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Question 1
Correct
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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: 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 2
Correct
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A 65-year-old male with a diagnosis of lung cancer presents with fatigue and lightheadedness. Upon examination, the following results are obtained:
Plasma sodium concentration 115 mmol/L (137-144)
Potassium 3.5 mmol/L (3.5-4.9)
Urea 3.2 mmol/L (2.5-7.5)
Creatinine 67 µmol/L (60-110)
What is the probable reason for his symptoms based on these findings?Your Answer: Syndrome of inappropriate ADH secretion
Explanation:Syndrome of Inappropriate ADH Secretion
Syndrome of inappropriate ADH secretion (SIADH) is a condition characterized by low levels of sodium in the blood. This is caused by the overproduction of antidiuretic hormone (ADH) by the posterior pituitary gland. Tumors such as bronchial carcinoma can cause the ectopic elaboration of ADH, leading to dilutional hyponatremia. The diagnosis of SIADH is one of exclusion, but it can be supported by a high urine sodium concentration with high urine osmolality.
Hypoadrenalism is less likely to cause hyponatremia, as it is usually associated with hyperkalemia and mild hyperuricemia. On the other hand, diabetes insipidus is a condition where the kidneys are unable to reabsorb water, leading to excessive thirst and urination.
It is important to diagnose and treat SIADH promptly to prevent complications such as seizures, coma, and even death. Treatment options include fluid restriction, medications to block the effects of ADH, and addressing the underlying cause of the condition.
In conclusion, SIADH is a condition that can cause low levels of sodium in the blood due to the overproduction of ADH. It is important to differentiate it from other conditions that can cause hyponatremia and to treat it promptly to prevent complications.
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This question is part of the following fields:
- Endocrinology
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Question 3
Correct
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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: 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 4
Incorrect
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A 35-year-old teacher presents at the Thyroid Clinic with a swelling in her neck that has been present for 4 months, along with a weight loss of 5 kg. During examination, a diffuse smooth swelling of the thyroid gland is observed, and she is found to be in atrial fibrillation. Lid lag and proximal myopathy are also noted, along with a rash on the anterior aspects of her legs, indicative of pretibial myxoedema. Which clinical sign is most indicative of Graves' disease as the underlying cause of her hyperthyroidism?
Your Answer: Diffuse thyroid swelling
Correct Answer: Pretibial myxoedema
Explanation:Most Specific Sign of Graves’ Disease
Graves’ disease is a type of hyperthyroidism that has a classic triad of signs, including thyroid ophthalmopathy, thyroid acropachy, and pretibial myxoedema. Among these signs, pretibial myxoedema is the most specific to Graves’ disease. It is characterized by swelling and lumpiness of the shins and lower legs, and is almost pathognomonic of the condition. Other signs of hyperthyroidism, such as weight loss and diffuse thyroid swelling, are non-specific and may occur with other thyroid diseases. Atrial fibrillation and proximal myopathy may also occur in Graves’ disease, but are not specific to this condition.
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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 25-year-old male patient arrives at the emergency department with symptoms of vomiting and dehydration. He reports a two-month history of weight loss and excessive thirst. Upon examination, the patient is diagnosed with diabetic ketoacidosis, with a blood glucose level of 29.3 mmol/L (3.0-6.0), a pH of 7.12 (7.36-7.44) on blood gas analysis, and +++ ketones in the urine. What is the percentage of individuals with type 1 diabetes who are initially diagnosed after presenting with diabetic ketoacidosis?
Your Answer: 25%
Explanation:Diabetic Ketoacidosis: A Dangerous Complication of Type 1 Diabetes
Approximately one quarter of patients with type 1 diabetes will experience their first symptoms in the form of diabetic ketoacidosis (DKA). However, it is important to note that these individuals may have previously ignored symptoms such as thirst, frequent urination, and weight loss. DKA is a serious and potentially life-threatening complication of diabetes that is characterized by high blood sugar levels, lactic acidosis, vomiting, and dehydration. It is crucial for individuals with type 1 diabetes to be aware of the signs and symptoms of DKA and seek medical attention immediately if they suspect they may be experiencing this condition. Proper management and treatment of DKA can help prevent serious complications and improve overall health outcomes.
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This question is part of the following fields:
- Endocrinology
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Question 6
Incorrect
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A 65-year-old woman is referred to the Diabetes Clinic with a new diagnosis of type 2 diabetes mellitus. She has a body mass index (BMI) of 34 kg/m2. Her finger-prick blood glucose test is 9 mmol/l. She has a past history of ischaemic heart disease and chronic kidney disease. Her medications include ramipril 10 mg daily, atorvastatin 40 mg, aspirin 75 mg and bisoprolol 5 mg. Her laboratory test results are as follows:
Investigation Result Normal range
HbA1C 61 mmol/mol < 53 mmol/mol (<7.0%)
Creatinine 178 µmol/l 50–120 µmol/l
Glomerular filtration rate (GFR) 26 ml/min > 90 ml/min
Which of the following drugs would be the most appropriate to manage this patient’s diabetes?Your Answer: Gliclazide
Correct Answer: Linagliptin
Explanation:Common Anti-Diabetic Medications and Their Mechanisms of Action
Linagliptin: This medication is a DPP-4 inhibitor that works by blocking the degradation of GLP-1, which increases insulin secretion and lowers blood sugar levels.
Glargine insulin: Glargine is a long-acting insulin that is preferred for people needing baseline control of sugar throughout the day and those at risk of hypoglycaemia. It has a lower risk of causing hypoglycaemia compared to other insulin types and may cause weight gain.
Rosiglitazone: This thiazolidinedione medication is an agonist for the peroxisome proliferator-activated receptors and is used for diabetes control. However, it can exacerbate heart conditions and cause weight gain, and is no longer recommended by BNF due to increased risk of heart attacks.
Metformin: This biguanide medication is commonly used as first-line treatment for diabetes, but its use is limited by gastrointestinal upset and is contraindicated in patients with poor renal function and low GFR.
Gliclazide: This sulfonylurea medication is an insulin secretagogue that stimulates the release of insulin. It is often used as a second-line medication, but its use is limited by the risk of hypoglycaemia and weight gain.
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This question is part of the following fields:
- Endocrinology
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Question 7
Incorrect
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What is the accurate description of growth hormone (GH) and its role in normal growth?
Your Answer: It has a proinsulin-like effect in addition to its other actions
Correct Answer: It stimulates cartilage and bone growth via somatomedin C
Explanation:Functions and Characteristics of Growth Hormone
Growth hormone (GH) plays a crucial role in stimulating cartilage and bone growth through the production of somatomedin C, also known as insulin-like growth factor 1 (IGF-1). While GH has direct effects throughout the body, its receptors have a limited distribution outside the central nervous system (CNS). GH is secreted in a pulsatile manner, with its concentration peaking during sleep. The synthesis of GH is stimulated by the action of somatostatin, which inhibits its release and is sometimes referred to as ‘growth hormone-inhibiting hormone’. In addition to its other actions, GH has a proinsulin-like effect, which is in contrast to its anti-insulin-like effects, such as promoting gluconeogenesis.
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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 35-year-old man is referred by his GP to the endocrine clinic after a blood test revealed hypercalcaemia. The man originally presented to his GP following episodes of abdominal pain and loin pain.
A thorough history from the patient reveals that his father had similar symptoms which started at the age of 49 but he later passed away from a pancreatic tumour. The patient’s grandfather also had a high calcium level, but the patient does not remember what happened to him. The Endocrinologist explains to the patient that he suffers from a disease which runs in the family and part of his treatment would involve the surgical removal of the majority of the parathyroid glands.
Which of the following should this patient also be considered at risk of?Your Answer: Phaeochromocytoma
Correct Answer: Pancreatic islet cell tumour
Explanation:The patient’s hypercalcaemia is due to a parathyroid gland issue, not a germ cell tumour of the testis, which is not related to the MEN syndromes. Pineal gland tumours can cause sleep pattern abnormalities, but this is not the case for this patient. Phaeochromocytoma, a tumour of the adrenal glands, typically presents with headaches, high blood pressure, palpitations, and anxiety, and is part of MEN 2a and 2b, but not MEN 1. Thyroid medullary carcinoma, which is part of MEN 2a and 2b, presents with diarrhoea and often metastasises by the time of diagnosis, but is not associated with MEN 1. Pancreatic islet cell tumours, also known as pancreatic neuroendocrine tumours, are part of MEN 1 and can cause hypoglycaemia if they arise from insulin-producing cells. These tumours can be benign or malignant, with the majority being benign. MEN syndromes are rare and characterised by adenomas and adenocarcinomas, with specific pathologies varying depending on the type of MEN syndrome.
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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 52-year-old woman presents with complaints of irregular periods, weight loss, and excessive sweating. She reports that her symptoms have been gradually worsening over the past few months and she also experiences itching. During the examination, her blood pressure is measured at 140/80 mmHg and her resting pulse is 95 bpm.
What is the most suitable test to perform for this patient?Your Answer: Thyroid-stimulating hormone (TSH) and T4 levels
Explanation:Investigations for Suspected Endocrine Disorder
When a patient presents with signs and symptoms of an endocrine disorder, several investigations may be necessary to confirm the diagnosis. Here are some tests that may be useful in different scenarios:
Thyroid-stimulating hormone (TSH) and T4 levels: These tests are essential when thyrotoxicosis is suspected. In rare cases, pruritus may also occur as a symptom.
Plasma renin and aldosterone levels: This investigation may be useful if Conn syndrome is suspected, but it is not necessary in patients without significant hypertension. Electrolyte levels should be checked before this test.
Full blood count and ferritin levels: These tests may be helpful in checking for anaemia, but they are less appropriate than TSH/T4 levels.
Midnight cortisol level: This test is useful when Cushing’s syndrome is suspected. In this case, the only symptom that is compatible with this disorder is irregular menses.
Test the urine for 24-hour free catecholamines: This test is used to investigate suspected phaeochromocytoma, which can cause similar symptoms to those seen in this case. However, hypertension is an important feature that is not present in this patient.
In conclusion, the choice of investigations depends on the suspected endocrine disorder and the patient’s clinical presentation.
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This question is part of the following fields:
- Endocrinology
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Question 10
Correct
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What is an example of an exocrine function of the pancreas?
Your Answer: Secretion of amylase
Explanation:Functions of Digestive Enzymes and Hormones
Amylase is an enzyme that aids in the digestion of carbohydrates. It is present in both pancreatic juices and saliva. The exocrine function of the pancreas involves the secretion of substances into ducts that ultimately pass to the exterior of the body. Examples of exocrine glands include sweat glands, salivary glands, and mammary glands. On the other hand, the endocrine function of the pancreas involves the secretion of substances directly into the bloodstream. Insulin, which is secreted from the beta cells of the islets of Langerhans of the pancreas, is an example of an endocrine function.
Bile is another substance that aids in digestion. It is secreted by hepatocytes and stored in the gallbladder. Following a meal, bile is released to aid in the digestion of fats. Intrinsic factor, which is secreted by the parietal cells of the stomach, is responsible for binding vitamin B12 to allow its absorption in the terminal ileum. Finally, noradrenaline is a hormone that is released by the adrenal medulla. It plays a role in the body’s fight or flight response.
In summary, the digestive system relies on a variety of enzymes and hormones to function properly. These substances are secreted by various glands and organs throughout the body, and they work together to break down food and absorb nutrients.
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This question is part of the following fields:
- Endocrinology
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Question 11
Correct
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A patient in their 60s presents with lethargy, weight loss and fainting episodes. In the Emergency Department, a postural drop in blood pressure is noted of >20 mmHg systolic from the supine to the standing position. Blood glucose is 2.9 mmol/l and Na+ is 122 mmol/l.
Which of the following is the patient’s condition due to?Your Answer: Decreased cortisol; decreased aldosterone
Explanation:Understanding Addison’s Disease: Hormonal Imbalances and Clinical Presentation
Addison’s disease, or primary adrenal failure, is a condition characterized by autoimmune destruction of the adrenal cortex, resulting in reduced levels of cortisol and aldosterone. This hormonal imbalance leads to a range of clinical symptoms, including hypotension, hyponatraemia, hyperkalaemia, acidosis, and skin and mucosal hyperpigmentation.
While other hormonal imbalances may occur in the adrenal glands, such as increased cortisol or aldosterone, they are less likely to result in the clinical presentation of Addison’s disease. For example, increased cortisol is unlikely due to autoimmune destruction of the zona fasciculata, while increased aldosterone is rare and typically caused by an adrenal adenoma. Similarly, decreased cortisol with normal aldosterone is more commonly associated with secondary adrenal failure caused by pituitary disease, but does not fit with the hyponatraemia seen in Addison’s disease.
Overall, understanding the hormonal imbalances and clinical presentation of Addison’s disease is crucial for accurate diagnosis and effective treatment.
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This question is part of the following fields:
- Endocrinology
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Question 12
Correct
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A 26-year-old professional athlete is being evaluated at the Endocrinology Clinic for presenting symptoms of low mood, decreased energy, and difficulty in preserving muscle mass. The patient also reports dry skin and hair loss. As part of the diagnostic process, the doctor requests a glucagon stimulation test.
What is elevated after the glucagon stimulation test?Your Answer: C-peptide, cortisol and growth hormone
Explanation:Glucagon and Hormone Production: Effects on C-peptide, Cortisol, Growth Hormone, and TSH
Glucagon, a hormone produced by the pancreas, has various effects on hormone production in the body. One of these effects is the stimulation of insulin and C-peptide production. C-peptide is cleaved from proinsulin during insulin production, and its levels can be used to measure insulin secretion. Glucagon also indirectly stimulates cortisol production by causing the release of adrenocorticotropic hormone (ACTH) via the hypothalamus. Additionally, glucagon can stimulate growth hormone production, making it an alternative test for measuring growth hormone levels. However, thyroid-stimulating hormone (TSH) secretion is not affected by glucagon injection. Understanding the effects of glucagon on hormone production can aid in the diagnosis and management of various endocrine disorders.
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This question is part of the following fields:
- Endocrinology
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Question 13
Correct
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A 27-year-old woman visits her GP complaining of experiencing sweating, agitation, palpitations, and restlessness for the past three days. She gave birth to a healthy baby through vaginal delivery at 39 weeks gestation two months ago. The patient has a medical history of coeliac disease. The following investigations were conducted:
Thyroid-stimulating hormone (TSH) 0.1 mU/L (0.5-5.5)
Free thyroxine (T4) 26 pmol/L (9.0 - 18)
What is the next appropriate step in managing this patient?Your Answer: Prescribe propranolol
Explanation:The appropriate management for the thyrotoxicosis phase of postpartum thyroiditis is prescribing propranolol for symptomatic relief. This patient’s presentation of hyperthyroidism 2 months postpartum suggests postpartum thyroiditis, which is typically self-resolving. Propranolol is the most suitable option for managing the symptoms of this condition. Prescribing NSAIDs and monitoring would be more appropriate for subacute (de Quervain’s) thyroiditis, which is not the case here. Prescribing carbimazole or levothyroxine would not be necessary or appropriate for this patient’s condition.
Understanding Postpartum Thyroiditis: Stages and Management
Postpartum thyroiditis is a condition that affects some women after giving birth. It is characterized by three stages: thyrotoxicosis, hypothyroidism, and normal thyroid function. During the thyrotoxicosis phase, the thyroid gland becomes overactive, leading to symptoms such as anxiety, palpitations, and weight loss. In the hypothyroidism phase, the thyroid gland becomes underactive, causing symptoms such as fatigue, weight gain, and depression. However, in the final stage, the thyroid gland returns to normal function, although there is a high recurrence rate in future pregnancies.
Thyroid peroxidase antibodies are found in 90% of patients with postpartum thyroiditis, which suggests an autoimmune component to the condition. Management of postpartum thyroiditis depends on the stage of the condition. During the thyrotoxic phase, symptom control is the main focus, and propranolol is typically used. Antithyroid drugs are not usually used as the thyroid gland is not overactive. In the hypothyroid phase, treatment with thyroxine is usually necessary to restore normal thyroid function.
It is important to note that many causes of hypothyroidism may have an initial thyrotoxic phase, as shown in a Venn diagram. Therefore, it is crucial to properly diagnose and manage postpartum thyroiditis to ensure the best possible outcomes for both the mother and the baby.
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This question is part of the following fields:
- Endocrinology
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Question 14
Incorrect
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A 35-year-old woman with a body mass index of 33 kg/m2 has a fasting blood sugar of 10 mmol/l and 11.7 mmol/l on two separate occasions. Her family history includes diabetes mellitus in her father and maternal uncle. Despite attempting to lose weight through diet and exercise, she has been unsuccessful in achieving a balanced diet. She is open to taking either orlistat or an anorexigenic agent. Further investigation reveals that her blood insulin level tends to be relatively high.
What is the most likely hormonal change to be observed in this patient?Your Answer: Increased cortisol
Correct Answer: Reduced adiponectin
Explanation:Endocrine Factors Predisposing to Type II Diabetes Mellitus
Type II diabetes mellitus is a metabolic disorder characterized by insulin resistance and high blood sugar levels. Several endocrine factors can predispose individuals to this condition. In obese patients with a positive family history of diabetes, adiponectin levels are reduced. Adiponectin is a hormone secreted by adipocytes that plays a role in glucose metabolism. In contrast, leptin levels are increased in these patients and usually correlate with the degree of insulin resistance. Growth hormone levels are increased in acromegaly, which can also predispose individuals to type II diabetes. Phaeochromocytoma, a rare tumor of the adrenal gland, can cause increased epinephrine levels and predispose individuals to diabetes. Similarly, Cushing syndrome, a condition characterized by increased cortisol levels, can also predispose individuals to type II diabetes. Understanding these endocrine factors can help clinicians identify individuals at risk for type II diabetes and implement appropriate preventive measures.
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This question is part of the following fields:
- Endocrinology
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Question 15
Correct
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You are asked to review a 27-year-old man who has had two episodes of pancreatitis. On reviewing his notes, the surgeons noticed that he appeared to have had a serum calcium of 3.2 mmol/l when it was checked at the general practice surgery a few weeks before the latest episode. Urinary calcium excretion is markedly reduced.
Which of the following diagnoses fits best with this clinical picture?Your Answer: Familial hypocalciuric hypercalcaemia
Explanation:Differentiating Hyper- and Hypocalcaemia Disorders
One young male patient has experienced two episodes of pancreatitis due to hypercalcaemia. However, his urinary calcium levels are reduced, which suggests that he may have familial hypocalciuric hypercalcaemia. On the other hand, pseudohypoparathyroidism would result in hypocalcaemia, while hyperparathyroidism would cause hypercalcaemia without reducing urinary calcium excretion. Hypoparathyroidism would also lead to hypocalcaemia, but the calcium levels would be raised. Finally, Paget’s disease would not affect urinary calcium excretion. Therefore, it is crucial to differentiate between these disorders to provide appropriate treatment.
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This question is part of the following fields:
- Endocrinology
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Question 16
Incorrect
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A 55-year-old man is scheduled for colorectal carcinoma resection and has type 2 diabetes. He is currently well-controlled on 5 mg glibenclamide daily. What is the best pre-operative plan for managing his blood sugar levels?
Your Answer: Continue glibenclamide at current dose
Correct Answer: Stop glibenclamide on the morning of surgery and commence insulin by intravenous infusion
Explanation:Management of Glibenclamide in a Patient Undergoing Major Surgery
During major surgery, it is crucial to maintain optimal glycaemic control in patients with diabetes. In the case of a patient taking glibenclamide, the most appropriate course of action is to discontinue the medication on the morning of surgery. Instead, the patient should be started on intravenous (IV) insulin and dextrose with potassium. This approach allows for frequent blood glucose measurements and adjustment of the insulin infusion rate as needed.
By stopping glibenclamide, the risk of hypoglycaemia during surgery is reduced. IV insulin and dextrose with potassium provide a more controlled and predictable method of glycaemic control during the stress of surgery. This approach ensures that the patient’s blood glucose levels remain within a safe range, reducing the risk of complications such as infection, delayed wound healing, and poor surgical outcomes.
In summary, the management of glibenclamide in a patient undergoing major surgery involves discontinuing the medication on the morning of surgery and starting the patient on IV insulin and dextrose with potassium. This approach allows for optimal glycaemic control during the stress of surgery and reduces the risk of complications.
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This question is part of the following fields:
- Endocrinology
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Question 17
Incorrect
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A 72-year-old woman takes medication for hypertension and raised cholesterol. At her annual check-up, she reports that she is feeling well. Among the results of her blood tests are the following: serum calcium 2.90 mmol/l (2.1–2.8 mmol/l), serum phosphate 0.80 mmol/l (1.0–1.5 mmol/l) and alkaline phosphatase 215 iu/l (53–128 iu/l).
Which of the following is the most likely explanation of these results in this woman?Your Answer: Paget's disease of bone
Correct Answer: Primary hyperparathyroidism
Explanation:Differential diagnosis for hypercalcaemia with hypophosphataemia and normal alkaline phosphatase
Primary hyperparathyroidism is a common cause of hypercalcaemia, often detected incidentally on routine blood tests. In this condition, the parathyroid glands produce excessive amounts of parathyroid hormone, which increases calcium reabsorption from bones and kidneys and decreases phosphate reabsorption from kidneys. As a result, patients may have elevated serum calcium and low serum phosphate levels, but normal or slightly elevated alkaline phosphatase levels.
Other possible causes of hypercalcaemia with hypophosphataemia and normal alkaline phosphatase include occult malignancy, especially if it involves bone, but this would usually result in a higher alkaline phosphatase level. Paget’s disease of bone, a chronic disorder of bone remodeling, may also cause hypercalcaemia, but it typically presents with a much higher alkaline phosphatase level as a marker of bone destruction.
Thyrotoxicosis, a condition of excess thyroid hormone, can also lead to hypercalcaemia, but this patient has no symptoms suggestive of hyperthyroidism. Phaeochromocytoma, a rare tumor of the adrenal gland that secretes catecholamines, may cause hypertension, but it is not typically associated with hypercalcaemia or hypophosphataemia.
Therefore, the most likely diagnosis in this case is primary hyperparathyroidism, which may be part of a multiple endocrine neoplasia (MEN) type 2 syndrome that also involves the thyroid gland and adrenal medulla. Further evaluation, including imaging studies and genetic testing, may be necessary to confirm the diagnosis and guide management.
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This question is part of the following fields:
- Endocrinology
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Question 18
Correct
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What is the underlying cause of primary hyperthyroidism associated with Graves' disease?
Your Answer: Anti-TSH receptor antibodies
Explanation:Graves’ Disease
Graves’ disease is a medical condition that is characterized by the presence of anti-TSH receptor antibodies that stimulate the thyroid gland. This results in hyperthyroidism and a diffusely enlarged thyroid gland, also known as a goitre. Patients with Graves’ disease may also experience other symptoms such as exophthalmos, which is the protrusion of the eyes, lid retraction, lid lag, and ophthalmoplegia.
It is important to note that Graves’ disease is often associated with other autoimmune diseases such as vitiligo, Addison’s disease, and type 1 diabetes. This means that patients with Graves’ disease may be at a higher risk of developing these conditions as well.
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This question is part of the following fields:
- Endocrinology
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Question 19
Correct
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Under what circumstances would the bone age match the chronological age?
Your 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 20
Correct
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A 67-year-old woman is brought to Accident and Emergency after being found near-unconscious by her daughter. Her daughter indicates that she has a long-term joint disorder that has been controlled with oral medication and uses steroids excessively. She has recently been suffering from depression and has had poor compliance with medications. On examination, she is responsive to pain. Her pulse is 130 bpm and blood pressure is 90/60 mmHg. She is afebrile.
Basic blood investigations reveal:
Investigation Patient Normal value
Haemoglobin 121 g/l 135–175 g/l
White cell count (WCC) 6.1 × 109/l 4–11 × 109/l
Platelets 233 × 109/l 150–400 × 109/l
Sodium (Na+) 129 mmol/l 135–145 mmol/l
Potassium (K+) 6.0 mmol/l 3.5–5.0 mmol/l
Creatinine 93 μmol/l 50–120 µmol/l
Glucose 2.7 mmol/l <11.1 mmol/l (random)
What is the most likely diagnosis?Your Answer: Addisonian crisis
Explanation:Differential Diagnosis: Addisonian Crisis and Other Conditions
Addisonian crisis is a condition caused by adrenal insufficiency, often due to autoimmune disease or other factors such as tuberculosis or adrenal haemorrhage. Symptoms are vague and insidious, including weight loss, depression, anorexia, and gastrointestinal upset. Diagnosis is made through a short ACTH stimulation test. Emergency treatment involves IV hydrocortisone and fluids, while long-term treatment involves oral cortisol and mineralocorticoid. Any stressful activity should lead to an increase in steroid dosage.
Other conditions, such as insulin overdose, salicylate overdose, meningococcal septicaemia, and paracetamol overdose, may present with similar symptoms but can be ruled out based on the clinical information given. Insulin overdose can cause low glucose levels due to loss of the anti-insulin effect of cortisol. Salicylate overdose can cause a range of symptoms, but the ones described here are not suggestive of this condition. Meningococcal septicaemia may present with hypotension and tachycardia, but the remaining features do not fit this diagnosis. Paracetamol overdose typically presents with liver toxicity symptoms, which are not described in the given information. Therefore, the specific symptoms described are indicative of an Addisonian crisis.
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This question is part of the following fields:
- Endocrinology
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Question 21
Correct
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A 50-year-old woman from the UK presents with lethargy, and dizziness when she gets out of bed in the mornings and stands from sitting. She has noticed that her appetite has been reduced for the last month but has not noticed any weight loss. On examination you notice that she has an area of hypopigmented skin on her back, but hyperpigmented skin around her mouth, and you suspect a diagnosis of Addison’s disease.
What is the most common cause of Addison’s disease in the UK?Your Answer: Autoimmune destruction
Explanation:Addison’s disease is most commonly caused by autoimmune destruction in the UK, accounting for up to 80% of cases. Therefore, it is crucial to screen individuals with Addison’s for other autoimmune conditions like thyroid diseases and diabetes. Congenital adrenal hyperplasia is a rare cause of Addison’s that typically presents in childhood with symptoms such as failure to thrive and grow. While tuberculosis is the most common cause of Addison’s worldwide, it is not the primary cause in the UK. Adrenal haemorrhage, which can result from severe bacterial infections like meningococcal, can also lead to Addison’s disease in a condition known as Waterhouse-Friderichsen syndrome. Finally, metastatic cancer is a rare but significant cause of addisonism.
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This question is part of the following fields:
- Endocrinology
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Question 22
Correct
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Which type of tumor is typically linked to a paraneoplastic syndrome?
Your Answer: Bronchial carcinoma
Explanation:Paraneoplastic Syndromes
Paraneoplastic syndromes are commonly linked to certain types of cancer, such as bronchial carcinoma, pancreatic carcinoma, breast carcinoma, and renal cell carcinoma. These syndromes are characterized by clinical effects that are associated with the presence of a neoplasm, but are not directly related to the infiltration of the primary tumor or its metastases. Paraneoplastic syndromes may or may not be caused by hormone secretion.
One example of a paraneoplastic syndrome is Cushing’s syndrome, which can occur in association with small cell bronchial carcinoma due to the secretion of ectopic ACTH. Another example is hypercalcemia, which can occur in the absence of bony metastases and may be caused by the secretion of a PTH-related peptide. Other paraneoplastic syndromes include myopathy and cerebellar ataxia.
In summary, paraneoplastic syndromes are a group of clinical effects that are associated with the presence of a neoplasm but are not directly related to the tumor itself. These syndromes can be caused by hormone secretion or other factors and can occur in a variety of cancer types.
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This question is part of the following fields:
- Endocrinology
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Question 23
Correct
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On a set of MRI scans being examined for a 21-year-old woman suspected of having Cushing syndrome due to weight gain and excess facial hair, which structure would be found posterior to the left suprarenal (adrenal) gland?
Your Answer: Crus of diaphragm
Explanation:Anatomy of the Posterior Abdominal Wall
The posterior abdominal wall is a complex structure consisting of various muscles, fascia, and organs. Here are some key components:
Crus of Diaphragm: The left suprarenal (adrenal) gland is located in the posterior abdomen and is enclosed by the perirenal fascia, which attaches it to the left crus of the diaphragm. The left crus is a tendinous structure arising from the anterior bodies of the L1 and L2 vertebrae.
Psoas Major Muscle: This muscle is responsible for the lateral flexion of the lumbar spine and assists in the stabilization and flexion of the hip. It is found in the posterior abdomen, bound by fascia.
Quadratus Lumborum Muscle: This quadrilateral muscle is associated with the lateral flexion and extension of the vertebral column. It is located posteriorly to the colon, kidney, psoas muscle, and diaphragm.
Transversus Abdominis Muscle: This is the innermost muscle forming the anterior abdominal muscles, lying posterior to the internal oblique and anterior to the transversalis fascia.
Thoracolumbar Fascia: This diamond-shaped fascia encloses the intrinsic muscles of the back and is affected in piriformis syndrome and sacro-iliac joint pains. It is not anatomically associated with the adrenal glands.
Understanding the Posterior Abdominal Wall Anatomy
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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 57-year-old man comes in for his yearly check-up with his GP. He has a history of type 2 diabetes and hypertension. Upon physical examination, there are no notable findings and no signs of fluid overload. His blood pressure is 126/84 mmHg, and his heart rate is 67 bpm. A urine dipstick test shows only 1+ protein.
The results of his routine blood panel are as follows:
- Haemoglobin: 139 g/L (125-175)
- White cell count: 5.7 ×109/L (4-11)
- Mean cell volume: 82 fL (75-100)
- Platelets: 359 ×109/L (150-400)
- Sodium: 137 mmol/L (135-145)
- Potassium: 4.8 mmol/L (3.5-5.5)
- Urea: 8.9 mmol/L (2-7)
- Creatinine: 169 μmol/ (75-110)
- Glucose: 6.7 mmol/L (4-7)
- HbA1c: 48 mmol/mol (42-53)
- eGFR: 29 ml/min (>60)
- Lactate: 2.4 mmol/L (0.5-2)
- Venous pH: 7.35 (7.35-7.45)
Currently, the patient is taking aspirin 75 mg daily, bisoprolol 5 mg daily, gliclazide 80 mg twice daily, metformin 1 g twice daily, and ramipril 2.5 mg daily. Based on this information, which medication should be discontinued?Your Answer: Metformin
Explanation:Medications and Renal Impairment
Metformin is a commonly used oral antidiabetic drug that inhibits hepatic gluconeogenesis, making it a first-line agent in the treatment of type 2 diabetes. However, it should be closely monitored in patients with impaired renal function due to the risk of developing lactate acidosis. Current guidelines recommend avoiding metformin in renal impairment if possible, reducing the dose if eGFR is less than 45 ml/min, and discontinuing it if less than 30 ml/min. Gliclazide, another antidiabetic drug, stimulates insulin release and is mostly cleared by the liver, but should be avoided in severe renal impairment and monitored in mild to moderate cases. Ramipril, an ACE inhibitor used in hypertension and heart failure, is beneficial in delaying diabetic nephropathy but may require dose adjustments in established renal impairment. Aspirin, commonly used in cardiovascular pathologies, should be avoided in severe renal failure but can be continued in moderate impairment. Bisoprolol, a cardio-specific beta-blocker, is safe to continue in renal impairment, with dose adjustments only needed when eGFR is less than 20 ml/min.
Overall, it is important to closely monitor medication use in patients with renal impairment and adjust doses or discontinue use as necessary to prevent adverse effects.
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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 mother brings her 9-month-old baby to clinic for a check-up. His prior medical history has been unremarkable and his immunisations are up-to-date. The mother is concerned about his growth. After you determine that the baby has grown appropriately since the last visit and is unchanged from the 50th centile, you provide the mother with advice regarding growth.
What signalling pathway does growth hormone (GH) use?Your Answer: By binding to the same class of receptor as aldosterone
Correct Answer: A tyrosine kinase receptor that uses the JAK/STAT pathway
Explanation:Comparison of Second Messenger Systems and Receptor Types in Hormonal Signaling
Hormones utilize various signaling pathways to transmit their messages to target cells. One important aspect of hormonal signaling is the use of second messengers, which relay the hormone signal from the cell surface to the intracellular environment. Here, we compare and contrast the second messenger systems and receptor types used by different hormones.
Growth hormone (GH) and prolactin both use the tyrosine kinase receptor, followed by activation of Janus kinase (JAK), signal transduction, and activation of transcription (STAT). In contrast, platelet-derived growth factor (PDGF), fibroblast growth factor (FGF), insulin-like growth factor 1 (IGF-1), and insulin use the MAP kinase or RAS system. Aldosterone uses steroid receptors, while GH uses the tyrosine kinase receptor.
Inositol trisphosphate (IP3) works as a second messenger for hypothalamic hormones such as gonadotropin-releasing hormone (GnRH), growth hormone-releasing hormone (GHRH), thyrotropin-releasing hormone (TRH), and pituitary hormones such as antidiuretic hormone (ADH) and oxytocin.
Cyclic guanosine monophosphate (cGMP) is a second messenger that activates protein kinases and mediates endothelium-derived relaxing factor (EDRF), atrial natriuretic peptide (ANP), and nitric oxide.
Cyclic adenosine monophosphate (cAMP) is a second messenger of follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroid-stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), human chorionic gonadotropin (hCG), and several other hormones, but not GH.
In summary, different hormones use distinct second messenger systems and receptor types to transmit their signals, highlighting the complexity and diversity of hormonal signaling pathways.
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This question is part of the following fields:
- Endocrinology
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Question 26
Correct
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A 21-year-old university student complains of a 2-month history of tiredness and weight loss. On further questioning the patient reveals that they have been excessively thirsty and have also been passing urine many times during the day and night. The patient is investigated further and is diagnosed with having type 1 diabetes mellitus.
Which of the following is deficient in this condition?Your Answer: Beta-islet cells
Explanation:The Different Types of Islet Cells in the Pancreas
The pancreas contains clusters of endocrine tissue called islets of Langerhans. These islets are composed of different types of cells that secrete various hormones. The most abundant type of islet cell is the beta-islet cell, which produces insulin. Insulin is essential for regulating blood sugar levels, and its deficiency is the hallmark of type 1 diabetes.
Gamma-islet cells, also known as pancreatic polypeptide-producing cells, make up a small percentage of islet cells and are not involved in insulin production. Alpha-islet cells, on the other hand, are located at the periphery of the islets and secrete glucagon, which raises blood sugar levels. Delta-islet cells produce somatostatin, a hormone that inhibits the release of insulin and glucagon.
Lastly, epsilon-islet cells produce ghrelin, a hormone that stimulates appetite. However, these cells make up less than 1% of the islet cells and are not as well understood as the other types.
In summary, the different types of islet cells in the pancreas play crucial roles in regulating blood sugar levels and other metabolic processes. Understanding their functions and interactions is essential for developing effective treatments for diabetes and other metabolic disorders.
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This question is part of the following fields:
- Endocrinology
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Question 27
Correct
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What is the probable diagnosis for a 15-year-old girl who experiences recurring pelvic pain but has not yet begun menstruating?
Your Answer: Haematocolpos
Explanation:Haematocolpos: A Condition of Blood Accumulation in the Vagina
Haematocolpos is a medical condition characterized by the accumulation of blood in the vagina. This condition is usually caused by an imperforate hymen, which prevents menstrual blood from flowing out of the body. As a result, the blood accumulates in the vagina, leading to discomfort and pain. Haematocolpos is a rare condition that affects mostly young girls who have not yet started menstruating. It can also occur in women who have undergone surgery to remove the cervix or uterus. Treatment for haematocolpos usually involves surgical intervention to remove the blockage and allow the blood to flow out of the body. With prompt diagnosis and treatment, most women with haematocolpos can recover fully and resume their normal activities.
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This question is part of the following fields:
- Endocrinology
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Question 28
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 29
Incorrect
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A 55-year-old male presents at a well man clinic. He has a significant family history of ischaemic heart disease and is a smoker of 10 cigarettes per day. He also consumes approximately 20 units of alcohol per week. On examination, he is found to be obese with a BMI of 32 kg/m2 and has a blood pressure of 152/88 mmHg. His investigations reveal a fasting plasma glucose of 10.5 mmol/L (3.0-6.0), HbA1c of 62 mmol/mol (20-46), and a cholesterol concentration of 5.5 mmol/L (<5.2).
Which intervention would be most effective in reducing his cardiovascular risk?Your Answer: Improve glycaemic control with metformin
Correct Answer: Stop smoking
Explanation:Managing Hypertension and Diabetes for Cardiovascular Risk Reduction
This patient is diagnosed with hypertension and diabetes, as indicated by the elevated fasting plasma glucose. While metformin has been found to reduce cardiovascular (CV) mortality in obese diabetics, ramipril reduces CV risk in hypertensive diabetics, and statins reduce CV mortality, none of these interventions are as effective as quitting smoking in reducing CV risk. The Nurses’ Health Study provides the best evidence for the risk of smoking in women, with past smokers and current smokers having a higher risk compared to non-smokers. In men, there is less definitive evidence, but it is unlikely that many practitioners would consider the other interventions to be more beneficial than smoking cessation. There is currently no evidence that weight loss alone reduces CV mortality, although this may be due to a lack of studies on the topic.
Overall, managing hypertension and diabetes is crucial for reducing the risk of cardiovascular disease. While medication can help, quitting smoking remains the most effective intervention for reducing CV risk. Further research is needed to determine the impact of weight loss on CV mortality.
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This question is part of the following fields:
- Endocrinology
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Question 30
Correct
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A 14-year-old boy presents with bilateral gynaecomastia. He stands at a height of 150 cm and weighs 60 kg, which is at the 50th centile. His sexual maturity rating is stage 2. What is the most probable cause of his gynaecomastia?
Your Answer: Pubertal gynaecomastia
Explanation:Pubertal Gynaecomastia in Young Boys
Pubertal gynaecomastia is a common occurrence in young boys, with unilateral disease being more prevalent than bilateral. However, it typically disappears within two years. While prolactinomas can cause gynaecomastia, they are not the most likely cause and are rare in this age group. It is important to note that the height and weight of the child are within normal range.
Overall, pubertal gynaecomastia is a temporary condition that affects many young boys during puberty. While it can be concerning for parents and children, it is typically not a cause for alarm and will resolve on its own. It is important to consult with a healthcare provider to rule out any underlying medical conditions, but in most cases, no treatment is necessary.
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This question is part of the following fields:
- Endocrinology
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