Which one of the following regarding the management of thyroid problems during pregnancy is incorrect?
Correct Answer C:
Pregnancy: thyroid problems: In pregnancy there is an increase in the levels of thyroxine-binding globulin (TBG). This causes an increase in the levels of total thyroxine but does not affect the free thyroxine level.
Thyrotoxicosis: Untreated thyrotoxicosis increases the risk of fetal loss, maternal heart failure and premature labour Graves' disease is the most common cause of thyrotoxicosis in pregnancy. It is also recognized that activation of the TSH receptor by HCG may also occur - often termed transient gestational hyperthyroidism. HCG levels will fall in second and third trimester.
Management:
Hypothyroidism: Key points:
A 53-year-old man with a history of type 2 diabetes mellitus is reviewed in the diabetes clinic. Twelve months ago his HbA1c was 9.7% despite maximal oral hypoglycaemic therapy. Insulin was started and his most recent HbA1c is 8.2%. He is considering applying for a HGV license and asks for advice.
What is the most appropriate advice?
Correct Answer B: Patients on insulin may now hold a HGV license if they meet strict DVLA criteria.
DVLA: diabetes mellitus: Until recently people with diabetes who used insulin could not hold a HGV license. The DVLA changed the rules in October 2011. The following standards need to be met (and also apply to patients using other hypoglycaemic inducing drugs such as sulfonylureas):
From a practical point of view patients on insulin who want to apply for a Group 2 (HGV) licence need to complete a D2 form. They may will also be required to produce a D4 Medical examination report.
Other specific points for group 1 drivers:
*to demonstrate adequate control, the Secretary of State's Honorary Medical Advisory Panel on Diabetes Mellitus has recommended that applicants will need to have used blood glucose meters with a memory function to measure and record blood glucose levels for at least 3 months prior to submitting their application.
What is the most appropriate screening investigation to exclude a phaeochromocytoma?
Correct Answer D: Phaeochromocytoma: do 24 hr urinary catecholamines, not VMA etc.
A 24 hr urinary collection of catecholamines is preferred to one of vanillylmandelic acid as it has a higher sensitivity. Three 24 hour collections are needed as some patients have intermittently raised levels.
Phaeochromocytoma: Phaeochromocytoma is a rare catecholamine secreting tumour. About 10% are familial and may be associated with MEN type II, neurofibromatosis and von Hippel-Lindau syndrome.
Basics:
Tests:
Surgery is the definitive management. The patient must first however be stabilized with medical management:
Which one of the following types of bariatric surgery is most likely to cause significant malabsorption?
Correct Answer C: Biliopancreatic diversion with duodenal switch is a primarily malabsorptive procedure and reserved for patients who are very obese.
Obesity: bariatric surgery: The use of bariatric surgery in the management of obesity has developed significantly over the past decade. It is now recognized that for many obese patients who fail to lose weight with lifestyle and drug interventions the risks and expense of long-term obesity outweigh those of surgery.
NICE guidelines on bariatric surgery for adults: Consider surgery for people with severe obesity if:
Consider surgery as a first-line option for adults with a BMI of more than 50 kg/m2 in whom surgical intervention is considered appropriate; consider orlistat before surgery if the waiting time is long.
Types of bariatric surgery:
Which operation?
An 24-year-old woman is reviewed due to facial hirsutism. You suspect a diagnosis of polycystic ovarian syndrome (PCOS).
Which one of the following features would suggest the need for further investigations before confidently making a diagnosis of PCOS?
Correct Answer A: Clitoromegaly is seen occasionally in PCOS but is normally associated with very high androgen levels. If clitoromegaly is found then further investigations to exclude an ovarian or adrenal androgen secreting tumour are required.
Polycystic ovarian syndrome: features and investigation: Polycystic ovary syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5- 20% of women of reproductive age. The aetiology of PCOS is not fully understood. Both hyperinsulinaemia and high levels of luteinizing hormone are seen in PCOS and there appears to be some overlap with the metabolic syndrome.
Features:
Investigations:
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