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Question 1
Incorrect
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A 57-year-old male presents for his first annual review of type 2 diabetes. He has also been experiencing osteoarthritis in his hips and 2nd/3rd metacarpophalangeal joints. His current medications include aspirin and metformin. Prior to starting a statin, his liver function tests are checked and reveal the following results: AST 78 U/L (5-40), ALT 88 U/L (5-40), Alkaline phosphatase 210 U/L (60-110), and Bilirubin 10 ”mol/L (0-22). He does not consume alcohol and has a BMI of 24 kg/m2. He has tested negative for hepatitis B and C viruses, ANA, ASMA, LKM, and AMA. His caeruloplasmin levels are normal. What is the probable cause of his presentation?
Your Answer: Rheumatoid arthritis
Correct Answer: Haemochromatosis
Explanation:Haemochromatosis
This patient’s medical history indicates the possibility of haemochromatosis, an iron storage disorder. The presence of diabetes despite a normal BMI, liver function abnormalities, and arthropathy are all suggestive of this condition. To confirm the diagnosis, the recommended investigation is to measure the patient’s serum ferritin levels followed by transferrin saturation. If haemochromatosis is confirmed, the treatment will involve regular venesection.
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This question is part of the following fields:
- Endocrinology
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Question 2
Incorrect
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A 50-year-old woman presents to her general practitioner, complaining of a lump in her neck. She is a non-smoker and has no significant past medical history. On examination, there is a 2-cm firm, non-tender nodule on the left side of the anterior triangle of the neck, in the area of the thyroid.
Investigations:
Thyroid stimulating hormone: 2.5 mu/l (0.4â4.0 mu/l)
Fine-needle aspiration biopsy: partial papillary architecture with some thyroid follicles present. Thyrocytes are abnormally large with an abnormal nucleus and cytoplasm and frequent mitoses. Psammoma bodies are also demonstrated in the sample.
Which of the following fits best with the underlying diagnosis?Your Answer: Medullary thyroid carcinoma
Correct Answer: Papillary thyroid carcinoma
Explanation:Thyroid Cancer Types and Diagnosis
Thyroid cancer can be classified into different types based on the cells involved. Papillary thyroid carcinoma is the most common type, where the papillary architecture of the thyroid is partially preserved. Surgery followed by radioiodine therapy is the standard treatment for this condition. Medullary thyroid carcinoma is less common and results in elevated calcitonin levels. Non-toxic multinodular goitre can be diagnosed through fine-needle aspiration biopsy, which shows colloid nodules. Follicular thyroid carcinoma exhibits variable morphology and is not consistent with fine-needle aspiration biopsy findings. Solitary toxic nodule can be ruled out if thyroid function is within normal limits. Proper diagnosis and treatment can lead to a high survival rate for patients under 40 years of age with papillary thyroid carcinoma.
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This question is part of the following fields:
- Endocrinology
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Question 3
Correct
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What is the underlying cause of primary hyperthyroidism associated with Graves' disease?
Your Answer: Anti-TSH receptor antibodies
Explanation:Graves’ Disease
Graves’ disease is a medical condition that is characterized by the presence of anti-TSH receptor antibodies that stimulate the thyroid gland. This results in hyperthyroidism and a diffusely enlarged thyroid gland, also known as a goitre. Patients with Graves’ disease may also experience other symptoms such as exophthalmos, which is the protrusion of the eyes, lid retraction, lid lag, and ophthalmoplegia.
It is important to note that Graves’ disease is often associated with other autoimmune diseases such as vitiligo, Addison’s disease, and type 1 diabetes. This means that patients with Graves’ disease may be at a higher risk of developing these conditions as well.
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This question is part of the following fields:
- Endocrinology
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Question 4
Correct
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A 21-year-old is brought unconscious to the Emergency Department. An alert ambulance attendant notes that the patient's breath smells like fruit punch. The patient was found holding a glass containing clear liquid and the ambulance attendant had noted a syringe on the patient's coffee table and a pool of vomit near the patient.
With which of the following would this presentation be most consistent?Your Answer: Diabetic ketoacidosis (DKA)
Explanation:Differentiating between medical conditions based on breath scent
When trying to identify a medical condition based on the scent of a patient’s breath, it is important to consider various factors. The presence of acetone on the breath is strongly suggestive of diabetic ketoacidosis (DKA), which is commonly seen in patients with poorly controlled type I diabetes. In contrast, profound hypoglycaemia resulting from insulin overdose does not produce a specific scent. Diabetic hyperosmolar coma, typically seen in older patients with type II diabetes, also does not produce a fruity scent. Heroin overdose and alcohol intoxication do not involve acetone production and therefore do not produce a fruity scent. It is important to consider all relevant factors when attempting to identify a medical condition based on breath scent.
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This question is part of the following fields:
- Endocrinology
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Question 5
Correct
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A 31-year-old woman presents with amenorrhoea and periodic breast discharge. She has never been pregnant and has not been sexually active for the past 2 years. She is not on any regular medications and has had regular menstrual cycles in the past. On breast examination, there are no abnormalities and she has normal secondary sexual characteristics.
What is the most suitable initial investigation for this patient?Your Answer: Prolactin level
Explanation:Investigating Hyperprolactinaemia: Tests and Imaging
Hyperprolactinaemia is a condition characterized by elevated levels of prolactin, commonly caused by a microadenoma in the pituitary gland. While no single test can determine the cause of hyperprolactinaemia, a prolactinoma is likely if the prolactin level is above 250 ng/ml. FSH levels may be low due to the inhibitory effect of raised prolactin, but this is not diagnostic. A skull X-ray may show an enlarged pituitary fossa, but only with large adenomas, making it an inappropriate investigation. Magnetic resonance imaging (MRI) is preferable to CT for further investigation into the cause of hyperprolactinaemia. Additionally, thyroid function tests may be necessary to investigate mildly raised prolactin levels in the absence of pituitary pathology.
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This question is part of the following fields:
- Endocrinology
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Question 6
Incorrect
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A 16-year-old girl visits her General Practitioner, concerned about her family's history of cardiovascular disease and wanting to investigate her own health after learning about healthy eating in school. She was found to have a fasting plasma cholesterol of 15 mmol/l.
What is the most probable reason for these findings?Your Answer: A deficiency of lipoprotein lipase
Correct Answer: A deficiency of apo B-100
Explanation:Cholesterol Metabolism: Deficiencies and High Levels of Key Proteins
Apo B-100 is a protein that binds to LDL receptors, allowing for the uptake of lipoproteins. A deficiency in apo B-100 or LDL receptors can lead to familial hypercholesterolemia and an accumulation of cholesterol.
Lipoprotein lipase is an enzyme that breaks down chylomicrons and VLDLs. A deficiency in this enzyme can result in the accumulation of both, but with normal or slightly raised cholesterol levels.
ACAT is an enzyme that catalyzes the re-synthesis of cholesterol esters. A deficiency in ACAT would lead to reduced plasma cholesterol levels.
High levels of HDL are protective as they increase cholesterol transport from tissues to the liver for conversion to bile acids and excretion in feces. However, high levels of HDL are rare.
LCAT is an enzyme that converts cholesterol taken up by HDL into a cholesterol ester, which is then transferred to lipoprotein remnants for uptake by the liver. High levels of LCAT can increase reverse cholesterol transport and reduce plasma cholesterol levels.
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This question is part of the following fields:
- Endocrinology
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Question 7
Incorrect
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A 20-year-old man with known type 1 diabetes is admitted to hospital with abdominal pain, drowsiness and severe dehydration. On examination he has a temperature of 38.2 degrees, and crackles at the bases of both lungs. Investigations show the following results:
Urinary ketones: 3+
Serum ketones: 3.6 mmol/l
Serum glucose: 21.8 mmol/l
pH 7.23
What is the most appropriate initial management?Your Answer: Insulin 0.1 units/kg/h via fixed rate insulin infusion
Correct Answer: 1 litre 0.9% normal saline over 1 h
Explanation:Management of Diabetic Ketoacidosis: Medications and Fluids
Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes that requires urgent treatment. The initial management of DKA involves fluid resuscitation with normal saline, followed by insulin infusion to correct hyperglycemia. Antibiotics are not the immediate management option of choice, even if an intercurrent infection is suspected. Glucose therapy should be administered only after initial fluid resuscitation and insulin infusion. Here is a breakdown of the medications and fluids used in the management of DKA:
1. 1 litre 0.9% normal saline over 1 h: This is the first-line treatment for DKA. Urgent fluid resuscitation is necessary to correct hypovolemia and improve tissue perfusion.
2. Amoxicillin 500 mg po TDS for 5 days: Antibiotics may be necessary if an intercurrent infection is suspected, but they are not the immediate management option of choice for DKA.
3. Clarithromycin 500 mg po bd for 5 days: Same as above.
4. Insulin 0.1 units/kg/h via fixed rate insulin infusion: After initial fluid resuscitation, insulin infusion is necessary to correct hyperglycemia and prevent further ketone production.
5. 1 litre 10% dextrose over 8 h: Glucose therapy is necessary to prevent hypoglycemia after insulin infusion, but it should not be administered initially as it can exacerbate hyperglycemia.
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This question is part of the following fields:
- Endocrinology
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Question 8
Incorrect
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A 42-year-old teacher presents to the general practitioner (GP) complaining of fatigue and muscle pains. The symptoms have been gradually worsening over the past few months, and now she feels too tired after work to attend her weekly yoga class. She has a history of seasonal allergies and takes antihistamines during the spring and summer. The patient is a non-smoker, drinks occasionally, and follows a vegetarian diet.
During examination, no abnormalities are found, and the GP orders blood tests for further investigation. The results reveal a serum vitamin D (25OHD) level of 18 nmol/l (normal value recommended > 50 nmol/l).
Which molecule involved in the vitamin D synthesis pathway binds to the vitamin D receptor to regulate calcium homeostasis?Your Answer: 24, 25-dihydroxycolecalciferol
Correct Answer: Calcitriol
Explanation:Understanding the Different Forms of Vitamin D
Vitamin D is an essential nutrient that plays a crucial role in calcium homeostasis. However, it exists in different forms, each with its own unique properties and functions. Here are the different forms of vitamin D and their roles:
1. Calcitriol: Also known as 1, 25-hydroxycolecalciferol, this form of vitamin D binds to the vitamin D receptor to create a ligand-receptor complex that alters cellular gene expression.
2. Previtamin D3: This is the precursor to vitamin D3 and does not play a direct role in calcium homeostasis.
3. Calcidiol: This is 25-hydroxycolecalciferol, the precursor to calcitriol. It has a very low affinity for the vitamin D receptor and is largely inactive.
4. Colecalciferol: This is vitamin D3, which is itself inactive and is the precursor to calcidiol.
5. 24, 25-dihydroxycolecalciferol: This is an inactive form of calcidiol and is excreted.
Understanding the different forms of vitamin D is important in determining the appropriate supplementation and treatment for vitamin D deficiency.
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This question is part of the following fields:
- Endocrinology
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Question 9
Incorrect
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A 36-year-old man visits his doctor's office accompanied by his wife, who expresses concern that her husband has been acting strangely and not like himself lately. Upon questioning, the patient appears confused and complains of a persistent headache. The doctor conducts an examination but finds no additional signs. To investigate further, the doctor orders a full blood count with electrolytes and renal function, as well as a urinary analysis. The results reveal hyponatremia with reduced plasma osmolality and high urinary osmolality and sodium. Which medication is most commonly associated with the syndrome of inappropriate antidiuretic hormone secretion (SIADH)?
Your Answer: Digoxin
Correct Answer: Carbamazepine
Explanation:Medications and their potential to cause SIADH
SIADH, or syndrome of inappropriate antidiuretic hormone secretion, is a condition where the body produces too much antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. Some medications have been known to cause SIADH, while others do not.
Carbamazepine is an anti-epileptic medication that can cause SIADH by promoting water reabsorption through stimulation of the V2 vasopressin receptor-protein G complex. Trimeprazine, a phenothiazine derivative used for motion sickness and pruritus, does not cause SIADH. Atropine, an antimuscarinic, and digoxin, a cardiac glycoside, also do not cause SIADH.
However, lithium, a mood stabilizer, can result in nephrogenic diabetes insipidus, leading to hypernatremia. It is important to be aware of the potential side effects of medications and to monitor patients for any signs of SIADH or other adverse reactions.
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This question is part of the following fields:
- Endocrinology
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Question 10
Incorrect
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A 26-year-old female trainee solicitor has been experiencing difficulty concentrating on her work for the past 2 months. She has been complaining that the work area is too hot. She appears nervous and has a fine tremor. Despite eating more, she has lost 4 kg in the last month. During a physical examination, her temperature is 37.8 °C, pulse is 110 bpm, respiratory rate is 18 per minute, and blood pressure is 145/85 mmHg. She has a wide, staring gaze and lid lag. What is the most likely laboratory finding in this woman?
Your Answer: Increased thyroid stimulating hormone (TSH)
Correct Answer: Decreased thyroid stimulating hormone (TSH)
Explanation:Understanding Thyroid Axis: Interpretation of Hormone Levels in Hyperthyroidism
Hyperthyroidism is a condition characterized by increased production of free thyroxine (T4 and T3) leading to a decrease in thyroid stimulating hormone (TSH) production at the pituitary gland. This results in a hypermetabolic state induced by excess thyroid hormone and overactivity of the sympathetic nervous system. Ocular changes such as a wide, staring gaze and lid lag are common. However, true thyroid ophthalmopathy associated with proptosis is seen only in Gravesâ disease.
Decreased plasma insulin indicates diabetes mellitus, while increased TSH in this setting indicates secondary hyperthyroidism, a rare condition caused by pathology at the level of the pituitary. Increased adrenocorticotropic hormone (ACTH) is not related to the patient’s symptoms, and increased calcitonin is not a feature of hyperthyroidism but may indicate medullary thyroid cancers. Understanding the interpretation of hormone levels in hyperthyroidism is crucial for accurate diagnosis and management.
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This question is part of the following fields:
- Endocrinology
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Question 11
Incorrect
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A 25-year-old woman visits her endocrinologist for follow-up. She has a medical history of primary hyperparathyroidism and prolactinoma. After undergoing genetic testing, she was diagnosed with multiple endocrine neoplasia type 1 (MEN1) syndrome. She is planning to start a family and wants to know the likelihood of her child inheriting MEN1. Her partner has no known medical conditions.
What is the mode of inheritance for MEN1 syndrome?Your Answer: Autosomal recessive
Correct Answer: Autosomal dominant
Explanation:Understanding the Inheritance Patterns of Multiple Endocrine Neoplasia (MEN) Syndromes
Multiple Endocrine Neoplasia (MEN) syndromes are a group of rare genetic disorders that predispose individuals to the development of tumors in multiple endocrine glands. Understanding the inheritance patterns of these syndromes is crucial for genetic counseling and early detection of tumors.
MEN1 is an autosomal dominant condition caused by a mutation in the menin gene. This means that if one parent carries the mutation, there is a 50% chance of passing it on to their children. Over 1000 mutations have been described in this gene, leading to a loss of tumor-suppressor function and an increased risk of tumors in the parathyroid, pancreas, and pituitary gland, as well as other organs.
Cystic fibrosis, on the other hand, is an example of an autosomal recessive condition. If both parents carry the mutation, there is a 25% chance of their child inheriting the condition.
X-linked dominant and recessive conditions are also possible, but they do not apply to MEN syndromes. In X-linked dominant conditions, affected mothers have a 50% chance of passing the condition to their children, while in X-linked recessive conditions, females can only be carriers but can still pass the condition to their sons.
It is important to note that while most MEN syndromes are inherited in an autosomal dominant pattern, sporadic cases can also occur. In these cases, a family history may be absent because the parent with the disease may have died before symptoms developed. Genetic testing and counseling can help identify individuals at risk and provide appropriate management and surveillance.
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This question is part of the following fields:
- Endocrinology
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Question 12
Incorrect
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A 63-year-old, non-smoking woman without previous cardiac history, has a total cholesterol of 9.0 mmol/l. She is overweight and has sleep apnoea. On examination you notice her skin is particularly dry and there appears to be some evidence of hair loss. Her blood pressure is 140/95 mmHg and pulse rate 60 bpm.
What would be the most appropriate next step in managing this patient?Your Answer: Measure her 24-hour urinary free cortisol
Correct Answer: Check her thyroid-stimulating hormone (TSH) and free thyroxine (T4) level
Explanation:Diagnostic and Treatment Options for a Patient with High Cholesterol
When a patient presents with symptoms such as dry skin, hair loss, obesity, sleep apnea, hypertension, and slow pulse, it is important to consider hypothyroidism as a possible cause. To confirm this diagnosis, checking the patient’s thyroid-stimulating hormone (TSH) and free thyroxine (T4) levels is recommended. Hypothyroidism can also cause dyslipidemia, which may be the underlying cause of the patient’s high cholesterol levels. Therefore, treating the hypothyroidism should be the initial step, and if cholesterol levels remain high, prescribing a statin may be appropriate.
It is also important to consider the possibility of familial hypercholesterolemia, especially if the patient’s cholesterol levels are very high (â„8 mmol/l). In this case, screening family members for raised cholesterol may be necessary if cholesterol levels do not decrease with l-thyroxine treatment.
While diabetes can increase the risk of thyroid disorders, checking the patient’s fasting blood glucose level may not be necessary initially. Additionally, measuring 24-hour urinary free cortisol is not recommended as the patient’s symptoms do not suggest Cushing syndrome as the diagnosis.
In summary, considering hypothyroidism as a possible cause of high cholesterol levels and checking TSH and T4 levels should be the initial step in diagnosis. Treating the underlying cause and prescribing a statin if necessary can help manage the patient’s cholesterol levels. Screening family members for familial hypercholesterolemia may also be necessary.
Diagnostic and Treatment Options for High Cholesterol in Patients with Suspected Hypothyroidism
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This question is part of the following fields:
- Endocrinology
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Question 13
Incorrect
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A 35-year-old woman presents with new-onset diabetes. She has no past drug or treatment history. Her fasting blood glucose is 7.3 mmol/l. Other significant medical history included occasional diarrhoea in the last 4 months, for which she took repeated courses of tinidazole. She also had an episode of severe leg pain three months ago, for which she takes warfarin. She is presently very depressed, as her sister has had renal calculus surgery, which has not gone well; she is in the Intensive Care Unit (ICU) with sepsis.
What is the most appropriate next test?Your Answer: C-peptide assay
Correct Answer: Genetic study
Explanation:Diagnostic Tests for a Patient with Possible Multiple Endocrine Neoplasia (MEN) 1 Syndrome
A woman presents with new-onset diabetes, diarrhoea, and a past episode of deep vein thrombosis (DVT), along with a family history of renal calculi at a young age. These symptoms suggest the possibility of multiple endocrine neoplasia (MEN) 1 syndrome, an autosomal dominant disease characterized by endocrine hyperfunction in various glands, particularly the parathyroid gland and enteropancreatic tumors. The most common tumors in the latter group are gastrinoma and insulinoma, with glucagonoma occurring rarely. Other symptoms may include depression, anemia, glossitis, and in rare cases, a skin manifestation called necrolytic migratory erythema.
To confirm a diagnosis of MEN 1, a genetic study to detect MEN 1 gene mutation on chromosome 11 is the best option. A family history of renal stones, as in this case, is the most common manifestation of MEN 1.
Other diagnostic tests, such as protein C assessment, colonoscopy, and blood test for Giardia antigen, are not relevant to this particular case. Measuring C-peptide levels can help distinguish between type I and type II diabetes or maturity-onset diabetes of the young (MODY), but it will not help in detecting the underlying disease. Giardiasis symptoms may include diarrhea, fatigue, abdominal cramps, bloating, gas, nausea, and weight loss, but tinidazole should have eliminated Giardia.
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This question is part of the following fields:
- Endocrinology
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Question 14
Correct
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A floppy 1-month-old infant presented with vomiting, weight loss and circulatory collapse. Blood tests demonstrated hyponatraemia and hyperkalaemia. Further tests confirmed metabolic acidosis and hypoglycaemia. The paediatrician noticed that the penis was enlarged and the scrotum pigmented. The child was treated with both a glucocorticoid and a mineralocorticoid.
What is the most likely underlying diagnosis?Your Answer: Congenital adrenal hyperplasia
Explanation:Congenital adrenal hyperplasia is a group of genetic conditions that affect the production of hormones and steroids from the adrenal glands. The most common cause is a deficiency in the enzyme 21-hydroxylase. This leads to overactivity of the steroid-producing cells and inadequate cortisol production, resulting in an excess of mineralocorticoids and androgens/oestrogens. Symptoms can include ambiguous genitalia at birth in females, hyperpigmentation and penile enlargement in males, and biochemical abnormalities such as hyponatraemia and hyperkalaemia. Treatment involves hormone replacement therapy. Addisonian crisis is a potentially fatal episode caused by glucocorticoid and mineralocorticoid deficiency, usually occurring in adulthood and precipitated by stress. It presents with hyponatraemia, hyperkalaemia, hypoglycaemia and hypercalcaemia, and is managed with urgent administration of glucocorticoids. Conn syndrome is associated with primary hyperaldosteronism and presents with hypernatraemia and hypokalaemia. Cushing syndrome is due to cortisol excess and presents with weight gain, hypertension, oedema, hyperglycaemia, hypokalaemia and skin pigmentation. Thyrotoxic crisis is a life-threatening condition associated with excessive production of thyroid hormones, presenting with a range of symptoms including tachycardia, hypertension, fever, poor feeding, weight loss, diarrhoea, nausea, vomiting, seizures and coma. Prompt treatment is essential to prevent serious complications.
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This question is part of the following fields:
- Endocrinology
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Question 15
Incorrect
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A 36-year-old woman has been referred by her GP due to passing an unusually large volume of urine and complaining of continuous thirst. The following investigations were conducted:
Random plasma:
Investigation Result
Sodium (Na+) 155 mmol/l
Osmolality 300 mOsmol/kg
Glucose 4.5 mmol/l
Urine:
Investigation Result
Osmolality 90 mOsmol/kg
Glucose 0.1 mmol/l
In healthy patients, the urine: plasma osmolality ratio is > 2. A water deprivation test was conducted, and after 6.5 hours of fluid deprivation, the patient's weight had dropped by >3%, and the serum osmolality was 310 mOsmol/kg. Urine osmolality at this stage was 210 mOsmol/kg. The patient was then given desmopressin intramuscularly (im) and allowed to drink. The urine osmolality increased to 700 mOsmol/kg, and her plasma osmolality was 292 mOsmol/kg.
What is the most likely diagnosis for this 36-year-old woman?Your Answer: Primary polydipsia
Correct Answer: A pituitary tumour
Explanation:Diagnosing Cranial Diabetes Insipidus: A Comparison with Other Conditions
Cranial diabetes insipidus (DI) is a condition where the kidneys are unable to reabsorb free water, resulting in excessive water loss. The most likely cause of this condition is a pituitary tumor, which reduces antidiuretic hormone (ADH) secretion. Other conditions, such as diabetes mellitus, chronic renal disease, lithium therapy, and primary polydipsia, may also cause polydipsia and polyuria, but they present with different symptoms and responses to treatment.
To diagnose cranial DI, doctors perform a water deprivation test and measure the urine: plasma osmolality ratio. In patients with cranial DI, the ratio is below 2, indicating that the kidneys are not concentrating urine as well as they should be. However, when given desmopressin im (exogenous ADH), the patient’s urine osmolality dramatically increases, showing that the kidneys can concentrate urine appropriately when stimulated by ADH. This confirms the absence of ADH as the cause of cranial DI.
Diabetes mellitus patients present with glycosuria and hyperglycemia, in addition to polydipsia and polyuria. Chronic renal disease and lithium therapy cause nephrogenic DI, which does not respond to desmopressin im. Primary polydipsia causes low urine osmolality, low plasma osmolality, and hyponatremia due to excessive water intake. However, patients with primary polydipsia retain some ability to concentrate urine, and removing the fluid source limits polyuria to some extent.
In conclusion, diagnosing cranial DI requires a thorough comparison with other conditions that cause polydipsia and polyuria. By understanding the symptoms and responses to treatment of each condition, doctors can accurately diagnose and treat patients with cranial DI.
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This question is part of the following fields:
- Endocrinology
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Question 16
Correct
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A 50-year-old man comes to the clinic complaining of headaches. His blood pressure measures 168/100 mmHg. Routine tests show sodium levels of 142 mmol/l (136â145), potassium levels of 2.8 mmol/l (3.5â5.0), chloride levels of 100 mmol/l (95â105), and normal levels of urea and creatinine. His plasma renin levels are undetectable, and his aldosterone levels are elevated. What is the most probable cause of his hypertension?
Your Answer: Primary hyperaldosteronism
Explanation:Differentiating Primary Hyperaldosteronism from Other Causes of Hypertension
Primary hyperaldosteronism, also known as Conn’s syndrome, is a condition characterized by elevated aldosterone levels leading to low renin levels through negative feedback loops. This is the primary cause of hypertension in this condition. On the other hand, secondary hypertension can be caused by various conditions such as acromegaly, Cushing’s syndrome, and phaeochromocytoma. However, these conditions are not associated with low renin and elevated aldosterone levels. Renal artery stenosis, on the other hand, causes both high renin and aldosterone levels, leading to secondary hyperaldosteronism. Therefore, differentiating primary hyperaldosteronism from other causes of hypertension is crucial in determining the appropriate treatment plan.
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This question is part of the following fields:
- Endocrinology
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Question 17
Correct
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A 40-year-old woman comes to the clinic complaining of fatigue, loss of appetite, and weight gain. Her blood work shows low levels of free T3 and T4, as well as low levels of thyroid stimulating hormone (TSH). Even after receiving thyrotrophin releasing hormone, her TSH levels remain low. What is the diagnosis?
Your Answer: Secondary hypothyroidism
Explanation:Understanding the Different Types of Hypothyroidism
Hypothyroidism is a condition where the thyroid gland fails to produce enough thyroid hormones. There are three types of hypothyroidism: primary, secondary, and tertiary.
Primary hypothyroidism is caused by a malfunctioning thyroid gland, often due to autoimmune thyroiditis or burnt out Grave’s disease. In this type, TRH and TSH levels are elevated, but T3 and T4 levels are low.
Secondary hypothyroidism occurs when the anterior pituitary gland fails to produce enough TSH, despite adequate TRH levels. This results in low levels of TSH, T3, and T4, even after a TRH stimulation test.
Tertiary hypothyroidism is rare and occurs when the hypothalamus fails to produce enough TRH. All three hormones are inappropriately low in this type.
Hashimoto’s thyroiditis is a form of autoimmune thyroid disease characterized by lymphocytic infiltration of the thyroid. It is a form of primary hypothyroidism.
De Quervain’s thyroiditis is a subacute thyroiditis, usually viral, which causes a transient period of primary hypothyroidism or hyperthyroidism in addition to a tender thyroid.
Understanding the different types of hypothyroidism is important for proper diagnosis and treatment.
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This question is part of the following fields:
- Endocrinology
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Question 18
Incorrect
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A 28-year-old male with type 1 diabetes is instructed to collect his urine for 24 hours. What level of urine albumin concentration indicates the presence of microalbuminuria?
Your Answer: 3.5 g/day
Correct Answer: 50 mg/day
Explanation:Microalbuminuria and Proteinuria
Microalbuminuria is a condition where the urine albumin excretion ranges from 30-300 mg per 24 hours. If the concentration exceeds 300 mg/24 hours, it signifies albuminuria, and if it exceeds 3.5 g/24 hours, it signifies overt proteinuria. Microalbuminuria is not only an early indicator of renal involvement but also a sign of increased cardiovascular risk, with a twofold risk above the already increased risk in diabetic patients. The albumin:creatinine ratio is a useful surrogate of the total albumin excretion, and it is measured using the first morning urine sample where possible. An albumin:creatinine ratio of â„2.5 mg/mmol (men) or 3.5 mg/mmol (women) indicates microalbuminuria, while a ratio of â„30 mg/mmol indicates proteinuria. these conditions is crucial in managing and preventing complications associated with renal and cardiovascular diseases.
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This question is part of the following fields:
- Endocrinology
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Question 19
Correct
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A 35-year-old female presents with symptoms of weight loss and irritability. Upon conducting thyroid function tests, the results reveal a Free T4 level of 32.9 pmol/L (9.8-23.1), TSH level of <0.02 mU/L (0.35-5.50), and Free T3 level of 11.1 pmol/L (3.5-6.5). During examination, the patient exhibits a fine tremor, pulse of 95 beats per minute, a smooth goitre with a bruit, and lid lag without any other eye signs. What is the most likely cause for these thyroid function test results?
Your Answer: Graves' disease
Explanation:TFTs and Hyperthyroidism
Thyroid function tests (TFTs) can help diagnose hyperthyroidism, which can be caused by Graves’ disease, Hashitoxicosis, or Multinodular goitre. However, the presence of a thyroid bruit, which suggests increased vascularity due to stimulation by a thyroid-stimulating hormone (TSH) receptor antibody, is a distinguishing feature of Graves’ disease. This condition is the only one where a thyroid bruit is expected. While eye signs such as proptosis, chemosis, and exophthalmos are common in Graves’ disease, they are not always present.
Overall, TFTs are a useful tool in identifying hyperthyroidism, and the presence of a thyroid bruit can help differentiate between the different causes. However, other symptoms and signs, such as eye changes, may also be present and should be taken into consideration when making a diagnosis.
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This question is part of the following fields:
- Endocrinology
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Question 20
Correct
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A 55-year-old male with a long history of smoking presents with a complaint of haemoptysis. Upon examination, muscle wasting and hypertension are observed. Further testing reveals elevated urine free cortisol, elevated ACTH, and non-suppressible cortisol following high dose dexamethasone testing. What is the most probable diagnosis?
Your Answer: Ectopic ACTH producing lung cancer
Explanation:Ectopic ACTH Production and Associated Tumours
Patients with Cushing’s syndrome and non-suppressible cortisol levels may have ectopic adrenocorticotropic hormone (ACTH) secretion, which is commonly associated with small cell lung cancer. Other tumours that may cause ectopic ACTH production include those of the thymus, pancreas, thyroid, and adrenal gland. Unlike typical hypercortisolism symptoms, patients with ectopic ACTH production may experience polyuria, polydipsia, oedema, muscle wasting, fatigue, hypertension, and hypokalaemia.
Laboratory tests can confirm excessive cortisol production and lack of dexamethasone suppression of morning cortisol levels. Plasma ACTH levels greater than 200 pg/mL may indicate ectopic ACTH production and prompt a search for an underlying malignancy, particularly a primary lung or pancreatic tumour. Therefore, it is crucial to investigate the possibility of ectopic ACTH production in patients with Cushing’s syndrome and non-suppressible cortisol levels, as it may indicate an underlying tumour.
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This question is part of the following fields:
- Endocrinology
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Question 21
Incorrect
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A 26-year-old man with a 10-year history of type I diabetes presents with a 1-day history of vomiting and a 4-day history of myalgia and sore throat. He appears dehydrated, BP 120/74 mmHg, pulse 101 bpm, temperature 37.9 °C, oxygen saturation 97% on room air. There is mild erythema in his throat and nil else to find on clinical examination. The following are his laboratory investigations:
Investigation Result Normal value
pH 7.12 7.35â7.45
Ketones 5 mmol/l <0.6
Glucose 32 mmol/l 4â10 mmol/l
Potassium 4.2 mmol/l 3.5â5 mmol/l
Bicarbonate 10 mmol/l 24â30 mmol/l
Base excess -5 mEq/l â2 to +2 mEg/l
C-reactive protein (CRP) 22 mg/l 0â10 mg/l
White Cell Count (WCC) 12.7 Ă 109/l 4-11
Which of the following initial treatment plans should be commenced?Your Answer: IV insulin, IV fluids, IV antibiotics
Correct Answer: IV insulin, IV fluids, potassium supplementation
Explanation:Management of Diabetic Ketoacidosis
Diabetic ketoacidosis (DKA) is a serious complication of diabetes that requires prompt management. The initial stages of DKA should involve the administration of IV insulin, IV fluids, and potassium supplementation. If the patient’s systolic blood pressure is below 90 mmHg, 500 ml of IV sodium chloride 0.9% should be given over 10-15 minutes, with repeat doses if necessary. Once blood pressure is over 90 mmHg, sodium chloride 0.9% should be given by intravenous infusion at a rate that replaces the deficit and provides maintenance. Potassium chloride should be included in the fluids, unless anuria is suspected or potassium levels are above 5.5 mmol/l. IV insulin should be infused at a fixed rate of 0.1 units/kg/hour, diluted with sodium chloride 0.9% to a concentration of 1 unit/ml.
If there are no signs of bacterial infection, antibiotics may not be necessary. In cases where there are symptoms of viral infection, such as a red sore throat and myalgia, IV antibiotics may not be required. Subcutaneous rapid-acting insulin should not be used, as IV insulin is more effective in rapidly treating hyperglycemia and can be titrated as needed on an hourly basis. Oral antibiotics may be considered if there are signs of bacterial infection.
In cases where the patient has established diabetes, long-acting insulin should be continued even if on IV insulin. Once blood glucose levels fall below 14 mmol/litre, glucose 10% should be given by intravenous infusion at a rate of 125 ml/hour, in addition to the sodium chloride 0.9% infusion. Glucose levels of 32 require the use of saline with potassium initially. Overall, prompt and appropriate management of DKA is crucial in preventing serious complications and improving patient outcomes.
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This question is part of the following fields:
- Endocrinology
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Question 22
Incorrect
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Through which of the following molecules is the hypercalcaemia of malignancy most commonly mediated?
Your Answer: Interleukin-6
Correct Answer: Parathyroid hormone related protein
Explanation:The Role of Parathyroid Hormone-Related Protein in Hypercalcaemia
Parathyroid hormone-related protein (PTHrP) is a group of protein hormones that are produced by various tissues in the body. Its discovery was made when it was found to be secreted by certain tumors, causing hypercalcaemia in affected patients. Further studies revealed that the uncontrolled secretion of PTHrP by many tumor cells leads to hypercalcaemia by promoting the resorption of calcium from bones and inhibiting calcium loss in urine, similar to the effects of hyperparathyroidism.
Overall, PTHrP plays a crucial role in regulating calcium levels in the body, and its overproduction can lead to serious health complications. the mechanisms behind PTHrP secretion and its effects on the body can aid in the development of treatments for hypercalcaemia and related conditions.
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This question is part of the following fields:
- Endocrinology
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Question 23
Correct
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A 54-year-old Hispanic male presents to his primary care physician complaining of fatigue. He has noticed a slight increase in weight and has been feeling increasingly tired over the past year. The patient has a history of asthma and manages it with inhaled salbutamol as needed, typically no more than once a week. He also has type 2 diabetes that is controlled through diet.
During the examination, the patient's blood pressure is measured at 172/98 mmHg, his body mass index is 29.7 kg/m2, and his pulse is 88 beats per minute. No other abnormalities are noted. Over the next month, his blood pressure readings are consistently high, measuring at 180/96, 176/90, and 178/100 mmHg.
Which medication would be recommended for the treatment of this patient's high blood pressure?Your Answer: Lisinopril
Explanation:Hypertension Treatment in Patients with Type 2 Diabetes
Patients with type 2 diabetes and sustained hypertension require treatment. The first-line treatment for hypertension in diabetes is ACE inhibitors. These medications have no adverse effects on glucose tolerance or lipid profiles and can delay the progression of microalbuminuria to nephropathy. Additionally, ACE inhibitors can reduce morbidity and mortality in patients with vascular disease and diabetes.
However, bendroflumethiazide should be avoided in patients with a history of gout as it may provoke an attack. Beta-blockers should also be avoided for routine treatment of uncomplicated hypertension in patients with diabetes. They can precipitate bronchospasm and should be avoided in patients with asthma. In cases where there is no alternative, a cardioselective beta blocker should be selected and initiated at a low dose by a specialist, with close monitoring for adverse effects.
Alpha-blockers, such as doxazosin, are reserved for the treatment of resistant hypertension in conjunction with other antihypertensives. It is important to follow guidelines, such as those provided by NICE and the British National Formulary, for the diagnosis and management of hypertension in adults with diabetes. A treatment algorithm for hypertension can also be helpful in guiding treatment decisions.
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This question is part of the following fields:
- Endocrinology
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Question 24
Incorrect
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A mother brings her 9-month-old baby to clinic for a check-up. His prior medical history has been unremarkable and his immunisations are up-to-date. The mother is concerned about his growth. After you determine that the baby has grown appropriately since the last visit and is unchanged from the 50th centile, you provide the mother with advice regarding growth.
What signalling pathway does growth hormone (GH) use?Your Answer: Cyclic guanosine monophosphate (GMP) as a second messenger
Correct Answer: A tyrosine kinase receptor that uses the JAK/STAT pathway
Explanation:Comparison of Second Messenger Systems and Receptor Types in Hormonal Signaling
Hormones utilize various signaling pathways to transmit their messages to target cells. One important aspect of hormonal signaling is the use of second messengers, which relay the hormone signal from the cell surface to the intracellular environment. Here, we compare and contrast the second messenger systems and receptor types used by different hormones.
Growth hormone (GH) and prolactin both use the tyrosine kinase receptor, followed by activation of Janus kinase (JAK), signal transduction, and activation of transcription (STAT). In contrast, platelet-derived growth factor (PDGF), fibroblast growth factor (FGF), insulin-like growth factor 1 (IGF-1), and insulin use the MAP kinase or RAS system. Aldosterone uses steroid receptors, while GH uses the tyrosine kinase receptor.
Inositol trisphosphate (IP3) works as a second messenger for hypothalamic hormones such as gonadotropin-releasing hormone (GnRH), growth hormone-releasing hormone (GHRH), thyrotropin-releasing hormone (TRH), and pituitary hormones such as antidiuretic hormone (ADH) and oxytocin.
Cyclic guanosine monophosphate (cGMP) is a second messenger that activates protein kinases and mediates endothelium-derived relaxing factor (EDRF), atrial natriuretic peptide (ANP), and nitric oxide.
Cyclic adenosine monophosphate (cAMP) is a second messenger of follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroid-stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), human chorionic gonadotropin (hCG), and several other hormones, but not GH.
In summary, different hormones use distinct second messenger systems and receptor types to transmit their signals, highlighting the complexity and diversity of hormonal signaling pathways.
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This question is part of the following fields:
- Endocrinology
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Question 25
Correct
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You encounter a 27-year-old patient who has recently found out that she is pregnant. Her medical history reveals that she was diagnosed with hypothyroidism eight years ago and has been on a stable dose of levothyroxine since then. What is the appropriate course of action regarding her medication?
Your Answer: The dose of levothyroxine should be increased when pregnancy is diagnosed
Explanation:Managing Hypothyroidism in Pregnancy: Recommendations for Levothyroxine Dosing and Thyroid Function Testing
Hypothyroidism in pregnancy requires careful management to ensure optimal outcomes for both the mother and fetus. The National Institute for Health and Care Excellence (NICE) guidelines recommend increasing the dose of levothyroxine by 25-50 ÎŒg and referring the patient to an endocrinologist upon diagnosis of pregnancy. It is important to note that iodine supplements are not recommended for treating hypothyroidism in pregnancy. Adequate thyroid function is crucial for fetal neurological development, so stopping levothyroxine is not an option. Thyroid function tests (TFTs) should be taken at baseline and every four weeks, as changes in drug pharmacodynamics and kinetics can occur during pregnancy. The target thyroid stimulating hormone range should be low-normal at 0.4-2 mU/l, and the dose of levothyroxine should remain unchanged until specialist review.
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This question is part of the following fields:
- Endocrinology
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Question 26
Incorrect
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A 50-year-old woman has been diagnosed with Addison's disease. What would be advantageous to prescribe for her along with hydrocortisone?
Your Answer: Combined oral contraceptive pill
Correct Answer: Fludrocortisone
Explanation:Medications for Addison’s Disease: What Works and What Doesn’t
Addison’s disease is a condition where the adrenal glands do not produce enough hormones. Patients with this condition require replacement therapy with both glucocorticoid and mineralocorticoid medications. Fludrocortisone is a common mineralocorticoid replacement therapy used in Addison’s disease. However, medications such as aspirin, the combined oral contraceptive pill, and the progesterone only pill have no role in treating this condition. Additionally, dexamethasone is not used as a replacement therapy for Addison’s disease. It is important for patients with Addison’s disease to work closely with their healthcare provider to determine the appropriate medications for their individual needs.
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This question is part of the following fields:
- Endocrinology
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Question 27
Incorrect
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These results were obtained on a 30-year-old male who has presented with tiredness:
Free T4 9.3 pmol/L (9.8-23.1)
TSH 49.31 mU/L (0.35-5.50)
What signs might be expected in this case?Your Answer: Fine tremor over outstretched hands
Correct Answer: Slow relaxation of biceps reflex
Explanation:Diagnosis and Symptoms of Hypothyroidism
Hypothyroidism is diagnosed through blood tests that show low levels of T4 and elevated levels of TSH. Physical examination may reveal slow relaxation of tendon jerks, bradycardia, and goitre. A bruit over a goitre is associated with Graves’ thyrotoxicosis, while palmar erythema and fine tremor occur in thyrotoxicosis. In addition to these common symptoms, hypothyroidism may also present with rarer features such as cerebellar features, compression neuropathies, hypothermia, and macrocytic anaemia. It is important to diagnose and treat hypothyroidism promptly to prevent further complications.
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This question is part of the following fields:
- Endocrinology
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Question 28
Incorrect
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A 32-year-old woman visits her GP with complaints of palpitations, tremors, sweating, and diarrhoea. She has a medical history of gestational hypertension and type 1 diabetes, which is managed with insulin. The patient gave birth to her first child 8 weeks ago without any complications.
Upon examination, the patient is alert and oriented. Her vital signs are as follows: heart rate of 109 bpm, respiratory rate of 19 breaths/minute, temperature of 37.7ÂșC, oxygen saturation of 98%, blood pressure of 129/88 mmHg, and blood glucose of 4 mmol/L.
What is the most likely diagnosis, and what is the appropriate treatment?Your Answer: Propylthiouracil
Correct Answer: Propranolol
Explanation:The recommended treatment for the thyrotoxicosis phase of postpartum thyroiditis is typically propranolol alone. This is because the condition is usually temporary and self-resolving, with thyroid function returning to normal within a year after childbirth. Carbimazole is not necessary as it is typically reserved for more severe cases of hyperthyroidism. Dexamethasone is not appropriate as it is used to treat thyroid storm, a complication of thyrotoxicosis that is not present in this case. Levothyroxine is also not indicated as it is used to treat hypothyroidism, which is the opposite of the patient’s current condition.
Understanding Postpartum Thyroiditis: Stages and Management
Postpartum thyroiditis is a condition that affects some women after giving birth. It is characterized by three stages: thyrotoxicosis, hypothyroidism, and normal thyroid function. During the thyrotoxicosis phase, the thyroid gland becomes overactive, leading to symptoms such as anxiety, palpitations, and weight loss. In the hypothyroidism phase, the thyroid gland becomes underactive, causing symptoms such as fatigue, weight gain, and depression. However, in the final stage, the thyroid gland returns to normal function, although there is a high recurrence rate in future pregnancies.
Thyroid peroxidase antibodies are found in 90% of patients with postpartum thyroiditis, which suggests an autoimmune component to the condition. Management of postpartum thyroiditis depends on the stage of the condition. During the thyrotoxic phase, symptom control is the main focus, and propranolol is typically used. Antithyroid drugs are not usually used as the thyroid gland is not overactive. In the hypothyroid phase, treatment with thyroxine is usually necessary to restore normal thyroid function.
It is important to note that many causes of hypothyroidism may have an initial thyrotoxic phase, as shown in a Venn diagram. Therefore, it is crucial to properly diagnose and manage postpartum thyroiditis to ensure the best possible outcomes for both the mother and the baby.
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This question is part of the following fields:
- Endocrinology
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Question 29
Incorrect
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A 45-year-old man visits his GP for a medication review for his hypertension. During the examination, the GP observes that the patient has prominent supraorbital ridges, large hands and feet, and acanthosis nigricans of the axillae. The GP also discovers enlargement of the thyroid gland and hepatomegaly. Besides hypertension, what other condition is frequently linked to acromegaly?
Your Answer: Right ventricular hypertrophy
Correct Answer: Diabetes mellitus
Explanation:Associations of Acromegaly with Various Medical Conditions
Acromegaly is a medical condition caused by hypersecretion of growth hormone. It is associated with various medical conditions, including insulin resistance and diabetes mellitus, which can lead to acromegaly. Left ventricular hypertrophy is also associated with acromegaly, which can cause right ventricular hypertrophy. Ulnar nerve entrapment is another association, along with carpal tunnel syndrome affecting the median nerve. Acanthosis nigricans involves hyperpigmentation of the skin, but there is no general pigmentation associated with acromegaly. Acromegaly is also associated with cardiovascular disease, which can increase the risk of atrial fibrillation, although it is not a direct cause.
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This question is part of the following fields:
- Endocrinology
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Question 30
Incorrect
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A 35-year-old teacher presents at the Thyroid Clinic with a swelling in her neck that has been present for 4 months, along with a weight loss of 5 kg. During examination, a diffuse smooth swelling of the thyroid gland is observed, and she is found to be in atrial fibrillation. Lid lag and proximal myopathy are also noted, along with a rash on the anterior aspects of her legs, indicative of pretibial myxoedema. Which clinical sign is most indicative of Graves' disease as the underlying cause of her hyperthyroidism?
Your Answer: Diffuse thyroid swelling
Correct Answer: Pretibial myxoedema
Explanation:Most Specific Sign of Graves’ Disease
Graves’ disease is a type of hyperthyroidism that has a classic triad of signs, including thyroid ophthalmopathy, thyroid acropachy, and pretibial myxoedema. Among these signs, pretibial myxoedema is the most specific to Graves’ disease. It is characterized by swelling and lumpiness of the shins and lower legs, and is almost pathognomonic of the condition. Other signs of hyperthyroidism, such as weight loss and diffuse thyroid swelling, are non-specific and may occur with other thyroid diseases. Atrial fibrillation and proximal myopathy may also occur in Graves’ disease, but are not specific to this condition.
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This question is part of the following fields:
- Endocrinology
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