Blackboard EMQs Endo Flashcards
An 19 year old girl wearing loose clothes comes to see you in your surgery. She is worried because all her friends have started their periods but she hasn’t. On direct questioning she refuses to comment about her eating habits & says that she has put on weight. Her current BMI is 14.
Match the options with the appropriate diagnosis. A. Bullimia nervosa B. Pregnancy C. Obesity D. Grave's disease E. Colonic malignancy F. Cushing's syndrome G. Anorexia nervosa H. Toxic solitary adenoma I. Hypothyroidism J. PCOS K. Bronchial carcinoma
G. Anorexia nervosa
Anorexia nervosa often occurs in women which is a key risk factor. Puberty/adolescence and obsessive personality traits are additional risks. There is a higher incidence reported in western cultures (presumably skinny models on TV, adverts etc…) and studies on immigrants moving to a western culture exhibited a higher incidence. There is also postulated to be a genetic contribution from twin studies.Those who in higher socioeconomic classes are more affected. BMI is usually <17.5 and the patient often has a fear of weight gain and will refuse intervention to gain weight. The patient often fails to acknowledge how thin they are and can indicate how some parts of her body are ‘big’. Amenorrhoea is also a common complaint. Often anorexics eat vegetarian or vegan diets and you should inquire about the patient’s eating habits.There are two subtypes of AN. Restrictive where the patient will diet and exercise or the bingeing/purging types where there is also calorie restriction but ocassional binges and purging afterwards. There is also a tendency to laxative, diuretic and enema abuse.
On examination, the patient may be wearing baggy clothing to conceal their weight. Low fat may lead to protruding bony structures like the scapula and there may be lanugo hair (fine body hair). Signs of vomiting include erosion of enamel and swollen salivary glands, and occassionally scars on the back of the hand (Russell’s sign). The mainstay of treatment is the creation of a structured eating plan with the aim of gaining weight gradually with some form of psychotherapy.
Bulimia nervosa (again, more prevalent in women) is characterised on the other hand by recurrent episodes of binge eating followed by compensatory behaviour (for example, self-induced vomiting, exercise and laxatives) to compensate for the binge. There is a sense of a lack of control during the binge. Patients are usually physically normal. The best treatment for bulimia is considered to be CBT where available.
A 78 year old gentleman with a 40 pack year history of smoking cigarettes presents to your surgery saying that his cough has changed in the last 3 weeks. He’s now coughing all through the day. On direct questioning he admits to having to buy trousers 3 inches smaller than he usually does.
Match the options with the appropriate diagnosis. A. Bullimia nervosa B. Pregnancy C. Obesity D. Grave's disease E. Colonic malignancy F. Cushing's syndrome G. Anorexia nervosa H. Toxic solitary adenoma I. Hypothyroidism J. PCOS K. Bronchial carcinoma
K. Bronchial carcinoma
The 40 pack year history of smoking and weight loss point to a bronchial carcinoma. Initial investigation is with a CXR. Diagnosis relies on pathological confirmation from a tissue sample, often obtained from bronchoscopy. First line treatment aims at surgical resection if possible. Small cell lung cancer is treated with chemotherapy and is associated with SIADH and ectopic ACTH. Non-small cell lung cancer is more often associated with clubbing. Squamous cell carcinoma is associated with PTHrp release and is treated with radiotherapy. Adenocarcinomas are usually located peripherally in the lung and are more common in non-smokers although most cases are still associated with smoking. The paraneoplastic syndromes may include Lambert-Eaton myasthenic syndrome.
A 38 year old female complains of feeling tired all the time. She says that because of this she has put on weight & has been feeling depressed. On examination you note that she is bradycardic, has slow-relaxing reflexes & takes a little while longer to respond to commands.
Match the options with the appropriate diagnosis. A. Bullimia nervosa B. Pregnancy C. Obesity D. Grave's disease E. Colonic malignancy F. Cushing's syndrome G. Anorexia nervosa H. Toxic solitary adenoma I. Hypothyroidism J. PCOS K. Bronchial carcinoma
I. Hypothyroidism
This patient has hypothyroidism. Worldwide, the most common cause is iodine deficiency. Other causes include Hashimoto’s or secondary and tertiary hypothyroidism. It can also result from viral de Quervain’s thyroiditis or postpartum thyroiditis. Symptoms include those mentioned (depression, fatigue, weight gain, bradycardia and sluggish reflexes) as well as others such as constipation, cold intolerance, menstrual problems in females, dry skin and muscle cramps. Diagnosis is based on measurement of TSH and thyroid hormones. Treatment is by replacement of T4 with or without T3 in combination. If the patient has normal T3 and T4 but mildly elevated TSH, this is described as subclinical hypothyroidism.
A 34 year old lady with amenorrhoea comes to see you because she has put on weight in the last 4 months. She says that it is not a lot, but she has had strange desires to eat plain starchy foods & that strong smelling foods make her nauseous.
Match the options with the appropriate diagnosis. A. Bullimia nervosa B. Pregnancy C. Obesity D. Grave's disease E. Colonic malignancy F. Cushing's syndrome G. Anorexia nervosa H. Toxic solitary adenoma I. Hypothyroidism J. PCOS K. Bronchial carcinoma
B. Pregnancy
This patient is pregnant. Always consider this in a presentation of amenorrhoea. In terms of the terminology you may come across in EMQs: a woman who has never been pregnant is a nulligravida, a woman who is pregnant for the first time is a primigravida and a woman in subsequent pregnancies is multiparous. Most women experience symptoms such as cravings for certain foods, nocturia, N&V and tiredness. The weight gain in this question is also a give away. There are also numerous signs associated with pregnancy – you can look these up if you are interested. Home pregnancy tests looks at urinary beta hCG. Some women may not realise they are pregnany for quite a long time and it may be difficult to tell in those who are obese.
A slim 29 year old lady wearing a T-shirt & skirt comes to see you in January. She was wondering what the lump was on one side of her neck. On direct questioning she says her periods have been heavy & irregular. On examination you note that she is tachycardic & has a tremor, but has no abnormalities of her eyes.
Match the options with the appropriate diagnosis. A. Bullimia nervosa B. Pregnancy C. Obesity D. Grave's disease E. Colonic malignancy F. Cushing's syndrome G. Anorexia nervosa H. Toxic solitary adenoma I. Hypothyroidism J. PCOS K. Bronchial carcinoma
H. Toxic solitary adenoma
This is a case of toxic solitary adenoma (a ‘hot’ adenoma). It typically presents with a large nodule in the thyroid gland and hyperthyroidism (in which case the nodule is typically >3cm). TSH is an effective screening test, which will be suppressed in a toxic adenoma (think about the thyroid axis). A thyroid scan shows a hot area and suppression of extranodular thyroid tissue. The hyperthyroidism generally does not remit and definitive treatment is most often with radioactive iodine (I-131). If the patient is pregnant, antithyroid drugs are first line and management should incorporate an MDT ethos. A key risk factor is iodine deficiency. Toxic adenomas are most common in ages 20-40 and radiation and female gender may be additional risk factors. There are no stigmata of Graves’ disease present such as eye abnormalities.
A 62 year old male heavy, long term smoker presenting with infection of a wound which refuses to heal.
Match the investigation results with the patient. A. Low ACTH, normal cortisol B. High ACTH, high cortisol C. High ACTH, low cortisol D. Low ACTH, high cortisol E. Low ACTH, low cortisol F. High ACTH, normal cortisol G. Normal ACTH, high cortisol
B. High ACTH, high cortisol
This wound is refusing to heal because of the high cortisol level, which is as a result of elevated ACTH due to a small cell lung cancer producing it ectopically as part of a paraneoplastic syndrome. Hence, ACTH and cortisol are both high here.
A 72 year old lady under long term therapy with biannual bone density assessment for rheumatoid arthritis.
Match the investigation results with the patient. A. Low ACTH, normal cortisol B. High ACTH, high cortisol C. High ACTH, low cortisol D. Low ACTH, high cortisol E. Low ACTH, low cortisol F. High ACTH, normal cortisol G. Normal ACTH, high cortisol
E. Low ACTH, low cortisol
This patient is on steroids for RA (hence the biannual bone density assessment). The anchor drug for RA is methotrexate which is the most commonly used DMARD. Other DMARDs include leflunomide, sulphasalazine and hydroxychloroquine. Corticosteroids given for RA will suppress the secretion of ACTH by the pituitary gland and as a result cause cortisol to become low.
An 18 year old woman with a bitemporal hemianopia, tiredness, hypoglycaemia and low BP and postural hypotension.
Match the investigation results with the patient. A. Low ACTH, normal cortisol B. High ACTH, high cortisol C. High ACTH, low cortisol D. Low ACTH, high cortisol E. Low ACTH, low cortisol F. High ACTH, normal cortisol G. Normal ACTH, high cortisol
E. Low ACTH, low cortisol
The bitemporal hemianopia suggests a pituitary adenoma compressing the optic chiasm. The patient presents with signs and symptoms of adrenal insufficiency indicating low cortisol. The cause is the pituitary adenoma (this is secondary adrenal insufficiency) leading to low ACTH.
A 43 year old woman who initially presented with a bilateral hemianopia & has gone on to develop Cushingoid signs.
Match the investigation results with the patient. A. Low ACTH, normal cortisol B. High ACTH, high cortisol C. High ACTH, low cortisol D. Low ACTH, high cortisol E. Low ACTH, low cortisol F. High ACTH, normal cortisol G. Normal ACTH, high cortisol
B. High ACTH, high cortisol
A pituitary adenoma here is secreting ACTH. This is Cushing’s disease responsible for most cases of Cushing’s syndrome. Hence, ACTH is high and so is cortisol.
A 55 year old man, whose abdominal CT shows an adrenal adenoma.
Match the investigation results with the patient. A. Low ACTH, normal cortisol B. High ACTH, high cortisol C. High ACTH, low cortisol D. Low ACTH, high cortisol E. Low ACTH, low cortisol F. High ACTH, normal cortisol G. Normal ACTH, high cortisol
D. Low ACTH, high cortisol
This is adrenal Cushing’s where an excess of cortisol is being produced by the adrenal gland adenoma. This excess cortisol suppresses ACTH production.
A 55 year old Asian man complaining of nocturia. Random blood glucose 10.2mmol/l. He is overweight.
Select the most appropriate treatment from the list of options. A. Statin B. Intravenous dextrose C. Laser treatment D. Insulin E. Oral glucose or sugar F. Diet alone G. Blood pressure control H. Oral hypoglycaemic drug I. Bed rest
F. Diet alone
This patient is symptomatic and has a random blood glucose of 10.2. This patient does not quite meet the diagnostic criteria for DM. Symptomatic patients need a single random blood glucose of >11.1 or single fasting glucose of >7. Asymptomatic patients need two separate elevated readings for a diagnosis. Alternatively if there are borderline results, an OGTT can be conducted to see if plasma glucose is raised >11.1 two hours after an oral glucose load of 75g. A patient is said to have impaired fasting glucose if fasting glucose falls between 6.1-6.9. Impaired glucose tolerance is present if plasma glucose 2 hours after oral glucose load in OGTT falls between 7.8-11.0. First line intervention in this situation, and in newly diagnosed DM is diet and lifestyle advice and changes.
A 47 year old man with diabetes for 10 years. At review BP 130/80, glycosylated haemoglobin 8.2% (normal <6.5%), plasma cholesterol 5.7mmol/l (normal 5.2-6.5mmol/l), despite careful dietary intervention
Select the most appropriate treatment from the list of options. A. Statin B. Intravenous dextrose C. Laser treatment D. Insulin E. Oral glucose or sugar F. Diet alone G. Blood pressure control H. Oral hypoglycaemic drug I. Bed rest
H. Oral hypoglycaemic drug
Careful dietary intervention has failed to keep HbA1c in check so the patient will need to be started on an oral hypoglycaemic drug. First line is metformin. It is worth noting that HbA1c values, since June 2011, are no longer expressed as a percentage and are now given in mmol/mol. HbA1c is glycated Hb and provides an estimation of glycaemic control over the life span of red blood cells (around 60 days). Fructosamine is measured instead if there is a Hb disorder or RBC life span is decreased as HbA1c is only reliable if normal Hb is present with normal RBC life spans. Fructosamine is a glycated plasma protein which provides information on glucose levels over the previous 1-3 weeks.
A 52 year old man with diabetes for 15 years. Recently found to have microalbuminuria. Glycosylated haemoglobin 7.2%. BP 150/85. Cholesterol 5.2mmol/l.
Select the most appropriate treatment from the list of options. A. Statin B. Intravenous dextrose C. Laser treatment D. Insulin E. Oral glucose or sugar F. Diet alone G. Blood pressure control H. Oral hypoglycaemic drug I. Bed rest
G. Blood pressure control
BP control with an ACE inhibitor is necessary to reduce progression of diabetic nephropathy. Microalbuminuria is the earliest detectable sign and indicates trace amounts of albumin not detectable with standard urinalysis. If untreated, microalbuminuria will progress to intermittent albuminuria and then to persistent albuminuria which is 5-10 years away from ESRF. The main contributor to the development of diabetic nephropathy is hypertension. Other contributors include poor glycaemic control and renovascular disease such as renal artery stenosis. It is important to test kidney function and urine regularly
A 55 year old woman in diabetic clinic. She has been waiting for 2 hours & starts feeling sweaty & weak
Select the most appropriate treatment from the list of options. A. Statin B. Intravenous dextrose C. Laser treatment D. Insulin E. Oral glucose or sugar F. Diet alone G. Blood pressure control H. Oral hypoglycaemic drug I. Bed rest
E. Oral glucose or sugar
This patient has symptoms of hypoglycaemia, present when glucose drops <3mmol/L. Symptoms include sweating, weakness, drowsiness, palpitations and anxiety. This is a mild case and can be managed with oral glucose or sugar. Patients with either long standing DM or on beta blockers may become unaware of hypoglycaemia and become profoundly hypoglycaemic before symptoms develop. In DM, hypoglycaemia is usually secondary to insulin or oral hypoglycaemics. Non DM causes of hypoglycaemia include insulinomas, alcohol, liver failure and Addison’s disease.
A 22 year old medical student notices that he is thirsty & drinking 3-4 litres of fluid a day while studying for finals. He tests his urine & finds glucose 3+ & ketones 2+.
Select the most appropriate treatment from the list of options. A. Statin B. Intravenous dextrose C. Laser treatment D. Insulin E. Oral glucose or sugar F. Diet alone G. Blood pressure control H. Oral hypoglycaemic drug I. Bed rest
D. Insulin
This young person has presented with T1DM, a condition characterised by absolute insulin deficiency. As a result, insulin treatment is required to prevent DKA and chronic complications of hyperglycaemia. The presentation is most often with polyuria, polydipsia, weight loss and weakness. Ketonuria in the presence of hyperglycaemia suggests T1DM. Ketonuria occurs due to the fact the body has no insulin to drive glucose into the cells and hence ketone bodies are utilised by the brain (fatty acids cannot cross the BBB). Diet, exercise and insulin therapy is crucial in T1DM.
45 year old man with 20 year history of diabetes. For the last few months he has had a burning sensation in his feet.
Select the most likely situation that is described by the following case scenarios. A. Autonomic neuropathy B. Retinopathy C. Peripheral neuropathy D. Hyperosmolar hyperglycaemic state E. Ischaemic heart disease F. Cataract G. Peripheral arterial disease H. Onset type 2 diabetes I. Necrobiosis lipoidica J. Gastroparesis K. Ketoacidosis L. Onset type 1 diabetes M. Nephropathy N. Hypoglycaemia
C. Peripheral neuropathy
This is a case of diabetic peripheral neuropathy. This is a microvascular complication of DM and is characterised by peripheral nerve dysfunction. Pain is a common complaint such as the burning sensation this patient describes. Patient’s may also describe the pain as prickling or sticking. Complications range from the painless neuropathic ulcer at areas of the foot where there is weight loading (particularly the metatarsal heads), to the Charcot foot with severe architectural destruction of the foot. Foot ulceration is a common precusor to amputation. Foot care is crucial in DM. Examination should include peripheral pulses, reflexes and sensation to light touch with a 10g monofilament, vibration (128Hz tuning fork), pinprick and proprioception. The pain may be treated with medications like pregabalin and gabapentin.
72 year old man with diabetes. He has been on insulin for 6 years. His daughter had noticed that he was increasingly vague. He was found unconscious. BP 160/90. Plasma urea, creatinine & electrolytes were normal.
Select the most likely situation that is described by the following case scenarios. A. Autonomic neuropathy B. Retinopathy C. Peripheral neuropathy D. Hyperosmolar hyperglycaemic state E. Ischaemic heart disease F. Cataract G. Peripheral arterial disease H. Onset type 2 diabetes I. Necrobiosis lipoidica J. Gastroparesis K. Ketoacidosis L. Onset type 1 diabetes M. Nephropathy N. Hypoglycaemia
N. Hypoglycaemia
This patient has symptoms of hypoglycaemia, present when glucose drops <3mmol/L. Symptoms include sweating, weakness, drowsiness, palpitations and anxiety. LOC can occur. Patients with either long standing DM or on beta blockers may become unaware of hypoglycaemia and become profoundly hypoglycaemic before symptoms develop. In DM, hypoglycaemia is usually secondary to insulin or oral hypoglycaemics. Non DM causes of hypoglycaemia include insulinomas, alcohol, liver failure and Addison’s disease. How would you manage this patient?
26 year old Asian man is found to have glycosuria. He has been waking up at night to pass urine for 2 months. His father & uncle are both diabetic.
Select the most likely situation that is described by the following case scenarios. A. Autonomic neuropathy B. Retinopathy C. Peripheral neuropathy D. Hyperosmolar hyperglycaemic state E. Ischaemic heart disease F. Cataract G. Peripheral arterial disease H. Onset type 2 diabetes I. Necrobiosis lipoidica J. Gastroparesis K. Ketoacidosis L. Onset type 1 diabetes M. Nephropathy N. Hypoglycaemia
H. Onset type 2 diabetes
The patient’s symptoms and FH argue for type 2 diabetes. There is a significant genetic component in T2DM. Onset is generally preceded by a period of insulin resistance and hyperinsulinaemia before high glucose becomes detectable. There is a high concurrent risk of obesity, dyslipidaemia and hypertension. Lifestyle changes and metformin are indicated in most patients. BP and lipid management are also needed to reduce macrovascular risk and improve prognosis. BP and blood sugars should be managed to reduce the risk of microvascular complications such as retinopathy and nephropathy.
32 year old woman who has been diabetic for 25 years. She can no longer cross a road on her own as she is worried that she may collapse.
Select the most likely situation that is described by the following case scenarios. A. Autonomic neuropathy B. Retinopathy C. Peripheral neuropathy D. Hyperosmolar hyperglycaemic state E. Ischaemic heart disease F. Cataract G. Peripheral arterial disease H. Onset type 2 diabetes I. Necrobiosis lipoidica J. Gastroparesis K. Ketoacidosis L. Onset type 1 diabetes M. Nephropathy N. Hypoglycaemia
A. Autonomic neuropathy
This is diabetic autonomic neuropathy which typically occurs later in the disease course. Patients have a reduced response in HR and BP and postural hypotension occurs due to efferent sympathetic denervation (reduced vasoconstriction of peripheral vascular beds). Patients can feel week, faint, dizzy and light headed and may faint on standing. There may also be GI symptoms from vagal dysfunction. Bladder dysfunction and erectile dysfunction can also occur. Women can complain of a reduced libido and increased pain during sex.
56 year old man with newly diagnosed diabetes is given laser treatment.
Select the most likely situation that is described by the following case scenarios. A. Autonomic neuropathy B. Retinopathy C. Peripheral neuropathy D. Hyperosmolar hyperglycaemic state E. Ischaemic heart disease F. Cataract G. Peripheral arterial disease H. Onset type 2 diabetes I. Necrobiosis lipoidica J. Gastroparesis K. Ketoacidosis L. Onset type 1 diabetes M. Nephropathy N. Hypoglycaemia
B. Retinopathy
This patient has a microvascular complication of diabetes – diabetic retinopathy, for which he has had retinal photocoagulation with a laser. This suggests either macular involvement or proliferative diabetic retinopathy which has necessitated either panretinal laser therapy or macular laser therapy. Diabetic retinopathy, if suspected, is diagnosed on photographing the fundus with digital methods (preferred over a fundoscope). Microaneurysms, cotton wool spots, haemorrhages, hard/lipid exudates and neovascularisation may all be seen depending on the stage. Young onset T1DM is more associated with retinopathy, and additional risks include a longer duration of DM and poor glycaemic control compounded by renal disease and hypertension. There are also ethnic variations in risk.
A 60 year old diabetic lady visits her GP complaining of tingling in her hands. This is worse at night. She describes numbness, and if there is feeling she describes tingling. This is in both hands only; not in her arms.
Match the description to the relevant diagnosis. A. Abducens nerve palsy B. Occulomotor nerve palsy C. Commmon peroneal nerve palsy D. Symmetrical sensory polyneuropathy E. Sciatica F. Diabetic amyotrophy G. Amaurosis fugax H. Charcot joint I. Carpal tunnel syndrome J. Ulnar nerve palsy K. Retinopathy
D. Symmetrical sensory polyneuropathy
Diabetic neuropathy can be autonomic or peripheral. This is a case of diabetic peripheral sensory neuropathy. This is a microvascular complication of DM and is characterised by peripheral nerve dysfunction. The tingling this patient describes is a common complaint and loss of sensation typically occurs in a symmetrical ‘glove and stocking’ distribution. Patient’s may also describe a pain or unpleasant sensation which is prickling, burning or sticking. Examination should include peripheral pulses, reflexes and sensation to light touch, vibration (128Hz tuning fork), pinprick and proprioception. Any pain can be treated with medications like gabapentin.
A 73 year old, previously fit male presents with difficulty ascending stairs. Abnormalities noted on examination are weakness of knee flexion, which is more pronounced on the left with some wasting of the quadriceps & diminished knee reflexes. He is noted to have glycosuria.
Match the description to the relevant diagnosis. A. Abducens nerve palsy B. Occulomotor nerve palsy C. Commmon peroneal nerve palsy D. Symmetrical sensory polyneuropathy E. Sciatica F. Diabetic amyotrophy G. Amaurosis fugax H. Charcot joint I. Carpal tunnel syndrome J. Ulnar nerve palsy K. Retinopathy
F. Diabetic amyotrophy
Diabetic amyotrophy, more common in T2DM, is an uncommon peripheral diabetic neuropathic complaint. It presents with severe muscle weakness and pain with proximal thigh muscle atrophy. This patient’s glycosuria suggests undiagnosed T2DM, which in any case, you can guess he has given the question stem is called ‘Diabetic Complications’. The weak knee flexion and quadriceps wasting is typical of diabetic amyotrophy. The reduced reflexes are another sign of peripheral neuropathy.
A 62 year old male diabetic presents with a bad limp. His wife has forced him to come as he can no longer manage well upstairs. He denies any pain in any joints or the legs and blames old age. You notice that his shoes do not seem to fit well. OE you find that his shoes do not seem to fit well. OE you find that the joint is red, swollen and looks misaligned.
Match the description to the relevant diagnosis. A. Abducens nerve palsy B. Occulomotor nerve palsy C. Commmon peroneal nerve palsy D. Symmetrical sensory polyneuropathy E. Sciatica F. Diabetic amyotrophy G. Amaurosis fugax H. Charcot joint I. Carpal tunnel syndrome J. Ulnar nerve palsy K. Retinopathy
H. Charcot foot
The Charcot foot, not to be confused with Charcot’s disease, occurs in about 1% of diabetics and is a progressive condition marked by severe architectural destruction of the foot. Go have a look at some photos. There are thought to be multiple aetiological factors from the loss of sensation peripherally to increased blood flow to the foot as a result of autonomic dysfunction.
A 66 year old male with type 2 diabetes complains of episodes of loss of vision in the right eye that may last up to 2 hours. On examination he is noted to have an irregularly irregular pulse of 70 beats per minute & a blood pressure of 155/95. Fundoscopy is normal
Match the description to the relevant diagnosis. A. Abducens nerve palsy B. Occulomotor nerve palsy C. Commmon peroneal nerve palsy D. Symmetrical sensory polyneuropathy E. Sciatica F. Diabetic amyotrophy G. Amaurosis fugax H. Charcot joint I. Carpal tunnel syndrome J. Ulnar nerve palsy K. Retinopathy
G. Amaurosis fugax
Amaurosis fugax is a transient and painless loss of vision in one eye due to the passage of an embolus into the central retinal artery. The AF has thrown off a cardiac embolus which has passed into the central retinal artery (resulting in a temporary loss of blood flow to the retina and hence loss of vision). This patient needs to be started on aspirin at once while a definitive treatment of the underlying aetiology is sought (treatment of AF).
Mrs Y describes numbness and paresthesia in her right hand. She describes this as “coming on gradually over months”. The tingling wakes her at night and she has tried changing sleeping positions to no avail. She has come to the doctor now as her hand is becoming weak and she has dropped mugs several times.
Match the description to the relevant diagnosis. A. Abducens nerve palsy B. Occulomotor nerve palsy C. Commmon peroneal nerve palsy D. Symmetrical sensory polyneuropathy E. Sciatica F. Diabetic amyotrophy G. Amaurosis fugax H. Charcot joint I. Carpal tunnel syndrome J. Ulnar nerve palsy K. Retinopathy
I. Carpal tunnel syndrome
Carpal tunnel syndrome is the most common nerve entrapment and women just past middle age are at the highest risk. Symptoms include numbness/tingling of the thumb and radial fingers, an aching wrist and clumsiness (especially with fine motor tasks). The symptoms are of gradual onset and often wake the patient up at night, and is relieved by shaking the wrist. Numbness is normally on the palmar aspect of the thumb, index and middle fingers (but not the little finger). When the patient wakes up, there may be difficulty flexing or extending fingers. Symptoms in the day tend to be associated with activity. The most sensitive and specific test for diagnosis is EMG and can confirm damage to the median nerve in the carpal tunnel and categorise the severity of the damage. There are specific tests for CTS such as Tinel’s test and Phalen’s test, though clinically these are not particularly useful due to sensitivity and specificity.
CTS is caused by anything that causes a reduction in the size of the carpal tunnel – from inflammation, arthritis and tenosynovitis to old fractures. In CTS there is preserved sensation of the palm as the palmar cutaneous branch comes off a few cm above the carpal tunnel.
Remember your anatomy in 2nd year? Probably not… but the median nerve lies in the carpal tunnel, deep to the flexor retinaculum and in the concavity bounded by the carpal bones. Other structures lying in the carpal tunnel include FPL, FDS and FDP.
80 year old presents with symptoms of dysphagia. He has been a lifelong smoker. On examination there is a reducible mass over lateral aspect of the neck.
Choose the most likely diagnosis from the list of options. A. Thyroid goitre B. Thyroiditis C. TB lymphadenitis D. Thyroglossal cyst E. Pharyngeal pouch F. Salivary gland tumour G. Lymphadenopathy secondary to infection H. Glandular fever I. Carotid body tumour J. Parotitis K. Mumps L. Lymphadenopathy secondary to malignancy M. Hodgkin's lymphoma N. Thyroid cancer
E. Pharyngeal pouch
A pharyngeal pouch is also called a Zenker’s diverticulum (it is a false diverticulum – i.e. it does not involve all layers of the oesophageal wall). The dehiscence of Killian lies in the posterior laryngopharynx which is where the wall herniates through giving an outpouching just above the cricopharyngeal muscle. It may help to gave a look at a picture in an anatomy textbook. A pharyngeal pouch can cause symptoms of dysphagia and the sensation of a lump in the neck. There may also be regurgitation of food, cough, halitosis and gurgling noises and the condition is associated with webs. Additionally, it may be asymptomatic. A barium swallow will confirm the dagnosis. Surgical intervetion may be necessary.
An anxious 19 year old female presents with a lump in the neck. She has lost 3kg in 3 months. On examination there is lymphadenopathy on both sides of the neck & larger nodes on the right. Her pulse is 96 regular; thyroid function tests are normal.
Choose the most likely diagnosis from the list of options. A. Thyroid goitre B. Thyroiditis C. TB lymphadenitis D. Thyroglossal cyst E. Pharyngeal pouch F. Salivary gland tumour G. Lymphadenopathy secondary to infection H. Glandular fever I. Carotid body tumour J. Parotitis K. Mumps L. Lymphadenopathy secondary to malignancy M. Hodgkin's lymphoma N. Thyroid cancer
M. Hodgkin’s lymphoma
The history of weight loss here along with cervical lymphadenopathy point to lymphoma. Hodgkin’s is localised to a single group of nodes (normally the cervical and/or supraclavicular) and extranodal involvement is rare. Mediastinal involvement is common. Spread is contiguous and B symptoms may be present such as a low grade fever, weight loss and night sweats. Pruritis may be found in approximately 10% of cases but has no prognostic significance. 50% of cases is associated with EBV infection and distribution is bimodal with peaks in young and old. There is classically pain in lymph nodes on alcohol consumption. While this question does not specifically scream out Hodgkin’s (though the pattern of involvement makes it more likely), the question is not complicated by the option of NHL. Furthermore, this is patient is 19 and unlikely to have head and neck cancer causing local lymphadenopathy and infection does not explain the weight loss over 3 months.
A 17 year old male presents with a 1 week history of fever, malaise, pain on swallowing & has found lumps in the neck. On examination a tender scrotal swelling is also noted.
Choose the most likely diagnosis from the list of options. A. Thyroid goitre B. Thyroiditis C. TB lymphadenitis D. Thyroglossal cyst E. Pharyngeal pouch F. Salivary gland tumour G. Lymphadenopathy secondary to infection H. Glandular fever I. Carotid body tumour J. Parotitis K. Mumps L. Lymphadenopathy secondary to malignancy M. Hodgkin's lymphoma N. Thyroid cancer
K. Mumps
Mumps is normally characterised by the hallmark finding of parotitis and swelling of the parotid gland(s) which is present in 95% of symptomatic mumps. Mumps epididymo-orchitis is also a common feature and is seen here as a tender scrotal swelling. The history this patient gives makes you think of an infection and the co-existent orchitis and neck lumps makes you think of mumps. Treatment of this viral infection involves isolation and supportive care with paracetamol or ibuprofen.
A 58 year old male presents to his GP with a lump in the neck and weight loss. He reports that he suffered from a mild upper respiratory infection in the previous week. On examination there is a hard mobile lump in the supraclavicular fossa.
Choose the most likely diagnosis from the list of options. A. Thyroid goitre B. Thyroiditis C. TB lymphadenitis D. Thyroglossal cyst E. Pharyngeal pouch F. Salivary gland tumour G. Lymphadenopathy secondary to infection H. Glandular fever I. Carotid body tumour J. Parotitis K. Mumps L. Lymphadenopathy secondary to malignancy M. Hodgkin's lymphoma N. Thyroid cancer
L. Lymphadenopathy secondary to malignancy
This 58 year old male reports weight loss. Combined with the presence of Virchow’s node (Troisier’s sign), a hard enlarged node in the left supraclavicular fossa, this points towards a malignancy in the abdominal cavity. The lymph drainage of the abdominal cavity drains into Virchow’s node as the lymph drains most of the body from the thoracic duct and enters the venous circulation at the left subclavian vein. An enlarged right supraclavicular LN may indicate thoracic malignancies such as lung cancer. The mild URTI is a red herring.
An 18 year old girl presents with a midline swelling in the neck which has recently become tender. It moves on swallowing & on protusion of the tongue.
Choose the most likely diagnosis from the list of options. A. Thyroid goitre B. Thyroiditis C. TB lymphadenitis D. Thyroglossal cyst E. Pharyngeal pouch F. Salivary gland tumour G. Lymphadenopathy secondary to infection H. Glandular fever I. Carotid body tumour J. Parotitis K. Mumps L. Lymphadenopathy secondary to malignancy M. Hodgkin's lymphoma N. Thyroid cancer
D. Thyroglossal cyst
This midline neck swelling moves up on both swallowing and tongue protrusion making this a thyroglossal cyst. It is a cyst that forms from a remnant thyroglossal duct and can hence develop anywhere along the length of this embryological duct, which is a midline structure between the foramen caecum at the back of the tongue and the thyroid gland.
A 28 year old woman has developed rapid weight loss & palpitations. You notice lid lag & a goitre on examination.
Choose the most likely diagnosis from the list of options. A. Streptococcus pyogenes B. Carotid artery aneurysm C. Heart failure D. Hypothyroidism E. Hodgkin's disease F. Grave's disease G. TB abscess H. Myasthenia gravis I. De Quervain's thyroiditis J. Superior vena cava syndrome K. Thyroglossal cyst L. Stomach cancer M. Pancreatic carcinoma
F. Grave’s disease
This woman has symptoms of hyperthyroidism (weight loss and palpitations) and a goitre. In countries where sufficient iodine intake is not an issue, Graves’ disease is the most common cause of hyperthyroidism. Graves’ gives a diffuse goitre. Peripheral manifestations such as ophthalmopathy, pretibial myxoedema and hyperthyroid acropachy do not occur with other causes of hyperthyroidism. Ophthalmopathy includes lid retraction, exophthalmos and eye movement restriction leading to diplopia. Acropachy is an uncommon manifestation presenting as clubbing with soft tissue swelling. Pretibial myxoedema is almost always associated with ophthalmopathy. Treatment aims to normalise thyroid function and is achieved by radioactive iodine, antithyroid medications or with surgery. They are all effective and relatively safe options. Symptomatic therapy is given with beta blockers such as propranolol.
A 17 year old man has noticed a painless smooth swelling just above the suprasternal notch. He has had the swelling for 2 years & is well. It moves with swallowing & tongue protusion.
Choose the most likely diagnosis from the list of options. A. Streptococcus pyogenes B. Carotid artery aneurysm C. Heart failure D. Hypothyroidism E. Hodgkin's disease F. Grave's disease G. TB abscess H. Myasthenia gravis I. De Quervain's thyroiditis J. Superior vena cava syndrome K. Thyroglossal cyst L. Stomach cancer M. Pancreatic carcinoma
K. Thyroglossal cyst
This midline neck swelling moves up on both swallowing and tongue protrusion making this a thyroglossal cyst. It is a cyst that forms from a remnant thyroglossal duct and can hence develop anywhere along the length of this embryological duct, which is a midline structure between the foramen caecum at the back of the tongue and the thyroid gland.
A 17 year old girl has developed an acutely painful goitre. She has a fever & pain on swallowing.
Choose the most likely diagnosis from the list of options. A. Streptococcus pyogenes B. Carotid artery aneurysm C. Heart failure D. Hypothyroidism E. Hodgkin's disease F. Grave's disease G. TB abscess H. Myasthenia gravis I. De Quervain's thyroiditis J. Superior vena cava syndrome K. Thyroglossal cyst L. Stomach cancer M. Pancreatic carcinoma
I. De Quervain’s thyroiditis
This girl has de Quervain’s thyroiditis (which can also be called subacute granulomatous thyroiditis) which is inflammation of the thyroid characterised by a triphasic course where there is transient thyrotoxicosis followed by a hypothyroid phase before a return to euthyroidism. The thyrotoxic phase (symptoms of hyperthyroidism may be present) is characterised by pain and tenderness of the thyroid, which tends to be larger, firm and tender to touch. This girl also has a fever and neck pain which is making it painful for her to swallow. This is a self-limiting condition and no specific treatment is needed though NSAIDs and beta blockers can be used for symptomatic relief. Roughly 30-40% describe a prior viral infection.
A 22 year old man has developed multiple hard swellings on the left side of the neck. He has had night sweats & anorexia for 2 months.
Choose the most likely diagnosis from the list of options. A. Streptococcus pyogenes B. Carotid artery aneurysm C. Heart failure D. Hypothyroidism E. Hodgkin's disease F. Grave's disease G. TB abscess H. Myasthenia gravis I. De Quervain's thyroiditis J. Superior vena cava syndrome K. Thyroglossal cyst L. Stomach cancer M. Pancreatic carcinoma
E. Hodgkin’s disease
This is a case of lymphoma. Reed-Sternberg cells are binucleate cells characteristically seen in Hodgkin’s lymphoma. Hodgkin’s is localised to a single group of nodes (normally the cervical and/or supraclavicular) and extranodal involvement is rare. Mediastinal involvement is common. Spread is contiguous and B symptoms may be present such as a low grade fever, weight loss and night sweats. Pruritis may be found in approximately 10% of cases but has no prognostic significance. 50% of cases is associated with EBV infection and distribution is bimodal with peaks in young and old. There is classically pain in lymph nodes on alcohol consumption.
A 67 year old male smoker has developed gross oedema of the neck & face. You also notice swelling of both hands.
Choose the most likely diagnosis from the list of options. A. Streptococcus pyogenes B. Carotid artery aneurysm C. Heart failure D. Hypothyroidism E. Hodgkin's disease F. Grave's disease G. TB abscess H. Myasthenia gravis I. De Quervain's thyroiditis J. Superior vena cava syndrome K. Thyroglossal cyst L. Stomach cancer M. Pancreatic carcinoma
J. Superior vena cava syndrome
SVC syndrome occurs due to SVCO. The most common cause of this is malignancy (this smoker probably has lung cancer which is the most likely cause in those >50). There are also benign causes such as iatrogenically due to pacemaker leads and central venous catheters causing SVC thrombosis. Common symptoms are facial swelling and arm swelling as seen, as well as dyspnoea, cough and facial plethora. There may also be a headache, chest pain, blurry vision and stridor. These symptoms tend to be worse on bending forwards or lying down. The most useful imaging test is a chest CT with IV contrast which establishes the diagnosis and also shows the exact location of the pathology. A CXR in SVCO can show a widened mediastinum or the lung cancer which is the cause.
A 20 year old medical student is concerned about recent weight gain & lethargy & constipation. You notice bradycardia & a goitre. Her ankle reflexes are sluggish. Her periods have stopped.
Choose the most likely diagnosis from the list of options. A. Streptococcus pyogenes B. Carotid artery aneurysm C. Heart failure D. Hypothyroidism E. Hodgkin's disease F. Grave's disease G. TB abscess H. Myasthenia gravis I. De Quervain's thyroiditis J. Superior vena cava syndrome K. Thyroglossal cyst L. Stomach cancer M. Pancreatic carcinoma
D. Hypothyroidism
This medical student has hypothyroidism. Worldwide, the most common cause is iodine deficiency. Other causes include Hashimoto’s or secondary and tertiary hypothyroidism. It can also result from viral de Quervain’s thyroiditis or postpartum thyroiditis. Symptoms include those mentioned (weight gain, lethargy, sluggish reflexes, bradycardia and constipation) as well as depression, fatigue, constipation, cold intolerance, menstrual problems in females, dry skin and muscle cramps. Diagnosis is based on measurement of TSH and thyroid hormones. Treatment is by replacement of T4 with or without T3 in combination. If the patient has normal T3 and T4 but mildly elevated TSH, this is described as subclinical hypothyroidism.
A 72 year old man with weight loss has developed a hard swelling in the left supraclavicular fossa.
Choose the most likely diagnosis from the list of options. A. Streptococcus pyogenes B. Carotid artery aneurysm C. Heart failure D. Hypothyroidism E. Hodgkin's disease F. Grave's disease G. TB abscess H. Myasthenia gravis I. De Quervain's thyroiditis J. Superior vena cava syndrome K. Thyroglossal cyst L. Stomach cancer M. Pancreatic carcinoma
l. Stomach cancer
The presence of Virchow’s node (Troisier’s sign), a hard enlarged node in the left supraclavicular fossa, points towards a malignancy in the abdominal cavity. This is most often stomach cancer. The lymph drainage of the abdominal cavity drains into Virchow’s node as the lymph drains most of the body from the thoracic duct and enters the venous circulation at the left subclavian vein.
12 yr old boy presents with 4 weeks weight loss, polyuria and polydipsia.
Choose the most likely investigation from the list. A. ACTH (synacthen) stimulation test B. Dexamethasone suppression test C. Liver function tests D. Abdominal ultrasound E. Fasting blood glucose F. Full blood count G. Water deprivation test H. Dietary history I. T3, T4 and TSH levels J. Urinary ketones K. Serum creatinine L. Serum aldosterone M. HbA1c levels
E. Fasting blood glucose
For the diagnosis of DM, symptomatic patients need a single random blood glucose of >11.1 or single fasting glucose of >7. Asymptomatic patients need two separate elevated readings for a diagnosis. Alternatively if there are borderline results, an OGTT can be conducted to see if plasma glucose is raised >11.1 two hours after an oral glucose load of 75g. A patient is said to have impaired fasting glucose if fasting glucose falls between 6.1-6.9. Impaired glucose tolerance is present if plasma glucose 2 hours after oral glucose load in OGTT falls between 7.8-11.0. This patient most likely has new onset T1DM.
44 yr old woman presents with tachycardia, atrial fibrillation, double vision and swelling above her ankles. She has lid lag on examination.
Choose the most likely investigation from the list. A. ACTH (synacthen) stimulation test B. Dexamethasone suppression test C. Liver function tests D. Abdominal ultrasound E. Fasting blood glucose F. Full blood count G. Water deprivation test H. Dietary history I. T3, T4 and TSH levels J. Urinary ketones K. Serum creatinine L. Serum aldosterone M. HbA1c levels
I. T3, T4 and TSH levels
This patient has Graves’ disease. T3, T4 and TSH need to be measured. We would expect to find a suppressed TSH with elevated T3 and T4 (unless in T3 toxicosis).
42 yr old man has hypertension, hyperglycaemia, myopathy, thinning of skin, buffalo hump and truncal obesity.
Choose the most likely investigation from the list. A. ACTH (synacthen) stimulation test B. Dexamethasone suppression test C. Liver function tests D. Abdominal ultrasound E. Fasting blood glucose F. Full blood count G. Water deprivation test H. Dietary history I. T3, T4 and TSH levels J. Urinary ketones K. Serum creatinine L. Serum aldosterone M. HbA1c levels
B. Dexamethasone suppression test
This patient has Cushing’s and will need a dexamethasone suppression test which is first line in anyone with suspected Cushing’s (unless they are on medications which will affect the result of the test), though alternatively a 24 hour urinary free coritsol and late night salivary cortisol can be done. The dexamethasone suppression test takes the form of either an overnight 1mg or a 48 hour 2mg test. Unsuppressed cortisol indicates Cushing’s syndrome.
18 yr old girl complains of her appearance. She is much too fat according to her. She also missed periods and has become hairier. On examination she is 10kg overweight.
Choose the most likely investigation from the list. A. ACTH (synacthen) stimulation test B. Dexamethasone suppression test C. Liver function tests D. Abdominal ultrasound E. Fasting blood glucose F. Full blood count G. Water deprivation test H. Dietary history I. T3, T4 and TSH levels J. Urinary ketones K. Serum creatinine L. Serum aldosterone M. HbA1c levels
D. Abdominal ultrasound
This patient’s history makes you think PCOS. Hirsutism, irregular and infrequent periods and weight gain are all features, as are acne, scalp hair loss and infertility. Hypertension is sometimes associated with this syndrome. On examination, sweaty/oily skin may be found and acanthosis nigricans may also be seen. An ultrasound is by no means the first test to order, as 1/4 of normal women and women with other problems like hyperprolactinaemia may also have polycystic ovaries, and they are present in 3/4 of those with PCOS. Serum androgens can be measured or the diagnosis can be made clinically.
34 yr old old man with insidious onset weakness and weight loss. On examination he has hyperpigmentation of the palmar creases and postural hypotension.
Choose the most likely investigation from the list. A. ACTH (synacthen) stimulation test B. Dexamethasone suppression test C. Liver function tests D. Abdominal ultrasound E. Fasting blood glucose F. Full blood count G. Water deprivation test H. Dietary history I. T3, T4 and TSH levels J. Urinary ketones K. Serum creatinine L. Serum aldosterone M. HbA1c levels
A. ACTH (synacthen) stimulation test
Hyperpigmentation in the palmar creases points towards Addison’s disease. Hyperpigmentation due to excess ACTH production can be mucosal or cutaneous and is more pronounced in the palms, knuckles and around scars. MSH is a byproduct of the production of ACTH from the cleavage of POMC. Sodium is low and potassium elevated. Vomiting is present in 75% of patients and nausea is a common finding. Additionally, postural hypotension may be present. The presence of other autoimmune diseases is a risk factor for the development of Addison’s. Diagnosis of Addison’s can be made on an ACTH stimulation test (synacthen test) whereby serum cortisol remains low despite the administration of synthetic ACTH. In an emergency, treatment should not be delayed by diagnostic testing.
64 yr old woman complaining of severe back pain for some weeks. For the last few days she has been very constipated and has been vomiting for 24 hours. She has been a smoker for many years and has had 3 courses of antibiotics for chest infections over the last 3 months.
For each patient choose a the most likely diagnosis from the list of options. A. Hyponatraemia B. Hypernatraemia C. Hypercalcaemia D. Hypothyroidism E. Hypercapnia F. Addisons disease G. Metabolic acidosis H. Hypoglycaemia I. Hypermagnesaemia J. Hypokalaemia K. Hyperkalaemia L. Hypocalcaemia
C. Hypercalcaemia
90% of hypercalcaemia is caused by primary hyperparathyroidism or cancer. Cancer is the likely cause in this woman. Malignancy can cause hypercalcaemia either by direct bony involvement leading to osteolytic lesions or paraneoplastic syndromes involving PTHrp release. The tumour is typically very advanced if hypercalcaemia is a feature. Less common causes include vitamin D overdose, hyperthyroidism, immobilisation, Paget’s and milk-alkali syndrome. The classic bone disease in hyperparathyroidism is osteitis fibrosa cystica which causes pain. Symptoms of high calcium include confusion, constipation, polyuria, polydipsia, depression, kidney stones and lethargy. This can be remembered by ‘stones, bones, abdominal groans and psychiatric moans’. The serum PTH level is elevated in primary hyperparathyroidism whereas it may be very low in malignancy due to negative feedback.
21 yr old woman has been complaining of increasing tiredness and feeling thirsty. Over the last day she had been confused. On arrival in A&E she was noted to have deep sighing respiration.
For each patient choose a the most likely diagnosis from the list of options. A. Hyponatraemia B. Hypernatraemia C. Hypercalcaemia D. Hypothyroidism E. Hypercapnia F. Addisons disease G. Metabolic acidosis H. Hypoglycaemia I. Hypermagnesaemia J. Hypokalaemia K. Hyperkalaemia L. Hypocalcaemia
G. Metabolic acidosis
90% of hypercalcaemia is caused by primary hyperparathyroidism or cancer. Cancer is the likely cause in this woman. Malignancy can cause hypercalcaemia either by direct bony involvement leading to osteolytic lesions or paraneoplastic syndromes involving PTHrp release. The tumour is typically very advanced if hypercalcaemia is a feature. Less common causes include vitamin D overdose, hyperthyroidism, immobilisation, Paget’s and milk-alkali syndrome. The classic bone disease in hyperparathyroidism is osteitis fibrosa cystica which causes pain. Symptoms of high calcium include confusion, constipation, polyuria, polydipsia, depression, kidney stones and lethargy. This can be remembered by ‘stones, bones, abdominal groans and psychiatric moans’. The serum PTH level is elevated in primary hyperparathyroidism whereas it may be very low in malignancy due to negative feedback.
56 yr old man who had been on amiodarone for 2 years for atrial fibrillation complained of increasing tiredness. He had gained 5kg in weight over the last 6 months. His wife complained that he felt cold even in a warm room.
For each patient choose a the most likely diagnosis from the list of options. A. Hyponatraemia B. Hypernatraemia C. Hypercalcaemia D. Hypothyroidism E. Hypercapnia F. Addisons disease G. Metabolic acidosis H. Hypoglycaemia I. Hypermagnesaemia J. Hypokalaemia K. Hyperkalaemia L. Hypocalcaemia
D. Hypothyroidism
Amiodarone can cause both hyperthyroidism (Jod-Basedow effect) and hypothyroidism (Wolff-Chaikoff effect). Amiodarone is 37.3% iodine by weight and is structurally similar to thyroxine.
22 yr old woman was admitted with abdominal pain. Her mother had pernicious anaemia. On examination vitiligo was noted and the creases of her palms appeared dark. BP was 100/50 lying and 80/60 standing.
For each patient choose a the most likely diagnosis from the list of options. A. Hyponatraemia B. Hypernatraemia C. Hypercalcaemia D. Hypothyroidism E. Hypercapnia F. Addisons disease G. Metabolic acidosis H. Hypoglycaemia I. Hypermagnesaemia J. Hypokalaemia K. Hyperkalaemia L. Hypocalcaemia
F. Addison’s disease
The presence of other autoimmune diseases such as T1DM, RA, vitiligo are all risk factors to the development of Addison’s. There is also a FH of pernicious anaemia. Postural hypotension and hyperpigmentation in the palmar creases all point towards Addison’s disease. Hyperpigmentation due to excess ACTH production can be mucosal or cutaneous and is more pronounced in the palms, knuckles and around scars. MSH is a byproduct of the production of ACTH from the cleavage of POMC. If serum electrolytes were done, sodium would be low and potassium elevated.
43 yr old woman, 24 hours after a total thyroidectomy for Grave’s disease develops stridor and carpo-pedal spasm.
For each patient choose a the most likely diagnosis from the list of options. A. Hyponatraemia B. Hypernatraemia C. Hypercalcaemia D. Hypothyroidism E. Hypercapnia F. Addisons disease G. Metabolic acidosis H. Hypoglycaemia I. Hypermagnesaemia J. Hypokalaemia K. Hyperkalaemia L. Hypocalcaemia
L. Hypocalcaemia
Hypocalcaemia can develop as a complication of thyroid surgery due to the loss of parathyroid glands which produce PTH. Trousseau’s sign is carpal spasm when a blood pressure cuff is used for several minutes. Carpopedal spasm that occurs with hypocalcaemia is a painful spasm and could be the presenting sign. Chvostek’s sign is twitching of the perioral muscles in response to tapping over the facial nerve at the ear. If urgent replacement is necessary, calcium gluconate can be given IV. It is preferred over calcium chloride as it causes less tissue necrosis if it leaks out. It is worth noting that digoxin may be ineffective until serum calcium is restored to normal.
60 year old T2DM presents with gradually worsening diabetes despite maximum oral medication. He has ketones in his urine and is unwell.
Match the appropriate treatment to these scenarios. A. Insulin B. Gliclazide C. Acarbose (Alpha glucosidase inhibitor) D. Diet and exercise E. Glucagon F. Diet and exercise G. Insulin H. Pioglitazone (Thiazolidinedione) I. Repaglinide (Meglitinide) J. Metformin
G. Insulin
Insulin therapy is recommended in T2DM not controlled on 2 oral agents and is usually started with basal insulin at night time (such as glargine and detemir, your long acting insulins). In any case, this patient is getting worse despite maximum oral medication, which may have included even a third non-insulin agent such as a DPP-4 inhibitor. Many patients will also need rapid acting insulin (such as lispro and aspart) before each meal. There are also other options for basal-bolus regimes such as intermediate acting insulin (NPH) and short-acting insulins. Metformin can be continued but sulphonylurea should be tapered as insulin doses increase. Flexible dosing is the preferred regime but pre-mixed insulin is an option. Insulin can also be used at the time for diagnosis in cases of marked hyperglycaemia. Self-monitored blood glucose testing will be necessary too and side effects include weight gain and hypoglycaemia.
This question requires you to have some knowledge of the stratified glycaemic management for DM. The general goal is HbA1c <7% (from 2011, these values are expressed in mmol/mol, so this would be <53 mmol/mol). HbA1c is glycated Hb and provides an estimation of glycaemic control over the life span of red blood cells (around 60 days).
BP control with an ACE inhibitor, lipid control with a statin, lifestyle changes and stopping smoking are all crucial in the treatment of T2DM and to try to reduce the mortality associated with macrovascular complications. First line intervention in newly diagnosed diabetes is diet and lifestyle advice and changes. If this fails to keep blood sugars in check then the patient will need to be started on an oral hypoglycaemic, and the first line is metformin. Metformin is a biguanide and suppresses hepatic glucose production.
An overweight 45 year old man who was diagnosed with diabetes a few months ago still has fasting glucose of 11 and HbA1C of 8.8%
Match the appropriate treatment to these scenarios. A. Insulin B. Gliclazide C. Acarbose (Alpha glucosidase inhibitor) D. Diet and exercise E. Glucagon F. Diet and exercise G. Insulin H. Pioglitazone (Thiazolidinedione) I. Repaglinide (Meglitinide) J. Metformin
J. Metformin
It has been a few months already, and we can assume that diet and lifestyle changes have not had an effect. This patient will need to be started on metformin.
56 yr old man with diabetes who is on maximum therapy of gliclazide needs higher control but is unable to tolerate metformin or acarbose and refuses any injections
Match the appropriate treatment to these scenarios. A. Insulin B. Gliclazide C. Acarbose (Alpha glucosidase inhibitor) D. Diet and exercise E. Glucagon F. Diet and exercise G. Insulin H. Pioglitazone (Thiazolidinedione) I. Repaglinide (Meglitinide) J. Metformin
H. Pioglitazone (Thiazolidinedione)
This man is on a sulphonylurea which is an insulin secretagogue. It is an old drug with a long track record and is being used in this case as the patient does not tolerate metformin, which would otherwise have been first line. Sulphonylureas can cause hypoglycaemia. They act at the pancreas by blocking ATP sensitive potassium channels which leads to beta cell depolarisation and calcium influx, which causes increased insulin release. They also act on peripheral insulin receptors and have hepatic effects. This man is on maximum therapy of gliclazide and is refusing any injections so this rules out insulin therapy so we must consider non-insulin agents as add-ons. These include alpha glucosidase inhibitors (but our patient also cannot tolerate acarbose), DPP-4 inhibitors (‘gliptins’), GLP1 agonists (exenatide) or TZDs. The latter is the only available option on the list.
