Endocrine

Question 1

treatment of myxoedemic coma

Answer 1

hydrocortisone and levothyroxine

Question 2

treatment of thyrotoxic storm

Answer 2

Beta blockers, propylthiouracil and hydrocortisone

Question 3

when should a second drug be added to metformin in T2DM

Answer 3

if HbA1C>58mmol/mol

Question 4

What diabetic drugs can be continued in pregnancy

Answer 4

Only metformin and insulin

Question 5

causes of Cushing’s

Answer 5

iatrogenic (exogenous steroids)
pituiatry ACTH producing tumour (cushings disease)
Ectopic ACTH from lung cancer
Primary adrenal tumour (ACTH independent)

Question 6

diagnosing Cushings

Answer 6

1. measure increased cortisol and exclude exogenous steroids
2. Dexamethasone suppresion test. If normal dex suppresses ACTH
   Cushings disease (pituitary) is suppressed by high dose
   Ectopic ACTH/Adrenal tumour is not suppressed
3. venous sampling at inferior petrosal sinus can detect ACTH from pituitary

Question 7

what electrolyte abnoramlity is seen in Cushings

Answer 7

excess cortisol leads to increased sodium, increased bicarb and decreased potassium

causes metabolic alkalosis

Question 8

treatment of cushings

Answer 8

if operable operate
if not suppress cortisol synthesis using drugs; metyrapone or ketoconazole

Question 9

causes of nephrogenic diabetes insipidus

management

Answer 9

genetic
electrolyte abnormalities (increased calcium, decreased potassium)
lithium
tubulointerstitial disease

thiazides and low salt/protein diet

Question 10

examples of following diabetic drugs + main side effects

biguanide
sulphonylureas
DPP4inhibitors
SGLT2 inhibitors
GLP1 agonists

Answer 10

biguanide - metformin - GI effects and lactic acidosis

sulphonylureas - gliclazide, glimperide - hypo risk, weight gain

DPP4inhibitors - gliptins - pancreatitis

SGLT2 inhibitors - gliflozins - UTIs

GLP1 agonists - glutides

Question 11

test results in primary hyperparathryoidism

most common cause

Answer 11

low phosphate and high PTH and calcium level

solitary adenoma of the parathyroid causing increased PTH

Question 12

test results in secondary hyperparathryoidism
causes

Answer 12

high PTH, low phosphate and low calcium

renal failure
vitamin D deficinecy

Question 13

test results of tertiary hyperparathyroidism

Answer 13

high PTH, high phosphate and high calcium with decreased vit D
caused by end stage renal failure

Question 14

what can happen if you wihtdraw steroids abruptly

Answer 14

precipitate an addisonian crisis

Question 15

diagnosis of gestational diabetes

Answer 15

fasting glucose of >5.6
or 2 hour glucose of >7.8

Question 16

What hormones do each layer of the adrenal gland produce

Answer 16

Zona glomerulosa - mineralocorticoids
Zona fasiculata - glucocorticoids
Zona reticularis - androgen precursors
Medulla - catecholamines

Question 17

What does metyrapone do?

Answer 17

It is a glucocorticoid synthesis inhibitor

Question 18

How do you measure
- urinary cortisol
- plasma cortisol
- salivary cortisol

Answer 18

Urinary - 24 hour collection
Plasma - 9am cortisol, evening or midnight. Midnight most different from normal
Salivary - late night highest specificity for Cushing diagnosis

Question 19

Treatment of adrenal crisis

Answer 19

High dose steroid replacement - IV hydrocortisone 100mg every six hours

IV saline (with dextrose if hypoglycaemic)

Question 20

Diagnosing adrenal insufficiency
Treatment

Answer 20

High dose short synacthen test - give ACTH and see if adrenals respond

Treatment is steroid replacement

Question 21

What is SIADH?
Diagnosis?
Causes?

Answer 21

Syndrome of inappropriate ADH secretion - more water reabsrobed by kidneys leading to dilute serum and concentrated urine

Diagnosis; low serum osmolaltiy with high urinary osmolality

Causes:
Lung diseases
Brain lesions
Drugs e.g. carbamazepine, SSRIs

Question 22

Symptoms and signs of hyponatraemia

Answer 22

Headache dizziness and nausea
Can result in coma if severe
Can be hypovolaemic or hypervolaemic hyponatraemia

Hypovolaemic:
Cool peripheries
Tachycardia
Postural Hypotension
Confusion
Dehydrated

Hypervolaemic:
Tachycardia
Raised JVP
Pulmonary oedema
Ascites
Peripheral oedema

Question 23

Causes of hyponatraemia

Answer 23

Renal loss; addisons, renal failure, excess diuretics

Loss elsewhere; diarrhoea, vomiting, burns, trauma

SIADH, water overload, severe hypothyroid, glucocorticoid insufficiency

Nephrotic syndrome, cardiac failure, cirrhosis, renal failure

Question 24

When does hypernatraemia occur

Answer 24

Dehydration without access to water e.g. in elderly demented patients

Question 25

What are the criteria for bariatric surgery

Answer 25

BMI of over 40 or 35-40 with other significant disease that could be improved with weight loss All non surgical measures have been tried Has been / will receive intensive management in a tier 3 service Fit enough for surgery

Question 26

What is osteomalacia

Answer 26

Softening of the bones secondary to vitamin D deficiency (primary, CKD or other) Presents with bone pain, fatigue, and proximal myopathy

Question 27

what gastric complications can T1DM cause

Answer 27

- gastroparesis; manage with metoclopramide, domperidone or erythromycin (prokinetic agents) - chronic diarrhoea - GORD

Question 28

what type of diabetes are C peptide levels raised in

Answer 28

type 2

Question 29

what antibodies can be raised in T1DM? (approx 80%)

Answer 29

anti-GAD islet cell antibodies insulin antibodies

Question 30

what is acromegaly what is the most common cause

Answer 30

excess growth hormone most commonly due to a pituitary adenoma

Question 31

tests to diagnose acromegaly

Answer 31

serum IGF-1 levels if raised do an oral glucose tolerance test (OGTT) - in acromegaly there is no suppression of GH due to increased glucose pituitary MRI may demonstrate a pituitary tumour

Question 32

management of acromegaly

Answer 32

trans-sphenoidal surgery if possible if not: - somatostatin analogues - GH receptor antagonist - dopamine agonists effective in minority

Question 33

features of addisons disease

Answer 33

- lethargy, anorexia, weakness, N & V - hyperpigmentation (primary addisons) - hypotension - hypoglycaemia - hyponatraemia and hyperkalaemia

Question 34

addisons disease management

Answer 34

glucocorticoid and mineralocorticoid replacement therapy hydrocortisone given daily in 2-3 divided doses fludrocortisone

Question 35

addisons treatment changes in an intercurrent illness

Answer 35

double glucocorticoid keep mineralocorticoid the same

Question 36

diagnostic criteria T1 DM

Answer 36

fasting glucose 7.0mmol/L or more random glucose (or glucose tolerance test) 11.1mmol/L or more on one occasion if symptomatic or two if asymptomatic

Question 37

when should SGLT2 inhibitors be used in T2DM

Answer 37

after metformin is titrated up in anyone with or at high risk of CVD

Question 38

2nd drug choice and when T2DM

Answer 38

when HbA1C >58 on metformin in CVD risk - SGLT2 inhibitor if not at risk - DPP4i, pioglitazone or a sulphonylurea

Question 39

HbA1C targets T2DM

Answer 39

48 53 if on a drug that has hypo risk e..g sulphonylurea

Question 40

types of thyroid cancers

Answer 40

papillary carcinoma - best prognosis, most common follicular carcinoma medullary carcinoma - part of MEN2 anaplastic carcinoma - worst prognosis

Question 41

triple therapy options in T2DM

Answer 41

metformin + sulphonylurea + DPP4i (gliptin) metformin + sulphonylurea + pioglitazone metformin + (pioglitazone or sulfonylurea or DPP-4 inhibitor) + SGLT2i if certain criteria met

Question 42

sulphonylureas: - names - main side effect + risk - pregnancy?

Answer 42

gliclazides weight gain risk of hypos avoid in pregnancy and breastfeeding

Question 43

hypoglycaemia with impaired GCS?

Answer 43

give IV glucose STAT if access

Question 44

treatment of a prolactinoma

Answer 44

cabergoline - a dopamine agonist dopamine inhibits prolactin release

Question 45

thyrotoxicosis with a tender goitre?

Answer 45

subacute (de quervain's) thyroiditis - typically follows a viral infection

Question 46

phases of subacute thyroiditis

Answer 46

1 - tender goitre, hyperthyroidism, ESR raised (3-6 weeks) 2 - euthyroid (1-3 weeks) 3 - hypothyroid (weeks to months) 4 - return to normal

Question 47

which hormones reduce in a stress response e.g. to surgery

Answer 47

insulin oestrogen testosterone

Question 48

primary hyperaldosteronism

Answer 48

hypertension hypokalaemia - muscle weakness alkalosis

Question 49

investigation primary hyperaldosteronism

Answer 49

plasma aldosterone/renin ratio - will show aldosterone too high and low renin (negative feedback) CT abdomen if raised adrenal venous sampling if CT inconclusive

Question 50

causes of primary hyperaldosteronism

Answer 50

bilateral adrenal hyperplasia (most common) adrenal adenoma secreting aldosterone (conn's syndrome) rarely familial or an adrenal carcinoma

Question 51

what is secondary hyperaldosteronsim

Answer 51

excessive renin stimulates the adrenal glands to secrete more aldosterone due to blood pressure in kidneys being disproportionately lower to rest of body e.g. renal artery stenosis or obstruction heart failure

Question 52

management of primary hyperaldosteronsim

Answer 52

bilateral adrenal hyperplasia - spironolactone (aldosterone antagonist) adrenal tumour - surgery

Question 53

DKA management

Answer 53

isotonic saline first! restore volume fixed rate insulin infusion (long acting insulin continued, short acting stopped) potassium may need replacing due to insulin moving it into intracellular place

Question 54

typical presentation of primary hyperparathyroidism

Answer 54

typically elderly females with an unquenchable thirst and polydipsia most commonly due to a solitary adenoma

Question 55

investigation results primary hyperparathyroidism

Answer 55

high calcium high or normal PTH low phosphate

Question 56

definitive management of primary hyperparathyroidism

Answer 56

total parathyroidectomy