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Question 1
Incorrect
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What role does adrenocorticotrophic hormone (ACTH) play in the body?
Your Answer: Stimulation of the release of prolactin
Correct 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 2
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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Question 3
Correct
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A 12-year-old boy is presenting with nocturnal enuresis, poor academic performance, and easy fatigue with physical activity. A full examination, including blood pressure, is unremarkable. Laboratory results show elevated WBC count and high bicarbonate levels. The 24-hour urine test reveals high potassium levels and low sodium levels. What is the likely diagnosis?
Your Answer: Bartter's syndrome
Explanation:Bartter’s Syndrome: A Rare Condition with Unique Symptoms
Bartter’s syndrome is a rare condition that is usually diagnosed in childhood. It is characterized by polyuria, nocturnal enuresis, and growth retardation. Patients with this syndrome also experience hypokalaemic metabolic alkalosis with urinary potassium wasting. This is due to the hyperplasia of the juxtaglomerular apparatus.
The absence of hypertension in the patient makes it unlikely that they have Conn’s or renal artery stenosis. Bartter’s syndrome is a unique condition that presents with specific symptoms and laboratory findings. It is important for healthcare providers to be aware of this condition and consider it in the differential diagnosis of patients with similar symptoms. Early diagnosis and treatment can improve the patient’s quality of life and prevent complications.
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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 42-year-old woman comes to the clinic with complaints of cold intolerance, constipation, weight gain, hair loss, and irregular periods. Her thyroid function tests reveal low levels of both serum T4 and serum thyroid-stimulating hormone (TSH). Despite administering thyrotropin-releasing hormone (TRH), there is no expected increase in TSH. What is the most probable reason for the patient's hypothyroidism?
Your Answer: Tertiary hypothyroidism
Correct Answer: Secondary hypothyroidism
Explanation:Causes and Indicators of Hypothyroidism
Hypothyroidism is a condition characterized by low levels of thyroid hormones in the body. There are several causes and indicators of hypothyroidism, including secondary hypothyroidism, Hashimoto’s thyroiditis, iodine deficiency, tertiary hypothyroidism, and T4 receptor insensitivity.
Secondary hypothyroidism occurs when there is a pituitary defect or a hypothalamic defect, resulting in decreased levels of both serum T4 and serum TSH. A pituitary defect can be indicated by the failure of TSH to increase after injection of TRH.
Hashimoto’s thyroiditis is an autoimmune disease that leads to primary hypothyroidism, with low serum T4 and increased levels of serum TSH.
Iodine deficiency causes hypothyroidism due to inadequate iodine being available for thyroid hormone production. TSH plasma levels are increased as a result of loss of negative feedback, similar to primary hypothyroidism.
Tertiary hypothyroidism, or a hypothalamic defect, is indicated by a normal to prolonged increase in TSH after injection of TRH.
T4 receptor insensitivity also presents with signs and symptoms of hypothyroidism. The negative feedback effects of T4 would also be affected, leading to increased serum TSH and increased serum T4 levels.
Overall, understanding the causes and indicators of hypothyroidism is crucial for proper diagnosis and 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 30-year-old female patient comes in for her annual check-up. She was diagnosed with diabetes mellitus at the age of 20 and is currently being treated with human mixed insulin twice daily. She has been experiencing dysuria for the past year and has received treatment with trimethoprim four times for cystitis. On examination, there are two dot haemorrhages bilaterally on fundal examination, but no other abnormalities are found. Her blood pressure is 116/76 mmHg. The following investigations were conducted: HbA1c 75 mmol/mol (20-46), fasting plasma glucose 12.1 mmol/L (3.0-6.0), serum sodium 138 mmol/L (137-144), serum potassium 3.6 mmol/L (3.5-4.9), serum urea 4.5 mmol/L (2.5-7.5), serum creatinine 90 µmol/L (60-110), urinalysis glucose +, and 24-hour urine albumin 220 mg/24 hrs (<200). What is the best treatment option to prevent the progression of renal disease?
Your Answer: Treat with ACEI
Explanation:Treatment Options for Diabetic Nephropathy
Diabetic nephropathy is a common complication of diabetes, affecting up to 40% of patients with type 1 diabetes and 5-40% of patients with type 2 diabetes. Without intervention, it can lead to macroalbuminuria and end-stage renal disease. Treatment options include ACE inhibitors, low dietary protein, and improved glycaemic control.
In the case of a patient with microalbuminuria and poor glycaemic control but normal blood pressure, ACE inhibitors would be the preferred choice for renal protection. This is supported by evidence showing a 50% lower albumin excretion rate at two years in treated versus untreated patients with type 1 diabetes. However, it is important to rule out any urinary tract infections, as they can contribute to albumin excretion.
While good glycaemic control has not shown clear benefits in treating microalbuminuria in patients with type 1 diabetes, it is still important to improve overall glycaemic control to prevent further complications. A low protein diet has been proven effective for overt proteinuria but not for microalbuminuria. Therefore, in this case, the focus should be on ACE inhibitors and glycaemic control.
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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 32-year-old woman visits her GP after experiencing sudden hair growth, specifically on her face. She is feeling increasingly self-conscious about it and wants to address the issue. Blood tests were conducted, revealing an elevated testosterone level of 9.8 nmol/l (reference range 0.8-3.1 nmol/l). What is the next course of action in managing her condition?
Your Answer: Reassure and advise her that no additional investigations are required
Correct Answer: Refer to Endocrinology as a suspected cancer referral
Explanation:Referral for Suspected Androgen-Secreting Tumour in a Patient with Hirsutism
This patient presents with sudden-onset hair growth and a raised testosterone level, which raises suspicion for an androgen-secreting tumour. An urgent referral for further investigation is necessary to rule out malignancy. While polycystic ovary syndrome can also cause hirsutism, the patient’s testosterone level warrants exclusion of a tumour. Topical eflornithine may provide symptomatic relief, but it is not a substitute for further investigation. Routine referral to endocrinology is not appropriate in this case, as it may delay diagnosis and treatment of a potential malignancy.
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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 woman arrives at the labour ward in active labour. She is experiencing regular contractions, sweating heavily, and in significant pain.
What hormone is responsible for her contractions?Your Answer: Gonadotropin-releasing hormone (GnRH)
Correct Answer: Oxytocin
Explanation:Hormones Involved in Labour: Understanding Their Functions
During labour, various hormones are released in the body to facilitate the birthing process. One of the main hormones involved is oxytocin, which is released from the posterior pituitary. Oxytocin stimulates the uterine muscles to contract, and its positive feedback loop further increases contractions by stimulating prostaglandin production and releasing more oxytocin.
antidiuretic hormone (ADH) is another hormone released from the posterior pituitary, but it regulates water homeostasis in the kidneys and is not involved in causing contractions during labour. Thyroid-stimulating hormone (TSH) from the anterior pituitary stimulates the thyroid’s production of T4 to T3, but it does not cause sweating or contractions during labour.
Prolactin, also released from the anterior pituitary, enables milk production, but it is not involved in active labour. Gonadotropin-releasing hormone (GnRH) from the hypothalamus acts on the anterior pituitary to release luteinising hormone (LH) and follicle-stimulating hormone (FSH), which are essential for reproduction but not involved in causing contractions during labour.
Understanding the functions of these hormones can help in managing labour and ensuring a safe delivery.
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This question is part of the following fields:
- Endocrinology
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Question 8
Incorrect
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A 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: Inform the DVLA he is unfit to drive
Correct 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 9
Incorrect
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A 65-year-old patient presents with decompensated liver disease due to hepatocellular carcinoma. She is currently encephalopathic and has an INR of 6. What low-dose medication can be safely administered?
Your Answer: Warfarin
Correct Answer: Codeine
Explanation:Adjusting Drug Dosages for Patients with Hepatic Impairment
Patients with hepatic impairment may require adjustments to their medication regimen to prevent further liver damage or reduced drug metabolism. Certain drugs should be avoided altogether, including paracetamol, carbamazepine, oral contraceptive pills, ergometrine, and anticoagulants or antiplatelets like aspirin or warfarin due to the risk of gastrointestinal bleeding. Other medications, such as opiates, methotrexate, theophylline, and phenytoin, may still be prescribed but at a reduced dose to minimize potential harm to the liver. It is important for healthcare providers to carefully consider the potential risks and benefits of each medication and adjust dosages accordingly for patients with hepatic impairment. Proper medication management can help improve patient outcomes and prevent further liver damage.
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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 45-year-old male presents with symptoms of polyuria and polydipsia. He is a non-smoker and drinks approximately 12 units of alcohol per week. He works as a taxi driver.
During examination, his BMI is found to be 33.4 kg/m2, and his blood pressure is 132/82 mmHg. All other aspects of his cardiovascular examination are normal.
Further investigations confirm a diagnosis of diabetes mellitus, with the following results:
- Fasting blood glucose: 12.1 mmol/L (3.0-6.0)
- HbA1c: 75 mmol/mol (20-42)
- Total cholesterol: 5.8 mmol/L (<5.2)
What would be the most appropriate initial treatment for this patient?Your Answer: Diet and lifestyle advice with metformin
Explanation:Early Use of Metformin for Type 2 Diabetes
Typical type 2 diabetes can be managed with diet and lifestyle advice along with metformin. However, the EASD/ADA guidelines were revised in 2007-2008 due to the growing evidence supporting the early use of metformin. As a result, relying solely on diet and lifestyle advice is no longer considered sufficient.
The updated guidelines emphasize the importance of early intervention with metformin to improve glycemic control and prevent complications associated with type 2 diabetes. This approach is particularly important for patients who are at high risk of developing cardiovascular disease or have other comorbidities. By starting treatment early, patients can achieve better outcomes and reduce the risk of long-term complications.
In summary, the early use of metformin is now recommended as a first-line treatment for type 2 diabetes, along with diet and lifestyle modifications. This approach can help patients achieve better glycemic control and reduce the risk of complications associated with the disease.
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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 66-year-old man visits his primary care physician for his annual check-up, reporting constant fatigue and thirst. He has a medical history of hypertension, hyperlipidemia, and obesity. The doctor orders a screening for type II diabetes and the results are as follows:
Test Result Normal Range
HbA1C 48 mmol/mol < 53 mmol/mol (<7.0%)
Fasting plasma glucose 7.2 mmol/l < 7 mmol/l
Glomerular filtration rate (GFR) 90 ml/min > 90 ml/min
Which of the following is included in the diagnostic criteria for type II diabetes?Your Answer: Random plasma glucose ≥10 mmol/l in a patient with classic symptoms of diabetes or hyperglycaemic crisis
Correct Answer: Fasting plasma glucose ≥7.0 mmol/l
Explanation:To diagnose diabetes, several criteria must be met. One way is to measure fasting plasma glucose levels, which should be at least 7.0 mmol/l after an eight-hour fast. Another method is to test for HbA1C levels, which should be at least 48 mmol/mol (6.5%) using a certified and standardized method. A 2-hour plasma glucose test after a 75 g glucose load should result in levels of at least 11.1 mmol/l. If a patient exhibits classic symptoms of diabetes or hyperglycemic crisis, a random plasma glucose test should show levels of at least 11.1 mmol/l. All results should be confirmed by repeat testing. It’s important to note that 1-hour plasma glucose levels are not used in the diagnostic criteria for type II diabetes, but are part of screening tests for gestational diabetes.
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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 27-year-old female office assistant comes to you with complaints of palpitations, restlessness, fatigue, and excessive sweating. She also mentions that she has been experiencing irregular periods and has lost some weight recently. Upon examination, you notice that she has tachycardia and tremors, and her reflexes are hyperactive. Blood tests reveal that she has hyperthyroidism. Further examination of her neck shows multiple small nodules in an enlarged thyroid gland.
What would be the best initial approach to manage this patient?Your Answer: Fine needle aspiration of the nodules
Correct Answer: Propranolol
Explanation:Treatment for Thyrotoxic Patient
This patient is experiencing symptoms of thyrotoxicosis and requires treatment to alleviate the effects of adrenergic stimulation. The first step in treatment would be to administer propranolol, a beta-blocker that can help relieve symptoms such as palpitations, tremors, and anxiety.
Once the patient’s symptoms have been managed, the next step would be to address the underlying cause of the thyrotoxicosis. This would involve treatment to restore the patient to a euthyroid state, which can be achieved through the use of radioiodine therapy. However, it is important to note that propranolol would still be necessary during this initial phase of treatment to manage symptoms and prevent complications.
In summary, the treatment plan for this patient with thyrotoxicosis involves a two-step approach: first, managing symptoms with propranolol, and second, restoring the patient to a euthyroid state with radioiodine therapy.
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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 36-year-old woman has been referred by her GP due to passing an unusually large volume of urine and complaining of continuous thirst. The following investigations were conducted:
Random plasma:
Investigation Result
Sodium (Na+) 155 mmol/l
Osmolality 300 mOsmol/kg
Glucose 4.5 mmol/l
Urine:
Investigation Result
Osmolality 90 mOsmol/kg
Glucose 0.1 mmol/l
In healthy patients, the urine: plasma osmolality ratio is > 2. A water deprivation test was conducted, and after 6.5 hours of fluid deprivation, the patient's weight had dropped by >3%, and the serum osmolality was 310 mOsmol/kg. Urine osmolality at this stage was 210 mOsmol/kg. The patient was then given desmopressin intramuscularly (im) and allowed to drink. The urine osmolality increased to 700 mOsmol/kg, and her plasma osmolality was 292 mOsmol/kg.
What is the most likely diagnosis for this 36-year-old woman?Your Answer: Primary polydipsia
Correct Answer: A pituitary tumour
Explanation:Diagnosing Cranial Diabetes Insipidus: A Comparison with Other Conditions
Cranial diabetes insipidus (DI) is a condition where the kidneys are unable to reabsorb free water, resulting in excessive water loss. The most likely cause of this condition is a pituitary tumor, which reduces antidiuretic hormone (ADH) secretion. Other conditions, such as diabetes mellitus, chronic renal disease, lithium therapy, and primary polydipsia, may also cause polydipsia and polyuria, but they present with different symptoms and responses to treatment.
To diagnose cranial DI, doctors perform a water deprivation test and measure the urine: plasma osmolality ratio. In patients with cranial DI, the ratio is below 2, indicating that the kidneys are not concentrating urine as well as they should be. However, when given desmopressin im (exogenous ADH), the patient’s urine osmolality dramatically increases, showing that the kidneys can concentrate urine appropriately when stimulated by ADH. This confirms the absence of ADH as the cause of cranial DI.
Diabetes mellitus patients present with glycosuria and hyperglycemia, in addition to polydipsia and polyuria. Chronic renal disease and lithium therapy cause nephrogenic DI, which does not respond to desmopressin im. Primary polydipsia causes low urine osmolality, low plasma osmolality, and hyponatremia due to excessive water intake. However, patients with primary polydipsia retain some ability to concentrate urine, and removing the fluid source limits polyuria to some extent.
In conclusion, diagnosing cranial DI requires a thorough comparison with other conditions that cause polydipsia and polyuria. By understanding the symptoms and responses to treatment of each condition, doctors can accurately diagnose and treat patients with cranial DI.
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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 72-year-old woman takes medication for hypertension and raised cholesterol. At her annual check-up, she reports that she is feeling well. Among the results of her blood tests are the following: serum calcium 2.90 mmol/l (2.1–2.8 mmol/l), serum phosphate 0.80 mmol/l (1.0–1.5 mmol/l) and alkaline phosphatase 215 iu/l (53–128 iu/l).
Which of the following is the most likely explanation of these results in this woman?Your Answer: Occult malignancy
Correct Answer: Primary hyperparathyroidism
Explanation:Differential diagnosis for hypercalcaemia with hypophosphataemia and normal alkaline phosphatase
Primary hyperparathyroidism is a common cause of hypercalcaemia, often detected incidentally on routine blood tests. In this condition, the parathyroid glands produce excessive amounts of parathyroid hormone, which increases calcium reabsorption from bones and kidneys and decreases phosphate reabsorption from kidneys. As a result, patients may have elevated serum calcium and low serum phosphate levels, but normal or slightly elevated alkaline phosphatase levels.
Other possible causes of hypercalcaemia with hypophosphataemia and normal alkaline phosphatase include occult malignancy, especially if it involves bone, but this would usually result in a higher alkaline phosphatase level. Paget’s disease of bone, a chronic disorder of bone remodeling, may also cause hypercalcaemia, but it typically presents with a much higher alkaline phosphatase level as a marker of bone destruction.
Thyrotoxicosis, a condition of excess thyroid hormone, can also lead to hypercalcaemia, but this patient has no symptoms suggestive of hyperthyroidism. Phaeochromocytoma, a rare tumor of the adrenal gland that secretes catecholamines, may cause hypertension, but it is not typically associated with hypercalcaemia or hypophosphataemia.
Therefore, the most likely diagnosis in this case is primary hyperparathyroidism, which may be part of a multiple endocrine neoplasia (MEN) type 2 syndrome that also involves the thyroid gland and adrenal medulla. Further evaluation, including imaging studies and genetic testing, may be necessary to confirm the diagnosis and guide management.
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This question is part of the following fields:
- Endocrinology
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Question 15
Incorrect
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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: Diclofenac 75 mg BD
Correct 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 naïve.
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 16
Incorrect
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A 28-year-old man comes to the clinic complaining of gradual weight loss. He has lost 8 kg over the past three months, and his previous weight was 62 kg.
Two years ago, he volunteered at a child rehabilitation program in India and contracted pulmonary tuberculosis, which was successfully treated. A recent chest x-ray showed no suspicious lesions in the lungs, and there is no lymphadenopathy. He denies having a fever or night sweats.
During the examination, he reveals that he has been drinking one bottle of wine per day for the past three weeks, following a breakup with his girlfriend.
Which test is likely to show a positive result for the weight loss?Your Answer: Thyroid profile
Correct Answer: Abdominal x ray
Explanation:Overlooked Causes of Weight Loss: Addison’s Disease
Weight loss can be caused by a variety of factors, and it is important to consider all possibilities when investigating the underlying cause. One often overlooked cause is Addison’s disease, which can occur as a result of past tuberculosis affecting the adrenal glands. This rare condition can be identified through abdominal x-rays, which may show adrenal calcification shadows.
While alcohol abuse can lead to liver damage and hepatitis, it is not likely to be the cause of weight loss in this case. Similarly, steatorrhoea, a manifestation of malabsorption, can cause weight loss, but there are no other indications of malabsorption in this patient’s history.
Thyrotoxicosis, or an overactive thyroid, can also cause weight loss, but it is usually accompanied by other symptoms such as anxiety, tremors, and eye signs. Finally, surreptitious laxative abuse can lead to weight loss, but it is not likely to be the cause in this case given the patient’s history of tuberculosis.
Overall, it is important to consider all possible causes of weight loss, including rare conditions like Addison’s disease, in order to provide the most effective treatment and care for patients.
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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 35-year-old woman with a body mass index of 33 kg/m2 has a fasting blood sugar of 10 mmol/l and 11.7 mmol/l on two separate occasions. Her family history includes diabetes mellitus in her father and maternal uncle. Despite attempting to lose weight through diet and exercise, she has been unsuccessful in achieving a balanced diet. She is open to taking either orlistat or an anorexigenic agent. Further investigation reveals that her blood insulin level tends to be relatively high.
What is the most likely hormonal change to be observed in this patient?Your Answer: Reduced adiponectin
Explanation:Endocrine Factors Predisposing to Type II Diabetes Mellitus
Type II diabetes mellitus is a metabolic disorder characterized by insulin resistance and high blood sugar levels. Several endocrine factors can predispose individuals to this condition. In obese patients with a positive family history of diabetes, adiponectin levels are reduced. Adiponectin is a hormone secreted by adipocytes that plays a role in glucose metabolism. In contrast, leptin levels are increased in these patients and usually correlate with the degree of insulin resistance. Growth hormone levels are increased in acromegaly, which can also predispose individuals to type II diabetes. Phaeochromocytoma, a rare tumor of the adrenal gland, can cause increased epinephrine levels and predispose individuals to diabetes. Similarly, Cushing syndrome, a condition characterized by increased cortisol levels, can also predispose individuals to type II diabetes. Understanding these endocrine factors can help clinicians identify individuals at risk for type II diabetes and implement appropriate preventive measures.
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This question is part of the following fields:
- Endocrinology
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Question 18
Incorrect
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Which statement about testosterone is accurate?
Your Answer: In the circulation is mostly bound to albumin
Correct Answer: Is a steroid hormone
Explanation:Testosterone: A Steroid Hormone
Testosterone is a type of steroid hormone that can be transformed into oestradiol. It has the ability to bind to intracellular receptors and is typically attached to sex-hormone binding globulin. This hormone plays a crucial role in the development of male reproductive tissues and secondary sexual characteristics. It is also present in females, albeit in smaller amounts, and is responsible for regulating their menstrual cycle and maintaining bone density.
In summary, testosterone is a vital hormone that affects both males and females. Its ability to bind to intracellular receptors and convert to oestradiol makes it a versatile hormone that plays a significant role in the human body. the functions of testosterone is essential in maintaining overall health and well-being.
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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 60-year-old man with a previous diagnosis of multiple endocrine neoplasia type 2 (MEN 2) presents to you 2 days after having undergone a total thyroidectomy. He reports experiencing cramps in his calves and thighs and tingling around his lips. Upon examination, you observe positive Chvostek’s sign and Trousseau sign. Further investigations reveal his serum calcium level to be 2 mmol/l and his serum phosphate level to be 1.8 mmol/l. What is the most likely explanation for these findings?
Your Answer: Vitamin D deficiency
Correct Answer: Acquired hypoparathyroidism
Explanation:Differential diagnosis of hypocalcaemia and hyperphosphataemia
Acquired hypoparathyroidism is a likely cause of the biochemical abnormalities observed in a patient who recently underwent a total thyroidectomy. This condition results from damage to the parathyroid glands during surgery, leading to insufficient secretion of parathyroid hormone and subsequent hypocalcaemia and hyperphosphataemia. Other potential causes of these abnormalities include chronic renal failure and vitamin D deficiency, but these do not match the patient’s clinical history. Pseudohypoparathyroidism, a rare genetic disorder characterized by target tissue resistance to parathyroid hormone, is not a likely explanation either. Pseudopseudohypoparathyroidism, another rare inherited disorder that mimics the physical features of pseudohypoparathyroidism without the biochemical changes, is not relevant to this case. Therefore, acquired hypoparathyroidism is the most probable diagnosis, and appropriate management should include calcium and vitamin D supplementation, as well as monitoring for potential complications such as seizures and tetany.
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This question is part of the following fields:
- Endocrinology
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Question 20
Incorrect
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A 55-year-old woman visits her GP with concerns about her susceptibility to osteoporosis. She underwent a hysterectomy and oophorectomy due to uterine fibroids five years ago, which resulted in mild hot flashes that have since subsided. The patient is anxious about the possibility of fractures after her mother broke her hip at the age of 72. She inquires about osteoporosis medications. Her BMI is 17.3 kg/m2, and her T score is <−2.5. She was on Depo-Provera from the age of 39 to 45, during which time she experienced amenorrhea. The physical examination, including breast examination, is normal. What would you suggest to her?
Your Answer: No treatment
Correct Answer: Bisphosphonate
Explanation:Treatment for Osteoporosis in a High-Risk Patient
Osteoporosis is a condition characterized by low bone density and increased risk of fractures. This condition is more common in women, especially those with a low body mass index (BMI), a positive family history, and those who have undergone oophorectomy. In this case, the patient has multiple risk factors for osteoporosis, but she no longer experiences menopausal symptoms.
To diagnose severe osteoporosis, a T score of <−2.5 SD is required, along with one or more fragility fractures. In this patient's case, the most appropriate therapy would be a bisphosphonate. This medication helps to increase bone density and reduce the risk of fractures. It is important to note that bisphosphonates have potential side effects, such as gastrointestinal upset and osteonecrosis of the jaw, but the benefits generally outweigh the risks. In summary, this patient’s high-risk factors for osteoporosis make her a candidate for treatment with a bisphosphonate. It is important to discuss the potential benefits and risks of this medication with the patient before starting treatment.
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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 35-year-old female presents with symptoms of weight loss and irritability. Upon conducting thyroid function tests, the results reveal a Free T4 level of 32.9 pmol/L (9.8-23.1), TSH level of <0.02 mU/L (0.35-5.50), and Free T3 level of 11.1 pmol/L (3.5-6.5). During examination, the patient exhibits a fine tremor, pulse of 95 beats per minute, a smooth goitre with a bruit, and lid lag without any other eye signs. What is the most likely cause for these thyroid function test results?
Your Answer: Amiodarone-induced thyrotoxicosis
Correct Answer: Graves' disease
Explanation:TFTs and Hyperthyroidism
Thyroid function tests (TFTs) can help diagnose hyperthyroidism, which can be caused by Graves’ disease, Hashitoxicosis, or Multinodular goitre. However, the presence of a thyroid bruit, which suggests increased vascularity due to stimulation by a thyroid-stimulating hormone (TSH) receptor antibody, is a distinguishing feature of Graves’ disease. This condition is the only one where a thyroid bruit is expected. While eye signs such as proptosis, chemosis, and exophthalmos are common in Graves’ disease, they are not always present.
Overall, TFTs are a useful tool in identifying hyperthyroidism, and the presence of a thyroid bruit can help differentiate between the different causes. However, other symptoms and signs, such as eye changes, may also be present and should be taken into consideration when making a diagnosis.
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This question is part of the following fields:
- Endocrinology
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Question 22
Incorrect
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A 28-year-old woman visited her GP with complaints of low mood, weight gain, and irregular menstrual cycles. The GP conducted some tests and referred her to the hospital. The results of the investigations are as follows:
- Sodium: 150 mmol/l (normal value: 135-145 mmol/l)
- Potassium: 2.5 mmol/l (normal value: 3.5-5.0 mmol/l)
- Fasting blood glucose: 7.7 mmol/l (normal value: <7 mmol/l)
- 24-hour urinary cortisol excretion: 840 nmol/24 h
- Plasma ACTH (0900 h): 132 ng/l (normal value: 0-50 ng/l)
- Dexamethasone suppression test:
- 0800 h serum cortisol after dexamethasone 0.5 mg/6 h orally (po) for two days: 880 nmol/l (<50 nmol/l).
- 0800 h serum cortisol after dexamethasone 2 mg/6 h PO for two days: 875 nmol/l (<50 nmol/l).
What is the most likely diagnosis for this 28-year-old woman?Your Answer: Conn’s syndrome
Correct Answer: Paraneoplastic syndrome secondary to small cell carcinoma of the lung
Explanation:Paraneoplastic Syndrome Secondary to Small Cell Carcinoma of the Lung Causing Cushing Syndrome
Cushing syndrome is a clinical state resulting from chronic glucocorticoid excess and lack of normal feedback mechanisms of the hypothalamo-pituitary-adrenal axis. While Cushing’s disease, paraneoplastic syndrome secondary to small cell carcinoma of the lung, and adrenocortical tumor are specific conditions resulting in Cushing syndrome, this patient’s symptoms are caused by paraneoplastic syndrome secondary to small cell carcinoma of the lung.
In some cases of small cell carcinoma of the lung, ectopic adrenocorticotropic hormone (ACTH) production occurs, leading to elevated plasma ACTH and cortisol levels. The mineralocorticoid activity of cortisol results in sodium retention and potassium excretion, leading to glucose intolerance and hyperglycemia. The differentiation between Cushing’s disease and ectopic ACTH secretion is made by carrying out low- and high-dose dexamethasone suppression tests. In cases of ectopic ACTH secretion, there is usually no response to dexamethasone, as pituitary ACTH secretion is already maximally suppressed by high plasma cortisol levels.
The absence of response to dexamethasone suggests an ectopic source of ACTH production, rather than Cushing’s disease. Other differential diagnoses for Cushing syndrome include adrenal neoplasia, Conn’s syndrome, and premature menopause. However, in this case, the blood test results suggest ectopic production of ACTH, indicating paraneoplastic syndrome secondary to small cell lung carcinoma as the most likely cause.
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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 35-year-old male with type 2 diabetes presents with a blood pressure reading of 140/85 mmHg and persistent traces of albuminuria in his urine examination. What is the most suitable course of treatment for this individual?
Your Answer: ACE inhibitor
Explanation:Diabetic Nephropathy and the Benefits of ACE Inhibitors
Diabetic nephropathy is a clinical condition characterized by persistent albuminuria, a decline in the glomerular filtration rate, and elevated arterial blood pressure. To confirm the diagnosis, albuminuria must be present on at least two occasions three to six months apart. Antihypertensive therapy can slow the progression of diabetic glomerulopathy, but ACE inhibitors have been shown to provide superior long-term protection.
Aside from its cardiovascular benefits, ACE inhibition has also been found to have a significant positive effect on the progression of diabetic retinopathy and the development of proliferative retinopathy. Therefore, ACE inhibitors are a recommended treatment option for patients with diabetic nephropathy. By this condition and the benefits of ACE inhibitors, healthcare professionals can provide better care for their patients with diabetes.
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This question is part of the following fields:
- Endocrinology
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Question 24
Correct
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A 65-year-old male with a diagnosis of lung cancer presents with fatigue and lightheadedness. Upon examination, the following results are obtained:
Plasma sodium concentration 115 mmol/L (137-144)
Potassium 3.5 mmol/L (3.5-4.9)
Urea 3.2 mmol/L (2.5-7.5)
Creatinine 67 µmol/L (60-110)
What is the probable reason for his symptoms based on these findings?Your Answer: Syndrome of inappropriate ADH secretion
Explanation:Syndrome of Inappropriate ADH Secretion
Syndrome of inappropriate ADH secretion (SIADH) is a condition characterized by low levels of sodium in the blood. This is caused by the overproduction of antidiuretic hormone (ADH) by the posterior pituitary gland. Tumors such as bronchial carcinoma can cause the ectopic elaboration of ADH, leading to dilutional hyponatremia. The diagnosis of SIADH is one of exclusion, but it can be supported by a high urine sodium concentration with high urine osmolality.
Hypoadrenalism is less likely to cause hyponatremia, as it is usually associated with hyperkalemia and mild hyperuricemia. On the other hand, diabetes insipidus is a condition where the kidneys are unable to reabsorb water, leading to excessive thirst and urination.
It is important to diagnose and treat SIADH promptly to prevent complications such as seizures, coma, and even death. Treatment options include fluid restriction, medications to block the effects of ADH, and addressing the underlying cause of the condition.
In conclusion, SIADH is a condition that can cause low levels of sodium in the blood due to the overproduction of ADH. It is important to differentiate it from other conditions that can cause hyponatremia and to treat it promptly to prevent complications.
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This question is part of the following fields:
- Endocrinology
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Question 25
Correct
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A 30-year-old man has been diagnosed with Addison's disease after presenting with symptoms of fatigue, weakness, gastrointestinal upset, and skin hyperpigmentation. Which adrenal hormone deficiency is typically responsible for the loss of sodium and water in Addison's disease?
Your Answer: Aldosterone
Explanation:Hormones Affected in Addison’s Disease
Addison’s disease is a condition where the adrenal glands do not produce enough hormones. This can lead to a variety of symptoms, including salt wasting and hyperkalaemia. Here are the hormones affected in Addison’s disease:
1. Aldosterone: Produced in the adrenal cortex, aldosterone is responsible for reabsorbing sodium and secreting potassium in the kidney. In Addison’s disease, aldosterone levels are low, leading to salt wasting and hyperkalaemia.
2. Cortisol: Low cortisol levels are a diagnostic marker for Addison’s disease. While cortisol does affect sodium homeostasis, its deficiency alone does not lead to salt wasting.
3. Adrenaline: The function of the adrenal medulla, which produces adrenaline, is preserved in Addison’s disease.
4. Angiotensin: While angiotensin does affect sodium reabsorption in the kidney, its levels would not be low in Addison’s disease.
5. Adrenocorticotropic hormone (ACTH): Levels of ACTH are high in Addison’s disease, which leads to the characteristic skin pigmentation.
Understanding the hormones affected in Addison’s disease can help with diagnosis and treatment of this condition.
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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 50-year-old woman is brought to the Emergency Department after being found near-unconscious by her husband. He claims she has been increasingly depressed and tired over the last few weeks. Past medical history includes coeliac disease, for which she follows a strict gluten-free diet, and vitiligo. She is on no medical treatment. On examination, she is responsive to pain. Her pulse is 130 bpm and blood pressure is 90/60 mmHg. She is afebrile. Pigmented palmar creases are also noted. Basic blood investigations reveal:
Investigation Result Normal value
Haemoglobin 121 g/l 115–155 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 3.5–5.5 mmol/l
What is the most likely diagnosis?Your Answer: Meningococcal septicaemia
Correct Answer: Addisonian crisis
Explanation:Differential Diagnosis: Addisonian Crisis and Other Conditions
Addisonian crisis is a condition caused by adrenal insufficiency, with autoimmune disease being the most common cause in the UK. Symptoms are vague and present insidiously, including depression, anorexia, and GI upset. Diagnosis is made through a short ACTH stimulation test. Emergency treatment involves IV hydrocortisone and fluids, while long-term treatment is based on oral cortisol and mineralocorticoid. Any stressful activity should lead to an increase in steroid dose.
Other conditions, such as insulin overdose, salicylate overdose, meningococcal septicaemia, and paracetamol overdose, have different clinical features and are not compatible with the symptoms described for Addisonian crisis. It is important to consider these differential diagnoses when evaluating a patient with similar symptoms.
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This question is part of the following fields:
- Endocrinology
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Question 27
Incorrect
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A 47-year-old man is diagnosed with hypertension after multiple readings show a blood pressure of 180/110 mmHg. Further investigation reveals a 4.3-cm right-sided adrenal lesion, and he is found to have elevated plasma free metanephrines at 3000 pmol/l (normal range: 80-510 pmol/l). He is scheduled for elective adrenalectomy. What initial treatment should be initiated to prepare this patient for surgery to remove his adrenal phaeochromocytoma?
Your Answer: Calcium channel blockers
Correct Answer: Alpha-adrenergic receptor blockers
Explanation:Management of Phaeochromocytoma: Medications and Precautions
Phaeochromocytoma is a neuroendocrine tumour that secretes adrenaline and noradrenaline, leading to sympathetic stimulation and clinical symptoms such as tachycardia, hypertension, anxiety, diaphoresis, and weight loss. Diagnosis is through measurement of catecholamines and metanephrines in plasma or urine. Surgery is required, but patients are at high risk due to potential life-threatening tachycardia and hypertension. Management includes the use of alpha-adrenergic receptor blockers such as phenoxybenzamine or doxazosin to dampen sympathetic activity. IV fluids should be readily available for potential blood loss during surgery. Beta-adrenergic receptor blockers can be used after alpha blockers, but not before to avoid unopposed alpha receptor stimulation and hypertensive crisis. Calcium channel blockers are not commonly used in phaeochromocytoma management. Low-salt diet and low fluid intake are not necessary precautions in this case, as the drop in blood pressure following surgery eliminates the risk of fluid overload.
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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 25-year-old veterinary student is being evaluated for possible Addison's disease due to symptoms of weight loss, hypotension, and fatigue. As part of the diagnostic process, the patient undergoes testing to measure cortisol levels before and after receiving synthetic adrenocorticotropic hormone (ACTH) injection (short-synacthen test). What is a true statement regarding cortisol in this scenario?
Your Answer: It is a protein
Correct Answer: It has a peak hormonal concentration in the morning
Explanation:Misconceptions about Cortisol: Clarifying the Facts
Cortisol is a hormone that has been the subject of many misconceptions. Here are some clarifications to set the record straight:
1. Peak Hormonal Concentration: Cortisol has a diurnal variation and peaks in the morning upon waking up. Its lowest level is around midnight.
2. Protein or Steroid: Cortisol is a steroid hormone, not a protein.
3. Blood Glucose: Cortisol increases blood glucose levels via various pathways, contrary to the belief that it lowers blood glucose.
4. Anabolic or Catabolic: Cortisol is a catabolic hormone that causes a breakdown of larger molecules to smaller molecules.
5. Stimulated by Renin or ACTH: Cortisol is stimulated by adrenocorticotropic hormone (ACTH) released from the anterior pituitary, not renin.
By understanding the true nature of cortisol, we can better appreciate its role in our bodies and how it affects our health.
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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 28-year-old woman has been living with type 1 diabetes mellitus for 15 years and has been under your care for the past nine years. During this time, her HbA1c levels have fluctuated between 64 mmol/mol and 75 mmol/mol (20-42).
Today, her blood pressure reads 130/84 mmHg. She has also noticed that her blood glucose levels at home have been fluctuating more than usual over the past three months. Additionally, she reports experiencing nausea after eating and requiring less food than usual to feel full.
Upon conducting investigations, the following results were obtained:
- Urea: 8.1 mmol/L (2.5-7.5)
- Creatinine: 112 µmol/L (60-110)
- Sodium: 138 mmol/L (137-144)
- Potassium: 4.2 mmol/L (3.5-4.9)
- Bicarbonate: 24 mmol/L (20-28)
- HbA1c: 42 mmol/mol (20-42)
- Urinalysis: Protein+
What is the most likely cause of her symptoms?Your Answer: Adrenal insufficiency
Correct Answer: Delayed gastric emptying
Explanation:Autonomic Neuropathy and Gastric Emptying
People with a long history of diabetes may experience nausea after eating, along with a feeling of fullness and reduced appetite. These symptoms suggest reduced gastric emptying, which is often associated with autonomic neuropathy. Other symptoms that may be present include postural hypotension, gustatory sweating, diarrhea, or changes in bowel habits. To confirm the diagnosis, a barium swallow and meal may be necessary. It is important to recognize these symptoms and seek medical attention to manage the underlying condition.
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This question is part of the following fields:
- Endocrinology
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Question 30
Incorrect
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At a routine occupational health check, a 30-year-old man is found to have mild hypercalcaemia. He is anxious because the problem failed to resolve in his father, despite neck surgery. 24-hour urinary calcium excretion levels are low.
Which of the following is the most likely diagnosis?Your Answer: Primary hyperparathyroidism
Correct Answer: Familial hypocalciuric hypercalcaemia (FHH)
Explanation:Differentiating Hypercalcaemia Causes: A Comparison
Hypercalcaemia can be caused by various conditions, including familial hypocalciuric hypercalcaemia (FHH), primary hyperparathyroidism, sarcoidosis, secondary hyperparathyroidism, and hypercalcaemia of malignancy. To differentiate these causes, 24-hour urinary calcium excretion levels are measured.
In FHH, urinary calcium excretion levels are low, while in primary hyperparathyroidism, they are elevated. Sarcoidosis can also cause hypercalcaemia, but with elevated urinary calcium excretion levels. On the other hand, secondary hyperparathyroidism is associated with hypocalcaemia. Lastly, hypercalcaemia of malignancy is characterized by elevated urinary calcium excretion levels.
Therefore, measuring 24-hour urinary calcium excretion levels is crucial in determining the underlying cause of hypercalcaemia.
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This question is part of the following fields:
- Endocrinology
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