Endocrinology Flashcards
1
Q
Following water deprivation, what is the results for different diseases?
A
Starting plasma osm. Final urine osm. Urine osm. post-DDAVP
Normal: Normal | > 600| > 600
Psychogenic polydipsia: Low | > 400 | >400
Cranial DI: High < 300 > 600
Nephrogenic DI: High < 300 < 300
2
Q
How do you perform water deprivation test?
A
Method
>prevent patient drinking water for 8-12hrs
>ask the patient to empty their bladder
>hourly urine and plasma osmolalities
3
Q
Drugs causing gynaecomastia?
A
spironolactone (most common drug cause)
cimetidine
digoxin
cannabis
finasteride
GnRH agonists e.g. goserelin, buserelin
oestrogens, anabolic steroids
4
Q
heavy alcohol consumption, He is noted to be polyuric. What is the likely mechanism which has caused this patient’s polyuria?
A
ADH suppression in the posterior pituitary gland subsequently leading to polyuria
5
Q
A 47-year-old woman is referred to the general medical clinic. She has gained 10 kg in weight in the past 3 months but her main problem is episodic sweating. These episodes of sweating are associated with double vision and typically occur early in the morning. Diagnosis??
A
Insulinoma
6
Q
Treatment of insulinoma??
A
Surgery
if not candidate of surgery, DIAZOXIDE and SOMATOSTATIN
7
Q
Pt had diarrhea and vomit. Na=115. He receives 2 litres of 0.9% saline over the next 16 hours. He then develops spastic quadriparesis and pseudobulbar palsy. A repeat serum sodium comes back 135 mmol/L. What is the most likely underlying pathophysiology?
A
Astrocyte apoptosis (osmotic demyelination syndrome) (central pontine myelinolysis)
8
Q
What is osmotic demyelination syndrome??
A
(central pontine myelinolysis)
Rapid correction of hyponatremia is a known risk factor for the development of osmotic demyelination syndrome (ODS) which is the most likely complication that has occurred in this case. When osmotic pressure is rapidly increased by the correction of low sodium, a rapid shift in osmolarity leads to dehydration of brain cells, particularly astrocytes, resulting in their injury or death (apoptosis) and subsequent demyelination.
9
Q
Severe hyponatremia can cause:
A
Cerebral edema, which in turn can cause brain herniation.
10
Q
Why does demylination occur in pt who is undergoing rapid sodium correction??
A
Chronic hyponatraemia → loss of osmotically active organic osmolytes (such as myoinositol, glutamate, glutamine) from astrocytes. These provide protection against cerebral oedema. Organic osmolytes cannot be replaced quickly enough when the brain volume begins to shrink in response to the correction of hyponatraemia
the dehydrated astrocytes and oligodendrocytes undergo apoptosis or other forms of injury → demyelination
11
Q
How can we avoid OSD/Demylination due to rapid correction of sodium??
A
Na+ levels are only raised by 4 to 6 mmol/l in a 24-hour period
symptoms usually occur after 2 days and are usually irreversible: dysarthria, dysphagia, paraparesis or quadriparesis, seizures, confusion, and coma
patients are awake but are unable to move or verbally communicate, also called ‘Locked-in syndrome’
12
Q
What should we do with the thyroxine if the pregnant lady was already on thyroxine before conception?
A
Women with hypothyroidism need to increase their thyroid hormone replacement dose by up to 50% as early as 4-6 weeks of pregnancy. ( In pregnancy, the increase in thyroid replacement is typically 20-50%, which normally equates to 25mcg-50mcg increase)
13
Q
How do we treat thyrotoxicosis in pregnancy??
A
Propylthiouracil is associated with an increased risk of severe hepatic injury
propylthiouracil is generally used in the first trimester of pregnancy in place of carbimazole, as carbimazole may be associated with an increased risk of congenital abnormalities
maternal free thyroxine levels should be kept in the upper third of the normal reference range to avoid fetal hypothyroidism
thyrotrophin receptor stimulating antibodies should be checked at 30-36 weeks gestation - helps to determine the risk of neonatal thyroid problems
14
Q
If a patient diagnosed with lung cancer and sodium levels are low, then what we suspect??
A
SIADH causing hyponatremia
15
Q
What are the most common risk factors for cervical cancer?
A
Human papillomavirus (HPV), particularly serotypes 16,18 & 33
16
Q
Other less common risk factors of CA Cervix??
A
Smoking
HIV
Early first/many intercourse
High parity
Low SES
COCPs
17
Q
How HPV cause cervical CA??
A
HPV 16 —-> produce oncogenes E6–> inhibits p53 TSG
HPV 18—> produces oncogenes E7—> inhibits RB TSG
18
Q
Single most useful test for determining the cause of hypercalcaemia in a pt having lethargy, depression and constipation??
A
PTH
19
Q
What are the “2 CHIMPANZEES”??
A
2= Thyrotoxicosis/ chronic hyperthyroidism
C= Calcium supplementation
H= HyperPTH
I= Iatrogenic | Immobilization
M= Milk alkali syndrome. MM. Meds (Lithium, Thiazides, antacids)
P= PIG Hyperplasia/adenoma | Paget disease of bone |Pyaas (dehydration)
A= Alcohol | Addison’s Disease | Acromegaly
N= Neoplasia (breast, ssc of lung)
Z= Zollinger Ellison Dis
EE= Excess Vit D and Vit E
S= Sarcoidosis
20
Q
In gestational diabetes, if blood glucose targets are not met with diet/metformin, then??
A
Short-acting insulin should be added to her existing treatment
21
Q
Modified-release metformin for??
A
The pts who cannot tolerate metformin due to its GIT side effects
22
Q
Risk factors for gestational DM??
A
1) BMI>30
2) previous macrosomic baby of 4.5kg or more
3) Prev GDM
4) 1st degree relative with DM
5) South asian/Black carribean/middle east
23
Q
When is the screening of GDM done?
A
OGTT at 24-28wks
if positive then repeat OGTT at 32 wks
24
Q
How do you diagnose GDM??
A
Fasting glucose >= 5.6mmol/l
After 2 2hrs >= 7.8mmol/l
25
How do you manage GDM??
Self monitor
{if fasting <7}, then diet
if targets not met in 1-22wks, then metformin
if still not met then SHORT ACTING insulin not long
{if fasting >7} then insulin
{if fasting 6-6.9 +complications} then insulin
{if pt not tolerate metformin or dose not want to take insulin} then Glibenclamide (Sulfonylurea)
(,,, mg/dl=18xmmol/l) (7mmol/l=126mg/dl)
26
How do you manage pre existing DM in a pregnant patient?
If BMI >27, them w8 loss
Stop all orals except metformin, and start insulin
Folic acid 5mg/day from pre-conception to 12wks
Detailed anomaly scan at 20wks
Tight sugar control
Treat retinopathy
27
What are the targets in pre existing DM and GDM??
Fasting ---> 5.3mmol/l (95mg/dl)
1 hr PP ---> 7.8mmol/l (140mg/dl)
2 hr PP ---> 6.4mmol/l (115mg/dl)
28
What happens in primary polydipsia??
Urine osmolality after fluid deprivation: high
Urine osmolality after desmopressin: high
29
What happens in nephrogenic DI??
Urine osmolality after fluid deprivation: LOW
Urine osmolality after desmopressin: LOW
30
What happens in cranial DI??
Urine osmolality after fluid deprivation: LOW
Urine osmolality after desmopressin: high
31
In hypercalcemia that is secondary to lung cancer/neoplasia, what happens to PTH??
LOW, bcz of presence of PTHrP
32
Give briefly diagnosis and management of DM-1??
1) Record HbA1C 3-6 monthly, target is 48mmol/mol (6.5% or lower)
2) Monitor RBS 4 times per day (before each meal and before sleep). More frequently if infection/pregnancy/complications/breastfeed/increased low RBS attacks.
3) Targets of RBS=
5-7mmol/l on waking
4-7mmol/l before meals at other day times
4) INSULIN:
i) Multiple basal bolus regimens
ii) Twice daily detemir/once daily glargine
iii) Rapid acting before meals
5) If BMI>25, then metformin
33
What is the first line test for acromegaly??
Serum IGF-1 levels
34
If a person with acromegaly is shown to have raised IGF-1 levels, then what other test is done to confirm the diagnosis??
OGTT followed by serial GH measurements
(a positive result would be a lack of GH suppression (<1ug/l) followed by OGTT)
(in normal patient, GH is suppressed to <2ug/l after hyperglycemia)
35
What are the complications that occur in acromegaly patient??
(HCD)
HTN (systemic NOT pulmonary)
CRCA | CMP
DM
36
What is the diagnostic criteria of DKA??
RBS >11mmol/l or k/c of DM
pH < 7.3
HCO3 < 15mmol/l
Ketones >3mmol/l or urine ketones ++ on dipstick
37
How to manage DKA??
Isotonic saline
IV insulin (0.1U/kg/hr).
If RBS <14mmol/l, then start 10% dextrose started at 125ml/l + 0.9% NaCl.
Add K+ to replacement fluids e cardiac monitoring.
Long acting insulin should be continued, short acting be stopped.
38
What is the fluid replacement regime for patient with a systolic BP on admission 90mmHg??
(for pts 25yrs and older)
(1,2,2,4,4,6)
{1L N/S over 1st hr}
{1L N/S with KCl over next 2hrs}
{1L N/S with KCl over next 2hrs}
{1L N/S with KCl over next 4hrs}
{1L N/S with KCl over next 4hrs}
{1L N/S with KCl over next 6hrs}
39
What are the guidelines for potassium infusion??
{If K is over 5.5mmol/L in 1st 24hrs, then no need to replace}
{If K is 3.5-5.5mmol/L in 1st 24hrs, then 40mmol/L of infusion is needed}
{If K is below 3.5mmol/L in 1st 24hrs, then call to senior for further K}
40
How can we safely say that DKA has resolved??
If pH is >7.3
Blood ketones<0.6mmol/L
HCO3 >15mmol/L
Ketonaemia and acidosis should settle within 24hrs.
Switch to S/C insulin if taking orally.
41
What are the complications that can occur from DKA itself/treatment?
Gastric stasis
Thromboembolism
Arrhythmias secondary to hyperkalaemia/iatrogenic hypokalaemia
Iatrogenic due to incorrect fluid therapy: cerebral oedema, hypokalaemia, hypoglycaemia
Acute respiratory distress syndrome
Acute kidney injury
42
Is 9am cortisol test an inconclusive test to exclude diagnosis of addisons disease??
9 am cortisol between 100-500nmol/l is inconclusive and requires further investigation with a short synacthen test
{Less than 100 suggests a definite Abnormality}
{>500 makes Addison very unlikely}
43
What is a short synacthen test??
ACTH stimulation test:
The definite investigation for Addison disease,
Give 250ug IM Synacthen and measure the cortisol levels before giving it and 30 mins after giving synacthen...
44
What are the electrolyte abnormalities in a patient of ADDISON?
Hyperkalemic metabolic acidosis
Hyponatremia
Hypoglycemia
45
Which diseases would have a brief period of hyper then hypothyroidism??
De Quervaine's (Subacute thyroiditis)
{Pt will have flu like/vitral symptoms before the period of hyper}
AMIODARONE
Postpartum thyroiditis
46
How to differentiate hyperthyroid brief period before hypo in pts of hashimoto thyroiditis and de quervains thyroiditis??
HASHIMOTO {a/w MALToma}hyperthyroid period is 6-12months
De Quervains thyroiditis hyperthyroid period is few weeks and this will be associated with a viral period
47
Can the patients on insulin with high HbA1C drive and get HGV licence??
Patients on insulin may now hold a HGV licence if they meet strict DVLA criteria relating to hypoglycemia
48
What is the criteria for metabolic syndrome?
Atleast 3 of the following 5:
1)Waist circumference (M>102cm) (F>88cm)
2) Increased TAGs >1.7mmol/L
3) Reduced HDL (M<1.03mmol/L)(F<1.3mmol/L)
4) Increased BP >135/80 or on active HTN treatment
5) Increased fasting glucose>5.6mmol/L or previously diagnosed DM-2
49
What electrolyte abnormality in Cushing syndrome?
HYPOKALEMIC METABOLIC ALKALOSIS
50
What are the first line and confirmatory tests for cushing syndrome?
First line: (Overnight) Low Dose dexamethasone suppression test- negative
ALSO DONE:
-24hr urinary free cortisol
-Bedtime salivary cortisol
(2 measurements are required for above both)
51
What are the localization tests for cushing??
First line localization: 9am and midnight plasma ACTH and cortisol.
High dose dexamethasone suppression test:
{If ACTH is suppressed and cortisol is not suppressed, then Cushing Syndrome (Cause is adrenal adenoma)}
{If both ACTH and cortisol are suppressed, then CD (Pituitary adenoma)}
{If both ACTH and cortisol are not suppressed, then Ectopic ACTH syndrome}
CRH stimulation test:
{If cortisol rises then pituitary source}
{If cortisol does not rise, then ectopic or adrenal source}
Petrosal sinus sampling of ACTH:
Pituitary vs ectopic
Insulin stress test:
True cushings vs pseudo-cushing
52
Which anti DM meds cause weight gain??
INSULIN
SULFONYLUREAS
THIAZOLIDINEDIONES
53
How are -tides (GLP1) given??
S/C within 60mins of morning and evening meals.
54
What is the advantage of liraglutide over exenetide??
Liraglutide is given in OD
55
What is the indication of adding exenetide/GLP1 to metformin and a sulfonylurea??
BMI >= 35 kg/m²
BMI < 35 kg/m² and insulin is unacceptable
56
A pt having IDA and Ca defficiency, also requiring levothyroxine for her hypothyroid status, how to give all meds?
Iron / calcium carbonate tablets can reduce the absorption of levothyroxine - should be given 4 hours apart
57
How to start levothyroxine in pt with heart disease??
The BNF recommends that for patients with cardiac disease, severe hypothyroidism or patients over 50 years the initial starting dose should be 25mcg od with dose slowly titrated. Other pts, start with 50-100 od
58
Once on thyroxine, what is the target and how to monitor??
Target: Normalization of TSH or between 0.5-2.5mU/L
Monitor TFTs after every 8-12 wks
59
Why cinacalcet is given for conservative treatment of hyperPTH??
This is a calcimimetic drug that mimics the action of calcium on tissues including the parathyroid gland. It increases the sensitivity of calcium receptors on parathyroid cells, reducing PTH levels and resulting in a decrease in serum calcium levels.
{For pts who are not suitable for surgery}
60
What to give to pts of DM for gastroparesis??
Metoclopramide
Domperidone
Erythromycin
(all are prokinetics)
61
For neuropathic pain in DM?
1st Amitryptilline OR Duloxetine OR pregabalin OR gabapentin.. if no effect with 1st line, you can add one of the other 3
Topical capsaicin
Tramadol as rescue therapy
62
What is the primary management of hypercalcemia??
Rehydration with N/S 3-4L/day. (It typically takes 7 days for maximum effects)
then Bisphosphonates
(Calcitonin a quicker effect than BP)
Steroids if sarcoidosis
If cannot tolerate fluids then give frusemide.
63
What is a glycemic index??
A capacity of a food to raise RBS compared with a glucose in normal glucose tolerant individual. Glucose will have a GI of 100
64
Foods with high GI??
White bread, White rice, Baked potato
65
Foods with medium GI??
Boiled new potato, Brown Rice, Digestive biscuit, Porridge, Couscous
66
Foods with low Gi??
Fruits and veges, peanuts
67
MOA of sulfonylureas??
Sulfonylureas - bind to an ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta cells. Block these channels causing membrane depolarisation and Opening of voltage-gated calcium channels --> insulin release.
68
How SU cause neuroglycopenia??
When used acutely they increase insulin secretion and decrease insulin clearance in the liver. So they cause hypoglycaemia, the main side effect, and then--> neuroglycopenia.
69
How do you treat neuroglycopenia??
Oral glucose
IM glucagon
IV glucose
70
If glitazone is given with _____, it increases the risk of peripheral edema??
INSULIN {TZD cause fluid retention, and so do insulin}
(SU, Metformin, sodium, K level dont affect fluid balance)
71
Best and most appropriate screening test for diabetic neuropathy??
Test sensation using 10g monofilament.
{This exerts a specific amount of pressure on the skin and patients who cannot feel "this" pressure are considered to have lost "protective foot sensation", which puts them at risk of developing diabetic foot ulcers}
72
If a pt is at risk of having CVD (10 yr risk of >=10%), then what should be the target to be achieved after 3 months of starting statin 20mg OD??
In the primary prevention of CVD/CKD/DM-1 using statins aim for a reduction in non-HDL cholesterol of > 40%. If this is not achieved, increase statin to 80mg.
73
If the pt had already had an attack of IHD/CVA/PAD, then what should be the statin starting dose??
Atorvastatin 80mg OD
(If no CI)
74
Main features of Gittleman syndrome??
"Normotension"
HypoK met alkalosis
HypoMg
HypocalciURIA
75
Conns syndrome?
Primary hyperaldosteronism
{HTN, HyperNa, HypoK met alkalosis}
76
Reidel's thyroiditis??
Invasive fibrous thyroiditis,
Retroperitoneal fibrosis,
Fibrosing mediastinitis.
77
What are the P"s of raised Prolactin??
Pregnancy
Prolactinoma
Physiological
Polycystic ovarian syndrome
Primary hypothyroidism
Phenothiazines, metocloPramide, domPeridone
non functioning Pituitary stalk adenoma
78
What is the recommended regimen for insulin in HHS??
IV insulin infusion of 0.05 units/kg/hour HHS, as the name suggests, is due to hyperglycaemia and high plasma osmolality, unlike DKA, HHS patients have enough circulating insulin to prevent ketogenesis and therefore ketonaemia is absent and acidosis is normal mild if present. HHS normally develops over a longer period of time than DKA (several days) and generally affects patients with type 2 diabetes. The main aspect of HHS treatment is fluids with a similar regime as used in DKA. Insulin is generally only started once a patient's blood glucose no longer falls with IV fluids or if there is significant ketonaemia (>1mmol/L or urine ketones>2+). In these cases, an IV insulin infusion of 0.05 units/kg/hour should be started.
79
How you decide whether to add another antiDM drug for DM-2??
Check HbA1C every 3-6months till stable, then 6 monthly.
TARGETS HbA1C:
Lifestyle ---> 48mmol/mol OR 6.5%
Lifestyle+Metformin
---> 48mmol/mol OR 6.5%
Any drug causing hypoglycemia (SU)---> 53mmol/mol OR 7%
80
What if a pt cannot tolerate metformin due to GI side effects??
MODIFIED RELEASE METFORMIN
81
When can we add -flozins/ SGLT2 inhibitors??
1) Max metformin but no effect
2) If pt has developed/is at the risk of CVD/CHF
3) If metformin CI, then as monotherapy IF THE PT HAS CVD/AT RISK {if the pt is not, then use DPP-4 in, Glitazones, SU}
82
What is dual therapy for DM-2??
Metformin + DPP-4 inhibitor
Metformin + pioglitazone
Metformin + sulfonylurea
Metformin + SGLT-2 inhibitor (if NICE criteria met)
83
What is the triple therapy for DM-2??
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
84
What is the further therapy after triple therapy of DM-2?
GLP-1 added to insulin
85
If nipple discharge with hypothyroidism and hypogonadism, then cause??
The presence of an elevated prolactin level along with secondary hypothyroidism and hypogonadism is indicative of stalk compression is consistent with a non-functioning pituitary adenoma
86
MOA of Meglitinides?
Like sulfonylureas they bind to an ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta cells
87
An insulin stress test is an important investigation for??
HYPOPITUITRISM
{insulin stress test for integrity of the hypothalamic-pituitary-adrenal axis.. In this test, insulin-induced hypoglycaemia should stimulate the pituitary gland to secrete (ACTH), which in turn stimulates the adrenal glands to produce cortisol. If there's a deficiency in ACTH due to hypopituitarism, cortisol response will be inadequate.}
88
How uterine fibroids can cause secondary polycythemia??
Excessive erythropoietin from uterine fibroids or some other tumours (e.g. cerebellar haemangioma, hypernephroma, hepatoma) can lead to secondary polycythaemia.
89
How do you treat thyrotoxicosis storm (pt is sweaty, confused, and agitated. Her heart rate is 110 bpm and her blood pressure is 166/113mmHg)??
IV hydrocortisone, propranolol, Lugol's iodine and carbimazole..
evidenced by the precipitant (recent major surgery) and the constellation of confusion, agitation, fever, hypertension, and tachycardia. Treatment is initiated before the thyroid function tests are back. Treatment consists broadly of counteracting the peripheral effects of thyroid hormone (using propranolol), preventing peripheral conversion of T4 to active T3 (using steroids), and inhibiting further thyroid hormone synthesis (using antithyroid drugs and Lugol's iodine).
90
Diagnostic criteria of DM-2??
If the patient is symptomatic:
fasting glucose greater than or equal to 7.0 mmol/l
random glucose greater than or equal to 11.1 mmol/l
91
Impaired fasting glucose (IFG)??
Fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l
92
Impaired glucose tolerance (IGT)??
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
93
What are the associations with retroperitoneal fibrosis??
Reidel thyroiditis
Prev radiotherapy
Inflammatory abdominal aortic aneurysm
Sarcoidosis
Drugs like Methysergide (not sulphonamides)
94
If symptomatic hypoglycemia (sweating, shaking, nausea, anxiety, weakness, confusion, and altered vision) what is the first hormone released?
GLUCAGON
95
A pt with history of treated Graves disease now comes to you with hypotension, hypothermia, hypoNa, hyperK, and now he becomes unconscious. now what should be the first investigation you would do immediately??
GLUCOSE (Hypo)
(Addison disease, bc of autoimmune adrenelitis)
Rx: IV fluids, IV dexa
{for Addisonian crisis}
-Hydrocortisone 100 mg im or iv, continue 6 hrly until pt stable.
-1 litre normal saline infused over 30-60 mins or with dextrose if hypoglycaemic
-oral replacement of hydrocortisone may begin after 24 hours and be reduced to maintenance over 3-4 days
96
Causes of Cranial DI??
-Idiopathic
-Post head injury
-Pituitary surgery
-Craniopharyngiomas
-Infiltrative
---histiocytosis X
---sarcoidosis
-DIDMOAD {association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness (also known as Wolfram's syndrome)}
-Haemochromatosis
97
MOA of Orlistat?
Inhibits gastric and pancreatic lipase to reduce the digestion of fat
98
Which type of DM is found to have identical twins concordance?
Type 2 diabetes mellitus is thought to be caused by a relative deficiency of insulin and the phenomenon of insulin resistance. Age, obesity and ethnicity are important aetiological factors. There is almost 100% concordance in identical twins and no HLA associations.
99
Is sensory pathway directly affected by primary hyperPTH?
NOOO
100
How do you manage PCOS?
1) GENERAL:
-wt loss
-COCPs if contraception required and for regulation of menses
2)Hirsutism and acne:
-COCPs (3rd gen/co-cyprinidol)
-If no effect, topical eflornithine can be tried
-spironolactone, flutamide and finasteride (UKSO consultant)
3) INFERTILITY:
-Wt loss
- metformin, clomifene or a combination
-Gonadotrophins
101
What do you suspect in pt with high T4 and osteoporotic hip fracture?
GRAVE'S DISEASE
102
Drugs causing leucopenia?
Amlodipine and bendroflumethiazide
103
Drugs causing neutrophilia?
Prednisolone can cause neutrophilia through:
Demargination of neutrophils via the endovascular lining.
Delayed migration of neutrophils into tissue.
Release of immature neutrophils from bone marrow.
104
What are the blood tests results in pseudohypoPTH?
↑ PTH
↓ calcium
↑ phosphate
105
Types of PseudohypoPTH?
In type I pseudohypoparathyroidism there is a complete receptor defect whereas in type II the cell receptor is intact.
106
How does one establishe a diagnosis of diabetes mellitus?
Diabetes meliitus diagnosis: fasting > 7.0, random > 11.1 - if asymptomatic need two readings... if symptomatic then only one such reading is enough
107
If hypoNa, HyperK, hypoglyc, hypotension, hypothyroid, then most appropriate intervention?
IV hydrocortisone
108
KALLMAN vs KLINFELTER?
KALLMAN:
The LH and FSH levels are inappropriately low-normal given the low testosterone concentration, which points towards a diagnosis of hypogonadotrophic hypogonadism.
Klinefelter's syndrome: the LH and FSH levels are raised
109
Premature ovarian failure VS Gonadotropin-pituitary adenoma?
POF:
FSH/LH=high
estradiol=low
PIt adenoma:
FSH/LH=normal
estradiol=high
110
MOA of Carbimazole?
Blocks thyroid peroxidase from coupling and iodinating the tyrosine residues on thyroglobulin → reducing thyroid hormone production
111
What if a Nuclear scintigraphy reveals patchy uptake?
Toxic multinodular goitre
Rx: RADIOIODINE
112
Cryptorchidism is more suggestive of Kallman's or Klinefelter's syndrome?/
KALLMAN SYNDROME
113
Is there any relation between HbA1C and avg RBS?
YES,
average plasma glucose =
(2 * HbA1c) - 4.5
{HbA1C in mmol/mol}
114
1st line treatment for MODY-1?
Sulfonylureas - bind to an ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta cells
115
What causes worsening of eye disease in a pt of Graves disease?
Radioiodine treatment may lead to the development / worsening of thyroid eye disease in up to 15% of patients with Grave's disease
(Remember steroids and radioTHERAPY is the treatment)
116
Carbenoxolone??
Carbenoxolone is a synthetic derivative of glycyrrhizinic acid, which is used for the treatment of peptic ulcer. It has mineralocorticoid activity and can cause hypokalaemia (low potassium levels), not hyperkalaemia (high potassium levels).
117
Which foods have high potassium and hence be avoided in pts with CKD?
-Salt substitutes (i.e. Contain potassium rather than sodium)
-Bananas
-Oranges
-Kiwi fruit
-Avocado
-Spinach
-Tomatoes
118
A pt with recurrent headaches, sweating, palpitations, and high BP, what is the most appropriate next step??
Phaeochromocytoma: do 24 hr urinary metanephrines, not catecholamines/VMA
119
What is a normal dynamic pituitary function test?
-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
-A normal response to dopamine antagonist is at least a twofold rise in prolactin.
{ADH does not show dynamic pit function}
120
What is the most common non-iatrogenic cause of Cushing's syndrome?
Pituitary tumor
(pathogenesis involves a pituitary adenoma secreting excess adrenocorticotropic hormone (ACTH), which stimulates the adrenal glands to produce an overabundance of cortisol.)
121
What are the factors that point towards starting a statin??
NICE specifically state that we should not use QRISK2 for type 1 diabetics. Instead, the following criteria are used:
-Older than 40 years
-Have had diabetes for more than 10 years
-Have established nephropathy or
-Other CVD risk factors
122
Hypercholesterolaemia rather than hypertriglyceridaemia in??
-Nephrotic syndrome
-Cholestasis
-Hypothyroidism
{All other cause predominant hyperTAGelimia}
123
Pt with DM and IHD presents with fruity odor with normal glucose and acidosis??
Most of pts with IHD and DM are on SGLT2 inhibitors.. SGLT-2 inhibitors reversibly inhibit sodium-glucose co-transporter 2 (SGLT-2) in the renal proximal convoluted tubule.
Can cause Normoglycemic ketoacidosis..
Other complications include:
1) Fournier gangrene
2) Urogenital infection
3) Lower limb amputations
124
How do you manage graves disease?
Initial treatment to control symptoms: Propranolol
If not controlled, then Carbimazole started
ATD Therapy:
-Start Carbimazole at 40mg and then reduce to maintain euthyroidism {Continue till 12-18 months} Complication of Carbimazole is AGRANULOCYTOSIS
-Alternative BLOCK AND REPLACE:
--Start carbimazole at 40mg
--Add thyroxine as pt becomes euthyroid
--6-9months treatment
{patients following an ATD titration regime have been shown to suffer fewer side-effects than those on a block-and-replace regime}
-Radioiodine Rx:
-If ATD relapse
CI: Pregnancy and age<16yrs
-Require thyroxine supplements after 5yrs
125
When is the OGTT done in a pregnant female having gestational DM in her last pregnancy?
ASAP after booking
If normal then repeat at 24-28wks
If any other RFs, then also do at 24-28wks
126
If glucose not controlled on metformin on high dose, then what to add?
His HbA1c is still significantly above target so some change to the medication is indicated.
The NICE type 2 diabetes mellitus guidelines would generally advocate the use of a sulfonylurea in this situation.
However. the patient is a taxi driver and overweight. A DPP-4 inhibitor such as sitagliptin would be ideal in this situation. There is no risk of hypoglycemia and they DPP-4 inhibitors are weight neutral.
127
What are the indications of referring a thyroid eye disease to ophthalmologist?
-Unexplained deterioration in vision
-Awareness of change in intensity or quality of colour vision in one or both eyes
-History of eye suddenly 'popping out' (globe subluxation)
-Obvious corneal opacity
-Cornea still visible when the eyelids are closed
-Disc swelling
128
COCPs vs estrogen only preparation?
HRT: adding a progestogen increases the risk of breast cancer
129
Which cancer is associated autoimmune thyroiditis?
Hashimoto's thyroiditis is associated with thyroid lymphoma
130
Which cancer is associated with acromegaly?
CRCA
131
What if the pt had a CVD but his HbA1C is controlled in target?
ADD FLOZINS LAZMI
132
How do you diagnose insulinoma?
-Supervised, prolonged fasting (up to 72 hours)
-CT pancreas
(High C peptide level is non diagnostic)
133
How to manage insulinoma?
=Surgery
=Diazoxide and somatostatin if patients are not candidates for surgery
134
LIDDLE's RIDDLE?
Hypertension and hypokalaemic alkalosis.
AD inherit
Disordered sodium channels in the DCT--> increased reabsorption of Na
Rx: amiloride or triamterene
135
If hyperuricemia and asymptomatic pt, then which test?
Lipid profile
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What are the causes of increased uric acid?
-Increased synthesis
--Lesch-Nyhan disease
--Myeloproliferative disorders
--Diet rich in purines
--Exercise
--Psoriasis
--Cytotoxics
-Decreased excretion
--Drugs: low-dose aspirin, diuretics, pyrazinamide
--Pre-eclampsia
--Alcohol
--Renal failure
--Lead
