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  • Question 1 - A 42-year-old woman comes to the clinic with complaints of cold intolerance, constipation,...

    Incorrect

    • 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: Hashimoto’s thyroiditis

      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.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 2 - What role does adrenocorticotrophic hormone (ACTH) play in the body? ...

    Incorrect

    • What role does adrenocorticotrophic hormone (ACTH) play in the body?

      Your Answer: Stimulation of the release of adrenaline and noradrenaline

      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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      • Endocrinology
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  • Question 3 - A 28-year-old woman is found to have a phaeochromocytoma. Which of the following...

    Incorrect

    • A 28-year-old woman is found to have a phaeochromocytoma. Which of the following is expected to be elevated in her urine levels?

      Your Answer: Cortisol

      Correct Answer: Metanephrines

      Explanation:

      Urinary Metabolites as Diagnostic Markers for Adrenal Disorders

      Adrenal disorders such as phaeochromocytomas, congenital adrenal hyperplasia, and Cushing syndrome can be diagnosed by measuring specific urinary metabolites. For example, metanephrines, vanillylmandelic acid (VMA), and homovanillic acid (HVA) are the principal metabolic products of adrenaline and noradrenaline, and their elevated levels in urine indicate the presence of phaeochromocytomas. Similarly, increased urinary excretion of pregnanetriol and dehydroepiandrosterone are indicative of congenital adrenal hyperplasia. Free urinary cortisol levels are elevated in Cushing syndrome, which is characterized by weight gain, fatty tissue deposits, and other symptoms. Additionally, increased urinary excretion of 5-hydroxyindoleacetic acid is seen in functioning carcinoids. However, it is important to note that elevated levels of these metabolites can also occur in other conditions such as extreme stress states or medication use. Therefore, careful interpretation of urinary metabolite levels is necessary for accurate diagnosis of adrenal disorders.

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      • Endocrinology
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  • Question 4 - A 58-year-old woman visited her doctor after fracturing her humerus in a minor...

    Incorrect

    • 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: Myeloma

      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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      • Endocrinology
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  • Question 5 - A 26-year-old professional athlete is being evaluated at the Endocrinology Clinic for presenting...

    Incorrect

    • A 26-year-old professional athlete is being evaluated at the Endocrinology Clinic for presenting symptoms of low mood, decreased energy, and difficulty in preserving muscle mass. The patient also reports dry skin and hair loss. As part of the diagnostic process, the doctor requests a glucagon stimulation test.
      What is elevated after the glucagon stimulation test?

      Your Answer: C-peptide

      Correct Answer: C-peptide, cortisol and growth hormone

      Explanation:

      Glucagon and Hormone Production: Effects on C-peptide, Cortisol, Growth Hormone, and TSH

      Glucagon, a hormone produced by the pancreas, has various effects on hormone production in the body. One of these effects is the stimulation of insulin and C-peptide production. C-peptide is cleaved from proinsulin during insulin production, and its levels can be used to measure insulin secretion. Glucagon also indirectly stimulates cortisol production by causing the release of adrenocorticotropic hormone (ACTH) via the hypothalamus. Additionally, glucagon can stimulate growth hormone production, making it an alternative test for measuring growth hormone levels. However, thyroid-stimulating hormone (TSH) secretion is not affected by glucagon injection. Understanding the effects of glucagon on hormone production can aid in the diagnosis and management of various endocrine disorders.

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      • Endocrinology
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  • Question 6 - A 25-year-old veterinary student is being evaluated for possible Addison's disease due to...

    Correct

    • 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 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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      • Endocrinology
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  • Question 7 - A 65-year-old woman is referred to the Diabetes Clinic with a new diagnosis...

    Correct

    • A 65-year-old woman is referred to the Diabetes Clinic with a new diagnosis of type 2 diabetes mellitus. She has a body mass index (BMI) of 34 kg/m2. Her finger-prick blood glucose test is 9 mmol/l. She has a past history of ischaemic heart disease and chronic kidney disease. Her medications include ramipril 10 mg daily, atorvastatin 40 mg, aspirin 75 mg and bisoprolol 5 mg. Her laboratory test results are as follows:
      Investigation Result Normal range
      HbA1C 61 mmol/mol < 53 mmol/mol (<7.0%)
      Creatinine 178 µmol/l 50–120 µmol/l
      Glomerular filtration rate (GFR) 26 ml/min > 90 ml/min
      Which of the following drugs would be the most appropriate to manage this patient’s diabetes?

      Your Answer: Linagliptin

      Explanation:

      Common Anti-Diabetic Medications and Their Mechanisms of Action

      Linagliptin: This medication is a DPP-4 inhibitor that works by blocking the degradation of GLP-1, which increases insulin secretion and lowers blood sugar levels.

      Glargine insulin: Glargine is a long-acting insulin that is preferred for people needing baseline control of sugar throughout the day and those at risk of hypoglycaemia. It has a lower risk of causing hypoglycaemia compared to other insulin types and may cause weight gain.

      Rosiglitazone: This thiazolidinedione medication is an agonist for the peroxisome proliferator-activated receptors and is used for diabetes control. However, it can exacerbate heart conditions and cause weight gain, and is no longer recommended by BNF due to increased risk of heart attacks.

      Metformin: This biguanide medication is commonly used as first-line treatment for diabetes, but its use is limited by gastrointestinal upset and is contraindicated in patients with poor renal function and low GFR.

      Gliclazide: This sulfonylurea medication is an insulin secretagogue that stimulates the release of insulin. It is often used as a second-line medication, but its use is limited by the risk of hypoglycaemia and weight gain.

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      • Endocrinology
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  • Question 8 - A 44-year-old chronic smoker was diagnosed with lung cancer 6 months ago after...

    Incorrect

    • A 44-year-old chronic smoker was diagnosed with lung cancer 6 months ago after presenting with weight loss, haemoptysis, and shortness of breath. He returns to the Emergency Department complaining of nausea and lethargy that have been worsening over the past 3 weeks. While waiting to see the doctor, he has a seizure. He has a history of hypertension. The following are the results of his investigations:
      Investigations Results Normal value
      Sodium (Na+) 120 mmol/l 135–145 mmol/l
      Serum osmolality 250 mOsmol/kg 280–290 mOsmol/kg
      Urine osmolality 1500 mOsmol/kg 50–1200 mOsmol/kg
      Haematocrit 27%

      What is the most likely diagnosis?

      Your Answer: Epilepsy

      Correct Answer: Syndrome of inappropriate antidiuretic secretion (SIADH)

      Explanation:

      Understanding Syndrome of Inappropriate Antidiuretic Secretion (SIADH)

      The patient in this scenario is likely experiencing a seizure due to hyponatremia caused by Syndrome of Inappropriate Antidiuretic Secretion (SIADH). SIADH is characterized by hyponatremia, serum hypo-osmolality, urine hyperosmolality, and a decreased hematocrit. The patient’s history of lung cancer is a clue to the underlying cause.

      Epilepsy is unlikely as there is no history of seizures mentioned. Central diabetes insipidus presents with hypernatremia, serum hyperosmolality, and urine hypo-osmolality, while nephrogenic diabetes insipidus presents with the same clinical picture. Psychogenic polydipsia is also ruled out as patients with this condition produce hypotonic urine, not hypertonic urine as seen in this patient’s presentation.

      Overall, understanding the symptoms and underlying causes of SIADH is crucial in diagnosing and treating patients with this condition.

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      • Endocrinology
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  • Question 9 - A 35-year-old man is referred by his GP to the endocrine clinic after...

    Incorrect

    • A 35-year-old man is referred by his GP to the endocrine clinic after a blood test revealed hypercalcaemia. The man originally presented to his GP following episodes of abdominal pain and loin pain.
      A thorough history from the patient reveals that his father had similar symptoms which started at the age of 49 but he later passed away from a pancreatic tumour. The patient’s grandfather also had a high calcium level, but the patient does not remember what happened to him. The Endocrinologist explains to the patient that he suffers from a disease which runs in the family and part of his treatment would involve the surgical removal of the majority of the parathyroid glands.
      Which of the following should this patient also be considered at risk of?

      Your Answer: Phaeochromocytoma

      Correct Answer: Pancreatic islet cell tumour

      Explanation:

      The patient’s hypercalcaemia is due to a parathyroid gland issue, not a germ cell tumour of the testis, which is not related to the MEN syndromes. Pineal gland tumours can cause sleep pattern abnormalities, but this is not the case for this patient. Phaeochromocytoma, a tumour of the adrenal glands, typically presents with headaches, high blood pressure, palpitations, and anxiety, and is part of MEN 2a and 2b, but not MEN 1. Thyroid medullary carcinoma, which is part of MEN 2a and 2b, presents with diarrhoea and often metastasises by the time of diagnosis, but is not associated with MEN 1. Pancreatic islet cell tumours, also known as pancreatic neuroendocrine tumours, are part of MEN 1 and can cause hypoglycaemia if they arise from insulin-producing cells. These tumours can be benign or malignant, with the majority being benign. MEN syndromes are rare and characterised by adenomas and adenocarcinomas, with specific pathologies varying depending on the type of MEN syndrome.

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      • Endocrinology
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  • Question 10 - A 45-year-old woman visits her GP for a check-up on her blood pressure,...

    Incorrect

    • A 45-year-old woman visits her GP for a check-up on her blood pressure, which has been difficult to manage despite lifestyle changes and taking a combination of ramipril and felodipine. On examination, there are no clinical indications to aid in diagnosis. The GP conducts a urinalysis, which comes back normal, and orders some blood tests. The results show:
      Investigation Result Normal value
      Sodium (Na+) 175 mmol/l 135–145 mmol/l
      Potassium (K+) 3.1 mmol/l 3.5–5.0 mmol/l
      Urea 4.1 mmol/l 2.5–6.5 mmol/l
      Creatinine 75 μmol/l 50–120 μmol/l
      eGFR >60 ml/min/1.73m2 >60 ml/min/1.73m2
      Based on this presentation, what is the most probable secondary cause of hypertension?

      Your Answer: Phaeochromocytoma

      Correct Answer: Primary hyperaldosteronism

      Explanation:

      Secondary Causes of Hypertension

      Hypertension, or high blood pressure, can have various underlying causes. While primary hypertension is the most common form, secondary hypertension can be caused by an underlying medical condition. Here are some of the secondary causes of hypertension:

      1. Primary Hyperaldosteronism: This is the most common form of secondary hypertension, caused by a solitary adrenal adenoma or bilateral adrenal hyperplasia. It is more prevalent in patients with hypertension who are resistant to treatment.

      2. Phaeochromocytoma: This rare condition can cause severe symptoms such as headaches, sweating, abdominal pain, and palpitations associated with periods of very high blood pressure.

      3. Glomerulonephritis: Renal disease can be a potential secondary cause of hypertension, typically manifesting as haematuria or proteinuria on urinalysis. The creatinine level may rise, and the estimated glomerular filtration rate (eGFR) falls.

      4. Diabetic Nephropathy: This condition presents with proteinuria (and likely glucose) on urinalysis. Renal disease may lead to a rise in creatinine and a fall in eGFR.

      5. Cushing Syndrome: While unlikely to cause isolated hypertension, other features of Cushing syndrome such as abdominal obesity, striae, and a round face would likely be present on examination.

      In conclusion, it is important to identify the underlying cause of hypertension to provide appropriate treatment and management.

    • This question is part of the following fields:

      • Endocrinology
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  • Question 11 - A 20-year-old man, who has recently started his second year of university, is...

    Incorrect

    • A 20-year-old man, who has recently started his second year of university, is brought to the Emergency Department by his friends early on a Friday evening. His friends report he has vomited several times and that he appears confused and ‘not himself’. Upon examination, the patient appears disorientated and unwell. His temperature is 37.2 °C, heart rate 118 bpm and regular, blood pressure 106/68 mmHg. He has dry mucous membranes and his breath smells like nail polish remover. The chest is normal on auscultation, and his abdomen is soft and appears to be non-tender. Capillary blood glucose is 26 mmol/l, and urine dip is strongly positive for glucose and ketones.
      Arterial blood gas (ABG) results are given below:
      Investigation Result Normal range
      pH 6.9 7.35–7.45
      paCO2 3.4 kPa 4.5–6.0 kPa
      paO2 12.5 kPa 10.0–14.0 kPa
      HCO3 8.3 mEq/l 22–28 mmol/l
      What is the most appropriate initial management for this patient?

      Your Answer: IV fluids and variable-rate insulin infusion

      Correct Answer: IV fluids and fixed-rate insulin infusion

      Explanation:

      Management of Diabetic Ketoacidosis (DKA)

      Diabetic ketoacidosis (DKA) is a serious complication of diabetes that requires urgent treatment. The management of DKA involves IV fluids to correct dehydration and electrolyte abnormalities, and a fixed-rate insulin infusion to reduce blood ketone and glucose levels. The aim is to normalise blood glucose levels and clear blood ketones. Once the blood glucose level falls below 12 mmol/l, IV fluids should be switched from normal saline to 5% dextrose to avoid inducing hypoglycaemia.

      It is important to identify the precipitating cause of DKA, which could be infection, surgery, medication, or non-compliance with insulin therapy. A toxicology screen is not indicated unless there is a suspicion of drug overdose.

      Oral rehydration is insufficient for managing DKA, and IV fluids are critical for correcting dehydration and electrolyte abnormalities. A variable-rate insulin infusion is not recommended as the focus of insulin therapy in DKA is to correct blood ketone levels.

      Confusion in DKA is likely related to dehydration and electrolyte abnormalities, and urgent CT brain is not indicated unless there is a suspicion of head injury. Overall, prompt recognition and management of DKA is essential to prevent life-threatening complications.

      Management of Diabetic Ketoacidosis (DKA)

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      • Endocrinology
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  • Question 12 - A 55-year-old woman visits her GP with concerns about her susceptibility to osteoporosis....

    Incorrect

    • 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: Calcium carbonate alone

      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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      • Endocrinology
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  • Question 13 - A 32-year-old woman reports to her community midwife with complaints of failure to...

    Correct

    • A 32-year-old woman reports to her community midwife with complaints of failure to lactate, lethargy, dizziness upon standing, and weight loss after a difficult childbirth complicated by placental abruption. What blood test results are expected?

      Your Answer: Decreased cortisol; normal aldosterone

      Explanation:

      Interpreting Cortisol and Aldosterone Levels in Sheehan’s Syndrome

      Sheehan’s syndrome is a condition that results in hypopituitarism, causing reduced adrenocorticotropic hormone (ACTH) production and secondary adrenal insufficiency. This can lead to postural hypotension and reduced cortisol levels, while aldosterone levels remain normal as they are not dependent on pituitary function.

      An increased cortisol level with decreased aldosterone would be an unusual result and does not fit the clinical picture of hypocortisolism. Similarly, an increased cortisol level with increased aldosterone may occur in rare cases of adrenal adenoma but does not fit the clinical picture of Sheehan’s syndrome.

      A decreased cortisol level with decreased aldosterone would be true in primary adrenal insufficiency, which is not the case in Sheehan’s syndrome. Finally, a decreased cortisol level with increased aldosterone would also be an unusual result as aldosterone levels are not affected in Sheehan’s syndrome.

      Therefore, when interpreting cortisol and aldosterone levels in a patient with Sheehan’s syndrome, a decreased cortisol level with normal aldosterone is expected.

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  • Question 14 - A 26-year-old female trainee solicitor has been experiencing difficulty concentrating on her work...

    Incorrect

    • A 26-year-old female trainee solicitor has been experiencing difficulty concentrating on her work for the past 2 months. She has been complaining that the work area is too hot. She appears nervous and has a fine tremor. Despite eating more, she has lost 4 kg in the last month. During a physical examination, her temperature is 37.8 °C, pulse is 110 bpm, respiratory rate is 18 per minute, and blood pressure is 145/85 mmHg. She has a wide, staring gaze and lid lag. What is the most likely laboratory finding in this woman?

      Your Answer: Increased calcitonin

      Correct Answer: Decreased thyroid stimulating hormone (TSH)

      Explanation:

      Understanding Thyroid Axis: Interpretation of Hormone Levels in Hyperthyroidism

      Hyperthyroidism is a condition characterized by increased production of free thyroxine (T4 and T3) leading to a decrease in thyroid stimulating hormone (TSH) production at the pituitary gland. This results in a hypermetabolic state induced by excess thyroid hormone and overactivity of the sympathetic nervous system. Ocular changes such as a wide, staring gaze and lid lag are common. However, true thyroid ophthalmopathy associated with proptosis is seen only in Graves’ disease.

      Decreased plasma insulin indicates diabetes mellitus, while increased TSH in this setting indicates secondary hyperthyroidism, a rare condition caused by pathology at the level of the pituitary. Increased adrenocorticotropic hormone (ACTH) is not related to the patient’s symptoms, and increased calcitonin is not a feature of hyperthyroidism but may indicate medullary thyroid cancers. Understanding the interpretation of hormone levels in hyperthyroidism is crucial for accurate diagnosis and management.

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      • Endocrinology
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  • Question 15 - What is a true statement about bariatric surgery? ...

    Incorrect

    • What is a true statement about bariatric surgery?

      Your Answer: Contraindicated in adolescents

      Correct Answer: Reduces cardiovascular mortality

      Explanation:

      Bariatric Surgery for Obesity: Benefits, Risks, and Complications

      Bariatric surgery is the most effective and long-lasting intervention for obesity, providing significant weight loss and resolution of associated health problems. The Swedish Obesity Study found that bariatric surgery reduced cardiovascular events and mortality rates for up to 15 years compared to standard care. While adolescents face social, psychological, and developmental challenges, they are not excluded from surgery, and some hospitals offer specialized programs for younger patients. Candidates for surgery typically have a body mass index (BMI) of 40 or higher, or a BMI of 35 or higher with serious co-morbidities such as sleep apnea or type 2 diabetes.

      Post-operative mortality rates range from 0.1-2%, and the risk of complications is similar to other major abdominal surgeries. However, if complications do occur, there is a higher likelihood of intervention. The specific complications depend on the type of procedure used. For laparoscopic adjustable gastric band surgery, complications may include band slippage, erosion, infection, pouch dilation, band/tubing leak, and megaoesophagus. For laparoscopic roux en y gastric bypass, complications may include stomal stenosis, internal hernia, and malnutrition. For laparoscopic sleeve gastrectomy, complications may include reflux, staple line leak, sleeve dilation, and weight gain. It is important for patients to understand the potential risks and benefits of bariatric surgery before making a decision.

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  • Question 16 - A 14-year-old boy presents with bilateral gynaecomastia. He stands at a height of...

    Incorrect

    • A 14-year-old boy presents with bilateral gynaecomastia. He stands at a height of 150 cm and weighs 60 kg, which is at the 50th centile. His sexual maturity rating is stage 2. What is the most probable cause of his gynaecomastia?

      Your Answer: Acromegaly

      Correct Answer: Pubertal gynaecomastia

      Explanation:

      Pubertal Gynaecomastia in Young Boys

      Pubertal gynaecomastia is a common occurrence in young boys, with unilateral disease being more prevalent than bilateral. However, it typically disappears within two years. While prolactinomas can cause gynaecomastia, they are not the most likely cause and are rare in this age group. It is important to note that the height and weight of the child are within normal range.

      Overall, pubertal gynaecomastia is a temporary condition that affects many young boys during puberty. While it can be concerning for parents and children, it is typically not a cause for alarm and will resolve on its own. It is important to consult with a healthcare provider to rule out any underlying medical conditions, but in most cases, no treatment is necessary.

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  • Question 17 - A teenager comes to see you in general practice with a swelling in...

    Correct

    • A teenager comes to see you in general practice with a swelling in the region of their throat. They are worried because they have read about an extremely invasive cancer which is difficult to treat.
      Which of the following is the patient referring to?

      Your Answer: Anaplastic thyroid cancer

      Explanation:

      Types of Thyroid Cancer and Their Prognosis

      Thyroid cancer is a type of cancer that affects the thyroid gland, a small butterfly-shaped gland located in the neck. There are different types of thyroid cancer, each with its own characteristics and prognosis.

      Anaplastic thyroid cancer is a rare but aggressive form of thyroid cancer that mostly affects the elderly. It presents as a hard mass within the thyroid and is responsible for a significant number of deaths from thyroid cancer.

      Follicular thyroid cancer is the second most common type of thyroid cancer. Although it is more aggressive than papillary thyroid cancer, it still has a good prognosis.

      Medullary thyroid cancer originates from the thyroid C cells and is associated with multiple endocrine neoplasia syndromes. Early diagnosis and treatment can improve the prognosis.

      Thyroid lymphoma is a rare form of lymphoma that affects the thyroid gland. It has a good prognosis with proper treatment.

      Papillary thyroid cancer is the most common type of thyroid cancer, occurring mostly in people between the ages of 25 and 50. It presents as an irregular mass arising from a normal thyroid and has a good prognosis.

      In summary, understanding the different types of thyroid cancer and their prognosis can help with early detection and treatment, leading to better outcomes for patients.

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  • Question 18 - A 55-year-old male with type 2 diabetes mellitus has been diagnosed with a...

    Incorrect

    • A 55-year-old male with type 2 diabetes mellitus has been diagnosed with a spot urinary albumin:creatinine ratio of 3.4 mg/mmol.
      Which medication can be prescribed to slow down the advancement of his kidney disease?

      Your Answer: Amiloride

      Correct Answer: Enalapril

      Explanation:

      Microalbuminuria as a Predictor of Diabetic Nephropathy

      Microalbuminuria is a condition where there is an increased amount of albumin in the urine, which is the first sign of diabetic nephropathy. In men, a urinary ACR of over 2.5 mg/mmol indicates microalbuminuria, while in women, it is over 3.5 mg/mmol. This condition is a predictor of the development of overt nephropathy, which is a severe kidney disease. Therefore, it is recommended that all patients with diabetes over the age of 12 years should be screened for microalbuminuria. Moreover, patients who develop microalbuminuria should receive an ACE inhibitor, even if they do not have systemic hypertension. An angiotensin-II receptor antagonist can also be used as an alternative to an ACE inhibitor. It is essential to diagnose and treat microalbuminuria early to prevent the progression of diabetic nephropathy.

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  • Question 19 - A 14-year-old boy is suspected of suffering from insulin-dependent diabetes. He undergoes a...

    Correct

    • A 14-year-old boy is suspected of suffering from insulin-dependent diabetes. He undergoes a glucose tolerance test following an overnight fast.
      Which of the following results would most likely confirm the diagnosis?

      Your Answer: A peak of plasma glucose occurring between 1 and 2 h that stays high

      Explanation:

      Interpreting Glucose Levels in Insulin-Dependent Diabetes

      Insulin-dependent diabetes is a condition that affects the body’s ability to regulate glucose levels. When interpreting glucose levels in insulin-dependent diabetes, there are several key factors to consider.

      One important factor is the peak of plasma glucose that occurs between 1 and 2 hours after glucose ingestion. In normal individuals, this peak is typically sharper and occurs earlier than in insulin-dependent diabetics. In diabetics, the plasma glucose remains elevated throughout the 4-hour test period.

      Another factor to consider is the presence or absence of an overshoot in the decline of plasma glucose at 3.5 hours. This overshoot, which is seen in normal individuals but not in diabetics, is a result of a pulse of insulin secretion.

      A plasma glucose level of 4 mmol/l at zero time is unlikely in a diabetic patient, as they typically have high basal glucose levels. Similarly, a glucose concentration of 5.2 mmol/l at 4 hours is not expected in insulin-dependent diabetics, as their plasma glucose levels remain elevated throughout the test period.

      Finally, it is important to consider the HbA1c level, which reflects average blood glucose levels over the past 2-3 months. In a diabetic patient who has been untreated for several weeks, the HbA1c would likely be elevated.

      Overall, interpreting glucose levels in insulin-dependent diabetes requires careful consideration of multiple factors to accurately assess the patient’s condition.

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  • Question 20 - Which statement about testosterone is accurate? ...

    Incorrect

    • 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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  • Question 21 - A 35-year-old woman arrives at the labour ward in active labour. She is...

    Incorrect

    • 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: Prolactin

      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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  • Question 22 - A 38-year-old patient presents with excessive thirst and abdominal pain.
    Bloods show:
    Investigation Result Normal...

    Incorrect

    • A 38-year-old patient presents with excessive thirst and abdominal pain.
      Bloods show:
      Investigation Result Normal value
      Calcium (Ca2+) 3.02 mmol/l 2.20–2.60 mmol/l
      Phosphate (PO43–) 0.42 mmol/l 0.70–1.40 mmol/l
      Alkaline phosphatase (ALP) 324 IU/l 30–130 IU/l
      Looking at these blood results, which of the following is the most likely cause?

      Your Answer: Hypoparathyroidism

      Correct Answer: Primary hyperparathyroidism

      Explanation:

      Causes and Clinical Presentations of Hyperparathyroidism, Bone Metastases, Excessive Vitamin D, Renal Failure, and Hypoparathyroidism

      Hyperparathyroidism is a condition where the parathyroid glands secrete an excessive amount of parathyroid hormone, leading to increased serum calcium levels. This can be caused by a solitary parathyroid adenoma of parathyroid hyperplasia. The clinical presentation includes excessive bone resorption, kidney stone formation, gastrointestinal symptoms, and neurological effects.

      Bone metastases also present with hypercalcaemia and a high alkaline phosphatase level, but phosphate levels will be normal. Vitamin D excess can also cause hypercalcaemia with a normal or high phosphate level, but alkaline phosphatase will be normal.

      In chronic renal failure, there is a reduction in the excretion of phosphate and a low glomerular filtration rate, leading to secondary hyperparathyroidism with hypocalcaemia and hyperphosphataemia.

      Hypoparathyroidism is associated with a decreased production of parathyroid hormone, leading to cramping and paraesthesiae due to low circulating calcium levels. Biochemical abnormalities include low circulating parathyroid hormone and calcium levels, raised phosphate levels, and normal alkaline phosphatase levels.

      Overall, understanding the causes and clinical presentations of these conditions is important for accurate diagnosis and appropriate treatment.

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  • Question 23 - Which hormone is responsible for the excess in Cushing's disease? ...

    Incorrect

    • Which hormone is responsible for the excess in Cushing's disease?

      Your Answer: Aldosterone

      Correct Answer: Adrenocorticotrophic hormone (ACTH)

      Explanation:

      Cushing’s Disease

      Cushing’s disease is a condition characterized by excessive cortisol production due to adrenal hyperfunction caused by an overproduction of ACTH from a pituitary corticotrophin adenoma. This results in both adrenal glands producing more cortisol and cortisol precursors. It is important to differentiate between primary and secondary hypercortisolaemia, which can be done by measuring ACTH levels in the blood. If ACTH levels are not suppressed, it indicates secondary hypercortisolaemia, which is driven by either pituitary or ectopic ACTH production. the underlying cause of hypercortisolaemia is crucial in determining the appropriate treatment plan for individuals with Cushing’s disease.

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  • Question 24 - A 60-year-old man with a previous diagnosis of multiple endocrine neoplasia type 2...

    Incorrect

    • 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: Renal failure

      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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  • Question 25 - On a set of MRI scans being examined for a 21-year-old woman suspected...

    Correct

    • On a set of MRI scans being examined for a 21-year-old woman suspected of having Cushing syndrome due to weight gain and excess facial hair, which structure would be found posterior to the left suprarenal (adrenal) gland?

      Your Answer: Crus of diaphragm

      Explanation:

      Anatomy of the Posterior Abdominal Wall

      The posterior abdominal wall is a complex structure consisting of various muscles, fascia, and organs. Here are some key components:

      Crus of Diaphragm: The left suprarenal (adrenal) gland is located in the posterior abdomen and is enclosed by the perirenal fascia, which attaches it to the left crus of the diaphragm. The left crus is a tendinous structure arising from the anterior bodies of the L1 and L2 vertebrae.

      Psoas Major Muscle: This muscle is responsible for the lateral flexion of the lumbar spine and assists in the stabilization and flexion of the hip. It is found in the posterior abdomen, bound by fascia.

      Quadratus Lumborum Muscle: This quadrilateral muscle is associated with the lateral flexion and extension of the vertebral column. It is located posteriorly to the colon, kidney, psoas muscle, and diaphragm.

      Transversus Abdominis Muscle: This is the innermost muscle forming the anterior abdominal muscles, lying posterior to the internal oblique and anterior to the transversalis fascia.

      Thoracolumbar Fascia: This diamond-shaped fascia encloses the intrinsic muscles of the back and is affected in piriformis syndrome and sacro-iliac joint pains. It is not anatomically associated with the adrenal glands.

      Understanding the Posterior Abdominal Wall Anatomy

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  • Question 26 - A 50-year-old woman with a history of severe depression and a radical mastectomy...

    Incorrect

    • A 50-year-old woman with a history of severe depression and a radical mastectomy for breast carcinoma one year ago presents with complaints of polyuria, nocturia, and excessive thirst. Her laboratory values show a serum sodium of 130 mmol/L (133-145), serum potassium of 3.6 mmol/L (3.5-5), serum calcium of 2.2 mmol/L (2.2-2.6), glucose of 5.8 mmol/L (3.5-6), urea of 4.3 mmol/L (3-8), and urine osmolality of 150 mosmol/kg (350-1000). What is the most likely diagnosis?

      Your Answer: Type 2 diabetes.

      Correct Answer: Psychogenic polydipsia

      Explanation:

      Psychogenic Polydipsia

      Psychogenic polydipsia is a rare condition where a person drinks excessive amounts of water without any physiological reason to do so. This disorder is usually well-tolerated unless it leads to hyponatremia. Psychogenic polydipsia is commonly observed in hospitalized schizophrenics, depressed patients, and children. The diagnosis of this condition is made by excluding other possible causes and requires specialized investigation and management. The water deprivation test is the most important test for diagnosing psychogenic polydipsia.

      In contrast, diabetes insipidus is a condition caused by a lack of action of ADH, which results in high osmolality and high sodium levels, leading to dehydration. This condition causes inappropriately dilute urine. To exclude diabetes insipidus, a water deprivation test is required. However, in patients with psychogenic polydipsia, the urine becomes appropriately concentrated upon water deprivation, whereas in diabetes insipidus, the urine remains dilute.

      In this patient, the history of depression, relative dilution of sodium, and low urine osmolality suggest a diagnosis of psychogenic polydipsia. The presence of hyponatremia further supports this diagnosis. Therefore, it is important to consider psychogenic polydipsia as a possible cause of excessive water drinking in patients with hyponatremia.

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  • Question 27 - These results were obtained from a 43-year-old female. Her serum levels showed an...

    Incorrect

    • These results were obtained from a 43-year-old female. Her serum levels showed an elevated level of aldosterone and a low level of renin. Specifically, her Na+ level was 154 mmol/l (135–145 mmol/l) and her K+ level was 3.7 mmol/l (3.5–5 mmol/l). What condition are these results consistent with?

      Your Answer: Renal artery stenosis

      Correct Answer: Conn’s syndrome

      Explanation:

      Electrolyte Imbalances in Various Conditions and Treatments

      Conn’s Syndrome and Hyperaldosteronism
      Conn’s syndrome is a type of primary hyperaldosteronism caused by the overproduction of aldosterone in the adrenal glands due to an adrenal adenoma. This results in elevated levels of aldosterone, causing water retention and increased excretion of potassium. Renin levels are low in this condition due to the raised sodium and plasma volume. Patients with Conn’s syndrome are typically hypertensive, but it is important to note that some patients may have normal potassium levels.

      Addison’s Disease and Adrenal Gland Failure
      Addison’s disease is caused by adrenal gland failure, resulting in a deficiency of glucocorticoids and mineralocorticoids. This leads to sodium loss and potassium retention.

      Renal Artery Stenosis and Secondary Hyperaldosteronism
      Patients with renal artery stenosis may also exhibit elevated sodium and low potassium levels. However, in this case, renin levels are elevated due to reduced renal perfusion, leading to secondary hyperaldosteronism.

      Bartter Syndrome and Congenital Salt-Wasting
      Bartter syndrome is a congenital condition that causes salt-wasting due to a defective channel in the loop of Henle. This results in sodium and chloride leakage, leading to hypokalemia and metabolic alkalosis. Renin and aldosterone production are increased in response to sodium and volume depletion.

      Furosemide Treatment and Loop Diuretics
      Furosemide is a loop diuretic that promotes sodium and chloride excretion, leading to potassium loss. Patients undergoing furosemide treatment may exhibit hyponatremia and hypokalemia.

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  • Question 28 - A 35-year-old male is scheduled for his annual diabetic review. During the examination,...

    Incorrect

    • A 35-year-old male is scheduled for his annual diabetic review. During the examination, it is noted that his body mass index has increased to 31.5 kg/m2. How do you calculate body mass index?

      Your Answer: Height/(Weight)2

      Correct Answer: Weight/(Height)2

      Explanation:

      BMI is a calculation of weight over height squared and is used to determine if someone is underweight, normal weight, overweight, or obese. A BMI above 30 indicates obesity and is associated with increased risks for various health issues and surgical complications.

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  • Question 29 - A 65-year-old man visits his GP complaining of erectile dysfunction that has been...

    Incorrect

    • A 65-year-old man visits his GP complaining of erectile dysfunction that has been ongoing for the past year. He has no prior history of this issue and is greatly troubled by it. The patient has a medical history of type II diabetes mellitus, hypertension, ischaemic heart disease, and poor urinary flow. He also had a thyroidectomy a few years ago, the reason for which is unclear. He is currently taking insulin, gliclazide, amlodipine, and aspirin. His most recent HbA1c was 12.1% or 108 mmol/mol. What is the probable cause of his erectile dysfunction?

      Your Answer: Hypertension

      Correct Answer: Diabetes

      Explanation:

      Medical Conditions and Erectile Dysfunction: Understanding the Causes

      Erectile dysfunction is a common condition that affects many men, and it can be caused by a variety of medical conditions. Understanding the underlying causes of erectile dysfunction is important for effective treatment. Here are some common medical conditions that can lead to erectile dysfunction:

      Diabetes: Diabetes is a major risk factor for erectile dysfunction. Autonomic neuropathy, a microvascular complication of diabetes, can cause symptoms such as erectile dysfunction. Poor control of diabetes can make this condition worse.

      Ischaemic heart disease: While ischaemic heart disease itself does not cause erectile dysfunction, risk factors such as diabetes and hypertension can make this condition worse. Proper management of these conditions is important for overall health and sexual function.

      Thyroidectomy: A previous thyroidectomy may have been performed for an overactive thyroid or a thyroid nodule, but it is not a direct cause of erectile dysfunction.

      Prostatic hyperplasia: Prostatic hyperplasia is a common condition among elderly men, but it is not typically associated with erectile dysfunction.

      Hypertension: Hypertension increases the risk for diabetes in non-diabetics, and diabetes can cause erectile dysfunction. However, hypertension itself is not a direct cause of erectile dysfunction.

      In conclusion, understanding the underlying medical conditions that can cause erectile dysfunction is important for proper diagnosis and treatment. Proper management of these conditions can improve overall health and sexual function.

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  • Question 30 - A 30-year-old male presents with a painful right breast that has been bothering...

    Incorrect

    • 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: Testicular lymphoma

      Correct 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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Endocrinology (6/30) 20%
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