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  • Question 1 - A 57-year-old woman presents to the physician with a recurring blistering rash on...

    Correct

    • A 57-year-old woman presents to the physician with a recurring blistering rash on her hands. The rash has also affected her legs, inguinal creases, and the corners of her mouth at different times. She was diagnosed with type 2 diabetes mellitus three months ago and has occasional loose stools. The patient denies experiencing palpitations, abdominal pain, or vomiting, but reports having occasional watery stools.

      During the physical examination, the physician observes coalescing erythematous plaques with crusting and scaling at the borders and central areas of brownish induration over the lower abdomen and in the perioral skin.

      What is the most likely diagnosis for this patient?

      Your Answer: Glucagonoma

      Explanation:

      The patient is likely suffering from a glucagonoma, a rare tumor that originates from the alpha cells of the pancreas. This condition causes the excessive secretion of glucagon, resulting in hyperglycemia or diabetes mellitus. One of the characteristic symptoms of glucagonoma is necrolytic migratory erythema, a painful and itchy rash that appears on the face, groin, and limbs.

      Gastrinoma, on the other hand, does not cause a blistering rash or diabetes mellitus. However, it is often associated with abdominal pain, diarrhea, and ulceration.

      Somatostatinoma typically presents with abdominal pain, constipation, hyperglycemia, and steatorrhea, which are not present in this patient.

      VIPoma is unlikely as it usually causes intractable diarrhea, hypokalemia, and achlorhydria.

      Although zinc deficiency can cause skin lesions that resemble necrolytic migratory erythema, the patient’s recent diabetes mellitus diagnosis and lack of other symptoms make glucagonoma the more likely diagnosis.

      Glucagonoma: A Rare Pancreatic Tumor

      Glucagonoma is a rare type of pancreatic tumor that usually originates from the alpha cells of the pancreas. These tumors are typically small and malignant, and they can cause a range of symptoms, including diabetes mellitus, venous thrombo-embolism, and a distinctive red, blistering rash known as necrolytic migratory erythema. To diagnose glucagonoma, doctors typically look for a serum level of glucagon that is higher than 1000pg/ml, and they may also use CT scanning to visualize the tumor. Treatment options for glucagonoma include surgical resection and octreotide, a medication that can help to control the symptoms of the disease. Overall, glucagonoma is a rare but serious condition that requires prompt diagnosis and treatment to manage its symptoms and prevent complications.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 2 - A 50-year-old woman with thyroid cancer undergoes a total thyroidectomy. The histology report...

    Incorrect

    • A 50-year-old woman with thyroid cancer undergoes a total thyroidectomy. The histology report reveals a diagnosis of medullary thyroid cancer. What test would be most useful for screening for disease recurrence?

      Your Answer: Serum TSH levels

      Correct Answer: Serum calcitonin levels

      Explanation:

      The detection of sub clinical recurrence can be facilitated by monitoring the serum levels of calcitonin, which is often secreted by medullary thyroid cancers.

      Thyroid cancer rarely causes hyperthyroidism or hypothyroidism as it does not usually secrete thyroid hormones. The most common type of thyroid cancer is papillary carcinoma, which is often found in young females and has an excellent prognosis. Follicular carcinoma is less common, while medullary carcinoma is a cancer of the parafollicular cells that secrete calcitonin and is associated with multiple endocrine neoplasia type 2. Anaplastic carcinoma is rare and not responsive to treatment, causing pressure symptoms. Lymphoma is also rare and associated with Hashimoto’s thyroiditis.

      Management of papillary and follicular cancer involves a total thyroidectomy followed by radioiodine to kill residual cells. Yearly thyroglobulin levels are monitored to detect early recurrent disease. Papillary carcinoma usually contains a mixture of papillary and colloidal filled follicles, while follicular adenoma presents as a solitary thyroid nodule and malignancy can only be excluded on formal histological assessment. Follicular carcinoma may appear macroscopically encapsulated, but microscopically capsular invasion is seen. Medullary carcinoma is associated with raised serum calcitonin levels and familial genetic disease in up to 20% of cases. Anaplastic carcinoma is most common in elderly females and is treated by resection where possible, with palliation achieved through isthmusectomy and radiotherapy. Chemotherapy is ineffective.

    • This question is part of the following fields:

      • Endocrine System
      41
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  • Question 3 - A 23-year-old male comes to his doctor with a 5-month history of headaches,...

    Correct

    • A 23-year-old male comes to his doctor with a 5-month history of headaches, palpitations, and excessive sweating. He also mentions unintentional weight loss. Upon examination, the patient is found to be tachycardic and sweating profusely. The doctor suspects that the man may have a tumor affecting the tissue responsible for producing adrenaline.

      What is the probable location of the tumor?

      Your Answer: Adrenal medulla

      Explanation:

      The secretion of adrenaline is primarily carried out by the adrenal medulla. A patient with a phaeochromocytoma, a type of cancer that affects the adrenal medulla, may experience symptoms such as tachycardia, headaches, and sweating due to excess adrenaline production.

      The adrenal cortex, which surrounds the adrenal medulla, is not involved in adrenaline synthesis. It is responsible for producing mineralocorticoids, glucocorticoids, and androgens.

      The medulla oblongata, located in the brainstem, regulates essential bodily functions but is not responsible for adrenaline secretion.

      The parathyroid gland, which produces parathyroid hormone to regulate calcium metabolism, is not related to adrenaline secretion.

      The Function of Adrenal Medulla

      The adrenal medulla is responsible for producing almost all of the adrenaline in the body, along with small amounts of noradrenaline. Essentially, it is a specialized and enlarged sympathetic ganglion. This gland plays a crucial role in the body’s response to stress and danger, as adrenaline is a hormone that prepares the body for the fight or flight response. When the body perceives a threat, the adrenal medulla releases adrenaline into the bloodstream, which increases heart rate, blood pressure, and respiration, while also dilating the pupils and increasing blood flow to the muscles. This response helps the body to react quickly and effectively to danger. Overall, the adrenal medulla is an important component of the body’s stress response system.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 4 - A 50-year-old man with type 2 diabetes mellitus visits his GP for his...

    Correct

    • A 50-year-old man with type 2 diabetes mellitus visits his GP for his annual health check-up. His HbA1c level is 86mmol/L and the GP is contemplating the addition of empagliflozin to his diabetes management plan.

      What is the mechanism of action of empagliflozin?

      Your Answer: Inhibition of the sodium-glucose transporter in the kidney

      Explanation:

      SGLT-2 inhibitors work by blocking the action of sodium-glucose co-transporter 2 (SGLT-2) in the renal proximal convoluted tubule, which leads to a decrease in glucose re-absorption into the circulation. Empagliflozin is an example of an SGLT-2 inhibitor.

      Sulphonylureas increase insulin secretion from β islet cells in the pancreas by blocking potassium channels, which causes islet cell depolarisation and release of insulin.

      DPP-4 inhibitors, such as sitagliptin, prevent the breakdown of GLP-1 (glucagon-like peptide) by inhibiting the enzyme DPP-4. This leads to suppression of glucagon release and an increase in insulin release.

      Acarbose inhibits α glucosidase and other enzymes in the small intestine, which prevents the breakdown of complex carbohydrates into glucose. This results in less glucose being available for absorption into the bloodstream.

      Thiazolidinediones reduce insulin resistance in peripheral tissues and decrease gluconeogenesis in the liver by stimulating PPAR-γ (peroxisome proliferator-activated receptor-gamma), which modulates the transcription of genes involved in glucose metabolism.

      Understanding SGLT-2 Inhibitors

      SGLT-2 inhibitors are medications that work by blocking the reabsorption of glucose in the kidneys, leading to increased excretion of glucose in the urine. This mechanism of action helps to lower blood sugar levels in patients with type 2 diabetes mellitus. Examples of SGLT-2 inhibitors include canagliflozin, dapagliflozin, and empagliflozin.

      However, it is important to note that SGLT-2 inhibitors can also have adverse effects. Patients taking these medications may be at increased risk for urinary and genital infections due to the increased glucose in the urine. Fournier’s gangrene, a rare but serious bacterial infection of the genital area, has also been reported. Additionally, there is a risk of normoglycemic ketoacidosis, a condition where the body produces high levels of ketones even when blood sugar levels are normal. Finally, patients taking SGLT-2 inhibitors may be at increased risk for lower-limb amputations, so it is important to closely monitor the feet.

      Despite these potential risks, SGLT-2 inhibitors can also have benefits. Patients taking these medications often experience weight loss, which can be beneficial for those with type 2 diabetes mellitus. Overall, it is important for patients to discuss the potential risks and benefits of SGLT-2 inhibitors with their healthcare provider before starting treatment.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 5 - A 26-year-old woman presents to the emergency department with complaints of severe abdominal...

    Correct

    • A 26-year-old woman presents to the emergency department with complaints of severe abdominal pain, polyuria, polydipsia, and lethargy. The pain started suddenly 2 hours ago and is spread across her entire abdomen. She has a medical history of appendicectomy eight years ago and type 1 diabetes mellitus. Upon examination, her pH is 7.25 (normal range: 7.35-7.45) and bicarbonate is 9 mmol/L (normal range: 22-29mmol/L). What additional investigations are necessary to confirm the most probable diagnosis?

      Your Answer: Blood ketones

      Explanation:

      Abdominal pain can be an initial symptom of DKA, which is the most probable diagnosis in this case. The patient’s symptoms, including abdominal pain, strongly suggest DKA. Blood ketones are the appropriate investigation as they are part of the diagnostic criteria for DKA, along with pH and bicarbonate.

      Amylase could help rule out acute pancreatitis, but it is not the most likely diagnosis, so it would not confirm it. Pancreatitis typically presents with severe upper abdominal pain and vomiting. Polydipsia and polyuria are more indicative of DKA, and the patient’s known history of type 1 diabetes mellitus makes DKA more likely.

      Beta-hCG would be an appropriate investigation for abdominal pain in a woman of childbearing age, but it is not necessary in this case as DKA is the most likely diagnosis.

      Blood glucose levels would be useful if the patient were not a known type 1 diabetic, but they do not form part of the diagnostic criteria for DKA. Blood glucose levels would also be helpful in distinguishing between DKA and HHS, but HHS is unlikely in this case as it occurs in patients with type 2 diabetes.

      Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus, accounting for around 6% of cases. It can also occur in rare cases of extreme stress in patients with type 2 diabetes mellitus. DKA is caused by uncontrolled lipolysis, resulting in an excess of free fatty acids that are converted to ketone bodies. The most common precipitating factors of DKA are infection, missed insulin doses, and myocardial infarction. Symptoms include abdominal pain, polyuria, polydipsia, dehydration, Kussmaul respiration, and breath that smells like acetone. Diagnostic criteria include glucose levels above 11 mmol/l or known diabetes mellitus, pH below 7.3, bicarbonate below 15 mmol/l, and ketones above 3 mmol/l or urine ketones ++ on dipstick.

      Management of DKA involves fluid replacement, insulin, and correction of electrolyte disturbance. Fluid replacement is necessary as most patients with DKA are deplete around 5-8 litres. Isotonic saline is used initially, even if the patient is severely acidotic. Insulin is administered through an intravenous infusion, and correction of electrolyte disturbance is necessary. Long-acting insulin should be continued, while short-acting insulin should be stopped. Complications may occur from DKA itself or the treatment, such as gastric stasis, thromboembolism, arrhythmias, acute respiratory distress syndrome, acute kidney injury, and cerebral edema. Children and young adults are particularly vulnerable to cerebral edema following fluid resuscitation in DKA and often need 1:1 nursing to monitor neuro-observations, headache, irritability, visual disturbance, focal neurology, etc.

    • This question is part of the following fields:

      • Endocrine System
      34.9
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  • Question 6 - A 45-year-old woman comes to the clinic complaining of polyuria. Upon further inquiry,...

    Incorrect

    • A 45-year-old woman comes to the clinic complaining of polyuria. Upon further inquiry, she reports experiencing polyphagia and polydipsia as well. Her blood test reveals hyperglycaemia and low C-peptide levels.

      What is the underlying mechanism causing her hyperglycaemia?

      Your Answer: Increased SGLT-2 expression

      Correct Answer: Decreased GLUT-4 expression

      Explanation:

      The movement of glucose into cells requires insulin. In this case, the patient is likely suffering from type 1 diabetes mellitus or latent autoimmune diabetes in adults (LADA) with low c-peptide levels, indicating a complete lack of insulin. As a result, insulin is unable to stimulate the expression of GLUT-4, which significantly reduces the uptake of glucose into skeletal and adipose cells.

      The patient’s low GLUT-1 expression is unlikely to be the cause of hyperglycemia. GLUT-1 is primarily expressed in fetal tissues and has a higher affinity for oxygen, allowing fetal cells to survive even in hypoglycemic conditions.

      GLUT-2 expression is mainly found in hepatocytes and beta-cells of the pancreas. It allows for the bi-directional movement of glucose, equalizing glucose concentrations inside and outside the cell membrane, and enabling glucose-sensitive cells to measure serum glucose levels and respond accordingly.

      GLUT-3 expression is mainly found in neuronal cells and has a high affinity, similar to GLUT-1. This allows for the survival of brain cells in hypoglycemic conditions.

      Insulin is a hormone produced by the pancreas that plays a crucial role in regulating the metabolism of carbohydrates and fats in the body. It works by causing cells in the liver, muscles, and fat tissue to absorb glucose from the bloodstream, which is then stored as glycogen in the liver and muscles or as triglycerides in fat cells. The human insulin protein is made up of 51 amino acids and is a dimer of an A-chain and a B-chain linked together by disulfide bonds. Pro-insulin is first formed in the rough endoplasmic reticulum of pancreatic beta cells and then cleaved to form insulin and C-peptide. Insulin is stored in secretory granules and released in response to high levels of glucose in the blood. In addition to its role in glucose metabolism, insulin also inhibits lipolysis, reduces muscle protein loss, and increases cellular uptake of potassium through stimulation of the Na+/K+ ATPase pump.

    • This question is part of the following fields:

      • Endocrine System
      58.6
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  • Question 7 - A 45-year-old male has presented to discuss the management of primary hyperparathyroidism. He...

    Incorrect

    • A 45-year-old male has presented to discuss the management of primary hyperparathyroidism. He was diagnosed 3 weeks ago after complaining of bone pain and gastrointestinal discomfort. Today's blood results indicate an electrolyte abnormality.

      What is the most probable electrolyte abnormality that will be observed on the blood results?

      Your Answer: Hypocalcaemia

      Correct Answer: Hypophosphataemia

      Explanation:

      Renal phosphate reabsorption is decreased by PTH.

      When PTH levels are excessive, as seen in hyperparathyroidism, renal reabsorption is reduced, leading to low serum phosphate levels. PTH inhibits osteoblasts, not osteoclasts, resulting in an increase in plasma calcium levels. PTH is released in response to low calcium levels and works to increase calcium resorption in the kidneys. Additionally, PTH increases magnesium resorption in the kidneys.

      It is important to note that PTH does not affect potassium levels.

      Understanding Parathyroid Hormone and Its Effects

      Parathyroid hormone is a hormone produced by the chief cells of the parathyroid glands. Its main function is to increase the concentration of calcium in the blood by stimulating the PTH receptors in the kidney and bone. This hormone has a short half-life of only 4 minutes.

      The effects of parathyroid hormone are mainly seen in the bone, kidney, and intestine. In the bone, PTH binds to osteoblasts, which then signal to osteoclasts to resorb bone and release calcium. In the kidney, PTH promotes the active reabsorption of calcium and magnesium from the distal convoluted tubule, while decreasing the reabsorption of phosphate. In the intestine, PTH indirectly increases calcium absorption by increasing the activation of vitamin D, which in turn increases calcium absorption.

      Overall, understanding the role of parathyroid hormone is important in maintaining proper calcium levels in the body. Any imbalances in PTH secretion can lead to various disorders such as hyperparathyroidism or hypoparathyroidism.

    • This question is part of the following fields:

      • Endocrine System
      36.8
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  • Question 8 - A 23-year-old male visits his GP complaining of polyuria, chronic thirst and pale-coloured...

    Incorrect

    • A 23-year-old male visits his GP complaining of polyuria, chronic thirst and pale-coloured urine that have persisted for 3 months. He had a concussion from a car accident a month before the onset of his urinary symptoms. The patient is diagnosed with cranial diabetes insipidus after undergoing several tests.

      What would the water deprivation test likely reveal in this case?

      Your Answer: Low urine osmolality after both fluid deprivation and desmopressin

      Correct Answer: Low urine osmolality after fluid deprivation, but high after desmopressin

      Explanation:

      The correct answer is low urine osmolality after fluid deprivation, but high after desmopressin, for a patient with cranial diabetes insipidus (DI). This condition is characterized by polyuria, chronic thirst, and pale-coloured urine, and is caused by insufficient antidiuretic hormone (ADH) secretion. As a result, the kidneys are unable to concentrate urine, leading to a low urine osmolality even during water deprivation. However, the kidneys will respond to desmopressin (synthetic ADH) to produce concentrated urine.

      High urine osmolality after both fluid deprivation and desmopressin is incorrect, as it would be seen in a healthy individual or a patient with primary polydipsia, a psychogenic disorder characterized by excessive drinking despite being properly hydrated.

      Low urine osmolality after both fluid deprivation and desmopressin is incorrect, as this is typical of nephrogenic DI, a condition in which the kidneys are insensitive to ADH.

      High urine osmolality after fluid deprivation, but normal after desmopressin is incorrect, as this would not be commonly seen with any pathological state.

      Low urine osmolality after desmopressin, but high after fluid deprivation is incorrect, as this would not be commonly seen with any pathological state.

      The water deprivation test is a diagnostic tool used to assess patients with polydipsia, or excessive thirst. During the test, the patient is instructed to refrain from drinking water, and their bladder is emptied. Hourly measurements of urine and plasma osmolalities are taken to monitor changes in the body’s fluid balance. The results of the test can help identify the underlying cause of the patient’s polydipsia. Normal results show a high urine osmolality after the administration of DDAVP, while psychogenic polydipsia is characterized by a low urine osmolality. Cranial DI and nephrogenic DI are both associated with high plasma osmolalities and low urine osmolalities.

    • This question is part of the following fields:

      • Endocrine System
      68.2
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  • Question 9 - A 29-year-old male attends a pre-operative assessment clinic for thyroidectomy due to failed...

    Correct

    • A 29-year-old male attends a pre-operative assessment clinic for thyroidectomy due to failed treatment with carbimazole and radio-iodine for Grave's disease. What is the potential complication that he is at a high risk of developing during this procedure?

      Your Answer: Recurrent laryngeal nerve palsy

      Explanation:

      The risk of complications during thyroidectomy is relatively low, but there are still potential risks to be aware of. One of the most common complications is damage to the recurrent laryngeal nerve, which can result in vocal cord paralysis and hoarseness. However, the vagal nerve and phrenic nerve are rarely damaged during the procedure as they are not in close proximity to the operating site. Trauma to the esophagus is also uncommon. If the parathyroid glands are inadvertently removed during the procedure, it can result in hypoparathyroidism rather than hyperparathyroidism.

      Thyroid disorders are commonly encountered in clinical practice, with hypothyroidism and thyrotoxicosis being the most prevalent. Women are ten times more likely to develop these conditions than men. The thyroid gland is a bi-lobed structure located in the anterior neck and is part of a hypothalamus-pituitary-end organ system that regulates the production of thyroxine and triiodothyronine hormones. These hormones help regulate energy sources, protein synthesis, and the body’s sensitivity to other hormones. Hypothyroidism can be primary or secondary, while thyrotoxicosis is mostly primary. Autoimmunity is the leading cause of thyroid problems in the developed world.

      Thyroid disorders can present in various ways, with symptoms often being the opposite depending on whether the thyroid gland is under or overactive. For example, hypothyroidism may result in weight gain, while thyrotoxicosis leads to weight loss. Thyroid function tests are the primary investigation for diagnosing thyroid disorders. These tests primarily look at serum TSH and T4 levels, with T3 being measured in specific cases. TSH levels are more sensitive than T4 levels for monitoring patients with existing thyroid problems.

      Treatment for thyroid disorders depends on the cause. Patients with hypothyroidism are given levothyroxine to replace the underlying deficiency. Patients with thyrotoxicosis may be treated with propranolol to control symptoms such as tremors, carbimazole to reduce thyroid hormone production, or radioiodine treatment.

    • This question is part of the following fields:

      • Endocrine System
      57.8
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  • Question 10 - A 25-year-old woman presents to the endocrinology clinic with a diagnosis of Grave's...

    Incorrect

    • A 25-year-old woman presents to the endocrinology clinic with a diagnosis of Grave's disease. The diagnosis was made based on her elevated levels of thyroid hormones T3 and T4, as well as symptoms of heat intolerance, weight loss, and tremors. Typically, where are the receptors for thyroid hormones found?

      Your Answer: Rough endoplasmic reticulum

      Correct Answer: Nucleus

      Explanation:

      Thyroid hormones can enter cells through diffusion or carriers. Once inside, they bind to intracellular DNA-binding proteins called thyroid hormone receptors located in the nucleus. This binding forms a complex that attaches to the thyroid hormone responsive element on DNA. The outcome of this process is an increase in mRNA production, protein synthesis, Na/K ATPase, mitochondrial function leading to higher oxygen consumption, and adrenoceptors.

      Thyroid disorders are commonly encountered in clinical practice, with hypothyroidism and thyrotoxicosis being the most prevalent. Women are ten times more likely to develop these conditions than men. The thyroid gland is a bi-lobed structure located in the anterior neck and is part of a hypothalamus-pituitary-end organ system that regulates the production of thyroxine and triiodothyronine hormones. These hormones help regulate energy sources, protein synthesis, and the body’s sensitivity to other hormones. Hypothyroidism can be primary or secondary, while thyrotoxicosis is mostly primary. Autoimmunity is the leading cause of thyroid problems in the developed world.

      Thyroid disorders can present in various ways, with symptoms often being the opposite depending on whether the thyroid gland is under or overactive. For example, hypothyroidism may result in weight gain, while thyrotoxicosis leads to weight loss. Thyroid function tests are the primary investigation for diagnosing thyroid disorders. These tests primarily look at serum TSH and T4 levels, with T3 being measured in specific cases. TSH levels are more sensitive than T4 levels for monitoring patients with existing thyroid problems.

      Treatment for thyroid disorders depends on the cause. Patients with hypothyroidism are given levothyroxine to replace the underlying deficiency. Patients with thyrotoxicosis may be treated with propranolol to control symptoms such as tremors, carbimazole to reduce thyroid hormone production, or radioiodine treatment.

    • This question is part of the following fields:

      • Endocrine System
      26.7
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