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Question 1
Incorrect
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A 20-year-old female with a BMI of 35 presents with heavy and irregular menstrual bleeding. What is the most probable diagnosis for her condition?
Your Answer: Prolactinoma
Correct Answer: Polycystic ovarian syndrome
Explanation:PCOS Diagnosis with Oligomenorrhoea, Menorrhagia, and Obesity
When a woman experiences both oligomenorrhoea (infrequent periods) and menorrhagia (heavy periods) while also being obese, it is highly likely that she has polycystic ovarian syndrome (PCOS). To confirm the diagnosis, at least two of three diagnostic criteria must be met. These criteria include the appearance of cysts on an ultrasound, oligomenorrhoea, and hyperandrogenism (excess male hormones). By meeting two of these criteria, a woman can be diagnosed with PCOS.
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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 30-year-old male presents with a painful right breast that has been bothering him for the past two months. He reports feeling tenderness and swelling during a squash match. Upon examination, palpable breast tissue is noted in both breasts with tenderness specifically in the right breast. Additionally, a non-tender lump of 3 cm in diameter is found in the right testicle, which does not transilluminate. What is the probable diagnosis?
Your Answer: Teratoma
Explanation:Testicular Lesions and Gynaecomastia in Young Males
This young male is presenting with tender gynaecomastia and a suspicious testicular lesion. The most likely diagnosis in this age group is a teratoma, as seminoma tends to be more common in older individuals. Gynaecomastia can be a presenting feature of testicular tumours, as the tumour may secrete beta HCG. Other tumour markers of teratoma include alphafetoprotein (AFP).
It is important to note that testicular lymphoma typically presents in individuals over the age of 40 and would not be associated with gynaecomastia. Therefore, in young males presenting with gynaecomastia and a testicular lesion, a teratoma should be considered as a possible diagnosis. Early detection and treatment are crucial for the best possible outcome.
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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 16-year-old girl visits her General Practitioner, concerned about her family's history of cardiovascular disease and wanting to investigate her own health after learning about healthy eating in school. She was found to have a fasting plasma cholesterol of 15 mmol/l.
What is the most probable reason for these findings?Your Answer: A deficiency of acyl CoA cholesterol acyltransferase (ACAT)
Correct Answer: A deficiency of apo B-100
Explanation:Cholesterol Metabolism: Deficiencies and High Levels of Key Proteins
Apo B-100 is a protein that binds to LDL receptors, allowing for the uptake of lipoproteins. A deficiency in apo B-100 or LDL receptors can lead to familial hypercholesterolemia and an accumulation of cholesterol.
Lipoprotein lipase is an enzyme that breaks down chylomicrons and VLDLs. A deficiency in this enzyme can result in the accumulation of both, but with normal or slightly raised cholesterol levels.
ACAT is an enzyme that catalyzes the re-synthesis of cholesterol esters. A deficiency in ACAT would lead to reduced plasma cholesterol levels.
High levels of HDL are protective as they increase cholesterol transport from tissues to the liver for conversion to bile acids and excretion in feces. However, high levels of HDL are rare.
LCAT is an enzyme that converts cholesterol taken up by HDL into a cholesterol ester, which is then transferred to lipoprotein remnants for uptake by the liver. High levels of LCAT can increase reverse cholesterol transport and reduce plasma cholesterol levels.
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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 32-year-old woman presents with sudden onset of abdominal pain. She has a medical history of polycystic kidney disease and is currently taking alfacalcidol, ramipril, Renagel, and EPO injections. Her eGFR upon admission is 24 ml/min/1.73 m2. What analgesic would you recommend for her pain?
Your Answer: Diclofenac 75 mg BD
Correct Answer: Paracetamol 1 g QDS
Explanation:Medication Considerations for Patients with Renal Dysfunction
Patients with renal dysfunction should avoid taking NSAIDs as they can worsen their condition and increase the risk of gastrointestinal bleeding, which is already a common complication of chronic renal failure. Instead, alternative pain management options should be explored. If opiates are necessary, they should be prescribed with caution as they can accumulate in the body due to reduced renal excretion, especially in patients who have not previously taken them. It is important for healthcare providers to carefully consider the potential risks and benefits of any medication before prescribing it to a patient with renal dysfunction. Proper medication management can help prevent further damage to the kidneys and improve overall patient outcomes.
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This question is part of the following fields:
- Endocrinology
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Question 5
Incorrect
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A 65-year-old male with a 10 year history of hypertension and diabetes has been on a medication regimen for the past two years. He takes metformin 1 g bd, gliclazide 80 mg bd, rosuvastatin 10 mg daily, ramipril 10 mg daily, aspirin 75 mg daily, and amlodipine 10 mg daily. During his annual review, his blood pressure is 138/82 mmHg, and he has background diabetic retinopathy. His foot pulses are normal, but he has peripheral sensory loss to the ankles in both feet. His lab results show HbA1c of 55 mmol/mol (20-46), urea of 12.5 mmol/L (2.5-7.5), creatinine of 176 µmol/L (60-110), and cholesterol of 4.8 mmol/L (<5.2). Which medication should be discontinued?
Your Answer: Gliclazide
Correct Answer: Metformin
Explanation:Metformin Use in Patients with Chronic Renal Impairment
Patients with chronic renal impairment may have elevated levels of creatinine and urea, which can affect the clearance of drugs like metformin. Current guidelines recommend discontinuing metformin if creatinine levels exceed 150 µmol/L to prevent life-threatening lactic acidosis. This complication was traditionally thought to be caused by an accumulation of the drug, but recent studies suggest that tissue hypoxia and other acute or chronic conditions may also play a role.
Metformin is excreted unchanged in the urine, and its half-life is prolonged in patients with decreased creatinine clearance. This can occur chronically in patients with chronic renal impairment or acutely with dehydration, shock, or intravascular administration of iodinated contrast agents. These factors can alter renal function and increase the risk of lactic acidosis.
While some conditions may act as triggers for lactic acidosis, such as sepsis, acute myocardial infarction, pulmonary embolism, cardiac failure, and chronic liver disease, it is unlikely that the patient in this case has renal artery stenosis requiring the withdrawal of the ACEi. Therefore, it is important to monitor patients with chronic renal impairment who are taking metformin and adjust their dosage or discontinue the drug if necessary to prevent serious complications.
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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 57-year-old male presents for his first annual review of type 2 diabetes. He has also been experiencing osteoarthritis in his hips and 2nd/3rd metacarpophalangeal joints. His current medications include aspirin and metformin. Prior to starting a statin, his liver function tests are checked and reveal the following results: AST 78 U/L (5-40), ALT 88 U/L (5-40), Alkaline phosphatase 210 U/L (60-110), and Bilirubin 10 µmol/L (0-22). He does not consume alcohol and has a BMI of 24 kg/m2. He has tested negative for hepatitis B and C viruses, ANA, ASMA, LKM, and AMA. His caeruloplasmin levels are normal. What is the probable cause of his presentation?
Your Answer: Rheumatoid arthritis
Correct Answer: Haemochromatosis
Explanation:Haemochromatosis
This patient’s medical history indicates the possibility of haemochromatosis, an iron storage disorder. The presence of diabetes despite a normal BMI, liver function abnormalities, and arthropathy are all suggestive of this condition. To confirm the diagnosis, the recommended investigation is to measure the patient’s serum ferritin levels followed by transferrin saturation. If haemochromatosis is confirmed, the treatment will involve regular venesection.
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This question is part of the following fields:
- Endocrinology
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Question 7
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: Proximal myopathy
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 8
Correct
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A 35-year-old patient visits the Endocrinology Clinic with a complaint of worsening headache and bitemporal hemianopia for the past three weeks. The patient has a family history of multiple endocrine neoplasia (MEN) syndrome type 1. The endocrinologist considers the possibility of MEN 1 and orders the appropriate investigations to arrive at a differential diagnosis. According to the definition, which three types of tumors must be present for a diagnosis of MEN 1, with at least two of them being present?
Your Answer: Pituitary adenoma, pancreatic islet cells, parathyroid
Explanation:Understanding Multiple Endocrine Neoplasia (MEN) Syndromes
Multiple Endocrine Neoplasia (MEN) syndromes are a group of inherited disorders that cause tumors to develop in the endocrine glands. MEN type 1 is characterized by the occurrence of tumors in any two of the parathyroids, anterior pituitary, and pancreatic islet cells. A pituitary adenoma is a common manifestation of MEN type 1, which can cause bitemporal hemianopia.
To remember the features of MEN type 1, think of the letter P: Pituitary adenoma, Parathyroid hyperplasia, and Pancreatic islet cell tumors. On the other hand, MEN type 2 involves medullary thyroid carcinoma with either phaeochromocytoma or parathyroid tumor.
It is essential to recognize the different MEN syndromes to facilitate early diagnosis and management. Regular screening and genetic counseling are recommended for individuals with a family history of MEN syndromes.
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This question is part of the following fields:
- Endocrinology
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Question 9
Incorrect
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A 20-year-old female comes to the clinic complaining of secondary amenorrhoea for the past six months. She recently experienced moderate vaginal bleeding and abdominal pain. Additionally, she has gained around 14 pounds in weight during this time. What is the probable diagnosis?
Your Answer: Polycystic ovarian syndrome
Correct Answer: Pregnancy
Explanation:Secondary Amenorrhea and Miscarriage: A Possible Sign of Pregnancy
Secondary amenorrhea, or the absence of menstrual periods for at least three consecutive months in women who have previously had regular cycles, can be a sign of pregnancy. In cases where a patient with secondary amenorrhea experiences a miscarriage, it is important to consider the possibility of pregnancy. This information is highlighted in the book Williams Gynecology, 4th edition, authored by Barbara L. Hoffman, John O. Schorge, Lisa M. Halvorson, Cherine A. Hamid, Marlene M. Corton, and Joseph I. Schaffer.
The authors emphasize the importance of considering pregnancy as a possible cause of secondary amenorrhea, especially in cases where a miscarriage has occurred. This highlights the need for healthcare providers to be vigilant in their assessment of patients with secondary amenorrhea and to consider pregnancy as a possible diagnosis. Early detection of pregnancy can help ensure appropriate prenatal care and management, which can improve outcomes for both the mother and the baby.
In conclusion, secondary amenorrhea followed by a miscarriage should raise suspicion of pregnancy. Healthcare providers should be aware of this possibility and consider pregnancy as a potential diagnosis in patients with secondary amenorrhea. Early detection and appropriate management of pregnancy can improve 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 10
Incorrect
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A 38-year-old female patient visits her doctor's office for a follow-up appointment. She was recently diagnosed with hypothyroidism and is currently taking a daily dose of 100 micrograms of thyroxine. The doctor has access to the patient's thyroid function and other test results from the previous week.
Which test would be most effective in monitoring the patient's progress and treatment?Your Answer: Free thyroxine levels
Correct Answer: Thyroid stimulating hormone (TSH) levels
Explanation:Thyroxine and TSH Levels in Hypothyroidism
Thyroxine is a medication that can help reduce the high levels of thyroid-stimulating hormone (TSH) that are often seen in individuals with hypothyroidism. When TSH levels are high, it indicates that the thyroid gland is not producing enough thyroid hormones, which can lead to a range of symptoms such as fatigue, weight gain, and depression. By taking thyroxine, individuals with hypothyroidism can help regulate their TSH levels and improve their overall health.
To monitor the effectiveness of thyroxine treatment, doctors often use TSH as a key monitoring test. The goal is to get TSH levels into the normal range, which indicates that the thyroid gland is producing enough hormones. Other tests that may be used in the initial investigation and diagnosis of hypothyroidism include triiodothyronine, free thyroxine (T4), thyroid peroxidase antibody, and protein-bound iodine levels. By using a combination of these tests, doctors can get a better of a patient’s thyroid function and develop an appropriate treatment plan.
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This question is part of the following fields:
- Endocrinology
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Question 11
Incorrect
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A 36-year-old man visits his doctor's office accompanied by his wife, who expresses concern that her husband has been acting strangely and not like himself lately. Upon questioning, the patient appears confused and complains of a persistent headache. The doctor conducts an examination but finds no additional signs. To investigate further, the doctor orders a full blood count with electrolytes and renal function, as well as a urinary analysis. The results reveal hyponatremia with reduced plasma osmolality and high urinary osmolality and sodium. Which medication is most commonly associated with the syndrome of inappropriate antidiuretic hormone secretion (SIADH)?
Your Answer: Digoxin
Correct Answer: Carbamazepine
Explanation:Medications and their potential to cause SIADH
SIADH, or syndrome of inappropriate antidiuretic hormone secretion, is a condition where the body produces too much antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. Some medications have been known to cause SIADH, while others do not.
Carbamazepine is an anti-epileptic medication that can cause SIADH by promoting water reabsorption through stimulation of the V2 vasopressin receptor-protein G complex. Trimeprazine, a phenothiazine derivative used for motion sickness and pruritus, does not cause SIADH. Atropine, an antimuscarinic, and digoxin, a cardiac glycoside, also do not cause SIADH.
However, lithium, a mood stabilizer, can result in nephrogenic diabetes insipidus, leading to hypernatremia. It is important to be aware of the potential side effects of medications and to monitor patients for any signs of SIADH or other adverse reactions.
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This question is part of the following fields:
- Endocrinology
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Question 12
Incorrect
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A 52-year-old man comes to his General Practice for a routine check-up of his type 2 diabetes. He was diagnosed with diabetes eight months ago and has been taking metformin 1 g twice daily. His BMI is 30 kg/m2. The results of his laboratory tests are as follows:
Investigation Result Normal range
HbA1C 62 mmol/mol < 53 mmol/mol (<7.0%)
Creatinine 80 µmol/l 50–120 µmol/l
Glomerular filtration rate (GFR) 92 ml/min > 90 ml/min
What would be the most appropriate choice for managing this patient's diabetes?Your Answer: Sulfonylurea
Correct Answer: Dipeptidyl peptidase-4 (DPP4) inhibitor
Explanation:Comparing Anti-Diabetic Medications: Choosing the Best Option for a Patient with High BMI
When selecting an anti-diabetic medication for a patient with a high BMI, it is important to consider the potential for weight gain and hypoglycaemia. Here, we compare four options:
1. Dipeptidyl peptidase-4 (DPP4) inhibitor: This medication sustains the release of insulin and lowers blood sugar levels without causing weight gain.
2. Sulfonylurea: This medication stimulates the release of insulin and is often used as a second-line agent, but can cause weight gain.
3. Acarbose: This medication does not significantly improve glucose control and can exacerbate gastrointestinal side-effects when used with metformin.
4. Insulin basal bolus regimen and pre-mixed insulin 70:30: These options provide optimal glucose control but carry the risk of hypoglycaemia and weight gain.
For this patient, a DPP4 inhibitor is the best option as it provides additional glucose control without causing weight gain. Sulfonylurea may also be considered, but the risk of weight gain should be monitored. Insulin regimens are not necessary at this time, but may be considered in the future if oral medications do not provide adequate control.
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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 50-year-old man comes to the clinic with recurring headaches. He reports experiencing impotence and a decrease in libido that has progressively worsened over the past year. During visual field examination, a bitemporal hemianopia is observed. Laboratory tests show an elevation in serum prolactin levels, while serum luteinizing hormone (LH) and testosterone are reduced. What is the most probable diagnosis?
Your Answer: Idiopathic panhypopituitarism
Correct Answer: Prolactinoma
Explanation:Differential diagnosis of a patient with hyperprolactinaemia, headaches, visual field defects, and hypogonadism
Prolactinoma, idiopathic panhypopituitarism, craniopharyngioma, isolated LH deficiency, and pituitary infarction are among the possible diagnoses for a patient presenting with hyperprolactinaemia, headaches, visual field defects, and hypogonadism. Prolactinomas are the most common functional pituitary tumours and can cause local effects on the optic chiasm and hypothalamus-pituitary-gonadal axis. Idiopathic panhypopituitarism would result in decreased levels of all anterior pituitary hormones, including prolactin. Craniopharyngioma, more common in children and adolescents, can lead to hypopituitarism but rarely causes hyperprolactinaemia. Isolated LH deficiency could explain the loss of libido and decreased plasma levels of LH and testosterone, but not the increase in prolactin or bitemporal hemianopia. Pituitary infarction, such as in Sheehan syndrome, can cause varying degrees of hypopituitarism but not hyperprolactinaemia. A thorough evaluation of the patient’s clinical and laboratory findings, imaging studies, and medical history is necessary to establish the correct diagnosis and guide the appropriate treatment.
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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 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: Bone metastases
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 15
Incorrect
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A 56-year-old male with a past medical history of alcoholic liver disease arrives at the Emergency department complaining of chest pain. After conducting an ECG and measuring troponin levels, it is confirmed that the patient is experiencing NSTEMI. What beta blocker would you prescribe to prevent any future myocardial events?
Your Answer: Bisoprolol 20 mg OD
Correct Answer: Propranolol 40 mg BD
Explanation:Safe Use of Beta Blockers in Liver Disease
Beta blockers are commonly used to prevent variceal bleeding. The recommended dose for this purpose is typically lower than the normal dose, but it can be increased if necessary. However, in patients with liver disease, the manufacturer recommends using a lower dose to avoid potential complications. Bisoprolol is one beta blocker that is safe to use in liver disease, but the maximum recommended dose is 10 mg once daily. Other beta blockers should be avoided in patients with liver disease due to the risk of adverse effects. It is important to consult with a healthcare provider to determine the appropriate dose and medication for each individual patient.
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This question is part of the following fields:
- Endocrinology
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Question 16
Incorrect
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A 42-year-old woman visits her General Practitioner (GP) complaining of increasing lethargy and weight gain over the past year. The GP finds nil of note on examination, but decides to carry out some blood tests, the results of which are shown below:
Investigation Result Normal value
Haemoglobin 145 g/l 115–155 g/l
White cell count (WCC) 9.1 × 109/l 4–11 × 109/l
Platelets 263 × 109/l 150–400 × 109/l
Mean corpuscular volume (MCV) 102 fl 76–98 fl
Urea and electrolytes normal, liver function tests (LFTs) normal; thyroid-stimulating hormone (TSH) 10.9 miu/l, free T4 5 pmol/l.
Which of the following statements is correct?Your Answer: Thyroid eye disease commonly occurs
Correct Answer: Menorrhagia may be a feature
Explanation:Understanding Hypothyroidism: Symptoms, Diagnosis, and Treatment
Hypothyroidism is a condition characterized by an underactive thyroid gland, resulting in low levels of thyroid hormones in the body. This can lead to a range of symptoms, including lethargy, weight gain, depression, sensitivity to cold, myalgia, dry skin, dry hair and/or hair loss, constipation, menstrual irregularities, carpal tunnel syndrome, memory problems, and myxoedema coma (a medical emergency).
Diagnosis of hypothyroidism involves measuring levels of thyroid-stimulating hormone (TSH) and thyroxine (T4) in the blood. A high TSH level and a low T4 level indicate hypothyroidism. Menorrhagia may be a feature of the condition.
Treatment involves initiating and titrating doses of levothyroxine until serum TSH normalizes and the patient’s signs and symptoms have resolved. The lowest dose of levothyroxine possible to maintain this should be used. If the patient has a goitre, nodule, or changes of the thyroid gland, the patient is suspected to have subacute thyroiditis, or if an associated endocrine disease is suspected, specialist referral is indicated.
While macrocytosis may indicate coexistent vitamin B12 deficiency, it is not always present in hypothyroidism. Anaemia is a frequent occurrence in thyroid disease, which is most commonly normocytic, but can also be macrocytic or microcytic.
Thyroid-stimulating autoantibodies commonly occur in hyperthyroidism, but not in hypothyroidism. Similarly, thyroid eye disease is a common feature in hyperthyroidism, but not in hypothyroidism.
In conclusion, understanding the symptoms, diagnosis, and treatment of hypothyroidism is crucial for managing this condition effectively.
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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 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: Primary hypothyroidism
Correct Answer: Need more information
Explanation:The Importance of fT4 in Thyroid Diagnosis
When diagnosing thyroid conditions, the fT4 level is a crucial piece of information that cannot be overlooked. A patient with high TSH could be hyperthyroid, hypothyroid, or euthyroid with this TSH level, and the fT4 level is needed to determine the correct diagnosis. While a normal fT3 level can rule out hyperthyroidism, it cannot exclude the diagnosis if the fT4 level is high. Similarly, fT3 levels are of no use in diagnosing hypothyroidism, as they can be normal in a hypothyroid patient due to increased T4 to T3 conversion. Without the fT4 level, a diagnosis of primary or secondary hypothyroidism or a TSH-secreting tumor cannot be made. Therefore, it is crucial to obtain the fT4 level when evaluating thyroid function.
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This question is part of the following fields:
- Endocrinology
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Question 18
Incorrect
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A 45-year-old man visits his GP for a medication review for his hypertension. During the examination, the GP observes that the patient has prominent supraorbital ridges, large hands and feet, and acanthosis nigricans of the axillae. The GP also discovers enlargement of the thyroid gland and hepatomegaly. Besides hypertension, what other condition is frequently linked to acromegaly?
Your Answer: Ulnar nerve entrapment
Correct Answer: Diabetes mellitus
Explanation:Associations of Acromegaly with Various Medical Conditions
Acromegaly is a medical condition caused by hypersecretion of growth hormone. It is associated with various medical conditions, including insulin resistance and diabetes mellitus, which can lead to acromegaly. Left ventricular hypertrophy is also associated with acromegaly, which can cause right ventricular hypertrophy. Ulnar nerve entrapment is another association, along with carpal tunnel syndrome affecting the median nerve. Acanthosis nigricans involves hyperpigmentation of the skin, but there is no general pigmentation associated with acromegaly. Acromegaly is also associated with cardiovascular disease, which can increase the risk of atrial fibrillation, although it is not a direct cause.
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This question is part of the following fields:
- Endocrinology
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Question 19
Incorrect
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A 50-year-old man comes to the clinic complaining of gynaecomastia. He is currently undergoing treatment for heart failure and gastro-oesophageal reflux. Which medication that he is taking is the most probable cause of his gynaecomastia?
Your Answer: Aspirin
Correct Answer: Spironolactone
Explanation:Medications Associated with Gynaecomastia
Gynaecomastia, the enlargement of male breast tissue, can be caused by various medications. Spironolactone, ciclosporin, cimetidine, and omeprazole are some of the drugs that have been associated with this condition. Ramipril has also been linked to gynaecomastia, but it is a rare occurrence.
Aside from these medications, other drugs that can cause gynaecomastia include digoxin, LHRH analogues, cimetidine, and finasteride. It is important to note that not all individuals who take these medications will develop gynaecomastia, and the risk may vary depending on the dosage and duration of treatment.
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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 16-year-old male presents with delayed pubertal development and a history of impaired sense of smell. He has a height on the 90th centile and weight on the 95th centile. There is no pubertal development in his external genitalia and his testicular volumes are 3 mL bilaterally. Upon investigation, his plasma luteinising hormone and follicle stimulating hormone levels are both 1.0 U/L (1-10), while his serum testosterone level is 2.0 pmol/L (9-33). His free T4 level is 20 pmol/L (10-22) and his plasma thyroid stimulating hormone level is 3.2 mU/L (0.4-5). A CT brain scan shows no abnormalities. What is the most likely diagnosis?
Your Answer: Kallmann’s syndrome
Explanation:The patient has Kallmann’s syndrome, characterized by hypogonadotrophic hypogonadism and anosmia. Klinefelter’s and Noonan’s also cause hypogonadism, while Prader-Willi is associated with hypogonadism and hyperphagia.
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This question is part of the following fields:
- Endocrinology
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Question 21
Incorrect
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What is a true statement about type 2 diabetes mellitus?
Your Answer: Drug treatment is associated with a 25% reduction in microvascular complications compared with diet alone.
Correct Answer: Metformin is the preferable treatment in the obese patient with type 2 diabetes
Explanation:Type 2 Diabetes and Drug Treatment Options
Type 2 diabetes is diagnosed when a person’s fasting plasma glucose level is consistently above 6.9 on two separate occasions. This condition is often associated with being overweight. To manage type 2 diabetes, drug treatment is necessary. The level of glycaemic lowering achieved through drug treatment is directly linked to a reduction in mortality.
Within 10 years of diagnosis, the rate of macrovascular complications is significantly higher than 20%. Therefore, it is crucial to choose the right drug therapy. The United Kingdom Prospective Diabetes Study (UKPDS) has shown that metformin is the preferred first-line drug therapy for type 2 diabetes.
Sulphonylureas are another drug therapy option, but they are associated with marginally higher cardiovascular mortality and weight gain. It is important to work with a healthcare professional to determine the best drug treatment plan for managing type 2 diabetes. By effectively managing blood glucose levels, individuals with type 2 diabetes can reduce their risk of complications and improve their overall health.
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This question is part of the following fields:
- Endocrinology
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Question 22
Incorrect
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What would be the natural response to hypocalcaemia in a normal and healthy individual, considering the various factors that influence serum calcium levels, including hormones?
Your Answer: Increased osteoclasts activity, low PTH, raised calcitonin
Correct Answer: Decreased kidney phosphate reabsorption, high PTH, low calcitonin
Explanation:The likely cause of haematemesis in IHD patients is crucial in providing appropriate treatment and management. The history of patients with Ischemic Heart Disease (IHD) is crucial in determining the cause of their current presentation with haematemesis. As most of these patients are receiving aspirin, it is important to consider the possibility of non-steroidal anti-inflammatory drug (NSAID)-induced peptic ulceration as the likely cause. To confirm this, an endoscopy should be performed, and the patient should be started on proton pump inhibition.
It is important to note that gastric carcinoma typically presents with dysphagia and weight loss, while gastritis and oesophagitis present with a burning sensation in the chest and epigastric area, worsened by lying flat and triggered by certain foods or drinks. On the other hand, a Mallory-Weiss tear usually presents with haematemesis after multiple vomiting episodes due to abrasion and trauma to the oesophageal endothelium.
The likely cause of haematemesis in IHD patients is crucial in providing appropriate treatment and management. By considering the patient’s medical history and conducting necessary tests, healthcare professionals can accurately diagnose and treat the underlying condition, ensuring the best possible outcome for the patient.
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This question is part of the following fields:
- Endocrinology
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Question 23
Incorrect
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What is the recommended course of treatment for a 16-year-old boy with Reifenstein syndrome who has hypospadias, micropenis, and small testes in the scrotum?
Your Answer: Surgical management
Correct Answer: Testosterone replacement
Explanation:Management of Reifenstein Syndrome: Hormonal and Surgical Options
Reifenstein syndrome is a rare X-linked genetic disease that results in partial androgen insensitivity. In phenotypic males with this condition, testosterone replacement therapy is recommended to increase the chances of fertility. However, if the patient had been raised as a female and chose to continue this way, oestrogen replacement therapy would be appropriate. Surgical management may be necessary if the patient has undescended testes, but in this case, orchidectomy is not indicated as the patient has small testes in the scrotum. While psychological counselling is always necessary, it is not the first line of treatment. Overall, the management of Reifenstein syndrome involves a combination of hormonal and surgical options tailored to the individual patient’s needs.
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This question is part of the following fields:
- Endocrinology
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Question 24
Incorrect
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A 58-year-old man comes to the clinic with a lump in the anterior of his neck. He denies any symptoms of thyrotoxicosis. His family members have noticed that his voice has become increasingly hoarse over the past few weeks. Fine-needle aspiration indicates papillary carcinoma of the thyroid.
Which of the following statements is true?Your Answer: Most cases are familial
Correct Answer: Thyroidectomy is curative in most cases
Explanation:Myth-busting Facts about Thyroid Cancer
Thyroidectomy is a common treatment for thyroid cancer, and it is curative in most cases. However, there are several misconceptions about this type of cancer that need to be addressed.
Firstly, papillary carcinoma, the most common type of thyroid cancer, is the least aggressive and can be cured with thyroidectomy. Secondly, a hoarse voice is not necessarily an indication of laryngeal involvement, but rather recurrent laryngeal nerve invasion.
Thirdly, while calcitonin levels are raised in medullary carcinoma of the thyroid, this type of cancer is rare and accounts for only a small percentage of cases. Finally, contrary to popular belief, most cases of thyroid cancer are sporadic, and only a small percentage are familial.
It is important to dispel these myths and educate the public about the realities of thyroid cancer to ensure accurate diagnosis and effective treatment.
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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 28-year-old woman visits her doctor complaining of weight loss, fatigue, heart palpitations, excessive sweating, and a lump in her throat that has been present for 2 months. After conducting tests, the doctor discovers a suppressed thyroid-stimulating hormone (TSH). What is the best course of treatment for this patient?
Your Answer: Carbimazole
Explanation:Treatment Options for Thyroid Disorders: Carbimazole, Thyroxine, Carbamazepine, Surgery, and Radionuclide Iodine
Thyroid disorders can present with a variety of symptoms and require different treatment options depending on the diagnosis. Primary hyperthyroidism, caused by a disorder of the thyroid gland itself, is confirmed with raised serum levels of fT3/fT4 and a suppressed/reduced TSH. Symptoms include sweating, weight loss, palpitations, a goitre, hyperactivity, insomnia, emotional lability, reduced libido, heat intolerance, diarrhoea, increased appetite and menstrual irregularities. First-line treatment is with a thionamide such as carbimazole, which inhibits the thyroid peroxidase enzyme involved in the production and release of thyroid hormones. However, carbimazole is associated with serious side effects such as agranulocytosis, angioedema, lymphadenopathy, hepatic disorders and acute pancreatitis.
Thyroxine is prescribed for patients with hypothyroidism, in which case the TSH would be raised and the T3/T4 hormones low. Symptoms of hypothyroidism include weight gain, constipation, oligomenorrhoea/amenorrhoea, cold intolerance, tiredness, depression, brittle hair and nails, as well as muscle weakness. Thyroxine is contraindicated in patients with hyperthyroidism as it worsens their symptoms and might precipitate a thyroid storm.
Carbamazepine is an anticonvulsant medication used in the treatment of epilepsy. It is a sodium channel blocker that prevents sodium binding and repetitive firing of action potentials. However, one of the most serious side effects associated with the use of carbamazepine is Stevens–Johnson syndrome and toxic epidermal necrolysis. It can be licensed for use in the treatment of trigeminal neuralgia, diabetic neuropathy and treatment of patients with bipolar disorder that is resistant to lithium.
Surgery is not first line for hyperthyroidism unless there is compression or compromise of the airway, medication has failed to control symptoms, or there is a concurrent suspicious or malignant thyroid nodule. Thyroidectomy has complications such as hypocalcaemia due to the removal of the parathyroid glands, vocal cord paralysis and hypothyroidism. Following a thyroidectomy, the patient will need to go on lifelong thyroid replacement therapy.
Radionu
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This question is part of the following fields:
- Endocrinology
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Question 26
Incorrect
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A 65-year-old male is seeking treatment for hypertension related to his type 2 diabetes. He is currently taking aspirin 75 mg daily, amlodipine 10 mg daily, and atorvastatin 20 mg daily. However, his blood pressure remains consistently high at around 160/92 mmHg.
What medication would you recommend adding to improve this patient's hypertension?Your Answer: Moxonidine
Correct Answer: Ramipril
Explanation:Hypertension Management in Type 2 Diabetes Patients
Patients with type 2 diabetes who have inadequately controlled hypertension should be prescribed an ACE inhibitor, which is the preferred antihypertensive medication for diabetes. Combining an ACE inhibitor with a calcium channel blocker like amlodipine can also be effective. However, beta-blockers should be avoided for routine hypertension treatment in diabetic patients. Methyldopa is a medication used specifically for hypertension during pregnancy, while moxonidine is reserved for cases where other medications have failed to control blood pressure. If blood pressure control is still insufficient with ramipril and amlodipine, a thiazide diuretic can be added to the treatment plan.
It is important to note that hypertension management in diabetic patients requires careful consideration of medication choices and potential interactions. Consulting with a healthcare provider is crucial to ensure safe and effective treatment. Further reading on this topic can be found in the Harvard Medical School’s article on medications for treating hypertension.
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This question is part of the following fields:
- Endocrinology
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Question 27
Incorrect
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What is a factor that can lead to a delay in bone maturation?
Your Answer: Congenital hypothyroidism in a 6-year-old boy treated with thyroxine since 7-days-old
Correct 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 28
Incorrect
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A 40-year-old woman comes to the clinic complaining of fatigue, loss of appetite, and weight gain. Her blood work shows low levels of free T3 and T4, as well as low levels of thyroid stimulating hormone (TSH). Even after receiving thyrotrophin releasing hormone, her TSH levels remain low. What is the diagnosis?
Your Answer: De Quervain’s thyroiditis
Correct Answer: Secondary hypothyroidism
Explanation:Understanding the Different Types of Hypothyroidism
Hypothyroidism is a condition where the thyroid gland fails to produce enough thyroid hormones. There are three types of hypothyroidism: primary, secondary, and tertiary.
Primary hypothyroidism is caused by a malfunctioning thyroid gland, often due to autoimmune thyroiditis or burnt out Grave’s disease. In this type, TRH and TSH levels are elevated, but T3 and T4 levels are low.
Secondary hypothyroidism occurs when the anterior pituitary gland fails to produce enough TSH, despite adequate TRH levels. This results in low levels of TSH, T3, and T4, even after a TRH stimulation test.
Tertiary hypothyroidism is rare and occurs when the hypothalamus fails to produce enough TRH. All three hormones are inappropriately low in this type.
Hashimoto’s thyroiditis is a form of autoimmune thyroid disease characterized by lymphocytic infiltration of the thyroid. It is a form of primary hypothyroidism.
De Quervain’s thyroiditis is a subacute thyroiditis, usually viral, which causes a transient period of primary hypothyroidism or hyperthyroidism in addition to a tender thyroid.
Understanding the different types of hypothyroidism is important for proper diagnosis and treatment.
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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 56-year-old man has undergone the following investigations by his General Practitioner (GP).
Plasma:
Investigations Results Normal Value
Total Ca2+ 1.85 mmol/l 2.20–2.60 mmol/l
Albumin 42 g/l 35–55 g/l
PO43- 1.8 mmol/l 0.70–1.40 mmol/l
Alkaline phosphatase 160 IU/l 30–130 IU/l
Parathyroid hormone (PTH) 80 ng/l 10–65 ng/l
What is the most probable underlying condition?Your Answer: Primary hypoparathyroidism
Correct Answer: Chronic renal failure
Explanation:Understanding Hyperparathyroidism and Related Conditions
Hyperparathyroidism is a condition characterized by high levels of parathyroid hormone (PTH) in the blood, which can lead to imbalances in calcium and phosphate levels. There are several different types of hyperparathyroidism, as well as related conditions that can affect the parathyroid gland and its function.
Chronic renal failure is one such condition, in which impaired 1α-hydroxylation of 25-hydroxycholecalciferol leads to reduced calcium and phosphate excretion due to renal impairment. This results in secondary hyperparathyroidism, with elevated PTH levels in response to low plasma ionized calcium. Alkaline phosphatase is also elevated due to renal osteodystrophy.
As chronic renal failure progresses, the parathyroid glands may become hyperplastic or adenomatous, leading to tertiary hyperparathyroidism. In this condition, PTH secretion is substantially increased, causing elevated calcium levels that are not limited by feedback control.
Malignant hyperparathyroidism is another condition that can mimic hyperparathyroidism, but is caused by the production of PTH-related protein (PTHrP) by cancer cells. In this case, PTH levels are low, but calcium levels are high and phosphate levels are low.
Primary hyperparathyroidism is characterized by high PTH levels, leading to high calcium and low phosphate levels. Primary hypoparathyroidism, on the other hand, is caused by gland failure and results in low PTH production, leading to low calcium and high phosphate levels. Secondary hypoparathyroidism occurs when PTH production is suppressed by hypercalcemia, but this is not the correct answer in a patient with low calcium levels.
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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 49-year-old woman with a history of type 2 diabetes for three years comes in for her annual check-up. Despite optimizing her oral hypoglycemic therapy, she has gained around 5 kg in weight over the past year and her HbA1c has worsened. She is also taking ramipril, bendroflumethiazide, and amlodipine, but her blood pressure remains difficult to control, with a reading of 172/102 mmHg. During the examination, she has developed abdominal striae, thin skin with bruising, and proximal weakness. The doctor suspects Cushing's syndrome. What is the most appropriate test for this patient?
Your Answer: 9 am cortisol concentration
Correct Answer: 24 hour urine free cortisol concentration
Explanation:Screening Tests for Cushing’s Syndrome
Cushing’s syndrome is a condition caused by excessive levels of cortisol in the body. To diagnose this condition, appropriate screening tests are necessary. The preferred test is the 1 mg overnight dexamethasone suppression test, where 1 mg of dexamethasone is given at 11 pm, and cortisol levels are measured at 9 am the following morning. A cortisol concentration less than 50 nmol/L after this test is considered normal.
Another effective test is a 24-hour urine collection to measure free cortisol in the urine. An elevated cortisol level, usually above 250 nmol/day, indicates Cushing’s syndrome. However, random cortisol or 9 am cortisol tests do not provide any diagnostic information.
In investigating the possible cause of Cushing’s syndrome, chest x-rays and adrenal CT scans are useful. These tests can help identify the underlying cause of the condition. It is important to perform appropriate screening tests to diagnose Cushing’s syndrome and determine the best course of treatment.
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This question is part of the following fields:
- Endocrinology
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