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  • Question 1 - A 65-year-old man presents to the Emergency Department with confusion, drowsiness, and nausea...

    Incorrect

    • A 65-year-old man presents to the Emergency Department with confusion, drowsiness, and nausea accompanied by vomiting. His daughter reports that he has been feeling fatigued and unwell with a persistent cough, and he has been smoking 20 cigarettes per day for 45 years. The patient is unable to provide a complete medical history due to his confusion, but he mentions that he sometimes coughs up blood and his urine has been darker than usual. On examination, he appears to be short of breath but euvolaemic. Blood tests reveal low serum sodium, high urinary sodium, low plasma osmolality, and high urinary osmolality. Renal and thyroid function tests are normal. A chest x-ray shows a lung carcinoma, leading you to suspect that this presentation may be caused by a syndrome of inappropriate antidiuretic hormone secretion.

      What is the underlying mechanism responsible for the hyponatraemia?

      Your Answer: Inhibition of the sodium-chloride cotransporters

      Correct Answer: Insertion of aquaporin-2 channels

      Explanation:

      The insertion of aquaporin-2 channels is promoted by antidiuretic hormone, which facilitates water reabsorption. However, in the case of syndrome of inappropriate antidiuretic hormone secretion (SiADH), which is caused by small cell lung cancer, the normal negative feedback loop fails, resulting in the continuous production of ADH even when serum osmolality returns to normal. This leads to euvolemic hyponatremia, where the body retains water but continues to lose sodium, resulting in concentrated urine. The underlying mechanism of this condition is the persistent increase in the number of aquaporin-2 channels, which promotes water reabsorption, rather than any effect on sodium transport mechanisms.

      Understanding Antidiuretic Hormone (ADH)

      Antidiuretic hormone (ADH) is a hormone that is produced in the supraoptic nuclei of the hypothalamus and released by the posterior pituitary gland. Its primary function is to conserve body water by promoting water reabsorption in the collecting ducts of the kidneys through the insertion of aquaporin-2 channels.

      ADH secretion is regulated by various factors. An increase in extracellular fluid osmolality, a decrease in volume or pressure, and the presence of angiotensin II can all increase ADH secretion. Conversely, a decrease in extracellular fluid osmolality, an increase in volume, a decrease in temperature, or the absence of ADH can decrease its secretion.

      Diabetes insipidus (DI) is a condition that occurs when there is either a deficiency of ADH (cranial DI) or an insensitivity to ADH (nephrogenic DI). Cranial DI can be treated with desmopressin, which is an analog of ADH.

      Overall, understanding the role of ADH in regulating water balance in the body is crucial for maintaining proper hydration and preventing conditions like DI.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 2 - A 29-year-old female presents to the emergency department after a mixed overdose. According...

    Incorrect

    • A 29-year-old female presents to the emergency department after a mixed overdose. According to her parents, she had locked herself in her room after an argument and they found her drowsy on the floor after forcing open the door. The patient has a history of depression and previous suicide attempts. Her grandmother's medical box, containing paracetamol, gliclazide, bisoprolol, and atorvastatin, was found empty, but the amount ingested is unknown. On examination, the patient is sweaty with a global tremor and is confused. She is tachycardic and appears generally weak.

      Which molecule is likely to be the first produced by the patient in response to the overdose?

      Your Answer: Glutathione

      Correct Answer: Glucagon

      Explanation:

      The initial hormone response to hypoglycaemia is the secretion of glucagon. In the case of a suspected gliclazide overdose, the most likely presentation would be hypoglycaemia, as evidenced by the patient’s sudden onset of sweating, weakness, and confusion. Other medications ingested are unlikely to produce these symptoms. When the body experiences hypoglycaemia, it first reduces insulin production and then increases glucagon secretion, which promotes gluconeogenesis to raise blood glucose levels.

      Glycogen synthase is an enzyme involved in glycogenesis, the process of converting glucose into glycogen for storage in the body. However, in the case of hypoglycaemia caused by gliclazide ingestion, the body would carry out gluconeogenesis to release glucose, rather than glycogenesis.

      While cortisol is released in response to hypoglycaemia, it is a later response and is secreted after glucagon. Cortisol is a glucocorticoid hormone that also promotes gluconeogenesis and glucose production.

      Glutathione is an antioxidant found in the liver that helps neutralize and eliminate the toxic metabolite N-acetyl-p-benzoquinone imine (NAPQI) produced by paracetamol. In cases of paracetamol overdose, glutathione levels are depleted, but this patient’s symptoms are too acute for a paracetamol overdose. Liver failure resulting from paracetamol overdose takes several hours to develop and even longer before physical symptoms appear. The antidote treatment for paracetamol overdose is acetylcysteine, which replenishes glutathione levels.

      Understanding Hypoglycaemia: Causes, Features, and Management

      Hypoglycaemia is a condition characterized by low blood sugar levels, which can lead to a range of symptoms and complications. There are several possible causes of hypoglycaemia, including insulinoma, liver failure, Addison’s disease, and alcohol consumption. The physiological response to hypoglycaemia involves hormonal and sympathoadrenal responses, which can result in autonomic and neuroglycopenic symptoms. While blood glucose levels and symptom severity are not always correlated, common symptoms of hypoglycaemia include sweating, shaking, hunger, anxiety, nausea, weakness, vision changes, confusion, and dizziness. In severe cases, hypoglycaemia can lead to convulsions or coma.

      Managing hypoglycaemia depends on the severity of the symptoms and the setting in which it occurs. In the community, individuals with diabetes who inject insulin may be advised to consume oral glucose or a quick-acting carbohydrate such as GlucoGel or Dextrogel. A ‘HypoKit’ containing glucagon may also be prescribed for home use. In a hospital setting, treatment may involve administering a quick-acting carbohydrate or subcutaneous/intramuscular injection of glucagon for unconscious or unable to swallow patients. Alternatively, intravenous glucose solution may be given through a large vein.

      Overall, understanding the causes, features, and management of hypoglycaemia is crucial for individuals with diabetes or other conditions that increase the risk of low blood sugar levels. Prompt and appropriate treatment can help prevent complications and improve outcomes.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 3 - A 7-year-old boy is brought to the doctor by his father with a...

    Incorrect

    • A 7-year-old boy is brought to the doctor by his father with a complaint of frequent urination and excessive thirst. Upon conducting a fasting blood glucose test, the results are found to be abnormally high. The doctor suspects type 1 diabetes and initiates first-line injectable therapy.

      What characteristic of this medication should be noted?

      Your Answer: Secreted in response to hypoglycaemia

      Correct Answer: Decreases serum potassium

      Explanation:

      Insulin stimulates the Na+/K+ ATPase pump, which leads to a decrease in serum potassium levels. This is the primary treatment for type 1 diabetes, where the pancreas no longer produces insulin, causing high blood sugar levels. Injectable insulin allows glucose to enter cells, and insulin also increases cellular uptake of potassium while decreasing serum potassium levels. Insulin also stimulates muscle protein synthesis, reducing muscle protein loss. Insulin is secreted in response to hyperglycaemia, where high blood sugar levels trigger the beta cells of the pancreas to release insulin in healthy individuals.

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

    • This question is part of the following fields:

      • Endocrine System
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  • Question 4 - A 57-year-old man comes to the diabetes clinic for a check-up. He has...

    Correct

    • A 57-year-old man comes to the diabetes clinic for a check-up. He has a medical history of type 2 diabetes, which is currently managed with metformin and sitagliptin, and hypertension, for which he takes ramipril. His recent blood tests show an increase in HbA1c from 51mmol/L to 59mmol/L. He has not experienced any hypoglycaemic events and reports good adherence to his medication and blood glucose monitoring. He expresses interest in trying an additional antidiabetic medication and is prescribed tolbutamide after receiving counselling on hypoglycaemic awareness.

      What is the mechanism of action of tolbutamide?

      Your Answer: Binds to and shuts pancreatic beta cell ATP-dependent K+ channels, causing membrane depolarisation and increased insulin exocytosis

      Explanation:

      Sulfonylureas are a type of medication used to treat type 2 diabetes mellitus. They work by increasing the amount of insulin produced by the pancreas, but only if the beta cells in the pancreas are functioning properly. Sulfonylureas bind to a specific channel on the cell membrane of pancreatic beta cells, known as the ATP-dependent K+ channel (KATP).

      While sulfonylureas can be effective in managing diabetes, they can also cause some adverse effects. The most common side effect is hypoglycemia, which is more likely to occur with long-acting preparations like chlorpropamide. Another common side effect is weight gain. However, there are also rarer side effects that can occur, such as hyponatremia (low sodium levels) due to inappropriate ADH secretion, bone marrow suppression, hepatotoxicity (liver damage), and peripheral neuropathy.

      It is important to note that sulfonylureas should not be used during pregnancy or while breastfeeding.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 5 - A 30-year-old female with a two year history of type 1 diabetes presents...

    Incorrect

    • 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: Chest and abdominal x ray

      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.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 6 - A 33-year-old woman with a history of coeliac disease presents to the emergency...

    Incorrect

    • A 33-year-old woman with a history of coeliac disease presents to the emergency department with palpitations, diaphoresis, and tremors. Upon examination, her vital signs reveal a heart rate of 110 bpm and respiratory rate of 24 per min. She displays hand tremors, bulging eyeballs, and diffuse swelling in her neck. Her blood tests show:

      TSH 0.1 mU/l
      Free T4 32.5 pmol/l
      Free T3 12.5 pmol/l

      What is the most probable underlying pathophysiology in this patient?

      Your Answer: Multiple toxic nodules

      Correct Answer: Antibodies to TSH receptors

      Explanation:

      Graves’ disease is the most probable cause of thyrotoxicosis in a middle-aged woman, particularly if she exhibits exophthalmos. This autoimmune disorder is characterised by the presence of antibodies to the thyroid stimulating hormone (TSH) receptors.

      Graves’ Disease: Common Features and Unique Signs

      Graves’ disease is the most frequent cause of thyrotoxicosis, which is commonly observed in women aged 30-50 years. The condition presents typical features of thyrotoxicosis, such as weight loss, palpitations, and heat intolerance. However, Graves’ disease also displays specific signs that are not present in other causes of thyrotoxicosis. These include eye signs, such as exophthalmos and ophthalmoplegia, as well as pretibial myxoedema and thyroid acropachy. The latter is a triad of digital clubbing, soft tissue swelling of the hands and feet, and periosteal new bone formation.

      Graves’ disease is characterized by the presence of autoantibodies, including TSH receptor stimulating antibodies in 90% of patients and anti-thyroid peroxidase antibodies in 75% of patients. Thyroid scintigraphy reveals a diffuse, homogenous, and increased uptake of radioactive iodine. These features help distinguish Graves’ disease from other causes of thyrotoxicosis and aid in its diagnosis.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 7 - A 39-year old male visits the GP complaining of nipple discharge. Upon examination,...

    Incorrect

    • A 39-year old male visits the GP complaining of nipple discharge. Upon examination, it is found that his serum prolactin levels are significantly high. Besides prolactin releasing hormone, which other hypothalamic hormone can stimulate the secretion of prolactin?

      Your Answer: Gonadotropin releasing hormone (GnRH)

      Correct Answer: Thyrotropin releasing hormone (TRH)

      Explanation:

      Understanding Prolactin and Its Functions

      Prolactin is a hormone that is produced by the anterior pituitary gland. Its primary function is to stimulate breast development and milk production in females. During pregnancy, prolactin levels increase to support the growth and development of the mammary glands. It also plays a role in reducing the pulsatility of gonadotropin-releasing hormone (GnRH) at the hypothalamic level, which can block the action of luteinizing hormone (LH) on the ovaries or testes.

      The secretion of prolactin is regulated by dopamine, which constantly inhibits its release. However, certain factors can increase or decrease prolactin secretion. For example, prolactin levels increase during pregnancy, in response to estrogen, and during breastfeeding. Additionally, stress, sleep, and certain drugs like metoclopramide and antipsychotics can also increase prolactin secretion. On the other hand, dopamine and dopaminergic agonists can decrease prolactin secretion.

      Overall, understanding the functions and regulation of prolactin is important for reproductive health and lactation.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 8 - A 35-year-old male presents with gynaecomastia. He is later diagnosed with a testicular...

    Correct

    • A 35-year-old male presents with gynaecomastia. He is later diagnosed with a testicular germ cell tumour.

      What is the underlying mechanism that causes this type of cancer to present with gynaecomastia?

      Your Answer: Testicular tumours secrete beta-HCG, which increases oestrogen levels, promoting the proliferation of breast tissue

      Explanation:

      Gynaecomastia can be caused by testicular cancer, specifically seminoma that secretes beta-HCG. This hormone acts as a tumour marker for testicular germ cell cancer and increases oestrogen levels, leading to an imbalance of oestrogen to androgen ratio. This imbalance promotes the growth of breast tissue, resulting in gynaecomastia.

      Alpha-fetoprotein is another tumour marker for testicular cancer, but it does not affect oestrogen levels or breast glandular tissue. It is important to note that gynaecomastia is a separate condition from metastatic testicular cancer in the breast.

      Testicular involution, or shrinkage of the testes, is not a common symptom of testicular cancer. Instead, patients typically present with a painless swelling or nodule in the testis.

      Elevated testosterone levels are not associated with testicular cancer, as they would prevent the growth of breast tissue and gynaecomastia.

      Understanding Gynaecomastia: Causes and Drug Triggers

      Gynaecomastia is a condition characterized by the abnormal growth of breast tissue in males, often caused by an increased ratio of oestrogen to androgen. It is important to distinguish the causes of gynaecomastia from those of galactorrhoea, which is caused by the actions of prolactin on breast tissue.

      Physiological changes during puberty can lead to gynaecomastia, but it can also be caused by syndromes with androgen deficiency such as Kallmann and Klinefelter’s, testicular failure due to mumps, liver disease, testicular cancer, and hyperthyroidism. Additionally, haemodialysis and ectopic tumour secretion can also trigger gynaecomastia.

      Drug-induced gynaecomastia is also a common cause, with spironolactone being the most frequent trigger. Other drugs that can cause gynaecomastia include cimetidine, digoxin, cannabis, finasteride, GnRH agonists like goserelin and buserelin, oestrogens, and anabolic steroids. However, it is important to note that very rare drug causes of gynaecomastia include tricyclics, isoniazid, calcium channel blockers, heroin, busulfan, and methyldopa.

      In summary, understanding the causes and drug triggers of gynaecomastia is crucial in diagnosing and treating this condition.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 9 - What is the crucial step in the production of all steroid hormones? ...

    Correct

    • What is the crucial step in the production of all steroid hormones?

      Your Answer: Conversion of cholesterol to pregnenolone

      Explanation:

      The Role of Pregnenolone in Steroid Hormone Synthesis

      In the production of steroid hormones in the human body, the conversion of cholesterol to pregnenolone is a crucial step. Pregnenolone serves as the precursor for all steroid hormones, and its formation is the limiting factor in the synthesis of these hormones. This conversion process occurs within the mitochondria of steroid-producing tissues. Essentially, the body needs to convert cholesterol to pregnenolone before it can produce any other steroid hormones. This highlights the importance of pregnenolone in the body’s endocrine system and its role in regulating various physiological processes.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 10 - A young man presents with polyuria, polydipsia and weight loss. He is subsequently...

    Correct

    • A young man presents with polyuria, polydipsia and weight loss. He is subsequently diagnosed with type 1 diabetes mellitus. What is he at an increased risk of developing?

      Your Answer: Addison's disease, Grave's disease, coeliac disease

      Explanation:

      Type 1 diabetes is linked to other autoimmune disorders like Addison’s disease, Grave’s disease, and coeliac disease, due to its own autoimmune nature. The other choices are incorrect as they contain a non-autoimmune disorder.

      Understanding Diabetes Mellitus: A Basic Overview

      Diabetes mellitus is a chronic condition characterized by abnormally raised levels of blood glucose. It is one of the most common conditions encountered in clinical practice and represents a significant burden on the health systems of the developed world. The management of diabetes mellitus is crucial as untreated type 1 diabetes would usually result in death. Poorly treated type 1 diabetes mellitus can still result in significant morbidity and mortality. The main focus of diabetes management now is reducing the incidence of macrovascular and microvascular complications.

      There are different types of diabetes mellitus, including type 1 diabetes mellitus, type 2 diabetes mellitus, prediabetes, gestational diabetes, maturity onset diabetes of the young, latent autoimmune diabetes of adults, and other types. The presentation of diabetes mellitus depends on the type, with type 1 diabetes mellitus often presenting with weight loss, polydipsia, polyuria, and diabetic ketoacidosis. On the other hand, type 2 diabetes mellitus is often picked up incidentally on routine blood tests and presents with polydipsia and polyuria.

      There are four main ways to check blood glucose, including a finger-prick bedside glucose monitor, a one-off blood glucose, a HbA1c, and a glucose tolerance test. The diagnostic criteria are determined by WHO, with a fasting glucose greater than or equal to 7.0 mmol/l and random glucose greater than or equal to 11.1 mmol/l being diagnostic of diabetes mellitus. Management of diabetes mellitus involves drug therapy to normalize blood glucose levels, monitoring for and treating any complications related to diabetes, and modifying any other risk factors for other conditions such as cardiovascular disease. The first-line drug for the vast majority of patients with type 2 diabetes mellitus is metformin, with second-line drugs including sulfonylureas, gliptins, and pioglitazone. Insulin is used if oral medication is not controlling the blood glucose to a sufficient degree.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 11 - A 25-year-old male patient presents to the endocrine clinic with delayed-onset puberty. His...

    Correct

    • A 25-year-old male patient presents to the endocrine clinic with delayed-onset puberty. His history revealed a cleft palate as a child which had been repaired successfully. On direct questioning, he revealed he had anosmia but was told this was due to a minor head injury aged 5. On examination, he was 1.80 metres tall, had sparse pubic hair and small volume testes (Tanner staging grade 1).

      Blood results revealed:

      FSH 2 IU/L (1-7)
      LH 2 IU/L (1-8)
      Testosterone 240 ng/dL (280-1100)

      What is the most likely cause of this patient's condition?

      Your Answer: Kallmann syndrome

      Explanation:

      The minor head injury is unlikely to be the cause of the patient’s anosmia. However, the combination of anosmia and cleft palate, along with the blood test results indicating hypogonadotropic hypogonadism, suggests that the patient may have Kallmann’s syndrome, which is an X-linked inherited disorder. Constitutional developmental delay is less likely due to the patient’s age and abnormal blood test results.

      Empty sella syndrome is a condition where the sella turcica, the area of the brain where the pituitary gland is located, is empty and filled with cerebrospinal fluid. Although this condition can be asymptomatic, it can also present with symptoms of hypopituitarism. However, since the patient also has anosmia and cleft palate, empty sella syndrome is less likely.

      Klinefelter’s syndrome is characterized by tall stature, gynecomastia, and small penis/testes. Blood tests would reveal elevated gonadotropins and low testosterone levels. However, since the patient’s FSH and LH levels are low, Klinefelter’s syndrome can be ruled out.

      Kallmann’s syndrome is a condition that can cause delayed puberty due to hypogonadotropic hypogonadism. It is often inherited as an X-linked recessive trait and is believed to be caused by a failure of GnRH-secreting neurons to migrate to the hypothalamus. One of the key indicators of Kallmann’s syndrome is anosmia, or a lack of smell, in boys with delayed puberty. Other features may include hypogonadism, cryptorchidism, low sex hormone levels, and normal or above-average height. Some patients may also have cleft lip/palate and visual/hearing defects.

      Management of Kallmann’s syndrome typically involves testosterone supplementation. Gonadotrophin supplementation may also be used to stimulate sperm production if fertility is desired later in life. It is important for individuals with Kallmann’s syndrome to receive appropriate medical care and monitoring to manage their symptoms and ensure optimal health outcomes.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 12 - A 28-year-old female patient presents to her GP with concerns about the appearance...

    Incorrect

    • A 28-year-old female patient presents to her GP with concerns about the appearance of lumps in her lower abdomen. She has been diagnosed with type 1 diabetes and has been using insulin for more than a decade. The lumps have developed in the areas where she administers her insulin injections.

      What is the probable cause of the lumps?

      Your Answer: Lipoma

      Correct Answer: Lipodystrophy

      Explanation:

      Small subcutaneous lumps at injection sites, known as lipodystrophy, can be caused by insulin.

      The type and location of the lump suggest that lipodystrophy is the most probable cause.

      Deposits of insulin and glucose are not responsible for the formation of these lumps.

      While a lipoma could also cause similar lumps, it is less likely than lipodystrophy, which is a known complication of insulin injections, especially at the injection site. These lumps can occur in multiple locations.

      Insulin therapy can have side-effects that patients should be aware of. One of the most common side-effects is hypoglycaemia, which can cause sweating, anxiety, blurred vision, confusion, and aggression. Patients should be taught to recognize these symptoms and take 10-20g of a short-acting carbohydrate, such as a glass of Lucozade or non-diet drink, three or more glucose tablets, or glucose gel. It is also important for every person treated with insulin to have a glucagon kit for emergencies where the patient is not able to orally ingest a short-acting carbohydrate. Patients who have frequent hypoglycaemic episodes may develop reduced awareness, and beta-blockers can further reduce hypoglycaemic awareness.

      Another potential side-effect of insulin therapy is lipodystrophy, which typically presents as atrophy or lumps of subcutaneous fat. This can be prevented by rotating the injection site, as using the same site repeatedly can cause erratic insulin absorption. It is important for patients to be aware of these potential side-effects and to discuss any concerns with their healthcare provider. By monitoring their blood sugar levels and following their treatment plan, patients can manage the risks associated with insulin therapy and maintain good health.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 13 - A 70-year-old male has been diagnosed with polymyalgia rheumatica and prescribed prednisolone. What...

    Incorrect

    • A 70-year-old male has been diagnosed with polymyalgia rheumatica and prescribed prednisolone. What is the most likely adverse effect he may experience?

      Your Answer: Hypernatremia

      Correct Answer: Hyperglycaemia

      Explanation:

      Hyperglycemia is the correct answer. Most patients who take steroids experience an increase in appetite and weight gain, so anorexia or weight loss are not appropriate responses.

      Steroid hormones can also affect the aldosterone receptor in the collecting duct, potentially leading to hyponatremia.

      Although changes in vision are possible due to steroid-induced cataracts, they are much less common.

      High levels of non-endogenous steroids have several risk factors, including hyperglycemia, high blood pressure, obesity (particularly around the waist), muscle wasting, poor wound healing, and mood swings or depression.

      Corticosteroids are commonly prescribed medications that can be taken orally or intravenously, or applied topically. They mimic the effects of natural steroids in the body and can be used to replace or supplement them. However, the use of corticosteroids is limited by their numerous side effects, which are more common with prolonged and systemic use. These side effects can affect various systems in the body, including the endocrine, musculoskeletal, gastrointestinal, ophthalmic, and psychiatric systems. Some of the most common side effects include impaired glucose regulation, weight gain, osteoporosis, and increased susceptibility to infections. Patients on long-term corticosteroids should have their doses adjusted during intercurrent illness, and the medication should not be abruptly withdrawn to avoid an Addisonian crisis. Gradual withdrawal is recommended for patients who have received high doses or prolonged treatment.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 14 - Sarah is a 15-year-old female who presented to the clinic with concerns about...

    Incorrect

    • Sarah is a 15-year-old female who presented to the clinic with concerns about her development. She has not grown as expected and remains shorter than most of the girls in her class. She also notes that she has not started her period yet, which is affecting her confidence.

      On examination, she is 150cm tall and has no breast development. Pubic hair is sparse and axillary hair is absent. The uterus and ovaries are not palpable. A cleft palate is noted on examination of the mouth. When cranial nerve I was examined, she was unable to detect the smell of the odours sampled.

      Blood tests show low levels of estrogen, follicular stimulating hormone (FSH) and luteinizing hormone (LH). Liver function tests were normal. Blood glucose reading was 5.6mmol/L. Iron studies were unremarkable.

      What is the likely cause for her symptoms?

      Your Answer: Turner syndrome

      Correct Answer: Kallmann syndrome

      Explanation:

      The patient’s symptoms of delayed puberty and underdeveloped secondary sexual characteristics, along with a cleft palate and anosmia, suggest Kallmann syndrome. This condition is characterized by hypogonadotropic hypogonadism, as evidenced by low-normal levels of LH and FSH, as well as low testosterone levels. Kallmann syndrome is an X-linked inherited disorder caused by the failure of gonadotrophin-releasing hormone-producing neurons to migrate properly during fetal development.

      While Klinefelter syndrome can also cause delayed puberty and small testes, it is associated with hypergonadotropic hypogonadism, which is characterized by elevated levels of FSH and LH but low testosterone levels. Anosmia is not typically a symptom of Klinefelter syndrome.

      Hemochromatosis, a condition in which iron accumulates in the body, can also cause hypogonadotropic hypogonadism by affecting the hypothalamus. However, this is unlikely in this case as the patient’s iron studies were normal and anosmia is not a common symptom of hemochromatosis.

      Kallmann’s syndrome is a condition that can cause delayed puberty due to hypogonadotropic hypogonadism. It is often inherited as an X-linked recessive trait and is believed to be caused by a failure of GnRH-secreting neurons to migrate to the hypothalamus. One of the key indicators of Kallmann’s syndrome is anosmia, or a lack of smell, in boys with delayed puberty. Other features may include hypogonadism, cryptorchidism, low sex hormone levels, and normal or above-average height. Some patients may also have cleft lip/palate and visual/hearing defects.

      Management of Kallmann’s syndrome typically involves testosterone supplementation. Gonadotrophin supplementation may also be used to stimulate sperm production if fertility is desired later in life. It is important for individuals with Kallmann’s syndrome to receive appropriate medical care and monitoring to manage their symptoms and ensure optimal health outcomes.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 15 - A 26-year-old woman with a history of type 1 diabetes mellitus and borderline...

    Correct

    • A 26-year-old woman with a history of type 1 diabetes mellitus and borderline personality disorder is brought to the emergency department by ambulance due to a decreased level of consciousness. She is currently on regular insulin. Upon examination, her Glasgow coma scale is 3/15. The venous blood gas results show a pH of 7.36 (7.35-7.45), K+ of 3.8 mmol/L (3.5-4.5), Na+ of 136 mmol/L (135-145), glucose of 1.2 mmol/L (4.0-7.0), HCO3- of 23 mmol/L (22-26), and Hb of 145 g/dL (12.1-15.1). What is the first hormone to be secreted in response to the likely diagnosis?

      Your Answer: Glucagon

      Explanation:

      The correct answer is Glucagon, as it is the first hormone to be secreted in response to hypoglycaemia. The patient’s reduced level of consciousness is likely due to profound hypoglycaemia caused by exogenous insulin administration. Borderline personality disorder patients have a higher incidence of self harm and suicidality than the general population. Insulin is not the correct answer as its secretion decreases in response to hypoglycaemia, and this patient has T1DM resulting in an absolute deficiency. Cortisol is also not the correct answer as it takes longer to be secreted, although it is another counter-regulatory hormone that seeks to raise blood glucose levels in response to hypoglycaemia.

      Understanding Hypoglycaemia: Causes, Features, and Management

      Hypoglycaemia is a condition characterized by low blood sugar levels, which can lead to a range of symptoms and complications. There are several possible causes of hypoglycaemia, including insulinoma, liver failure, Addison’s disease, and alcohol consumption. The physiological response to hypoglycaemia involves hormonal and sympathoadrenal responses, which can result in autonomic and neuroglycopenic symptoms. While blood glucose levels and symptom severity are not always correlated, common symptoms of hypoglycaemia include sweating, shaking, hunger, anxiety, nausea, weakness, vision changes, confusion, and dizziness. In severe cases, hypoglycaemia can lead to convulsions or coma.

      Managing hypoglycaemia depends on the severity of the symptoms and the setting in which it occurs. In the community, individuals with diabetes who inject insulin may be advised to consume oral glucose or a quick-acting carbohydrate such as GlucoGel or Dextrogel. A ‘HypoKit’ containing glucagon may also be prescribed for home use. In a hospital setting, treatment may involve administering a quick-acting carbohydrate or subcutaneous/intramuscular injection of glucagon for unconscious or unable to swallow patients. Alternatively, intravenous glucose solution may be given through a large vein.

      Overall, understanding the causes, features, and management of hypoglycaemia is crucial for individuals with diabetes or other conditions that increase the risk of low blood sugar levels. Prompt and appropriate treatment can help prevent complications and improve outcomes.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 16 - A man in his early 50s comes to the hospital with a fever...

    Incorrect

    • A man in his early 50s comes to the hospital with a fever and cough. An X-ray shows pneumonia in his left lower lobe. Upon arrival at the emergency department, his blood pressure is 83/60mmHg and his heart rate is 112/min. The doctor prescribes antibiotics and IV fluids.

      What is the primary way the body reacts to a drop in blood pressure?

      Your Answer: Decreased heart rate and vasoconstriction

      Correct Answer: Insertion of AQP-2 channels in collecting ducts

      Explanation:

      When blood pressure drops, the body initiates several physiological responses, one of which is the activation of the renin-angiotensin aldosterone system (RAAS). This system breaks down bradykinin, a potent vasodilator, through the action of angiotensin-converting enzyme (ACE).

      RAAS activation results in increased aldosterone levels, which in turn increases the number of epithelial sodium channels (ENAC) to enhance sodium reabsorption.

      Another response to low blood pressure is the release of antidiuretic hormone, which promotes the insertion of aquaporin-2 channels in the collecting duct. This mechanism increases water reabsorption to help maintain fluid balance in the body.

      Understanding Antidiuretic Hormone (ADH)

      Antidiuretic hormone (ADH) is a hormone that is produced in the supraoptic nuclei of the hypothalamus and released by the posterior pituitary gland. Its primary function is to conserve body water by promoting water reabsorption in the collecting ducts of the kidneys through the insertion of aquaporin-2 channels.

      ADH secretion is regulated by various factors. An increase in extracellular fluid osmolality, a decrease in volume or pressure, and the presence of angiotensin II can all increase ADH secretion. Conversely, a decrease in extracellular fluid osmolality, an increase in volume, a decrease in temperature, or the absence of ADH can decrease its secretion.

      Diabetes insipidus (DI) is a condition that occurs when there is either a deficiency of ADH (cranial DI) or an insensitivity to ADH (nephrogenic DI). Cranial DI can be treated with desmopressin, which is an analog of ADH.

      Overall, understanding the role of ADH in regulating water balance in the body is crucial for maintaining proper hydration and preventing conditions like DI.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 17 - A 23-year-old male patient visits his GP complaining of breast tissue enlargement that...

    Correct

    • A 23-year-old male patient visits his GP complaining of breast tissue enlargement that has been progressively worsening for the past 3 months. He also reports the presence of a new lump on his left testicle. Upon thorough examination and taking a detailed medical history, the GP suspects that the patient may be suffering from testicular cancer.

      What is the probable diagnosis?

      Your Answer: HCG secreting seminoma

      Explanation:

      Gynaecomastia can be caused by testicular conditions such as seminoma that secrete hCG.

      Understanding Gynaecomastia: Causes and Drug Triggers

      Gynaecomastia is a condition characterized by the abnormal growth of breast tissue in males, often caused by an increased ratio of oestrogen to androgen. It is important to distinguish the causes of gynaecomastia from those of galactorrhoea, which is caused by the actions of prolactin on breast tissue.

      Physiological changes during puberty can lead to gynaecomastia, but it can also be caused by syndromes with androgen deficiency such as Kallmann and Klinefelter’s, testicular failure due to mumps, liver disease, testicular cancer, and hyperthyroidism. Additionally, haemodialysis and ectopic tumour secretion can also trigger gynaecomastia.

      Drug-induced gynaecomastia is also a common cause, with spironolactone being the most frequent trigger. Other drugs that can cause gynaecomastia include cimetidine, digoxin, cannabis, finasteride, GnRH agonists like goserelin and buserelin, oestrogens, and anabolic steroids. However, it is important to note that very rare drug causes of gynaecomastia include tricyclics, isoniazid, calcium channel blockers, heroin, busulfan, and methyldopa.

      In summary, understanding the causes and drug triggers of gynaecomastia is crucial in diagnosing and treating this condition.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 18 - A patient currently being treated for bipolar disorder with lithium is referred to...

    Incorrect

    • A patient currently being treated for bipolar disorder with lithium is referred to hospital after developing severe polyuria. She denies polydipsia.

      Blood tests reveal the following:

      Na+ 154 mmol/L (135 - 145)
      K+ 3.5 mmol/L (3.5 - 5.0)
      Bicarbonate 24 mmol/L (22 - 29)
      Urea 8 mmol/L (2.0 - 7.0)
      Creatinine 110 µmol/L (55 - 120)
      Blood glucose 7mmol/L (4 - 11)

      Based on the results, a decision is made to carry out a water deprivation test. The patient is considered to have capacity and agrees to this. As part of this test, desmopressin is given.

      Considering the most likely diagnosis, which of the following results would be most likely to be seen in a 45-year-old patient?

      Your Answer: High urine osmolality after fluid deprivation and normal urine osmolality after desmopressin provision

      Correct Answer: Low urine osmolality after fluid deprivation and low urine osmolality after desmopressin provision

      Explanation:

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

    • This question is part of the following fields:

      • Endocrine System
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  • Question 19 - A 54-year-old man with a history of type II diabetes mellitus presents for...

    Incorrect

    • A 54-year-old man with a history of type II diabetes mellitus presents for a routine check-up. He reports no symptoms of increased urination or thirst. Laboratory results reveal an HbA1c level of 67 mmol/mol and a random plasma glucose level of 15.6 mg/l. The patient is currently taking metformin, and his physician decides to add gliclazide to his medication regimen. What is the mechanism of action of gliclazide?

      Your Answer: Inhibits dipeptidyl peptides-4

      Correct Answer: Stimulates sulphonylurea-1 receptors

      Explanation:

      The primary mode of action of gliclazide, which belongs to the sulphonylurea class, is to activate the sulphonylurea-1 receptors present on pancreatic cells, thereby promoting insulin secretion. The remaining choices pertain to alternative medications for diabetes.

      Common Medications for Type 2 Diabetes

      Type 2 diabetes is a chronic condition that affects millions of people worldwide. Fortunately, there are several medications available to help manage the disease. Some of the most commonly prescribed drugs include sulphonylureas, metformin, alpha-glucosidase inhibitors (such as acarbose), glitazones, and insulin.

      Sulphonylureas are a type of medication that stimulates the pancreas to produce more insulin. This helps to lower blood sugar levels and improve glucose control. Metformin, on the other hand, works by reducing the amount of glucose produced by the liver and improving insulin sensitivity. Alpha-glucosidase inhibitors, like acarbose, slow down the digestion of carbohydrates in the small intestine, which helps to prevent spikes in blood sugar levels after meals.

      Glitazones, also known as thiazolidinediones, improve insulin sensitivity and reduce insulin resistance. They work by activating a specific receptor in the body that helps to regulate glucose metabolism. Finally, insulin is a hormone that is naturally produced by the pancreas and helps to regulate blood sugar levels. In some cases, people with type 2 diabetes may need to take insulin injections to help manage their condition.

      Overall, these medications can be very effective in helping people with type 2 diabetes to manage their blood sugar levels and prevent complications. However, it’s important to work closely with a healthcare provider to determine the best treatment plan for each individual.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 20 - A 33-year-old man arrives at the emergency department with symptoms of increased thirst...

    Correct

    • A 33-year-old man arrives at the emergency department with symptoms of increased thirst and frequent urination. He had suffered a head injury a few days ago and had previously been discharged after investigations. Upon examination, he appears dehydrated and is admitted to a medical ward. The urine osmolality test results show a low level of 250 mosmol/kg after water deprivation and a high level of 655 mosmol/kg after desmopressin administration. Based on this information, where is the deficient substance typically active?

      Your Answer: Collecting duct

      Explanation:

      The site of action for antidiuretic hormone (ADH) is the collecting ducts in the kidneys. A diagnosis of cranial diabetes insipidus, which can occur after head trauma, is confirmed by low urine osmolalities. In this condition, there is a deficiency of ADH, which is synthesized in the hypothalamus but acts on the collecting ducts to promote water reabsorption. Therefore, the hypothalamus is not the site of action for ADH, despite being where it is synthesized. The Loop of Henle and proximal convoluted tubule are also not the primary sites of action for ADH. ADH is released from the posterior pituitary gland, but its action occurs in the collecting ducts.

      Understanding Antidiuretic Hormone (ADH)

      Antidiuretic hormone (ADH) is a hormone that is produced in the supraoptic nuclei of the hypothalamus and released by the posterior pituitary gland. Its primary function is to conserve body water by promoting water reabsorption in the collecting ducts of the kidneys through the insertion of aquaporin-2 channels.

      ADH secretion is regulated by various factors. An increase in extracellular fluid osmolality, a decrease in volume or pressure, and the presence of angiotensin II can all increase ADH secretion. Conversely, a decrease in extracellular fluid osmolality, an increase in volume, a decrease in temperature, or the absence of ADH can decrease its secretion.

      Diabetes insipidus (DI) is a condition that occurs when there is either a deficiency of ADH (cranial DI) or an insensitivity to ADH (nephrogenic DI). Cranial DI can be treated with desmopressin, which is an analog of ADH.

      Overall, understanding the role of ADH in regulating water balance in the body is crucial for maintaining proper hydration and preventing conditions like DI.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 21 - A 60-year-old woman complains of persistent diarrhoea, wheezing, and flushing. During the physical...

    Incorrect

    • A 60-year-old woman complains of persistent diarrhoea, wheezing, and flushing. During the physical examination, an irregular pulsatile hepatomegaly and a pansystolic murmur that is most pronounced during inspiration are detected. What diagnostic test could provide insight into the probable underlying condition?

      Your Answer: Echocardiogram

      Correct Answer: Urinary 5-HIAA (5-hydroxyindole acetic acid)

      Explanation:

      Carcinoid Syndrome and its Diagnosis

      Carcinoid syndrome is characterized by the presence of vasoactive amines such as serotonin in the bloodstream, leading to various clinical features. The primary carcinoid tumor is usually found in the small intestine or appendix, but it may not cause significant symptoms as the liver detoxifies the blood of these amines. However, systemic effects occur when malignant cells spread to other organs, such as the lungs, which are not part of the portal circulation. One of the complications of carcinoid syndrome is damage to the right heart valves, which can cause tricuspid regurgitation, as evidenced by a pulsatile liver and pansystolic murmur.

      To diagnose carcinoid syndrome, the 5-HIAA test is usually performed, which measures the breakdown product of serotonin in a 24-hour urine collection. If the test is positive, imaging and histology are necessary to confirm malignancy.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 22 - A teenage girl and her mother come to the doctor's office with concerns...

    Correct

    • A teenage girl and her mother come to the doctor's office with concerns about ambiguous genitalia. After gathering information and conducting various tests, the doctor determines that the cause is congenital adrenal hyperplasia, which is linked to a deficiency in which specific enzyme?

      Your Answer: 21-hydroxylase

      Explanation:

      Insufficient production of cortisol and compensatory adrenal hyperplasia are the consequences of 21-hydroxylase deficiency. This leads to elevated androgen production and ambiguous genitalia. However, enzymes such as 5-a reductase, aromatase, 17B-HSD, and aldosterone synthase are not involved in this disorder. Other enzymes, including 11-beta hydroxylase and 17-hydroxylase, may also be involved.

      Congenital adrenal hyperplasia is a genetic condition that affects the adrenal glands and can result in various symptoms depending on the specific enzyme deficiency. One common form is 21-hydroxylase deficiency, which can cause virilization of female genitalia, precocious puberty in males, and a salt-losing crisis in 60-70% of patients during the first few weeks of life. Another form is 11-beta hydroxylase deficiency, which can also cause virilization and precocious puberty, as well as hypertension and hypokalemia. A third form is 17-hydroxylase deficiency, which typically does not cause virilization in females but can result in intersex characteristics in boys and hypertension.

      Overall, congenital adrenal hyperplasia can have significant impacts on a person’s physical development and health, and early diagnosis and treatment are important for managing symptoms and preventing complications.

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      • Endocrine System
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  • Question 23 - A 55-year-old man presents to your clinic with numbness and paraesthesia in his...

    Correct

    • A 55-year-old man presents to your clinic with numbness and paraesthesia in his right thumb and index finger. His hands seem enlarged and you observe significant gaps between his teeth. Which hormone is expected to be elevated?

      Your Answer: Growth hormone

      Explanation:

      Excessive growth hormone can cause prognathism, spade-like hands, and tall stature. Patients may experience discomfort due to ill-fitting hats or shoes, as well as joint pain, headaches, and visual issues. It is important to note that gigantism occurs when there is an excess of growth hormone secretion before growth plate fusion, while acromegaly occurs when there is an excess of secretion after growth plate fusion.

      Understanding Growth Hormone and Its Functions

      Growth hormone (GH) is a hormone produced by the somatotroph cells in the anterior pituitary gland. It plays a crucial role in postnatal growth and development, as well as in regulating protein, lipid, and carbohydrate metabolism. GH acts on a transmembrane receptor for growth factor, leading to receptor dimerization and direct or indirect effects on tissues via insulin-like growth factor 1 (IGF-1), which is primarily secreted by the liver.

      GH secretion is regulated by various factors, including growth hormone releasing hormone (GHRH), fasting, exercise, and sleep. Conversely, glucose and somatostatin can decrease GH secretion. Disorders associated with GH include acromegaly, which results from excess GH, and GH deficiency, which can lead to short stature.

      In summary, GH is a vital hormone that plays a significant role in growth and metabolism. Understanding its functions and regulation can help in the diagnosis and treatment of GH-related disorders.

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      • Endocrine System
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  • Question 24 - A 50-year-old man with type 2 diabetes mellitus, who is currently on metformin,...

    Correct

    • A 50-year-old man with type 2 diabetes mellitus, who is currently on metformin, visits for his diabetic check-up. His blood sugar levels are not well-controlled and the doctor decides to prescribe gliclazide in addition to his current medication. During the consultation, the doctor discusses the potential side effects of sulfonylureas. What is a possible side effect of sulfonylureas?

      Your Answer: Hypoglycaemia

      Explanation:

      Hypoglycaemia is a significant adverse effect of sulfonylureas, including gliclazide, which stimulate insulin secretion from the pancreas. Patients taking sulfonylureas should be educated about the possibility of hypoglycaemia and instructed on how to manage it if it occurs. Acarbose commonly causes flatulence, while PPAR agonists (glitazones) can lead to fluid retention, and metformin may cause nausea and diarrhoea.

      Sulfonylureas are a type of medication used to treat type 2 diabetes mellitus. They work by increasing the amount of insulin produced by the pancreas, but only if the beta cells in the pancreas are functioning properly. Sulfonylureas bind to a specific channel on the cell membrane of pancreatic beta cells, known as the ATP-dependent K+ channel (KATP).

      While sulfonylureas can be effective in managing diabetes, they can also cause some adverse effects. The most common side effect is hypoglycemia, which is more likely to occur with long-acting preparations like chlorpropamide. Another common side effect is weight gain. However, there are also rarer side effects that can occur, such as hyponatremia (low sodium levels) due to inappropriate ADH secretion, bone marrow suppression, hepatotoxicity (liver damage), and peripheral neuropathy.

      It is important to note that sulfonylureas should not be used during pregnancy or while breastfeeding.

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      • Endocrine System
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  • Question 25 - A 70-year-old man with chronic back pain and renal failure presents with the...

    Correct

    • A 70-year-old man with chronic back pain and renal failure presents with the following blood test results:

      Reference range
      Ca2+ 2.10 2.15-2.55 mmol/l
      Parathyroid hormone 9.8 1-6.5 pmol/l
      Phosphate 0.75 0.6-1.25 mmol/l

      What is the probable diagnosis?

      Your Answer: Secondary hyperparathyroidism

      Explanation:

      Secondary hyperparathyroidism is characterized by elevated levels of PTH, while calcium levels are either normal or low. This condition occurs due to the parathyroid glands’ hyperplasia in response to chronic hypocalcemia or hyperphosphatemia, which is a natural physiological reaction. The body releases calcium from the kidneys, gastrointestinal system, and bones.

      Parathyroid Glands and Disorders of Calcium Metabolism

      The parathyroid glands play a crucial role in regulating calcium levels in the body. Hyperparathyroidism is a disorder that occurs when these glands produce too much parathyroid hormone (PTH), leading to abnormal calcium metabolism. Primary hyperparathyroidism is the most common form and is usually caused by a solitary adenoma. Secondary hyperparathyroidism occurs as a result of low calcium levels, often in the setting of chronic renal failure. Tertiary hyperparathyroidism is a rare condition that occurs when hyperplasia of the parathyroid glands persists after correction of underlying renal disorder.

      Diagnosis of hyperparathyroidism is based on hormone profiles and clinical features. Treatment options vary depending on the type and severity of the disorder. Surgery is usually indicated for primary hyperparathyroidism if certain criteria are met, such as elevated serum calcium levels, hypercalciuria, and nephrolithiasis. Secondary hyperparathyroidism is typically managed with medical therapy, while surgery may be necessary for persistent symptoms such as bone pain and soft tissue calcifications. Tertiary hyperparathyroidism may resolve on its own within a year after transplant, but surgery may be required if an autonomously functioning parathyroid gland is present. It is important to consider differential diagnoses, such as benign familial hypocalciuric hypercalcaemia, which is a rare but relatively benign condition.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 26 - A 35-year-old woman comes in with symptoms of renal colic. Upon conducting tests,...

    Correct

    • A 35-year-old woman comes in with symptoms of renal colic. Upon conducting tests, the following results are obtained:
      Corrected Calcium 3.84 mmol/l
      PTH 88 pg/ml (increased)
      Her serum urea and electrolytes are within normal range.
      What is the probable diagnosis?

      Your Answer: Primary hyperparathyroidism

      Explanation:

      The most probable diagnosis in this scenario is primary hyperparathyroidism, as serum urea and electrolytes are normal, making tertiary hyperparathyroidism less likely.

      Primary Hyperparathyroidism: Causes, Symptoms, and Treatment

      Primary hyperparathyroidism is a condition that is commonly seen in elderly females and is characterized by an unquenchable thirst and an inappropriately normal or raised parathyroid hormone level. It is usually caused by a solitary adenoma, hyperplasia, multiple adenoma, or carcinoma. While around 80% of patients are asymptomatic, the symptomatic features of primary hyperparathyroidism may include polydipsia, polyuria, depression, anorexia, nausea, constipation, peptic ulceration, pancreatitis, bone pain/fracture, renal stones, and hypertension.

      Primary hyperparathyroidism is associated with hypertension and multiple endocrine neoplasia, such as MEN I and II. To diagnose this condition, doctors may perform a technetium-MIBI subtraction scan or look for a characteristic X-ray finding of hyperparathyroidism called the pepperpot skull.

      The definitive management for primary hyperparathyroidism is total parathyroidectomy. However, conservative management may be offered if the calcium level is less than 0.25 mmol/L above the upper limit of normal, the patient is over 50 years old, and there is no evidence of end-organ damage. Patients who are not suitable for surgery may be treated with cinacalcet, a calcimimetic that mimics the action of calcium on tissues by allosteric activation of the calcium-sensing receptor.

      In summary, primary hyperparathyroidism is a condition that can cause various symptoms and is commonly seen in elderly females. It can be diagnosed through various tests and managed through surgery or medication.

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      • Endocrine System
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  • Question 27 - A 55-year-old man comes in for his regular check-up with his GP. He...

    Correct

    • A 55-year-old man comes in for his regular check-up with his GP. He has a medical history of chronic pancreatitis and diabetes mellitus and is currently taking the maximum doses of metformin and gliclazide. During a random plasma glucose test, his levels show 18.0 mmol/l and his urinalysis reveals glycosuria with minimal ketones. The GP suspects that his body is not producing enough insulin and decides to initiate insulin therapy. Can you identify the location in the body where insulin is produced?

      Your Answer: Pancreatic beta cells

      Explanation:

      Diabetes mellitus in this patient is most likely caused by chronic pancreatitis, which has resulted in the destruction of the pancreatic endocrine cells responsible for producing endogenous insulin. These cells are located in the Islets of Langerhans and are known as pancreatic beta cells (β-cells). Other cells in the pancreas, such as alpha cells (which secrete glucagon) and delta cells (which secrete somatostatin), do not produce insulin. Similarly, gastric G cells secrete gastrin and are not involved in insulin production.

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

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      • Endocrine System
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  • Question 28 - A 55-year-old male comes to see you with worries about his weight. He...

    Correct

    • A 55-year-old male comes to see you with worries about his weight. He has a BMI of 32 and you suspect he may have metabolic syndrome. What is one of the diagnostic criteria for this condition?

      Your Answer: Dyslipidaemia

      Explanation:

      Metabolic syndrome is a group of risk factors for cardiovascular disease that are closely related to insulin resistance and central obesity.

      The diagnostic criteria for metabolic syndrome vary widely, but the International Diabetes Federation (IDF) and American Heart Association (AHA) have established their own criteria, which are commonly used. A diagnosis is made if three or more of the following criteria are present: increased waist circumference (depending on ethnicity) or a BMI greater than 30, dyslipidemia with elevated triglycerides greater than 150 mg/dL or reduced HDL-cholesterol, hypertension, and impaired glucose tolerance.

      The Physiology of Obesity: Leptin and Ghrelin

      Leptin is a hormone produced by adipose tissue that plays a crucial role in regulating body weight. It acts on the hypothalamus, specifically on the satiety centers, to decrease appetite and induce feelings of fullness. In cases of obesity, where there is an excess of adipose tissue, leptin levels are high. Leptin also stimulates the release of melanocyte-stimulating hormone (MSH) and corticotrophin-releasing hormone (CRH), which further contribute to the regulation of appetite. On the other hand, low levels of leptin stimulate the release of neuropeptide Y (NPY), which increases appetite.

      Ghrelin, on the other hand, is a hormone that stimulates hunger. It is mainly produced by the P/D1 cells lining the fundus of the stomach and epsilon cells of the pancreas. Ghrelin levels increase before meals, signaling the body to prepare for food intake, and decrease after meals, indicating that the body has received enough nutrients.

      In summary, the balance between leptin and ghrelin plays a crucial role in regulating appetite and body weight. In cases of obesity, there is an imbalance in this system, with high levels of leptin and potentially disrupted ghrelin signaling, leading to increased appetite and weight gain.

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      • Endocrine System
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  • Question 29 - A 15-year-old girl comes to the Emergency Department complaining of sudden onset pain...

    Correct

    • A 15-year-old girl comes to the Emergency Department complaining of sudden onset pain in the right iliac fossa, along with nausea, vomiting, and fever. She has no significant medical or surgical history. During the examination, you observe rebound tenderness at McBurney's point, guarding, and a positive Rovsing's sign. You suspect appendicitis and decide to take her for surgery.

      What is the most probable physiological response in this situation?

      Your Answer: Increased glucagon secretion

      Explanation:

      Glucagon secretion increases in response to physiological stresses such as inflammation of the appendix and surgery. This is because glucagon helps to increase glucose availability in the body through glycogenolysis and gluconeogenesis. During times of stress, the body’s response is to increase glucose and oxygen availability, increased sympathetic activity, and redirect energy towards more crucial functions such as increasing blood pressure and heart rate.

      However, insulin and glucagon have opposite effects on glucose regulation. Therefore, any factor that stimulates glucagon secretion must decrease insulin levels. This is because insulin reduces glucose availability in the body, which weakens the body’s ability to cope with stress.

      The hypothalamic-pituitary-adrenal axis is also activated during times of stress, leading to the production of cortisol. Cortisol plays an important role in releasing glucose from fat storage, which is necessary for the body’s stress response. Therefore, the level of ACTH, which stimulates cortisol production, would increase rather than decrease.

      Cortisol and glucocorticoids also inhibit thyroid hormone secretion. As a result, the level of T4, which is a modulator of metabolic rate, would decrease during times of stress. This is because the body needs to divert energy away from metabolism and towards more acute functions during times of stress.

      Glucagon: The Hormonal Antagonist to Insulin

      Glucagon is a hormone that is released from the alpha cells of the Islets of Langerhans in the pancreas. It has the opposite metabolic effects to insulin, resulting in increased plasma glucose levels. Glucagon functions by promoting glycogenolysis, gluconeogenesis, and lipolysis. It is regulated by various factors such as hypoglycemia, stresses like infections, burns, surgery, increased catecholamines, and sympathetic nervous system stimulation, as well as increased plasma amino acids. On the other hand, glucagon secretion decreases with hyperglycemia, insulin, somatostatin, and increased free fatty acids and keto acids.

      Glucagon is used to rapidly reverse the effects of hypoglycemia in diabetics. It is an essential hormone that plays a crucial role in maintaining glucose homeostasis in the body. Its antagonistic relationship with insulin helps to regulate blood glucose levels and prevent hyperglycemia. Understanding the regulation and function of glucagon is crucial in the management of diabetes and other metabolic disorders.

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      • Endocrine System
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  • Question 30 - Which one of the following statements is true of glucagon? ...

    Correct

    • Which one of the following statements is true of glucagon?

      Your Answer: Produced in response to an increase of amino acids

      Explanation:

      Glucagon is a polypeptide protein that is synthesized by the alpha cells of the pancreatic islets of Langerhans. It is released in response to low blood sugar levels and the presence of amino acids. Glucagon is responsible for elevating the levels of glucose and ketones in the bloodstream.

      Glucagon: The Hormonal Antagonist to Insulin

      Glucagon is a hormone that is released from the alpha cells of the Islets of Langerhans in the pancreas. It has the opposite metabolic effects to insulin, resulting in increased plasma glucose levels. Glucagon functions by promoting glycogenolysis, gluconeogenesis, and lipolysis. It is regulated by various factors such as hypoglycemia, stresses like infections, burns, surgery, increased catecholamines, and sympathetic nervous system stimulation, as well as increased plasma amino acids. On the other hand, glucagon secretion decreases with hyperglycemia, insulin, somatostatin, and increased free fatty acids and keto acids.

      Glucagon is used to rapidly reverse the effects of hypoglycemia in diabetics. It is an essential hormone that plays a crucial role in maintaining glucose homeostasis in the body. Its antagonistic relationship with insulin helps to regulate blood glucose levels and prevent hyperglycemia. Understanding the regulation and function of glucagon is crucial in the management of diabetes and other metabolic disorders.

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      • Endocrine System
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