Endocrinology Module 6

A 50-year-old patient with Type 1 Diabetes is on his second presentation to the emergency department this month following a severe hypoglycemic episode. The patient uses multiple daily insulin injections and a DEXCOM G6 continuous glucose monitoring system (CGMS). He is perplexed as to why he would become severely hypoglycemic, when his CGM readings have mostly been ‘high’.

Apart from insulin, his current medications include aspirin, simvastatin, metoprolol for previous ischaemic heart disease and oral hydroxyurea which was recently started by his haematologist following a new diagnosis of essential thrombocytopenia.

What would be the best course of action to prevent such events for recurring?

Which of the following statements best describes one of the known pathophysiology of Polycystic Ovary Syndrome (PCOS)?

Which of the following is NOT part of the diagnostic criteria for Polycystic Ovary Syndrome (PCOS)?

A 28-year-old woman presents to the clinic with complaints of excessive hair growth on her face, chest, and back. She has regular menstrual cycles and denies any significant acne or alopecia.

Laboratory tests reveal:

• normal levels of total testosterone and DHEAS.
• normal levels of 17-hydroxyprogesterone
• normal 24-hour urinary cortisol.

An ultrasound of the ovaries shows no evidence of polycystic ovaries.

Which of the following conditions is most likely causing her symptoms?

A previously fit and well 25-year-old female on the oral contraceptive pill but on no other medication, presents with symptoms suggestive of polycystic ovary syndrome (PCOS) including irregular menstrual cycles and hirsutism. Laboratory tests show evidence of hyperandrogenism.

Which of the following is the most appropriate next step in the management of this patient?

What role does anti-mullerian hormone (AMH) play in the diagnosis of Polycystic Ovary Syndrome (PCOS)?

A 58-year-old male with a medical history of type 2 diabetes mellitus, hypertension, and ischemic heart disease presents to the emergency department with severe pain, swelling, and erythema in the perineal region. He also reports fever and malaise over the past 48 hours. His medications include metoprolol, metformin, empagliflozin, lisinopril, and aspirin.

Two weeks ago, his diabetes regimen was adjusted to better control his blood sugar levels. On physical examination, crepitus is noted in the affected area, and laboratory tests reveal elevated blood glucose and white blood cell counts.

Imaging confirms the diagnosis of Fournier’s gangrene. He is admitted for urgent surgical intervention and broad-spectrum antibiotics.

Which medication is most likely associated with the development of this patient’s condition?

A 42 year old female presented with acute back pain after lifting a chair. The pain is intense, increases on movement, and radiates bilaterally to the hypochondriacal region.

Upon questioning she denied previous fractures, but admitted to a gradual loss of height (5cm from her young adult height) and occasional self-limiting back pain.

Her past medical history included spontaneous menopause at the age of 37. She had never taken any regular medications in the past, calcium or Vitamin D supplements.

Examination revealed a thin woman who had a dorsal hyperkyphosis. Severe back pain was ellicited on movement and local percussion.

Investigations: Bone mineral density (BMD) was assessed by dual-energy x’ray absorptionmetry at the hip and the lumber spine (L1-L4).

BMD T-score at lumber spine: -3.0

BMD T-score at total hip: -2.8

What is the underlying diagnosis?

A 40 year old man develops sudden onset of severe frontal headache, diplopia associated with nausea and vomiting.

Examination reveals CN III palsy and bitemporal hemianopia.

MRI shows pituitary apoplexy.

What is the most appropriate next step?

A 37 year old patient with schizophrenia on olanzapine complaint of muscle ache. His prolactin levels has been recorded as 870 and 980 (normal 60-600) on two separate occasions. He is on no other medication.

Examination reveals mild gynaecomastia, no galactorrhea or virilisation. Testicular size is normal.  There are no signs of hypothyroidism.

What is the next step in management?

The following sign is most specific for Cushing’s syndrome:

Which feature is most specific for Cushing’s disease?

A 30 year old woman treated with cabergoline 0.5mg weekly for amenorrhea secondary to a 4mm prolactinoma.

She consults you two weeks after recording a positive pregnancy test.

The most appropriate management is to:

Which condition causes a predominant increase in LDL-cholesterol?

Which medication should be avoided when managing a thyroid storm?

Carbimazole inhibits which pathway?

A 20 year old male patient with Type 1 diabetes on insulin pump presents with mild DKA with pH of 7.2 and a BSL of 23.

What is the most appropriate initial intervention?

The presence of multifocal subperiosteal bone resorption, is most specific for which condition?

An 85-year-old man from rest home with a background of type 2 diabetes presents to the emergency department with decreased level of consciousness. It seems that for the last 3 days, he has had watery diarrhea with six to ten bowel movements per day.

After looking at his medication list from the rest home, it appeared that this man had not taken his insulin for the past 3 days.

On examination, he is afebrile and clinically dehydrated.

• serum blood glucose level is 25
• serum sodium 150
• serum potassium 5.1
• serum Cr 280
• serum Urea 42
• plasma osmolality 375

You decide to administer IV Insulin for this man.

Which set of electrolytes are most likely to change after intravenous insulin is administered?

Which medication is not helpful in preventing post-menopausal osteoporosis?

The most potent biphosphonate is?

What is the BMI threshold for recommending metabolic surgery in caucasian patients with Type 2 diabetes regardless of their glycemic control?

Romosozumab is a novel monoclonal antibody used in preventing fracture in women with osteoporosis.

It works by binding against which protein?

Clinical inertia is likely the largest barrier to effective diabetes management in NZ and worldwide. The following interventions are all recommended to improve clinic inertia except?

A 42 year old Maori male presents to his GP for a routine check up. He is a current smoker and has a history of hypertension, hyperlipidemia and a BMI of 30. His HbA1c taken last week was 45 mmol/mol. He is currently asymptomatic. 

What is the best course of action for this man right now?

In patients with Type 2 diabetes and a BMI over 30 kg/m2, what is the recommended target total body weight loss to help achieve remission?

When managing patients with Type 2 diabetes, a more aggressive target of HbA1c of <48mmol/mol may be appropriate for the following patient group except?

The combination of dual SGLT2i/GLP1RA therapy in Type 2 Diabetes is likely to cause the following effect, except?

Oral metformin is considered to be relatively safe for patients with chronic kidney disease. However, at what point should metformin be stopped?

Which of the following diabetic medication causes weight loss without inducing hypoglycemia?

A 47 year old Tongan male was recently diagnosed with Type 2 diabetes with a HbA1c of 50. He was advised on lifestyle changes and was commenced on oral metformin. However, three months later, his HbA1c has risen to 60 mmol/mol. His renal function is normal and he is of normal weight. There is no history of heart failure.

His GP is now considering adding a second agent. Which of the following medication would be the most appropriate for this man?

Retatrutide helps achieve weight loss in non-diabetic patients via the following mechanisms except?