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Medicine - Endocrinology Flashcards

1
Q

What are the criteria for diagnosis of type 2 diabetes?

A 
Either symptoms + 1 pos test result or no symptoms + 2 pos test results
Pos test thresholds: 
- Fasting glucose >7.0
- OGTT >11.1
- Random glucose >11.1 
- HbA1c > 6.5%/ 48mmol/L
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2
Q

What are the test ranges for impaired gluose tolerance and impaired fasting glucose?

A

IGT: OGTT/random = 7.8-11.1; HbA1c = 42-47

IFG = 6.1-7.0

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3
Q

What is the classic triad of symptoms of type 2 diabetes?

A

Polydipsia
Polyuria
Fatigue

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4
Q

Recall 2 possible consequences of diabetic neuropathy and drugs that can be used to manage each of these possibiities

A
  1. Vagal neuropathy –> gastroparesis: domperidone/ metoclopramide
  2. Neuropathic pain: amitryptiline, duloxetine, gabapentin, pregabalin
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5
Q

Summarise the pathogenesis of diabetic foot

A
  1. Peripheral arterial disease reduces O2 delivery –> intermittent claudication
  2. Neuropathy –> loss of sensation, eventually Charcot’s foot
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6
Q

What is Charcot’s foot?

A

Rare consequence of T2DM in which foot becomes rocker-bottomed

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7
Q

Recall some ways in which diabetic foot can be screened for, and the frequency with which these tests should be done

A

Screening should be done annually
Test for ischaemia: palpate the dorsalis pedis and posterior tibial pulse
Test for neuropathy with 10g monofilament test

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8
Q

How should diabetic nephropathy be screened for?

A

Yearly albumin:creatinine ratio

Microalbuminuria is the first sign of diabetic nephropathy

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9
Q

What is the best management for diabetic nephropathy?

A

ACE inhibitors

However, these are toxic in AKI so eGFR needs to be monitored

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10
Q

How big a drop in eGFR would warrant stopping an ACE inhibitor in a diabetic patient?

A

> 20%

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11
Q

Why is an initial drop in eGFR expected when starting patients on an ACE inhibitor?

A

Dilate the efferent arteriole

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12
Q

Recall 3 things that may cause a falsely high HbA1c

A

Alcoholism
B12 deficiency
Iron deficiency anaemia

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13
Q

What is the BM target for T1DM patients who are monitoring BMs throughout the day?

A

Waking target: 5-7mmol/L

Rest of the day: 4-7mmol/L

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14
Q

Recall the names of 2 long-acting insulins

A

Lantus

Glargine

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15
Q

When are BD mixed regimens of insulin given?

A

Breakfast and dinner

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16
Q

Name a diabetes prevention programme

A

DESMOND

Diabetes education + self-management: ongoing and newly diagnosed

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17
Q

Recall some possible risk-factor modifying therapies that can be used in diabetes mellitus

A

Aspirin 75mg OD
Atorvastatin 20mg OD
Antihypertensives

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18
Q

What is the maximum dose of metformin?

A

2g/day

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19
Q

Recall 4 important side effects of metformin

A

Appetite suppression
B12 deficiency (due to reduced absorption)
Lactate acidosis
GI upset

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20
Q

How can you manage GI upset that is due to metformin?

A

Change immediate release to a modified release mechanism

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21
Q

When should dual therapy be considered in type 2 diabetes?

A

If HbA1c >58/ 7.5%

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22
Q

What are the options for dual therapy for type 2 diabetes?

A

Metformin + 1 of:

  • Sulphonylurea
  • Thiazolidinediones
  • Gliptins
  • SGLT2 inhibitors
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23
Q

Recall 2 examples of sulphonylureas

A

Glibenclamide

Gliclazide

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24
Q

Recall an example of a thiazolidinedione

A

Pioglitazone

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25
Q

Recall an example of a gliptin drug

A

Sitagliptin

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26
Q

What is the mechanism of action of gliptins?

A

DPP4 inhibitors

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27
Q

Recall an example of a SGLT2 inhibitor

A

Empagliflozin

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28
Q

Recall 2 important side effects of sulphonylureas

A

Weight gain

Hypoglycaemia

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29
Q

What sort of diabetes drug is MODY most sensitive to?

A

Sulphonylureas

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30
Q

What is the inheritance pattern of MODY?

A

Autosomal dominant

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31
Q

MODY must be diagnosed before what age?

A

25

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32
Q

What is the best investigation to confirm the diagnosis of MODY?

A

C peptides

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33
Q

What is the most common type of MODY, and which gene mutation causes it?

A

MODY 3

Mutated HNF-1 alpha

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34
Q

What is LADA?

A

Latent autoimmune diabetes in adults

Late onset T1DM in 20-50yo, no family history

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35
Q

What are the 2 best investigations for confirming the diagnosis of LADA?

A 
GAD Abs 
C peptide (will be low)
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36
Q

What 3 things are required to diagnosis DKA?

A

Diabetes, Ketones, Acidosis
Diabetes - BM >11.1
Ketones - >3
Acidosis - pH <7.3

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37
Q

Recall 4 common causes of DKA

A

Missed insulin
Trauma
Infection
EtOH

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38
Q

What 3 investigations are most useful for assessing the extent of the damage done by a DKA acutely?

A

ABG
ECG
U&Es

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39
Q

Recall the 5 main principles of managing DKA acutely

A
  1. Fluids
  2. Insulin
  3. Potassium (run KCl in NaCL bag)
  4. 10% dextrose (when BM < 15)
  5. VTE prophylaxis (very dehydrated)
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40
Q

What dose of insulin should be started in DKA vs HHS?

A

DKA: 0.1U/kg/hr
HHS: 0.5U/kg/hr

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41
Q

Recall the 3 biochemical criteria used to diagnose HHS

A

pH >7.3
Osmolarity >320mmol/L
BM >30

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42
Q

Over what time period does HHS develop?

A

Over a few days

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43
Q

Recall the 3 components of HHS management

A
  1. Fluids
  2. Monitoring (ensure Na+ is not corrected too quickly)
  3. Insulin
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44
Q

Recall 2 differentials for someone whose TFTs show low TSH and low T4

A

Secondary hypothyroidism

Sick euthyroid

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45
Q

Recall the Thy classification

A

Thy 1 = unsatisfactory sample (1c = cyst)
Thy 2 = benign
Thy 3 = atypia of undetermined significance
Thy 4 = Suspicious of malignancy
Thy 5 = malignancy

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46
Q

What classification system is used to classify thyroid nodules?

A

Thy classification

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47
Q

What are the 4 histological types of thyroid cancer

A

Anaplastic
Medullary
Papillary
Follicular

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48
Q

Which type of thyroid cancer is associated with a raised calcitonin?

A

Medullary

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49
Q

Recall 2 differentials for low uptake hyperthyroidism

A

Sub-acute (De Quervain’s) thyroiditis

Postpartum thyroiditis

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50
Q

Recall 3 differentials for high uptake hyperthyroidism

A

Grave’s disease
Toxic multinodular goitre
Single toxic adenoma

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51
Q

Recall 7 signs of thyroid eye disease

A 
Mnemonic = NO SPECS 
No signs or symptoms sometimes OR
Only signs (eg upper lid retraction) OR 
Signs AND symptoms: 
Proptosis 
Extra-ocular muscle pathology 
Corneal involvement 
Sight loss due to optic nerve involvement
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52
Q

Why might eye movement be restricted in thyroid eye disease?

A

Rectus thickening restricts movement

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53
Q

What is the best preventative measure to prevent Grave’s disease?

A

Stop smoking

54
Q

Which subtypes of MEN are associated with medullary thyroid cancer?

A

2A and 2B

55
Q

Recall the management of Grave’s disease

A

1st line:

  • Propranolol (NOT bisoprolol)
  • Anti-thyroid drug eg carbimazole or propylthiouracil OR
  • If unlikely to respond to ATDs, radioiodine (I-131)
56
Q

Recall 2 possible side effects of radioiodine

A

Hypothyroidism

Thyroid storm

57
Q

Recall how a patient should be prepared for thyroidectomy

A
  1. Need to be euthyroid on medication
  2. Laryngoscopy to check vocal cords
  3. Either thionamides or propranolol
    Stop thionamides (PTU) 10 days before surgery as it increases vascularity
58
Q

Recall some symptoms of a thyroid storm

A 
Hyperthermia 
Tachycardia 
Jaundice
Altered mental state
Cardiac (AF/high-output CF)
59
Q

How should a thyroid storm be managed?

A

IV propranolol –> Thionamides (PTU)

Hydrocortisone –> iodine

60
Q

What is the most common cause of primary hypothyroidism in the UK?

A

Hashimoto’s

61
Q

What is RIedel’s thyroiditis

A

Hypothyroidism caused by chronic inflammatory thyroid gland fibrosis

62
Q

Recall 2 drugs that can cause hypothyroidism

A

Lithium

Amiodarone

63
Q

What is the starting dose of levothyroxine?

A

50-100mcg

64
Q

How long after starting levothyroxine should the TFTs be checked?

A

8-12 weeks

65
Q

Recall 2 medications that interact with levothyroxine

A

Iron

CaCO3

66
Q

Recall 4 features of myxoedema coma

A

Hypothermia
Hyporeflexia
Bradycardia
Seizures

67
Q

How should myxoedema coma be managed?

A

IV thyroxine
IV hydrocortisome
IV fluids

68
Q

What are the most common causes of Addison’s disease?

A

In the UK: autoimmune adrenal failure

Worldwide: TB

69
Q

Recall 2 ways that Addison’s/adrenal failure can be investigated for

A
  1. 9am cortisol

2. Short synACTHen test

70
Q

Recall 3 possible cause of an Addisonian crisis? (different from Addison’s disease)

A
  1. Adrenal haemorrhage (Waterhouse-Friderichson syndrome from meningococcaemia)
  2. Steroid withdrawal
  3. Sepsis/ surgery causing an acute exacerbation of chronic insufficiency (autoimmune/ TB)
71
Q

How should an Addisonian crisis be managed?

A

Immediately:

  • IM hydrocortisone 100mg STAT
  • IV fluid bolus with glucose

Continuing management:

  • IV fluids
  • IV/IM hydrocortisone
72
Q

What is the most common cause of Cushing’s syndrome?

A

Glucocorticoid therapy

73
Q

What are some differentials for ACTH-dependent Cushing’s?

A

Cushing’s disease (80% pituitary tumour)

Ectopic ACTH production

74
Q

What are the possible causes of pseudo-Cushing’s?

A

Alcoholism or severe depression

75
Q

How can Cushing’s and pseudo-Cushing’s be differentiated?

A

Both will give a positive LDDST and 24hr free urinary cortisol
Can tell the difference between them with insulin stress test

76
Q

Recall 2 screening tests for Cushing’s

A
  1. 11pm salivary cortisol (if low the cause is NOT Cushing’s)
  2. LDDST
77
Q

How can the cause of Cushing’s syndrome be confirmed?

A

Inferior petrosal sinus sampling

Catheter is fed into the jugular vein

78
Q

What is Nelson’s syndrome?

A

Possible complication of adrenalectomy

Removal of adrenal gland –> pituitary enlargement and very high ACTH

79
Q

What is the most common electrolyte disturbance in Conn’s syndrome?

A

Hypokalaemia

80
Q

What is the best initial investigation in suspected Conn’ syndrome?

A

Aldosterone: renin ratio

81
Q

What are the best tests to determine the cause of hyperaldosteronism?

A

HR-CT and adrenal vein sampling

82
Q

What are the possible causes of hyperaldosteronism?

A
  1. Conn’s syndrome

2. Renal artery stenosis

83
Q

What will be the aldosterone: renin ration in Conn’s syndrome vs renal artery stenosis?

A

Conn’s: high

Renal artery stenosis: normal

84
Q

What medications can be used to manage hyperaldosteronism?

A

Spironolactone and epleronone

85
Q

What test can be used to diagnose diabetes insipidus?

A

Water deprivation test

86
Q

Recall 2 possible renal and 2 non-renal causes of hypernatraemia

A

Renal: osmotic diuresis (T2DM) or diabetes insipidus

Non-renal: GI losses or sweat losses of water

87
Q

What is the possible complication of correcting hypernatraemia too quickly?

A

Cerebral oedema

88
Q

What is the possible complication of correcting hyponatraemia too quickly?

A

Central pontine myelinolysis

89
Q

In which patients is a urine sodium measurement not reliable?

A

Those on diuretics

90
Q

Recall some drugs that can cause SIADH

A 
SSRIs and TCAs
Carbemazapine 
Sulphonylureas (eg gliclazide) 
PPIs (omeprazole/ lanzoprazole) 
Opiates
91
Q

Recall 2 causes of pseudohyponatraemia

A

Hyperlipidaemia

Hyperproteinaemia

92
Q

Recall 2 drugs that can be used to treat SIADH

A

Demeocycline

Vaptans (eg tolvaptan)

93
Q

Recall 3 classes of drugs that could cause hyperkalaemia

A

ARBs
ACE inhibitors
Aldosterone antagonists

94
Q

Recall one antibiotic that can cause hyperkalaemia

A

Tacrolimus - it can reduce K+ excretion

95
Q

Which type of renal tubular acisosis can cause hyperkalaemia

A

Type 4

96
Q

Recall the management of hyperkalaemia

A 
10mls 10% calcium gluconate 
120mls 20% dextrose
Maybe:  
10U insulin 
nebulised salbutamol 
If really bad: 
Calcium risonium
97
Q

For each of the following endocrine conditions, say whether they can cause hypo or hyperkalaemia:

  • Addisson’s
  • Conn’s
  • Cushing’s
A

Adisson’s: Causes hyperkalaemia
Conn’s: Causes hypokalaemia
Cushing’s: Causes hypokalaemia

98
Q

Which types of renal tubular acidosis can cause hypokalaemia (rarely)?

A

Types 1 and 2

99
Q

Which hormone will likely be high in renal artery stenosis?

A

Renin

100
Q

Describe the symptoms of hyper vs hypoclacaemia

A

Hypercalcaemia: bones, stones, abdominal groans, psychiatric moans

Hypocalcaemia: paraesthesia, muscle cramps, long QT

101
Q

What is a ‘pepperpot skull?

A

Radiological sign: Multiple tiny well-defined lucencies in the calvaria (top part of the skull) caused by resorption of trabecular bone in hyperparathyroidism

102
Q

How should hypercalcaemia be managed?

A

IV fluids –> bisphosphonates

103
Q

Recall the progression of multiple myeloma

A

(1) MGUS
(2) Smouldering myeloma
(3) Multiple myeloma
(4) B cell leukaemia

104
Q

At what point in the myeloma progression does a patient get the symptoms of CRAB?

A

Not until it gets to multiple myeloma

105
Q

What is the limit for monoclonal serum protein in MGUS?

A

Must be <30g/L

106
Q

What is the limit for bone marrow plasma cells in MGUS?

A

<10%

107
Q

Which type of immunoglobin will be high in myeloma?

A

IgG or IgA

If Waldenstrom’s - IgM

108
Q

What is the most useful form of imaging in myeloma?

A

Whole body low dose CT

109
Q

Which CD markers are positive in immunotyping in myeloma?

A

CD38
CD138
CD56/58

110
Q

What is the pathophysiology of refeeding syndrome?

A

Refeeding –> rise in insulin –> intracellular shift in phosphate –> hypophosphataemia

111
Q

What are some symptoms of the refeeding syndrome?

A 
Rhabdomyolysis 
Low RR
Arrhythmia 
Shock
Seizures
Coma
112
Q

What is fibromuscular dysplasia?

A

Idiopathic, non-atherosclerotic, non-inflammatory disorder of arteries
2 subtypes:
- Renal artery
- Cervical artery

113
Q

What are the symptoms of fibromuscular dysplasia?

A

Renal artery FMD: resistant hypertension

Cervical artery FMD: chronic migraines

114
Q

What is the best investigation for assessing fibromuscular dysplasia?

A

Catheter angiography

115
Q

What is the mainstay of management of fibromuscular dysplasia?

A

Stop smoking
Anti-platelets (clopidogrel)
Anti-hypertension (ACEi or ARB)
Surgery (surgical stenting)

116
Q

Recall some causes of vitamin B12 deficiency

A

Autoimmunity
Atrophic gastritis
Gastrectomy
Malnutrition

117
Q

Recall 2 drugs that can treat vitamin B12 deficiency

A

Cyanocobalamin IM

Hydroxocobalamin IM

118
Q

Recall some causes of hypomagnesaemia

A 
Diuretics/ PPIs
Diarrhoea 
TPN
EtOH
Gitelman's/Barter's
Hypokalaemia, hypocalcaemia
119
Q

What are the symptoms of hypomagnesaemia most similar to?

A

Hypocalcaemia

120
Q

What are the ECG features of hypomagnesaemia most similar to?

A

Hypokalaemia

121
Q

What is the threshold for giving IV magnesium sulphate as a Mg replacement, rather than just PO tablets?

A

Mg <0.4mmol/L

122
Q

How should suspected SIADH be investigated?

A
  1. Serum corrected calcium - must exclude hypercalcaemia secondary to hyperPTHism
  2. Water deprivation test
123
Q

What is the mechanism of hyponatraemia development in SIADH?

A

Increased water absorption in the collecting duct

124
Q

What would be the main abnormality on TFTs in thyrotoxic crisis?

A

Marked elevation of free T4

125
Q

What change in vision is caused by a lesion in the optic chiasm?

A

Bitemporal hemianopia

126
Q

What change in vision is caused by a lesion in the optic tract?

A

Homonymous hemianopia

127
Q

What change in vision is caused by a lesion in the optic radiation?

A

Superior quandrantopia

128
Q

Give some examples of causes of metabolic acidosis with increased anion gap

A

DKA is a big one

Also: lactate acidosis, uraemia secondary to renal failure and salicylate/biguianide poisoning

129
Q

In DKA, for how long should insulin infusion be continued before switching to SC insulin?

A

Until blood ketones <0.3mmol/L

130
Q

How frequently should potassium be monitored in the acute setting of DKA being treated with an insulin infusion?

A

4 hourly

131
Q

How should a known type 1 diabetic patient’s insulin be managed when they are in DKA and require an insulin infusion?

A

Long acting basal insulin should be continued alongside the infusion as this simplifies the change from infusion to SC insulin in due course

132
Q

Recall 4 side effects of carbimazole

A

Maculopapular rash
Bone marrow suppression leading to agranulocytosis
Pruritis
Jaundice

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