MLA Endocrinology Flashcards
1
Q
OGTT threshold for diabetes diagnosis?
A
> 11.1
2
Q
Which investigation as an alternative to HbA1c is recommended in patients with existing haemoglobinopathy?
A
Fructosamine test
3
Q
What is the diagnostic threshold for type 2 diabetes mellitus on fasting blood glucose?
A
> 7.0
4
Q
What is the HbA1c range associated with impaired glucose tolerance?
A
42-47
5
Q
Which auto-antibody (3) is associated with type 1 diabetes mellitus?
A
Islet cell
Anti-GAD
ZnT8
6
Q
Which blood test should be performed in patients with suspected type 1 diabetes?
A
C-peptide (low) indicates insulin deficiency (marker of beta-cell function)
7
Q
Which type of T1DM presents in adulthood?
A
Latent autoimmune diabetes in adults (LADA)
8
Q
What is the cause of type 3c diabetes mellitus?
A
Pancreatogenic e.g., chronic pancreatitis, pancreatic cancer, CF, haemochromatosis
9
Q
What are the side effects associated with metformin?
A
Diarrhoea
Lactic acidosis
10
Q
What are the common adverse effects associated with SGLT-2 inhibitors?
A
UTIs
Thrush
Fournier’s gangrene
Euglycaemic ketoacidosis
11
Q
What should be done to sustained release metformin in patients presenting with diarrhoea?
A
Switch to a modified release
12
Q
Which anti-hyperglycaemic drug is associated with weight gain?
A
Sulfonylureas / glitazones
13
Q
Which cancer risk is increased in patients on glitazones?
A
Bladder cancer
14
Q
What is the initial insulin regimen for diabetes?
A
Basal bolus regimen
15
Q
What severe features are associated with non-proliferative diabetic retinopathy?
A
Cotton wool spots
16
Q
On biopsy, what is the characteristic finding observed in patients with diabetic nephropathy?
A
Kimmelstein-Wilson nodules
17
Q
Which neuropathic medication is indicated in the management of diabetic neuropathy?
A
Duloextine
Amitriptyline
Gabapentin
Pregablin
18
Q
Which nerve in the thigh is affected in amyotrophy (diabetes)?
A
Femoral nerve
19
Q
What rheumatological manifestations are associated with T2DM?
A
Charcot neuroarthropathy
Adhesive capsulitis
20
Q
What is the glucose threshold for hypoglycaemia in patients with diabetes?
A
<4.0 mmol/L
21
Q
Which drug class can cause impaired hypoglycaemia awareness?
A
Beta-blockers
22
Q
What is the first-line management option in patients with hypoglycaemia (conscious)?
A
Oral glucogel
Sugary drink
23
Q
Unconscious - hypoglycaemia management (1st line)
A
IM glucagon or IV glucose (10-20%)
24
Q
pH diagnostic threshold for DKA?
A
<7.3
25
Bicarbonate threshold for DKA?
<15
26
1st line management for DKA?
1L stat 0.9% sodium chloride then 1 hour then 2 hours.
27
Following fluid resuscitation, what is the next most appropriate management for DKA?
Fixed-rate insulin 0.1 Units /kg
28
What is the glucose threshold to begin administering glucose?
CBG <14
29
What is the complication of rapid correction of glucose?
Central pontine myleinolysis
30
What is the fasting plasma glucose level for gestational diabetes?
5.6
31
What is the 2-hour OGTT threshold for gestational diabetes?
7.8
32
What are the foetal complications associated with gestational diabetes?
Macrosomia
Shoulder dystocia
Polyhydramnios
Hypoglycaemia (neonatal)
Stillbirth
33
When is a 75 g 2 hour OGTT test performed during pregnancy?
At 24-28 weeks
34
If the FPG is >7.0 during pregnancy, what medication is recommended?
Insulin
35
1st line management for gestational diabetes if fasting blood glucose is 6.0 - 6.9?
Metformin
36
When are diabetic drugs discontinued during gestational diabetes?
Immediately postpartum
37
Which criteria is used to diagnose FH?
Simon–Broome Criteria
38
What is the inheritance pattern for familial hypercholesterolaemia?
Autosomal dominant
39
What is the total cholesterol threshold for FH?
>7.5 mmol/L
40
What is the first line management of cranial diabetes insipidus?
Desmopressin
41
What is a common cause of pseudohyponatraemia?
High glucose, lipids or paraproteins
42
What sodium level is associated with severe hyponatraemia?
<120 mmol/L (normal range 135-145)
43
What is the management of hyponatraemia in patients with SIADH?
Fluid restriction and vaptans
44
What is the most common cause of hypercalcaemia?
Primary hyperparathyroidism (parathyroid adenoma)
45
What ECG findings are consistent with hypercalcaemia?
Short QT interval
J waves
46
What is the most important blood test to perform in a patient with hypercalcaemia?
Serum parathyroid hormone
47
What is the first line management of hypercalcaemia?
Intravenous fluids 4-6 L in 24 hours
48
What is the second step in the management of hypercalcaemia?
IV bisphosphonates
49
What is the main cause of secondary hyperparathyroidism?
Vitamin D deficiency, Chronic kidney disease
50
What is the mechanism of action of Denusomab?
RANK-L inhibitor
51
What is a common complication of thyroidectomy?
Hypocalcaemia
52
What is the first line management of severe symptomatic hypocalcaemia?
IV calcium gluconate
53
What ECG findings are associated with hypokalaemia?
ST depression
T-wave flattening
PR prolongation
U waves
54
What is the standard rate of potassium replacement in hypokalaemia?
10 mmol/hour
55
What drug is indicated to stabilise the cardiac membrane in patients with hyperkalaemia and ECG changes?
Calcium gluconate
56
Where is aldosterone produced in the adrenal cortex?
Zona glomerulosa
57
Where are glucocorticoids produced in the adrenal cortex?
Zona fasciculata
58
Which drugs can induce adrenal insufficiency?
Long-term steroids
Ketoconazole
59
What is the first line test for diagnosing Addison's disease?
9 am cortisol + ACTH (Synacthen test)
60
What is the first line management for an Addisonian crisis?
IV hydrocortisone
61
Sick day rules for Addison's disease?
Double hydrocortisone dose and keep the fludrocortisone dose the same
62
What is the acid-base status for Addison's?
Hyperkalaemic metabolic acidosis
63
What is the most common autoimmune cause of hypothyroidism?
Hashimoto’s thyroiditis, primary atrophic hypothyroidism
64
Which mineral deficiency is associated with hypothyroidism?
Iodine deficiency
65
What is a hallmark feature of severe hypothyroidism?
Myxoedema coma - marked by hypothermia, hypoventilation, hyponatraemia, heart failure and confusion
66
Which blood test is recommended as first line for suspected hypothyroidism?
Serum TSH
67
↓ T4/T3, ↑ TSH Diagnosis?
Primary hypothyroidism
68
↓ T4/T3 and TSH diagnosis?
Secondary hypothyroidism
69
Which autoantibody is associated with hypothyroidism?
Serum thyroid peroxidase antibodies
70
In patients with normal thyroid function, yet symptoms of hypothryoidism, what investigation is recommended?
Neck ultrasound
71
Elevated TSH levels, and normal free T4, suggests what?
Subclinical hypothyroidism
72
What is the long-term therapy for hypothyroidism?
Levothyroxine monotherapy
73
How is levothyroxine taken?
Oral on an empty stomach, in the morning before food
74
How frequently should TSH be monitored following levothyroxine therapy?
Every 3 months
75
How should the levothyroxine dose be adjusted during pregnancy?
Increase by 25-50 micrograms
76
What is the criteria for starting levothyroxine in subclinical hypothyroidism?
TSH is >10 mU/L and FT4 is within the reference range on 2 separate occasions 3 months apart.
or
* If <65 years, consider a 6-month trial of LT4 if:
- TSH is 5.5 – 10 mU/L on 2 separate occasions 3 months apart, and there are symptoms of hypothyroidism.
77
What is the management for asymptomatic subclinical hypothyroidism?
Watch and wait; repeat TFTs in 6 months
78
What is the first line management for myxoedema coma?
* Oxygen
* Rewarming (for hypothermia)
* Rehydration
* IV T4/T3
* IV hydrocortisone (in case hypothyroidism is secondary to hypopituitarism)
79
What autoantibody is associated with Graves' disease?
Anti-TSH receptor antibody
80
What is the second most common cause of hyperthyroidism?
Toxic multinodular goitre
81
Which drug is associated with AIT Type 1 hyperthyroidism?
Amiodarone
82
Which ovarian tumour is associated with hyperthyroidism?
Struma ovarii
83
Which is a dose-dependent risk factor for Graves orbitopathy?
Smoking
84
What are the signs of Graves' orbitopathy?
Periorbital oedema, proptosis, conjunctival oedema, increased tears, ophthalmoplegia, optic nerve atrophy
85
Goitre description in Graves' disease?
Diffuse symmetrical
86
What is the goitre presentation in toxic adenoma?
Unilateral non-tender thyroid mass
87
Which imaging. modality is indicated in patients with a palpable thyroid goitre?
Neck ultrasound
88
What are the TFT results for amiodarone-induced hyperthyroidism?
Low TSH and raised FT4
89
What is the definitive imaging investigation for Graves' disease?
Radioisotope uptake scan (Tc99) - diffuse uptake
90
Multiple hot nodules with suppression of the rest of the thyroid gland is consistent with what diagnosis?
* Toxic multinodular goitre
91
Thyrotoxicosis following a flu-like illness?
* De Quervains thyroiditis
92
Which investigation is indicated for Graves' orbitopathy?
CT/MRI of orbits
93
What is the first line management for symptomatic hyperthyroidism?
Beta-blockade e.g., atenolol, propanolol
94
What is the mechanism of action of carbimazole?
Competitive inhibitor of thyroid peroxidase - blocks thyroid hormone synthesis
95
Which anti-thyroid drug inhibits peripheral conversion of T4 to active T3?
o Propylthiouracil
96
Which anti-thyroid drug is preferred during the first trimester of pregnancy/pre-pregnancy?
o Propylthiouracil
97
What are the contraindications of carbimazole?
Severe blood disorders, acute pancreatitis, women of childbearing potential (Risk of congenital malformations during the 1st trimester).
98
Which drugs are interacted with carbimazole?
Azathioprine (Increased myelosuppression); warfarin (enhances anticoagulant effect – INR monitoring); methotrexate, digoxin.
99
What is the most concerning adverse effect associated with carbimazole?
Agranulocytosis
100
What is the major adverse effect associated with propylthiouracil?
Liver disease
101
Normal duration of carbimazole for Grave's disease?
18 months
102
What is the definitive management for Grave's disease?
Radioactive iodine (1-131)
103
How does radioactive iodine therapy work in the management of hyperthyroidism?
Destroys thyroid follicular cells
104
What are the contraindications of radioactive iodine thearpy?
Pregnancy
Breastfeeding
Active/severe orbitopathy
105
How long should pregnancy be avoided following radioactive iodine therapy?
4-6 months
106
What is the indication for a thyroidectomy in hyperthyroidism?
Local compression secondary to thyroid goitre e.g., upper airway obstruction/dysphagia
107
What is the pre-operative management for hyperthyroidism?
Euthyroid state and control hypertension
Prescribe oral potassium iodide and propranolol
108
What is first line management for Grave's orbitopathy?
Smoking cessation, and consider steroids
109
What is the main cardiac complication associated with hyperthyroidism?
Atrial fibrillation (3-fold increase)
110
What rheum complication is associated with hyperthyroidism?
Osteoporosis
111
What are the complications of surgery associated with hyperthyroidism?
Recurrent laryngeal nerve palsy
Hypothyroidism
Hypoparathyroidism (more common)
112
What is the long-term complication associated with subclinical hyperthyroidism?
Osteoporosis and atrial fibrillation
113
What is the tumour marker for papillary thyroid cancer?
Thyroglobulin
114
What are the histological findings associated with papillary thyroid carcinoma?
Orphan Annie eyes, and Psammoma bodies
115
Which thyroid cancer is associated with a very good prognosis?
Papillary thyroid carcinoma
116
Which thyroid cancer is very aggressive, and common in the elderly?
Anaplastic thyroid cancer
117
What is the tumour marker associated with medullary thyroid cancer?
Calcitonin
118
Which familial disorder is associated with medullary thyroid cancer?
Men2a/2b
119
What is the diagnostic investigation for thyroid cancer?
Fine needle aspiration cytology (FNAC)
120
What is the most common cause of primary adrenal insufficiency?
Autoimmune mediated
121
Why is there hyperpigmentation in Addison's disease?
increased MSH levels (POMC precursor)
122
What electrolyte imbalance is associated with Addison's disease?
Hyponatraemia
Hyperkalaemia
123
What is the acid-base imbalance associated with Addison's disease?
Metabolic acidosis
124
What is the first-line investigation for Addison's disease?
9 am cortisol (<100 - diagnostic - admit)
100 -500 refer to endocrinology
125
What is the diagnostic investigation to confirm adrenal insufficiency?
Short SynACTHen test
Administer 250ug Synacthen intramuscularly and measure the subsequent cortisol response (within 30 minutes) . In patients with adrenal hypofunction, there is reduced cortisol secretion unresponsive to ACTH stimulation, thus the cortisol response is absent – minimal change.
126
What is the dose administration for hydrocortisone replacement in Addison's disease?
3 divided doses (10 mg on waking, 5 mg at noon and 5 mg in the early evening).
127
What happens to the hydrocortisone in patients with intercurrent illness?
Double dose
128
What is the mineralocorticoid replacement of choice for Addison's disease?
Fludrocortisone
129
What is the first line drug for the management of an Addisonian crisis?
IV hydrocortisone and rapid IV fluid rehydration
130
What is the most common cause of hyperaldosteronism?
Bilateral adrenal hyperplasia
131
What electrolyte imbalance is associated with primary hyperaldosteronism?
Hypokalaemia, Hypernatraemia
132
What is the first line of investigation for hyperaldosteronism?
Plasma aldosterone: renin ratio
(Raised - renin is suppressed)
133
What is the diagnostic investigation to confirm primary hyperaldosteronism?
CT adrenals
134
Which investigation is indicated to differentiate between unilateral and bilateral hyperaldosteronism?
Adrenal venous sampling
135
What is the medical management for hyperaldosteronism?
spironolactone, eplerenone
136
What is the management for a unilateral adrenal adenoma?
Unilateral laparoscopic adrenalectomy
137
For bilateral adrenal disease (hyperaldosteronism), what is the preferred management?
Spironolactone
138
Which cells produce catecholamines?
Chromaffin cells of the adrenal medulla
139
Which three familial syndromes are associated with phaeochromocytoma?
* Von-Hippel Lindau
MEN2
NF1
140
What is associated with Von-Hippel Lindau syndrome?
Phaeo, renal cell carcinoma, renal cysts, hemangioblastoma
141
What is MEN Type2a syndrome?
Phaeochromocytoma
Parathyroid adenoma
Medullary thyroid cancer
142
What is the first line investigation for suspected phaeochromocytoma?
24h urinary metadrenaline/metanephrines
143
What precursor test is involved for screening for phaeos?
Meta-lodobenzylguanidine scan
144
What is the first line management for phaeo?
* Alpha blockade (first) – phenoxybenzamine for 7-14 days preoperatively.
- An alpha blockade is first to prevent the precipitating of a hypertensive crisis.
145
What are the two drugs indicated for the management of Phaeochromocytoma?
Alpha-blockade and beta-blockade
146
What is the definitive management for phaeochromocytoma?
Adrenalectomy
147
What is the normal range of calcium?
2.2 to 2.6 mmol/L
148
What is the main cause of secondary hyperparathyroidism?
Chronic kidney disease
149
Which type of hyperparathyroidism can be associated with normal serum levels of PTH?
Primary hyperparathyroidism
150
Raised Calcium
Low phosphate
Normal/raised PTH
Raised ALP
Most likely diagnosis?
Primary hyperparathyroidism
151
Low calcium
Raised phosphate
Raised PTH/ALP
Most likely diagnosis?
Secondary hyperparathyroidism
152
Raised PTH, ALP, and low Vitamin D, low calcium and low phosphate
Most likely diagnosis?
Osteomalacia
153
Which marker is raised in Paget's disease?
Serum ALP
154
Serum PTH level in hypercalcaemia of malignancy?
Low
155
What is pseudohypoparathyriodism?
PTH resistance (Type 1a = Albright’s Hereditary Osteodystrophy phenotype).
156
Which sign denotes tapping over the facial nerve eliciting twitching of the upper lip?
* Chvostek’s sign
157
Which sign is associated with a carpal spasm following inflation of a BP cuff?
* Trousseau’s sign
158
What is Albright Hereditary Osteodystrophy?
* Short stature
* Round face
* Shortened fourth/fifth metacarpal bones.
* Lab: Hypocalcaemia and hyperphosphatemia + raised PTH.
159
What is pseudopseudohypoparathyriodism?
phenotypic expression of ABO without PTH resistance
160
What ECG changes are associated with hypercalcaemia?
Short QT interval
Prolonged PR interval
Widened QRS complex and bradycardia
161
What is the first line management of hypercalcaemia?
0.9% saline fluid resuscitation
162
Following fluid resuscitation what is the next line in management?
* Bisphosphonates (IV)
163
Which adrenal zone secretes cortisol?
Zona fasciculata
164
Which lung cancer is associated with ectopic secretion of ACTH?
Small cell lung carcinoma
165
What is the first line investigation for suspected Cushing's syndrome?
* Urine-free cortisol (at least two measurements)
* Late-night salivary cortisol (at least two measurements)
* 1-mg overnight dexamethasone suppression test (DST)
166
What is the second line investigation to differentiate between ACTH-dependent and ACTH-independent aetiologies of Cushing's syndrome?
Serum ACTH
167
For ACTH-independent causes of Cushing's syndrome, what is the next line of investigation?
CT adrenals
168
For ACTH-dependent causes of Cushing's syndrome, what is the next line of investigation?
Bilateral inferior petrosal sinus sampling
169
Raised cortisol and raised ACTH following a high dose dexamethasone test, indicates what?
Ectopic ACTH aetiology
170
Serum cortisol result following high dose dexamethasone suppression test, in Cushing's disease?
Suppressed
171
What is the medical management for Cushing's?
metyrapone
172
What is the definitive management for an adrenal cause of Cushing's?
Adrenalectomy and steroid replacement
173
What is the preferred definitive management for Cushing's disease?
Surgical transsphenoidal resection
174
Which skin condition is suggestive of insulin resistance?
Acanthosis nigricans
175
What is the diagnostic cut-off for HbA1c for diabetes?
>48 mmol/mol (>6.5%)
176
What factors can affect HbA1c results?
Haemoglobinopathies, severe anaemia, post-splenectomy, recent blood transfusion
177
Fasting plasma glucose cut-off for diabetes diagnosis?
>7.0 mmol/L
178
OGTT cut-off for diabetes diagnosis?
>11.1 mmol/L
179
What is the first line medical management for T2DM?
Metformin
180
What is a common side effect of metformin?
Diarrhoea
181
Metformin management in patients presenting with diarrhoea (side effect)?
Switch to modified-release
182
Which drug should be co-prescribed with Metformin in diabetic patients with chronic heart failure or established CVD?
SGLT-2 inhibitor
183
When should an SGLT-2 inhibitor be prescribed in the medical management plan for diabetic patients with underlying heart disease?
Once the metformin dose is optimised
184
What is the second line medical management for T2DM?
If monotherapy is ineffective consider adding one of the following:
* A DPP-4 inhibitor (e.g., Sitagliptin)
* Pioglitazone
* Sulfonylurea
* SGLT-2 inhibitor
185
What is the preferred triple therapy for T2DM?
* Triple therapy: DPP-4 inhibitor, pioglitazone, a sulfonylurea or an SGLT-2 inhibitor (canagliflozin or empagliflozin)
- Note: Dapagliflozin is recommended only in combination with metformin and sulfonylurea, not pioglitazone.
186
What is the BMI cut off for starting a GLP-1 receptor agonist?
- BMI >35 kg/m2
187
When should a GLP-1 agonist be discontinued?
If there is not demonstrated weight loss within 6 months (<3%)
188
How frequently should HbA1c be measured?
Every 3-6 months
189
What is performed during an annual diabetes check-up?
Diabetic foot check
Annual retinopathy, neuropathy and nephropathy screening
190
What is the HbA1c target for lifestyle and diet management in T2DM?
48 mmol/mol
191
What is the HbA1c target for lifestyle and single drug medical management in T2DM?
48
192
What is the HbA1c target for lifestyle and medical management (drug associated with hypoglycaemia e.g., sulfonylurea) in T2DM?
53
193
At what HbA1c should an additional diabetic drug be commenced?
>58
194
What is an absolute contraindication for metformin?
Severe renal insufficiency - eGFR <30 mL/min
195
What is the risk of metformin in patients with renal impairment?
Lactic acidosis
196
What class of diabetic drug is glimepiride?
Sulphonylureas
197
Which drug is associated with interacting with ATP-sensitive potassium channels to promote insulin pancreatic secretion?
Sulphonylureas
198
What is the main adverse effect associated with Sulphonylureas?
Weight gain
199
Which two diabetic drugs are associated with weight gain?
Sulphonylureas and glitazones
200
What is the mechanism of action of gliptins?
DPP-4 inhibitors
201
What are the adverse effects associated with SGLT-2 inhibitor use?
Genital mycotic (fungal) infections – candida albicans (vaginal thrush and balanitis); normoglycemic ketoacidosis, increased risk of Fournier’s gangrene.
202
What type of calcium channel blocker is Verapamil?
non-dihydropyridine calcium channel blocker
203
Which calcium channel blocker is contraindicated in HFrEF?
non-dihydropyridine calcium channel blocker E.G., Verapamil
204
