Endocrine

Question 1

Causes of OP

Answer 1

Drugs-steroids, heparin, thyroxine, Li, phenytoin, cyclosporine
GI- malabsorption, PBC
Malnutrition
Malignancy - MM, metastatic ca, lymphoma, leukaemia
CTD- Mefans, Ehlers-danlos, OI, RA
Endo- hyperthyroid, hyperPTH, Cushings, Gh deficiency, hyperprolactin, hypogonadism

Question 2

Causes of osteomalacia

Answer 2

1. VitD deficiency - malabsorption in fat, metabolism (CKD, pseudo hypoPTH), decreased bioavailability (sunlight, nephrotic syndrome, peritoneal dialysis)
2. Low Phosphate availability - antacids, hereditary, Fanconi
3. NAGMA with hypokalaemia (Type 1 RTA, SS, SLE)

Question 3

DEXA scan indications

Answer 3

Minimal trauma fracture
Female >65y, male >70y
Monitoring at 1 year with low BMD
Prolonged steroid (10mg 3 months)
Hypogonadism
1' HyperPTH, cirrhosis, CKD, Crohns, malabsorption, RA

Question 4

Ix for OP

Answer 4

DEXA scan
Ca, PO4, vitD, ALP
Secondary causes - FBC, ESR, EUC, LFT, EPG
Endo - TFT, cortisol, testosterone in male
Xrays - loss of trabecular bone, codfish deformity, wedging
Iliac crest biopsy if Ddx OP vs osteomalacia

Question 5

Mx of OP

Answer 5

Ca 1200-1500mg in diet
VitD for severe >25nM give 3000-5000IU 2-3 months
Cease smoking, alcohol
Bisphosphonates (>70y with BMD

Question 6

Causes of hypercalcaemia

Answer 6

HyperPTH (adenoma, MEN)
Malignancy
Increased vit D (diet, sarcoidosis)
High bone turnover (hyperthyroid, thiazides, vitA)
CKD -> 2' hyper PTH
FHH
Li

Question 7

Features of Pagets

Answer 7

Bone turnover -high ALP, bone pain, 2’ OA, height/hat size change, pathological #, bone deformity
Neuro - hearing loss, gait (cerebellar, SCC, basilar long tract), cranial n, headache
CCF
Renal Ca stones
Gout
HyperCa
Osteosarcoma (rare)

Question 8

Pagets examination

Answer 8

Short stature, bony deformity
Skull diameter >55cm, prominent skull veins, bony warmth, bruit
Fundi -angioid streaks, papilloedema, optic atrophy, acuity, fields
CN VIII
Neck - basilar invagination (short neck, extended)
CCF
Back, hips, legs, knees *hip abd
Sarcomas (tender swelling)
UA for blood (renal stones), height

Question 9

Pagets Ix

Answer 9

Ca
Disease activity - ALP, urinary hydroxyproline
Bone scan for eary lytic phase, bony enlargement, increased density, irregular widened cortex, cortical infarcts on convex side
CT/MRI for suspicious lesions ?sarcoma

Question 10

Pagets Mx

Answer 10

NSAIDs for pain
bisphosphonates, C, vitD
Calcitonin for bony pain and neuro Sx
Mithramycin IV for emergency ex. SCC
Surgery ex. bowed femur/difficult mobility
Sarcoma - neoadjuvant chemo then surgery

Question 11

Acromegaly features

Answer 11

Frontal bossing, prognathism, large hands/feet
Diabetes
OSA
CCF
Hypogonadism, impotence
Sweating, headache, carpal tunnel, peripheral neuropathy, paraesthesiae
Myopathy
Skin tags, colonic polyps
Organomegaly

Question 12

Acromegaly Mx

Answer 12

Goal is normal IGF-1 and appropriate GH suppression <1.2mIU/L by glucose suppression test
1. Long-acting somatostatin analogues - octreotide LAR 20mg SC monthly, lanreotide autogel 60mg SC monthly
Cabergoline 2nd line - usually post-surgery
2. Transsphenoidal resection of adenoma - 50-80% success, only 10% postop hypopituitarism
3. RTx 2nd line if surgery incomplete
Screening:
Cardio - TTE q5years
GI - colonoscopy
Thyroid
Metabolic syndrome - BP, lipids, BSL
MSK

Question 13

T1DM antibodies

Answer 13

IAA
IA-2
ZnT8
GAD

Question 14

Diabetes diet

Answer 14

Exchanges 15g carbs = 60 Cal : usually 3x per meal, 2x for snack
Carbs 50%
Protein 20%
Fat <30% (Polyunsaturated fat 10%, saturated fat <10%, cholesterol <300mg)
Fibre 30g

Question 15

Diabetes history

Answer 15

Dx - age, Sx, Ix
Mx - Meds, insulin and admin technique
Glucose control - hyperglycaemia, hypos, admissions, monitoring, infections
Microvascular - eyes, kidneys, neuropathy, autonomic
Macrovascular - cardiac, stroke, claudication
Diet, exercise, weight

Question 16

Biguanides

Answer 16

ex. metformin
Weight loss
AE: lactic acidosis, GI, not if GFR <30, B12 malabsorption

Question 17

Sulfonylureas

Answer 17

eg. Gliclazide, glipizide (for skinny), glibenclamide
Increase insulin secretion
AE: weight gain, hypos *glibenclamide, BM supp, jaundice, rash, alcohol intolerance/flushing, SIADH

Question 18

Thiazolidenediones

Answer 18

eg. pioglitazone, rosglitazone
Reduce insulin resistance, BSL, TGs
3rd agent if HbA1c still >7% on metformin+SU
AE: weight gain, oedema, IHD, lipids, macular oedema
Monitor LFTs, cease if ALT >2.5x
CI: NYHA 3/4

Question 19

Acarbose

Answer 19

Inhibits intestinal a-glucosidase

Question 20

DDP4 inhibitors

Answer 20

eg. sitagliptin, saxagliptin
Inhibit DDP4 breakdown of GLP-1 -> increases GLP-1
Increase insulin, suppress glucagon
Weight neutral
Linagliptin +metformin+SU, others with one other

Question 21

GLP-1 analogues

Answer 21

Exanatide
Weight loss
AE: Pancreatitis

Question 22

Causes of hypoglycaemia on insulin Rx

Answer 22

Change in diet, exercise, or weight
Injection errors
Diabetic nephropathy
Other endocrine: Insulin Abs, hypothyroid, adrenal insuff, panhypopit, insulinoma, malabsorption

Question 23

Causes of insulin resistance (>200U/day)

Answer 23

Obesity
Antagonist hormones (GH in puberty, cortisol, thyroxine, glucagon)
Insulin antibodies
Lipoatrophic diabetes a/w acanthosis nigricans
Injection into lipoatrophic sites