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Question 1
Incorrect
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A 35-year-old woman comes in with symptoms of renal colic. Upon conducting tests, the following results are obtained:
Corrected Calcium 3.84 mmol/l
PTH 88 pg/ml (increased)
Her serum urea and electrolytes are within normal range.
What is the probable diagnosis?Your Answer: Secondary hyperparathyroidism
Correct Answer: Primary hyperparathyroidism
Explanation:The most probable diagnosis in this scenario is primary hyperparathyroidism, as serum urea and electrolytes are normal, making tertiary hyperparathyroidism less likely.
Primary Hyperparathyroidism: Causes, Symptoms, and Treatment
Primary hyperparathyroidism is a condition that is commonly seen in elderly females and is characterized by an unquenchable thirst and an inappropriately normal or raised parathyroid hormone level. It is usually caused by a solitary adenoma, hyperplasia, multiple adenoma, or carcinoma. While around 80% of patients are asymptomatic, the symptomatic features of primary hyperparathyroidism may include polydipsia, polyuria, depression, anorexia, nausea, constipation, peptic ulceration, pancreatitis, bone pain/fracture, renal stones, and hypertension.
Primary hyperparathyroidism is associated with hypertension and multiple endocrine neoplasia, such as MEN I and II. To diagnose this condition, doctors may perform a technetium-MIBI subtraction scan or look for a characteristic X-ray finding of hyperparathyroidism called the pepperpot skull.
The definitive management for primary hyperparathyroidism is total parathyroidectomy. However, conservative management may be offered if the calcium level is less than 0.25 mmol/L above the upper limit of normal, the patient is over 50 years old, and there is no evidence of end-organ damage. Patients who are not suitable for surgery may be treated with cinacalcet, a calcimimetic that mimics the action of calcium on tissues by allosteric activation of the calcium-sensing receptor.
In summary, primary hyperparathyroidism is a condition that can cause various symptoms and is commonly seen in elderly females. It can be diagnosed through various tests and managed through surgery or medication.
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This question is part of the following fields:
- Endocrine System
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Question 2
Correct
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A 14-year-old boy is brought to the clinic by his mother due to concerns about his height compared to other boys his age. The boy also shares that he often receives comments about his appearance, with some likening him to a toy doll. What can be inferred about the pattern of hormone release that he may be lacking?
Your Answer: It is released in a pulsatile manner
Explanation:The doll-like appearance of the boy in his presentation suggests that he may be suffering from growth hormone deficiency, which can cause short stature, forehead prominence, and maxillary hypoplasia. The hypothalamus controls the release of growth hormone through the pulsatile release of growth hormone releasing hormone. Therefore, measuring GHRH levels is not a useful method for investigating growth hormone deficiency.
Understanding Growth Hormone and Its Functions
Growth hormone (GH) is a hormone produced by the somatotroph cells in the anterior pituitary gland. It plays a crucial role in postnatal growth and development, as well as in regulating protein, lipid, and carbohydrate metabolism. GH acts on a transmembrane receptor for growth factor, leading to receptor dimerization and direct or indirect effects on tissues via insulin-like growth factor 1 (IGF-1), which is primarily secreted by the liver.
GH secretion is regulated by various factors, including growth hormone releasing hormone (GHRH), fasting, exercise, and sleep. Conversely, glucose and somatostatin can decrease GH secretion. Disorders associated with GH include acromegaly, which results from excess GH, and GH deficiency, which can lead to short stature.
In summary, GH is a vital hormone that plays a significant role in growth and metabolism. Understanding its functions and regulation can help in the diagnosis and treatment of GH-related disorders.
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This question is part of the following fields:
- Endocrine System
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Question 3
Correct
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A 14-year-old boy presents to the emergency department with complaints of severe abdominal pain, nausea, and vomiting for the past 6 hours. The patient appears drowsy and has dry mucous membranes. His vital signs include a heart rate of 94 beats per minute, respiratory rate of 19 breaths per minute, and blood pressure of 89/62 mmHg. There is a fruity smell to his breath, and a bedside glucose finger prick reveals a glucose level of 263 mg/dL. The doctor orders an insulin infusion while waiting for laboratory results. Which insulin preparation is most appropriate for this patient's management?
Your Answer: Short-acting (regular) insulin
Explanation:The onset of action and peak of NPH and regular insulin are a result of the combination of both human recombinant insulin preparations in the mixture.
Understanding Insulin Therapy
Insulin therapy has been a game-changer in the management of diabetes mellitus since its development in the 1920s. It remains the only available treatment for type 1 diabetes mellitus (T1DM) and is widely used in type 2 diabetes mellitus (T2DM) when oral hypoglycemic agents fail to provide adequate control. However, understanding the different types of insulin can be overwhelming, and it is crucial to have a basic grasp to avoid potential harm to patients.
Insulin can be classified by manufacturing process, duration of action, and type of insulin analogues. Patients often require a combination of preparations to ensure stable glycemic control throughout the day. Rapid-acting insulin analogues act faster and have a shorter duration of action than soluble insulin and may be used as the bolus dose in ‘basal-bolus’ regimes. Short-acting insulins, such as Actrapid and Humulin S, may also be used as the bolus dose in ‘basal-bolus’ regimes. Intermediate-acting insulins, like isophane insulin, are often used in a premixed formulation with long-acting insulins, such as insulin determir and insulin glargine, given once or twice daily. Premixed preparations combine intermediate-acting insulin with either a rapid-acting insulin analogue or soluble insulin.
The vast majority of patients administer insulin subcutaneously, and it is essential to rotate injection sites to prevent lipodystrophy. Insulin pumps are available, which delivers a continuous basal infusion and a patient-activated bolus dose at meal times. Intravenous insulin is used for patients who are acutely unwell, such as those with diabetic ketoacidosis. Inhaled insulin is available but not widely used, and oral insulin analogues are in development but have considerable technical hurdles to clear. Overall, understanding insulin therapy is crucial for healthcare professionals to provide safe and effective care for patients with diabetes mellitus.
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This question is part of the following fields:
- Endocrine System
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Question 4
Correct
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A young man comes to the clinic with symptoms suggestive of mania. After further inquiry and assessment, he is found to have tachycardia, sweaty palms, and a recent bout of diarrhea. What is the probable diagnosis?
Your Answer: Grave's disease
Explanation:The correct diagnosis for this patient is Grave’s disease, which is characterized by hyperthyroidism. While mania may be a symptom, it is important to note that tachycardia, sweaty hands, and exophthalmos are specific to Grave’s disease.
Bipolar disorder may also present with manic episodes, but it does not typically include the other symptoms associated with hyperthyroidism.
Hashimoto’s thyroiditis is another autoimmune thyroid disorder, but it causes hypothyroidism instead of hyperthyroidism. Symptoms of hypothyroidism may include bradycardia and dry skin.
Graves’ Disease: Common Features and Unique Signs
Graves’ disease is the most frequent cause of thyrotoxicosis, which is commonly observed in women aged 30-50 years. The condition presents typical features of thyrotoxicosis, such as weight loss, palpitations, and heat intolerance. However, Graves’ disease also displays specific signs that are not present in other causes of thyrotoxicosis. These include eye signs, such as exophthalmos and ophthalmoplegia, as well as pretibial myxoedema and thyroid acropachy. The latter is a triad of digital clubbing, soft tissue swelling of the hands and feet, and periosteal new bone formation.
Graves’ disease is characterized by the presence of autoantibodies, including TSH receptor stimulating antibodies in 90% of patients and anti-thyroid peroxidase antibodies in 75% of patients. Thyroid scintigraphy reveals a diffuse, homogenous, and increased uptake of radioactive iodine. These features help distinguish Graves’ disease from other causes of thyrotoxicosis and aid in its diagnosis.
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This question is part of the following fields:
- Endocrine System
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Question 5
Correct
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A 55-year-old male comes to see you with worries about his weight. He has a BMI of 32 and you suspect he may have metabolic syndrome. What is one of the diagnostic criteria for this condition?
Your Answer: Dyslipidaemia
Explanation:Metabolic syndrome is a group of risk factors for cardiovascular disease that are closely related to insulin resistance and central obesity.
The diagnostic criteria for metabolic syndrome vary widely, but the International Diabetes Federation (IDF) and American Heart Association (AHA) have established their own criteria, which are commonly used. A diagnosis is made if three or more of the following criteria are present: increased waist circumference (depending on ethnicity) or a BMI greater than 30, dyslipidemia with elevated triglycerides greater than 150 mg/dL or reduced HDL-cholesterol, hypertension, and impaired glucose tolerance.
The Physiology of Obesity: Leptin and Ghrelin
Leptin is a hormone produced by adipose tissue that plays a crucial role in regulating body weight. It acts on the hypothalamus, specifically on the satiety centers, to decrease appetite and induce feelings of fullness. In cases of obesity, where there is an excess of adipose tissue, leptin levels are high. Leptin also stimulates the release of melanocyte-stimulating hormone (MSH) and corticotrophin-releasing hormone (CRH), which further contribute to the regulation of appetite. On the other hand, low levels of leptin stimulate the release of neuropeptide Y (NPY), which increases appetite.
Ghrelin, on the other hand, is a hormone that stimulates hunger. It is mainly produced by the P/D1 cells lining the fundus of the stomach and epsilon cells of the pancreas. Ghrelin levels increase before meals, signaling the body to prepare for food intake, and decrease after meals, indicating that the body has received enough nutrients.
In summary, the balance between leptin and ghrelin plays a crucial role in regulating appetite and body weight. In cases of obesity, there is an imbalance in this system, with high levels of leptin and potentially disrupted ghrelin signaling, leading to increased appetite and weight gain.
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This question is part of the following fields:
- Endocrine System
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Question 6
Correct
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Which of the following most accurately explains how glucocorticoids work?
Your Answer: Binding of intracellular receptors that migrate to the nucleus to then affect gene transcription
Explanation:The effects of glucocorticoids are mediated by intracellular receptors that bind to them and are subsequently transported to the nucleus, where they modulate gene transcription.
Corticosteroids are commonly prescribed medications that can be taken orally or intravenously, or applied topically. They mimic the effects of natural steroids in the body and can be used to replace or supplement them. However, the use of corticosteroids is limited by their numerous side effects, which are more common with prolonged and systemic use. These side effects can affect various systems in the body, including the endocrine, musculoskeletal, gastrointestinal, ophthalmic, and psychiatric systems. Some of the most common side effects include impaired glucose regulation, weight gain, osteoporosis, and increased susceptibility to infections. Patients on long-term corticosteroids should have their doses adjusted during intercurrent illness, and the medication should not be abruptly withdrawn to avoid an Addisonian crisis. Gradual withdrawal is recommended for patients who have received high doses or prolonged treatment.
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This question is part of the following fields:
- Endocrine System
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Question 7
Incorrect
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A 40-year-old woman comes to her doctor complaining of sudden palpitations and occasional headaches without any apparent cause. She has no significant medical history and denies any stress in her personal or professional life. During the examination, she appears to be sweating and has a pale conjunctiva. Her heart rate is 120 beats per minute, regularly regular, and her blood pressure is 150/100 mmHg. The doctor suspects a phaeochromocytoma, a tumor of the adrenal medulla.
Which test is the most likely to provide a definitive diagnosis?Your Answer: 24 hour urinary free cortisol
Correct Answer: Urinary free adrenaline
Explanation:Extra-adrenal tumors are often located near the aortic bifurcation and can be identified through a urinary free adrenaline test, which measures the levels of adrenaline and noradrenaline produced by the adrenal medulla. Meanwhile, a 24-hour urinary free cortisol test is used to diagnose Cushing’s Disease, which is caused by excessive cortisol production from the zona fasciculata of the adrenal cortex. The aldosterone-renin ratio test is used to diagnose Conn’s Disease, which is caused by excessive aldosterone production from the zona glomerulosa of the adrenal cortex. Androgens are produced by the zona reticularis of the adrenal cortex. Addison’s Disease, a deficiency of cortisol, can be diagnosed through a short synacthen test.
Adrenal Physiology: Medulla and Cortex
The adrenal gland is composed of two main parts: the medulla and the cortex. The medulla is responsible for secreting the catecholamines noradrenaline and adrenaline, which are released in response to sympathetic nervous system stimulation. The chromaffin cells of the medulla are innervated by the splanchnic nerves, and the release of these hormones is triggered by the secretion of acetylcholine from preganglionic sympathetic fibers. Phaeochromocytomas, which are tumors derived from chromaffin cells, can cause excessive secretion of both adrenaline and noradrenaline.
The adrenal cortex is divided into three distinct zones: the zona glomerulosa, zona fasciculata, and zona reticularis. Each zone is responsible for secreting different hormones. The outer zone, zona glomerulosa, secretes aldosterone, which regulates electrolyte balance and blood pressure. The middle zone, zona fasciculata, secretes glucocorticoids, which are involved in the regulation of metabolism, immune function, and stress response. The inner zone, zona reticularis, secretes androgens, which are involved in the development and maintenance of male sex characteristics.
Most of the hormones secreted by the adrenal cortex, including glucocorticoids and aldosterone, are bound to plasma proteins in the circulation. Glucocorticoids are inactivated and excreted by the liver. Understanding the physiology of the adrenal gland is important for the diagnosis and treatment of various endocrine disorders.
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This question is part of the following fields:
- Endocrine System
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Question 8
Incorrect
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Which of the following is not secreted by the islets of Langerhans?
Your Answer: Pancreatic polypeptide
Correct Answer: Secretin
Explanation:Mucosal cells in the duodenum and jejunum release secretin.
Hormones Released from the Islets of Langerhans
The islets of Langerhans in the pancreas are responsible for the production and secretion of several hormones that play a crucial role in regulating blood glucose levels. The beta cells in the islets of Langerhans are responsible for producing insulin, which accounts for 70% of the total secretions. Insulin helps to lower blood glucose levels by promoting the uptake of glucose by cells and tissues throughout the body.
The alpha cells in the islets of Langerhans produce glucagon, which has the opposite effect of insulin. Glucagon raises blood glucose levels by stimulating the liver to release stored glucose into the bloodstream. The delta cells in the islets of Langerhans produce somatostatin, which helps to regulate the release of insulin and glucagon.
Finally, the F cells in the islets of Langerhans produce pancreatic polypeptide, which plays a role in regulating pancreatic exocrine function and appetite. Together, these hormones work to maintain a delicate balance of blood glucose levels in the body.
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This question is part of the following fields:
- Endocrine System
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Question 9
Incorrect
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A 4-month-old boy is being evaluated for possible hypospadias. In boys with this condition, where is the urethral opening most commonly found?
Your Answer: On the distal dorsal surface of the penis
Correct Answer: On the distal ventral surface of the penis
Explanation:The anomaly is typically situated on the underside and frequently towards the end. Urethral openings found closer to the body are a known occurrence. Surgical removal of the foreskin may hinder the process of repairing the defect.
Understanding Hypospadias: A Congenital Abnormality of the Penis
Hypospadias is a congenital abnormality of the penis that affects approximately 3 out of 1,000 male infants. It is usually identified during the newborn baby check, but if missed, parents may notice an abnormal urine stream. This condition is characterized by a ventral urethral meatus, a hooded prepuce, and chordee in more severe forms. In some cases, the urethral meatus may open more proximally in the more severe variants, but 75% of the openings are distally located.
There appears to be a significant genetic element to hypospadias, with further male children having a risk of around 5-15%. While it most commonly occurs as an isolated disorder, associated conditions include cryptorchidism (present in 10%) and inguinal hernia.
Once hypospadias has been identified, infants should be referred to specialist services. Corrective surgery is typically performed when the child is around 12 months of age. It is essential that the child is not circumcised prior to the surgery as the foreskin may be used in the corrective procedure. In boys with very distal disease, no treatment may be needed.
Overall, understanding hypospadias is important for parents and healthcare providers to ensure proper management and treatment for affected infants.
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This question is part of the following fields:
- Endocrine System
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Question 10
Correct
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A 42-year-old woman visits her GP complaining of chest pain. She has a history of hypertension and is currently taking metformin for diabetes. The GP observes that her BMI is 45. What is a possible complication of the metabolic syndrome in this case?
Your Answer: Ischemic stroke
Explanation:Metabolic syndrome is a group of risk factors for cardiovascular disease that are caused by insulin resistance and central obesity.
Obesity is associated with higher rates of illness and death, as well as decreased productivity and functioning, increased healthcare expenses, and social and economic discrimination.
The consequences of obesity include strokes, type 2 diabetes, heart disease, certain cancers (such as breast, colon, and endometrial), polycystic ovarian syndrome, obstructive sleep apnea, fatty liver, gallstones, and mental health issues.
The Physiology of Obesity: Leptin and Ghrelin
Leptin is a hormone produced by adipose tissue that plays a crucial role in regulating body weight. It acts on the hypothalamus, specifically on the satiety centers, to decrease appetite and induce feelings of fullness. In cases of obesity, where there is an excess of adipose tissue, leptin levels are high. Leptin also stimulates the release of melanocyte-stimulating hormone (MSH) and corticotrophin-releasing hormone (CRH), which further contribute to the regulation of appetite. On the other hand, low levels of leptin stimulate the release of neuropeptide Y (NPY), which increases appetite.
Ghrelin, on the other hand, is a hormone that stimulates hunger. It is mainly produced by the P/D1 cells lining the fundus of the stomach and epsilon cells of the pancreas. Ghrelin levels increase before meals, signaling the body to prepare for food intake, and decrease after meals, indicating that the body has received enough nutrients.
In summary, the balance between leptin and ghrelin plays a crucial role in regulating appetite and body weight. In cases of obesity, there is an imbalance in this system, with high levels of leptin and potentially disrupted ghrelin signaling, leading to increased appetite and weight gain.
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This question is part of the following fields:
- Endocrine System
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