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Question 1
Incorrect
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A 29-year-old female has been diagnosed with hyperthyroidism. She is experiencing heat intolerance and is very frightened by her palpitations. The GP prescribes Carbimazole and a second medication to manage the palpitations. Which receptors are being overstimulated by the increased catecholamine effects in this patient, leading to her palpitations?
Your Answer: α1 receptors
Correct Answer: β1 receptors
Explanation:The sensitivity of the body to catecholamines is heightened by thyroid hormones. When catecholamines activate the β1 receptors in the heart, it leads to an elevation in heart rate.
Thyroid disorders are commonly encountered in clinical practice, with hypothyroidism and thyrotoxicosis being the most prevalent. Women are ten times more likely to develop these conditions than men. The thyroid gland is a bi-lobed structure located in the anterior neck and is part of a hypothalamus-pituitary-end organ system that regulates the production of thyroxine and triiodothyronine hormones. These hormones help regulate energy sources, protein synthesis, and the body’s sensitivity to other hormones. Hypothyroidism can be primary or secondary, while thyrotoxicosis is mostly primary. Autoimmunity is the leading cause of thyroid problems in the developed world.
Thyroid disorders can present in various ways, with symptoms often being the opposite depending on whether the thyroid gland is under or overactive. For example, hypothyroidism may result in weight gain, while thyrotoxicosis leads to weight loss. Thyroid function tests are the primary investigation for diagnosing thyroid disorders. These tests primarily look at serum TSH and T4 levels, with T3 being measured in specific cases. TSH levels are more sensitive than T4 levels for monitoring patients with existing thyroid problems.
Treatment for thyroid disorders depends on the cause. Patients with hypothyroidism are given levothyroxine to replace the underlying deficiency. Patients with thyrotoxicosis may be treated with propranolol to control symptoms such as tremors, carbimazole to reduce thyroid hormone production, or radioiodine treatment.
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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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A 23-year-old male visits his GP complaining of polyuria, chronic thirst and pale-coloured urine that have persisted for 3 months. He had a concussion from a car accident a month before the onset of his urinary symptoms. The patient is diagnosed with cranial diabetes insipidus after undergoing several tests.
What would the water deprivation test likely reveal in this case?Your Answer: Low urine osmolality after both fluid deprivation and desmopressin
Correct Answer: Low urine osmolality after fluid deprivation, but high after desmopressin
Explanation:The correct answer is low urine osmolality after fluid deprivation, but high after desmopressin, for a patient with cranial diabetes insipidus (DI). This condition is characterized by polyuria, chronic thirst, and pale-coloured urine, and is caused by insufficient antidiuretic hormone (ADH) secretion. As a result, the kidneys are unable to concentrate urine, leading to a low urine osmolality even during water deprivation. However, the kidneys will respond to desmopressin (synthetic ADH) to produce concentrated urine.
High urine osmolality after both fluid deprivation and desmopressin is incorrect, as it would be seen in a healthy individual or a patient with primary polydipsia, a psychogenic disorder characterized by excessive drinking despite being properly hydrated.
Low urine osmolality after both fluid deprivation and desmopressin is incorrect, as this is typical of nephrogenic DI, a condition in which the kidneys are insensitive to ADH.
High urine osmolality after fluid deprivation, but normal after desmopressin is incorrect, as this would not be commonly seen with any pathological state.
Low urine osmolality after desmopressin, but high after fluid deprivation is incorrect, as this would not be commonly seen with any pathological state.
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 3
Correct
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As a medical student in a GP practice, you encounter a mother who brings in her 5-year-old son. The child has been eating well but is falling through the centiles and gaining height slowly. After conducting a thorough history, examination, and blood tests, you diagnose the child with growth-hormone insufficiency. The mother has several questions about the condition, including when the human body stops producing growth hormone. Can you provide information on the developmental stage that signals the cessation of growth hormone release in the human body?
Your Answer: Growth hormone is secreted for life
Explanation:Throughout adulthood, the maintenance of tissues still relies on sufficient levels of growth hormone. This hormone not only promotes growth, but also supports cellular regeneration and reproduction. While it is crucial for normal growth during childhood, it also helps to preserve muscle mass, facilitate organ growth, and boost the immune system, making its lifelong release necessary. Therefore, growth hormone is a key factor in growth during all stages of life, including before, during, and after puberty.
Understanding Growth Hormone and Its Functions
Growth hormone (GH) is a hormone produced by the somatotroph cells in the anterior pituitary gland. It plays a crucial role in postnatal growth and development, as well as in regulating protein, lipid, and carbohydrate metabolism. GH acts on a transmembrane receptor for growth factor, leading to receptor dimerization and direct or indirect effects on tissues via insulin-like growth factor 1 (IGF-1), which is primarily secreted by the liver.
GH secretion is regulated by various factors, including growth hormone releasing hormone (GHRH), fasting, exercise, and sleep. Conversely, glucose and somatostatin can decrease GH secretion. Disorders associated with GH include acromegaly, which results from excess GH, and GH deficiency, which can lead to short stature.
In summary, GH is a vital hormone that plays a significant role in growth and metabolism. Understanding its functions and regulation can help in the diagnosis and treatment of GH-related disorders.
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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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Samantha, a 75-year-old woman, presents to the GP with a complaint of breast growth that has developed rapidly over the past 3 months. She has never experienced this issue before and is worried about how it will affect her relationship with her husband. Despite her concern, Samantha insists that she has no trouble with sexual function. She has recently been diagnosed with a heart problem and is taking multiple medications for it, although she cannot recall their names. Other than that, she claims to be in good health.
Upon examination, all of Samantha's vital signs are within normal limits. After measuring her height and weight, her body mass index is calculated to be 24 kg/m². Each breast is approximately 10 cm in diameter, with large nipples and tenderness but no pain. Moderate cardiomegaly and a 3rd heart sound are noted during chest assessment. No abnormalities are found during an abdominal examination. Pitting edema is present up to her mid calf.
Based on the history and examination, what is the most probable cause of Samantha's gynaecomastia?Your Answer: Digoxin
Explanation:Digoxin is the correct answer as it can lead to drug-induced gynaecomastia. Ronald is likely taking digoxin due to his heart failure, and this medication has a side effect of causing breast tissue growth in men. This is thought to occur because digoxin has a similar structure to oestrogen and can directly stimulate oestrogen receptors.
While cirrhosis can also cause gynaecomastia, it is unlikely in this case as there are no signs or symptoms of liver disease. Cirrhosis typically causes gynaecomastia due to the liver’s reduced ability to clear oestrogens from the bloodstream.
Obesity is not the correct answer as Ronald is not obese, with a BMI of 24 kg/m². However, obesity is a common cause of gynaecomastia as excess fat can be distributed to the breasts and result in increased aromatisation of androgens to oestrogens.
An oestrogen-secreting tumour is not the correct answer as there is no evidence in Ronald’s history or examination to suggest he has one, although these tumours can cause gynaecomastia in men.
Understanding Gynaecomastia: Causes and Drug Triggers
Gynaecomastia is a condition characterized by the abnormal growth of breast tissue in males, often caused by an increased ratio of oestrogen to androgen. It is important to distinguish the causes of gynaecomastia from those of galactorrhoea, which is caused by the actions of prolactin on breast tissue.
Physiological changes during puberty can lead to gynaecomastia, but it can also be caused by syndromes with androgen deficiency such as Kallmann and Klinefelter’s, testicular failure due to mumps, liver disease, testicular cancer, and hyperthyroidism. Additionally, haemodialysis and ectopic tumour secretion can also trigger gynaecomastia.
Drug-induced gynaecomastia is also a common cause, with spironolactone being the most frequent trigger. Other drugs that can cause gynaecomastia include cimetidine, digoxin, cannabis, finasteride, GnRH agonists like goserelin and buserelin, oestrogens, and anabolic steroids. However, it is important to note that very rare drug causes of gynaecomastia include tricyclics, isoniazid, calcium channel blockers, heroin, busulfan, and methyldopa.
In summary, understanding the causes and drug triggers of gynaecomastia is crucial in diagnosing and treating this condition.
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This question is part of the following fields:
- Endocrine System
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Question 5
Incorrect
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As a medical student observing a health visitor in community care, I noticed that she was measuring the height and weight of all the children. I was curious about what drives growth during the early childhood stage (from birth to 3 years old). Can you explain this to me?
Your Answer: Growth hormone and insulin
Correct Answer: Nutrition and insulin
Explanation:Understanding Growth and Factors Affecting It
Growth is a significant difference between children and adults, and it occurs in three stages: infancy, childhood, and puberty. Several factors affect fetal growth, including environmental, placental, hormonal, and genetic factors. Maternal nutrition and uterine capacity are the most crucial environmental factors that affect fetal growth.
In infancy, nutrition and insulin are the primary drivers of growth. High fetal insulin levels result from poorly controlled diabetes in the mother, leading to hypoglycemia and macrosomia in the baby. Growth hormone is not a significant factor in infancy, as babies have low amounts of receptors. Hypopituitarism and thyroid have no effect on growth in infancy.
In childhood, growth is driven by growth hormone and thyroxine, while in puberty, growth is driven by growth hormone and sex steroids. Genetic factors are the most important determinant of final adult height.
It is essential to monitor growth in children regularly. Infants aged 0-1 years should have at least five weight recordings, while children aged 1-2 years should have at least three weight recordings. Children older than two years should have annual weight recordings. Children below the 2nd centile for height should be reviewed by their GP, while those below the 0.4th centile for height should be reviewed by a paediatrician.
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This question is part of the following fields:
- Endocrine System
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Question 6
Correct
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Which of the following explains the mechanism by which PTH increases serum calcium levels?
Your Answer: Activation of vitamin D to increase absorption of calcium from the small intestine.
Explanation:The activity of the 1-α-hydroxylase enzyme, which converts 25-hydroxycholecalciferol to 1,25-dihydroxycholecalciferol (the active form of vitamin D), is increased by PTH. Osteoblasts mediate the effects of PTH on osteoclasts, as osteoclasts do not have a PTH receptor.
Understanding Parathyroid Hormone and Its Effects
Parathyroid hormone is a hormone produced by the chief cells of the parathyroid glands. Its main function is to increase the concentration of calcium in the blood by stimulating the PTH receptors in the kidney and bone. This hormone has a short half-life of only 4 minutes.
The effects of parathyroid hormone are mainly seen in the bone, kidney, and intestine. In the bone, PTH binds to osteoblasts, which then signal to osteoclasts to resorb bone and release calcium. In the kidney, PTH promotes the active reabsorption of calcium and magnesium from the distal convoluted tubule, while decreasing the reabsorption of phosphate. In the intestine, PTH indirectly increases calcium absorption by increasing the activation of vitamin D, which in turn increases calcium absorption.
Overall, understanding the role of parathyroid hormone is important in maintaining proper calcium levels in the body. Any imbalances in PTH secretion can lead to various disorders such as hyperparathyroidism or hypoparathyroidism.
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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 23-year-old woman presents with clinical manifestations of hyperthyroidism and is diagnosed with Graves disease. What is the most appropriate explanation for the pathophysiology of this condition?
Your Answer: Formation of IgG antibodies to the TSH receptors on the thyroid gland
Explanation:Graves disease typically results in the formation of IgG antibodies that target the TSH receptors located on the thyroid gland, leading to a significant decrease in TSH levels.
Thyroid Hormones and LATS in Graves Disease
Thyroid hormones are produced by the thyroid gland and include triiodothyronine (T3) and thyroxine (T4), with T3 being the major hormone active in target cells. The synthesis and secretion of these hormones involves the active concentration of iodide by the thyroid, which is then oxidized and iodinated by peroxidase in the follicular cells. This process is stimulated by thyroid-stimulating hormone (TSH), which is released by the pituitary gland. The normal thyroid has approximately three months’ worth of reserves of thyroid hormones.
In Graves disease, patients develop IgG antibodies to the TSH receptors on the thyroid gland. This results in chronic and long-term stimulation of the gland with the release of thyroid hormones. As a result, individuals with Graves disease typically have raised thyroid hormones and low TSH levels. It is important to check for thyroid receptor autoantibodies in individuals presenting with hyperthyroidism, as they are present in up to 85% of cases. This condition is known as LATS (long-acting thyroid stimulator) and can lead to a range of symptoms and complications if left untreated.
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This question is part of the following fields:
- Endocrine System
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Question 8
Incorrect
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A 54-year-old man with type 2 diabetes mellitus visits the Endocrinology clinic for evaluation. He is currently on maximum doses of metformin and glibenclamide, but his HbA1c levels have increased from 58 mmol/mol to 67 mmol/mol over the past six months. The consultant recommends adding sitagliptin as a third antidiabetic medication. What is the mechanism of action of this new medication?
Your Answer: Decrease blood glucose by inhibiting renal glucose re-uptake via sodium-glucose co-transporter 2( SGLT2)
Correct Answer: Inhibit the peripheral breakdown of incretins, enhancing their ability to stimulate insulin release
Explanation:Diabetes mellitus is a condition that has seen the development of several drugs in recent years. One hormone that has been the focus of much research is glucagon-like peptide-1 (GLP-1), which is released by the small intestine in response to an oral glucose load. In type 2 diabetes mellitus (T2DM), insulin resistance and insufficient B-cell compensation occur, and the incretin effect, which is largely mediated by GLP-1, is decreased. GLP-1 mimetics, such as exenatide and liraglutide, increase insulin secretion and inhibit glucagon secretion, resulting in weight loss, unlike other medications. They are sometimes used in combination with insulin in T2DM to minimize weight gain. Dipeptidyl peptidase-4 (DPP-4) inhibitors, such as vildagliptin and sitagliptin, increase levels of incretins by decreasing their peripheral breakdown, are taken orally, and do not cause weight gain. Nausea and vomiting are the major adverse effects of GLP-1 mimetics, and the Medicines and Healthcare products Regulatory Agency has issued specific warnings on the use of exenatide, reporting that it has been linked to severe pancreatitis in some patients. NICE guidelines suggest that a DPP-4 inhibitor might be preferable to a thiazolidinedione if further weight gain would cause significant problems, a thiazolidinedione is contraindicated, or the person has had a poor response to a thiazolidinedione.
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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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At their yearly diabetic check-up, a 65-year-old individual is discovered to have insufficient glycaemic management despite being treated with metformin and pioglitazone. As a result, it is determined to initiate an SGLT-2 inhibitor alongside their current medication.
What is the site of action for this newly prescribed drug?Your Answer: Renal proximal convoluted tubules
Explanation:SGLT-2 inhibitors work by reversibly blocking the activity of sodium-glucose co-transporter 2 (SGLT-2) in the renal proximal convoluted tubule. This is the correct answer.
Understanding SGLT-2 Inhibitors
SGLT-2 inhibitors are medications that work by blocking the reabsorption of glucose in the kidneys, leading to increased excretion of glucose in the urine. This mechanism of action helps to lower blood sugar levels in patients with type 2 diabetes mellitus. Examples of SGLT-2 inhibitors include canagliflozin, dapagliflozin, and empagliflozin.
However, it is important to note that SGLT-2 inhibitors can also have adverse effects. Patients taking these medications may be at increased risk for urinary and genital infections due to the increased glucose in the urine. Fournier’s gangrene, a rare but serious bacterial infection of the genital area, has also been reported. Additionally, there is a risk of normoglycemic ketoacidosis, a condition where the body produces high levels of ketones even when blood sugar levels are normal. Finally, patients taking SGLT-2 inhibitors may be at increased risk for lower-limb amputations, so it is important to closely monitor the feet.
Despite these potential risks, SGLT-2 inhibitors can also have benefits. Patients taking these medications often experience weight loss, which can be beneficial for those with type 2 diabetes mellitus. Overall, it is important for patients to discuss the potential risks and benefits of SGLT-2 inhibitors with their healthcare provider before starting treatment.
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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 26-year-old woman with a history of type 1 diabetes mellitus and borderline personality disorder is brought to the emergency department by ambulance due to a decreased level of consciousness. She is currently on regular insulin. Upon examination, her Glasgow coma scale is 3/15. The venous blood gas results show a pH of 7.36 (7.35-7.45), K+ of 3.8 mmol/L (3.5-4.5), Na+ of 136 mmol/L (135-145), glucose of 1.2 mmol/L (4.0-7.0), HCO3- of 23 mmol/L (22-26), and Hb of 145 g/dL (12.1-15.1). What is the first hormone to be secreted in response to the likely diagnosis?
Your Answer: Glucagon
Explanation:The correct answer is Glucagon, as it is the first hormone to be secreted in response to hypoglycaemia. The patient’s reduced level of consciousness is likely due to profound hypoglycaemia caused by exogenous insulin administration. Borderline personality disorder patients have a higher incidence of self harm and suicidality than the general population. Insulin is not the correct answer as its secretion decreases in response to hypoglycaemia, and this patient has T1DM resulting in an absolute deficiency. Cortisol is also not the correct answer as it takes longer to be secreted, although it is another counter-regulatory hormone that seeks to raise blood glucose levels in response to hypoglycaemia.
Understanding Hypoglycaemia: Causes, Features, and Management
Hypoglycaemia is a condition characterized by low blood sugar levels, which can lead to a range of symptoms and complications. There are several possible causes of hypoglycaemia, including insulinoma, liver failure, Addison’s disease, and alcohol consumption. The physiological response to hypoglycaemia involves hormonal and sympathoadrenal responses, which can result in autonomic and neuroglycopenic symptoms. While blood glucose levels and symptom severity are not always correlated, common symptoms of hypoglycaemia include sweating, shaking, hunger, anxiety, nausea, weakness, vision changes, confusion, and dizziness. In severe cases, hypoglycaemia can lead to convulsions or coma.
Managing hypoglycaemia depends on the severity of the symptoms and the setting in which it occurs. In the community, individuals with diabetes who inject insulin may be advised to consume oral glucose or a quick-acting carbohydrate such as GlucoGel or Dextrogel. A ‘HypoKit’ containing glucagon may also be prescribed for home use. In a hospital setting, treatment may involve administering a quick-acting carbohydrate or subcutaneous/intramuscular injection of glucagon for unconscious or unable to swallow patients. Alternatively, intravenous glucose solution may be given through a large vein.
Overall, understanding the causes, features, and management of hypoglycaemia is crucial for individuals with diabetes or other conditions that increase the risk of low blood sugar levels. Prompt and appropriate treatment can help prevent complications and improve outcomes.
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This question is part of the following fields:
- Endocrine System
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Question 11
Incorrect
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A 55-year-old male comes to see you with worries about his weight. He has a BMI of 32 and you suspect he may have metabolic syndrome. What is one of the diagnostic criteria for this condition?
Your Answer: HDL-cholesterol >50 mg/dL
Correct Answer: Dyslipidaemia
Explanation:Metabolic syndrome is a group of risk factors for cardiovascular disease that are closely related to insulin resistance and central obesity.
The diagnostic criteria for metabolic syndrome vary widely, but the International Diabetes Federation (IDF) and American Heart Association (AHA) have established their own criteria, which are commonly used. A diagnosis is made if three or more of the following criteria are present: increased waist circumference (depending on ethnicity) or a BMI greater than 30, dyslipidemia with elevated triglycerides greater than 150 mg/dL or reduced HDL-cholesterol, hypertension, and impaired glucose tolerance.
The Physiology of Obesity: Leptin and Ghrelin
Leptin is a hormone produced by adipose tissue that plays a crucial role in regulating body weight. It acts on the hypothalamus, specifically on the satiety centers, to decrease appetite and induce feelings of fullness. In cases of obesity, where there is an excess of adipose tissue, leptin levels are high. Leptin also stimulates the release of melanocyte-stimulating hormone (MSH) and corticotrophin-releasing hormone (CRH), which further contribute to the regulation of appetite. On the other hand, low levels of leptin stimulate the release of neuropeptide Y (NPY), which increases appetite.
Ghrelin, on the other hand, is a hormone that stimulates hunger. It is mainly produced by the P/D1 cells lining the fundus of the stomach and epsilon cells of the pancreas. Ghrelin levels increase before meals, signaling the body to prepare for food intake, and decrease after meals, indicating that the body has received enough nutrients.
In summary, the balance between leptin and ghrelin plays a crucial role in regulating appetite and body weight. In cases of obesity, there is an imbalance in this system, with high levels of leptin and potentially disrupted ghrelin signaling, leading to increased appetite and weight gain.
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This question is part of the following fields:
- Endocrine System
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Question 12
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 13
Incorrect
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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 activity of Na-K-Cl cotransporter in the loops of Henle
Correct 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 14
Correct
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A 50-year-old woman with thyroid cancer undergoes a total thyroidectomy. The histology report reveals a diagnosis of medullary thyroid cancer. What test would be most useful for screening for disease recurrence?
Your Answer: Serum calcitonin levels
Explanation:The detection of sub clinical recurrence can be facilitated by monitoring the serum levels of calcitonin, which is often secreted by medullary thyroid cancers.
Thyroid cancer rarely causes hyperthyroidism or hypothyroidism as it does not usually secrete thyroid hormones. The most common type of thyroid cancer is papillary carcinoma, which is often found in young females and has an excellent prognosis. Follicular carcinoma is less common, while medullary carcinoma is a cancer of the parafollicular cells that secrete calcitonin and is associated with multiple endocrine neoplasia type 2. Anaplastic carcinoma is rare and not responsive to treatment, causing pressure symptoms. Lymphoma is also rare and associated with Hashimoto’s thyroiditis.
Management of papillary and follicular cancer involves a total thyroidectomy followed by radioiodine to kill residual cells. Yearly thyroglobulin levels are monitored to detect early recurrent disease. Papillary carcinoma usually contains a mixture of papillary and colloidal filled follicles, while follicular adenoma presents as a solitary thyroid nodule and malignancy can only be excluded on formal histological assessment. Follicular carcinoma may appear macroscopically encapsulated, but microscopically capsular invasion is seen. Medullary carcinoma is associated with raised serum calcitonin levels and familial genetic disease in up to 20% of cases. Anaplastic carcinoma is most common in elderly females and is treated by resection where possible, with palliation achieved through isthmusectomy and radiotherapy. Chemotherapy is ineffective.
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This question is part of the following fields:
- Endocrine System
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Question 15
Incorrect
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A patient currently being treated for bipolar disorder with lithium is referred to hospital after developing severe polyuria. She denies polydipsia.
Blood tests reveal the following:
Na+ 154 mmol/L (135 - 145)
K+ 3.5 mmol/L (3.5 - 5.0)
Bicarbonate 24 mmol/L (22 - 29)
Urea 8 mmol/L (2.0 - 7.0)
Creatinine 110 µmol/L (55 - 120)
Blood glucose 7mmol/L (4 - 11)
Based on the results, a decision is made to carry out a water deprivation test. The patient is considered to have capacity and agrees to this. As part of this test, desmopressin is given.
Considering the most likely diagnosis, which of the following results would be most likely to be seen in a 45-year-old patient?Your Answer: High urine osmolality after fluid deprivation and low urine osmolality after desmopressin provision
Correct Answer: Low urine osmolality after fluid deprivation and low urine osmolality after desmopressin provision
Explanation: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 16
Incorrect
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A 32-year-old woman comes to the clinic complaining of fatigue and weight loss that has been going on for 6 weeks. She reports feeling dizzy when she stands up and has noticed a tan all over her body, despite it being early spring in the UK.
Upon conducting a blood test, it is found that she has hyponatraemia and hyperkalaemia, with normal full blood count results. A lying-standing blood pressure reading shows a postural drop of 36 mmHg.
What is the most likely cause of this woman's presentation in the UK, given her symptoms and test results?Your Answer: Pituitary tumour
Correct Answer: Autoimmune adrenal insufficiency
Explanation:The most likely cause of this patient’s symptoms is autoimmune adrenalitis, which is responsible for the majority of cases of hypoadrenalism. In this condition, auto-antibodies attack the adrenal gland, leading to a decrease or complete loss of cortisol and aldosterone production. This results in low blood pressure, electrolyte imbalances, and a significant drop in blood pressure upon standing. The body compensates for the low cortisol levels by producing more adrenocorticotropic hormone (ACTH), which can cause the skin to take on a bronze hue.
While iodine deficiency is a common cause of hypothyroidism worldwide, it is not consistent with this patient’s presentation. A mutation in the HFE gene can lead to haemochromatosis, which can cause reduced libido and skin darkening, but it does not match the electrolyte abnormalities described. Pituitary tumors and tuberculosis can also cause hypoadrenalism, but they are less common in the UK compared to autoimmune causes.
Addison’s disease is the most common cause of primary hypoadrenalism in the UK, with autoimmune destruction of the adrenal glands being the main culprit, accounting for 80% of cases. This results in reduced production of cortisol and aldosterone. Symptoms of Addison’s disease include lethargy, weakness, anorexia, nausea and vomiting, weight loss, and salt-craving. Hyperpigmentation, especially in palmar creases, vitiligo, loss of pubic hair in women, hypotension, hypoglycemia, and hyponatremia and hyperkalemia may also be observed. In severe cases, a crisis may occur, leading to collapse, shock, and pyrexia.
Other primary causes of hypoadrenalism include tuberculosis, metastases (such as bronchial carcinoma), meningococcal septicaemia (Waterhouse-Friderichsen syndrome), HIV, and antiphospholipid syndrome. Secondary causes include pituitary disorders, such as tumours, irradiation, and infiltration. Exogenous glucocorticoid therapy can also lead to hypoadrenalism.
It is important to note that primary Addison’s disease is associated with hyperpigmentation, while secondary adrenal insufficiency is not.
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This question is part of the following fields:
- Endocrine System
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Question 17
Correct
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A 15-year-old girl is brought to her pediatrician by her father who is worried that his daughter has not yet had a menstrual period. The girl reports that she has been unable to smell for as long as she can remember but is otherwise in good health. During the examination, the girl is found to have underdeveloped breasts and no pubic hair. Her vital signs and body mass index are within normal limits.
What is the probable reason for the girl's condition?Your Answer: Kallman syndrome
Explanation:The most likely diagnosis for this girl is Kallmann syndrome, which is characterized by a combination of hypogonadotropic hypogonadism and anosmia. This genetic disorder occurs due to a failure in neuron migration, resulting in deficient hypothalamic gonadotropin releasing hormone (GnRH) and a lack of secondary sexual characteristics. Anosmia is a distinguishing feature of Kallmann syndrome compared to other causes of hypogonadotropic hypogonadism. Congenital adrenal hypoplasia, which results in insufficient cortisol production due to adrenal cortex enzyme deficiency, can also cause hypogonadotropic hypogonadism but is less likely in this case due to the presence of anosmia. Imperforate hymen, which presents with lower abdominal/pelvic pain without vaginal bleeding, is not consistent with this patient’s symptoms. Malnutrition is not indicated as a possible diagnosis.
Kallmann’s syndrome is a condition that can cause delayed puberty due to hypogonadotropic hypogonadism. It is often inherited as an X-linked recessive trait and is believed to be caused by a failure of GnRH-secreting neurons to migrate to the hypothalamus. One of the key indicators of Kallmann’s syndrome is anosmia, or a lack of smell, in boys with delayed puberty. Other features may include hypogonadism, cryptorchidism, low sex hormone levels, and normal or above-average height. Some patients may also have cleft lip/palate and visual/hearing defects.
Management of Kallmann’s syndrome typically involves testosterone supplementation. Gonadotrophin supplementation may also be used to stimulate sperm production if fertility is desired later in life. It is important for individuals with Kallmann’s syndrome to receive appropriate medical care and monitoring to manage their symptoms and ensure optimal health outcomes.
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This question is part of the following fields:
- Endocrine System
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Question 18
Correct
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A 23-year-old man was diagnosed with maturity-onset diabetes of the young (MODY) type 1 and has been on an oral anti-diabetic agent for the past year. What is the mechanism of action of the drug he is most likely taking?
Your Answer: Binding to ATP-dependent K+ channel on the pancreatic beta cell membrane
Explanation:The patient is likely taking a sulfonylurea medication, which works by binding to the ATP-dependent K+ channel on the pancreatic beta-cell membrane to promote endogenous insulin secretion. This is the recommended first-line treatment for patients with MODY type 1, as their genetic defect results in reduced insulin secretion. Thiazolidinediones (glitazones) activate peroxisome proliferator-activated receptor-gamma (PPARγ) and are not typically used in this population. Metformin (biguanide class) inhibits hepatic glucose production and increases peripheral uptake, but is less effective than sulfonylureas in MODY type 1. Acarbose inhibits intestinal alpha-glucosidase and is not used in MODY patients. Dipeptidyl peptidase-4 inhibitors (gliptins) are commonly used in type 2 diabetes but are not first-line treatment for MODY.
Sulfonylureas are a type of medication used to treat type 2 diabetes mellitus. They work by increasing the amount of insulin produced by the pancreas, but only if the beta cells in the pancreas are functioning properly. Sulfonylureas bind to a specific channel on the cell membrane of pancreatic beta cells, known as the ATP-dependent K+ channel (KATP).
While sulfonylureas can be effective in managing diabetes, they can also cause some adverse effects. The most common side effect is hypoglycemia, which is more likely to occur with long-acting preparations like chlorpropamide. Another common side effect is weight gain. However, there are also rarer side effects that can occur, such as hyponatremia (low sodium levels) due to inappropriate ADH secretion, bone marrow suppression, hepatotoxicity (liver damage), and peripheral neuropathy.
It is important to note that sulfonylureas should not be used during pregnancy or while breastfeeding.
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This question is part of the following fields:
- Endocrine System
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Question 19
Incorrect
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A 38-year-old woman presents with symptoms of irritability and changes in bowel habits. During examination, a smooth enlargement of the thyroid gland is noted. Thyroid function tests are ordered and the results are as follows:
TSH 0.1 mug/l
Free T4 35 pmol/l
What is the most likely underlying diagnosis?Your Answer: Multinodular goitre
Correct Answer: Graves disease
Explanation:When TSH receptor antibodies are present, they stimulate the thyroid to produce T4. This results in a decrease in TSH levels due to negative feedback on the pituitary. However, in cases where hyperthyroidism is caused by pregnancy, the TSH levels are usually elevated.
Understanding Thyroid Disease and its Management
Thyroid disease can present with various manifestations, which can be classified based on the presence or absence of clinical signs of thyroid dysfunction and the presence of a mass. To assess thyroid disease, a thorough history and examination, including ultrasound, are necessary. If a nodule is identified, it should be sampled through an image-guided fine needle aspiration. Radionucleotide scanning is not very useful.
Thyroid tumors can be papillary, follicular, anaplastic, medullary, or lymphoma. Multinodular goitre is a common reason for presentation, and if the patient is asymptomatic and euthyroid, they can be reassured. However, if they have compressive symptoms, surgery is required, and total thyroidectomy is the best option. Patients with endocrine dysfunction are initially managed by physicians, and surgery may be offered alongside radioiodine for those with Graves disease that fails with medical management or in patients who prefer not to be irradiated. Patients with hypothyroidism do not generally get offered a thyroidectomy.
Complications following surgery include anatomical damage to the recurrent laryngeal nerve, bleeding, and damage to the parathyroid glands resulting in hypocalcaemia. For further information, the Association of Clinical Biochemistry guidelines for thyroid function tests and the British Association of Endocrine Surgeons website can be consulted.
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This question is part of the following fields:
- Endocrine System
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Question 20
Correct
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A 50-year-old man comes to the clinic complaining of gynaecomastia. He is currently undergoing treatment for heart failure and gastro-oesophageal reflux. Which medication that he is taking is the most probable cause of his gynaecomastia?
Your Answer: Spironolactone
Explanation:Medications Associated with Gynaecomastia
Gynaecomastia, the enlargement of male breast tissue, can be caused by various medications. Spironolactone, ciclosporin, cimetidine, and omeprazole are some of the drugs that have been associated with this condition. Ramipril has also been linked to gynaecomastia, but it is a rare occurrence.
Aside from these medications, other drugs that can cause gynaecomastia include digoxin, LHRH analogues, cimetidine, and finasteride. It is important to note that not all individuals who take these medications will develop gynaecomastia, and the risk may vary depending on the dosage and duration of treatment.
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This question is part of the following fields:
- Endocrine System
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Question 21
Incorrect
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A 25-year-old woman visits the endocrinology department for weight management issues. She has been struggling with her weight since she was a child and currently has a BMI of 46 kg/m². Despite eating large portions at meals, she never feels full and snacks between meals. Her parents and two older siblings are all at a healthy weight. Genetic testing reveals a de novo mutation in the satiety signalling pathway. Which hormone's decreased synthesis may be responsible for her condition?
Your Answer: Ghrelin
Correct Answer: Leptin
Explanation:Leptin is the hormone that lowers appetite, while ghrelin is the hormone that increases appetite. Leptin is produced by adipose tissue and plays a crucial role in regulating feelings of fullness and satiety. Mutations that affect leptin signaling can lead to severe childhood-onset obesity. On the other hand, ghrelin is known as the hunger hormone and stimulates appetite. However, decreased ghrelin synthesis does not cause obesity. Insulin is an anabolic hormone that promotes glucose uptake and lipogenesis, while obestatin’s role in satiety is still controversial.
The Physiology of Obesity: Leptin and Ghrelin
Leptin is a hormone produced by adipose tissue that plays a crucial role in regulating body weight. It acts on the hypothalamus, specifically on the satiety centers, to decrease appetite and induce feelings of fullness. In cases of obesity, where there is an excess of adipose tissue, leptin levels are high. Leptin also stimulates the release of melanocyte-stimulating hormone (MSH) and corticotrophin-releasing hormone (CRH), which further contribute to the regulation of appetite. On the other hand, low levels of leptin stimulate the release of neuropeptide Y (NPY), which increases appetite.
Ghrelin, on the other hand, is a hormone that stimulates hunger. It is mainly produced by the P/D1 cells lining the fundus of the stomach and epsilon cells of the pancreas. Ghrelin levels increase before meals, signaling the body to prepare for food intake, and decrease after meals, indicating that the body has received enough nutrients.
In summary, the balance between leptin and ghrelin plays a crucial role in regulating appetite and body weight. In cases of obesity, there is an imbalance in this system, with high levels of leptin and potentially disrupted ghrelin signaling, leading to increased appetite and weight gain.
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This question is part of the following fields:
- Endocrine System
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Question 22
Correct
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A 50-year-old woman has just had a thyroidectomy to treat medullary thyroid cancer. What is the clinical tumor marker used to screen for recurrence?
Your Answer: Calcitonin
Explanation:Calcitonin is used in clinical practice to detect recurrence of medullary thyroid cancer. Thyroid function tests are not used for diagnosis or follow-up of malignancies. However, regular monitoring of TSH levels may be necessary for patients taking thyroxine.
Thyroid cancer rarely causes hyperthyroidism or hypothyroidism as it does not usually secrete thyroid hormones. The most common type of thyroid cancer is papillary carcinoma, which is often found in young females and has an excellent prognosis. Follicular carcinoma is less common, while medullary carcinoma is a cancer of the parafollicular cells that secrete calcitonin and is associated with multiple endocrine neoplasia type 2. Anaplastic carcinoma is rare and not responsive to treatment, causing pressure symptoms. Lymphoma is also rare and associated with Hashimoto’s thyroiditis.
Management of papillary and follicular cancer involves a total thyroidectomy followed by radioiodine to kill residual cells. Yearly thyroglobulin levels are monitored to detect early recurrent disease. Papillary carcinoma usually contains a mixture of papillary and colloid filled follicles, while follicular adenoma presents as a solitary thyroid nodule and malignancy can only be excluded on formal histological assessment. Follicular carcinoma may appear macroscopically encapsulated, but microscopically capsular invasion is seen. Medullary carcinoma is associated with raised serum calcitonin levels and familial genetic disease in up to 20% of cases. Anaplastic carcinoma is most common in elderly females and is treated by resection where possible, with palliation achieved through isthmusectomy and radiotherapy. Chemotherapy is ineffective.
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This question is part of the following fields:
- Endocrine System
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Question 23
Incorrect
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A 20-year-old woman arrives at the emergency department complaining of abdominal pain, nausea, and vomiting. She reports having a cough and fever for the past few days. Upon examination, she has dry mucous membranes and her breath has a fruity odor. Her vital signs are as follows: blood pressure 95/55 mmHg, heart rate 120/min, respiratory rate 29/min, temperature 37.8ºC (100ºF), and oxygen saturation 98% on room air. Laboratory results show:
- Sodium (Na+): 124 mmol/L (135 - 145)
- Potassium (K+): 5.5 mmol/L (3.5 - 5.0)
- Bicarbonate: 13 mmol/L (22 - 29)
- Serum glucose: 30 mmol/L (4 - 7.8)
- pH: 7.15 (7.35 - 7.45)
- Serum ketones: 3.5 mmol/L (0 - 0.6)
What is the most likely cause of the increased ketones in this patient?Your Answer: Glycolysis
Correct Answer: Lipolysis
Explanation:DKA is a condition that arises due to uncontrolled lipolysis, leading to an excess of free fatty acids that are converted to ketone bodies. This life-threatening complication of diabetes is characterized by elevated levels of blood glucose, ketones, and acidosis, with symptoms such as nausea, vomiting, abdominal pain, dehydration, and fruity breath odor. DKA is commonly observed in type 1 diabetes mellitus and can be triggered by non-compliance with treatment or an infection. Insulin deficiency and increased levels of counterregulatory hormones cause lipolysis in adipose tissue, leading to the release of free fatty acids that undergo hepatic oxidation to form ketone bodies. In DKA, increased gluconeogenesis and glycogenolysis occur due to insulin deficiency and counterregulatory hormones, leading to the synthesis of glucose from non-carbohydrate precursors and breakdown of glycogen, respectively. Glycolysis is not involved in DKA as it does not lead to the breakdown of fatty acids.
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 24
Correct
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A 65-year-old man presents to the Emergency Department with confusion, drowsiness, and nausea accompanied by vomiting. His daughter reports that he has been feeling fatigued and unwell with a persistent cough, and he has been smoking 20 cigarettes per day for 45 years. The patient is unable to provide a complete medical history due to his confusion, but he mentions that he sometimes coughs up blood and his urine has been darker than usual. On examination, he appears to be short of breath but euvolaemic. Blood tests reveal low serum sodium, high urinary sodium, low plasma osmolality, and high urinary osmolality. Renal and thyroid function tests are normal. A chest x-ray shows a lung carcinoma, leading you to suspect that this presentation may be caused by a syndrome of inappropriate antidiuretic hormone secretion.
What is the underlying mechanism responsible for the hyponatraemia?Your Answer: Insertion of aquaporin-2 channels
Explanation:The insertion of aquaporin-2 channels is promoted by antidiuretic hormone, which facilitates water reabsorption. However, in the case of syndrome of inappropriate antidiuretic hormone secretion (SiADH), which is caused by small cell lung cancer, the normal negative feedback loop fails, resulting in the continuous production of ADH even when serum osmolality returns to normal. This leads to euvolemic hyponatremia, where the body retains water but continues to lose sodium, resulting in concentrated urine. The underlying mechanism of this condition is the persistent increase in the number of aquaporin-2 channels, which promotes water reabsorption, rather than any effect on sodium transport mechanisms.
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 25
Incorrect
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A 55-year-old male visits his doctor complaining of a milky discharge from his nipples. He has a history of schizophrenia and has been taking olanzapine for a while now. No recent changes have been made to his medication.
Which compound with elevated levels is most likely causing this symptom?Your Answer: Prolactin, released from the posterior pituitary
Correct Answer: Prolactin, released from the anterior pituitary
Explanation:The patient is experiencing galactorrhea, which is commonly associated with hyperprolactinemia. Prolactin stimulates milk production in the mammary glands, and the patient’s hyperprolactinemia is likely due to his use of olanzapine, which acts as a dopamine antagonist. Dopamine normally inhibits prolactin secretion. The other answer choices are incorrect as they do not accurately explain the mechanism behind the patient’s presentation.
Understanding Prolactin and Its Functions
Prolactin is a hormone that is produced by the anterior pituitary gland. Its primary function is to stimulate breast development and milk production in females. During pregnancy, prolactin levels increase to support the growth and development of the mammary glands. It also plays a role in reducing the pulsatility of gonadotropin-releasing hormone (GnRH) at the hypothalamic level, which can block the action of luteinizing hormone (LH) on the ovaries or testes.
The secretion of prolactin is regulated by dopamine, which constantly inhibits its release. However, certain factors can increase or decrease prolactin secretion. For example, prolactin levels increase during pregnancy, in response to estrogen, and during breastfeeding. Additionally, stress, sleep, and certain drugs like metoclopramide and antipsychotics can also increase prolactin secretion. On the other hand, dopamine and dopaminergic agonists can decrease prolactin secretion.
Overall, understanding the functions and regulation of prolactin is important for reproductive health and lactation.
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This question is part of the following fields:
- Endocrine System
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Question 26
Correct
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A patient with a recent diagnosis of schizophrenia at the age of 40 is prescribed risperidone. During their consultation with the doctor, they are informed that some of the potential side effects are caused by elevated levels of prolactin.
What is the mechanism behind this occurrence?Your Answer: Inhibition of dopamine activity
Explanation:Dopamine plays a crucial role in inhibiting the release of prolactin. As atypical antipsychotics like risperidone block dopamine activity, they can lead to increased levels of prolactin. While these drugs may also inhibit histamine and serotonin to varying degrees, it is the inhibition of dopamine that is directly linked to prolactin release. Stimulation of dopamine or serotonin activity would not interfere with prolactin release in the same way that dopamine inhibition does.
Understanding Prolactin and Its Functions
Prolactin is a hormone that is produced by the anterior pituitary gland. Its primary function is to stimulate breast development and milk production in females. During pregnancy, prolactin levels increase to support the growth and development of the mammary glands. It also plays a role in reducing the pulsatility of gonadotropin-releasing hormone (GnRH) at the hypothalamic level, which can block the action of luteinizing hormone (LH) on the ovaries or testes.
The secretion of prolactin is regulated by dopamine, which constantly inhibits its release. However, certain factors can increase or decrease prolactin secretion. For example, prolactin levels increase during pregnancy, in response to estrogen, and during breastfeeding. Additionally, stress, sleep, and certain drugs like metoclopramide and antipsychotics can also increase prolactin secretion. On the other hand, dopamine and dopaminergic agonists can decrease prolactin secretion.
Overall, understanding the functions and regulation of prolactin is important for reproductive health and lactation.
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This question is part of the following fields:
- Endocrine System
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Question 27
Correct
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As a medical student observing a metabolic medicine clinic, a 40-year-old woman comes in seeking answers about her obesity. With a BMI of 46 kg/m² and a family history of obesity, she is referred for further investigation. After genetic sequencing, it is discovered that she has a mutation in a hormone-regulating gene that is secreted by adipose tissue.
Which hormone is likely impacted by this genetic mutation?Your Answer: Leptin
Explanation:Leptin is produced by adipose tissue and is responsible for regulating feelings of fullness and satiety. Mutations in the leptin gene can lead to severe obesity in infants due to increased appetite and reduced feelings of satiety. Ghrelin, on the other hand, is a hormone released by the stomach that stimulates hunger. Melatonin, produced by the pineal gland, regulates the sleep-wake cycle and circadian rhythms but is not known to play a significant role in obesity. Obestatin, released by stomach epithelial cells, has a controversial role in obesity.
The Physiology of Obesity: Leptin and Ghrelin
Leptin is a hormone produced by adipose tissue that plays a crucial role in regulating body weight. It acts on the hypothalamus, specifically on the satiety centers, to decrease appetite and induce feelings of fullness. In cases of obesity, where there is an excess of adipose tissue, leptin levels are high. Leptin also stimulates the release of melanocyte-stimulating hormone (MSH) and corticotrophin-releasing hormone (CRH), which further contribute to the regulation of appetite. On the other hand, low levels of leptin stimulate the release of neuropeptide Y (NPY), which increases appetite.
Ghrelin, on the other hand, is a hormone that stimulates hunger. It is mainly produced by the P/D1 cells lining the fundus of the stomach and epsilon cells of the pancreas. Ghrelin levels increase before meals, signaling the body to prepare for food intake, and decrease after meals, indicating that the body has received enough nutrients.
In summary, the balance between leptin and ghrelin plays a crucial role in regulating appetite and body weight. In cases of obesity, there is an imbalance in this system, with high levels of leptin and potentially disrupted ghrelin signaling, leading to increased appetite and weight gain.
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This question is part of the following fields:
- Endocrine System
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Question 28
Incorrect
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A 65-year-old man with a history of type 2 diabetes is being seen by his primary care physician.
He is currently taking metformin 1g twice daily and lisinopril for his high blood pressure.
His most recent HbA1c result is:
HbA1c 58 mmol/L (<42)
After further discussion, he has agreed to add a second medication for his diabetes. He has been informed that potential side effects may include weight gain, hypoglycemia, and gastrointestinal issues.
What is the mechanism of action for this new medication?Your Answer: Inhibition of dipeptidyl peptidase 4 (DPP-4)
Correct Answer: Binding to KATP channels on pancreatic beta cell membrane
Explanation:Sulfonylureas are a type of medication used to treat type 2 diabetes mellitus. They work by increasing the amount of insulin produced by the pancreas, but only if the beta cells in the pancreas are functioning properly. Sulfonylureas bind to a specific channel on the cell membrane of pancreatic beta cells, known as the ATP-dependent K+ channel (KATP).
While sulfonylureas can be effective in managing diabetes, they can also cause some adverse effects. The most common side effect is hypoglycemia, which is more likely to occur with long-acting preparations like chlorpropamide. Another common side effect is weight gain. However, there are also rarer side effects that can occur, such as hyponatremia (low sodium levels) due to inappropriate ADH secretion, bone marrow suppression, hepatotoxicity (liver damage), and peripheral neuropathy.
It is important to note that sulfonylureas should not be used during pregnancy or while breastfeeding.
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This question is part of the following fields:
- Endocrine System
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Question 29
Incorrect
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What is the association between brown tumours of bone and a specific condition or disease?
Your Answer: Hypoparathyroidism
Correct Answer: Hyperparathyroidism
Explanation:Brown tumors are bone tumors that develop due to excessive osteoclast activity, typically in cases of hyperparathyroidism. These tumors are composed of fibrous tissue, woven bone, and supporting blood vessels, but lack any matrix. They do not appear on x-rays due to their radiolucent nature. Osteoclasts consume the trabecular bone that osteoblasts produce, leading to a cycle of reparative bone deposition and resorption that can cause bone pain and involve the periosteum, resulting in an expansion beyond the typical shape of the bone. The tumors are called brown due to the deposition of haemosiderin at the site.
Primary Hyperparathyroidism: Causes, Symptoms, and Treatment
Primary hyperparathyroidism is a condition that is commonly seen in elderly females and is characterized by an unquenchable thirst and an inappropriately normal or raised parathyroid hormone level. It is usually caused by a solitary adenoma, hyperplasia, multiple adenoma, or carcinoma. While around 80% of patients are asymptomatic, the symptomatic features of primary hyperparathyroidism may include polydipsia, polyuria, depression, anorexia, nausea, constipation, peptic ulceration, pancreatitis, bone pain/fracture, renal stones, and hypertension.
Primary hyperparathyroidism is associated with hypertension and multiple endocrine neoplasia, such as MEN I and II. To diagnose this condition, doctors may perform a technetium-MIBI subtraction scan or look for a characteristic X-ray finding of hyperparathyroidism called the pepperpot skull.
The definitive management for primary hyperparathyroidism is total parathyroidectomy. However, conservative management may be offered if the calcium level is less than 0.25 mmol/L above the upper limit of normal, the patient is over 50 years old, and there is no evidence of end-organ damage. Patients who are not suitable for surgery may be treated with cinacalcet, a calcimimetic that mimics the action of calcium on tissues by allosteric activation of the calcium-sensing receptor.
In summary, primary hyperparathyroidism is a condition that can cause various symptoms and is commonly seen in elderly females. It can be diagnosed through various tests and managed through surgery or medication.
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This question is part of the following fields:
- Endocrine System
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Question 30
Correct
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A 10-year-old girl with no previous medical history presents to the emergency department with vomiting and diarrhea. She also complains of abdominal pain. A venous blood gas test is performed and shows the following results:
Normal range
pH: 7.14 (7.35 - 7.45)
pO2: 11.6 (10 - 14)kPa
pCO2: 3.3 (4.5 - 6.0)kPa
HCO3: 10 (22 - 26)mmol/l
BE: -16 (-2 to +2)mmol/l
Lactate: 4.1 0.6-1.8mmol/l
Potassium: 5.4 3.5-5 mmol/l
A blood glucose finger-prick test is also performed, which reads Glucose = 24. Based on the information provided, what is the most likely diagnosis?Your Answer: Diabetic ketoacidosis
Explanation:Diabetic ketoacidosis is depicted in this image. It is a critical condition that requires urgent attention, with a focus on administering insulin, fluid resuscitation, and closely monitoring potassium levels.
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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