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Question 1
Correct
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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: 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 2
Incorrect
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A 60-year-old man with a history of recent thyrotoxicosis underwent major surgery a week ago. He now presents with altered mental status, tachycardia, high-grade fever, vomiting and cardiac failure. A diagnosis of thyroid storm (crisis) is made. What is the most important next step in management?
Your Answer: Potassium iodide should be given immediately before propylthiouracil
Correct Answer: Transfer the patient to ITU
Explanation:Thyroid storm, also referred to as thyrotoxic crisis, is an acute, life-threatening, hypermetabolic state induced by excessive release of thyroid hormones (THs) in individuals with thyrotoxicosis.
Patients with thyroid storm should be treated in an ICU setting for close monitoring of vital signs and for access to invasive monitoring and inotropic support, if necessary.
– Supportive measures
If needed, immediately provide supplemental oxygen, ventilatory support, and intravenous fluids. Dextrose solutions are the preferred intravenous fluids to cope with continuously high metabolic demand.
– Correct electrolyte abnormalities.
– Treat cardiac arrhythmia, if necessary.
– Aggressively control hyperthermia by applying ice packs and cooling blankets and by administering acetaminophen (15 mg/kg orally or rectally every 4 hours).
– Antiadrenergic drugs.
– Thionamides: Correct the hyperthyroid state. Administer antithyroid medications to block further synthesis of thyroid hormones (THs).
High-dose propylthiouracil (PTU) or methimazole may be used for treatment of thyroid storm.
– Administer glucocorticoids to decrease peripheral conversion of T4 to T3. This may also be useful in preventing relative adrenal insufficiency due to hyperthyroidism and improving vasomotor symptoms.
– Bile acid sequestrants prevent reabsorption of free THs in the gut (released from conjugated TH metabolites secreted into bile through the enterohepatic circulation).
– Treat the underlying condition. -
This question is part of the following fields:
- Endocrinology
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Question 3
Correct
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Which of the following is most consistent with achondroplasia?
Your 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 4
Correct
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A 30-year-old man with type-1 diabetes mellitus on insulin presents in the A&E with fever, cough, vomiting and abdominal pain. Examination reveals a dry mucosa, decreased skin turgor and a temperature of 37.8 °C. Chest examination reveals bronchial breathing in the right lower lobe, and a chest X-ray shows it to be due to a right lower zone consolidation. Other investigations show: Blood glucose: 35 mmol/L, Na+: 132 mmol/L, K+: 5.5 mmol/L, urea: 8.0 mmol/L, creatinine: 120 μmol/L, pH: 7.15, HCO3: 12 mmol/L, p(CO2): 4.6 kPa, chloride: 106 mmol/l. Urinary ketones are positive (+++). The patient is admitted to the hospital and treated. Which of the following should not be used while treating him?
Your Answer: Bicarbonate
Explanation:Bicarbonate therapy is not indicated in mild and moderate forms of DKA because metabolic acidosis will correct with insulin therapy. The use of bicarbonate in severe DKA is controversial due to a lack of prospective randomized studies. It is thought that the administration of bicarbonate may actually result in peripheral hypoxemia, worsening of hypokalaemia, paradoxical central nervous system acidosis, cerebral oedema in children and young adults, and an increase in intracellular acidosis. Because severe acidosis is associated with worse clinical outcomes and can lead to impairment in sensorium and deterioration of myocardial contractility, bicarbonate therapy may be indicated if the pH is 6.9 or less.
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This question is part of the following fields:
- Endocrinology
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Question 5
Correct
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A 55-year-old woman is referred to urogynaecology with symptoms of urge incontinence. A trial of bladder retraining is unsuccessful. It is therefore decided to use a muscarinic antagonist. Which one of the following medications is an example of a muscarinic antagonist?
Your Answer: Tolterodine
Explanation:A muscarinic receptor antagonist (MRA) is a type of anticholinergic agent that blocks the activity of the muscarinic acetylcholine receptor. There are six antimuscarinic drugs currently marketed for the treatment of urge incontinence: oxybutynin, tolterodine, propiverine, trospium, darifenacin, and solifenacin.
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This question is part of the following fields:
- Endocrinology
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Question 6
Correct
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Raloxifene is used in the treatment of osteoporosis, which of the following best describes it?
Your Answer: A selective oestrogen receptor modulator
Explanation:Raloxifene is a selective oestrogen-receptor modulator (SERM) that has been approved for use in the prevention and treatment of osteoporosis in postmenopausal women.
A SERM interacts with oestrogen receptors, functioning as an agonist in some tissues and an antagonist in other tissues. Because of their unique pharmacologic properties, these agents can achieve the desired effects of oestrogen without the possible stimulatory effects on the breasts or uterus. -
This question is part of the following fields:
- Endocrinology
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Question 7
Correct
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A 40-year-old man is referred by his general practitioner. He has a family history of premature cardiovascular disease. Cholesterol testing reveals triglyceride levels of 4.2 mmol/l and a high-density lipoprotein (HDL) level of 0.8 mmol/l. You advise him to start fibrate therapy. Which of the following best describes the mode of action for fibrates?
Your Answer: They are inhibitors of lipoprotein lipase activity and increase HDL synthesis
Explanation:Treatment with fibrates, a widely used class of lipid-modifying agents, results in a substantial decrease in plasma triglycerides and is usually associated with a moderate decrease in LDL cholesterol and an increase in HDL cholesterol concentrations.
Evidence from studies is available to implicate 5 major mechanisms underlying the above-mentioned modulation of lipoprotein phenotypes by fibrates:
1. Induction of lipoprotein lipolysis.
2. Induction of hepatic fatty acid (FA) uptake and reduction of hepatic triglyceride production.
3. Increased removal of LDL particles. Fibrate treatment results in the formation of LDL with a higher affinity for the LDL receptor, which is thus catabolized more rapidly.
4. Reduction in neutral lipid (cholesteryl ester and triglyceride) exchange between VLDL and HDL may result from decreased plasma levels of TRL.
5. Increase in HDL production and stimulation of reverse cholesterol transport. Fibrates increase the production of apoA-I and apoA-II in the liver, which may contribute to the increase of plasma HDL concentrations and a more efficient reverse cholesterol transport. -
This question is part of the following fields:
- Endocrinology
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Question 8
Correct
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A 46-year-old woman was referred to the endocrinology department with hypercalcemia and raised parathyroid hormone levels. Her blood tests are highly suggestive of primary hyperparathyroidism. She has type 2 diabetes controlled by metformin alone. Her albumin-adjusted serum calcium level is 3.5 mmol/litre. Which of the following is the most important reason for her referral?
Your Answer: Albumin-adjusted serum calcium level of 3.5 mmol/litre
Explanation:Indications for surgery for the treatment of primary hyperparathyroidism:
1. Symptoms of hypercalcaemia such as thirst, frequent or excessive urination, or constipation
2. End-organ disease (renal stones, fragility fractures or osteoporosis)
3. An albumin-adjusted serum calcium level of 2.85 mmol/litre or above. -
This question is part of the following fields:
- Endocrinology
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Question 9
Incorrect
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A 60-year-old man known to have type 2 diabetes comes for regular follow up. He is on metformin 2 g per day and gliclazide 160 mg per day. His recent HbA1c was 8.4% and his blood pressure was 140/75 mmHg. Eye examination reveals dot and blot haemorrhages and microaneurysms. None are close to the macula. Which of the following defines his eye condition?
Your Answer: Pre-proliferative retinopathy
Correct Answer: Background diabetic retinopathy
Explanation:Patients with diabetes often develop ophthalmic complications, the most common and potentially most blinding of these complications is diabetic retinopathy.
The following are the 5 stages in the progression of diabetic retinopathy:
1. Dilation of the retinal venules and formation of retinal capillary microaneurysms.
2. Increased vascular permeability.
3. Vascular occlusion and retinal ischemia.
4. Proliferation of new blood vessels on the surface of the retina.
5. Vitreous haemorrhage and contraction of the fibrovascular proliferation.
The first 2 stages of diabetic retinopathy are known as background or nonproliferative retinopathy. Initially, the retinal venules dilate, then microaneurysms (tiny red dots on the retina that cause no visual impairment) appear. As the microaneurysms or retinal capillaries become more permeable, hard exudates appear, reflecting the leakage of plasma.Mild nonproliferative diabetic retinopathy (NPDR) or background diabetic retinopathy is indicated by the presence of at least 1 microaneurysm, while neovascularization is the hallmark of Proliferative Diabetic Retinopathy (PDR).
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This question is part of the following fields:
- Endocrinology
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Question 10
Incorrect
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Which of the following is correct regarding post-menopausal hormone replacement therapy (HRT) according to randomised clinical studies ?
Your Answer: Reduces the incidence of stroke
Correct Answer: Increases plasma triglycerides
Explanation:Oestrogen therapy reduces plasma levels of LDL cholesterol and increases levels of HDL cholesterol. It can improve endothelial vascular function, however, it also has adverse physiological effects, including increasing the plasma levels of triglycerides (small dense LDL particles). Therefore, although HRT may have direct beneficial effects on cardiovascular outcomes, these effects may be reduced or balanced by the adverse physiological effects.
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This question is part of the following fields:
- Endocrinology
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Question 11
Incorrect
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A young woman is concerned that she has put on weight since she was a medical student, as she now no longer finds time to exercise. She decides to try various weight loss tablets temporarily. After 2 months, she is successfully losing weight but also has trouble with increased stool frequency, difficulty in climbing stairs and getting up out of chairs. However, she has no problems walking on the flat. She also has difficulty in sleeping at the moment but puts that down to the increased frequency of headaches for the past 2 months. Which one of the following is the most likely cause of her weakness?
Your Answer: She is abusing laxatives
Correct Answer: She is abusing thyroxine tablets
Explanation:Exogenous thyroid hormone use has been associated with episodes of thyroid storm as well as thyrotoxic periodic paralysis.
It presents with marked proximal muscle weakness in both upper and lower limbs, hypokalaemia and signs of hyperthyroidism.
Hyperthyroidism generally presents with tachycardia, hypertension, hyperthermia, and cardiac arrhythmiasLaxatives and diuretics can result in electrolyte abnormalities.
Medical complications associated with laxatives include chronic diarrhoea which disrupts the normal stool electrolyte concentrations that then leads to serum electrolyte shifts; acutely, hypokalaemia is most typically seen. The large intestine suffers nerve damage from the chronic laxative use that renders it unable to function properly. The normal peristalsis and conduction are affected; the disorder is thought to be secondary to a degeneration of Auerbach’s Plexi. However, it does not cause muscle weakness.Insulin tends to cause weight gain, not weight loss.
Metformin does not cause muscle weakness but can cause headaches. -
This question is part of the following fields:
- Endocrinology
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Question 12
Correct
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A 28-year-old woman is referred to the endocrinology clinic. She has been trying to conceive for the last 3 years without any success. Her prolactin level is 2600 mU/l (normal <360). The Endocrinologist arranges pituitary magnetic resonance imaging (MRI) that demonstrates a microprolactinoma. Which two of the following pharmacological agents may be appropriate treatment choices?
Your Answer: Carbergoline
Explanation:Cabergoline, an ergot derivative, is a long-acting dopamine agonist. It is usually better tolerated than Bromocriptine (BEC), and its efficacy profiles are somewhat superior to those of BEC. It offers the convenience of twice-a-week administration, with a usual starting dose of 0.25 mg biweekly to a maximum dose of 1 mg biweekly. Some studies have shown efficacy even with once-a-week dosing. Cabergoline appears to be more effective in lowering prolactin levels and restoring ovulation. Up to 70% of patients who do not respond to BEC respond to cabergoline.
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This question is part of the following fields:
- Endocrinology
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Question 13
Correct
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Following a head injury, a 22-year-old patient develops polyuria and polydipsia. He is suspected to have cranial diabetes insipidus so he undergoes a water deprivation test. Which one of the following responses would most indicate a positive (abnormal) result?
Your Answer: Failure to concentrate the urine during water deprivation, but achievement of urine osmolality of 720 mmol/kg following the administration of desmopressin
Explanation:The water deprivation test (i.e., the Miller-Moses test), is a semiquantitative test to ensure adequate dehydration and maximal stimulation of ADH for diagnosis. It is typically performed in patients with more chronic forms of Diabetes Insipidus (DI). The extent of deprivation is usually limited by the patient’s thirst or by any significant drop in blood pressure or related clinical manifestation of dehydration.
In healthy individuals, water deprivation leads to a urinary osmolality that is 2-4 times greater than plasma osmolality. Additionally, in normal, healthy subjects, administration of ADH produces an increase of less than 9% in urinary osmolality. The time required to achieve maximal urinary concentration ranges from 4-18 hours.
In central and nephrogenic 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 will 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. -
This question is part of the following fields:
- Endocrinology
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Question 14
Incorrect
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Which of the following is most consistent with congenital adrenal hyperplasia (CAH)?
Your Answer: Hyporeninaemia
Correct Answer: Premature epiphyseal closure
Explanation:Exposure to excessive androgens is usually accompanied by premature epiphyseal maturation and closure, resulting in a final adult height that is typically significantly below that expected from parental heights.
congenital adrenal hyperplasia (CAH) is associated with precocious puberty caused by long term exposure to androgens, which activate the hypothalamic-pituitary-gonadal axis. Similarly, CAH is associated with hyperpigmentation and hyperreninemia due to sodium loss and hypovolaemia.
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This question is part of the following fields:
- Endocrinology
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Question 15
Correct
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A 74-year-old woman is admitted with headaches, polyuria and polydipsia of recent onset. She has a history of mastectomy for breast cancer. A CT head scan shows multiple cerebral metastases. Her admission biochemistry results are as follows: Sodium 153 mmol/l, Potassium 4.0 mmol/L, Urea 5.0 mmol/L, Creatinine 110 micromol/L, Glucose 5mmol/l. Over the next 24 hours, she has a urinary volume of 4.4 litres and further tests reveal plasma osmolality 320mOsm/kg and urinary osmolality: 254mOsm/kg. Which one of the following treatments should be used?
Your Answer: Desmopressin (DDAVP)
Explanation:Diabetes insipidus (DI) is defined as the passage of large volumes (>3 L/24 hr) of dilute urine (< 300 mOsm/kg). It has the following 2 major forms:
– Central (neurogenic, pituitary, or neurohypophyseal) DI, characterized by decreased secretion of antidiuretic hormone (ADH; also referred to as arginine vasopressin [AVP])
– Nephrogenic DI, characterized by decreased ability to concentrate urine because of resistance to ADH action in the kidney
This patient has the central type from metastases.
In patients with central DI, desmopressin is the drug of choice. It is a synthetic analogue of antidiuretic hormone (ADH). It is available in subcutaneous, IV, intranasal, and oral preparations. Generally, it can be administered 2-3 times per day. Patients may require hospitalization to establish fluid needs. Frequent electrolyte monitoring is recommended during the initial phase of treatment. -
This question is part of the following fields:
- Endocrinology
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Question 16
Correct
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A 26-year-old woman presents for her first cervical smear. What is the most important aetiological factor causing cervical cancer?
Your Answer: Human papilloma virus 16 & 18
Explanation:It has been determined that HPV infection is the most powerful epidemic factor. This virus is needed, but not sufficient for the development of cervical cancer.
The WHO’s International Agency for Research on Cancer (IARC) classified HPV infection as carcinogenic to humans (HPV types 16 and 18), probably carcinogenic (HPV types 31 and 33) and possibly carcinogenic (other HPV types except 6 and 11).
Tobacco smoking, the use of contraceptives, and the number of births are factors that showed no statistically significant deviations in the studied population compared to other countries in the region, as well as European countries. They have an equal statistical significance in all age groups. -
This question is part of the following fields:
- Endocrinology
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Question 17
Correct
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A 40-year-old man presents with a history of carpal tunnel syndrome and osteoarthritis of his weight-bearing joints. He has recently begun to suffer from symptoms of sleep apnoea. On examination, he has a prominent jawline and macroglossia. His BP is elevated at 155/95 mmHg and there is peripheral visual field loss. Which of the following is true?
Your Answer: Pegvisomant can be used where IGF-1 is not normalised post surgery
Explanation:The patient has Acromegaly.
Acromegaly is a chronic disorder characterised by growth hormone (GH) hypersecretion, predominantly caused by a pituitary adenoma.Random GH level testing is not recommended for diagnosis given the pulsatile nature of secretion. Stress, physical exercise, acute critical illness and fasting state can cause a physiological higher peak in GH secretion.
Pegvisomant is a US Food and Drug Administration-approved treatment for use after surgery. In a global non-interventional safety surveillance study, pegvisomant normalised IGF-1 in 67.5% of patients after 5 years (most likely due to lack of dose-up titration), and also improved clinical symptoms. Pegvisomant improves insulin sensitivity, and long-term follow-up showed significantly decreased fasting glucose over time, while the first-generation SRL only have a marginal clinical impact on glucose homeostasis in acromegaly. Pegvisomant does not have any direct anti-proliferative effects on pituitary tumour cells, but tumour growth is rare overall.
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This question is part of the following fields:
- Endocrinology
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Question 18
Correct
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A 50-year-old man is found incidentally to have hypercalcaemia during a routine health screen. Which one of the following biochemical findings would be most suggestive of primary hyperparathyroidism rather than any other cause of hypercalcaemia?
Your Answer: Serum PTH concentration within the normal range
Explanation:Primary hyperparathyroidism (PHPT) is diagnosed based upon levels of blood calcium and parathyroid hormone (PTH). In most people with PHPT, both levels are higher than normal. Occasionally, a person may have an elevated calcium level and a normal or minimally elevated PTH level. Since PTH should normally be low when calcium is elevated, a minimally elevated PTH is considered abnormal and indicates PHPT.
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This question is part of the following fields:
- Endocrinology
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Question 19
Correct
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Regarding the thymus, which of the following is true?
Your Answer: DiGeorge’s syndrome is a developmental abnormality affecting the thymus
Explanation:The thymus is a lymphoid organ located in the anterior mediastinum. In early life, the thymus is responsible for the development and maturation of cell-mediated immunologic functions. The thymus is composed predominantly of epithelial cells and lymphocytes. Precursor cells migrate to the thymus and differentiate into lymphocytes. Most of these lymphocytes are destroyed, with the remainder of these cells migrating to tissues to become T cells.
DiGeorge’s syndrome (DGS) is a developmental abnormality affecting the thymus. The classic triad of features of DGS on presentation is conotruncal cardiac anomalies, hypoplastic thymus, and hypocalcaemia (resulting from parathyroid hypoplasia). -
This question is part of the following fields:
- Endocrinology
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Question 20
Incorrect
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A 40-year-old woman presents with weight loss, palpitations, diarrhoea and cessation of periods. She has been treated by her GP for anxiety. Examination reveals a single nodule on the left of her thyroid, about 1.5 cm in diameter. Thyroid scan shows increased uptake within the nodule with reduced activity throughout the rest of the gland. Thyroid function tests showed a free thyroxine of 30 pmol/l (9–25 pmol/l), TSH < 0.05 mU/l (0.5–5). Based on these findings, what would be the definitive treatment?
Your Answer: Surgical excision
Correct Answer: Radioactive iodine therapy
Explanation:Patients who have autonomously functioning nodules should be treated definitely with radioactive iodine or surgery.
Na131 I treatment – In the United States and Europe, radioactive iodine is considered the treatment of choice for Toxic Nodular Goitre. Except for pregnancy, there are no absolute contraindications to radioiodine therapy. -
This question is part of the following fields:
- Endocrinology
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Question 21
Incorrect
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A 50-year-old woman came to the diabetes clinic for her regular follow up. The following results are obtained: Urine analysis: Protein+, HBA1c 86mmol/mol (10.0%). What is her average blood glucose level during the past 2 months?
Your Answer: 10
Correct Answer: 15
Explanation:The level of haemoglobin A1c (HbA1c), also known as glycated haemoglobin, determines how well a patient’s blood glucose level has been controlled over the previous 8–12 weeks. Recent studies have been made to correlate between HbA1c and average glucose level.
Using the following formula: Average blood glucose (mmol/l) = (1.98 x 1 HbA1c) – 4.29 -
This question is part of the following fields:
- Endocrinology
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Question 22
Correct
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Which of the following allows for a diagnose of diabetes mellitus?
Your Answer: Symptomatic patient with random glucose 12.0 mmol/L on one occasion
Explanation:Criteria for the diagnosis of diabetes
1. A1C ≥6.5%. The test should be performed in a laboratory using a method that is certified and standardized.*
OR
2. Fasting glucose ≥126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.*
OR
3. 2-h plasma glucose ≥200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.*
OR
4. In a patient with classic symptoms of hyperglycaemia or hyperglycaemic crisis, a random plasma glucose ≥200 mg/dl (11.1 mmol/l).
*In the absence of unequivocal hyperglycaemia, criteria 1–3 should be confirmed by repeat testing. -
This question is part of the following fields:
- Endocrinology
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Question 23
Correct
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A 60–year-old woman comes to the hospital for chemotherapy for breast cancer. On examination, her pulse is 120 bpm and regular and BP is 90/60. Her JVP is not seen, her heart sounds are normal, and her chest is clear. There is evidence of a right mastectomy. Abdominal and neurological examination is normal. Short synacthen test was ordered and the results came as follows: Time (min): 0, 30, 60. Cortisol (nmol/l): 90, 130, 145. Which two of the following would be your immediate management?
Your Answer: Intravenous normal saline 1l in first hour
Explanation:Synacthen test interpretation:
– Basal Cortisol level should be greater than 180nmol/L
– 30min or 60min Cortisol should be greater than 420nmol/L (whatever the basal level)
– The increment should be at least 170nmol/L, apart from in severely ill patients where adrenal output is already maximal.
The patient’s results show that she has Acute Adrenal Insufficiency
The guidelines include the following recommendations for emergency treatment:
Administer hydrocortisone: Immediate bolus injection of 100 mg hydrocortisone intravenously or intramuscularly followed by continuous intravenous infusion of 200 mg hydrocortisone per 24 hours (alternatively, 50 mg hydrocortisone per intravenous or intramuscular injection every 6 h)
Rehydrate with rapid intravenous infusion of 1000 mL of isotonic saline infusion within the first hour, followed by further intravenous rehydration as required (usually 4-6 L in 24 h; monitor for fluid overload in case of renal impairment and elderly patients)
Contact an endocrinologist for urgent review of the patient, advice on further tapering of hydrocortisone, and investigation of the underlying cause of the disease, including the diagnosis of primary versus secondary adrenal insufficiency
Tapering of hydrocortisone can be started after clinical recovery guided by an endocrinologist; in patients with primary adrenal insufficiency, mineralocorticoid replacement must be initiated (starting dose 100 μg fludrocortisone once daily) as soon as the daily glucocorticoid dose is below 50 mg of hydrocortisone every 24 hours -
This question is part of the following fields:
- Endocrinology
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Question 24
Incorrect
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A 45-year-old man presents with tiredness and central weight gain. He underwent pituitary surgery for a non-functional pituitary tumour two years ago. Although he recovered from his pituitary surgery well, he has been found to have complete anterior hypopituitarism. Accordingly he is receiving stable replacement therapy with testosterone monthly injections, thyroxine and hydrocortisone. On examination, there are no specific abnormalities, his vision is 6/9 in both eyes and he has no visual field defects. From his notes, you see that he has gained 8 kg in weight over the last six months and his BMI is 31. His blood pressure is 122/72 mmHg. Thyroid function tests and testosterone concentrations have been normal. A post-operative MRI scan report shows that the pituitary tumour has been adequately cleared with no residual tissue. Which of the following is the most likely cause of his current symptoms?
Your Answer: Somatisation disorder
Correct Answer: Growth hormone deficiency
Explanation:The somatotroph cells of the anterior pituitary gland produce growth hormone (GH).
GH deficiency in adults usually manifests as reduced physical performance and impaired psychological well-being. It results in alterations in the physiology of different systems of the body, manifesting as altered lipid metabolism, increased subcutaneous and visceral fat, decreased muscle mass, decreased bone density, low exercise performance, and reduced quality of life. -
This question is part of the following fields:
- Endocrinology
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Question 25
Correct
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A 27-year-old woman presents with recurrent headaches and sweating. On examination, a nodule is felt in the region of the thyroid gland. She mentions that her mother had kidney stones and died following a tumour in her neck. A surgeon recommends complete thyroidectomy as her treatment of choice. What is the most important investigation to be done before the surgery?
Your Answer: 24-hour urinary catecholamines
Explanation:The patient is most likely to have Medullary Thyroid Carcinoma (MTC).
Sporadic, or isolated MTC accounts for 75% of cases and inherited MTC constitutes the rest.
Inherited MTC occurs in association with multiple endocrine neoplasia (MEN) type 2A and 2B syndromes, but non-MEN familial MTC also occurs.
A 24-hour urinalysis for catecholamine metabolites (e.g., vanillylmandelic acid [VMA], metanephrine) has to be done to rule out concomitant pheochromocytoma in patients with MEN type 2A or 2B, as Pheochromocytoma must be treated before MTC. -
This question is part of the following fields:
- Endocrinology
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Question 26
Correct
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A 25-year-old woman with type-1 diabetes mellitus attends for her routine review and says she is keen on becoming pregnant. Which of the following is most likely to make you ask her to defer pregnancy at this stage?
Your Answer: Hb A1C 9.4%
Explanation:Pregnancies affected by T1DM are at increased risk for preterm delivery, preeclampsia, macrosomia, shoulder dystocia, intrauterine fetal demise, fetal growth restriction, cardiac and renal malformations, in addition to rare neural conditions such as sacral agenesis.
Successful management of pregnancy in a T1DM patient begins before conception. Research indicates that the implementation of preconception counselling, emphasizing strict glycaemic control before and throughout pregnancy, reduces the rate of perinatal mortality and malformations.
The 2008 bulletin from the National Institute for Health and Clinical Excellence recommends that preconception counselling be offered to all patients with diabetes. Physicians are advised to guide patients on achieving personalized glycaemic control goals, increasing the frequency of glucose monitoring, reducing their HbA1C levels, and recommend avoiding pregnancy if the said level is > 10%.
Other sources suggest deferring pregnancy until HbA1C levels are > 8%, as this margin is associated with better outcomes. -
This question is part of the following fields:
- Endocrinology
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Question 27
Correct
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A 70-year-old man presents to the emergency department acutely unwell. He is shocked, drowsy and confused. He is known to be type-2 diabetic maintained on metformin. Blood tests reveal a metabolic acidosis with an anion gap of 24 mmol/l. Ketones are not significantly elevated and random blood glucose was 8.7 mmol/l. What is the mainstay of treatment for this condition?
Your Answer: Rehydration
Explanation:Lactic acidosis is occasionally responsible for metabolic acidosis in diabetics. It may occur in the presence of normal blood levels of the ketone bodies, and such cases are often described as having “non-ketotic diabetic acidosis.
It is most commonly associated with tissue hypoperfusion and states of acute circulatory failure.
Appropriate measures include treatment of shock, restoration of circulating fluid volume, improved cardiac function, identification of sepsis source, early antimicrobial intervention, and resection of any potential ischemic regions. Reassessment of lactate levels for clearance assists ongoing medical management. -
This question is part of the following fields:
- Endocrinology
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Question 28
Correct
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A 15-year-old boy presents with poor development of secondary sex characteristics, colour blindness and a decreased sense of smell. On examination, his testes are small soft and located in the scrotum. What is the most probable diagnosis?
Your Answer: Kallmann’s syndrome
Explanation:Classic Kallmann syndrome (KS) is due to isolated hypogonadotropic hypogonadism. Most patients have gonadotropin-releasing hormone (GnRH) deficiency, as suggested by their response to pulsatile GnRH therapy. The hypothalamic-pituitary function is otherwise normal in most patients, and hypothalamic-pituitary imaging reveals no space-occupying lesions. By definition, either anosmia or severe hyposmia is present in patients with Kallmann syndrome.
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This question is part of the following fields:
- Endocrinology
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Question 29
Correct
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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: 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 30
Incorrect
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A 65-year-old man with a history of type 2 diabetes comes to the clinic for review. His HbA1c is elevated at 64 mmol/mol despite taking 1g of metformin BD. On examination, his blood pressure is 142/88 mmHg, his pulse is 82 beats per minute and regular. His BMI is 33 kg/m². A decision is made to start him on dapagliflozin. Which of the following would you expect on starting therapy?
Your Answer: Hypoglycaemia
Correct Answer: Increased total cholesterol
Explanation:Dapagliflozin works by inhibiting sodium glucose cotransporter 2 (SGLT2) and blocking resorption of glucose in the kidney, leading to an increase in urinary glucose excretion and lowering of both plasma glucose levels and body weight.
All studies with SGLT2 inhibitors have found significant reductions in BP, with greater reductions seen in systolic (1.66 to 6.9mmHg) than diastolic (0.88 to 3.5mmHg) BP.
While some trials have shown no change in lipid parameters, others have shown a modest but statistically significant increase in both HDL and LDL cholesterol with no effect on triglycerides or the LDL/HDL ratio. -
This question is part of the following fields:
- Endocrinology
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