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Question 1
Correct
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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: 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 2
Incorrect
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A 50-year-old male presents to the endocrinology clinic with symptoms of hypogonadism. He reports consuming five cans of lager per week, which is believed to be the cause of his abnormal liver function tests. The patient has a history of type 2 diabetes and osteoarthritis affecting his hips and knees. What tests should be performed to determine the underlying diagnosis?
Your Answer: Ultrasound scan of abdomen
Correct Answer: Serum ferritin and iron studies
Explanation:Haemochromatosis as a Cause of Hypogonadism
The patient’s medical history suggests that haemochromatosis may be the underlying cause of their hypogonadism. While their moderate alcohol consumption of 10 units per week may contribute to liver dysfunction, other potential explanations should be explored. Additionally, the patient’s history of type 2 diabetes and seronegative arthropathy are consistent with iron storage diseases. Haemochromatosis can lead to reduced insulin production, resulting in a presentation similar to type 2 diabetes. To confirm the diagnosis, serum ferritin and transferrin saturation levels should be evaluated, as elevated levels of both are highly indicative of haemochromatosis.
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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 35-year-old man presents to his primary care physician with a consistent blood pressure reading of >140/90 mmHg. Laboratory tests indicate a serum potassium level of 2.8 mmol/l. Upon reviewing the patient's medical history, it is discovered that an external radiology report had previously noted a small retroperitoneal mass of unknown significance. What would be the anticipated serum renin and aldosterone levels in this case?
Your Answer: Normal renin; increased aldosterone
Correct Answer: Decreased renin; increased aldosterone
Explanation:Understanding the Relationship between Renin and Aldosterone Levels in Different Conditions
Renin and aldosterone are two important hormones involved in regulating blood pressure and electrolyte balance in the body. The levels of these hormones can vary in different conditions, providing important clues for diagnosis and treatment.
Decreased renin and increased aldosterone levels are typically seen in Conn syndrome, which is caused by a functioning adenoma in the adrenal cortex. This results in overproduction of aldosterone and a negative feedback loop that reduces renin levels.
On the other hand, increased renin and decreased aldosterone levels are characteristic of primary adrenal insufficiency, which can be caused by autoimmune destruction of the adrenal glands or other factors. This leads to a different clinical picture and requires different management.
A rare finding is decreased renin and aldosterone levels, which can occur in pseudohypoaldosteronism and Liddle’s syndrome. These conditions are associated with genetic mutations that affect the regulation of sodium channels in the kidneys.
Increased renin and aldosterone levels are seen in secondary hyperaldosteronism, which can be caused by various conditions such as renal artery stenosis, congestive cardiac failure, nephrotic syndrome, liver cirrhosis, and renin-secreting tumors.
Finally, normal renin levels with increased aldosterone levels suggest a negative feedback effect of aldosterone on renin production. This can occur in various conditions such as primary hyperaldosteronism or other forms of secondary hyperaldosteronism.
In summary, understanding the relationship between renin and aldosterone levels can provide important insights into the underlying pathophysiology of different conditions and guide appropriate management strategies.
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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 58-year-old woman visited her doctor after fracturing her humerus in a minor accident. She reported feeling fatigued, weak, and depressed. The doctor conducted the following tests:
Total Ca2+ 3.22 mmol/l (2.12–2.65 mmol/l)
Albumin 40 g/l (35–50 g/l)
PO43− 0.45 mmol/l (0.8–1.5 mmol/l)
Alkaline phosphatase 165 iu/l (30–150 iu/l)
Based on these results, what is the likely diagnosis?Your Answer: Secondary hyperparathyroidism
Correct Answer: Primary hyperparathyroidism
Explanation:Understanding Primary Hyperparathyroidism: Causes, Symptoms, and Diagnosis
Primary hyperparathyroidism is a medical condition that is usually caused by a parathyroid adenoma or, in rare cases, by multiple endocrine neoplasia (MEN) syndromes. This condition is characterized by an increase in parathyroid hormone (PTH) levels, which leads to increased calcium reabsorption and decreased phosphate reabsorption in the kidneys, as well as increased calcium absorption from the bones. As a result, patients with primary hyperparathyroidism typically exhibit hypercalcemia and hypophosphatemia, with normal or low albumin levels. Additionally, alkaline phosphatase levels are usually elevated due to increased bone turnover.
The most common symptoms of primary hyperparathyroidism are related to high calcium levels, including weakness, fatigue, and depression. Diagnosis is typically made through blood tests that measure PTH, calcium, phosphate, and alkaline phosphatase levels, as well as imaging studies such as ultrasound or sestamibi scans.
Other conditions that can cause hypercalcemia include excess vitamin D, bone metastases, secondary hyperparathyroidism, and myeloma. However, each of these conditions has distinct diagnostic features that differentiate them from primary hyperparathyroidism. For example, excess vitamin D causes hypercalcemia and hyperphosphatemia, with normal alkaline phosphatase levels, while bone metastases typically present with elevated alkaline phosphatase levels and normal or elevated phosphate levels.
Overall, understanding the causes, symptoms, and diagnostic features of primary hyperparathyroidism is essential for accurate diagnosis and effective treatment of 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 28-year-old woman is referred by her general practitioner due to irregular and unpredictable menstrual cycle and headaches. Magnetic resonance imaging of the brain shows a midline lesion. Further investigations reveal that her prolactin level is 2314 ng/ml (2–29 ng/ml). To reduce the prolactin level, which mediator is manipulated for medical treatment?
Your Answer: Dopamine
Explanation:Targeting Hormones in Prolactinoma Treatment
Prolactinoma is a pituitary lesion that results in excessive prolactin secretion. To reduce prolactin levels, dopamine agonists like bromocriptine are used. While there are other hormones that can affect prolactin secretion, they are not therapeutic targets in prolactinoma treatment. Corticotropin-releasing hormone (CRH) increases adrenocorticotropic hormone secretion, while gonadotropin-releasing hormone (GnRH) can indirectly decrease GnRH secretion. Somatostatin decreases thyroid-stimulating hormone and growth hormone secretion, but does not affect prolactin. Thyrotropin-releasing hormone (TRH) increases prolactin and TSH release, but is not a therapeutic target due to its effects on thyroid regulation and the superiority of dopamine agonists.
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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 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 7
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 8
Correct
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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: 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 9
Correct
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What role does adrenocorticotrophic hormone (ACTH) play in the body?
Your Answer: Stimulation of the release of glucocorticoids
Explanation:The Adrenal Cortex and Pituitary Gland
The adrenal cortex is composed of two layers, the cortical and medullary layers. The zona glomerulosa of the adrenal cortex secretes aldosterone, while the zona fasciculata secretes glucocorticoids and the zona reticularis secretes adrenal androgens. However, both layers are capable of secreting both glucocorticoids and androgens. The release of glucocorticoids from the adrenal cortex is stimulated by ACTH.
Antidiuretic hormone (ADH), also known as vasopressin, is secreted from the posterior pituitary and acts on the collecting ducts of the kidney to promote water reabsorption. Growth hormone, secreted by the anterior pituitary, promotes the growth of soft tissues. Prolactin secretion from the anterior pituitary is under inhibitory control from dopamine.
In summary, the adrenal cortex and pituitary gland play important roles in regulating hormone secretion and bodily functions. The adrenal cortex is responsible for the secretion of aldosterone, glucocorticoids, and adrenal androgens, while the pituitary gland secretes ADH, growth hormone, and prolactin.
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This question is part of the following fields:
- Endocrinology
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Question 10
Correct
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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: 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 11
Correct
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A 45-year-old man presents to his general practitioner (GP) for a check-up following prescription of an angiotensin-converting enzyme (ACE) inhibitor for hypertension. He reports no side-effects of the medication. On measurement of his blood pressure, it is recorded as 176/140 mmHg. The GP repeats the measurement and records similar values. The physician considers secondary causes of hypertension and enquires about symptoms associated with some of the causes. The patient reports headache, sweating and occasional palpitations. On examination, he has a pulse rate of 110 bpm and dilation of both pupils. The GP suspects the patient may be suffering from the rare condition known as phaeochromocytoma.
What percentage of cases of phaeochromocytoma are due to a malignant cause?Your Answer: 10%
Explanation:Understanding Phaeochromocytoma: Malignancy and Survival Rates
Phaeochromocytoma is a rare condition characterized by catecholamine-secreting tumors that can cause life-threatening secondary hypertension. While the majority of these tumors are benign, approximately 10% are malignant. Malignancy is defined by the presence of metastases and is more common in extra-adrenal tumors.
The classical presentation of phaeochromocytoma, regardless of malignancy, includes severe hypertension, headaches, palpitations, and diaphoresis. However, complete surgical resection of the tumor can resolve hypertension in most cases.
For malignant phaeochromocytoma, the 5-year survival rate is approximately 50%, while the survival rate for non-malignant disease is around 95%. It’s important to understand the potential for malignancy and the associated survival rates when diagnosing and treating phaeochromocytoma.
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This question is part of the following fields:
- Endocrinology
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Question 12
Correct
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What is a common clinical feature of hyperthyroidism?
Your Answer: Heat intolerance
Explanation:Thyroid Disorders
Thyroid disorders are characterized by the dysfunction of the thyroid gland, which can lead to a variety of symptoms. Hypothyroidism, for example, is marked by weight gain, bradycardia, and dry skin. On the other hand, hyperthyroidism is the excess secretion of thyroid hormones, which can stimulate basal metabolic rate and heighten catecholamine sensitivity. The three most common causes of primary hyperthyroidism are Graves’ disease, toxic adenoma, and toxic multinodular goitre. Other causes include de Quervain’s (post-viral) thyroiditis and drugs such as amiodarone.
One of the key symptoms of thyroid disorders is polydipsia, which refers to excessive thirst. Excess levothyroxine ingestion can also cause a biochemical picture similar to primary thyroid disease, with a suppression of thyroid-stimulating hormone and an elevated free thyroxine (T4) in plasma. It is important to understand the different types of thyroid disorders and their causes in order to properly diagnose and treat them. By doing so, individuals can manage their symptoms and improve their overall quality of life.
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This question is part of the following fields:
- Endocrinology
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Question 13
Incorrect
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A 26-year-old waitress presents with a 2-day history of increasing confusion. She has no significant medical history, takes only oral contraceptives, and denies any substance use. Blood and urine tests suggest a possible diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following statements regarding SIADH secretion is accurate?
Your Answer: Hypernatraemia is typical
Correct Answer: It may occur in subarachnoid haemorrhage
Explanation:Understanding SIADH: Causes and Treatment Options
SIADH, or syndrome of inappropriate antidiuretic hormone secretion, is a condition characterized by excessive production of ADH, leading to hyponatraemia. While it can occur in various medical conditions, subarachnoid haemorrhage is a known cause of SIADH. In such cases, monitoring sodium levels is crucial. The treatment of choice for SIADH is fluid restriction, but in severe cases, hypertonic saline may be used. Demeclocycline, a tetracycline, is sometimes used to treat hyponatraemia in SIADH. It’s important to note that small cell lung cancer, not adenocarcinoma of the lung, is a well-known cause of SIADH through ectopic ADH secretion. Understanding the causes and treatment options for SIADH is essential for managing this condition effectively.
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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 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 15
Correct
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A 32-year-old woman visits her GP with complaints of palpitations, tremors, sweating, and diarrhoea. She has a medical history of gestational hypertension and type 1 diabetes, which is managed with insulin. The patient gave birth to her first child 8 weeks ago without any complications.
Upon examination, the patient is alert and oriented. Her vital signs are as follows: heart rate of 109 bpm, respiratory rate of 19 breaths/minute, temperature of 37.7ºC, oxygen saturation of 98%, blood pressure of 129/88 mmHg, and blood glucose of 4 mmol/L.
What is the most likely diagnosis, and what is the appropriate treatment?Your Answer: Propranolol
Explanation:The recommended treatment for the thyrotoxicosis phase of postpartum thyroiditis is typically propranolol alone. This is because the condition is usually temporary and self-resolving, with thyroid function returning to normal within a year after childbirth. Carbimazole is not necessary as it is typically reserved for more severe cases of hyperthyroidism. Dexamethasone is not appropriate as it is used to treat thyroid storm, a complication of thyrotoxicosis that is not present in this case. Levothyroxine is also not indicated as it is used to treat hypothyroidism, which is the opposite of the patient’s current 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 16
Correct
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What is a factor that can lead to a delay in bone maturation?
Your Answer: Newly diagnosed growth hormone deficiency in a 6-year-old girl
Explanation:Factors affecting bone age in children
Bone age, which refers to the degree of maturation of a child’s bones, can be influenced by various factors. In a child with normal thyroid function, bone age would be expected to be normal if they are receiving adequate treatment. However, in cases of growth hormone deficiency, bone age may be delayed. On the other hand, in cases of exogenous obesity resulting from over-nutrition and lack of exercise, bone age may be advanced.
If a child has an underlying endocrine disorder such as hypothyroidism, their bone age may be delayed. Turner’s syndrome, a genetic disorder affecting females, is also associated with delayed bone age by approximately 2 years during childhood. Conversely, congenital adrenal hyperplasia and central precocious puberty can cause advanced bone age.
In summary, bone age can be affected by various factors, including thyroid function, growth hormone deficiency, obesity, endocrine disorders, and genetic conditions. these factors can help healthcare providers assess a child’s growth and development and provide appropriate treatment if necessary.
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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 50-year-old male with type 2 diabetes presents for his annual review. Despite following a diet plan, his glycaemic control is not optimal and his most recent HbA1c is 63 mmol/mol (20-46). You decide to initiate treatment with metformin 500 mg bd. As per NICE NG28 guidelines for diabetes management, what is the recommended interval for rechecking his HbA1c after each intensification of treatment?
Your Answer: Three to six months
Explanation:HbA1c as a Tool for Glycaemic Control
The glycated haemoglobin (HbA1c) is a measure of the glucose levels in the blood over a period of time. It reflects the glycosylation of the haemoglobin molecule by glucose, and there is a strong correlation between the glycosylation of this molecule and average plasma glucose concentrations. This makes it a widely used tool in clinical practice to assess glycaemic control. Studies have also shown that HbA1c has prognostic significance in both microvascular and macrovascular risk.
The life span of a red blood cell is 120 days, and HbA1c reflects the average blood glucose levels during the half-life of the red cell, which is about 60 days. According to NICE guidelines, it is recommended to re-check HbA1c with each treatment intensification at 3/6 monthly intervals. HbA1c as a tool for glycaemic control is crucial in managing diabetes and reducing the risk of complications.
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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 woman is undergoing investigation by her GP for potential issues in her hypothalamic-pituitary-thyroid axis. The following findings were recorded:
Thyroid-stimulating hormone (TSH) 5.2 mu/l (0.4-4.0 mu/l)
fT4 8.0 pmol/l (9.0-26.0 pmol/l)
fT3 3.5 pmol/l (3.0-9.0 pmol/l)
What condition is indicated by these results?Your Answer: Subclinical hypothyroidism
Correct Answer: Hypothyroidism
Explanation:Thyroid Disorders: Understanding the Different Presentations
Thyroid disorders can present with various symptoms and laboratory findings. Here are some of the common presentations of different thyroid disorders:
Hypothyroidism: This condition is characterized by elevated TSH and low fT4 levels. It is more common in females and occurs mainly in middle life. The elevated TSH is due to reduced negative feedback at the level of the pituitary.
Thyroid Hormone Resistance: In this condition, TSH and fT4 levels are raised. Thyroid hormone resistance results in decreased response to a given thyroid hormone, which prompts the thyroid axis to increase TSH and fT4 levels. The patient may not be symptomatic and may even present hypothyroid clinically.
Hyperthyroidism: This condition is characterized by low TSH and usually raised fT4 and fT3 levels.
Pituitary TSH-Secreting Tumour: This condition presents with raised TSH and fT4 levels.
Subclinical Hypothyroidism: This condition presents with elevated TSH but normal fT4 levels.
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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 76-year-old man presents with back pain after a fall. He has a history of prostate cancer with metastases to the liver and bones. He takes tamsulosin and bendroflumethiazide daily and paracetamol as needed. Upon admission, his renal function is stable, but his liver function is abnormal with an INR of 2, ALT of 210 U/L, AST of 90 U/L, ALP of 180 U/L, bilirubin of 30 mmol/L, and albumin of 24 g/L. What pain relief medication would you recommend for him?
Your Answer: Paracetamol 1 g QDS with codeine phosphate 30 mg QDS PRN
Explanation:Medication Considerations for Patients with Liver Dysfunction
When prescribing medication for patients with liver dysfunction, it is important to exercise caution and consider the potential risks. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided, especially in patients with coagulopathy, as they can increase the risk of gastrointestinal bleeding. Opiates should also be prescribed with caution, particularly in patients who are opiate naĂ¯ve.
In cases of acute or acute-on-chronic liver failure, paracetamol may not be recommended. However, in patients with fully compensated cirrhosis, it can be used with caution and at a reduced dose. It is crucial for healthcare providers to carefully evaluate the potential risks and benefits of any medication before prescribing it to a patient with liver dysfunction. By doing so, they can help minimize the risk of adverse effects and ensure the best possible outcomes for their patients.
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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 35-year-old male is scheduled for his annual diabetic review. During the examination, it is noted that his body mass index has increased to 31.5 kg/m2. How do you calculate body mass index?
Your Answer: Weight/(Height)2
Explanation:BMI is a calculation of weight over height squared and is used to determine if someone is underweight, normal weight, overweight, or obese. A BMI above 30 indicates obesity and is associated with increased risks for various health issues and surgical complications.
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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 38-year-old woman comes to you with a swollen neck and upon examination, you find an unusual neck mass that raises suspicion of thyroid cancer. You arrange for a fine-needle aspiration and a histology report from a thyroid lobectomy reveals chromatin clearing, nuclear shape alteration, and irregularity of the nuclear membrane. There is no evidence of C cell differentiation, and the patient has no family history of cancer. What is the most probable diagnosis?
Your Answer: Anaplastic carcinoma of the thyroid
Correct Answer: Papillary carcinoma of the thyroid
Explanation:Thyroid cancer can take different forms, with papillary carcinoma being the most common and typically affecting women between 35 and 40 years old. This type of cancer has a good long-term prognosis. Medullary carcinoma arises from C cells that produce calcitonin and CEA, and can be sporadic or associated with a genetic syndrome. Follicular carcinoma is difficult to diagnose through FNA and requires a full histological specimen to confirm, with distinguishing features being vascular and capsule invasion. Anaplastic carcinoma is the most aggressive thyroid tumor, typically affecting older individuals and lacking biological features of the original thyroid cells. Thyroid lymphomas are rare and typically affect women over 50 with Hashimoto’s thyroiditis.
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This question is part of the following fields:
- Endocrinology
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Question 22
Correct
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A 38-year-old patient presents with excessive thirst and abdominal pain.
Bloods show:
Investigation Result Normal value
Calcium (Ca2+) 3.02 mmol/l 2.20–2.60 mmol/l
Phosphate (PO43–) 0.42 mmol/l 0.70–1.40 mmol/l
Alkaline phosphatase (ALP) 324 IU/l 30–130 IU/l
Looking at these blood results, which of the following is the most likely cause?Your Answer: Primary hyperparathyroidism
Explanation:Causes and Clinical Presentations of Hyperparathyroidism, Bone Metastases, Excessive Vitamin D, Renal Failure, and Hypoparathyroidism
Hyperparathyroidism is a condition where the parathyroid glands secrete an excessive amount of parathyroid hormone, leading to increased serum calcium levels. This can be caused by a solitary parathyroid adenoma of parathyroid hyperplasia. The clinical presentation includes excessive bone resorption, kidney stone formation, gastrointestinal symptoms, and neurological effects.
Bone metastases also present with hypercalcaemia and a high alkaline phosphatase level, but phosphate levels will be normal. Vitamin D excess can also cause hypercalcaemia with a normal or high phosphate level, but alkaline phosphatase will be normal.
In chronic renal failure, there is a reduction in the excretion of phosphate and a low glomerular filtration rate, leading to secondary hyperparathyroidism with hypocalcaemia and hyperphosphataemia.
Hypoparathyroidism is associated with a decreased production of parathyroid hormone, leading to cramping and paraesthesiae due to low circulating calcium levels. Biochemical abnormalities include low circulating parathyroid hormone and calcium levels, raised phosphate levels, and normal alkaline phosphatase levels.
Overall, understanding the causes and clinical presentations of these conditions is important for accurate diagnosis and appropriate treatment.
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This question is part of the following fields:
- Endocrinology
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Question 23
Correct
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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: 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 24
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A 78-year-old man with diabetes mellitus came in with abrupt onset of uncontrolled flinging movements of the right arm that ceased during sleep. What could be the probable cause?
Your Answer: Contralateral subthalamic nucleus infarction
Explanation:Hemiballismus and its Causes
Hemiballismus is a medical condition characterized by involuntary flinging motions of the extremities, which can be violent and continuous. It usually affects only one side of the body and can involve proximal, distal, or facial muscles. The movements worsen with activity and decrease with relaxation. This condition is caused by a decrease in activity of the subthalamic nucleus of the basal ganglia, which results in decreased suppression of involuntary movements.
Hemiballismus can be caused by a variety of factors, including strokes, traumatic brain activity, amyotrophic lateral sclerosis, hyperglycemia, malignancy, vascular malformations, tuberculomas, and demyelinating plaques. In patients with diabetes, it is likely due to a vascular event in the contralateral subthalamic nucleus.
Treatment for hemiballismus should begin with identifying and treating the underlying cause. If pharmacological treatment is necessary, an antidopaminergic such as haloperidol or chlorpromazine may be used. Other options include topiramate, intrathecal baclofen, botulinum toxin, and tetrabenazine. In cases where other treatments have failed, functional neurosurgery may be an option.
In summary, hemiballismus is a condition that causes involuntary flinging motions of the extremities and can be caused by various factors. Treatment should begin with identifying and treating the underlying cause, and pharmacological and surgical options may be necessary in some cases.
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This question is part of the following fields:
- Endocrinology
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Question 25
Correct
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A 50-year-old woman is undergoing evaluation for hypertension that is not responding to treatment. She has a previous medical history of medullary thyroid carcinoma. Her physical examination is unremarkable. During her work-up, she is found to have hypercalcemia with a level of 2.8 mmol/l. Her parathyroid hormone (PTH) is slightly elevated above the normal range. What is the underlying diagnosis?
Your Answer: Multiple endocrine neoplasia type 2A
Explanation:Differential Diagnosis: Hypercalcaemia with Medullary Thyroid Carcinoma
Multiple endocrine neoplasia type 2A (MEN 2A) is a genetic disorder caused by a gain in function mutation in the RET proto-oncogene. The classic triad of MEN 2A includes medullary thyroid carcinoma, primary hyperparathyroidism, and phaeochromocytoma. In cases where a patient presents with a history of medullary thyroid carcinoma and hypercalcaemia with inappropriately elevated PTH levels, primary parahyperthyroidism is implied, and the combination of these symptoms with treatment-resistant hypertension is virtually diagnostic of MEN 2A.
Other conditions associated with hypercalcaemia include multiple myeloma, but PTH levels would be appropriately low. Marfan’s syndrome, a hereditary disorder of connective tissue, is not typically associated with dysfunction of the parathyroid hormone axis. Multiple endocrine neoplasia type 1 (MEN1) is a main differential diagnosis, but patients with MEN1 typically suffer from hyperparathyroidism, pituitary adenomas (typically prolactinomas), and pancreatic islet cell tumours, not the symptoms described here. Neurofibromatosis, a disorder caused by a mutation in the neurofibromin gene, is associated with multiple neural tumours and various other manifestations, but disruption of the parathyroid hormone axis is not a feature.
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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 55-year-old man comes to his GP complaining of tingling in both hands that began a month ago and has been progressively worsening. He has no significant medical history. During the examination, you observe that the man has large hands, widely spaced teeth, and a prominent brow. You suspect that he may have acromegaly.
What is the most suitable initial investigation for acromegaly?Your Answer: Serum IGF1 levels
Explanation:Investigations for Acromegaly: Serum IGF1 Levels, CT/MRI Head, and Visual Field Testing
Acromegaly is a condition caused by excess growth hormone (GH) production, often from a pituitary macroadenoma. To diagnose acromegaly, insulin-like growth factor 1 (IGF1) levels are measured instead of GH levels, as IGF1 has a longer half-life and is more stable in the blood. If IGF1 levels are high, a glucose tolerance test is used to confirm the diagnosis. CT scans of the head are not as sensitive as MRI scans for investigating pituitary tumors, which are a common cause of acromegaly. Visual field testing is also important to assess whether a pituitary tumor is compressing the optic chiasm, but it is not specific to acromegaly and is part of the physical exam.
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This question is part of the following fields:
- Endocrinology
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Question 27
Correct
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A 72-year-old patient is found to have an HbA1c of 43 mmol/mol at a recent chronic disease health check after being assessed as being at high risk of diabetes mellitus. The patient is being called in to discuss the result with her registered general practitioner. How should the patient’s diagnosis be coded in her notes?
Your Answer: Pre-diabetes
Explanation:Understanding Blood Sugar Levels and Diabetes Diagnosis
Blood sugar levels are an important indicator of a person’s risk for developing diabetes. Pre-diabetes is a term used to describe individuals with elevated blood sugar levels that do not yet qualify as diabetes. A diagnosis of pre-diabetes indicates a high risk of developing diabetes and warrants intervention to identify modifiable risk factors and reduce the risk through lifestyle changes.
Normoglycaemic individuals have blood sugar levels within the normal range of 3.9-5.5 mmol/l. Diabetes mellitus type 2 is diagnosed when HbA1c is 48 mmol/mol or higher, or fasting glucose is 7.1 mmol/l or higher. A positive result on one occasion is enough for diagnosis if the patient presents with symptoms of diabetes, but two separate confirmatory tests are required for asymptomatic patients.
Impaired fasting glucose is defined as a fasting glucose level of 6.1-6.9 mmol/l, while impaired glucose tolerance is defined as a serum glucose level of 7.8-11.0 mmol/l at 2 hours post-ingestion of a 75-g oral glucose load. Understanding these levels and their implications can help individuals take proactive steps to manage their blood sugar levels and reduce their risk of developing diabetes.
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This question is part of the following fields:
- Endocrinology
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Question 28
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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 29
Correct
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What is a metabolic effect of exenatide?
Your Answer: Suppresses appetite
Explanation:The Metabolic Effects of Exenatide
Exenatide is a medication that imitates the actions of GLP-1, a hormone produced in the gut. It has been found to have beneficial effects on the metabolism of individuals with diabetes mellitus. One of the main effects of exenatide is its ability to suppress appetite, which can help individuals with diabetes to manage their weight. Additionally, exenatide inhibits glucose production in the liver, which can help to regulate blood sugar levels. It also slows gastric emptying, which can help to prevent spikes in blood sugar after meals. Finally, exenatide stimulates insulin release, which can help to lower blood sugar levels. It is important to note that exenatide does not increase insulin sensitivity, which is achieved by other medications such as metformin and the glitazones. Overall, exenatide has a range of metabolic effects that can be beneficial for individuals with diabetes mellitus.
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This question is part of the following fields:
- Endocrinology
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Question 30
Incorrect
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A 65-year-old man with diabetes and a history of chronic kidney disease visits for his regular check-up. The focus is on his elevated levels of phosphate and parathyroid hormone, despite having normal calcium levels. The doctor decides to prescribe a vitamin D analogue. What would be the most suitable option?
Your Answer: Cholecalciferol (vit D3)
Correct Answer: Alfacalcidol (1-hydroxycholecalciferol)
Explanation:Alfacalcidol as an Effective Treatment for CKD Patients
Alfacalcidol, also known as 1-hydroxycholecalciferol, is a form of vitamin D that is already hydroxylated and does not require activation by the kidney enzyme 1-hydroxylase. This makes it an effective alternative for patients with chronic kidney disease (CKD) as their impaired kidney function can compromise the bioavailability of other forms of vitamin D. Calcitriol is another option for CKD patients.
On the other hand, ascorbic acid, also known as vitamin C, is not involved in the modification of calcium metabolism but rather in the treatment of scurvy, a vitamin C deficiency. Cholecalciferol or vitamin D3, which is obtained from the diet or generated by UV action in the skin, must undergo hydroxylation in the kidney. Vitamin D2, on the other hand, requires activation by the kidney enzyme 1-hydroxylase, which can be impaired in CKD patients.
Lastly, riboflavin or vitamin B2 has no effect on calcium metabolism. In summary, alfacalcidol is an effective treatment option for CKD patients as it does not require activation by the kidney enzyme and can improve the bioavailability of vitamin D.
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This question is part of the following fields:
- Endocrinology
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