SECTION 2-A: SETTING UP YOUR MIND-STRATEGY FOR PREPARATION
COMMUNICATION SKILLS
CARDIOVASCULAR AND HEMATOLOGY
HYPERLIPIDEMIA(cardiovascular and hematology)
1. INTRODUCTION
Clinical commonality → common
Ways patient may present
Lab results of high cholesterol → usually asymptomatic unless it causes stroke, cardiovascular incident, chest pain/MI or PAD
Hypertension + hyperlipidemia
Type 2 diabetes + hyperlipidemia
Hyperlipidemia with patient insisting on statins
Body pains / statin-induced myopathy while on statin
Fatty liver + hyperlipidemia
Combined high lipid + triglycerides
Concern about FH of high cholesterol → wants to get tested
Newly diagnosed hypertension + dyslipidemia
2. CO — "Hello, Mr./Mrs. [Name], I am doctor Muwaff." "How can I help you today?" "Can you tell me more about it?"
lab results of high Cholesterol
body pains on statin
concern about FH of high cholesterol want to get tested
NB normal Level <5.1mmol (<200mg/dl)
3. SQ
Symptoms suggesting undiagnosed DM• → diabetes is not a main cause/consequence of hyperlipidemia; they commonly coexist
IHD• → chest pain
Claudications• → PAD
Swelling around tendons• → xanthoma; think familial hyperlipidemia•
4. DD
–
5. RF
–
6. PMH
DM (⤴) → ask "Do you have high blood sugar?"
CV incident•
MI / Angina (⤴) → ask "Any history of heart attack or chest pain with activity?"
PAD / claudications (⤴) → ask "Any claudication in your legs with activity?"
TIA / Stroke• → ask "Any history of clots in your brain, stroke or mini-stroke?"
HTN• → ask "Do you have high blood pressure?"
CKD• → ask "Do you have any kidney disease?"
Hypothyroid• → ask "Any history of thyroid problems or lazy thyroid?"
7. DRUG
drug increase lipid
Antipsychotics•
isotretinoin•
steroids•
possible interaction with statins → higher risk of statin-induced myopathy; note during general drug history rather than asking each specifically
macrolide•
itraconazole•
protease inhibitor•
fusidic acid•
8. ALLERGY
–
9. FH
high Cholesterol / dyslipidemia
coronary event (⤴) → <60 in 1st-degree relative; <50 in 2nd-degree relative → significant, think familial hyperlipidemia (⤴)
10. PS
–
11. MENSTRUAL AND SEXUAL
–
12. ICE
–
13. SUMMARY
–
14. EXP/INV
INV
T.cholesterol, LDL, HDL, TG (fasting not needed) → request non-fasting initially; if TG specifically high, repeat fasting
CK• (if history of muscle pain with or without statin)
LFT•
KFT•
TSH•
Hba1c• → baseline; statins can increase HbA1c
NICE 2021
NB: HDL Risk ration: Total cholesterol/ HDL, high risk if ≥6
EXP → "Hyperlipidemia means having too much fat in your blood, which can harm your health."
15. MNG
Management framing
MNG (May 2023): ask your self:
does this patient needs Referral?
Does this patient needs Statins?
Non-pharmacological
Control comorbidities•
Stop Smoking•
Diet advice•
Exercise advice•
If age 25–84 → do 10 years CV risk using QRISK 3 tool; if >10% → first rule out secondary causes
Secondary cause │ Action/detail
─────────────────────────┼───────────────────────────────────────────────────────────────────────────────────────────
uncontrolled DM (⤴) │ Control comorbidity before deciding on statin
hypothyroid (⤴) │ Control hypothyroid → can improve dyslipidemia; lecturer: most reversible secondary cause
kidney disease (⤴) │ Control comorbidity
liver disease• │ Control comorbidity
Lifestyle trial is offered and reassess CV risk → reduce weight•, stop smoking (⤴), reduce alcohol•, healthy diet (⤴), physical exercise (⤴) → reassess lipid + CV risk after 3–6 months
If CV risk becomes <10% → continue lifestyle pathway
If still >10% after lifestyle → offer benefit and risk of statins → Pharmacological
Healthy diet include <30% fat intake diet, 7% or less of total energy intake is saturated fats, replace saturated by mono and poly-unsaturated fats
TG <5.7mmol/L / <500mg/dl → lifestyle modification + follow-up
Pharmacological
Statin pathway → QRISK3 >10% → rule out secondary causes → lifestyle 3–6 months → if lifestyle failed/still >10%, offer benefit/risk → if agreed, atorvastatin 20mg → repeat CV risk + lipid in 3 months
Don’t do pre statin CV risk (give statin immediately) in:
Situation │ Action
─────────────────────────────────────────────────┼───────────────────────────────────────────────────────────────────────────
Type 1 DM above 40 (⤴) │ give atorvastatin 20mg
Type 2 DM >10 years (⤴) │ give atorvastatin 20mg
CKD (⤴) │ give atorvastatin 20mg → consult specialist if eGFR<30 for higher doses
Known Familial Hyperlipidemia (⤴) │ give statin immediately without pre-statin CV risk
Age ≥85• especially if smoking (⤴) or high BP │ give statin immediately without pre-statin CV risk
PH of CVD: MI/angina/PAD/TIA/stroke (⤴) │ atorvastatin 80mg
Type 1 DM >10 years + age 18–40 → lecturer: "consider" statin
Consider Statins in Hyperlipidemia with: (take specialist opinion)
Situation │ Action
──────────────────────────────────┼─────────────────
PH of ttt for HIV (ARVT)• │ Consider statin
On steroid (⤴) │ Consider statin
antipsychotics (⤴) │ Consider statin
immunosuppression• │ Consider statin
AI e.g SLE• │ Consider statin
Severe obesity BMI >40• │ Consider statin
Avoid Statin in Hyperlipidemia with Hypothyroid (⤴) until correction of Hypothyroid state (high risk of statin induced Myopathy in uncontrolled hypothyroid) → control hypothyroid then give statin if lipid still high
First Line: Atorvastatin 20mg at night → tell patient "Take it at night"; ask when it is taken when checking compliance
For previous CV incident (⤴): atorvastatin 80mg or lower if patient prefer or risk of adverse effects
Benefits: reduce LDL, reduce risk of stroke and coronary artery disease
SE: GI upset•, Myalgia•, arthralgia•, risk of high Sugar and DM (⤴)
CI
Situation │ Action
────────────────────────────┼───────────────────────────────────────────────────────────
Pregnancy• │ stop statin if pregnant
BF• │ contraindicated
Liver disease (⤴) │ contraindication/caution
high AST, ALT X3• │ stop if ×3 elevated; if less than ×3 → monitor
elevated hba1c (⤴) │ don’t stop statin
Stop statin if took macrolide (⤴), itraconazole (⤴), protease inhibitor (⤴), oral fusidic acid (⤴) → stop until interacting drug is stopped
Don’t take dose larger than 10mg simvastatin• with amiodarone•, amlodipine•, diltiazem•, verapamil•
If not reaching target despite proper titration → CUD-V• → check compliance; Increase statin dose or add ezetimibe → atorvastatin up to 80mg
If muscle pain on statin
CK (⤴) → stop if above 5 times OR symptoms severe regardless of CK → reintroduce when CK is reduced & symptoms improve
consider re introduce with lower dose, give every other day or change to another statin
Lecturer comparison
Statin type │ Examples │ Statin-induced myopathy risk
─────────────┼────────────────────────────┼─────────────────────────────
Hydrophilic │ Pravastatin, rosuvastatin │ Less
Lipophilic │ Simvastatin, atorvastatin │ More
Do not give statin to treat hyperlipidemia with uncontrolled hypothyroid (⤴) (risk of statin myopathy) → control hypothyroid then give statin if lipid still high
Triglyceride treatment
TG result / situation │ Action
─────────────────────────────────────────────┼─────────────────────────────────────────────────────────────────────────────────────────────────
<5.7mmol/L / <500mg/dl │ lifestyle modification + follow-up
5.7–<10mmol/L / 500–<885mg/dl │ reduce CV risk & give fenofibrate 135mg once daily
10–20mmol/L / 885–1770mg/dl │ repeat fasting within 5 days–2 weeks → if still high seek specialist advice → Referral
>20mmol/L / >1770mg/dl │ Refer Urgently → Referral
isolated high TG• │ don’t give statin
Fenofibrate• │ Only Fenofibrates allowed to be combined with statins
Referral
Refer this patient if:
Criterion │ Action / detail
──────────────────────────────────────────────┼───────────────────────────────────────────────────────────────────────────────────────
FH of premature Coronary Heart Disease (⤴) │ event before 60 in 1st relative → refer
T.cholesterol >9 (350mg/dl)• │ or non HDL 7.5mmol (290mg/dl)• → suspected F.H → refer
Suspect homozygous FH (⤴) │ adults >13 mmol/L; age <15 years >11 mmol/L → arrange specialist assessment
TG >20mmol/L / >1770mg/dl (⤴) │ if wasn’t fasting → repeat fasting; if still high → Refer Urgently
Abnormal CV examination• │ refer; lecturer: murmur / aortic atherosclerotic or ejection murmur
Child T.cholesterol >6.7mmol / 260mg/dl• │ lower threshold → refer for suspected F.H
Very high TG (⤴) → lecturer: complications include phlebitis/inflammation of veins and pancreatitis
Refer any patient with FH of Familial Hyperlipidemia (⤴) for DNA testing REGARDLESS OF AGE
Children with a parent affected by FH (⤴) should be considered for genetic testing during childhood, preferably before age 10 years. If testing was not performed earlier, revisit and discuss genetic testing again once the child reaches 10 years of age.
Assessment for suspected FH (⤴) in primary care may be supported by recognised diagnostic tools such as the Simon Broome or DLCN systems. Interpretation should be undertaken by clinicians familiar with these scoring methods.
TG 10–20mmol/L / 885–1770mg/dl (⤴) → repeat within 5 days to 2 weeks Fasting → if still high seek specialist advice
Follow-up
Repeat lipid profile after 3 months
Monitor LFT (⤴) 3, 12 months
Hba1c Screen (⤴)
Target lipid lowering is:
Target │ Goal
───────────────────────────────────────┼───────────────────────────────
T.Cholesterol• │ <4 or ≥25% reduction
Non HDL cholesterol (Total-HDL)• │ ≥40% reduction
CV risk• │ lecturer: reduce to <10%
If target achieved → maintain and monitor + follow-up
If CV risk <10% → lifestyle + repeat lipid and CV risk in 6 months
FU every 6weeks till target achieved (<5.7 (500mg/dl), ideally <1.7 (150mg/dl)), then every 6month
Follow up annually patients on statin treatment
Safety netting
SN: any muscle pain → tell patient "Come back if you develop any muscle pain" → think statin-induced myopathy
algorithm/picture → transcript: high lipid/TG → assess referral criteria → if none, immediate-statin group vs QRISK3 pathway → lifestyle/statin as indicated → repeat lipid + LFT/HbA1c → target achieved: maintain/monitor; target not achieved: check compliance → increase atorvastatin up to 80mg or add ezetimibe
(⤴) = already mentioned earlier (same context)
RESPIRATORY
GIT
ENDOCRINOLOGY
TYPE 2 DIABETES MELLITUS (NEW)(endocrinology)
1. INTRODUCTION
Type 2 DM may remain silent for a long time → first presentation may already be a complication
Presentation scenarios
Diagnostic criteria already fulfilled ± another comorbidity → e.g. high triglyceride
Symptomatic newly diagnosed DM
Lab result ± symptoms
Asymptomatic but worried/concerned → e.g. vision loss
First presentation with complication → blurring vision/cataract, tingling/numbness → peripheral neuritis
As BBN → clue suggesting breaking bad news, e.g. visa rejection report due to diagnosis
2. CO — "Hello, Mr./Mrs. [Name], I am doctor Muwaff." "How can I help you today?" "Can you tell me more about it?"
Symptoms or complications or Lab result
3. SQ
Symptoms → PPP
Polyuria → "Do you go to bathroom a lot?"
Polydipsia → "Do you drink a lot? Do you feel thirsty a lot?"
Polyphagia → "You feel that you are hungry despite eating?"
Complications → Eye, Neuro, ED, CV, infections skin & UTI
Eye → blurring of vision → diabetic retinopathy/cataract
Neuro → tingling/numbness in hands/feet
ED → ask privately/sensitively: "May I ask you a personal question? Do you have any difficulty attaining erection?"
CV → chest pain with exertion
Infections → skin rash/wounds; UTI → painful urination
Distinguish → DM itself = PPP; complications = dysuria/UTI, peripheral neuritis, visual problems
Ask about any lab test already done
4. DD
Other causes of LUTS
UTI
BPH → frequent small-volume urination rather than true polyuria
Secondary causes of DM
Cushing → bruises easily
Haemochromatosis → dark skin
PCO → obese female + infertile
5. RF
Bad/acetone breath + nausea + vomiting + abdominal pain → DKA
DKA is rare in type 2; HONK/hyperosmolar non-ketotic hyperglycaemia is more common
Painless acute blurring of vision → retinal neovascularization
Severe unilateral eye pain → acute angle-closure glaucoma
New-onset DM + recent/profound weight loss + age >60 → think cancer/pancreatic cancer
Key = catabolic weight loss → age >60 or high HbA1c alone is not enough
Say → since this is new presentation in old age + weight loss + severe DM symptoms,
concerned to rule out cancer and refer immediately without delay
concerned to rule out cancer and refer immediately without delay
6. PMH
HTN
IHD
Hyperlipidemia
GDM
PCO
Pancreatic surgery → pancreatic/islet-cell injury may result in DM
7. DRUG
Steroids → hyperglycaemia / secondary DM
8. ALLERGY
–
9. FH
DM → type 2 has polygenetic inheritance
10. PS
Cause/risk factors → diet, exercise, smoking, alcohol, obesity
Alcohol → think chronic pancreatitis; tummy pain going to back
Effect → sleep affected by polyuria
11. MENSTRUAL AND SEXUAL
–
12. ICE
Ideas → patient's perception/understanding of DM
Concerns → e.g. worry about vision loss
Expectations → ICE may indicate need for BBN approach, e.g. visa-rejection scenario
13. SUMMARY
–
14. INV / EXP
INV
Diagnosis → symptoms + 1 test OR 2 tests without symptoms
No symptoms → 2 different tests OR same test repeated on another occasion/sample
Diagnostic thresholds
RBS / Post-OGTT / 2HPP → ≥11.1 mmol/L (200 mg/dL)
FBS → ≥7 mmol/L (126 mg/dL)
HbA1c → ≥6.5% (48 mmol/mol)
OGTT → can diagnose DM outside pregnancy; less commonly used because patient must wait for hours
Other risk factors → lipid profile, FBC, LFT, KFT
Young patient / possible type 1 → C-peptide & insulin antibodies
C-peptide → endogenous insulin production; positive insulin antibodies → autoimmune cause
Secondary cause → investigate only if suspected, e.g. iron profile for haemochromatosis
Concern about DM + no symptoms → DM risk score; if high → HbA1c & FBS
HbA1c not measured/reliable → seek specialist assessment if diagnosis uncertain
Age <18, pregnancy, atypical presentation e.g. symptoms <2 months
Concurrent medication causing hyperglycaemia, renal dysfunction, pancreatic disease,
Hb anomaly e.g. SCD
Hb anomaly e.g. SCD
Instead → glucose profiles / total estimated glycated haemoglobin / fructosamine
→ fructosamine reflects ~2–3 weeks vs HbA1c ~2–3 months
→ fructosamine reflects ~2–3 weeks vs HbA1c ~2–3 months
EXP
“it’s a condition where the level of sugar in the blood is higher than
normal, there is a chemical called insulin produced form organ in your body called
Pancreas, it make the sugar in the blood in normal level, DM is usually due to
either insufficient insulin released from the pancreas, or resistance of your body to
the insulin, or both”
normal, there is a chemical called insulin produced form organ in your body called
Pancreas, it make the sugar in the blood in normal level, DM is usually due to
either insufficient insulin released from the pancreas, or resistance of your body to
the insulin, or both”
15. MNG
Non-pharmacological
Lecturer's grouped mnemonic → "Don't fast, low sugar is sad."
D – Diabetes education
Offer/refer to DESMOND → Diabetes Education & Self Management for Ongoing & Newly Diagnosed
Educational programme, not routine diabetic-clinic referral
"We'll enroll you in educational program."
F – Foot
Foot emergencies & who to contact; foot care & footwear advice
Never walk barefoot; regularly check feet for wounds/infection
"It's better to take care of your foot. Do not ever walk barefooted. Check your foot regularly.
If you have any infection of your foot, you have to seek medical advice or go to emergency."
If you have any infection of your foot, you have to seek medical advice or go to emergency."
L – Lifestyle
Lose weight; diet advice + examples
Exercise → 30 min/day, at least 5 days/week
Quit smoking; reduce alcohol; control other risk factors
Dietician referral if needed → coming under Referral
S – Sick-day rules
Frequent SMBG every 2–3 h, high fluid intake, frequent ketone dipstick, normal feeding
Insulin → continue; monitor/adjust dose, do not stop
Stop relevant oral drugs / GLP-1 if dehydration risk
"I will give you a leaflet, details more about it, what to do in case you got sick."
S – SMBG
Insulin / oral hypoglycaemics / pregnant or planning pregnancy → SMBG
Acute illness → short-term SMBG; multiple daily insulin → continuous monitoring recommended
A – 1 first diagnosis item + 6 annuals → coming under Referral / Follow-up
D – Drugs → coming under Pharmacological
Pharmacological
Drugs → in DM lifestyle only is not sufficient
2026 approach → individualized according to patient circumstances
Initial treatment
Condition │ Treatment
──────────────────────────────────┼───────────────────────────────────────────────────
Most patients │ Metformin MR + SGLT2 inhibitor
Metformin intolerance │ SGLT2 inhibitor only
Frailty / high fall risk │ Metformin only initially
│ → SGLT2: dehydration → hypotension → falls
High CV risk / established CVD │ Metformin + SGLT2 + semaglutide —————————————continue irrespective of HbA1c…even becomes normal…the only instance is BMI<18 =stop GLP1)
Obesity / early-onset type 2 DM │ Metformin + SGLT2 + GLP-1 agonist / tirzepatide
GFR 20–30 │ Stop metformin → SGLT2 + DPP-4 inhibitor
│ → lecturer notes ADA uses GLP-1 instead of DPP-4
GFR <20 │ DPP-4 inhibitor only
Heart failure │ Metformin + SGLT2
│ → avoid pioglitazone
If target not reached after ~3 months
Add DPP-4 inhibitor if not already used
Do not combine DPP-4 with GLP-1 agonist/tirzepatide
Still uncontrolled → sulfonylurea OR pioglitazone OR insulin ————————————————————————————————————————————————————————————————— all in one line—[met+sglt (+ if special group -glp-1)] ————then——— [sita - glicla - pio]
If glycaemic target reached → do not stop/reduce metformin/SGLT2/GLP solely because HbA1c is low if no hypoglycaemia
Statin → CV risk >10% or type 2 DM >10 years; example → atorvastatin 20 mg
HbA1c targets
Situation │ Target
───────────────────────────────────┼─────────
Not on hypoglycaemia-causing drug │ 6.5%
On hypoglycaemic e.g. sulfonylurea │ 7%
Frail elderly │ Flexible
Referral
Dietician → additional dietary advice if needed
First diagnosis → dental clinic check-up referral
New-onset DM + profound weight loss + age >60 → immediate referral to rule out cancer
Follow-up
1 first Dx + 6 annuals → V-ACNES
First Dx → dental clinic check-up → under Referral
V → annual influenza vaccine + PCV
A → annual ACR for nephropathy
C → annual CV risk assessment
N → annual foot assessment for neuropathy
E → eye clinic/fundoscopy → abnormal annually; otherwise every 2 years
S → screen smoking status (⤴)
HbA1c → every 3–6 months; ideally after 3 months
Safety netting
Hypoglycaemia → especially if on hypoglycaemia-causing treatment
Severe polyuria/polydipsia, severe hyperglycaemic symptoms or very high glucose → seek review
(⤴) = already mentioned earlier (same context)
examination - not done
OSTEOPOROSIS(endocrinology)
1. INTRODUCTION
Clinical commonality → encountered in practice
Ways patient may present
Established osteoporotic/fragility fracture → commonly thoracic back pain with vertebral fracture
"I have loss of height," → vertebral compression fracture may cause forward deformity + reduced height
Sudden back pain without a fall → simple stress on fragile vertebra may cause compression fracture
Sudden hip / groin / thigh pain
Previous diagnosed fracture
High risk without established fracture → e.g. asthmatic patient on prolonged oral steroid
Follow-up of chronic disease → osteoporosis risk detected during assessment
DEXA result showing osteoporosis
FRAX result showing increased fracture risk
2. CO (CHIEF COMPLAINT) — "Hello, Mr./Mrs. [Name], I am doctor Muwaff." "How can I help you today?" "Can you tell me more about it?"
Loss of height
Back pain
Hip / groin / thigh pain
Previous fracture
Follow-up of chronic disease
DEXA result
FRAX result
3. SQ (SCHEME OF QUESTIONS — SYMPTOM CHARACTERIZATION). [pain /fall/fracture/risk]
Falls → ask "Any falls?" and assess fall risk •
Pain → "You have any back pain? Any hip pain? Any groin pain? Any thigh pain?"
Previous fracture → ask "What happened? What kind of fracture?" •
Fragility/pathological fracture = low-energy trauma / fall from person's height; major RTA is not a fragility fracture
Osteoporosis risk checklist → keep as a checklist; no need to ask every item
Higher-risk group
Female >65 / male >75
Younger patient → history of fragility fracture / prolonged steroid use •
One chronic condition sufficient → hyperthyroidism •, hyperparathyroidism, menopause •, premature ovarian failure •, IBD •, PMR, RA •, coeliac disease •, CKD •
Lower-risk group → need ≥2
Low BMI <18
History of recurrent falls
Alcohol >14 units/week •
DM •
Cushing •
COPD •
4. DD (DIFFERENTIAL DIAGNOSIS)
–
5. RF (RED FLAGS)
Sudden/severe bone pain → especially back or thigh
Sudden recent upper thoracic back pain → consider urgent referral; longstanding pain is relatively less urgent
Jaw pain if already on bisphosphonate → risk of jaw necrosis •
6. PMH (PAST MEDICAL HISTORY)
Previous fracture (⤴)
Long-standing illness
Thyroid disease (⤴)
Ovarian failure (⤴)
IBD (⤴)
RA (⤴)
Coeliac disease (⤴)
CKD (⤴)
DM (⤴)
Cushing (⤴)
COPD (⤴)
7. DRUG (DRUG HISTORY)
PPI
SSRI
Pioglitazone
Prolonged steroid use (⤴)
8. ALLERGY
–
9. FH (FAMILY HISTORY)
Hip fracture → specifically ask about family history of hip fracture
10. PS (PSYCHOSOCIAL)
Cause → smoking •
Cause → alcohol (⤴)
Effect → fractures
Effect → falls → may reduce activity and cause profound disability
11. MENSTRUAL AND SEXUAL (HISTORY)
–
12. ICE (IDEAS, CONCERNS, EXPECTATIONS)
–
13. SUMMARY
–
**EXAMINATION** (no dedicated examiation is in slide/web )
Fall risk → offer help; let patient stand carefully
Examine symptomatic joint → e.g. back if back pain
BMI
14. EXP / INV
EXP — osteoporosis
Explain → "your bones become thinner. This make it more easy to break. It's painless condition, only painful when you get fracture. We want to reduce your risk of getting fractures."
If established pain/fracture → explain that back pain may be because osteoporosis caused a fragility fracture
Bone remodeling → bone resorption outpaces bone formation → ↓ bone density/strength → ↑ fracture risk
INV
Baseline → FBC, ESR, thyroid, liver, kidney, calcium, vitamin D
Suspected fracture → X-ray of affected/suspected joint
FRAX (FRAX first then dexa)
Determines 10-year risk of fragility fracture; incorporates clinical risk factors ± DEXA → DEXA makes result more accurate
Can be used age 40–90
Major osteoporotic fractures → spine, hip, distal forearm
Risk interpretation
FRAX result Risk
────────────────── ─────────────
>20% MOF OR >3% hip High
10–20% MOF Intermediate
<10% MOF Low
DEXA — when to do (FRAX/risks decides this)
Intermediate FRAX → do DEXA and integrate result back into FRAX (mynote- if high - do DEXA). high FRAX without DEXA → bone protection; low FRAX → no DEXA routinely or the following risks
Female >65 / male >75
Family history of fragility fracture
Prolonged steroid → ≥7.5 mg daily for ≥3 months or equivalent; lecturer → rough equivalent exposure
Chronic disease → hyperthyroid, menopause, premature ovarian failure, IBD, PMR, RA, coeliac disease, CKD
BMI <18.5 + extra factor
X-ray evidence of osteoporosis/osteopenia
DEXA result
T-score Interpretation / action
─────────── ─────────────────────────────
> -1 Normal → repeat in 3 years
-1 to -2.5 Osteopenia
≤ -2.5 Osteoporosis
Steroid-specific DEXA
T-score Action
───────────────────── ───────────────────────
More negative than -1.5 Start bone protection
0 to -1.5 Repeat DEXA in 3 years
algorithm/picture
High FRAX → no DEXA → immediate bone protection
Intermediate FRAX → DEXA → integrate result into FRAX
Low FRAX → no DEXA routinely
DEXA > -1 → repeat DEXA in 3 years
DEXA -1 to -2.5 → repeat FRAX in 2 years + DEXA in 3 years….if on steroid + more negative than -1.5, bone protection;
Fragility fracture + age >70 / steroid at any age / DEXA more negative than -1.5 → bone protection regardless of FRAX
15. MNG (MANAGEMENT)
Non-pharmacological
Stop smoking (⤴)
Reduce alcohol (⤴)
Avoid falls (⤴) → remove furniture/environmental hazards; occupational therapy; hip protectors; walking aids
Maintain activity
Calcium-rich diet → milk, yogurt, cheese
Vitamin D-rich diet → tuna, sardine, salmon, mackerel + sunlight exposure
Suspected vertebral-fracture group
Loss of height / kyphosis / back pain ± fall + confirmed osteoporosis
X-ray → coming under INV
Painkiller → coming under Pharmacological
Physiotherapy + back brace
Specialist/vertebral augmenatation → coming under Referral
Pharmacological
Calcium / vitamin D
Treatment Dose / action
──────────────────── ─────────────────────────
Calcium 700–1000 mg/day
Vitamin D 400–800 units/day
Vitamin D deficiency Treat deficiency
Painkiller → suspected vertebral fracture
Bone protection indicated if → high-risk FRAX / DEXA ≤ -2.5 / fragility fracture + age >70, steroid at any age, or DEXA < -1.5
Alendronate
First-line bone protection → 70 mg once weekly OR 10 mg once daily
Administration → 30 minutes before breakfast; take with cold water; remain upright for ½ hour
SE → tummy pain, burning chest
Effect → by 6–12 months
Before starting → dental check-up
Avoid → severe CKD
Duration → usually 3–5 years; if on steroid, continue until steroid stopped
Denosumab
Injection → every 6 months
SE → back and muscle pain
Use → if bisphosphonate not tolerated/contraindicated; specialist initiated
Before initiation → calcium, vitamin D, kidney function, phosphorus, PTH
HRT → not routinely used for osteoporosis prevention; exception = premature ovarian failure before age 40
"Can I take the hormone replacement therapy instead of bisphosphonate?"
Strontium ranelate → withdrawn because of cardiovascular risk; preserved only in rare refractory cases
Referral
Bisphosphonate not tolerated/contraindicated → specialist for denosumab
Suspected vertebral fracture → specialist to consider vertebral augmentation; lecturer → urgent referral around within 2 weeks, not usually same-day emergency
Follow-up (2 year rule)
Review in 4–6 weeks → ask about bisphosphonate side effects
Repeat DEXA / FRAX in 2 years or if any new risk factor develops
During bisphosphonate therapy → repeat DEXA every 2 years
If repeat DEXA becomes more positive than -2.5 → stop bisphosphonate; repeat DEXA after 2 years
Safety netting
Return if new risk factor develops → fragility fracture, steroid intake (⤴), chronic disease, menopause (⤴)
Return for drug adverse effects → e.g. jaw pain on bisphosphonate (⤴)
• = first occurrence of a concept tracked for cross-referencing
(⤴) = same concept already mentioned earlier (same context)
HYPERTHYROIDISM(endocrinology)
1. INTRODUCTION
Hyperthyroidism → increased thyroid hormone activity; typically low TSH with high T3/T4
Graves' disease → most common cause; autoimmune antibodies stimulate TSH receptors; eye bulging is specifically associated with Graves'
Ways patient may present
Palpitations/tachycardia (e.g. pulse 120), weight loss, eye bulging and hand tremors
Pregnant → known or previously unknown hyperthyroidism; may be concerned about management/medication
Hyperthyroidism with recent-onset atrial fibrillation → temporary rate control for high pulse + refer for rhythm control; AF may revert when hyperthyroidism is controlled
2. CO — "Hello, Mr./Mrs. [Name], I am doctor Muwaff." "How can I help you today?" "Can you tell me more about it?" → weight loss, palpitations, tremors
3. SQ
Other hyperthyroid symptoms
Sweating •
Irregular periods
Frequent soft stool → not frank loose bowel motion/diarrhoea
Goiter → thyroid/neck swelling •
Eye symptoms •
Eye pain, photophobia, change in appearance
Double vision, deterioration of acuity, pop out sound
4. DD
Graves' disease → most common cause; autoimmune
De Quervain thyroiditis → sudden painful swelling after viral inflammation; hyperthyroid → hypothyroid → euthyroid
Toxic nodular/multinodular goiter → previous goiter (⤴); usually older woman
Toxic nodule → usually benign adenoma; malignant thyroid enlargement is usually non-functional/cold
Anxiety → fear; sweating (⤴), palpitations and shivering with normal T3/T4
Pheochromocytoma → shivering + sweating (⤴), with headache + episodic very high BP
Postpartum thyroiditis → 2–6 months postpartum: hyperthyroid → hypothyroid → euthyroid by 12 months; some become permanently hypothyroid
Gestational thyrotoxicosis → onset during pregnancy with severe nausea/vomiting + abnormal TFT; may need admission •
Hashimoto thyroiditis → may start with transient hyperthyroidism but is more commonly diagnosed in hypothyroid stage
5. RF
High fever + psychosis → thyroid storm •
Compression symptoms → SOB, stridor, hoarseness; may reflect large goiter/compression (⤴)
FH thyroid cancer
PH neck irradiation
Dysthyroid optic neuropathy → blurring of field of vision, loss of colour vision, double vision (⤴), restricted eye movement; requires urgent ophthalmology •
6. PMH
–
7. DRUG
Amiodarone
L-thyroxine overdose in hypothyroid patient → can cause hyperthyroid symptoms
8. ALLERGY
–
9. FH
Thyroid cancer (not thyroid disease)
Autoimmune diseases
10. PS
Cause/augmenting factors
Smoking → worsens thyroid eye disease •
Diet → high iodine intake can be a risk factor
Stress → can worsen shivering/sweating (⤴)
Effect
Work → tremor/shivering can affect motion
Home → can affect sleep
11. MENSTRUAL AND SEXUAL
–
12. ICE
–
13. SUMMARY
–
14. EXP/INV
INV
TSH, T3, T4
Thyroid antibodies if Graves' suspected → anti-TSH Ab, ThyroGA/thyroglobulin Ab, TPO Ab
ESR, CRP → especially to assess for De Quervain thyroiditis
US if goiter (⤴) → assess suspicious features and whether aspiration cytology may be indicated
Specialist iodine uptake → homogeneous uptake suggests Graves'; heterogeneous suggests multinodular goiter; single nodule suggests toxic nodule; little/no uptake suggests De Quervain/inflammation
“to know your thyroid function & to detect any activity in your immune system toward thyroid cells”
EXP
“the gland that is responsible about energy in our body is producing chemicals more than usual”
15. MNG
Non-pharmacological
Stop smoking (⤴)
Thyroid eye disease → use sunglasses + elevate head of bed to avoid orbital eye swelling (⤴)
Preconception → effective contraception until satisfactory control
Recent radioactive iodine treatment → avoid pregnancy for at least 6 months
Pharmacological
Primary-care symptom control → beta blocker for tachycardia/symptoms; if contraindicated e.g. asthma → calcium-channel blocker
Secondary care → “What they will give me, doctor?” → “In 2ry care they will give you: Carbimazole”
Carbimazole → congenital-anomaly risk in childbearing period; effective contraception
Radioactive iodine → contraindicated in pregnancy; may cause hypothyroidism
Pregnancy
1st trimester → propylthiouracil; if already taking carbimazole, change to PTU immediately → "I will check the dose," (pregnancy start - PTU)
Last 2 trimesters → carbimazole
Keep T4 high-normal → avoid maternal/fetal hypothyroidism
Carbimazole & PTU safe in breastfeeding → use lowest effective dose
Specialist treatment options → carbimazole/PTU, radioactive iodine or surgery
Referral
All cases → refer to specialist
Urgent referral → solitary enlarged nodule, prepubertal presentation, age >65, neck LNs
Urgent referral → previous neck irradiation + FH thyroid cancer
Urgent referral → hoarseness/compression symptoms of goiter (⤴)
Same-day ophthalmology → dysthyroid optic neuropathy (⤴)
Admission → thyroid storm (⤴)
Admission → gestational thyrotoxicosis with severe nausea/vomiting (⤴)
Pregnancy/preconception → refer to specialist
Follow-up
Pregnancy → check TSH/T4 monthly
Pregnancy → check antibodies at 24–28 weeks for risk of neonatal hyperthyroidism
Postpartum → check TSH & T4 at 6–8 weeks; urgent referral if abnormal
Safety netting
Carbimazole → “come back if sore throat” → possible agranulocytosis; go to emergency for CBC
Any red flags → return urgently
Other specialist treatment
Surgery
(⤴) = already mentioned earlier (same context)
HYPOTHYROIDISM(endocrinology)
1. INTRODUCTION
Hypothyroidism → commonly primary; TSH high, usually due to autoimmune disease such as Hashimoto thyroiditis
Other causes → iodine deficiency, surgical removal of thyroid tissue, drugs
Secondary hypothyroidism → rare; pituitary no longer produces TSH → low TSH + low T3/T4
Ways patient may present
Typical hypothyroid symptoms
Female → menorrhagia or amenorrhea
Wants to get pregnant / counselling regarding thyroid function
Fatigue as the initial presentation
Postpartum depression with hypothyroidism
Mild hyperlipidemia with hypothyroidism → control hypothyroidism first; lipids may normalize/improve markedly
2. CO — "Hello, Mr./Mrs. [Name], I am doctor Muwaff." "How can I help you today?" "Can you tell me more about it?" → weight gain, period disturbance, fatigue/sleeping all the time, coldness, dry skin, hair fall, constipation, goiter, depression
3. SQ
Hypothyroid symptoms
Weight gain
Period disturbance
Fatigue / sleeping all the time → sleeping all day, not merely feeling lazy
Coldness
Dry skin
Hair fall
Constipation
• Goiter / swelling of the neck
Depression → hypothyroidism can cause depression
4. DD
De Quervain thyroiditis → prior hyper symptoms followed by hypo stage
Postpartum thyroiditis → recent delivery; hypo stage
Euthyroid sick syndrome
PH of recent significant illness
T3 low; TSH normal or high
Treat the illness → repeat thyroid testing in 6 weeks; transient
5. RF
Family history of thyroid cancer
Previous neck irradiation
Hoarseness or stridor
(⤴) Large goiter
Myxedema coma
Hypothermia
Coma
Seizure → these severe features necessitate admission
6. PMH
Associated autoimmune disease
DM
Addison
Coeliac disease
Vitiligo
7. DRUG
Current or recent
Carbimazole
Propylthiouracil
Amiodarone
Lithium
Radioactive iodine
8. ALLERGY
–
9. FH
Thyroid cancer
Autoimmune diseases
10. PS
Cause → diet deficient in iodine; ask about typical daily diet and whether it contains enough iodine
Effect → cannot resume daily activity because of fatigue
11. MENSTRUAL AND SEXUAL
Menstrual disturbance → menorrhagia or amenorrhea
Pregnancy plans → patient may present wanting to get pregnant
12. ICE
–
13. SUMMARY
–
14. INV
Thyroid function → TSH, T3, T4
Thyroid antibodies → anti-TSH Ab, ThyroGA, TPO Ab if thinking autoimmune disease / Hashimoto
HbA1c → if suspecting autoimmune diabetes
Ultrasound → if (⤴) goiter is present/felt
Explain rationale → “to know your thyroid function & to detect any activity in your immune system toward thyroid cells”
14. EXP
“the gland that is responsible about energy in our body is producing chemicals less than usual”
15. MNG
Non-pharmacological
Healthy diet with sufficient iodine
Pharmacological
Levothyroxine
1.6 mcg/kg → round to nearest 25; e.g. 70 kg: 1.6 × 70 = 112 ≈ 100 mcg
Elderly / heart disease / >65 years → start 25–50 mcg because of cardiac risk with excessive thyroid hormone
Administration advice → take alone on an empty stomach ≥30 min before breakfast
Missed dose → do not take 2 pills the next day
Drug interactions → iron, warfarin, carbamazepine, rifampicin; do not take around the same time
Pregnancy → levothyroxine is not contraindicated; increase dose as needed and aim for low-normal TSH, 0.5–2.5
Associated hyperlipidemia → treat hypothyroidism before statins; uncontrolled hypothyroidism + statin increases risk of statin-induced myopathy
Referral
Refer if red flags
Refer if secondary hypothyroidism → low TSH + low T4
Follow-up
TSH takes time to normalize → around 6 weeks
Pregnancy → follow up monthly
Safety netting
Return if severely ill
Return if hyper symptoms develop → possible overtreatment
Return if worse after treatment → consider associated glucocorticoid deficiency / underlying Addison disease
(⤴) = already mentioned earlier (same context)