endocrinology

Question 1

addisons disease mx in illness

Answer 1

double hydrocortisone dose and keep fludrocortisone the same

Question 2

dequervains thyroidirtis iodine uptake scane

Answer 2

globally reduced

painful goitre

Question 3

Men1 3 ps
men2a 2 ps
men 2b 1 p

Answer 3

parathyroid pituitary pancreas men 1 gene
parathyroid phaeo ret oncogene
phaeo

Question 4

mx of DKA

Answer 4

fluid replacement: most patients with DKA are deplete around 5-8 litres. Isotonic saline is used initially. Please see an example fluid regime below.
insulin: an intravenous infusion should be started at 0.1 unit/kg/hour. Once blood glucose is < 15 mmol/l an infusion of 5% dextrose should be started
correction of hypokalaemia
long-acting insulin should be continued, short-acting insulin should be stopped

Question 5

whipples triad of insulinom

Answer 5

Symptoms and signs of hypoglycemia
Plasma glucose < 2.5 mmol/L
Reversibility of symptoms on the administration of glucose

Question 6

pioglitazone c/i

Answer 6

Pioglitazone can cause fluid retention and is therefore contraindicated in patients with heart failure.
and c/i in history of bladder cancer

Question 7

drug causes of gynaecomastia

Answer 7

C: cirrhosis.
O: obesity.
D: digoxin.
E: estrogen.
S: spironolactone.

Question 8

sick euthyroid syndrome

Answer 8

In sick euthyroid syndrome (now referred to as non-thyroidal illness) it is often said that everything (TSH, thyroxine and T3) is low. In the majority of cases however the TSH level is within the >normal range (inappropriately normal given the low thyroxine and T3).

Question 9

waterhouse friderichsen syndrome

Answer 9

adrenal gland failure due to bleeding into the adrenal glands, commonly caused by severe bacterial infection. Typically, it is caused by Neisseria meningitidis

Question 10

t1dm bm targets

Answer 10

Blood glucose targets
5-7 mmol/l on waking and
4-7 mmol/l before meals at other times of the day

Question 11

when to give bisphosphonate in high calcium low bone density

Answer 11

ca above 3 iv bisphos

Question 12

cause

Answer 12

neuropathy of nervous system

Question 13

when to add drug 2 in t2dm mx

Answer 13

HbA1c more than 58 on metformin

Question 14

thyroid storm

Answer 14

Precipitating events:
thyroid or non-thyroidal surgery
trauma
infection
acute iodine load e.g. CT contrast media

Clinical features include:
fever > 38.5ºC
tachycardia
confusion and agitation
nausea and vomiting
hypertension
heart failure
abnormal liver function test - jaundice may be seen clinically

Management:
symptomatic treatment e.g. paracetamol
treatment of underlying precipitating event
beta-blockers: typically IV propranolol
anti-thyroid drugs: e.g. methimazole or propylthiouracil
Lugol’s iodine
dexamethasone - e.g. 4mg IV qds - blocks the conversion of T4 to T3

Question 15

mody fx

Answer 15

MODY 3
60% of cases
due to a defect in the HNF-1 alpha gene
is associated with an increased risk of HCC

Features of MODY
typically develops in patients < 25 years
a family history of early onset diabetes is often present
ketosis is not a feature at presentation
patients with the most common form are very sensitive to sulfonylureas, insulin is not usually necessary

Question 16

kallmans syndrome

Answer 16

secondary hypogonadism

characteristically suffer from anosmia and would not exhibit gynaecomastia.

Question 17

criteria for glp-1 mimetic

Answer 17

BMI >= 35 kg/m² in people of European descent and there are problems associated with high weight, or
BMI < 35 kg/m² and insulin is unacceptable because of occupational implications or weight loss would benefit other comorbidities.

Question 18

impaired fasting glucose and impaired glucose tolerance definitions

Answer 18

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

Impaired glucose tolerance (IGT) is defined as fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l

Question 19

drug causes of raised prolactin

Answer 19

Drug causes of raised prolactin
metoclopramide, domperidone
phenothiazines
haloperidol
very rare: SSRIs, opioids

Question 20

pseudo cushings

Answer 20

mimics Cushing’s
often due to alcohol excess or severe depression
causes false positive dexamethasone suppression test or 24 hr urinary free cortisol
insulin stress test may be used to differentiate

Question 21

hhs vs DKA on bloods

Answer 21

HHS is characterised by: a higher blood glucose (>30 mmol/L), much milder hyperketonaemia (ketones <3 mmol/l) and a higher pH (>7.3).

Question 22

hba1c overestimates glucose levels in

Answer 22

splenectomy

Question 23

Thiazolidinediones are associated with

pioglitazone

Answer 23

an increased risk of bladder cancer
weight gain
liver impairment: monitor LFTs
fluid retention - therefore contraindicated in heart failure. The risk of fluid retention is increased if the patient also takes insulin
recent studies have indicated an increased risk of fractures

Question 24

Nelson’s syndrome

Answer 24

rapid enlargement of a pituitary corticotroph adenoma (ACTH producing adenoma) that occurs after the removal of both adrenal glands (bilateral adrenalectomy) which is an operation used for Cushing’s syndrome

Question 25

pregabalin c/i

Answer 25

BPH- urinary retention risk

Question 26

sulfonylurea adverse effects

gliclazide

Answer 26

Common adverse effects
hypoglycaemic episodes (more common with long-acting preparations such as chlorpropamide)
weight gain

Rarer adverse effects
hyponatraemia secondary to syndrome of inappropriate ADH secretion
bone marrow suppression
hepatotoxicity (typically cholestatic)
peripheral neuropathy

Question 27

max dose metformin

Answer 27

1g bd

Question 28

types of thyroid cancer

Answer 28

1) Papillary - 65%, generally young females. Metastasis to cervical lymph nodes. Thyroglobulin can be used as a tumour marker. Characteristic Orphan Annie eyes on light microscopy. Good prognosis
2) Follicular - 20%, generally women >50 years old. Metastasis to lung and bones. Thyroglobulin can be used as a tumour marker. Moderate prognosis
3) Medullary - 5%, sporadic or part of MEN2 syndrome. It originates from the parafollicular cells which produce calcitonin - can be used as a tumour marker.
4) Anaplastic - very rare. Elderly patient. Very poor prognosis

Question 29

complications of acromegaly

Answer 29

hypertension
diabetes (>10%)
cardiomyopathy
colorectal cancer

Features
coarse facial appearance, spade-like hands, increase in shoe size
large tongue, prognathism, interdental spaces
excessive sweating and oily skin: caused by sweat gland hypertrophy
features of pituitary tumour: hypopituitarism, headaches, bitemporal hemianopia
raised prolactin in 1/3 of cases → galactorrhoea
6% of patients have MEN-1

Question 30

thiazides can cause

Answer 30

hyper calcaemia

Question 31

klinefelters

Answer 31

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

Question 32

acromegaly ix

Answer 32

Serum IGF-1 levels have now overtaken the oral glucose tolerance test (OGTT) with serial GH measurements as the first-line test. The OGTT test is recommended to confirm the diagnosis if IGF-1 levels are raised.

Question 33

bp targets in diabetes

Answer 33

Type 2 diabetes blood pressure target
no organ damage: < 140 / 80
end-organ damage: < 130 / 80

Question 34

Endocrine parameters reduced in stress response:

Answer 34

insulin
testosterone
oestrogen

Question 35

corticosteroids in glycaemic control

Answer 35

Corticosteroids oppose the action of insulin and stimulate hepatic gluconeogenesis. Even a short course of corticosteroids can adversely affect glycaemic control.

Question 36

carbimazole s/e

Answer 36

agranulocytosis

crosses the placenta, but may be used in low doses during pregnancy

Question 37

The severity of Grave’s eye disease can be graded using the mnemonic NOSPECS

Answer 37

No signs / symptoms
Only signs (e.g: upper lid retraction)
Signs & symptoms (including soft-tissue involvement)
Proptosis
Extra-ocular muscle involvement
Corneal involvement
Sight loss due to optic nerve involvement

Question 38

glucose monitoring in t1dm

Answer 38

recommend testing at least 4 times a day, including before each meal and before bed
more frequent monitoring is recommended if frequency of hypoglycaemic episodes increases; during periods of illness; before, during and after sport; when planning pregnancy, during pregnancy and while breastfeeding

Question 39

neuroblastoma fx and ix

Answer 39

Features
abdominal mass
pallor, weight loss
bone pain, limp
hepatomegaly
paraplegia
proptosis

Investigation
raised urinary vanillylmandelic acid (VMA) and homovanillic acid (HVA) levels
calcification may be seen on abdominal x-ray
biopsy

Question 40

types of insulin

Answer 40

offer multiple daily injection basal–bolus insulin regimens, rather than twice‑daily mixed insulin regimens, as the insulin injection regimen of choice for all adults
twice‑daily insulin detemir is the regime of choice. Once-daily insulin glargine or insulin detemir is an alternative
offer rapid‑acting insulin analogues injected before meals, rather than rapid‑acting soluble human or animal insulins, for mealtime insulin replacement for adults with type 1 diabetes

Question 41

Iron reduces the absorption

Answer 41

of thyroxine

Question 42

role of mg

Answer 42

Magnesium is required for both PTH secretion and its action on target tissues. Hypomagnesaemia may both cause hypocalcaemia and render patients unresponsive to treatment with calcium and vitamin D supplementation.

Question 43

sick day diabetes rules

Answer 43

Increase frequency of blood glucose monitoring to four hourly or more frequently
Encourage fluid intake aiming for at least 3 litres in 24hrs
If unable to take struggling to eat may need sugary drinks to maintain carbohydrate intake
It is useful to educate patients so that they have a box of ‘sick day supplies’ that they can access if they become unwell
Access to a mobile phone has been shown to reduce progression of ketosis to diabetic ketoacidosis