Endocrinology & Diabetes

Endocrinology & Diabetes UK Medical PG Question 1: A 42-year-old woman presents with fatigue, muscle aches, and widespread pain. She has multiple tender points but normal inflammatory markers. Sleep is poor. What is the most appropriate initial treatment?

• A. NSAIDs
• B. Prednisolone
• C. Pregabalin (Correct Answer)
• D. Methotrexate
• E. Physiotherapy alone

Endocrinology & Diabetes Explanation: ***Pregabalin*** - **Pregabalin** is a **gabapentinoid** drug that modulates voltage-gated calcium channels, decreasing the release of excitatory neurotransmitters involved in central pain sensitization characteristic of **fibromyalgia**. - It is one of the FDA-approved medications (along with duloxetine and milnacipran) specifically recommended for managing the **widespread pain** and associated symptoms like **poor sleep** in fibromyalgia. *NSAIDs* - Non-steroidal anti-inflammatory drugs (NSAIDs) target inflammatory pain, which is generally absent in **fibromyalgia** as evidenced by **normal inflammatory markers**. - NSAIDs are usually **ineffective** in treating the centralized pain and hyperalgesia seen in this condition, making them a poor choice for monotherapy. *Prednisolone* - **Prednisolone** is a powerful corticosteroid used for conditions driven by **inflammation** (e.g., active arthritis or vasculitis). - The patient has normal inflammatory markers and a clinical presentation consistent with a non-inflammatory central pain syndrome, making steroids **inappropriate** and potentially harmful. *Methotrexate* - **Methotrexate** is a **Disease-Modifying Anti-Rheumatic Drug (DMARD)** indicated for managing autoimmune inflammatory diseases like **Rheumatoid Arthritis** or **Psoriatic Arthritis**. - Since the patient does not show evidence of an inflammatory or autoimmune joint disease, this immunosuppressant drug treatment is **not warranted**. *Physiotherapy alone* - While non-pharmacological therapies like **aerobic exercise** and **Cognitive Behavioral Therapy (CBT)** are essential long-term components, they are often insufficient alone to manage severe initial symptoms, particularly **poor sleep** and disabling pain. - Initial treatment typically requires a combination of pharmacological agents (like **Pregabalin**) combined with supportive non-pharmacological management for optimal symptom control.

Endocrinology & Diabetes UK Medical PG Question 2: A 49-year-old man presents with progressive weakness in his arms and legs over 24 months. He has bulbar symptoms including dysphagia and dysarthria. EMG shows widespread denervation. What is the most important prognostic factor?

• A. Age at onset
• B. Rate of progression
• C. Bulbar involvement (Correct Answer)
• D. Site of onset
• E. Family history

Endocrinology & Diabetes Explanation: ***Bulbar involvement*** - The presence of **bulbar symptoms** (dysphagia and dysarthria) at presentation or early in the disease course is the single most important predictor of shorter survival in **Amyotrophic Lateral Sclerosis (ALS)**. - This is primarily because bulbar dysfunction leads quickly to difficulty swallowing, increasing the risk of **aspiration pneumonia** and malnutrition, and often precedes necessary respiratory intervention. *Age at onset* - While a factor, **older age (>65 years)** at onset is associated with a worse prognosis but is generally considered less influential than the pattern of motor neuron involvement. - Patients with **younger onset** (e.g., in their 40s) tend to have a slightly better prognosis than those with onset in their 70s. *Rate of progression* - The **rate of progression** directly determines the prognosis (survival time) itself, reflecting the speed of motor neuron loss. - However, **bulbar involvement** is often the underlying *predictor* or characteristic that drives a rapid rate of progression, making the bulbar site the more fundamental prognostic factor. *Site of onset* - The specific **site of onset** is critical, distinguishing between **limb-onset** and **bulbar-onset** ALS. - Because bulbar onset conveys the worst prognosis, selecting the specific involvement (**bulbar**) is more precise than selecting the general concept of

Endocrinology & Diabetes UK Medical PG Question 3: A 28-year-old woman presents with sudden onset severe headache during exercise. She vomits and has neck stiffness. CT head shows subarachnoid hemorrhage. What is the most likely cause?

• A. Arteriovenous malformation
• B. Berry aneurysm (Correct Answer)
• C. Carotid dissection
• D. Hypertensive hemorrhage
• E. Trauma

Endocrinology & Diabetes Explanation: ***Berry aneurysm*** - The sudden onset of a severe, explosive **thunderclap headache** coupled with signs of meningeal irritation (vomiting, neck stiffness) and the finding of **subarachnoid hemorrhage (SAH)** on CT head is the classic presentation of a ruptured saccular (**berry**) aneurysm. - Exertion (exercise) acts as a common trigger for aneurysm rupture due to the sudden increase in **intracranial pressure** and transmural wall stress. *Arteriovenous malformation* - AVMs more commonly present with **intraparenchymal hemorrhage** (ICH) or seizures, rather than isolated SAH, especially when triggered by exertion. - While AVMs can cause SAH, they are a less frequent cause of widespread spontaneous SAH compared to ruptured **berry aneurysms**. *Carotid dissection* - Carotid artery dissection typically manifests as severe neck/facial pain, headache, and signs of **cerebral ischemia** (stroke symptoms) due to vessel stenosis or occlusion. - Dissections rarely cause primary, widespread SAH; they are more often associated with **subintimal hemorrhage** leading to stroke or pseudoaneurysm formation. *Hypertensive hemorrhage* - Hemorrhage due to chronic or severe hypertension (hypertensive hemorrhage) almost exclusively causes deep **intraparenchymal hemorrhage** (ICH), usually in the basal ganglia, thalamus, or brainstem. - The primary finding of SAH, rather than ICH and the patient's young age, makes uncontrolled hypertension highly unlikely as the underlying cause. *Trauma* - Although trauma is the single most frequent overall cause of SAH, the clinical history describes a **spontaneous event** triggered by exertion (exercise) without any external injury. - Traumatic SAH is clinically differentiated by the history of a specific injury and usually involves bleeding adjacent to the site of impact.

Endocrinology & Diabetes UK Medical PG Question 4: A 46-year-old man presents with recurrent episodes of severe flushing and diarrhea. CT shows liver metastases and a pancreatic mass. Chromogranin A is markedly elevated. What is the most likely primary tumor?

• A. Pancreatic adenocarcinoma
• B. Pancreatic neuroendocrine tumor (Correct Answer)
• C. Hepatocellular carcinoma
• D. Cholangiocarcinoma
• E. Gastrinoma

Endocrinology & Diabetes Explanation: ***Pancreatic neuroendocrine tumor*** - The classic presentation of recurrent **flushing** and **diarrhea**, combined with a **pancreatic mass** and **liver metastases**, is highly characteristic of a functional **neuroendocrine tumor (NET)**, specifically a **carcinoid syndrome**. - Markedly elevated **Chromogranin A** is a widely used and sensitive biochemical marker for **neuroendocrine tumors**, confirming this diagnosis. *Pancreatic adenocarcinoma* - This tumor typically presents with symptoms such as **jaundice**, **weight loss**, and **abdominal pain**, not **flushing** and **diarrhea**. - **Chromogranin A** is not elevated in pancreatic adenocarcinoma; **CA 19-9** is a more common tumor marker. *Hepatocellular carcinoma* - While **liver metastases** are mentioned, the primary tumor is a **pancreatic mass**, not a primary liver tumor. - It does not typically cause **flushing** and **diarrhea**, nor is **Chromogranin A** a marker for hepatocellular carcinoma. *Cholangiocarcinoma* - This is a cancer of the **bile ducts** and usually presents with **jaundice**, **pruritus**, and **dark urine**, not **flushing** and **diarrhea**. - The primary mass is in the **pancreas**, not the bile ducts, and **Chromogranin A** is not elevated in cholangiocarcinoma. *Gastrinoma* - A **gastrinoma** is a type of pancreatic neuroendocrine tumor that primarily causes **Zollinger-Ellison syndrome**, characterized by severe **peptic ulcer disease** and **diarrhea** due to excessive gastrin. - While it's a NET, the prominent **flushing** is not a typical feature of gastrinoma; this symptom strongly points towards a tumor producing other vasoactive substances (e.g., serotonin, VIP) consistent with a broader **carcinoid syndrome** presentation.

Endocrinology & Diabetes UK Medical PG Question 5: A 43-year-old man presents with recurrent episodes of severe sweating, palpitations, and headache. His BP during episodes is 240/130 mmHg. What is the most appropriate preoperative management?

• A. Beta-blockers only
• B. Alpha-blockers only
• C. Alpha-blockers then beta-blockers (Correct Answer)
• D. ACE inhibitors
• E. Calcium channel blockers

Endocrinology & Diabetes Explanation: ***Alpha-blockers then beta-blockers***- The clinical presentation (paroxysmal **hypertension**, headache, palpitations, and sweating) is highly suggestive of a **pheochromocytoma**.- Preoperative stabilization requires adequate **alpha-adrenergic blockade** first (e.g., phenoxybenzamine or doxazosin) to control blood pressure and allow for volume expansion, followed by **beta-blockade** to manage tachycardia or arrhythmias.*Beta-blockers only*- Using beta-blockers alone is contraindicated as it causes **unopposed alpha-adrenergic stimulation**, leading to severe **vasoconstriction** and potentially a fatal hypertensive crisis or pulmonary edema.- Beta-blockers are only instituted *after* achieving complete alpha-blockade and adequate blood pressure control, typically to manage persistent tachycardia.*Alpha-blockers only*- While alpha-blockade is the essential first step, it is usually insufficient for full preoperative management, as patients often require subsequent **beta-blockade** to control catecholamine-induced tachycardia and arrhythmias.- Complete preparation requires both classes of medication to fully mitigate cardiovascular risk before surgery.*ACE inhibitors*- These medications target the **renin-angiotensin-aldosterone system** and are ineffective at blocking the direct severe vasoconstrictive effects of excessive circulating catecholamines.- They may also increase the risk of severe **hypotension** after tumor removal if the patient is relatively volume-depleted from prolonged vasoconstriction.*Calcium channel blockers*- While some CCBs (like nicardipine) can be used as **adjuncts** for blood pressure control, they cannot replace the mandatory initial step of **alpha-adrenergic blockade** and volume repletion.- They do not address the need for full adrenergic receptor blockade necessary to prevent cardiovascular catastrophe during surgical manipulation of the tumor.

Endocrinology & Diabetes Flashcard 1 of 5

Question: A diagnosis of _____ should be suspected in patients with adrenal insufficiency, hypoparathyroidism and thyroid disease

Answer: autoimmune polyglandular syndrome (1/2)

Endocrinology & Diabetes Flashcard 2 of 5

Question: In T2DM management when should SGLT-2 inhibitors be introduced?

Answer: • If a patient develops CVD (e.g. diagnosed with ischaemic heart disease) • a QRISK >= 10% or chronic heart failure

Endocrinology & Diabetes Flashcard 3 of 5

Question: DKA primarily affects patients with _____, but can rarely affect patients with type 2 diabetes

Answer: type 1 diabetes

Endocrinology & Diabetes Flashcard 4 of 5

Question: Patients with symptoms of type 2 diabetes can be diagnosed if: • HbA1c is _____ OR • Fasting glucose is ≥7 mmol/L OR • Random glucose/OGTT is ≥11.1 mmol/L

Answer: ≥48 mmol/mol

Endocrinology & Diabetes Flashcard 5 of 5

Question: Add _____ if fasting glucose level is >=7 mmol/l

Answer: Insulin