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Question 1
Correct
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A 28-year-old female patient presents to her GP with complaints of ongoing fatigue and struggles with weight loss. She frequently feels cold and has been experiencing constipation. After discussing her symptoms with her family, she was advised to seek medical attention as her mother had similar symptoms when diagnosed with Hashimoto's thyroiditis. What autoantibody is most likely to be present in her blood?
Your Answer: Thyroid peroxidase antibody
Explanation:Autoantibodies and their association with different conditions
Autoantibodies are antibodies that target the body’s own tissues and organs. Different autoantibodies are associated with different conditions. Here are some examples:
Thyroid peroxidase antibody: These antibodies occur in Hashimoto’s thyroiditis, an autoimmune condition that affects the thyroid gland. Thyroid peroxidase antibodies prevent the production of thyroid hormones, leading to hypothyroidism.
Glutamic acid decarboxylase antibody: These antibodies are associated with type I diabetes mellitus and stiff person syndrome. They are measured when type I diabetes is suspected.
21-Hydroxylase antibody: This autoantibody is most common in patients with primary hypoadrenalism (Addison’s disease).
Tissue transglutaminase antibody (anti-TTG): Anti-TTG antibodies are associated with Coeliac disease and affect the metabolism of gluten.
Thyroid-stimulating hormone receptor stimulating antibody (TSAb): TSAb antibodies are usually present in Graves’ disease, an autoimmune condition that affects the thyroid gland. TSAb antibodies result in the overproduction of thyroid hormones, leading to symptoms associated with thyrotoxicosis.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 2
Incorrect
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A 30-year-old woman with type 1 diabetes since the age of 18 has an urgent appointment in the diabetes clinic. She has been managing her diabetes well with insulin and has no other medical issues. However, she recently discovered that she is pregnant and is worried about any potential harm to the fetus. She has no intention of terminating the pregnancy. She took two pregnancy tests after missing her period one week ago, both of which were positive. She has been taking a basal-bolus insulin regimen and atorvastatin. Her retinal screening and urine testing were done nine months ago, and her HbA1c was last measured three months ago at 39 mmol/mol. She has been advised to continue with her insulin but has stopped taking atorvastatin due to concerns about its effects during pregnancy. What is the best course of action to prevent diabetes-related complications?
Your Answer:
Correct Answer: Refer for retinal screening
Explanation:Patients who have diabetes and are pregnant should undergo retinal screening more frequently due to an increased risk of retinopathy. To ensure good diabetic control before planning for pregnancy, it is recommended to repeat the retinal screening and test the urine. If good diabetic control has not been achieved, contraception should be used, and termination should be offered if pregnancy occurs due to the higher risks involved. In this case, the patient has good diabetic control, as shown by the absence of complications and HbA1c levels. Drugs such as atorvastatin and ACE inhibitors should be stopped before pregnancy, and labetalol is a suitable option for blood pressure control. The insulin dose may not need to be adjusted, but blood glucose levels should be closely monitored during pregnancy. However, if the patient has not had retinal screening in the last six months, it is recommended to offer this urgently as diabetic retinopathy can develop rapidly during pregnancy.
Gestational diabetes is a common medical disorder that affects around 4% of pregnancies. It can develop during pregnancy or be a pre-existing condition. According to NICE, 87.5% of cases are gestational diabetes, 7.5% are type 1 diabetes, and 5% are type 2 diabetes. Risk factors for gestational diabetes include a BMI of > 30 kg/m², previous gestational diabetes, a family history of diabetes, and family origin with a high prevalence of diabetes. Screening for gestational diabetes involves an oral glucose tolerance test (OGTT), which should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.
To diagnose gestational diabetes, NICE recommends using the following thresholds: fasting glucose is >= 5.6 mmol/L or 2-hour glucose is >= 7.8 mmol/L. Newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week and taught about self-monitoring of blood glucose. Advice about diet and exercise should be given, and if glucose targets are not met within 1-2 weeks of altering diet/exercise, metformin should be started. If glucose targets are still not met, insulin should be added to the treatment plan.
For women with pre-existing diabetes, weight loss is recommended for those with a BMI of > 27 kg/m^2. Oral hypoglycaemic agents, apart from metformin, should be stopped, and insulin should be commenced. Folic acid 5 mg/day should be taken from pre-conception to 12 weeks gestation, and a detailed anomaly scan at 20 weeks, including four-chamber view of the heart and outflow tracts, should be performed. Tight glycaemic control reduces complication rates, and retinopathy should be treated as it can worsen during pregnancy.
Targets for self-monitoring of pregnant women with diabetes include a fasting glucose level of 5.3 mmol/l and a 1-hour or 2-hour glucose level after meals of 7.8 mmol/l or 6.4 mmol/l, respectively. It is important to manage gestational diabetes and pre-existing diabetes during pregnancy to reduce the risk of complications for both the mother and baby.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 3
Incorrect
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A 25-year-old female presents with worsening acne and a marked increase in the development of body and facial hair which she finds very distressing. She is also overweight and is markedly stressed by her physical appearance and the development of stretch marks over her abdomen. She has tried multiple hair removal techniques with only mild success.
On examination, she has a body mass index of 28 kg/m², coarse hair over the anterior and posterior part of her chest and under her chin. Her Blood Pressure is 135/90 mmHg.
Her lab results are as follows:
9:00 am Cortisol 345 nmol/l (170 700 nmol/l)
LH 17 iU/l (1 20 iU/l)
Basal FSH 7.1 iU/l (1.0 8.8 iU/l)
DHEAS 545 µg/dl (31 228 µg/dl)
Prolactin 160 mU/l (<360 mU/l)
17 OH Progesterone 1025 ng/dl (<80 ng/dl)
Testosterone 3.9 nmol/l (0.9 3.1 nmol/l)
Ultrasound abdomen and pelvis reveals two cysts in the right ovary.
What is the most appropriate treatment option for her condition?Your Answer:
Correct Answer: Reverse circadian rhythm steroids
Explanation:Polycystic ovarian syndrome should not be automatically assumed when cysts are detected during a routine ultrasound as it is a common finding.
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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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 4
Incorrect
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A 61-year-old man is referred to the Emergency Department by his General Practitioner (GP). He has recently started lisinopril 10 mg for hypertension, and the GP is concerned by a deterioration in his creatinine level. According to the GP letter, he has had high blood pressure for the past ten years and was diagnosed with chronic kidney disease some two years ago. On examination, in the Emergency Department, he appears to be in good health; his blood pressure is 140/90 mmHg, and pulse 80 bpm and regular. Investigations: Investigations Results Normal Values Potassium (K+) 4.5 (4.2 mmol/l on ACEi initiation some 14 days ago) 3.5–5.0 mmol/l Creatinine 190 µmol/l (170 µmol/l on ACEi initiation some 14 days ago) 50–120 µmol/l What is the most appropriate course of action?
Your Answer:
Correct Answer: Continue Ramipril 5 mg and re-check U&Es in one week
Explanation:Managing Creatinine Levels in Patients on Ramipril Therapy
When a patient’s creatinine levels rise while on ramipril therapy, it is important to carefully consider the next steps. According to NICE guidelines, a rise of > 30% is considered significant, while a rise of < 20% is not clinically significant. In this case, the rise in creatinine levels (from 185 to 220 µmol/l) is below 20%, so ramipril can be continued. However, it is important to monitor the patient closely and re-check U&Es in one week to ensure that the creatinine levels do not continue to rise.
It is not recommended to increase the ramipril dose to 10 mg daily or decrease it to 2.5 mg daily, as the rise in creatinine levels is not significant enough to warrant a change in dosage. Similarly, stopping ramipril for one week and re-checking U&Es is not necessary at this stage.
Withdrawal of ramipril is only indicated if there is a significant rise in creatinine levels that can be linked to the medication. In this case, the patient could benefit from continued ACEI therapy, so it should be continued while closely monitoring the patient’s creatinine levels.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 5
Incorrect
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These thyroid function tests were obtained from a 60-year-old female who presents with fatigue. Past history includes hypertension and osteoporosis, for which she takes medication.
Free T4 23.5 pmol/L (10-22)
Free T3 2.8 pmol/L (5-10)
TSH 7.2 mU/L (0.4-5)
What is the most probable reason for these findings?Your Answer:
Correct Answer: Amiodarone therapy
Explanation:Abnormal Thyroid Function Tests and their Causes
Thyroid function tests (TFTs) can be abnormal due to various reasons, but one common cause is the use of amiodarone. This medication inhibits the conversion of thyroxine (T4) to tri-iodothyronine (T3) in the peripheral tissues, leading to elevated T4 levels and low T3 levels. As T3 is the most active thyroid hormone, the low T3 levels result in increased secretion of thyroid-stimulating hormone (TSH) at the pituitary level. This is why bizarre TFTs are often seen in patients taking amiodarone.
On the other hand, lithium is another medication that can affect thyroid function. It typically causes low T4 levels and elevated TSH levels. Sick euthyroidism is another condition that can cause variable TFTs, but it usually occurs in patients who are critically ill.
In summary, abnormal TFTs can be caused by various factors, including medication use and underlying medical conditions. the underlying causes of these abnormalities is important for accurate diagnosis and appropriate management.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 6
Incorrect
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A 54-year-old man presents to clinic after routine blood tests revealed a K+ level of 2.8 mmol/l. He has a history of angina and renal stones but reports feeling well. On examination, his chest is clear and abdomen is soft and non-tender. His vital signs are within normal limits and his ECG shows normal sinus rhythm. Further investigations reveal a urinary K+ level of 26 mmol/l (normal <20) and a creatinine level of 117 µmol/l. What is the most likely cause of his hypokalaemia?
Your Answer:
Correct Answer: Renal tubular acidosis type 1
Explanation:Hypokalaemia can be caused by various diagnoses, except for renal tubular acidosis type 4, which leads to hyperkalaemia. When presented with a patient with hypokalaemia, the first step is to check the urinary K+ levels. If they are low, gastrointestinal losses like vomiting or diarrhoea or decreased K+ intake should be considered. However, if the urinary K+ levels are high, the blood pressure should be checked. If it is normal, Liddle’s Syndrome should be considered, which causes hypertension. If the patient is not hypertensive, the bicarbonate levels should be checked. In this case, the bicarbonate levels are low, indicating renal tubular acidosis. The patient’s history of renal stones suggests that the diagnosis is renal tubular acidosis type 1. Renal tubular acidosis type 2 is associated with conditions like Wilson’s disease, lead poisoning, and myeloma.
Renal tubular acidosis (RTA) is a condition that results in hyperchloraemic metabolic acidosis, which is characterized by a normal anion gap. There are three types of RTA, each with its own unique set of causes and complications. Type 1 RTA, also known as distal RTA, is caused by an inability to generate acid urine in the distal tubule, leading to hypokalaemia. This type of RTA can be caused by a variety of factors, including rheumatoid arthritis, SLE, and amphotericin B toxicity. Complications may include nephrocalcinosis and renal stones.
Type 2 RTA, or proximal RTA, is characterized by a decreased reabsorption of HCO3- in the proximal tubule, which also leads to hypokalaemia. This type of RTA can be caused by a variety of factors, including Wilson’s disease and outdated tetracyclines. Complications may include osteomalacia.
Type 3 RTA, or mixed RTA, is an extremely rare form of the condition that is caused by carbonic anhydrase II deficiency. This results in hypokalaemia.
Type 4 RTA, or hyperkalaemic RTA, is caused by a reduction in aldosterone, which leads to a reduction in proximal tubular ammonium excretion. This type of RTA can be caused by hypoaldosteronism and diabetes, and it results in hyperkalaemia.
Overall, RTA is a complex condition that can have a variety of causes and complications. It is important to work with a healthcare provider to determine the underlying cause of the condition and develop an appropriate treatment plan.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 7
Incorrect
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A 65-year-old female who is a retired teacher presents to the Emergency department with sudden difficulty breathing after a long flight. She has not experienced any other health issues recently.
During the examination, her pulse is found to be 98 bpm, her oxygen saturation is 92% on air, and her blood pressure is 120/80 mmHg. Her legs and chest appear normal.
The medical team suspects a pulmonary embolism and starts her on IV heparin therapy. A VQ scan confirms the diagnosis.
Despite not showing any signs of thyrotoxicosis, the doctors perform thyroid function tests due to her previous occupation. The results show:
TSH 1.5 mU/L (0.35-5.0)
free T4 44.2 pmol/L (9.8-21.2)
free T3 6.5 pmol/L (3.5-6.8)
What is the probable cause of the abnormal thyroid function tests in this patient?Your Answer:
Correct Answer: Heparin treatment
Explanation:Heparin’s Effect on Thyroxine Levels
Heparin has been found to have an in vitro effect on thyroxine (T4) levels, meaning that it affects the levels of T4 in a laboratory setting. When administered intravenously, heparin can interfere with thyroid function tests, sometimes causing bound thyroid hormone to be displaced. However, these test results do not indicate primary hyperthyroidism, as the thyroid-stimulating hormone is not suppressed. Instead, they suggest subclinical hyperthyroidism, which is characterized by low or suppressed TSH levels and normal T4 levels.
Overall, it is important to be aware of the potential effects of heparin on thyroid function tests and to interpret results carefully in order to accurately diagnose and treat thyroid disorders.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 8
Incorrect
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A 48-year-old man presented to his GP after discovering high blood pressure readings at the local pharmacy. His blood pressure was measured at 180/100 mmHg in the surgery. The GP prescribed ramipril 2.5mg and titrated up to 10mg, but his blood pressure remained consistently high. Amlodipine was added, but had little effect even at the maximum dose. After a third agent failed to provide an adequate response, the GP referred the patient to the endocrine clinic.
During observation at the clinic, the man's blood pressure was measured at 190/105 mmHg with a heart rate of 98 beats per minute. On examination, he was thin with a body mass index of 23 kg/m². His apex was diffuse and displaced with normal heart sounds. The chest was clear and abdomen was soft and non-tender with no evidence of masses or renal bruits. A hard, painless nodule was noted over his thyroid gland.
Further investigations revealed raised 24 hour urinary catecholamines and confirmed a diagnosis of phaeochromocytoma. The patient was treated with an alpha blocker and beta blocker while awaiting surgery. During this time, the thyroid nodule was also investigated and found to be a cold nodule on radionucleotide scanning.
What is the expected histological type of thyroid cancer in this case?Your Answer:
Correct Answer: Medullary
Explanation:Thyroid cancer rarely causes hyperthyroidism or hypothyroidism as it does not usually secrete thyroid hormones. The most common type of thyroid cancer is papillary carcinoma, which is often found in young females and has an excellent prognosis. Follicular carcinoma is less common, while medullary carcinoma is a cancer of the parafollicular cells that secrete calcitonin and is associated with multiple endocrine neoplasia type 2. Anaplastic carcinoma is rare and not responsive to treatment, causing pressure symptoms. Lymphoma is also rare and associated with Hashimoto’s thyroiditis.
Management of papillary and follicular cancer involves a total thyroidectomy followed by radioiodine to kill residual cells. Yearly thyroglobulin levels are monitored to detect early recurrent disease. Papillary carcinoma usually contains a mixture of papillary and colloidal filled follicles, while follicular adenoma presents as a solitary thyroid nodule and malignancy can only be excluded on formal histological assessment. Follicular carcinoma may appear macroscopically encapsulated, but microscopically capsular invasion is seen. Medullary carcinoma is associated with raised serum calcitonin levels and familial genetic disease in up to 20% of cases. Anaplastic carcinoma is most common in elderly females and is treated by resection where possible, with palliation achieved through isthmusectomy and radiotherapy. Chemotherapy is ineffective.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 9
Incorrect
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A 40-year-old man presents to endocrinology clinic with concerns about gynaecomastia. He had previously seen his GP for this issue, which was initially thought to be related to alcohol excess and possible liver involvement. However, after stopping alcohol and normal liver function tests, this diagnosis was ruled out. The patient has no significant medical history except for a tibial fracture a year ago and a recent diagnosis of migraines. He takes paracetamol for the migraines but finds it ineffective, especially at night. Upon further questioning, he reports difficulty maintaining an erection. On examination, he has gynaecomastia but is otherwise unremarkable. Repeat blood tests in the clinic reveal low morning serum testosterone levels, with normal FSH and LH. What additional investigation would be most helpful in making a diagnosis?
Your Answer:
Correct Answer: Serum prolactin
Explanation:If a patient presents with symptoms of hypogonadism such as erectile dysfunction and gynaecomastia, along with a new onset of headaches at night, it is likely that they have a prolactinoma. This condition can be detected by high levels of prolactin in the blood. To confirm the diagnosis, an MRI of the pituitary gland should be performed. A CT scan of the brain is unlikely to be helpful in detecting any lesions. A liver biopsy may be necessary if there is unexplained liver failure, and transferrin saturation can be considered if haemochromatosis is suspected. It is important to investigate and treat this condition promptly to prevent further complications.
Hypogonadism in men can be caused by primary factors such as diseases of the testes, childhood mumps, or secondary factors such as diseases of the hypothalamus or pituitary, Klinefelter syndrome, and Kallmann syndrome. Additionally, testosterone levels in men tend to decrease with age.
When men experience testosterone deficiency, they may notice a variety of changes in their bodies. These changes can include a loss of libido, erectile dysfunction, lethargy, decreased muscle mass and strength, reduced facial hair growth, and impaired glucose tolerance. It is important for men to be aware of these symptoms and seek medical attention if they suspect they may be experiencing hypogonadism.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 10
Incorrect
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A 32-year-old woman is seen in your pre-natal endocrinology clinic. She has been on a daily dose of 100 micrograms of levothyroxine for hypothyroidism and is currently 8 weeks pregnant. Her TSH level is 5.0 mU/L (0.5-5.5) and her free T4 level is 10.0 pmol/L (9.0 - 18). What adjustments would you suggest for her levothyroxine dosage?
Your Answer:
Correct Answer: Increase levothyroxine dose to 150 micrograms daily
Explanation:During pregnancy, there is an increase in the levels of thyroxine-binding globulin (TBG), which causes an increase in the levels of total thyroxine. However, this does not affect the free thyroxine level. If left untreated, thyrotoxicosis can increase the risk of fetal loss, maternal heart failure, and premature labor. Graves’ disease is the most common cause of thyrotoxicosis during pregnancy, but transient gestational hyperthyroidism can also occur due to the activation of the TSH receptor by HCG. Propylthiouracil has traditionally been the antithyroid drug of choice, but it is associated with an increased risk of severe hepatic injury. Therefore, NICE Clinical Knowledge Summaries recommend using propylthiouracil in the first trimester and switching to carbimazole in the second trimester. Maternal free thyroxine levels should be kept in the upper third of the normal reference range to avoid fetal hypothyroidism. Thyrotrophin receptor stimulating antibodies should be checked at 30-36 weeks gestation to determine the risk of neonatal thyroid problems. Block-and-replace regimes should not be used in pregnancy, and radioiodine therapy is contraindicated.
On the other hand, thyroxine is safe during pregnancy, and serum thyroid-stimulating hormone should be measured in each trimester and 6-8 weeks post-partum. Women require an increased dose of thyroxine during pregnancy, up to 50% as early as 4-6 weeks of pregnancy. Breastfeeding is safe while on thyroxine. It is important to manage thyroid problems during pregnancy to ensure the health of both the mother and the baby.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 11
Incorrect
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A 42-year-old man presents to the Neurology clinic for assessment. He has a history of migraine with aura and is currently taking topiramate. No other medications are being taken. The following investigations were conducted:
- Na+ 138 mmol/L (135 - 145)
- K+ 3.1 mmol/L (3.5 - 5.0)
- Urea 5.7 mmol/L (2.0 - 7.0)
- Creatinine 78 µmol/L (55 - 120)
Venous blood gas:
- pH 7.29 (7.35 - 7.45)
- Bicarbonate 16 mmol/L (22 - 29)
Urinalysis:
- Glucose 3+
- Protein 2+
- Blood negative
What is the most likely diagnosis?Your Answer:
Correct Answer: Type 2 renal tubular acidosis
Explanation:The most likely diagnosis for this patient is type 2 renal tubular acidosis, which is caused by a defect in the proximal tubular cells. This leads to incomplete reabsorption of protein, glucose, and bicarbonate, resulting in metabolic acidosis with hypokalaemia, proteinuria, and glycosuria. The use of topiramate is likely the cause of this condition.
Membranous glomerulonephritis is an unlikely diagnosis as it typically presents with nephrotic range proteinuria and is associated with NSAIDs and penicillamine rather than topiramate.
Type 1 renal tubular acidosis is also an unlikely diagnosis as it affects the distal tubular cells rather than the proximal tubular cells and is not associated with proteinuria and glycosuria.
Type 3 renal tubular acidosis is rare and typically seen in children or as a result of congenital carbonic anhydrase deficiency, making it an unlikely diagnosis for this patient.
Renal tubular acidosis (RTA) is a condition that results in hyperchloraemic metabolic acidosis, which is characterized by a normal anion gap. There are three types of RTA, each with its own unique set of causes and complications. Type 1 RTA, also known as distal RTA, is caused by an inability to generate acid urine in the distal tubule, leading to hypokalaemia. This type of RTA can be caused by a variety of factors, including rheumatoid arthritis, SLE, and amphotericin B toxicity. Complications may include nephrocalcinosis and renal stones.
Type 2 RTA, or proximal RTA, is characterized by a decreased reabsorption of HCO3- in the proximal tubule, which also leads to hypokalaemia. This type of RTA can be caused by a variety of factors, including Wilson’s disease and outdated tetracyclines. Complications may include osteomalacia.
Type 3 RTA, or mixed RTA, is an extremely rare form of the condition that is caused by carbonic anhydrase II deficiency. This results in hypokalaemia.
Type 4 RTA, or hyperkalaemic RTA, is caused by a reduction in aldosterone, which leads to a reduction in proximal tubular ammonium excretion. This type of RTA can be caused by hypoaldosteronism and diabetes, and it results in hyperkalaemia.
Overall, RTA is a complex condition that can have a variety of causes and complications. It is important to work with a healthcare provider to determine the underlying cause of the condition and develop an appropriate treatment plan.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 12
Incorrect
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A 28-year-old female with a history of successfully treated thyrotoxicosis experienced a relapse in the third trimester of her pregnancy. She was briefly treated with carbimazole but had to discontinue due to intolerance. Now four weeks postpartum, she continues to experience symptoms such as tremors, sweats, palpitations, weight loss, and flushing. She wishes to breastfeed her healthy infant boy. On examination, she has a fine tremor, a pulse rate of 110/min-1, and lid lag. She also has a palpable goitre with an audible bruit and exhibits exophthalmos, chemosis, and lid-lag upon eye examination. Her lab results show a low TSH level and high free T4 and T3 levels. What is the most appropriate treatment for her thyrotoxicosis?
Your Answer:
Correct Answer: Propylthiouracil
Explanation:Management of Relapsed Graves’ Thyrotoxicosis in Pregnancy
This patient has a history of Graves’ thyrotoxicosis and dysthyroid eye disease, which has relapsed during pregnancy. The first step in management is to render the patient euthyroid before any definitive therapy can be considered. While beta blockers can relieve symptoms, they do not treat the underlying thyrotoxicosis.
Given the patient’s previous intolerance to carbimazole, propylthiouracil is a suitable alternative. The lowest effective dose should be used to minimize the risk of exposure to the infant, who is being breastfed. Although the infant’s thyroid function should be monitored, the levels of propylthiouracil in breast milk are likely too small to affect the infant.
Once the patient is euthyroid, definitive therapy can be considered. This may involve radio-iodine or surgery, and the timing of this can be discussed with the patient. Overall, careful management is required to ensure the health of both the mother and the infant.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 13
Incorrect
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A 25-year-old female patient comes to the clinic complaining of amenorrhoea. Upon conducting blood tests, the following results were obtained:
Prolactin 320 IU/L (<230)
Oestrogen 900 pmol/L (100-400 follicular phase)
LH <1 IU/L -
FSH 2 IU/L -
Based on these findings, what is the most probable diagnosis?Your Answer:
Correct Answer: Pregnancy
Explanation:Elevated Prolactin Levels in Pregnancy
During pregnancy, a woman’s body undergoes various hormonal changes that can affect her blood results. High levels of estrogen and low levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) are typical during pregnancy, as the body does not require any more follicles at this time. Additionally, prolactin levels may also be elevated during pregnancy. This hormone is responsible for stimulating milk production in the breasts.
There are several reasons why prolactin levels may be elevated during pregnancy. The most common cause is pregnancy itself, as the body prepares for lactation. Other causes include lactation, a pituitary gland tumor (macroadenoma or microadenoma), nipple stimulation, breast trauma, post-seizures, and certain medications such as metoclopramide, antipsychotics, anticonvulsants, antidepressants, and dopamine antagonists.
It is important to note that elevated prolactin levels during pregnancy are normal and expected. However, if prolactin levels remain elevated after pregnancy or are accompanied by other symptoms such as headaches or vision changes, it is important to seek medical attention to rule out any underlying conditions.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 14
Incorrect
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A 56-year-old man presented to endocrine clinic with gradually worsening low mood, malaise, and reduced exercise capacity. He had a history of non-functioning pituitary adenoma (NFPA) surgery resulting in partial anterior hypopituitarism and was on thyroxine and hydrocortisone replacement therapy. He had central adiposity and a medical history of dyslipidaemia, epilepsy, and ischaemic heart disease (IHD). Due to his medical history, an insulin tolerance test was contraindicated.
The following investigations were conducted: 9am cortisol 415 nmol/l, IGF-1 8 nmol/l (16 - 118), FT4 15.4nmol/l (11.5 - 22.7), and TSH 0.03mU/l (0.35 - 5.5).
What is the most appropriate test to confirm the diagnosis of adult GH deficiency in this case?Your Answer:
Correct Answer: Growth hormone releasing hormone (GHRH)-arginine stimulation test
Explanation:A normal IGF-1 level may be present in some patients with GHD, as this can be affected by factors such as age, the timing of GHD onset, and the extent of hypopituitarism. The Domperidone test is utilized to assess disorders related to hyperprolactinemia and macroprolactinaemia, while the glucose tolerance test, combined with IGF-1 level measurement, is employed to evaluate suspected cases of acromegaly.
Understanding Hypopituitarism: Causes, Symptoms, and Management
Hypopituitarism is a medical condition that occurs when the pituitary gland fails to produce enough hormones. This can be caused by various factors such as compression of the gland by non-secretory pituitary macroadenoma, pituitary apoplexy, Sheehan’s syndrome, hypothalamic tumors, trauma, iatrogenic irradiation, and infiltrative diseases like hemochromatosis and sarcoidosis. The symptoms of hypopituitarism depend on which hormones are deficient. For instance, low ACTH can cause tiredness and postural hypotension, while low FSH/LH can lead to amenorrhea, infertility, and loss of libido. Low TSH can cause constipation and feeling cold, while low GH can result in short stature if it occurs during childhood. Low prolactin can cause problems with lactation.
To diagnose hypopituitarism, hormone profile testing and imaging are usually conducted. Treatment involves addressing the underlying cause, such as surgical removal of pituitary macroadenoma, and replacement of deficient hormones. It is important to manage hypopituitarism promptly to prevent complications and improve the patient’s quality of life.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 15
Incorrect
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A 50 year-old female presents to the clinic referred by her primary care physician. She reports experiencing fatigue, weight loss, and increased sweating over the past four months. Additionally, she has noticed a decrease in her sex drive.
During the examination, the patient appears pale and has a pulse rate of 121 beats per minute with a bounding pulse character. Her blood pressure is 118/79 mmHg, and heart sounds 1 and 2 are present with no added sounds. The patient's chest is clear, and her abdomen is soft and non-tender with no organomegaly. She has a smooth goitre but no signs of thyroid eye disease. Examination of her cranial nerves is normal.
Recent blood tests reveal the following results:
- Hb: 11.3 g/dl
- Platelets: 190 * 109/l
- WBC: 10.9 * 109/l
- Na+: 129 mmol/l
- K+: 4.3 mmol/l
- Urea: 7.9 mmol/l
- Creatinine: 94 µmol/l
- ALP: 155 u/l
- Calcium: 2.40 mmol/l
- Albumin: 40 g/L
- TSH: 11 mU/L
- Free T4: 41 pmol/L
- Free T3: 11 pmol/L
What is the most likely diagnosis for this patient?Your Answer:
Correct Answer: TSH secreting pituitary tumour
Explanation:Macroadenomas are a common type of pituitary tumor that can cause symptoms of thyrotoxicosis, such as weight loss, sweating, fatigue, and rapid heartbeat. Additionally, patients may experience signs of hypopituitarism.
Understanding Thyroid Function Tests
Thyroid function tests are used to diagnose thyroid disorders such as hypothyroidism and hyperthyroidism. The interpretation of these tests is usually straightforward. In cases of thyrotoxicosis, such as Graves’ disease, the TSH level will be low and the free T4 level will be high. In primary hypothyroidism, the TSH level will be high and the free T4 level will be low. In cases of secondary hypothyroidism, both TSH and free T4 levels will be low, and replacement steroid therapy is required prior to thyroxine.
Sick euthyroid syndrome, now referred to as non-thyroidal illness, is common in hospital inpatients and is characterized by low levels of both TSH and free T4. T3 levels are particularly low in these patients. Subclinical hypothyroidism is characterized by high TSH levels and normal free T4 levels. Poor compliance with thyroxine can also result in high TSH levels and normal free T4 levels. Steroid therapy can result in low TSH levels and normal free T4 levels.
It is important to note that many causes of hypothyroidism may have an initial thyrotoxic phase. Understanding the results of thyroid function tests can help diagnose and manage thyroid disorders effectively.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 16
Incorrect
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A 58-year-old male presents with impotence. He was diagnosed with diabetes mellitus 8 years ago and has been taking metformin for the last 2 years. He has noticed a decline in his erectile function over the last year and is now completely impotent. He is a non-smoker and drinks approximately 8 units of alcohol per week.
On examination, he is obese with a blood pressure of 150/90 mmHg. Testicular examination reveals normal testes of approximately 18 ml in volume. There are no abnormalities on cardiovascular, respiratory or abdominal examinations.
Investigations reveal:
- Haemoglobin: 140 g/L (130-180)
- White cell count: 8.5 ×109/L (4-11)
- Platelets: 190 ×109/L (150-400)
- Serum sodium: 143 mmol/L (137-144)
- Serum potassium: 4.2 mmol/L (3.5-4.9)
- Serum urea: 6.8 mmol/L (2.5-7.5)
- Serum creatinine: 105 µmol/L (60-110)
- Serum alkaline phosphatase: 90 U/L (45-105)
- Serum aspartate aminotransferase: 28 U/L (1-31)
- Serum gamma GT: 40 U/L (<50)
- HbA1c: 7.5% (3.8-6.4)
- Fasting plasma glucose: 8.0 mmol/L (3.0-6.0)
- Plasma testosterone: 6.8 nmol/L (9-33)
- Plasma FSH: 3.9 mU/L (3-12)
- Plasma luteinising hormone: 4.9 mU/L (3-10)
What further investigation would you recommend for this patient?Your Answer:
Correct Answer: Prolactin concentration
Explanation:Hypogonadotrophic Hypogonadism and its Possible Causes
Hypogonadotrophic hypogonadism (HH) is a common condition associated with type 2 diabetes and obesity. The exact mechanism responsible for this condition is still unknown. In this case, the patient has HH with normal luteinising hormone/follicle-stimulating hormone (LH/FSH) levels despite low testosterone concentrations.
Haemochromatosis is unlikely as there are no suggestive symptoms and signs such as arthritis, pigmentation, hepatomegaly, or deranged liver function tests. However, hyperprolactinaemia may be associated with HH, and signs such as galactorrhoea may be present. It is important to exclude this possibility. Additionally, a measure of free testosterone may be necessary as total testosterone levels can be low due to SHBG being decreased in obesity and with ageing.
If HH is confirmed, a pituitary MRI would be the best imaging technique to exclude other pituitary pathology. It is important to identify the underlying cause of HH to determine the appropriate treatment plan.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 17
Incorrect
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A 65-year-old man with a history of ischaemic heart disease and type 2 diabetes mellitus presents for his annual review and is found to have non-visible haematuria. He reports feeling well and is not experiencing any symptoms. Upon urine dipstick testing, blood ++ is detected, with no presence of protein or leucocytes. The test is repeated one week later.
The patient is currently taking aspirin, bisoprolol, atorvastatin, ramipril, metformin, and pioglitazone. Which medication should be discontinued while awaiting further investigations?Your Answer:
Correct Answer: Pioglitazone
Explanation:An elevated risk of bladder cancer is linked to thiazolidinediones.
Thiazolidinediones: A Class of Diabetes Medications
Thiazolidinediones are a type of medication used to treat type 2 diabetes. They work by activating the PPAR-gamma receptor, which helps to reduce insulin resistance in the body. However, one medication in this class, rosiglitazone, was withdrawn in 2010 due to concerns about its cardiovascular side effects.
The PPAR-gamma receptor is a type of nuclear receptor found inside cells. It is normally activated by free fatty acids and is involved in regulating the function and development of fat cells.
While thiazolidinediones can be effective in treating diabetes, they can also have some adverse effects. These can include weight gain, liver problems (which should be monitored with regular liver function tests), and fluid retention. Because of the risk of fluid retention, these medications are not recommended for people with heart failure. Recent studies have also suggested that there may be an increased risk of fractures and bladder cancer in people taking thiazolidinediones, particularly pioglitazone.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 18
Incorrect
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A 30-year-old female presents to the infertility clinic with an inability to conceive. She is overweight, with a body-mass index of 30 kg/m², and has noticed increased hair growth over her face and chest over the last 12 months. Her periods are irregular and she has also noticed a deepening of her voice. An ultrasound of the pelvis has revealed the presence of multiple cysts in both ovaries. She has been treated with cyproterone acetate for her hirsutism but was informed that she should not attempt conception whilst on the drug. She now wishes to conceive.
On examination, she has a cushingoid appearance, with abdominal striae and her blood pressure is 140/85 mmHg.
Laboratory investigations reveal:
9:00 am Cortisol 710 nmol/l (170 700 nmol/l)
LH 28 iU/l (1 20 iU/l)
Basal FSH 4.7 iU/l (1.0 8.8 iU/l)
DHEAS 509 µg/dl (31 228 µg/dl)
Prolactin 602 mU/l (<360 mU/l)
17 OH Progesterone 54 ng/dl (<80 ng/dl)
What is the most appropriate treatment option for infertility in this patient?Your Answer:
Correct Answer: Clomiphene citrate
Explanation:To diagnose PCOS according to the Rotterdam criteria, at least two of the following must be present: clinical or biochemical evidence of hyperandrogenism, evidence of oligo- or anovulation, and the presence of polycystic ovaries on ultrasound.
Numerous clinical trials have been conducted to determine the most effective drug for aiding fertility in PCOS patients. A study published in the New England Journal of Medicine found that Clomiphene is superior to metformin in achieving live birth in infertile women with PCOS, although multiple births can be a complication. Another article published in Trends in Endocrinology and Metabolism reported that both Clomiphene and metformin are better than placebo for increasing ovulation and pregnancy rates in PCOS patients, but Clomiphene is more effective than metformin for ovulation, pregnancy, and live-birth rates in patients with a BMI over 30.
In PCOS, serum prolactin levels may be slightly elevated, but they rarely exceed 1500 mU/l. Reverse circadian rhythm steroids are used to treat congenital adrenal hyperplasia, while cabergoline is used to manage hyperprolactinemia. Spironolactone can improve hirsutism in PCOS due to its antiandrogenic activity, but it does not affect fertility.
Managing Polycystic Ovarian Syndrome
Polycystic ovarian syndrome (PCOS) is a condition that affects a significant percentage of women of reproductive age. Its management is complex due to the unclear cause of the condition. However, it is known that PCOS is associated with high levels of luteinizing hormone and hyperinsulinemia, and there is some overlap with the metabolic syndrome. General management includes weight reduction if appropriate and the use of combined oral contraceptives (COC) to regulate the menstrual cycle and induce a monthly bleed.
Hirsutism and acne are common symptoms of PCOS, and a COC pill may be used to manage them. Third-generation COCs with fewer androgenic effects or co-cyprindiol with an anti-androgen action are possible options. If these do not work, topical eflornithine may be tried, or spironolactone, flutamide, and finasteride may be used under specialist supervision.
Infertility is another issue that women with PCOS may face. Weight reduction is recommended if appropriate, and the management of infertility should be supervised by a specialist. There is an ongoing debate about whether metformin, clomifene, or a combination should be used to stimulate ovulation. A 2007 trial published in the New England Journal of Medicine suggested that clomifene was the most effective treatment. However, there is a potential risk of multiple pregnancies with anti-oestrogen therapies such as clomifene. The RCOG published an opinion paper in 2008 and concluded that on current evidence, metformin is not a first-line treatment of choice in the management of PCOS. Metformin is also used, either combined with clomiphene or alone, particularly in patients who are obese. Gonadotrophins may also be used.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 19
Incorrect
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A 50-year-old male presents to his general practitioner with complaints of lethargy and weight loss over the past three months. He has a history of diabetes mellitus for the past six years and is currently taking gliclazide 160 mg daily and metformin 1 g twice daily. On examination, his BMI is 25.6 kg/m2, pulse is 88 beats per minute, and blood pressure is 164/102 mmHg. Fundal examination reveals dot haemorrhages in the temporal retina of both eyes with occasional hard exudates. Loss of position and vibration sensation are noted to the mid tibia bilaterally.
Further investigations reveal a haemoglobin level of 140 g/L, white cell count of 4.8 ×109/L, platelets of 195 ×109/L, serum sodium of 137 mmol/L, serum potassium of 4.6 mmol/L, serum urea of 16.7 mmol/L, serum creatinine of 220 µmol/L, HbA1c of 78 mmol/mol (9.3%), and urinalysis showing protein++ and blood+.
What is the most appropriate therapeutic strategy for this patient?Your Answer:
Correct Answer: Stop metformin and gliclazide and start insulin
Explanation:Treatment Options for a Patient with Weight Loss and Poor Glycaemic Control
In the case of a patient with weight loss, modest BMI, and poor glycaemic control with established retinopathy and nephropathy, switching to insulin is recommended. While some authorities suggest stopping metformin in patients with a creatinine above 150 µmol/L, many patients continue on metformin with higher creatinine levels without any negative effects. Adding pioglitazone to either metformin or gliclazide would provide little benefit as the patient’s current issue appears to be insulinopenia, leading to weight loss and osmotic symptoms. Maximising oral hypoglycaemic agents, which are already at near-maximum doses, would also be of little benefit. Given the symptoms of insulinopaenia, a GLP-1 agonist is unlikely to be effective in this case.
Overall, the best course of action for this patient would be to switch to insulin therapy to improve glycaemic control and address the underlying issue of insulinopenia.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 20
Incorrect
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A 30 year old man presents to the endocrinology clinic. He is worried because his mother had a 'brain tumour' removed 2 years ago and has now been told she has another tumour in her abdomen after going to her doctor with reflux and indigestion. She has been told it might be a genetic problem and is awaiting testing. He is concerned he might also have the condition and so his GP has referred him to the clinic.
He is currently asymptomatic.
On examination there is no abnormality on the cardiovascular, respiratory, abdominal or neurological examinations.
The doctor explains that the most appropriate person to see would be the geneticist to whom his mother has been referred. He asks him to obtain the details if his mother is willing to provide them and says that he will refer him. In the meantime, he offers to carry out some screening blood tests.
Given the likely underlying diagnosis, which of the following is most likely to be abnormal?Your Answer:
Correct Answer: Parathyroid hormone
Explanation:Understanding Multiple Endocrine Neoplasia
Multiple endocrine neoplasia (MEN) is an autosomal dominant disorder that affects the endocrine system. There are three main types of MEN, each with its own set of associated features. MEN type I is characterized by the 3 P’s: parathyroid hyperplasia leading to hyperparathyroidism, pituitary tumors, and pancreatic tumors such as insulinomas and gastrinomas. MEN type IIa is associated with the 2 P’s: parathyroid hyperplasia leading to hyperparathyroidism and phaeochromocytoma, as well as medullary thyroid cancer. MEN type IIb is characterized by phaeochromocytoma, medullary thyroid cancer, and a marfanoid body habitus.
The most common presentation of MEN is hypercalcaemia, which is often seen in MEN type I due to parathyroid hyperplasia. MEN type IIa and IIb are both associated with medullary thyroid cancer, which is caused by mutations in the RET oncogene. MEN type I is caused by mutations in the MEN1 gene. Understanding the different types of MEN and their associated features is important for early diagnosis and management of this rare but potentially serious condition.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 21
Incorrect
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A 56-year-old man comes to the diabetes clinic for evaluation. He has been experiencing symptoms of polyuria, polydipsia, and lethargy for the past few months, and his fasting glucose level is elevated at 7.8 mmol/l. He has no family history of diabetes and is currently being treated for hypertension and dyslipidemia by his primary care physician. During the examination, his blood pressure is 150/90 mmHg, his pulse is regular at 72 beats per minute, and his body mass index is 33 kg/m². His renal function is normal, and he tests positive for GAD+ antibodies.
What is the most appropriate approach to managing his glucose control?Your Answer:
Correct Answer: Metformin
Explanation:Patients who are diagnosed with type 2 diabetes are often tested for GAD autoantibodies, and it has been found that a significant number of them are positive for these antibodies. These individuals are believed to progress to insulin therapy faster than those who are negative for the antibodies, with an average time of 3-5 years compared to 7 years for standard patients.
Despite this difference, the management of these patients is the same as for those without the autoantibodies. Metformin is still the initial therapy of choice, and weight reduction is recommended to delay the need for insulin. Insulin-sparing strategies, such as the use of SGLT-2 inhibitors or GLP-1 agonists, may also be employed during the first few years after diagnosis.
NICE has updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022 to reflect advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. For the average patient taking metformin for T2DM, lifestyle changes and titrating up metformin to aim for a HbA1c of 48 mmol/mol (6.5%) is recommended. A second drug should only be added if the HbA1c rises to 58 mmol/mol (7.5%). Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates, controlling intake of saturated fats and trans fatty acids, and initial target weight loss of 5-10% in overweight individuals.
Individual HbA1c targets should be agreed upon with patients to encourage motivation, and HbA1c should be checked every 3-6 months until stable, then 6 monthly. Targets should be relaxed on a case-by-case basis, with particular consideration for older or frail adults with type 2 diabetes. Metformin remains the first-line drug of choice, and SGLT-2 inhibitors should be given in addition to metformin if the patient has a high risk of developing cardiovascular disease (CVD), established CVD, or chronic heart failure. If metformin is contraindicated, SGLT-2 monotherapy or a DPP-4 inhibitor, pioglitazone, or sulfonylurea may be used.
Further drug therapy options depend on individual clinical circumstances and patient preference. Dual therapy options include adding a DPP-4 inhibitor, pioglitazone, sulfonylurea, or SGLT-2 inhibitor (if NICE criteria are met). If a patient does not achieve control on dual therapy, triple therapy options include adding a sulfonylurea or GLP-1 mimetic. GLP-1 mimetics should only be added to insulin under specialist care. Blood pressure targets are the same as for patients without type 2 diabetes, and ACE inhibitors or ARBs are first-line for hypertension. Antiplatelets should not be offered unless a patient has existing cardiovascular disease, and only patients with a 10-year cardiovascular risk > 10% should be offered a statin.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 22
Incorrect
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A 32-year-old woman who is 38-weeks pregnant presents to the hospital in labor. She has a firm, rigid abdomen and the fetal monitor shows signs of distress. Upon examination, she is diagnosed with placental abruption and undergoes an emergency cesarean section. Due to excessive bleeding of over 3 liters, the major hemorrhage protocol is initiated.
After being discharged from the hospital, she visits her primary care physician complaining of an inability to breastfeed and persistent fatigue. Her doctor suspects that she may be suffering from Sheehan syndrome.
Which specific anatomical structure has suffered from infarction, leading to the development of this syndrome?Your Answer:
Correct Answer: Pituitary gland
Explanation:Understanding Sheehan Syndrome: Effects on the Pituitary Gland and Hormone Production
Sheehan syndrome is a condition that occurs as a result of severe postpartum blood loss, which leads to the infarction of the pituitary gland. This can disrupt the production of growth hormone and prolactin, causing agalactorrhea. Additionally, other anterior pituitary hormones such as gonadotropins, adrenocorticotropic hormone, and thyroid-stimulating hormone may also be affected.
It’s important to note that the infarction occurs in the pituitary gland itself, not the hypothalamus. While hypothalamic dysfunction can disrupt the release of hormones that act on the pituitary gland, this is not the case in Sheehan syndrome.
The adrenal gland is not directly affected by Sheehan syndrome, but the resulting hypopituitarism can cause adrenocorticotropic hormone deficiency, leading to secondary adrenal insufficiency.
Breast lactocytes are not directly affected by Sheehan syndrome either. Instead, it is the pituitary gland’s secretion of prolactin that stimulates lactocytes to produce milk.
Finally, while TSH deficiency can result from hypopituitarism caused by Sheehan syndrome, the thyroid gland itself is not affected. Understanding the effects of Sheehan syndrome on the pituitary gland and hormone production is crucial for proper diagnosis and treatment.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 23
Incorrect
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A 50-year-old male complains of frequent sweating and persistent headaches.
An oral glucose tolerance test is conducted and the results are as follows:
Time (mins) 0 30 60 90 120
Growth hormone (ng/ml) 2.1 2.3 3.0 3.5 3.6
Glucose 9.5 11.2 12.1 13.5 16.1
What additional investigation will be necessary in the future, given the probable diagnosis?Your Answer:
Correct Answer: Colonoscopy
Explanation:Regular colonoscopic screening should be offered to patients with acromegaly, beginning at the age of 40 years. The frequency of subsequent colonoscopies should be determined based on the results of the initial screening and the activity of the underlying acromegaly. The diagnosis of acromegaly can be confirmed through clinical features and the results of an oral glucose tolerance test, which should show suppression of growth hormone in response to a rise in glucose. Due to the high prevalence of cardiovascular disease in acromegaly patients, screening for cardiovascular risk factors is recommended and should be managed aggressively. Additionally, patients with acromegaly have an increased risk of developing colorectal carcinoma due to high levels of insulin-like growth factor, and colonoscopy is the most sensitive test for screening.
Acromegaly is a condition that can be managed through various treatment options. The first-line treatment for the majority of patients is trans-sphenoidal surgery. However, if the pituitary tumour is inoperable or surgery is unsuccessful, medication may be indicated. One such medication is a somatostatin analogue, which directly inhibits the release of growth hormone. Octreotide is an example of this medication and is effective in 50-70% of patients. Another medication is pegvisomant, which is a GH receptor antagonist that prevents dimerization of the GH receptor. It is administered once daily subcutaneously and is very effective, decreasing IGF-1 levels in 90% of patients to normal. However, it does not reduce tumour volume, so surgery is still needed if there is a mass effect. Dopamine agonists, such as bromocriptine, were the first effective medical treatment for acromegaly but are now superseded by somatostatin analogues and are only effective in a minority of patients. External irradiation may be used for older patients or following failed surgical/medical treatment.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 24
Incorrect
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As the medical doctor on an acute medical unit, you receive a referral for a 27-year-old adopted female with a history of recurrent kidney stones who has been found to have hypokalaemia (K+ 2.6 mmol/l) by her GP. Despite feeling well and denying any vomiting or diarrhoea, her blood results show the following:
- Na+ 141 mmol/l
- K+ 2.6 mmol/l
- Bicarbonate 18 mmol/l
- Urea 5.0 mmol/l
- Creatinine 67 µmol/l
- Anion gap 13 mEq/L
What is the most likely cause of her presentation?Your Answer:
Correct Answer: Renal tubular acidosis type 1
Explanation:The individual’s medical history includes repeated occurrences of kidney stones, low potassium levels, acidosis, and a normal anion gap, which are indicative of renal tubular acidosis type 1. While renal tubular acidosis type 2 may present with comparable biochemical characteristics, it is less probable to be accompanied by a history of kidney stones. Renal tubular acidosis type 3 is no longer considered a valid classification.
Renal tubular acidosis (RTA) is a condition that results in hyperchloraemic metabolic acidosis, which is characterized by a normal anion gap. There are three types of RTA, each with its own unique set of causes and complications. Type 1 RTA, also known as distal RTA, is caused by an inability to generate acid urine in the distal tubule, leading to hypokalaemia. This type of RTA can be caused by a variety of factors, including rheumatoid arthritis, SLE, and amphotericin B toxicity. Complications may include nephrocalcinosis and renal stones.
Type 2 RTA, or proximal RTA, is characterized by a decreased reabsorption of HCO3- in the proximal tubule, which also leads to hypokalaemia. This type of RTA can be caused by a variety of factors, including Wilson’s disease and outdated tetracyclines. Complications may include osteomalacia.
Type 3 RTA, or mixed RTA, is an extremely rare form of the condition that is caused by carbonic anhydrase II deficiency. This results in hypokalaemia.
Type 4 RTA, or hyperkalaemic RTA, is caused by a reduction in aldosterone, which leads to a reduction in proximal tubular ammonium excretion. This type of RTA can be caused by hypoaldosteronism and diabetes, and it results in hyperkalaemia.
Overall, RTA is a complex condition that can have a variety of causes and complications. It is important to work with a healthcare provider to determine the underlying cause of the condition and develop an appropriate treatment plan.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 25
Incorrect
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A 50-year old woman has been diagnosed with type 2 diabetes and shows signs of possible cortisol excess, including striae, centripetal obesity, and proximal myopathy. Her initial lab results show elevated white cell count, AST, ALT, and alkaline phosphatase, as well as low potassium levels and high urine free cortisol and ACTH levels. An ultrasound reveals bulky adrenal glands, and a low dose dexamethasone suppression test confirms cortisol excess. A high dose dexamethasone suppression test and MRI of the pituitary gland are also performed. What is the next appropriate step for this patient?
Your Answer:
Correct Answer: Inferior petrosal sinus sampling
Explanation:Diagnosis and Investigation of Cushing’s Syndrome
This patient is showing signs of Cushing’s syndrome, which is likely caused by Cushing’s disease. Symptoms include malaise, psychological issues, diabetes, hypertension, and skin changes. The low dose dexamethasone test confirmed the diagnosis by failing to suppress to less than 50. However, the source of the ACTH needs to be determined to differentiate between Cushing’s disease and ectopic Cushing’s. A high dose dexamethasone test is unreliable, and a normal MRI scan cannot identify all microadenomas. Therefore, the most appropriate investigation is inferior petrosal sinus (IPS) sampling with cortisol releasing hormone (CRH) stimulation to compare IPS and plasma ratios of ACTH to confirm the pituitary origin. The adrenal changes seen on ultrasound scanning are likely due to chronic ACTH stimulation.
Overall, the diagnosis and investigation of Cushing’s syndrome require careful consideration and testing to determine the source of the ACTH and differentiate between Cushing’s disease and ectopic Cushing’s. The IPS sampling with CRH stimulation is the most appropriate investigation to confirm the pituitary origin of the ACTH.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 26
Incorrect
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A 63-year-old woman visits her doctor with complaints of hair loss, weight gain, and feeling lethargic. She reports no other health issues. The doctor orders thyroid function tests, and the results are:
- Thyroid stimulating hormone (TSH) 0.3 mu/l
- Free T4 8 pmol/l
What test is most likely to provide a definitive diagnosis?Your Answer:
Correct Answer: MRI pituitary gland
Explanation:The patient is diagnosed with hypothyroidism, which is typically primary with a high TSH and low T4. The common causes include autoimmune conditions such as Hashimoto’s disease or atrophic, iodine deficiency, thyroiditis (post-viral or post-partum), and iatrogenic factors such as thyroidectomy, radioiodine, or certain medications. Secondary hypothyroidism is rare and results in a low TSH and low T4, indicating pituitary insufficiency. In such cases, an MRI of the gland is recommended.
Understanding Thyroid Function Tests
Thyroid function tests are used to diagnose thyroid disorders such as hypothyroidism and hyperthyroidism. The interpretation of these tests is usually straightforward. In cases of thyrotoxicosis, such as Graves’ disease, the TSH level will be low and the free T4 level will be high. In primary hypothyroidism, the TSH level will be high and the free T4 level will be low. In cases of secondary hypothyroidism, both TSH and free T4 levels will be low, and replacement steroid therapy is required prior to thyroxine.
Sick euthyroid syndrome, now referred to as non-thyroidal illness, is common in hospital inpatients and is characterized by low levels of both TSH and free T4. T3 levels are particularly low in these patients. Subclinical hypothyroidism is characterized by high TSH levels and normal free T4 levels. Poor compliance with thyroxine can also result in high TSH levels and normal free T4 levels. Steroid therapy can result in low TSH levels and normal free T4 levels.
It is important to note that many causes of hypothyroidism may have an initial thyrotoxic phase. Understanding the results of thyroid function tests can help diagnose and manage thyroid disorders effectively.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 27
Incorrect
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A 32-year-old woman contacts the endocrinology nurse seeking advice. She has been experiencing vomiting for the past 24 hours and has been unable to take her regular medications due to this. She has a medical history of Addison's disease and usually takes oral hydrocortisone and fludrocortisone. She denies any other symptoms apart from reduced oral intake and has not experienced dizziness on standing, blackouts, or diarrhea. Her temperature has been normal. She has IM hydrocortisone available at home. What is the most appropriate advice to give regarding her hydrocortisone?
Your Answer:
Correct Answer: Advise her to take the IM hydrocortisone at home whilst vomiting
Explanation:If a person with Addison’s disease experiences vomiting and is unable to take their regular oral hydrocortisone, they should be administered IM hydrocortisone until the vomiting subsides. This is crucial to prevent an Addisonian crisis. It is recommended that all patients with Addison’s disease have access to IM hydrocortisone in case of such situations. In case of systemic involvement, hospitalization for IV fluids and IV hydrocortisone may be necessary.
Addison’s disease is a condition that requires patients to undergo glucocorticoid and mineralocorticoid replacement therapy. This treatment involves taking a combination of hydrocortisone and fludrocortisone. Hydrocortisone is usually given in 2 or 3 divided doses, with patients requiring 20-30 mg per day, mostly in the first half of the day. Fludrocortisone is also included in the treatment regimen. Patient education is crucial in managing Addison’s disease. Patients should be reminded not to miss glucocorticoid doses, and they may consider wearing Medic Alert bracelets and steroid cards. Additionally, patients should be provided with hydrocortisone for injection with needles and syringes to treat an adrenal crisis. It is also important to discuss how to adjust the glucocorticoid dose during an intercurrent illness.
During an intercurrent illness, the glucocorticoid dose should be doubled, while the fludrocortisone dose remains the same. The Addison’s Clinical Advisory Panel has produced guidelines that detail specific scenarios for managing intercurrent illness. These guidelines can be found on the CKS link for more information. Proper management of Addison’s disease is essential to ensure that patients receive the appropriate treatment and care they need to manage their condition effectively.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 28
Incorrect
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A 50-year-old man presented to the hospital complaining of severe pain in his thighs and buttocks, which made it difficult for him to walk. He had noticed increasing difficulty climbing stairs and rising from chairs over the past two months. The pain started gradually in his right leg and then spread to his left leg. The pain was not related to exertion and was now severe enough to keep him awake at night. He also reported feeling fatigued and had lost 8 kg in weight over the past six months despite having a good appetite.
The patient was diagnosed with diabetes two years ago but was an infrequent attender at his General Practitioner's diabetic clinic. He claimed to adhere to his diabetic diet and continued to take the chlorpropamide prescribed from the clinic. He lived alone, smoked 20 cigarettes a day, and drank approximately 12 units of alcohol per week.
On examination, the patient appeared thin and uncomfortable. There was wasting of the quadriceps muscles bilaterally with loss of power (grade 3/5). Knee and ankle jerks could not be elicited, and both plantar responses were extensor. There was some loss of light touch and pinprick sensation over both feet and ankles.
Urinalysis revealed trace amounts of protein and glucose 1%. Based on these symptoms, what is the most likely diagnosis?Your Answer:
Correct Answer: Diabetic amyotrophy
Explanation:Diabetic Amyotrophy
Diabetic amyotrophy is a type of neuropathy that is believed to be caused by inflammation rather than long-term poor blood sugar control. It is more common among individuals with type 2 diabetes. This condition typically affects the femoral nerve, lumbosacral plexus, or lumbar roots.
The clinical symptoms of diabetic amyotrophy include pain in the hip, buttock, or thigh, accompanied by weakness. Sensory loss is usually minimal, and plantar responses may be either flexor or extensor. Electromyography (EMG) typically shows multifocal denervation in paraspinous and leg muscles.
Fortunately, partial or complete resolution of diabetic amyotrophy can occur with proper management of hyperglycemia. It is important for individuals with diabetes to be aware of this condition and to seek medical attention if they experience any of the symptoms associated with diabetic amyotrophy. By controlling blood sugar levels, individuals can reduce their risk of developing this condition and improve their overall health and well-being.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 29
Incorrect
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A 57 year-old man with type 2 diabetes mellitus visits his GP for his yearly check-up. He is currently taking metformin 500mg twice daily and gliclazide 40mg once daily for his diabetes. However, he has been experiencing frequent episodes of hypoglycaemia which is affecting his work as a construction worker. His latest HbA1c reading was 66 mmol/mol. Additionally, he has a medical history of stage 2 heart failure, hypertension and mild chronic obstructive pulmonary disease.
What treatment modification would be most appropriate?Your Answer:
Correct Answer: Stop gliclazide and start sitagliptin
Explanation:The cause of this patient’s hypoglycaemic episodes is likely the sulfonylurea medication they are taking. According to NICE guidelines, if a patient experiences hypoglycaemic side effects from sulfonylurea, they can switch to a combination of metformin and either a glitazone or a DPP-4 inhibitor. However, pioglitazone is not recommended for patients with heart failure, so a combination of metformin and sitagliptin is the best option for this patient. Glibenclamide is not suitable in this case due to its long-acting hypoglycaemic effects.
NICE has updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022 to reflect advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. For the average patient taking metformin for T2DM, lifestyle changes and titrating up metformin to aim for a HbA1c of 48 mmol/mol (6.5%) is recommended. A second drug should only be added if the HbA1c rises to 58 mmol/mol (7.5%). Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates, controlling intake of saturated fats and trans fatty acids, and initial target weight loss of 5-10% in overweight individuals.
Individual HbA1c targets should be agreed upon with patients to encourage motivation, and HbA1c should be checked every 3-6 months until stable, then 6 monthly. Targets should be relaxed on a case-by-case basis, with particular consideration for older or frail adults with type 2 diabetes. Metformin remains the first-line drug of choice, and SGLT-2 inhibitors should be given in addition to metformin if the patient has a high risk of developing cardiovascular disease (CVD), established CVD, or chronic heart failure. If metformin is contraindicated, SGLT-2 monotherapy or a DPP-4 inhibitor, pioglitazone, or sulfonylurea may be used.
Further drug therapy options depend on individual clinical circumstances and patient preference. Dual therapy options include adding a DPP-4 inhibitor, pioglitazone, sulfonylurea, or SGLT-2 inhibitor (if NICE criteria are met). If a patient does not achieve control on dual therapy, triple therapy options include adding a sulfonylurea or GLP-1 mimetic. GLP-1 mimetics should only be added to insulin under specialist care. Blood pressure targets are the same as for patients without type 2 diabetes, and ACE inhibitors or ARBs are first-line for hypertension. Antiplatelets should not be offered unless a patient has existing cardiovascular disease, and only patients with a 10-year cardiovascular risk > 10% should be offered a statin.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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Question 30
Incorrect
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A 34-year-old man and his wife have been struggling to conceive for the past decade. During his examination, you notice that he is tall and thin with bilateral gynaecomastia. Your colleague has conducted some initial tests, and one of them has come back indicating elevated levels of urinary gonadotrophins. What is the probable diagnosis?
Your Answer:
Correct Answer: Klinefelter's syndrome
Explanation:Genetic Disorders and Andropause
Gaucher’s and Marfan syndrome are genetic disorders that do not cause infertility. Noonan’s syndrome, on the other hand, is associated with short stature. Klinefelter’s syndrome is a sex chromosome disorder that affects males, with a prevalence of 1 in 400 to 1 in 600 births. This disorder is characterized by the presence of an extra X chromosome, resulting in a karyotype of 47 XXY, XXXYY, or XXYY.
Andropause is a term used to describe the gradual decrease in serum testosterone concentration that occurs with age. However, this condition typically does not occur until after the age of 50. It is important to note that while these conditions may have some similarities, they are distinct and require different approaches to diagnosis and treatment. Proper diagnosis and management of these conditions can help individuals lead healthy and fulfilling lives.
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This question is part of the following fields:
- Endocrinology, Diabetes And Metabolic Medicine
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