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ICSM Year 6 > Medicine - Endocrinology > Flashcards

Medicine - Endocrinology Flashcards

(180 cards)

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1
Q

What are the criteria for diagnosis of type 2 diabetes?

A 
Either symptoms + 1 pos test result or no symptoms + 2 pos test results
Pos test thresholds: 
- Fasting glucose >7.0
- OGTT >11.1
- Random glucose >11.1 
- HbA1c > 6.5%/ 48mmol/L
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2
Q

What are the test ranges for impaired gluose tolerance and impaired fasting glucose?

A

IGT: OGTT/random = 7.8-11.1; HbA1c = 42-47

IFG = 6.1-7.0

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3
Q

What is the classic triad of symptoms of type 2 diabetes?

A

Polydipsia
Polyuria
Fatigue

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4
Q

Recall 2 possible consequences of diabetic neuropathy and drugs that can be used to manage each of these possibiities

A
  1. Vagal neuropathy –> gastroparesis: domperidone/ metoclopramide
  2. Neuropathic pain: amitryptiline, duloxetine, gabapentin, pregabalin
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5
Q

Summarise the pathogenesis of diabetic foot

A
  1. Peripheral arterial disease reduces O2 delivery –> intermittent claudication
  2. Neuropathy –> loss of sensation, eventually Charcot’s foot
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6
Q

What is Charcot’s foot?

A

Rare consequence of T2DM in which foot becomes rocker-bottomed

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7
Q

Recall some ways in which diabetic foot can be screened for, and the frequency with which these tests should be done

A

Screening should be done annually
Test for ischaemia: palpate the dorsalis pedis and posterior tibial pulse
Test for neuropathy with 10g monofilament test

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8
Q

How should diabetic nephropathy be screened for?

A

Yearly albumin:creatinine ratio

Microalbuminuria is the first sign of diabetic nephropathy

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9
Q

What is the best management for diabetic nephropathy?

A

ACE inhibitors

However, these are toxic in AKI so eGFR needs to be monitored

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10
Q

How big a drop in eGFR would warrant stopping an ACE inhibitor in a diabetic patient?

A

> 20%

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11
Q

Why is an initial drop in eGFR expected when starting patients on an ACE inhibitor?

A

Dilate the efferent arteriole

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12
Q

Recall 3 things that may cause a falsely high HbA1c

A

Alcoholism
B12 deficiency
Iron deficiency anaemia

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13
Q

What is the BM target for T1DM patients who are monitoring BMs throughout the day?

A

Waking target: 5-7mmol/L

Rest of the day: 4-7mmol/L

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14
Q

Recall the names of 2 long-acting insulins

A

Lantus

Glargine

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15
Q

When are BD mixed regimens of insulin given?

A

Breakfast and dinner

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16
Q

Name a diabetes prevention programme

A

DESMOND

Diabetes education + self-management: ongoing and newly diagnosed

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17
Q

Recall some possible risk-factor modifying therapies that can be used in diabetes mellitus

A

Aspirin 75mg OD
Atorvastatin 20mg OD
Antihypertensives

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18
Q

What is the maximum dose of metformin?

A

2g/day

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19
Q

Recall 4 important side effects of metformin

A

Appetite suppression
B12 deficiency (due to reduced absorption)
Lactate acidosis
GI upset

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20
Q

How can you manage GI upset that is due to metformin?

A

Change immediate release to a modified release mechanism

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21
Q

When should dual therapy be considered in type 2 diabetes?

A

If HbA1c >58/ 7.5%

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22
Q

What are the options for dual therapy for type 2 diabetes?

A

Metformin + 1 of:

  • Sulphonylurea
  • Thiazolidinediones
  • Gliptins
  • SGLT2 inhibitors
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23
Q

Recall 2 examples of sulphonylureas

A

Glibenclamide

Gliclazide

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24
Q

Recall an example of a thiazolidinedione

A

Pioglitazone

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25
Recall an example of a gliptin drug
Sitagliptin
26
What is the mechanism of action of gliptins?
DPP4 inhibitors
27
Recall an example of a SGLT2 inhibitor
Empagliflozin
28
Recall 2 important side effects of sulphonylureas
Weight gain | Hypoglycaemia
29
What sort of diabetes drug is MODY most sensitive to?
Sulphonylureas
30
What is the inheritance pattern of MODY?
Autosomal dominant
31
MODY must be diagnosed before what age?
25
32
What is the best investigation to confirm the diagnosis of MODY?
C peptides
33
What is the most common type of MODY, and which gene mutation causes it?
MODY 3 | Mutated HNF-1 alpha
34
What is LADA?
Latent autoimmune diabetes in adults | Late onset T1DM in 20-50yo, no family history
35
What are the 2 best investigations for confirming the diagnosis of LADA?
``` GAD Abs C peptide (will be low) ```
36
What 3 things are required to diagnosis DKA?
Diabetes, Ketones, Acidosis Diabetes - BM >11.1 Ketones - >3 Acidosis - pH <7.3
37
Recall 4 common causes of DKA
Missed insulin Trauma Infection EtOH
38
What 3 investigations are most useful for assessing the extent of the damage done by a DKA acutely?
ABG ECG U&Es
39
Recall the 5 main principles of managing DKA acutely
1. Fluids 2. Insulin 3. Potassium (run KCl in NaCL bag) 4. 10% dextrose (when BM < 15) 5. VTE prophylaxis (very dehydrated)
40
What dose of insulin should be started in DKA vs HHS?
DKA: 0.1U/kg/hr HHS: 0.5U/kg/hr
41
Recall the 3 biochemical criteria used to diagnose HHS
pH >7.3 Osmolarity >320mmol/L BM >30
42
Over what time period does HHS develop?
Over a few days
43
Recall the 3 components of HHS management
1. Fluids 2. Monitoring (ensure Na+ is not corrected too quickly) 3. Insulin
44
Recall 2 differentials for someone whose TFTs show low TSH and low T4
Secondary hypothyroidism | Sick euthyroid
45
Recall the Thy classification
Thy 1 = unsatisfactory sample (1c = cyst) Thy 2 = benign Thy 3 = atypia of undetermined significance Thy 4 = Suspicious of malignancy Thy 5 = malignancy
46
What classification system is used to classify thyroid nodules?
Thy classification
47
What are the 4 histological types of thyroid cancer
Anaplastic Medullary Papillary Follicular
48
Which type of thyroid cancer is associated with a raised calcitonin?
Medullary
49
Recall 2 differentials for low uptake hyperthyroidism
Sub-acute (De Quervain's) thyroiditis | Postpartum thyroiditis
50
Recall 3 differentials for high uptake hyperthyroidism
Grave's disease Toxic multinodular goitre Single toxic adenoma
51
Recall 4 signs of thyroid eye disease
``` Mnemonic = PECS Proptosis Extra-ocular muscle pathology Corneal involvement Sight loss due to optic nerve involvement ```
52
Why might eye movement be restricted in thyroid eye disease?
Rectus thickening restricts movement
53
What is the best preventative measure to prevent Grave's disease?
Stop smoking
54
Which subtypes of MEN are associated with medullary thyroid cancer?
2A and 2B
55
Recall the management of Grave's disease
1st line: - Propranolol (NOT bisoprolol) - Anti-thyroid drug eg carbimazole or propylthiouracil OR - If unlikely to respond to ATDs, radioiodine (I-131)
56
Recall 2 possible side effects of radioiodine
Hypothyroidism | Thyroid storm
57
Recall how a patient should be prepared for thyroidectomy
1. Need to be euthyroid on medication 2. Laryngoscopy to check vocal cords 3. Either thionamides or propranolol Stop thionamides (PTU) 10 days before surgery as it increases vascularity
58
Recall some symptoms of a thyroid storm
``` Hyperthermia Tachycardia Jaundice Altered mental state Cardiac (AF/high-output CF) ```
59
How should a thyroid storm be managed?
IV propranolol --> Thionamides (PTU) | Hydrocortisone --> iodine
60
What is the most common cause of primary hypothyroidism in the UK?
Hashimoto's
61
What is Riedel’s thyroiditis
Hypothyroidism caused by chronic inflammatory thyroid gland fibrosis
62
Recall 2 drugs that can cause hypothyroidism
Lithium | Amiodarone
63
What is the starting dose of levothyroxine?
50-100mcg
64
How long after starting levothyroxine should the TFTs be checked?
8-12 weeks
65
Recall 2 medications that interact with levothyroxine
Iron | CaCO3
66
Recall 4 features of myxoedema coma
Hypothermia Hyporeflexia Bradycardia Seizures
67
How should myxoedema coma be managed?
IV thyroxine IV hydrocortisome IV fluids
68
What are the most common causes of Addison's disease?
In the UK: autoimmune adrenal failure | Worldwide: TB
69
Recall 2 ways that Addison's/adrenal failure can be investigated for
1. 9am cortisol | 2. Short synACTHen test
70
Recall 3 possible cause of an Addisonian crisis (different from Addison's disease)
1. Adrenal haemorrhage (Waterhouse-Friderichson syndrome from meningococcaemia) 2. Steroid withdrawal 3. Sepsis/ surgery causing an acute exacerbation of chronic insufficiency (autoimmune/ TB)
71
How should an Addisonian crisis be managed?
Immediately: - IM hydrocortisone 100mg STAT - IV fluid bolus with glucose Continuing management: - IV fluids - IV/IM hydrocortisone
72
What is the most common cause of Cushing's syndrome?
Glucocorticoid therapy
73
What are some differentials for ACTH-dependent Cushing's?
Cushing's disease (80% pituitary tumour) | Ectopic ACTH production
74
What are the possible causes of pseudo-Cushing's?
Alcoholism or severe depression
75
How can Cushing's and pseudo-Cushing's be differentiated?
Both will give a positive LDDST and 24hr free urinary cortisol Can tell the difference between them with insulin stress test
76
Recall 2 screening tests for Cushing's
1. 11pm salivary cortisol (if low the cause is NOT Cushing's) 2. LDDST
77
How can the cause of Cushing's syndrome be confirmed?
Inferior petrosal sinus sampling | Catheter is fed into the jugular vein
78
What is Nelson's syndrome?
Possible complication of adrenalectomy | Removal of adrenal gland --> pituitary enlargement and very high ACTH
79
What is the most common electrolyte disturbance in Conn's syndrome?
Hypokalaemia
80
What is the best initial investigation in suspected Conn' syndrome?
Aldosterone: renin ratio
81
What are the best tests to determine the cause of hyperaldosteronism?
HR-CT and adrenal vein sampling
82
What are the possible causes of hyperaldosteronism?
1. Conn's syndrome | 2. Renal artery stenosis
83
What will be the aldosterone: renin ration in Conn's syndrome vs renal artery stenosis?
Conn's: high | Renal artery stenosis: normal
84
What medications can be used to manage hyperaldosteronism?
Spironolactone and epleronone
85
What test can be used to diagnose diabetes insipidus?
Water deprivation test
86
Recall 2 possible renal and 2 non-renal causes of hypernatraemia
Renal: osmotic diuresis (T2DM) or diabetes insipidus | Non-renal: GI losses or sweat losses of water
87
What is the possible complication of correcting hypernatraemia too quickly?
Cerebral oedema
88
What is the possible complication of correcting hyponatraemia too quickly?
Central pontine myelinolysis
89
In which patients is a urine sodium measurement not reliable?
Those on diuretics
90
Recall some drugs that can cause SIADH
``` SSRIs and TCAs Carbemazapine Sulphonylureas (eg gliclazide) PPIs (omeprazole/ lanzoprazole) Opiates ```
91
Recall 2 causes of pseudohyponatraemia
Hyperlipidaemia | Hyperproteinaemia
92
Recall 2 drugs that can be used to treat SIADH
Demeocycline | Vaptans (eg tolvaptan)
93
Recall 3 classes of drugs that could cause hyperkalaemia
ARBs ACE inhibitors Aldosterone antagonists
94
Recall one antibiotic that can cause hyperkalaemia
Tacrolimus - it can reduce K+ excretion
95
Which type of renal tubular acisosis can cause hyperkalaemia
Type 4
96
Recall the management of hyperkalaemia
``` 10mls 10% calcium gluconate 120mls 20% dextrose Maybe: 10U insulin nebulised salbutamol If really bad: Calcium risonium ```
97
For each of the following endocrine conditions, say whether they can cause hypo or hyperkalaemia: - Addisson's - Conn's - Cushing's
Adisson's: Causes hyperkalaemia Conn's: Causes hypokalaemia Cushing's: Causes hypokalaemia
98
Which types of renal tubular acidosis can cause hypokalaemia (rarely)?
Types 1 and 2
99
Which hormone will likely be high in renal artery stenosis?
Renin
100
Describe the symptoms of hyper vs hypoclacaemia
Hypercalcaemia: bones, stones, abdominal groans, psychiatric moans Hypocalcaemia: paraesthesia, muscle cramps, long QT
101
What is a 'pepperpot skull?
Radiological sign: Multiple tiny well-defined lucencies in the calvaria (top part of the skull) caused by resorption of trabecular bone in hyperparathyroidism
102
How should hypercalcaemia be managed?
IV fluids --> bisphosphonates
103
Recall the progression of multiple myeloma
(1) MGUS (2) Smouldering myeloma (3) Multiple myeloma (4) B cell leukaemia
104
At what point in the myeloma progression does a patient get the symptoms of CRAB?
Not until it gets to multiple myeloma
105
What is the limit for monoclonal serum protein in MGUS?
Must be <30g/L
106
What is the limit for bone marrow plasma cells in MGUS?
<10%
107
Which type of immunoglobin will be high in myeloma?
IgG or IgA | If Waldenstrom's - IgM
108
What is the most useful form of imaging in myeloma?
Whole body low dose CT
109
Which CD markers are positive in immunotyping in myeloma?
CD38 CD138 CD56/58
110
What is the pathophysiology of refeeding syndrome?
Refeeding --> rise in insulin --> intracellular shift in phosphate --> hypophosphataemia
111
What are some symptoms of the refeeding syndrome?
``` Rhabdomyolysis Low RR Arrhythmia Shock Seizures Coma ```
112
What is fibromuscular dysplasia?
Idiopathic, non-atherosclerotic, non-inflammatory disorder of arteries 2 subtypes: - Renal artery - Cervical artery
113
What are the symptoms of fibromuscular dysplasia?
Renal artery FMD: resistant hypertension | Cervical artery FMD: chronic migraines
114
What is the best investigation for assessing fibromuscular dysplasia?
Catheter angiography
115
What is the mainstay of management of fibromuscular dysplasia?
Stop smoking Anti-platelets (clopidogrel) Anti-hypertension (ACEi or ARB) Surgery (surgical stenting)
116
Recall some causes of vitamin B12 deficiency
Autoimmunity Atrophic gastritis Gastrectomy Malnutrition
117
Recall 2 drugs that can treat vitamin B12 deficiency
Cyanocobalamin IM | Hydroxocobalamin IM
118
Recall some causes of hypomagnesaemia
``` Diuretics/ PPIs Diarrhoea TPN EtOH Gitelman's/Barter's Hypokalaemia, hypocalcaemia ```
119
What are the symptoms of hypomagnesaemia most similar to?
Hypocalcaemia
120
What are the ECG features of hypomagnesaemia most similar to?
Hypokalaemia
121
What is the threshold for giving IV magnesium sulphate as a Mg replacement, rather than just PO tablets?
Mg <0.4mmol/L
122
How should suspected SIADH be investigated?
1. Serum corrected calcium - must exclude hypercalcaemia secondary to hyperPTHism 2. Water deprivation test
123
What is the mechanism of hyponatraemia development in SIADH?
Increased water absorption in the collecting duct
124
What would be the main abnormality on TFTs in thyrotoxic crisis?
Marked elevation of free T4
125
What change in vision is caused by a lesion in the optic chiasm?
Bitemporal hemianopia
126
What change in vision is caused by a lesion in the optic tract?
Homonymous hemianopia
127
What change in vision is caused by a lesion in the optic radiation?
Superior quandrantopia
128
Give some examples of causes of metabolic acidosis with increased anion gap
DKA is a big one | Also: lactate acidosis, uraemia secondary to renal failure and salicylate/biguianide poisoning
129
In DKA, for how long should insulin infusion be continued before switching to SC insulin?
Until blood ketones <0.3mmol/L
130
How frequently should potassium be monitored in the acute setting of DKA being treated with an insulin infusion?
4 hourly
131
How should a known type 1 diabetic patient's insulin be managed when they are in DKA and require an insulin infusion?
Long acting basal insulin should be continued alongside the infusion as this simplifies the change from infusion to SC insulin in due course
132
Recall 4 side effects of carbimazole
Maculopapular rash Bone marrow suppression leading to agranulocytosis Pruritis Jaundice
133
How should primary hyperaldosteronism due to BL adrenal hypertrophy be managed?
Spironolactone
134
What is the first drug to give in phaeochromocytoma?
Phenoxybenzamine
135
How should once daily insulin regimes be managed pre-operatively?
Reduced dose insulin on the day of the op and the day before
136
Why might someone get hyponatraemia post-SAH?
SAH can lead to SIADH
137
What is the best test for diagnosing phaeochromocytoma?
Plasma and serum catecholamines
138
How can a splenectomy affect blood sugar levels?
Can give a falsely high reading due to the increased life span of RBCs
139
What is the immediate management of pituitary apoplexy?
IV hydrocortisone
140
What is the treatment for malignant hyperthermia?
IV dantrolene
141
Where are ischaemic and neuropathic ulcers typically found?
Ischaemic = usually on toes, distally Neuropathic = usually on the base of the foot
142
How should Charcot's foot be managed?
* Rule out infection (cellulitis) and give Abx if unsure * If acute, treat as a fracture so no weight-bearing and use a boot or cast * XR to check for signs of gas gangrene/osteomyelitis
143
What temperature difference between feet would indicate a neuropathy?
>2 degrees
144
What are normal and abnormal doppler sounds for the lower limb?
Bi/triphasic = normal Monophonic or bruit sounds = abnormal
145
What is the management of thyroid cancer?
* Thyroidectomy * Radioactive iodine ablation (treatment dose) - to kill any remaining cells * Replace thyroxine to a supraphysiological level so that the brain does not signal to the thyroid gland to start producing thyroxine as this could stimulate cancer cells
146
What is the TSH target with supraphysiological thyroxine replacement?
<0.1
147
When would a radioiodine challenge be indicated following thyroid cancer treatment?
If thyroglobulin or TSH levels began to rise (no uptake should be seen)
148
What is the management of an adrenal adenoma dependent on the size?
* <4cm - usually watch and wait with interval scanning * 4-6cm - possible risk of malignancy, usually removed * >6cm - increased malignancy risk, definitely remove
149
What thionamides are used in each part of pregnancy?
* PTH in 1st trimester * Carbimazole in 2nd and 3rd trimester
150
Why is carbimazole not recommended in the first trimester of pregnancy?
Small chance of a skin reaction
151
What would be the result of a low and high dose dexamethasone test in Cushing's disease?
Low dose - not suppressed High dose - suppressed
152
What is a common derangement in blood results as a result of glucocorticoid treatment?
Neutrophilia
153
Over-replacement of thyroxine increases the risk of what?
Osteoporosis
154
When should diabetics have empagaflozin/SGLT2 inhibitors added to their regime?
Current NICE advice is that patients with type 2 diabetes who are at high risk of developing cardiovascular disease, those who do develop cardiovascular disease, and those with chronic heart failure, should receive an SGLT2 inhibitor.
155
What adverse side effect are SGLT2 inhibitors linked to aside from increased incidence of UTIs?
Fournier's gangrene
156
What is Fournier's gangrene?
* A fulminant form of infective necrotising fasciitis affecting the genitalia and/or perineum * Most common in diabetic and immune compromised patients * Due to the rapid progression of this condition, it can often cause multiple organ failure and death due to sepsis
157
What is the Mx of Fournier's gangrene?
Early surgical debridement and Abx
158
What is the HbA1c target for a patient on a sulphonylurea?
53mmol This target is based on a balance between reducing the risk of microvascular complications while also minimising the risk of hypoglycaemia, which in turn can lead to falls, cognitive impairment, and cardiovascular events.
159
What are the main side effects of sulpgonylureas?
* Weight gain - avoid in obese diabetics * Hypoglycaemic episodes
160
What Ix should be done for suspected acromegaly?
* First line - IGF-1 levels * If raised, OGTT and serial GH levels * Pituitary MRI can then be done to determine cause of acromegaly
161
What are the BP targets for diabetics?
T2DM blood pressure targets are the same as non-T2DM. If < 80 years: * Clinic reading: < 140 / 90 * ABPM / HBPM: < 135 / 85
162
What is the Mx of Addisonian crisis?
IV hydrocortisone (fludrocortisone is not required in the acute setting)
163
What are the targets for treatment of DKA?
The recommended targets of treatment are: * Reduction of blood ketone concentration by 0.5 mmol/L/hour * Increase the venous bicarbonate by 3.0 mmol/L/hour * Reduce capillary blood glucose by 3 mmol/L/hour * Maintain potassium between 4.0 and 5.5 mmol/L
164
When should you wait an hour before starting the fixed rate insulin in DKA Mx?
With children - as there is some evidence it reduces the risk of cerebral oedema There is no need to delay insulin treatment in adults.
165
What is the most common cause of hypothyroidism worldwide?
Iodine deficiency
166
Where is iodine deficiency particularly common?
Asia and Africa, especially in mountainous regions
167
How is diabetic neuropathy tested?
10g monofilament test
168
What would the typical TFT results be in sick euthyroid syndrome?
TsH - normal Free T3/4 - low On the background of an acute illness
169
What is a common side effect of spironolactone in men?
Gynaecomastia
170
When would SGLT2 monotherapy be appropriate?
If metformin is contraindicated + patient has a risk of CVD, established CVD or chronic heart failure → SGLT-2 monotherapy
171
What is the immediate Mx of changes in vision on a background of thyroid disease?
Urgent ophthalmology review (as you are worried about thyroid eye disease)
172
What is the management of a fracture in a post-menopausal woman?
Bisphosphonates + calcium supplements NO need for a DEXA scan prior to starting
173
What type of condition can cause a falsely low HbA1c reading?
Haemoglobinopathies/sickle cell disease - due to reduced RBC lifespan
174
What are some symptoms of gastroparesis?
* Erratic blood glucose control * Early satiety * Bloating * Nausea and vomiting
175
What is the treatment of hypoglycaemia if the patient is conscious/has a safe swallow?
10-20g glucose gel, repeated after 15 minutes if blood glucose levels do not improve, for up to 3 treatments in total.
176
Alongside steroids, what else should patients with Addison's disease be prescribed?
Hydrocortisone injection kit
177
What is meant by thyroid acropachy?
Soft tissue swelling underneath the nail bed which can look similar to clubbing
178
What are the typical TFT results in subclinical hypothyroidism?
TSH - raised T4/3 - normal
179
How should subclinical hypothyroidism treated?
Treatment is dependent on age and TSH levels **TSH is > 10mU/L** - consider offering levothyroxine if the TSH level is > 10 mU/L on 2 separate occasions 3 months apart **TSH is between 5.5 - 10mU/L** + if < 65 years, consider offering a 6-month trial of levothyroxine if: * The TSH level is 5.5 - 10mU/L on 2 separate occasions 3 months apart AND * There are symptoms of hypothyroidism In older people (especially those aged over 80 years) follow a 'watch and wait' strategy is often used If asymptomatic people, observe and repeat thyroid function in 6 months
180

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