Endo

Question 1

Pregnant patient - TFTs

Answer 1

TSH can be mildly suppressed in up to 13% of pregnancy in first trim. T3 and T4 can slightly increased too due to HCG stimulation

T-binding globulin has twofold increase due to reduced hepatic clearance and increased synthesis due to oestrogen

Question 2

Best management for hirtuism in PCOS

Answer 2

weight loss
5% weight loss has 40% improvement of hirtuism

Crypterone acetate& ethinyloestradiol or COCP can be used

Question 3

Patient collapses. Raised c peptide, hypoglycemic

Answer 3

Could be sulphonylurea abuse, esp if family member has T2DM
Could be insulinoma, but rare
Could be Addisonian crisis - low BP, hyperkal hyponat

Insulin abuse would have suppressed c peptide

Question 4

Management of prolactinoma

Answer 4

Cabergoline, very effective, unlikely to need surgery

Question 5

Management for acromegaly

Answer 5

Treat with Somatostatin Analogues (Octreotide) then transphenoidal surgery

Question 6

Patient with hyperthyroidism on amiodarone due to paroxysmal VT. On Doppler USS blood flow is increased

Management

Answer 6

Start carbimazole 40mg OD

Amiodarone should ideally be stopped but given the VT this is difficult

USS with increased blood flow is Type 1 amiodarone hyperthy, treat with carbimazole
decreased blood flow is Type 2, corticosteroids

Type 2 is usually with no underlying disease

Question 7

Thyrotoxicosis in pregnancy…management

Answer 7

propylthiouracil in first trim, then carbimazole

If painful goitre, raised ESR could be subacute so NSAIDs

Question 8

Bartter Vs gittelman

Answer 8

Bartter is usually in childhood with failure to thrive

Also has elevated urinary calcium excretion

Question 9

77 with Colles wrist fracture. Management

Answer 9

Start alendronate in patients >= 75 years following a fragility fracture, without waiting for a DEXA scan

Question 10

Cause of adrenal insufficiency in developing world

Answer 10

TB is most common cause

Remember can get transient low T4 , but corrects with steroid replacement

Question 11

Management of patient that presents with hypoglycemia. BG of T2DM, on metformin and gliclazide

Not responsive to 10% dextrose

What is management

Answer 11

Octreotide in sulphonylurea OD
- blocks insulin secretion

(aka Sandostatin - synthetic somatostatin)

Question 12

Most likely cause of Low TSH levels in hospitalised patients

Answer 12

Sick thyroid syndrome 3x more likely than hyperthyroidism

Question 13

Management of gestational diabetes

Answer 13

Fasting >=5.6
2hr glucose >= 7.8

Fasting glucose 5.6 - 7 then diet,+/- Metformin after 1-2/52

6-6.9 with complications -macrosomia or hydramnios, then offer insulin

Fasting >7 then start insulin

Question 14

Management of subclinical hypothyroidism

Answer 14

Treat if TSH above 10 (if younger than 70)

TSH 4-10 then treat if symptomatic

Question 15

Hyponatremia with normal osmolarity

Answer 15

Pseudohyponatraemia

… serum Na is measured as a ratio of Na to plasma volume. If the patients plasma has high amounts of proteins or lipids, the plasma volume will be increased resulting in a measured hyponatraemia. This is not a true hyponatraemia as the actual ratio of sodium to plasma fluid will be normal.

So look out for hyperproteinaemia (e.g. TPN, IVIG) and hyperlipidaemia (in particular hypertriglyceridemia)

Question 16

Management for patient with familial hypercholesterolemia

Answer 16

First line: high dose statins.

Second line: Ezetimibe (inhibits the intestinal absorption of cholesterol)

Question 17

Calcium in adrenal Insufficiency

Answer 17

hypercalcemia—
combination of increased calcium input into the extracellular space and reduced calcium removal by the kidney

hyponatraemia in 85–90%
hyperkalaemia in 60–65%,
“hypercalcaemia is a rare occurrence”

Question 18

familial benign hypocalciuric hypercalcaemia Vs primary hyperparathyroidism

Answer 18

Both may have high calcium with high or (inappropriately) normal PTH

But FHH has low urinary calcium
High calcium should lead to high urinary calcium

FHH is auto dom asymp hypercal - defect in the calcium-sensing receptor

Question 19

What is familial benign hypocalciuric hypercalcaemia

Answer 19

FHH is auto dom asymp hypercal - defect in the calcium-sensing receptor

Question 20

macroadenoma with high prolactin management

Answer 20

If prolactin extremely high (>6000) then prolactinoma, so treat with bromocriptine or cabergoline (dopamine-R agonist)

In macroadenoma, other may be reduced and prolactin can be raised ( 600–3000 mU/L) secondary to pit stalk blockage w prevention of dopamine reaching the pituitary
Mx Trans-sphenoidal surgery

Question 21

Management of insulinoma

Answer 21

CT scan - 10% are malignant 10% are multiple
50% are MEN1
Refer to surgery
Diazoxide and somatostatin are tx options if not surgery

Question 22

52y w galactorrhoea. Generally fatigued. Prolactin 440, what is next test?

Answer 22

Pregnancy, TFTs (hypothy common cause)

MRI if these ruled out

Question 23

Management of hyperparathyroidism

Answer 23

Total parathyroidectomy

Conservative if calcium less than 0.25 above AND under 50y AND not symptomatic (fragility#, renal stones) AND eGFR over 60

Can use calcimemetics like cinacalcet

Question 24

Hypokal differentials

Answer 24

CCL (Cushing’s Conn’s liddle) hypertension
Gitelman gentleman (older but still only 20s), decreased Ca urine
Bart has a Cat (bart is also child)
Liddle you get when you’re little

Question 25

Diagnosis of growth hormone deficiency

Answer 25

First line: IGF-1 may be raised (but N in 30-40%) If unsure: oral glucose tolerance test (OGTT) with serial GH measurements (normally would get suppressed to <2 in hypergly) Contraindicated w IHD or seizures so use arginine-GHRH simulation test

Question 26

Management of acute thyrotoxicosis

Answer 26

IV propranolol Propylthiouracil or Methimazole Lugol's iodine Dexamethasone (blocks T4 to T3 conversion Stop aspirin as it can worsen storm by displacing T4 from thyroid binding globulin

Question 27

Markers of severe DKA

Answer 27

``` pH <7 Blood ketones >6 Bicarb <5 Anon gap >16 K <3.5 on admission Tachy or Bradycardia Sys BP <90 O2<92 GCS<12 ```

Question 28

Myxedema coma management

Answer 28

Combo of levo and liothyronine Fluid resus Not great evidence for T3 because of lack of RCT but T3 has faster onset

Question 29

Pregnant woman with history of Graves

Answer 29

thyrotrophin (TSH) receptor stimulating antibodies should be checked at 30-36 weeks gestation - helps to determine the risk of neonatal thyroid problems

Question 30

Management of papillary thyroid cancer

Answer 30

Thyroidectomy and radio iodide therapy

Question 31

Progression of Subacute (De Quervain's) thyroiditis

Answer 31

4 phases 1) lasts 3-6/52, hyperthy, painful goitre, raised ESR, decreased uptake 2) 1-3/52 euthy 3) weeks-months hypothy 4) goes back to normal

Question 32

Incidental 3mm thyroid mass found on CT. Asymptomatic

Answer 32

non-palpable nodule found on imaging that are < 1cm don't need biopsy, managed in primary care

Question 33

Signs of congenital adrenal deficiency pneumonic

Answer 33

2 1 def- Low mineralocorticoids - Increased androgens (normal BP - virilizing) 1 7 def- Increased mineralocoticoids- Low androgens (HTN - non virilizing) 1 1 def- Increased mineralocorticoids- Increased androgens (HTN - virilizing)

Question 34

Electrolytes suggestive of laxative abuse

Answer 34

Hypokal with reduced k urinary excretion | Kidneys trying to hold on to it May have calluses on hand from vomiting

Question 35

CK and thyroid disease

Answer 35

CK is modestly elevated (<10x upper limit) in up to 90% of untreated hypothy, and up to 79% complain of muscle symptoms Polymyositis unlikely if <1000

Question 36

Pt has hx of phaeochromocytoma and presents w thyroid swelling. What is the most appropriate next test to confirm the diagnosis?

Answer 36

Calcitonin levels - as could be MEN 2a or b, with a Medullary thyroid cancer parafollicular (C) cells, which secrete calcitonin)

Question 37

classic hx of pseudo-cushings

Answer 37

``` severe psychotic depression or alcohol use mildly raised 24-h urinary free cortisol (unlike 3x upper limit in Cushing's) low dose (1mg) dex ... cortisol 55 nmol/L (<50) ```

Question 38

interpretation of raised dehydroepiandrosterone sulphate in PCOS investigations

Answer 38

DHEA is produced by adrenal cortex | If raised it points to an adrenal rather than an ovarian source, making ovarian tumour unlikely

Question 39

urinary sodium in vol depletion

Answer 39

low urinary sodium (appropriate response to volume depletion)

Question 40

hyperthyroid in pregnancy

Answer 40

propylthiouracil in first trimester then carbimazole

Question 41

post-partum thyroiditis

Answer 41

``` usually hyper (don't treat, maybe propanolol then hypothy (can treat) then euthyroid ```

Question 42

``` severe psychotic depression mildly raised 24-h urinary free cortisol low dose (1mg) dex ... cortisol 55 nmol/L (<50) ```

Answer 42

classic hx of pseudo-cushings often due to alcohol excess or severe depression

Question 43

cause of amenorrhoea in low BMI

Answer 43

hypothalamic amenorrhoea

Question 44

The history of T1DM and coeliac, with a new likely diagnosis of Hashimotos..... probable diagnosis and what test?

Answer 44

Very suggestive of Autoimmune polyendocrinopathy syndrome type 2, which Addisons is strongly linked to treating for Hashmitos which could result in an Addisonian crisis short synacthen test

Question 45

low calcium, high phosphate, high PTH

Answer 45

could be secondary hyperparathyroidism in context of CKD - CKD leads to high phosphate, and low Vit D... causing osteomalacia ``` or pseudohypoparathyroidism, where there is receptor insensitivity to PTH due to G-protein mutation... audo dom short fourth and fifth metacarpals cognitive impairment obesity round face ```

Question 46

pseudohypoparathyroidism types

Answer 46

1a Has a characteristic phenotypic appearance (Albright's hereditary osteodystrophy) Type 1b and 2 no phenotype but has biochem but 2 has normal cAMP response to PTH stimulation

Question 47

pt w low Ca, Mg, and PTH

Answer 47

Magnesium deficiency causes hypocalcaemia Without sufficient levels of magnesium, PTH cannot function properly e.g. due to PPI

Question 48

Secondary hyperparathyroidism vs vit d deficiency/osteomalacia

Answer 48

both low calcium high PTH vit d def usually has low Phosphate too, whereas that's high in secondary hyperpara (CKD leads to low Vit D and high phosphate -reduced excretion) Vit D def /Osteomalacia has raised ALP

Question 49

Low Calcium, Raised ALP

Answer 49

could be osteomalacia - check Vit D esp if phenytoin, Coeliacs, cirrhosis, Type 2 RTA (hypokal)

Question 50

hx of weight loss | Low TSH and T4. Management?

Answer 50

In approximately 5% of patients with clinical and biochemical hyperthyroidism, T3 may be elevated prior to T4. This is known as T3 toxicosis. If TSH and T4 T3 are low then its subclinical thyrotoxicosis

Question 51

Management of secondary hyperparathyroidism

Answer 51

Reduce phosphate in diet - reduction in foods like chocolate, nuts, shellfish and cola Next step is a phosphate binder like Sevelamer or Lanthanum carbonate Vit D replacement alfacalcidol Can have parathyroidectomy

Question 52

Common consequences of acromegaly

Answer 52

T2DM Hypertension LVH, doesn't improve after treatment 33% have sleep apnoea, but tends to improve after treatment 30% have premalig colononic polyps, and 5% develop cancer colonoscopic screening, starting at the age of 40 years