Endocrinology

Question 1

Diabetes T1 family history

Answer 1

HLA DR3-DQ2 or HLADR4-DQ8

Question 2

Diabetes T1 presentation

Answer 2

Classic triad - polydipsia, polyuria, weight loss (BMI<25)

Question 3

Diabetes T2 management

Answer 3

• Lifestyle
• Medications
  1. METFORMIN (side effect lactic acidosis) - increase insulin sensitivity, first choice in obese patients
  2. If HbA1c remains high then dual therapy with metformin:
• DPP4 inhibitor
• Gliclazide (sulphonylurea) - increase insulin secretion
• Pioglitazone
  3. If still high - triple therapy
  4. Insulin

Question 4

Diabetes ketoacidosis presentation

Answer 4

• Complication of T1DM
• Extreme diabetes symptoms plus N+V, weight loss, confusion, lethargy, abdo pain
• KUSSMAUL’S BREATHING (deep, rapid breath)
• PEAR DROP BREATH

Question 5

Diabetes ketoacidosis investigations/treatment

Answer 5

• Plasma ketones >3mmol/L
• Blood pH <7.35
• Urine dipstick: glycosuria, ketonuria
• Serum U+E - raised urea and creatinine, low total K+, high serum K+

1. ABC management
2. Replace fluid - 0.9% salive IV
3. IV insulin
4. Restore electrolytes - e.g. K+

Question 6

Hyperosmolar hyperglycaemic state (HHS) def

Answer 6

• High glucose levels
• Hyper osmolality
• MILD/NO KETOSIS
• Complication of T2DM

Question 7

Hyperosmolar hyperglycaemic state investigations/treatment

Answer 7

• Urine dipstick - glucosuria
• Plasma osmolality - high
• U+E - low total K+, high serum K+
• Replace fluid - 0.9% salineIV
• Insulin - at low rate because may result in shock
• Restore electrolytes - e.g. K+
• LMWH

Question 8

Graves disease (Hyperthyroidism) def/presentation

Answer 8

• Autoimmune form of hyperthyroidism
• F 9x>M
• Hyperthyroidism symptoms plus thyroid eye disease - eyelid retraction, periorbital swelling, proptosis

Question 9

Hyperthyroidism pres/investigation/treatment

Answer 9

• HLA-DR3
• Everything goes fast - hot and sweaty, diarrhoea, hyperphagia, weight loss, palpitation, tremor
• TFTs - increased T4/T3, primary: decreased TSH, secondary: increased TSH
• 1st line - CARBIMAZOLE - blocks synthesis of T4
• Beta blockers - rapid symptom relief

Question 10

Hypothyroidism pres/investigation/management

Answer 10

• F 6x>M
• Everything goes slow - fatigue, weight gain, loss of appetite, cold, constipation, lethargy, depression
• TFTs - decreased T4/T3, primary: increased TSH, secondary: decreased TSH
• LEVOTHYROXINE (T4) - thyroid hormone replacement

Question 11

Hypothyroidism causes

Answer 11

• Autoimmune causes - Hashimotos and primary atrophic hypothyroidism

Question 12

Cushing’s syndrome (pituitary adenoma) def

Answer 12

• Long term exposure to excessive cortisol hormone released by adrenal glands

Question 13

Cushing’s syndrome (pituitary adenoma) investigation/treatment

Answer 13

• Random plasma cortisol raised
• Overnight dexamethasone suppression test - cortisol will not be suppressed in Cushing’s disease
• Plasma ACTH
• Iatrogenic - stop medication if possible
• Removal of pituitary adenoma - TRANSSPHENOIDAL SURGERY
• Adrenalectomy

Question 14

Acromegaly (pituitary adenoma) def/investigations/treatment

Answer 14

• Release of excess growth hormone causing overgrowth of all systems
• 1st line - insulin like growth factor 1 test - raised
• Gold standard - oral glucose tolerance test
• 1st line - transsphenoidal resection surgery (if adenoma)
• 2nd line - somatostatin analogue e.g. octreotide

Question 15

Prolactinoma (pituitary adenoma) def/pres/treatment

Answer 15

• Benign adenoma of pituitary gland producing excess prolactin
• Visual field defect
• Menstrual irregularity
• Galactorrhoea
• Infertility
• Gold standard - transsphenoidal resection surgery of pituitary gland
• 1st line - dopamine agonists as dopamine has inhibitory effect on prolactin

Question 16

Conn’s syndrome def/pres/treatment (pituitary adenoma)

Answer 16

• Primary hyperaldosteronism due to an aldosterone producing adenoma
• High sodium and water retention, increased potassium excretion
• Hypertension
• Hypokalaemia
• Nocturia
• Polyuria
• 1st line - spironolactone
• Gold standard: laparoscopic adrenalectomy

Question 17

Addison’s disease def/pres

Answer 17

• Primary ADRENAL INSUFFICIENCY (80% causes autoimmune destruction)
• Often diagnosed late
• Tanned
• Lean
• Fatigue
• PIGMENTED PALMAR CREASES

Question 18

Addison’s disease investigation/treatment

Answer 18

• 1st line - U+E - hyponatraemia, hyperkalaemia, hypoglycaemia
• GOLD STANDARD - Short SynACTHen Test (ACTH stimulation test)
• Presents with low cortisol, high ACTH
• Replace steroids depending on signs and symptoms:
• Hydrocortisone - replaces cortisol
• Fludrocortisone - replaces aldosterone

Question 19

Syndrome of inappropriate ADH (SIADH) def/pres/investigation/management

Answer 19

• Inappropriately large amounts of ADH secretion causing water to be reabsorbed
• Non-specific pres - headache, nausea, fatigue, cramps, confusion
• Diagnosis of exclusion
• Treat underlying cause

Question 20

Hyperkalaemia def/investigation/treatment

Answer 20

• K+ in serum blood >5.5mmol/L
• ECG - small/absent P waves, prolonged PR interval (>200ms), wide QRS interval (>200ms), TALL TENTED T WAVES
• INSULIN + DEXTROSE or nebulised salbutamol to drive K+ intracellularly
• Calcium gluconate - protect myocardium

Question 21

Hypokalaemia def/investigations/treatment

Answer 21

• K+ in serum blood <3.5mmol/L
• ECG - prolonged PR interval, ST depression, FLAT T WAVES, prominent U waves
• Per oral/IV POTASSIUM

Question 22

Diabetes insipidus def/diagnosis/treatment

Answer 22

• Impaired water resorption from kidneys
• Gold standard - 8 hour water deprivation test
• Then desmopressin test to establish cranial or nephrogenic cause
• Treat underlying cause
• Cranial - desmopression (synthetic ADH) to replace ADH
• Nephrogenic - if cause persists, give bendroflumethiazide

Question 23

Hyperparathyroidism def/symptoms/investigations/treatment

Answer 23

• Primary: 1 parathyroid gland produces excess PTH
• Secondary: increased secretion of PTH to compensate hypocalcaemia
• Bone pain, renal calculi, abdo groans
• Hypercalcaemia
• PTH/bone profile (blood test): high PTH, high calcium, low phosphates
• Primary - raised calcium
• Secondary - low serum calcium, high PTH
• Watchful waiting
• Primary - surgical removal of adenoma, give bisphosphonates
• Secondary - calcium correction, treat underlying

Question 24

Hypoparathyroidism def/symptoms/investigations/treatment

Answer 24

• Primary - gland failure (autoimmune destruction), congenital DiGeorge syndrome (22q11 del)
• Secondary - surgical removal of gland, decreased calcium (required for PTH secretion), decreased Mg (required for PTH secretion)
• CATS go Numb
• Convulsions, Arrhythmias, Tetany, Spasm, Numbness
• Chvostek’s sign - facial nerve tap induces spasm
• Trousseau’s sign - BP cuff cause wrist flexion
• Bloods - bone profile
• Decreased calcium, increased/normal phosphate, decreased PTH
• IV calcium
• AdCal D3 - calcitriol
• Synthetic PTH if required