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
