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Question 1
Incorrect
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You assess a 65-year-old patient who has type two diabetes and has no other current health issues or significant medical history. The patient is currently taking metformin 1g bd. Their HbA1c was 56 mmol/mol six months ago and has increased to 59 mmol/mol in their most recent test from last week. What is the most appropriate action to take in this situation?
Your Answer: Repeat HbA1c in 6 months
Correct Answer: Add additional oral agent to metformin
Explanation:If a patient with type 2 diabetes mellitus is taking the maximum dose of metformin and has an HbA1c level of 58 mmol/mol or higher, it is recommended to add a second drug to their treatment regimen. The patient should be closely monitored and have their HbA1c level checked again in 3-6 months to ensure stability on the new therapy. It is important to intensify treatment at this stage, but referral to secondary care is not necessary and primary care should manage the patient’s management. Insulin therapy is not recommended yet, and a further oral agent should be added first. If the second agent fails to reduce HbA1c, triple therapy may be considered. Lifestyle advice and management should also be provided at each review.
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 doesn’t 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:
- Metabolic Problems And Endocrinology
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Question 2
Incorrect
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What is a metabolic effect of exenatide?
Your Answer: Improves insulin sensitivity
Correct Answer: Accelerates gastric emptying
Explanation:Exenatide and its Metabolic Effects
Exenatide is a medication that imitates the effects of GLP-1, a hormone produced in the gut. It has been found to have beneficial effects on the metabolism of individuals with diabetes mellitus. This medication has several metabolic effects, including the suppression of appetite, inhibition of glucose production in the liver, slowing of gastric emptying, and stimulation of insulin release. However, it doesn’t increase insulin sensitivity, which is achieved by other drugs such as metformin and the glitazones. Overall, exenatide has been shown to have a positive impact on the management of diabetes by regulating various metabolic processes.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 3
Incorrect
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You are seeing a woman in her 60s with type 2 diabetes for review. She holds a group 1 driving license.
Her current treatment consists of metformin 500 mg TDS and gliclazide 80 mg BD. As part of her review, you discuss any episodes of hypoglycaemia.
She tells you that she has had episodes of hypoglycaemia since she was last seen for review almost a year ago. On further questioning, there have been two episodes when she felt significantly unwell. During these episodes, her husband checked her finger prick blood sugar and it was less than 3 mmol/L. On both of these occasions, she felt sweaty, shaky and nauseated.
Her husband is with her and he tells you that she quite quickly became unwell and 'confused' with these episodes and he had to help her rest on the sofa and give her some dextrose tablets to get her sugar back up. She has not had any episodes of hypoglycaemia whilst driving.
With regard to her driving, what should you advise?Your Answer: He must report the episodes of hypoglycaemia to the DVLA but he can continue driving
Correct Answer: He should only drive with another person in the car in case he requires assistance or becomes unwell whilst driving
Explanation:New Medical Driving Standards for Diabetes Patients
The medical driving standards for individuals with diabetes have recently changed. For those with a group 1 entitlement who are managed with tablets that carry the risk of inducing hypoglycaemia, they must stop driving and inform the DVLA if they have had more than one episode of severe hypoglycaemia within the preceding 12 months. Severe hypoglycaemia is defined as an episode that requires external help. In this case, the patient has experienced two episodes where external help from his wife was needed. As a result, the patient should cease driving until 12 months after the last but one episode and can only resume driving when stable control is demonstrated. These new standards aim to ensure the safety of both the driver and other individuals on the road.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 4
Correct
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A 52-year-old woman presents to you with complaints of excessive sweating. She has noticed these symptoms over the past few months. Additionally, she reports that her periods have become less frequent and she has experienced some weight loss. During the examination, her pulse rate is 96 bpm and her blood pressure is 130/76 mmHg. She exhibits a fine tremor in her outstretched arms and has lost 4 kg in the last six months. What diagnostic test would be helpful in confirming the diagnosis?
Your Answer: Thyroid function tests
Explanation:Assessing Excessive Sweating in Primary Care
Excessive sweating can be a symptom of various medical conditions, and the first step in assessing someone presenting with sweating problems is to determine if the symptoms are focal or generalized. Generalized sweating is most likely due to a secondary medical condition. In this case, the patient presents with additional clinical features that suggest a secondary cause.
In this age group, the most common cause of sweating would relate to the menopause. However, in this case, the patient reports weight loss, irregular periods, fine tremor, and tachycardia, which are not typical menopausal symptoms. Bringing together all of these features, a diagnosis of hyperthyroidism is likely. Thyroid function tests will confirm the diagnosis.
It is important to note that diabetes can cause weight loss, but the clinical picture doesn’t fit, and a fasting blood sugar would not give a diagnosis. FSH levels can sometimes be used if menopause is suspected, but in a woman of typical age and with typical menopausal symptoms, blood tests are not needed, and a clinical diagnosis should be made. A pelvic ultrasound is not indicated in this case, as the stem doesn’t suggest any endometrial or ovarian pathology.
In rare cases, phaeochromocytoma can present with labile blood pressure and episodes of sweating and tachycardia. However, this is not likely in the primary care setting, and thyroid dysfunction is much more common. The patient is symptomatic with a normal BP when examined. Therefore, a diagnosis of hyperthyroidism is the most likely cause of the patient’s excessive sweating, and further tests will confirm the diagnosis.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 5
Incorrect
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A 75-year-old male with a history of insulin dependent diabetes presents with persistent abdominal bloating and vomiting. The gastroenterologist suspects gastroparesis. What would be the best initial course of action for management?
Your Answer: Cyclizine
Correct Answer: Metoclopramide
Explanation:Gastroparesis can cause persistent vomiting in a poorly controlled diabetic, and cyclizine is not a recommended treatment for this condition. Instead, prokinetic drugs such as metoclopramide or domperidone can be used. Amoxicillin is not useful in managing gastroparesis, but erythromycin can be used off-label as a prokinetic. While metformin is helpful in controlling diabetes, it is not involved in the acute management of gastroparesis.
Diabetes can cause peripheral neuropathy, which typically results in sensory loss rather than motor loss. This can lead to a glove and stocking distribution of symptoms, with the lower legs being affected first. Painful diabetic neuropathy is a common issue that can be managed with medications such as amitriptyline, duloxetine, gabapentin, or pregabalin. If these drugs do not work, tramadol may be used as a rescue therapy for exacerbations of neuropathic pain. Topical capsaicin may also be used for localized neuropathic pain. Pain management clinics may be helpful for patients with resistant problems.
Gastrointestinal autonomic neuropathy is another complication of diabetes that can cause symptoms such as gastroparesis, erratic blood glucose control, bloating, and vomiting. This can be managed with medications such as metoclopramide, domperidone, or erythromycin, which are prokinetic agents. Chronic diarrhea is another common issue that often occurs at night. Gastroesophageal reflux disease is also a complication of diabetes that is caused by decreased lower esophageal sphincter pressure.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 6
Incorrect
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A 30-year-old woman with hyperthyroidism is diagnosed with Graves' disease and prescribed carbimazole for treatment. During counselling, she is informed about the potential side-effects of the medication.
What is the most severe adverse reaction of carbimazole?Your Answer: Hypoprothrombinaemia
Correct Answer: Agranulocytosis
Explanation:Carbimazole: Potential Side Effects and Risks
Carbimazole is a medication used to treat hyperthyroidism, but it can also cause several side effects and risks. One of the most serious risks is agranulocytosis, which occurs in 0.3-0.6% of patients and has a mortality rate of 21.5%. Patients taking carbimazole should be aware of symptoms of infection, such as a sore throat, and seek medical attention if they experience them. Hypoprothrombinaemia, which can cause bleeding, is another potential side effect. While less serious than agranulocytosis, it is important to check a patient’s prothrombin time before invasive procedures. Cholestatic jaundice is a rare side effect that typically resolves after stopping carbimazole. Hepatitis has also been reported, but is not listed as a side effect in the British National Formulary (BNF). Finally, alopecia is a listed side effect, but is not as serious as agranulocytosis. Patients taking carbimazole should be aware of these potential risks and side effects.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 7
Correct
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A 25-year-old woman with type 1 diabetes mellitus attends for her routine review and says she is keen on becoming pregnant.
What factor is most likely to make you ask her to defer her pregnancy at this stage?Your Answer: HbA1c 80 mmol/mol
Explanation:Managing Diabetes in Pregnancy: Key Considerations
Pregnancy in women with type 1 diabetes is associated with increased risks of congenital abnormalities, neonatal morbidity and mortality, and operative delivery rates. However, pre-pregnancy counselling and achieving near-normal levels of glycosylated haemoglobin (HbA1c) can improve pregnancy outcomes. While microalbuminuria and background retinopathy may not be contraindications to pregnancy, regular monitoring and prompt referral to specialists are necessary to prevent progression of these complications. Sensory neuropathy may cause severe vomiting due to gastroparesis, but it is not a contraindication to pregnancy. Additionally, women with diabetes should take 5 mg folic acid daily pre-pregnancy to reduce the risk of neural tube defects. Good diabetic control remains the most important factor in managing diabetes in pregnancy.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 8
Incorrect
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A 35-year-old man with type I diabetes is diagnosed with microalbuminuria. What is the accurate statement about diabetic nephropathy in patients with type I diabetes?
Your Answer: Aggressive antihypertensive therapy will stop the decline in glomerular filtration rate in patients with proteinuria
Correct Answer: Approximately one in five patients with microalbuminuria will progress to diabetic nephropathy
Explanation:Understanding Diabetic Nephropathy: Myths and Facts
Diabetic nephropathy is a serious complication of diabetes that can lead to renal failure. However, there are several myths and misconceptions surrounding this condition. Here are some important facts to help you better understand diabetic nephropathy:
Myth: Only patients with proteinuria are at risk of developing diabetic nephropathy.
Fact: Microalbuminuria, a small increase in albumin excretion in the urine, is an early sign of diabetic nephropathy. Approximately 40% of patients with type 1 diabetes of 30 years’ disease duration have microalbuminuria. Optimal control of blood pressure, blood glucose, and lipids can help prevent the progression of microalbuminuria to proteinuria.Myth: Aggressive antihypertensive therapy can stop the decline in glomerular filtration rate in patients with proteinuria.
Fact: Even with aggressive antihypertensive therapy, patients with proteinuria still lose glomerular filtration rate at a rate of approximately 4 ml/min/year.Myth: ACE inhibitors are only indicated for patients with proteinuria, not microalbuminuria.
Fact: ACE inhibitors should be started and increased up to the full dose in all adults with diabetic nephropathy, including those with microalbuminuria. ACE inhibitors significantly reduce the risk of all-cause mortality for patients with diabetic kidney disease.Myth: Microalbuminuria, once developed, doesn’t regress.
Fact: In about one-third of cases, microalbuminuria can return to normal.Myth: The combination of proteinuria and hypertension only slightly increases the risk of mortality.
Fact: When proteinuria and hypertension are present, the standardised mortality ratio is increased by 11 times in men and 18 times in women. Many of the deaths are due to cardiovascular disease.Debunking Myths About Diabetic Nephropathy
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 9
Correct
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You are a healthcare professional working in a general practice. Your next patient is a 70-year-old man who has come for a follow-up appointment to review his recent blood test results. During his last visit, you had expressed concern about his elevated plasma glucose levels and advised him to make some lifestyle changes. He informs you that he has made some dietary modifications and has started walking to the nearby stores instead of driving.
The patient has a medical history of coeliac disease, osteoarthritis, and chronic kidney disease. His fasting blood test results are as follows:
- Hemoglobin (Hb): 146 g/L (normal range for males: 135-180; females: 115-160)
- Platelets: 235 * 109/L (normal range: 150-400)
- White blood cells (WBC): 7.0 * 109/L (normal range: 4.0-11.0)
- Sodium (Na+): 139 mmol/L (normal range: 135-145)
- Potassium (K+): 4.4 mmol/L (normal range: 3.5-5.0)
- Urea: 10.4 mmol/L (normal range: 2.0-7.0)
- Creatinine: 216 µmol/L (normal range: 55-120)
- Estimated glomerular filtration rate (eGFR): 28 ml/minute
- C-reactive protein (CRP): <5 mg/L (normal range: <5)
- Plasma glucose: 7.3 mmol/L (normal range: <6 mmol/L)
- Hemoglobin A1c (HbA1c): 54 mmol/mol
What would be the most appropriate course of action for managing this patient's HbA1c levels?Your Answer: Sitagliptin
Explanation:This individual has been diagnosed with type 2 diabetes mellitus, as evidenced by elevated blood glucose levels on two separate occasions and an HbA1c measurement of >48 mmol/mol. Despite receiving lifestyle advice, medication is necessary for treatment.
Due to an eGFR of <30ml/minute, metformin is not a suitable treatment option. Instead, sitagliptin, a DPP-4 inhibitor, is the most appropriate choice. While DESMOND, an NHS course aimed at educating individuals with type 2 diabetes and their families, may be beneficial for ongoing management, it doesn’t replace the need for medication in this case. Metformin is a medication commonly used to treat type 2 diabetes mellitus, as well as polycystic ovarian syndrome and non-alcoholic fatty liver disease. Unlike other medications, such as sulphonylureas, metformin doesn’t cause hypoglycaemia or weight gain, making it a first-line treatment option, especially for overweight patients. Its mechanism of action involves activating the AMP-activated protein kinase, increasing insulin sensitivity, decreasing hepatic gluconeogenesis, and potentially reducing gastrointestinal absorption of carbohydrates. However, metformin can cause gastrointestinal upsets, reduced vitamin B12 absorption, and in rare cases, lactic acidosis, particularly in patients with severe liver disease or renal failure. It is contraindicated in patients with chronic kidney disease, recent myocardial infarction, sepsis, acute kidney injury, severe dehydration, and those undergoing iodine-containing x-ray contrast media procedures. When starting metformin, it should be titrated up slowly to reduce the incidence of gastrointestinal side-effects, and modified-release metformin can be considered for patients who experience unacceptable side-effects.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 10
Correct
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A 50-year-old man comes to the clinic with complaints of ataxia and bilateral gynaecomastia.
What is the most probable diagnosis?Your Answer: Klinefelter's syndrome
Explanation:Gynaecomastia and Ataxia: Indicators of Lung Cancer
Gynaecomastia and ataxia are both symptoms that can indicate the presence of lung cancer. While Klinefelter’s syndrome can cause gynaecomastia and cerebellar stroke can cause ataxia, the combination of the two makes it more likely to be lung cancer. Gynaecomastia is a non-metastatic paraneoplastic syndrome that is often associated with non-small cell lung cancer. It can be painful and may also be accompanied by testicular atrophy. Ataxia, on the other hand, can occur as a result of paraneoplastic cerebellar degeneration associated with the malignancy.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 11
Incorrect
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A 35-year-old man who has had asthma since childhood is seen in the asthma clinic. His asthma has been poorly controlled over the last two years and he has seen a number of different practitioners. In an attempt to gain control over his asthma, his inhaled steroids have been increased on several occasions and he has had several prolonged courses of oral steroids. He comments that he has put on a lot of weight over the last four years and bruises easily. He finds that he is tired all the time and finds it difficult to get out of a chair. On examination, he has purple striae over his abdomen and urinalysis is positive to glucose.
What is the most likely diagnosis?Your Answer: Diabetes mellitus
Correct Answer: Cushing syndrome
Explanation:Understanding Cushing Syndrome and its Differential Diagnosis
Cushing syndrome is a condition characterized by excessive levels of cortisol in the body. It can be caused by prolonged use of oral corticosteroids or, in rare cases, by a tumor in the adrenal gland. Patients with Cushing syndrome may present with symptoms such as weight gain, moon face, buffalo hump, easy bruising, and thinning of the skin.
It is important to differentiate Cushing syndrome from other conditions with similar symptoms. Addison’s disease, for example, is caused by adrenal failure and presents with weakness, fatigue, and hyperpigmentation of the skin. Conn syndrome, on the other hand, is characterized by hypertension and hypokalemia due to excess aldosterone secretion from an adrenal adenoma.
Diabetes mellitus is a common complication of Cushing syndrome, as it can impair glucose metabolism. Hypothyroidism, while also causing fatigue and weight gain, doesn’t typically present with striae or glycosuria.
In summary, a thorough evaluation is necessary to accurately diagnose Cushing syndrome and differentiate it from other conditions with similar symptoms.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 12
Incorrect
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Mrs. Johnson is a type 2 diabetic who is scheduled to see the Community Diabetes Nurse because of poorly controlled HbA1c despite taking three different oral medications for her diabetes. The nurse discusses the options of starting either a GLP-1 mimetic like exenatide or starting insulin therapy. As she is an active senior citizen, she chooses to start a GLP-1 mimetic. The nurse advises her that this class of drug may cause some gastrointestinal side effects, but if she experiences severe abdominal pain, she should seek immediate medical attention.
What acute abdominal issue can arise from taking a GLP-1 mimetic?Your Answer: Acute mesenteric ischaemia
Correct Answer: Acute pancreatitis
Explanation:GLP-1 mimetics have been linked with an increased risk of severe pancreatitis, according to an alert issued by the MHRA in 2014. It is important to suspend GLP-1 mimetics immediately if pancreatitis is suspected. However, they do not cause appendicitis, drug-induced hepatitis, or acute mesenteric ischaemia.
Diabetes mellitus is a condition that has seen the development of several drugs in recent years. One hormone that has been the focus of much research is glucagon-like peptide-1 (GLP-1), which is released by the small intestine in response to an oral glucose load. In type 2 diabetes mellitus (T2DM), insulin resistance and insufficient B-cell compensation occur, and the incretin effect, which is largely mediated by GLP-1, is decreased. GLP-1 mimetics, such as exenatide and liraglutide, increase insulin secretion and inhibit glucagon secretion, resulting in weight loss, unlike other medications. They are sometimes used in combination with insulin in T2DM to minimize weight gain. Dipeptidyl peptidase-4 (DPP-4) inhibitors, such as vildagliptin and sitagliptin, increase levels of incretins by decreasing their peripheral breakdown, are taken orally, and do not cause weight gain. Nausea and vomiting are the major adverse effects of GLP-1 mimetics, and the Medicines and Healthcare products Regulatory Agency has issued specific warnings on the use of exenatide, reporting that it has been linked to severe pancreatitis in some patients. NICE guidelines suggest that a DPP-4 inhibitor might be preferable to a thiazolidinedione if further weight gain would cause significant problems, a thiazolidinedione is contraindicated, or the person has had a poor response to a thiazolidinedione.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 13
Correct
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A 57-year-old woman with recently diagnosed type 2 diabetes presents to you seeking advice. Her husband, who is also diabetic, takes a statin and his specialist always aims to get his cholesterol below 4 mmol/L.
The patient is a non-smoker and her blood pressure is within target. She has no history of cardiovascular disease and is not currently taking any lipid lowering therapy. Her total cholesterol level is 4.2 mmol/L and her eGFR is 68 ml/min/1.73 m2. There is no evidence of albuminuria.
What would be your recommended next step in managing this patient's lipid levels?Your Answer: Initiate treatment with atorvastatin 10 mg
Explanation:Management of Lipid Modification Therapy in Type 2 Diabetes
When managing lipid modification therapy in patients with type 2 diabetes, it is important to consider their risk of developing cardiovascular disease (CVD). According to NICE guidance issued in 2014, patients without established CVD should be offered lipid modification therapy if their 10-year risk of developing CVD using the QRISK2 assessment tool is 10% or more. However, this advice only applies to type 2 diabetes and not type 1 diabetes. Additionally, if the patient has pre-existing CV disease, a formal risk assessment is not needed, and lipid lowering therapy should be advised for secondary prevention.
Other factors that should be considered when managing lipid modification therapy include the patient’s estimated glomerular filtration rate (eGFR) and the presence of albuminuria. A risk assessment tool should not be used for patients with an eGFR less than 60 ml/min/1.73 m2 and/or albuminuria, as they are at increased risk of CVD and should be offered atorvastatin 20 mg for primary or secondary prevention of CVD.
In summary, when managing lipid modification therapy in patients with type 2 diabetes, it is important to assess their risk of developing CVD, consider their eGFR and albuminuria, and determine if they have pre-existing CV disease. This information will help determine whether a formal risk assessment is needed or if lipid lowering therapy should be advised for secondary prevention.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 14
Correct
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What is the most appropriate next step in managing a patient with erectile dysfunction who has a reduced morning serum total testosterone level?
Your Answer: No action
Explanation:Testing for Reduced Serum Testosterone
Patients who exhibit symptoms of reduced serum testosterone should undergo a repeat test, preferably in the morning, along with FSH, LH, and prolactin. This helps determine which part of the hypothalamic-pituitary-gonadal axis is affected. It is crucial to take action as the patient may have an underlying endocrinological cause. If the repeat test shows abnormal results, referral to a secondary care physician is necessary. The physician may then consider treatments such as testogel or nebido.
In summary, testing for reduced serum testosterone is essential in diagnosing and treating patients with symptoms of low testosterone levels. A repeat test, along with other hormone tests, can help identify the root cause of the problem and guide appropriate treatment.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 15
Correct
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A 64-year-old man is being seen in a diabetes clinic due to poor glycaemic control despite weight loss, adherence to a diabetic diet, and current diabetes medications. He has no significant medical history. What medication could be prescribed to increase his insulin sensitivity?
Your Answer: Pioglitazone
Explanation:Glitazones act as PPAR-gamma receptor agonists, which helps to decrease insulin resistance in the periphery.
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:
- Metabolic Problems And Endocrinology
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Question 16
Correct
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A 42-year-old woman with type 1 diabetes mellitus has not attended the diabetic clinic for five years.
Examination shows no abnormalities.
Investigations show:
Haemoglobin 90 g/L (115-165)
MCV 94 fL (80-96)
Haematocrit 28% -
HbA1c 87 mmol/mol (20-42)
10.1% (3.8-6.4)
A blood smear shows normochromic, normocytic anaemia.
Which of the following is the most likely cause?Your Answer: Erythropoietin deficiency
Explanation:Possible Causes of Anemia in Older Adults
The most probable reason for anemia in older adults is progressive renal failure, which results in decreased erythropoietin release from the kidneys. Sideroblastic anemia, which is associated with myelodysplasia, is more common in older age groups. While chronic lymphocytic leukemia (CLL) and microangiopathic hemolysis are potential causes, they are less likely. It is important to identify the underlying cause of anemia in older adults to ensure appropriate treatment and management.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 17
Incorrect
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A 55-year-old man with a history of hypertension and atrial fibrillation has been diagnosed with type 2 diabetes. Despite dietary changes, his HbA1c has worsened and he has started taking metformin. What annual blood test should be monitored?
Your Answer: Creatine kinase (CK)
Correct Answer: Urea and electrolytes (U&E)
Explanation:To ensure safe use of metformin, it is important to regularly monitor renal function in patients. Prior to prescribing metformin, renal function should be assessed and then monitored periodically thereafter. Patients with normal renal function should have their renal function checked at least once a year, while those with additional risk factors for renal impairment should have it checked at least twice a year. If the estimated glomerular filtration rate (eGFR) falls below 30, metformin should not be initiated. If the eGFR drops below 45, the metformin dosage should be reevaluated.
Metformin is a medication commonly used to treat type 2 diabetes mellitus, as well as polycystic ovarian syndrome and non-alcoholic fatty liver disease. Unlike other medications, such as sulphonylureas, metformin doesn’t cause hypoglycaemia or weight gain, making it a first-line treatment option, especially for overweight patients. Its mechanism of action involves activating the AMP-activated protein kinase, increasing insulin sensitivity, decreasing hepatic gluconeogenesis, and potentially reducing gastrointestinal absorption of carbohydrates. However, metformin can cause gastrointestinal upsets, reduced vitamin B12 absorption, and in rare cases, lactic acidosis, particularly in patients with severe liver disease or renal failure. It is contraindicated in patients with chronic kidney disease, recent myocardial infarction, sepsis, acute kidney injury, severe dehydration, and those undergoing iodine-containing x-ray contrast media procedures. When starting metformin, it should be titrated up slowly to reduce the incidence of gastrointestinal side-effects, and modified-release metformin can be considered for patients who experience unacceptable side-effects.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 18
Correct
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A 56-year-old man presents for follow-up in the diabetes clinic. He was diagnosed with type 2 diabetes mellitus (T2DM) approximately 8 years ago and is currently taking gliclazide and atorvastatin. Two years ago, he underwent successful treatment for bladder cancer. However, a recent trial of metformin was discontinued due to gastrointestinal side-effects. He works as an accountant, doesn't smoke, and has a BMI of 31 kg/m². His annual blood work reveals the following results:
- Sodium (Na+): 138 mmol/l
- Potassium (K+): 4.1 mmol/l
- Urea: 4.3 mmol/l
- Creatinine: 104 µmol/l
- HbA1c: 62 mmol/mol (7.8%)
What would be the most appropriate course of action for his management?Your Answer: Add sitagliptin
Explanation:Due to his history of bladder cancer and obesity, pioglitazone is not recommended. Instead, sitagliptin, a DPP-4 inhibitor, would be the most suitable option. Exenatide is effective in promoting weight loss in obese diabetic patients, but it is not applicable to him as he doesn’t meet the NICE body mass index criteria of 35 kg/m².
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 doesn’t 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:
- Metabolic Problems And Endocrinology
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Question 19
Incorrect
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A 52-year-old man is seeking your advice after being diagnosed with diabetes insipidus during an outpatient appointment. He is worried about the diagnosis and wants to discuss its implications. What is the correct statement about diabetes insipidus?
Your Answer: Polyuria and polydipsia infrequently occur
Correct Answer: Fluid deprivation followed by desmopressin differentiates the main causes
Explanation:Understanding Diabetes Insipidus: Differentiating Causes and Symptoms
Diabetes insipidus is a condition that can be classified into two major forms: cranial and nephrogenic. Cranial diabetes insipidus is characterized by decreased secretion of antidiuretic hormone (ADH), while nephrogenic diabetes insipidus is characterized by decreased ability to concentrate urine due to resistance to ADH action in the kidney.
To differentiate between the two forms, a fluid deprivation test followed by desmopressin administration is conducted. In cranial diabetes insipidus, urine osmolality increases after desmopressin administration, while in nephrogenic diabetes insipidus, it remains unchanged.
Contrary to popular belief, drugs can cause diabetes insipidus, with nephrogenic diabetes insipidus being the most common side effect of lithium. Other drugs such as ofloxacin and orlistat have also been implicated.
Hypernatremia may become apparent as dehydration develops, and the predominant manifestations of diabetes insipidus are polyuria, polydipsia, and nocturia. Large volumes of dilute urine are produced, with more than 3 liters in 24 hours and less than 300 mOsm/kg.
In conclusion, understanding the causes and symptoms of diabetes insipidus is crucial in diagnosing and treating the condition.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 20
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A 52-year-old female presents to you with recent test results. She had a fall a few months ago resulting in a Colles' fracture of her right wrist. A DEXA scan has confirmed that she has osteoporosis. She mentions that she has lost over a stone in weight in the past year despite having a good appetite and wonders if her weight loss could be contributing to her 'thin bones'. She also reports a change in bowel habit with looser stools, but no rectal bleeding or alternating bowel habit. She experiences frequent hot flashes and sweating episodes, and her periods have become less frequent. On examination, her blood pressure is 136/84 mmHg, pulse rate is 98 bpm regular, and she is apyrexial. Palpating her radial pulse reveals palmar erythema, warm peripheries, and a slight tremor. Her abdomen is soft and non-tender with no palpable masses, and per rectal examination is normal.
What investigation would confirm the diagnosis?Your Answer: Serum immunoglobulin electrophoresis
Correct Answer: Thyroid function tests
Explanation:Secondary Causes of Osteoporosis
There are various secondary causes that should be considered when diagnosing osteoporosis. While primary osteoporosis occurs naturally with age and menopause, certain risk factors such as smoking, alcohol consumption, family history, and low body mass index can exacerbate bone density loss. However, secondary causes can be treated specifically, making it important to identify them.
Endocrine causes such as hyperthyroidism, hyperparathyroidism, hypogonadism, Cushing’s syndrome, and premature menopause can lead to osteoporosis. Inflammatory causes like rheumatoid arthritis and inflammatory bowel disease, iatrogenic causes such as the use of steroids, anticonvulsants, and heparin, malignant causes like myeloma and leukaemias, and gastrointestinal causes like malabsorption problems can also contribute to osteoporosis.
For instance, a woman of menopausal age with osteoporosis confirmed on DEXA scanning following a Colles’ fracture reports weight loss, looser stools, sweating episodes, and oligomenorrhoea. Clinical examination reveals a modest tachycardia, warm peripheries, palmar erythema, and a tremor. In this case, hyperthyroidism is suspected as the cause of osteoporosis at a relatively young age and the signs and symptoms elicited. Therefore, thyroid function tests will confirm the diagnosis.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 21
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A 55-year-old man is scheduled for a CT scan with intravenous contrast as part of his medical evaluation. He has a medical history of hypertension, type 2 diabetes mellitus, and depression. The patient is currently taking the following medications:
- Amlodipine 10 mg once daily
- Metformin 1g twice daily
- Simvastatin 20 mg once nightly
- Citalopram 20 mg once daily
According to the BNF guidelines, what is the most appropriate advice to provide regarding his metformin treatment?Your Answer: Discontinue on the day of the scan and restart after 24 hours
Correct Answer: Discontinue on the day of the scan and restart after 48 hours
Explanation:Metformin should not be taken on the day of a procedure involving iodine-containing x-ray contrast media, and it should also be avoided for 48 hours following the procedure.
Metformin is a medication commonly used to treat type 2 diabetes mellitus, as well as polycystic ovarian syndrome and non-alcoholic fatty liver disease. Unlike other medications, such as sulphonylureas, metformin doesn’t cause hypoglycaemia or weight gain, making it a first-line treatment option, especially for overweight patients. Its mechanism of action involves activating the AMP-activated protein kinase, increasing insulin sensitivity, decreasing hepatic gluconeogenesis, and potentially reducing gastrointestinal absorption of carbohydrates. However, metformin can cause gastrointestinal upsets, reduced vitamin B12 absorption, and in rare cases, lactic acidosis, particularly in patients with severe liver disease or renal failure. It is contraindicated in patients with chronic kidney disease, recent myocardial infarction, sepsis, acute kidney injury, severe dehydration, and those undergoing iodine-containing x-ray contrast media procedures. When starting metformin, it should be titrated up slowly to reduce the incidence of gastrointestinal side-effects, and modified-release metformin can be considered for patients who experience unacceptable side-effects.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 22
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A 35-year-old woman presents with excessive sweating and weight loss. Her partner reports that she is constantly on edge and you notice a fine tremor during the consultation. A large, non-tender goitre is also noted. However, examination of her eyes reveals no exophthalmos.
Free T4 levels are at 26 pmol/l, while Free T3 levels are at 12.2 pmol/l (3.0-7.5). Her TSH levels are less than 0.05 mu/l. What is the most probable diagnosis?Your Answer: Toxic multinodular goitre
Correct Answer: Graves' disease
Explanation:Graves’ Disease: Common Features and Unique Signs
Graves’ disease is the most frequent cause of thyrotoxicosis, which is commonly observed in women aged 30-50 years. The condition presents typical features of thyrotoxicosis, such as weight loss, palpitations, and heat intolerance. However, Graves’ disease also displays specific signs that are not present in other causes of thyrotoxicosis. These include eye signs, such as exophthalmos and ophthalmoplegia, as well as pretibial myxoedema and thyroid acropachy. The latter is a triad of digital clubbing, soft tissue swelling of the hands and feet, and periosteal new bone formation.
Graves’ disease is characterized by the presence of autoantibodies, including TSH receptor stimulating antibodies in 90% of patients and anti-thyroid peroxidase antibodies in 75% of patients. Thyroid scintigraphy reveals a diffuse, homogenous, and increased uptake of radioactive iodine. These features help distinguish Graves’ disease from other causes of thyrotoxicosis and aid in its diagnosis.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 23
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A 45-year-old man comes to the surgery complaining of a productive cough. Upon examination, he has a fever and bronchial breathing in the right lower zone. The working diagnosis is pneumonia and amoxicillin is prescribed with a chest x-ray scheduled for the following day. The patient has a medical history of Addison's disease and takes hydrocortisone (20 mg in the morning and 10 mg in the afternoon). What is the best course of action regarding his steroid dosage?
Your Answer: Continue to take the same dose
Correct Answer: Double hydrocortisone to 40 mg mornings and 20 mg afternoon
Explanation:Corticosteroids are commonly prescribed medications that can be taken orally or intravenously, or applied topically. They mimic the effects of natural steroids in the body and can be used to replace or supplement them. However, the use of corticosteroids is limited by their numerous side effects, which are more common with prolonged and systemic use. These side effects can affect various systems in the body, including the endocrine, musculoskeletal, gastrointestinal, ophthalmic, and psychiatric systems. Some of the most common side effects include impaired glucose regulation, weight gain, osteoporosis, and increased susceptibility to infections. Patients on long-term corticosteroids should have their doses adjusted during intercurrent illness, and the medication should not be abruptly withdrawn to avoid an Addisonian crisis. Gradual withdrawal is recommended for patients who have received high doses or prolonged treatment.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 24
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An 82-year-old nursing-home resident has rapidly become unconscious. His blood sugar is measured at 1.5 mmol/l (normal 3-6 mmol/l). He takes tolbutamide for type 2 diabetes.
Select from the list the single most important initial action.Your Answer: Administer glucagon 1 mg by subcutaneous or intramuscular injection
Explanation:Emergency Treatment for Hypoglycaemia: Administering Glucagon and Arranging Hospital Admission
Hypoglycaemia is a medical emergency that can cause neurological and cardiac manifestations, including coma, convulsions, and arrhythmias. If the patient loses consciousness, administering glucagon 1 mg by subcutaneous or intramuscular injection is necessary to increase plasma glucose concentration. Once the patient regains consciousness, oral glucose should be given, and hospital admission should be arranged urgently. Administering a soluble aspirin or sugar in water orally would not be appropriate in this scenario. It is crucial to act quickly and seek medical attention to prevent further complications.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 25
Incorrect
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A 50-year-old woman with type 2 diabetes mellitus presents with a sodium level of 127 mmol/l. She doesn't smoke. Which medication is the most probable cause of this abnormality?
Your Answer: Pioglitazone
Correct Answer: Glimepiride
Explanation:SIADH is a well-known side effect of sulfonylureas like glimepiride.
SIADH is a condition where the body retains too much water, leading to low sodium levels in the blood. This can be caused by various factors such as malignancy (particularly small cell lung cancer), neurological conditions like stroke or meningitis, infections like tuberculosis or pneumonia, certain drugs like sulfonylureas and SSRIs, and other factors like positive end-expiratory pressure and porphyrias. Treatment involves slowly correcting the sodium levels, restricting fluid intake, and using medications like demeclocycline or ADH receptor antagonists. It is important to correct the sodium levels slowly to avoid complications like central pontine myelinolysis.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 26
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A 65-year-old man comes to the clinic complaining of a sleep disorder. He reports experiencing a creeping, crawling sensation in his legs, which is so intense that he feels the need to constantly rub his legs together to relieve the sensation. He also has an irresistible urge to move around. He feels chronically sleep deprived, only able to sleep in the early hours of the morning and often falling asleep during the day. He recently started taking thyroxine replacement and has a medical history of hypertension, type 2 diabetes, and steatohepatitis, for which he takes amlodipine, ramipril, and gliclazide. On examination, his blood pressure is 145/82 mmg, and his respiratory, cardiovascular, and neurological examinations are normal. What is the most likely factor in his medical history associated with his presentation?
Your Answer: Steatohepatitis
Correct Answer: Hypothyroidism
Explanation:Restless Legs Syndrome: Causes and Treatment
Restless legs syndrome (RLS) is a condition characterized by an irresistible urge to move the legs, often accompanied by uncomfortable sensations. While RLS may be idiopathic, it can also be caused by underlying conditions such as hypothyroidism, anaemias, renal failure, polyneuropathies, rheumatoid arthritis, Sjögren’s syndrome, and amyloidosis. Treating any underlying secondary cause can improve symptoms, as can dopamine agonists. However, clinicians may dismiss the seriousness of RLS in the absence of demonstrable neurology, despite the significant impact on quality of life that sleep disturbance can have. It is important to recognize and address RLS to improve patients’ overall well-being.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 27
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A 68-year-old man has a new diagnosis of type 2 diabetes mellitus. He has a body mass index of 28 kg/m2, an estimated glomerular filtration rate (eGFR) of 30 ml/min/1.73 m2 and he has 1+ protein on urinalysis. He has a past history of heart failure.
What is the most appropriate initial medication to be prescribed for this patient? Choose ONE option only.Your Answer: Acarbose
Correct Answer: Gliclazide
Explanation:Common Medications for Type 2 Diabetes: Mechanisms and Considerations
Gliclazide is a sulfonylurea medication commonly used for type 2 diabetes mellitus. It works by increasing insulin release from the pancreas and can be used in mild to moderate renal failure. Acarbose, on the other hand, is an intestinal alpha-glucosidase inhibitor that delays the digestion and absorption of starch and sucrose, resulting in lower blood glucose levels. Glibenclamide, a long-acting sulfonylurea, is associated with a higher risk of hypoglycemia and should be avoided in the elderly. Metformin, a biguanide, reduces insulin resistance and hepatic glucose production but can cause lactic acidosis in certain circumstances and is contraindicated in patients with renal or hepatic impairment. Pioglitazone, a thiazolidinedione, promotes insulin sensitivity but is contraindicated in heart failure due to its association with fluid retention. When prescribing these medications, it is important to consider their mechanisms of action and potential risks in patients with comorbidities.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 28
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A 65-year-old woman has a diagnosis of subclinical hypothyroidism, but over the past six months has been increasingly fatigued, constipated and always feels cold. She has gained 3 lb in the same timeframe despite no change to her diet or lifestyle. Her General Practitioner suspects the development of primary hypothyroidism and arranges a thyroid function blood test to confirm.
Which of the following biochemical changes is most likely to appear first?
Your Answer: Increase in serum thyroid-stimulating hormone (TSH)
Explanation:Hypothyroidism develops gradually over a long period of time. In the early stages, the body compensates for the low levels of free thyroxine by increasing the production of thyroid-stimulating hormone (TSH). This can result in subclinical hypothyroidism, where TSH levels are slightly elevated and thyroxine levels are low-normal. Subclinical hypothyroidism affects 3-8% of the population and carries a risk of progressing to overt hypothyroidism. Treatment should be considered if TSH levels are 10 U/ml or higher, or if there are other factors such as a goitre, positive anti-thyroid peroxidase antibodies, or subfertility. As hypothyroidism progresses, there is a decrease in free triiodothyronine (T3) and free thyroxine (T4) levels, followed by a decrease in thyroxine-binding globulin (TBG) levels. Total triiodothyronine (T3) levels tend to decrease later in the course of hypothyroidism, after a rise in TSH.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 29
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A 44-year-old woman presented with complaints of constant fatigue and underwent a blood test. All results were within normal range except for her thyroid function test (TFT) which revealed:
TSH 12.5 mU/l
Free T4 7.5 pmol/l
What would be the most suitable course of action?Your Answer: Levothyroxine 75 mcg daily 30 minutes before breakfast, caffeine and other medication(s)
Explanation:The TFTs indicate a diagnosis of hypothyroidism, which can be treated with levothyroxine. Carbimazole is not suitable for this condition as it is used to treat hyperthyroidism. To ensure proper absorption, levothyroxine should be taken 30 minutes before consuming food, caffeine, or other medications.
Managing Hypothyroidism: Dosage, Goals, and Side-Effects
Hypothyroidism is a condition where the thyroid gland doesn’t produce enough thyroid hormone. The management of hypothyroidism involves the use of levothyroxine, a synthetic form of thyroid hormone. The initial starting dose of levothyroxine should be lower in elderly patients and those with ischaemic heart disease. For patients with cardiac disease, severe hypothyroidism, or patients over 50 years, the initial starting dose should be 25mcg od with dose slowly titrated. Other patients should be started on a dose of 50-100 mcg od. After a change in thyroxine dose, thyroid function tests should be checked after 8-12 weeks. The therapeutic goal is to achieve a ‘normalisation’ of the thyroid stimulating hormone (TSH) level, with a TSH value of 0.5-2.5 mU/l being the preferred range.
Women with established hypothyroidism who become pregnant should have their dose increased ‘by at least 25-50 micrograms levothyroxine’* due to the increased demands of pregnancy. The TSH should be monitored carefully, aiming for a low-normal value. There is no evidence to support combination therapy with levothyroxine and liothyronine.
Levothyroxine therapy may cause side-effects such as hyperthyroidism due to over-treatment, reduced bone mineral density, worsening of angina, and atrial fibrillation. Interactions with iron and calcium carbonate may reduce the absorption of levothyroxine, so they should be given at least 4 hours apart.
In summary, the management of hypothyroidism involves careful dosage adjustment, regular monitoring of thyroid function tests, and aiming for a TSH value in the normal range. Women who become pregnant should have their dose increased, and combination therapy with levothyroxine and liothyronine is not recommended. Patients should also be aware of potential side-effects and interactions with other medications.
*source: NICE Clinical Knowledge Summaries
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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Question 30
Incorrect
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A 28-year-old woman has relapsed Graves’ disease. The thyroid-stimulating hormone (TSH) level is less than 0.05 μU/l (normal range 1.7–3.2 μU/l and the free thyroxine (T4) is 32.5 pmol/l (normal range 11–22 pmol/l). She has severe bilateral thyroid eye disease with marked orbital oedema and proptosis. She is being considered for radioactive iodine treatment, as drug treatment has failed.
Which of the following statements concerning the management of thyroid eye disease is correct?Your Answer: Orbital irradiation is commonly used to treat thyroid eye disease
Correct Answer: Her thyroid eye disease may be worsened by radioiodine treatment
Explanation:Thyroid Eye Disease: Treatment and Management
Thyroid eye disease (TED) is a condition that affects the eyes and is often associated with thyroid dysfunction. Radioiodine treatment may worsen the eye disease, with exacerbation being more common than with drug therapy alone. However, only a small percentage of cases threaten sight, with most causing discomfort and deteriorating cosmetic appearance. Orbital irradiation is not commonly used to treat TED, as studies have not clearly demonstrated its efficacy. Corrective eye muscle surgery should be delayed until the disease has been stable for at least six months and may be of value in improving diplopia. Urgent orbital decompression surgery may be required for severe sight-threatening disease. Methylcellulose drops may be prescribed by general practitioners to alleviate symptoms due to corneal exposure. Systemic corticosteroids and oral non-steroidal anti-inflammatory drugs may ease discomfort and decrease inflammation when symptoms are severe, while intravenous corticosteroids are used if vision is threatened. Smoking is an important risk factor for TED, increasing the risk of developing the disease by seven to eight times. The risk increases with the number of cigarettes smoked and reduces on stopping. Smoking also increases the risk of worsening after radioiodine.
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This question is part of the following fields:
- Metabolic Problems And Endocrinology
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