Endocrinology

Question 1

characteristic cutaneous signs of thyrotoxicosis

Answer 1

hair loss
pretibial myxoedema
onycholysis
bulging eyes (exophthalmos/proptosis)

Question 2

characteristic cutaneous signs of hyothyroidism

Answer 2

hair loss
eyebrow loss outer part
cold, pale skin
characteristic face

Question 3

characteristic cutaneous signs of cushing’s syndrome

Answer 3

central obesity
wasted limbs ('lemon on sticks')
moon face
buffalo hump
supraclavicular fat pads
striae

Question 4

characteristic cutaneous signs of addisons disease

Answer 4

hyperpigmentation (face, neck, palmar creases, mouth)

Question 5

characteristic cutaneous signs of acromegaly

Answer 5

acral (distal) and soft tissue overgrowth
big jaws (macrognathia), hands and feet
skin is thick
facial features are coarse

Question 6

characteristic cutaneous signs of hyperandrogenism (females)

Answer 6

hirsutism
temporal balding
acne

Question 7

characteristic cutaneous signs of hypopituitarism

Answer 7

pale or yellow tinged thinned skin

fine wrinkling around eyes and mouth

Question 8

characteristic cutaneous signs of pseudohypoparathyroidism

Answer 8

short stature
short neck
short 4th and 5th metacarpals

Question 9

characteristic cutaneous signs of hypoparathyroidism

Answer 9

dry, scale, puffy skin
brittle nails
coarse hair

Question 10

microvascular complications of hyperglycaemia

Answer 10

retinopathy
nephropathy
neuropathy

Question 11

macrovascular complications of hyperglycaemia

Answer 11

stroke
renovascular disease
limb ischaemia
heart disease

Question 12

symptoms of hyperglycaemia (DM)

Answer 12

polyuria
polydipsia
unexplained weight loss
visual blurring
genital thrush
lethargy

Question 13

diagnosis of DM if symptomatic

Answer 13

fasting BM ≥7 OR
random BM ≥11.1
(only one reading required if symptomatic)

HbA1c ≥48 (6.5%)

Question 14

diagnosis of DM if asymptomatic

Answer 14

fasting BM ≥7 OR
random BM ≥11.1 OR
OGTT 2h value ≥11.1
(need 2 readings if asymptomatic)

HbA1c ≥48 (6.5%)

Question 15

what is type 1 DM

Answer 15

 Insulin deficiency from AUTOIMMUNE DESTRUCTION of insulin-secreting pancreatic beta-cells
 Patients must have insulin, and are prone to ketoacidosis and weight loss

Question 16

what is LADA

Answer 16

o Latent autoimmune diabetes of adults (LADA) is a form of type 1 DM, with slower progression to insulin dependence in later life.

usually have glutamic acid decarboxylase autoantibodies (GADA).

Question 17

what is type 2 DM

Answer 17

 Reduced insulin secretion ± increased insulin resistance
 Associated with obesity, lack of exercise, calorie and alcohol excess
 ≥80% concordance in identical twins, indicating STRONGER GENETIC INFLUENCE THAN IN TYPE 1 DM.

o Typically progresses from a preliminary phase of impaired glucose tolerance or impaired fasting glucose.

Question 18

what is MODY

Answer 18

Maturity onset diabetes of the young (MODY) is a rare autosomal dominant form of type 2 DM affecting young people with a positive family history.

Question 19

what is impaired glucose tolerance

Answer 19

known as pre-diabetes.
- Fasting plasma glucose <7mmol/l and OGTT 2h glucose ≥7.8mmol/l but ≤11.1mmol/l

OGTT is not used routinely now – this has been replaced by HbA1c which indicates that a HbA1c of 42-47 (6-6.4%) indicates pre-diabetes and therefore a high risk of diabetes.

Question 20

what is impaired fasting glucose

Answer 20

• Fasting plasma glucose between 6.1 and 6.9 mmol/L and;

- A blood glucose of <7.8 mmol/L after a 2h OGTT

Question 21

which factors increase your risk of IGT or IFT

Answer 21

overweight/obese
FHx of diabetes
sedentary lifestyle
hypertension
high cholesterol
gestational diabetes

Question 22

secondary causes of DM

Answer 22

steroids, anti-HIV drugs, atypical antipsychotics, thiazides

Pancreatic - pancreatitis, surgery (>90% pancreas removed), trauma, pancreatic destruction (haemochromatosis, CF), pancreatic cancer.

cushing's disease
acromegaly
phaeochromocytoma
hyperthyroidism
pregnancy

Question 23

complications of gestational diabetes

Answer 23

miscarriage
pre-eclampsia
macrosomia
shoulder dystocia
pre-term labour
congenital malformations
worsening of diabetic complications e.g. retinopathy, nephropathy.

Question 24

who is at risk of gestational diabetes

Answer 24

age >25y
FHx positive
weight gain
non-caucasian
HIV positive
previous gestational DM

Question 25

pre-conception advice to prevent gestational DM

Answer 25

control/reduce weight aim for good glucose control offer FOLIC ACID 5mg OD for 12 weeks

Question 26

how to diagnose gestational DM

Answer 26

oral glucose tolerance test - if risk factors at booking visit e.g. previous gestational DM

Question 27

if previously diabetic, how would you change their medications

Answer 27

oral hypoglycaemic - stop metformin - continue

Question 28

features suggesting type 1DM

Answer 28

weight loss persistent hyperglycaemia despite diet and meds presence of autoantibodies --> islet cell antibody and anti-glutamic acid decarboxylase antibodies. ketonuria on dipstick

Question 29

what is metabolic syndrome

Answer 29

combination of diabetes, high blood pressure and obesity. ``` CENTRAL OBESITY + 2 of: - BP ≥130/85 - triglycerides ≥1.7 - HDL ≤1.03 (male)/ 1.29 (female) - fasting glucose ≥5.6 or - DM ```

Question 30

complications of metabolic syndrome

Answer 30

``` vascular events (MI) DM gallstones pancreatic cancer microalbuminuria neurodegeneration fertility problems ```

Question 31

treatment of metabolic syndrome

Answer 31

``` exercise weight loss ± mediterranean (?keogenic) diet - antihypertensives - hypoglycaemic (metformin) - statins ```

Question 32

first line for diabetic who is overweight and | hbA1c to aim for

Answer 32

metformin + lifestyle advice HbA1c of 48 mmol/mol (6.5%) if GI side effects - try metformin MR stop metformin if eGFR <30 (lactic acidosis risk)

Question 33

when would you start 2 medications in a diabetic and HbA1c aimed for

Answer 33

``` HbA1c >58 (7.5%) consider: - metformin + DPP4 inhibitor (gliptins) - metformin + pioglitazone - metformin + gliclazide - metformin + SGLT-2 ``` aim for HbA1c of 53mmol/mol (7%)

Question 34

when would you start 3 medications in a diabetic patient and what hbA1c to aim for

Answer 34

if HbA1c remains above 58 despite dual therapy. consider: - metformin + gliptin + SU - metformin + pioglitazone + SU or - start insulin based treatment aim for HbA1c ≤53 (7%)

Question 35

if metformin is contraindicated, what is first line for type 2 DM

Answer 35

DPP4 inhibitor OR pioglitazone OR sulphonylurea

Question 36

C/I to pioglitazones

Answer 36

heart failure or history of heart failure hepatic impairment diabetic ketoacidosis current, or a history of, bladder cancer uninvestigated macroscopic haematuria.

Question 37

general advice for DM management

Answer 37

structured education programme offer lifestyle advice start statin control BP give foot-care advice advise informing DVLA and not to drive if hypoglycaemic episodes not in control

Question 38

if triple therapy is not effective, not tolerates or C/I then NICE advices what

Answer 38

- metformin + sulfonylurea + GLP-1 o BMI ≥35kg/m2 AND specific psychological or other medical problems associated with obesity OR o BMI <35kg/m2 AND for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity related comorbidities (only continue if there is a reduction of at least 11mmol/l in HbA1c and a weight loss of at least 3% of initial body weight in 6 months.

Question 39

sick day rules for diabetics

Answer 39

- Increase frequency of blood glucose monitoring to 4 hourly or more - Encourage fluid intake aiming for at least 3 litres in 2h - In struggling to eat, may need sugary drinks to maintain carbohydrate intake - Continue to take insulin, as increased cortisol levels during stress can increase glucose levels in the body for which insulin is required.

Question 40

2nd line treatment if metformin C/I and DM still not controlled

Answer 40

gliptin + pioglitazone gliptin + SU pioglitazone + SU

Question 41

3rd life treatment if metformin C/I

Answer 41

consider insulin-based treatment