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  • Question 1 - A 65-year-old man with type 2 diabetes mellitus has been taking metformin 1g...

    Incorrect

    • A 65-year-old man with type 2 diabetes mellitus has been taking metformin 1g twice daily for the past 6 months. Despite this, his HbA1c has remained above target at 64 mmol/mol (8.0%).

      He has a history of left ventricular failure following a myocardial infarction 2 years ago. He has been trying to lose weight since but still has a body mass index of 33 kg/m². He is also prone to recurrent urinary tract infections.

      You intend to intensify treatment by adding a second medication.

      What is the mechanism of action of the most appropriate anti-diabetic drug for him?

      Your Answer: Inhibition of renal sodium-glucose co-transporter-2 (SGLT2) to increase glucose excretion

      Correct Answer: Inhibition of dipeptidyl peptidase-4 (DPP-4) to increase incretin levels

      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.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 2 - A 55-year-old male visits his GP for an insurance medical. The GP observes...

    Correct

    • A 55-year-old male visits his GP for an insurance medical. The GP observes that the patient has rough facial features, an enlarged tongue, and greasy skin. The patient is also experiencing profuse sweating. Which hormone excess is likely to be accountable for these symptoms?

      Your Answer: Growth hormone

      Explanation:

      Acromegaly is a condition that results from an excess of growth hormone, which can cause a person to have a coarse facial appearance, a larger tongue, and excessive sweating and oily skin. This condition is often caused by a pituitary adenoma.

      If a person has an excess of insulin, they may experience hypoglycemia and confusion. This can occur in cases of factitious illness, over-administration of insulin in diabetics, and insulinomas (neuroendocrine pancreatic tumors).

      An excess of glucagon can cause hyperglycemia. Glucagon is secreted by alpha cells in the pancreas and is often elevated in cases of glucagonomas (neuroendocrine pancreatic tumors).

      An excess of thyroid-stimulating hormone can be seen in cases of primary hypothyroidism and secondary hyperthyroidism.

      Acromegaly is a condition characterized by excess growth hormone, which is usually caused by a pituitary adenoma in over 95% of cases. However, in some cases, it can be caused by ectopic GHRH or GH production by tumors, such as those found in the pancreas. The condition is associated with a number of physical features, including a coarse facial appearance, spade-like hands, and an increase in shoe size. Other features include a large tongue, prognathism, interdental spaces, excessive sweating, and oily skin, which are caused by sweat gland hypertrophy. In some cases, patients may also experience hypopituitarism, headaches, bitemporal hemianopia, and raised prolactin levels, which can lead to galactorrhea. Approximately 6% of patients with acromegaly also have MEN-1.

      Complications associated with acromegaly include hypertension, diabetes (which affects over 10% of patients), cardiomyopathy, and colorectal cancer. It is important to diagnose and treat acromegaly early to prevent these complications from developing.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 3 - A patient with a recent diagnosis of schizophrenia at the age of 40...

    Correct

    • 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.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 4 - Which of the following is not secreted by the islets of Langerhans? ...

    Correct

    • Which of the following is not secreted by the islets of Langerhans?

      Your Answer: Secretin

      Explanation:

      Mucosal cells in the duodenum and jejunum release secretin.

      Hormones Released from the Islets of Langerhans

      The islets of Langerhans in the pancreas are responsible for the production and secretion of several hormones that play a crucial role in regulating blood glucose levels. The beta cells in the islets of Langerhans are responsible for producing insulin, which accounts for 70% of the total secretions. Insulin helps to lower blood glucose levels by promoting the uptake of glucose by cells and tissues throughout the body.

      The alpha cells in the islets of Langerhans produce glucagon, which has the opposite effect of insulin. Glucagon raises blood glucose levels by stimulating the liver to release stored glucose into the bloodstream. The delta cells in the islets of Langerhans produce somatostatin, which helps to regulate the release of insulin and glucagon.

      Finally, the F cells in the islets of Langerhans produce pancreatic polypeptide, which plays a role in regulating pancreatic exocrine function and appetite. Together, these hormones work to maintain a delicate balance of blood glucose levels in the body.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 5 - A 23-year-old male patient visits his GP complaining of breast tissue enlargement that...

    Correct

    • A 23-year-old male patient visits his GP complaining of breast tissue enlargement that has been progressively worsening for the past 3 months. He also reports the presence of a new lump on his left testicle. Upon thorough examination and taking a detailed medical history, the GP suspects that the patient may be suffering from testicular cancer.

      What is the probable diagnosis?

      Your Answer: HCG secreting seminoma

      Explanation:

      Gynaecomastia can be caused by testicular conditions such as seminoma that secrete hCG.

      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.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 6 - As a medical student in a GP practice, you encounter a mother who...

    Correct

    • 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.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 7 - A 55-year-old male comes to see you with worries about his weight. He...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 8 - A 32-year-old man visits the clinic complaining of weakness and frequent muscle cramps...

    Correct

    • A 32-year-old man visits the clinic complaining of weakness and frequent muscle cramps that have been ongoing for the past two weeks. Upon examination, you observe widespread hyporeflexia. A blood test reveals hypokalaemia, but the cause has not yet been determined. Which of the following conditions is linked to hypokalaemia?

      Your Answer: Conn's syndrome

      Explanation:

      Primary hyperaldosteronism, also known as Conn’s syndrome, can lead to hypertension, hypernatraemia, and hypokalemia. This condition is caused by an excess of aldosterone, which is responsible for maintaining potassium balance by activating Na+/K+ pumps. However, in excess, aldosterone can cause the movement of potassium into cells, resulting in hypokalaemia. The kidneys play a crucial role in maintaining potassium balance, along with other factors such as insulin, catecholamines, and aldosterone. On the other hand, congenital adrenal hypoplasia, Addison’s disease, rhabdomyolysis, and metabolic acidosis are all causes of hyperkalaemia, which is an excess of potassium in the blood. Addison’s disease and adrenal hypoplasia result in mineralocorticoid deficiency, which can lead to hyperkalaemia. Acidosis can also cause hyperkalaemia by causing positively charged hydrogen ions to enter cells while positively charged potassium ions leave cells and enter the bloodstream.

      Primary hyperaldosteronism is a condition characterized by hypertension, hypokalaemia, and alkalosis. It was previously believed that adrenal adenoma, also known as Conn’s syndrome, was the most common cause of this condition. However, recent studies have shown that bilateral idiopathic adrenal hyperplasia is responsible for up to 70% of cases. It is important to differentiate between the two causes as it determines the appropriate treatment. Adrenal carcinoma is an extremely rare cause of primary hyperaldosteronism.

      To diagnose primary hyperaldosteronism, the 2016 Endocrine Society recommends a plasma aldosterone/renin ratio as the first-line investigation. This test should show high aldosterone levels alongside low renin levels due to negative feedback from sodium retention caused by aldosterone. If the results are positive, a high-resolution CT abdomen and adrenal vein sampling are used to differentiate between unilateral and bilateral sources of aldosterone excess. If the CT is normal, adrenal venous sampling (AVS) can be used to distinguish between unilateral adenoma and bilateral hyperplasia.

      The management of primary hyperaldosteronism depends on the underlying cause. Adrenal adenoma is treated with surgery, while bilateral adrenocortical hyperplasia is managed with an aldosterone antagonist such as spironolactone. It is important to accurately diagnose and manage primary hyperaldosteronism to prevent complications such as cardiovascular disease and stroke.

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      • Endocrine System
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  • Question 9 - A 57-year-old woman presents for her routine check-up. She has recently been prescribed...

    Correct

    • A 57-year-old woman presents for her routine check-up. She has recently been prescribed insulin for management of her type 2 diabetes. While discussing her medical history, she reports experiencing numbness in her entire right foot. Upon examination, an ulcer is observed on the webbing between her fourth and fifth toes.

      What would be the most appropriate next course of action to investigate this woman's condition?

      Your Answer: Full neurovascular examination of the lower limbs

      Explanation:

      The two main factors that contribute to diabetic foot disease are loss of sensation and peripheral arterial disease. When reviewing a diabetic patient who presents with a complication, it is crucial to recognize that those with a loss of protective sensation are at a high risk of developing diabetic foot disease. Therefore, any ulcers must be promptly managed to prevent severe infection.

      Out of the given options, the most appropriate next step in managing this patient is to conduct a full neurovascular examination of their lower limbs. While checking the HbA1C levels is important, it is not the immediate concern for this patient. Similarly, examining foot sensation using a 10g monofilament is a crucial step, but it is only a part of a comprehensive neurovascular examination. Measuring C-peptide is not relevant to the current situation.

      Diabetic foot disease is a significant complication of diabetes mellitus that requires regular screening. In 2015, NICE published guidelines on diabetic foot disease. The disease is caused by two main factors: neuropathy, which results in a loss of protective sensation, and peripheral arterial disease, which can cause macro and microvascular ischaemia. Symptoms of diabetic foot disease include loss of sensation, absent foot pulses, reduced ankle-brachial pressure index (ABPI), intermittent claudication, calluses, ulceration, Charcot’s arthropathy, cellulitis, osteomyelitis, and gangrene.

      All patients with diabetes should be screened for diabetic foot disease at least once a year. Screening for ischaemia involves palpating for both the dorsalis pedis pulse and posterial tibial artery pulse, while screening for neuropathy involves using a 10 g monofilament on various parts of the sole of the foot. NICE recommends that patients be risk-stratified into low, moderate, and high-risk categories based on factors such as deformity, previous ulceration or amputation, renal replacement therapy, and the presence of calluses or neuropathy. Patients who are moderate or high-risk should be regularly followed up by their local diabetic foot centre.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 10 - A 60-year-old patient visits their doctor complaining of dehydration caused by vomiting and...

    Correct

    • A 60-year-old patient visits their doctor complaining of dehydration caused by vomiting and diarrhoea. The kidneys detect reduced renal perfusion, leading to activation of the renin-angiotensin-aldosterone system. What is the specific part of the adrenal gland required for this system?

      Your Answer: Zona glomerulosa

      Explanation:

      Aldosterone is produced in the zona glomerulosa of the adrenal gland.

      Renin is released by juxtaglomerular cells located in the nephron.

      ACE is produced by the pulmonary endothelium in the lungs.

      The adrenal gland is composed of the zona glomerulosa, fasciculata, and reticularis.

      Glucocorticoids are produced in the zona fasciculata.

      Adrenal Physiology: Medulla and Cortex

      The adrenal gland is composed of two main parts: the medulla and the cortex. The medulla is responsible for secreting the catecholamines noradrenaline and adrenaline, which are released in response to sympathetic nervous system stimulation. The chromaffin cells of the medulla are innervated by the splanchnic nerves, and the release of these hormones is triggered by the secretion of acetylcholine from preganglionic sympathetic fibers. Phaeochromocytomas, which are tumors derived from chromaffin cells, can cause excessive secretion of both adrenaline and noradrenaline.

      The adrenal cortex is divided into three distinct zones: the zona glomerulosa, zona fasciculata, and zona reticularis. Each zone is responsible for secreting different hormones. The outer zone, zona glomerulosa, secretes aldosterone, which regulates electrolyte balance and blood pressure. The middle zone, zona fasciculata, secretes glucocorticoids, which are involved in the regulation of metabolism, immune function, and stress response. The inner zone, zona reticularis, secretes androgens, which are involved in the development and maintenance of male sex characteristics.

      Most of the hormones secreted by the adrenal cortex, including glucocorticoids and aldosterone, are bound to plasma proteins in the circulation. Glucocorticoids are inactivated and excreted by the liver. Understanding the physiology of the adrenal gland is important for the diagnosis and treatment of various endocrine disorders.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 11 - A 30-year-old woman complains of menstrual irregularity and galactorrhoea for the past year....

    Correct

    • A 30-year-old woman complains of menstrual irregularity and galactorrhoea for the past year. She also experiences occasional headaches. During examination, she was found to have bitemporal superior quadrantanopia. What is the most probable diagnosis?

      Your Answer: Prolactinoma

      Explanation:

      Prolactinomas cause amenorrhoea, infertility, and galactorrhoea. If the tumour extends outside the sella, visual field defects or other mass effects may occur. Other types of tumours will produce different symptoms depending on their location and structure involved. Craniopharyngiomas originate from the pituitary gland and will produce poralhemianopia if large enough, as well as symptoms related to pituitary hormones. Non-functioning pituitary tumours will have similar symptoms without the pituitary hormone side effects. Tumours of the hypothalamus will present with symptoms of euphoria, headache, weight loss, and mass effect if large enough.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 12 - A patient on the geriatrics ward has symptoms consistent with hypoparathyroidism. A blood...

    Correct

    • A patient on the geriatrics ward has symptoms consistent with hypoparathyroidism. A blood test is requested to check PTH levels, serum calcium, phosphate and vitamin D.

      Which of the following levels also need to be specifically checked?

      Your Answer: Magnesium

      Explanation:

      The correct answer is magnesium, as it is necessary for the secretion and function of parathyroid hormone. Adequate magnesium levels are required for the hormone to have its desired effects. CRP, urea, and platelets are not relevant to this situation and do not need to be tested.

      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.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 13 - A 25-year-old female visits her GP complaining of chronic thirst, polyuria, and nocturia...

    Incorrect

    • A 25-year-old female visits her GP complaining of chronic thirst, polyuria, and nocturia that have persisted for 2 months. She has a medical history of premenstrual dysphoric disorder diagnosed 3 years ago. After a series of tests, the patient is diagnosed with primary polydipsia. What results are expected from her water deprivation test?

      Your Answer: Low urine osmolality after fluid deprivation, but normal after desmopressin

      Correct Answer: High urine osmolality after both fluid deprivation and desmopressin

      Explanation:

      The patient has primary polydipsia, a psychogenic disorder causing excessive drinking despite being hydrated. Urine osmolality is high after both fluid deprivation and desmopressin, as the patient still produces and responds to ADH. Low urine osmolality after both fluid deprivation and desmopressin is typical of nephrogenic DI, while low urine osmolality after fluid deprivation but high after desmopressin is typical of cranial DI. Low urine osmolality after desmopressin and low urine osmolality after fluid deprivation but normal after desmopressin are not 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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      • Endocrine System
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  • Question 14 - What is the crucial step in the production of all steroid hormones? ...

    Correct

    • What is the crucial step in the production of all steroid hormones?

      Your Answer: Conversion of cholesterol to pregnenolone

      Explanation:

      The Role of Pregnenolone in Steroid Hormone Synthesis

      In the production of steroid hormones in the human body, the conversion of cholesterol to pregnenolone is a crucial step. Pregnenolone serves as the precursor for all steroid hormones, and its formation is the limiting factor in the synthesis of these hormones. This conversion process occurs within the mitochondria of steroid-producing tissues. Essentially, the body needs to convert cholesterol to pregnenolone before it can produce any other steroid hormones. This highlights the importance of pregnenolone in the body’s endocrine system and its role in regulating various physiological processes.

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      • Endocrine System
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  • Question 15 - A 50-year-old woman has just had a thyroidectomy to treat medullary thyroid cancer....

    Incorrect

    • 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: Free T3

      Correct 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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      • Endocrine System
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  • Question 16 - A 62-year-old male with type 2 diabetes is urgently referred by his GP...

    Incorrect

    • A 62-year-old male with type 2 diabetes is urgently referred by his GP due to poor glycaemic control for the past three days, with home blood glucose readings around 25 mmol/L. He is currently being treated with metformin and lisinopril. Yesterday, his GP checked his U+E and found that his serum sodium was 138 mmol/L (137-144), serum potassium was 5.8 mmol/L (3.5-4.9), serum urea was 20 mmol/L (2.5-7.5), and serum creatinine was 350 µmol/L (60-110). On examination, he has a temperature of 39°C, a pulse of 108 bpm, a blood pressure of 96/60 mmHg, a respiratory rate of 32/min, and oxygen saturations of 99% on air. His cardiovascular, respiratory, and abdominal examination are otherwise normal. Further investigations reveal a plasma glucose level of 17 mmol/L (3.0-6.0) and urine analysis showing blood ++ and protein ++, but ketones are negative. What is the likely diagnosis?

      Your Answer: Hyperosmolar non-ketotic state

      Correct Answer: Sepsis

      Explanation:

      The causes of septic shock are important to understand in order to provide appropriate treatment and improve patient outcomes. Septic shock can cause fever, hypotension, and renal failure, as well as tachypnea due to metabolic acidosis. However, it is crucial to rule out other conditions such as hyperosmolar hyperglycemic state or diabetic ketoacidosis, which have different symptoms and diagnostic criteria.

      While metformin can contribute to acidosis, it is unlikely to be the primary cause in this case. Diabetic patients may be prone to renal tubular acidosis, but this is not likely to be the cause of an acute presentation. Instead, a type IV renal tubular acidosis, characterized by hyporeninaemic hypoaldosteronism, may be a more likely association.

      Overall, it is crucial to carefully evaluate patients with septic shock and consider all possible causes of their symptoms. By ruling out other conditions and identifying the underlying cause of the acidosis, healthcare providers can provide targeted treatment and improve patient outcomes. Further research and education on septic shock and its causes can also help to improve diagnosis and treatment in the future.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 17 - Release of somatostatin from the pancreas will lead to what outcome? ...

    Incorrect

    • Release of somatostatin from the pancreas will lead to what outcome?

      Your Answer: Contraction of the gallbladder

      Correct Answer: Decrease in pancreatic exocrine secretions

      Explanation:

      Octreotide is utilized to treat high output pancreatic fistulae by reducing exocrine pancreatic secretions, although parenteral feeding is the most effective treatment. It is also used to treat variceal bleeding and acromegaly.

      Octreotide inhibits the release of growth hormone and insulin from the pancreas. Additionally, somatostatin, which is released by the hypothalamus, triggers a negative feedback response on growth hormone.

      Somatostatin: The Inhibitor Hormone

      Somatostatin, also known as growth hormone inhibiting hormone (GHIH), is a hormone produced by delta cells found in the pancreas, pylorus, and duodenum. Its main function is to inhibit the secretion of growth hormone, insulin, and glucagon. It also decreases acid and pepsin secretion, as well as pancreatic enzyme secretion. Additionally, somatostatin inhibits the trophic effects of gastrin and stimulates gastric mucous production.

      Somatostatin analogs are commonly used in the management of acromegaly, a condition characterized by excessive growth hormone secretion. These analogs work by inhibiting growth hormone secretion, thereby reducing the symptoms associated with acromegaly.

      The secretion of somatostatin is regulated by various factors. Its secretion increases in response to fat, bile salts, and glucose in the intestinal lumen, as well as glucagon. On the other hand, insulin decreases the secretion of somatostatin.

      In summary, somatostatin plays a crucial role in regulating the secretion of various hormones and enzymes in the body. Its inhibitory effects on growth hormone, insulin, and glucagon make it an important hormone in the management of certain medical conditions.

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      • Endocrine System
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  • Question 18 - At their yearly diabetic check-up, a 65-year-old individual is discovered to have insufficient...

    Correct

    • 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.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 19 - Cortisol is mainly synthesized by which of the following? ...

    Correct

    • Cortisol is mainly synthesized by which of the following?

      Your Answer: Zona fasciculata of the adrenal

      Explanation:

      The adrenal gland’s zona fasciculata produces cortisol, with a relative glucocorticoid activity of 1. Prednisolone has a relative glucocorticoid activity of 4, while dexamethasone has a relative glucocorticoid activity of 25.

      Cortisol: Functions and Regulation

      Cortisol is a hormone produced in the zona fasciculata of the adrenal cortex. It plays a crucial role in various bodily functions and is essential for life. Cortisol increases blood pressure by up-regulating alpha-1 receptors on arterioles, allowing for a normal response to angiotensin II and catecholamines. However, it inhibits bone formation by decreasing osteoblasts, type 1 collagen, and absorption of calcium from the gut, while increasing osteoclastic activity. Cortisol also increases insulin resistance and metabolism by increasing gluconeogenesis, lipolysis, and proteolysis. It inhibits inflammatory and immune responses, but maintains the function of skeletal and cardiac muscle.

      The regulation of cortisol secretion is controlled by the hypothalamic-pituitary-adrenal (HPA) axis. The pituitary gland secretes adrenocorticotropic hormone (ACTH), which stimulates the adrenal cortex to produce cortisol. The hypothalamus releases corticotrophin-releasing hormone (CRH), which stimulates the pituitary gland to release ACTH. Stress can also increase cortisol secretion.

      Excess cortisol in the body can lead to Cushing’s syndrome, which can cause a range of symptoms such as weight gain, muscle weakness, and high blood pressure. Understanding the functions and regulation of cortisol is important for maintaining overall health and preventing hormonal imbalances.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 20 - A 38-year-old male visits his primary care physician complaining of polyuria, nocturia, and...

    Incorrect

    • A 38-year-old male visits his primary care physician complaining of polyuria, nocturia, and chronic dry mouth that have persisted for 4 months. He has a medical history of systemic lupus erythematosus (SLE) with associated renal involvement. His recent eGFR result was:

      eGFR 23ml/min/1.73m²

      The physician orders a water deprivation test along with other investigations.

      What is the probable diagnosis for this patient, and what can be expected from his water deprivation test?

      Your Answer: High urine osmolality after both fluid deprivation and desmopressin

      Correct Answer: Low urine osmolality after both fluid deprivation and desmopressin

      Explanation:

      The correct answer is low urine osmolality after both fluid deprivation and desmopressin in the water deprivation test for a patient with nephrogenic diabetes insipidus (DI). This condition is characterized by renal insensitivity to antidiuretic hormone (ADH), resulting in an inability to concentrate urine. As a result, urine osmolality will be low even during water deprivation and will not respond to desmopressin (synthetic ADH). This is in contrast to primary polydipsia, where high urine osmolality would be seen after both fluid deprivation and desmopressin, and cranial DI, where low urine osmolality would be seen during water deprivation but high urine osmolality would be seen after desmopressin.

      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.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 21 - A teenage girl and her mother come to the doctor's office with concerns...

    Correct

    • A teenage girl and her mother come to the doctor's office with concerns about ambiguous genitalia. Upon conducting a thorough medical history and various tests, the doctor diagnoses the girl with congenital adrenal hyperplasia. What is the reason for adrenal hyperplasia being a characteristic of this condition?

      Your Answer: Inefficient cortisol synthesis

      Explanation:

      Low cortisol production and compensatory adrenal hyperplasia are caused by 21-hydroxylase deficiency, leading to increased androgen production and ambiguous genitalia. The enzymes 11-beta hydroxylase and 17-hydroxylase are also involved. Testosterone and estrogen synthesis is not affected as they are produced in the testes and ovaries, respectively. Congenital adrenal hyperplasia is not caused by aldosterone synthesis, despite it occurring in the adrenal cortex.

      Congenital adrenal hyperplasia is a genetic condition that affects the adrenal glands and can result in various symptoms depending on the specific enzyme deficiency. One common form is 21-hydroxylase deficiency, which can cause virilization of female genitalia, precocious puberty in males, and a salt-losing crisis in 60-70% of patients during the first few weeks of life. Another form is 11-beta hydroxylase deficiency, which can also cause virilization and precocious puberty, as well as hypertension and hypokalemia. A third form is 17-hydroxylase deficiency, which typically does not cause virilization in females but can result in intersex characteristics in boys and hypertension.

      Overall, congenital adrenal hyperplasia can have significant impacts on a person’s physical development and health, and early diagnosis and treatment are important for managing symptoms and preventing complications.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 22 - A 14-year-old boy presents to the emergency department with complaints of severe abdominal...

    Incorrect

    • A 14-year-old boy presents to the emergency department with complaints of severe abdominal pain, nausea, and vomiting for the past 6 hours. The patient appears drowsy and has dry mucous membranes. His vital signs include a heart rate of 94 beats per minute, respiratory rate of 19 breaths per minute, and blood pressure of 89/62 mmHg. There is a fruity smell to his breath, and a bedside glucose finger prick reveals a glucose level of 263 mg/dL. The doctor orders an insulin infusion while waiting for laboratory results. Which insulin preparation is most appropriate for this patient's management?

      Your Answer: Insulin Aspart

      Correct Answer: Short-acting (regular) insulin

      Explanation:

      The onset of action and peak of NPH and regular insulin are a result of the combination of both human recombinant insulin preparations in the mixture.

      Understanding Insulin Therapy

      Insulin therapy has been a game-changer in the management of diabetes mellitus since its development in the 1920s. It remains the only available treatment for type 1 diabetes mellitus (T1DM) and is widely used in type 2 diabetes mellitus (T2DM) when oral hypoglycemic agents fail to provide adequate control. However, understanding the different types of insulin can be overwhelming, and it is crucial to have a basic grasp to avoid potential harm to patients.

      Insulin can be classified by manufacturing process, duration of action, and type of insulin analogues. Patients often require a combination of preparations to ensure stable glycemic control throughout the day. Rapid-acting insulin analogues act faster and have a shorter duration of action than soluble insulin and may be used as the bolus dose in ‘basal-bolus’ regimes. Short-acting insulins, such as Actrapid and Humulin S, may also be used as the bolus dose in ‘basal-bolus’ regimes. Intermediate-acting insulins, like isophane insulin, are often used in a premixed formulation with long-acting insulins, such as insulin determir and insulin glargine, given once or twice daily. Premixed preparations combine intermediate-acting insulin with either a rapid-acting insulin analogue or soluble insulin.

      The vast majority of patients administer insulin subcutaneously, and it is essential to rotate injection sites to prevent lipodystrophy. Insulin pumps are available, which delivers a continuous basal infusion and a patient-activated bolus dose at meal times. Intravenous insulin is used for patients who are acutely unwell, such as those with diabetic ketoacidosis. Inhaled insulin is available but not widely used, and oral insulin analogues are in development but have considerable technical hurdles to clear. Overall, understanding insulin therapy is crucial for healthcare professionals to provide safe and effective care for patients with diabetes mellitus.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 23 - A 28-year-old woman comes to her outpatient appointment after being diagnosed with Grave's...

    Correct

    • A 28-year-old woman comes to her outpatient appointment after being diagnosed with Grave's disease. This condition is known for having three distinct signs, in addition to thyroid eye disease. What are the other signs?

      Your Answer: Thyroid acropachy & pretibial myxoedema

      Explanation:

      Grave’s disease is commonly linked to several other conditions, including thyroid eye disease, thyroid acropachy, and pretibial myxoedema.

      This autoimmune disease, known as Grave’s thyroiditis, is caused by antibodies that target the thyroid stimulating hormone (TSH) receptor, leading to prolonged stimulation.

      One of the most noticeable symptoms of Grave’s disease is exophthalmos, which occurs when TSH receptor antibodies bind to receptors at the back of the eye, causing inflammation and an increase in glycosaminoglycans. This results in swelling of the eye muscles and connective tissue.

      Pretibial myxoedema is a skin condition that often develops in individuals with Grave’s disease. It is characterized by localized lesions on the skin in front of the tibia, which are caused by an increase in glycosaminoglycans in the pretibial dermis.

      Thyroid acropachy is another condition associated with Grave’s disease, which involves swelling of soft tissues, clubbing of the fingers, and periosteal reactions in the extremities.

      Graves’ Disease: Common Features and Unique Signs

      Graves’ disease is the most frequent cause of thyrotoxicosis, which is commonly observed in women aged 30-50 years. The condition presents typical features of thyrotoxicosis, such as weight loss, palpitations, and heat intolerance. However, Graves’ disease also displays specific signs that are not present in other causes of thyrotoxicosis. These include eye signs, such as exophthalmos and ophthalmoplegia, as well as pretibial myxoedema and thyroid acropachy. The latter is a triad of digital clubbing, soft tissue swelling of the hands and feet, and periosteal new bone formation.

      Graves’ disease is characterized by the presence of autoantibodies, including TSH receptor stimulating antibodies in 90% of patients and anti-thyroid peroxidase antibodies in 75% of patients. Thyroid scintigraphy reveals a diffuse, homogenous, and increased uptake of radioactive iodine. These features help distinguish Graves’ disease from other causes of thyrotoxicosis and aid in its diagnosis.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 24 - An 8-year-old girl has been brought to the GP by her mother who...

    Incorrect

    • An 8-year-old girl has been brought to the GP by her mother who is worried that her daughter may be starting puberty too early. The mother reports an enlargement in nipple size, some breast development, and the appearance of light hairs on the edge of the labia majora.

      At what Tanner stage is the girl currently?

      Your Answer: III

      Correct Answer: II

      Explanation:

      Puberty: Normal Changes in Males and Females

      Puberty is a natural process that marks the transition from childhood to adolescence. In males, the first sign of puberty is testicular growth, which typically occurs around the age of 12. Testicular volume greater than 4 ml indicates the onset of puberty. The maximum height spurt for boys occurs at the age of 14. On the other hand, in females, the first sign of puberty is breast development, which usually occurs around the age of 11.5. The height spurt for girls reaches its maximum early in puberty, at the age of 12, before menarche. Menarche, or the first menstrual period, typically occurs at the age of 13, with a range of 11-15 years. Following menarche, there is only a slight increase of about 4% in height.

      During puberty, it is normal for boys to experience gynaecomastia, or the development of breast tissue. Girls may also experience asymmetrical breast growth. Additionally, diffuse enlargement of the thyroid gland may be seen in both males and females. These changes are all part of the normal process of puberty and should not be a cause for concern.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 25 - A 50-year-old man comes to the clinic complaining of gynaecomastia. He is currently...

    Incorrect

    • 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: Aspirin

      Correct 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.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 26 - An 80-year-old patient, Gwyneth, is being examined by her physician for recurring dizziness...

    Correct

    • An 80-year-old patient, Gwyneth, is being examined by her physician for recurring dizziness upon standing up, which is interfering with her daily activities. Gwyneth is in good health and does not take any regular medications. The physician diagnoses Gwyneth with orthostatic hypotension and prescribes fludrocortisone as a treatment.

      What is the most probable side effect that Gwyneth may encounter?

      Your Answer: Fluid retention

      Explanation:

      Corticosteroids are a class of medications commonly prescribed for various clinical uses, such as treating allergies, inflammatory conditions, auto-immunity, and endogenous steroid replacement.

      There are different types of corticosteroids, each with varying levels of glucocorticoid and mineralocorticoid activity. Glucocorticoids mimic cortisol, which is involved in carbohydrate metabolism and the stress response, while mineralocorticoids mimic aldosterone, which regulates sodium and water retention in response to low blood pressure.

      The clinical uses and side effects of corticosteroids depend on their level of glucocorticoid and mineralocorticoid activity. Fludrocortisone, for example, has minimal glucocorticoid activity and high mineralocorticoid activity.

      Therefore, fluid retention is the most associated side effect with mineralocorticoid activity, while depression, hyperglycemia, osteoporosis, and peptic ulceration are side effects associated with glucocorticoid activity.

      Corticosteroids are commonly prescribed medications that can be taken orally or intravenously, or applied topically. They mimic the effects of natural steroids in the body and can be used to replace or supplement them. However, the use of corticosteroids is limited by their numerous side effects, which are more common with prolonged and systemic use. These side effects can affect various systems in the body, including the endocrine, musculoskeletal, gastrointestinal, ophthalmic, and psychiatric systems. Some of the most common side effects include impaired glucose regulation, weight gain, osteoporosis, and increased susceptibility to infections. Patients on long-term corticosteroids should have their doses adjusted during intercurrent illness, and the medication should not be abruptly withdrawn to avoid an Addisonian crisis. Gradual withdrawal is recommended for patients who have received high doses or prolonged treatment.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 27 - A 50-year-old man visits his GP with concerns about weight gain, decreased energy,...

    Correct

    • A 50-year-old man visits his GP with concerns about weight gain, decreased energy, low libido, and difficulty maintaining erections. The doctor orders a blood test to check his serum testosterone levels. What is responsible for stimulating testosterone secretion in the body?

      Your Answer: Luteinising Hormone

      Explanation:

      Understanding Androgens and Male Hormones

      Androgens are the primary male sex hormones that play a crucial role in the development and functioning of reproductive organs and secondary sex characteristics. Testosterone is the main androgen, while dihydrotestosterone and androstenedione are other types. These hormones are also essential in maintaining bone density and mass to prevent osteoporosis.

      The regulation of hormone levels in the body relies on negative feedback. Luteinising hormone (LH) stimulates the Leydig cells in the testes to produce testosterone, which is synthesized from cholesterol. When testosterone levels are high, LH is suppressed through negative feedback. A small amount of testosterone is also produced in the adrenal glands.

      Other important male hormones include follicle-stimulating hormone (FSH) and dihydrotestosterone (DHT). DHT and testosterone bind to the same androgen receptors, contributing to the development of external genitalia in the fetus, secondary sex characteristics during puberty, and sperm production. DHT is a form of endogenous testosterone converted by the enzyme 5 alpha-reductase in the prostate.

      FSH and testosterone work together to stimulate the Sertoli cells in the testes to secrete androgen-binding protein, which binds to testosterone to maintain high levels. Androgen-binding protein is secreted into the lumen of the seminiferous tubules and interstitial fluid around spermatogenic cells. Once the required level of spermatogenesis is achieved, inhibin prevents the release of more FSH.

      In summary, understanding the role of androgens and male hormones is crucial in comprehending male reproductive health and development.

      Disorders of sex hormones can have various effects on the body, as shown in the table below. Primary hypogonadism, also known as Klinefelter’s syndrome, is characterized by high levels of gonadotrophins and low levels of testosterone. Patients with this condition often have small, firm testes, lack secondary sexual characteristics, and are infertile. They may also experience gynaecomastia, which increases their risk of breast cancer. Diagnosis is made through chromosomal analysis.

      Hypogonadotrophic hypogonadism, or Kallmann syndrome, is a cause of delayed puberty due to low levels of sex hormones. It is usually inherited as an X-linked recessive trait and is caused by the failure of GnRH-secreting neurons to migrate to the hypothalamus. Patients with this condition may have hypogonadism, cryptorchidism, anosmia, and low sex hormone levels. However, their LH and FSH levels are inappropriately low or normal. They are typically of normal or above-average height, but may also have cleft lip/palate and visual/hearing defects.

      Androgen insensitivity syndrome is an X-linked recessive condition that causes end-organ resistance to testosterone, resulting in genotypically male children (46XY) having a female phenotype. This condition is also known as complete androgen insensitivity syndrome or testicular feminisation syndrome. Patients with this condition may experience primary amenorrhoea, undescended testes causing groin swellings, and breast development due to the conversion of testosterone to oestradiol. Diagnosis is made through a buccal smear or chromosomal analysis to reveal a 46XY genotype. Management involves counselling to raise the child as female, bilateral orchidectomy to reduce the risk of testicular cancer due to undescended testes, and oestrogen therapy.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 28 - A 16-year-old patient presents to his GP with concerns about his physical development....

    Correct

    • A 16-year-old patient presents to his GP with concerns about his physical development. The patient reports feeling self-conscious about his body shape and experiencing bullying at school. On examination, the patient is noted to have gynaecomastia and microorchidism. The patient is referred to a paediatrician, who subsequently refers the patient to the genetics team. As part of their assessment, the genetics team orders a karyotype.

      What karyotype results would be expected for this patient, given the likely diagnosis?

      Your Answer: Klinefelter syndrome (47,XXY)

      Explanation:

      Understanding Klinefelter’s Syndrome

      Klinefelter’s syndrome is a genetic condition that is characterized by an extra X chromosome, resulting in a karyotype of 47, XXY. Individuals with this syndrome often have a taller than average stature, but lack secondary sexual characteristics. They may also have small, firm testes and be infertile. Gynaecomastia, or the development of breast tissue, is also common in individuals with Klinefelter’s syndrome, and there is an increased risk of breast cancer. Despite elevated levels of gonadotrophins, testosterone levels are typically low.

      Diagnosis of Klinefelter’s syndrome is made through karyotyping, which involves analyzing an individual’s chromosomes. It is important for individuals with this condition to receive appropriate medical care and support, as well as genetic counseling for family planning.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 29 - A 25-year-old woman comes to the clinic with a thyroid cancer. She has...

    Incorrect

    • A 25-year-old woman comes to the clinic with a thyroid cancer. She has no significant family history and is in good health. During the examination, a nodule is found in the left lobe of her thyroid, which appears to be a small, distinct mass separate from the gland. What is the most probable cause of this finding?

      Your Answer: Medullary carcinoma

      Correct Answer: Papillary carcinoma

      Explanation:

      The most frequent subtype of thyroid cancer is papillary carcinoma, which can lead to lymph node metastasis. This occurrence is uncommon in follicular tumors. Anaplastic carcinoma is rare in this age group and would result in more localized symptoms.

      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.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 30 - A 42-year-old woman visits her GP complaining of chest pain. She has a...

    Correct

    • A 42-year-old woman visits her GP complaining of chest pain. She has a history of hypertension and is currently taking metformin for diabetes. The GP observes that her BMI is 45. What is a possible complication of the metabolic syndrome in this case?

      Your Answer: Ischemic stroke

      Explanation:

      Metabolic syndrome is a group of risk factors for cardiovascular disease that are caused by insulin resistance and central obesity.

      Obesity is associated with higher rates of illness and death, as well as decreased productivity and functioning, increased healthcare expenses, and social and economic discrimination.

      The consequences of obesity include strokes, type 2 diabetes, heart disease, certain cancers (such as breast, colon, and endometrial), polycystic ovarian syndrome, obstructive sleep apnea, fatty liver, gallstones, and mental health issues.

      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.

    • This question is part of the following fields:

      • Endocrine System
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