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Question 1
Correct
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A 15-year-old male arrives at the emergency department with intense abdominal pain and a decreased Glasgow coma score (GCS). Over the past few weeks, he has been experiencing excessive urination, abnormal thirst, and weight loss. Laboratory results reveal:
Ketones 4.2 mmol/L (<0.6 mmol/L)
Glucose 20 mmol/L
pH 7.25
What is the probable cause of the acidosis and hyperketonemia in this case?Your Answer: Uncontrolled lipolysis
Explanation:The likely cause of the patient’s condition is diabetic ketoacidosis, which is a result of uncontrolled lipolysis. This process leads to an excess of free fatty acids that are eventually converted into ketone bodies. It is important to note that proteolysis, the breakdown of proteins into smaller polypeptides, does not yield ketone bodies and is not the cause of this condition. While glycogenolysis and gluconeogenesis are increased due to the lack of insulin and rise of glucagon, they do not result in acidosis or elevated levels of ketone bodies. It is ketogenesis, not ketolysis, that leads to the increased levels of ketone bodies.
Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus, accounting for around 6% of cases. It can also occur in rare cases of extreme stress in patients with type 2 diabetes mellitus. DKA is caused by uncontrolled lipolysis, resulting in an excess of free fatty acids that are converted to ketone bodies. The most common precipitating factors of DKA are infection, missed insulin doses, and myocardial infarction. Symptoms include abdominal pain, polyuria, polydipsia, dehydration, Kussmaul respiration, and breath that smells like acetone. Diagnostic criteria include glucose levels above 11 mmol/l or known diabetes mellitus, pH below 7.3, bicarbonate below 15 mmol/l, and ketones above 3 mmol/l or urine ketones ++ on dipstick.
Management of DKA involves fluid replacement, insulin, and correction of electrolyte disturbance. Fluid replacement is necessary as most patients with DKA are deplete around 5-8 litres. Isotonic saline is used initially, even if the patient is severely acidotic. Insulin is administered through an intravenous infusion, and correction of electrolyte disturbance is necessary. Long-acting insulin should be continued, while short-acting insulin should be stopped. Complications may occur from DKA itself or the treatment, such as gastric stasis, thromboembolism, arrhythmias, acute respiratory distress syndrome, acute kidney injury, and cerebral edema. Children and young adults are particularly vulnerable to cerebral edema following fluid resuscitation in DKA and often need 1:1 nursing to monitor neuro-observations, headache, irritability, visual disturbance, focal neurology, etc.
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This question is part of the following fields:
- Endocrine System
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Question 2
Incorrect
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Which of the following is not secreted by the islets of Langerhans?
Your Answer: Somatostatin
Correct Answer: Secretin
Explanation:Mucosal cells in the duodenum and jejunum release secretin.
Hormones Released from the Islets of Langerhans
The islets of Langerhans in the pancreas are responsible for the production and secretion of several hormones that play a crucial role in regulating blood glucose levels. The beta cells in the islets of Langerhans are responsible for producing insulin, which accounts for 70% of the total secretions. Insulin helps to lower blood glucose levels by promoting the uptake of glucose by cells and tissues throughout the body.
The alpha cells in the islets of Langerhans produce glucagon, which has the opposite effect of insulin. Glucagon raises blood glucose levels by stimulating the liver to release stored glucose into the bloodstream. The delta cells in the islets of Langerhans produce somatostatin, which helps to regulate the release of insulin and glucagon.
Finally, the F cells in the islets of Langerhans produce pancreatic polypeptide, which plays a role in regulating pancreatic exocrine function and appetite. Together, these hormones work to maintain a delicate balance of blood glucose levels in the body.
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This question is part of the following fields:
- Endocrine System
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Question 3
Incorrect
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A young male with a history of diabetes mellitus type 1 is admitted to the emergency department. He was previously found to be confused by his roommates in his room. As well as this, he complains of nausea and abdominal pain.
An ECG is performed and shows tall tented T waves.
A simple blood test reveals marked hyperglycemia. A urinalysis shows the presence of ketones ++.
His bloods show the following:
Hb 136 g/L Male: (135-180)
Platelets 210 * 109/L (150 - 400)
WBC 9.5 * 109/L (4.0 - 11.0)
Na+ 137 mmol/L (135 - 145)
K+ 7.1 mmol/L (3.5 - 5.0)
Bicarbonate 31 mmol/L (22 - 29)
Urea 8.0 mmol/L (2.0 - 7.0)
Creatinine 155 ”mol/L (55 - 120)
He is given insulin, calcium gluconate and IV saline.
What is the main mechanism as to why the patient's potassium level will decrease?Your Answer: Insulin signals increase of voltage-gated potassium channels
Correct Answer: Insulin increases sodium potassium pump
Explanation:Insulin stimulates the Na+/K+ ATPase pump, leading to a decrease in serum potassium levels. This is primarily achieved through increased activity of the sodium-potassium pump, which is triggered by phosphorylation of the transmembrane subunits in response to insulin. While calcium gluconate is used to protect the heart during hyperkalaemia-induced arrhythmias, it does not affect potassium levels. Although IV fluids can improve renal function and potassium clearance, they are not the primary method for reducing potassium levels. Calcium-activated potassium channels are present throughout the body and are activated by an increase in intracellular calcium levels during action potentials.
Insulin is a hormone produced by the pancreas that plays a crucial role in regulating the metabolism of carbohydrates and fats in the body. It works by causing cells in the liver, muscles, and fat tissue to absorb glucose from the bloodstream, which is then stored as glycogen in the liver and muscles or as triglycerides in fat cells. The human insulin protein is made up of 51 amino acids and is a dimer of an A-chain and a B-chain linked together by disulfide bonds. Pro-insulin is first formed in the rough endoplasmic reticulum of pancreatic beta cells and then cleaved to form insulin and C-peptide. Insulin is stored in secretory granules and released in response to high levels of glucose in the blood. In addition to its role in glucose metabolism, insulin also inhibits lipolysis, reduces muscle protein loss, and increases cellular uptake of potassium through stimulation of the Na+/K+ ATPase pump.
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This question is part of the following fields:
- Endocrine System
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Question 4
Correct
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A 45-year-old woman comes to the clinic complaining of polyuria. Upon further inquiry, she reports experiencing polyphagia and polydipsia as well. Her blood test reveals hyperglycaemia and low C-peptide levels.
What is the underlying mechanism causing her hyperglycaemia?Your Answer: Decreased GLUT-4 expression
Explanation:The movement of glucose into cells requires insulin. In this case, the patient is likely suffering from type 1 diabetes mellitus or latent autoimmune diabetes in adults (LADA) with low c-peptide levels, indicating a complete lack of insulin. As a result, insulin is unable to stimulate the expression of GLUT-4, which significantly reduces the uptake of glucose into skeletal and adipose cells.
The patient’s low GLUT-1 expression is unlikely to be the cause of hyperglycemia. GLUT-1 is primarily expressed in fetal tissues and has a higher affinity for oxygen, allowing fetal cells to survive even in hypoglycemic conditions.
GLUT-2 expression is mainly found in hepatocytes and beta-cells of the pancreas. It allows for the bi-directional movement of glucose, equalizing glucose concentrations inside and outside the cell membrane, and enabling glucose-sensitive cells to measure serum glucose levels and respond accordingly.
GLUT-3 expression is mainly found in neuronal cells and has a high affinity, similar to GLUT-1. This allows for the survival of brain cells in hypoglycemic conditions.
Insulin is a hormone produced by the pancreas that plays a crucial role in regulating the metabolism of carbohydrates and fats in the body. It works by causing cells in the liver, muscles, and fat tissue to absorb glucose from the bloodstream, which is then stored as glycogen in the liver and muscles or as triglycerides in fat cells. The human insulin protein is made up of 51 amino acids and is a dimer of an A-chain and a B-chain linked together by disulfide bonds. Pro-insulin is first formed in the rough endoplasmic reticulum of pancreatic beta cells and then cleaved to form insulin and C-peptide. Insulin is stored in secretory granules and released in response to high levels of glucose in the blood. In addition to its role in glucose metabolism, insulin also inhibits lipolysis, reduces muscle protein loss, and increases cellular uptake of potassium through stimulation of the Na+/K+ ATPase pump.
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This question is part of the following fields:
- Endocrine System
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Question 5
Correct
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A 14-year-old girl is referred to the endocrine clinic by her GP due to bed wetting episodes. She experiences constant thirst and frequent urination. A dipstick test reveals diluted urine with low osmolality, and her blood tests show hypernatremia with high serum osmolality. Her family has a history of diabetes insipidus. What is the most suitable follow-up examination?
Your Answer: Water deprivation test
Explanation:A water deprivation test is the most appropriate method for diagnosing diabetes insipidus. This test involves withholding water from the patient for a period of time to stimulate the release of antidiuretic hormone (ADH) and monitor changes in serum and urine osmolality. Other methods such as urinary sodium or bladder ultrasound scan are not as effective in diagnosing this condition.
The water deprivation test is a diagnostic tool used to assess patients with polydipsia, or excessive thirst. During the test, the patient is instructed to refrain from drinking water, and their bladder is emptied. Hourly measurements of urine and plasma osmolalities are taken to monitor changes in the body’s fluid balance. The results of the test can help identify the underlying cause of the patient’s polydipsia. Normal results show a high urine osmolality after the administration of DDAVP, while psychogenic polydipsia is characterized by a low urine osmolality. Cranial DI and nephrogenic DI are both associated with high plasma osmolalities and low urine osmolalities.
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This question is part of the following fields:
- Endocrine System
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Question 6
Incorrect
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A 23-year-old female patient visits her GP clinic due to her struggle with weight loss. Her BMI is almost 40 kg/mÂČ, which is severely impacting her mental and physical well-being. Despite following a strict diet and exercise routine, she has not seen any significant improvement. The GP decides to prescribe orlistat as an anti-obesity medication.
What is the mechanism of action of orlistat in promoting weight loss?Your Answer: Improves satiety by reducing gastric emptying
Correct Answer: Reduces fat digestion by inhibiting lipase
Explanation:Orlistat functions by inhibiting gastric and pancreatic lipase, which reduces the digestion of fat.
2,4-Dinitrophenol (DNP) induces mitochondrial uncoupling and can result in weight loss without calorie reduction. However, it is hazardous when used improperly and is not prescribed outside of the US.
Weight gain can be caused by increased insulin secretion.
Orlistat reduces fat digestion by inhibiting lipase, which decreases the amount of fat that can be absorbed. This can result in light-colored, floating stools due to the high fat content.
Liraglutide is a medication that slows gastric emptying to increase satiety and is primarily prescribed as an adjunct in type 2 diabetics.
Serotonin reuptake inhibitors are not utilized for weight loss.
Obesity can be managed through a step-wise approach that includes conservative, medical, and surgical options. The first step is usually conservative, which involves implementing changes in diet and exercise. If this is not effective, medical options such as Orlistat may be considered. Orlistat is a pancreatic lipase inhibitor that is used to treat obesity. However, it can cause adverse effects such as faecal urgency/incontinence and flatulence. A lower dose version of Orlistat is now available without prescription, known as ‘Alli’. The National Institute for Health and Care Excellence (NICE) has defined criteria for the use of Orlistat. It should only be prescribed as part of an overall plan for managing obesity in adults who have a BMI of 28 kg/m^2 or more with associated risk factors, or a BMI of 30 kg/m^2 or more, and continued weight loss of at least 5% at 3 months. Orlistat is typically used for less than one year.
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This question is part of the following fields:
- Endocrine System
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Question 7
Correct
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A young man presents with polyuria, polydipsia and weight loss. He is subsequently diagnosed with type 1 diabetes mellitus. What is he at an increased risk of developing?
Your Answer: Addison's disease, Grave's disease, coeliac disease
Explanation:Type 1 diabetes is linked to other autoimmune disorders like Addison’s disease, Grave’s disease, and coeliac disease, due to its own autoimmune nature. The other choices are incorrect as they contain a non-autoimmune disorder.
Understanding Diabetes Mellitus: A Basic Overview
Diabetes mellitus is a chronic condition characterized by abnormally raised levels of blood glucose. It is one of the most common conditions encountered in clinical practice and represents a significant burden on the health systems of the developed world. The management of diabetes mellitus is crucial as untreated type 1 diabetes would usually result in death. Poorly treated type 1 diabetes mellitus can still result in significant morbidity and mortality. The main focus of diabetes management now is reducing the incidence of macrovascular and microvascular complications.
There are different types of diabetes mellitus, including type 1 diabetes mellitus, type 2 diabetes mellitus, prediabetes, gestational diabetes, maturity onset diabetes of the young, latent autoimmune diabetes of adults, and other types. The presentation of diabetes mellitus depends on the type, with type 1 diabetes mellitus often presenting with weight loss, polydipsia, polyuria, and diabetic ketoacidosis. On the other hand, type 2 diabetes mellitus is often picked up incidentally on routine blood tests and presents with polydipsia and polyuria.
There are four main ways to check blood glucose, including a finger-prick bedside glucose monitor, a one-off blood glucose, a HbA1c, and a glucose tolerance test. The diagnostic criteria are determined by WHO, with a fasting glucose greater than or equal to 7.0 mmol/l and random glucose greater than or equal to 11.1 mmol/l being diagnostic of diabetes mellitus. Management of diabetes mellitus involves drug therapy to normalize blood glucose levels, monitoring for and treating any complications related to diabetes, and modifying any other risk factors for other conditions such as cardiovascular disease. The first-line drug for the vast majority of patients with type 2 diabetes mellitus is metformin, with second-line drugs including sulfonylureas, gliptins, and pioglitazone. Insulin is used if oral medication is not controlling the blood glucose to a sufficient degree.
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This question is part of the following fields:
- Endocrine System
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Question 8
Correct
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A 27-year-old man presents to the consultant's office with complaints of increased thirst and frequent urination for the past month. He has a history of physical injuries due to a motor vehicle accident that occurred 4 months ago. The patient is currently not on any medications and is in good health. Urinalysis reveals a decreased sodium concentration and urine osmolarity of 90 mOsm/L. What renal tubular changes would be anticipated in this patient due to his current condition?
Your Answer: Decreased expression of aquaporin-2 channels in the collecting ducts
Explanation:The insertion of aquaporin-2 channels by antidiuretic hormone promotes water reabsorption, which is compromised in central diabetes insipidus (DI) caused by physical trauma to the pituitary gland. Symptoms include increased thirst, polydipsia, and polyuria, with urinalysis showing decreased urine osmolality and sodium concentration. Aldosterone regulates epithelial sodium channel (ENaC) and K+/H+ exchanger, while angiotensin II regulates Na+/H+ exchanger in proximal tubules. Loop diuretics decrease activity of Na-K-Cl cotransporter in the loops of Henle. However, none of these are relevant to this patient’s presentation.
Understanding Antidiuretic Hormone (ADH)
Antidiuretic hormone (ADH) is a hormone that is produced in the supraoptic nuclei of the hypothalamus and released by the posterior pituitary gland. Its primary function is to conserve body water by promoting water reabsorption in the collecting ducts of the kidneys through the insertion of aquaporin-2 channels.
ADH secretion is regulated by various factors. An increase in extracellular fluid osmolality, a decrease in volume or pressure, and the presence of angiotensin II can all increase ADH secretion. Conversely, a decrease in extracellular fluid osmolality, an increase in volume, a decrease in temperature, or the absence of ADH can decrease its secretion.
Diabetes insipidus (DI) is a condition that occurs when there is either a deficiency of ADH (cranial DI) or an insensitivity to ADH (nephrogenic DI). Cranial DI can be treated with desmopressin, which is an analog of ADH.
Overall, understanding the role of ADH in regulating water balance in the body is crucial for maintaining proper hydration and preventing conditions like DI.
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This question is part of the following fields:
- Endocrine System
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Question 9
Correct
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Which one of the following is not a result of cortisol in the stress response?
Your Answer: Hypoglycaemia
Explanation:Hyperglycaemia is caused by an effect that opposes insulin.
Surgery triggers a stress response that causes hormonal and metabolic changes in the body. This response is characterized by substrate mobilization, muscle protein loss, sodium and water retention, suppression of anabolic hormone secretion, activation of the sympathetic nervous system, and immunological and haematological changes. The hypothalamic-pituitary axis and the sympathetic nervous systems are activated, and the normal feedback mechanisms of control of hormone secretion fail. The stress response is associated with increased growth hormone, cortisol, renin, adrenocorticotropic hormone (ACTH), aldosterone, prolactin, antidiuretic hormone, and glucagon, while insulin, testosterone, oestrogen, thyroid stimulating hormone, luteinizing hormone, and follicle stimulating hormone are decreased or remain unchanged. The metabolic effects of cortisol are enhanced, including skeletal muscle protein breakdown, stimulation of lipolysis, anti-insulin effect, mineralocorticoid effects, and anti-inflammatory effects. The stress response also affects carbohydrate, protein, lipid, salt and water metabolism, and cytokine release. Modifying the response can be achieved through opioids, spinal anaesthesia, nutrition, growth hormone, anabolic steroids, and normothermia.
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This question is part of the following fields:
- Endocrine System
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Question 10
Correct
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A 36-year-old woman visits her GP complaining of frequent urination. She has been waking up several times at night to urinate for the past two weeks and has been feeling more thirsty than usual. Her temperature is 37.3ÂșC. She has a history of bipolar disorder and is currently on lithium medication.
What could be the possible cause of her polyuria?Your Answer: Lithium reducing ADH-dependent water reabsorption in the collecting duct
Explanation:The site of action for antidiuretic hormone (ADH) is the collecting ducts. Lithium treatment for bipolar disorder can lead to diabetes insipidus, which is characterized by increased thirst (polydipsia) and increased urination (polyuria). Lithium use can cause nephrogenic diabetes insipidus, where the kidneys are unable to respond adequately to ADH. Normally, ADH induces the expression of aquaporin 2 channels in the collecting duct, which stimulates water reabsorption.
Central diabetes insipidus occurs when there is damage to the posterior pituitary gland, resulting in insufficient production and release of ADH. However, lithium use causes nephrogenic diabetes insipidus instead of central diabetes insipidus.
Although insulin resistance and hyperglycemia can also cause polyuria and polydipsia, as seen in diabetic ketoacidosis, the use of lithium suggests that the patient’s symptoms are due to diabetes insipidus rather than diabetes mellitus.
Lithium inhibits the expression of aquaporin channels in the renal collecting duct, rather than the distal convoluted tubule, which causes diabetes insipidus.
While a urinary tract infection can also present with polyuria and nocturia, the presence of lithium in the patient’s drug history and the fact that the patient also has polydipsia suggest nephrogenic diabetes insipidus. Diabetes insipidus causes increased thirst due to the excessive volume of urine produced, leading to water loss from the body. In addition, a urinary tract infection would likely cause dysuria (burning or stinging when passing urine) and lower abdominal pain.
Understanding Antidiuretic Hormone (ADH)
Antidiuretic hormone (ADH) is a hormone that is produced in the supraoptic nuclei of the hypothalamus and released by the posterior pituitary gland. Its primary function is to conserve body water by promoting water reabsorption in the collecting ducts of the kidneys through the insertion of aquaporin-2 channels.
ADH secretion is regulated by various factors. An increase in extracellular fluid osmolality, a decrease in volume or pressure, and the presence of angiotensin II can all increase ADH secretion. Conversely, a decrease in extracellular fluid osmolality, an increase in volume, a decrease in temperature, or the absence of ADH can decrease its secretion.
Diabetes insipidus (DI) is a condition that occurs when there is either a deficiency of ADH (cranial DI) or an insensitivity to ADH (nephrogenic DI). Cranial DI can be treated with desmopressin, which is an analog of ADH.
Overall, understanding the role of ADH in regulating water balance in the body is crucial for maintaining proper hydration and preventing conditions like DI.
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This question is part of the following fields:
- Endocrine System
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