ENDO

Question 1

Commonest cause of acromegaly

Answer 1

Benign growth hormone secreting pituitary adenoma

Question 2

DDx acromegaly

Answer 2

Cushings
Hypothyroidism

Question 3

Signs of active disease

Answer 3

Headache
Visual field defect
Sweating

HTN
Hyperglycaemia

Question 4

Associated conditions

Answer 4

Diabetes mellitus

Question 5

Complications to look for A-M

Answer 5

Acanthosis nigricans
BP raised
CTS
DM
Enlarged organs
Field defect (BTH)
Goitre, GI malignancy
HF, Hirsute, hypopituitarism
IGF 1 raised
Joint arthropathy
Kyphosis
Lactation
Myopathy (proximal)

Question 6

Investigations to diagnose acromegaly

Answer 6

Serum IGF-1
Non suppression of GH after OGTT
MRI pituitary fossa

Question 7

Ix for complications of acromegaly

Answer 7

CXR (cardiomegaly/ heart failure)
ECG (ischaemia, DM and HTN)
Echo
Pituitary function testing (LH/FSH, TSH, ACTH, PRL)
Visual perimetry
OSA (polysomnography)

Colonoscopy

Question 8

Anterior pituitary hormones

Answer 8

LH/FSH
Prolactin
TSH
ACTH
GH
MSH

Question 9

What syndrome could acromegaly be assocaited with?

Answer 9

MEN 1

Question 10

Outline the MEN syndromes

Answer 10

MEN 1: Pituitary, parathyroid, pancreatic
MEN2a: parathyroid, phaeo, MTC
MEN 2b: Mucosal neuromas, Marfanoid, MTC, phaeo

Question 11

Examination of hands in acromegaly

Answer 11

Sweating
Pulse
Coarse, spade like hands
CTS release scar
Sensation over lateral 3.5 fingers
Tinel’s and Phalen’s
Wasting of thenar eminance
Weakness of opposition and thumb abduction

Question 12

Possible findings on cardiovascular examination of a patient with Acromegaly

Answer 12

Irregularly irregular HR, HTN, Displaced apex beat, S3, bibasal crackles

Question 13

Why may prolactin be raised in acromegaly?

Answer 13

1/3 of patients will have pituitary adenoma that secretes both PRL and GH

Question 14

Bedside tests acromegaly

Answer 14

BP
Urine dip
CBG
Fundoscopy (hypertensive or diabetic retinopathy)
ECG

REVIEW OLD PHOTOGRAPHS

Question 15

Blood tests in acromegaly

Answer 15

Serum IGF1
OGTT and GH measurement
TFTs (differential of hypothyroidism)
BM and hba1c
BONE PROFILE FOR CALCIUM!!!
BNP

Question 16

Management of acromegaly

Answer 16

Non-pharmacological
MDT: Endocrinologist, specialist nurses, support groups and psychologist, PT/OT
DVLA if driving impairment from vision

dietary and lifestyle advice to minimise CVS risk factors

Medical
Somatostatin analogues: octreotide
Dopamine agonists - cabergoline
GH receptor antagonist - pegvisomant

Surgical - 1st line Transsphenoidal hypophysectomy
Radiotherapy if non surgical candidate

Question 17

Complications of transsphenoidal surgery

Answer 17

Diabetes insipidus
Meningitis
Panhypopituitarism

Question 18

What test used to monitor response to treatment in acromegaly?

Answer 18

IGF-1

Question 19

Macroglossia DDx

Answer 19

Downs syndrome
acromegaly
Hypothyroidism
Amyloidosis

Question 20

Acanthosis nigricans ddx

Answer 20

DM
Obesity
CUshing’s
Acromegaly
Ethnicity
Malignancy

Question 21

How can the causes of cushing;s syndrome be classified?

Answer 21

ACTH dependent
ACTH independent

Question 22

ACTH dependent causes

Answer 22

ACTH-secreting pituitary adenoma (cushing’s disease)

Ectopic ACTH secretion e.g. small cell lung cancer

Question 23

ACTH independent

Answer 23

Iatrogenic (RA, asthma. COPD)
Adrenocortical adenomas or carcinomas

Question 24

what is cushing’s syndrome

Answer 24

A collection of signs and symptoms secondary to excess glucocorticoid

Question 25

When would a cushing's pateint also exhibit hyperpigmentation?

Answer 25

Only when there is excess ACTH

Question 26

Neurological signs in Cushing's

Answer 26

proximal myopathy bitemporal hemianopia

Question 27

Cushing's DDx

Answer 27

Hypothyroidism Acromegaly Pseudo-Cushing's

Question 28

Cushing's investigations to confirm diagnosis

Answer 28

24hr urinary cortisol collection Low dose dexamethasone suppression test

Question 29

Investigations to localise lesion in cushings

Answer 29

ACTH level High: ectopic ACTH secreting tumour or pituitary adenoma Low: adrenal adenoma/carcinoma MRI pituitary fossae Adrenal CT +/- whole body CT Bilateral inferior petrosal sinus vein sampling - lateralise pituitary adenoma and confirm if pituitary or adrenal cause High dose-dex suppression Cortisol will fall in ACTH dependent Cushing's disease but not in ectopic ACTH secretion or adrenal adenoma/carcinoma

Question 30

Bedside tests in Cushing's

Answer 30

Obs (BP) BM Urine dip for glucose ECG: IHD VBG: hypokalaemic metabolic alkalosis Bloods: FBC, UE, LFT, Hba1c, lipids CXR: underlying lung lesion Fundoscopy (Cataracts)

Question 31

Cushing's management

Answer 31

MDT Non-pharm: patient education, lifestyle support to minimise CVS risks, psychologists, endocrinologist Medical: Anti-glucocorticoids e.g. metyrapone Surgical (1st line): transsphenoidal hypophysectomy adrenalectomy pituitary irradiation

Question 32

scars to look for in patient with previous cushing's syndrome

Answer 32

bilateral adrenalectomy scars

Question 33

complication of bilateral adrenalectomy

Answer 33

nelson's

Question 34

what is nelson's?

Answer 34

Bilateral adrenalectomy for cushing's causing massive production of ACTH (And MSH) due to lack of -ve feedback -> hyperpigmentation and pituitary overgrowth (pronouncedBTH)

Question 35

Define osteoporosis

Answer 35

DEXA scan -> bone densite > 2.5 standard deviations below from the mean value of a healthy young individual (T-score)

Question 36

Inherited causes of proximal myopathy

Answer 36

Myotonic dystrophy Muscular dystrophy

Question 37

Endocrine causes of proximal myopathy

Answer 37

Cushings Hyperparathyroidism Thyrotoxicosis Diabetic amyotrophy

Question 38

Inflammatory causes of proximal myopathy

Answer 38

Polymyositis Rheumatoid arthritis

Question 39

Metabolic causes of proximal myopathy

Answer 39

Osteomalacia

Question 40

Malignancy causes of proximal myopathy

Answer 40

Paraneoplastic LEMS

Question 41

Drug causes of proximal myopathy

Answer 41

Alcohol Statins Steroids