Medical Specialties

Question 1

Cushing’s Syndrome

Answer 1

Raised Cortisol

Question 2

Thyroid Cancer types + prognosis
PAPILLARY

Answer 2

Papillary
65%, generally young females.

Metastasis to cervical lymph nodes.

Thyroglobulin (Tg blood test) can be used as a tumour marker.

Characteristic Orphan Annie eyes on light microscopy.
‘papillary projections and pale empty nuclei’ (aka orphan annie eyes) histologically

Management of papillary and follicular cancer

• total thyroidectomy
• followed by radioiodine (I-131) to kill residual cells
• yearly thyroglobulin levels to detect early recurrent disease

Question 3

Thyroid Cancer types + prognosis
FOLLICULAR

Answer 3

Follicular
20% - gen. women >50
Mets to lung and bone
Tg can be used as tumour marker
Moderate prognosis
Usually presents as solitary thyroid nodule in adenoma
If capsular invasion seen microscopically tumour = follicular carcinoma
Management same as papillary

Question 4

Thyroid Cancer types + prognosis
MEDULLARY

Answer 4

5%, either sporadic or part of MEN2 Syndrome
MEN2A = Parathyroid hyperplasia, medullary thyroid carcinoma, phaeochromocytoma,
MEN2B = Mucosal neuroma, marfanoid appearance, medullary thyroid carcinoma, phaeochromocytoma
CALCITONIN = tumour marker (as Ca. origanates from parafollicular C cells not thyroid tissue)

Question 5

Thyroid Cancer types + prognosis
ANAPLASTIC

Answer 5

Very rare, in elderly patients, poor prognosis

Question 6

Thyroid Cancer types + prognosis
LYMPHOMA

Answer 6

5%, may present with dysphagia and stridor
Associated with Hashimoto’s thyroiditis

Question 7

Diagnostic criteria for DKA

Answer 7

The diagnostic criteria for diagnosing DKA are:

1. pH <7.3 and/or bicarbonate <15mmol/L.
2. Blood glucose >11mmol/L or known diabetes mellitus.
3. Ketonaemia >3mmol/L or significant ketonuria ++ on urine dipstick.

Features

• abdominal pain
• polyuria, polydipsia, dehydration
• Kussmaul respiration (deep hyperventilation)
• Acetone-smelling breath (‘pear drops’ smell)

Question 8

Management of DKA

Answer 8

Main principles of management
1. fluid replacement
most patients with DKA are deplete around 5-8 litres
isotonic saline is used initially, even if the patient is severely acidotic

2. 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
3. correction of electrolyte disturbance
   serum potassium is often high on admission despite total body potassium being low
   this often falls quickly following treatment with insulin resulting in hypokalaemia
   potassium may therefore need to be added to the replacement fluids
   if the rate of potassium infusion is greater than 20 mmol/hour then cardiac monitoring may be required
   long-acting insulin should be continued, short-acting insulin should be stopped

Question 9

DKA resolution

Answer 9

DKA resolution is defined as:
pH >7.3 and
blood ketones < 0.6 mmol/L and
bicarbonate > 15.0mmol/L

Further points
both the ketonaemia and acidosis should have been resolved within 24 hours. If this hasn’t happened the patient requires senior review from an endocrinologist
if the above criteria are met and the patient is eating and drinking switch to subcutaneous insulin
the patient should be reviewed by the diabetes specialist nurse prior to discharge

Question 10

Methotrexate

1. Indications
2. Side effects
3. Pregnancy

Answer 10

1. Indications

• inflammatory arthritis, especially rheumatoid arthritis
• psoriasis
• some chemotherapy acute lymphoblastic leukaemia

2. Adverse effects

• • mucositis
• • myelosuppression (give folic acid to prevent this)
• • pneumonitis
• • pulmonary fibrosis
• • liver fibrosis

3. Pregnancy

• • women should avoid pregnancy for at least 6 months after treatment has stopped
• • the BNF also advises that men using methotrexate need to use effective contraception for at least 6 months after treatment

Question 11

Glaucoma

Answer 11

Acute angle-closure

• associated with hypermetropia (long-sightedness)