

and MODY3 (HNF1A mutation), - more commonly causes T2DM

but others include MODY1 (HNF4A),

MODY4 (PDX1),

MODY5 (HNF1B), and so on. renal cysts + genital issues

183
Q

Liddle’s syndrome? mx?

A

Liddle’s syndrome is a rare autosomal dominant condition that causes hypertension and hypokalaemic alkalosis.

Due to Na in DCT issues

mx - amiloride / triamterene

184
Q

Dx of T2DM?

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)

If the patient is asymptomatic the above criteria apply but must be demonstrated on two separate occasions.

7/11 snacks !!

185
Q

What does drug induced acne look like?

A

Seen with glucocorticoids

This is characterised as monomorphic papular rash without comedones or cysts.

This does not respond to acne treatment but improves on drug discontinuation

186
Q

Excessive flatulence is an extremely common side effect of what diabetic drug?

A

Acarbose - not used anymore

187
Q

Addisons what adrenal steroid may be reduced?

A

Dehydroepiandrosterone DHEA

188
Q

Hypothyroidism under medication - raised tsh but normal t4 interpretation?

A

Poor compliance - likely took doses prior to test

189
Q

Bendroflumethiazide - effect on ca?

A

Hypercalcaemia due to renal ca reabsorption increased

190
Q

When to screeen for GDM?

A

the oral glucose tolerance test (OGTT) is the test of choice

women who’ve previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs

women with any of the other risk factors should be offered an OGTT at 24-28 weeks

191
Q

Skin manifestations of hypothyroidism?

A

dry (anhydrosis), cold, yellowish skin
non-pitting oedema (e.g. hands, face)
dry, coarse scalp hair, loss of lateral aspect of eyebrows
eczema
xanthomata
pruritis

192
Q

Skin manifestations of hyperthyroidism?

A

pretibial myxoedema: erythematous, oedematous lesions above the lateral malleoli
thyroid acropachy: clubbing
scalp hair thinning
increased sweating

193
Q

T2DM what type of insulin to offer?

A

Neutral Protamine Hagedorn (NPH) insulin [also known as isophane insulin] - OD / BD

Can add short acting esp if HbA1c >75

Insulin detemir or insulin glargine considered instead of NPH insulin if - needs assistance from carer for this, would reduce from BD to OD, lifestyle restriction due to symptomatic hypos

194
Q

BPH why avoid amitriptyline?

A

Risk of urinary retention

195
Q

pegvisomant when is this used and moa?

A

Used in acromegaly

GH receptor antagonist - doesnt reduce tumour volume but decreases IGF1 in 90% of cases to normal

196
Q

DKA - on fixed rate insulin but not given long acting what to do?

A

Give long acting and when appropriate stop infusion with next meal?

197
Q

How to calculate average plasma glucose based on HbA1c?

A

average plasma glucose = (2 * HbA1c) - 4.5

198
Q

Mx of HHS?

A

IVF +- K (.5 - 1l / hr )

VTE prophylaxis due to hyperviscosity -> main cause of complications

No insulin unless BMs stop dropping with IVF

198
Q

Features of HHS?

A

hypovolaemia

marked hyperglycaemia (>30 mmol/L)

significantly raised serum osmolarity (> 320 mosmol/kg) - can be calculated by: 2 * Na+ + glucose + urea

no significant hyperketonaemia (<3 mmol/L)

no significant acidosis (bicarbonate > 15 mmol/l or pH > 7.3 - acidosis can occur due to lactic acidosis or renal impairment)

199
Q

The hyponatraemia and potassium towards the upper end of the normal range, coupled with hypoglycaemia

Suggest what disorder?

A

Addisons disease

200
Q

Acute hyponatreamia with severe symptoms mx?

A

Patients with acute, severe (<120 mmol/L) or symptomatic hyponatraemia require close monitoring, preferably in an HDU or above setting.

Hypertonic saline (typically 3% NaCl) is used to correct the sodium level more quickly than would be done in patients with chronic hyponatraemia.

201
Q

Pathophys of osmotic demyelination syndrome?

A

Astrocyte apoptosis

202
Q

Primary polydipsia is aka?

A

Psychogenic polydipsia

203
Q
A

MRCP - Passmed (17 decks)

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