Endocrine

Question 1

Approximately how many adults in the UK have type 1 diabetes?

Answer 1

370,000

Question 2

The incidence of type 1 diabetes peaks between which stages of life?

Answer 2

Early childhood (6 months to 5 years) and then in puberty

Question 3

Name 5 types of diabetes?

Answer 3

1. Type 1
2. Type 2
3. Gestational
4. Monogenic
5. Drug/chemical induced

Question 4

What % chance have you got of developing type 1 diabetes, if your sibling has it?

Answer 4

10%

Question 5

What are the classic symptoms of type 1 diabetes in children? (4)

Answer 5

1. weight loss
2. fatigue
3. thirst (polydipsia)
4. polyuria

Question 6

What are the classic symptoms/presenting features of type 1 diabetes in adults? (5)

Answer 6

1. Rapid weight loss
2. Ketosis
3. Age of onset younger than 50 years
4. BMI < 25kg/m2
5. Personal/family history of autoimmune diseases

Question 7

Which blood test is performed to investigate type 1 diabetes, and what result indicates suspected T1DM?

Answer 7

Random plasma glucose >11mmol/L

Question 8

How soon should a child be seen if T1DM is suspected?

Answer 8

Same day referral to paediatric diabetes team

Question 9

If the presentation of T1DM is atypical, what further investigations can be carried out? (2 blood tests?)

Answer 9

1. C-peptide

2. Diabetes-specific autoantibody

Question 10

Which immunisations are particularly important for children with T1DM to have? (2)

Answer 10

1. Influenza

2. Pneumococcal infections

Question 11

How many people in the UK have been diagnosed type 2 diabetes (T2DM)?

Answer 11

3.5 million

Question 12

What is type 2 diabetes?

Answer 12

A resistance to insulin and a relative insulin deficiency, resulting in persistent hyperglycaemia

Question 13

What causes type 1 diabetes?

Answer 13

Usually it is a destruction of beta-cells in the pancreatic islets of Langerhans. Most commonly due to autoimmunity.

Question 14

What are the risk factors for T2DM? (9)

Answer 14

1. Obesity and inactivity
2. Family history
3. Ethnicity - afro/caribbean
4. History of gestational diabetes
5. Poor dietary habits (low fibre, high GI)
6. Drugs: e.g. statins corticosteroids, thiazide diuretic combined with a beta-blocker
7. Polycystic ovarian syndrome
8. Low birth weight for gestational age
9. Metabolic syndrome: raised BP, abnormal blood lipid levels, fatty liver, central obesity

Question 15

What are the characteristic features/symptoms of T2DM?

Answer 15

Thirst, polyuria, blurred vision recurrent infections, tiredness …however these are not usually severe and may be absent.

Question 16

What are the complications of poorly managed/undiagnosed T2DM? (the list is endless, but think in terms of microvascular/microvascular/metabolic etc).

Answer 16

1. Macrovascular complications - CVD, cerebrovascular disease, peripheral arterial disease
2. Microvascular complications - nephropathy, retinopathy and neuropathy
3. Metabolic complications - dyslipidaemia and DKA
4. Anxiety and depression
5. Infections - particularly UTIs and skin infections
6. Dementia

Question 17

Which blood tests are measured to investigate suspected T2DM? and which corresponding levels would indicate it? (3)

Answer 17

1. HbA1c >48mmol/mol
2. Plasma glucose >11mmol/L
3. Fasting plasma glucose >7mmol/L

Question 18

When should HbA1c not be used to diagnose diabetes? (3)

Answer 18

1. In children and young people
2. Pregnant women or women <2 months postpartum
3. People with end-stage CKD, HIV, pancreatic damage, on corticosteroids

Question 19

In which gender is hypothyroidism more common?

Answer 19

Females

Question 20

In the UK what is the most common cause of primary hypothyroidism?

Answer 20

Autoimmune thyroiditis (Hashimoto’s or atrophic)

Question 21

Worldwide, what is the most common cause of primary hypothyroidism?

Answer 21

Iodine deficiency

Question 22

What are the causes of primary hypothyroidism? (7)

Answer 22

1. Iodine deficiency
2. Autoimmune thyroiditis
3. Thyroid trauma (e.g. surgery/radiotherapy)
4. Drugs: Amiodarone, lithium, interferons, thalidomide, rifampicin, and 15% of people treated with carbimazole/propylthiouracil for hyperthyroidism, will go on to develop hypothyroidism.
5. Transient thyroiditis
6. Thyroid infiltrative disorders
7. Congenital hypothyroidism

Question 23

What are the causes of secondary hypothyroidism? (2)

Answer 23

1. Pituitary dysfunction - tumours (pituitary adenoma), surgery, radiotherapy, trauma, infection, Sheehan’s syndrome, TB, syphilis, sarcoidosis
2. Hypothalamic dysfunction - tumours (gliomas), drugs (retinoids/bexarotene), and all above as for pituitary.

Question 24

What are the risk factors for hypothyroidism? (4)

Answer 24

1. Poor intake of dietary iodine (found in fish and dairy products)
2. Family history (including other autoimmune diseases too)
3. Down’s syndrome
4. Amiodarone/Lithium use
   There are many other diseases/conditions that can cause hypothyroidism too.

Question 25

What are the symptoms of hypothyroidism? (8)

Answer 25

1. Fatigue 2. Cold intolerance 3. Weight gain 4. Constipation 5. Non-specific weakness, myalgia 6. Depression, impaired concentration and memory 7. Dry skin 8. Menstrual irregularities

Question 26

What is Cushing's syndrome?

Answer 26

It is a clinical manifestation of pathological hypercortisolism from any cause.

Question 27

How does Cushing's syndrome typically present?

Answer 27

Patients often display weight gain with central obesity, facial rounding and plethora, proximal muscle weakness, and thinning of the skin.

Question 28

What complications can people with Cushing's syndrome develop? (4)

Answer 28

Metabolic complications including; 1. Diabetes 2. Dyslipidaemia 3. Metabolic bone disease 4. Hypertension

Question 29

What causes Cushing's syndrome? (3)

Answer 29

1. ACTH-secreting pituitary tumours (AKA Cushing's disease) 2. Autonomous adrenal cortisol overproduction 3. Ectopic ACTH-secreting tumours

Question 30

What are the risk factors for developing Cushing's syndrome? (4)

Answer 30

1. Exogenous corticosteroid use 2. Pituitary adenoma 3. Adrenal adenoma 4. Adrenal carcinoma

Question 31

What symptoms are key diagnostic factors? (at least 4)

Answer 31

1. Present of risk factors 2. Facial plethora 3. Supraclavicular fullness 4. Violaceous striae

Question 32

What are the diagnostic investigations to consider for Cushing's syndrome? (4)

Answer 32

1. Urine pregnancy test 2. Serum glucose 3. Late-night salivary cortisol 4. 1mg overnight dexamethasone suppression test

Question 33

What is Addison's disease?

Answer 33

Addison's disease (primary adrenal insufficiency) is a result of destruction of the adrenal cortex --> this causes reduced production of glucocorticoids (e.g. cortisol), mineralocorticoids (e.g. aldosterone) and adrenal androgens (e.g. dehydroepiandrosterone)

Question 34

What is the most common cause of Addison's disease in the developed world?

Answer 34

Autoimmune disease (70-90% of cases)

Question 35

In lesser developed countries, what is the most common cause of Addison's disease?

Answer 35

TB

Question 36

Aside from autoimmune disease and TB, what are the other, rarer causes of Addison's disease? (5)

Answer 36

1. Adrenal metastases 2. Adrenal haemorrhage 3. Infections e.g. cytomegalovirus and HIV 4. Amyloidosis 5. Congenital adrenal hyperplasia

Question 37

Addison's disease is associated with other autoimmune conditions, what are they? (3)

Answer 37

1. Hypothyroidism 2. Type 1 diabetes 3. Autoimmune polyendocrine syndrome (60% of people with Addison's)

Question 38

What are the two types of autoimmune polyendocrine syndrome?

Answer 38

1. Polyglandular autoimmune syndrome type 1 | 2. Polyglandular autoimmune syndrome type 2 (more common) - linked to HLA DR3 and DR4

Question 39

What is the most common complication of Addison's disease?

Answer 39

Adrenal crisis

Question 40

What is an adrenal crisis?

Answer 40

This occurs when a person with Addison's disease suffers severe physical stress. The adrenal gland cannot supply the extra corticosteroids needed to cope with the stress, and life-threatening symptoms develop. Adrenal crisis may precipitate severe dehydration, hypotension, hypovolaemic shock, altered consciousness, seizures, stroke or cardiac arrest.

Question 41

Addison's disease is hard to diagnose, as the symptoms are non-specific and overlap with other conditions, however, when should Addison's disease be suspected in someone? (6)

Answer 41

In a person with persistent, non-specific symptoms including: 1. Fatigue 2. Hyperpigmentation (affects 92% of people with Addison's) 3. GI symptoms - weight loss, loss of appetite, cravings for salt, soy sauce or liquorice 4. MSK symptoms - muscle weakness, cramps and joint pains 5. CV symptoms - postural dizziness due to hypotension 6. Headache, low-grade fever, increased thirst/urination

Question 42

Addison's disease should be considered in people with what other conditions? (6)

Answer 42

1. Hypothyroidism - particularly if symptoms worsen when starting levothyroxine 2. Type 1 diabetes 3. Pernicious anaemia 4. Alopecia 5. Coeliac disease 6. Hyponatraemia and hyperkalaemia

Question 43

What are the differential diagnoses for Addison's disease? (6)

Answer 43

1. Gastroenteritis - nausea and vomiting are key features of adrenal crisis 2. Depression - chronic fatigue, malaise, anorexia may mimic depression 3. Eating disorders 4. Type 1 diabetes 5. Chronic fatigue syndrome 6. Hyperemesis and chloasma of pregnancy

Question 44

If Addison's disease or adrenal insufficiency is suspected, what investigation can be requested?

Answer 44

A serum cortisol level and U&Es | - ideally the serum cortisol level should be obtained between 8-9am

Question 45

What is hyperparathyroidism?

Answer 45

An enlargement of one of the glands resulting in over production of calcium

Question 46

What is primary hyperparathyroidism associated with?

Answer 46

Primary hyperparathyroidism may be associated with uncommon familial disorders including multiple endocrine neoplasia type 1 and type 2A syndromes, familial hyperparathyroidism-jaw tumour syndrome, and familial isolated hyperparathyroidism

Question 47

How does parathyroid hormone result in hypercalcaemia?

Answer 47

Excess PTH causes hypercalcaemia by increasing renal calcium reabsorption and mobilizing calcium from bone. It also indirectly increases intestinal calcium absorption, by increasing synthesis of serum 1,25-dihydroxyvitamin D3 (calcitriol, the active form of vitamin D3)