Week 23 - Cases 1-4

Question 1

what is balantitis circinata

Answer 1

a skin condition associated with reactive arthritis which presents with ring shaped dematitis on the glans penis

Question 2

what is balantitis xerotica albicans

Answer 2

lichen sclerosis affecting the male genitals

Question 3

what can candidal balantitis be caused by

Answer 3

diabetes

Question 4

what are the risk factors for candidal balantitis

Answer 4

• Diabetes mellitus
• Use of oral antibiotics
• Poor hygiene in uncircumcised males
• Immunosuppression (including HIV infection)

Question 5

what is the criteria to diagnose diabetes in symptomatic patients

Answer 5

fasting glucose test greater than or equal to 7

random glucose test greater than or equal to 11.1

Question 6

what is the criteria to diagnosis diabetes if the patient is asymptomatic

Answer 6

Fasting Glucose Test greater than or equal to 7
Random Glucose Test greater than or equal to 11.1.

• this criteria must be met on 2 separate occasions

Question 7

if a patient is asymptomatic what should be requested in regards to the HbA1c request

Answer 7

a second Hba1c shoud be requested.

Two consecutive Hba1c results equal to or greater than 48 is diagnostic of type 2 diabetes. However, it is not as sensitive as fasting samples and therefore cannot exclude diabetes if the HBA1c is less than 48.

Question 8

what are the occasions where you should not use hb1Ac to diagnose diabetes

Answer 8

● Pregnant women or women who are 2 months postpartum.

● People with symptoms of diabetes for less than 2 months.

● People at high diabetes risk who are acutely ill.

● People taking
medication that may cause hyperglycaemia (for example long-term corticosteroid treatment).

● People with acute pancreatic damage,
including pancreatic surgery
.
● People with end-stage renal disease (ESRD).

● People with HIV infection

Question 9

what are the hallmark symptoms of type 2 diabetes

Answer 9

● Tiredness
● Polyuria/polydipsia
● Recurrent infections e.g., thrush
● Increased hunger
● Unintentional weight loss
● Blurred vision (retinopathy)
● Foot ulcers/sores (due to peripheral neuropathy)
● Areas of dark skin e.g., in armpits/neck (acanthosis nigricans):

Question 10

what is acanthosis nigricans due to

Answer 10

insulin resistance

Question 11

what is checked at an annual diabetic review

Answer 11

urine
HbA1c
Foot examination
height and weight
BP
eye tests
cholesterol
blood sugards

Question 12

what is the most common cause of blindness in adults aged 35-65 years of age

Answer 12

retinopathy

Question 13

what is important to monitor in regards to the kidneys in diabetics

Answer 13

the albumin:crreatinine ratio

Question 14

how do we decide if medication is necessary for a patient with diabetes

Answer 14

HbA1c is checked every 3-6 months until it is at a stable level on unchanging therapy, if lifestyle measures have failed and HbA1c is 48 or higher, then medication is considered

Question 15

what is the first line medical treatment of type 2 diabetes and what is its mechanism of action

Answer 15

Metformin is the first line medical therapy for type 2 Diabetes. It is a biguanide which leads to activation of AMP-activated protein kinase (AMPK). This has a dual effect of increasing insulin sensitivity and decreasing hepatic gluconeogenesis.

Question 16

what is the most common side effect of metformin

Answer 16

GI disturbances

an initial starting regimine would be 500mg once daily, but this can be titrated up to 1g twice daily if necessary. taking metformin with meals or using modified release preparations can reduce GI side effects

Question 17

what kind of medications might need to be considered, other than blood sugar medications

Answer 17

statins and anti-hypertensives

Question 18

who are statins recommended in

Answer 18

Recommended in most Type 1 diabetics, and Type 2 diabetics with a QRISK over 10%

Question 19

what is the BP target for patients with diabetes

Answer 19

below 140/80 for all patients with diabetes

If there is ‘end organ damage’ (kidneys, eyes or any conditions affecting blood vessels), then it is 130/80.

Question 20

what is the diagnostic criteria for diabetic ketoacidosis

Answer 20

● Capillary Blood Glucose (BM) >11 (or known diabetes)
● Capillary Ketones >3mmol/L (or urinary >2+)
● Venous pH <7.3 or venous bicarb <15mmol/L

Must have all three for a diagnosis.

Question 21

what are the principles of management of diabetic ketoacidosis

Answer 21

● Fluid resuscitation to restore circulatory volume
● Correct electrolyte imbalances (in particular; potassium)
● To treat hyperglycaemia, clear ketones and suppress further ketogenesis

Management of diabetic ketoacidosis (DKA) is mostly following a set algorithm which all trusts will have, however establishing why someone has developed DKA is just as important. For example: Treating an underlying infection.

Question 22

is sliding scale insulin used for diabetic ketoacidosis treatment

Answer 22

no, the treatment is a fixed rate infusion of insulin

Question 23

what is the aggressive fluid resuscitation given for diabetic ketoacidosis

Answer 23

Initially, aggressive fluid therapy is needed. One litre of IV fluid over one hour (if the systolic BP is over 90), or if it is lower, boluses of fluid are required (This would be 500ml of 0.9% sodium chloride over less than 15 minutes).

Question 24

what electrolyte is essential to monitor during DKA therapy

Answer 24

potassium

Question 25

when is diabetic ketoacidosis treatment stopped and what is given next

Answer 25

When a patient is eating and drinking normally, and their pH is over 7.3, or their blood ketones are less than 0.6 mmol/L, stop the fixed rate insulin infusion, and go onto subcutaneous insulin.

Question 26

what is the diagnosis for type 1 diabetes in adults - as stated by NICE

Answer 26

Diagnose Type 1 diabetes on clinical grounds in adults presenting with hyperglycaemia, bearing in mind that people with Type 1 diabetes typically (but not always) have one or more of: ketosis rapid weight loss age of onset below 50 years BMI below 25 kg/m² personal and/or family history of autoimmune disease

Question 27

what are the three different types of insulin available in the UK

Answer 27

Human Insulin produced by recombinant DNA technology. Human insulin analogues: modified insulin to produce specific kinetic characteristics e.g., modified duration of action. Animal insulins (rarely used) from pigs or cows.

Question 28

what is a basal bolus mode of administration

Answer 28

This is where a long-acting insulin is given by subcutaneous injection to act as the endogenous insulin (basal or base insulin); and then rapid acting insulin is given with meals to replicate the normal response to food (bolus). Typically, three boluses are given a day with meals, but the amount of insulin will vary, as will the number of boluses, if a different number of meals are consumed. Patients become experts at managing their own diabetes.

Question 29

what are mixed, bi-phasic regime of administration

Answer 29

These are quite varied, but usually have one, two or three insulin injections per day. Premixed insulin preparations, which contain insulins of different durations of action.

Question 30

what is a continuous regime administration

Answer 30

Continuous regime: Insulin pumps can be used to deliver rapid acting insulin at a very slow rate as background insulin and extra mealtime insulin can be delivered by the patient according to what they eat. The insulin is delivered subcutaneously via a cannula and there are two main types – ‘tethered pumps’ and ‘patch pumps’. They can give patients more control over what they eat, and more stable blood glucose levels.

Question 31

how many times a day should a type 1 diabetic check their insulin

Answer 31

at least four times a day

Question 32

when is it particularly important to check glucose levels

Answer 32

check before each meal, and before bed

Question 33

what are the blood glucose targets for diabetes, in waking and then before meals

Answer 33

5-7 mmol/L – on waking 4-7 mmol/L – before meals, and at other times of the day

Question 34

what are the sick day rules for a patient with diabetes

Answer 34

Checking blood sugar more frequently Staying hydrated Eat little, and often Keep taking medications

Question 35

what is hyperosmolar hyperglycaemic state

Answer 35

There is also a condition known as hyperosmolar hyperglycaemic state (HHS) which presents in patients with type 2 diabetes. Patients often have glucose levels over 40 mmol/L. Profound dehydration accompanies this, and the mortality from this is much higher than diabetic ketoacidosis (DKA) (10-20%)

Question 36

what are the results seen with primary hyperthyroidism

Answer 36

Elevated Free T4 (thyroxine) and free T3 (triiodothyronine) with suppressed TSH (thyroid stimulating hormone).

Question 37

what is TSH low in primary hyperthyroidism

Answer 37

Production of TSH (thyroid stimulating hormone) is regulated by feedback from circulating free thyroid hormone concentrations. Elevated levels of Free T4 (thyroxine) and Free T3 (triiodothyronine) therefore suppress TSH (thyroid stimulating hormone) production from the anterior pituitary.

Question 38

what does a normal thyroid consist of microscopically

Answer 38

consists of follicles lined by a cuboidal epithelium and filled with pink, homogenous colloid. The follicles vary somewhat in size. The interstitium, which may contain “C” cells is not prominent.

Question 39

What are the three most common causes of hyperthyroidism in the UK?

Answer 39

toxic multinodular goitre Grave's disease Solitary toxic adenoma

Question 40

what examination signs are specific for Grave's idsease

Answer 40

pretibial myxoedema opthalmoplegia thyroid acropathy exopthalmos

Question 41

Which thyroid auto-immune antibodies are most likely to be raised in Graves’?

Answer 41

thyroglobulin antibodies present in 80% Hashimoto's thyroiditis

Question 42

what are the clinical signs of thyroid eye disease

Answer 42

Retraction of upper and lower lids ( sympathetic overdrive) Lid lag Swelling of the eyelids / conjunctiva ( “chemosis”) Exposure /dehydration of the cornea ( dry eye &inadequate blink coverage) Protrusion of the eyeballs “ Exophthalmos”/”Proptosis” ( swollen orbit) Double vision/squint ( inflammation and fibrosis of muscles) Optic neuropathy ( visual failure from optic nerve compression)

Question 43

what is given to treat thyroid eye disease

Answer 43

Treat thyroid dysfunction Stop smoking Artificial tears Selenium Surgical intervention to improve lid closure Prisms in glasses for squint/ diplopia ( may need surgery eventually) If severe /threat to optic nerve high dose steroid/immunosuppression Surgical orbital decompression

Question 44

what are the three main treatment options for hyperthyroidism

Answer 44

- Antithyroid medication: methimazole, carbimazole, propylthiouracil - Total thyroidectomy - Radioactive iodine therapy

Question 45

what are prescribed for hyperthyroid patients to help control physical symptoms such as anxiety, tremor and palpitations

Answer 45

beta-blockers they are not a definitive treatment but can be useful to control symptoms in the short term, whilst awaiting definitive therapy

Question 46

what are the potentially serious side effects of carbimazole

Answer 46

● Neutropenia (low neutrophil counts, a type of granulocyte white blood cell) ● Agranulocytosis (an acute febrile condition marked by severe decrease in blood granulocytes)

Question 47

if someone on carbimazole was pregnant, what would you do to their medication

Answer 47

switch them to polyuracil

Question 48

how frequently do you monitor blood tests after giving carbimazole

Answer 48

Initially, you should order TFTs (thyroid function tests) every 4-6 weeks (whilst the dose is being titrated). This should be reduced to approximately every 3-6 months once the patient is euthyroid, and a maintenance dose is achieved.

Question 49

How does radioactive iodine work? What are its complications, and which other medical specialty should review patients, prior to treatment?

Answer 49

Radioactive Iodine-131 is taken orally and is then rapidly taken up by the thyroid gland. The release of radiation destroys the tissue over a period of 6-18 weeks. Early complications include neck discomfort, and possible precipitation of Graves’ ophthalmopathy. Ophthalmology should review to check that they don’t have Graves’ opthalmopathy. Longer term there is a progressive incidence of hypothyroidism with most patients requiring treatment with thyroxine after several years.

Question 50

what are the blood test results for primary hypothyroidism

Answer 50

Low T3 (Triiodothyronine), with low T4 (thyroxine) production from the thyroid means there is reduced negative feedback to the pituitary. As such, the TSH (thyroid stimulating hormone) is raised. This has likely been caused by radio-active iodine.

Question 51

what is the most common cause of primary hypothyroidism in the UK

Answer 51

autoimmune thyroiditis (Hashimoto's) antibody-mediated destruction of thyroid tissue.

Question 52

What do these thyroid function tests show? * TSH 9.41 (0.40-5.00 mU/L) * T3 4.2 (3.00-6.00 pmol/l * T4 12.5 (10-21 mol/l)

Answer 52

Subclinical hypothyroidism. T3 and T4 are at the lower end of normal range, however TSH is raised due to reduced negative feedback to the pituitary from T3/T4.

Question 53

Billy is a 72 year old gentleman who has recently been discharged from hospital following admission for a fractured neck of femur. On his discharge summary the hospital doctor has asked you to review Billy because his thyroid blood test is abnormal. What does it show? How will you manage him? * TSH 0.3 (0.40-5.00 mU/L) * T3 2.8 (3.00-6.00 pmol/l * T4 11.1 (10-21 mol/l)

Answer 53

Most likely Euthyroid Sick Syndrome – systemic illness causing transiently low T3/4 and TSH. Rarely, these TFT results could be due to secondary hypothyroidism Check if they are symptomatic. If they are euthyroid clinically, repeat TFTs in 1 month

Question 54

what happens to levothyroxine treatment when someone is pregnant

Answer 54

Increase levothyroxine by 20-50micrograms (or 25%). Repeat TFTs (thyroid function tests) every 4-6 weeks. Titrate to TSH (thyroid stimulating hormone) <2.5pmol/l. She needs to be referred to be under the care of an endocrinologist ante natally. She will need close monitoring of her Thyroid Antibodies. If antibodies are raised at 28/40, she will need additional growth scans.

Question 55

Sahar Mahmood, a 50-year-old female, attends for an appointment with the practice nurse. She is well and reports no current symptoms but has a family history of cardiovascular disease, so was keen to have her blood pressure checked, and routine blood tests. Her Hba1c is 52. Should you:

Answer 55

Repeat Hba1c in 3 weeks Sahar’s Hba1c is in the diabetic range however she is asymptomatic, therefore needs a second Hba1c test to confirm the diagnosis.

Question 56

Rebecca Fortune is a 72-year-old female who has just been diagnosed with Type 2 diabetes. Her Hab1c is 85 and she reports mild polydypsia. She has a past medical history of hypertension, peripheral vascular disease, and she smokes 15 cigarettes per day. Her QRISK is calculated at 41.9%. Alongside lifestyle interventions, what medical therapy will you initiate?

Answer 56

Metformin + Canagliflozin Rebecca has established cardiovascular disease. NICE guidance would therefore recommend initiating Metformin, and Canagliflozin as first-line therapy.

Question 57

Rachael Whittaker presents to her GP with weight loss, anxiety, and tremor. Alongside raised T4, what other blood test would suggest Grave’s disease, as the underlying cause of her hyperthyroidism?

Answer 57

Raised TSH receptor antibodies You would expect TSH levels to be low / undetectable in all hyperthyroid patients. Raised TSH receptor antibodies are present in 90% of patients with Graves’ disease. Anti-TPO and Thyroglobulin antibodies are associated with Hashimoto’s thyroiditis.

Question 58

Justin Clarke presents to the emergency department with decreased GCS. He is a known type 1 diabetic, and friends report he can be a little inconsistent with taking his insulin. His blood glucose level is 27.5, his blood ketone levels are 5.3 and pH on venous blood gas is 7.10. What is your immediate management of Justin?

Answer 58

Commence a fixed-rate insulin infusion + IV fluids This patient fulfils the diagnostic criteria for DKA. He therefore needs fluid resuscitation with careful monitoring of serum potassium and a fixed rate insulin infusion.

Question 59

Commence a fixed-rate insulin infusion + IV fluids Correct answer. This patient fulfils the diagnostic criteria for DKA. He therefore needs fluid resuscitation with careful monitoring of serum potassium and a fixed rate insulin infusion.

Answer 59

- needs to be on effective contraception to avoid pregnancy - should report any symptoms of infection, especially a sore throat urgently to a medical professional - there may be a small risk of pancreatitis with carbimazole

Question 60

what does carbimazole cause

Answer 60

agranulocytosis and neutropenia therefore is important to check the patients FBC

Question 61

in what form does carbimazole come and how often is it taken

Answer 61

it is in tablet form and is taken daily

Question 62

what is diabetes insipidus characterised by

Answer 62

polydipsia, polyuria and formation of inappropriately hypotonic (dilute) urine

Question 63

what are the two types of diabetes insipidus that exist

Answer 63

Two types exist: central DI, due to reduced synthesis or release of arginine vasopressin (AVP) from the hypothalamo-pituitary axis; and nephrogenic DI, due to renal insensitivity to AVP.

Question 64

what are the recognised risk factors for central DI

Answer 64

pituitary surgery, craniopharyngioma, infiltrative pituitary stalk lesions, traumatic brain injury, subarachnoid haemorrhage, congenital hypothalamo-pituitary defects, autoimmune disorders, and Wolfram syndrome

Question 65

what are the risk factors for nephrogenic DI

Answer 65

include lithium therapy, chronic kidney disease, and chronic hypercalcaemia or hypokalaemia.

Question 66

what are both types of DI associated with

Answer 66

hypernatraemia, and this may present as a medical emergency

Question 67

what is the treatment of choice in central DI

Answer 67

the synthetic AVP analogue desmopressin (DDAVP) is the treatment of choice

Question 68

what is the treatment of choice for nephrogenic DI

Answer 68

is treated with an adequate fluid intake; salt restriction and diuretics may help reduce polyuria.

Question 69

what does diabetes insipidus result from

Answer 69

It may result from an absolute or relative deficiency of arginine vasopressin (AVP), also known as antidiuretic hormone (ADH), which is produced by the hypothalamus and secreted via the posterior pituitary, or by resistance to its action within the renal collecting ducts.

Question 70

what are the first line investigations used for diabetes insipidus

Answer 70

urine osmolality serum osmolality serum glucose serum sodium