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Question 1
Correct
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A 45-year-old woman presents to her General Practitioner with a 2-month history of fatigue and muscle weakness.
During the examination, her blood pressure is found to be 160/95 mmHg. The rest of the examination is normal. The General Practitioner decides to order routine blood tests. The results are as follows:
Investigation Result Normal value
Sodium (Na+) 151 mmol
Potassium (K+) 3.0 mmol
Bicarbonate 29 mmol/l
Urea 5.2 mmol/l
Creatinine 70.5 µmol/l
Random glucose 5.8 mmol/l
What is the most appropriate first-line investigation to make a diagnosis?Your Answer: Aldosterone/renin ratio
Explanation:The patient’s symptoms of hypertension, hypokalaemia, and hypernatraemia suggest a diagnosis of hyperaldosteronism, which is characterized by increased water and sodium reabsorption in the kidneys and potassium loss due to high aldosterone levels. While muscle weakness and lethargy are common symptoms, they are only present in 40% of cases. Metabolic alkalosis is another common finding. Primary hyperaldosteronism is often caused by bilateral idiopathic adrenal hyperplasia, rather than an adrenal adenoma. To diagnose hyperaldosteronism, a plasma aldosterone/renin ratio is recommended as the first-line investigation, followed by a high-resolution CT scan of the abdomen and adrenal vein sampling to differentiate between unilateral and bilateral sources of aldosterone excess. While an overnight dexamethasone suppression test is useful for diagnosing Cushing syndrome, it is not relevant in this case. Urine dipstick and formal urinalysis would be helpful in identifying renal causes of secondary hypertension, but are not necessary in this case.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 2
Incorrect
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A 56-year-old man undergoes a routine medical check-up for his job. He shows no symptoms and his clinical examination is normal. What test result confirms a diagnosis of impaired fasting glucose?
Your Answer: 75g oral glucose tolerance test 2 hour value of 8.4 mmol/L
Correct Answer: Fasting glucose 6.8 mmol/L on two occasions
Explanation:An oral glucose tolerance test result of 8.4 mmol/L after 2 hours with a 75g glucose load suggests impaired glucose tolerance instead of impaired fasting glucose.
Type 2 diabetes mellitus can be diagnosed through a plasma glucose or HbA1c sample. The diagnostic criteria vary depending on whether the patient is experiencing symptoms or not. If the patient is symptomatic, a fasting glucose level of 7.0 mmol/l or higher or a random glucose level of 11.1 mmol/l or higher (or after a 75g oral glucose tolerance test) indicates diabetes. If the patient is asymptomatic, the same criteria apply but must be demonstrated on two separate occasions.
In 2011, the World Health Organization released supplementary guidance on the use of HbA1c for diagnosing diabetes. A HbA1c level of 48 mmol/mol (6.5%) or higher is diagnostic of diabetes mellitus. However, a HbA1c value of less than 48 mmol/mol (6.5%) does not exclude diabetes and may not be as sensitive as fasting samples for detecting diabetes. For patients without symptoms, the test must be repeated to confirm the diagnosis. It is important to note that increased red cell turnover can cause misleading HbA1c results.
There are certain conditions where HbA1c cannot be used for diagnosis, such as haemoglobinopathies, haemolytic anaemia, untreated iron deficiency anaemia, suspected gestational diabetes, children, HIV, chronic kidney disease, and people taking medication that may cause hyperglycaemia (such as corticosteroids).
Impaired fasting glucose (IFG) is defined as a fasting glucose level of 6.1 mmol/l or higher but less than 7.0 mmol/l. Impaired glucose tolerance (IGT) is defined as a fasting plasma glucose level less than 7.0 mmol/l and an OGTT 2-hour value of 7.8 mmol/l or higher but less than 11.1 mmol/l. People with IFG should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person does not have diabetes but does have IGT.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 3
Correct
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A 42-year-old man is worried about his chances of developing heart disease due to his family history. His father passed away from a heart attack at the age of 45. During his medical check-up, his lipid profile is as follows:
HDL: 1.4 mmol/l
LDL: 5.7 mmol/l
Triglycerides: 2.3 mmol/l
Total cholesterol: 8.2 mmol/l
Upon clinical examination, the doctor notices tendon xanthomata around his ankles. What is the most probable diagnosis?Your Answer: Familial hypercholesterolaemia
Explanation:Familial hypercholesterolaemia can be diagnosed when there are tendon xanthomata and elevated cholesterol levels present.
Familial Hypercholesterolaemia: Causes, Diagnosis, and Management
Familial hypercholesterolaemia (FH) is a genetic condition that affects approximately 1 in 500 people. It is an autosomal dominant disorder that results in high levels of LDL-cholesterol, which can lead to early cardiovascular disease if left untreated. FH is caused by mutations in the gene that encodes the LDL-receptor protein.
To diagnose FH, NICE recommends suspecting it as a possible diagnosis in adults with a total cholesterol level greater than 7.5 mmol/l and/or a personal or family history of premature coronary heart disease. For children of affected parents, testing should be arranged by age 10 if one parent is affected and by age 5 if both parents are affected. The Simon Broome criteria are used for clinical diagnosis, which includes total cholesterol and LDL-C levels, tendon xanthoma, and family history of myocardial infarction or raised cholesterol levels.
Management of FH involves referral to a specialist lipid clinic and the use of high-dose statins as first-line treatment. CVD risk estimation using standard tables is not appropriate for FH. First-degree relatives have a 50% chance of having the disorder and should be offered screening, including children who should be screened by age 10 if there is one affected parent. Statins should be discontinued in women 3 months before conception due to the risk of congenital defects.
Overall, early diagnosis and management of FH are crucial in preventing cardiovascular disease and improving patient outcomes.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 4
Incorrect
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A 42-year-old woman visits her primary care physician complaining of sudden headaches accompanied by sweating and palpitations. During the examination, the patient appears anxious and has a pale complexion. Her blood pressure is measured at 230/190 mmHg, and a 24-hour urine collection shows elevated levels of catecholamines. What is the most probable reason for this woman's hypertension?
Your Answer: Cushing syndrome
Correct Answer: Phaeochromocytoma
Explanation:Differentiating Adrenal Gland Disorders: Phaeochromocytoma, Conn Syndrome, Cushing Syndrome, PKD, and RAS
Adrenal gland disorders can present with similar symptoms, making it challenging to differentiate between them. However, understanding the unique features of each condition can aid in accurate diagnosis and appropriate management.
Phaeochromocytoma is a tumour of the adrenal gland that causes paroxysmal secretion of catecholamines, resulting in hypertension, headache, sweating, and anxiety. It is associated with the 10% rule, where 10% of cases are extramedullary, malignant, familial, and bilateral.
Conn syndrome, or primary aldosteronism, is characterised by hypertension, hypokalaemia, and metabolic alkalosis. The most common causes are aldosterone-producing adenomas and bilateral adrenal hyperplasia.
Cushing syndrome is caused by prolonged hypercortisolism and presents with centripetal obesity, secondary hypertension, glucose intolerance, proximal myopathy, and hirsutism. Sweating, palpitations, and elevated catecholamines are not typical of hypercortisolism.
Polycystic kidney disease (PKD) is associated with hypertension due to progressive kidney enlargement. It is a significant independent risk factor for progression to end-stage renal failure, but it does not cause elevated catecholamine levels.
Renal artery stenosis (RAS) is a major cause of renovascular hypertension, but it is not associated with elevated catecholamines or the symptoms described. Patients with RAS may also have a history of atherosclerosis, dyslipidaemia, smoking, and hypertension resistant to multiple antihypertensive medications.
In summary, understanding the unique features of adrenal gland disorders can aid in accurate diagnosis and appropriate management.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 5
Incorrect
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A 28-year-old woman presents to her GP with complaints of weight gain, hair loss, constipation, feeling cold all the time, and absence of menstrual periods. She also had difficulty breastfeeding after giving birth. Her medical history is unremarkable except for a previous episode of hypovolaemic shock due to significant blood loss during delivery, which required a prolonged hospital stay. What is the most probable diagnosis for her symptoms?
Your Answer: Hypothyroidism
Correct Answer: Sheehan's syndrome
Explanation:Sheehan’s syndrome, also known as postpartum hypopituitarism, is characterized by a decrease in pituitary gland function caused by ischemic necrosis resulting from hypovolemic shock after childbirth. The symptoms can be diverse and may take several years to manifest due to the pituitary damage. The patient’s presentation of amenorrhea, lactation difficulties, and hypothyroidism suggests pituitary dysfunction, which can be attributed to her complicated delivery, leading to a diagnosis of Sheehan’s syndrome.
Understanding Amenorrhoea: Causes, Investigations, and Management
Amenorrhoea is a condition characterized by the absence of menstrual periods in women. It can be classified into two types: primary and secondary. Primary amenorrhoea occurs when menstruation fails to start by the age of 15 in girls with normal secondary sexual characteristics or by the age of 13 in girls with no secondary sexual characteristics. On the other hand, secondary amenorrhoea is the cessation of menstruation for 3-6 months in women with previously normal and regular menses or 6-12 months in women with previous oligomenorrhoea.
There are various causes of amenorrhoea, including gonadal dysgenesis, testicular feminization, congenital malformations of the genital tract, functional hypothalamic amenorrhoea, congenital adrenal hyperplasia, imperforate hymen, hypothalamic amenorrhoea, polycystic ovarian syndrome, hyperprolactinemia, premature ovarian failure, Sheehan’s syndrome, Asherman’s syndrome, and thyrotoxicosis. To determine the underlying cause of amenorrhoea, initial investigations such as full blood count, urea & electrolytes, coeliac screen, thyroid function tests, gonadotrophins, prolactin, and androgen levels are necessary.
The management of amenorrhoea depends on the underlying cause. For primary amenorrhoea, it is important to investigate and treat any underlying cause. Women with primary ovarian insufficiency due to gonadal dysgenesis may benefit from hormone replacement therapy to prevent osteoporosis. For secondary amenorrhoea, it is important to exclude pregnancy, lactation, and menopause in women 40 years of age or older and treat the underlying cause accordingly. It is important to note that hypothyroidism may also cause amenorrhoea.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 6
Incorrect
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You are performing the yearly evaluation of a 42-year-old woman with type 1 diabetes mellitus. Your objective is to screen for diabetic neuropathy that may affect her feet. What is the most suitable screening test to utilize?
Your Answer: Test sensation using cotton wool
Correct Answer: Test sensation using a 10 g monofilament
Explanation:To evaluate diabetic neuropathy in the feet, it is recommended to utilize a monofilament weighing 10 grams.
Diabetic foot disease is a significant complication of diabetes mellitus that requires regular screening. In 2015, NICE published guidelines on diabetic foot disease. The disease is caused by two main factors: neuropathy, which results in a loss of protective sensation, and peripheral arterial disease, which increases the risk of macro and microvascular ischaemia. Symptoms of diabetic foot disease include loss of sensation, absent foot pulses, reduced ankle-brachial pressure index (ABPI), intermittent claudication, calluses, ulceration, Charcot’s arthropathy, cellulitis, osteomyelitis, and gangrene. All patients with diabetes should be screened for diabetic foot disease at least once a year. Screening for ischaemia involves palpating for both the dorsalis pedis pulse and posterial tibial artery pulse, while screening for neuropathy involves using a 10 g monofilament on various parts of the sole of the foot. NICE recommends that patients be risk-stratified into low, moderate, and high-risk categories based on factors such as deformity, previous ulceration or amputation, renal replacement therapy, neuropathy, and non-critical limb ischaemia. Patients who are moderate or high-risk should be regularly followed up by their local diabetic foot centre.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 7
Incorrect
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A 50-year-old woman is undergoing evaluation for hypertension that is not responding to treatment. She has a 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 for Hypercalcaemia with Elevated PTH Levels
Hypercalcaemia with elevated parathyroid hormone (PTH) levels can be indicative of several conditions. Here are some possible differential diagnoses:
Multiple Endocrine Neoplasia Type 2A (MEN 2A)
MEN 2A is caused by a gain in function mutation in the RET proto-oncogene. The classic triad of MEN 2A is medullary thyroid carcinoma, primary hyperparathyroidism, and phaeochromocytoma. Patients with MEN 2A may also have treatment-resistant hypertension.Marfan Syndrome
Marfan syndrome is a hereditary disorder of connective tissue. Patients with Marfan syndrome are typically tall and thin with hyperlax joints, recurrent dislocation of the lens of the eye, and cardiovascular anomalies (particularly aortic regurgitation). However, dysfunction of the parathyroid hormone axis is not usually associated with this condition.Multiple Endocrine Neoplasia Type 1 (MEN 1)
MEN 1 also occurs due to a mutation in the RET gene. However, patients with MEN 1 classically suffer from hyperparathyroidism, pituitary adenomas (typically prolactinomas), and pancreatic islet cell tumors, and not the features described in the case.Multiple Myeloma
Multiple myeloma is also associated with hypercalcaemia, but PTH levels would be appropriately low.Neurofibromatosis
Neurofibromatosis is a disorder caused by a mutation in the neurofibromin gene on chromosome 17. It is associated with multiple neural tumors together with a variety of skin, musculoskeletal, and ocular manifestations, but disruption of the parathyroid hormone axis is not a feature. -
This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 8
Correct
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A 52-year-old woman with a body mass index (BMI) of 32 was diagnosed with type 2 diabetes mellitus during a routine check-up six months ago. Despite being advised about a low-energy, weight-reducing diet and exercise, she has not followed through with these recommendations and her postprandial blood glucose concentration is 13.8 mmol/l (reference range <11.1 mmol/l). What would be the drug of choice in this case?
Your Answer: Metformin
Explanation:Medications for Type 2 Diabetes
Metformin: The Initial Drug Treatment of Choice
For adults with type 2 diabetes, standard-release metformin is the recommended initial drug treatment. The dose should be gradually increased to avoid gastrointestinal side effects. If significant GI side effects occur, modified-release metformin can be tried. Metformin reduces hepatic gluconeogenesis and increases insulin sensitivity, leading to an increase in peripheral glucose uptake. However, caution should be exercised when using metformin in patients with renal failure, and it should be stopped if the estimated glomerular filtration rate is less than 30 ml/min per 1.73m2.Tolbutamide and Chlorpropamide: First-Generation Sulfonylureas
Tolbutamide and chlorpropamide are first-generation sulfonylureas that are no longer routinely used in the treatment of type 2 diabetes due to a higher incidence of side effects compared to newer, second-generation sulfonylureas. Chlorpropamide is not available in the UK.Insulin: Considered for Dual Therapy
Insulin-based treatment should be considered in type 2 diabetes patients who have not achieved optimal glycated haemoglobin control with dual therapy using metformin and another oral drug. Metformin should continue to be offered to patients without contraindications or intolerance.Pioglitazone: An Alternative Second-Line Agent
Pioglitazone can be considered as an alternative second-line agent for patients with type 2 diabetes who cannot take metformin or have not tolerated it well. It can also be used in dual therapy for first intensification of treatment. -
This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 9
Incorrect
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As the on-call FY2 covering the wards, you are asked to assess a 55-year-old woman who was admitted yesterday with community-acquired left basal pneumonia. Over the past 12 hours, she has deteriorated significantly with a temperature of 40.5ºC, blood pressure 160/95 mmHg, and heart rate of 130 bpm. On examination, she appears jaundiced, agitated, and confused. Her medical history includes hayfever and Graves' disease, but she has been generally healthy otherwise. What is the most important initial treatment to start for this patient, given the likely diagnosis?
Your Answer: Lugol's solution (aqueous iodine oral solution)
Correct Answer: IV propranolol
Explanation:Thyroid storm is a medical emergency that can occur in patients with hyperthyroidism, such as those with Graves’ disease. It is characterized by symptoms such as high fever, rapid heartbeat, jaundice, and altered mental status. In such cases, IV beta-blockers, such as propranolol, are the first-line treatment to inhibit the peripheral adrenergic effects of excess thyroid hormone. However, propranolol should not be used in patients with asthma or reversible COPD, and caution should be exercised in patients with heart failure. Lugol’s solution can also be used to inhibit the release of stored thyroid hormone, but it is usually delayed until after antithyroid therapy has been initiated. Therapeutic plasma exchange may be considered for patients who do not respond to medical therapy. In this case, the patient’s jaundice is likely due to her hyperthyroid crisis, and there is no evidence of biliary disease or cholecystitis. Therefore, IV co-amoxiclav, which is the first-line antibiotic for community-acquired pneumonia, would be appropriate for this patient. If propranolol is contraindicated, a cardiac-specific beta-blocker or calcium-channel blocker may be used instead. However, in this patient, IV propranolol should be used as the first-line treatment.
Understanding Thyroid Storm
Thyroid storm is a rare but serious complication of thyrotoxicosis, which is characterized by an overactive thyroid gland. It is usually seen in patients who already have thyrotoxicosis and is not typically the first symptom. It is important to note that an excess of thyroxine caused by medication does not usually lead to thyroid storm.
There are several events that can trigger thyroid storm, including surgery, trauma, infection, and exposure to iodine, such as through CT contrast media. The clinical features of thyroid storm include fever, tachycardia, confusion, nausea, vomiting, hypertension, heart failure, and abnormal liver function tests.
The management of thyroid storm involves treating the underlying cause and providing symptomatic relief. This may include medications such as beta-blockers, anti-thyroid drugs, Lugol’s iodine, and dexamethasone. Paracetamol may also be used to manage fever.
In summary, thyroid storm is a serious complication of thyrotoxicosis that requires prompt medical attention. Understanding the triggers and clinical features of thyroid storm can help with early diagnosis and effective management.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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Question 10
Correct
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A 72-year-old woman presents to her General Practitioner for review, two months after being discharged from hospital. She has hypothyroidism, maintained on 75 µg levothyroxine once a day. Following discharge, she also began taking amlodipine, amitriptyline, ferrous fumarate and ranitidine.
Investigations reveal that her thyroid-stimulating hormone (TSH) level is 9.1 mU/l (normal range: 0.25–4.0 mU/l), while her free thyroxine (T4) is 8.1 pmol/l (normal range: 12.0–22.0 pmol/l).
She is compliant with her medications and takes them all together in the morning.
Which of the following is the most likely cause of this patient’s results?
Your Answer: Ferrous fumarate
Explanation:Interactions with Levothyroxine: Understanding the Effects of Different Medications
Levothyroxine is a medication used to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone. However, certain medications can interact with levothyroxine and affect its absorption and effectiveness. Let’s explore the effects of different medications on levothyroxine and how they can impact thyroid function tests.
Ferrous Fumarate: Iron salts can reduce the absorption of levothyroxine, leading to inadequate replacement and hypothyroidism. It is recommended to take these medications at least four hours apart to avoid this interaction.
Amitriptyline: While thyroid hormones can enhance the effect of amitriptyline, this medication does not reduce the effect of levothyroxine and would not cause hypothyroidism.
Amlodipine: There is no interaction between amlodipine and levothyroxine, and this medication would not affect thyroid function tests.
Aspirin: Similarly, there is no interaction between aspirin and levothyroxine, and the use of this medication would not impact thyroid function tests.
Ranitidine: While antacids can reduce levothyroxine absorption, ranitidine is an H2 receptor antagonist and not classified as an antacid. Therefore, there is no interaction between ranitidine and levothyroxine.
In conclusion, it is important to be aware of potential interactions between medications and levothyroxine to ensure adequate treatment of hypothyroidism. By understanding the effects of different medications, healthcare professionals can make informed decisions and adjust medication schedules as needed.
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This question is part of the following fields:
- Endocrinology/Metabolic Disease
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