Endocrinology Flashcards
What are some signs of diabetic autonomic neuropathy?
Resting tachycardia Gastroparesis Anhydrosis Impotence Constipation Urinary retention
Which enzyme is blocked by orlistat?
Lipase
Leads to undigested fat passing out as unpleasant oily compound, patients are rapidly self educated as to what appropriate food to eat
Which hormone leads to enhanced insulin release?
GLP-1
Produced in small intestine
Leads to slowing of gastric transit time, satiety and enhanced insulin release
Which hormone promotes hyperglycaemia?
Glucagon
A 43 year old man with type 2 diabetes is seen in the hepatology clinic with an alt of 189. He denies alcohol consumption. Liver biopsy demonstrates macrovesicular steatosis with centrolobular inflammatory infiltrate and mild fibrosis. What is the most likely diagnosis?
Non alcoholic fatty liver disease
Driven by metabolic syndrome in particular central adiposity and insulin resistance
An 88 year old woman has been treated with glibenclamide for 10 years. She has become increasingly confused over last few months in her nursing home and one morning is found unconscious in her soaked bed. Her pupils are dilated and react sluggishly to light. What is the likely complication?
Hypoglycaemic coma
Recurrent hypoglycaemic episodes
Occurs more frequently with long acting sulfonylureas such as glibenclamide
76 year old man treated with metformin and glibenclamide for 20 years. He complains of sudden onset diplopia. He has right sided ptosis and is unable to adduct his right eye. Pupils are equal and react normally to light. What is the likely complication?
Mononeuropathy affecting the 3rd nerve
Classically painless and pupil is spared
75 year old man treated with insulin for 40 years. Complains of gradually failing vision and difficulty reading the newspaper. Pupils are both small but react equally to light. Visual acuity is 6/18 in both eyes but falls to 6/36 when using a pinhole. Fundoscopy reveals scattered dots, blots and exudates in the peripheral retina. What is the likely complication?
Cataracts
He has background retinopathy but this would not account for his visual loss
55 year old woman treated with glibenclamide for 5 years. Complains of severe pain in both feet and legs. Muscle bulk appears normal but tone and power assessment is limited by her pain. Reports subjective loss of light touch sensation. Joint position sense and ankle jerks are impaired. What is the likely complication?
Peripheral sensory neuropathy
Where are leydig cells found? What do they do?
Between seminiferous tubules
Produce androgens in men: including testosterone
Where are Sertoli cells? What do they do?
Arranged into tubular structures with a lumen: seminiferous tubules
Have basal compartment where spermatogonia divide and a luminal compartment where spermatids mature
Testosterone diffuses into Sertoli cells where it is converted to more active form: 5-hydroxytestosterone
What cell type is found in the epididymis?
Tall columnar epithelial cells with atypical long microvilli
They phagocytose dead spermatozoa and produce substances which aid in sperm maturation
According to NICE, bariatric surgery is a treatment option for people with obesity if what criteria are fulfilled?
All appropriate non-surgical measures have been tried
Person has been receiving or will receive intensive management in a tier 3 service
Person is generally fit for anaesthesia and surgery
Person commits to the need for long-term follow-up
Patients who have recent onset T2DM and a BMI of 35
Patients without co-morbidities and a BMI of 40
What are the categories of obesity?
Healthy weight: 18.5–24.9 Overweight: 25–29.9 Obesity I: 30–34.9 Obesity II: 35–39.9 Obesity III: 40 or more
NICE recommends using different thresholds for BMI to trigger action to prevent type 2 diabetes among Asian (South Asian and Chinese), black African and African-Caribbean populations.
What are the BMI thresholds to identify (a) increased risk, and (b) high risk, in these populations?
23-27.4 kg/m2: increased risk
27.5 kg/m2 or higher: high risk of developing chronic health conditions
Orlistat is an approved drug for the treatment of obesity available on prescription. What is its mechanism of action?
Orlistat inhibits the action of lipase in the GI tract so 30% less dietary fat is absorbed, resulting in lower calorie intake
What proportion of women were classified as obese in England in 2014 (Health Survey for England)?
27%
In which two school years is the National Child Measurement Programme carried out in England?
Reception (age 4-5) and Year 6 (age 10-11)
A 43 year old patient with poorly controlled type 1 diabetes mellitus presents with sudden, painful visual loss. He is non compliant with his therapy and has known diabetic nephropathy and peripheral neuropathy. What is the likely cause of his painful visual loss?
Neovascular glaucoma - proliferative diabetic neuropathy involves growth of new blood vessels. These can grow over the lens and into the anterior chamber, blocking the trabecular meshwork and causing a type of acute angle closure glaucoma which presents as painful visual loss and a hazy cornea, associated with nausea and vomiting
In what ways does vitamin D lead to raised serum calcium levels?
Increases calcium absorption in the small intestine
Increases calcium reabsorption in the renal parenchyma
What effect does hypercalcaemia have on parathyroid hormone levels?
Hypercalcaemia inhibits PTH release
What are the effects of parathyroid hormone?
Enhances osteoclast activity by binding to osteoblasts which increases their expression of RANKL and inhibits their expression of OPG. RANKL binds to RANK stimulates osteoclast precursors to be activated
Increases calcium reabsorption in kidney but inhibits reabsorption of phosphate
Stimulates conversion of 25hydroxy vitamin D to calcitriol via 25hydroxy vitamin D3, 1 alpha hydroxylase enzyme
Enhances absorption of calcium in intestine by increasing vit D levels
Which vessel does the recurrent laryngeal nerve run close to which means it is at risk of damage in thyroid surgery?
Inferior thyroid artery
What is whipples triad?
For diagnosis of true Hypoglycaemia:
Presence of hypoglycaemia on a lab sample
Signs/symptoms consistent with hypoglycaemia
Resolution of signs/symptoms when blood glucose normalises
List 5 drugs which are associated with causing pancreatitis
Steroids Oestrogens Thiazides Sodium valproate Azathioprine Chemo with cisplatin/vinca alkaloids Radiotherapy: chronic pancreatitis
What is a differential for bilateral facial nerve palsy with bilateral parotid swelling?
Sarcoidosis
What clinical feature might be expected in a patient with a deficiency of glycogen synthase?
Fasting hypoglycaemia
What are the 2 main stimuli for glycogen formation?
Presence of insulin
Rising glucose level in the blood
What enzymes are required for glycogen formation?
Phosphoglucomutase
Glucose 1 phosphate uridyltransferase
Glycogen synthase
Branching enzyme
What enzymes are required for glycogen degradation ?
Glycogen phosphorylase
Debranching enzyme
What is the difference between cushings disease and Cushing’s syndrome?
Disease: pituitary adenoma secreting acth leading to adrenal hyperplasia
Syndrome: anything leading to chronic glucocorticoid excess
What is the typical cushingoid appearance?
Rounded face Central obesity Thin limbs Abdominal striae Supraclavicular fat deposition Thin skin Bruising
What is phaechromocytoma? What symptoms does it produce?
Catecholamine producing tumour
Causes secondary hypertension
Palpitations, sweating, headaches particularly during exercise
What symptoms would you expect with acromegaly?
Headache
Large hands
Prominent facial features
Bitemporal hemianopia
What is Wemer syndrome?
Multiple endocrine neoplasia type 1
Tumours affecting 3 Ps: pituitary, parathyroids and pancreas
Pituitary symptoms: headache, acromegaly and gynaecomastia
Zollinger Ellison syndrome due to gastrin: duodenal ulcers
What is sipple syndrome?
Multiple endocrine neoplasia type II
Parathyroid, medullary thyroid and phaechromocytoma
What is lynch syndrome?
Hereditary non polyposis colorectal carcinoma
What are pigmented palmar creases a sign of?
Addison’s disease
What electrolyte abnormality would you expect in a patient with Addison’s disease?
Hyponatraemia and hyperkalaemia
What may be symptoms of Addison’s disease?
Fatigue Postural hypotension Anorexia Nausea and vomiting Weight loss
A 22 year old man presents with a short history of thirst, weight loss and polyuria. A random capillary glucose is 32mmol/L. During the examination it is difficult to get an o2 sats reading. What aspect of his management is vital to his immediate survival?
IV fluids
DKA can require an enormous amount of rehydration
Patient is shocked which is why it’s difficult to get a sats reading
Insulin administration is the next most crucial intervention
What is background retinopathy?
Micro aneurysms
Small dot and blot haemorrhages
Hard exudates
What is pre proliferative retinopathy?
Ischaemia on top of background retinopathy
Cotton wool spots
What is maculopathy?
Breakdown of blood retina barrier causing central loss of vision
What are symptoms of PCOS?
Increasing weight
Irregular periods
Hirstutism
What is a first line treatment for PCOS?
Metformin
What are symptoms of primary hyperparathryoidism?
Bones: pain/fracture
Stones: renal, polydipsia, polyuria
Groans: peptic ulceration, constipation, pancreatitis
Moans: depression
What is congenital adrenal hyperplasia?
Lack of enzyme 21 alpha hydroxylase which leads to an increase in 17 hydroxyprogesterone which is subsequently metabolised to testosterone, leading to hirstutism
What test would you use to look for Cushing’s?
Random cortisol
What test would you use to look for Addison’s disease?
Synacthen
What is the tensilon test used to diagnose?
Myasthenia gravis
What type of respiration is seen in DKA?
Kussmaul respiration
Laboured, deep and gasping
What clinical signs would you expect to find in a patient with DKA?
Vomiting Drowsiness Kussmaul respiration Raised blood glucose Ketonuria Metabolic acidosis
State 4 investigations you would do for a patient with a suspected DKA
FBC U&Es LFTs Calcium and phosphate ABGs Urine cultures Blood cultures Chest X-ray
What are the 2 most important components of your treatment regimen for DKA?
0.9% normal saline IV
Soluble insulin IV
What 2 important laboratory measurements apart from blood glucose that you will monitor over the next 6 hours in a patient diagnosed with DKA?
Serum potassium
Bicarbonate
What 3 points of advice would you give to a diabetic patient to minimise the risk of long time complications?
Keep to a healthy diet
Regular compliance with insulin
Regular self blood glucose monitoring
What can be some precipitating causes of DKA?
Increased levels of stress hormones due to: MI Infection Surgical emergency Errors of insulin administration Deliberate omission of insulin
A 68 year old female presents with painful weakness of the upper legs, nocturia and difficulty ascending stairs which has deteriorated over the last 2 months. On examination she has loss of muscle bulk in quads and weakness of flexion bilaterally, right more than left. The knee reflex is lost. What is the likely diagnosis?
Diabetic amyotrophy
Which diabetes drugs work to reduce glucose absorption from the gut?
Acarbos
Which diabetes drugs act to increase glucose uptake by fat and muscle?
Metformin
Pioglitazone
Insulin
Which diabetes drugs act to improve impaired insulin secretion?
Insulin Sulphonylureas Meglitinides GLP-1 receptor agonists DDP-4 inhibitors
Which diabetes drugs are used to reduce glucose production?
Metformin
GLP-1 receptor agonists
DDP-4 inhibitors
Insulin
What is the prevalence of T2DM in the uk?
6%
What is the most common risk factor for diabetes?
Obesity
What impact can T2DM have on a person’s life?
Reduced life expectancy (up to 10 years)
Mortality rates from CHD up to five times higher
Leading cause of renal failure
Leading cause of blindness in people of working age
Additional risks in pregnancy
How do you diagnose diabetes?
Fasting plasma glucose 7 or more, 2 readings
Random plasma glucose 11.1 or more with symptoms
Oral glucose tolerance test 11.1 or more
How do you diagnose impaired glucose tolerance?
Oral glucose tolerance test readings between 7.8 and 11.1
How do you diagnose impaired fasting glycaemia?
Fasting plasma glucose between 6.1 and 7
What does glucose bind to in HbA1c?
N terminal valine of Hb
What value of HbA1c is diagnostic for diabetes?
48 or more
What value of HbA1c is diagnostic for impaired glucose tolerance?
42-47