A 45-year-old man presents with bitemporal hemianopia and spade-like hands.
What is the definite test to confirm the diagnosis?
Correct Answer C: The diagnostic test for acromegaly is an oral glucose tolerance with growth hormone measurements.
Acromegaly: investigations:
Growth hormone (GH) levels vary during the day and are therefore not diagnostic. The definitive test is the oral glucose tolerance (OGTT) with serial GH measurements. Serum IGF-1 may also be used as a screening test and is sometimes used to monitor disease.
Oral glucose tolerance test:
A pituitary MRI may demonstrate a pituitary tumour.
A 25-year-old Asian woman who is 26 weeks pregnant has an oral glucose tolerance test (OGTT). This was requested due to a combination of her ethnicity and a background of obesity. A recent ultrasound shows that the fetus is large for dates. The following results are obtained:
What is the most appropriate management?
Correct Answer A: Insulin should be started straight away given the blood glucose levels and evidence of macrosomia. Some endocrinologists would consider using either metformin or glibenclamide but gliclazide (option D) is not mentioned in the NICE guidelines.
Pregnancy: diabetes mellitus: Diabetes mellitus may be a pre-existing problem or develop during pregnancy, gestational diabetes. Itcomplicates around 1 in 40 pregnancies.
Risk factors for gestational diabetes:
Screening for gestational diabetes:
NICE issued guidelines on the management of diabetes mellitus in pregnancy in 2008.
Management of pre-existing diabetes:
Management of gestational diabetes:
A 33-year-old woman is referred to the endocrinology clinic with thyrotoxicosis. Recent blood tests show the following:
A smooth, non-tender goitre is noted on examination the neck. The patient also has exophthalmos although there is no ophthalmoplegia, no reduction in visual acuity and no eye symptoms present.
Correct Answer B: This patient has Graves' disease as evidenced by the thyrotoxicosis, goitre, thyroid eye disease and anti-thyroid peroxidase antibodies.
Radioiodine treatment should be avoided given the presence of thyroid eye disease so carbimazole is a better treatment option.
If her eye disease was severe then an ophthalmologist should be consulted. Options for severe thyroid eye disease include systemic steroids and radiotherapy.
Graves' disease: management:
Despite many trials there is no clear guidance on the optimal management of Graves' disease. Treatment options include titration of anti-thyroid drugs (ATDs, for example carbimazole), block-and-replace regimes, radioiodine treatment and surgery. Propranolol is often given initially to block adrenergic effects.
ATD titration:
Block-and-replace:
The major complication of carbimazole therapy is agranulocytosis.
Radioiodine treatment:
A 45-year-old man is reviewed in the diabetes clinic. The following results are obtained:
Gliclazide is added to the metformin he already takes.
What is the minimum time period after which the HbA1c should be repeated ?
Correct Answer D: HbA1C - recheck after 2-3 months.
A more accurate answer would probably be 2 months but this is not given as an option. See the explanation below.
Glycosylated haemoglobin: Glycosylated haemoglobin (HbA1c) is the most widely used measure of long-term glycaemic control in diabetes mellitus. HbA1c is produced by the glycosylation of haemoglobin at a rate proportional to the glucose concentration.
The level of HbA1c therefore is dependent on:
HbA1c is generally thought to reflect the blood glucose over the previous '2-3 months' although there is some evidence it is weighed more strongly to glucose levels of the past 2-4 weeks.
The relationship between HbA1c and average blood glucose is complex but has been studied by the Diabetes Control and Complications Trial (DCCT). A new internationally standardized method for reporting HbA1c has been developed by the International Federation of Clinical Chemistry (IFCC). This will report HbA1c in mmol per mol of haemoglobin without glucose attached.
From the above we can see that average plasma glucose = (2 * HbA1c) - 4.5
Which one of the following is not associated with primary hyperparathyroidism?
Correct Answer A: Primary hyperparathyroidism is associated with hypertension.
Primary hyperparathyroidism:
In exams primary hyperparathyroidism is stereotypically seen in elderly females with an unquenchable thirst and an inappropriately normal or raised parathyroid hormone level. It is most commonly due to a solitary adenoma.
Causes of primary hyperparathyroidism:
Features - 'bones, stones, abdominal groans and psychic moans':
Associations:
Investigations:
Treatment:
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