Endocrinology Flashcards
1
Q
In what conditions can you not use HbA1C to diagnose T2DM?
A
Haemoglobinopathies
Haemolytic anaemia
Untreated iron deficiency anaemia
Gestational diabetes
Children
HIV
CKD
Medications causing hyperglycaemia
2
Q
Alterations to metformin dose during ramadan
A
split dose to 1/3rd before sunrise and 2/3rds after sunset
3
Q
Alteration to sulfonyulrea dose during ramadan
A
OD - take after sunset
BD - take large proportion after sunset
4
Q
Dietary advice for T2DM during ramadan
A
Meal containing long acting carbohydrates prior to sunrise
5
Q
Sick day rules for diabetes
A
Four hourly BMs
3 litres of fluid
May need sugary fluids if can’t drink
Continue normal insulin
Stop metformin if dehydrated
Continue oral hypoglycaemic meds
6
Q
Conditions that need to be met to hold HGV licence if diabetic
A
No severe hypo in 12 months
Full hypo awareness
Adequate control shown by regular BMs
Understands risks of hypos
No other debarring conditions from diabetes
7
Q
Conditions that need to be met to hold group 1 license if diabetic on insulin
A
Hypoglycaemic awareness
No hypo needing help in last 12 months
No relevant visual impairment
8
Q
What is the target when treating hyperlipidaemia?
A
40% reduction in non-HDL cholesterol
9
Q
Pre-diabetes range for HbA1c in mmol/mol
A
42-47
10
Q
Non-drug causes of gynaecomastia
A
Physiological - normal in puberty
Androgen deficiency syndromes (Kallman, Klinefelters)
Testicular failure
Liver disease
Testicular cancer
Ectopic tumour secretion
Hyperthyroidism
Haemodialysis
11
Q
Drug causes of gynaecomastia
A
Spironolactone
Cimetidine
Digoxin
Cannabis
Finasteride
GnRH agonists - goserelin, buserelin
Oestrogens, anabolic steroids
12
Q
Orlistat - mechanism of action
A
Pancreatic lipase inhibitor
13
Q
Orlistat - side effects
A
Faecal urgency
Incontinence
Flatulence
14
Q
Criteria for starting orlistat
A
BMI over 28 with associated risk factors
BMI over 30
15
Q
Criteria for continuing orlistat
A
Continued weight loss - 5% at 3 months
16
Q
How long is orlistat used for?
A
1 year
17
Q
TFTs in secondary hypothyroidism
A
Low TSH
Low T4
18
Q
Investigations for secondary hypothyroidism
A
MRI pituitary
19
Q
Cause of secondary hypothyroidism
A
Pituitary insufficiency
20
Q
First line insulin regime for new T1DM
A
Basal bolus with twice daily insulin detemir
21
Q
Pre-diabetes range for HbA1c in %
A
6.0-6.4%
22
Q
Possible consequences of untreated subclinical hyperthyroidism
A
Supraventricular arrhythmias and osteoporosis
23
Q
When do patients require a gradual withdrawal of systemic corticosteroids?
A
> 40mg pred daily for >1 week
> 3 weeks treatment
Recently received repeated courses
24
Q
What ketones should prompt admission to hospital in T1DM?
A
3
25
Medication that interacts with orlistat
Contraception and anti-epileptics
due to GI side effects affecting absorption
26
At what renal function should you review metformin?
At what renal function should you stop stop metformin?
Review at creat >130 or eGFR <45
Stop if creat >150 or eGFR <30
27
Should you ever start metformin in prediabetes?
Yes if HbA1c going up despite lifestyle measures
28
Extra investigations for new T2DM diagnosed over age 60 or weight loss
CT abdomen to exclude pancreatic ca
29
Blood glucose targets in T1DM - on waking
5-7 mmol/l
30
Blood glucose targets in T1DM - before meals during the day
4-7 mmol/l
31
Which group of patients taking insulin do not need to inform DVLA?
Taking insulin for less than 3 months
Taking for gestational diabetes up to 3 months post partum
32
Which type of drugs reduced hypoglycaemia awareness?
Beta blockers
33
TSH goal in treating hypothyroidism
0.5 to 2.5 mU/l
34
Instructions to patients on how to take levothyroxine
30 minutes before breakfast or caffeine or other medication
35
Blood pressure target in T1DM with no end organ damage
135/85
36
Blood pressure target in T1Dm if albuminuria or 2 or more features of metabolic syndrome
130/80
37
Criteria for diagnosing T1DM
Fasting glucose ≥ 7
Random glucose ≥ 11.1
If not symptomatic needs to be on two occasions
38
Target HbA1c in T1DM
≤48
39
T1DM investigations
Urine dip
Fasting + random glucose
C-peptide
Anti-glutamic acid antibodies (anti-GAD)
Islet cell antibodies
Insulin autoantibodies
Insulinoma-associated-2 autoantibodies
40
Tests to do when differentiating between T1 and T2 diabetes
C-peptide
| Insulin antibodies
41
What are the insulin antibodies to test for?
Anti-glutamic acid antibodies
Islet cell antibodies
Insulin autoantibodies
Insulinoma-associated-2 autoantibodies
42
HbA1c target for T2DM being managed with lifestyle measures
48
43
HbA1c target for T2DM being managed with lifestyle measures and metformin
48
44
HbA1c target for T2DM being managed with any drug that can cause hypoglycaemia
53
45
At what HbA1c do you add a second medication to metformin?
58
46
At what HbA1c do you start metformin?
48
47
2nd line medication options to add to metformin in the management of T2DM
Sulfonylurea
Gliptin
Pioglitazone
SGLT2 inhibitor
48
3rd line medication options to add to metformin in managmeent of T2DM
Sulfonylurea
Gliptin
Pioglitazone
SGLT2 inhibitor
OR consider insulin
49
Which medication should you continue when starting insulin in T2DM?
Metformin only
50
Medication options for T2DM who can't tolerate metformin
Sulfonylurea
Gliptin
Pioglitazone
Start with 1, add 2nd if HbA1c ≥ 58
51
When to consider insulin in T2DM who can't tolerate metformin?
After 2 drugs started and HbA1c rising to ≥ 58 or remains high
52
Dietary advice in T2DM
High fibre low GI carbs
Low fat dairy products
Oily fish
Reduce saturated fats + trans fats
Discourage diabetic foods
53
Target weight loss in T2DM
5-10%
| Even if normal weight
54
When to start cholesterol medication in T2DM?
If 10 year cardiovascular risk score is >10% using QRISK 2
55
Primary prevention statin
Atorvastatin 20mg
56
Secondary prevention statin
Atorvastatin 80mg
57
BP targets in T2DM if age <80
clinic 140/90
| ABPM 135/85
58
BP targets in T2DM if age >80
clinic 150/90
| ABPM 145/85
59
First line treatment for hypertension in T2DM
ACEI or ARB
Use ARB if black/Caribbean
60
What will cause a lower than expected HbA1c?
Reduced red cell lifespan due to
- sickle cell anaemia
- GP6D deficiency
- hereditary spherocytosis
61
What will cause a higher than expected HbA1c?
Increased red cell lifespan due to
- Vit B12/folate acid deficiency
- iron deficiency anaemia
- splenectomy
62
Examples of SGLT-2 inhibitors
Canagliflozin
Dapagliflozin
Empagliflozin
63
What type of drug is canagliflozin?
SGLT2 inhibitor
64
What type of drug is dapagliflozin?
SGLT2 inhibitor
65
What type of drug is empagliflozin?
SGLT2 inhibitor
66
Mechanism of action of SGLT-2 inhibitors
Reversibly inhibit sodium-glucose cotransporter 2 in the renal PCT
to reduce glucose reabsorption and increase urinary glucose excretion
67
Side effects of SGLT-2 inhibitors
Urinary and genital infections
Fournier's gangrene
Normoglycaemic ketoacidosis
Increased risk of lower limb amputation so need to monitor feet carefully
68
Examples of sulfonylureas
Gliclazide
Tolbutamide
69
What type of drug is gliclazide?
Sulfonylurea
70
What type of drug is tolbutamide?
Sulfonyulrea
71
Effect of SGLT-2 inhibitors on weight
Weight loss
72
Do SGLT-2 inhibitors cause hypoglycaemia?
Not by themselves
73
Mechanism of action of sulfonylureas
Increase pancreatic insulin secretion
74
Where in the pancreas do sulfonylureas work?
ATP dependent K+ channels on the cell membrane of pancreatic beta cells
to increase pancreatic insulin secretion
75
Side effects of sulfonylureas
Hypoglycaemia
Weight gain
SIADH
Bone marrow suppression
Cholestatic liver damage
Peripheral neuropathy
76
Effect of sulfonylureas on weight
Weight gain
77
Do sulfonylureas cause hypoglycaemia?
Yes
78
Which T2DM medication can cause liver damage?
Sulfonylureas cause cholestatic liver damage
Pioglitazone causes liver impairment, need to monitor LFTs
79
Example of thiazolidinediones
Pioglitazone
80
What type of drug is pioglitazone?
Thiazolidinedione
81
Mechanism of action of pioglitazone
Reduces peripheral insulin resistance
by agonising the PPAR-gamma receptor
82
Which T2DM medication reduces peripheral insulin resistance?
Pioglitazone
83
Side effects of pioglitazone
Weight gain
Liver impairment
Fluid retention so C/I in heart failure
Increased risk of fractures
Increased risk of bladder ca
84
Effect of pioglitazone on weight
Weight gain
85
Can pioglitazone cause hypoglycaemia?
Not when taken in isolation
86
Examples of meglitinides
Repaglinide
Nateglinide
87
What type of medication is repaglinide?
meglitinide, used in T2DM
88
What type of medication is nateglinide?
Meglitinide, used in T2DM
89
For which group of patients are meglitinides helpful?
Those with erratic lifestyles
90
Mechanism of action of meglitinides
Increase pancreatic insulin secretion
91
Side effects of meglitinides
Weight gain
| Hypoglycaemia
92
Examples of rapid acting insulins
Aspart (novorapid)
Lispro (humalog)
93
Examples of short acting insulins
Actrapid
Humulin S
94
Examples of intermediate acting insulins
Isophane
Aspart protamine
lispro protamine
95
Examples of long acting insulins
Detemir (levemir)
Glargine (lantus)
96
Examples of GLP-1 mimics
Exenatide
Liraglutide
97
What type of drug is exenatide?
GLP-1 mimic
98
How is exenatide taken?
sub cut 60 minutes before morning and evening meal
99
How is liraglutide taken?
sub cut once daily
100
What type of drug is liraglutide?
GLP-1 mimic
101
Mechanism of action of GLP-1 mimics
Increase insulin secretion and inhibit glucagon secretion
102
Side effects of GLP-1 mimics
Nausea and vomiting
Renal impairment
Severe pancreatitis
103
Criteria for starting GLP-1 mimics
Triple therapy not effective AND one of:
BMI ≥ 35 + obesity related health problems
BMI <35 + insulin would cause occupational problems + weight related health conditions
104
Criteria for continuing GLP-1 mimics
Drop of 11 mmol/mol (1%) in HbA1c AND weight loss of 3% in 6 months
105
Effect of GLP-1 mimics on weight
Weight loss
106
Do GLP-1 mimics cause hypoglycaemia?
Not in isolation
107
Examples of DPP-4 inhibitors
Vildagliptin
Sitagliptin
108
What type of drug is vildagliptin?
DPP-4 inhibitor
109
What type of drug is sitagliptin?
DPP-4 inhibitor
110
What drug classification is generally referred to as gliptins?
DPP-4 inhibitors
111
Examples of gliptins
Vildagliptin
| Sitagliptin
112
Mechanism of action of DPP-4 inhibitors/gliptins
Increase levels of incretins (GLP1 and GIP) by decreasing their peripheral breakdown
113
How are DPP-4 inhibitors/gliptins taken?
Orally
114
Impact of DPP-4 inhibitors/gliptins on weight
Weight neutral
115
Do DPP-4 inhibitors cause hypoglycaemia?
No
116
Two key causes of diabetic foot disease
Neuropathy
| Peripheral artery disease
117
Screening for diabetic foot disease
Every year
Check for ischaemia by palpating pulses
Check for neuropathy using a 10g monofilament
118
Presentation of diabetic foot disease
Neuropathy
Ischaemia - absent foot pulses, intermittent claudication
Calluses
Ulceration
Charcot's arthropathy
Cellulitis
Osteomyelitis
Gangrene
119
Diabetic foot disease - low risk
No risk factors except callus
120
Diabetic foot disease - moderate risk
1 of:
Deformity
Neuropathy
Non-critical limb ischaemia
121
Diabetic foot disease - high risk
Previous ulceration or amputation
on RRT
2 of: deformity, neuropathy, non-critical limb ischaemia
122
Inheritance of MODY
Autosomal dominance
123
Presentation of MODY
T2DM in patients <25y
FH of early onset diabetes
no ketosis at presentation
124
What does MODY stand for?
Maturity onset diabetes of the young
125
Where is prolacin secreted from?
Anterior pituitary gland
126
What is the primary prolactin releasing inhibitory factor?
Dopamine
127
Features of excess prolactin in men
Impotence
Loss of libido
Galactorrhoea
128
Features of excess prolactin in women
Amenorrhoea
| Galactorrhoea
129
Causes of raised prolactin
Prolactinoma
Pregnancy
Physiological - stress, exercise, sleep
Acromegaly
PCOS
Primary hypothyroidism
Drugs
130
Drug causes of raised prolactin
Metoclopramide
Domperidone
Pheothiazines
Haloperidol
131
Which medication can be used to control galactorrhoea?
Bromocriptine
132
Features of metabolic syndrome
```
Elevated waist circumference
Elevated triglycerides
Reduced HDL
Raised BP or on treatment for HTN
Raised fasting glucose or T2DM
```
Raised uric acid
NAFLD
PCOS
133
Causes of thyrotoxicosis
Grave's disease
Toxic multinodular goitre
Amiodarone
Acute phase of subacute thyroiditis, post partum thyroiditis or Hashimotos
134
Investigations of thyrotoxicosis
Low TSH
High T4
TSH receptor antibodies in Grave's disease
135
Management of thyrotoxicosis
Propranolol
Carbimazole
Radioiodine treatment
136
Carbimazole mechanism of action
Reduces thyroid hormone production
137
Carbimazole side effects
Agranulocytosis
138
Can carbimazole be used in pregnancy?
in 2nd and 3rd trimester
139
Two regimes for using carbimazole
"antithyroid drug titration" start at 40mg then reduce till euthyroid
"block and replacement" carbimazole 40mg then add thyroxine when euthyroid
140
Side effects of radioiodine
May make thyroid eye disease worse
Majority will become hypothyroid requiring thyroxine within 5 years
141
Antibodies in Grave's disease
TSH receptor stimulating antibodies in 90%
Anti-thyroid peroxidase antibodies in 75%
142
Grave's specific findings
Thyroid eye disease
Pretibial myxodemea
Thyroid acropachy
143
What is thyroid acropachy?
Digital clubbing
Soft tissue swelling in hands and feet
Periosteal new bone formation
144
How many with Grave's disease get thyroid eye disease?
25-50%
145
Risk factors for thyroid eye disease
Smoking
| Radioiodine
146
Features of thyroid eye disease
```
Exophthalmos
Conjunctival oedema
Optic disc swelling
Ophthalmoplegia
Risk of exposure keratopathy
```
147
Management of thyroid eye disease
Topical lubricants to prevent corneal inflammation
Steroids
Radiotherapy
Surgery
148
What is toxic multinodular goitre?
Autonomously functioning thyroid nodules that secrete excess thyroid hormone
149
Causes of hypothyroidism
Hashimoto's thyroiditis
Subacute thyroiditis (de Quervian's)
Iodine deficiency
Post partum thyroiditis
Reidel thyroiditis
Drugs - lithium, amiodarone, carbimazole
150
When to have a lower starting dose for levothyroxine?
Age >50
| History of ischaemic heart disease
151
Goal of levothyroxine treatment
Normal TSH
152
Side effects of levothyroxine
Hyperthyroidism
Reduced bone mineral density
Angina
AF
153
Interactions to levothyroxine
Iron, calcium carbonate
Reduce absorption therefore give 4 hours apart
154
TFTs in primary hypothyroidism
Raised TSH, Low T4
155
TFTs in secondary hypothyroidism
Low TSH, Low T4
156
TFTs in sick euthyroid syndrome
Low TSH, Low T4
157
Cause of low TSH and low T4
Secondary hypothyroidism
| Sick euthyroid syndrome
158
TFTs in subclinical hypothyroidism
Raised TSH, normal T4
159
TFTs in poor thyroxine compliance
Raised TSH, normal T4
160
Cause of raised TSH and normal T4
Subclinical hypothyroidism
| Poor thyroxine compliance
161
Cause of raised TSH and low T4
Primary hypothyroidism
162
What is Reidel thyroiditis?
Fibrous tissue replacing normal thyroid parenchyma
163
Features of Reidel thyroiditis
Painless goitre, hard, fixed
Middle aged women
Associated with retroperitoneal fibrosis
164
Drug causes of hypothyroidism
Lithium
Amiodarone
Antithyroid drugs e.g. carbimazole
165
What is Hashimoto's thyroiditis?
Chronic autoimmune thyroiditis causing hypothyroidism
| May have a transient thyrotoxicosis
166
Is there a goitre in Hashimoto's thyroiditis?
Firm, non-tender goitre
167
Associations with Hashimoto's thyroiditis
Coeliac
T1DM
Vitiligo
MALT lymphoma
168
Investigations for Hashimoto's thyroidits
Raised TSH low T4
Anti-thyroid peroxidase antibodies
Anti-thyroglobulin antibodies
169
Is there a goitre in Subacute thyroidits?
Painful goitre
170
Presentation of subacute thyroidits
After viral infection
| Initially hyperthyroid, then euthyroid, then hypothyroid
171
Management of subacute thyroidits
Self limiting
Asprin and NSAIDs for thyroid pain
Steroids in severe cases
172
Changes to thyroxine dose in pregnancy
Increase up to 50% by 4-6 weeks
173
Is thyroxine safe in pregnancy and breastfeeding?
Yes
174
Thyrotoxicosis management in 1st trimester
Propylthiouracil
175
Thyrotoxicosis management in 2nd and 3rd trimester
carbimazole
176
What level do you maintain maternal thyroxine levels at during pregnancy?
Upper 3rd of normal to avoid fetal hypothyroidism
177
Why do we change thyrotoxicosis management during pregnancy?
Carbimazole increases risk of congenital abnormality
| Propylthiouracil has increased risk of hepatic injury
178
Causes of thyrotoxicosis during pregnancy
Grave's disease
| Transient gestation hyperthyroidism - activation of TSH receptor by HCG
179
What complications can thyrotoxicosis cause during pregnancy?
Increased risk of fetal loss
Maternal heart failure
Premature labour
180
Causes of primary hypoadrenalism
Addison's disease
TB
Metastases e.g. bronchial carcinoma
Waterhouse-Friderichsen syndrome
HIV
181
Causes of secondary hypoadrenalism
Pituitary disorders e.g. tumours, irradiation, infiltration
182
What is Bartter's syndrome?
Inherited cause of hypokalaemaia
due to defective chloride absorption at the Na/K/Cl cotransporter in the ascending LoH
183
Inheritance of Bartter's syndrome
Autosomal recessive
184
Features of Bartter's syndrome
Normotension
Hypokalaemia
FTT
Polyuria, polydipsia
185
Drugs causing gynaecomastia
```
Spironolactone
Cimetidine
Digoxin
Cannabis
Finasteride
GnRH agonists - goserelin
Oestrogen, steroids
```
186
Two key causes of hypercalcaemia
Primary hyperparathyroidism
| Malignancy - bone mets, myeloma, squamous cell lung ca
187
Causes of hypercalcaemia
```
Primary hyperparathyroidism
Malignancy
Sarcoidosis
Vit D toxicity
Acromegaly
Milk-alkali syndrome
Addison's
```
188
Drugs causing hypercalcaemia
Thiazides
| Calcium containing antacids
189
Causes of hypoglycaemia
```
Insulinoma
Insulin/Sulphonylureas
liver failure
Addison's
Alcohol
Nesidioblastosis - beta cell hyperplasia
```
190
Treatment of hypoglycaemia
10-20g oral glucose
Glucogel
Glucagon
191
Investigations to confirm Cushing's syndrome
Overnight dexamethasone suppression test
24 hour urinary free cortisol
192
Management of pheochromocytoma
Stabilise medically then surgery
Alpha blocker first - phenoxybenzamine
Then beta blocker - propranolol
193
What is a pheochromocytoma?
Rare catecholamine secreting tumour
194
Features of phaeochromocytoma
```
Episodic
HTN
Headaches
Palpitations
Sweating
Anxiety
```
195
Investigations for phaeochromocytoma
24 hour urinary collection of metanephrines
196
What is carcinoid syndrome?
When metastases present in the liver and release serotonin into systemic circulation
Can also occur with lung carcinoid
197
Investigations for carcinoid tumours
Urinary 5-HIAA
| Plasma chromogranin A Y
198
Management of carcinoid tumours
Somtatostatin analogues - ocreotide
Cyproheptadine may help with diarrhoea
199
What is pituitary apoplexy?
Sudden enlargement of pituitary tumour secondary to haemorrhage or infarction
200
Criteria for diagnosing DKA
Glucose >11 or known diabetic
pH <7.3
Bicarb <15
Ketones >3
201
What is neuroblastoma?
Common childhood malignancy arising from the neural crest tissue of adrenal medulla and sympathetic nervous system
202
Symptoms of neuroblastoma
```
Abdo mass
Pallor
Weight loss
Bone pain, limp
Hepatomegaly
Paraplegia
Proptosis
```
203
Investigations for neuroblastoma
Raised urinary VMA and HVA levels
Calcification on abdo xray
Biopsy
204
Phaeochromocytoma associations
MEN type II
Neurofibromatosis
Von Hippel-Lindau syndrome
205
What is a prolactinoma?
Pituitary adenoma which produces an excess of prolactin
206
Management of prolactinoma
Medically - dopamine agonists (cabergoline bromocriptine)
Surgery if meds not tolerated
207
Examples of dopamine agonists
Bromocriptine
| Cabergoline
208
What type of drug is bromocriptine?
Dopamine agonist
209
What type of drug is cabergoline?
Dopamine agonist
210
Features of hypoparathyroidism
```
Paraesthesia
Oral numbness
Facial twitching
Muscle spasm
Bone pain
Depression, confusion
Cataracts
Seizures
```
211
Signs of hypoparathyroidism
Chvostek's sign
| Trousseau's sign
212
ECG in hypoparathyroidism
Prolonged QTc
213
Management of hypoparathyroidism
```
Severe = IV calcium
Mild/mod = oral calcium + vit D
```
214
Primary hypoparathyroidism causes
Reduced PTH secretion e.g. secondary to thyroid surgery
215
Primary hypoparathyroidism - investigations
Low calcium
High phosphate
Low/inappropriately normal PTH
216
Primary hypoparathyroidism - management
Alfacalcidol
217
Pseudohypoparathyroidism - investigations
Low calcium
High phosphate
High PTH
218
Pseudohypoparathyroidim - features
Low IQ
Short stature
Shortened 4/5th metatarsals
219
What is pseudohypoparathyroidism?
Inadequate response to PTH, normal amount of PTH
220
What is pseudopseudohypoparathyroidism?
Same phenotype as pseudohypoparathyroidism but normal biochemistry
221
Primary hyperparathryoidism - causes
Solitary adenoma (80%)
Hyperplasia
Multiple adenoma
Carcinoma
222
Primary hyperparathryoidism - who is typically affected?
Elderly women
Thirsty
With normal or raised PTH
223
Primary hyperparathryoidism - associations
Hypertension
| MEN I and MEN II
224
Primary hyperparathryoidism - investigations
Raised calcium
Low phosphate
PTH raised or inappropriately normal
Xray: pepperpot skull
225
Primary hyperparathryoidism - features
```
Polydipsia, polyuria
Peptic ulcer
Constipation
Pancreatitis
Bone pain or fractures
Renal stones
Depression
Hypertension
```
226
Secondary hyperparathyroidism - causes
Any disorder causing hypocalcaemia will elevate PTH and cause secondary hyperparathyroidism
CKD
Malabsorption e.g. crohns, coeliac, chronic pancreatitis
Chronic inadequate sunlight
227
Secondary hyperparathyroidism - investigations
Raised calcium
| Raised PTH
228
Secondary hyperparathyroidism - management
Reduce serum phosphate
| Boost dietary calcium
229
What is tertiary hyperparathyroidism?
Parathyroid glands develop autonomous function in patients with long standing secondary hyperparathyroidism
Management = subtotal parathyroidectomy
230
Features of MEN I
Hyperparathyroid secondary to hyperplasia
Pituitary tumour
Insulinoma
Gastrinoma causing recurrent peptic ulcer
231
Most common presentation of MEN I
Hypercalcaemia
232
Features of MEN IIa
Medullary thyroid cancer
Parathyroid tumours
Phaeochromocytoma
233
Features of MEN IIb
Medullary and thyroid cancer
Phaeochromocytoma
Marfanoid body habitus
Neuromas
234
Key features of Kallman's syndrome
Ansomnia
Delayed puberty
Hypogonadism
Cleft lip/palate
235
Key features of Klinefelter's syndrome
```
Tall
Infertile
Small testes
Lack secondary sexual characteristics
Gynaecomastia
```
236
Key features of androgen insensitivity syndrome
Primary amenorrhoea
| Groin swellings from undescended testes
237
Hormones in testosterone secreting tumour
LH low
| Testosterone high
238
Hormones in androgen insensitivity syndrome
LH high
Oestrogen high
Testosterone high
239
Inheritance of androgen insensitivity syndrome
X linked recessive
240
Key features of 5-alpha reductase deficiency
Males unable to convert testosterone
Ambiguous genitalia at birth
Hypospadias
Virilisation at puberty
241
Hormones in Kallman's syndrome
LH low
FSH low
Testosterone low
242
Inheritance of Kallman's syndrome
X linked recessive
243
Hormones in Klinefelter's syndrome
LH high
FSH high
Testosterone low
244
What is primary hyperaldosteronism?
Excess production of aldosterone
245
Primary hyperaldosteronism - causes
Bilateral idiopathic adrenal hyperplasia
Adrenal adenoma (Conn's syndrome)
Adrenal carcinoma
246
Primary hyperaldosteronism - features
```
HTN
Hypokalaemia
Muscle weakness
Polyuria, polydipsia
Alkalosis
```
247
Primary hyperaldosteronism - investigations
```
Low potassium
Low renin, high aldosterone
Aldosterone: renin ratio high
CT abdomen
Adrenal vein sampling - if one side has high aldosterone then adenoma likely
```
248
When to consider Conn's syndrome?
Hypertension with hypokalaemia
Refractory hypertension
Hypertension <40 years
249
Primary hyperaldosteronism - management of bilateral idiopathic adrenal hyperplasia
Aldosterone antagonist e.g. spironolactone
250
Example of an aldosterone antagonist
Spironolactone
251
What type of drug is spironolactone?
Aldosterone antagonist
252
Management of Conn's syndrome
surgical excision
253
Causes of primary adrenal insufficiency
Addison's
Congenital adrenal hyperplasia
Waterhouse-Friederichsen syndrome
254
Causes of secondary adrenal insufficiency
Exogenous steroids
| Sheehan's syndrome
255
Features of adrenal insufficiency
```
Fatigue
Dehydration
N+V
Salt craving
Hyperpigmentation
Postural hypotension
```
256
Features of adrenal crisis
Collapse
Shock
Pyrexia
257
Investigations of adrenal insufficiency
Low sodium High potassium
Low aldosterone High renin
Hypoglycaemia
ACTH - high in primary, low in secondary
ACTH stimulation test
CT adrenals
258
Causes of acute adrenal insufficiency
```
Infection
Trauma
Surgery
Missed medication
Waterhouse-Friderichsen syndrome
```
259
Management of acute adrenal insufficiency
IV fluids
100mg IV hydrocortisone
Dextrose if hypoglycaemic
260
What is Addison's disease?
Autoimmune destruction of the adrenal glands
| Causes primary adrenal insufficiency
261
Investigations for Addison's disease
Low sodium High potassium
ACTH stimulation test
Random cortisol at 9am
262
Management of Addison's disease
Hydrocortisone - in 2 or 3 divided doses
| Fludrocortisone
263
Addison's disease - sick day rules
Double hydrocortisone
| Keep fludrocortisone the same
264
Causes of Cushing's syndrome
ACTH dependent:
- Cushing's disease
- Ectopic ACTH secreting tumours
ACTH independent:
- exogenous steroids
- adrenal adenoma
- adrenal carcinoma
265
What is Cushing's diseaes?
Pituitary tumour secreting ACTH causing adrenal hyperplasia
266
What is pseudocushings?
Cushings caused by alcohol, depression, HIV, diabetes
| Insulin stress test to differentiate from Cushing's
267
Investigations to confirm Cushing's
24h urinary free cortisol >3x upper limit of normal
1mg overnight dexamethasone suppression test
Late night cortisol
268
What is acromegaly?
Excess growth hormone secretion
269
Causes of acromegaly
Pituitary adenoma in 95%
Ectopic GHRH
GH production by tumours e.g. pancreatic
270
Acromegaly - investigations
Raised glucose, phosphate, calcium, TAG
IGF-1
Oral glucose tolerance test to confirm raised IGF-1
MRI pituitary + hypothalamus
271
Management of acromegaly
Trans-sphenoidal surgery
Somatostatin analogues - ocreotide
Dopamine agonists - cabergoline
272
Complications of acromegaly
HTN
Diabetes
Cardiomegaly
Colorectal cancer
273
Who should get primary prevention with statins?
High risk of cardiovascular disease with 10 year risk >10%
274
How do we calculate cardiovascular risk?
QRISK2
275
Which patient groups can we not use QRISK2 on?
T1DM
eGFR <60 or albuminuria
History of familial hyperlipidaemia
276
When to investigate for familial hypercholesterolaemia
Total cholesterol >7.5
Family history of premature coronary heart disease
Refer if total cholesterol >9.0 or LDL >7.5 even with no family history
277
When to offer statins to T1DM?
Older 40
Diabetes for >10 years
Nephropathy
Other CVD risk factors
278
Prescribing statins to CKD patients
All CKD patients should get atorvastatin 20mg
Increase dose if greater than 40% reduction in non-HDL cholesterol not achieved and eGFR >30
279
When to follow up patients who have been started on a statin?
3 months
280
Goal of statin therapy
Reduce non-HDL cholesterol by 40%
If hasn't met this then increase atorvastatin to 80mg
281
Goal for physical activity
150 minutes moderate intensity aerobic activity or 75 minutes vigorous intensity
Muscle strengthening activities on 2 days
282
Who should get atorvastatin for primary prevention?
QRISK2 >10%
most T1DM
CKD if eGFR <60
283
Consequence of vitamin A deficiency
Night blindness
284
Consequence of vitamin B1 deficiency
'Beriberi'
Polyneuropathy
Wernicke-Korsakoff
Heart failure
285
Consequence of vitamin B3 deficiency
'Pellagra'
Dermatitis
Diarrhoea
Deficiency
286
Which vitamin is folic acid?
B9
287
Which vitamin is niacin?
B3
288
Which vitamin is thiamine?
B1
289
Consequence of vitamin C deficiency
Scurvy
Gingivitis
Bleeding
290
Which vitamin is ascorbic acid?
C
291
Which vitamin is cyanocobalamin?
B12
292
Consequence of vitamin K deficiency
Haemorrhagic disease of the newborn
293
Inheritance of familial hypercholesterolaemia
Autosomal dominant
294
Statins and pregnancy
Discontinue 3 months before conception due to risk of congenital defects
295
For which patient groups does QRISK2 underestimate cardiovascular risk?
HIV
Serious mental health problems
Drugs causing dyslipidaemia e.g. antipsychogics, steroids, immunosupressants
Autoimmune or inflammatory disorders
296
Foods high in potassium
```
Salt substitutes
Bananas
Oranges
Kiwi
Avocado
Spinach
Tomatoes
```
297
Causes of hypokalaemia with hypertension
Cushing's syndrome
Conn's syndrome
Liddle's syndrome
298
Causes of hypokalaemia without hypertension
```
Diuretics
GI loss
Renal tubular acidosis
Bartter's syndrome
Gitelman syndrome
```
299
Hyperkalaemia - ECG changes
tall tented T waves
small P waves
Widened QRS
300
Causes of predominantly hypercholesterolaemia
Nephrotic syndrome
Cholestatis
Hypothyroidism
301
How does ezetimibe work?
Decreases cholesterol absorption in the small intestine
302
Management of SIADH
Fluid restrict
| Demeclocycline
303
First line management for diabetic neuropathy
Amitriptyline
Duloxetine
Gabapentin
Pregabalin
304
Management gastroparesis in diabetics
Metoclopramide
Domperidone
Erythromycin
