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  • Question 1 - A 55-year-old man visits his General Practitioner (GP) complaining of tingling in both...

    Correct

    • A 55-year-old man visits his General Practitioner (GP) complaining of tingling in both hands that began a month ago and has progressively worsened. He has no significant medical history. During the examination, you observe that the man has large hands, widely spaced teeth, and a prominent brow. You suspect that he may have acromegaly. What is the most suitable initial investigation for acromegaly?

      Your Answer: Serum IGF1 levels

      Explanation:

      Investigations for Acromegaly: Serum IGF1 Levels, CT/MRI Head, and Visual Field Testing

      Acromegaly is a condition caused by excess growth hormone (GH) production, often from a pituitary macroadenoma. To diagnose acromegaly, insulin-like growth factor 1 (IGF1) levels are measured instead of GH levels, as IGF1 has a longer half-life and is more stable in the blood. If IGF1 levels are high, a glucose tolerance test is used to confirm the diagnosis. CT scans of the head are not as sensitive as MRI scans for detecting pituitary tumors, which are often the cause of acromegaly. Visual field testing is also important to determine if a pituitary tumor is compressing the optic chiasm, but it is not a specific investigation for acromegaly.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 2 - A 35-year-old man presents to his General Practitioner with weight loss, dry eyes...

    Incorrect

    • A 35-year-old man presents to his General Practitioner with weight loss, dry eyes and palpitations. He reports feeling jittery and nervous for the past few weeks. Upon examination, a fine tremor, regular pulse of 105 bpm, exophthalmos and a moderate, smooth goitre are noted. The results of his thyroid function tests are as follows:
      Investigation Result Normal Value
      Thyroid-stimulating hormone (TSH) 0.03 mU/l 0.25–4.0 mU/l
      Free T4 38.5 pmol/l 12.0–22.0 pmol/l
      Free T3 11.8 pmol/l 3.1–6.8 pmol/l
      Thyroid peroxidase (TPO) antibodies Positive
      What is the most likely diagnosis?

      Your Answer: Hypothyroidism

      Correct Answer: Graves' disease

      Explanation:

      Differentiating Causes of Thyrotoxicosis: A Brief Overview

      Thyrotoxicosis, or hyperthyroidism, can be caused by various conditions, including Graves’ disease, De Quervain’s thyroiditis, Hashimoto’s thyroiditis, hypothyroidism, and toxic multinodular goitre. Among these, Graves’ disease is the most common cause, characterized by autoimmune dysfunction and typical hyperthyroid symptoms. About a third of patients with Graves’ disease also develop eye signs, while pretibial myxoedema or clubbing of the fingers may occur rarely. De Quervain’s thyroiditis, on the other hand, is associated with transient hyperthyroidism following a viral infection and neck pain. Hashimoto’s thyroiditis, an autoimmune condition, causes hypothyroidism instead of hyperthyroidism. Hypothyroidism presents with weight gain, fatigue, constipation, dry skin, and depression, and is characterized by raised TSH and reduced T4 or T3. Finally, toxic multinodular goitre is the second most common cause of hyperthyroidism in the UK, presenting with a multinodular goitre and hyperthyroidism without Graves’ disease symptoms. However, in the case presented, the positive TPO antibodies and typical Graves’ disease symptoms make it the most likely diagnosis.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      4.1
      Seconds
  • Question 3 - A 35-year-old woman presents with amenorrhoea and occasional breast discharge. She has never...

    Incorrect

    • A 35-year-old woman presents with amenorrhoea and occasional breast discharge. She has never been pregnant and has not been sexually active for the past year. She is not on any regular medications and has had regular menstrual cycles in the past. On breast examination, there are no palpable abnormalities and she has normal secondary sexual characteristics. What is the most appropriate initial investigation?

      Your Answer: Skull computed tomography (CT)

      Correct Answer: Prolactin level

      Explanation:

      Investigating Hyperprolactinaemia: Tests and Imaging

      Hyperprolactinaemia is a condition characterized by elevated levels of prolactin, often caused by a microadenoma in the pituitary gland. While no single test can determine the cause of hyperprolactinaemia, a prolactinoma is likely if the prolactin level is above 250 ng/ml. Inhibitory effects of raised prolactin may result in low levels of follicle-stimulating hormone (FSH), but this is not diagnostic. Magnetic resonance imaging (MRI) is the preferred imaging technique for investigating the cause of hyperprolactinaemia, rather than a skull computed tomography (CT) or X-ray, which may only show enlarged pituitary fossa with large adenomas. Additionally, thyroid function tests may be necessary to investigate mildly raised prolactin levels in the absence of pituitary pathology.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      5.5
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  • Question 4 - 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: Decreased cortisol; increased aldosterone

      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 5 - A 65-year-old man comes in for his annual check-up for type 2 diabetes...

    Incorrect

    • A 65-year-old man comes in for his annual check-up for type 2 diabetes mellitus. During the review, his HbA1c level is found to be 58 mmol/mol. The patient is currently taking metformin 1g twice daily and is fully compliant. He has no allergies and is not taking any other medications. The patient had a transurethral resection for bladder cancer five years ago and is still under urology follow-up with no signs of disease recurrence. He has no other medical history, exercises regularly, and maintains a healthy diet. The patient's BMI is 25kg/m².

      What would be the most appropriate next step?

      Your Answer: Add pioglitazone

      Correct Answer: Add gliclazide

      Explanation:

      For a patient with T2DM who is on metformin and has an HbA1c level of 58 mmol/mol, the most appropriate choice for a second antidiabetic agent is gliclazide, according to NICE guidelines and the patient’s clinical factors. Pioglitazone is not recommended due to the patient’s history of bladder cancer, and SGLT-2 inhibitors and GLP-1 receptor agonists are not appropriate in this case. Modified-release metformin is not recommended for improving HbA1c control. Dual therapy with a sulfonylurea, DPP-4 inhibitor, or pioglitazone is recommended by NICE once HbA1c is 58 mmol/mol or over on metformin, but the choice of agent depends on the individual clinical scenario.

      NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022, reflecting advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. The first-line drug of choice remains metformin, which should be titrated up slowly to minimize gastrointestinal upset. HbA1c targets should be agreed upon with patients and checked every 3-6 months until stable, with consideration for relaxing targets on a case-by-case basis. Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates and controlling intake of foods containing saturated fats and trans fatty acids. Blood pressure targets are the same as for patients without type 2 diabetes, and antiplatelets should not be offered unless a patient has existing cardiovascular disease. Only patients with a 10-year cardiovascular risk > 10% should be offered a statin, with atorvastatin 20mg as the first-line choice.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 6 - A 28-year-old woman presents to her GP with a range of symptoms that...

    Correct

    • A 28-year-old woman presents to her GP with a range of symptoms that have been progressively worsening over the past 6 months. Despite no changes in her diet, she has gained over 3 stone of weight, with a concentration on her face and neck. She has also noticed stretch marks on her abdomen and excessive hair growth on her body and face. Upon referral to an endocrinologist, she is diagnosed with a pituitary adenoma causing an increased secretion of adrenocorticotropic hormone.
      What is the best description of this condition?

      Your Answer: Cushing's disease

      Explanation:

      The patient is experiencing Cushing’s disease, which is caused by excessive secretion of adrenocorticotropic hormone (ACTH) from the anterior pituitary gland, often due to a pituitary adenoma. Addison’s disease and acromegaly can be ruled out based on the patient’s symptoms. It is important to differentiate between Cushing’s triad, which includes irregular breathing, bradycardia, and systolic hypertension caused by increased intracranial pressure, and Cushing’s syndrome, a collection of symptoms resulting from prolonged exposure to cortisol. Cushing’s disease is a specific type of Cushing’s syndrome characterized by increased ACTH production due to a pituitary adenoma or excess production of hypothalamus CRH.

      Understanding the Causes of Cushing’s Syndrome

      Cushing’s syndrome is a condition that occurs when the body is exposed to high levels of cortisol for an extended period. While exogenous causes of Cushing’s syndrome, such as glucocorticoid therapy, are more common, endogenous causes can also occur. The causes of Cushing’s syndrome can be divided into two categories: ACTH dependent and ACTH independent.

      ACTH dependent causes of Cushing’s syndrome include Cushing’s disease, which is caused by a pituitary tumor secreting ACTH and producing adrenal hyperplasia. Ectopic ACTH production, which is caused by small cell lung cancer, is another ACTH dependent cause. On the other hand, ACTH independent causes of Cushing’s syndrome include iatrogenic causes such as steroid use, adrenal adenoma, adrenal carcinoma, Carney complex, and micronodular adrenal dysplasia.

      In addition to these causes, there is also a condition called Pseudo-Cushing’s, which mimics Cushing’s syndrome. This condition is often caused by alcohol excess or severe depression and can cause false positive dexamethasone suppression tests or 24-hour urinary free cortisol tests. To differentiate between Cushing’s syndrome and Pseudo-Cushing’s, an insulin stress test may be used. Understanding the causes of Cushing’s syndrome is crucial in diagnosing and treating this condition.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      2.1
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  • Question 7 - A 28-year-old woman has recently discovered that she is expecting her second child....

    Incorrect

    • A 28-year-old woman has recently discovered that she is expecting her second child. During her first pregnancy, she experienced gestational diabetes. However, after giving birth, she was informed that she no longer had diabetes. What is the best course of action for her current pregnancy?

      Your Answer: Do oral glucose tolerance test at 16-18 weeks

      Correct Answer: Do oral glucose tolerance test as soon as possible after booking

      Explanation:

      The guidelines of NICE have been revised, stating that women who are at risk of gestational diabetes should undergo an oral glucose tolerance test immediately after booking, instead of waiting until 16-18 weeks as previously recommended.

      Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      8.3
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  • Question 8 - A 32-year-old woman reports to her community midwife with complaints of failure to...

    Incorrect

    • A 32-year-old woman reports to her community midwife with complaints of failure to lactate, lethargy, dizziness upon standing, and weight loss after a difficult childbirth complicated by placental abruption. What blood test results are expected?

      Your Answer: Increased cortisol; increased aldosterone

      Correct Answer: Decreased cortisol; normal aldosterone

      Explanation:

      Interpreting Cortisol and Aldosterone Levels in Sheehan’s Syndrome

      Sheehan’s syndrome is a condition that results in hypopituitarism, causing reduced production of adrenocorticotropic hormone (ACTH) and secondary adrenal insufficiency. This can lead to decreased cortisol levels, which can cause postural hypotension. However, aldosterone levels remain normal as they are not dependent on pituitary function.

      In rare cases of adrenal adenoma, increased levels of both cortisol and aldosterone may occur, but this does not fit the clinical picture of Sheehan’s syndrome. Similarly, decreased levels of both cortisol and aldosterone would be indicative of primary adrenal insufficiency, which is not the case here.

      An unusual result would be increased cortisol levels with decreased aldosterone levels, which does not fit the clinical picture of hypocortisolism in Sheehan’s syndrome. Conversely, decreased cortisol levels with increased aldosterone levels would also be an unusual result, as aldosterone levels are not typically affected in Sheehan’s syndrome.

      Therefore, when interpreting cortisol and aldosterone levels in a patient with suspected Sheehan’s syndrome, it is important to consider the expected pattern of decreased cortisol levels with normal aldosterone levels.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 9 - You assess a 75-year-old patient with a complex medical history and taking multiple...

    Incorrect

    • You assess a 75-year-old patient with a complex medical history and taking multiple medications. The patient presents with significant bilateral breast tissue growth. Which medication is the most probable cause of this condition?

      Your Answer: Terbinafine

      Correct Answer: Goserelin (Zoladex)

      Explanation:

      Gynaecomastia may occur as a side effect of using GnRH agonists like goserelin for prostate cancer management. Tamoxifen can be prescribed to address gynaecomastia.

      Understanding Gynaecomastia: Causes and Drug Triggers

      Gynaecomastia is a medical condition that occurs when males develop an abnormal amount of breast tissue. This condition is usually caused by an increased ratio of oestrogen to androgen. It is important to differentiate the causes of galactorrhoea, which is due to the actions of prolactin on breast tissue, from those of gynaecomastia.

      There are several causes of gynaecomastia, including physiological changes that occur during puberty, syndromes with androgen deficiency such as Kallman’s and Klinefelter’s, testicular failure, liver disease, testicular cancer, ectopic tumour secretion, hyperthyroidism, and haemodialysis. Additionally, certain drugs can trigger gynaecomastia, with spironolactone being the most common drug cause. Other drugs that can cause gynaecomastia include cimetidine, digoxin, cannabis, finasteride, GnRH agonists like goserelin and buserelin, oestrogens, and anabolic steroids.

      It is important to note that while drug-induced gynaecomastia is rare, there are still some drugs that can trigger this condition. Some of the very rare drug causes of gynaecomastia include tricyclics, isoniazid, calcium channel blockers, heroin, busulfan, and methyldopa. Understanding the causes and drug triggers of gynaecomastia can help individuals seek appropriate medical attention and treatment.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      3.1
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  • Question 10 - A 45-year-old woman presents to her general practitioner with a complaint of feeling...

    Incorrect

    • A 45-year-old woman presents to her general practitioner with a complaint of feeling tired and lethargic for the past six months. She also reports a weight gain of approximately 10 kg during this time. Upon conducting a blood test, the following results were obtained: Hb 141 g/l, Na+ 141 mmol/l, Bilirubin 7 µmol/l, Platelets 331 * 109/l, K+ 4.1 mmol/l, ALP 71 u/l, WBC 4.6 * 109/l, Urea 3.9 mmol/l, ALT 31 u/l, Neuts 3.1 * 109/l, Creatinine 86 µmol/l, γGT 51 u/l, Lymphs 1.2 * 109/l, TSH 0.1 mu/l, Albumin 41 g/l, Eosin 0.2 * 109/l, free-T4 3 nmol/l, and CRP 4.1 mg/l. What would be the most appropriate next investigation to determine the cause of her fatigue?

      Your Answer: Urine electrophoresis

      Correct Answer: MRI brain and pituitary

      Explanation:

      When a patient has normal blood tests except for low thyroid function, which is indicated by low TSH and low free-T4, and presents with symptoms of hypothyroidism, it may be a case of secondary hypothyroidism caused by pituitary failure. This is a rare condition that requires imaging of the pituitary gland to rule out any anatomical or vascular causes, such as a tumor.

      Understanding the Causes of Hypothyroidism

      Hypothyroidism is a condition that affects a small percentage of women in the UK, with females being more susceptible than males. The most common cause of hypothyroidism is Hashimoto’s thyroiditis, an autoimmune disease that may be associated with other conditions such as IDDM, Addison’s or pernicious anaemia. Other causes of hypothyroidism include subacute thyroiditis, Riedel thyroiditis, thyroidectomy or radioiodine treatment, drug therapy, and dietary iodine deficiency. It is important to note that some of these causes may have an initial thyrotoxic phase.

      In rare cases, hypothyroidism may also be caused by pituitary failure, which is known as secondary hypothyroidism. Additionally, there are certain conditions that may be associated with hypothyroidism, such as Down’s syndrome, Turner’s syndrome, and coeliac disease.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      2.8
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  • Question 11 - A 55-year-old man is hospitalized for a chest infection and undergoes a standard...

    Correct

    • A 55-year-old man is hospitalized for a chest infection and undergoes a standard blood test in the emergency room. The results show his HbA1c level as follows:
      HbA1c 48 mmol/mol (27-48 mmol/mol)
      What medical condition could cause this reading to inaccurately reflect his blood sugar levels?

      Your Answer: Splenectomy

      Explanation:

      If a person has undergone a splenectomy, their HbA1c level may be falsely elevated due to the longer lifespan of their red blood cells. HbA1c testing is commonly used to determine diabetes, as it provides an average blood glucose level over a three-month period, which is the lifespan of a typical red blood cell. A higher HbA1c reading can be caused by either a higher average blood glucose concentration or a longer red cell lifespan. Therefore, only a splenectomy would result in an overestimation of blood sugar levels, as it increases the lifespan of red blood cells, while all other conditions would decrease their lifespan and lower the HbA1c reading.

      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 12 - A 35-year-old man with type 1 diabetes visits his GP for a check-up...

    Correct

    • A 35-year-old man with type 1 diabetes visits his GP for a check-up on his blood sugar levels. He has been monitoring his daily blood glucose readings and the GP calculates an average of 7.8 mmol/L, indicating the need for better control. However, his HbA1c level is 41.5 mmol/mol (5.9%), indicating good glycaemic control. What could be causing this inconsistency?

      Your Answer: Sickle-cell anaemia

      Explanation:

      Individuals with sickle cell anaemia and other haemoglobinopathies may have inaccurate HbA1c readings due to the shortened lifespan of their red blood cells, resulting in lower than actual levels. Conversely, conditions such as splenectomy, iron-deficiency anaemia, B12 deficiency, and alcoholism can lead to falsely elevated HbA1c levels. The accuracy of HbA1c as a measure of average blood glucose concentration is dependent on the lifespan of red blood cells.

      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
      1.9
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  • Question 13 - Which of the following is most commonly associated with the syndrome of inappropriate...

    Correct

    • Which of the following is most commonly associated with the syndrome of inappropriate ADH secretion?

      Your Answer: Small cell lung cancer

      Explanation:

      SIADH is a frequent endocrine complication associated with small cell lung cancer.

      SIADH is a condition where the body retains too much water, leading to low sodium levels in the blood. This can be caused by a variety of factors, including malignancies such as small cell lung cancer, neurological conditions like stroke or meningitis, infections such as tuberculosis or pneumonia, and certain drugs like sulfonylureas and SSRIs. Other causes may include positive end-expiratory pressure and porphyrias. Treatment for SIADH involves slowly correcting the sodium levels to avoid complications like central pontine myelinolysis. This can be done through fluid restriction, the use of demeclocycline to reduce responsiveness to ADH, or the use of ADH receptor antagonists. It is important to note that certain drugs, such as glimepiride and glipizide, have been reported to cause SIADH according to the BNF.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 14 - A 49-year-old woman presents to her GP with tearfulness and a low mood...

    Incorrect

    • A 49-year-old woman presents to her GP with tearfulness and a low mood for the past few weeks. The GP notes from her medical history that she has a history of renal stones.
      What is the most probable diagnosis?

      Your Answer: Secondary hyperparathyroidism

      Correct Answer: Primary hyperparathyroidism

      Explanation:

      Differential Diagnosis for a Patient with Low Mood and Renal Stones

      Primary Hyperparathyroidism:
      This condition can cause hypercalcemia, which may present as renal stones, osteoporosis, arthritis, nausea and vomiting, peptic ulcer disease, constipation, polyuria, depression, memory loss, and delirium.

      Hyperthyroidism:
      Hyperthyroidism may present with restlessness, irritability, insomnia, tremor, palpitations, weight loss, sweating, heat intolerance, diarrhea, oligomenorrhea, hair thinning, and muscle weakness. Graves’ disease may also cause a goiter and thyroid eye disease, presenting as proptosis, dry eyes, periorbital edema, and lagophthalmos.

      Hypothyroidism:
      Typical features of hypothyroidism include dry skin, brittle and diminished hair, lethargy, cold intolerance, dull or blank expression, puffy eyelids, and weight gain. Patients may also experience cerebellar ataxia, ascites, non-pitting edema of the hands and feet, and congestive cardiac failure.

      Pseudopseudohypoparathyroidism:
      This condition may present with short fourth and fifth metacarpals, round face, short stature, basal ganglia calcification, and decreased IQ.

      Secondary Hyperparathyroidism:
      This condition may present with signs and symptoms of hypocalcemia, including perioral paresthesia, seizures, spasms, anxiety, increased smooth muscle tone, disorientation, dermatitis, impetigo herpetiformis, cataracts, Chvostek’s sign, and long Q–T interval.

      Differential Diagnosis for a Patient with Low Mood and Renal Stones

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 15 - A 32-year-old woman with Addison's disease is seen for a follow-up appointment. She...

    Correct

    • A 32-year-old woman with Addison's disease is seen for a follow-up appointment. She reports a productive cough and feeling feverish for the past three days. Upon examination, her chest is clear, pulse is 84 beats per minute, and temperature is 37.7ºC. Due to her medical history, an antibiotic is prescribed.

      What advice should be given regarding her adrenal replacement therapy?

      Your Answer: Double the hydrocortisone dose, keep the same fludrocortisone dose

      Explanation:

      In the case of a patient with Addison’s disease who develops an additional illness, it is recommended to increase the dose of glucocorticoids while maintaining the same dose of fludrocortisone.

      Addison’s disease is a condition that requires patients to undergo both glucocorticoid and mineralocorticoid replacement therapy. This treatment usually involves taking a combination of hydrocortisone and fludrocortisone. Hydrocortisone is typically given in 2 or 3 divided doses, with patients requiring 20-30 mg per day, mostly in the first half of the day. Patient education is crucial, and it is essential to emphasize the importance of not missing glucocorticoid doses. Additionally, patients should consider wearing MedicAlert bracelets and steroid cards, and they should be provided with hydrocortisone for injection with needles and syringes to treat an adrenal crisis.

      During an intercurrent illness, it is crucial to manage the glucocorticoid dose properly. In simple terms, the glucocorticoid dose should be doubled, while the fludrocortisone dose should remain the same. The Addison’s Clinical Advisory Panel has produced guidelines that detail specific scenarios, and patients should refer to these guidelines for more information. It is essential to discuss how to adjust the glucocorticoid dose during an intercurrent illness with a healthcare professional. Proper management of Addison’s disease is crucial to ensure that patients can lead healthy and fulfilling lives.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 16 - A 67-year-old woman is brought to the Emergency Department after being found near-unconscious...

    Incorrect

    • A 67-year-old woman is brought to the Emergency Department after being found near-unconscious by her husband. Her husband indicates that she has a long-term joint disorder for which she has been taking oral steroids for many years. She has recently been suffering from depression and has had poor compliance with medications.
      On examination, she is responsive to pain. Her pulse is 130 beats per minute, and her blood pressure is 90/60 mmHg. She is afebrile.
      Basic blood investigations reveal the following:
      Investigation Patient Normal value
      Haemoglobin (Hb) 121 g/l 135–175 g/l
      White cell count (WCC) 6.1 × 109/l 4.0–11.0 × 109/l
      Platelets (PLT) 233 × 109/l 150–400 × 109/l
      Sodium (Na+) 129 mmol/l 135–145 mmol/l
      Potassium (K+) 6.0 mmol/l 3.5–5.0 mmol/l
      Creatinine (Cr) 93 μmol/l 50–120 µmol/l
      Glucose 2.7 mmol/l < 11.1 mmol/l (random)
      What is the most likely diagnosis?

      Your Answer: Insulin overdose

      Correct Answer: Addisonian crisis

      Explanation:

      Differential Diagnosis: Addisonian Crisis and Other Conditions

      Addisonian Crisis: A Brief Overview

      Addison’s disease, or adrenal insufficiency, is a condition that results from the destruction of the adrenal cortex, leading to a deficiency in glucocorticoid and mineralocorticoid hormones. The majority of cases in the UK are due to autoimmune disease, while tuberculosis is the most common cause worldwide. Patients with Addison’s disease may present with vague symptoms such as anorexia, weight loss, and gastrointestinal upset, as well as hyperpigmentation of the skin. Basic investigations may reveal hyponatremia, hyperkalemia, and hypoglycemia. A short ACTH stimulation test is used to confirm the diagnosis. Emergency treatment involves IV or IM hydrocortisone and fluids, while long-term treatment is based on oral cortisol and mineralocorticoid replacement.

      Differential Diagnosis

      Insulin Overdose: While hypoglycemia is a common feature of insulin overdose, the clinical information provided suggests that the low glucose level is due to the loss of the anti-insulin effect of cortisol, which is a hallmark of Addison’s disease.

      Meningococcal Septicaemia: Although hypotension and tachycardia may be present in meningococcal septicaemia, the other features described do not support this diagnosis.

      Paracetamol Overdose: Paracetamol overdose can cause liver toxicity, but the clinical features described are not typical of this condition and are more suggestive of an Addisonian crisis.

      Salicylate Overdose: Salicylate overdose can cause a range of symptoms, including nausea, vomiting, and abdominal pain, but the clinical features described do not support this diagnosis.

      Conclusion

      Based on the information provided, an Addisonian crisis is the most likely diagnosis. However, further investigations may be necessary to rule out other conditions. Prompt recognition and treatment of an Addisonian crisis are essential to prevent life-threatening complications.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 17 - 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: Wagenmann–Froboese syndrome or MEN 2b

      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 18 - A 72-year-old man comes to the clinic complaining of fatigue, low mood, and...

    Correct

    • A 72-year-old man comes to the clinic complaining of fatigue, low mood, and difficulty passing stools. Upon conducting a set of initial blood tests, the following results are obtained:
      Calcium 3.2 mmol/l
      Albumin 38 g/l
      What is the most effective diagnostic test to identify the underlying reason for his elevated calcium levels?

      Your Answer: Parathyroid hormone

      Explanation:

      Parathyroid hormone levels serve as a valuable tool in identifying the underlying causes of hypercalcaemia, with malignancy and primary hyperparathyroidism being the most prevalent culprits. If the parathyroid hormone levels are normal or elevated, it indicates the presence of primary hyperparathyroidism.

      Understanding the Causes of Hypercalcaemia

      Hypercalcaemia is a medical condition characterized by high levels of calcium in the blood. In most cases, two conditions account for 90% of hypercalcaemia cases. The first is primary hyperparathyroidism, which is the most common cause in non-hospitalized patients. The second is malignancy, which is the most common cause in hospitalized patients. Malignancy-related hypercalcaemia may be due to various processes, including PTHrP from the tumor, bone metastases, and myeloma. For this reason, measuring parathyroid hormone levels is crucial when investigating patients with hypercalcaemia.

      Other causes of hypercalcaemia include sarcoidosis, tuberculosis, histoplasmosis, vitamin D intoxication, acromegaly, thyrotoxicosis, milk-alkali syndrome, drugs such as thiazides and calcium-containing antacids, dehydration, Addison’s disease, and Paget’s disease of the bone. It is important to note that hypercalcaemia may occur with prolonged immobilization in patients with Paget’s disease of the bone, although this condition is usually normal.

      In summary, hypercalcaemia can be caused by various medical conditions, with primary hyperparathyroidism and malignancy being the most common. Measuring parathyroid hormone levels is essential in investigating patients with hypercalcaemia. Other causes of hypercalcaemia include sarcoidosis, tuberculosis, histoplasmosis, vitamin D intoxication, acromegaly, thyrotoxicosis, milk-alkali syndrome, drugs, dehydration, Addison’s disease, and Paget’s disease of the bone.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 19 - A 55-year-old woman presents to a walk-in clinic with complaints of fatigue and...

    Incorrect

    • A 55-year-old woman presents to a walk-in clinic with complaints of fatigue and feeling cold for the past two months. She has become increasingly distressed by these symptoms and reports a recent weight gain of approximately 5kg. Which of her regular medications could potentially be causing these symptoms?

      Your Answer: Citalopram

      Correct Answer: Lithium

      Explanation:

      Hypothyroidism can be caused by long-term use of lithium.

      The patient’s symptoms suggest hypothyroidism, and the only medication on the list that can lead to this condition is lithium. While the other drugs listed may cause individual side effects that could contribute to the patient’s presentation, none of them would produce all of the symptoms described.

      Amlodipine may cause weight gain due to fluid retention, but it is unlikely to cause as much as 5 kg, and it would not cause mood changes or fatigue to the extent described. Bisoprolol can cause significant fatigue, but it would not cause weight gain. Citalopram may cause significant weight gain and mood changes, but it is unlikely to cause the patient to feel cold. Atorvastatin can also cause weight gain, but this is rare.

      Understanding the Causes of Hypothyroidism

      Hypothyroidism is a condition that affects a small percentage of women in the UK, with females being more susceptible than males. The most common cause of hypothyroidism is Hashimoto’s thyroiditis, an autoimmune disease that may be associated with other conditions such as IDDM, Addison’s or pernicious anaemia. Other causes of hypothyroidism include subacute thyroiditis, Riedel thyroiditis, thyroidectomy or radioiodine treatment, drug therapy, and dietary iodine deficiency. It is important to note that some of these causes may have an initial thyrotoxic phase.

      In rare cases, hypothyroidism may also be caused by pituitary failure, which is known as secondary hypothyroidism. Additionally, there are certain conditions that may be associated with hypothyroidism, such as Down’s syndrome, Turner’s syndrome, and coeliac disease.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 20 - A 32-year-old female presents to her GP with complaints of weight gain, hair...

    Incorrect

    • A 32-year-old female presents to her GP with complaints of weight gain, hair thinning, fatigue, and dry skin. What is the most probable reason for her symptoms?

      Your Answer: Adrenal insufficiency

      Correct Answer: Hypothyroidism

      Explanation:

      Differential Diagnosis of Endocrine Disorders: Symptoms and Treatment Options

      Hypothyroidism, adrenal insufficiency, Cushing syndrome, primary hypoparathyroidism, and secondary hypoparathyroidism are all endocrine disorders that can present with various symptoms. Hypothyroidism may cause cerebellar ataxia, myxoedema, and congestive cardiac failure, and is treated with replacement of thyroid hormone. Adrenal insufficiency may cause tiredness, weakness, and postural hypotension, among other symptoms. Cushing syndrome may present with central obesity, skin and muscle atrophy, and osteoporosis. Primary hypoparathyroidism may cause hypocalcaemia symptoms, while secondary hypoparathyroidism may also present with hypocalcaemia symptoms. Treatment options vary depending on the specific disorder.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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Endocrinology/Metabolic Disease (7/20) 35%
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