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Question 1
Incorrect
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A 55-year-old male patient has been diagnosed with acromegaly. What is the most suitable treatment option for him?
Your Answer: Bromocriptine
Correct Answer: Trans-sphenoidal hypophysectomy
Explanation:Treatment Options for Acromegaly
Acromegaly is a condition characterized by the excessive production of growth hormone (GH) in adults. The most effective treatment for this condition is surgery, which may prove curative. Although somatostatin therapy can reduce GH levels, it is not recommended for young patients like this man, as it requires lifelong therapy. On the other hand, radiotherapy can take a long time to be effective, and surgical resection is the preferred option. Therefore, surgery is the most appropriate treatment for acromegaly in this man, as it offers the best chance of a cure. Proper treatment can help manage the symptoms of acromegaly and improve the patient’s quality of life.
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This question is part of the following fields:
- Endocrinology
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Question 2
Incorrect
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A 65-year-old man with diabetes and a history of chronic kidney disease visits for his regular check-up. The focus is on his elevated levels of phosphate and parathyroid hormone, despite having normal calcium levels. The doctor decides to prescribe a vitamin D analogue. What would be the most suitable option?
Your Answer: Ascorbic acid (vit C)
Correct Answer: Alfacalcidol (1-hydroxycholecalciferol)
Explanation:Alfacalcidol as an Effective Treatment for CKD Patients
Alfacalcidol, also known as 1-hydroxycholecalciferol, is a form of vitamin D that is already hydroxylated and does not require activation by the kidney enzyme 1-hydroxylase. This makes it an effective alternative for patients with chronic kidney disease (CKD) as their impaired kidney function can compromise the bioavailability of other forms of vitamin D. Calcitriol is another option for CKD patients.
On the other hand, ascorbic acid, also known as vitamin C, is not involved in the modification of calcium metabolism but rather in the treatment of scurvy, a vitamin C deficiency. Cholecalciferol or vitamin D3, which is obtained from the diet or generated by UV action in the skin, must undergo hydroxylation in the kidney. Vitamin D2, on the other hand, requires activation by the kidney enzyme 1-hydroxylase, which can be impaired in CKD patients.
Lastly, riboflavin or vitamin B2 has no effect on calcium metabolism. In summary, alfacalcidol is an effective treatment option for CKD patients as it does not require activation by the kidney enzyme and can improve the bioavailability of vitamin D.
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This question is part of the following fields:
- Endocrinology
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Question 3
Correct
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Which statement about testosterone is accurate?
Your Answer: Is a steroid hormone
Explanation:Testosterone: A Steroid Hormone
Testosterone is a type of steroid hormone that can be transformed into oestradiol. It has the ability to bind to intracellular receptors and is typically attached to sex-hormone binding globulin. This hormone plays a crucial role in the development of male reproductive tissues and secondary sexual characteristics. It is also present in females, albeit in smaller amounts, and is responsible for regulating their menstrual cycle and maintaining bone density.
In summary, testosterone is a vital hormone that affects both males and females. Its ability to bind to intracellular receptors and convert to oestradiol makes it a versatile hormone that plays a significant role in the human body. the functions of testosterone is essential in maintaining overall health and well-being.
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This question is part of the following fields:
- Endocrinology
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Question 4
Incorrect
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You review a 56-year-old man who has type II diabetes. He is taking metformin 2 g per day and his HbA1c is 62 mmol/mol. You consider adding sitagliptin to his regime.
Which of the following fits best with the mode of action of sitagliptin?Your Answer: It is a PPAR-gamma agonist
Correct Answer: It is an inhibitor of DPP-IV
Explanation:Different Mechanisms of Action for Diabetes Medications
Sitagliptin is a medication that inhibits dipeptidyl peptidase IV (DPP-IV), an enzyme responsible for breaking down glucagon-like peptide 1 (GLP-1). By inhibiting DPP-IV, sitagliptin promotes an increase in GLP-1 levels, which leads to a decrease in glucagon release and lower blood glucose levels.
On the other hand, an increase in DPP-IV activity would promote glucagon release and inhibit insulin secretion, worsening hyperglycemia. This is why sitagliptin inhibition of DPP-IV is beneficial for managing diabetes.
Pioglitazone, a thiazolidinedione medication, is a PPAR-gamma agonist. This means that it activates peroxisome proliferator-activated receptor gamma (PPAR-gamma), a protein that regulates glucose and lipid metabolism. By activating PPAR-gamma, pioglitazone increases insulin sensitivity and decreases insulin resistance, leading to lower blood glucose levels.
Glucokinase activators are a type of medication that is currently undergoing trials for the management of type II diabetes. These medications activate glucokinase, an enzyme that plays a crucial role in glucose metabolism. By activating glucokinase, these medications increase glucose uptake and utilization, leading to lower blood glucose levels.
In summary, different diabetes medications work through different mechanisms of action to manage blood glucose levels. Sitagliptin inhibits DPP-IV to increase GLP-1 levels, pioglitazone activates PPAR-gamma to increase insulin sensitivity, and glucokinase activators activate glucokinase to increase glucose uptake and utilization.
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This question is part of the following fields:
- Endocrinology
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Question 5
Incorrect
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A 65-year-old man visits his GP complaining of erectile dysfunction that has been ongoing for the past year. He has no prior history of this issue and is greatly troubled by it. The patient has a medical history of type II diabetes mellitus, hypertension, ischaemic heart disease, and poor urinary flow. He also had a thyroidectomy a few years ago, the reason for which is unclear. He is currently taking insulin, gliclazide, amlodipine, and aspirin. His most recent HbA1c was 12.1% or 108 mmol/mol. What is the probable cause of his erectile dysfunction?
Your Answer: Ischaemic heart disease
Correct Answer: Diabetes
Explanation:Medical Conditions and Erectile Dysfunction: Understanding the Causes
Erectile dysfunction is a common condition that affects many men, and it can be caused by a variety of medical conditions. Understanding the underlying causes of erectile dysfunction is important for effective treatment. Here are some common medical conditions that can lead to erectile dysfunction:
Diabetes: Diabetes is a major risk factor for erectile dysfunction. Autonomic neuropathy, a microvascular complication of diabetes, can cause symptoms such as erectile dysfunction. Poor control of diabetes can make this condition worse.
Ischaemic heart disease: While ischaemic heart disease itself does not cause erectile dysfunction, risk factors such as diabetes and hypertension can make this condition worse. Proper management of these conditions is important for overall health and sexual function.
Thyroidectomy: A previous thyroidectomy may have been performed for an overactive thyroid or a thyroid nodule, but it is not a direct cause of erectile dysfunction.
Prostatic hyperplasia: Prostatic hyperplasia is a common condition among elderly men, but it is not typically associated with erectile dysfunction.
Hypertension: Hypertension increases the risk for diabetes in non-diabetics, and diabetes can cause erectile dysfunction. However, hypertension itself is not a direct cause of erectile dysfunction.
In conclusion, understanding the underlying medical conditions that can cause erectile dysfunction is important for proper diagnosis and treatment. Proper management of these conditions can improve overall health and sexual function.
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This question is part of the following fields:
- Endocrinology
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Question 6
Incorrect
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A 65-year-old male with a 10 year history of hypertension and diabetes has been on a medication regimen for the past two years. He takes metformin 1 g bd, gliclazide 80 mg bd, rosuvastatin 10 mg daily, ramipril 10 mg daily, aspirin 75 mg daily, and amlodipine 10 mg daily. During his annual review, his blood pressure is 138/82 mmHg, and he has background diabetic retinopathy. His foot pulses are normal, but he has peripheral sensory loss to the ankles in both feet. His lab results show HbA1c of 55 mmol/mol (20-46), urea of 12.5 mmol/L (2.5-7.5), creatinine of 176 µmol/L (60-110), and cholesterol of 4.8 mmol/L (<5.2). Which medication should be discontinued?
Your Answer: Gliclazide
Correct Answer: Metformin
Explanation:Metformin Use in Patients with Chronic Renal Impairment
Patients with chronic renal impairment may have elevated levels of creatinine and urea, which can affect the clearance of drugs like metformin. Current guidelines recommend discontinuing metformin if creatinine levels exceed 150 µmol/L to prevent life-threatening lactic acidosis. This complication was traditionally thought to be caused by an accumulation of the drug, but recent studies suggest that tissue hypoxia and other acute or chronic conditions may also play a role.
Metformin is excreted unchanged in the urine, and its half-life is prolonged in patients with decreased creatinine clearance. This can occur chronically in patients with chronic renal impairment or acutely with dehydration, shock, or intravascular administration of iodinated contrast agents. These factors can alter renal function and increase the risk of lactic acidosis.
While some conditions may act as triggers for lactic acidosis, such as sepsis, acute myocardial infarction, pulmonary embolism, cardiac failure, and chronic liver disease, it is unlikely that the patient in this case has renal artery stenosis requiring the withdrawal of the ACEi. Therefore, it is important to monitor patients with chronic renal impairment who are taking metformin and adjust their dosage or discontinue the drug if necessary to prevent serious complications.
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This question is part of the following fields:
- Endocrinology
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Question 7
Incorrect
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What test is utilized to examine for primary adrenal insufficiency, also known as Addison's disease?
Your Answer: Oral glucose tolerance test
Correct Answer: Short ACTH stimulation (Synacthen®) test
Explanation:Medical Tests for Hormonal Disorders
There are several medical tests used to diagnose hormonal disorders. One such test is the Synacthen test, which measures serum cortisol levels before and after administering synthetic ACTH. If cortisol levels rise appropriately, Addison’s disease can be excluded. However, an insufficient response may indicate adrenal gland atrophy or destruction.
Another test used to investigate hormonal disorders is the dexamethasone suppression test, which is used to diagnose Cushing’s syndrome. Additionally, the oral glucose tolerance test (OGTT) is used to screen for diabetes mellitus. In the UK, the OGTT involves administering 75 g of oral anhydrous glucose and measuring plasma glucose levels at 0 minutes (fasting) and 120 minutes. This test is also used to investigate suspected acromegaly by measuring the suppression of growth hormone following an oral glucose load.
Lastly, a glucose challenge is used during pregnancy to screen for gestational diabetes. This test involves administering 50 g of oral glucose and measuring plasma glucose levels after 30 minutes. By utilizing these medical tests, healthcare professionals can accurately diagnose and treat hormonal disorders.
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This question is part of the following fields:
- Endocrinology
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Question 8
Correct
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A 28-year-old obese man presents to clinic. He is found to have a body mass index (BMI) of 36 kg/m2 and wants advice regarding treatment of his obesity.
Which of the following pertains to the treatment of obesity?Your Answer: Orlistat causes weight loss by inhibiting pancreatic and gastric lipase
Explanation:Misconceptions and Clarifications about Weight Loss Methods
Orlistat: A common misconception is that Orlistat causes weight loss by reducing appetite. In reality, it inhibits pancreatic and gastric lipase, which leads to the malabsorption of intestinal triglycerides and causes steatorrhoea.
Fenfluramine: Another misconception is that Fenfluramine causes systemic hypertension. It was actually banned due to its association with valvular heart disease and pulmonary hypertension.
Liposuction: Liposuction is not a weight loss method and should not be used as a substitute for diet and exercise. It is a cosmetic procedure that removes localized fat deposits.
Weight Loss: Weight loss is not a linear process and can vary from person to person. While glycogen depletion may contribute to initial weight loss, it is not the sole factor. Incremental weight loss occurs as adipose tissue is broken down.
Surgery: Restrictive surgery may be considered for morbidly obese patients under the age of 18, but this is not recommended as an initial option according to NICE guidelines.
Debunking Weight Loss Myths and Clarifying Methods
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This question is part of the following fields:
- Endocrinology
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Question 9
Incorrect
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The zona glomerulosa of the adrenal cortex is mainly accountable for producing which hormones?
Your Answer: Adrenal androgens
Correct Answer: Aldosterone
Explanation:The Adrenal Cortex and its Layers
The adrenal cortex is composed of two layers: the cortical and medullary layers. The zona glomerulosa, found in the cortical layer, is responsible for the secretion of aldosterone. Meanwhile, the zona fasciculata, also in the cortical layer, mainly secretes glucocorticoids, while the zona reticularis secretes adrenal androgens. However, both layers are capable of secreting both glucocorticoids and androgens.
In summary, the adrenal cortex is divided into two layers, each with its own specific functions. The zona glomerulosa secretes aldosterone, while the zona fasciculata and zona reticularis secrete glucocorticoids and adrenal androgens, respectively. Despite their specific functions, both layers are capable of secreting both glucocorticoids and androgens.
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This question is part of the following fields:
- Endocrinology
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Question 10
Correct
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A 54-year-old truck driver weighing 104 kg visits your clinic. The practice nurse conducted a fasting glucose test, which showed a reading of 7.9 mmol/L. The test was repeated, and the result was 8.6 mmol/L. Despite receiving diet and lifestyle advice, the patient's HbA1c level is 69 mmol/mol (8.5%) after three months. What is the next course of action?
Your Answer: Commence metformin
Explanation:Primary Care Management of Type 2 Diabetes
The primary focus in diabetes care is to manage patients with type 2 diabetes in primary care. For individuals who are likely to be insulin resistant, the preferred treatment option is insulin sensitising therapy with minimal weight gain. Metformin is a medication that induces a small amount of weight loss and has a low risk of hypoglycaemia, which is particularly important for those who have jobs that require them to be alert and focused. To ensure that healthcare professionals are up to date with the latest management strategies for type 2 diabetes, the American Diabetes Association has recently published a comprehensive management pathway. By following this pathway, healthcare providers can ensure that their patients receive the best possible care and achieve optimal health outcomes.
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This question is part of the following fields:
- Endocrinology
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Question 11
Incorrect
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A 44-year-old woman without prior medical history visits her primary care physician complaining of hand pain and overall bone pain that has persisted for four weeks. She also reports experiencing pain in her groin that spreads to her lower back approximately 20 minutes before urination. Additionally, she has been experiencing frequent thirst despite drinking fluids regularly. Laboratory tests reveal hypercalcemia and hypophosphatemia. What is the probable diagnosis?
Your Answer: Vitamin D insufficiency
Correct Answer: Primary hyperparathyroidism
Explanation:Diagnosis of Hyperparathyroidism
Primary hyperparathyroidism is the most likely diagnosis for a patient presenting with hypercalcaemia, polydipsia, and renal calculus formation. This condition is typically caused by a parathyroid adenoma that secretes excess parathyroid hormone (PTH), leading to increased osteoclastic activity and bone resorption. PTH also increases calcium absorption from the intestines and renal activation of vitamin D, further contributing to hypercalcaemia. Hypophosphataemia is a common feature of hyperparathyroidism due to the promotion of renal phosphate excretion by PTH.
Metastatic carcinoma and multiple myeloma are unlikely diagnoses for this patient as there is no evidence of malignancy in the patient’s history, and phosphate levels are typically normal or increased in these conditions. Secondary hyperparathyroidism, on the other hand, occurs as a compensatory mechanism for hypocalcaemia, which is not present in this patient. Chronic kidney disease is the most common cause of secondary hyperparathyroidism, which is associated with reduced activation of vitamin D and impaired calcium absorption.
Overall, primary hyperparathyroidism is the most likely diagnosis for this patient based on their symptoms and laboratory results.
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This question is part of the following fields:
- Endocrinology
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Question 12
Incorrect
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A 35-year-old woman comes to the Endocrinology Clinic complaining of bruising, striae, acne and hirsutism. During the examination, the patient seems lethargic and depressed, with centripetal obesity and proximal myopathy. Her blood pressure is 165/106 mmHg and blood tests show Na+ 136 mmol/l, K+ 2.8 mmol/l and random glucose 8.2 mmol/l. The doctor orders a low-dose dexamethasone test and a 24-hour urinary cortisol test. What is the most common cause of Cushing syndrome?
Your Answer: Pseudo-Cushing's syndrome
Correct Answer: Iatrogenic
Explanation:Causes of Cushing Syndrome: Understanding the Different Types
Cushing Syndrome is a rare condition that occurs when the body is exposed to high levels of cortisol for an extended period. Cortisol is a hormone produced by the adrenal glands that helps regulate metabolism and stress response. There are several different causes of Cushing Syndrome, including:
1. Iatrogenic: This is the most common cause of Cushing Syndrome and is related to the use of corticosteroid medication. People who take oral corticosteroids are at a higher risk, but the condition can also affect those who misuse inhaled or topical corticosteroids.
2. Ectopic ACTH secretion: This is a very rare cause of Cushing Syndrome that arises due to ACTH secretion from a carcinoid tumor.
3. Primary adrenal disorder: This is primary hypercortisolism, which is an unusual cause for Cushing Syndrome.
4. Pituitary-dependent: This is Cushing’s disease, which is much rarer than Cushing Syndrome, arising from a pituitary tumor.
5. Pseudo-Cushing’s syndrome: This describes hypercortisolism arising as a result of a separate condition, such as malnutrition or chronic alcoholism, resulting in the same phenotype and biochemical abnormalities of Cushing Syndrome.
Understanding the different types of Cushing Syndrome can help with diagnosis and treatment. It is important to work with a healthcare provider to determine the underlying cause and develop an appropriate treatment plan.
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This question is part of the following fields:
- Endocrinology
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Question 13
Incorrect
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A 32-year-old woman visits her GP after experiencing sudden hair growth, specifically on her face. She is feeling increasingly self-conscious about it and wants to address the issue. Blood tests were conducted, revealing an elevated testosterone level of 9.8 nmol/l (reference range 0.8-3.1 nmol/l). What is the next course of action in managing her condition?
Your Answer: Prescribe topical Eflornithine
Correct Answer: Refer to Endocrinology as a suspected cancer referral
Explanation:Referral for Suspected Androgen-Secreting Tumour in a Patient with Hirsutism
This patient presents with sudden-onset hair growth and a raised testosterone level, which raises suspicion for an androgen-secreting tumour. An urgent referral for further investigation is necessary to rule out malignancy. While polycystic ovary syndrome can also cause hirsutism, the patient’s testosterone level warrants exclusion of a tumour. Topical eflornithine may provide symptomatic relief, but it is not a substitute for further investigation. Routine referral to endocrinology is not appropriate in this case, as it may delay diagnosis and treatment of a potential malignancy.
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This question is part of the following fields:
- Endocrinology
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Question 14
Incorrect
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A 16-year-old boy with an 8-year history of type I diabetes presents to the Emergency Department (ED) with a 24-hour history of vomiting. He tested his glucose and ketones at home and they were both high, glucose 30 mmol/L, ketones 3 mmol/L, so he attended the ED. He admits to omitting his insulin frequently. He appears dehydrated, has ketotic fetor, BP 112/76 mmHg, pulse 108 beats per minute, temp 37 degrees, oxygen saturations 98% on room air. Clinical examination is otherwise normal. The following are his laboratory investigations:
Test Result Normal range
pH 7.2 7.35–7.45
Ketones 3 mmol/l < 0.6 mmol/l
Glucose 28 mmol/l 3.5–5.5 mmol/l
Bicarbonate 11 mmol/l 24–30 mmol/l
Base excess -5 mEq/l −2 to +2 mEq/l
C-reactive protein (CRP) 3 mg/l 0–10 mg/l
What is required to make a diagnosis of diabetic ketoacidosis in this patient?Your Answer: Glucose < 11 mmol/l
Correct Answer:
Explanation:Understanding Diabetic Ketoacidosis: Diagnostic Criteria and Metabolic Imbalance
Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes that results from a complex metabolic imbalance. The diagnostic criteria for DKA include hyperglycaemia (glucose >11 mmol/l), ketosis (>3 mmol/l), and acidemia (pH <7.3, bicarbonate <15 mmol/l). DKA is caused by insulin deficiency and an increase in counterregulatory hormones, which lead to enhanced hepatic gluconeogenesis and glycogenolysis, severe hyperglycaemia, and enhanced lipolysis. The resulting accumulation of ketone bodies, including 3-beta hydroxybutyrate, leads to metabolic acidosis. Fluid depletion, electrolyte shifts, and depletion are also common in DKA. While anion gap is not included in the UK diagnostic criteria, it is typically high in DKA (>10). Understanding the diagnostic criteria and metabolic imbalance of DKA is crucial for its prevention and management.
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This question is part of the following fields:
- Endocrinology
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Question 15
Incorrect
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A 42-year-old male presents to the Emergency department with complaints of headaches and tiredness during exercise for the past three weeks. He is a smoker of five cigarettes per day and drinks approximately 20 units of alcohol each week. There is no significant family history. On examination, his pulse is 78 beats per minute, and his blood pressure is 182/102 mmHg. However, there are no abnormalities on examination of heart, chest, or abdomen. The investigations reveal a sodium level of 144 mmol/L (137-144), haemoglobin level of 155 g/L (130-180), potassium level of 2.8 mmol/L (3.5-4.9), white cell count of 8.2 ×109/L (4-11), urea level of 5.0 mmol/L (2.5-7.5), platelet count of 188 ×109/L (150-400), creatinine level of 90 µmol/L (60-110), and glucose level of 5.6 mmol/L (3.0-6.0). The ECG shows tall R waves in leads V5-6 and deep S waves in leads V1-2. The chest x-ray is reported as normal. What possible diagnosis would you consider for this patient?
Your Answer: Coarctation of the aorta
Correct Answer: Conn’s syndrome
Explanation:Hypertension and Hypokalaemia: Possible Diagnosis of Primary Hyperaldosteronism
This patient is showing signs of hypertension, as indicated by the left ventricular hypertrophy on their ECG. Additionally, their hypertension is accompanied by hypokalaemia, which may suggest a diagnosis of primary hyperaldosteronism, also known as Conn’s syndrome. This condition is caused by excessive production of aldosterone from either an adrenal adenoma or bilateral adrenal hyperplasia, resulting in salt and water retention, hypertension, and potassium excretion leading to hypokalaemia. In some cases, primary hyperaldosteronism has been detected in up to 5% of patients in hypertension clinics. It is important to investigate potential secondary causes for hypertension, particularly in young or difficult-to-control hypertensive patients. Renal artery stenosis is unlikely to cause such severe hypokalaemia, and one would expect a mildly elevated creatinine if it were severe enough to cause hypertension.
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This question is part of the following fields:
- Endocrinology
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Question 16
Incorrect
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A 48-year old teacher is found to have a raised fasting glucose and abnormal cholesterol results following routine blood testing as a part of her NHS health check. She is noted to have a BMI of 32. She is also hypertensive. The reviewing physician suspects that the patient has metabolic syndrome.
Which of the following statements is true about the metabolic syndrome?Your Answer: Hypouricaemia is a feature
Correct Answer: Patients usually have high circulating insulin levels
Explanation:Understanding Metabolic Syndrome and its Associated Features
Metabolic syndrome is a condition characterized by three or more of the following: increased waist circumference, BMI >30 kg/m2, raised triglycerides, reduced HDL cholesterol, hypertension, and raised fasting glucose. It typically occurs in individuals with central obesity and insulin resistance, leading to elevated circulating insulin and C-peptide levels. However, significant weight loss can reverse insulin resistance and resolve the features of metabolic syndrome.
Contrary to what one might expect, high serum HDL is typical in metabolic syndrome, while low serum HDL is a diagnostic criteria. Additionally, metabolic syndrome is a key risk factor for non-alcoholic fatty liver disease (NAFLD), which is fairly common in these patients. Hyperuricaemia is also common in metabolic syndrome, rather than hypouricaemia.
Finally, while metabolic syndrome incidence does increase with age, it does not necessarily peak in the fifth decade of life. Understanding these features can aid in the diagnosis and management of metabolic syndrome and its associated conditions.
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This question is part of the following fields:
- Endocrinology
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Question 17
Incorrect
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What is the probable diagnosis for a 15-year-old girl who experiences recurring pelvic pain but has not yet begun menstruating?
Your Answer: Anovulatory cycles
Correct Answer: Haematocolpos
Explanation:Haematocolpos: A Condition of Blood Accumulation in the Vagina
Haematocolpos is a medical condition characterized by the accumulation of blood in the vagina. This condition is usually caused by an imperforate hymen, which prevents menstrual blood from flowing out of the body. As a result, the blood accumulates in the vagina, leading to discomfort and pain. Haematocolpos is a rare condition that affects mostly young girls who have not yet started menstruating. It can also occur in women who have undergone surgery to remove the cervix or uterus. Treatment for haematocolpos usually involves surgical intervention to remove the blockage and allow the blood to flow out of the body. With prompt diagnosis and treatment, most women with haematocolpos can recover fully and resume their normal activities.
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This question is part of the following fields:
- Endocrinology
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Question 18
Incorrect
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A 32-year-old woman visits her GP with complaints of palpitations, tremors, sweating, and diarrhoea. She has a medical history of gestational hypertension and type 1 diabetes, which is managed with insulin. The patient gave birth to her first child 8 weeks ago without any complications.
Upon examination, the patient is alert and oriented. Her vital signs are as follows: heart rate of 109 bpm, respiratory rate of 19 breaths/minute, temperature of 37.7ºC, oxygen saturation of 98%, blood pressure of 129/88 mmHg, and blood glucose of 4 mmol/L.
What is the most likely diagnosis, and what is the appropriate treatment?Your Answer: Dexamethasone
Correct Answer: Propranolol
Explanation:The recommended treatment for the thyrotoxicosis phase of postpartum thyroiditis is typically propranolol alone. This is because the condition is usually temporary and self-resolving, with thyroid function returning to normal within a year after childbirth. Carbimazole is not necessary as it is typically reserved for more severe cases of hyperthyroidism. Dexamethasone is not appropriate as it is used to treat thyroid storm, a complication of thyrotoxicosis that is not present in this case. Levothyroxine is also not indicated as it is used to treat hypothyroidism, which is the opposite of the patient’s current condition.
Understanding Postpartum Thyroiditis: Stages and Management
Postpartum thyroiditis is a condition that affects some women after giving birth. It is characterized by three stages: thyrotoxicosis, hypothyroidism, and normal thyroid function. During the thyrotoxicosis phase, the thyroid gland becomes overactive, leading to symptoms such as anxiety, palpitations, and weight loss. In the hypothyroidism phase, the thyroid gland becomes underactive, causing symptoms such as fatigue, weight gain, and depression. However, in the final stage, the thyroid gland returns to normal function, although there is a high recurrence rate in future pregnancies.
Thyroid peroxidase antibodies are found in 90% of patients with postpartum thyroiditis, which suggests an autoimmune component to the condition. Management of postpartum thyroiditis depends on the stage of the condition. During the thyrotoxic phase, symptom control is the main focus, and propranolol is typically used. Antithyroid drugs are not usually used as the thyroid gland is not overactive. In the hypothyroid phase, treatment with thyroxine is usually necessary to restore normal thyroid function.
It is important to note that many causes of hypothyroidism may have an initial thyrotoxic phase, as shown in a Venn diagram. Therefore, it is crucial to properly diagnose and manage postpartum thyroiditis to ensure the best possible outcomes for both the mother and the baby.
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This question is part of the following fields:
- Endocrinology
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Question 19
Incorrect
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A 25-year-old woman comes to the clinic with a neck nodule that she has observed for the past month. Upon examination, a non-painful 3.5 cm nodule is found on the right side of her neck, located deep to the lower half of the right sternocleidomastoid. The nodule moves upwards when she swallows, and no other masses are palpable in her neck. What is the nature of this mass?
Your Answer: Branchial cyst
Correct Answer: Thyroid nodule
Explanation:Thyroid Nodule and its Investigation
A thyroid nodule is suspected in this patient due to the movement observed during swallowing. The possible causes of a thyroid nodule include colloid cyst, adenoma, and carcinoma. To investigate this lesion, the most appropriate method would be fine needle aspiration. This procedure involves inserting a thin needle into the nodule to collect a sample of cells for examination under a microscope. Fine needle aspiration is a minimally invasive and safe procedure that can provide valuable information about the nature of the thyroid nodule. It can help determine whether the nodule is benign or malignant, and guide further management and treatment options. Therefore, if a thyroid nodule is suspected, fine needle aspiration should be considered as the first step in the diagnostic process.
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This question is part of the following fields:
- Endocrinology
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Question 20
Incorrect
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A 28-year-old woman is found to have a phaeochromocytoma. Which of the following is expected to be elevated in her urine levels?
Your Answer: Dehydroepiandrosterone
Correct Answer: Metanephrines
Explanation:Urinary Metabolites as Diagnostic Markers for Adrenal Disorders
Adrenal disorders such as phaeochromocytomas, congenital adrenal hyperplasia, and Cushing syndrome can be diagnosed by measuring specific urinary metabolites. For example, metanephrines, vanillylmandelic acid (VMA), and homovanillic acid (HVA) are the principal metabolic products of adrenaline and noradrenaline, and their elevated levels in urine indicate the presence of phaeochromocytomas. Similarly, increased urinary excretion of pregnanetriol and dehydroepiandrosterone are indicative of congenital adrenal hyperplasia. Free urinary cortisol levels are elevated in Cushing syndrome, which is characterized by weight gain, fatty tissue deposits, and other symptoms. Additionally, increased urinary excretion of 5-hydroxyindoleacetic acid is seen in functioning carcinoids. However, it is important to note that elevated levels of these metabolites can also occur in other conditions such as extreme stress states or medication use. Therefore, careful interpretation of urinary metabolite levels is necessary for accurate diagnosis of adrenal disorders.
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This question is part of the following fields:
- Endocrinology
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Question 21
Incorrect
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A 27-year-old woman visits her GP for a routine health examination before beginning a new job. During the examination, thyroid function tests are conducted on her serum, which reveal elevated thyroid-stimulating hormone (TSH), reduced total thyroxine (T4), reduced free T4, and reduced triiodothyronine (T3) uptake. What is the most probable clinical manifestation that this patient will exhibit?
Your Answer: Tachycardia
Correct Answer: Weight gain
Explanation:Understanding the Symptoms of Hypothyroidism and Hyperthyroidism
Hypothyroidism and hyperthyroidism are two conditions that affect the thyroid gland, resulting in a range of symptoms. In hypothyroidism, there is a decrease in T4/T3, leading to symptoms such as lethargy, weight gain, depression, sensitivity to cold, myalgia, dry skin, dry hair and/or hair loss, constipation, menstrual irregularities, carpal tunnel syndrome, memory problems, difficulty concentrating, and myxoedema coma (a medical emergency). On the other hand, hyperthyroidism results in an increase in thyroid hormones, causing symptoms such as hyperactivity, diarrhea, heat intolerance, and tachycardia. Understanding these symptoms can help in the diagnosis and management of these conditions.
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This question is part of the following fields:
- Endocrinology
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Question 22
Correct
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A 65-year-old male is seeking treatment for hypertension related to his type 2 diabetes. He is currently taking aspirin 75 mg daily, amlodipine 10 mg daily, and atorvastatin 20 mg daily. However, his blood pressure remains consistently high at around 160/92 mmHg.
What medication would you recommend adding to improve this patient's hypertension?Your Answer: Ramipril
Explanation:Hypertension Management in Type 2 Diabetes Patients
Patients with type 2 diabetes who have inadequately controlled hypertension should be prescribed an ACE inhibitor, which is the preferred antihypertensive medication for diabetes. Combining an ACE inhibitor with a calcium channel blocker like amlodipine can also be effective. However, beta-blockers should be avoided for routine hypertension treatment in diabetic patients. Methyldopa is a medication used specifically for hypertension during pregnancy, while moxonidine is reserved for cases where other medications have failed to control blood pressure. If blood pressure control is still insufficient with ramipril and amlodipine, a thiazide diuretic can be added to the treatment plan.
It is important to note that hypertension management in diabetic patients requires careful consideration of medication choices and potential interactions. Consulting with a healthcare provider is crucial to ensure safe and effective treatment. Further reading on this topic can be found in the Harvard Medical School’s article on medications for treating hypertension.
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This question is part of the following fields:
- Endocrinology
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Question 23
Incorrect
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A 55-year-old male presents at a well man clinic. He has a significant family history of ischaemic heart disease and is a smoker of 10 cigarettes per day. He also consumes approximately 20 units of alcohol per week. On examination, he is found to be obese with a BMI of 32 kg/m2 and has a blood pressure of 152/88 mmHg. His investigations reveal a fasting plasma glucose of 10.5 mmol/L (3.0-6.0), HbA1c of 62 mmol/mol (20-46), and a cholesterol concentration of 5.5 mmol/L (<5.2).
Which intervention would be most effective in reducing his cardiovascular risk?Your Answer: Improve hypertension control with ramipril
Correct Answer: Stop smoking
Explanation:Managing Hypertension and Diabetes for Cardiovascular Risk Reduction
This patient is diagnosed with hypertension and diabetes, as indicated by the elevated fasting plasma glucose. While metformin has been found to reduce cardiovascular (CV) mortality in obese diabetics, ramipril reduces CV risk in hypertensive diabetics, and statins reduce CV mortality, none of these interventions are as effective as quitting smoking in reducing CV risk. The Nurses’ Health Study provides the best evidence for the risk of smoking in women, with past smokers and current smokers having a higher risk compared to non-smokers. In men, there is less definitive evidence, but it is unlikely that many practitioners would consider the other interventions to be more beneficial than smoking cessation. There is currently no evidence that weight loss alone reduces CV mortality, although this may be due to a lack of studies on the topic.
Overall, managing hypertension and diabetes is crucial for reducing the risk of cardiovascular disease. While medication can help, quitting smoking remains the most effective intervention for reducing CV risk. Further research is needed to determine the impact of weight loss on CV mortality.
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This question is part of the following fields:
- Endocrinology
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Question 24
Incorrect
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A 55-year-old man with a history of hypertension presents with pruritus and lethargy. His serum biochemistry results show low calcium, high phosphate, and raised parathyroid hormone levels. His blood test results are as follows:
Investigation Result Normal value
Sodium (Na+) 138 mmol/l 135–145 mmol/l
Potassium (K+) 4.8 mmol/l 3.5–5.0 mmol/l
Urea 15.5 mmol/l 2.5–6.5 mmol/l
Creatinine 590 μmol/l 50–120 mmol/l
What is the most likely diagnosis for this patient?Your Answer: Loop diuretic overuse
Correct Answer: Secondary hyperparathyroidism
Explanation:Causes of Secondary Hyperparathyroidism in a Patient with Chronic Renal Failure
Secondary hyperparathyroidism can occur in patients with chronic renal failure due to imbalances in phosphorus and calcium levels. In this case, the patient has hyperphosphatemia and hypocalcemia, leading to overproduction of parathyroid hormone (PTH) by the parathyroid gland.
Loop diuretic overuse can also affect PTH levels, but it would result in additional electrolyte imbalances such as hyponatremia and hypokalemia. The role of hypertension in causing chronic renal failure is unclear in this patient.
Primary hyperparathyroidism, where the parathyroid gland overproduces PTH resulting in high serum calcium, is not present in this case. Tertiary hyperparathyroidism, which occurs after a chronic period of secondary hyperparathyroidism and results in dysregulation of calcium homeostasis and high serum calcium levels, is also not present.
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This question is part of the following fields:
- Endocrinology
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Question 25
Incorrect
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A 30-year-old woman complains of menstrual irregularity and galactorrhoea for the past year. She also experiences occasional headaches. During examination, she was found to have bitemporal superior quadrantanopia. What is the most probable diagnosis?
Your Answer: Non-functioning pituitary tumour
Correct Answer: Prolactinoma
Explanation:Prolactinomas cause amenorrhoea, infertility, and galactorrhoea. If the tumour extends outside the sella, visual field defects or other mass effects may occur. Other types of tumours will produce different symptoms depending on their location and structure involved. Craniopharyngiomas originate from the pituitary gland and will produce poralhemianopia if large enough, as well as symptoms related to pituitary hormones. Non-functioning pituitary tumours will have similar symptoms without the pituitary hormone side effects. Tumours of the hypothalamus will present with symptoms of euphoria, headache, weight loss, and mass effect if large enough.
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This question is part of the following fields:
- Endocrinology
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Question 26
Incorrect
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What is the joint that is most frequently impacted by diabetic Charcot's?
Your Answer: Sacroiliac joint
Correct Answer: Tarsometatarsal joints
Explanation:Charcot’s Joint: A Destructive Process Affecting Weight-Bearing Joints
Charcot’s joint is a condition that primarily affects the weight-bearing joints in the extremities, including the feet, ankles, knees, and hips. The most commonly affected joints are the tarsometatarsal and metatarsophalangeal joints, as well as the ankle. This condition is characterized by a destructive process that can lead to joint deformity and instability.
Patients with Charcot’s joint typically have decreased sensation in the affected area and peripheral neuropathy. The most common cause of peripheral neuropathy is diabetes, which has a high affinity for the joints in the foot. Other causes of peripheral neuropathy, such as leprosy, syringomyelia, and tabes dorsalis, are much less common.
Charcot’s joint can be a debilitating condition that can significantly impact a patient’s quality of life. Early diagnosis and treatment are essential to prevent joint deformity and instability. Treatment may include immobilization, orthotics, and surgery in severe cases. With proper management, patients with Charcot’s joint can maintain mobility and function.
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This question is part of the following fields:
- Endocrinology
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Question 27
Incorrect
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A 50-year-old male with type 2 diabetes presents for his annual review. Despite following a diet plan, his glycaemic control is not optimal and his most recent HbA1c is 63 mmol/mol (20-46). You decide to initiate treatment with metformin 500 mg bd. As per NICE NG28 guidelines for diabetes management, what is the recommended interval for rechecking his HbA1c after each intensification of treatment?
Your Answer: Annually
Correct Answer: Three to six months
Explanation:HbA1c as a Tool for Glycaemic Control
The glycated haemoglobin (HbA1c) is a measure of the glucose levels in the blood over a period of time. It reflects the glycosylation of the haemoglobin molecule by glucose, and there is a strong correlation between the glycosylation of this molecule and average plasma glucose concentrations. This makes it a widely used tool in clinical practice to assess glycaemic control. Studies have also shown that HbA1c has prognostic significance in both microvascular and macrovascular risk.
The life span of a red blood cell is 120 days, and HbA1c reflects the average blood glucose levels during the half-life of the red cell, which is about 60 days. According to NICE guidelines, it is recommended to re-check HbA1c with each treatment intensification at 3/6 monthly intervals. HbA1c as a tool for glycaemic control is crucial in managing diabetes and reducing the risk of complications.
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This question is part of the following fields:
- Endocrinology
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Question 28
Correct
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These results were obtained on a 30-year-old male who has presented with tiredness:
Free T4 9.3 pmol/L (9.8-23.1)
TSH 49.31 mU/L (0.35-5.50)
What signs might be expected in this case?Your Answer: Slow relaxation of biceps reflex
Explanation:Diagnosis and Symptoms of Hypothyroidism
Hypothyroidism is diagnosed through blood tests that show low levels of T4 and elevated levels of TSH. Physical examination may reveal slow relaxation of tendon jerks, bradycardia, and goitre. A bruit over a goitre is associated with Graves’ thyrotoxicosis, while palmar erythema and fine tremor occur in thyrotoxicosis. In addition to these common symptoms, hypothyroidism may also present with rarer features such as cerebellar features, compression neuropathies, hypothermia, and macrocytic anaemia. It is important to diagnose and treat hypothyroidism promptly to prevent further complications.
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This question is part of the following fields:
- Endocrinology
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Question 29
Incorrect
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A 55-year-old woman visits her GP with concerns about her susceptibility to osteoporosis. She underwent a hysterectomy and oophorectomy due to uterine fibroids five years ago, which resulted in mild hot flashes that have since subsided. The patient is anxious about the possibility of fractures after her mother broke her hip at the age of 72. She inquires about osteoporosis medications. Her BMI is 17.3 kg/m2, and her T score is <−2.5. She was on Depo-Provera from the age of 39 to 45, during which time she experienced amenorrhea. The physical examination, including breast examination, is normal. What would you suggest to her?
Your Answer: Calcium carbonate alone
Correct Answer: Bisphosphonate
Explanation:Treatment for Osteoporosis in a High-Risk Patient
Osteoporosis is a condition characterized by low bone density and increased risk of fractures. This condition is more common in women, especially those with a low body mass index (BMI), a positive family history, and those who have undergone oophorectomy. In this case, the patient has multiple risk factors for osteoporosis, but she no longer experiences menopausal symptoms.
To diagnose severe osteoporosis, a T score of <−2.5 SD is required, along with one or more fragility fractures. In this patient's case, the most appropriate therapy would be a bisphosphonate. This medication helps to increase bone density and reduce the risk of fractures. It is important to note that bisphosphonates have potential side effects, such as gastrointestinal upset and osteonecrosis of the jaw, but the benefits generally outweigh the risks. In summary, this patient’s high-risk factors for osteoporosis make her a candidate for treatment with a bisphosphonate. It is important to discuss the potential benefits and risks of this medication with the patient before starting treatment.
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This question is part of the following fields:
- Endocrinology
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Question 30
Incorrect
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A 14-year-old boy is suspected of suffering from insulin-dependent diabetes. He undergoes a glucose tolerance test following an overnight fast.
Which of the following results would most likely confirm the diagnosis?Your Answer: A plasma glucose level of 4 mmol/l at zero time
Correct Answer: A peak of plasma glucose occurring between 1 and 2 h that stays high
Explanation:Interpreting Glucose Levels in Insulin-Dependent Diabetes
Insulin-dependent diabetes is a condition that affects the body’s ability to regulate glucose levels. When interpreting glucose levels in insulin-dependent diabetes, there are several key factors to consider.
One important factor is the peak of plasma glucose that occurs between 1 and 2 hours after glucose ingestion. In normal individuals, this peak is typically sharper and occurs earlier than in insulin-dependent diabetics. In diabetics, the plasma glucose remains elevated throughout the 4-hour test period.
Another factor to consider is the presence or absence of an overshoot in the decline of plasma glucose at 3.5 hours. This overshoot, which is seen in normal individuals but not in diabetics, is a result of a pulse of insulin secretion.
A plasma glucose level of 4 mmol/l at zero time is unlikely in a diabetic patient, as they typically have high basal glucose levels. Similarly, a glucose concentration of 5.2 mmol/l at 4 hours is not expected in insulin-dependent diabetics, as their plasma glucose levels remain elevated throughout the test period.
Finally, it is important to consider the HbA1c level, which reflects average blood glucose levels over the past 2-3 months. In a diabetic patient who has been untreated for several weeks, the HbA1c would likely be elevated.
Overall, interpreting glucose levels in insulin-dependent diabetes requires careful consideration of multiple factors to accurately assess the patient’s condition.
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This question is part of the following fields:
- Endocrinology
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Question 31
Correct
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A 26-year-old female medical student experiences severe epigastric pain, following an evening indulging in large amounts of fatty foods. She went to visit her general practitioner (GP) who, upon further investigation, organised an analysis of her lipoprotein profile.
Analysis showed a deficiency of apolipoprotein (apo) C-II; all other lipoproteins were normal.
Which of the following profiles is plasma electrophoresis most likely to show?Your Answer: Elevated levels of both chylomicrons and VLDLs
Explanation:Understanding Lipoprotein Abnormalities: Causes and Clinical Features
Lipoprotein abnormalities can lead to various health conditions, including atherosclerosis and pancreatitis. The Frederickson classification system categorizes hyperlipoproteinaemias based on their underlying defects, serum abnormalities, and clinical features.
One common cause of elevated levels of both chylomicrons and VLDLs is a deficiency in apo C-II, an essential cofactor of lipoprotein lipase. This deficiency impairs the hydrolysis of triglycerides in chylomicrons and VLDLs, resulting in their accumulation in the bloodstream.
On the other hand, low VLDL levels and no other changes may indicate a deficiency in VLDL production. However, it is important to note that low levels of both chylomicrons and VLDLs may not necessarily indicate a deficiency in either lipoprotein. In fact, both chylomicrons and VLDLs would be expected to be high in this scenario.
Understanding the causes and clinical features of lipoprotein abnormalities is crucial in diagnosing and managing related health conditions.
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This question is part of the following fields:
- Endocrinology
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Question 32
Incorrect
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A 65-year-old patient presents with decompensated liver disease due to hepatocellular carcinoma. She is currently encephalopathic and has an INR of 6. What low-dose medication can be safely administered?
Your Answer: Warfarin
Correct Answer: Codeine
Explanation:Adjusting Drug Dosages for Patients with Hepatic Impairment
Patients with hepatic impairment may require adjustments to their medication regimen to prevent further liver damage or reduced drug metabolism. Certain drugs should be avoided altogether, including paracetamol, carbamazepine, oral contraceptive pills, ergometrine, and anticoagulants or antiplatelets like aspirin or warfarin due to the risk of gastrointestinal bleeding. Other medications, such as opiates, methotrexate, theophylline, and phenytoin, may still be prescribed but at a reduced dose to minimize potential harm to the liver. It is important for healthcare providers to carefully consider the potential risks and benefits of each medication and adjust dosages accordingly for patients with hepatic impairment. Proper medication management can help improve patient outcomes and prevent further liver damage.
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This question is part of the following fields:
- Endocrinology
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Question 33
Incorrect
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What is the recommended course of treatment for a 16-year-old boy with Reifenstein syndrome who has hypospadias, micropenis, and small testes in the scrotum?
Your Answer: Psychological counselling
Correct Answer: Testosterone replacement
Explanation:Management of Reifenstein Syndrome: Hormonal and Surgical Options
Reifenstein syndrome is a rare X-linked genetic disease that results in partial androgen insensitivity. In phenotypic males with this condition, testosterone replacement therapy is recommended to increase the chances of fertility. However, if the patient had been raised as a female and chose to continue this way, oestrogen replacement therapy would be appropriate. Surgical management may be necessary if the patient has undescended testes, but in this case, orchidectomy is not indicated as the patient has small testes in the scrotum. While psychological counselling is always necessary, it is not the first line of treatment. Overall, the management of Reifenstein syndrome involves a combination of hormonal and surgical options tailored to the individual patient’s needs.
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This question is part of the following fields:
- Endocrinology
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Question 34
Incorrect
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A 52-year-old woman presents with complaints of irregular periods, weight loss, and excessive sweating. She reports that her symptoms have been gradually worsening over the past few months and she also experiences itching. During the examination, her blood pressure is measured at 140/80 mmHg and her resting pulse is 95 bpm.
What is the most suitable test to perform for this patient?Your Answer: Full blood count and ferritin levels
Correct Answer: Thyroid-stimulating hormone (TSH) and T4 levels
Explanation:Investigations for Suspected Endocrine Disorder
When a patient presents with signs and symptoms of an endocrine disorder, several investigations may be necessary to confirm the diagnosis. Here are some tests that may be useful in different scenarios:
Thyroid-stimulating hormone (TSH) and T4 levels: These tests are essential when thyrotoxicosis is suspected. In rare cases, pruritus may also occur as a symptom.
Plasma renin and aldosterone levels: This investigation may be useful if Conn syndrome is suspected, but it is not necessary in patients without significant hypertension. Electrolyte levels should be checked before this test.
Full blood count and ferritin levels: These tests may be helpful in checking for anaemia, but they are less appropriate than TSH/T4 levels.
Midnight cortisol level: This test is useful when Cushing’s syndrome is suspected. In this case, the only symptom that is compatible with this disorder is irregular menses.
Test the urine for 24-hour free catecholamines: This test is used to investigate suspected phaeochromocytoma, which can cause similar symptoms to those seen in this case. However, hypertension is an important feature that is not present in this patient.
In conclusion, the choice of investigations depends on the suspected endocrine disorder and the patient’s clinical presentation.
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This question is part of the following fields:
- Endocrinology
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Question 35
Incorrect
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A 7-year-old boy who attends a regular school has been brought to the clinic due to his short stature. He measures 3 cm below the third centile for his age and weighs 800 grams less than the third centile. His bone age is 4.5 years. The boy's mother and father have heights on the 30th and 60th centiles, respectively.
Which of the following statements is true?Your Answer: Physical measurements are compatible with growth hormone deficiency
Correct Answer: Findings of poorly felt femoral pulses suggest that chromosome analysis might be required
Explanation:Factors to Consider in Evaluating Growth and Puberty Delay
When evaluating a child’s growth and puberty delay, it is important to consider the family history of delayed growth and puberty. A single measurement of growth is not enough to determine if there is a growth hormone deficiency or thyroid disease. It is also important to check for poorly felt femoral pulses, which may indicate coarctation and Turner’s syndrome.
Constitutional short stature is the most common reason for growth delay. To assess growth velocity, another measurement of growth is necessary. It is important to take into account all of these factors when evaluating a child’s growth and puberty delay to ensure an accurate diagnosis and appropriate treatment plan. Proper evaluation and management can help prevent potential complications and improve the child’s overall health and well-being.
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This question is part of the following fields:
- Endocrinology
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Question 36
Incorrect
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A 21-year-old woman is brought to the Emergency Department following a fall over the curb. She tells you that she is a refugee from Afghanistan. Imaging reveals a fracture of the pubic rami.
What is the most probable reason for this injury?Your Answer:
Correct Answer: Osteomalacia
Explanation:Common Musculoskeletal Conditions: Osteomalacia, Tuberculosis, Osteoporosis, Osteogenesis Imperfecta, and Osteosarcoma
Osteomalacia is a condition that occurs due to vitamin D deficiency or defects in phosphate metabolism, resulting in soft bones. Patients may experience bone and joint pain, muscle weakness, or fractures. Treatment involves vitamin D or calcium supplementation, braces, or surgery.
Tuberculosis can affect the musculoskeletal system, particularly the spine and weightbearing joints. Extrapulmonary tuberculosis can cause a pathological fracture, but osteomalacia is more likely in this case.
Osteoporosis is a metabolic bone disease that commonly affects patients over 50 years old. It results from an imbalance in bone formation and resorption, leading to osteoporotic fractures from low energy trauma.
Osteogenesis imperfecta is a congenital disease characterized by easily fractured bones, bone deformities, and bowed legs and arms. It is caused by mutations in collagen type 1.
Osteosarcoma is a primary bone tumor that frequently presents in children and young adults. Symptoms include bone pain and tissue swelling or mass, most commonly affecting the knee joint.
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This question is part of the following fields:
- Endocrinology
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Question 37
Incorrect
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What is a clinical characteristic of acromegaly?
Your Answer:
Correct Answer: Prominent supraorbital ridge
Explanation:Acromegaly: Causes, Symptoms, and Complications
Acromegaly is a condition that results from the overproduction of growth hormone (GH) caused by a pituitary tumour. This leads to the growth of soft tissues, which manifests in various clinical features such as enlarged hands, a prominent supraorbital ridge, protruding jaw, enlarged tongue, and carpal tunnel syndrome. Other symptoms include oily skin and tingling sensations. The tumour may also cause visual field disturbances and hypopituitarism due to its mass effect.
If left untreated, acromegaly can lead to complications such as hypertension, cardiomyopathy, hyperglycaemia/diabetes mellitus, and bowel tumours. Cardiomyopathy is a significant cause of mortality in untreated acromegaly. While pituitary adenoma is the most common cause of GH excess, ectopic secretion of GH-releasing hormone from neoplasia such as a carcinoid tumour of the lung is a rare cause.
In summary, acromegaly is a condition that results from the overproduction of GH caused by a pituitary tumour. It leads to various clinical features and can cause complications if left untreated. Early diagnosis and treatment are crucial to prevent long-term health problems.
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This question is part of the following fields:
- Endocrinology
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Question 38
Incorrect
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A 35-year-old diabetic is discovered in an unconscious state and is transported to the Emergency Department. Upon admission, the patient's body mass index (BMI) is measured at 26 kg/m2, and a diagnosis of diabetic ketoacidosis (DKA) is established.
Regarding diabetic ketoacidosis (DKA), which of the following statements is accurate?Your Answer:
Correct Answer: Patients with DKA are at high risk of thromboembolism
Explanation:Understanding Diabetic Ketoacidosis: Myths and Facts
Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can lead to life-threatening consequences. However, there are several myths and misconceptions surrounding this condition. Here are some important facts to help you better understand DKA:
Patients with DKA are at high risk of thromboembolism: Patients with DKA are at an increased risk of developing venous thromboembolism (VTE), especially in the pediatric age group and in patients with type-1 diabetes. Low-molecular-weight heparin is recommended to prevent this risk.
DKA can be treated with oral hypoglycemics: This is a myth. Oral hypoglycemics are ineffective in managing DKA as the underlying cause is an imbalance between insulin and other regulatory hormones.
Respiratory acidosis is typical: Metabolic acidosis occurs in DKA, and patients may develop a compensatory respiratory alkalosis (Kussmaul respiration).
Hypokalemia is common at presentation: There is a risk of developing hypokalemia during admission due to insulin administration, but potassium levels are usually normal or high on admission.
It often occurs in type II diabetes: This is a myth. DKA usually occurs in people with type I diabetes as it is related to low insulin levels, which leads to ketogenesis.
Understanding these facts about DKA can help in its early recognition and prompt management, leading to better outcomes for patients.
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This question is part of the following fields:
- Endocrinology
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Question 39
Incorrect
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You encounter a 27-year-old patient who has recently found out that she is pregnant. Her medical history reveals that she was diagnosed with hypothyroidism eight years ago and has been on a stable dose of levothyroxine since then. What is the appropriate course of action regarding her medication?
Your Answer:
Correct Answer: The dose of levothyroxine should be increased when pregnancy is diagnosed
Explanation:Managing Hypothyroidism in Pregnancy: Recommendations for Levothyroxine Dosing and Thyroid Function Testing
Hypothyroidism in pregnancy requires careful management to ensure optimal outcomes for both the mother and fetus. The National Institute for Health and Care Excellence (NICE) guidelines recommend increasing the dose of levothyroxine by 25-50 μg and referring the patient to an endocrinologist upon diagnosis of pregnancy. It is important to note that iodine supplements are not recommended for treating hypothyroidism in pregnancy. Adequate thyroid function is crucial for fetal neurological development, so stopping levothyroxine is not an option. Thyroid function tests (TFTs) should be taken at baseline and every four weeks, as changes in drug pharmacodynamics and kinetics can occur during pregnancy. The target thyroid stimulating hormone range should be low-normal at 0.4-2 mU/l, and the dose of levothyroxine should remain unchanged until specialist review.
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This question is part of the following fields:
- Endocrinology
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Question 40
Incorrect
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A 38-year-old woman presents with complaints of fever, malaise and pain in the neck, particularly when swallowing. She reports having had a viral respiratory infection a week ago. Upon examination, an enlarged thyroid, heart palpitations and excessive sweating are noted. Further tests reveal elevated ESR, leukocytosis, thyroid antibodies and low TSH levels. Additionally, a radionuclide thyroid uptake test shows decreased iodide uptake. What is the most probable diagnosis?
Your Answer:
Correct Answer: de Quervain's thyroiditis
Explanation:Differentiating Thyroid Disorders: A Comparison of De Quervain’s, Graves’, Hashimoto’s, Subacute Lymphocytic, and Riedel’s Thyroiditis
Thyroid disorders can present with similar symptoms, making it challenging to differentiate between them. De Quervain’s thyroiditis, also known as subacute granulomatous thyroiditis, typically affects women after a viral respiratory infection. Symptoms of thyrotoxicosis may occur initially, but the disease can progress to hypothyroidism with thyroid gland destruction. In contrast, Graves’ disease is characterized by a markedly increased uptake of iodine on a radionuclide thyroid test. Hashimoto’s thyroiditis is an autoimmune disease that can present with a hyperthyroid phase, but the patient is unlikely to experience fever and neck pain. Subacute lymphocytic thyroiditis occurs only after pregnancy, while Riedel’s thyroiditis is a rare disorder characterized by extensive fibrosis of the thyroid gland, mimicking a carcinoma. Understanding the unique features of each thyroid disorder is crucial for accurate diagnosis and appropriate treatment.
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This question is part of the following fields:
- Endocrinology
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Question 41
Incorrect
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A 35-year-old hypertensive man presented with the following blood results:
Investigation Result Normal value
Sodium (Na+) 147 mmol/l 135–145 mmol/l
Potassium (K+) 2.8 mmol/l 3.5–5.0 mmol/l
Urea 4.0 mmol/l 2.5–6.5 mmol/l
Creatinine 50 μmol/l 50–120 μmol/l
Glucose 4.0 mmol/l
Random: 3.5–5.5 mmol/l
Fasting: <7 mmol/l
Hba1c: <53 mmol/l (<7.0%)
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Conn's syndrome
Explanation:Differential diagnosis of hypertension with electrolyte abnormalities
When a young patient presents with hypertension and hypokalaemia, it is important to consider secondary causes of hypertension, such as Conn’s syndrome (primary hyperaldosteronism), which can explain both findings. Coarctation of the aorta is another secondary cause of hypertension, but it does not account for the electrolyte abnormalities. Cushing’s disease/syndrome may also present with hypertension and electrolyte abnormalities, but typically with additional symptoms and higher fasting glucose levels. Polycystic kidney disease can cause hypertension, but not the electrolyte abnormalities. Primary (essential) hypertension is the most common form of hypertension, but secondary causes should be ruled out, especially in younger patients with atypical features.
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This question is part of the following fields:
- Endocrinology
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Question 42
Incorrect
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A 30-year-old man is being evaluated by his physician for possible issues with his hypothalamic-pituitary-thyroid axis. The following findings were recorded:
Thyroid-stimulating hormone (TSH) 5.5 mu/l (0.4-4.0 mu/l)
fT3 3.5 pmol/l (3.0-9.0 pmol/l)
What condition is indicated by these results?Your Answer:
Correct Answer: Need more information
Explanation:The Importance of fT4 in Thyroid Diagnosis
When diagnosing thyroid conditions, the fT4 level is a crucial piece of information that cannot be overlooked. A patient with high TSH could be hyperthyroid, hypothyroid, or euthyroid with this TSH level, and the fT4 level is needed to determine the correct diagnosis. While a normal fT3 level can rule out hyperthyroidism, it cannot exclude the diagnosis if the fT4 level is high. Similarly, fT3 levels are of no use in diagnosing hypothyroidism, as they can be normal in a hypothyroid patient due to increased T4 to T3 conversion. Without the fT4 level, a diagnosis of primary or secondary hypothyroidism or a TSH-secreting tumor cannot be made. Therefore, it is crucial to obtain the fT4 level when evaluating thyroid function.
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This question is part of the following fields:
- Endocrinology
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Question 43
Incorrect
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A 35-year-old male with type 2 diabetes presents with a blood pressure reading of 140/85 mmHg and persistent traces of albuminuria in his urine examination. What is the most suitable course of treatment for this individual?
Your Answer:
Correct Answer: ACE inhibitor
Explanation:Diabetic Nephropathy and the Benefits of ACE Inhibitors
Diabetic nephropathy is a clinical condition characterized by persistent albuminuria, a decline in the glomerular filtration rate, and elevated arterial blood pressure. To confirm the diagnosis, albuminuria must be present on at least two occasions three to six months apart. Antihypertensive therapy can slow the progression of diabetic glomerulopathy, but ACE inhibitors have been shown to provide superior long-term protection.
Aside from its cardiovascular benefits, ACE inhibition has also been found to have a significant positive effect on the progression of diabetic retinopathy and the development of proliferative retinopathy. Therefore, ACE inhibitors are a recommended treatment option for patients with diabetic nephropathy. By this condition and the benefits of ACE inhibitors, healthcare professionals can provide better care for their patients with diabetes.
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This question is part of the following fields:
- Endocrinology
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Question 44
Incorrect
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For which medical condition is Pioglitazone prescribed?
Your Answer:
Correct Answer: Type II diabetes mellitus
Explanation:Pioglitazone for Type 2 Diabetes: Mechanism of Action and Side Effects
Pioglitazone is a medication used to treat insulin resistance in patients with type 2 diabetes. It works by activating PPAR gamma, a protein that regulates the expression of genes involved in glucose and lipid metabolism. This leads to improved insulin sensitivity and better control of blood sugar levels. Pioglitazone has been shown to lower HbA1c levels by approximately 1%.
However, pioglitazone is associated with several side effects. One of the most common is fluid retention, which can lead to swelling in the legs and feet. It can also cause a loss of bone mineral density, which may increase the risk of fractures. Additionally, pioglitazone has been linked to an increased risk of bladder cancer, particularly in patients with a history of bladder tumors or polyps. For this reason, it should not be prescribed to these patients.
In summary, pioglitazone is an effective medication for treating insulin resistance in type 2 diabetes. However, it is important to be aware of its potential side effects, particularly the risk of bladder cancer in certain patients. Patients taking pioglitazone should be monitored closely for any signs of fluid retention or bone loss, and those with a history of bladder tumors or polyps should not take this medication.
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This question is part of the following fields:
- Endocrinology
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Question 45
Incorrect
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A 50-year-old woman is undergoing evaluation for hypertension that is not responding to treatment. She has a previous medical history of medullary thyroid carcinoma. Her physical examination is unremarkable. During her work-up, she is found to have hypercalcemia with a level of 2.8 mmol/l. Her parathyroid hormone (PTH) is slightly elevated above the normal range. What is the underlying diagnosis?
Your Answer:
Correct Answer: Multiple endocrine neoplasia type 2A
Explanation:Differential Diagnosis: Hypercalcaemia with Medullary Thyroid Carcinoma
Multiple endocrine neoplasia type 2A (MEN 2A) is a genetic disorder caused by a gain in function mutation in the RET proto-oncogene. The classic triad of MEN 2A includes medullary thyroid carcinoma, primary hyperparathyroidism, and phaeochromocytoma. In cases where a patient presents with a history of medullary thyroid carcinoma and hypercalcaemia with inappropriately elevated PTH levels, primary parahyperthyroidism is implied, and the combination of these symptoms with treatment-resistant hypertension is virtually diagnostic of MEN 2A.
Other conditions associated with hypercalcaemia include multiple myeloma, but PTH levels would be appropriately low. Marfan’s syndrome, a hereditary disorder of connective tissue, is not typically associated with dysfunction of the parathyroid hormone axis. Multiple endocrine neoplasia type 1 (MEN1) is a main differential diagnosis, but patients with MEN1 typically suffer from hyperparathyroidism, pituitary adenomas (typically prolactinomas), and pancreatic islet cell tumours, not the symptoms described here. Neurofibromatosis, a disorder caused by a mutation in the neurofibromin gene, is associated with multiple neural tumours and various other manifestations, but disruption of the parathyroid hormone axis is not a feature.
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This question is part of the following fields:
- Endocrinology
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Question 46
Incorrect
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A 50-year-old woman with a history of severe depression and a radical mastectomy for breast carcinoma one year ago presents with complaints of polyuria, nocturia, and excessive thirst. Her laboratory values show a serum sodium of 130 mmol/L (133-145), serum potassium of 3.6 mmol/L (3.5-5), serum calcium of 2.2 mmol/L (2.2-2.6), glucose of 5.8 mmol/L (3.5-6), urea of 4.3 mmol/L (3-8), and urine osmolality of 150 mosmol/kg (350-1000). What is the most likely diagnosis?
Your Answer:
Correct Answer: Psychogenic polydipsia
Explanation:Psychogenic Polydipsia
Psychogenic polydipsia is a rare condition where a person drinks excessive amounts of water without any physiological reason to do so. This disorder is usually well-tolerated unless it leads to hyponatremia. Psychogenic polydipsia is commonly observed in hospitalized schizophrenics, depressed patients, and children. The diagnosis of this condition is made by excluding other possible causes and requires specialized investigation and management. The water deprivation test is the most important test for diagnosing psychogenic polydipsia.
In contrast, diabetes insipidus is a condition caused by a lack of action of ADH, which results in high osmolality and high sodium levels, leading to dehydration. This condition causes inappropriately dilute urine. To exclude diabetes insipidus, a water deprivation test is required. However, in patients with psychogenic polydipsia, the urine becomes appropriately concentrated upon water deprivation, whereas in diabetes insipidus, the urine remains dilute.
In this patient, the history of depression, relative dilution of sodium, and low urine osmolality suggest a diagnosis of psychogenic polydipsia. The presence of hyponatremia further supports this diagnosis. Therefore, it is important to consider psychogenic polydipsia as a possible cause of excessive water drinking in patients with hyponatremia.
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This question is part of the following fields:
- Endocrinology
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Question 47
Incorrect
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What is the most frequent organic cause of anxiety symptoms?
Your Answer:
Correct Answer: Hypoglycaemia
Explanation:Organic Causes of Anxiety
Anxiety can be caused by various factors, including organic causes. One of the more common organic causes of anxiety is hypoglycaemia. However, there are other organic causes that can also lead to anxiety. These include alcohol withdrawal, drug intoxication or withdrawal, thyroxine, and paroxysmal supraventricular tachycardias. While phaeochromocytoma is a rare cause of anxiety, carcinoid does not cause anxiety at all. It is important to note that carcinoma of the bronchus and hyperparathyroidism are more likely to present with depression rather than anxiety.
It is crucial to identify the underlying cause of anxiety to provide appropriate treatment. If an organic cause is suspected, further evaluation and testing may be necessary to determine the root cause of the anxiety. By addressing the underlying cause, it may be possible to alleviate or even eliminate the symptoms of anxiety. Therefore, it is important to consider all possible causes of anxiety, including organic causes, to provide the best possible care for patients.
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This question is part of the following fields:
- Endocrinology
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Question 48
Incorrect
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In addition to its effects on bone, PTH primarily acts on which organ?
Your Answer:
Correct Answer: Kidney
Explanation:The Effects of PTH on Bone and Kidney
Parathyroid hormone (PTH) has two main targets in the body: the bone and the kidney. Its primary goal in the bone is to increase calcium levels by stimulating the activity of osteoclasts, which break down bone tissue to release calcium into the bloodstream. In the kidney, PTH has a different effect. It increases the reabsorption of calcium and decreases the absorption of phosphate, which helps to maintain the balance of these minerals in the body. Additionally, PTH stimulates the production of 1-alpha hydroxylation of vitamin D in the kidney, which is important for calcium absorption and bone health. Overall, PTH plays a crucial role in regulating calcium and phosphate levels in the body, and its effects on bone and kidney function are essential for maintaining healthy bones and overall health.
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This question is part of the following fields:
- Endocrinology
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Question 49
Incorrect
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A newly diagnosed type 2 diabetic patient in their 60s is admitted through the Emergency department due to hyperglycemia. The patient is dehydrated and has acute on chronic renal impairment, with an eGFR of 30 ml/min/1.73 m2. What diabetes medication(s) can be safely prescribed?
Your Answer:
Correct Answer: Gliclazide and saxagliptin
Explanation:Caution in Prescribing Hypoglycaemic Medication in Renal Impairment
When prescribing hypoglycaemic medication to patients with renal impairment, caution should be exercised. This is because reduced renal excretion increases the risk of hypoglycaemia. Metformin should not be prescribed or should be discontinued when the estimated glomerular filtration rate (eGFR) is less than 45 ml/min due to the potential for lactic acidosis. Liraglutide, an injectable GLP1 agonist, should also be avoided if the eGFR is less than 60 ml/min/1.73 m2. Rosiglitazone has been withdrawn from the market and should not be prescribed. Gliclazide and other sulfonylureas can be used in renal impairment, but a reduced dose may be necessary due to the potential for hypoglycaemia caused by reduced renal excretion. Saxagliptin, a DPP4 inhibitor, should be prescribed at half dose if the eGFR is less than 50 ml/min/1.73 m2. It is important to consider the patient’s renal function when prescribing hypoglycaemic medication to avoid adverse effects.
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This question is part of the following fields:
- Endocrinology
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Question 50
Incorrect
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A 38-year-old woman presents with a 6-month history of excessive sweating, palpitations, and weight loss. She now complains of a headache. On examination, her blood pressure is 230/130 mmHg, with a postural drop to 180/110 mmHg. She has a bounding pulse of 115 bpm, a tremor, and appears pale. The rest of the examination is unremarkable. Which hormone is most likely responsible for her symptoms and signs?
Your Answer:
Correct Answer: Catecholamines
Explanation:Explanation of Hormones and their Role in Hypertension
The patient’s symptoms suggest a rare tumour called phaeochromocytoma, which secretes catecholamines and causes malignant hypertension. Excess cortisol production in Cushing’s syndrome can also cause hypertension, but it does not explain the patient’s symptoms. Renin abnormalities can lead to hypertension, but it is not the cause of the patient’s symptoms. Hyperaldosteronism can also cause hypertension, but it does not explain the patient’s symptoms. Although hyperthyroidism can explain most of the patient’s symptoms, it is less likely to cause severe hypertension or headaches. Therefore, the patient’s symptoms are most likely due to the secretion of catecholamines from the phaeochromocytoma tumour.
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This question is part of the following fields:
- Endocrinology
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Question 51
Incorrect
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A 35-year-old woman presents with new-onset diabetes. She has no past drug or treatment history. Her fasting blood glucose is 7.3 mmol/l. Other significant medical history included occasional diarrhoea in the last 4 months, for which she took repeated courses of tinidazole. She also had an episode of severe leg pain three months ago, for which she takes warfarin. She is presently very depressed, as her sister has had renal calculus surgery, which has not gone well; she is in the Intensive Care Unit (ICU) with sepsis.
What is the most appropriate next test?Your Answer:
Correct Answer: Genetic study
Explanation:Diagnostic Tests for a Patient with Possible Multiple Endocrine Neoplasia (MEN) 1 Syndrome
A woman presents with new-onset diabetes, diarrhoea, and a past episode of deep vein thrombosis (DVT), along with a family history of renal calculi at a young age. These symptoms suggest the possibility of multiple endocrine neoplasia (MEN) 1 syndrome, an autosomal dominant disease characterized by endocrine hyperfunction in various glands, particularly the parathyroid gland and enteropancreatic tumors. The most common tumors in the latter group are gastrinoma and insulinoma, with glucagonoma occurring rarely. Other symptoms may include depression, anemia, glossitis, and in rare cases, a skin manifestation called necrolytic migratory erythema.
To confirm a diagnosis of MEN 1, a genetic study to detect MEN 1 gene mutation on chromosome 11 is the best option. A family history of renal stones, as in this case, is the most common manifestation of MEN 1.
Other diagnostic tests, such as protein C assessment, colonoscopy, and blood test for Giardia antigen, are not relevant to this particular case. Measuring C-peptide levels can help distinguish between type I and type II diabetes or maturity-onset diabetes of the young (MODY), but it will not help in detecting the underlying disease. Giardiasis symptoms may include diarrhea, fatigue, abdominal cramps, bloating, gas, nausea, and weight loss, but tinidazole should have eliminated Giardia.
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This question is part of the following fields:
- Endocrinology
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Question 52
Incorrect
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A 14-year-old boy presents with bilateral gynaecomastia. He stands at a height of 150 cm and weighs 60 kg, which is at the 50th centile. His sexual maturity rating is stage 2. What is the most probable cause of his gynaecomastia?
Your Answer:
Correct Answer: Pubertal gynaecomastia
Explanation:Pubertal Gynaecomastia in Young Boys
Pubertal gynaecomastia is a common occurrence in young boys, with unilateral disease being more prevalent than bilateral. However, it typically disappears within two years. While prolactinomas can cause gynaecomastia, they are not the most likely cause and are rare in this age group. It is important to note that the height and weight of the child are within normal range.
Overall, pubertal gynaecomastia is a temporary condition that affects many young boys during puberty. While it can be concerning for parents and children, it is typically not a cause for alarm and will resolve on its own. It is important to consult with a healthcare provider to rule out any underlying medical conditions, but in most cases, no treatment is necessary.
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This question is part of the following fields:
- Endocrinology
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Question 53
Incorrect
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A 54-year-old Hispanic male presents to his primary care physician complaining of fatigue. He has noticed a slight increase in weight and has been feeling increasingly tired over the past year. The patient has a history of asthma and manages it with inhaled salbutamol as needed, typically no more than once a week. He also has type 2 diabetes that is controlled through diet.
During the examination, the patient's blood pressure is measured at 172/98 mmHg, his body mass index is 29.7 kg/m2, and his pulse is 88 beats per minute. No other abnormalities are noted. Over the next month, his blood pressure readings are consistently high, measuring at 180/96, 176/90, and 178/100 mmHg.
Which medication would be recommended for the treatment of this patient's high blood pressure?Your Answer:
Correct Answer: Lisinopril
Explanation:Hypertension Treatment in Patients with Type 2 Diabetes
Patients with type 2 diabetes and sustained hypertension require treatment. The first-line treatment for hypertension in diabetes is ACE inhibitors. These medications have no adverse effects on glucose tolerance or lipid profiles and can delay the progression of microalbuminuria to nephropathy. Additionally, ACE inhibitors can reduce morbidity and mortality in patients with vascular disease and diabetes.
However, bendroflumethiazide should be avoided in patients with a history of gout as it may provoke an attack. Beta-blockers should also be avoided for routine treatment of uncomplicated hypertension in patients with diabetes. They can precipitate bronchospasm and should be avoided in patients with asthma. In cases where there is no alternative, a cardioselective beta blocker should be selected and initiated at a low dose by a specialist, with close monitoring for adverse effects.
Alpha-blockers, such as doxazosin, are reserved for the treatment of resistant hypertension in conjunction with other antihypertensives. It is important to follow guidelines, such as those provided by NICE and the British National Formulary, for the diagnosis and management of hypertension in adults with diabetes. A treatment algorithm for hypertension can also be helpful in guiding treatment decisions.
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This question is part of the following fields:
- Endocrinology
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Question 54
Incorrect
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A 42-year-old teacher visits her GP, complaining of hot flashes and night sweats. She suspects that she may be experiencing symptoms of menopause. Can you identify which set of results below are consistent with postmenopausal values?
A: FSH (follicular phase 2.9-8.4 U/L) 0.5
LH (follicular phase 1.3-8.4 U/L) 1.1
Oestrogen (pmol/L) 26
Progesterone (pmol/L) <5
B: FSH (follicular phase 2.9-8.4 U/L) 0.5
LH (follicular phase 1.3-8.4 U/L) 1.2
Oestrogen (pmol/L) 120
Progesterone (pmol/L) 18
C: FSH (follicular phase 2.9-8.4 U/L) 68
LH (follicular phase 1.3-8.4 U/L) 51
Oestrogen (pmol/L) 42
Progesterone (pmol/L) <5
D: FSH (follicular phase 2.9-8.4 U/L) 1.0
LH (follicular phase 1.3-8.4 U/L) 0.8
Oestrogen (pmol/L) 250
Progesterone (pmol/L) 120
E: FSH (follicular phase 2.9-8.4 U/L) 8.0
LH (follicular phase 1.3-8.4 U/L) 7.2
Oestrogen (pmol/L) 144
Progesterone (pmol/L) <5Your Answer:
Correct Answer: C
Explanation:postmenopausal Blood Tests
postmenopausal blood tests often reveal elevated levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), as well as low levels of estrogen. These changes in hormone levels are responsible for most of the symptoms associated with menopause, which can be difficult to diagnose. However, once characteristic symptoms are well-established, gonadotrophin levels are typically significantly elevated.
The menopause is defined as the date of a woman’s last period, without further menses for at least a year. As such, the diagnosis can only be made retrospectively. Prior to menopause, women may experience irregular menstruation, heavy bleeding, and mood-related symptoms. While fertility is greatly reduced during this time, there is still some risk of pregnancy, and many healthcare providers recommend continuing contraception for a year after the last menstrual period.
In summary, postmenopausal blood tests can provide valuable information about a woman’s hormone levels and help diagnose menopause. However, it’s important to recognize that menopause is a gradual process that can be accompanied by a range of symptoms. Women should work closely with their healthcare providers to manage these symptoms and ensure their ongoing health and well-being.
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This question is part of the following fields:
- Endocrinology
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Question 55
Incorrect
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A 42-year-old man has been experiencing gradual enlargement of his hands and feet for the past 4 years, resulting in the need for larger gloves and shoes. Recently, he has also noticed his voice becoming deeper. His family has observed that he snores frequently and he has been experiencing daytime sleepiness. Over the past 6 months, he has been experiencing progressive blurring of vision accompanied by headaches and dizziness. Upon examination, his visual acuity is 20/20-2 and visual field testing reveals bitemporal hemianopias. What is the most appropriate initial investigation to confirm a diagnosis in this man?
Your Answer:
Correct Answer: Insulin-like growth factor 1 (IGF-1) measurement
Explanation:Diagnostic Tests for Acromegaly: IGF-1 Measurement vs. OGTT and Other Tests
Acromegaly, a condition caused by a GH-secreting pituitary adenoma, can be diagnosed through various tests. Previously, the OGTT with growth hormone assay was used for screening and monitoring, but it has now been replaced by the IGF-1 measurement as the first-line investigation to confirm the diagnosis.
The insulin tolerance test, which induces hypoglycaemia and increases GH release, is not useful in confirming the presence of a GH-secreting adenoma. Random GH assay is also not helpful as normal subjects have undetectable GH levels throughout the day, making it difficult to differentiate from levels seen in acromegaly.
While up to 20% of GH-secreting pituitary adenomas co-secrete prolactin, the prolactin level alone is not diagnostic. Therefore, the IGF-1 measurement is the preferred test for diagnosing acromegaly.
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This question is part of the following fields:
- Endocrinology
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Question 56
Incorrect
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A 68-year-old woman presents to the Emergency Department with acute agitation, fever, nausea and vomiting. On examination, she is disorientated and agitated, with a temperature of 40 °C and heart rate of 130 bpm, irregular pulse, and congestive cardiac failure. She has a history of hyperthyroidism due to Graves’ disease, neutropenia and agranulocytosis, and cognitive impairment. She lives alone. Laboratory investigations reveal the following results:
Test Result Normal reference range
Free T4 > 100 pmol/l 11–22 pmol/l
Free T3 > 30 pmol/l 3.5–5 pmol/l
Thyroid stimulating hormone (TSH) < 0.01 µU/l 0.17–3.2 µU/l
TSH receptor antibody > 30 U/l < 0.9 U/l
What should be included in the management plan for this 68-year-old patient?Your Answer:
Correct Answer: Propylthiouracil, iodine, propranolol, hydrocortisone
Explanation:Treatment Options for Thyroid Storm in Graves’ Disease Patients
Thyroid storm is a life-threatening condition that requires immediate medical attention in patients with Graves’ disease. The following are some treatment options for thyroid storm and their potential effects on the patient’s condition.
Propylthiouracil, iodine, propranolol, hydrocortisone:
This combination of medications can help inhibit the synthesis of new thyroid hormone, tone down the severe adrenergic response, and prevent T4 from being converted to the more potent T3. Propylthiouracil and iodine block the synthesis of new thyroid hormone, while propranolol and hydrocortisone help decrease the heart rate and blood pressure.Carbimazole, iodine, tri-iodothyronine:
Carbimazole and iodine can inhibit the synthesis of thyroid hormone, but tri-iodothyronine is very potent and would do the opposite of the therapeutic aim.Esmolol, thyroxine, dexamethasone:
Esmolol and dexamethasone can tone down the severe adrenergic response and prevent T4 from being turned into T3. However, thyroxine would do the opposite of the therapeutic aim and make the situation worse.Lugol’s iodine, furosemide, thyroxine:
Lugol’s iodine can be used to treat hyperthyroidism, but furosemide is not appropriate for addressing thyroid storm. Thyroxine would make the situation worse.Prednisolone, paracetamol, tri-iodothyronine:
Prednisolone can prevent T4 from being converted to T3, but it is usually available in oral form and may not be efficient in addressing thyroid storm. Tri-iodothyronine would exacerbate the patient’s condition, and paracetamol is not indicated for this condition.In conclusion, the treatment options for thyroid storm in Graves’ disease patients depend on the patient’s condition and medical history. It is important to consult with a healthcare professional to determine the best course of action.
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This question is part of the following fields:
- Endocrinology
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Question 57
Incorrect
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A 57-year-old man comes in for his yearly check-up with his GP. He has a history of type 2 diabetes and hypertension. Upon physical examination, there are no notable findings and no signs of fluid overload. His blood pressure is 126/84 mmHg, and his heart rate is 67 bpm. A urine dipstick test shows only 1+ protein.
The results of his routine blood panel are as follows:
- Haemoglobin: 139 g/L (125-175)
- White cell count: 5.7 ×109/L (4-11)
- Mean cell volume: 82 fL (75-100)
- Platelets: 359 ×109/L (150-400)
- Sodium: 137 mmol/L (135-145)
- Potassium: 4.8 mmol/L (3.5-5.5)
- Urea: 8.9 mmol/L (2-7)
- Creatinine: 169 μmol/ (75-110)
- Glucose: 6.7 mmol/L (4-7)
- HbA1c: 48 mmol/mol (42-53)
- eGFR: 29 ml/min (>60)
- Lactate: 2.4 mmol/L (0.5-2)
- Venous pH: 7.35 (7.35-7.45)
Currently, the patient is taking aspirin 75 mg daily, bisoprolol 5 mg daily, gliclazide 80 mg twice daily, metformin 1 g twice daily, and ramipril 2.5 mg daily. Based on this information, which medication should be discontinued?Your Answer:
Correct Answer: Metformin
Explanation:Medications and Renal Impairment
Metformin is a commonly used oral antidiabetic drug that inhibits hepatic gluconeogenesis, making it a first-line agent in the treatment of type 2 diabetes. However, it should be closely monitored in patients with impaired renal function due to the risk of developing lactate acidosis. Current guidelines recommend avoiding metformin in renal impairment if possible, reducing the dose if eGFR is less than 45 ml/min, and discontinuing it if less than 30 ml/min. Gliclazide, another antidiabetic drug, stimulates insulin release and is mostly cleared by the liver, but should be avoided in severe renal impairment and monitored in mild to moderate cases. Ramipril, an ACE inhibitor used in hypertension and heart failure, is beneficial in delaying diabetic nephropathy but may require dose adjustments in established renal impairment. Aspirin, commonly used in cardiovascular pathologies, should be avoided in severe renal failure but can be continued in moderate impairment. Bisoprolol, a cardio-specific beta-blocker, is safe to continue in renal impairment, with dose adjustments only needed when eGFR is less than 20 ml/min.
Overall, it is important to closely monitor medication use in patients with renal impairment and adjust doses or discontinue use as necessary to prevent adverse effects.
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This question is part of the following fields:
- Endocrinology
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Question 58
Incorrect
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A 50-year-old man underwent blood tests after a recent kidney stone surgery. The test results are as follows:
Corrected calcium: 3.01 mmol/L (normal range: 2.1-2.5)
Phosphate: 0.49 mmol/L (normal range: 0.80-1.4)
Alkaline phosphatase (alk phos): 166 U/L (normal range: 30-135)
Parathyroid hormone (PTH): 71 ng/L (normal range: 14-72 ng/L)
Estimated glomerular filtration rate (eGFR): >60 ml/min/1.73m2
What is the most likely reason for the high calcium level based on these results?Your Answer:
Correct Answer: Primary hyperparathyroidism
Explanation:High Serum Calcium Levels
When analyzing blood test results, a high serum calcium level in combination with a low phosphate level, high serum alkaline phosphatase (ALP), and normal glomerular filtration rate (GFR) may indicate primary hyperparathyroidism. While the parathyroid hormone (PTH) may fall within the reference range, it is considered inappropriate for the high calcium levels, as it should be suppressed as part of the negative feedback mechanism. It is important to note that a result within the reference range may still be abnormal.
Primary hyperparathyroidism is typically caused by a solitary adenoma, hyperplasia of all the parathyroid glands, multiple adenomas, or parathyroid carcinoma. Other conditions, such as vitamin D excess or bony metastases, may also cause high calcium levels, but the PTH would be suppressed if it were the primary pathology. Severe hypercalcemia can lead to dehydration, but dehydration itself would not cause such high serum calcium levels. Sclerosing cholangitis may cause elevated ALP levels of liver origin, but it would not explain the other results. the potential causes of high serum calcium levels can aid in proper diagnosis and treatment.
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This question is part of the following fields:
- Endocrinology
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Question 59
Incorrect
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Which statement about leptin is accurate?
Your Answer:
Correct Answer: Produces satiety
Explanation:The Role of Leptin in Regulating Appetite and Body Weight
Leptin is a hormone that is produced by adipocytes, or fat cells, and its concentration in the bloodstream is directly related to the amount of fat in the body. When leptin levels are high, it acts on receptors in the hypothalamus to produce feelings of satiety, or fullness, which can help to reduce food intake. This makes leptin an important regulator of appetite and body weight.
However, in some cases, patients may develop leptin resistance, which means that their bodies are no longer able to respond to the hormone in the same way. This can lead to continued weight gain and difficulty in controlling food intake, even when leptin levels are high. Despite this, researchers continue to study the role of leptin in the body and explore potential treatments for obesity and other related conditions.
Overall, the physiology of leptin and its effects on appetite and body weight is an important area of research that has the potential to improve the health and well-being of millions of people around the world. By developing new treatments and interventions that target leptin and other related hormones, we may be able to help patients achieve and maintain a healthy weight and reduce their risk of developing chronic diseases such as diabetes, heart disease, and cancer.
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This question is part of the following fields:
- Endocrinology
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Question 60
Incorrect
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A 65-year-old man with a history of diabetes mellitus complains of a swollen right ankle joint that is not painful. Upon examination, radiographs reveal a joint that has been destroyed and contains a significant number of loose bodies. What is the most likely diagnosis?
Your Answer:
Correct Answer: Charcot's joint
Explanation:Charcot’s Joint: A Destructive Process Affecting Weight-Bearing Joints
Charcot’s joint is a condition that primarily affects the weight-bearing joints in the extremities, including the feet, ankles, knees, and hips. It is a destructive process that can often be mistaken for an infection in these areas. The condition is characterized by a decreased sensation in the affected area and peripheral neuropathy. It is most commonly associated with diabetes mellitus, leprosy, and tabes dorsalis.
Charcot’s joint is a serious condition that can lead to significant disability if left untreated. It is important to recognize the symptoms and seek medical attention promptly. Treatment typically involves immobilization of the affected joint and management of the underlying condition. With proper care, it is possible to prevent further damage and preserve joint function.
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This question is part of the following fields:
- Endocrinology
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Question 61
Incorrect
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A 36-year-old man visits his doctor's office accompanied by his wife, who expresses concern that her husband has been acting strangely and not like himself lately. Upon questioning, the patient appears confused and complains of a persistent headache. The doctor conducts an examination but finds no additional signs. To investigate further, the doctor orders a full blood count with electrolytes and renal function, as well as a urinary analysis. The results reveal hyponatremia with reduced plasma osmolality and high urinary osmolality and sodium. Which medication is most commonly associated with the syndrome of inappropriate antidiuretic hormone secretion (SIADH)?
Your Answer:
Correct Answer: Carbamazepine
Explanation:Medications and their potential to cause SIADH
SIADH, or syndrome of inappropriate antidiuretic hormone secretion, is a condition where the body produces too much antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. Some medications have been known to cause SIADH, while others do not.
Carbamazepine is an anti-epileptic medication that can cause SIADH by promoting water reabsorption through stimulation of the V2 vasopressin receptor-protein G complex. Trimeprazine, a phenothiazine derivative used for motion sickness and pruritus, does not cause SIADH. Atropine, an antimuscarinic, and digoxin, a cardiac glycoside, also do not cause SIADH.
However, lithium, a mood stabilizer, can result in nephrogenic diabetes insipidus, leading to hypernatremia. It is important to be aware of the potential side effects of medications and to monitor patients for any signs of SIADH or other adverse reactions.
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This question is part of the following fields:
- Endocrinology
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Question 62
Incorrect
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A 67-year-old man with a 20-year history of insulin dependent diabetes mellitus presents with a haemoglobin A1C of 10.3% (89 mmol/mol). He reports experiencing abdominal pain after meals for the past year, which has been gradually worsening. Upon physical examination, his abdomen appears normal. What is the most probable pathological finding in this patient?
Your Answer:
Correct Answer: Mesenteric artery occlusion
Explanation:Possible Causes of Chronic Abdominal Pain
Chronic abdominal pain can be caused by reduced blood flow to the bowel, which can lead to a pain similar to angina. This condition is more common in patients with diabetes mellitus, as atherosclerosis can affect the major arteries to the bowel. Acute pancreatitis is not a likely cause of this pain, as it would cause acute and severe abdominal pain, unrelated to meals. Aortic aneurysm can also be a consequence of atherosclerosis, and an abdominal mass may be palpated on examination. However, typically there is no pain until the aneurysm ruptures, which is a surgical emergency. Chronic renal failure, which is one of the main causes of diabetes, would not cause meal-related abdominal pain, and we are not told any serum electrolyte values to indicate this. Hepatic infarction, which refers to diffuse hepatic injury from acute hypoperfusion resulting from obstruction of the arterial circulation or more rarely the portal venous circulation, is rare due to the liver’s dual blood supply. Causes of hepatic infarction include atherosclerotic occlusion, embolus, arthritis of the hepatic artery, neoplastic invasion by malignant tumors in the liver hilus, and hypercoagulation states, such as polycythemia.
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This question is part of the following fields:
- Endocrinology
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Question 63
Incorrect
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A 27-year-old woman visits her GP complaining of experiencing sweating, agitation, palpitations, and restlessness for the past three days. She gave birth to a healthy baby through vaginal delivery at 39 weeks gestation two months ago. The patient has a medical history of coeliac disease. The following investigations were conducted:
Thyroid-stimulating hormone (TSH) 0.1 mU/L (0.5-5.5)
Free thyroxine (T4) 26 pmol/L (9.0 - 18)
What is the next appropriate step in managing this patient?Your Answer:
Correct Answer: Prescribe propranolol
Explanation:The appropriate management for the thyrotoxicosis phase of postpartum thyroiditis is prescribing propranolol for symptomatic relief. This patient’s presentation of hyperthyroidism 2 months postpartum suggests postpartum thyroiditis, which is typically self-resolving. Propranolol is the most suitable option for managing the symptoms of this condition. Prescribing NSAIDs and monitoring would be more appropriate for subacute (de Quervain’s) thyroiditis, which is not the case here. Prescribing carbimazole or levothyroxine would not be necessary or appropriate for this patient’s condition.
Understanding Postpartum Thyroiditis: Stages and Management
Postpartum thyroiditis is a condition that affects some women after giving birth. It is characterized by three stages: thyrotoxicosis, hypothyroidism, and normal thyroid function. During the thyrotoxicosis phase, the thyroid gland becomes overactive, leading to symptoms such as anxiety, palpitations, and weight loss. In the hypothyroidism phase, the thyroid gland becomes underactive, causing symptoms such as fatigue, weight gain, and depression. However, in the final stage, the thyroid gland returns to normal function, although there is a high recurrence rate in future pregnancies.
Thyroid peroxidase antibodies are found in 90% of patients with postpartum thyroiditis, which suggests an autoimmune component to the condition. Management of postpartum thyroiditis depends on the stage of the condition. During the thyrotoxic phase, symptom control is the main focus, and propranolol is typically used. Antithyroid drugs are not usually used as the thyroid gland is not overactive. In the hypothyroid phase, treatment with thyroxine is usually necessary to restore normal thyroid function.
It is important to note that many causes of hypothyroidism may have an initial thyrotoxic phase, as shown in a Venn diagram. Therefore, it is crucial to properly diagnose and manage postpartum thyroiditis to ensure the best possible outcomes for both the mother and the baby.
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This question is part of the following fields:
- Endocrinology
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Question 64
Incorrect
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A 56-year-old man has undergone the following investigations by his General Practitioner (GP).
Plasma:
Investigations Results Normal Value
Total Ca2+ 1.85 mmol/l 2.20–2.60 mmol/l
Albumin 42 g/l 35–55 g/l
PO43- 1.8 mmol/l 0.70–1.40 mmol/l
Alkaline phosphatase 160 IU/l 30–130 IU/l
Parathyroid hormone (PTH) 80 ng/l 10–65 ng/l
What is the most probable underlying condition?Your Answer:
Correct Answer: Chronic renal failure
Explanation:Understanding Hyperparathyroidism and Related Conditions
Hyperparathyroidism is a condition characterized by high levels of parathyroid hormone (PTH) in the blood, which can lead to imbalances in calcium and phosphate levels. There are several different types of hyperparathyroidism, as well as related conditions that can affect the parathyroid gland and its function.
Chronic renal failure is one such condition, in which impaired 1α-hydroxylation of 25-hydroxycholecalciferol leads to reduced calcium and phosphate excretion due to renal impairment. This results in secondary hyperparathyroidism, with elevated PTH levels in response to low plasma ionized calcium. Alkaline phosphatase is also elevated due to renal osteodystrophy.
As chronic renal failure progresses, the parathyroid glands may become hyperplastic or adenomatous, leading to tertiary hyperparathyroidism. In this condition, PTH secretion is substantially increased, causing elevated calcium levels that are not limited by feedback control.
Malignant hyperparathyroidism is another condition that can mimic hyperparathyroidism, but is caused by the production of PTH-related protein (PTHrP) by cancer cells. In this case, PTH levels are low, but calcium levels are high and phosphate levels are low.
Primary hyperparathyroidism is characterized by high PTH levels, leading to high calcium and low phosphate levels. Primary hypoparathyroidism, on the other hand, is caused by gland failure and results in low PTH production, leading to low calcium and high phosphate levels. Secondary hypoparathyroidism occurs when PTH production is suppressed by hypercalcemia, but this is not the correct answer in a patient with low calcium levels.
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This question is part of the following fields:
- Endocrinology
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Question 65
Incorrect
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Which substance, when found in high levels in the bloodstream, hinders the production and release of parathyroid hormone (PTH)?
Your Answer:
Correct Answer: Calcium
Explanation:Regulation of PTH secretion
Parathyroid hormone (PTH) secretion is regulated by various factors. One of these factors is the concentration of calcium in the plasma. When the calcium concentration is high, PTH synthesis and secretion are suppressed. On the other hand, an increase in serum phosphate stimulates PTH secretion. Another factor that affects PTH secretion is the extracellular free calcium level. When the level of extracellular free calcium rises, it stimulates a parathyroid membrane-bound calcium receptor, which inhibits PTH secretion. Therefore, the regulation of PTH secretion is a complex process that involves multiple factors, including calcium and phosphate levels in the blood. Proper regulation of PTH secretion is essential for maintaining calcium and phosphate homeostasis in the body.
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This question is part of the following fields:
- Endocrinology
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Question 66
Incorrect
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A 58-year-old woman visited her doctor after fracturing her humerus in a minor accident. She reported feeling fatigued, weak, and depressed. The doctor conducted the following tests:
Total Ca2+ 3.22 mmol/l (2.12–2.65 mmol/l)
Albumin 40 g/l (35–50 g/l)
PO43− 0.45 mmol/l (0.8–1.5 mmol/l)
Alkaline phosphatase 165 iu/l (30–150 iu/l)
Based on these results, what is the likely diagnosis?Your Answer:
Correct Answer: Primary hyperparathyroidism
Explanation:Understanding Primary Hyperparathyroidism: Causes, Symptoms, and Diagnosis
Primary hyperparathyroidism is a medical condition that is usually caused by a parathyroid adenoma or, in rare cases, by multiple endocrine neoplasia (MEN) syndromes. This condition is characterized by an increase in parathyroid hormone (PTH) levels, which leads to increased calcium reabsorption and decreased phosphate reabsorption in the kidneys, as well as increased calcium absorption from the bones. As a result, patients with primary hyperparathyroidism typically exhibit hypercalcemia and hypophosphatemia, with normal or low albumin levels. Additionally, alkaline phosphatase levels are usually elevated due to increased bone turnover.
The most common symptoms of primary hyperparathyroidism are related to high calcium levels, including weakness, fatigue, and depression. Diagnosis is typically made through blood tests that measure PTH, calcium, phosphate, and alkaline phosphatase levels, as well as imaging studies such as ultrasound or sestamibi scans.
Other conditions that can cause hypercalcemia include excess vitamin D, bone metastases, secondary hyperparathyroidism, and myeloma. However, each of these conditions has distinct diagnostic features that differentiate them from primary hyperparathyroidism. For example, excess vitamin D causes hypercalcemia and hyperphosphatemia, with normal alkaline phosphatase levels, while bone metastases typically present with elevated alkaline phosphatase levels and normal or elevated phosphate levels.
Overall, understanding the causes, symptoms, and diagnostic features of primary hyperparathyroidism is essential for accurate diagnosis and effective treatment of this condition.
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This question is part of the following fields:
- Endocrinology
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Question 67
Incorrect
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A 45-year-old man presents to his general practitioner (GP) for a check-up following prescription of an angiotensin-converting enzyme (ACE) inhibitor for hypertension. He reports no side-effects of the medication. On measurement of his blood pressure, it is recorded as 176/140 mmHg. The GP repeats the measurement and records similar values. The physician considers secondary causes of hypertension and enquires about symptoms associated with some of the causes. The patient reports headache, sweating and occasional palpitations. On examination, he has a pulse rate of 110 bpm and dilation of both pupils. The GP suspects the patient may be suffering from the rare condition known as phaeochromocytoma.
What percentage of cases of phaeochromocytoma are due to a malignant cause?Your Answer:
Correct Answer: 10%
Explanation:Understanding Phaeochromocytoma: Malignancy and Survival Rates
Phaeochromocytoma is a rare condition characterized by catecholamine-secreting tumors that can cause life-threatening secondary hypertension. While the majority of these tumors are benign, approximately 10% are malignant. Malignancy is defined by the presence of metastases and is more common in extra-adrenal tumors.
The classical presentation of phaeochromocytoma, regardless of malignancy, includes severe hypertension, headaches, palpitations, and diaphoresis. However, complete surgical resection of the tumor can resolve hypertension in most cases.
For malignant phaeochromocytoma, the 5-year survival rate is approximately 50%, while the survival rate for non-malignant disease is around 95%. It’s important to understand the potential for malignancy and the associated survival rates when diagnosing and treating phaeochromocytoma.
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This question is part of the following fields:
- Endocrinology
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Question 68
Incorrect
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Under what circumstances would the bone age match the chronological age?
Your Answer:
Correct Answer: Familial short stature
Explanation:Factors Affecting Bone Age
Bone age is affected by various factors such as hypothyroidism, constitutional delay of growth and puberty, growth hormone deficiency, precocious puberty, and familial short stature. In hypothyroidism, bone age is delayed due to the underproduction of thyroid hormones. On the other hand, constitutional delay of growth and puberty causes delayed physiological maturation, including secondary sexual characteristics and bone age. Growth hormone deficiency also results in delayed skeletal maturation. In contrast, precocious puberty causes advanced bone age. Lastly, in familial short stature, bone age is equal to chronological age, but linear growth is poor, resulting in a short stature. these factors is crucial in diagnosing and managing growth and development issues in children. Proper evaluation and treatment can help ensure optimal growth and development.
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This question is part of the following fields:
- Endocrinology
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Question 69
Incorrect
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A 26-year-old waitress presents with a 2-day history of increasing confusion. She has no significant medical history, takes only oral contraceptives, and denies any substance use. Blood and urine tests suggest a possible diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following statements regarding SIADH secretion is accurate?
Your Answer:
Correct Answer: It may occur in subarachnoid haemorrhage
Explanation:Understanding SIADH: Causes and Treatment Options
SIADH, or syndrome of inappropriate antidiuretic hormone secretion, is a condition characterized by excessive production of ADH, leading to hyponatraemia. While it can occur in various medical conditions, subarachnoid haemorrhage is a known cause of SIADH. In such cases, monitoring sodium levels is crucial. The treatment of choice for SIADH is fluid restriction, but in severe cases, hypertonic saline may be used. Demeclocycline, a tetracycline, is sometimes used to treat hyponatraemia in SIADH. It’s important to note that small cell lung cancer, not adenocarcinoma of the lung, is a well-known cause of SIADH through ectopic ADH secretion. Understanding the causes and treatment options for SIADH is essential for managing this condition effectively.
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This question is part of the following fields:
- Endocrinology
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Question 70
Incorrect
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A patient with lipoprotein lipase deficiency visits his General Practitioner (GP) for his regular blood test.
Which of the following results would you expect?Your Answer:
Correct Answer: Elevated levels of both chylomicrons and VLDLs
Explanation:Understanding Lipoprotein Lipase and its Effects on Lipid Levels
Lipoprotein lipase plays a crucial role in the metabolism of lipids in the body. Its deficiency can result in various lipid abnormalities, which can be classified according to the Fredrickson classification of hyperlipoproteinaemias. Familial hyperchylomicronaemia, a type I primary hyperlipidaemia, is characterized by elevated levels of both chylomicrons and VLDLs due to lipoprotein lipase deficiency. On the other hand, lipoprotein lipase is not directly involved in LDL levels, which are influenced by LDL-receptor and lipoprotein lipase C. Similarly, low VLDL levels are not expected in the absence of lipoprotein lipase, as it is important in hydrolysing both chylomicrons and VLDLs. Overall, understanding the role of lipoprotein lipase can help in identifying and managing lipid abnormalities.
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This question is part of the following fields:
- Endocrinology
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Question 71
Incorrect
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A 42-year-old woman complains of fatigue after experiencing flu-like symptoms two weeks ago. Upon examination, she has a smooth, small goiter and a pulse rate of 68 bpm. Her lab results show a Free T4 level of 9.3 pmol/L (normal range: 9.8-23.1) and a TSH level of 49.3 mU/L (normal range: 0.35-5.50). What additional test would you perform to confirm the diagnosis?
Your Answer:
Correct Answer: Thyroid peroxidase (TPO) antibodies
Explanation:Diagnosis and Management of Primary Hypothyroidism
The patient’s test results indicate a case of primary hypothyroidism, characterized by low levels of thyroxine (T4) and elevated thyroid-stimulating hormone (TSH). The most likely cause of this condition is Hashimoto’s thyroiditis, which is often accompanied by the presence of thyroid peroxidase antibodies. While the patient has a goitre, it appears to be smooth and non-threatening, so a thyroid ultrasound is not necessary. Additionally, a radio-iodine uptake scan is unlikely to show significant uptake and is therefore not recommended. Positive TSH receptor antibodies are typically associated with Graves’ disease, which is not the likely diagnosis in this case. For further information on Hashimoto’s thyroiditis, patients can refer to Patient.info.
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This question is part of the following fields:
- Endocrinology
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Question 72
Incorrect
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A 47-year-old female is worried about the possibility of developing obesity and its connection to the metabolic syndrome and diabetes. She is seeking information on the specific criteria for diagnosing the metabolic syndrome.
Which of the following is a specific criterion used in diagnosing the metabolic syndrome?Your Answer:
Correct Answer: A waist circumference of more than 102 cm (40 inches)
Explanation:Metabolic syndrome is diagnosed when a person has three or more of the following factors: increased waist circumference, raised triglycerides, reduced HDL-cholesterol, raised blood pressure, and raised fasting plasma glucose. Central obesity is more strongly correlated with metabolic risk factors than BMI, and measuring waist circumference is recommended. Metabolic syndrome is associated with increased risk of developing diabetes and ischaemic heart disease.
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This question is part of the following fields:
- Endocrinology
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Question 73
Incorrect
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What are the symptoms of Addison's disease?
Your Answer:
Correct Answer: Hypoglycaemia
Explanation:Addison’s Disease
Addison’s disease is a condition that occurs when the adrenal cortex is destroyed, leading to a deficiency in glucocorticoid and mineralocorticoid. These hormones are essential for various bodily functions, including glucose production from amino acids. The symptoms of Addison’s disease include lethargy, fatigue, muscle weakness, dizziness, fainting, non-specific abdominal pain, and gastrointestinal disturbances such as diarrhea and vomiting. Signs of the condition include postural hypotension and hyperpigmentation.
Biochemically, Addison’s disease is characterized by hyponatremia, hyperkalemia, and hypoglycemia. In the United Kingdom, the most common cause of primary adrenal insufficiency is autoimmune destruction of the adrenal cortex, which may be associated with other autoimmune diseases such as type 1 diabetes and autoimmune thyroid disease. Worldwide, tuberculosis is the leading cause of primary adrenal insufficiency. Other rare causes of the condition include congenital adrenal hyperplasia, HIV infection, infiltrating metastases, and haemochromatosis involving the adrenal glands.
In summary, Addison’s disease is a condition that results from the destruction of the adrenal cortex, leading to a deficiency in essential hormones. The symptoms and signs of the condition can be varied, and the biochemical features include hyponatremia, hyperkalemia, and hypoglycemia. While autoimmune destruction of the adrenal cortex is the most common cause of primary adrenal insufficiency in the United Kingdom, tuberculosis is the leading cause worldwide. Other rare causes of the condition include congenital adrenal hyperplasia, HIV infection, infiltrating metastases, and haemochromatosis involving the adrenal glands.
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This question is part of the following fields:
- Endocrinology
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Question 74
Incorrect
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A 33-year-old woman with Addison's disease is currently taking hydrocortisone 10 mg in the morning and 10 mg in the evening, but she has been struggling with poor compliance. She believes that the hydrocortisone is causing stomach upset and is interested in switching to enteric coated prednisolone. What would be the appropriate daily dose of prednisolone for her?
Your Answer:
Correct Answer: 5 mg daily
Explanation:Glucocorticoid Therapy: Hydrocortisone vs. Prednisolone
Glucocorticoid therapy is a common treatment for various inflammatory conditions. Hydrocortisone and prednisolone are two commonly used glucocorticoids, but they differ in their potency and mineralocorticoid activity. Hydrocortisone has a relatively high mineralocorticoid activity, which can cause fluid retention and make it unsuitable for long-term disease suppression. However, it can be used for adrenal replacement therapy and emergency management of some conditions. Its moderate anti-inflammatory potency also makes it useful as a topical corticosteroid for managing inflammatory skin conditions with fewer side effects.
On the other hand, prednisolone and prednisone have predominantly glucocorticoid activity, making them the preferred choice for long-term disease suppression. Prednisolone is the most commonly used corticosteroid taken orally for this purpose. It is important to note that the approximate equivalent glucocorticoid action of prednisolone to hydrocortisone is 4:1. Therefore, the equivalent dose for 20 mg of hydrocortisone is roughly 5 mg per day of prednisolone.
In summary, the choice of glucocorticoid therapy depends on the specific condition being treated and the desired duration of treatment. Hydrocortisone is useful for short-term and emergency management, while prednisolone is preferred for long-term disease suppression. It is important to consult with a healthcare provider to determine the appropriate glucocorticoid therapy and dosage.
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This question is part of the following fields:
- Endocrinology
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Question 75
Incorrect
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A 38-year-old female patient visits her doctor's office for a follow-up appointment. She was recently diagnosed with hypothyroidism and is currently taking a daily dose of 100 micrograms of thyroxine. The doctor has access to the patient's thyroid function and other test results from the previous week.
Which test would be most effective in monitoring the patient's progress and treatment?Your Answer:
Correct Answer: Thyroid stimulating hormone (TSH) levels
Explanation:Thyroxine and TSH Levels in Hypothyroidism
Thyroxine is a medication that can help reduce the high levels of thyroid-stimulating hormone (TSH) that are often seen in individuals with hypothyroidism. When TSH levels are high, it indicates that the thyroid gland is not producing enough thyroid hormones, which can lead to a range of symptoms such as fatigue, weight gain, and depression. By taking thyroxine, individuals with hypothyroidism can help regulate their TSH levels and improve their overall health.
To monitor the effectiveness of thyroxine treatment, doctors often use TSH as a key monitoring test. The goal is to get TSH levels into the normal range, which indicates that the thyroid gland is producing enough hormones. Other tests that may be used in the initial investigation and diagnosis of hypothyroidism include triiodothyronine, free thyroxine (T4), thyroid peroxidase antibody, and protein-bound iodine levels. By using a combination of these tests, doctors can get a better of a patient’s thyroid function and develop an appropriate treatment plan.
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This question is part of the following fields:
- Endocrinology
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Question 76
Incorrect
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The hormone CRH, which originates from the hypothalamus, triggers the release of which hormone?
Your Answer:
Correct Answer: Adrenocorticotrophic hormone
Explanation:Hormones and their Secretion
The hypothalamus releases corticotrophin-releasing hormone (CRH) which triggers the anterior pituitary gland to release adrenocorticotrophic hormone (ACTH). ACTH then acts on the adrenal cortex to stimulate the secretion of cortisol. Meanwhile, the anterior pituitary gland also secretes thyroid-stimulating hormone (TSH) which stimulates the thyroid gland to produce thyroid hormones. On the other hand, the adrenal medulla secretes adrenaline and noradrenaline in response to stress or danger.
In summary, the hypothalamus, anterior pituitary gland, adrenal cortex, and adrenal medulla work together to regulate the secretion of various hormones in the body. These hormones play important roles in maintaining homeostasis and responding to stressors.
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This question is part of the following fields:
- Endocrinology
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Question 77
Incorrect
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What condition is non-alcoholic steatohepatitis linked to?
Your Answer:
Correct Answer: Insulin resistance
Explanation:Non-Alcoholic Steatohepatitis (NASH)
Non-alcoholic steatohepatitis (NASH) is a liver condition that is linked to insulin resistance, hyperlipidaemia, and chronic moderately elevated liver enzymes. Unlike alcoholic liver disease, NASH is not caused by excessive alcohol consumption. Instead, it is associated with metabolic disorders such as obesity, type 2 diabetes, and high blood pressure.
Diagnosing NASH requires a liver biopsy, which is the only way to confirm the presence of lesions that are suggestive of ethanol intake in a patient who consumes less than 40 g of alcohol per week. It is important to note that NASH is not a benign condition and can lead to serious complications such as cryptogenic cirrhosis, which is a type of liver disease that can be fatal.
To prevent NASH, it is important to maintain a healthy lifestyle by eating a balanced diet, exercising regularly, and avoiding excessive alcohol consumption.
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This question is part of the following fields:
- Endocrinology
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Question 78
Incorrect
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A 76-year-old woman presents with lethargy. She has a history of Graves’ disease and thyrotoxicosis. Her thyroid-stimulating hormone (TSH) levels are found to be 7.3 μU/l (normal range: 0.17–3.2 μU/l). A full blood count is performed and reveals the following: haemoglobin (Hb) is low, mean corpuscular volume (MCV) is high, platelet count is normal, white cell count (WCC) is normal.
What is the most likely cause of her anaemia?Your Answer:
Correct Answer: Hypothyroidism
Explanation:Differential diagnosis of macrocytic anaemia in a patient with a history of Graves’ disease
This patient presents with a macrocytic anaemia, which can have various causes. Given her history of Graves’ disease and autoimmune hyperthyroidism, it is important to consider hypothyroidism as a possible cause, despite the usual association of hyperthyroidism with a suppressed TSH. Pernicious anaemia, another autoimmune disease that can lead to vitamin B12 deficiency, should also be considered. However, in this case, the high TSH makes hypothyroidism more likely. Vitamin B12 deficiency and folate deficiency can also cause macrocytic anaemia, but the patient’s history and laboratory findings suggest hypothyroidism as the primary diagnosis. Haemolysis is not a likely cause in this patient.
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This question is part of the following fields:
- Endocrinology
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Question 79
Incorrect
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A 45-year-old man visits his GP for a medication review for his hypertension. During the examination, the GP observes that the patient has prominent supraorbital ridges, large hands and feet, and acanthosis nigricans of the axillae. The GP also discovers enlargement of the thyroid gland and hepatomegaly. Besides hypertension, what other condition is frequently linked to acromegaly?
Your Answer:
Correct Answer: Diabetes mellitus
Explanation:Associations of Acromegaly with Various Medical Conditions
Acromegaly is a medical condition caused by hypersecretion of growth hormone. It is associated with various medical conditions, including insulin resistance and diabetes mellitus, which can lead to acromegaly. Left ventricular hypertrophy is also associated with acromegaly, which can cause right ventricular hypertrophy. Ulnar nerve entrapment is another association, along with carpal tunnel syndrome affecting the median nerve. Acanthosis nigricans involves hyperpigmentation of the skin, but there is no general pigmentation associated with acromegaly. Acromegaly is also associated with cardiovascular disease, which can increase the risk of atrial fibrillation, although it is not a direct cause.
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This question is part of the following fields:
- Endocrinology
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Question 80
Incorrect
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A 10-year-old boy comes to you with a midline cyst that rises upwards when he sticks out his tongue. You suspect it to be a thyroglossal cyst. Where does the thyroid gland originate from?
Your Answer:
Correct Answer: Foramen caecum
Explanation:Development of the Thyroid Gland and its Relationship to Other Structures
The thyroid gland develops from the foramen caecum on the tongue, which is a diverticulum between the first and second branchial arches. It descends to its final position in the neck, passing anteriorly to the hyoid bone. During this descent, a thyroglossal duct traces its path, which usually obliterates but can cause formation of a thyroglossal cyst if persistent. The third branchial pouch forms the inferior parathyroid glands and some cells of the thymus, while the fourth branchial pouch forms the superior parathyroid glands. It is important to note that the foramen caecum of the frontal bone shares its name with the structure on the tongue where the thyroid gland begins development, but the thyroid gland does not start development from the base of the skull. Understanding the relationship between these structures is crucial in the study of embryology and endocrinology.
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This question is part of the following fields:
- Endocrinology
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Question 81
Incorrect
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A 32-year-old woman presents with sudden onset of abdominal pain. She has a medical history of polycystic kidney disease and is currently taking alfacalcidol, ramipril, Renagel, and EPO injections. Her eGFR upon admission is 24 ml/min/1.73 m2. What analgesic would you recommend for her pain?
Your Answer:
Correct Answer: Paracetamol 1 g QDS
Explanation:Medication Considerations for Patients with Renal Dysfunction
Patients with renal dysfunction should avoid taking NSAIDs as they can worsen their condition and increase the risk of gastrointestinal bleeding, which is already a common complication of chronic renal failure. Instead, alternative pain management options should be explored. If opiates are necessary, they should be prescribed with caution as they can accumulate in the body due to reduced renal excretion, especially in patients who have not previously taken them. It is important for healthcare providers to carefully consider the potential risks and benefits of any medication before prescribing it to a patient with renal dysfunction. Proper medication management can help prevent further damage to the kidneys and improve overall patient outcomes.
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This question is part of the following fields:
- Endocrinology
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Question 82
Incorrect
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A 52-year-old male who works as a truck driver and has been diagnosed with type 2 diabetes for the past 8 years is due for his annual check-up. Despite being on maximum oral hypoglycemic therapy, his HbA1c levels are alarmingly high at 91 mmol/mol (20-42). He has not experienced any hypoglycemic episodes or developed retinopathy. You suggest switching to insulin, but he declines as it would result in him losing his HGV license and having to reapply. The DVLA is aware of his diabetes and current treatment. What is the most appropriate course of action in this scenario?
Your Answer:
Correct Answer: Continue to review patient in clinic and accept that he continues to drive
Explanation:Diabetes and Driving: the Guidelines
When it comes to diabetes and driving, there are certain guidelines that must be followed. In cases where a patient has poor glycaemic control, but no other features that would prevent them from driving, they cannot be forced to switch to insulin or have their driving privileges revoked. However, patients who hold a HGV license and are treated on insulin will initially lose their license and have to re-apply for it.
It’s important to note that regular medical check-ups are necessary for patients who wish to maintain their HGV license. These check-ups should occur every three years to ensure that the patient’s diabetes is under control and that they are fit to drive.
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This question is part of the following fields:
- Endocrinology
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Question 83
Incorrect
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A 28-year-old woman visited her GP with complaints of low mood, weight gain, and irregular menstrual cycles. The GP conducted some tests and referred her to the hospital. The results of the investigations are as follows:
- Sodium: 150 mmol/l (normal value: 135-145 mmol/l)
- Potassium: 2.5 mmol/l (normal value: 3.5-5.0 mmol/l)
- Fasting blood glucose: 7.7 mmol/l (normal value: <7 mmol/l)
- 24-hour urinary cortisol excretion: 840 nmol/24 h
- Plasma ACTH (0900 h): 132 ng/l (normal value: 0-50 ng/l)
- Dexamethasone suppression test:
- 0800 h serum cortisol after dexamethasone 0.5 mg/6 h orally (po) for two days: 880 nmol/l (<50 nmol/l).
- 0800 h serum cortisol after dexamethasone 2 mg/6 h PO for two days: 875 nmol/l (<50 nmol/l).
What is the most likely diagnosis for this 28-year-old woman?Your Answer:
Correct Answer: Paraneoplastic syndrome secondary to small cell carcinoma of the lung
Explanation:Paraneoplastic Syndrome Secondary to Small Cell Carcinoma of the Lung Causing Cushing Syndrome
Cushing syndrome is a clinical state resulting from chronic glucocorticoid excess and lack of normal feedback mechanisms of the hypothalamo-pituitary-adrenal axis. While Cushing’s disease, paraneoplastic syndrome secondary to small cell carcinoma of the lung, and adrenocortical tumor are specific conditions resulting in Cushing syndrome, this patient’s symptoms are caused by paraneoplastic syndrome secondary to small cell carcinoma of the lung.
In some cases of small cell carcinoma of the lung, ectopic adrenocorticotropic hormone (ACTH) production occurs, leading to elevated plasma ACTH and cortisol levels. The mineralocorticoid activity of cortisol results in sodium retention and potassium excretion, leading to glucose intolerance and hyperglycemia. The differentiation between Cushing’s disease and ectopic ACTH secretion is made by carrying out low- and high-dose dexamethasone suppression tests. In cases of ectopic ACTH secretion, there is usually no response to dexamethasone, as pituitary ACTH secretion is already maximally suppressed by high plasma cortisol levels.
The absence of response to dexamethasone suggests an ectopic source of ACTH production, rather than Cushing’s disease. Other differential diagnoses for Cushing syndrome include adrenal neoplasia, Conn’s syndrome, and premature menopause. However, in this case, the blood test results suggest ectopic production of ACTH, indicating paraneoplastic syndrome secondary to small cell lung carcinoma as the most likely cause.
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This question is part of the following fields:
- Endocrinology
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Question 84
Incorrect
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A 16-year-old girl has been referred due to a six-month history of amenorrhea and weight loss, without identifiable organic cause. What signs would indicate a possible diagnosis of anorexia nervosa (AN)?
Possible revised output with paragraph spacing:
A 16-year-old girl has been referred to the clinic with a six-month history of amenorrhea and weight loss. Despite medical investigations, no organic cause has been identified for her symptoms. The healthcare provider suspects that the patient may have anorexia nervosa (AN), a serious eating disorder characterized by self-imposed starvation and distorted body image. To confirm or rule out this diagnosis, the provider needs to look for specific features that are commonly associated with AN.Your Answer:
Correct Answer: Delusion of being overweight
Explanation:Features of Anorexia Nervosa
Anorexia Nervosa (AN) is a serious eating disorder that is characterized by several features. One of the most prominent features is a phobic avoidance of normal weight, which leads to relentless dieting and self-induced vomiting. Laxative use and excessive exercise are also common behaviors associated with AN. Another feature of AN is amenorrhea, which is the absence of menstrual periods.
Physical symptoms of AN include hypotension and the growth of lanugo hair, which is fine, downy hair that grows on the body as a result of malnutrition. Denial and concealment are also common behaviors associated with AN, as individuals with this disorder often try to hide their symptoms from others.
In addition to these physical and behavioral symptoms, individuals with AN may also have an over-perception of their body image, leading them to see themselves as overweight even when they are underweight. Finally, AN is often associated with enmeshed families, where family members are overly involved in each other’s lives and have difficulty setting boundaries.
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This question is part of the following fields:
- Endocrinology
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Question 85
Incorrect
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A 60-year-old man with a 10-year history of type 2 diabetes comes in for his annual check-up. He is currently taking ramipril, pioglitazone, metformin, simvastatin, and acarbose. During previous examinations, he has been found to have microalbuminuria and a decreasing eGFR. His most recent eGFR measurement was 29 ml/minute/1.73 m2. He has an average build and height.
Which medication should be discontinued?Your Answer:
Correct Answer: Metformin
Explanation:Using eGFR to Determine Dose Adjustments in Renal Impairment
Published information on the effects of renal impairment on drug elimination often uses creatinine clearance as a measure of glomerular filtration rate. However, in patients of average build and height, laboratories may report estimated glomerular filtration rate (eGFR) based on the modification of diet in renal disease (MDRD) formula. This can be used to determine appropriate dose adjustments for medications.
The British National Formulary (BNF) recommends avoiding metformin if the eGFR is less than 30 ml/minute/1.73 m2 due to the risk of lactic acidosis. This is a serious condition that can occur when metformin accumulates in the body due to impaired renal function. By using eGFR to guide dose adjustments, healthcare providers can help prevent adverse drug reactions and ensure safe and effective medication use in patients with renal impairment.
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This question is part of the following fields:
- Endocrinology
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Question 86
Incorrect
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A 45-year-old woman visits her GP for a check-up on her blood pressure, which has been difficult to manage despite lifestyle changes and taking a combination of ramipril and felodipine. On examination, there are no clinical indications to aid in diagnosis. The GP conducts a urinalysis, which comes back normal, and orders some blood tests. The results show:
Investigation Result Normal value
Sodium (Na+) 175 mmol/l 135–145 mmol/l
Potassium (K+) 3.1 mmol/l 3.5–5.0 mmol/l
Urea 4.1 mmol/l 2.5–6.5 mmol/l
Creatinine 75 μmol/l 50–120 μmol/l
eGFR >60 ml/min/1.73m2 >60 ml/min/1.73m2
Based on this presentation, what is the most probable secondary cause of hypertension?Your Answer:
Correct Answer: Primary hyperaldosteronism
Explanation:Secondary Causes of Hypertension
Hypertension, or high blood pressure, can have various underlying causes. While primary hypertension is the most common form, secondary hypertension can be caused by an underlying medical condition. Here are some of the secondary causes of hypertension:
1. Primary Hyperaldosteronism: This is the most common form of secondary hypertension, caused by a solitary adrenal adenoma or bilateral adrenal hyperplasia. It is more prevalent in patients with hypertension who are resistant to treatment.
2. Phaeochromocytoma: This rare condition can cause severe symptoms such as headaches, sweating, abdominal pain, and palpitations associated with periods of very high blood pressure.
3. Glomerulonephritis: Renal disease can be a potential secondary cause of hypertension, typically manifesting as haematuria or proteinuria on urinalysis. The creatinine level may rise, and the estimated glomerular filtration rate (eGFR) falls.
4. Diabetic Nephropathy: This condition presents with proteinuria (and likely glucose) on urinalysis. Renal disease may lead to a rise in creatinine and a fall in eGFR.
5. Cushing Syndrome: While unlikely to cause isolated hypertension, other features of Cushing syndrome such as abdominal obesity, striae, and a round face would likely be present on examination.
In conclusion, it is important to identify the underlying cause of hypertension to provide appropriate treatment and management.
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This question is part of the following fields:
- Endocrinology
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Question 87
Incorrect
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What are the cells in the pancreas that produce glucagon?
Your Answer:
Correct Answer: Alpha cells
Explanation:Endocrine Cells and Their Secretions
The pancreas is an important organ in the endocrine system, and it contains different types of cells that secrete various hormones. Alpha cells in the pancreas produce glucagon, which helps to increase blood sugar levels. Beta cells, on the other hand, secrete insulin, which helps to lower blood sugar levels. Delta cells produce somatostatin, which regulates the release of insulin and glucagon.
In addition to the pancreas, the thyroid gland also contains specialized cells called parafollicular C cells. These cells secrete calcitonin, which helps to regulate calcium levels in the body. Finally, Sertoli cells are found in the seminiferous tubules of the testes and are involved in the development of sperm. the different types of endocrine cells and their secretions is important for maintaining proper hormonal balance in the body.
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This question is part of the following fields:
- Endocrinology
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Question 88
Incorrect
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A 16-year-old male presents with delayed pubertal development and a history of impaired sense of smell. He has a height on the 90th centile and weight on the 95th centile. There is no pubertal development in his external genitalia and his testicular volumes are 3 mL bilaterally. Upon investigation, his plasma luteinising hormone and follicle stimulating hormone levels are both 1.0 U/L (1-10), while his serum testosterone level is 2.0 pmol/L (9-33). His free T4 level is 20 pmol/L (10-22) and his plasma thyroid stimulating hormone level is 3.2 mU/L (0.4-5). A CT brain scan shows no abnormalities. What is the most likely diagnosis?
Your Answer:
Correct Answer: Kallmann’s syndrome
Explanation:The patient has Kallmann’s syndrome, characterized by hypogonadotrophic hypogonadism and anosmia. Klinefelter’s and Noonan’s also cause hypogonadism, while Prader-Willi is associated with hypogonadism and hyperphagia.
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This question is part of the following fields:
- Endocrinology
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Question 89
Incorrect
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What is a factor that can lead to a delay in bone maturation?
Your Answer:
Correct Answer: Newly diagnosed growth hormone deficiency in a 6-year-old girl
Explanation:Factors affecting bone age in children
Bone age, which refers to the degree of maturation of a child’s bones, can be influenced by various factors. In a child with normal thyroid function, bone age would be expected to be normal if they are receiving adequate treatment. However, in cases of growth hormone deficiency, bone age may be delayed. On the other hand, in cases of exogenous obesity resulting from over-nutrition and lack of exercise, bone age may be advanced.
If a child has an underlying endocrine disorder such as hypothyroidism, their bone age may be delayed. Turner’s syndrome, a genetic disorder affecting females, is also associated with delayed bone age by approximately 2 years during childhood. Conversely, congenital adrenal hyperplasia and central precocious puberty can cause advanced bone age.
In summary, bone age can be affected by various factors, including thyroid function, growth hormone deficiency, obesity, endocrine disorders, and genetic conditions. these factors can help healthcare providers assess a child’s growth and development and provide appropriate treatment if necessary.
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This question is part of the following fields:
- Endocrinology
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Question 90
Incorrect
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A 26-year-old professional athlete is being evaluated at the Endocrinology Clinic for presenting symptoms of low mood, decreased energy, and difficulty in preserving muscle mass. The patient also reports dry skin and hair loss. As part of the diagnostic process, the doctor requests a glucagon stimulation test.
What is elevated after the glucagon stimulation test?Your Answer:
Correct Answer: C-peptide, cortisol and growth hormone
Explanation:Glucagon and Hormone Production: Effects on C-peptide, Cortisol, Growth Hormone, and TSH
Glucagon, a hormone produced by the pancreas, has various effects on hormone production in the body. One of these effects is the stimulation of insulin and C-peptide production. C-peptide is cleaved from proinsulin during insulin production, and its levels can be used to measure insulin secretion. Glucagon also indirectly stimulates cortisol production by causing the release of adrenocorticotropic hormone (ACTH) via the hypothalamus. Additionally, glucagon can stimulate growth hormone production, making it an alternative test for measuring growth hormone levels. However, thyroid-stimulating hormone (TSH) secretion is not affected by glucagon injection. Understanding the effects of glucagon on hormone production can aid in the diagnosis and management of various endocrine disorders.
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This question is part of the following fields:
- Endocrinology
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Question 91
Incorrect
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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:
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 adrenocorticotropic hormone (ACTH) production and secondary adrenal insufficiency. This can lead to postural hypotension and reduced cortisol levels, while aldosterone levels remain normal as they are not dependent on pituitary function.
An increased cortisol level with decreased aldosterone would be an unusual result and does not fit the clinical picture of hypocortisolism. Similarly, an increased cortisol level with increased aldosterone may occur in rare cases of adrenal adenoma but does not fit the clinical picture of Sheehan’s syndrome.
A decreased cortisol level with decreased aldosterone would be true in primary adrenal insufficiency, which is not the case in Sheehan’s syndrome. Finally, a decreased cortisol level with increased aldosterone would also be an unusual result as aldosterone levels are not affected in Sheehan’s syndrome.
Therefore, when interpreting cortisol and aldosterone levels in a patient with Sheehan’s syndrome, a decreased cortisol level with normal aldosterone is expected.
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This question is part of the following fields:
- Endocrinology
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Question 92
Incorrect
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A 55-year-old man comes to his GP complaining of tingling in both hands that began a month ago and has been progressively worsening. 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:
Correct 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 investigating pituitary tumors, which are a common cause of acromegaly. Visual field testing is also important to assess whether a pituitary tumor is compressing the optic chiasm, but it is not specific to acromegaly and is part of the physical exam.
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This question is part of the following fields:
- Endocrinology
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Question 93
Incorrect
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Which hormone is responsible for the excess in Cushing's disease?
Your Answer:
Correct Answer: Adrenocorticotrophic hormone (ACTH)
Explanation:Cushing’s Disease
Cushing’s disease is a condition characterized by excessive cortisol production due to adrenal hyperfunction caused by an overproduction of ACTH from a pituitary corticotrophin adenoma. This results in both adrenal glands producing more cortisol and cortisol precursors. It is important to differentiate between primary and secondary hypercortisolaemia, which can be done by measuring ACTH levels in the blood. If ACTH levels are not suppressed, it indicates secondary hypercortisolaemia, which is driven by either pituitary or ectopic ACTH production. the underlying cause of hypercortisolaemia is crucial in determining the appropriate treatment plan for individuals with Cushing’s disease.
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This question is part of the following fields:
- Endocrinology
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Question 94
Incorrect
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A 56-year-old male presents to the general practitioner (GP) with worries about his facial appearance, which he believes has changed significantly over the past five years. He also reports that his shoes no longer fit properly, and that his hands seem larger. The GP suspects that he may be suffering from acromegaly, and the patient is referred to the Endocrinology Department for further evaluation and treatment.
Regarding acromegaly, which of the following statements is accurate?Your Answer:
Correct Answer: There is an increased risk of colon cancer
Explanation:Understanding Acromegaly: Symptoms, Causes, and Risks
Acromegaly is a rare hormonal disorder that results from excess growth hormone (GH) in adulthood. This condition is typically caused by a pituitary tumour, which secretes GH and insulin growth factor 1 (IGF-1), leading to increased cellular growth and turnover. Unfortunately, this increased cellular activity also increases the risk of colon cancer.
While an enlarged upper jaw is often associated with acromegaly, it is actually the lower jaw that is more commonly affected, resulting in the classic underbite seen in these patients. Additionally, untreated acromegaly can lead to osteoarthritis, which is associated with excessive cartilage and connective tissue growth, but not autoimmune destruction of the joint.
It is important to recognize the symptoms of acromegaly, such as enlarged hands and feet, thickened skin, and deepening of the voice, as early diagnosis and treatment can prevent further complications.
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This question is part of the following fields:
- Endocrinology
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Question 95
Incorrect
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A 68-year-old woman presents with weight loss and heat intolerance. Her lab results show elevated free T4 and free T3 levels, and a suppressed TSH level. She is currently on medications for atrial fibrillation, ischaemic heart disease, and type 2 diabetes. Which medication is the most likely culprit for these abnormal thyroid function tests?
Your Answer:
Correct Answer: Amiodarone
Explanation:Amiodarone and its Effects on Thyroid Function
Amiodarone is a medication that can cause abnormalities in thyroid function tests, leading to both hypothyroidism and hyperthyroidism. Hypothyroidism may occur due to interference with the conversion of thyroxine (T4) to tri-iodothyronine (T3), while hyperthyroidism may result from thyroiditis or the donation of iodine (amiodarone contains a large amount of iodine). In addition to thyroid dysfunction, amiodarone can also cause pulmonary fibrosis and photosensitivity reactions. It is important for healthcare providers to monitor thyroid function in patients taking amiodarone and manage any resulting thyroid dysfunction appropriately.
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This question is part of the following fields:
- Endocrinology
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Question 96
Incorrect
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A 63-year-old, non-smoking woman without previous cardiac history, has a total cholesterol of 9.0 mmol/l. She is overweight and has sleep apnoea. On examination you notice her skin is particularly dry and there appears to be some evidence of hair loss. Her blood pressure is 140/95 mmHg and pulse rate 60 bpm.
What would be the most appropriate next step in managing this patient?Your Answer:
Correct Answer: Check her thyroid-stimulating hormone (TSH) and free thyroxine (T4) level
Explanation:Diagnostic and Treatment Options for a Patient with High Cholesterol
When a patient presents with symptoms such as dry skin, hair loss, obesity, sleep apnea, hypertension, and slow pulse, it is important to consider hypothyroidism as a possible cause. To confirm this diagnosis, checking the patient’s thyroid-stimulating hormone (TSH) and free thyroxine (T4) levels is recommended. Hypothyroidism can also cause dyslipidemia, which may be the underlying cause of the patient’s high cholesterol levels. Therefore, treating the hypothyroidism should be the initial step, and if cholesterol levels remain high, prescribing a statin may be appropriate.
It is also important to consider the possibility of familial hypercholesterolemia, especially if the patient’s cholesterol levels are very high (≥8 mmol/l). In this case, screening family members for raised cholesterol may be necessary if cholesterol levels do not decrease with l-thyroxine treatment.
While diabetes can increase the risk of thyroid disorders, checking the patient’s fasting blood glucose level may not be necessary initially. Additionally, measuring 24-hour urinary free cortisol is not recommended as the patient’s symptoms do not suggest Cushing syndrome as the diagnosis.
In summary, considering hypothyroidism as a possible cause of high cholesterol levels and checking TSH and T4 levels should be the initial step in diagnosis. Treating the underlying cause and prescribing a statin if necessary can help manage the patient’s cholesterol levels. Screening family members for familial hypercholesterolemia may also be necessary.
Diagnostic and Treatment Options for High Cholesterol in Patients with Suspected Hypothyroidism
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This question is part of the following fields:
- Endocrinology
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Question 97
Incorrect
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A 21-year-old university student complains of a 2-month history of tiredness and weight loss. On further questioning the patient reveals that they have been excessively thirsty and have also been passing urine many times during the day and night. The patient is investigated further and is diagnosed with having type 1 diabetes mellitus.
Which of the following is deficient in this condition?Your Answer:
Correct Answer: Beta-islet cells
Explanation:The Different Types of Islet Cells in the Pancreas
The pancreas contains clusters of endocrine tissue called islets of Langerhans. These islets are composed of different types of cells that secrete various hormones. The most abundant type of islet cell is the beta-islet cell, which produces insulin. Insulin is essential for regulating blood sugar levels, and its deficiency is the hallmark of type 1 diabetes.
Gamma-islet cells, also known as pancreatic polypeptide-producing cells, make up a small percentage of islet cells and are not involved in insulin production. Alpha-islet cells, on the other hand, are located at the periphery of the islets and secrete glucagon, which raises blood sugar levels. Delta-islet cells produce somatostatin, a hormone that inhibits the release of insulin and glucagon.
Lastly, epsilon-islet cells produce ghrelin, a hormone that stimulates appetite. However, these cells make up less than 1% of the islet cells and are not as well understood as the other types.
In summary, the different types of islet cells in the pancreas play crucial roles in regulating blood sugar levels and other metabolic processes. Understanding their functions and interactions is essential for developing effective treatments for diabetes and other metabolic disorders.
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This question is part of the following fields:
- Endocrinology
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Question 98
Incorrect
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A 50-year-old man comes to the clinic complaining of headaches. His blood pressure measures 168/100 mmHg. Routine tests show sodium levels of 142 mmol/l (136–145), potassium levels of 2.8 mmol/l (3.5–5.0), chloride levels of 100 mmol/l (95–105), and normal levels of urea and creatinine. His plasma renin levels are undetectable, and his aldosterone levels are elevated. What is the most probable cause of his hypertension?
Your Answer:
Correct Answer: Primary hyperaldosteronism
Explanation:Differentiating Primary Hyperaldosteronism from Other Causes of Hypertension
Primary hyperaldosteronism, also known as Conn’s syndrome, is a condition characterized by elevated aldosterone levels leading to low renin levels through negative feedback loops. This is the primary cause of hypertension in this condition. On the other hand, secondary hypertension can be caused by various conditions such as acromegaly, Cushing’s syndrome, and phaeochromocytoma. However, these conditions are not associated with low renin and elevated aldosterone levels. Renal artery stenosis, on the other hand, causes both high renin and aldosterone levels, leading to secondary hyperaldosteronism. Therefore, differentiating primary hyperaldosteronism from other causes of hypertension is crucial in determining the appropriate treatment plan.
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This question is part of the following fields:
- Endocrinology
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Question 99
Incorrect
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A 42-year-old woman presents to her general practitioner (GP) with complaints of feeling ‘run down’. She reports increasing fatigue and lethargy over the past few months. Her appetite is poor, but she is gaining weight, and she is experiencing constipation. On examination, her skin is dry and cold. She has a painless midline neck swelling, which feels irregular and rubbery. The GP orders blood tests to investigate the cause of the patient’s symptoms.
What would you anticipate to observe on the thyroid function tests?Your Answer:
Correct Answer: TSH: high; free T4: low; free T3: low
Explanation:The levels of TSH, free T4, and free T3 can provide insight into the functioning of the thyroid gland. High TSH and low free T4 and free T3 levels suggest Hashimoto’s thyroiditis, a type of autoimmune primary hypothyroidism. Low TSH and high free T4 and free T3 levels indicate primary hyperthyroidism, such as Graves’ disease. Low TSH and low free T4 and free T3 levels suggest secondary or tertiary hypothyroidism. High TSH and normal free T4 and free T3 levels suggest subclinical hypothyroidism, which may progress to primary hypothyroidism. Low TSH and normal free T4 and free T3 levels suggest subclinical hyperthyroidism, which may progress to primary hyperthyroidism.
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This question is part of the following fields:
- Endocrinology
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Question 100
Incorrect
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A 42-year-old woman visits her General Practitioner (GP) complaining of increasing lethargy and weight gain over the past year. The GP finds nil of note on examination, but decides to carry out some blood tests, the results of which are shown below:
Investigation Result Normal value
Haemoglobin 145 g/l 115–155 g/l
White cell count (WCC) 9.1 × 109/l 4–11 × 109/l
Platelets 263 × 109/l 150–400 × 109/l
Mean corpuscular volume (MCV) 102 fl 76–98 fl
Urea and electrolytes normal, liver function tests (LFTs) normal; thyroid-stimulating hormone (TSH) 10.9 miu/l, free T4 5 pmol/l.
Which of the following statements is correct?Your Answer:
Correct Answer: Menorrhagia may be a feature
Explanation:Understanding Hypothyroidism: Symptoms, Diagnosis, and Treatment
Hypothyroidism is a condition characterized by an underactive thyroid gland, resulting in low levels of thyroid hormones in the body. This can lead to a range of symptoms, including lethargy, weight gain, depression, sensitivity to cold, myalgia, dry skin, dry hair and/or hair loss, constipation, menstrual irregularities, carpal tunnel syndrome, memory problems, and myxoedema coma (a medical emergency).
Diagnosis of hypothyroidism involves measuring levels of thyroid-stimulating hormone (TSH) and thyroxine (T4) in the blood. A high TSH level and a low T4 level indicate hypothyroidism. Menorrhagia may be a feature of the condition.
Treatment involves initiating and titrating doses of levothyroxine until serum TSH normalizes and the patient’s signs and symptoms have resolved. The lowest dose of levothyroxine possible to maintain this should be used. If the patient has a goitre, nodule, or changes of the thyroid gland, the patient is suspected to have subacute thyroiditis, or if an associated endocrine disease is suspected, specialist referral is indicated.
While macrocytosis may indicate coexistent vitamin B12 deficiency, it is not always present in hypothyroidism. Anaemia is a frequent occurrence in thyroid disease, which is most commonly normocytic, but can also be macrocytic or microcytic.
Thyroid-stimulating autoantibodies commonly occur in hyperthyroidism, but not in hypothyroidism. Similarly, thyroid eye disease is a common feature in hyperthyroidism, but not in hypothyroidism.
In conclusion, understanding the symptoms, diagnosis, and treatment of hypothyroidism is crucial for managing this condition effectively.
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This question is part of the following fields:
- Endocrinology
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