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  • Question 1 - During a geriatrics ward round, you assess a 87-year-old woman who was admitted...

    Incorrect

    • During a geriatrics ward round, you assess a 87-year-old woman who was admitted with community acquired pneumonia and AKI requiring IV antibiotics and fluids. She was delirious on admission but has been improving. Her confusion screen bloods show abnormal thyroid function tests:
      Calcium 2.2 mmol/L (2.1 - 2.6)
      Phosphate 1.0 mmol/L (0.8 - 1.4)
      Magnesium 0.8 mmol/L (0.7 - 1.0)
      Vitamin B12 550 pg/ml (110 - 1500)
      Folate 5.6 µg/ml (2.5 - 20)
      TSH 4.6 mU/L (0.5 - 5.5)
      Free T4 6.0 pmol/L (9.0 - 18)
      Free T3 3.6 pmol/L (4 - 7.4)
      She is currently feeling much better on day 6 of her 7 day course of antibiotics and is asymptomatic. She takes bisoprolol, digoxin, ramipril, atorvastatin, and rivaroxaban regularly.
      What is the appropriate course of action for her abnormal thyroid function tests?

      Your Answer: Radio-isotope scan

      Correct Answer: Ask her GP to repeat thyroid function tests (TFTs) in 6 weeks

      Explanation:

      It is common for elderly patients who are unwell to have abnormal thyroid function tests, known as sick euthyroid. This is likely the case for the woman in question, as she has no history of thyroid disease and is not taking levothyroxine. It may be reasonable to consider starting levothyroxine, but it would be preferable to wait until her current illness has resolved. Discontinuing her antibiotics before completing her course is not appropriate, as they are unlikely to be causing the abnormal TFTs and she is currently asymptomatic. It is also unnecessary to perform a radio-isotope scan, as there is no suspicion of malignancy. Her thyroid function tests tomorrow are expected to be similar.

      Understanding Sick Euthyroid Syndrome

      Sick euthyroid syndrome, also known as non-thyroidal illness, is a condition where the levels of TSH, thyroxine, and T3 are low. However, it is important to note that in most cases, the TSH level is within the normal range, which is considered inappropriate given the low levels of thyroxine and T3. This condition is reversible and typically resolves upon recovery from the underlying systemic illness. As such, treatment is usually not necessary.

      In summary, sick euthyroid syndrome is a condition where the thyroid hormone levels are low, but the TSH level is within the normal range. It is a reversible condition that typically resolves upon recovery from the underlying illness. No treatment is usually required for this condition.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 2 - A 42-year-old man presents with a six-month history of anorexia and weight loss,...

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    • A 42-year-old man presents with a six-month history of anorexia and weight loss, excess pigmentation and dizziness on standing. He has a previous history of autoimmune hypothyroidism that is managed with thyroxine.
      Examination reveals postural hypotension and skin discolouration. Initial investigations reveal hyponatraemia: Na+ 118 mmol/l (135-145 mmol/l) and hyperkalaemia: K+ 5.6 mmol/l (normal range: 3.6-5.2 mmol/l).
      Which of the following tests will be most useful to confirm the diagnosis?

      Your Answer:

      Correct Answer: Short Synacthen® test

      Explanation:

      Diagnosis and Management of Adrenal Failure: The Short Synacthen® Test

      Adrenal failure is a condition characterized by multiple signs and symptoms and abnormal biochemistry. The diagnosis of adrenal failure is established by a failure of the plasma cortisol concentration to increase in response to adrenocorticotropic hormone (ACTH). The short corticotropin test is the gold standard diagnostic tool for this condition. If this test is not possible, an initial screening procedure comprising the measurement of morning plasma ACTH and cortisol levels is recommended. Diagnosis of the underlying cause should include a validated assay of autoantibodies against 21-hydroxylase. Treatment involves once-daily fludrocortisone and hydrocortisone or prednisolone. Follow-up should aim at monitoring appropriate dosing of corticosteroids and associated autoimmune diseases, particularly autoimmune thyroid disease. Serum urea and ESR may not be diagnostic, while serum calcium and thyroid function tests can be abnormal in untreated Addison’s disease. This article discusses the diagnosis and management of adrenal failure, with a focus on the short Synacthen® test.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 3 - A 42-year-old woman presents to the Emergency Department with dizziness and headache. On...

    Incorrect

    • A 42-year-old woman presents to the Emergency Department with dizziness and headache. On examination, her blood pressure is found to be 190/120 mmHg. She said that she had been diagnosed with hypertension on two previous occasions but discontinued drugs both times. She is a computer analyst and drinks 3–5 units of alcohol every day. Blood tests reveal:
      Investigation Result Normal Value
      Potassium (K+) 3.8 mmol/l 3.5–5.0 mmol/l
      Corrected calcium (Ca2+) 3.03 mmol/l 2.20-2.60 mmol/l
      Sodium (Na+) 140 mmol/l 135–145 mmol/l
      Albumin 38 g/l 35–55 g/l
      Magnesium (Mg2+) 0.60 mmol/l 0.75–1.00 mmol/l
      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Sipple syndrome or MEN 2a

      Explanation:

      Possible Causes of Hypertension, Hypercalcemia, and Low Magnesium in a Patient

      One possible diagnosis for a patient with severe hypertension, hypercalcemia, and low magnesium is MEN 2a, also known as Sipple syndrome. This is because these symptoms can be explained by the presence of a phaeochromocytoma and hyperparathyroidism, which are both associated with MEN 2a.

      Conn syndrome, which is characterized by asymptomatic hypertension and hypokalemia, is not the most likely diagnosis in this case since the patient is normokalemic and has high calcium levels. Phaeochromocytoma could explain the hypertension, but not the hypercalcemia and low magnesium.

      MEN 1, also known as Wermer syndrome, is associated with hyperparathyroidism, pancreatic endocrine tumors, and pituitary tumors, but rarely with phaeochromocytoma. Wagenmann-Froboese syndrome, or MEN 2b, is associated with medullary thyroid carcinoma and phaeochromocytoma, but hyperparathyroidism is rarely present.

      Therefore, based on the patient’s symptoms, MEN 2a or Sipple syndrome is the most likely diagnosis.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 4 - A 16-year-old woman who takes insulin for type I diabetes presents to the...

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    • A 16-year-old woman who takes insulin for type I diabetes presents to the Emergency Department feeling unwell. She states she has had vomiting and diarrhoea for two days and since she is not eating, she has not been taking her full insulin doses. Her capillary glucose is 37 mmol/l, and there are 4+ ketones on urinalysis. An arterial blood gas is performed, and the results are as follows:
      Investigation Result Normal value
      pH 7.12 7.35–7.45
      Partial pressure of carbon dioxide (pCO2) 3.5 kPa 4.5–6.0 kPa
      Partial pressure of oxygen (pO2) 13 kPa 10–14 kPa
      Sodium (Na+) 121 mmol/l 135–145 mmol/l
      Potassium (K+) 6.2 mmol/l 3.5–5.0 mmol/l
      Bicarbonate 13 mmol/l 22–28 mmol/l
      Which of the following is the most appropriate initial treatment option?
      Select the SINGLE best treatment from the list below.

      Your Answer:

      Correct Answer: Intravenous (IV) 0.9% sodium chloride bolus

      Explanation:

      Management of Diabetic Ketoacidosis (DKA)

      Diabetic ketoacidosis (DKA) is a serious complication of diabetes that requires prompt treatment. The key principles of DKA management include initial fluid resuscitation with normal saline, followed by an IV insulin infusion at a fixed rate of 0.1 unit/kg per hour. Once the blood glucose level reaches 15 mmol/l, an infusion of 5% dextrose is added. Correction of electrolyte disturbance, particularly hypokalaemia, is also essential.

      Empirical IV antibiotics are not useful in DKA unless triggered by an infection, in which case emergency DKA treatment should be started first. An insulin sliding scale is not used in DKA management.

      It is important to note that IV 10 units Actrapid and 50 ml 50% dextrose are not used in DKA management. Similarly, IV sodium bicarbonate bolus is not recommended. Instead, careful monitoring of electrolyte levels and appropriate fluid and insulin therapy are crucial for successful management of DKA.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 5 - A 56-year-old man is evaluated after being diagnosed with hypertension. As part of...

    Incorrect

    • A 56-year-old man is evaluated after being diagnosed with hypertension. As part of his assessment, he underwent a series of blood tests to screen for other risk factors:

      Na+ 142 mmol/l
      K+ 3.9 mmol/l
      Urea 6.2 mmol/l
      Creatinine 91 µmol/l
      Fasting glucose 7.7 mmol/l
      Total cholesterol 7.2 mmol/l

      Due to the fasting glucose result, you order a HbA1c:

      HbA1c 31 mmol/mol (5.0%)

      What could account for the discrepancy between the HbA1c and fasting glucose levels?

      Your Answer:

      Correct Answer: Sickle-cell anaemia

      Explanation:

      Understanding Glycosylated Haemoglobin (HbA1c) in Diabetes Mellitus

      Glycosylated haemoglobin (HbA1c) is a commonly used measure of long-term blood sugar control in diabetes mellitus. It is produced when glucose attaches to haemoglobin in the blood at a rate proportional to the glucose concentration. The level of HbA1c is influenced by the lifespan of red blood cells and the average blood glucose concentration. However, certain conditions such as sickle-cell anaemia, GP6D deficiency, and haemodialysis can interfere with accurate interpretation of HbA1c levels.

      HbA1c is believed to reflect the blood glucose levels over the past 2-4 weeks, although it is generally thought to represent the previous 3 months. It is recommended that HbA1c be checked every 3-6 months until stable, then every 6 months. The Diabetes Control and Complications Trial (DCCT) has studied the complex relationship between HbA1c and average blood glucose. The International Federation of Clinical Chemistry (IFCC) has developed a new standardised method for reporting HbA1c in mmol per mol of haemoglobin without glucose attached.

      Understanding HbA1c is crucial in managing diabetes mellitus and achieving optimal blood sugar control.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 6 - You are asked to assess a 76-year-old man on the surgical ward. The...

    Incorrect

    • You are asked to assess a 76-year-old man on the surgical ward. The nursing staff has documented his blood glucose level at 2.4mmol/L. He is recuperating after undergoing surgery for a hip fracture. He has a medical history of hypertension, diabetes, and chronic kidney disease.

      During your examination, he appears somewhat restless but coherent enough to respond to your inquiries. His heart rate is 78 bpm, and his blood pressure is 134/82 mmHg.

      What would be the most appropriate initial treatment?

      Your Answer:

      Correct Answer: Glucogel, orally

      Explanation:

      Dextrose IV is not the recommended treatment for correcting hypoglycemia. If the patient is conscious, a fast-acting glucose liquid should be given. However, if the patient is unconscious or unable to swallow, subcutaneous or intramuscular injection of glucagon may be necessary. While a sandwich can be helpful after treating the hypoglycemic episode, it is not a quick-acting carbohydrate and should not be used in the acute phase.

      Understanding Hypoglycaemia: Causes, Symptoms, and Management

      Hypoglycaemia is a condition characterized by low blood sugar levels, which can lead to a range of symptoms and complications. There are several possible causes of hypoglycaemia, including insulinoma, self-administration of insulin or sulphonylureas, liver failure, Addison’s disease, and alcohol consumption. The physiological response to hypoglycaemia involves hormonal and sympathoadrenal responses, which can result in a range of symptoms such as sweating, shaking, hunger, weakness, confusion, and even convulsions or coma in severe cases.

      It is important to note that blood glucose levels and the severity of symptoms are not always correlated, especially in patients with diabetes. Blood glucose concentrations below 3.3 mmol/L can cause autonomic symptoms, while concentrations below 2.8 mmol/L can cause neuroglycopenic symptoms. Management of hypoglycaemia depends on the severity of the symptoms and the setting in which it occurs. In the community, oral glucose or quick-acting carbohydrates may be given, while in a hospital setting, subcutaneous or intramuscular injection of glucagon or intravenous glucose solution may be necessary.

      In summary, hypoglycaemia is a serious condition that requires prompt recognition and management to prevent complications. Understanding the causes, symptoms, and appropriate management strategies can help individuals with diabetes and healthcare professionals to effectively manage this condition.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 7 - A 28-year-old woman is referred by her General Practitioner due to irregular and...

    Incorrect

    • A 28-year-old woman is referred by her General Practitioner due to irregular and unpredictable menstrual cycle and headaches. Magnetic resonance imaging of the brain shows a midline lesion. Further investigations reveal that her prolactin level is 2314 ng/ml (normal range: 2–29 ng/ml). To reduce the prolactin level, which mediator is manipulated for medical treatment?

      Your Answer:

      Correct Answer: Dopamine

      Explanation:

      Targeting Hormones in Prolactinoma Treatment

      Prolactinoma is a pituitary lesion that results in excessive prolactin secretion. To reduce prolactin levels, dopamine agonists like bromocriptine are used to target dopamine receptors in the anterior pituitary. While increased prolactin can indirectly decrease gonadotropin-releasing hormone (GnRH) secretion, GnRH receptors are not a therapeutic target in prolactin disorders. Corticotropin-releasing hormone (CRH) increases adrenocorticotropic hormone secretion and is not a target in prolactin disorders. Somatostatin decreases thyroid-stimulating hormone (TSH) and growth hormone secretion but does not affect prolactin levels. Thyrotropin-releasing hormone (TRH) increases prolactin and TSH release, but its use is limited due to side-effects on thyroid regulation and the superiority of dopamine agonists.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 8 - A 28-year-old male patient visits his GP complaining of fatigue and increased urination....

    Incorrect

    • A 28-year-old male patient visits his GP complaining of fatigue and increased urination. The symptoms began two months ago and have been progressively worsening. The patient has a medical history of hypertension and is classified as morbidly obese. Upon conducting a fasting glucose test, the results show 8.2 mmol/L. The doctor decides to measure the patient's C-peptide levels, which are found to be low. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Type 1 diabetes mellitus

      Explanation:

      Patients with T1DM typically have low C-peptide levels.

      The patient in question is exhibiting classic symptoms of diabetes, including polyuria and tiredness, and their fasting glucose level is 8.2 mmol/L, which meets the diagnostic criteria for diabetes according to the World Health Organization. Given their age and risk factors, NICE guidelines recommend testing for C-peptide levels. C-peptide is a byproduct of proinsulin cleavage into insulin, and low levels indicate a lack of insulin production, which is characteristic of T1DM.

      Impaired fasting glucose is an incorrect answer because the patient’s fasting glucose level is above the diagnostic threshold for diabetes. Maturity-onset diabetes of the young is also incorrect because it is an autosomal-dominant condition that typically presents as T2DM in patients under 25, and C-peptide levels remain normal. Suggests diabetes mellitus but further testing is needed is also incorrect because the patient’s symptoms and fasting glucose level meet the diagnostic criteria for diabetes.

      Diagnosis of Type 1 Diabetes Mellitus

      Type 1 diabetes mellitus (T1DM) is typically diagnosed through symptoms and signs that are similar to those seen in diabetic ketoacidosis (DKA), although the diagnosis may take longer. Symptoms of DKA include abdominal pain, polyuria, polydipsia, dehydration, Kussmaul respiration, and an acetone-smelling breath. To confirm a diagnosis, urine should be dipped for glucose and ketones, and fasting glucose and random glucose levels should be measured. C-peptide levels are typically low in patients with T1DM, and diabetes-specific autoantibodies can be useful in distinguishing between type 1 and type 2 diabetes. Antibodies to glutamic acid decarboxylase (anti-GAD), islet cell antibodies (ICA), insulin autoantibodies (IAA), and insulinoma-associated-2 autoantibodies (IA-2A) are commonly used.

      The diagnostic criteria for T1DM include a fasting glucose level greater than or equal to 7.0 mmol/l or a random glucose level greater than or equal to 11.1 mmol/l if the patient is symptomatic. If the patient is asymptomatic, the criteria must be demonstrated on two separate occasions. To distinguish between type 1 and type 2 diabetes, age of onset, speed of onset, weight of the patient, and symptoms should be considered. NICE recommends further investigation for adults suspected of having T1DM if the clinical presentation includes atypical features. Conversely, for patients suspected of having type 2 diabetes, if they respond well to oral hypoglycaemic agents and are over the age of 40 years, further testing for T1DM may not be necessary.

      Example scenarios include a 15-year-old with weight loss and lethargy, a 38-year-old obese man with polyuria, a 52-year-old woman with polyuria and polydipsia, and a 59-year-old obese man with polyuria. The appropriate diagnostic tests should be conducted based on the patient’s symptoms and risk factors.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 9 - A middle-aged patient presents with lethargy, weight loss and fainting episodes. In the...

    Incorrect

    • A middle-aged patient presents with lethargy, weight loss and fainting episodes. In the Emergency Department, a postural drop in blood pressure is noted of > 20 mmHg systolic from the supine to the standing position. Blood glucose is 2.9 mmol/l, and Na+ is 122 mmol/l.
      What is the cause of this patient's condition?

      Your Answer:

      Correct Answer: Decreased cortisol; decreased aldosterone

      Explanation:

      Understanding Addison’s Disease: Hormonal Imbalances and Clinical Presentation

      Addison’s disease, or primary adrenal failure, is a condition characterized by autoimmune destruction of the adrenal cortex, resulting in reduced levels of cortisol and aldosterone. This hormonal imbalance leads to a range of clinical symptoms, including hypotension, hyponatraemia, hyperkalaemia, acidosis, and skin and mucosal hyperpigmentation.

      While other hormonal imbalances may occur in the adrenal glands, such as increased cortisol or aldosterone, they are less likely to result in the clinical presentation of Addison’s disease. For example, increased cortisol is unlikely due to autoimmune destruction of the zona fasciculata, while increased aldosterone is rare and typically caused by an adrenal adenoma. Similarly, decreased cortisol with normal aldosterone is more commonly associated with secondary adrenal failure caused by pituitary disease, but does not fit with the hyponatraemia seen in Addison’s disease.

      Overall, understanding the hormonal imbalances and clinical presentation of Addison’s disease is crucial for accurate diagnosis and effective treatment.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 10 - A 35-year-old man presents with complaints of frequent headaches. He also admits to...

    Incorrect

    • A 35-year-old man presents with complaints of frequent headaches. He also admits to experiencing erectile dysfunction and decreased sex drive that has progressively worsened over the past six months. Visual field examination reveals a bitemporal hemianopia. Laboratory examination reveals an elevation in serum prolactin, while serum luteinizing hormone (LH) and testosterone are decreased.
      What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Prolactinoma

      Explanation:

      Differentiating Pituitary Disorders: Causes and Symptoms

      Pituitary disorders can present with a variety of symptoms, making it important to differentiate between them for proper diagnosis and treatment. Here are some common causes and symptoms of pituitary disorders:

      Prolactinoma: This is the most common functional pituitary tumor, which can cause headaches, visual field defects, and suppression of the normal hypothalamus-pituitary-gonadal axis, leading to loss of libido and gonadotrophin levels.

      Craniopharyngioma: More common in children and adolescents, this tumor can lead to hypopituitarism, growth hormone deficiency, and visual changes. It can sometimes cause increased serum prolactin.

      Idiopathic panhypopituitarism: This condition manifests with decreases in all anterior pituitary hormones, including prolactin.

      Isolated LH deficiency: This can explain loss of libido and decreased plasma levels of LH and testosterone, but not the increase in prolactin or bitemporal hemianopia.

      Pituitary infarction: This can occur in women who hemorrhage excessively during parturition, leading to varying degrees of hypopituitarism, but not hyperprolactinemia.

      By understanding the specific causes and symptoms of pituitary disorders, healthcare professionals can provide appropriate treatment and improve patient outcomes.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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