Title 01 .ENDOCRINOLOGY MCQs.pdf ✅

A 23-year-old woman presents for review. She has not had a normal period for around 8 months now. A recent pregnancy test was negative. Blood tests are ordered: FSH 2.2 IU/L (0-20 IU/L) Oestradiol 84 pmol/l (100-500 pmol/l) Thyroid stimulating hormone 3.1 mIU/L Prolactin 2 ng/ml (0-10 ng/ml) Free androgen index 3 ( < 7 ) What is the most likely cause of her symptoms? A. Prolactinoma B. Premature ovarian failure C. Polycystic ovarian syndrome D. Addison's disease E. Excessive exercise ANSWER: E. Excessive exercise EXPLANATION: The bloods show a hypothalamic amenorrhoea which may be caused by stress or excessive exercise. The FSH would be raised in premature ovarian failure. NOTES Amenorrhoea Amenorrhoea may be divided into primary (failure to start menses by the age of 16 years) or secondary (cessation of established, regular menstruation for 6 months or longer). Causes of primary amenorrhoea • Turner's syndrome • testicular feminisation • congenital adrenal hyperplasia • congenital malformations of the genital tract Secondary amenorrhoea is defined as when menstruation has previously occurred but has now stopped for at least 6 months. Causes of secondary amenorrhoea (after excluding pregnancy) • hypothalamic amenorrhoea (e.g. Stress, excessive exercise) • polycystic ovarian syndrome (PCOS) • hyperprolactinaemia • premature ovarian failure • thyrotoxicosis* • Sheehan's syndrome • Asherman's syndrome (intrauterine adhesions) Initial investigations • exclude pregnancy with urinary or serum bHCG • gonadotrophins: low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure) • prolactin • androgen levels: raised levels may be seen in PCOS • oestradiol • thyroid function tests *hypothyroidism may also cause amenorrhoea. ed, regular menstruation for 6 months or Q-2 A 55-year-old taxi driver with type 2 diabetes mellitus comes for review. When he was diagnosed 12 months ago he was started on metformin and the dose was titrated up. His IFCC- HbA1c one year ago was 75 mmol/mol (DCCT-HbA1c 9%) and is now 69 mmol/mol (8.5%). His body mass index is 33 kg/m2. What is the most appropriate next step in management? A. Add exenatide B. Add sitagliptin C. Add glipizide D. Make no changes to his medication E. Add insulin ANSWER: B. Add sitagliptin EXPLANATION: His HbA1c is still significantly above target so some change to the medication is indicated. The NICE type 2 diabetes mellitus guidelines would generally advocate the use of a sulfonylurea in this situation. Q-1 ENDOCRINOLOGY MCQs
However. the patient is a taxi driver and overweight. A DPP-4 inhibitor such as sitagliptin would be ideal in this situation. There is no risk of hypoglycaemia and they DPP-4 inhibitors are weight neutral. NOTES: Diabetes mellitus: management of type 2 NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2015. Key points are listed below: HbA1c targets have changed. They are now dependent on what antidiabetic drugs a patient is receiving and other factors such as frailty there is more flexibility in the second stage of treating patients (i.e. after metformin has been started) - you now have a choice of 4 oral antidiabetic agents It's worthwhile thinking of the average patient who is taking metformin for T2DM, you can titrate up metformin and encourage lifestyle changes to aim for a HbA1c of 48 mmol/mol (6.5%), but should only add a second drug if the HbA1c rises to 58 mmol/mol (7.5%) Dietary advice: encourage high fibre, low glycaemic index sources of carbohydrates include low-fat dairy products and oily fish control the intake of foods containing saturated fats and trans fatty acids limited substitution of sucrose-containing foods for other carbohydrates is allowable, but care should be taken to avoid excess energy intake discourage use of foods marketed specifically at people with diabetes initial target weight loss in an overweight person is 5-10% HbA1c targets: This is area which has changed in 2015 individual targets should be agreed with patients to encourage motivation HbA1c should be checked every 3-6 months until stable, then 6 monthly NICE encourage us to consider relaxing targets on 'a case-by- case basis, with particular consideration for people who are older or frail, for adults with type 2 diabetes' in 2015 the guidelines changed so HbA1c targets are now dependent on treatment: Lifestyle or single drug treatment Practical examples: a patient is newly diagnosed with HbA1c and wants to try lifestyle treatment first. You agree a target of 48 mmol/mol (6.5%) you review a patient 6 months after starting metformin. His HbA1c is 51 mmol/mol (6.8%). You increase his metformin from 500mg bd to 500mg tds and reinforce lifestyle factors Patient already on treatment: Drug treatment: The 2015 NICE guidelines introduced some changes into the management of type 2 diabetes. There are essentially two pathways, one for patients who can tolerate metformin, and one for those who can't: Tolerates metformin: metformin is still first-line and should be offered if the HbA1c rises to 48 mmol/mol (6.5%)* on lifestyle interventions if the HbA1c has risen to 58 mmol/mol (7.5%) then a second drug should be added from the following list: → sulfonylurea → gliptin → pioglitazone → SGLT-2 inhibitor Management of T2DM HbA1c target Already on one drug, but HbA1c has risen to 58 mmol/mol (7.5%) 53 mmol/mol (7.0%) Management of T2DM HbA1c target Lifestyle 48 mmol/mol (6.5%) Lifestyle + metformin 48 mmol/mol (6.5%) Includes any drug which may cause hypoglycaemia (e.g. lifestyle + sulfonylurea) 53 mmol/mol (7.0%)