A 35-year-old female who has recently being diagnosed with Grave's disease presents for review 3 months after starting a 'block and replace' regime with carbimazole and thyroxine. She is concerned about developing thyroid eye disease.
What is the best way that her risk of developing thyroid eye disease can be reduced?
Correct Answer D: Smoking is the most important modifiable risk factor for the development of thyroid eye disease.
Thyroid eye disease:
Thyroid eye disease affects between 25-50% of patients with Graves' disease. It is thought to be caused by an autoimmune response against an autoantigen, possibly the TSH receptor, which in turns causes retro-orbital inflammation. The patient may be eu-, hypo- or hyperthyroid at the time of presentation.
Prevention:
Features:
Management:
Exophthalmos
A 3-year-old boy is investigated for lethargy. Examination is unremarkable with a blood pressure of 90/46 mmHg (normal for his age). Blood tests reveal:
Which one of the following conditions is most likely to be responsible?
Correct Answer D: Bartter's syndrome is associated with normotension.
Bartter's syndrome is an inherited cause (usually autosomal recessive) of severe hypokalaemia due to defective chloride absorption at the Na+ K+ 2Cl- cotransporter in the ascending loop of Henle.
Hypokalaemia and hypertension:
For exams it is useful to be able to classify the causes of hypokalaemia in to those associated with hypertension, and those which are not.
Hypokalaemia with hypertension:
Carbenoxolone, an anti-ulcer drug, and liquorice excess can potentially cause hypokalaemia associated with hypertension.
Hypokalaemia without hypertension:
*21-hydroxylase deficiency, which accounts for 90% of congenital adrenal hyperplasia cases, is not associated with hypertension.
**Type 4 renal tubular acidosis is associated with hyperkalaemia
A 45-year-old man is investigated following referral to the endocrinology clinic with polydipsia. Plasma glucose and calcium are normal. A water deprivation test is performed with the following results:
What is the most likely diagnosis?
Correct Answer E: A dramatic improvement is seen in the ability of the kidneys to concentrate urine following the administration of DDAVP. This points towards a diagnosis of cranial diabetes insipidus.
Water deprivation test:
Method:
Osmolality readings to differentiate the predisposing cause:
A 78-year-old nursing home resident is admitted to the acute medical unit after being found collapsed in his room. A carer from the nursing home is present and reports that he has had regular 'hypos' recently. On admission he was drowsy and the blood glucose was 1.8 mmol/l. Following intravenous dextrose the patient's condition significantly improved. His medication on admission is as follows:
What is the most appropriate initial action?
Correct Answer C: Neither metformin nor pioglitazone cause hypoglycaemia. The gliclazide dose is therefore responsible and should be stopped whilst deciding upon longer term changes to his medication.
Diabetes mellitus: management of type 2:
NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2009. Key points are listed below:
Dietary advice:
HbA1c:
Blood pressure:
The NICE treatment algorithm has become much more complicated following the introduction of new therapies for type 2 diabetes. We suggest reviewing this using the link provided. Below is a very selected group of points from the algorithm:
Starting insulin:
Other risk factor modification:
*Many local protocols now recommend starting metformin upon diagnosis
A 45-year-old female is admitted to the Emergency Department with abdominal pain associated with vomiting. She has a past medical history of hypothyroidism and takes thyroxine. On examination she is pyrexial at 37.6ºC. Pulse is 110 bpm with a blood pressure of 100/64 mmHg. Blood results show the following:
What treatment should be given first?
Correct Answer E: This is a typical history of Addison's. Patients may have a history of other autoimmune conditions such as thyroid disorders. Steroids should be given as soon as possible.
Addison's disease:
Autoimmune destruction of the adrenal glands is the commonest cause of hypoadrenalism in the UK, accounting for 80% of cases.
Other causes of hypoadrenalism: Primary causes:
Secondary causes:
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