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Question 1
Incorrect
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A 65-year-old woman presents at clinic complaining of worsening hoarseness of voice and dyspnoea over the past month. She has a history of toxic multinodular goitre successfully treated with radioiodine. On examination, she has a firm asymmetrical swelling of the thyroid gland. Laryngoscopy demonstrates a right vocal cord paralysis and apparent external compression of the trachea.
What is the most likely diagnosis?Your Answer:
Correct Answer: Anaplastic thyroid cancer
Explanation:Thyroid malignancies are divided into papillary carcinomas (80%), follicular carcinomas (10%), medullary thyroid carcinomas (5-10%), anaplastic carcinomas (1-2%), primary thyroid lymphomas (rare), and primary thyroid sarcomas (rare).
Hürthle cell carcinoma is a rare thyroid malignancy that is often considered a variant of follicular carcinoma.
– Papillary and Follicular carcinoma are slow-growing tumours
– Sporadic cases of Medullary thyroid carcinoma also typically manifest with painless solitary thyroid nodules in the early stages.
– Anaplastic thyroid carcinoma has the most aggressive biologic behaviour of all thyroid malignancies and has one of the worst survival rates of all malignancies in general. It manifests as a rapidly growing thyroid mass in contrast to a well-differentiated carcinoma, which are comparatively slow-growing. Patients commonly present with associated symptoms due to local invasion. Hoarseness and dyspnoea resulting from the involvement of the recurrent laryngeal nerve and airway occur in as many as 50% of patients.
– Almost all patients with primary thyroid lymphoma have either a clinical history or histological evidence of chronic lymphocytic thyroiditis. The risk of primary thyroid lymphoma increases 70-fold in patients with chronic lymphocytic thyroiditis compared with the general population. Regional and distant lymphadenopathy is common. -
This question is part of the following fields:
- Endocrinology
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Question 2
Incorrect
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A 32-year-old woman presents to the GP with tiredness and anxiety during the third trimester of her second pregnancy.
The Examination is unremarkable, with a BP of 110/70 mmHg and a pulse of 80. Her BMI is 24 and she has an abdomen consistent with a 31-week pregnancy. The GP decides to check some thyroid function tests.
Which of the following is considered to be normal?Your Answer:
Correct Answer: Elevated total T4
Explanation:During pregnancy, profound changes in thyroid physiology occur to provide sufficient thyroid hormone (TH) to both the mother and foetus. This is particularly important during early pregnancy because the fetal thyroid starts to produce considerable amounts of TH only from approximately 20 weeks of gestation, until which time the foetus heavily depends on the maternal supply of TH. This supply of TH to the foetus, as well as increased concentrations of TH binding proteins (thyroxine-binding globulin) and degradation of TH by placental type 3 iodothyronine deiodinase, necessitate an increased production of maternal TH. This requires an intact thyroid gland and adequate availability of dietary iodine and is in part mediated by the pregnancy hormone human chorionic gonadotropin, which is a weak agonist of the thyroid-stimulating hormone (TSH) receptor. As a consequence, serum-free thyroxine (FT4) concentrations increase and TSH concentrations decrease from approximately the eighth week throughout the first half of pregnancy, resulting in different reference intervals for TSH and FT4 compared to the non-pregnant state.
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This question is part of the following fields:
- Endocrinology
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Question 3
Incorrect
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A 50-year-old woman was investigated following an osteoporotic hip fracture. The following results are obtained:
TSH < 0.05 mu/l,
Free T4 29 pmol/L.
Which of the following autoantibodies is most likely to be present?Your Answer:
Correct Answer: TSH receptor stimulating autoantibodies
Explanation:The patient has hyperthyroidism and its most common cause is Grave’s Disease.
Grave’s Disease is an autoimmune disease due to circulating autoantibodies known as TSH receptor stimulating autoantibodies or Thyroid-stimulating immunoglobulins (TSIs) that bind to and activate thyrotropin receptors, causing the thyroid gland to grow and the thyroid follicles to increase the synthesis of thyroid hormone. -
This question is part of the following fields:
- Endocrinology
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Question 4
Incorrect
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A 11-year-old is referred to neurology due to episodes her GP feels are epileptiform. Her mother reports that she appears to just 'stop', sometimes even in mid conversation, for several seconds at random times during the day. During these episodes, she can be unresponsive to questioning and has no recollection of them.
Which of these drugs is contraindicated in this condition?Your Answer:
Correct Answer: Carbamazepine
Explanation:The patient’s history points to absence seizures. Carbamazepine has been shown to aggravate generalized seizure types, especially absence seizures, because it acts directly on the ventrobasal complex of the thalamus which is critical to the neurophysiology of absence seizures.
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This question is part of the following fields:
- Neurology
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Question 5
Incorrect
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A 55-year-old woman admitted to the hospital with her third urinary tract infection in as many months. She has type-2 diabetes and started Empagliflozin (a sodium glucose co-transporter 2 inhibitor) 4 months ago. You suspect recurrent urinary tract infections secondary to her empagliflozin.
Where is the main site of action of the drug?Your Answer:
Correct Answer: Early proximal convoluted tubule
Explanation:Selective sodium-glucose transporter-2 (SGLT2) is expressed in the proximal renal tubules and is responsible for the majority of the reabsorption of filtered glucose from the tubular lumen.
Empagliflozin; SGLT2 inhibitors reduce glucose reabsorption and lower the renal threshold for glucose, thereby increasing urinary glucose excretion, thus increasing the risk of urinary tract infections. -
This question is part of the following fields:
- Endocrinology
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Question 6
Incorrect
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Primary hyperaldosteronism is characterized by which of the following features?
Your Answer:
Correct Answer: Muscular weakness
Explanation:Primary hyperaldosteronism, also known as Conn’s Syndrome, is one of the most common causes of secondary hypertension (HTN).
The common clinical scenarios in which the possibility of primary hyperaldosteronism should be considered include the following:
– Patients with spontaneous or unprovoked hypokalaemia, especially if the patient is also hypertensive
– Patients who develop severe and/or persistent hypokalaemia in the setting of low to moderate doses of potassium-wasting diuretics
– Patients with treatment-refractory/-resistant hypertension (HTN)
Patients with severe hypokalaemia report fatigue, muscle weakness, cramping, headaches, and palpitations. They can also have polydipsia and polyuria from hypokalaemia-induced nephrogenic diabetes insipidus. Long-standing HTN may lead to cardiac, retinal, renal, and neurologic problems, with all the associated symptoms and signs. -
This question is part of the following fields:
- Endocrinology
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Question 7
Incorrect
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A 28-year-old woman is evaluated in the endocrinology clinic for increased urine output. She weighs 60 kg and has a 24-hour urine output of 3500 ml. Her basal urine osmolality is 210 mOsm/kg.
She undergoes a fluid deprivation test and her urine osmolality after fluid deprivation (loss of weight 3 kg) is 350 mOsm/kg. Subsequent injection of subcutaneous DDAVP (desmopressin acetate) did not result in a further significant rise of urine osmolality after 2 hours (355 mOsm/kg).
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Primary polydipsia
Explanation:In central and nephrogenic diabetes insipidus (DI), urinary osmolality will be less than 300 mOsm/kg after water deprivation. After the administration of ADH, the osmolality will rise to more than 750 mOsm/kg in central DI but will not rise at all in nephrogenic DI. In primary polydipsia, urinary osmolality be above 750 mOsm/kg after water deprivation. A urinary osmolality that is 300-750 mOsm/kg after water deprivation and remains below 750 mOsm/kg after administration of ADH may be seen in partial central DI, partial nephrogenic DI, and primary polydipsia.
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This question is part of the following fields:
- Endocrinology
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Question 8
Incorrect
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A 46-year-old plumber develops chronic, severe pain after sustaining a brachial plexus injury as a result of a motorbike accident. He has had no benefit from paracetamol or ibuprofen. In addition, he has had an unsuccessful trial of amitriptyline. Following recent NICE guidelines, which of the following is the most appropriate medication to consider?
Your Answer:
Correct Answer: Pregabalin
Explanation:Neuropathic pain may be defined as pain which arises following damage or disruption of the nervous system. It is often difficult to treat and responds poorly to standard analgesia.
The most recent update to the NICE guidelines for management of neuropathic pain occurred in 2013: first-line treatment* includes amitriptyline. If the first-line drug treatment does not work then move on to one of the other 3 drugs: duloxetine, gabapentin or pregabalin. Tramadol may be used as ‘rescue therapy’ for exacerbations of neuropathic pain. Topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia). Pain management clinics may be useful in patients with resistant problems.*please note that for some specific conditions the guidance may vary. For example carbamazepine is used first-line for trigeminal neuralgia.
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This question is part of the following fields:
- Neurology
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Question 9
Incorrect
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Which of the following is most consistent with achondroplasia?
Your Answer:
Correct Answer: May be diagnosed radiologically at birth
Explanation:Achondroplasia is the most common type of short-limb disproportionate dwarfism. A single gene mapped to the short arm of chromosome 4 (band 4p16.3) is responsible for achondroplasia and is transmitted as an autosomal dominant trait. All people with achondroplasia have a short stature.
Characteristic features of achondroplasia include an average-size trunk, short arms and legs with particularly short upper arms and thighs, limited range of motion at the elbows, and an enlarged head (macrocephaly) with a prominent forehead. Fingers are typically short and the ring finger and middle finger may diverge, giving the hand a three-pronged (trident) appearance. People with achondroplasia are generally of normal intelligence.
Examination of the infant after birth shows increased front-to-back head size. There may be signs of hydrocephalus. It may be diagnosed radiographically at birth, or becomes obvious within the first year with disparity between a large skull, normal trunk length and short limbs. -
This question is part of the following fields:
- Endocrinology
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Question 10
Incorrect
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A 35-year-old man is referred to the clinic by his GP. He complains of lethargy and tiredness. He has recently been discharged from the hospital after being admitted to the intensive care unit following a motorbike accident.
His thyroid function testing is :
TSH 0.3 IU/l (0.5-4.5),
Free T4 8 pmol/l (9-25),
Free T3 3.1 pmol/l (3.4-7.2).
Which of the following is most likely to be the diagnosis?Your Answer:
Correct Answer: Sick euthyroid syndrome
Explanation:Euthyroid sick syndrome (also known as nonthyroidal illness syndrome) can be described as abnormal findings on thyroid function tests that occurs in the setting of a nonthyroidal illness (NTI), without pre-existing hypothalamic-pituitary and thyroid gland dysfunction. After recovery from an NTI, these thyroid function test result abnormalities should be completely reversible.
Multiple alterations in serum thyroid function test findings have been recognized in patients with a wide variety of NTIs without evidence of pre-existing thyroid or hypothalamic-pituitary disease. The most prominent alterations are low serum triiodothyronine (T3) and elevated reverse T3 (rT3), leading to the general term low T3 syndrome. Thyroid-stimulating hormone (TSH), thyroxine (T4), free T4 (FT4), and free T4 index (FTI) also are affected in variable degrees based on the severity and duration of the NTI. As the severity of the NTI increases, both serum T3 and T4 levels drop, but they gradually normalize as the patient recovers.
Reverse T3 is used to differentiate between this condition and secondary thyroid failure. -
This question is part of the following fields:
- Endocrinology
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Question 11
Incorrect
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A 53-year-old cashier with a history of chronic back pain presents for a check-up. He is aware of a dragging feeling affecting his left foot when he tries to walk. This has developed since a minor injury to his left knee. On examination, he has weakness of dorsiflexion and eversion of the left foot. The right is unaffected and plantar flexion and inversion are normal on the left. MRI of the spinal cord shows degenerative disc changes at multiple levels, but no evidence of cord or nerve root impingement. Nerve conduction studies and EMG results are pending. Which of the following sensory loss patterns would you expect to find in association with this motor defect?
Your Answer:
Correct Answer: Sensory loss over the dorsum of the foot and anterolateral leg
Explanation:This patient presentation is unlikely to be an L5 nerve root lesion given the results of the MRI scan. Therefore, the most likely diagnosis is a mononeuritis affecting the left common peroneal nerve. This would lead to sensory loss over the dorsum of the foot and anterolateral leg on the left.
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This question is part of the following fields:
- Neurology
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Question 12
Incorrect
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A 25-year-old man wants to start a relationship but is concerned about his small phallus. He also has difficulty becoming aroused. On examination, he is slim and has gynecomastia. There is a general paucity of body hair, his penis and testes are small.
Which diagnosis fits best with this history and examination?Your Answer:
Correct Answer: Klinefelter’s syndrome
Explanation:The patient most likely has Klinefelter’s syndrome.
Klinefelter syndrome (KS) refers to a group of chromosomal disorders in which the normal male karyotype, 46,XY, has at least one extra X chromosome. XXY aneuploidy, the most common human sex chromosome disorder. It is also the most common chromosomal disorder associated with male hypogonadism and infertility.
Klinefelter syndrome is characterized by hypogonadism (micro-orchidism, oligospermia/azoospermia), gynecomastia in late puberty, hyalinization and fibrosis of the seminiferous tubules, elevated urinary gonadotropin levels, and behavioural concerns. -
This question is part of the following fields:
- Endocrinology
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Question 13
Incorrect
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A 27-year-old realtor presented with progressive weakness of both legs over the last 3 years. He complained of being unable to see well at night and having an impaired sense of smell. On examination he had a shortened fourth toe bilaterally with pes cavus. Neurological examination revealed a loss of pinprick sensation to bilateral knees, and weakness of both legs that was more prominent distally. Which of the following would be the best blood test to order to make a diagnosis?
Your Answer:
Correct Answer: Phytanic acid
Explanation:The diagnosis is Refsum’s disease. This is an autosomal recessive disorder that causes a sensorimotor peripheral neuropathy. It is caused by defective alpha oxidation of phytanic acid leading to its accumulation in tissues. Cardiac conduction abnormalities and cardiomyopathies may also occur.
Epiphyseal dysplasia causes a characteristic shortening of the fourth toe. Serum phytanic acid levels are elevated. Treatment is by dietary restriction of foods containing phytanic acid (dairy products, fish, beef and lamb). -
This question is part of the following fields:
- Neurology
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Question 14
Incorrect
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A 20-year-old woman presents for review. She is concerned due to absence of menstruation for 5 months.
She is 1.76 m in height and weighs only 43.7 kg (7 stone).
A pregnancy test is negative and thyroid function testing is normal.
Which of the following is the diagnosis of this case?Your Answer:
Correct Answer: Weight-related amenorrhoea
Explanation:Low body weight. Excessively low body weight — about 10 percent under normal weight — interrupts many hormonal functions in your body, potentially halting ovulation.
In Polycystic ovaries there is excess weight gain. -
This question is part of the following fields:
- Endocrinology
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Question 15
Incorrect
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Which of the following statements regarding dipeptidyl peptidase-4 inhibitors in the management of type 2 diabetes mellitus is correct?
Your Answer:
Correct Answer: Do not cause weight gain
Explanation:Several dipeptidyl peptidase-4 (DPP-4) inhibitors are in clinical development; these are orally active and increase levels of active glucagon-like peptide-1 (GLP-1), which in turn increases insulin secretion and reduces glucagon secretion, thereby lowering glucose levels.
Sitagliptin and vildagliptin both have a long duration of action, allowing once-daily administration. Both sitagliptin and vildagliptin are safe and tolerable with a low risk of hypoglycaemia. In drug-naïve subjects with type 2 diabetes, both sitagliptin and vildagliptin reduce A1C levels by ,1% as monotherapy. -
This question is part of the following fields:
- Endocrinology
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Question 16
Incorrect
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A 17-year-old girl presented with fever, headache and photophobia. Cerebrospinal fluid examination reveals:
Opening pressure 260 mm H20 (50-180)
Total protein 0.8 g/l (0.15-0.45)
Glucose 4.2 mmol/l (3.3-4.4)
White cell count 60 per ml (<5)
Lymphocytes 90%
Plasma glucose 6.4 mmol/l (3.0-6.0)
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Viral meningitis
Explanation:Normal cerebrospinal fluid (CSF) glucose together with lymphocytosis, an increased opening pressure and raised CSF protein are typical of a viral meningitis.
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This question is part of the following fields:
- Neurology
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Question 17
Incorrect
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A 38-year-old musician presented with a two-day history of sudden-onset occipital headache associated with nausea and vomiting. The next day, his right hand became weak for a few hours. On the same day he had an episode of sensory disturbance in his right upper limb consisting of tingling in his hand that spread up the arm, to his shoulder lasting less than two minutes in total. On the day of admission he had a similar episode of sensory disturbance lasting 30 seconds in total. On examination he had bilateral papilledema, no neck stiffness and an otherwise normal neurological examination. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Venous sinus thrombosis
Explanation:Cerebral venous sinus thrombosis (CVST) is associated with headache (>90% of cases), seizures, focal weakness (40%) and papilledema (40%), all seen in this patient.
Risk factors for CVST include genetic or acquired prothrombotic disorders, pregnancy, the oral contraceptive pill, vasculitis, malignancy, dehydration and infection. However, there are multiple other associated factors.
Diagnosis is normally confirmed with magnetic resonance venography (MRV). Treatment is with anticoagulation, initially with heparin and subsequently with warfarin. -
This question is part of the following fields:
- Neurology
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Question 18
Incorrect
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A 55-year-old man with a three-year history of type 2 diabetes comes to the clinic for review. He is currently managed with metformin 1 g BD and feels that his home blood glucose monitoring has deteriorated over the past few months. There is a history of hypertension and dyslipidaemia for which he takes Ramipril 10 mg daily and atorvastatin 20 mg.
On examination, his BP is 155/82 mmHg, his pulse is 71 and regular. His chest is clear. His BMI is 32.
Investigations show:
Haemoglobin 12.9 g/dl (13.5 – 17.7),
White cell count 5.0 x109/l (4 – 11),
Platelets 180 x109/l (150 – 400),
Sodium 140 mmol/l (135 – 146),
Potassium 5.0 mmol/l (3.5 – 5),
Creatinine 123 mmol/l (79 – 118),
HbA1c 8.0% (<7.0).
He would like to start sitagliptin.
Which of the following adverse effects would you warn him about?Your Answer:
Correct Answer: Pancreatitis
Explanation:Sitagliptin-induced pancreatitis can occur at any time after the initiation of therapy, even after several years. Patients taking sitagliptin who present with signs and symptoms of mild or severe pancreatitis should immediately discontinue sitagliptin and use an alternate medication regimen for control of type 2 diabetes.
In response to pancreatitis reported in post-marketing surveillance through the Adverse Event Reporting System (AERS), the FDA has issued revised prescribing information for sitagliptin stating that cases of acute pancreatitis have been reported with use, to monitor closely for signs and symptoms of pancreatitis, and to use sitagliptin with caution in patients with a history of pancreatitis. -
This question is part of the following fields:
- Endocrinology
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Question 19
Incorrect
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A 18-year-old gentleman is referred to dermatology. He has around 10 hyperpigmented macules on his torso which vary in size from 1.5-5 cm in size. His GP also noted some freckles in the groin region. He is also currently under orthopaedic review due to a worsening scoliosis of the spine. His father suffered from similar problems before having a fatal myocardial infarction two years ago. Which chromosome is most likely to have a gene defect?
Your Answer:
Correct Answer: Chromosome 17
Explanation:The patient’s history and presentation and familial history, meets the diagnostic criteria for Neurofibromatosis type I, presenting with neurofibromas noted in this patient as hyperpigmented macules and freckles, musculoskeletal disorders like the scoliosis in this case, and a familial history. Neurofibromatosis type I is caused by a mutation on Chromosome 17.
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This question is part of the following fields:
- Neurology
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Question 20
Incorrect
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A 40-year-old man comes to the endocrine clinic after his second episode of acute pancreatitis.
On examination, he has a BP of 125/70 mmHg, his pulse is regular 70 bpm and his BMI is 23. There is evidence of eruptive xanthomas on examination of his skin.
It was noted that his fasting triglycerides level is 8.5 mmol/l (0.7-2.1) at his follow up appointment although his LDL level is not particularly raised.
Which of the following is the most appropriate therapy for him?Your Answer:
Correct Answer: Fenofibrate
Explanation:Three classes of medications are appropriate for the management of major triglyceride elevations: fibric acid derivatives, niacin, and omega-3 fatty acids.
Fibrate is used as a first-line agent for reduction of triglycerides in patients at risk for triglyceride-induced pancreatitis.
High-dose niacin (vitamin B-3) (1500 or more mg/d) decreases triglyceride levels by at least 40% and can raise HDL cholesterol levels by 40% or more. Niacin also reliably and significantly lowers LDL cholesterol levels, which the other major triglyceride-lowering medications do not.
Omega-3 fatty acids are attractive because of their low risk of major adverse effects or interaction with other medications. At high doses (>4 g/d), triglycerides are reduced.
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This question is part of the following fields:
- Endocrinology
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Question 21
Incorrect
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A 41-year-old gentleman undergoes a temporal lobectomy after the discovery of a brain tumour. Which one of the following consequences would be least likely to develop?
Your Answer:
Correct Answer: Astereognosis
Explanation:Astereognosis is associated with lesions to the parietal lobe, not the temporal lobe, so this symptom would not arise in this patient.
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This question is part of the following fields:
- Neurology
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Question 22
Incorrect
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A 41-year-old yoga instructor presents with a 2-month history of left-hand weakness. She has no significant past medical history. On examination, there is mild weakness of the left upper and lower limbs with a right sided facial weakness, which spares the forehead. Which of the following is the most likely location of the lesion?
Your Answer:
Correct Answer: Right pons
Explanation:The pons is above the level of decussation of the corticospinal tracts so a pontine lesion would cause a contralateral limb weakness.
The facial motor nucleus is located in the pons and supplies the ipsilateral facial muscles.
A right cerebral lesion would give left upper and lower limb weakness. It would also cause a left sided facial weakness.
A left cerebral lesion would give right upper and lower limb weakness with right facial weakness.
Finally, a cervical spinal cord lesion would not cause a facial weakness. -
This question is part of the following fields:
- Neurology
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Question 23
Incorrect
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A 60-year-old man presents to his GP complaining of a cough and breathlessness for 2 weeks. He reports that before the onset of these symptoms, he was fit and well and was not on any medication. He is a known smoker of 10 cigarettes per day and has been smoking for over 25 years.
On examination, the GP diagnosed a mild viral chest infection and reassured the patient that the symptoms would settle of their own accord.
Two weeks later, the patient presented again to the GP, this time complaining of thirst, polyuria and generalised muscle weakness. The GP noticed the presence of ankle oedema.
A prick test confirmed the presence of hyperglycaemia and the patient was referred to the hospital for investigations where the medical registrar ordered a variety of blood tests.
Some of these results are shown:
Na 144 mmol/L,
K 2.2 mmol/L,
Bicarbonate 34 mmol/L,
Glucose 16 mmol/L.
What is the most likely diagnosis?Your Answer:
Correct Answer: Ectopic ACTH production
Explanation:The patient has small cell lung cancer presented by paraneoplastic syndrome; Ectopic ACTH secretion.
Small cell lung cancer (SCLC), previously known as oat cell carcinoma is a neuroendocrine carcinoma that exhibits aggressive behaviour, rapid growth, early spread to distant sites, exquisite sensitivity to chemotherapy and radiation, and a frequent association with distinct paraneoplastic syndromes.
Common presenting signs and symptoms of the disease, which very often occur in advanced-stage disease, include the following:
– Shortness of breath
– Cough
– Bone pain
– Weight loss
– Fatigue
– Neurologic dysfunction
Most patients with this disease present with a short duration of symptoms, usually only 8-12 weeks before presentation. The clinical manifestations of SCLC can result from local tumour growth, intrathoracic spread, distant spread, and/or paraneoplastic syndromes.
SIADH is present in 15% of the patients and Ectopic secretion of ACTH is present in 2-5% of the patients leading to ectopic Cushing’s syndrome. -
This question is part of the following fields:
- Endocrinology
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Question 24
Incorrect
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The chorda tympani of the facial nerve (CN VII) carries:
Your Answer:
Correct Answer: parasympathetic fibres to the submandibular and sublingual glands and taste fibres from the anterior two-thirds of the tongue
Explanation:In the petrous temporal bone the facial nerve produces three branches:
1. The greater petrosal nerve, which transmits preganglionic parasympathetic fibres to the sphenopalatine ganglion. These postganglionic fibres supply the lacrimal gland and the glands in the nasal cavity;
2. The nerve to stapedius;
3. Parasympathetic fibres to the submandibular and sublingual glands and taste fibres from the anterior two-thirds of the tongue. -
This question is part of the following fields:
- Neurology
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Question 25
Incorrect
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A 77-year-old woman is admitted in an unconscious state. On examination in casualty, her temperature is 33 °C and she was in left ventricular failure.
Her blood glucose level is 5.7 mmol/l and random cortisol is elevated. Free T4 is 4.4 pmol/l.
A CT scan of her brain reveals no focal lesion and a cursory assessment reveals no gross focal neurology.
Which diagnosis fits best with this woman’s clinical picture?Your Answer:
Correct Answer: Profound hypothyroidism
Explanation:Elderly patients with severe hypothyroidism often present with variable symptoms that may be masked or potentiated by co-morbid conditions. Characteristic symptoms may include fatigue, weight gain, cold intolerance, hoarseness, constipation, and myalgias. Neurologic symptoms may include ataxia, depression, and mental status changes ranging from mild confusion to overt dementia.
Clinical findings that may raise suspicion of thyroid hormone deficiency include hypothermia, bradycardia, goitrous enlargement of the thyroid, cool dry skin, myxoedema, delayed relaxation of deep tendon reflexes, a pericardial or abdominal effusion, hyponatremia, and hypercholesterolemia.The patient has a greatly reduced free T4 concentration, is hypothermic, unconscious and has evidence of associated heart failure. All of those support the diagnosis of profound hypothyroidism.
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This question is part of the following fields:
- Endocrinology
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Question 26
Incorrect
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A 40 year-old lawyer suffered a road traffic accident. MRI reveals that he may have hemisection of the spinal cord. Which of the following findings is most likely to occur?
Your Answer:
Correct Answer: Ipsilateral hyperreflexia
Explanation:Spinal cord hemisection, also known as Brown-Sequard syndrome, is associated with symptoms affecting one spinothalamic and one corticospinal tract. Symptoms include ipsilateral paralysis, loss of vibration and position sense, and hyperreflexia below the level of the lesion. Contralateral loss of pain and temperature sensation is also seen, usually beginning 2-3 segments below the level of the lesion.
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This question is part of the following fields:
- Neurology
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Question 27
Incorrect
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A 30-year-old woman presents with amenorrhoea and galactorrhoea. She has normal visual fields. You are concerned that she may have a prolactinoma.
Investigations were done and the results are as shown below:
Hb 12.5 g/dL,
WCC 4.9 x109/L,
PLT 199 x109/L,
Na+ 140 mmol/L,
K+ 4.9 mmol/L,
Creatinine 90 ىmol/L,
Prolactin 1150 mU/l.
MRI shows a 7 mm pituitary microadenoma.
Which of the following hormones would you expect to be lower than normal?Your Answer:
Correct Answer: LH
Explanation:Prolactinomas, benign lesions that produce the hormone prolactin, are the most common hormone-secreting pituitary tumours.
Based on its size, a prolactinoma can be classified as a microprolactinoma (< 10 mm diameter) or a macroprolactinoma (>10 mm diameter). If the prolactinoma is large enough to compress the surrounding normal hormone-secreting pituitary cells, it may result in deficiencies of one or more hormones (e.g., thyroid-stimulating hormone [TSH], growth hormone [GH], adrenocorticotropic hormone). However, the patient has microadenoma so it is unlikely to cause compression manifestations.
Hyperprolactinemia inhibits GnRH secretion from the medial basal hypothalamus and LH release from the pituitary. -
This question is part of the following fields:
- Endocrinology
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Question 28
Incorrect
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Which of the following may cause a downbeat nystagmus?
Your Answer:
Correct Answer: Chiari type I malformation
Explanation:Downbeat nystagmus (DBN) suggests a lesion in the lower part of the medulla. Chiari Type I malformation usually presents with symptoms due to brain stem and lower cranial nerve dysfunction, which includes DBN.
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This question is part of the following fields:
- Neurology
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Question 29
Incorrect
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A 53 year-old dancer presents to the ED with increasing weakness. She has no pertinent past medical history aside from a recent diarrhoeal illness, which she attributes to an undercooked chicken meal. Her husband says that she has been unable to get up out of a chair for the past day. Upon examination, there is bilateral limb weakness and areflexia noted, but it is more severe in the lower limbs. You notice that if she lies flat in the bed, her oxygen saturations fall by around 2% on the pulse oximeter and she is unable to perform spirometry. Which of the following represents the most appropriate immediate management of choice in this patient?
Your Answer:
Correct Answer: ITU review for consideration of ventilation
Explanation:This woman has a history that is suggestive of Guillain– Barré syndrome. This may be precipitated by Campylobacter, and her history of recent diarrhoeal illness is pointing towards that. Certain features point to a poor prognosis, including rapidity of onset, reduced vital capacity or respiratory failure, age >40 and reduced amplitude of compound muscle action potential. Her inability to perform spirometry and desaturating whilst lying flat are suggestive of impending respiratory muscle weakness. Review for consideration of ventilation is recommended. Further management of choice for Guillain-Barre syndrome is IV immunoglobulins. Steroids have no value in the treatment of the condition.
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This question is part of the following fields:
- Neurology
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Question 30
Incorrect
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A 26-year-old woman presents to a reproductive endocrinology clinic with a history of not being able to conceive after 2 years of using no contraception. Polycystic ovarian syndrome maybe her diagnosis.
Which of the following is most likely to be associated with this condition?Your Answer:
Correct Answer: Elevated LH/FSH ratio
Explanation:In patients with polycystic ovarian syndrome (PCOS), FSH levels are within the reference range or low. Luteinizing hormone (LH) levels are elevated for Tanner stage, sex, and age. The LH-to-FSH ratio is usually greater than 3.
Women with PCOS have abnormalities in the metabolism of androgens and oestrogen and in the control of androgen production. PCOS can result from abnormal function of the hypothalamic-pituitary-ovarian (HPO) axis.
The major features of PCOS include menstrual dysfunction, anovulation, and signs of hyperandrogenism. Other signs and symptoms of PCOS may include the following:
– Hirsutism
– Infertility
– Obesity and metabolic syndrome
– Diabetes
– Obstructive sleep apnoeaAndrogen excess can be tested by measuring total and free testosterone levels or a free androgen index. An elevated free testosterone level is a sensitive indicator of androgen excess. Other androgens, such as dehydroepiandrosterone sulphate (DHEA-S), may be normal or slightly above the normal range in patients with polycystic ovarian syndrome (PCOS). Levels of sex hormone-binding globulin (SHBG) are usually low in patients with PCOS.
Some women with PCOS have insulin resistance and an abnormal lipid profile (cholesterol >200 mg/dL; LDL >160 mg/dL). Approximately one-third of women with PCOS who are overweight have impaired glucose tolerance or type 2 diabetes mellitus by 30 years of age.
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This question is part of the following fields:
- Endocrinology
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