Endocrinology Flashcards
1
Q
Complications of Acromegaly?
A
HTN
DM
Cardiomyopathy
Colorectal cancer
2
Q
Screening for acromegaly?
A
IGF-1 (high)
3
Q
Diagnosis of acromegaly if IGF-1 high?
A
OGTT fails to suppress GH to <2
4
Q
Management of acromegaly?
A
Trans sphenoidal surgery
If refractory:
- Octreotide
- Pegvisomant
- Bromocriptine
5
Q
Causes of primary adrenal insuficiency?
A
Addison’s disease
Surgical removal
Trauma
TB
Waterhouse-Friedrichsen syndrome (post meningococcal septicaemia)
Metastasis (bronchial)
Antiphospholipid
6
Q
Secondary causes of adrenal insuficiency?
A
Congenital syndromes
Neoplasms
Sheehan syndrome
7
Q
Tertiary causes of adrenal insufficiency?
A
Inadequate stimulation from hypothalamus and CRH due to suppression from long term steroids
8
Q
Addison’s symptoms others dont?
A
Hyperpigmentation
9
Q
ACTH in primary adrenal insufficiency?
A
High
10
Q
Addison’s disease has low what?
A
Cortisol and aldosterone
11
Q
What antibodies are associated with addisons?
A
adrenal cortex antibodies and 21-hydroxylase antibodies
12
Q
9am cortisol findings for ? adrenal insufficiency?
A
> 500 very unlikely
<100 abnormal
100-500 do short synacthen test
13
Q
Diagnosis of addison’s disease?
A
Short synacthen test
250 nano grams IM of synthetic ACTH. Check cortisol before, 30 mins and 60 mins after. Should double
14
Q
Treatment of addisonian crisis?
A
IV/IM 100mg hydrocortisone then 50mg QDS 24 hours, then reduce
1L IVF 30-60 mins, then 4-6L 24 hours
15
Q
ALP high in pregnancy?
A
Physiological
16
Q
Raised ALP and raised calcium?
A
Bone mets
Hyperparathyroidism
17
Q
Raised ALP and low calcium?
A
Osteomalacia
Renal failure
18
Q
What is androgen insensitivity syndrome?
A
X linked recessive resistance to testosterone with XY children appearing female
19
Q
What is Autoimmune polyendocrinopathy syndrome (APS)?
A
Addison’s associated with other endocrine deficiencies.
Type 2 most common linked to HLA DR3/DR4
20
Q
What is type 2 autoimmune polyendocrinopathy syndrome (APS)?
A
Addison’s disease
+
T1DM/ autoimmune thyroid disease
21
Q
What is Bartter’s Syndrome?
A
Defective NKCC2 (Na/K/2Cl co-transporter) causing hypoK from young age with normotension
22
Q
What is congenital adrenal hyperplasia?
A
Group of AR disorders with impaired steroid biosynthesis leading to high ACTH and androgens
23
Q
3 types of congenital adrenal hyperplasia (CAH)?
A
21 hydroxylase
11 beta hydroxylase
17 hydroxylase
Deficiency
24
Q
Presentation of congenital adrenal hyperplasia (CAH)?
A
Virilisation- ambiguous genitals
Salt wasting crisis
Precocious puberty
Infertility
Accelerated growth
25
Which CAH is salt wasting crisis seen in?
11 beta hydroxylase deficiency
26
11 beta hydroxylase CAH seen as?
HTN
HypoK
Salt wasting crisis
27
Diagnosis of congenital adrenal hyperplasia?
ACTH stimulation testing causing abnormal increase in 17OHP
28
Management of congenital adrenal hyperplasia?
Glucocorticoid replacement to reduce ACTH
29
VBG in cushings?
HypoK metabolic alkalosis
30
Ectopic ACTH commonly from?
SCLC
31
Diagnosis of cushings syndrome?
Low dose overnight dexamethasone suppression test- mornign cortisol spike not suppressed
32
Investigation for localisation of cushing syndrome?
High dose overnight dexamethasone test with cortisol and ACTH
Pituitary adenoma- cortisol and ACTH suppressed
Adrenal adenoma- cortisol not suppressed, ACTH suppressed
Ectopic ACTH- cortisol and ACTH not suppressed
33
Test for pseudo-cushings?
Insulin stress test
34
Pre-diabetes values?
Fasting 6.1-6.9
OGTT 7.8-11
HbA1c 42-47
35
Diagnosis of diabetes?
Symptomatic any once
Asymptomatic on 2 occasions
OGTT >11.1
Fasting >7
HbA1c >48
36
What is impaired fasting glucose?
6.1+ but <7
Always do OGTT to rule of DM
37
What is impaired glucose tolerance?
Fasting <7 and OGTT 7.8+ but <11.1
38
Ramadan and metformin rules?
1/3 dose before sunrise (Suhoor) and 2/3 after sunset (Iftar)
39
Ramadan and SU's?
OD after sunset
If BD larger dose after sunset
40
Diagnosis of DKA?
BM >11
Ketones 3 blood, ++ urine
Acidosis pH 7.3 or HCO3- <15
41
Management of DKA?
IVF
K as needed in second bag
FRII 0.1 units/kg/hour
Continue long acting insulin
42
Which drugs can cause euglycaemic DKA?
Empagliflozin (SGT2 inhibitors)
43
How is a FRII set up?
50ml of 0.9% sodium chloride with 50 units of actrapid
ADD base fluid to 10% dextrose when BM <14
44
When to consider ICU in DKA?
pH <7
Bicarb <5
Ketones >6
45
When is there resolution in DKA?
pH >7.3
Blood ketones <0.6
Bicarbonate >15
46
HbA1c Target for newly diagnosed T2DM/ on metformin/ lifestyle measures?
48
47
HbA1c to add on second line drug?
58
48
HbA1c target if on oral hypoglycaemics?
53
49
T2DM treatment?
- Metformin or MR 1g BD max
If contraindicated: SGLT2 if QRISK >10/ HF/ CVD. If non of these DDP-4 inhibitor or SU
- Second line
+ DDP-4 inhibitor
+ Pioglitazone
+ SU
- Third line
+ another of the above
- Fourth line
BMI >35 GLP-1 mimetic
BMI <35 Insulin
If QRISK >10% at any time add SGLT2 inhibitor
50
Where is insulin synthesised?
Rough endoplasmic reticulum
51
Name 2 rapid acting insulins?
Novorapid- Aspart
Humalog- Lispro
52
Name 2 short acting insulins?
Actrapid
Humulin S
53
Name 2 long acting insulins?
Lantus- glargine
Levemir- determir
54
Name 2 ultra long acting insulins?
Tresiba
Toujeo
55
How much dose one unit of insulin decrease CBG?
2-3
56
What medications can reduce awareness to hypoglycaemia?
Beta blockers
57
Mechanism of action of metformin?
Biguanide increasing insulin sensitivity and decreasing hepatic gluconeogenesis
58
Contraindications to metformin?
eGFR <30
Serum creat >150
59
Mechanism of action of pioglitazone?
Thiazolinediones
Agonist to PPAR-y reducing peripheral insulin resistance
60
Concerns with pioglitazone?
Not in HF
Weight gain
Bladder cancer
Increased risk of fractures
61
Mechanism of action for DDP-4 inhibitors?
Sitagliptin inhibiting peripheral breakdown of GLP-1
62
Sitagliptin is a?
DDP-4 inhibitor
63
Gliclazide is a?
SU
64
Mechanism of action of Sulphonyureas?
e.g., gliclazide stimulates B cells to produce insulin by binding to SUR.
65
SEs of sulphonyureas?
Hypoglycaemia
Weight gain
SV disease
66
What is empagliflozin?
SGLT2 inhibitor
67
What is the mechanism of action of SGLT2 inhibitors e.g., empagliflozin?
Inhibits glucose reabsorption via SGLT2 receptors in the PCT
68
SEs of SGLT2 inhibitors e.g., gliflozins?
UTIs
Fornieres gangrene
Euglycaemic DKA
Weight loss
69
What are exenatide/ liraglutide?
GLP-1 mimetics
70
Mechanism of action of GLP-1 mimetics?
Increases insulin secretion and inhibits glucagon secretion
71
Where is GLP-1 produced?
Small intestine
72
SE of GLP-1 mimetics?
Weight loss
73
For ongoing prescription of GLP-1 mimetics must have what at 6 months?
>11 reduction in HbA1c
3% weight loss
74
Management of diabetic neuropathy (glove and stocking distribution)?
Amitriptyline
Duloxetine
Pregabalin
Gabapentin
75
Management of gastroparesis in diabetes?
Pro kinetics such as domperidone, metoclopramide, erythromycin
76
What is MODY?
AD inheritance of non ketotic hyperglycaemia without features of T1 or T2DM <25 years old
77
Most common MODY?
MODY 2 with GCK mutation
78
Management of MODY 2?
Diet control
79
Mutation of MODY 3?
HNF1A
80
Management of MODY 3?
SU's e.g., gliclazide
or insulin
81
Complications of HHS?
VTE
Profound hypotension
Reduced GCS
82
Define HHS?
Hyperglycaemia >30 without ketosis <3, acidosis pH >7.3, bicarb <15
High osmolality 320+
83
How do you calculate osmolality?
2 Na + glucose + urea
84
Management of HHS?
IVF normal saline
Glucose should fall no more than 5 an hour
If fluids not working insulin 0.05units/kg/hr
85
Statins in T1DM?
20mg if >40, diagnosed >10 years ago, nephropathy
86
Statins in CKD?
All patients
87
Gestational diabetes diagnosis?
Fasting 5.6+
OGTT 7.8+
88
If gestational DM with fasting glucose <7 treat with?
Diet and exercise
If not meeting BM targets add metformin
If not meeting targets insulin
89
When to give insulin in gestational DM?
If fasting glucose initially >7
Evidence of macrosomia or hydraminos
Not responding to metformin
90
What inheritance is Familial Hypercholesterolaemia?
AD with mutation in LDL receptor protein
91
Diagnosis of FH?
Simon Broome criteria
92
Management of FH?
High dose statin
93
Statins in pregnancy?
No stop 3 months prior to conception
94
Causes of hypoglycaemia?
Insulinoma
Insulin, BB, SU, GLP-1
Liver failure
Sepsis
Alcohol
Addison's
95
What is an insulinoma?
Tumour of the beta cells
96
Investigations for hypoglycaemia?
C-peptide
Insulin
Proinsulin
9am cortisol
97
What does raised C-peptide and serum insulin mean?
Endogenous cause e.g., insulinoma, SU abuse
98
Serum insulin raised but C peptide low?
Exogenous insulin e.g., overdose of insulin
99
Low insulin and low c-peptide in hypoglycaemia?
Non insulin related cause e.g., adrenal insufficiency, alcohol, sepsis
100
Management of unconscious hypoglycaemia?
200ml 10% dex IV
100ml 20% dex IV
IM glucagon
101
102
What is a phaeochromocytoma?
Adrenal medulla tumour of the chromaffin cells
103
3 associations of phaeochromocytomas?
MEN 2
VHL
NF 1
104
Rule of 10 in phaeochromocytoma?
10% bilateral, malignant, extra adrenal
105
Most common extra adrenal site of phaeochromocytoma?
Organ of zulerkandl a paraganglionic at the aortic bifurcation
106
Investigation for phaeochromocytoma?
24h urinary metanephrines
107
Management of phaeochromocytoma?
Alpha blockade- phenoxybenzamine
Beta blockade- propranolol
Surgical removal
108
Drugs that raise prolactin?
Metoclopramide
Domperidone
Phenothiazines
Haloperidol
SSRIs
109
Macro adenoma or micro adenoma?
>1xm macro
110
Prolactinoma prolactin level?
3,000+
111
Diagnosis of prolactinoma?
MRI
112
Treatment of prolactinoma?
Cabergoline
Bromocriptine - pregnancy
Surgery
113
Causes of delayed puberty?
Functional- constitutional
Hypogonadotrophic hypogonadism- low GnRH
Hypergonadotrophic hypogonadism- impaired response to FSH/LH
114
What childhood infection can cause hypogonadism?
Mumps
115
What is Turner’s syndrome?
XO
Webbed neck
Coarctation of the aorta
Bicuspid valve
Horseshoe kidney
RAS
116
What type of hypogonadism is Klinefelters?
Primary with no response to high LH with low testosterone
117
Diagnosis of Klinefelters?
Karyotype - chromosomal analysis
118
What is kallman syndrome?
X linked recessive hypogonadotrophic hypogonadism with GnRH secreting neurones failing
119
How is kallman syndrome seen?
Delayed puberty in men with anosmia
120
LH and testosterone in kallman syndrome?
LH low
Testosterone low
121
LH and testosterone in androgen insensitivity syndrome?
LH high
Testosterone normal/high
122
Drugs causing gynaecomastia?
Spironolactone
Cimetidine
Digoxin
Cannabis
Finasteride
123
What is the mechanism of action of ADH?
Upregulates aquaporins in collecting ducts to concentrate urine
124
Causes of SIADH?
SCLC
Pancreatic or prostate cancer
Meningitis, stroke, SAH
SSRIs, tricyclics, carbemazepine, SU, vinicristine
125
Osmolalities in SIADH
Serum osmolality <270
Urine osmolality >100
Urine Na >40
126
Emergency management of hyponatraemia?
150ml of 3% NaCl
127
Management of SIADH?
Fluid restriction
Domeclocycline to reduce responsiveness to ADH
128
What is Familial hypocalciuric hypercalcaemia?
AD disorder with high PTH as higher set point of calcium sensors, increasing calcium
129
3 causes of hypokalaemia that are inherited?
Bartter’s, Gitelman’s, Liddle’s
130
What is Bartter’s syndrome?
AR defective Na/K/Cl co-transporter in thick ascending loop of Henle causing: normotension, Hypok, metabolic acidosis and high urinary calcium.
131
What is Gitelman’s syndrome?
AR defective Na/Cl transporter in the DCT causing: normotension, HypoK, HypoMg, metabolic alkalosis and low urinary calcium.
132
What is Liddle’s syndrome?
AD disorder of Na channels in DCT seen as resistant HTN, with low renin and aldosterone, HypoK and metabolic alkalosis.
133
Treatment of Liddle’s syndrome?
Amiloride or triamterene
134
Bloods of sick euthyroid syndrome?
Low T4 and TSH in inpatient
135
Management of sick euthyroid syndrome?
Monitor, only use medications if symptomatic, TSH >10
136
Most common cause of thyrotoxicosis?
Graves disease
137
Most common cause of hypothyroidism?
Hashimoto’s thyroiditis
138
Causes of thyrotoxicosis?
Graves, toxic multinodular goitre, drugs (amiodarone, contrast)
139
Causes of hypothyroidism?
Hashimoto’s thyroiditis
De Quervains thyroiditis
Riedel thyroiditis
Postpartum thyroiditis
Iodine deficiency
Drugs
140
Thyroid scintigraphy in de Quervain's thyroiditis?
Globally reduced uptake
141
What drugs can cause hypothyroidism?
Lithium, amiodarone
142
Bloods of subclinical hyperthyroidism?
Normal T3/T4 but low TSH
143
Management of subclinical hyperthyroidism?
Monitor TFTs every 6 months
144
What effect can hyperthyroidism have on your heart?
Reversible cardiomyopathy with high OP HF
145
What antibodies are in Graves disease?
TSH receptor antibodies
Anti thyroid peroxidase antibodies
146
What is the biggest risk factor for developing Graves eye disease?
Smoking
147
Management of Graves disease?
Symptom control- propranolol
Anti-thyroid- carbimazole, or propylthiouracil
Radioiodine
148
Contraindications to carbimazole?
Pregnancy and for 6 months after
<16 years
Breast feeding
Relative- thyroid eye disease
149
Anti thyroid medications in pregnancy?
Propylthiouracil for first trimester only, methimazole in second and third trimester
150
Management of thyrotoxic crisis?
IV propranolol
IV propylthiouracil
Dexamethasone IV to limit conversion
Active cooling
151
What dose to use of levothyroxine?
If cardiac disease, severe hypothyroidism, >50 start at 25 micrograms
If else 50-100 micrograms OD
152
Levothyroxine in pregnancy?
Safe but will need increase
153
Interactions with levothyroxine?
Iron and calcium carbonate, take 4 hours after
154
Antibodies is hashimoto’s thyroiditis?
Anti thyroid peroxidase (TPO) and anti-thyroglobulin (Tg)
155
Complication of hashimoto’s thyroiditis?
MALT lymphoma
156
Hashimotos hyperthyroid or hypothyroid?
Initial hyperthyroid followed but hypothyroid
157
What cells are present in de Quervains thyroiditis?
Granulomatous cells
158
Presentation of subacute de Quervains thyroiditis?
Painful goitre triggered by URTI with initial hyperthyroidism followed by hypothyroidism
159
Management of de quervains?
NSAID for pain but otherwise self limiting
160
What antibodies are seen in post partum thyroiditis?
Anti TPO
161
Management of post-partum thyroiditis?
In hyperthyroid- propranolol, in hypothyroid levothyroxine
162
Management of myxoedemic coma?
* IV levothyroxine
* IVF
* IV corticosteroids while exclude coexisting adrenal insufficiency
* Correct electrolytes
* Active rewarming
163
Papillary adenocarcinoma contains what type of cells?
Follicular
164
Papillary adenocarcinoma biopsy?
Psammoma bodies
Orphan annie nuclei (clear ground glass nuclei)
165
Risk factors for papillary adenocarcinoma?
Radiation exposure from a young age <20y
166
Tumour marker for papillary and follicular adenocarcinoma?
Thyroglobulin
167
Biopsy of follicular adenocarcinoma?
Hurtle cell change, encapsulated
168
Management of papillary or follicular adenocarcinoma?
Surgical removal then radioiodine, then thyroxine to suppress
Monitor thyroglobulin yearly
169
Who is anaplastic (undifferentiated) carcinoma seen?
Elderly with poor prognosis and compressive symptoms
170
Biopsy of anaplastic carcinoma?
Giant osteoclasts, sarcomatous spindles
171
What cells does medullary carcinoma originate?
C cells (parafollicular cells) from the neural crest
172
Tumour markers for medullary carcinoma?
CEA, calcitonin
173
Management of medullary carcinoma?
Thyroidectomy and LN dissection
Calcitonin monitoring
174
What is Orlistat?
Pancreatic lipase inhibitor
175
When to use Orlistat?
BMI 30+ with risk factors
BMI 38+
176
What is liraglutide?
GLP-1 mimetic given as OD SC injection if BMI 35+
177
What is waterhouse-friderichsen syndrome?
Adrenal gland insufficiency from adrenal haemorrhage due to bacterial infection most commonly N. meningitis
178
X-ray of waterhouse-friedrichsen syndrome?
Adrenal calcification
179
What is Diabetes Insipidus (AKA Arginine vasopressin disorder)?
Lack of ADH and therefore cant concentrate urine
180
How is diabetes insipidus divided?
Craniogenic (AVP deficiency), Nephrogenic (AVP resistance)
181
What is complete vs partial cranial diabetes insipidus?
Partial is <50% increase in urine osmolality
Complete is >50% increase in urine osmolality
182
Causes of craniogenic diabetes insipidus?
Inherited (AD neurohypohyseal), hypopituitasm
183
Causes of nephrogenic diabetes insipidus?
Inherited (Wolfram’s syndrome), drugs, electrolyte abnormalities, CKD
184
Findings in diabetes insipidus?
High Na
Urine sodium LOW
Urine osmolality <300
Serum osmolality high >300
185
Diagnostic test for diabetes insipidus?
Water deprivation test followed by synthetic ADH (desmopressin)
186
Management of craniogenic DI?
Desmopressin
187
Management of nephrogenic DI?
Treat underlying cause
188
What are the 4 parts of the adrenals?
Zona glomerulusa- aldosterone
Zona fascilulata- cortisol
Zona reticualris- androgens
Medulla- adrenaline and noradrenaline
189
Causes of primary hyperaldosteronism?
Adrenal hyperplasia, Conn’s syndrome (adrenal adenoma)
Functioning carcinomas Familial hyperaldosteronism
190
Bloods in primary hyperaldosteronism?
High aldosterone, low renin
191
Causes of secondary hyperaldosteronism (High renin)?
RAS, renal secreting tumours, renal salt wasting
192
Features of hyperaldosteronism?
Hypertension
Hypokalaemia
Metabolic alkalosis
193
Screening for hyperaldosteronism?
Aldosterone/ renin ratio
194
Further investigations for hyperaldosteronism following aldosterone/renin ratio?
HR CT abdomen, selective adrenal vein sampling
195
Management of unilateral cause of hyperaldosteronism?
Surgical removal
196
Management of bilateral hyperaldosteronism?
Spironolactone
197
Describe the action of the parathyroid glands?
Secrete PTH due to low calcium and Mg acting on the intestines, kidneys and bones
198
ALP with raised calcium causes?
Bone mets, hyperparathyroidism
199
ALP with low calcium causes?
Osteomalacia, renal failure
200
Symptoms of hypercalcaemia?
Painful bones, abdominal groans, renal stones, psychiatric moans
201
Causes of primary hyperparathyroidism?
Adenoma, hyperplasia, carcinoma
202
Bloods of primary hyperparathyroidism?
High/ normal PTH, high calcium, low phosphate, high urinary calcium
203
X-ray of primary hyperparathyroidism?
Pepper pot skull and osteitis fibrosa cystica
204
Causes of secondary hyperparathyroidism?
PTH release due to low calcium secondary to poor diet, CKD, malabsorption
205
Bloods of secondary hyperparathyroidism?
High PTH, low/normal calcium, low urinary calcium
206
What is tertiary hyperparathyroidism?
Prolonged secondary hyperparathyroidism causing hyperplasia despite resolution often from CKD
207
Bloods in tertiary hyperparathyroidism?
High PTH, high calcium, high phosphate
208
Management of primary hyperparathyroidism?
* Stop thiazides, vit D and dehydration
* IVF
* Parathyroidectomy
209
Management of secondary hyperparathyroidism in CKD?
Alfacalcidol (activated Vit D3) if fails Cinacalcet (calcium mimic)
210
Complication of hyperparathyroidism parathyroidectomy?
Hungry-bone syndrome (large influx of calcium and phosphate back into bone resulting in profound hypocalcaemia)
211
Causes of hypercalcaemia?
- Primary/ tertiary hyperparathyroidism
- Malignancy- SCLC PTHrP, bone mets, myeloma
- Sarcoidosis
- Milk-alkali syndrome
- Vit D intoxication
- Acromegaly
- Thyrotoxicosis
- Dehydration
- Adddison’s disease
- Familial hypocalciuric hypercalcaemia
212
What is milk-alkali syndrome?
Excess antacids containing calcium causing hypercalcaemia
213
Treatment of hypercalcaemia?
IVF, IV bisphosphonates, steroids in sarcoidosis
214
What is Familial hypocalciuric hypercalcaemia?
AD disorder with high PTH, high calcium, low urinary calcium associated with pancreatitis and renal stones
215
Management of hypertriglyceridemia?
Fibrates
216
MEN is inherited?
Autosomal dominant
217
MEN 1 mutation?
MEN 1 gene
218
MEN 2a and 2b mutation?
RET oncogene
219
MEN 1 contains?
3 P's
Pituitary adenoma
Parathyroid hyperplasia
Pancreatic tumours
220
MEN 1 most common presentation?
Hypercalcaemia from hyperparathyroidism
221
MEN 2 contains?
2 P's
Parathyroid hyperplasia
Medullary thyroid carcinoma
Phaeochromocytoma
222
MEN 2b contains?
1 P
Mucosal neuromas
Medullary thyroid cancer
Phaeochromocytoma
223
How is von-hipple lindae disease seen?
RCC
Phaeochromocytoma
Haemgioblastomas
224
Bloods in PCOS?
LH: FSH ratio >2
Normal FSH
Total testosterone normal/raised
SHBG low/ normal
225
Rotterdam diagnostic criteria for PCOS?
* Polycystic ovaries (>12, or ovary volume >10)
* Oligo-anovulation
* Clinical of biochemical hyperandrogenism
226
Treatment of PCOS?
weight loss, COCP, spironolactone
227
Management of fertility in PCOS?
clomiphene (induces ovulation), metformin
228
Signs of hypoparathyroidism?
Hypocalcaemia
Tetany
Trousseau sign
Chvostek sign
229
ECG in hypocalcaemia?
Prolonged QTc
230
What is pseudohypoparathyroidism?
AD condition where target cells insensitive to PTH due to abnormality in G protein
231
How is pseudo hypoparathyroidism seen?
- low IQ
- short stature
- obesity
- short 4-5th metacarpals:
- low calcium
- high phosphate
- high PTH
232
Diagnosis of pseudohypoparathyroidism?
Urinary cAMP and phosphate following PTH infusion
233
What is pseudo-pseudo hypoparathyroidism?
pseudohypoparathyroidism with normal biochemistry
234
Mild hyperkalaemia?
5.5-5.9
235
Moderate hyperkalaemia?
6-6.4
236
Severe hyperkalaemia?
6.5
237
Causes of hyperkalaemia?
Renal:
- AKI
- CKD
- Drugs
- RTA
- Addisons disease
Shift of K:
- metabolic acidosis (DKA)
- Drugs
Increased circulating K:
- exogenous potassium
- Burns, traum
- rhabdomyolysis
- Tumour lysis syndrome
- Massive blood transfusion
238
Drugs causing hyperkalaemia?
Inhibiting RAAS:
- ACEi
- ARBs
- NSAIDs
- Heparin
- Cyclosporin
Inhibiting excretion:
- Amiloride
- Spironolactone
Trimethoprim
Shift of K:
- digoxin poisoning
- suxamethonium
239
Management of HyperK?
Stop K containing fluids/ drugs inhibiting
Correct AKI
10ml calcium gluconate 10 mins
Insulin 10 units actrapid in 50ml 50% glucose slow IV
Salbutamol neb
240
Resistant hyperkalaemia?
K binders
Dialysis
241
Causes of hypokalaemia:
Alkalosis
- Vomiting
- Thiazides/ loops
- Cushing syn
- Conn's
Acidosis
- Diarrhoea
- RTA
- Acetazolamide
- partially tx DKA
Other:
Bertter's, Gitelmans, liddle's, congenital adrenal hyperplasia
242
What can cause renal K wasting and therefore make it hard to correct hypoK?
HypoMg
243
Causes of hypoK with HTN?
Cushings syndrome
conn's syndrome
Liddle syndrome
11-beta hydroxylase deficiency AKA congenital adrenal hyperplasia
244
What is Hypokalaemic periodic paralysis?
rare AD condition with paralysis at night due to mutation in muscle voltage gated calcium channels. Can be precipitated by carbohydrate meals
245
Causes of hypoCa?
Pituitary (PTH low)
- hypoparathyroidism
- Irradiation
- Di George
- Low Mg
High PTH:
- Vitamin D def
- Pseudohypoparathyroidism
Other:
- hungry bone syndrome
- Acute pancreatitis
- CKD
- Massive blood transfusion
246
Management of severe hypocalcaemia?
Calcium gluconate
247
Drugs causing hypoNa?
Diuretics
SSRIs
Carbemazepine
248
What is pseudohypoNa?
serum osmolality >275
Due to hyperlipidaemia, high protein (myeloma)
249
Causes of hypovolaemic hyponatraemia?
Extra renal (urinary sodium <20):
- Burns, sepsis, D/V
- Addison's
- Cerebral salt wasting
250
Causes of euvolaemic hyponatraemia?
SIADH (urine osmolality >100)
Hypothyroidism
Psychogenic polydipsia (urine osmolality <100)
251
Treatment of euvolaemic hyponatraemia?
WR 750ml
Tolvaptan, demeclocycline
252
Causes of hypervolaemic hyponatraemia?
Renal, heart, liver failure, nephrotic syndrome
253
Management of hypervolaemic hypoNa?
Fluid restriction
254
Emergency management of hypoNa?
200mls of 2.7% hypertonic saline immediately as an IV bolus over 30 minutes, repeat U+E (15-30 mins).
255
Ectopic hormone syndromes from SCLC?
SIADH
Cushings
256
Ectopic hormone syndromes from squamous cell lung cancer?
Hyperparathyroidism (PTHrP)
b-hCG (gynaecomastia)
257
What is Pagets disease?
Increased but uncontrolled bone turnover due to excessive osteoclastic resorption and activity
258
Presentation of pagets disease?
- Bone pain
- Frontal bossing
- Compression of local structures e.g., hearing loss, carpal tunnel
- Pathological fractures
259
Bloods in pagets disease?
isolated raised ALP
Normal phosphate and calcium
260
X rays in pagets?
osteolysis, increased bone size and sclerosis, osteoporosis circumscripta
261
Bone scintigraphy in Pagets?
increased uptake at sites of active bone lesions
262
Management of Pagets?
Analgesia
Bisphosphonates:
- PO risedronate
- IV zoledronate in reflux
- Calcitonin
263
Medications which increase the risk of osteoporosis?
SSRIs
AED
PPIs
Glitazones
Anastrozole
264
Who should have FRAX score calculated?
>75
265
FRAX result for DEXA?
>10%
266
DEXA score for osteoporosis?
-2.5 or less
267
Who is straight to DEXA without FRAX score?
>50 with hx of fragility fracture
or > 40 and significant risk factor
268
DEXA score -1 to -2.5?
Osteopenia
269
Who do you treat without DEXA for osteoporosis?
Post-menopausal women with fragility fracture
75+ fragility fracture
270
Management of osteoporosis?
Vit D + calcium
Bisphosphonate:
- Alendronic acid OW
- Hip fracture IV zolendronate
- Denosumab
271
Which bisphosphonate to use in hip fracture?
Zolendronate IV yearly
272
Contraindications to bisphophonates?
eGFR <35
SEs
Reflux
273
Mechanism of action of denosumab?
RANKL receptor inhibitor
274
What is osteomalacia?
Vit D deficiency in adults causing weaker bones due to lack of mineralisation
275
Causes of osteomalacia?
Vit D deficiency (malabsoprtion)
CKD
Low phospahte
276
Bloods in osteomalacia?
Low Vit D
Low calcium
Low phosphate
High ALP
277
Imaging in osteomalacia?
Looser zones- areas of translucency
278
Management of osteomalacia?
Vit D and calcium
279
Rickets signs?
Cupping, fraying and splaying at metaphysis
Rosary sign with beading at costochondral junction
280
What are porphyrias?
group of enzymatic deficiencies in the haem synthesis pathway causing build up of precursors
281
What 3 conditions are included in porphyrias?
Acute intermittent porphyria
Porphyria cutanea tarda (PCT)
Vareigate porphyria
282
What is acute intermittent porphyria?
AD defect in porphobilinogen deaminase
283
How is acute intermittent porphyria seen?
Triggers e.g., alcohol, medications causing dark red urine, abdominal pain and vomiting
No cutaneous features
284
Management of acute intermittent porphyria attack?
Stop trigger
Carb loading IV dextrose
IV haematin
285
Complication of acute intermittent porphyria?
HCC
286
what is porphyria cutanea tarda?
AD uroporphyrin decarboxylase deficiency or by CLD
287
Features of porphyria cutanea tarda?
Photosensitive blistering rash
Mila
rasied uroporphyrinogen III levels
Pink flourescence urine under woods lamp
288
What is variegate porphyria?
AD protoporphyrinogen oxidase deficiency
289
How is variegate porphyria seen?
Photosensitive rash
Abdo and neuro symptoms
290
Which porphyria has raised faecal poprphyrias?
Variegate
291
What are carcinoid tumours?
Slow growing neuroendocrine tumours commonly in the appendix and small intestine
292
Presentation of carcinoid tumouirs?
Flushing
Abdo pain
Diarrhoea
PS
Cushings
293
Investigations for carcinoid tumours?
Urinary 5-HIAA
Plasma chromogranin A y
CT/MRI
294
Management of carcinoid tumours?
Octreotide (somatostatin analogue)
295
Test for GH deficiency in adults?
insulin tolerance test
296
If insulin tolerance test for GH deficiency contraindicated by IHD/ seizures next step?
Arginine-GHRH stimulation test
297
In hypothyroidism with adrenal failure which hormone cant you start first?
do not start levothyroxine before glucocorticoid replacement as can cause an adrenal crisis
298
Over replacement with levothyroxine can cause?
Osteoporosis
299
<1cm thyroid mass, without rapid growth, vocal cord paralysis or neck radiation invetsigation in 20-60 year olds?
GP monitor
300
Most common electrolyte abnormality in alcohol withdrawal?
HypoPO42-
301
Management of hyperglycaemia not DKA in T1DM on insulin?
Only STAT insulin if symptomatic or high ketones.0.6
302
How do you calculate serum osmolality?
2[Na + K] + urea+ glucose
303
Gestational DM following pregnancy with normal BM after birth, monitoring?
Fasting BM 6-13 weeks postpartum
304
Medications to stop in thyrotoxic storm?
Aspirin- displaces T4 from TBG
Amiodarone
305
Management of SU (gliclazide) overdose with hypoglycaemia?
IV dextrose
If ineffective Octreotide
306
Bilateral carpal tunnel syndrome query?
Acromegaly
