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Question 1
Incorrect
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A 36-year-old woman visits her new GP for routine blood tests after recently moving locations. She mentions that her previous GP had told her she had a ‘thyroid problem’ and had prescribed medication, but she cannot recall any further details. Her blood test results are as follows:
Investigation Result Normal value
Thyroid-stimulating hormone (TSH) 18 mu/l 0.5–5.5 mu/l
Free thyroxine (T4) 9.2 pmol/l 9–18 pmol/l
What could be the possible cause of these biochemical results?Your Answer: Primary hypothyroidism
Correct Answer: Poor compliance with thyroxine
Explanation:Thyroid Function Tests: Understanding the Results
Thyroid function tests are commonly used to diagnose and monitor thyroid disorders. The results of these tests can provide valuable information about the functioning of the thyroid gland. Here are some common thyroid function test results and what they may indicate:
Poor Compliance with Thyroxine
Patients who are not compliant with their thyroxine medication may only take it a few days before a routine blood test. This can result in normal thyroxine levels due to the supplementation, but the TSH levels may not have enough time to reach the normal range due to the required negative feedback.Sick Euthyroid Syndrome
In this condition, all TSH, thyroxine, and T3 levels are low. However, the TSH level is often within the normal range. This condition is reversible upon recovery from the systemic illness.Thyrotoxicosis
Thyrotoxicosis is characterized by low TSH and high T4 levels.Primary Hypothyroidism
Primary hypothyroidism results in low T4 levels and subsequent high TSH levels due to negative feedback.Secondary Hypothyroidism
In secondary hypothyroidism, both TSH and T4 levels are low. This condition occurs due to the failure of the anterior pituitary to secrete TSH despite adequate thyrotropin-releasing hormone (TRH) levels. TRH is elevated, but TSH, T3, and T4 are low, and TSH fails to rise even after a TRH stimulation test.Understanding the results of thyroid function tests can help healthcare providers diagnose and manage thyroid disorders effectively.
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This question is part of the following fields:
- Endocrinology
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Question 2
Incorrect
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A 35-year-old hypertensive man presented with the following blood results:
Investigation Result Normal value
Sodium (Na+) 147 mmol/l 135–145 mmol/l
Potassium (K+) 2.8 mmol/l 3.5–5.0 mmol/l
Urea 4.0 mmol/l 2.5–6.5 mmol/l
Creatinine 50 μmol/l 50–120 μmol/l
Glucose 4.0 mmol/l
Random: 3.5–5.5 mmol/l
Fasting: <7 mmol/l
Hba1c: <53 mmol/l (<7.0%)
Which of the following is the most likely diagnosis?Your Answer: Cushing's disease/syndrome
Correct Answer: Conn's syndrome
Explanation:Differential diagnosis of hypertension with electrolyte abnormalities
When a young patient presents with hypertension and hypokalaemia, it is important to consider secondary causes of hypertension, such as Conn’s syndrome (primary hyperaldosteronism), which can explain both findings. Coarctation of the aorta is another secondary cause of hypertension, but it does not account for the electrolyte abnormalities. Cushing’s disease/syndrome may also present with hypertension and electrolyte abnormalities, but typically with additional symptoms and higher fasting glucose levels. Polycystic kidney disease can cause hypertension, but not the electrolyte abnormalities. Primary (essential) hypertension is the most common form of hypertension, but secondary causes should be ruled out, especially in younger patients with atypical features.
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This question is part of the following fields:
- Endocrinology
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Question 3
Incorrect
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A 56-year-old male with a past medical history of alcoholic liver disease arrives at the Emergency department complaining of chest pain. After conducting an ECG and measuring troponin levels, it is confirmed that the patient is experiencing NSTEMI. What beta blocker would you prescribe to prevent any future myocardial events?
Your Answer: Bisoprolol 20 mg OD
Correct Answer: Propranolol 40 mg BD
Explanation:Safe Use of Beta Blockers in Liver Disease
Beta blockers are commonly used to prevent variceal bleeding. The recommended dose for this purpose is typically lower than the normal dose, but it can be increased if necessary. However, in patients with liver disease, the manufacturer recommends using a lower dose to avoid potential complications. Bisoprolol is one beta blocker that is safe to use in liver disease, but the maximum recommended dose is 10 mg once daily. Other beta blockers should be avoided in patients with liver disease due to the risk of adverse effects. It is important to consult with a healthcare provider to determine the appropriate dose and medication for each individual patient.
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This question is part of the following fields:
- Endocrinology
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Question 4
Incorrect
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A 28-year-old obese man presents to clinic. He is found to have a body mass index (BMI) of 36 kg/m2 and wants advice regarding treatment of his obesity.
Which of the following pertains to the treatment of obesity?Your Answer: Weight loss will be very slow at first when only glycogen breaks down, but this is followed 3–4 weeks later by a period of incremental weight loss due to breakdown of adipose tissue
Correct Answer: Orlistat causes weight loss by inhibiting pancreatic and gastric lipase
Explanation:Misconceptions and Clarifications about Weight Loss Methods
Orlistat: A common misconception is that Orlistat causes weight loss by reducing appetite. In reality, it inhibits pancreatic and gastric lipase, which leads to the malabsorption of intestinal triglycerides and causes steatorrhoea.
Fenfluramine: Another misconception is that Fenfluramine causes systemic hypertension. It was actually banned due to its association with valvular heart disease and pulmonary hypertension.
Liposuction: Liposuction is not a weight loss method and should not be used as a substitute for diet and exercise. It is a cosmetic procedure that removes localized fat deposits.
Weight Loss: Weight loss is not a linear process and can vary from person to person. While glycogen depletion may contribute to initial weight loss, it is not the sole factor. Incremental weight loss occurs as adipose tissue is broken down.
Surgery: Restrictive surgery may be considered for morbidly obese patients under the age of 18, but this is not recommended as an initial option according to NICE guidelines.
Debunking Weight Loss Myths and Clarifying Methods
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This question is part of the following fields:
- Endocrinology
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Question 5
Correct
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A 36-year-old woman has been referred by her GP due to passing an unusually large volume of urine and complaining of continuous thirst. The following investigations were conducted:
Random plasma:
Investigation Result
Sodium (Na+) 155 mmol/l
Osmolality 300 mOsmol/kg
Glucose 4.5 mmol/l
Urine:
Investigation Result
Osmolality 90 mOsmol/kg
Glucose 0.1 mmol/l
In healthy patients, the urine: plasma osmolality ratio is > 2. A water deprivation test was conducted, and after 6.5 hours of fluid deprivation, the patient's weight had dropped by >3%, and the serum osmolality was 310 mOsmol/kg. Urine osmolality at this stage was 210 mOsmol/kg. The patient was then given desmopressin intramuscularly (im) and allowed to drink. The urine osmolality increased to 700 mOsmol/kg, and her plasma osmolality was 292 mOsmol/kg.
What is the most likely diagnosis for this 36-year-old woman?Your Answer: A pituitary tumour
Explanation:Diagnosing Cranial Diabetes Insipidus: A Comparison with Other Conditions
Cranial diabetes insipidus (DI) is a condition where the kidneys are unable to reabsorb free water, resulting in excessive water loss. The most likely cause of this condition is a pituitary tumor, which reduces antidiuretic hormone (ADH) secretion. Other conditions, such as diabetes mellitus, chronic renal disease, lithium therapy, and primary polydipsia, may also cause polydipsia and polyuria, but they present with different symptoms and responses to treatment.
To diagnose cranial DI, doctors perform a water deprivation test and measure the urine: plasma osmolality ratio. In patients with cranial DI, the ratio is below 2, indicating that the kidneys are not concentrating urine as well as they should be. However, when given desmopressin im (exogenous ADH), the patient’s urine osmolality dramatically increases, showing that the kidneys can concentrate urine appropriately when stimulated by ADH. This confirms the absence of ADH as the cause of cranial DI.
Diabetes mellitus patients present with glycosuria and hyperglycemia, in addition to polydipsia and polyuria. Chronic renal disease and lithium therapy cause nephrogenic DI, which does not respond to desmopressin im. Primary polydipsia causes low urine osmolality, low plasma osmolality, and hyponatremia due to excessive water intake. However, patients with primary polydipsia retain some ability to concentrate urine, and removing the fluid source limits polyuria to some extent.
In conclusion, diagnosing cranial DI requires a thorough comparison with other conditions that cause polydipsia and polyuria. By understanding the symptoms and responses to treatment of each condition, doctors can accurately diagnose and treat patients with cranial DI.
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This question is part of the following fields:
- Endocrinology
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Question 6
Correct
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A 68-year-old woman presents with weight loss and heat intolerance. Her lab results show elevated free T4 and free T3 levels, and a suppressed TSH level. She is currently on medications for atrial fibrillation, ischaemic heart disease, and type 2 diabetes. Which medication is the most likely culprit for these abnormal thyroid function tests?
Your Answer: Amiodarone
Explanation:Amiodarone and its Effects on Thyroid Function
Amiodarone is a medication that can cause abnormalities in thyroid function tests, leading to both hypothyroidism and hyperthyroidism. Hypothyroidism may occur due to interference with the conversion of thyroxine (T4) to tri-iodothyronine (T3), while hyperthyroidism may result from thyroiditis or the donation of iodine (amiodarone contains a large amount of iodine). In addition to thyroid dysfunction, amiodarone can also cause pulmonary fibrosis and photosensitivity reactions. It is important for healthcare providers to monitor thyroid function in patients taking amiodarone and manage any resulting thyroid dysfunction appropriately.
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This question is part of the following fields:
- Endocrinology
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Question 7
Correct
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A 48-year old teacher is found to have a raised fasting glucose and abnormal cholesterol results following routine blood testing as a part of her NHS health check. She is noted to have a BMI of 32. She is also hypertensive. The reviewing physician suspects that the patient has metabolic syndrome.
Which of the following statements is true about the metabolic syndrome?Your Answer: Patients usually have high circulating insulin levels
Explanation:Understanding Metabolic Syndrome and its Associated Features
Metabolic syndrome is a condition characterized by three or more of the following: increased waist circumference, BMI >30 kg/m2, raised triglycerides, reduced HDL cholesterol, hypertension, and raised fasting glucose. It typically occurs in individuals with central obesity and insulin resistance, leading to elevated circulating insulin and C-peptide levels. However, significant weight loss can reverse insulin resistance and resolve the features of metabolic syndrome.
Contrary to what one might expect, high serum HDL is typical in metabolic syndrome, while low serum HDL is a diagnostic criteria. Additionally, metabolic syndrome is a key risk factor for non-alcoholic fatty liver disease (NAFLD), which is fairly common in these patients. Hyperuricaemia is also common in metabolic syndrome, rather than hypouricaemia.
Finally, while metabolic syndrome incidence does increase with age, it does not necessarily peak in the fifth decade of life. Understanding these features can aid in the diagnosis and management of metabolic syndrome and its associated conditions.
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This question is part of the following fields:
- Endocrinology
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Question 8
Incorrect
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A 45-year-old man visits his GP for a medication review for his hypertension. During the examination, the GP observes that the patient has prominent supraorbital ridges, large hands and feet, and acanthosis nigricans of the axillae. The GP also discovers enlargement of the thyroid gland and hepatomegaly. Besides hypertension, what other condition is frequently linked to acromegaly?
Your Answer: Pigmentation of the skin
Correct Answer: Diabetes mellitus
Explanation:Associations of Acromegaly with Various Medical Conditions
Acromegaly is a medical condition caused by hypersecretion of growth hormone. It is associated with various medical conditions, including insulin resistance and diabetes mellitus, which can lead to acromegaly. Left ventricular hypertrophy is also associated with acromegaly, which can cause right ventricular hypertrophy. Ulnar nerve entrapment is another association, along with carpal tunnel syndrome affecting the median nerve. Acanthosis nigricans involves hyperpigmentation of the skin, but there is no general pigmentation associated with acromegaly. Acromegaly is also associated with cardiovascular disease, which can increase the risk of atrial fibrillation, although it is not a direct cause.
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This question is part of the following fields:
- Endocrinology
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Question 9
Correct
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A 67-year-old woman visits her GP with complaints of constipation that has been ongoing for a month. She requests medication to alleviate the symptoms. The patient reports feeling more fatigued than usual and has noticed recent weight gain. During the examination, the GP observes dry scaly skin. The patient's medical history indicates recent consultation with an endocrinologist.
What would lead to elevated thyroid-stimulating hormone (TSH) levels and normal T4 in this case?Your Answer: Poor compliance with thyroxine
Explanation:Understanding Thyroid Disorders: Differentiating Poor Compliance with Thyroxine from Other Conditions
Thyroid disorders can present with a variety of symptoms, making it important to differentiate between different conditions. In the case of poor compliance with thyroxine medication, a patient may present with signs of a low thyroid state, but blood results will show a high TSH and normal T4, indicating recent medication use.
Primary hypothyroidism, on the other hand, would show a low T4 and high TSH, while thyrotoxicosis would reveal a low TSH and high T4, accompanied by symptoms such as tachycardia and tremors. Secondary hypothyroidism would present with low levels of both T4 and TSH, indicating a pituitary problem.
Sick euthyroid syndrome, which often occurs in individuals with systemic illness, would show low levels of TSH, thyroxine, and T3, but the TSH level may still be within the normal range. Understanding these differences can help healthcare professionals make accurate diagnoses and provide appropriate treatment.
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This question is part of the following fields:
- Endocrinology
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Question 10
Incorrect
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A 42-year-old woman complains of fatigue after experiencing flu-like symptoms two weeks ago. Upon examination, she has a smooth, small goiter and a pulse rate of 68 bpm. Her lab results show a Free T4 level of 9.3 pmol/L (normal range: 9.8-23.1) and a TSH level of 49.3 mU/L (normal range: 0.35-5.50). What additional test would you perform to confirm the diagnosis?
Your Answer: TSH receptor antibodies
Correct Answer: Thyroid peroxidase (TPO) antibodies
Explanation:Diagnosis and Management of Primary Hypothyroidism
The patient’s test results indicate a case of primary hypothyroidism, characterized by low levels of thyroxine (T4) and elevated thyroid-stimulating hormone (TSH). The most likely cause of this condition is Hashimoto’s thyroiditis, which is often accompanied by the presence of thyroid peroxidase antibodies. While the patient has a goitre, it appears to be smooth and non-threatening, so a thyroid ultrasound is not necessary. Additionally, a radio-iodine uptake scan is unlikely to show significant uptake and is therefore not recommended. Positive TSH receptor antibodies are typically associated with Graves’ disease, which is not the likely diagnosis in this case. For further information on Hashimoto’s thyroiditis, patients can refer to Patient.info.
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This question is part of the following fields:
- Endocrinology
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Question 11
Incorrect
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A 30-year-old man is being evaluated by his physician for possible issues with his hypothalamic-pituitary-thyroid axis. The following findings were recorded:
Thyroid-stimulating hormone (TSH) 5.5 mu/l (0.4-4.0 mu/l)
fT3 3.5 pmol/l (3.0-9.0 pmol/l)
What condition is indicated by these results?Your Answer: Secondary hypothyroidism
Correct Answer: Need more information
Explanation:The Importance of fT4 in Thyroid Diagnosis
When diagnosing thyroid conditions, the fT4 level is a crucial piece of information that cannot be overlooked. A patient with high TSH could be hyperthyroid, hypothyroid, or euthyroid with this TSH level, and the fT4 level is needed to determine the correct diagnosis. While a normal fT3 level can rule out hyperthyroidism, it cannot exclude the diagnosis if the fT4 level is high. Similarly, fT3 levels are of no use in diagnosing hypothyroidism, as they can be normal in a hypothyroid patient due to increased T4 to T3 conversion. Without the fT4 level, a diagnosis of primary or secondary hypothyroidism or a TSH-secreting tumor cannot be made. Therefore, it is crucial to obtain the fT4 level when evaluating thyroid function.
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This question is part of the following fields:
- Endocrinology
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Question 12
Incorrect
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A 35-year-old woman comes to the Endocrinology Clinic complaining of bruising, striae, acne and hirsutism. During the examination, the patient seems lethargic and depressed, with centripetal obesity and proximal myopathy. Her blood pressure is 165/106 mmHg and blood tests show Na+ 136 mmol/l, K+ 2.8 mmol/l and random glucose 8.2 mmol/l. The doctor orders a low-dose dexamethasone test and a 24-hour urinary cortisol test. What is the most common cause of Cushing syndrome?
Your Answer: Primary adrenal disorder
Correct Answer: Iatrogenic
Explanation:Causes of Cushing Syndrome: Understanding the Different Types
Cushing Syndrome is a rare condition that occurs when the body is exposed to high levels of cortisol for an extended period. Cortisol is a hormone produced by the adrenal glands that helps regulate metabolism and stress response. There are several different causes of Cushing Syndrome, including:
1. Iatrogenic: This is the most common cause of Cushing Syndrome and is related to the use of corticosteroid medication. People who take oral corticosteroids are at a higher risk, but the condition can also affect those who misuse inhaled or topical corticosteroids.
2. Ectopic ACTH secretion: This is a very rare cause of Cushing Syndrome that arises due to ACTH secretion from a carcinoid tumor.
3. Primary adrenal disorder: This is primary hypercortisolism, which is an unusual cause for Cushing Syndrome.
4. Pituitary-dependent: This is Cushing’s disease, which is much rarer than Cushing Syndrome, arising from a pituitary tumor.
5. Pseudo-Cushing’s syndrome: This describes hypercortisolism arising as a result of a separate condition, such as malnutrition or chronic alcoholism, resulting in the same phenotype and biochemical abnormalities of Cushing Syndrome.
Understanding the different types of Cushing Syndrome can help with diagnosis and treatment. It is important to work with a healthcare provider to determine the underlying cause and develop an appropriate treatment plan.
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This question is part of the following fields:
- Endocrinology
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Question 13
Correct
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Which test can be used to distinguish between insulinoma and exogenous insulin administration in a patient experiencing hypoglycaemia?
Your Answer: Plasma C peptide
Explanation:The Role of C Peptide in Distinguishing Between Exogenous and Endogenous Insulin
Plasma C peptide levels are useful in differentiating between the presence of exogenous insulin and excess endogenous insulin during hypoglycemia. If there is an excess of exogenous insulin, the C peptide level will be suppressed, but the insulin level will still be detectable or elevated. However, it is important to note that not all clinical laboratory assays can detect the new insulin analogues.
C peptide also has other uses, such as checking for pancreatic insulin reserve. This information can help distinguish between type 1 diabetes, which is caused by autoimmune destruction of the pancreas, and type 2 diabetes, which is caused by insulin resistance or relative insulin insufficiency.
Proinsulin is the storage form of insulin, and only a small amount enters systemic circulation. It is cleaved into insulin and a connecting (C) peptide, which are secreted in equal amounts. However, there is more measurable C peptide in circulation due to its longer half-life.
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This question is part of the following fields:
- Endocrinology
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Question 14
Correct
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A 76-year-old woman presents with lethargy. She has a history of Graves’ disease and thyrotoxicosis. Her thyroid-stimulating hormone (TSH) levels are found to be 7.3 μU/l (normal range: 0.17–3.2 μU/l). A full blood count is performed and reveals the following: haemoglobin (Hb) is low, mean corpuscular volume (MCV) is high, platelet count is normal, white cell count (WCC) is normal.
What is the most likely cause of her anaemia?Your Answer: Hypothyroidism
Explanation:Differential diagnosis of macrocytic anaemia in a patient with a history of Graves’ disease
This patient presents with a macrocytic anaemia, which can have various causes. Given her history of Graves’ disease and autoimmune hyperthyroidism, it is important to consider hypothyroidism as a possible cause, despite the usual association of hyperthyroidism with a suppressed TSH. Pernicious anaemia, another autoimmune disease that can lead to vitamin B12 deficiency, should also be considered. However, in this case, the high TSH makes hypothyroidism more likely. Vitamin B12 deficiency and folate deficiency can also cause macrocytic anaemia, but the patient’s history and laboratory findings suggest hypothyroidism as the primary diagnosis. Haemolysis is not a likely cause in this patient.
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This question is part of the following fields:
- Endocrinology
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Question 15
Correct
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A 21-year-old female medical student, who is an insulin-dependent diabetic, went on a weekend trip to visit some friends at another university. She forgot to pack her insulin.
When she returned, she went to visit her General Practitioner (GP).
What would analysis of her blood results most likely reveal?Your Answer: Unchanged HbA1c
Explanation:Effects of Insulin Absence in Insulin-Dependent Diabetes Patients
Insulin-dependent diabetes patients rely on insulin to regulate their blood glucose levels. Without insulin, several physiological changes occur in the body. The HbA1c levels, which reflect the average blood glucose levels over several weeks, would not change significantly over a few days without insulin. However, missing insulin doses for a weekend can put the patient at risk of developing diabetic ketoacidosis (DKA), a life-threatening condition. In the absence of insulin, the body cannot utilise glucose, leading to hyperglycaemia and the generation of ketones as an alternative energy source. The raised glucagon levels in response to the absence of insulin would raise glucose levels in the bloodstream, but target organs would still not be able to utilise this resource. Triglyceride hydrolysis and increased release from adipose tissue would give raised fatty acid levels, which are utilised to synthesise ketones. Overall, the absence of insulin in insulin-dependent diabetes patients can have significant effects on their metabolic processes.
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This question is part of the following fields:
- Endocrinology
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Question 16
Correct
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What is the hormone that is released from the posterior pituitary gland?
Your Answer: Oxytocin
Explanation:Peptides Secreted by the Pituitary Gland
The pituitary gland secretes various hormones that regulate different bodily functions. The posterior lobe of the pituitary gland secretes two peptides, oxytocin and antidiuretic hormone (ADH). Oxytocin, which is produced in the hypothalamus, stimulates uterine contractions during labor and is involved in the release of milk from the lactating breast. ADH, also known as vasopressin, is also produced in the hypothalamus and regulates water balance in the body.
On the other hand, the anterior lobe of the pituitary gland secretes six peptide hormones. These hormones include adrenocorticotrophic hormone (ACTH), prolactin, thyroid-stimulating hormone (TSH), growth hormone (GH), follicle-stimulating hormone (FSH), and luteinizing hormone (LH). ACTH stimulates the adrenal gland to produce cortisol, which helps the body respond to stress. Prolactin stimulates milk production in the mammary glands. TSH stimulates the thyroid gland to produce thyroid hormones, which regulate metabolism. GH promotes growth and development in children and helps maintain muscle and bone mass in adults. FSH and LH regulate the reproductive system, with FSH stimulating the growth of ovarian follicles in females and sperm production in males, while LH triggers ovulation in females and testosterone production in males.
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This question is part of the following fields:
- Endocrinology
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Question 17
Correct
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A 16-year-old girl has been referred due to a six-month history of amenorrhea and weight loss, without identifiable organic cause. What signs would indicate a possible diagnosis of anorexia nervosa (AN)?
Possible revised output with paragraph spacing:
A 16-year-old girl has been referred to the clinic with a six-month history of amenorrhea and weight loss. Despite medical investigations, no organic cause has been identified for her symptoms. The healthcare provider suspects that the patient may have anorexia nervosa (AN), a serious eating disorder characterized by self-imposed starvation and distorted body image. To confirm or rule out this diagnosis, the provider needs to look for specific features that are commonly associated with AN.Your Answer: Delusion of being overweight
Explanation:Features of Anorexia Nervosa
Anorexia Nervosa (AN) is a serious eating disorder that is characterized by several features. One of the most prominent features is a phobic avoidance of normal weight, which leads to relentless dieting and self-induced vomiting. Laxative use and excessive exercise are also common behaviors associated with AN. Another feature of AN is amenorrhea, which is the absence of menstrual periods.
Physical symptoms of AN include hypotension and the growth of lanugo hair, which is fine, downy hair that grows on the body as a result of malnutrition. Denial and concealment are also common behaviors associated with AN, as individuals with this disorder often try to hide their symptoms from others.
In addition to these physical and behavioral symptoms, individuals with AN may also have an over-perception of their body image, leading them to see themselves as overweight even when they are underweight. Finally, AN is often associated with enmeshed families, where family members are overly involved in each other’s lives and have difficulty setting boundaries.
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This question is part of the following fields:
- Endocrinology
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Question 18
Incorrect
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A 55-year-old man with a history of hypertension and type 2 diabetes presents to the Emergency department with complaints of central chest pain that radiates down his left arm. He is currently taking ramipril, metformin, atorvastatin, and gliclazide. On examination, his blood pressure is 129/72 mmHg, and his pulse is 81. Bibasal crackles are heard on auscultation of his chest.
The following investigations were conducted:
- Haemoglobin: 138 g/L (130-180)
- White cell count: 8.9 ×109/L (4-11)
- Platelet: 197 ×109/L (150-400)
- Sodium: 141 mmol/L (135-146)
- Potassium: 4.1 mmol/L (3.5-5)
- Creatinine: 123 µmol/L (79-118)
- Glucose: 12.3 mmol/L (<7.0)
- ECG: Anterolateral ST depression
The patient is given sublingual GTN. What is the next most appropriate therapy?Your Answer: Clopidogrel 300 mg
Correct Answer: Aspirin 300 mg, clopidogrel 300 mg and unfractionated heparin
Explanation:Treatment Plan for High-Risk Patient with Type 2 Diabetes Mellitus
This patient, who has a history of type 2 diabetes mellitus, is considered high risk and requires immediate treatment. The recommended treatment plan includes loading the patient with both aspirin and clopidogrel to reduce the risk of further complications. If the patient experiences further chest pain or if ECG signs do not improve, additional interventions such as angiography may be necessary.
In addition to aspirin and clopidogrel, unfractionated heparin is also recommended as an alternative to fondaparinux for patients who are likely to undergo coronary angiography within 24 hours of admission. If the patient does not progress to angiogram, screening for ischaemia should be considered prior to discharge.
Overall, it is important to closely monitor this high-risk patient and adjust the treatment plan as necessary to ensure the best possible outcome.
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This question is part of the following fields:
- Endocrinology
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Question 19
Correct
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A 52-year-old male who works as a truck driver and has been diagnosed with type 2 diabetes for the past 8 years is due for his annual check-up. Despite being on maximum oral hypoglycemic therapy, his HbA1c levels are alarmingly high at 91 mmol/mol (20-42). He has not experienced any hypoglycemic episodes or developed retinopathy. You suggest switching to insulin, but he declines as it would result in him losing his HGV license and having to reapply. The DVLA is aware of his diabetes and current treatment. What is the most appropriate course of action in this scenario?
Your Answer: Continue to review patient in clinic and accept that he continues to drive
Explanation:Diabetes and Driving: the Guidelines
When it comes to diabetes and driving, there are certain guidelines that must be followed. In cases where a patient has poor glycaemic control, but no other features that would prevent them from driving, they cannot be forced to switch to insulin or have their driving privileges revoked. However, patients who hold a HGV license and are treated on insulin will initially lose their license and have to re-apply for it.
It’s important to note that regular medical check-ups are necessary for patients who wish to maintain their HGV license. These check-ups should occur every three years to ensure that the patient’s diabetes is under control and that they are fit to drive.
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This question is part of the following fields:
- Endocrinology
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Question 20
Incorrect
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A previously healthy 70-year-old man presents with his daughter, who reports that her father has been experiencing a poor appetite, weight loss of at least 4.5 kg, and lack of energy for the past three months. The patient denies any cough or fever, but he tires easily.
Upon examination, the patient appears subdued, is afebrile, and has an irregular pulse of 100 beats per minute and a blood pressure of 156/88 mmHg. Fundoscopic examination reveals grade II hypertensive changes, and the JVP is elevated by 8 cm. Crackles are heard at both lung bases, but the abdomen is normal. The patient has general weakness, particularly in the hip flexors, but the neurologic exam is otherwise unremarkable.
Laboratory investigations show a hemoglobin level of 110 g/L (115-165), a white cell count of 7.3 ×109/L (4-11), and a urea level of 8.8 mmol/L (2.5-7.5). What diagnostic test would be most helpful in establishing the diagnosis?Your Answer: Echocardiography
Correct Answer: Serum thyroid-stimulating hormone
Explanation:Thyrotoxicosis as a Possible Cause of Heart Failure and Proximal Myopathy
This patient is showing signs of heart failure, along with fast atrial fibrillation, weight loss, and proximal myopathy. Although hyperthyroidism is typically associated with an increased appetite, elderly patients may experience apathy and loss of appetite. These symptoms suggest thyrotoxicosis, which would be confirmed by a suppressed thyroid-stimulating hormone (TSH) level. The absence of a thyroid goitre does not rule out Graves’ disease or a toxic nodule as the underlying cause.
Echocardiography can confirm the heart failure, but it cannot determine the underlying cause. Therefore, the examiners want the reader to deduce that thyrotoxicosis may be the culprit. It is important to consider this possibility in patients presenting with heart failure and proximal myopathy, even in the absence of a thyroid goitre.
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This question is part of the following fields:
- Endocrinology
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Question 21
Incorrect
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A 55-year-old male with a long history of smoking presents with a complaint of haemoptysis. Upon examination, muscle wasting and hypertension are observed. Further testing reveals elevated urine free cortisol, elevated ACTH, and non-suppressible cortisol following high dose dexamethasone testing. What is the most probable diagnosis?
Your Answer: Pituitary tumour
Correct Answer: Ectopic ACTH producing lung cancer
Explanation:Ectopic ACTH Production and Associated Tumours
Patients with Cushing’s syndrome and non-suppressible cortisol levels may have ectopic adrenocorticotropic hormone (ACTH) secretion, which is commonly associated with small cell lung cancer. Other tumours that may cause ectopic ACTH production include those of the thymus, pancreas, thyroid, and adrenal gland. Unlike typical hypercortisolism symptoms, patients with ectopic ACTH production may experience polyuria, polydipsia, oedema, muscle wasting, fatigue, hypertension, and hypokalaemia.
Laboratory tests can confirm excessive cortisol production and lack of dexamethasone suppression of morning cortisol levels. Plasma ACTH levels greater than 200 pg/mL may indicate ectopic ACTH production and prompt a search for an underlying malignancy, particularly a primary lung or pancreatic tumour. Therefore, it is crucial to investigate the possibility of ectopic ACTH production in patients with Cushing’s syndrome and non-suppressible cortisol levels, as it may indicate an underlying tumour.
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This question is part of the following fields:
- Endocrinology
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Question 22
Correct
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These results were obtained on a 30-year-old male who has presented with tiredness:
Free T4 9.3 pmol/L (9.8-23.1)
TSH 49.31 mU/L (0.35-5.50)
What signs might be expected in this case?Your Answer: Slow relaxation of biceps reflex
Explanation:Diagnosis and Symptoms of Hypothyroidism
Hypothyroidism is diagnosed through blood tests that show low levels of T4 and elevated levels of TSH. Physical examination may reveal slow relaxation of tendon jerks, bradycardia, and goitre. A bruit over a goitre is associated with Graves’ thyrotoxicosis, while palmar erythema and fine tremor occur in thyrotoxicosis. In addition to these common symptoms, hypothyroidism may also present with rarer features such as cerebellar features, compression neuropathies, hypothermia, and macrocytic anaemia. It is important to diagnose and treat hypothyroidism promptly to prevent further complications.
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This question is part of the following fields:
- Endocrinology
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Question 23
Incorrect
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Under what circumstances would the bone age match the chronological age?
Your Answer: Constitutional delay of growth and puberty
Correct Answer: Familial short stature
Explanation:Factors Affecting Bone Age
Bone age is affected by various factors such as hypothyroidism, constitutional delay of growth and puberty, growth hormone deficiency, precocious puberty, and familial short stature. In hypothyroidism, bone age is delayed due to the underproduction of thyroid hormones. On the other hand, constitutional delay of growth and puberty causes delayed physiological maturation, including secondary sexual characteristics and bone age. Growth hormone deficiency also results in delayed skeletal maturation. In contrast, precocious puberty causes advanced bone age. Lastly, in familial short stature, bone age is equal to chronological age, but linear growth is poor, resulting in a short stature. these factors is crucial in diagnosing and managing growth and development issues in children. Proper evaluation and treatment can help ensure optimal growth and development.
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This question is part of the following fields:
- Endocrinology
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Question 24
Correct
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A 45-year-old patient is undergoing treatment with recombinant human growth hormone (GH). What is a known side effect of GH therapy?
Your Answer: Raised intracranial pressure
Explanation:Side Effects of Recombinant Human Growth Hormone Treatment
Recombinant human growth hormone (hGH) treatment is associated with several side effects. One of the most common side effects is raised intracranial pressure (ICP) with a normal MRI, which is a secondary form of idiopathic intracranial hypertension (IIH). This is believed to be caused by the antidiuretic effect of hGH, particularly in patients with impaired renal homeostasis. However, in patients with intact homeostatic mechanisms, hGH can elevate plasma renin and aldosterone, which counteracts the antidiuretic effect. If IIH is diagnosed, hGH treatment should be stopped and resumed at a lower dose if IIH resolves.
Aside from IIH, other recognized side effects of hGH include slipped upper femoral epiphysis (SUFE), malignancies, gynaecomastia, and impaired glucose metabolism. However, melanoma, osteoporosis, prostatic hypertrophy, and prolongation of the QT interval are not commonly recognized side effects of hGH treatment. It is important to monitor patients closely for these side effects and adjust treatment accordingly to minimize any potential harm.
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This question is part of the following fields:
- Endocrinology
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Question 25
Incorrect
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A 12-year-old boy is presenting with nocturnal enuresis, poor academic performance, and easy fatigue with physical activity. A full examination, including blood pressure, is unremarkable. Laboratory results show elevated WBC count and high bicarbonate levels. The 24-hour urine test reveals high potassium levels and low sodium levels. What is the likely diagnosis?
Your Answer: Primary hyperaldosteronism (Conn's syndrome)
Correct Answer: Bartter's syndrome
Explanation:Bartter’s Syndrome: A Rare Condition with Unique Symptoms
Bartter’s syndrome is a rare condition that is usually diagnosed in childhood. It is characterized by polyuria, nocturnal enuresis, and growth retardation. Patients with this syndrome also experience hypokalaemic metabolic alkalosis with urinary potassium wasting. This is due to the hyperplasia of the juxtaglomerular apparatus.
The absence of hypertension in the patient makes it unlikely that they have Conn’s or renal artery stenosis. Bartter’s syndrome is a unique condition that presents with specific symptoms and laboratory findings. It is important for healthcare providers to be aware of this condition and consider it in the differential diagnosis of patients with similar symptoms. Early diagnosis and treatment can improve the patient’s quality of life and prevent complications.
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This question is part of the following fields:
- Endocrinology
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Question 26
Correct
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The blood results of a 55-year-old woman were obtained and the following values were recorded in her plasma: Total Ca2+ was 1.80 mmol/l (2.12–2.65 mmol/l), Albumin was 40 g/l (35–50 g/l), PO43− was 2.0 mmol/l (0.8–1.5 mmol/l), Alkaline phosphatase was 120 iu/l (30–150 iu/l), and Parathyroid hormone (PTH) was 75 ng/l (15–65 ng/l). Based on these results, what condition is this consistent with?
Your Answer: Pseudohypoparathyroidism
Explanation:Understanding Pseudohypoparathyroidism: A Rare Genetic Condition
Pseudohypoparathyroidism is a rare genetic condition that occurs when the target cells fail to respond to parathyroid hormone (PTH). Unlike hypoparathyroidism, where the gland fails to secrete enough PTH, PTH levels are elevated in pseudohypoparathyroidism. However, the lack of response to PTH results in low calcium and high phosphate levels, which is the opposite of what PTH is supposed to do.
Symptoms of pseudohypoparathyroidism may include shortened metacarpals (especially the fourth and fifth), a round face, short stature, calcified basal ganglia, and a low IQ.
It’s important to differentiate pseudohypoparathyroidism from other conditions such as primary hyperparathyroidism, primary hypoparathyroidism, and post-thyroidectomy hypoparathyroidism. In primary hyperparathyroidism, there is overproduction of PTH, causing hypercalcemia and hypophosphatemia. In primary hypoparathyroidism, there is gland failure, resulting in low PTH secretion and low calcium levels. Post-thyroidectomy hypoparathyroidism occurs when the parathyroids are damaged or removed during surgery, resulting in low PTH levels.
Another condition that may present with similar morphological features as pseudohypoparathyroidism is pseudopseudohypoparathyroidism. However, in this condition, the biochemistry is normal.
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This question is part of the following fields:
- Endocrinology
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Question 27
Incorrect
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A 33-year-old patient with a history of phaeochromocytoma develops a neck mass. Resection of the neck mass demonstrates a multifocal tumour with haemorrhage, necrosis and spread outside the thyroid capsule. The tumour is composed of polygonal cells in nests. Amyloid deposits are seen in the intervening fibrovascular stroma.
What is the most likely secretion of the polygonal cells?Your Answer: Thyroxine (T4)
Correct Answer: Calcitonin
Explanation:Hormones and Tumors: Understanding the Link
Calcitonin, PTH, TSH, T4, and T3 are hormones that can be produced by various tumors. Medullary carcinoma of the thyroid, which can occur sporadically or as part of multiple endocrine neoplasia (MEN) types IIa and IIb, is known for its local production of amyloid and secretion of calcitonin. PTH can be produced by parathyroid tumors, while PTH-related protein can be a paraneoplastic product of various tumors, including lung cancer. TSH is produced by pituitary adenomas, while T4 and T3 are produced by thyroid tumors composed of follicular cells. Understanding the link between hormones and tumors can aid in diagnosis and treatment.
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This question is part of the following fields:
- Endocrinology
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Question 28
Incorrect
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A 16-year-old boy with an 8-year history of type I diabetes presents to the Emergency Department (ED) with a 24-hour history of vomiting. He tested his glucose and ketones at home and they were both high, glucose 30 mmol/L, ketones 3 mmol/L, so he attended the ED. He admits to omitting his insulin frequently. He appears dehydrated, has ketotic fetor, BP 112/76 mmHg, pulse 108 beats per minute, temp 37 degrees, oxygen saturations 98% on room air. Clinical examination is otherwise normal. The following are his laboratory investigations:
Test Result Normal range
pH 7.2 7.35–7.45
Ketones 3 mmol/l < 0.6 mmol/l
Glucose 28 mmol/l 3.5–5.5 mmol/l
Bicarbonate 11 mmol/l 24–30 mmol/l
Base excess -5 mEq/l −2 to +2 mEq/l
C-reactive protein (CRP) 3 mg/l 0–10 mg/l
What is required to make a diagnosis of diabetic ketoacidosis in this patient?Your Answer: pH<7.30
Correct Answer:
Explanation:Understanding Diabetic Ketoacidosis: Diagnostic Criteria and Metabolic Imbalance
Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes that results from a complex metabolic imbalance. The diagnostic criteria for DKA include hyperglycaemia (glucose >11 mmol/l), ketosis (>3 mmol/l), and acidemia (pH <7.3, bicarbonate <15 mmol/l). DKA is caused by insulin deficiency and an increase in counterregulatory hormones, which lead to enhanced hepatic gluconeogenesis and glycogenolysis, severe hyperglycaemia, and enhanced lipolysis. The resulting accumulation of ketone bodies, including 3-beta hydroxybutyrate, leads to metabolic acidosis. Fluid depletion, electrolyte shifts, and depletion are also common in DKA. While anion gap is not included in the UK diagnostic criteria, it is typically high in DKA (>10). Understanding the diagnostic criteria and metabolic imbalance of DKA is crucial for its prevention and management.
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This question is part of the following fields:
- Endocrinology
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Question 29
Correct
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A 28-year-old patient is admitted with vomiting and abdominal pain. She was noted to have marked buccal pigmentation.
Examination reveals dehydration, pulse 100 bpm, blood pressure (BP) 90/60 mmHg. Initial blood tests show: glucose 2.9 mmol/l, sodium (Na+) 126 mmol/l, potassium (K+) 4.9 mmol/l, urea 8.2 mmol/l, creatinine 117 µmol/l.
Which of the following is the most likely diagnosis?Your Answer: Addison’s disease
Explanation:Medical Conditions: Addison’s Disease and Other Differential Diagnoses
Addison’s Disease:
Addison’s disease, or primary hypoadrenalism, is a condition characterized by chronic adrenal insufficiency. The most common cause in the UK is autoimmune destruction of the adrenals, while worldwide tuberculosis is the most common cause. Other causes include long-term exogenous steroid use, cancer, or haemorrhage damage. Symptoms develop gradually, but patients can present in Addisonian crisis if there is a sudden deterioration in adrenal function or a physiological stress that the residual adrenal function is not capable of coping with. Treatment is with long-term replacement of corticosteroids and aldosterone. Treatment of a crisis requires intravenous glucocorticoids, as well as supportive measures and fluid resuscitation.Differential Diagnoses:
Peutz–Jeghers syndrome is an autosomal dominant condition characterized by perioral freckling and small bowel polyps. Insulinoma causes hypoglycaemia, but the other features are absent. Cushing syndrome is a result of excess corticosteroid, while Conn syndrome is also known as primary hyperaldosteronism. -
This question is part of the following fields:
- Endocrinology
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Question 30
Correct
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A 32-year-old woman who has three children presents to the general practice clinic with complaints of feeling tired and overwhelmed. She had previously been prescribed citalopram for about 6 months after the birth of her first child. Her medical history includes the use of depo progesterone for contraception, which she believes is hindering her ability to lose weight. On examination, her BMI is 29 and her blood pressure is 142/72 mmHg. Laboratory tests reveal a slightly elevated TSH level of 4.5 µU/l. Based on these findings, what is the most likely diagnosis?
Your Answer: Subclinical hypothyroidism
Explanation:Understanding Thyroid Function and Sub-Clinical Hypothyroidism
Thyroid function can be assessed through the levels of thyroid-stimulating hormone (TSH) and free T4 in the blood. Subclinical hypothyroidism is diagnosed when TSH is mildly elevated, while free T4 remains within the normal range. This indicates that the thyroid is working hard to produce even this amount of T4. Treatment with thyroxine replacement is debated and usually reserved for patients with symptoms and thyroid autoantibodies.
Hypothyroidism is diagnosed when free T4 levels fall below the minimum range, while thyrotoxicosis is ruled out when free T4 is not raised and there are no symptoms. Depression may be a plausible diagnosis, but an elevated TSH level suggests otherwise. Sick euthyroid syndrome may occur in critically ill patients and involves abnormal levels of free T4 and T3 despite seemingly normal thyroid function.
Overall, understanding thyroid function and sub-clinical hypothyroidism can help guide appropriate diagnosis and treatment decisions.
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This question is part of the following fields:
- Endocrinology
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