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Question 1
Incorrect
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A 40-year-old woman presents to her GP with complaints of fatigue, lethargy, flu-like myalgias, and syncopal episodes. She also reports feeling low in mood. Upon investigation, the following results were obtained:
Serum:
Investigation Result Normal value
Sodium (Na+) 127 mmol/l 135–145 mmol/l
Potassium (K+) 5.7 mmol/l 3.5–5.0 mmol/l
Short adrenocorticotropic hormone (ACTH) stimulation test:
Plasma cortisol:
0900 h 145 nmol/l
30 min after ACTH 210 nmol/l
60 min after ACTH 350 nmol/l
0900 h ACTH: 4 pg/ml (<5 pg/ml low)
What is the most likely diagnosis?Your Answer: Anorexia nervosa
Correct Answer: Hypopituitarism
Explanation:Distinguishing between Hypopituitarism and Other Conditions: A Biochemical Analysis
Hypopituitarism is a condition characterized by reduced ACTH production, leading to decreased adrenal activity and a deficiency in cortisol. This deficiency results in sodium loss and potassium retention, as seen in the patient’s biochemistry. However, the mineralocorticoid is mostly under the influence of the renin-angiotensin-aldosterone axis and would not be greatly affected. An initial blood sample is taken to assess the baseline level of cortisol, followed by an injection to stimulate the body’s production of cortisol. A sluggish rise in cortisol is observed due to adrenal atrophy resulting from chronically low stimulation by endogenous ACTH.
Other conditions, such as Conn’s syndrome, tuberculosis, anorexia nervosa, and Cushing’s disease, can present with similar symptoms but have distinct biochemical profiles. Conn’s syndrome results in hypernatraemia and hypokalaemia due to high aldosterone levels. Tuberculosis can cause Addison’s disease, resulting in a similar biochemical picture but with high ACTH at baseline. Anorexia nervosa patients are typically hypokalaemic, and the short ACTH stimulation test would likely be normal. Cushing’s disease, on the other hand, results in hypernatraemia and hypokalaemia due to cortisol’s mineralocorticoid activity.
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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 27-year-old woman visits her GP complaining of experiencing sweating, agitation, palpitations, and restlessness for the past three days. She gave birth to a healthy baby through vaginal delivery at 39 weeks gestation two months ago. The patient has a medical history of coeliac disease. The following investigations were conducted:
Thyroid-stimulating hormone (TSH) 0.1 mU/L (0.5-5.5)
Free thyroxine (T4) 26 pmol/L (9.0 - 18)
What is the next appropriate step in managing this patient?Your Answer: Prescribe NSAIDs and monitor
Correct Answer: Prescribe propranolol
Explanation:The appropriate management for the thyrotoxicosis phase of postpartum thyroiditis is prescribing propranolol for symptomatic relief. This patient’s presentation of hyperthyroidism 2 months postpartum suggests postpartum thyroiditis, which is typically self-resolving. Propranolol is the most suitable option for managing the symptoms of this condition. Prescribing NSAIDs and monitoring would be more appropriate for subacute (de Quervain’s) thyroiditis, which is not the case here. Prescribing carbimazole or levothyroxine would not be necessary or appropriate for this patient’s condition.
Understanding Postpartum Thyroiditis: Stages and Management
Postpartum thyroiditis is a condition that affects some women after giving birth. It is characterized by three stages: thyrotoxicosis, hypothyroidism, and normal thyroid function. During the thyrotoxicosis phase, the thyroid gland becomes overactive, leading to symptoms such as anxiety, palpitations, and weight loss. In the hypothyroidism phase, the thyroid gland becomes underactive, causing symptoms such as fatigue, weight gain, and depression. However, in the final stage, the thyroid gland returns to normal function, although there is a high recurrence rate in future pregnancies.
Thyroid peroxidase antibodies are found in 90% of patients with postpartum thyroiditis, which suggests an autoimmune component to the condition. Management of postpartum thyroiditis depends on the stage of the condition. During the thyrotoxic phase, symptom control is the main focus, and propranolol is typically used. Antithyroid drugs are not usually used as the thyroid gland is not overactive. In the hypothyroid phase, treatment with thyroxine is usually necessary to restore normal thyroid function.
It is important to note that many causes of hypothyroidism may have an initial thyrotoxic phase, as shown in a Venn diagram. Therefore, it is crucial to properly diagnose and manage postpartum thyroiditis to ensure the best possible outcomes for both the mother and the baby.
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This question is part of the following fields:
- Endocrinology
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Question 3
Incorrect
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The blood results of a 55-year-old woman were obtained and the following values were recorded in her plasma: Total Ca2+ was 1.80 mmol/l (2.12–2.65 mmol/l), Albumin was 40 g/l (35–50 g/l), PO43− was 2.0 mmol/l (0.8–1.5 mmol/l), Alkaline phosphatase was 120 iu/l (30–150 iu/l), and Parathyroid hormone (PTH) was 75 ng/l (15–65 ng/l). Based on these results, what condition is this consistent with?
Your Answer: Pseudopseudohypoparathyroidism
Correct Answer: Pseudohypoparathyroidism
Explanation:Understanding Pseudohypoparathyroidism: A Rare Genetic Condition
Pseudohypoparathyroidism is a rare genetic condition that occurs when the target cells fail to respond to parathyroid hormone (PTH). Unlike hypoparathyroidism, where the gland fails to secrete enough PTH, PTH levels are elevated in pseudohypoparathyroidism. However, the lack of response to PTH results in low calcium and high phosphate levels, which is the opposite of what PTH is supposed to do.
Symptoms of pseudohypoparathyroidism may include shortened metacarpals (especially the fourth and fifth), a round face, short stature, calcified basal ganglia, and a low IQ.
It’s important to differentiate pseudohypoparathyroidism from other conditions such as primary hyperparathyroidism, primary hypoparathyroidism, and post-thyroidectomy hypoparathyroidism. In primary hyperparathyroidism, there is overproduction of PTH, causing hypercalcemia and hypophosphatemia. In primary hypoparathyroidism, there is gland failure, resulting in low PTH secretion and low calcium levels. Post-thyroidectomy hypoparathyroidism occurs when the parathyroids are damaged or removed during surgery, resulting in low PTH levels.
Another condition that may present with similar morphological features as pseudohypoparathyroidism is pseudopseudohypoparathyroidism. However, in this condition, the biochemistry is normal.
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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 25-year-old woman visits her endocrinologist for follow-up. She has a medical history of primary hyperparathyroidism and prolactinoma. After undergoing genetic testing, she was diagnosed with multiple endocrine neoplasia type 1 (MEN1) syndrome. She is planning to start a family and wants to know the likelihood of her child inheriting MEN1. Her partner has no known medical conditions.
What is the mode of inheritance for MEN1 syndrome?Your Answer: X-linked dominant
Correct Answer: Autosomal dominant
Explanation:Understanding the Inheritance Patterns of Multiple Endocrine Neoplasia (MEN) Syndromes
Multiple Endocrine Neoplasia (MEN) syndromes are a group of rare genetic disorders that predispose individuals to the development of tumors in multiple endocrine glands. Understanding the inheritance patterns of these syndromes is crucial for genetic counseling and early detection of tumors.
MEN1 is an autosomal dominant condition caused by a mutation in the menin gene. This means that if one parent carries the mutation, there is a 50% chance of passing it on to their children. Over 1000 mutations have been described in this gene, leading to a loss of tumor-suppressor function and an increased risk of tumors in the parathyroid, pancreas, and pituitary gland, as well as other organs.
Cystic fibrosis, on the other hand, is an example of an autosomal recessive condition. If both parents carry the mutation, there is a 25% chance of their child inheriting the condition.
X-linked dominant and recessive conditions are also possible, but they do not apply to MEN syndromes. In X-linked dominant conditions, affected mothers have a 50% chance of passing the condition to their children, while in X-linked recessive conditions, females can only be carriers but can still pass the condition to their sons.
It is important to note that while most MEN syndromes are inherited in an autosomal dominant pattern, sporadic cases can also occur. In these cases, a family history may be absent because the parent with the disease may have died before symptoms developed. Genetic testing and counseling can help identify individuals at risk and provide appropriate management and surveillance.
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This question is part of the following fields:
- Endocrinology
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Question 5
Correct
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What is the most frequent organic cause of anxiety symptoms?
Your Answer: Hypoglycaemia
Explanation:Organic Causes of Anxiety
Anxiety can be caused by various factors, including organic causes. One of the more common organic causes of anxiety is hypoglycaemia. However, there are other organic causes that can also lead to anxiety. These include alcohol withdrawal, drug intoxication or withdrawal, thyroxine, and paroxysmal supraventricular tachycardias. While phaeochromocytoma is a rare cause of anxiety, carcinoid does not cause anxiety at all. It is important to note that carcinoma of the bronchus and hyperparathyroidism are more likely to present with depression rather than anxiety.
It is crucial to identify the underlying cause of anxiety to provide appropriate treatment. If an organic cause is suspected, further evaluation and testing may be necessary to determine the root cause of the anxiety. By addressing the underlying cause, it may be possible to alleviate or even eliminate the symptoms of anxiety. Therefore, it is important to consider all possible causes of anxiety, including organic causes, to provide the best possible care for patients.
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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 21-year-old female medical student, who is an insulin-dependent diabetic, went on a weekend trip to visit some friends at another university. She forgot to pack her insulin.
When she returned, she went to visit her General Practitioner (GP).
What would analysis of her blood results most likely reveal?Your Answer: Below normal glucagon levels
Correct Answer: Unchanged HbA1c
Explanation:Effects of Insulin Absence in Insulin-Dependent Diabetes Patients
Insulin-dependent diabetes patients rely on insulin to regulate their blood glucose levels. Without insulin, several physiological changes occur in the body. The HbA1c levels, which reflect the average blood glucose levels over several weeks, would not change significantly over a few days without insulin. However, missing insulin doses for a weekend can put the patient at risk of developing diabetic ketoacidosis (DKA), a life-threatening condition. In the absence of insulin, the body cannot utilise glucose, leading to hyperglycaemia and the generation of ketones as an alternative energy source. The raised glucagon levels in response to the absence of insulin would raise glucose levels in the bloodstream, but target organs would still not be able to utilise this resource. Triglyceride hydrolysis and increased release from adipose tissue would give raised fatty acid levels, which are utilised to synthesise ketones. Overall, the absence of insulin in insulin-dependent diabetes patients can have significant effects on their metabolic processes.
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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 42-year-old woman complains of fatigue after experiencing flu-like symptoms two weeks ago. Upon examination, she has a smooth, small goiter and a pulse rate of 68 bpm. Her lab results show a Free T4 level of 9.3 pmol/L (normal range: 9.8-23.1) and a TSH level of 49.3 mU/L (normal range: 0.35-5.50). What additional test would you perform to confirm the diagnosis?
Your Answer: Radioiodine uptake scan
Correct Answer: Thyroid peroxidase (TPO) antibodies
Explanation:Diagnosis and Management of Primary Hypothyroidism
The patient’s test results indicate a case of primary hypothyroidism, characterized by low levels of thyroxine (T4) and elevated thyroid-stimulating hormone (TSH). The most likely cause of this condition is Hashimoto’s thyroiditis, which is often accompanied by the presence of thyroid peroxidase antibodies. While the patient has a goitre, it appears to be smooth and non-threatening, so a thyroid ultrasound is not necessary. Additionally, a radio-iodine uptake scan is unlikely to show significant uptake and is therefore not recommended. Positive TSH receptor antibodies are typically associated with Graves’ disease, which is not the likely diagnosis in this case. For further information on Hashimoto’s thyroiditis, patients can refer to Patient.info.
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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 50-year-old woman is undergoing evaluation for hypertension that is not responding to treatment. She has a previous medical history of medullary thyroid carcinoma. Her physical examination is unremarkable. During her work-up, she is found to have hypercalcemia with a level of 2.8 mmol/l. Her parathyroid hormone (PTH) is slightly elevated above the normal range. What is the underlying diagnosis?
Your Answer: Multiple endocrine neoplasia type 1
Correct Answer: Multiple endocrine neoplasia type 2A
Explanation:Differential Diagnosis: Hypercalcaemia with Medullary Thyroid Carcinoma
Multiple endocrine neoplasia type 2A (MEN 2A) is a genetic disorder caused by a gain in function mutation in the RET proto-oncogene. The classic triad of MEN 2A includes medullary thyroid carcinoma, primary hyperparathyroidism, and phaeochromocytoma. In cases where a patient presents with a history of medullary thyroid carcinoma and hypercalcaemia with inappropriately elevated PTH levels, primary parahyperthyroidism is implied, and the combination of these symptoms with treatment-resistant hypertension is virtually diagnostic of MEN 2A.
Other conditions associated with hypercalcaemia include multiple myeloma, but PTH levels would be appropriately low. Marfan’s syndrome, a hereditary disorder of connective tissue, is not typically associated with dysfunction of the parathyroid hormone axis. Multiple endocrine neoplasia type 1 (MEN1) is a main differential diagnosis, but patients with MEN1 typically suffer from hyperparathyroidism, pituitary adenomas (typically prolactinomas), and pancreatic islet cell tumours, not the symptoms described here. Neurofibromatosis, a disorder caused by a mutation in the neurofibromin gene, is associated with multiple neural tumours and various other manifestations, but disruption of the parathyroid hormone axis is not a feature.
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This question is part of the following fields:
- Endocrinology
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Question 9
Incorrect
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A 32-year-old woman visits her GP with complaints of palpitations, tremors, sweating, and diarrhoea. She has a medical history of gestational hypertension and type 1 diabetes, which is managed with insulin. The patient gave birth to her first child 8 weeks ago without any complications.
Upon examination, the patient is alert and oriented. Her vital signs are as follows: heart rate of 109 bpm, respiratory rate of 19 breaths/minute, temperature of 37.7ºC, oxygen saturation of 98%, blood pressure of 129/88 mmHg, and blood glucose of 4 mmol/L.
What is the most likely diagnosis, and what is the appropriate treatment?Your Answer: Carbimazole
Correct Answer: Propranolol
Explanation:The recommended treatment for the thyrotoxicosis phase of postpartum thyroiditis is typically propranolol alone. This is because the condition is usually temporary and self-resolving, with thyroid function returning to normal within a year after childbirth. Carbimazole is not necessary as it is typically reserved for more severe cases of hyperthyroidism. Dexamethasone is not appropriate as it is used to treat thyroid storm, a complication of thyrotoxicosis that is not present in this case. Levothyroxine is also not indicated as it is used to treat hypothyroidism, which is the opposite of the patient’s current condition.
Understanding Postpartum Thyroiditis: Stages and Management
Postpartum thyroiditis is a condition that affects some women after giving birth. It is characterized by three stages: thyrotoxicosis, hypothyroidism, and normal thyroid function. During the thyrotoxicosis phase, the thyroid gland becomes overactive, leading to symptoms such as anxiety, palpitations, and weight loss. In the hypothyroidism phase, the thyroid gland becomes underactive, causing symptoms such as fatigue, weight gain, and depression. However, in the final stage, the thyroid gland returns to normal function, although there is a high recurrence rate in future pregnancies.
Thyroid peroxidase antibodies are found in 90% of patients with postpartum thyroiditis, which suggests an autoimmune component to the condition. Management of postpartum thyroiditis depends on the stage of the condition. During the thyrotoxic phase, symptom control is the main focus, and propranolol is typically used. Antithyroid drugs are not usually used as the thyroid gland is not overactive. In the hypothyroid phase, treatment with thyroxine is usually necessary to restore normal thyroid function.
It is important to note that many causes of hypothyroidism may have an initial thyrotoxic phase, as shown in a Venn diagram. Therefore, it is crucial to properly diagnose and manage postpartum thyroiditis to ensure the best possible outcomes for both the mother and the baby.
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This question is part of the following fields:
- Endocrinology
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Question 10
Incorrect
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A 35-year-old patient presents to her doctor with complaints of excessive sweating and feeling very warm. Upon examination, no significant thyroid nodule is observed. The patient's blood tests reveal the following results:
Investigation Result Normal value
Thyroid-stimulating hormone (TSH) < 0.1 µU/l 0.4–4.0 µU/l
Free thyroxine (T4) 30 pmol/l 10–20 pmol/l
What is the most probable diagnosis?Your Answer: Thyroid adenoma
Correct Answer: Graves’ disease
Explanation:Thyroid Disorders: Causes and Symptoms
Thyroid disorders are common and can cause a range of symptoms. Here are some of the most common thyroid disorders and their associated symptoms:
1. Graves’ disease: This is the most common cause of thyrotoxicosis in the UK. Symptoms include a low TSH and an elevated T4.
2. De Quervain’s thyroiditis: This is a subacute thyroiditis that can cause hypothyroidism.
3. Hashimoto’s thyroiditis: This is an autoimmune disorder that is associated with hypothyroidism.
4. Toxic multinodular goitre: There is insufficient information to suggest that the patient has this condition.
5. Thyroid adenoma: Patients usually present with a neck lump, which is not seen in this case.
If you are experiencing any symptoms of a thyroid disorder, it is important to speak with your healthcare provider for proper diagnosis and treatment.
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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 63-year-old, non-smoking woman without previous cardiac history, has a total cholesterol of 9.0 mmol/l. She is overweight and has sleep apnoea. On examination you notice her skin is particularly dry and there appears to be some evidence of hair loss. Her blood pressure is 140/95 mmHg and pulse rate 60 bpm.
What would be the most appropriate next step in managing this patient?Your Answer: Check her fasting blood glucose level
Correct Answer: Check her thyroid-stimulating hormone (TSH) and free thyroxine (T4) level
Explanation:Diagnostic and Treatment Options for a Patient with High Cholesterol
When a patient presents with symptoms such as dry skin, hair loss, obesity, sleep apnea, hypertension, and slow pulse, it is important to consider hypothyroidism as a possible cause. To confirm this diagnosis, checking the patient’s thyroid-stimulating hormone (TSH) and free thyroxine (T4) levels is recommended. Hypothyroidism can also cause dyslipidemia, which may be the underlying cause of the patient’s high cholesterol levels. Therefore, treating the hypothyroidism should be the initial step, and if cholesterol levels remain high, prescribing a statin may be appropriate.
It is also important to consider the possibility of familial hypercholesterolemia, especially if the patient’s cholesterol levels are very high (≥8 mmol/l). In this case, screening family members for raised cholesterol may be necessary if cholesterol levels do not decrease with l-thyroxine treatment.
While diabetes can increase the risk of thyroid disorders, checking the patient’s fasting blood glucose level may not be necessary initially. Additionally, measuring 24-hour urinary free cortisol is not recommended as the patient’s symptoms do not suggest Cushing syndrome as the diagnosis.
In summary, considering hypothyroidism as a possible cause of high cholesterol levels and checking TSH and T4 levels should be the initial step in diagnosis. Treating the underlying cause and prescribing a statin if necessary can help manage the patient’s cholesterol levels. Screening family members for familial hypercholesterolemia may also be necessary.
Diagnostic and Treatment Options for High Cholesterol in Patients with Suspected Hypothyroidism
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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 36-year-old woman visits her new GP for routine blood tests after recently moving locations. She mentions that her previous GP had told her she had a ‘thyroid problem’ and had prescribed medication, but she cannot recall any further details. Her blood test results are as follows:
Investigation Result Normal value
Thyroid-stimulating hormone (TSH) 18 mu/l 0.5–5.5 mu/l
Free thyroxine (T4) 9.2 pmol/l 9–18 pmol/l
What could be the possible cause of these biochemical results?Your Answer: Thyrotoxicosis
Correct Answer: Poor compliance with thyroxine
Explanation:Thyroid Function Tests: Understanding the Results
Thyroid function tests are commonly used to diagnose and monitor thyroid disorders. The results of these tests can provide valuable information about the functioning of the thyroid gland. Here are some common thyroid function test results and what they may indicate:
Poor Compliance with Thyroxine
Patients who are not compliant with their thyroxine medication may only take it a few days before a routine blood test. This can result in normal thyroxine levels due to the supplementation, but the TSH levels may not have enough time to reach the normal range due to the required negative feedback.Sick Euthyroid Syndrome
In this condition, all TSH, thyroxine, and T3 levels are low. However, the TSH level is often within the normal range. This condition is reversible upon recovery from the systemic illness.Thyrotoxicosis
Thyrotoxicosis is characterized by low TSH and high T4 levels.Primary Hypothyroidism
Primary hypothyroidism results in low T4 levels and subsequent high TSH levels due to negative feedback.Secondary Hypothyroidism
In secondary hypothyroidism, both TSH and T4 levels are low. This condition occurs due to the failure of the anterior pituitary to secrete TSH despite adequate thyrotropin-releasing hormone (TRH) levels. TRH is elevated, but TSH, T3, and T4 are low, and TSH fails to rise even after a TRH stimulation test.Understanding the results of thyroid function tests can help healthcare providers diagnose and manage thyroid disorders effectively.
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This question is part of the following fields:
- Endocrinology
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Question 13
Correct
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Through which of the following molecules is the hypercalcaemia of malignancy most commonly mediated?
Your Answer: Parathyroid hormone related protein
Explanation:The Role of Parathyroid Hormone-Related Protein in Hypercalcaemia
Parathyroid hormone-related protein (PTHrP) is a group of protein hormones that are produced by various tissues in the body. Its discovery was made when it was found to be secreted by certain tumors, causing hypercalcaemia in affected patients. Further studies revealed that the uncontrolled secretion of PTHrP by many tumor cells leads to hypercalcaemia by promoting the resorption of calcium from bones and inhibiting calcium loss in urine, similar to the effects of hyperparathyroidism.
Overall, PTHrP plays a crucial role in regulating calcium levels in the body, and its overproduction can lead to serious health complications. the mechanisms behind PTHrP secretion and its effects on the body can aid in the development of treatments for hypercalcaemia and related conditions.
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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 54-year-old Hispanic male presents to his primary care physician complaining of fatigue. He has noticed a slight increase in weight and has been feeling increasingly tired over the past year. The patient has a history of asthma and manages it with inhaled salbutamol as needed, typically no more than once a week. He also has type 2 diabetes that is controlled through diet.
During the examination, the patient's blood pressure is measured at 172/98 mmHg, his body mass index is 29.7 kg/m2, and his pulse is 88 beats per minute. No other abnormalities are noted. Over the next month, his blood pressure readings are consistently high, measuring at 180/96, 176/90, and 178/100 mmHg.
Which medication would be recommended for the treatment of this patient's high blood pressure?Your Answer: Doxazosin
Correct Answer: Lisinopril
Explanation:Hypertension Treatment in Patients with Type 2 Diabetes
Patients with type 2 diabetes and sustained hypertension require treatment. The first-line treatment for hypertension in diabetes is ACE inhibitors. These medications have no adverse effects on glucose tolerance or lipid profiles and can delay the progression of microalbuminuria to nephropathy. Additionally, ACE inhibitors can reduce morbidity and mortality in patients with vascular disease and diabetes.
However, bendroflumethiazide should be avoided in patients with a history of gout as it may provoke an attack. Beta-blockers should also be avoided for routine treatment of uncomplicated hypertension in patients with diabetes. They can precipitate bronchospasm and should be avoided in patients with asthma. In cases where there is no alternative, a cardioselective beta blocker should be selected and initiated at a low dose by a specialist, with close monitoring for adverse effects.
Alpha-blockers, such as doxazosin, are reserved for the treatment of resistant hypertension in conjunction with other antihypertensives. It is important to follow guidelines, such as those provided by NICE and the British National Formulary, for the diagnosis and management of hypertension in adults with diabetes. A treatment algorithm for hypertension can also be helpful in guiding treatment decisions.
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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 67-year-old woman visits her GP with complaints of constipation that has been ongoing for a month. She requests medication to alleviate the symptoms. The patient reports feeling more fatigued than usual and has noticed recent weight gain. During the examination, the GP observes dry scaly skin. The patient's medical history indicates recent consultation with an endocrinologist.
What would lead to elevated thyroid-stimulating hormone (TSH) levels and normal T4 in this case?Your Answer: Sick euthyroid syndrome
Correct Answer: Poor compliance with thyroxine
Explanation:Understanding Thyroid Disorders: Differentiating Poor Compliance with Thyroxine from Other Conditions
Thyroid disorders can present with a variety of symptoms, making it important to differentiate between different conditions. In the case of poor compliance with thyroxine medication, a patient may present with signs of a low thyroid state, but blood results will show a high TSH and normal T4, indicating recent medication use.
Primary hypothyroidism, on the other hand, would show a low T4 and high TSH, while thyrotoxicosis would reveal a low TSH and high T4, accompanied by symptoms such as tachycardia and tremors. Secondary hypothyroidism would present with low levels of both T4 and TSH, indicating a pituitary problem.
Sick euthyroid syndrome, which often occurs in individuals with systemic illness, would show low levels of TSH, thyroxine, and T3, but the TSH level may still be within the normal range. Understanding these differences can help healthcare professionals make accurate diagnoses and provide appropriate treatment.
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This question is part of the following fields:
- Endocrinology
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Question 16
Correct
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A 55-year-old woman is undergoing investigation by her GP for potential issues in her hypothalamic-pituitary-thyroid axis. The following findings were recorded:
Thyroid-stimulating hormone (TSH) 5.2 mu/l (0.4-4.0 mu/l)
fT4 8.0 pmol/l (9.0-26.0 pmol/l)
fT3 3.5 pmol/l (3.0-9.0 pmol/l)
What condition is indicated by these results?Your Answer: Hypothyroidism
Explanation:Thyroid Disorders: Understanding the Different Presentations
Thyroid disorders can present with various symptoms and laboratory findings. Here are some of the common presentations of different thyroid disorders:
Hypothyroidism: This condition is characterized by elevated TSH and low fT4 levels. It is more common in females and occurs mainly in middle life. The elevated TSH is due to reduced negative feedback at the level of the pituitary.
Thyroid Hormone Resistance: In this condition, TSH and fT4 levels are raised. Thyroid hormone resistance results in decreased response to a given thyroid hormone, which prompts the thyroid axis to increase TSH and fT4 levels. The patient may not be symptomatic and may even present hypothyroid clinically.
Hyperthyroidism: This condition is characterized by low TSH and usually raised fT4 and fT3 levels.
Pituitary TSH-Secreting Tumour: This condition presents with raised TSH and fT4 levels.
Subclinical Hypothyroidism: This condition presents with elevated TSH but normal fT4 levels.
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This question is part of the following fields:
- Endocrinology
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Question 17
Incorrect
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A 42-year-old male presents to the Emergency department with complaints of headaches and tiredness during exercise for the past three weeks. He is a smoker of five cigarettes per day and drinks approximately 20 units of alcohol each week. There is no significant family history. On examination, his pulse is 78 beats per minute, and his blood pressure is 182/102 mmHg. However, there are no abnormalities on examination of heart, chest, or abdomen. The investigations reveal a sodium level of 144 mmol/L (137-144), haemoglobin level of 155 g/L (130-180), potassium level of 2.8 mmol/L (3.5-4.9), white cell count of 8.2 ×109/L (4-11), urea level of 5.0 mmol/L (2.5-7.5), platelet count of 188 ×109/L (150-400), creatinine level of 90 µmol/L (60-110), and glucose level of 5.6 mmol/L (3.0-6.0). The ECG shows tall R waves in leads V5-6 and deep S waves in leads V1-2. The chest x-ray is reported as normal. What possible diagnosis would you consider for this patient?
Your Answer: Phaeochromocytoma
Correct Answer: Conn’s syndrome
Explanation:Hypertension and Hypokalaemia: Possible Diagnosis of Primary Hyperaldosteronism
This patient is showing signs of hypertension, as indicated by the left ventricular hypertrophy on their ECG. Additionally, their hypertension is accompanied by hypokalaemia, which may suggest a diagnosis of primary hyperaldosteronism, also known as Conn’s syndrome. This condition is caused by excessive production of aldosterone from either an adrenal adenoma or bilateral adrenal hyperplasia, resulting in salt and water retention, hypertension, and potassium excretion leading to hypokalaemia. In some cases, primary hyperaldosteronism has been detected in up to 5% of patients in hypertension clinics. It is important to investigate potential secondary causes for hypertension, particularly in young or difficult-to-control hypertensive patients. Renal artery stenosis is unlikely to cause such severe hypokalaemia, and one would expect a mildly elevated creatinine if it were severe enough to cause hypertension.
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This question is part of the following fields:
- Endocrinology
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Question 18
Incorrect
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A 30-year-old female with a two year history of type 1 diabetes presents with a two day history of colicky abdominal pain and vomiting. She has been relatively anorexic and has cut down on her insulin today as she has not been able to eat that much.
On examination she has a sweet smell to her breath, has some loss of skin turgor, has a pulse of 102 bpm regular and a blood pressure of 112/70 mmHg. Her abdomen is generally soft with some epigastric tenderness.
BM stix analysis reveals a glucose of 19 mmol/L (3.0-6.0).
What investigation would be the most important for this woman?Your Answer: Plasma glucose concentration
Correct Answer: Blood gas analysis
Explanation:Diabetic Ketoacidosis: Diagnosis and Investigations
Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can lead to life-threatening consequences. Symptoms include ketotic breath, vomiting, abdominal pain, and dehydration. To confirm the diagnosis, it is essential to prove the presence of acidosis and ketosis. The most urgent and important investigation is arterial or venous blood gas analysis, which can reveal the level of acidosis and low bicarbonate.
Other investigations that can be helpful include a full blood count (FBC) to show haemoconcentration and a raised white cell count, and urinalysis to detect glucose and ketones. However, venous or capillary ketones are needed to confirm DKA. A plasma glucose test is also part of the investigation, but it is not as urgent as the blood gas analysis.
An abdominal x-ray is not useful in diagnosing DKA, and a chest x-ray is only indicated if there are signs of a lower respiratory tract infection. Blood cultures are unlikely to grow anything, and amylase levels are often raised but do not provide diagnostic information in this case.
It is important to note that DKA can occur even if the plasma glucose level is normal. Therefore, prompt diagnosis and treatment are crucial to prevent complications and improve outcomes.
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This question is part of the following fields:
- Endocrinology
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Question 19
Correct
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A 42-year-old man comes to the clinic complaining of gynaecomastia.
What is the most probable reason for his gynaecomastia?Your Answer: Seminoma
Explanation:The causes of Gynaecomastia are varied and can be indicative of underlying health issues. This condition is characterized by the enlargement of male breast tissue, which is caused by an imbalance in the testosterone to oestradiol ratio. It is important to note that hyperprolactinaemia and hypopituitarism do not affect this ratio and are not commonly associated with gynaecomastia.
It is also important to note that hypothyroidism and CAH are not known to cause this condition. However, gynaecomastia can be a symptom of seminoma, a type of testicular cancer, due to the secretion of human chorionic gonadotropin (HCG). Therefore, seeking medical attention if gynaecomastia is present is crucial.
Prolactinoma, on the other hand, is a benign tumour of the pituitary gland that is typically asymptomatic. It is not known to cause gynaecomastia, but it is important to monitor its growth and seek medical attention if any symptoms arise. Understanding the causes of gynaecomastia can help individuals identify potential health issues and seek appropriate treatment.
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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 26-year-old woman presents to the Emergency Department with confusion and decreased consciousness. Upon examination, she has a respiratory rate of 30/min and is tachypnoeic. Oxygen saturations are 98%. Urgent blood gases reveal a pH of 7.04, pO2 16.0 kPa, pCO2 2.6 kPa, HCO3- 3 mmol/l. What is the probable diagnosis?
Your Answer: Diazepam overdose
Correct Answer: Diabetic ketoacidosis (DKA)
Explanation:Causes of Metabolic Acidosis and Alkalosis
Metabolic acidosis is a condition characterized by low pH, low carbon dioxide, and low bicarbonate levels. One of the most common causes of metabolic acidosis is diabetic ketoacidosis (DKA), which can lead to confusion and reduced consciousness. Treatment for DKA involves an insulin infusion and intravenous fluids.
On the other hand, respiratory alkalosis is characterized by high pH and low carbon dioxide levels. Asthma and pulmonary embolism are two conditions that can cause tachypnea and respiratory alkalosis due to increased minute volume and blowing off carbon dioxide.
In contrast, metabolic alkalosis is characterized by high pH and high bicarbonate levels. Conn’s syndrome, also known as hyperaldosteronism, is a condition that typically causes hypertension and metabolic alkalosis.
Lastly, diazepam overdose can cause hypoventilation and respiratory acidosis, which is characterized by low pH and high carbon dioxide levels.
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This question is part of the following fields:
- Endocrinology
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Question 21
Correct
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A 47-year-old female is worried about the possibility of developing obesity and its connection to the metabolic syndrome and diabetes. She is seeking information on the specific criteria for diagnosing the metabolic syndrome.
Which of the following is a specific criterion used in diagnosing the metabolic syndrome?Your Answer: A waist circumference of more than 102 cm (40 inches)
Explanation:Metabolic syndrome is diagnosed when a person has three or more of the following factors: increased waist circumference, raised triglycerides, reduced HDL-cholesterol, raised blood pressure, and raised fasting plasma glucose. Central obesity is more strongly correlated with metabolic risk factors than BMI, and measuring waist circumference is recommended. Metabolic syndrome is associated with increased risk of developing diabetes and ischaemic heart disease.
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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 38-year-old woman comes to you with a swollen neck and upon examination, you find an unusual neck mass that raises suspicion of thyroid cancer. You arrange for a fine-needle aspiration and a histology report from a thyroid lobectomy reveals chromatin clearing, nuclear shape alteration, and irregularity of the nuclear membrane. There is no evidence of C cell differentiation, and the patient has no family history of cancer. What is the most probable diagnosis?
Your Answer: Follicular carcinoma of the thyroid
Correct Answer: Papillary carcinoma of the thyroid
Explanation:Thyroid cancer can take different forms, with papillary carcinoma being the most common and typically affecting women between 35 and 40 years old. This type of cancer has a good long-term prognosis. Medullary carcinoma arises from C cells that produce calcitonin and CEA, and can be sporadic or associated with a genetic syndrome. Follicular carcinoma is difficult to diagnose through FNA and requires a full histological specimen to confirm, with distinguishing features being vascular and capsule invasion. Anaplastic carcinoma is the most aggressive thyroid tumor, typically affecting older individuals and lacking biological features of the original thyroid cells. Thyroid lymphomas are rare and typically affect women over 50 with Hashimoto’s thyroiditis.
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This question is part of the following fields:
- Endocrinology
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Question 23
Incorrect
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A 61-year-old man is undergoing assessment for a thyroid nodule. An ultrasound shows a solitary nodule measuring 1.5 cm in the left lower lobe. Fine-needle aspiration reveals hypochromatic empty nuclei without nucleoli and psammoma bodies.
What is the most probable diagnosis?Your Answer: Follicular thyroid carcinoma
Correct Answer: Papillary thyroid carcinoma
Explanation:Papillary thyroid carcinoma is the most common type of thyroid cancer and has a good prognosis. It is characterized by ground-glass or Orphan Annie nuclei with calcified spherical bodies. Medullary thyroid carcinoma can occur sporadically or as part of multiple endocrine neoplasia syndromes and arises from the parafollicular C cells. Lymphoma of the thyroid is a rare cancer, except in individuals with Hashimoto’s thyroiditis. Anaplastic thyroid carcinoma is a highly aggressive form of thyroid cancer with a poor prognosis. Follicular thyroid carcinoma presents with a microfollicular pattern and is difficult to diagnose on fine-needle aspiration alone.
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This question is part of the following fields:
- Endocrinology
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Question 24
Incorrect
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A 42-year-old woman presents to her general practitioner (GP) with complaints of feeling ‘run down’. She reports increasing fatigue and lethargy over the past few months. Her appetite is poor, but she is gaining weight, and she is experiencing constipation. On examination, her skin is dry and cold. She has a painless midline neck swelling, which feels irregular and rubbery. The GP orders blood tests to investigate the cause of the patient’s symptoms.
What would you anticipate to observe on the thyroid function tests?Your Answer: TSH: low; free T4: normal; free T3: normal
Correct Answer: TSH: high; free T4: low; free T3: low
Explanation:The levels of TSH, free T4, and free T3 can provide insight into the functioning of the thyroid gland. High TSH and low free T4 and free T3 levels suggest Hashimoto’s thyroiditis, a type of autoimmune primary hypothyroidism. Low TSH and high free T4 and free T3 levels indicate primary hyperthyroidism, such as Graves’ disease. Low TSH and low free T4 and free T3 levels suggest secondary or tertiary hypothyroidism. High TSH and normal free T4 and free T3 levels suggest subclinical hypothyroidism, which may progress to primary hypothyroidism. Low TSH and normal free T4 and free T3 levels suggest subclinical hyperthyroidism, which may progress to primary hyperthyroidism.
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This question is part of the following fields:
- Endocrinology
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Question 25
Incorrect
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A 35-year-old woman visits her GP complaining of secondary amenorrhoea and suspects she may be pregnant. Which of the following sets of results is indicative of early pregnancy?
A
FSH (follicular phase 2.9-8.4 U/L): 0.5
LH (follicular phase 1.3-8.4 U/L): 1.1
Oestrogen (pmol/L): 26
Progesterone (pmol/L): <5
B
FSH (follicular phase 2.9-8.4 U/L): 0.5
LH (follicular phase 1.3-8.4 U/L): 1.2
Oestrogen (pmol/L): 120
Progesterone (pmol/L): 18
C
FSH (follicular phase 2.9-8.4 U/L): 68
LH (follicular phase 1.3-8.4 U/L): 51
Oestrogen (pmol/L): 42
Progesterone (pmol/L): <5
D
FSH (follicular phase 2.9-8.4 U/L): 1.0
LH (follicular phase 1.3-8.4 U/L): 0.8
Oestrogen (pmol/L): 120
Progesterone (pmol/L): 160
E
FSH (follicular phase 2.9-8.4 U/L): 8.0
LH (follicular phase 1.3-8.4 U/L): 7.2
Oestrogen (pmol/L): 144
Progesterone (pmol/L): <5Your Answer: A
Correct Answer: D
Explanation:Blood Test Ranges in Pregnancy
During pregnancy, blood tests may have different ranges due to the dilutional effect caused by the increased circulating volume, which can peak at almost 4L. This can result in lower levels of sodium, potassium, albumin, gamma globulins, hemoglobin, urea, creatinine, and urate. Additionally, pregnancy is associated with raised prolactin, low LH and FSH, and increased levels of estrogen and progesterone, with progesterone typically being greater than estrogen.
Compared to non-pregnant women, pregnant women may have increased white blood cell count and platelets, as well as higher levels of cholesterol, triglycerides, and ESR. Alkaline phosphatase levels may also be increased, as the placenta produces this enzyme. It is important to note that while some changes in blood test results are due to the dilutional effect of pregnancy, others may indicate underlying health issues, such as iron deficiency anemia. Therefore, it is crucial for healthcare providers to interpret blood test results in the context of pregnancy and individual patient health.
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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 man comes to the clinic complaining of headaches. His blood pressure measures 168/100 mmHg. Routine tests show sodium levels of 142 mmol/l (136–145), potassium levels of 2.8 mmol/l (3.5–5.0), chloride levels of 100 mmol/l (95–105), and normal levels of urea and creatinine. His plasma renin levels are undetectable, and his aldosterone levels are elevated. What is the most probable cause of his hypertension?
Your Answer: Cushing's syndrome
Correct Answer: Primary hyperaldosteronism
Explanation:Differentiating Primary Hyperaldosteronism from Other Causes of Hypertension
Primary hyperaldosteronism, also known as Conn’s syndrome, is a condition characterized by elevated aldosterone levels leading to low renin levels through negative feedback loops. This is the primary cause of hypertension in this condition. On the other hand, secondary hypertension can be caused by various conditions such as acromegaly, Cushing’s syndrome, and phaeochromocytoma. However, these conditions are not associated with low renin and elevated aldosterone levels. Renal artery stenosis, on the other hand, causes both high renin and aldosterone levels, leading to secondary hyperaldosteronism. Therefore, differentiating primary hyperaldosteronism from other causes of hypertension is crucial in determining the appropriate treatment plan.
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This question is part of the following fields:
- Endocrinology
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Question 27
Incorrect
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What is a clinical characteristic of acromegaly?
Your Answer: Hypotension
Correct Answer: Prominent supraorbital ridge
Explanation:Acromegaly: Causes, Symptoms, and Complications
Acromegaly is a condition that results from the overproduction of growth hormone (GH) caused by a pituitary tumour. This leads to the growth of soft tissues, which manifests in various clinical features such as enlarged hands, a prominent supraorbital ridge, protruding jaw, enlarged tongue, and carpal tunnel syndrome. Other symptoms include oily skin and tingling sensations. The tumour may also cause visual field disturbances and hypopituitarism due to its mass effect.
If left untreated, acromegaly can lead to complications such as hypertension, cardiomyopathy, hyperglycaemia/diabetes mellitus, and bowel tumours. Cardiomyopathy is a significant cause of mortality in untreated acromegaly. While pituitary adenoma is the most common cause of GH excess, ectopic secretion of GH-releasing hormone from neoplasia such as a carcinoid tumour of the lung is a rare cause.
In summary, acromegaly is a condition that results from the overproduction of GH caused by a pituitary tumour. It leads to various clinical features and can cause complications if left untreated. Early diagnosis and treatment are crucial to prevent long-term health problems.
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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 16-year-old female presents with a four-month history of amenorrhoea. During investigations, her GP notes an elevated prolactin concentration of 1500 mU/L (50-550). The patient's mother reports that she had previously experienced regular periods since her menarche at 12 years of age. Physical examination reveals a healthy female with normal pubertal development and no abnormalities in any system. There is no galactorrhoea upon expression. Further investigations show oestradiol levels of 5000 pmol/L (130-800), prolactin levels of 2000 mU/L (50-550), LH levels of 2 U/L (3-10), and FSH levels of 2 U/L (3-15). What test should be requested for this patient?
Your Answer: MRI scan of the pituitary
Correct Answer: Pregnancy test
Explanation:Pregnancy Hormones
During pregnancy, a woman’s body undergoes significant hormonal changes. One of the key hormones involved is oestradiol, which is produced in large quantities by the placenta. In pregnant women, oestradiol levels can be significantly elevated, which can be confirmed through a pregnancy test. Additionally, pregnant women often have suppressed levels of LH/FSH and elevated levels of prolactin, which helps to produce breast milk. Prolactin levels can increase by 10 to 20 times during pregnancy and remain high if the woman is breastfeeding after the baby is born. It’s important to note that even routine examinations may not detect a pregnancy until later stages, such as 16 weeks. these hormonal changes can help women better prepare for and manage their pregnancies.
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This question is part of the following fields:
- Endocrinology
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Question 29
Incorrect
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What are the potential adverse effects of using recombinant human growth hormone (rhGH) therapy?
Your Answer: Proliferative retinopathy
Correct Answer: Idiopathic intracranial hypertension
Explanation:Side Effects of Recombinant Human Growth Hormone Therapy
Recombinant human growth hormone (RHGH) is a safer alternative to the old pituitary derived growth hormone (GH) as it is not associated with Creutzfeldt-Jakob disease (CJD). However, RHGH therapy has been linked to certain side effects. Patients undergoing RHGH therapy may experience headaches and idiopathic intracranial hypertension (IIH) due to fluid retention caused by the therapy. Additionally, RHGH therapy may lead to proliferative retinopathy in patients with diabetes and aplastic anemia in those with Paroxysmal nocturnal hemoglobinuria. It is important for patients to be aware of these potential side effects and to discuss any concerns with their healthcare provider.
Overall, while RHGH therapy is a beneficial treatment for growth hormone deficiency, it is important to monitor for potential side effects and adjust treatment as necessary. Proper communication between patients and healthcare providers can help ensure the best possible outcomes for patients undergoing RHGH therapy.
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This question is part of the following fields:
- Endocrinology
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Question 30
Incorrect
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What test is utilized to examine for primary adrenal insufficiency, also known as Addison's disease?
Your Answer: Oral glucose tolerance test
Correct Answer: Short ACTH stimulation (Synacthen®) test
Explanation:Medical Tests for Hormonal Disorders
There are several medical tests used to diagnose hormonal disorders. One such test is the Synacthen test, which measures serum cortisol levels before and after administering synthetic ACTH. If cortisol levels rise appropriately, Addison’s disease can be excluded. However, an insufficient response may indicate adrenal gland atrophy or destruction.
Another test used to investigate hormonal disorders is the dexamethasone suppression test, which is used to diagnose Cushing’s syndrome. Additionally, the oral glucose tolerance test (OGTT) is used to screen for diabetes mellitus. In the UK, the OGTT involves administering 75 g of oral anhydrous glucose and measuring plasma glucose levels at 0 minutes (fasting) and 120 minutes. This test is also used to investigate suspected acromegaly by measuring the suppression of growth hormone following an oral glucose load.
Lastly, a glucose challenge is used during pregnancy to screen for gestational diabetes. This test involves administering 50 g of oral glucose and measuring plasma glucose levels after 30 minutes. By utilizing these medical tests, healthcare professionals can accurately diagnose and treat hormonal disorders.
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This question is part of the following fields:
- Endocrinology
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Question 31
Incorrect
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A mother brings her 9-month-old baby to clinic for a check-up. His prior medical history has been unremarkable and his immunisations are up-to-date. The mother is concerned about his growth. After you determine that the baby has grown appropriately since the last visit and is unchanged from the 50th centile, you provide the mother with advice regarding growth.
What signalling pathway does growth hormone (GH) use?Your Answer: Inositol trisphosphate (IP3)
Correct Answer: A tyrosine kinase receptor that uses the JAK/STAT pathway
Explanation:Comparison of Second Messenger Systems and Receptor Types in Hormonal Signaling
Hormones utilize various signaling pathways to transmit their messages to target cells. One important aspect of hormonal signaling is the use of second messengers, which relay the hormone signal from the cell surface to the intracellular environment. Here, we compare and contrast the second messenger systems and receptor types used by different hormones.
Growth hormone (GH) and prolactin both use the tyrosine kinase receptor, followed by activation of Janus kinase (JAK), signal transduction, and activation of transcription (STAT). In contrast, platelet-derived growth factor (PDGF), fibroblast growth factor (FGF), insulin-like growth factor 1 (IGF-1), and insulin use the MAP kinase or RAS system. Aldosterone uses steroid receptors, while GH uses the tyrosine kinase receptor.
Inositol trisphosphate (IP3) works as a second messenger for hypothalamic hormones such as gonadotropin-releasing hormone (GnRH), growth hormone-releasing hormone (GHRH), thyrotropin-releasing hormone (TRH), and pituitary hormones such as antidiuretic hormone (ADH) and oxytocin.
Cyclic guanosine monophosphate (cGMP) is a second messenger that activates protein kinases and mediates endothelium-derived relaxing factor (EDRF), atrial natriuretic peptide (ANP), and nitric oxide.
Cyclic adenosine monophosphate (cAMP) is a second messenger of follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroid-stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), human chorionic gonadotropin (hCG), and several other hormones, but not GH.
In summary, different hormones use distinct second messenger systems and receptor types to transmit their signals, highlighting the complexity and diversity of hormonal signaling pathways.
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This question is part of the following fields:
- Endocrinology
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Question 32
Incorrect
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For which medical condition is Pioglitazone prescribed?
Your Answer: Hypertension
Correct Answer: Type II diabetes mellitus
Explanation:Pioglitazone for Type 2 Diabetes: Mechanism of Action and Side Effects
Pioglitazone is a medication used to treat insulin resistance in patients with type 2 diabetes. It works by activating PPAR gamma, a protein that regulates the expression of genes involved in glucose and lipid metabolism. This leads to improved insulin sensitivity and better control of blood sugar levels. Pioglitazone has been shown to lower HbA1c levels by approximately 1%.
However, pioglitazone is associated with several side effects. One of the most common is fluid retention, which can lead to swelling in the legs and feet. It can also cause a loss of bone mineral density, which may increase the risk of fractures. Additionally, pioglitazone has been linked to an increased risk of bladder cancer, particularly in patients with a history of bladder tumors or polyps. For this reason, it should not be prescribed to these patients.
In summary, pioglitazone is an effective medication for treating insulin resistance in type 2 diabetes. However, it is important to be aware of its potential side effects, particularly the risk of bladder cancer in certain patients. Patients taking pioglitazone should be monitored closely for any signs of fluid retention or bone loss, and those with a history of bladder tumors or polyps should not take this medication.
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This question is part of the following fields:
- Endocrinology
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Question 33
Incorrect
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A 54-year-old woman complains of lethargy and mild headaches. You decide to perform a thyroid function test to investigate further.
The results of the test are as follows:
- Free T4: 9 pmol/l (normal range: 9.8-23.1)
- TSH: 0.33mU/l (normal range: 0.35-5.50)
What would be the best course of action for this patient?Your Answer: Order a thyroid uptake scan
Correct Answer: Refer to an endocrinologist
Explanation:Importance of Proper Diagnosis in Secondary Hypothyroidism
Secondary hypothyroidism is a condition where the thyroid gland is not producing enough hormones due to a problem in the pituitary gland. It is important to properly diagnose the underlying cause of this condition to avoid missing any potential pathology in the pituitary gland. While commencing treatment with thyroxine may alleviate symptoms, it does not address the root cause of the problem.
Therefore, it is recommended to refer patients with secondary hypothyroidism to an endocrinologist for further investigation and imaging of the pituitary gland. This will ensure that any underlying issues are properly identified and addressed, leading to more effective treatment and management of the condition. Proper diagnosis is crucial in managing secondary hypothyroidism and preventing potential complications.
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This question is part of the following fields:
- Endocrinology
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Question 34
Correct
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A 28-year-old patient is admitted with vomiting and abdominal pain. She was noted to have marked buccal pigmentation.
Examination reveals dehydration, pulse 100 bpm, blood pressure (BP) 90/60 mmHg. Initial blood tests show: glucose 2.9 mmol/l, sodium (Na+) 126 mmol/l, potassium (K+) 4.9 mmol/l, urea 8.2 mmol/l, creatinine 117 µmol/l.
Which of the following is the most likely diagnosis?Your Answer: Addison’s disease
Explanation:Medical Conditions: Addison’s Disease and Other Differential Diagnoses
Addison’s Disease:
Addison’s disease, or primary hypoadrenalism, is a condition characterized by chronic adrenal insufficiency. The most common cause in the UK is autoimmune destruction of the adrenals, while worldwide tuberculosis is the most common cause. Other causes include long-term exogenous steroid use, cancer, or haemorrhage damage. Symptoms develop gradually, but patients can present in Addisonian crisis if there is a sudden deterioration in adrenal function or a physiological stress that the residual adrenal function is not capable of coping with. Treatment is with long-term replacement of corticosteroids and aldosterone. Treatment of a crisis requires intravenous glucocorticoids, as well as supportive measures and fluid resuscitation.Differential Diagnoses:
Peutz–Jeghers syndrome is an autosomal dominant condition characterized by perioral freckling and small bowel polyps. Insulinoma causes hypoglycaemia, but the other features are absent. Cushing syndrome is a result of excess corticosteroid, while Conn syndrome is also known as primary hyperaldosteronism. -
This question is part of the following fields:
- Endocrinology
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Question 35
Incorrect
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With which condition are hyperparathyroidism and phaeochromocytoma commonly associated?
Your Answer: Adenoma of thyroid
Correct Answer: Medullary carcinoma of thyroid
Explanation:Sipple Syndrome (MEN 2A)
Sipple syndrome, also known as Multiple Endocrine Neoplasia (MEN) 2A, is a group of endocrine disorders that occur together in the same patient and are typically inherited. This syndrome is caused by a defect in a gene that controls the normal growth of endocrine tissues. As a result, individuals with Sipple syndrome may develop bilateral medullary carcinoma or C cell hyperplasia, phaeochromocytoma, and hyperparathyroidism.
Sipple syndrome is inherited in an autosomal dominant fashion, which means that if a person has the defective gene, they have a 50% chance of passing it on to their offspring. This syndrome affects both males and females equally, and the peak incidence of medullary carcinoma in these patients is typically in their 30s.
In summary, Sipple syndrome is a rare inherited disorder that affects multiple endocrine glands. It is important for individuals with a family history of this syndrome to undergo genetic testing and regular screenings to detect any potential tumors or abnormalities early on.
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This question is part of the following fields:
- Endocrinology
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Question 36
Correct
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A 67-year-old woman with a history of renal stones and osteoporosis presents with abnormal laboratory results. Her bone density scan shows a T score of -3.2 in the femur and -2.7 in the spine. She has no other symptoms and is not taking any medications. Upon further investigation, a right-sided parathyroid nodule is discovered through Sestamibi Technetium (99mTc) and ultrasound scan. The patient's laboratory results are as follows: calcium 2.9 mmol/l (normal range 2.20-2.6 mmol/l), phosphate 0.6 mmol/l (normal range 0.7-1.5 mmol/l), PTH 80 ng/l (normal range 15-60 ng/l), creatinine 72 μmol/l (normal range 50-120 μmol/l), and 24-hour urinary calcium : creatinine 0.03 (normal range <0.02). What is the most appropriate treatment for this patient?
Your Answer: Parathyroid surgery
Explanation:Management of Primary Hyperparathyroidism: Indications for Surgery and Treatment Options
Primary hyperparathyroidism is a condition characterized by persistent hypercalcemia with an inappropriately elevated or normal parathyroid hormone (PTH). Patients with this condition may also have hypercalciuria, which can lead to renal stones and nephrocalcinosis. Parathyroidectomy is the recommended treatment for primary hyperparathyroidism, with success rates of about 97%.
Indications for parathyroidectomy include symptomatic disease, age under 50 years, adjusted serum calcium concentration that is 0.25 mmol/l or more above the upper end of the reference range, estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m2, renal stones or presence of nephrocalcinosis on ultrasound or CT, and presence of osteoporosis or osteoporotic fracture.
Patients with calcium >3.4 mmol/l or who are significantly symptomatic or have an acute kidney injury and dehydration should be admitted for urgent treatment and assessment. However, asymptomatic patients with normal renal function and likely longstanding hypercalcemia may not require hospitalization.
For patients who are not candidates for surgery or decline it, other treatment options include bisphosphonate therapy, cinacalcet, and vitamin D replacement. Bisphosphonate therapy can improve bone mineral density but will not prevent further renal stones. Cinacalcet is an allosteric modulator of the calcium-sensing receptor that can be used in patients who meet hypercalcemia criteria for parathyroidectomy but cannot undergo surgery. However, it can cause mild-to-moderate adverse events such as nausea, vomiting, arthralgia, diarrhea, myalgia, and paraesthesia. Vitamin D replacement should be considered if vitamin D levels are low, but careful monitoring is required to avoid masking hypercalcemia and increasing the risk of parathyroid tumorigenesis.
In summary, the management of primary hyperparathyroidism involves identifying indications for parathyroidectomy and considering alternative treatment options for patients who are not candidates for surgery or decline it. Close monitoring and follow-up are essential to ensure optimal outcomes.
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This question is part of the following fields:
- Endocrinology
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Question 37
Correct
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What is the accurate description of growth hormone (GH) and its role in normal growth?
Your Answer: It stimulates cartilage and bone growth via somatomedin C
Explanation:Functions and Characteristics of Growth Hormone
Growth hormone (GH) plays a crucial role in stimulating cartilage and bone growth through the production of somatomedin C, also known as insulin-like growth factor 1 (IGF-1). While GH has direct effects throughout the body, its receptors have a limited distribution outside the central nervous system (CNS). GH is secreted in a pulsatile manner, with its concentration peaking during sleep. The synthesis of GH is stimulated by the action of somatostatin, which inhibits its release and is sometimes referred to as ‘growth hormone-inhibiting hormone’. In addition to its other actions, GH has a proinsulin-like effect, which is in contrast to its anti-insulin-like effects, such as promoting gluconeogenesis.
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This question is part of the following fields:
- Endocrinology
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Question 38
Correct
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A 39-year-old man comes to his GP complaining of sudden headaches accompanied by sweating and palpitations. Upon examination, the patient appears anxious and has a pale complexion. His blood pressure measures 240/200 mmHg, and a 24-hour urine collection shows increased levels of catecholamines. What is the probable cause of this man's hypertension?
Your Answer: Phaeochromocytoma
Explanation:Differentiating Causes of Hypertension: A Brief Overview
Hypertension, or high blood pressure, is a common medical condition that affects millions of people worldwide. While there are many possible causes of hypertension, some are more common than others. In this article, we will discuss some of the most common causes of hypertension and how to differentiate them.
Phaeochromocytoma is a tumour of the adrenal gland that can cause hypertension, headache, sweating, and anxiety. It is often associated with the 10% rule, which states that 10% of cases are extramedullary, 10% are malignant, 10% are familial, and 10% are bilateral.
Conn syndrome, or primary aldosteronism, is characterized by hypertension, hypokalaemia, and metabolic alkalosis. The most common causes are aldosterone-producing adenomas and bilateral adrenal hyperplasia.
Renal artery stenosis (RAS) is a major cause of renovascular hypertension. However, it is not associated with elevated catecholamines or the symptoms described.
Polycystic kidney disease (PKD) is a genetic disorder that can cause hypertension due to progressive kidney enlargement. However, patients with PKD do not have elevated catecholamine levels.
Cushing syndrome is caused by prolonged hypercortisolism and can cause centripetal obesity, secondary hypertension, glucose intolerance, proximal myopathy, and hirsutism. Sweating, palpitations, and elevated catecholamines are not typical of hypercortisolism.
In conclusion, hypertension can have many different causes, and it is important to differentiate them to provide appropriate treatment. By understanding the characteristic features of each condition, healthcare professionals can make an accurate diagnosis and provide effective management.
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This question is part of the following fields:
- Endocrinology
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Question 39
Incorrect
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A 60-year-old man with a 10-year history of type 2 diabetes comes in for his annual check-up. He is currently taking ramipril, pioglitazone, metformin, simvastatin, and acarbose. During previous examinations, he has been found to have microalbuminuria and a decreasing eGFR. His most recent eGFR measurement was 29 ml/minute/1.73 m2. He has an average build and height.
Which medication should be discontinued?Your Answer: Pioglitazone
Correct Answer: Metformin
Explanation:Using eGFR to Determine Dose Adjustments in Renal Impairment
Published information on the effects of renal impairment on drug elimination often uses creatinine clearance as a measure of glomerular filtration rate. However, in patients of average build and height, laboratories may report estimated glomerular filtration rate (eGFR) based on the modification of diet in renal disease (MDRD) formula. This can be used to determine appropriate dose adjustments for medications.
The British National Formulary (BNF) recommends avoiding metformin if the eGFR is less than 30 ml/minute/1.73 m2 due to the risk of lactic acidosis. This is a serious condition that can occur when metformin accumulates in the body due to impaired renal function. By using eGFR to guide dose adjustments, healthcare providers can help prevent adverse drug reactions and ensure safe and effective medication use in patients with renal impairment.
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This question is part of the following fields:
- Endocrinology
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Question 40
Incorrect
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A 50-year-old woman presents to her general practitioner, complaining of a lump in her neck. She is a non-smoker and has no significant past medical history. On examination, there is a 2-cm firm, non-tender nodule on the left side of the anterior triangle of the neck, in the area of the thyroid.
Investigations:
Thyroid stimulating hormone: 2.5 mu/l (0.4–4.0 mu/l)
Fine-needle aspiration biopsy: partial papillary architecture with some thyroid follicles present. Thyrocytes are abnormally large with an abnormal nucleus and cytoplasm and frequent mitoses. Psammoma bodies are also demonstrated in the sample.
Which of the following fits best with the underlying diagnosis?Your Answer: Follicular thyroid carcinoma
Correct Answer: Papillary thyroid carcinoma
Explanation:Thyroid Cancer Types and Diagnosis
Thyroid cancer can be classified into different types based on the cells involved. Papillary thyroid carcinoma is the most common type, where the papillary architecture of the thyroid is partially preserved. Surgery followed by radioiodine therapy is the standard treatment for this condition. Medullary thyroid carcinoma is less common and results in elevated calcitonin levels. Non-toxic multinodular goitre can be diagnosed through fine-needle aspiration biopsy, which shows colloid nodules. Follicular thyroid carcinoma exhibits variable morphology and is not consistent with fine-needle aspiration biopsy findings. Solitary toxic nodule can be ruled out if thyroid function is within normal limits. Proper diagnosis and treatment can lead to a high survival rate for patients under 40 years of age with papillary thyroid carcinoma.
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This question is part of the following fields:
- Endocrinology
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Question 41
Correct
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A 42-year-old teacher presents to the general practitioner (GP) complaining of fatigue and muscle pains. The symptoms have been gradually worsening over the past few months, and now she feels too tired after work to attend her weekly yoga class. She has a history of seasonal allergies and takes antihistamines during the spring and summer. The patient is a non-smoker, drinks occasionally, and follows a vegetarian diet.
During examination, no abnormalities are found, and the GP orders blood tests for further investigation. The results reveal a serum vitamin D (25OHD) level of 18 nmol/l (normal value recommended > 50 nmol/l).
Which molecule involved in the vitamin D synthesis pathway binds to the vitamin D receptor to regulate calcium homeostasis?Your Answer: Calcitriol
Explanation:Understanding the Different Forms of Vitamin D
Vitamin D is an essential nutrient that plays a crucial role in calcium homeostasis. However, it exists in different forms, each with its own unique properties and functions. Here are the different forms of vitamin D and their roles:
1. Calcitriol: Also known as 1, 25-hydroxycolecalciferol, this form of vitamin D binds to the vitamin D receptor to create a ligand-receptor complex that alters cellular gene expression.
2. Previtamin D3: This is the precursor to vitamin D3 and does not play a direct role in calcium homeostasis.
3. Calcidiol: This is 25-hydroxycolecalciferol, the precursor to calcitriol. It has a very low affinity for the vitamin D receptor and is largely inactive.
4. Colecalciferol: This is vitamin D3, which is itself inactive and is the precursor to calcidiol.
5. 24, 25-dihydroxycolecalciferol: This is an inactive form of calcidiol and is excreted.
Understanding the different forms of vitamin D is important in determining the appropriate supplementation and treatment for vitamin D deficiency.
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This question is part of the following fields:
- Endocrinology
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Question 42
Incorrect
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A 50-year-old male presents to the endocrinology clinic with symptoms of hypogonadism. He reports consuming five cans of lager per week, which is believed to be the cause of his abnormal liver function tests. The patient has a history of type 2 diabetes and osteoarthritis affecting his hips and knees. What tests should be performed to determine the underlying diagnosis?
Your Answer: Viral serology
Correct Answer: Serum ferritin and iron studies
Explanation:Haemochromatosis as a Cause of Hypogonadism
The patient’s medical history suggests that haemochromatosis may be the underlying cause of their hypogonadism. While their moderate alcohol consumption of 10 units per week may contribute to liver dysfunction, other potential explanations should be explored. Additionally, the patient’s history of type 2 diabetes and seronegative arthropathy are consistent with iron storage diseases. Haemochromatosis can lead to reduced insulin production, resulting in a presentation similar to type 2 diabetes. To confirm the diagnosis, serum ferritin and transferrin saturation levels should be evaluated, as elevated levels of both are highly indicative of haemochromatosis.
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This question is part of the following fields:
- Endocrinology
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Question 43
Incorrect
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A 16-year-old girl has been referred due to a six-month history of amenorrhea and weight loss, without identifiable organic cause. What signs would indicate a possible diagnosis of anorexia nervosa (AN)?
Possible revised output with paragraph spacing:
A 16-year-old girl has been referred to the clinic with a six-month history of amenorrhea and weight loss. Despite medical investigations, no organic cause has been identified for her symptoms. The healthcare provider suspects that the patient may have anorexia nervosa (AN), a serious eating disorder characterized by self-imposed starvation and distorted body image. To confirm or rule out this diagnosis, the provider needs to look for specific features that are commonly associated with AN.Your Answer: Hypotrichosis
Correct Answer: Delusion of being overweight
Explanation:Features of Anorexia Nervosa
Anorexia Nervosa (AN) is a serious eating disorder that is characterized by several features. One of the most prominent features is a phobic avoidance of normal weight, which leads to relentless dieting and self-induced vomiting. Laxative use and excessive exercise are also common behaviors associated with AN. Another feature of AN is amenorrhea, which is the absence of menstrual periods.
Physical symptoms of AN include hypotension and the growth of lanugo hair, which is fine, downy hair that grows on the body as a result of malnutrition. Denial and concealment are also common behaviors associated with AN, as individuals with this disorder often try to hide their symptoms from others.
In addition to these physical and behavioral symptoms, individuals with AN may also have an over-perception of their body image, leading them to see themselves as overweight even when they are underweight. Finally, AN is often associated with enmeshed families, where family members are overly involved in each other’s lives and have difficulty setting boundaries.
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This question is part of the following fields:
- Endocrinology
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Question 44
Incorrect
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A 16-year-old athlete attends a routine check-up. Her past medical history is significant for type 1 diabetes since the age of 7. Her glucose is well controlled with self-administration of insulin. She reports that she is training for the upcoming national championship. She has specific questions regarding the effects and actions of insulin.
Which of the following is correct regarding the action of insulin?Your Answer: Insulin promotes sodium secretion in the renal tubules
Correct Answer: Insulin increases protein synthesis in muscle
Explanation:The Effects of Insulin on the Body: Promoting Protein Synthesis, Sodium Secretion, and More
Insulin is a crucial hormone synthesized in pancreatic β cells that plays a vital role in the metabolism of carbohydrates and lipids in the body. This peptide hormone promotes glycogen synthesis, increases potassium uptake, and reduces lipolysis and proteolysis in cells. Additionally, insulin is known to increase protein synthesis in muscle and decrease triglyceride synthesis and storage in adipocytes.
One of the lesser-known effects of insulin is its ability to promote sodium secretion in the renal tubules. Insulin is also responsible for increasing tubular sodium reabsorption in the kidney, which halves sodium excretion.
Furthermore, insulin is used in the management of hyperkalaemia as it increases serum potassium levels by causing a shift of potassium into the cells, thereby lowering circulating potassium and increasing intracellular potassium concentration.
However, insulin does decrease glycogen storage in cells by activating enzymes involved in glycogen synthesis in the liver and tissues, causing the conversion of glucose to glycogen.
In summary, insulin has a wide range of effects on the body, from promoting protein synthesis to regulating potassium and sodium levels.
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This question is part of the following fields:
- Endocrinology
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Question 45
Incorrect
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A 14-year-old girl (who has been recently diagnosed with anorexia nervosa) exercises regularly. During one period of exercise, she becomes very light-headed. Several minutes later, she breaks into a sweat and develops palpitations. A friend takes her to an Emergency Department where a serum glucose of 2.2 mmol/l is demonstrated. The patient is given a soft drink to sip and feels better half an hour later.
Which of the following hormones most likely triggered the sweating and palpitations the patient experienced?Your Answer: Thyroxine
Correct Answer: Epinephrine
Explanation:Hormones and their Role in Hypoglycaemia
Hypoglycaemia, or low blood sugar, can be caused by various factors including exercise and minimal glycogen and lipid stores. Hormones play a crucial role in the body’s response to hypoglycaemia.
Epinephrine is released in response to hypoglycaemia and promotes hepatic glucose production and release. Adrenocorticotropic hormone (ACTH) triggers cortisol release, which stimulates gluconeogenesis over several hours. Calcitonin modulates serum calcium levels but does not play a direct role in hypoglycaemia.
Insulin secretion is associated with hypoglycaemia but does not cause symptoms such as sweating or palpitations. Similarly, thyroxine can cause similar symptoms but is not responsible for a specific role in the body’s response to hypoglycaemia. Understanding the role of hormones in hypoglycaemia can aid in its diagnosis and management.
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This question is part of the following fields:
- Endocrinology
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Question 46
Incorrect
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A 67-year-old woman is brought to Accident and Emergency after being found near-unconscious by her daughter. Her daughter indicates that she has a long-term joint disorder that has been controlled with oral medication and uses steroids excessively. She has recently been suffering from depression and has had poor compliance with medications. On examination, she is responsive to pain. Her pulse is 130 bpm and blood pressure is 90/60 mmHg. She is afebrile.
Basic blood investigations reveal:
Investigation Patient Normal value
Haemoglobin 121 g/l 135–175 g/l
White cell count (WCC) 6.1 × 109/l 4–11 × 109/l
Platelets 233 × 109/l 150–400 × 109/l
Sodium (Na+) 129 mmol/l 135–145 mmol/l
Potassium (K+) 6.0 mmol/l 3.5–5.0 mmol/l
Creatinine 93 μmol/l 50–120 µmol/l
Glucose 2.7 mmol/l <11.1 mmol/l (random)
What is the most likely diagnosis?Your Answer: Insulin overdose
Correct Answer: Addisonian crisis
Explanation:Differential Diagnosis: Addisonian Crisis and Other Conditions
Addisonian crisis is a condition caused by adrenal insufficiency, often due to autoimmune disease or other factors such as tuberculosis or adrenal haemorrhage. Symptoms are vague and insidious, including weight loss, depression, anorexia, and gastrointestinal upset. Diagnosis is made through a short ACTH stimulation test. Emergency treatment involves IV hydrocortisone and fluids, while long-term treatment involves oral cortisol and mineralocorticoid. Any stressful activity should lead to an increase in steroid dosage.
Other conditions, such as insulin overdose, salicylate overdose, meningococcal septicaemia, and paracetamol overdose, may present with similar symptoms but can be ruled out based on the clinical information given. Insulin overdose can cause low glucose levels due to loss of the anti-insulin effect of cortisol. Salicylate overdose can cause a range of symptoms, but the ones described here are not suggestive of this condition. Meningococcal septicaemia may present with hypotension and tachycardia, but the remaining features do not fit this diagnosis. Paracetamol overdose typically presents with liver toxicity symptoms, which are not described in the given information. Therefore, the specific symptoms described are indicative of an Addisonian crisis.
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This question is part of the following fields:
- Endocrinology
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Question 47
Incorrect
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A 28-year-old woman visited her GP complaining 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 were as follows:
- Sodium: 150 mmol/l (135–145 mmol/l)
- Potassium: 2.5 mmol/l (3.5–5 mmol/l)
- Fasting blood glucose: 7.7 mmol/l (5–7.2 mmol/l)
- 24-hour urinary cortisol excretion: 840 nmol/24 hours (<300 nmol/24 hours)
- Plasma adrenocorticotropic hormone (ACTH): undetectable
- Dexamethasone suppression test:
- 0800 h serum cortisol after dexamethasone 0.5 mg/6 hours orally (po) for 2 days: 880 nmol/l (<50 nmol/l)
- 0800 h serum cortisol after dexamethasone 2 mg/6 hours po for 2 days: 875 nmol/l (<50 nmol/l)
What is the most probable clinical diagnosis?Your Answer: Conn’s syndrome
Correct Answer: Adrenocortical tumour
Explanation:Adrenocortical Tumour: Localizing the Source of Excessive Cortisol Production
Cushing’s syndrome is characterized by the overproduction of glucocorticoids, which can lead to weight gain, mood disturbances, and irregular menses. In this case, the patient has proven high 24-hour urinary cortisol excretion, indicating excessive cortisol levels. However, the lack of response to low-dose dexamethasone and the low potassium and high sodium levels suggest that an adrenocortical tumour is the most likely cause.
An adrenocortical tumour results in excess cortisol secretion by the adrenal glands, leading to negative feedback at the pituitary level and very low or undetectable levels of ACTH. This is consistent with the patient’s presentation, ruling out Cushing’s disease, Conn’s syndrome, and acromegaly. Additionally, the absence of detectable ACTH levels rules out paraneoplastic syndrome secondary to small cell carcinoma of the lung.
In conclusion, the patient’s clinical picture and test results suggest an adrenocortical tumour as the source of excessive cortisol production.
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This question is part of the following fields:
- Endocrinology
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Question 48
Incorrect
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A 72-year-old man comes to the clinic for his yearly check-up and expresses worry about osteoporosis. He has questions about bone formation and calcium homeostasis, and you explain the role of parathyroid hormone (PTH) in regulating calcium levels.
Which of the following statements about PTH is accurate?Your Answer: It causes a decrease in serum calcium
Correct Answer: It causes indirect osteoclastic activation via RANK-L
Explanation:Parathyroid hormone (PTH) indirectly activates osteoclasts by increasing the production of RANK-L by osteoblasts. This leads to bone degradation and the release of calcium. PTH also decreases the release of osteoprotegerin, which is a decoy receptor for RANK-L. This further enhances osteoclast activity and bone degradation. Additionally, PTH causes a decrease in serum calcium by promoting calcium release from bone. It also enhances renal phosphate excretion by decreasing phosphate reabsorption.
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This question is part of the following fields:
- Endocrinology
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Question 49
Correct
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A 38-year-old woman presents with a 6-month history of excessive sweating, palpitations, and weight loss. She now complains of a headache. On examination, her blood pressure is 230/130 mmHg, with a postural drop to 180/110 mmHg. She has a bounding pulse of 115 bpm, a tremor, and appears pale. The rest of the examination is unremarkable. Which hormone is most likely responsible for her symptoms and signs?
Your Answer: Catecholamines
Explanation:Explanation of Hormones and their Role in Hypertension
The patient’s symptoms suggest a rare tumour called phaeochromocytoma, which secretes catecholamines and causes malignant hypertension. Excess cortisol production in Cushing’s syndrome can also cause hypertension, but it does not explain the patient’s symptoms. Renin abnormalities can lead to hypertension, but it is not the cause of the patient’s symptoms. Hyperaldosteronism can also cause hypertension, but it does not explain the patient’s symptoms. Although hyperthyroidism can explain most of the patient’s symptoms, it is less likely to cause severe hypertension or headaches. Therefore, the patient’s symptoms are most likely due to the secretion of catecholamines from the phaeochromocytoma tumour.
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This question is part of the following fields:
- Endocrinology
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Question 50
Correct
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A 55-year-old male with a long history of smoking presents with a complaint of haemoptysis. Upon examination, muscle wasting and hypertension are observed. Further testing reveals elevated urine free cortisol, elevated ACTH, and non-suppressible cortisol following high dose dexamethasone testing. What is the most probable diagnosis?
Your Answer: Ectopic ACTH producing lung cancer
Explanation:Ectopic ACTH Production and Associated Tumours
Patients with Cushing’s syndrome and non-suppressible cortisol levels may have ectopic adrenocorticotropic hormone (ACTH) secretion, which is commonly associated with small cell lung cancer. Other tumours that may cause ectopic ACTH production include those of the thymus, pancreas, thyroid, and adrenal gland. Unlike typical hypercortisolism symptoms, patients with ectopic ACTH production may experience polyuria, polydipsia, oedema, muscle wasting, fatigue, hypertension, and hypokalaemia.
Laboratory tests can confirm excessive cortisol production and lack of dexamethasone suppression of morning cortisol levels. Plasma ACTH levels greater than 200 pg/mL may indicate ectopic ACTH production and prompt a search for an underlying malignancy, particularly a primary lung or pancreatic tumour. Therefore, it is crucial to investigate the possibility of ectopic ACTH production in patients with Cushing’s syndrome and non-suppressible cortisol levels, as it may indicate an underlying tumour.
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This question is part of the following fields:
- Endocrinology
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Question 51
Incorrect
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A 26-year-old waitress presents with a 2-day history of increasing confusion. She has no significant medical history, takes only oral contraceptives, and denies any substance use. Blood and urine tests suggest a possible diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following statements regarding SIADH secretion is accurate?
Your Answer: Hypernatraemia is typical
Correct Answer: It may occur in subarachnoid haemorrhage
Explanation:Understanding SIADH: Causes and Treatment Options
SIADH, or syndrome of inappropriate antidiuretic hormone secretion, is a condition characterized by excessive production of ADH, leading to hyponatraemia. While it can occur in various medical conditions, subarachnoid haemorrhage is a known cause of SIADH. In such cases, monitoring sodium levels is crucial. The treatment of choice for SIADH is fluid restriction, but in severe cases, hypertonic saline may be used. Demeclocycline, a tetracycline, is sometimes used to treat hyponatraemia in SIADH. It’s important to note that small cell lung cancer, not adenocarcinoma of the lung, is a well-known cause of SIADH through ectopic ADH secretion. Understanding the causes and treatment options for SIADH is essential for managing this condition effectively.
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This question is part of the following fields:
- Endocrinology
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Question 52
Incorrect
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A 45-year-old man presents to his general practitioner (GP) for a check-up following prescription of an angiotensin-converting enzyme (ACE) inhibitor for hypertension. He reports no side-effects of the medication. On measurement of his blood pressure, it is recorded as 176/140 mmHg. The GP repeats the measurement and records similar values. The physician considers secondary causes of hypertension and enquires about symptoms associated with some of the causes. The patient reports headache, sweating and occasional palpitations. On examination, he has a pulse rate of 110 bpm and dilation of both pupils. The GP suspects the patient may be suffering from the rare condition known as phaeochromocytoma.
What percentage of cases of phaeochromocytoma are due to a malignant cause?Your Answer: 50%
Correct Answer: 10%
Explanation:Understanding Phaeochromocytoma: Malignancy and Survival Rates
Phaeochromocytoma is a rare condition characterized by catecholamine-secreting tumors that can cause life-threatening secondary hypertension. While the majority of these tumors are benign, approximately 10% are malignant. Malignancy is defined by the presence of metastases and is more common in extra-adrenal tumors.
The classical presentation of phaeochromocytoma, regardless of malignancy, includes severe hypertension, headaches, palpitations, and diaphoresis. However, complete surgical resection of the tumor can resolve hypertension in most cases.
For malignant phaeochromocytoma, the 5-year survival rate is approximately 50%, while the survival rate for non-malignant disease is around 95%. It’s important to understand the potential for malignancy and the associated survival rates when diagnosing and treating phaeochromocytoma.
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This question is part of the following fields:
- Endocrinology
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Question 53
Incorrect
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What is the most suitable vitamin D supplement for a patient with liver and kidney failure, considering the need for enzymatic conversion of naturally occurring analogues?
Your Answer: Cholecalciferol (vitamin D3)
Correct Answer: Calcitriol (1,25 dihydroxycholecalciferol)
Explanation:Vitamin D Activation
Vitamin D is an essential nutrient that plays a crucial role in maintaining bone health and immune function. However, not all forms of vitamin D are active and readily available for use by the body.
Alphacalcidol, a partly activated form of vitamin D, is not the correct answer as it still requires further hydroxylation by the liver. Similarly, cholecalciferol (vitamin D3) and ergocalciferol (vitamin D2) are naturally occurring analogues that require activation by both the liver and kidneys.
The correct answer is calcitriol (1,25 dihydroxycholecalciferol), an active form of vitamin D that has undergone the necessary hydroxylation by both the kidneys and liver.
It is important to understand the different forms of vitamin D and their activation processes in order to ensure adequate intake and absorption for optimal health.
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This question is part of the following fields:
- Endocrinology
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Question 54
Incorrect
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A 35-year-old woman comes to the Endocrinology Clinic complaining of bruising, striae, acne and hirsutism. During the examination, the patient seems lethargic and depressed, with centripetal obesity and proximal myopathy. Her blood pressure is 165/106 mmHg and blood tests show Na+ 136 mmol/l, K+ 2.8 mmol/l and random glucose 8.2 mmol/l. The doctor orders a low-dose dexamethasone test and a 24-hour urinary cortisol test. What is the most common cause of Cushing syndrome?
Your Answer: Pseudo-Cushing's syndrome
Correct Answer: Iatrogenic
Explanation:Causes of Cushing Syndrome: Understanding the Different Types
Cushing Syndrome is a rare condition that occurs when the body is exposed to high levels of cortisol for an extended period. Cortisol is a hormone produced by the adrenal glands that helps regulate metabolism and stress response. There are several different causes of Cushing Syndrome, including:
1. Iatrogenic: This is the most common cause of Cushing Syndrome and is related to the use of corticosteroid medication. People who take oral corticosteroids are at a higher risk, but the condition can also affect those who misuse inhaled or topical corticosteroids.
2. Ectopic ACTH secretion: This is a very rare cause of Cushing Syndrome that arises due to ACTH secretion from a carcinoid tumor.
3. Primary adrenal disorder: This is primary hypercortisolism, which is an unusual cause for Cushing Syndrome.
4. Pituitary-dependent: This is Cushing’s disease, which is much rarer than Cushing Syndrome, arising from a pituitary tumor.
5. Pseudo-Cushing’s syndrome: This describes hypercortisolism arising as a result of a separate condition, such as malnutrition or chronic alcoholism, resulting in the same phenotype and biochemical abnormalities of Cushing Syndrome.
Understanding the different types of Cushing Syndrome can help with diagnosis and treatment. It is important to work with a healthcare provider to determine the underlying cause and develop an appropriate treatment plan.
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This question is part of the following fields:
- Endocrinology
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Question 55
Incorrect
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A 55-year-old male with a history of diabetes mellitus for five years presents with restricted myocardial dysfunction and skin pigmentation. His ALT level is elevated at 153 IU/L. What is the most suitable investigation for this patient?
Your Answer: Serum caeruloplasmin
Correct Answer: Serum ferritin and transferrin saturation
Explanation:Haemochromatosis
Haemochromatosis is a genetic condition that results in excessive absorption of iron from the gut, leading to the accumulation of iron in various organs such as the liver, pancreas, heart, endocrine glands, and joints. This condition is characterized by extremely high levels of ferritin (>500) and transferrin saturation. The transferrin saturation test measures the amount of iron bound to the protein that carries iron in the blood, while the total iron binding capacity (TIBC) test determines how well the blood can transport iron. The serum ferritin test, on the other hand, shows the level of iron in the liver.
To confirm the diagnosis of haemochromatosis, a test to detect the HFE mutation is usually conducted. If the mutation is not present, then hereditary haemochromatosis is not the cause of the iron build-up. It is important to note that other conditions such as Wilson’s disease, hepatitis B infection, and autoimmune hepatitis may also cause raised ferritin levels, but they do not result in myocardial dysfunction or skin pigmentation.
In summary, haemochromatosis is a genetic disorder that causes excessive absorption of iron from the gut, leading to the accumulation of iron in various organs. Diagnosis is usually confirmed through a combination of tests, including the HFE mutation test, transferrin saturation test, TIBC test, and serum ferritin test. It is important to differentiate haemochromatosis from other conditions that may cause similar symptoms but require different treatment approaches.
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This question is part of the following fields:
- Endocrinology
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Question 56
Correct
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A 50-year-old male with type 2 diabetes presents for his annual review. Despite following a diet plan, his glycaemic control is not optimal and his most recent HbA1c is 63 mmol/mol (20-46). You decide to initiate treatment with metformin 500 mg bd. As per NICE NG28 guidelines for diabetes management, what is the recommended interval for rechecking his HbA1c after each intensification of treatment?
Your Answer: Three to six months
Explanation:HbA1c as a Tool for Glycaemic Control
The glycated haemoglobin (HbA1c) is a measure of the glucose levels in the blood over a period of time. It reflects the glycosylation of the haemoglobin molecule by glucose, and there is a strong correlation between the glycosylation of this molecule and average plasma glucose concentrations. This makes it a widely used tool in clinical practice to assess glycaemic control. Studies have also shown that HbA1c has prognostic significance in both microvascular and macrovascular risk.
The life span of a red blood cell is 120 days, and HbA1c reflects the average blood glucose levels during the half-life of the red cell, which is about 60 days. According to NICE guidelines, it is recommended to re-check HbA1c with each treatment intensification at 3/6 monthly intervals. HbA1c as a tool for glycaemic control is crucial in managing diabetes and reducing the risk of complications.
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This question is part of the following fields:
- Endocrinology
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Question 57
Incorrect
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A 57-year-old man comes in for his yearly check-up with his GP. He has a history of type 2 diabetes and hypertension. Upon physical examination, there are no notable findings and no signs of fluid overload. His blood pressure is 126/84 mmHg, and his heart rate is 67 bpm. A urine dipstick test shows only 1+ protein.
The results of his routine blood panel are as follows:
- Haemoglobin: 139 g/L (125-175)
- White cell count: 5.7 ×109/L (4-11)
- Mean cell volume: 82 fL (75-100)
- Platelets: 359 ×109/L (150-400)
- Sodium: 137 mmol/L (135-145)
- Potassium: 4.8 mmol/L (3.5-5.5)
- Urea: 8.9 mmol/L (2-7)
- Creatinine: 169 μmol/ (75-110)
- Glucose: 6.7 mmol/L (4-7)
- HbA1c: 48 mmol/mol (42-53)
- eGFR: 29 ml/min (>60)
- Lactate: 2.4 mmol/L (0.5-2)
- Venous pH: 7.35 (7.35-7.45)
Currently, the patient is taking aspirin 75 mg daily, bisoprolol 5 mg daily, gliclazide 80 mg twice daily, metformin 1 g twice daily, and ramipril 2.5 mg daily. Based on this information, which medication should be discontinued?Your Answer: Ramipril
Correct Answer: Metformin
Explanation:Medications and Renal Impairment
Metformin is a commonly used oral antidiabetic drug that inhibits hepatic gluconeogenesis, making it a first-line agent in the treatment of type 2 diabetes. However, it should be closely monitored in patients with impaired renal function due to the risk of developing lactate acidosis. Current guidelines recommend avoiding metformin in renal impairment if possible, reducing the dose if eGFR is less than 45 ml/min, and discontinuing it if less than 30 ml/min. Gliclazide, another antidiabetic drug, stimulates insulin release and is mostly cleared by the liver, but should be avoided in severe renal impairment and monitored in mild to moderate cases. Ramipril, an ACE inhibitor used in hypertension and heart failure, is beneficial in delaying diabetic nephropathy but may require dose adjustments in established renal impairment. Aspirin, commonly used in cardiovascular pathologies, should be avoided in severe renal failure but can be continued in moderate impairment. Bisoprolol, a cardio-specific beta-blocker, is safe to continue in renal impairment, with dose adjustments only needed when eGFR is less than 20 ml/min.
Overall, it is important to closely monitor medication use in patients with renal impairment and adjust doses or discontinue use as necessary to prevent adverse effects.
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This question is part of the following fields:
- Endocrinology
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Question 58
Incorrect
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A 78-year-old man with diabetes mellitus came in with abrupt onset of uncontrolled flinging movements of the right arm that ceased during sleep. What could be the probable cause?
Your Answer: Ipsilateral cerebellar infarction
Correct Answer: Contralateral subthalamic nucleus infarction
Explanation:Hemiballismus and its Causes
Hemiballismus is a medical condition characterized by involuntary flinging motions of the extremities, which can be violent and continuous. It usually affects only one side of the body and can involve proximal, distal, or facial muscles. The movements worsen with activity and decrease with relaxation. This condition is caused by a decrease in activity of the subthalamic nucleus of the basal ganglia, which results in decreased suppression of involuntary movements.
Hemiballismus can be caused by a variety of factors, including strokes, traumatic brain activity, amyotrophic lateral sclerosis, hyperglycemia, malignancy, vascular malformations, tuberculomas, and demyelinating plaques. In patients with diabetes, it is likely due to a vascular event in the contralateral subthalamic nucleus.
Treatment for hemiballismus should begin with identifying and treating the underlying cause. If pharmacological treatment is necessary, an antidopaminergic such as haloperidol or chlorpromazine may be used. Other options include topiramate, intrathecal baclofen, botulinum toxin, and tetrabenazine. In cases where other treatments have failed, functional neurosurgery may be an option.
In summary, hemiballismus is a condition that causes involuntary flinging motions of the extremities and can be caused by various factors. Treatment should begin with identifying and treating the underlying cause, and pharmacological and surgical options may be necessary in some cases.
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This question is part of the following fields:
- Endocrinology
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Question 59
Incorrect
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An investigator intended to test the antiglycaemic action of a new drug, which acts by increasing the peripheral uptake of glucose and reduces postprandial glucose level. He noted that in the elderly control group, subjects receiving an oral glucose load have higher postprandial insulin concentrations and more rapid glucose clearance, compared to subjects receiving isoglycaemic intravenous glucose infusion.
Which of the following is the most likely mediator of this effect?Your Answer: Secretin
Correct Answer: Glucagon-like peptide-1 (GLP-1)
Explanation:Gastrointestinal Hormones and their Functions
The gastrointestinal tract secretes various hormones that play important roles in digestion and metabolism. One such hormone is glucagon-like peptide-1 (GLP-1), which is an incretin hormone that enhances insulin secretion in response to oral glucose intake. On the other hand, cholecystokinin induces gallbladder contraction and bile release, while secretin increases pancreatic and biliary bicarbonate secretion and reduces gastric acid secretion. Gastrin, on the other hand, stimulates gastric acid secretion. Lastly, somatostatin inhibits the secretion of gastric acid and other gastrointestinal hormones. Understanding the functions of these hormones is crucial in maintaining a healthy digestive system.
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This question is part of the following fields:
- Endocrinology
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Question 60
Correct
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Which gland produces thyroid stimulating hormone (TSH) in the endocrine system?
Your Answer: Anterior pituitary
Explanation:The Thyroid Hormone Axis
The thyroid hormone axis is a complex system that involves the hypothalamus, pituitary gland, and thyroid gland. The hypothalamus produces a hormone called thyrotropin-releasing hormone (TRH), which stimulates the anterior pituitary gland to release thyroid-stimulating hormone (TSH). TSH then stimulates the thyroid gland to produce and release the thyroid hormones thyroxine (T4) and tri-iodothyronine (T3).
Both T4 and T3 are primarily bound to proteins in the bloodstream, but it is the free, unbound hormones that are biologically active. The secretion of TSH is inhibited by the presence of thyroid hormones in the bloodstream. This negative feedback loop helps to regulate the levels of thyroid hormones in the body.
In summary, the thyroid hormone axis is a tightly regulated system that involves multiple hormones and glands working together to maintain proper levels of thyroid hormones in the body.
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This question is part of the following fields:
- Endocrinology
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Question 61
Incorrect
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A child who is 4 years old has a height measurement that falls below the third centile. What is the most probable cause of their stunted growth?
Your Answer: Maternal deprivation
Correct Answer: Familial short stature
Explanation:Causes of Short Stature
Short stature is a common condition that can be caused by various factors. The most common cause of short stature is familial short stature, which is inherited from parents. Maternal deprivation and chronic illnesses such as congenital heart disease can also lead to short stature, but these are less frequent causes. On the other hand, Klinefelter’s syndrome is associated with tall stature. This genetic disorder affects males and is characterized by an extra X chromosome.
Another factor that can cause short stature is poorly controlled chronic diabetes. This condition can lead to malnutrition, delayed growth, and puberty. It is important to note that short stature does not necessarily indicate a health problem, as some people are naturally shorter than others. However, if short stature is accompanied by other symptoms such as delayed puberty or growth failure, it is important to seek medical attention. Overall, the various causes of short stature can help individuals and healthcare providers identify and address any underlying health issues.
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This question is part of the following fields:
- Endocrinology
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Question 62
Incorrect
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A 55-year-old man comes to his GP complaining of tingling in both hands that began a month ago and has been progressively worsening. He has no significant medical history. During the examination, you observe that the man has large hands, widely spaced teeth, and a prominent brow. You suspect that he may have acromegaly.
What is the most suitable initial investigation for acromegaly?Your Answer: Serum growth hormone
Correct Answer: Serum IGF1 levels
Explanation:Investigations for Acromegaly: Serum IGF1 Levels, CT/MRI Head, and Visual Field Testing
Acromegaly is a condition caused by excess growth hormone (GH) production, often from a pituitary macroadenoma. To diagnose acromegaly, insulin-like growth factor 1 (IGF1) levels are measured instead of GH levels, as IGF1 has a longer half-life and is more stable in the blood. If IGF1 levels are high, a glucose tolerance test is used to confirm the diagnosis. CT scans of the head are not as sensitive as MRI scans for investigating pituitary tumors, which are a common cause of acromegaly. Visual field testing is also important to assess whether a pituitary tumor is compressing the optic chiasm, but it is not specific to acromegaly and is part of the physical exam.
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This question is part of the following fields:
- Endocrinology
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Question 63
Incorrect
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A 55-year-old man with a history of hypertension presents with pruritus and lethargy. His serum biochemistry results show low calcium, high phosphate, and raised parathyroid hormone levels. His blood test results are as follows:
Investigation Result Normal value
Sodium (Na+) 138 mmol/l 135–145 mmol/l
Potassium (K+) 4.8 mmol/l 3.5–5.0 mmol/l
Urea 15.5 mmol/l 2.5–6.5 mmol/l
Creatinine 590 μmol/l 50–120 mmol/l
What is the most likely diagnosis for this patient?Your Answer: Tertiary hyperparathyroidism
Correct Answer: Secondary hyperparathyroidism
Explanation:Causes of Secondary Hyperparathyroidism in a Patient with Chronic Renal Failure
Secondary hyperparathyroidism can occur in patients with chronic renal failure due to imbalances in phosphorus and calcium levels. In this case, the patient has hyperphosphatemia and hypocalcemia, leading to overproduction of parathyroid hormone (PTH) by the parathyroid gland.
Loop diuretic overuse can also affect PTH levels, but it would result in additional electrolyte imbalances such as hyponatremia and hypokalemia. The role of hypertension in causing chronic renal failure is unclear in this patient.
Primary hyperparathyroidism, where the parathyroid gland overproduces PTH resulting in high serum calcium, is not present in this case. Tertiary hyperparathyroidism, which occurs after a chronic period of secondary hyperparathyroidism and results in dysregulation of calcium homeostasis and high serum calcium levels, is also not present.
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This question is part of the following fields:
- Endocrinology
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Question 64
Correct
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A 42-year-old man has been experiencing gradual enlargement of his hands and feet for the past 4 years, resulting in the need for larger gloves and shoes. Recently, he has also noticed his voice becoming deeper. His family has observed that he snores frequently and he has been experiencing daytime sleepiness. Over the past 6 months, he has been experiencing progressive blurring of vision accompanied by headaches and dizziness. Upon examination, his visual acuity is 20/20-2 and visual field testing reveals bitemporal hemianopias. What is the most appropriate initial investigation to confirm a diagnosis in this man?
Your Answer: Insulin-like growth factor 1 (IGF-1) measurement
Explanation:Diagnostic Tests for Acromegaly: IGF-1 Measurement vs. OGTT and Other Tests
Acromegaly, a condition caused by a GH-secreting pituitary adenoma, can be diagnosed through various tests. Previously, the OGTT with growth hormone assay was used for screening and monitoring, but it has now been replaced by the IGF-1 measurement as the first-line investigation to confirm the diagnosis.
The insulin tolerance test, which induces hypoglycaemia and increases GH release, is not useful in confirming the presence of a GH-secreting adenoma. Random GH assay is also not helpful as normal subjects have undetectable GH levels throughout the day, making it difficult to differentiate from levels seen in acromegaly.
While up to 20% of GH-secreting pituitary adenomas co-secrete prolactin, the prolactin level alone is not diagnostic. Therefore, the IGF-1 measurement is the preferred test for diagnosing acromegaly.
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This question is part of the following fields:
- Endocrinology
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Question 65
Incorrect
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A 32-year-old teacher comes to the clinic with a complaint of secondary amenorrhoea lasting for six months. She reports experiencing white discharge from her breasts. Despite taking a home urine pregnancy test, the result was negative. What is the most useful blood test to aid in the diagnosis?
Your Answer: Anti-Müllerian hormone
Correct Answer: Prolactin
Explanation:Prolactinomas: Pituitary Tumours that Affect Hormone Secretion
Prolactinomas are tumours that develop in the pituitary gland and secrete prolactin, a hormone that stimulates milk production in women. These tumours can be either microscopic or macroscopic, with the latter causing mass effects that can lead to headaches, visual disturbances, and other symptoms. In addition to galactorrhoea, prolactinomas can also cause menstrual disturbances, amenorrhoea, and infertility. Some prolactinomas may also co-secrete other pituitary hormones, such as growth hormone, which can further complicate the diagnosis and treatment of the condition.
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This question is part of the following fields:
- Endocrinology
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Question 66
Incorrect
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A 40-year-old woman visits her primary care physician (PCP) complaining of depression. During the examination, the PCP notices a lump in the center of her neck and proceeds to conduct a cardiovascular and thyroid assessment. The patient displays signs of fatigue and has a subdued mood. Her heart rate is 68 bpm and her blood pressure is 112/82 mmHg, and there is paleness in the conjunctivae. The lump is symmetrical without skin alterations, moves upward when swallowing, and has a nodular consistency.
What is the most appropriate initial test to perform for diagnostic assistance?Your Answer: Radio-isotope scan
Correct Answer: Thyroid function tests
Explanation:Thyroid Function Tests: Initial Investigation for Hypothyroidism
When a patient presents with symptoms and signs suggestive of hypothyroidism, the most appropriate initial test is thyroid function tests. However, if a neck swelling is also present, an ultrasound scan may be useful to assess for a goitre. If a cystic swelling is identified, a fine-needle aspirate sample may be taken for cytological analysis. A radio-isotope scan may also be performed to further assess thyroid pathology. While a full blood count is typically checked at the same time, it is not the best answer given the scenario.
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This question is part of the following fields:
- Endocrinology
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Question 67
Incorrect
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What is an example of an exocrine function of the pancreas?
Your Answer: Secretion of bile
Correct Answer: Secretion of amylase
Explanation:Functions of Digestive Enzymes and Hormones
Amylase is an enzyme that aids in the digestion of carbohydrates. It is present in both pancreatic juices and saliva. The exocrine function of the pancreas involves the secretion of substances into ducts that ultimately pass to the exterior of the body. Examples of exocrine glands include sweat glands, salivary glands, and mammary glands. On the other hand, the endocrine function of the pancreas involves the secretion of substances directly into the bloodstream. Insulin, which is secreted from the beta cells of the islets of Langerhans of the pancreas, is an example of an endocrine function.
Bile is another substance that aids in digestion. It is secreted by hepatocytes and stored in the gallbladder. Following a meal, bile is released to aid in the digestion of fats. Intrinsic factor, which is secreted by the parietal cells of the stomach, is responsible for binding vitamin B12 to allow its absorption in the terminal ileum. Finally, noradrenaline is a hormone that is released by the adrenal medulla. It plays a role in the body’s fight or flight response.
In summary, the digestive system relies on a variety of enzymes and hormones to function properly. These substances are secreted by various glands and organs throughout the body, and they work together to break down food and absorb nutrients.
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This question is part of the following fields:
- Endocrinology
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Question 68
Incorrect
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What is the joint that is most frequently impacted by diabetic Charcot's?
Your Answer: Sacroiliac joint
Correct Answer: Tarsometatarsal joints
Explanation:Charcot’s Joint: A Destructive Process Affecting Weight-Bearing Joints
Charcot’s joint is a condition that primarily affects the weight-bearing joints in the extremities, including the feet, ankles, knees, and hips. The most commonly affected joints are the tarsometatarsal and metatarsophalangeal joints, as well as the ankle. This condition is characterized by a destructive process that can lead to joint deformity and instability.
Patients with Charcot’s joint typically have decreased sensation in the affected area and peripheral neuropathy. The most common cause of peripheral neuropathy is diabetes, which has a high affinity for the joints in the foot. Other causes of peripheral neuropathy, such as leprosy, syringomyelia, and tabes dorsalis, are much less common.
Charcot’s joint can be a debilitating condition that can significantly impact a patient’s quality of life. Early diagnosis and treatment are essential to prevent joint deformity and instability. Treatment may include immobilization, orthotics, and surgery in severe cases. With proper management, patients with Charcot’s joint can maintain mobility and function.
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This question is part of the following fields:
- Endocrinology
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Question 69
Correct
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A patient with diabetes who is 60 years old is admitted with confusion and is found to have a blood glucose level of 1.2 mmol/L.
Which injectable diabetes therapy is a mixed insulin?Your Answer: Humulin M3
Explanation:Insulin Types and Mixtures
Insulin is a hormone that regulates blood sugar levels in the body. Premix or mixed insulin is a combination of short and long-acting insulin. It is identified by a number that represents the percentage of rapid-acting insulin it contains. For instance, Novomix 30 has 30% rapid-acting insulin and 70% long-acting insulin. Mixed insulin is usually taken twice daily and must be administered with meals as it contains rapid-acting insulin.
Insulin detemir, also known as Levemir, is a long-acting analogue that lasts for about 12-20 hours and is usually given twice a day. Insulin glargine, also known as Lantus, is another long-acting analogue that lasts for about 20-24 hours and is usually given once a day. Novorapid is a fast-acting insulin that is often used to cover the increase in blood glucose levels following a meal. Patients taking Novorapid will usually require treatment with a long-acting insulin.
Exenatide is an injectable therapy for type 2 diabetes that is based on the hormone glucagon-like peptide 1 (GLP-1) and is not insulin. It is important to note that lipohypertrophy can occur in all insulin treatments. This refers to the accumulation of fatty deposits at injection sites, which can affect the rate of insulin absorption and, in turn, affect the patient’s glycaemic control. Therefore, it is crucial to rotate injection sites regularly to avoid lipohypertrophy.
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This question is part of the following fields:
- Endocrinology
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Question 70
Incorrect
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Under what circumstances would the bone age match the chronological age?
Your Answer: Precocious puberty
Correct Answer: Familial short stature
Explanation:Factors Affecting Bone Age
Bone age is affected by various factors such as hypothyroidism, constitutional delay of growth and puberty, growth hormone deficiency, precocious puberty, and familial short stature. In hypothyroidism, bone age is delayed due to the underproduction of thyroid hormones. On the other hand, constitutional delay of growth and puberty causes delayed physiological maturation, including secondary sexual characteristics and bone age. Growth hormone deficiency also results in delayed skeletal maturation. In contrast, precocious puberty causes advanced bone age. Lastly, in familial short stature, bone age is equal to chronological age, but linear growth is poor, resulting in a short stature. these factors is crucial in diagnosing and managing growth and development issues in children. Proper evaluation and treatment can help ensure optimal growth and development.
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This question is part of the following fields:
- Endocrinology
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Question 71
Incorrect
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Which substance, when found in high levels in the bloodstream, hinders the production and release of parathyroid hormone (PTH)?
Your Answer: Chloride
Correct Answer: Calcium
Explanation:Regulation of PTH secretion
Parathyroid hormone (PTH) secretion is regulated by various factors. One of these factors is the concentration of calcium in the plasma. When the calcium concentration is high, PTH synthesis and secretion are suppressed. On the other hand, an increase in serum phosphate stimulates PTH secretion. Another factor that affects PTH secretion is the extracellular free calcium level. When the level of extracellular free calcium rises, it stimulates a parathyroid membrane-bound calcium receptor, which inhibits PTH secretion. Therefore, the regulation of PTH secretion is a complex process that involves multiple factors, including calcium and phosphate levels in the blood. Proper regulation of PTH secretion is essential for maintaining calcium and phosphate homeostasis in the body.
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This question is part of the following fields:
- Endocrinology
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Question 72
Incorrect
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A 35-year-old hypertensive man presented with the following blood results:
Investigation Result Normal value
Sodium (Na+) 147 mmol/l 135–145 mmol/l
Potassium (K+) 2.8 mmol/l 3.5–5.0 mmol/l
Urea 4.0 mmol/l 2.5–6.5 mmol/l
Creatinine 50 μmol/l 50–120 μmol/l
Glucose 4.0 mmol/l
Random: 3.5–5.5 mmol/l
Fasting: <7 mmol/l
Hba1c: <53 mmol/l (<7.0%)
Which of the following is the most likely diagnosis?Your Answer: Primary (essential) hypertension
Correct Answer: Conn's syndrome
Explanation:Differential diagnosis of hypertension with electrolyte abnormalities
When a young patient presents with hypertension and hypokalaemia, it is important to consider secondary causes of hypertension, such as Conn’s syndrome (primary hyperaldosteronism), which can explain both findings. Coarctation of the aorta is another secondary cause of hypertension, but it does not account for the electrolyte abnormalities. Cushing’s disease/syndrome may also present with hypertension and electrolyte abnormalities, but typically with additional symptoms and higher fasting glucose levels. Polycystic kidney disease can cause hypertension, but not the electrolyte abnormalities. Primary (essential) hypertension is the most common form of hypertension, but secondary causes should be ruled out, especially in younger patients with atypical features.
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This question is part of the following fields:
- Endocrinology
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Question 73
Correct
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A 42-year-old teacher visits her GP, complaining of hot flashes and night sweats. She suspects that she may be experiencing symptoms of menopause. Can you identify which set of results below are consistent with postmenopausal values?
A: FSH (follicular phase 2.9-8.4 U/L) 0.5
LH (follicular phase 1.3-8.4 U/L) 1.1
Oestrogen (pmol/L) 26
Progesterone (pmol/L) <5
B: FSH (follicular phase 2.9-8.4 U/L) 0.5
LH (follicular phase 1.3-8.4 U/L) 1.2
Oestrogen (pmol/L) 120
Progesterone (pmol/L) 18
C: FSH (follicular phase 2.9-8.4 U/L) 68
LH (follicular phase 1.3-8.4 U/L) 51
Oestrogen (pmol/L) 42
Progesterone (pmol/L) <5
D: FSH (follicular phase 2.9-8.4 U/L) 1.0
LH (follicular phase 1.3-8.4 U/L) 0.8
Oestrogen (pmol/L) 250
Progesterone (pmol/L) 120
E: FSH (follicular phase 2.9-8.4 U/L) 8.0
LH (follicular phase 1.3-8.4 U/L) 7.2
Oestrogen (pmol/L) 144
Progesterone (pmol/L) <5Your Answer: C
Explanation:postmenopausal Blood Tests
postmenopausal blood tests often reveal elevated levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), as well as low levels of estrogen. These changes in hormone levels are responsible for most of the symptoms associated with menopause, which can be difficult to diagnose. However, once characteristic symptoms are well-established, gonadotrophin levels are typically significantly elevated.
The menopause is defined as the date of a woman’s last period, without further menses for at least a year. As such, the diagnosis can only be made retrospectively. Prior to menopause, women may experience irregular menstruation, heavy bleeding, and mood-related symptoms. While fertility is greatly reduced during this time, there is still some risk of pregnancy, and many healthcare providers recommend continuing contraception for a year after the last menstrual period.
In summary, postmenopausal blood tests can provide valuable information about a woman’s hormone levels and help diagnose menopause. However, it’s important to recognize that menopause is a gradual process that can be accompanied by a range of symptoms. Women should work closely with their healthcare providers to manage these symptoms and ensure their ongoing health and well-being.
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This question is part of the following fields:
- Endocrinology
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Question 74
Incorrect
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A 7-year-old boy who attends a regular school has been brought to the clinic due to his short stature. He measures 3 cm below the third centile for his age and weighs 800 grams less than the third centile. His bone age is 4.5 years. The boy's mother and father have heights on the 30th and 60th centiles, respectively.
Which of the following statements is true?Your Answer: From these measurements the child is failing to grow
Correct Answer: Findings of poorly felt femoral pulses suggest that chromosome analysis might be required
Explanation:Factors to Consider in Evaluating Growth and Puberty Delay
When evaluating a child’s growth and puberty delay, it is important to consider the family history of delayed growth and puberty. A single measurement of growth is not enough to determine if there is a growth hormone deficiency or thyroid disease. It is also important to check for poorly felt femoral pulses, which may indicate coarctation and Turner’s syndrome.
Constitutional short stature is the most common reason for growth delay. To assess growth velocity, another measurement of growth is necessary. It is important to take into account all of these factors when evaluating a child’s growth and puberty delay to ensure an accurate diagnosis and appropriate treatment plan. Proper evaluation and management can help prevent potential complications and improve the child’s overall health and well-being.
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This question is part of the following fields:
- Endocrinology
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Question 75
Incorrect
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A 33-year-old patient with a history of phaeochromocytoma develops a neck mass. Resection of the neck mass demonstrates a multifocal tumour with haemorrhage, necrosis and spread outside the thyroid capsule. The tumour is composed of polygonal cells in nests. Amyloid deposits are seen in the intervening fibrovascular stroma.
What is the most likely secretion of the polygonal cells?Your Answer: Thyroid stimulating hormone (TSH)
Correct Answer: Calcitonin
Explanation:Hormones and Tumors: Understanding the Link
Calcitonin, PTH, TSH, T4, and T3 are hormones that can be produced by various tumors. Medullary carcinoma of the thyroid, which can occur sporadically or as part of multiple endocrine neoplasia (MEN) types IIa and IIb, is known for its local production of amyloid and secretion of calcitonin. PTH can be produced by parathyroid tumors, while PTH-related protein can be a paraneoplastic product of various tumors, including lung cancer. TSH is produced by pituitary adenomas, while T4 and T3 are produced by thyroid tumors composed of follicular cells. Understanding the link between hormones and tumors can aid in diagnosis and treatment.
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This question is part of the following fields:
- Endocrinology
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Question 76
Incorrect
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A 23-year-old man presents to the Emergency Department after being involved in a fight. He had been in the shower after a gym session, when someone made a derogatory comment about his body, and that started the fight. A history reveals that he has had three girlfriends in the last 3 months, but none of the relationships have lasted. He admits that he struggles to achieve an erection. On examination, the patient is of normal height with normal pubic hair. His penis is small and his breasts are enlarged. He said that he had started growing breasts from the age of 11. This often caused him embarrassment. His blood pressure is 119/73 mmHg.
Which of the following syndromes must be ruled out?Your Answer: 17-α hydroxylase deficiency
Correct Answer: Reifenstein syndrome
Explanation:Comparing Different Syndromes with Similar Symptoms
When presented with a patient who has female breast development and erectile dysfunction, it is important to consider various syndromes that could be causing these symptoms. One such syndrome is Reifenstein syndrome, which is characterized by partial androgen insensitivity. Another possibility is Turner syndrome, which presents with short stature and amenorrhea in phenotypic females. However, Kallmann syndrome, which includes anosmia as a component, can be ruled out in this case. Similarly, Klinefelter syndrome, which typically results in tall stature and infertility, does not match the patient’s normal height and erectile dysfunction. Finally, 17-α hydroxylase deficiency can be eliminated as a possibility due to the absence of hypertension, which is a common symptom of this enzyme defect. By comparing and contrasting these different syndromes, healthcare professionals can more accurately diagnose and treat patients with similar symptoms.
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This question is part of the following fields:
- Endocrinology
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Question 77
Incorrect
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A 42-year-old obese woman, with a history of type II diabetes mellitus, complains of weight gain during the past 3 years, despite her adherence to a balanced diet. She has diffuse skeletal pain. She is not married and does not have a sexual partner. Her family history is unremarkable. Her blood pressure is 160/105 mmHg. Her face is plethoric and round and she has hypertrichosis of the upper lip (hirsutism). There are purple striae on the abdomen and thigh, and mild wasting of the upper and lower limb muscles. Her full blood count shows a slight increase in the polymorphonuclear leukocyte count, without a left shift. Her haemoglobin is 180 (115–155 g/l).
Which of the following changes in serum calcium, phosphate and parathyroid hormone concentrations would you expect to find in this patient?Your Answer: Calcium - decreased; phosphate - increased; parathyroid hormone - decreased
Correct Answer: Calcium - decreased; phosphate - decreased; parathyroid hormone - increased
Explanation:Interpreting Calcium, Phosphate, and Parathyroid Hormone Levels in a Patient with Prolonged Hypercortisolism
A patient presents with diffuse bone pain and laboratory results show decreased calcium and phosphate levels, along with increased parathyroid hormone levels. This is indicative of secondary hyperparathyroidism, which is a common complication of hypercortisolism. Elevated serum cortisol levels can lead to hypocalcaemia and secondary hyperparathyroidism, causing increased osteoclast activity and osteoblast dysfunction, ultimately resulting in osteoporosis and pathological fractures.
If the patient had increased phosphate levels instead of decreased levels, it would suggest renal impairment. If the patient had increased calcium levels and decreased phosphate levels, it would suggest primary hyperparathyroidism. If the patient had decreased calcium levels and increased phosphate levels, it would suggest hypoparathyroidism. If all levels were normal, it may be too early in the course of hypercortisolism to see changes in these markers.
In summary, interpreting calcium, phosphate, and parathyroid hormone levels can provide valuable information in diagnosing and managing complications of hypercortisolism.
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This question is part of the following fields:
- Endocrinology
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Question 78
Correct
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A 10-year-old girl has been diagnosed with type 1 diabetes mellitus. This condition is associated with defective β cells in the pancreatic islets of Langerhans.
With which kind of capillary are the pancreatic islets of Langerhans closely associated?Your Answer: Fenestrated
Explanation:Capillaries can be classified into different types based on their structure and function. Fenestrated capillaries have pores that allow for the rapid passage of large molecules such as insulin. These are found in endocrine organs like the pancreas, thyroid, and adrenal cortex. Discontinuous capillaries, with or without fenestrations, have wide gaps between endothelial cells and are commonly found in the liver, bone marrow, and spleen. These gaps allow for the passage of large molecules from the organ into the bloodstream. Continuous capillaries have tightly joined endothelial cells and are found in the central nervous system, skeletal muscle, and lungs. The term sinusoid is an imprecise descriptor of capillaries, as it can refer to both discontinuous and fenestrated capillaries. In the liver, sinusoids are lined by discontinuous endothelium with fenestrations in some areas and none in others. In the bone marrow, discontinuous capillaries (sinusoids) allow for the passage of mature blood cells into circulation.
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This question is part of the following fields:
- Endocrinology
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Question 79
Incorrect
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The hormone CRH, which originates from the hypothalamus, triggers the release of which hormone?
Your Answer: Adrenaline
Correct Answer: Adrenocorticotrophic hormone
Explanation:Hormones and their Secretion
The hypothalamus releases corticotrophin-releasing hormone (CRH) which triggers the anterior pituitary gland to release adrenocorticotrophic hormone (ACTH). ACTH then acts on the adrenal cortex to stimulate the secretion of cortisol. Meanwhile, the anterior pituitary gland also secretes thyroid-stimulating hormone (TSH) which stimulates the thyroid gland to produce thyroid hormones. On the other hand, the adrenal medulla secretes adrenaline and noradrenaline in response to stress or danger.
In summary, the hypothalamus, anterior pituitary gland, adrenal cortex, and adrenal medulla work together to regulate the secretion of various hormones in the body. These hormones play important roles in maintaining homeostasis and responding to stressors.
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This question is part of the following fields:
- Endocrinology
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Question 80
Incorrect
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A 28-year-old male with type 1 diabetes is instructed to collect his urine for 24 hours. What level of urine albumin concentration indicates the presence of microalbuminuria?
Your Answer: 1 g/day
Correct Answer: 50 mg/day
Explanation:Microalbuminuria and Proteinuria
Microalbuminuria is a condition where the urine albumin excretion ranges from 30-300 mg per 24 hours. If the concentration exceeds 300 mg/24 hours, it signifies albuminuria, and if it exceeds 3.5 g/24 hours, it signifies overt proteinuria. Microalbuminuria is not only an early indicator of renal involvement but also a sign of increased cardiovascular risk, with a twofold risk above the already increased risk in diabetic patients. The albumin:creatinine ratio is a useful surrogate of the total albumin excretion, and it is measured using the first morning urine sample where possible. An albumin:creatinine ratio of ≥2.5 mg/mmol (men) or 3.5 mg/mmol (women) indicates microalbuminuria, while a ratio of ≥30 mg/mmol indicates proteinuria. these conditions is crucial in managing and preventing complications associated with renal and cardiovascular diseases.
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This question is part of the following fields:
- Endocrinology
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Question 81
Incorrect
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A cohort of individuals with type I diabetes mellitus, aged 50-60 years, with blood glucose levels between 8.0 and 10.0 mmol/l for a minimum of 10 years, underwent rectal biopsies. The results revealed the presence of osmotic cellular injury in arterioles. What clinical complication is linked with this type of injury?
Your Answer: Rectal ulceration
Correct Answer: Impotence
Explanation:The Sorbitol/Aldose Reductase Pathway and Diabetic Complications
Hyperglycaemia in diabetes can lead to the formation of sorbitol in tissues that do not require insulin for glucose uptake, such as the retina, kidney, and nerves. This occurs through the sorbitol/aldose reductase pathway, which is implicated in microvascular damage to nervous tissue, retina, and kidney. When glucose is present in excess, it enters this pathway where aldose reductase reduces it to sorbitol, which cannot cross cell membranes and accumulates, producing osmotic stresses on cells by drawing water into the cell. Sorbitol dehydrogenase can then oxidise sorbitol to fructose, which also produces NADH from NAD+. Excessive activation of this pathway leads to increased levels of reactive oxygen species, which can promote cell damage.
While most body cells require insulin for glucose to enter the cell, the cells of the retina, kidney, and nervous tissues are insulin-independent, allowing for a free interchange of glucose intracellularly to extracellularly. Any glucose not used for energy will be converted into sorbitol, leading to osmotic cellular injury. This can result in microvascular damage to nervous tissue, retina, and kidney, causing diabetic complications.
Cerebral infarction, congestive heart failure, pyelonephritis, and rectal ulceration are not directly related to osmotic vascular injury caused by the sorbitol/aldose reductase pathway. However, atherosclerotic cerebrovascular disease and coronary artery disease are more frequent with diabetes mellitus and can cause damage to the brain and heart, respectively.
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This question is part of the following fields:
- Endocrinology
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Question 82
Incorrect
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A 35-year-old woman presents with new-onset diabetes. She has no past drug or treatment history. Her fasting blood glucose is 7.3 mmol/l. Other significant medical history included occasional diarrhoea in the last 4 months, for which she took repeated courses of tinidazole. She also had an episode of severe leg pain three months ago, for which she takes warfarin. She is presently very depressed, as her sister has had renal calculus surgery, which has not gone well; she is in the Intensive Care Unit (ICU) with sepsis.
What is the most appropriate next test?Your Answer: Blood test for Giardia antigen
Correct Answer: Genetic study
Explanation:Diagnostic Tests for a Patient with Possible Multiple Endocrine Neoplasia (MEN) 1 Syndrome
A woman presents with new-onset diabetes, diarrhoea, and a past episode of deep vein thrombosis (DVT), along with a family history of renal calculi at a young age. These symptoms suggest the possibility of multiple endocrine neoplasia (MEN) 1 syndrome, an autosomal dominant disease characterized by endocrine hyperfunction in various glands, particularly the parathyroid gland and enteropancreatic tumors. The most common tumors in the latter group are gastrinoma and insulinoma, with glucagonoma occurring rarely. Other symptoms may include depression, anemia, glossitis, and in rare cases, a skin manifestation called necrolytic migratory erythema.
To confirm a diagnosis of MEN 1, a genetic study to detect MEN 1 gene mutation on chromosome 11 is the best option. A family history of renal stones, as in this case, is the most common manifestation of MEN 1.
Other diagnostic tests, such as protein C assessment, colonoscopy, and blood test for Giardia antigen, are not relevant to this particular case. Measuring C-peptide levels can help distinguish between type I and type II diabetes or maturity-onset diabetes of the young (MODY), but it will not help in detecting the underlying disease. Giardiasis symptoms may include diarrhea, fatigue, abdominal cramps, bloating, gas, nausea, and weight loss, but tinidazole should have eliminated Giardia.
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This question is part of the following fields:
- Endocrinology
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Question 83
Correct
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What condition is non-alcoholic steatohepatitis linked to?
Your Answer: Insulin resistance
Explanation:Non-Alcoholic Steatohepatitis (NASH)
Non-alcoholic steatohepatitis (NASH) is a liver condition that is linked to insulin resistance, hyperlipidaemia, and chronic moderately elevated liver enzymes. Unlike alcoholic liver disease, NASH is not caused by excessive alcohol consumption. Instead, it is associated with metabolic disorders such as obesity, type 2 diabetes, and high blood pressure.
Diagnosing NASH requires a liver biopsy, which is the only way to confirm the presence of lesions that are suggestive of ethanol intake in a patient who consumes less than 40 g of alcohol per week. It is important to note that NASH is not a benign condition and can lead to serious complications such as cryptogenic cirrhosis, which is a type of liver disease that can be fatal.
To prevent NASH, it is important to maintain a healthy lifestyle by eating a balanced diet, exercising regularly, and avoiding excessive alcohol consumption.
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This question is part of the following fields:
- Endocrinology
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Question 84
Correct
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Which statement about leptin is accurate?
Your Answer: Produces satiety
Explanation:The Role of Leptin in Regulating Appetite and Body Weight
Leptin is a hormone that is produced by adipocytes, or fat cells, and its concentration in the bloodstream is directly related to the amount of fat in the body. When leptin levels are high, it acts on receptors in the hypothalamus to produce feelings of satiety, or fullness, which can help to reduce food intake. This makes leptin an important regulator of appetite and body weight.
However, in some cases, patients may develop leptin resistance, which means that their bodies are no longer able to respond to the hormone in the same way. This can lead to continued weight gain and difficulty in controlling food intake, even when leptin levels are high. Despite this, researchers continue to study the role of leptin in the body and explore potential treatments for obesity and other related conditions.
Overall, the physiology of leptin and its effects on appetite and body weight is an important area of research that has the potential to improve the health and well-being of millions of people around the world. By developing new treatments and interventions that target leptin and other related hormones, we may be able to help patients achieve and maintain a healthy weight and reduce their risk of developing chronic diseases such as diabetes, heart disease, and cancer.
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This question is part of the following fields:
- Endocrinology
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Question 85
Incorrect
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A 32-year-old male with type 1 diabetes presents with pain, swelling, and redness in his left middle finger for the past two days. He experienced this after pricking his finger while gardening and pruning a bush. Despite his diabetic control being reasonable with a HbA1c of 54 mmol/mol (20-46) on basal bolus insulin consisting of Lispro tds and Humulin I in the evenings, he is now diagnosed with cellulitis. On examination, his middle finger is painful, red, and swollen, with the redness extending to the metacarpophalangeal joint. However, his hand movements are intact, and he is clinically stable with normal observations.
What is the most appropriate initial treatment for this patient?Your Answer: Oral clindamycin
Correct Answer: Oral flucloxacillin
Explanation:The patient has digital cellulitis likely caused by Strep. pyogenes or Staph. aureus. Flucloxacillin is the initial treatment, but if there is tendon involvement, IV antibiotics should be initiated. Clindamycin can be used in combination with flucloxacillin for rapid control or in severe cases. Oral antibiotics can be tried if hand movements are intact. The patient should be closely monitored and readmitted for IV antibiotics if there is no improvement within 48 hours.
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This question is part of the following fields:
- Endocrinology
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Question 86
Incorrect
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A 45-year-old male with type 2 diabetes is struggling to manage his high blood pressure despite being on medication. His current treatment includes atenolol, amlodipine, and ramipril, but his blood pressure consistently reads above 170/100 mmHg. During examination, grade II hypertensive retinopathy is observed. His test results show sodium levels at 144 mmol/L (137-144), potassium at 3.1 mmol/L (3.5-4.9), urea at 5.5 mmol/L (2.5-7.5), creatinine at 100 mol/L (60-110), glucose at 7.9 mmol/L (3.0-6.0), and HbA1c at 53 mmol/mol (20-46) or 7% (3.8-6.4). An ECG reveals left ventricular hypertrophy. What possible diagnosis should be considered as the cause of his resistant hypertension?
Your Answer: Renal artery stenosis
Correct Answer: Conn’s syndrome (primary hyperaldosteronism)
Explanation:Primary Hyperaldosteronism and Resistant Hypertension
This patient is experiencing resistant hypertension despite being on an angiotensin-converting enzyme inhibitor (ACEi), which should typically increase their potassium concentration. Additionally, their potassium levels are low, which is a strong indication of primary hyperaldosteronism.
Primary hyperaldosteronism can be caused by either an adrenal adenoma (known as Conn syndrome) or bilateral adrenal hyperplasia. To diagnose this condition, doctors typically look for an elevated aldosterone:renin ratio, which is usually above 1000. This condition can be difficult to manage, but identifying it early can help prevent further complications.
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This question is part of the following fields:
- Endocrinology
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Question 87
Incorrect
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A 20-year-old man with known type 1 diabetes is admitted to hospital with abdominal pain, drowsiness and severe dehydration. On examination he has a temperature of 38.2 degrees, and crackles at the bases of both lungs. Investigations show the following results:
Urinary ketones: 3+
Serum ketones: 3.6 mmol/l
Serum glucose: 21.8 mmol/l
pH 7.23
What is the most appropriate initial management?Your Answer: Clarithromycin 500 mg po bd for 5 days
Correct Answer: 1 litre 0.9% normal saline over 1 h
Explanation:Management of Diabetic Ketoacidosis: Medications and Fluids
Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes that requires urgent treatment. The initial management of DKA involves fluid resuscitation with normal saline, followed by insulin infusion to correct hyperglycemia. Antibiotics are not the immediate management option of choice, even if an intercurrent infection is suspected. Glucose therapy should be administered only after initial fluid resuscitation and insulin infusion. Here is a breakdown of the medications and fluids used in the management of DKA:
1. 1 litre 0.9% normal saline over 1 h: This is the first-line treatment for DKA. Urgent fluid resuscitation is necessary to correct hypovolemia and improve tissue perfusion.
2. Amoxicillin 500 mg po TDS for 5 days: Antibiotics may be necessary if an intercurrent infection is suspected, but they are not the immediate management option of choice for DKA.
3. Clarithromycin 500 mg po bd for 5 days: Same as above.
4. Insulin 0.1 units/kg/h via fixed rate insulin infusion: After initial fluid resuscitation, insulin infusion is necessary to correct hyperglycemia and prevent further ketone production.
5. 1 litre 10% dextrose over 8 h: Glucose therapy is necessary to prevent hypoglycemia after insulin infusion, but it should not be administered initially as it can exacerbate hyperglycemia.
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This question is part of the following fields:
- Endocrinology
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Question 88
Incorrect
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A 63-year-old man presents to the Acute Medicine Unit with hyponatraemia. He reports feeling generally unwell and apathetic, and has experienced a 6 kg weight loss over the past three months. He has no history of medication use and is a heavy smoker. Upon examination, he is euvolaemic and a chest X-ray reveals a right hilar mass. His blood results show a serum sodium level of 123 mmol/l (normal range: 135-145 mmol/l), serum osmolality of 267 mosmol/kg (normal range: 275-295 mosmol/kg), urine sodium of 55 mmol/l (normal range: <20 mmol/l), urine osmolality of 110 mosmol/l (normal range: <100 mosmol/kg), and morning cortisol of 450 nmol/l (normal range: 119-618 mmol/l). What is the most appropriate initial management for his hyponatraemia?
Your Answer: Intranasal desmopressin 10 μg
Correct Answer: Fluid restriction 800 ml/24 hours
Explanation:Treatment Options for Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)
Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a condition characterized by euvolaemic hypo-osmolar hyponatraemia with inappropriately elevated urinary sodium and normal thyroid and adrenal function. The first-line treatment for moderate SIADH is fluid restriction, which aims to increase serum sodium concentration by 5-8 mmol/L per 24 hours. However, some treatment options can worsen the condition.
Intravenous 0.9% saline infusion over 12 hours is not recommended for SIADH patients as it can lower serum sodium even further. This is because the kidney regulates sodium and water independently, and in SIADH, only water handling is out of balance from too much ADH.
Intranasal desmopressin 10 μg is also not recommended as it limits the amount of free water excreted by the kidneys, worsening hyponatraemia.
Intravenous hydrocortisone 100 mg is used if steroid deficiency is suspected as the underlying cause of hyponatraemia. However, if the morning cortisol is normal, it is not necessary.
Performing a water-deprivation test is used in the diagnosis of diabetes insipidus, which presents with excess thirst, urination, and often hypernatraemia and raised plasma osmolality. It is not a treatment option for SIADH.
In conclusion, fluid restriction is the first-line treatment for moderate SIADH, and other treatment options should be avoided unless there is a specific underlying cause for hyponatraemia.
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This question is part of the following fields:
- Endocrinology
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Question 89
Correct
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A newly diagnosed type 2 diabetic patient in their 60s is admitted through the Emergency department due to hyperglycemia. The patient is dehydrated and has acute on chronic renal impairment, with an eGFR of 30 ml/min/1.73 m2. What diabetes medication(s) can be safely prescribed?
Your Answer: Gliclazide and saxagliptin
Explanation:Caution in Prescribing Hypoglycaemic Medication in Renal Impairment
When prescribing hypoglycaemic medication to patients with renal impairment, caution should be exercised. This is because reduced renal excretion increases the risk of hypoglycaemia. Metformin should not be prescribed or should be discontinued when the estimated glomerular filtration rate (eGFR) is less than 45 ml/min due to the potential for lactic acidosis. Liraglutide, an injectable GLP1 agonist, should also be avoided if the eGFR is less than 60 ml/min/1.73 m2. Rosiglitazone has been withdrawn from the market and should not be prescribed. Gliclazide and other sulfonylureas can be used in renal impairment, but a reduced dose may be necessary due to the potential for hypoglycaemia caused by reduced renal excretion. Saxagliptin, a DPP4 inhibitor, should be prescribed at half dose if the eGFR is less than 50 ml/min/1.73 m2. It is important to consider the patient’s renal function when prescribing hypoglycaemic medication to avoid adverse effects.
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This question is part of the following fields:
- Endocrinology
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Question 90
Incorrect
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A 30-year-old woman complains of menstrual irregularity and galactorrhoea for the past year. She also experiences occasional headaches. During examination, she was found to have bitemporal superior quadrantanopia. What is the most probable diagnosis?
Your Answer: Non-functioning pituitary tumour
Correct Answer: Prolactinoma
Explanation:Prolactinomas cause amenorrhoea, infertility, and galactorrhoea. If the tumour extends outside the sella, visual field defects or other mass effects may occur. Other types of tumours will produce different symptoms depending on their location and structure involved. Craniopharyngiomas originate from the pituitary gland and will produce poralhemianopia if large enough, as well as symptoms related to pituitary hormones. Non-functioning pituitary tumours will have similar symptoms without the pituitary hormone side effects. Tumours of the hypothalamus will present with symptoms of euphoria, headache, weight loss, and mass effect if large enough.
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This question is part of the following fields:
- Endocrinology
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Question 91
Incorrect
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A 25-year-old male patient arrives at the emergency department with symptoms of vomiting and dehydration. He reports a two-month history of weight loss and excessive thirst. Upon examination, the patient is diagnosed with diabetic ketoacidosis, with a blood glucose level of 29.3 mmol/L (3.0-6.0), a pH of 7.12 (7.36-7.44) on blood gas analysis, and +++ ketones in the urine. What is the percentage of individuals with type 1 diabetes who are initially diagnosed after presenting with diabetic ketoacidosis?
Your Answer: 10%
Correct Answer: 25%
Explanation:Diabetic Ketoacidosis: A Dangerous Complication of Type 1 Diabetes
Approximately one quarter of patients with type 1 diabetes will experience their first symptoms in the form of diabetic ketoacidosis (DKA). However, it is important to note that these individuals may have previously ignored symptoms such as thirst, frequent urination, and weight loss. DKA is a serious and potentially life-threatening complication of diabetes that is characterized by high blood sugar levels, lactic acidosis, vomiting, and dehydration. It is crucial for individuals with type 1 diabetes to be aware of the signs and symptoms of DKA and seek medical attention immediately if they suspect they may be experiencing this condition. Proper management and treatment of DKA can help prevent serious complications and improve overall health outcomes.
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This question is part of the following fields:
- Endocrinology
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Question 92
Correct
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A 50-year-old woman comes to you with a thyroid lump and you suspect she may have follicular carcinoma of the thyroid. What is the most appropriate course of action in this scenario?
Your Answer: Spreads mainly via blood
Explanation:Thyroid Carcinoma: Diagnosis and Management
Thyroid carcinoma is a type of cancer that affects the thyroid gland. There are different types of thyroid carcinoma, including follicular, papillary, anaplastic, and medullary carcinomas. The spread of the cancer varies depending on the type of carcinoma.
Follicular carcinoma spreads mainly via the bloodstream, while papillary and medullary carcinomas spread via the lymphatic system. Anaplastic cancer spreads locally. The prognosis for thyroid carcinoma is generally good, with a 90% survival rate at 10 years, especially in young people without local or metastatic spread.
The initial treatment for differentiated thyroid carcinoma, such as follicular and papillary carcinomas, is total or near-total thyroidectomy. Fine needle aspiration cytology can help differentiate between follicular adenoma and carcinoma, but a thyroid lobectomy is often necessary to confirm the diagnosis. The distinguishing features of follicular carcinoma are vascular invasion and capsule invasion, which can only be seen accurately on a full histological specimen.
Solitary thyroid nodules are best investigated using a combination of clinical examination, thyroid function tests, ultrasound and radio-isotope scans, and often FNA. Thyroid tumours can be classified as adenomas, carcinomas, and lymphomas. Carcinomas can be further sub-classified as papillary, follicular, anaplastic, or medullary.
In conclusion, the diagnosis and management of thyroid carcinoma require a multidisciplinary approach. Early detection and treatment can lead to a good prognosis, but accurate diagnosis is crucial for effective management.
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This question is part of the following fields:
- Endocrinology
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Question 93
Incorrect
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A 68-year-old woman presents with weight loss and heat intolerance. Her lab results show elevated free T4 and free T3 levels, and a suppressed TSH level. She is currently on medications for atrial fibrillation, ischaemic heart disease, and type 2 diabetes. Which medication is the most likely culprit for these abnormal thyroid function tests?
Your Answer: Glibenclamide
Correct Answer: Amiodarone
Explanation:Amiodarone and its Effects on Thyroid Function
Amiodarone is a medication that can cause abnormalities in thyroid function tests, leading to both hypothyroidism and hyperthyroidism. Hypothyroidism may occur due to interference with the conversion of thyroxine (T4) to tri-iodothyronine (T3), while hyperthyroidism may result from thyroiditis or the donation of iodine (amiodarone contains a large amount of iodine). In addition to thyroid dysfunction, amiodarone can also cause pulmonary fibrosis and photosensitivity reactions. It is important for healthcare providers to monitor thyroid function in patients taking amiodarone and manage any resulting thyroid dysfunction appropriately.
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This question is part of the following fields:
- Endocrinology
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Question 94
Correct
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A 49-year-old woman, without past medical history, is referred by her General Practitioner to a Lipid Clinic. She has a body mass index (BMI) of 29 kg/m2. She has a background history of sleep apnoea and complains of weight gain, fatigue and constipation.
On examination, you notice that her skin is dry and she has scalp hair loss. Her laboratory results are as follows:
Investigation Result Normal value
Total cholesterol 8.2 mmol/l < 5.2 mmol/l
Low density-lipoprotein (LDL) cholesterol 5.2 mmol/l < 3.5 mmol/l
High-density lipoprotein (HDL) cholesterol 1.8 mmol/l > 1.0 mmol/l
Triglycerides 1.2 mmol/l 0–1.5 mmol/l
What is the most appropriate next step in her management?Your Answer: Measure thyroid-stimulating hormone and free T4
Explanation:Management of Hypercholesterolemia in a Patient with Suspected Hypothyroidism
To manage hypercholesterolemia in a patient with suspected hypothyroidism, it is important to confirm the diagnosis of hypothyroidism first. Blood tests for thyroid function, specifically thyroid-stimulating hormone and free T4, should be conducted. If hypothyroidism is confirmed, it should be treated accordingly.
Statin therapy, such as atorvastatin, is the first-line pharmacological agent for managing hypercholesterolemia. However, in this case, potential hypothyroidism needs to be treated first before starting statin therapy. If high cholesterol levels persist after treating hypothyroidism, a statin therapy can be started, and fibrate therapy can be added if necessary.
While dietary and lifestyle advice is important, it is unlikely to address the underlying problems in this case. Therefore, it is crucial to confirm and treat hypothyroidism before managing hypercholesterolemia.
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This question is part of the following fields:
- Endocrinology
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Question 95
Incorrect
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A 55-year-old man with a history of hypertension and type 2 diabetes presents to the Emergency department with complaints of central chest pain that radiates down his left arm. He is currently taking ramipril, metformin, atorvastatin, and gliclazide. On examination, his blood pressure is 129/72 mmHg, and his pulse is 81. Bibasal crackles are heard on auscultation of his chest.
The following investigations were conducted:
- Haemoglobin: 138 g/L (130-180)
- White cell count: 8.9 ×109/L (4-11)
- Platelet: 197 ×109/L (150-400)
- Sodium: 141 mmol/L (135-146)
- Potassium: 4.1 mmol/L (3.5-5)
- Creatinine: 123 µmol/L (79-118)
- Glucose: 12.3 mmol/L (<7.0)
- ECG: Anterolateral ST depression
The patient is given sublingual GTN. What is the next most appropriate therapy?Your Answer: Beta blockade
Correct Answer: Aspirin 300 mg, clopidogrel 300 mg and unfractionated heparin
Explanation:Treatment Plan for High-Risk Patient with Type 2 Diabetes Mellitus
This patient, who has a history of type 2 diabetes mellitus, is considered high risk and requires immediate treatment. The recommended treatment plan includes loading the patient with both aspirin and clopidogrel to reduce the risk of further complications. If the patient experiences further chest pain or if ECG signs do not improve, additional interventions such as angiography may be necessary.
In addition to aspirin and clopidogrel, unfractionated heparin is also recommended as an alternative to fondaparinux for patients who are likely to undergo coronary angiography within 24 hours of admission. If the patient does not progress to angiogram, screening for ischaemia should be considered prior to discharge.
Overall, it is important to closely monitor this high-risk patient and adjust the treatment plan as necessary to ensure the best possible outcome.
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This question is part of the following fields:
- Endocrinology
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Question 96
Incorrect
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A 50-year-old man presents to a psychiatrist with complaints of recent mood swings and increased irritability towards his spouse. He reports experiencing diarrhea, a significant increase in appetite, weight gain, and difficulty standing up from a seated position. Upon examination, an irregularly irregular heartbeat is noted.
What is the most probable diagnosis?Your Answer: Cushing’s syndrome
Correct Answer: Hyperthyroidism
Explanation:Endocrine Disorders: Hyperthyroidism, Phaeochromocytoma, Cushing’s Syndrome and Cushing’s Disease, and Schizoaffective Disorder
Hyperthyroidism is a condition characterized by an overactive thyroid gland. Symptoms include weight loss, increased appetite, heat intolerance, palpitations, and irritability. Signs include a fast heart rate, tremors, and thin hair. Graves’ disease, a type of hyperthyroidism, may also cause eye problems. Diagnosis is made through blood tests that show elevated thyroid hormones and low thyroid-stimulating hormone levels. Treatment options include medications like beta-blockers and carbimazole, radioiodine therapy, or surgery.
Phaeochromocytoma is a rare tumor that causes excessive production of adrenaline and noradrenaline. Symptoms include high blood pressure, palpitations, and weight loss. Diagnosis is made through blood and urine tests, as well as imaging studies. Treatment involves surgical removal of the tumor.
Cushing’s syndrome is a condition caused by high levels of cortisol in the body. Symptoms include weight gain, mood changes, fatigue, and easy bruising. Diagnosis is made through blood and urine tests, as well as imaging studies. Treatment options include surgery, radiation therapy, and medications.
Cushing’s disease is a type of Cushing’s syndrome caused by a pituitary tumor that produces too much adrenocorticotropic hormone (ACTH). Symptoms are similar to those of Cushing’s syndrome. Diagnosis is made through blood and urine tests, as well as imaging studies. Treatment options include surgery, radiation therapy, and medications.
Schizoaffective disorder is a mental illness that combines symptoms of schizophrenia and mood disorders like depression or bipolar disorder. Symptoms include hallucinations, delusions, and mood swings. Treatment involves a combination of medications and therapy.
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This question is part of the following fields:
- Endocrinology
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Question 97
Correct
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A 40-year-old woman visits her primary care physician (PCP) complaining of depression. The PCP observes a lump in the center of her neck and proceeds to conduct a cardiovascular and thyroid function assessment. During the examination, the patient appears sluggish and has a subdued mood. Her heart rate is 68 bpm and her blood pressure is 112/82 mmHg; there is paleness of the conjunctivae. The lump is symmetrically enlarged without skin alterations; it moves upward when swallowing and has a nodular consistency.
What is the most appropriate initial test to perform for diagnostic assistance?Your Answer: Thyroid function tests
Explanation:Thyroid Function Tests: Initial Investigation for Hypothyroidism
When a patient presents with symptoms and signs suggestive of hypothyroidism, the most appropriate initial test is thyroid function tests. However, if a neck swelling is also present, an ultrasound scan may be useful to assess for a goitre. If a cystic swelling is identified, a fine-needle aspirate sample may be taken for cytological analysis. A radio-isotope scan may also be performed to further assess thyroid pathology. While a full blood count is typically checked at the same time, it is not the best answer given the scenario.
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This question is part of the following fields:
- Endocrinology
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Question 98
Incorrect
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A 28-year-old woman is referred by her general practitioner due to irregular and unpredictable menstrual cycle and headaches. Magnetic resonance imaging of the brain shows a midline lesion. Further investigations reveal that her prolactin level is 2314 ng/ml (2–29 ng/ml). To reduce the prolactin level, which mediator is manipulated for medical treatment?
Your Answer: Thyrotropin-releasing hormone (TRH)
Correct Answer: Dopamine
Explanation:Targeting Hormones in Prolactinoma Treatment
Prolactinoma is a pituitary lesion that results in excessive prolactin secretion. To reduce prolactin levels, dopamine agonists like bromocriptine are used. While there are other hormones that can affect prolactin secretion, they are not therapeutic targets in prolactinoma treatment. Corticotropin-releasing hormone (CRH) increases adrenocorticotropic hormone secretion, while gonadotropin-releasing hormone (GnRH) can indirectly decrease GnRH secretion. Somatostatin decreases thyroid-stimulating hormone and growth hormone secretion, but does not affect prolactin. Thyrotropin-releasing hormone (TRH) increases prolactin and TSH release, but is not a therapeutic target due to its effects on thyroid regulation and the superiority of dopamine agonists.
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This question is part of the following fields:
- Endocrinology
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Question 99
Incorrect
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What is the hormone that is released from the posterior pituitary gland?
Your Answer: Adrenocorticotrophic hormone (ACTH)
Correct Answer: Oxytocin
Explanation:Peptides Secreted by the Pituitary Gland
The pituitary gland secretes various hormones that regulate different bodily functions. The posterior lobe of the pituitary gland secretes two peptides, oxytocin and antidiuretic hormone (ADH). Oxytocin, which is produced in the hypothalamus, stimulates uterine contractions during labor and is involved in the release of milk from the lactating breast. ADH, also known as vasopressin, is also produced in the hypothalamus and regulates water balance in the body.
On the other hand, the anterior lobe of the pituitary gland secretes six peptide hormones. These hormones include adrenocorticotrophic hormone (ACTH), prolactin, thyroid-stimulating hormone (TSH), growth hormone (GH), follicle-stimulating hormone (FSH), and luteinizing hormone (LH). ACTH stimulates the adrenal gland to produce cortisol, which helps the body respond to stress. Prolactin stimulates milk production in the mammary glands. TSH stimulates the thyroid gland to produce thyroid hormones, which regulate metabolism. GH promotes growth and development in children and helps maintain muscle and bone mass in adults. FSH and LH regulate the reproductive system, with FSH stimulating the growth of ovarian follicles in females and sperm production in males, while LH triggers ovulation in females and testosterone production in males.
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This question is part of the following fields:
- Endocrinology
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Question 100
Incorrect
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A 50-year-old woman has been diagnosed with Addison's disease. What would be advantageous to prescribe for her along with hydrocortisone?
Your Answer: Aspirin
Correct Answer: Fludrocortisone
Explanation:Medications for Addison’s Disease: What Works and What Doesn’t
Addison’s disease is a condition where the adrenal glands do not produce enough hormones. Patients with this condition require replacement therapy with both glucocorticoid and mineralocorticoid medications. Fludrocortisone is a common mineralocorticoid replacement therapy used in Addison’s disease. However, medications such as aspirin, the combined oral contraceptive pill, and the progesterone only pill have no role in treating this condition. Additionally, dexamethasone is not used as a replacement therapy for Addison’s disease. It is important for patients with Addison’s disease to work closely with their healthcare provider to determine the appropriate medications for their individual needs.
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This question is part of the following fields:
- Endocrinology
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Question 101
Correct
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A 63-year-old man, who has had diabetes for the past eight years, visits the Endocrine Clinic with complaints of abdominal fullness and occasional pain. He reports experiencing anorexia, acid reflux, belching, and bloating. He is currently taking glimepiride, metformin, and exenatide and has generally had good control of his blood sugar. However, his last two tests have shown a trend of increasing fasting glucose levels. What is the next appropriate step in managing his condition?
Your Answer: Change diabetic medication
Explanation:Changing Diabetic Medication for Gastroparesis
A diabetic patient is experiencing delayed gastric emptying, a common side-effect of GLP-1 agonists like exenatide. To achieve better glycaemic control and prevent current side-effects, the patient’s diabetic medication needs to be changed. However, converting to insulin is not necessary for gastroparesis. Intensifying the current medication is not appropriate due to significant side-effects. Before considering a prokinetic agent like metoclopramide or domperidone, the GLP-1 analogue should be stopped. Treatment for H. pylori infection is not warranted as the patient’s symptoms are not indicative of peptic ulcer disease.
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This question is part of the following fields:
- Endocrinology
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Question 102
Correct
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A 48-year old teacher is found to have a raised fasting glucose and abnormal cholesterol results following routine blood testing as a part of her NHS health check. She is noted to have a BMI of 32. She is also hypertensive. The reviewing physician suspects that the patient has metabolic syndrome.
Which of the following statements is true about the metabolic syndrome?Your Answer: Patients usually have high circulating insulin levels
Explanation:Understanding Metabolic Syndrome and its Associated Features
Metabolic syndrome is a condition characterized by three or more of the following: increased waist circumference, BMI >30 kg/m2, raised triglycerides, reduced HDL cholesterol, hypertension, and raised fasting glucose. It typically occurs in individuals with central obesity and insulin resistance, leading to elevated circulating insulin and C-peptide levels. However, significant weight loss can reverse insulin resistance and resolve the features of metabolic syndrome.
Contrary to what one might expect, high serum HDL is typical in metabolic syndrome, while low serum HDL is a diagnostic criteria. Additionally, metabolic syndrome is a key risk factor for non-alcoholic fatty liver disease (NAFLD), which is fairly common in these patients. Hyperuricaemia is also common in metabolic syndrome, rather than hypouricaemia.
Finally, while metabolic syndrome incidence does increase with age, it does not necessarily peak in the fifth decade of life. Understanding these features can aid in the diagnosis and management of metabolic syndrome and its associated conditions.
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This question is part of the following fields:
- Endocrinology
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Question 103
Incorrect
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A 50-year-old man underwent blood tests after a recent kidney stone surgery. The test results are as follows:
Corrected calcium: 3.01 mmol/L (normal range: 2.1-2.5)
Phosphate: 0.49 mmol/L (normal range: 0.80-1.4)
Alkaline phosphatase (alk phos): 166 U/L (normal range: 30-135)
Parathyroid hormone (PTH): 71 ng/L (normal range: 14-72 ng/L)
Estimated glomerular filtration rate (eGFR): >60 ml/min/1.73m2
What is the most likely reason for the high calcium level based on these results?Your Answer: Dehydration
Correct Answer: Primary hyperparathyroidism
Explanation:High Serum Calcium Levels
When analyzing blood test results, a high serum calcium level in combination with a low phosphate level, high serum alkaline phosphatase (ALP), and normal glomerular filtration rate (GFR) may indicate primary hyperparathyroidism. While the parathyroid hormone (PTH) may fall within the reference range, it is considered inappropriate for the high calcium levels, as it should be suppressed as part of the negative feedback mechanism. It is important to note that a result within the reference range may still be abnormal.
Primary hyperparathyroidism is typically caused by a solitary adenoma, hyperplasia of all the parathyroid glands, multiple adenomas, or parathyroid carcinoma. Other conditions, such as vitamin D excess or bony metastases, may also cause high calcium levels, but the PTH would be suppressed if it were the primary pathology. Severe hypercalcemia can lead to dehydration, but dehydration itself would not cause such high serum calcium levels. Sclerosing cholangitis may cause elevated ALP levels of liver origin, but it would not explain the other results. the potential causes of high serum calcium levels can aid in proper diagnosis and treatment.
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This question is part of the following fields:
- Endocrinology
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Question 104
Incorrect
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A 76-year-old woman presents with lethargy. She has a history of Graves’ disease and thyrotoxicosis. Her thyroid-stimulating hormone (TSH) levels are found to be 7.3 μU/l (normal range: 0.17–3.2 μU/l). A full blood count is performed and reveals the following: haemoglobin (Hb) is low, mean corpuscular volume (MCV) is high, platelet count is normal, white cell count (WCC) is normal.
What is the most likely cause of her anaemia?Your Answer: Vitamin B12 deficiency
Correct Answer: Hypothyroidism
Explanation:Differential diagnosis of macrocytic anaemia in a patient with a history of Graves’ disease
This patient presents with a macrocytic anaemia, which can have various causes. Given her history of Graves’ disease and autoimmune hyperthyroidism, it is important to consider hypothyroidism as a possible cause, despite the usual association of hyperthyroidism with a suppressed TSH. Pernicious anaemia, another autoimmune disease that can lead to vitamin B12 deficiency, should also be considered. However, in this case, the high TSH makes hypothyroidism more likely. Vitamin B12 deficiency and folate deficiency can also cause macrocytic anaemia, but the patient’s history and laboratory findings suggest hypothyroidism as the primary diagnosis. Haemolysis is not a likely cause in this patient.
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This question is part of the following fields:
- Endocrinology
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Question 105
Incorrect
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A patient in their 60s presents with lethargy, weight loss and fainting episodes. In the Emergency Department, a postural drop in blood pressure is noted of >20 mmHg systolic from the supine to the standing position. Blood glucose is 2.9 mmol/l and Na+ is 122 mmol/l.
Which of the following is the patient’s condition due to?Your Answer: Decreased cortisol; normal aldosterone
Correct Answer: Decreased cortisol; decreased aldosterone
Explanation:Understanding Addison’s Disease: Hormonal Imbalances and Clinical Presentation
Addison’s disease, or primary adrenal failure, is a condition characterized by autoimmune destruction of the adrenal cortex, resulting in reduced levels of cortisol and aldosterone. This hormonal imbalance leads to a range of clinical symptoms, including hypotension, hyponatraemia, hyperkalaemia, acidosis, and skin and mucosal hyperpigmentation.
While other hormonal imbalances may occur in the adrenal glands, such as increased cortisol or aldosterone, they are less likely to result in the clinical presentation of Addison’s disease. For example, increased cortisol is unlikely due to autoimmune destruction of the zona fasciculata, while increased aldosterone is rare and typically caused by an adrenal adenoma. Similarly, decreased cortisol with normal aldosterone is more commonly associated with secondary adrenal failure caused by pituitary disease, but does not fit with the hyponatraemia seen in Addison’s disease.
Overall, understanding the hormonal imbalances and clinical presentation of Addison’s disease is crucial for accurate diagnosis and effective treatment.
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This question is part of the following fields:
- Endocrinology
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Question 106
Incorrect
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A 26-year-old female medical student experiences severe epigastric pain, following an evening indulging in large amounts of fatty foods. She went to visit her general practitioner (GP) who, upon further investigation, organised an analysis of her lipoprotein profile.
Analysis showed a deficiency of apolipoprotein (apo) C-II; all other lipoproteins were normal.
Which of the following profiles is plasma electrophoresis most likely to show?Your Answer: Low levels of both chylomicrons and VLDLs
Correct Answer: Elevated levels of both chylomicrons and VLDLs
Explanation:Understanding Lipoprotein Abnormalities: Causes and Clinical Features
Lipoprotein abnormalities can lead to various health conditions, including atherosclerosis and pancreatitis. The Frederickson classification system categorizes hyperlipoproteinaemias based on their underlying defects, serum abnormalities, and clinical features.
One common cause of elevated levels of both chylomicrons and VLDLs is a deficiency in apo C-II, an essential cofactor of lipoprotein lipase. This deficiency impairs the hydrolysis of triglycerides in chylomicrons and VLDLs, resulting in their accumulation in the bloodstream.
On the other hand, low VLDL levels and no other changes may indicate a deficiency in VLDL production. However, it is important to note that low levels of both chylomicrons and VLDLs may not necessarily indicate a deficiency in either lipoprotein. In fact, both chylomicrons and VLDLs would be expected to be high in this scenario.
Understanding the causes and clinical features of lipoprotein abnormalities is crucial in diagnosing and managing related health conditions.
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This question is part of the following fields:
- Endocrinology
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Question 107
Correct
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A 55-year-old man is scheduled for colorectal carcinoma resection and has type 2 diabetes. He is currently well-controlled on 5 mg glibenclamide daily. What is the best pre-operative plan for managing his blood sugar levels?
Your Answer: Stop glibenclamide on the morning of surgery and commence insulin by intravenous infusion
Explanation:Management of Glibenclamide in a Patient Undergoing Major Surgery
During major surgery, it is crucial to maintain optimal glycaemic control in patients with diabetes. In the case of a patient taking glibenclamide, the most appropriate course of action is to discontinue the medication on the morning of surgery. Instead, the patient should be started on intravenous (IV) insulin and dextrose with potassium. This approach allows for frequent blood glucose measurements and adjustment of the insulin infusion rate as needed.
By stopping glibenclamide, the risk of hypoglycaemia during surgery is reduced. IV insulin and dextrose with potassium provide a more controlled and predictable method of glycaemic control during the stress of surgery. This approach ensures that the patient’s blood glucose levels remain within a safe range, reducing the risk of complications such as infection, delayed wound healing, and poor surgical outcomes.
In summary, the management of glibenclamide in a patient undergoing major surgery involves discontinuing the medication on the morning of surgery and starting the patient on IV insulin and dextrose with potassium. This approach allows for optimal glycaemic control during the stress of surgery and reduces the risk of complications.
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This question is part of the following fields:
- Endocrinology
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Question 108
Incorrect
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A 56-year-old man is brought into the Emergency Department following a fall in the local supermarket. He is in an acute confusional state and unaccompanied, so a history is not available. Upon examination, the doctor noted digital clubbing and signs of a right-sided pleural effusion. The patient was euvolaemic.
Investigations:
Serum:
Na+ 114 mmol/l (135–145 mmol/l)
K+ 3.6 mmol/l (3.5–5 mmol/l)
Urea 2.35 mmol/l (2.5–6.7 mmol/l)
Osmolality 255 mOsmol/kg (282–295 mOsm/kg)
Urine:
Osmolality 510 mOsmol/kg (raised)
Na+ 50 mmol/l (25–250 mmol/l, depending on hydration state)
Which of the following could be the diagnosis?Your Answer: Addison’s disease
Correct Answer: Small cell lung cancer
Explanation:Causes of Hyponatraemia: Differential Diagnosis
Hyponatraemia is a common electrolyte disturbance that can be caused by a variety of conditions. In this case, the patient’s acute confusional state is likely due to significant hyponatraemia. The low serum urea level and osmolality suggest dilutional hyponatraemia, but the raised urine osmolality indicates continued secretion of antidiuretic hormone (ADH), known as syndrome of inappropriate ADH secretion (SIADH).
SIADH can be associated with malignancy (such as small cell lung cancer), central nervous system disorders, drugs, and major surgery. In this patient’s case, the unifying diagnosis is small cell lung cancer causing SIADH. Digital clubbing also points towards a diagnosis of lung cancer.
Other conditions that can cause hyponatraemia include nephrotic syndrome, Addison’s disease, cystic fibrosis, and excessive diuretic therapy. However, these conditions have different biochemical profiles and clinical features.
Therefore, a thorough differential diagnosis is necessary to determine the underlying cause of hyponatraemia and guide appropriate management.
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This question is part of the following fields:
- Endocrinology
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Question 109
Incorrect
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A 57-year-old woman presents to the diabetic clinic with concerns about her worsening blood sugar control. She was diagnosed with diabetes three years ago and has had hypertension for five years. Her current medications include atenolol, amlodipine, and metformin.
During the examination, her weight is recorded as 98.5 kg, which is 5 kg more than her previous weight after losing 4 kg. Her BMI is 34.6, and her blood pressure is 156/94 mmHg. There are no signs of neuropathy or retinopathy. Her fasting glucose is 8.2 mmol/L (148 mg/dL), and her HbA1c has increased by 1% to 77 mmol/mol (20-42) since her last visit six months ago.
The patient expresses difficulty adhering to her diet and requests assistance with her weight. What would be your recommendation for treating her obesity?Your Answer: Gastric bypass surgery
Correct Answer: Orlistat
Explanation:Treatment Options for Obesity and Diabetes
This patient is dealing with both obesity and diabetes, and it is common for their glycaemic control to worsen as their weight increases. While bariatric surgery and sibutramine have been recommended in the past, they are not suitable options for this patient due to their medical history and potential risks. Instead, the pancreatic lipase inhibitor orlistat is recommended as it can reduce the absorption of dietary fat by 30%. However, it is important to note that this medication can cause side effects such as flatulence and diarrhoea.
Previously, it was recommended that patients demonstrate at least a 2.5 kg weight loss with diet before starting orlistat. However, this is no longer necessary. Weight loss is expected to improve glycaemic control, but it is important to note that the sulphonylurea gliclazide may cause weight gain. Overall, a combination of medication and diet changes can help manage obesity and diabetes in patients.
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This question is part of the following fields:
- Endocrinology
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Question 110
Correct
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What is the probable diagnosis for a 15-year-old girl who experiences recurring pelvic pain but has not yet begun menstruating?
Your Answer: Haematocolpos
Explanation:Haematocolpos: A Condition of Blood Accumulation in the Vagina
Haematocolpos is a medical condition characterized by the accumulation of blood in the vagina. This condition is usually caused by an imperforate hymen, which prevents menstrual blood from flowing out of the body. As a result, the blood accumulates in the vagina, leading to discomfort and pain. Haematocolpos is a rare condition that affects mostly young girls who have not yet started menstruating. It can also occur in women who have undergone surgery to remove the cervix or uterus. Treatment for haematocolpos usually involves surgical intervention to remove the blockage and allow the blood to flow out of the body. With prompt diagnosis and treatment, most women with haematocolpos can recover fully and resume their normal activities.
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This question is part of the following fields:
- Endocrinology
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