Endocrinology and metabolic incorrects Flashcards
28 YO man has polyuria and polydipsia, has bipolar disorder for which he has taken lithium for 2 years
bloods normal osmolality, normal lithium levels
what is the most useful diagnostic investigation?
serum corrected calcium!!!
you must exclude hypercalcemia due to hyperparathyroidism before progressing to water deprivation test
A 52 year old woman has a brief episode of dizziness on standing. She has had 4 days of dysuria, loin pain and fever. She has been feeling tired for 4 months and has lost 3 kg in weight.
Her temperature is 37.4°C, pulse rate 90 bpm, BP 100/55 mmHg lying and 90/50 mmHg sitting, respiratory rate 18 breaths per minute and oxygen saturation 95% breathing air. Her JVP is not visible.
Investigations:
Haemoglobin 106 g/L (115–150)
White cell count 14 × 109/L (3.8–10.0) Platelets 201 × 109/L (150–400)
Sodium 130 mmol/L (135–146) Potassium 5.6 mmol/L (3.5–5.3) Urea 9.5 mmol/L (2.5–7.8) Creatinine 98 μmol/L (60–120)
Random plasma glucose 3.2 mmol/L
12-lead ECG: sinus rhythm
Which is the most appropriate additional investigation?
A. CT of head
B. CT pulmonary angiography
C. Echocardiography
D. Plasma cortisol and adrenocorticotropic hormone
E. Urinary and serum osmolality
UKMLA ppq
D
Justification for correct answer(s): Classic presentation of adrenal crisis. Nearly all patients have a history of lethargy and weight loss. Plasma cortisol and ACTH should be sent immediately so that definitive treatment can be initiated. You would not wait for results before starting IV steroids. - Justification for Unselected: Presentation does not fit with either a PE or cerebral disease. Hypotension more likely to be due to adrenal insufficiency than cardiac disease. Urine and plasma osmolality is not required as there is more likely
abdominal pain may also be present, dizziness
patient with hypocalcemia and proximal muscle weakeness
features suggest osteomalacia
what investigation is most likely to confirm the diagnosis?
serum 25-OH cholecalciferol
diabetic patient with hypoglycemia. anxious and noticeably tremulous as she drinks from her waterbottle
next step in management??
oral glucose TABLETS!!!
Not oral glucose gel as patient is conscious enough to swallow
note must be tablets or gel or glucose liquid not sandwich
if severely drowsy with IV access = IIV. glucose
if a triple combination of drugs has failed to reduce HbA1c then what is r recommended?, particularly if the BMI > 35
would you stop a flozin or a gliptin?
stoping AND switching one of the drugs for a GLP-1 mimetic
eg liraglutide!!! or exanatide!!!! - they cause weight loss
prioritise stoping a gliptin over a flozin due to the cardioprotective effects of flozins
also note that:
metformin is first line for diabetes
SGLT-2 inhibitors (flozins)
should also be given in addition to metformin if any of the following apply:
the patient has a high risk of developing cardiovascular disease (CVD, e.g. QRISK ≥ 10%)
the patient has established CVD
the patient has chronic heart failure
metformin should be established and titrated up before introducing the SGLT-2 inhibitor
Poorly controlled hypertension, already taking an ACE inhibitor and a calcium channel blocker. next step in management?
already taking an ACE inhibitor, calcium channel blocker and a standard-dose thiazide diuretic eg bendroflumethiazide. next step?
add a thiazide diuretic
specifically indapamide!!!
not bendroflumethiazide
add on an alpha-blocker or beta blocker eg carvedilol!!
gestational diabetes mellitus
Her fasting glucose was 7.1mmol/L with 2-hour glucose of 8.9mmol/L.
What is the most appropriate management option in this scenario?
insulin!!!!
as fasting glucose is >/= 7
angiodema - swelling of face and lips is associated with ramipril
poorly controlled HTN already on candesartan (ace inhibitor) and indapamide (thiazide diuretic)
what do you add on?
amlodipine!!! (CCB)
note after an ace inhibitor then you can add on a thiazide duiretic or CCB but if the person has gout you opt for CCB
low calcium and phosphate combined with the raised alkaline phosphatase
Bone pain, tenderness and proximal myopathy/muscle weakness
most likely diagnosis?
osteomalacia
in which population is ccbs 1st line for htn
> 55 AND no diabetes
or black
subclinical hypothyroidism management
very mildly raised TSH but normal T3 and T4)
what if patient over 80?
6 months trial of thyroxine - do this if symptomatic or subclinical hypothyroidism on 2 tests 3 months apart
a ‘watch and wait’ approach in patients over the age of 80 years old.!!
the PTH in primary hyperparathyroidism may be normal or high!!
sexual dysfunction is a side effect of which medication?
thiazide like diuretics - eg indapamide
features of addisonian crisis?
Hyponatraemia
Hyperkalaemia
Hypoglycaemia!!!!
all patients with Peripheral artery disease should be on a statin and what medication!!?
clopidogrel!!
preferred to aspirin, especially if patient has a salicylate allergy
diabetes definition?
fasting glucose at 0 hours > 7
ogtt 2 hour value > 11
most common cause of primary hyperparathyroidism?
solitary parathyroid adenoma
NOT
paraythyroid hyperplasia
This patient has a diagnosis of stage 2 hypertension as characterised by his clinic and ABPM blood pressure readings. Further, he has a Q-Risk score of >10%. As such, he should be offered medical management of his hypertension and a statin alongside lifestyle advice. Given his age (57) and lack of medical history, first-line antihypertensive would be a calcium channel blocker.
A 63-year-old woman presents to the GP for a review after recently being treated for myocardial infarction via percutaneous coronary intervention. It was found that her fasting glucose is elevated at 8.4 mmol/L. She feels well and has no polyuria or polydipsia.
Her other medical history includes hypertension, she smokes 15 cigarettes a day and drinks 12 units of alcohol a week.
What is the most appropriate next step for the GP to take?
remeasure fasting glucose within 2 weeks!!
as patient is asymptomatic, you need 2 raised measurements to diagnose!!
contrast to hypertension which you would further investigate with ABPM
A diagnosis of diabetic ketoacidosis is made. Initial intravenous fluid hydration is started, followed by starting a fixed-rate insulin infusion with a 0.9% sodium chloride substrate.
At 6 hours, a repeat venous blood gas is performed. Key values include:
pH 7.20 (7.35-7.45)
Glucose 13.6 mmol/L
Ketones 1.1 mmol/L (<0.6)
What is the next management step?
Diabetic ketoacidosis: once blood glucose is < 14 mmol/l an infusion of 10% dextrose should be started
if the ketonaemia and acidosis have not been resolved within 24 hours then the patient should be reviewed by a senior endocrinologist
Switch to subcutaneous insulin once the patient is eating and drinking ONLY once DKA has been resolved
A patient with type 2 diabetes mellitus is started on sitagliptin. What is the mechanism of action of sitagliptin?
good side effect of them?
Gliptins (DPP-4 inhibitors) reduce the peripheral breakdown of incretins such as GLP-1
do not cause weight gain
pancreatitis is a rare side effect of which diabetic medicaiton?
DDP4 inhibitors eg sitagliptin
DKA resolution is defined as:
pH >7.3 and (normal is >7.35)
blood ketones < 0.6 mmol/L and
bicarbonate > 15.0mmol/L (normal is >22)
once a patient reaches this point, what is further management?
Switch the patient to subcutaneous insulin so long as she is eating and drinking normally
management for diabetic patients with foot problems eg loss of sensation
refer to local diabetic foot team!!
not the vascular team
what is the hba1c target on diabetic medication?
Lifestyle + metformin 48 mmol/mol (6.5%)
Includes any drug which may cause hypoglycaemia (e.g. lifestyle + sulfonylurea) 53 mmol/mol (7.0%)
Patients with type I diabetes and a BMI > 25 should be considered for X? in addition to insulin
metformin
which CCBs are more likely to cause ankle swelling?
Dihydropyridines (e.g. amlodipine, felodipine, nifedipine) are more likely to cause ankle swelling than verapamil
Nice They advise that all women aged >= 65 years and all men aged >= 75 years should be assessed for fragility risk/frax score
when should Younger patients should be assessed?
previous fragility fracture
current use or frequent recent use of oral or systemic glucocorticoid
history of falls
family history of hip fracture!!
other causes of secondary osteoporosis, for example:
hypogonadism in either sex including low testosterone in men and premature menopause in women
endocrine conditions, including diabetes mellitus, Cushing’s disease, hyperthyroidism
conditions associated with malabsorption, including inflammatory bowel disease, coeliac disease, and chronic pancreatitis.
rheumatoid arthritis and other inflammatory arthropathies.
low body mass index (BMI) (less than 18.5 kg/m²)
smoking!!
alcohol intake of more than 14 units per week for women and more than 14 units per week for men!!
A 55-year-old woman presents for review. Her mother has just been discharged after suffering a hip fracture. She is concerned that she may have ‘inherited’ osteoporosis and is asking what she should do. She has no significant past medical history of note, takes no regular medication and has never sustained any fractures. She smokes around 20 cigarettes per day and drinks about 3-4 units of alcohol per day.
What is the most appropriate course of action?
use the frax tool
A 38-year-old man presents to the Emergency Department with sudden onset of uncontrollable epistaxis and chest pain. He is severely anxious and has already vomited on the way to hospital. The medical history reveals that he is a long-term user of recreational drugs especially amphetamine. His blood pressure reading is 205/110 mmHg and fundoscopy reveals retinal bleeding with papilloedema.
Which of the following is the most likely cause of this man’s symptoms?
malignant hypertension !!!
blood pressure is extremely high and there are potentially life-threatening symptoms indicative of acute impairment of one or more organ systems eg the kidneys, heart or eyes.
Signs and symptoms include:
Papilloedema (must be present before a diagnosis of malignant hypertension can be made)
Retinal bleeding
Increased cranial pressure causing headache and nausea
Chest pain due to increased workload on the heart
Haematuria due to kidney failure
Nosebleeds which are difficult to stop
Diagnosis:
Systolic blood pressure >= 180mmHg or diastolic blood pressure >= 120mmHg.
Evidence of acute organ damage
56-year-old man has a diagnosis of type 2 diabetes. Despite taking metformin 1g twice daily and gliclazide 160mg twice daily, his glycaemic control remains suboptimal. His latest HbA1c is 75 mmol/mol (9.0%).
He had previously tried sitagliptin but discontinued this drug due to persistent nausea.
He is overweight with a body mass index of 29 kg/m². He has no other medical conditions. He is fully compliant with his medications and attended a diabetes education programme last year. He is extremely reluctant to have any injectable treatment and does not wish to engage in any further conversation about this.
What is the most appropriate step with regards to his diabetes treatment?
commence on sglt2 as side effect = weight loss
answer is not glp1 eg liraglutide as this involves subcut injections
You are reviewing the blood test results for a 42-year-old woman with type II diabetes mellitus who commenced on gliclazide three months ago. She was initially trialled on metformin including modified release, however, she had intolerable GI side effects including nausea, abdominal discomfort, and diarrhoea. Results showed an HbA1c of 52 mmol/mol.
What should be the next step in your management?
Repeat HbA1c in 3-6 months
36%
the Hba1c target for patients on a drug which may cause hypoglycaemia (eg sulfonylurea) is 53 mmol/mol
low dose dex does not suppress but high dose dex suppresses
diagnosis?
cushings disease
Ectopic ACTH producing small cell lung cancer is incorrect as the high-dose dexamethasone test would not suppress cortisol or ACTH, as ACTH is produced outside the HPA axis. Furthermore, the patient does not have any respiratory symptoms.
new symptoms of muscle pain, weakness and tiredness. He feels nauseated and has vomited once this morning. He has a past medical history of osteoarthritis, gout, type 2 diabetes, hypercholesterolaemia, atrial fibrillation and an appendicectomy as a child. He is currently taking regular paracetamol, allopurinol, metformin, simvastatin, bisoprolol and warfarin.
normal creatine kinase
ph shows acidosis
what medication is causing this?
metformin - lactic acidosis
diabetic sick day rules?
continue same dose insulin but check blood sugars more frequently
check ketones frequently
aim to drink at least 3L of fluid
In the primary prevention of CVD using statins aim for a reduction in non-HDL cholesterol of?
> 40%
name an antihypertensive that can cause flattening of T waves on ECG
indapamide - thiazide diuretic
For patients of black African or African-Caribbean origin taking a calcium channel blocker for hypertension, if they require a second agent consider?
an angiotensin receptor blocker in preference to an ACE inhibitor
first line insulin regime for type 1 diabetes?
Twice-daily basal insulin detemir, insulin aspart bolus with meals
46%
for DKA Start fixed-rate insulin, continue regular long-acting insulin, and stop regular short-acting insulin
65%
A 72-year-old gentleman is admitted to the emergency department with abdominal pain, nausea, fatigue, and confusion. He has a past medical history of stage IV lung cancer, diagnosed two months ago. Blood samples are taken and sent to the lab.
Given the most likely electrolyte abnormality, what would you most likely observe on this patient’s ECG?
Shortening of the QT interval
58%
symptoms of hypercalcemia secondary to malignancy
Hypothermia causes J waves on ECG
A 19-year-old man presents to the Emergency Department (ED) in the early hours of the morning looking very confused. The on-call doctor tries to take a history from the man however he has trouble speaking. He is unable to walk in a straight line and keeps bumping into other people in the ED. His girlfriend who has accompanied him informs the doctor that he recently contracted malaria for which he was taking quinine sulfate. Which of the following is the most appropriate first-line investigation for this man?
blood glucose measurement!!
hypoglycemia often mistaken for being drunk
A 51-year-old woman who is known to have poorly controlled type 1 diabetes mellitus is reviewed. Her main presenting complaint is bloating and vomiting after eating. She also notes that her blood glucose readings have become more erratic recently. Which one of the following medications is most likely to be beneficial?
metoclopramide!!
or domperidone or erythromycin!!
patient has gastroparesis secondary to diabetes
which diabetic medication is associated with increased risk of ulcers and lower limb amputation?
canagliflozin!!
sgtl2
first line treatment for peripheral neuropathy? in diabetes
first-line treatment: amitriptyline!! duloxetine!!!, gabapentin or pregabalin
hydrocortisone dose in addisons disease?
Hydrocortisone 20mg at 8am and 10mg at 5pm
what antihypertensive drug is first line for black patients who also have T2DM?
angiotensin 2 receptor blocker
During Ramadan, one-third of the normal metformin dose should be taken before sunrise and two-thirds should be taken after sunset
side effect of pioglitazone?
worsening of heart failure
Gestational diabetes can be diagnosed by either a:
fasting glucose is >= 5.6 mmol/L, or
2-hour glucose level of >= 7.8 mmol/L
‘5678’
A 45-year-old patient presents to general practice for his annual diabetes review. He had previously had ureas and electrolytes done and his HbA1c measured (results in the table below). The patient has a body mass index of 36 kg/m². He was started on metformin as his condition was not well-controlled using conservative measures.
HbA1c 55 mmol/mol (<48)
eGFR 25 ml/min
What is the most appropriate course of action?
Stop metformin and start linagliptin!!!
For type 2 diabetics requiring treatment, metformin is contraindicated in those with eGFR < 30!!
Which of the following features would point towards a diagnosis of Grave’s disease over another cause of hyperthyroidism?
achropachy (clubbing)
over replacement with levothyroxine. increases risk of?
osteoporosis
stemi, what amount of statin should be rpescribed on discharge?
how does this differ from preventative dose?
artovastatin 80mg
prevention = 20mg
target blood pressures in HTN?
clinic reading: < 140 / 90
ABPM / HBPM: < 135 / 85
pregnancy is a contraindication to statin therapy!!
Asymptomatic patients with an abnormal HbA1c or fasting glucose must be confirmed with a second abnormal reading before a diagnosis of type 2 diabetes is confirmed
most common cause of primary hyperaldosteronism?
Bilateral idiopathic adrenal hyperplasia - treat with aldosterone antoagnosit eg spiriniolactone
an adrenal adenoma is less common and is treated with surgery
side effect of sulfurnylureas eg gliclazide?
hypoglycemia
CKD is a risk factor for osteoporosis
insulin value given in DKA?
0.1 unit/kg/hour
A person with Addisons’ who vomits should take IM hydrocortisone until vomiting stops
recommended number of times to monitor blood glucose in T1DM
Before each meal and before bed
carpal spasm sign is known as?
trousseaus sign
T2DM initial therapy: if metformin is contraindicated eg EGFR + patient has a risk of CVD, established CVD or chronic heart failure → SGLT-2 monotherapy
what antihypertensive causes gingival hyperplasia?
amlodipine
which antihypertensive drug can exacerbate HF?
Verapamil
most common complication of thyroid eye disease?
exposure keratopathy
hyperaldosteronism
A plasma aldosterone/renin ratio is subsequently performed which suggests a peripheral cause of the patient’s presentation.
What is investigation could be used to further differentiate the likely underlying diagnosis?
Adrenal venous sampling (AVS) can be used to distinguish between unilateral adenoma and bilateral hyperplasia in primary hyperaldosteronism
He was started on metformin and the dose was titrated up. At what threshold should you consider adding a second agent?
HBA1c of 58
DKA management?
Shock = 500ml fluid Bolus stat as patients dehydrated
Actrapid!! 0.1units/kg/hour IV!
40 mmol potassium
0.9% saline 1L over 2 hours
Continue long acting insulin
Blood gas check initially then after one hour
Important on blood Gas = PH, bicarbonate and potassium
Hypercoagulable state - LMWH
Resolves when ketones <0.6, sugars <11, ph>7.3
Check guidelines in paces notes
PMH of hypertension and high cholesterol. T2DM. On metformin HBA1C 49. What do you add on?
Add dapagliflozin! And SGLT2 inhibitor to protect from CVd
Alcohol excess can mimic cushings disease
dose of Artovastatin after an MI?
80 MG
Contrast 20mg in primary prevention
If metformin is not tolerated due to side effects, what do you try nexts?
Modified release metformin
Second drug should be added if HBA1C is >58
First line diagnostic investigation in cushings?
Low dose dex
Cushing’s syndrome = hypokalemic metabolic alkalosis
