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year 6 > Medicine - Endocrinology > Flashcards

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

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54
Q

Which subtypes of MEN are associated with medullary thyroid cancer?

A

2A and 2B

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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)

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56
Q

Recall 2 possible side effects of radioiodine

A

Hypothyroidism
Thyroid storm

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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
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58
Q

Recall some symptoms of a thyroid storm

A

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

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59
Q

How should a thyroid storm be managed?

A

IV propranolol –> Thionamides (PTU)
Hydrocortisone –> iodine

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60
Q

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

A

Hashimoto’s

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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 (>500nm UNLIKELY, <100 likely, 100-500 do short synACTHen test)
  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
- 1L normal saline IV fluid bolus ober 30-60 min with dextrose if hypoglycaemia

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

133
Q

How should primary hyperaldosteronism due to BL adrenal hypertrophy be managed?

A

Spironolactone

134
Q

What is the first drug to give in phaeochromocytoma?

A

Phenoxybenzamine

135
Q

How should once daily insulin regimes be managed pre-operatively?

A

Reduced dose insulin on the day of the op and the day before

136
Q

Why might someone get hyponatraemia post-SAH?

A

SAH can lead to SIADH

137
Q

What is the best test for diagnosing phaeochromocytoma?

A

Plasma and serum catecholamines

138
Q

How can a splenectomy affect blood sugar levels?

A

Can give a falsely high reading due to the increased life span of RBCs

139
Q

What is the immediate management of pituitary apoplexy?

A

IV hydrocortisone

140
Q

What is the treatment for malignant hyperthermia?

A

IV dantrolene

141
Q

describe how short synacthen test works

A

Measure cortisol and ACTH at the start of the test
Administer 250µg synthetic ACTH by IM injection
Check cortisol at 30 and 60 mins
Healthy people should produce >550nM of cortisol within 30 mins

142
Q

management cushing’s

A

pituitary adenoma: surgery

adrenal adenoma: adrenalectomy + steroid replacement (beware Nelson’s syndrome)

ectopic ACTH: metyrapone, ketoconazole, mifepristone

143
Q

causes of hypernatraemia

A

increased sodium and or loss of water

increased sodium
1. medical (rehydration with hypertonic saline)
2. dietary (high dietary salt, salty formula)
3. Conn’s syndrome
4. Cushing’s syndrome (at high concentrations, cortisol has an MR effect)
5. RTA (low BP in renal artery, increased renin, increased aldosterone)

loss of water:
renal loss:
1. osmotic diuresis
2. diabetes insipidus
3. loop diuretics

non renal loss:
1. GI- vomiting, diarrhoea
2. skin- sweat, burns

Patient cannot control water intake e.g. children, elderly

144
Q

investigations diabetes inspidus

A

Serum glucose (exclude diabetes mellitus)
Serum potassium (exclue hypokalaemia)
Serum calcium (exclude hypercalcaemia)
Plasma and urine osmolality
Water deprivation test - urine osmolality will fail to increase

145
Q

causes of nephrogenic DI

A

hypercalcaemia, hypokalaemia, lithium, sickle cell anaemia

146
Q

features of multipe myeloma

A

hypercalcaemia, anaemia, renal failure, bone pain

other: hyperviscosity symptoms

147
Q

management multiple myeloma

A

induction: thalidomide + dexamethasone

bone pain: bisphosphonates + analgesia

148
Q

investigations multiple myeloma

A

protein electrophoresis

FBC, U&Es, LFTs, blood film (rouleaux formation)

whole body MRI/CT

bone marrow aspirate + biosy

149
Q

who is at risk of refeeding syndrome

A

one of:
BMI <16, little nutritional intake >10 days, hypokalaemia/hypophosphataemia/hypomatramiea prior to refeeding, WL >15% over 3-6 months

two of:
BMI <18.5, little nutritional intake >5 days, WL >10% over 3-6 months, hx of alcohol abuse/antacids/insulin therapy

150
Q
A

year 6 (20 decks)

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