Endo

Question 1

Secondary causes of DM

Answer 1

Drugs: steroids, ART, antipsychotics, thiazides
Pancreatic: CF, chronic pancreatitis, pancreatic cancer
Endo: phaeo, Cushings, acromegaly, thyrotox
Other: glycogen storage diseases, PCOS

Question 2

Metabolic syndrome

Answer 2

Central obesity and two of:
increased triglycerides
decreased HDL
HTN
Hyperglycemia (DM, IGT, IFG)

Question 3

Diabetes lifestyle management

Answer 3

DELAAYS
Diet - increased complex carbs and soluble fibre, reduced fat and sodium
Exercise
Lipids - statins
ABP - reduce sodium and EtOH and keep BP <130/80 with ACEi doing this best (B-b masks hypos and thiazide increases glucose)
Aspirin - for all > 50 or under 50 and have CV RF
Yearly / 6 monthly follow-up
smoking cessation

Question 4

Diabetes management

Answer 4

1. DELAAYS
2. Metformin (C/I: GFR<30, tissue hypoxia (sepsis/MI as lactate increases), morning before GA and contrast)
3. Metformin + sulfonylurea (gliclazide taken with breakfast)
4. can add insulin OR sitagliptin/exenatide if obese or employment/social issues with insulin

Question 5

Insulin regimes

Answer 5

BD Biphasic Regime
 BD insulin mixture 30min before breakfast and dinner
 Rapid-acting: e.g. actrapid
 Intermediate- / long-acting: e.g. insulatard
 T2 or T1 DM with regular lifestyle: children, older pts.
 Assoc, with fasting hyperglycaemia

Basal-Bolus Regime
 Bedtime long-acting (e.g. glargine) + short acting
before each meal (e.g. lispro)
 Adjust dose according to meal size
 ~50% of insulin given as long-acting
 T1DM allowing flexible lifestyle
 Best outcome

OD Long-Acting Before Bed
 Initial regime when switching from tablets in T2DM

Question 6

Diabetic retinopathy

Answer 6

Background Retinopathy
 Dots: microaneurysms
 Blot haemorrhages
 Hard exudates: yellow lipid patches

Pre-proliferative Retinopathy
 Cotton-wool spots (retinal infarcts)
 Venous beading
 Haemorrhages

Proliferative Retinopathy
 New vessels
 Pre-retinal or vitreous haemorrhage

Maculopathy
 ↓ acuity may be only sign
 Hard exudates w/i one disc width of macula

Question 7

Diabetic neuropathy

Answer 7

Peripheral Neuropathy:
Includes absent ankle jerk which is treated paracetamol/ amitriptyline/ gabapentin/ baclofen

Mononeuritis multiplex:
e.g. CN3/6 palsies

Femoral Amyotrophy:
 Painful asymmetric weakness and wasting of quads with loss of knee jerks
 Dx: nerve conduction and electromyography

Autonomic Neuropathy
 Postural hypotension – Rx: fludrocortisone
 Gastroparesis → early satiety, GORD, bloating
 Diarrhoea: Rx c¯ codeine phosphate
 Urinary retention
 ED

Question 8

Causes of hypos

Answer 8

EXPLAIN
 Exogenous drugs (insulin or sulphonyl)
 Pituitary insufficiency
 Liver failure
 Addison’s
 Islet cell tumours (insulinomas)
 Immune (insulin receptor Abs: Hodgkin’s)
 Non-pancreatic neoplasms: e.g. fibrosarcomas

Question 9

Cause from Ix for hypo

Answer 9

Look at ketones, C-peptide and insulin

Hyperinsulinaemic hypoglycaemia
 Drugs: ↑ C-pep = sulfonylurea; normal C-pep = insulin
 Insulinoma (MEN1)

↓ insulin, no ketones
 Non-pancreatic neoplasms
 Insulin receptor Abs

↓ insulin, ↑ ketones
 Alcohol binge with no food
 Pituitary insufficiency
 Addison’s

Question 10

Hypo Mx

Answer 10

Alert and Orientated: Oral Carb
 Rapid acting: lucozade
 Long acting: toast, sandwich

Drowsy / confused but swallow intact: Buccal Carb
 Hypostop / Glucogel
 Consider IV access

Unconscious or Concerned re Swallow: IV dextrose
 100ml 20% glucose (50ml 50% dextrose: not used)

Deteriorating / refractory / insulin-induced / no access:
 1mg glucagon IM/SC
 Won’t work in drunks + short duration of effect (20min)
 Insulin release may → rebound hypoglycaemia

Question 11

Thyroid storm Rx

Answer 11

1. Fluid resuscitation + NGT
2. Bloods: TFTs + cultures if infection suspected
3. Propranolol PO/IV
4. Digoxin may be needed
5. Carbimazole then Lugol’s Iodine 4h later to inhibit thyroid
6. Hydrocortisone
7. Rx cause

Question 12

Causes of hypothyroidism

Answer 12

Primary:

1. Atrophic thyroiditis: most common in UK; antibodies but no goitre, associated with pernicious anaemia, vitiligo
2. hashimoto’s thyroiditis: TPO +ve with goitre
3. Iodine deficiency
4. Post de quervain’s thyroiditis

Post-surgical
Secondary to hypopituitarism

Question 13

Myxoedema coma features

Answer 13

 Looks hypothyroid
 Hypothermia
 Hypoglycaemia
 Heart failure: bradycardia and ↓BP
 Coma and seizures

Question 14

Myxoedema coma Mx

Answer 14

 Bloods: TFTs, FBC, U+E, glucose, cortisol
 Correct any hypoglycaemia
 T3/T4 IV slowly (may ppt. myocardial ischaemia)
 Hydrocortisone 100mg IV
 Rx hypothermia and heart failure

Question 15

Plummer’s vs multinodular goitre

Answer 15

Multinodular goitre evolves from simple goitre caused by iron deficiency or autoimmune; it usually is euthyroid or subclinical hyperthyroidism

Plummer’s is a toxic multinodular goitre where one of the nodules becomes toxic, so can cause thyrotox and will show uneven uptake on hot nodule

Question 16

Graves Ab

Answer 16

anti-TSH (T2 hypersensitivity)

Question 17

Hashimoto’s thyroiditis Ab

Answer 17

anti-TPO, anti-Tg (T2 and T4 hypersensitivity)

Question 18

de Quervain’s Ag

Answer 18

usually caused by Coxsackie virus; shows reduced iodine uptake

Question 19

Subacute lymphocytic thyroid disease

Answer 19

Diffuse painless goitre
May occur post-partum
Thyrotoxicosis → hypo→eu

Question 20

Riedel’s thyoiditis

Answer 20

Hard fixed thyroid mass
Mass effects only (dysphagia, obstruction etc)
Assoc. with retroperitoneal fibrosis

Question 21

Follicular adenoma

Answer 21

Single thyroid nodule ± thyrotoxicosis (majority are cold); treat with hemi-thyroidectomy

Question 22

thyroid cyst

Answer 22

Solitary thyroid nodule
Asympto or pressure symptoms
Can → localised pain due to cyst bleed
Rx: aspiration or excision

Question 23

Thyroid cancer

Answer 23

Papillary is most common, mainly affects 20-40y.o., which spreads to jugulodigastric lymph node or lung
Follicular (bones or lung mets) and papillary stem from follicular cells and have Tg as tumour marker

Medullary associated with MEN2, so must do phaeo screen pre-op. Stem from parafollicular C-cells and use CEA snd calcitonin as tumour markers

Anasplastic are undifferentiated follicular cells that are sen in elderly (>60) and have rapid aggressive growth

Question 24

Risk factors for malignancy in thyroid nodules

Answer 24

 Solitary
 Solid
 Younger
 Male
 Cold (non-functional)
 Risk factor: e.g. radiation exposure

Question 25

Complications of thyroid surgery (usually a collar incision)

Answer 25

Early  Reactionary haemorrhage → haematoma (<1%)  Laryngeal oedema  Recurrent laryngeal nerve palsy (0.5%) (Right RLN more common - oblique ascent)  Hypoparathyroidism (2.5%) → ↓ Ca2+ → Chvostek’s and Trousseau’s  Thyroid storm - Rx: propranolol, antithyroid drugs, Lugol’s Late:  Hypothyroidism  Recurrent hyperthyroidism  Keloid scar

Question 26

Ix and Rx for primary hyperparathyroidism

Answer 26

 ↑Ca2+ + ↑ or inappropriately normal PTH, ↑ALP, ↓PO4  ECG: ↓QTc → bradycardia → 1st degree block  X-ray: osteitis fibrosa cystica → phalangeal erosions  DEXA: osteoporosis Treat hypercalcaemia with:  ↑ fluid intake  Avoid dietary Ca2+ and thiazides (↑ serum Ca) Can remove adenoma but risk of hypoparathyroidism and recurrent laryngeal nerve palsy

Question 27

Hypoparathyroidism Causes

Answer 27

 Autoimmune  Congenital: DiGeorge (CATCH22)  Iatrogenic: Surgery; radiation Rx: ca supplements and calcitriol

Question 28

Pseudohypoparathyroidism

Answer 28

 Failure of target organ response to PTH  Symptoms of hypocalcaemia  Short 4th and 5th metacarpals, short stature  Ix: ↓Ca, ↑PTH  Rx: Ca supplements + calcitriol

Question 29

ACTH independent causes (low ACTH)

Answer 29

```  Iatrogenic steroids: commonest cause  Adrenal adenoma / Ca: carcinoma often → virilisation  Adrenal nodular hyperplasia  Carney complex: LAME Syndrome  McCune-Albright ```

Question 30

ACTH dependent causes (high ACTH)

Answer 30

Cushing’s disease:  Bilat adrenal hyperplasia from ACTH-secreting pituitary tumour (basophilic microadenoma)  Cortisol suppression occurs with high-dose dex Ectopic-ACTH: excise tumour and give metyrapone  SCLC  Carcinoid tumour  Skin pigmentation, metabolic alkalosis, wt. loss, hyperglycaemia  No suppression with any dose of dex

Question 31

Nelson's syndrome

Answer 31

 Rapid enlargement of a pituitary adenoma following bilateral adrenelectomy for Cushing’s syndrome  Not typically performed nowadays Presentation:  Mass effects: bitemporal hemianopia  Hyperpigmentation

Question 32

Primary hyperaldosteronism causes; Ix; Rx

Answer 32

High BP and hypokalaemia ``` Bilateral adrenal hyperplasia Adrenocortical adenoma (Conn's) ``` Aldosterone:renin ratio elevated; adrenal CT/MRI needed Conn's: laparoscopic adrenelectomy Hyperplasia: spironolactone

Question 33

Secondary hyperaldosteronism

Answer 33

Due to ↑ renin from ↓ renal perfusion ``` Causes  RAS  Diuretics  CCF  Hepatic failure  Nephrotic syndrome ``` Ix  Aldosterone:renin ratio: normal

Question 34

Bartter's syndrome

Answer 34

 Autosommal recesive  Blockage of NaCl reabsorption in loop of Henle (as if taking frusemide)  Congenital salt wasting → RAS activation → hypokalaemia and metabolic alkalosis + hyponatraemia  Normal BP

Question 35

Secondary Adrenal insufficiency

Answer 35

Causes  Chronic steroid use → suppression of HPA axis  Pituitary apoplexy / Sheehan’s  Pituitary microadenoma Features  Normal mineralocorticoid production  No pigmentation (ACTH ↓)

Question 36

Phaeo

Answer 36

Rule of 10s  10% malignant  10% extra-adrenal (found by aortic bifurcation)  10% bilateral  10% part of hereditary syndromes: MEN2a and 2b; Neurofibrimatosis; Von Hippel-Lindau: RCC + cerebellar signs ``` Ix:  Plasma + urine metadrenaline  Also vanillylmandelic acid  Abdo CT/MRI  MIBG (mete-iodobenzylguanidine) scan ```

Question 37

Hypertensive crisis Rx

Answer 37

 Phentolamine 2-5mg IV (α-blocker) then labetalol 50mg IV  Repeat to safe BP (e.g. 110 diastolic)  Phenoxybenzaime 10mg/d PO when BP controlled  Elective surgery after 4-6wks to allow full α-blockade and volume expansion

Question 38

MEN1

Answer 38

 Pituitary adenoma: prolactin or GH  Parathyroid adenoma / hyperplasia  Pancreatic tumours: gastrinoma or insulinoma

Question 39

MEN2

Answer 39

 Thyroid medullary carcinoma  Adrenal phaeochromocytoma  A) Hyperthyroidism  B) Marfanoid habitus

Question 40

Carney Complex/LAME Syndrome

Answer 40

LAMES Lentigenes - spotty skin pigmentation (Peutz Jehgers is DDx) Atrial Myxoma Endocrine tumours (pituitary, adrenal hyperplasia) Schwannomas

Question 41

Peutz-Jeghers

Answer 41

 Mucocutaneous freckles on lips, oral mucosa and palms / soles  GI hamartomas: obstruction, bleeds  Pancreatic endocrine tumours  ↑ risk of cancer: CRC, pancreas, liver, lungs, breast

Question 42

Von Hippel-Lindau

Answer 42

```  Renal cysts  Bilateral renal cell carcinoma  Haemangioblastomas - Often in cerebellum → cerebellar signs  Phaeochromocytoma  Pancreatic endocrine tumours ```

Question 43

Neurofibrimatosis

Answer 43

```  Dermal neurofibromas  Café-au-lait spots  Lisch nodules  Axillary freckling  Phaeochromocytoma ```

Question 44

Autoimmune polyendocrine syndrome

Answer 44

Type 1: AR - Addison's, candidiasis, hypoparathyroidism Type 2 (schmidt's syndrome): polygenic - Addison's, thyroid disease, T1DM

Question 45

Craniopharyngeoma

Answer 45

 Originates from Rathke’s pouch  Commonest childhood intracranial tumour → growth failure  Calcification seen on CT/MRI

Question 46

DI causes

Answer 46

``` Cranial  Idiopathic: 50%  Congenital: DIDMOAD  Tumours  Trauma  Vascular: haemorrhage (Sheehan’s syn.)  Infection: meningoencephalitis  Infiltration: sarcoidosis ``` ``` Nephrogenic  Congenital  Metabolic: ↓K, ↑Ca  Drugs: Li, demecleocycline, vaptans  Post-obstructive uropathy ```

Question 47

Waterhouse-Friedrichsen syndrome

Answer 47

Adrenal failure with haemorrhage from N meningitidis