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  • Question 1 - The following results were obtained on a 57-year-old male who complains of fatigue:
    Free...

    Correct

    • The following results were obtained on a 57-year-old male who complains of fatigue:
      Free T4 9.8 pmol/L (9.0-25.0)
      TSH 50.02 mU/L (0.27-4.20)
      What physical signs would you anticipate during the examination?

      Your Answer: Slow relaxation of tendon jerks

      Explanation:

      Symptoms and Signs of Hypothyroidism

      Hypothyroidism is a condition that is characterized by an underactive thyroid gland, which leads to a decrease in the production of thyroid hormones. This condition is associated with several symptoms and signs, including a relative bradycardia, slow relaxation of tendon jerks, pale complexion, thinning of the hair, and weight gain. In severe cases of hypothyroidism, hypothermia may also be present.

      A relative bradycardia refers to a slower than normal heart rate, which is a common symptom of hypothyroidism. Additionally, slow relaxation of tendon jerks is another sign of this condition. This refers to a delay in the relaxation of muscles after a reflex is elicited. Other physical signs of hypothyroidism include a pale complexion and thinning of the hair, which can be attributed to a decrease in metabolic activity.

      Weight gain is also a common symptom of hypothyroidism, as the decrease in thyroid hormone production can lead to a slower metabolism and decreased energy expenditure. In severe cases of hypothyroidism, hypothermia may also be present, which refers to a body temperature that is lower than normal.

      It is important to note that while a thyroid bruit is typical of Graves’ thyrotoxicosis, it is not a common sign of hypothyroidism. Overall, the symptoms and signs of hypothyroidism can vary in severity and may require medical intervention to manage.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 2 - A 42-year-old woman presents to a consultant endocrinologist for a discussion regarding her...

    Incorrect

    • A 42-year-old woman presents to a consultant endocrinologist for a discussion regarding her thyroid function test outcomes. The results are as follows:

      - Elevated TSH
      - Decreased FT4
      - Decreased FT3
      - Positive Anti-TPO

      What is the association of her condition with any of the following options?

      Your Answer: Congestive heart failure

      Correct Answer: MALT lymphoma

      Explanation:

      The development of Hashimoto’s thyroiditis is linked to

      Understanding Hashimoto’s Thyroiditis

      Hashimoto’s thyroiditis is a chronic autoimmune disorder that affects the thyroid gland. It is more common in women and is typically associated with hypothyroidism, although there may be a temporary period of thyrotoxicosis during the acute phase. The condition is characterized by a firm, non-tender goitre and the presence of anti-thyroid peroxidase (TPO) and anti-thyroglobulin (Tg) antibodies.

      Hashimoto’s thyroiditis is often associated with other autoimmune conditions such as coeliac disease, type 1 diabetes mellitus, and vitiligo. Additionally, there is an increased risk of developing MALT lymphoma with this condition. It is important to note that many causes of hypothyroidism may have an initial thyrotoxic phase, as shown in the Venn diagram. Understanding the features and associations of Hashimoto’s thyroiditis can aid in its diagnosis and management.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 3 - A 72-year-old woman presents to the emergency department with right hip pain following...

    Correct

    • A 72-year-old woman presents to the emergency department with right hip pain following a fall at home. She is unable to bear weight and her right leg appears externally rotated and shorter. Her medical history includes osteoarthritis in her knee, type 2 diabetes mellitus, and hypertension. She is currently being tapered off prednisolone for polymyalgia rheumatica which was diagnosed 2 years ago. Which medication in her regimen may have contributed to her increased risk?

      Your Answer: Prednisolone

      Explanation:

      Patients who take systemic corticosteroids over a long period of time are at a higher risk of developing osteoporosis and experiencing fractures. In this case, the patient’s hip fracture may have been caused by her pre-existing osteoporosis.

      Corticosteroids are commonly prescribed medications that can be taken orally or intravenously, or applied topically. They mimic the effects of natural steroids in the body and can be used to replace or supplement them. However, the use of corticosteroids is limited by their numerous side effects, which are more common with prolonged and systemic use. These side effects can affect various systems in the body, including the endocrine, musculoskeletal, gastrointestinal, ophthalmic, and psychiatric systems. Some of the most common side effects include impaired glucose regulation, weight gain, osteoporosis, and increased susceptibility to infections. Patients on long-term corticosteroids should have their doses adjusted during intercurrent illness, and the medication should not be abruptly withdrawn to avoid an Addisonian crisis. Gradual withdrawal is recommended for patients who have received high doses or prolonged treatment.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 4 - A 50-year-old man has a laparotomy and repair of incisional hernia. Which hormone...

    Correct

    • A 50-year-old man has a laparotomy and repair of incisional hernia. Which hormone is most unlikely to be released in higher amounts after the surgery?

      Your Answer: Insulin

      Explanation:

      Reduced secretion of insulin and thyroxine is common after surgery, which can make it challenging to manage diabetes in people with insulin resistance due to the additional release of glucocorticoids.

      Surgery triggers a stress response that causes hormonal and metabolic changes in the body. This response is characterized by substrate mobilization, muscle protein loss, sodium and water retention, suppression of anabolic hormone secretion, activation of the sympathetic nervous system, and immunological and haematological changes. The hypothalamic-pituitary axis and the sympathetic nervous systems are activated, and the normal feedback mechanisms of control of hormone secretion fail. The stress response is associated with increased growth hormone, cortisol, renin, adrenocorticotrophic hormone (ACTH), aldosterone, prolactin, antidiuretic hormone, and glucagon, while insulin, testosterone, oestrogen, thyroid stimulating hormone, luteinizing hormone, and follicle stimulating hormone are decreased or remain unchanged. The metabolic effects of cortisol are enhanced, including skeletal muscle protein breakdown, stimulation of lipolysis, anti-insulin effect, mineralocorticoid effects, and anti-inflammatory effects. The stress response also affects carbohydrate, protein, lipid, salt and water metabolism, and cytokine release. Modifying the response can be achieved through opioids, spinal anaesthesia, nutrition, growth hormone, anabolic steroids, and normothermia.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 5 - A 65-year-old male, who is a known type 2 diabetic, visits his GP...

    Correct

    • A 65-year-old male, who is a known type 2 diabetic, visits his GP for a diabetes check-up. He is currently taking metformin and his GP has prescribed a sulphonylurea to improve his blood sugar management. What is the mode of action of this medication?

      Your Answer: Closes potassium-ATP channels on the beta cells

      Explanation:

      Sulfonylureas bind to potassium-ATP channels on the cell membrane of pancreatic beta cells, mimicking the role of ATP from the outside. This results in the blocking of these channels, causing membrane depolarisation and the opening of voltage-gated calcium channels. As a result, insulin release is stimulated.

      While acute use of sulfonylureas increases insulin secretion and decreases insulin clearance in the liver, it can also cause hypoglycaemia, which is the main side effect. This can lead to the serious complication of neuroglycopenia, resulting in a lack of glucose supply to the brain, causing confusion and possible coma. Treatment for this should involve oral glucose, intramuscular glucagon, or intravenous glucose.

      Chronic exposure to sulfonylureas does not result in an acute increase in insulin release, but a decrease in plasma glucose concentration does remain. Additionally, chronic exposure to sulfonylureas leads to down-regulation of their receptors.

      Sulfonylureas are a type of medication used to treat type 2 diabetes mellitus. They work by increasing the amount of insulin produced by the pancreas, but only if the beta cells in the pancreas are functioning properly. Sulfonylureas bind to a specific channel on the cell membrane of pancreatic beta cells, known as the ATP-dependent K+ channel (KATP).

      While sulfonylureas can be effective in managing diabetes, they can also cause some adverse effects. The most common side effect is hypoglycemia, which is more likely to occur with long-acting preparations like chlorpropamide. Another common side effect is weight gain. However, there are also rarer side effects that can occur, such as hyponatremia (low sodium levels) due to inappropriate ADH secretion, bone marrow suppression, hepatotoxicity (liver damage), and peripheral neuropathy.

      It is important to note that sulfonylureas should not be used during pregnancy or while breastfeeding.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 6 - A 54-year-old female visits her doctor complaining of chronic thirst, polyuria, and nocturia...

    Correct

    • A 54-year-old female visits her doctor complaining of chronic thirst, polyuria, and nocturia that have persisted for 2 months. She has a medical history of polycystic kidney disease that has led to chronic kidney disease (CKD). Her most recent eGFR result was 28 mL/min/1.73m². Following a series of tests, she is diagnosed with nephrogenic diabetes insipidus. What would the water deprivation test likely reveal in this patient's case?

      Your Answer: Low urine osmolality after both fluid deprivation and desmopressin

      Explanation:

      The correct answer is low urine osmolality after both fluid deprivation and desmopressin. This is indicative of nephrogenic diabetes insipidus, a condition where the kidneys are insensitive to antidiuretic hormone (ADH), resulting in an inability to concentrate urine. This leads to low urine osmolality even during water deprivation and no response to desmopressin. High urine osmolality after both fluid deprivation and desmopressin would be seen in a healthy individual or primary polydipsia, while low urine osmolality after desmopressin but high after fluid deprivation is not commonly seen in any pathological state. Similarly, low urine osmolality after fluid deprivation but high after desmopressin is typically seen in cranial DI, which is not the best answer as the patient has no risk factors for this condition.

      The water deprivation test is a diagnostic tool used to assess patients with polydipsia, or excessive thirst. During the test, the patient is instructed to refrain from drinking water, and their bladder is emptied. Hourly measurements of urine and plasma osmolalities are taken to monitor changes in the body’s fluid balance. The results of the test can help identify the underlying cause of the patient’s polydipsia. Normal results show a high urine osmolality after the administration of DDAVP, while psychogenic polydipsia is characterized by a low urine osmolality. Cranial DI and nephrogenic DI are both associated with high plasma osmolalities and low urine osmolalities.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 7 - Which of the following hinders the production of insulin secretion? ...

    Incorrect

    • Which of the following hinders the production of insulin secretion?

      Your Answer: Lipids

      Correct Answer: Adrenaline

      Explanation:

      The release of insulin can be inhibited by alpha adrenergic drugs, beta blockers, and sympathetic nerves.

      Insulin is a hormone produced by the pancreas that plays a crucial role in regulating the metabolism of carbohydrates and fats in the body. It works by causing cells in the liver, muscles, and fat tissue to absorb glucose from the bloodstream, which is then stored as glycogen in the liver and muscles or as triglycerides in fat cells. The human insulin protein is made up of 51 amino acids and is a dimer of an A-chain and a B-chain linked together by disulfide bonds. Pro-insulin is first formed in the rough endoplasmic reticulum of pancreatic beta cells and then cleaved to form insulin and C-peptide. Insulin is stored in secretory granules and released in response to high levels of glucose in the blood. In addition to its role in glucose metabolism, insulin also inhibits lipolysis, reduces muscle protein loss, and increases cellular uptake of potassium through stimulation of the Na+/K+ ATPase pump.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 8 - A 47-year-old woman comes in for her yearly diabetic check-up. Despite being on...

    Incorrect

    • A 47-year-old woman comes in for her yearly diabetic check-up. Despite being on metformin and gliclazide for a year, her HbA1c level remains at 57 mmol/mol. She mentions difficulty losing weight, and her BMI is recorded as 36 kg/m². The doctor decides to prescribe sitagliptin. How does this medication lower blood sugar levels?

      Your Answer: Reducing reabsorption of glucose in the kidneys

      Correct Answer: Reducing the peripheral breakdown of incretin

      Explanation:

      DPP-4 inhibitors, also known as gliptins, function by decreasing the breakdown of incretins like GLP-1 in the periphery. This leads to an increase in incretin levels, which in turn lowers blood glucose levels.

      It is important to note that increasing the peripheral breakdown of incretin would have the opposite effect and worsen glycaemic control.

      Metformin, on the other hand, works by enhancing the uptake of insulin in the periphery.

      Reducing the secretion of insulin from the pancreas would not be an effective mechanism and would actually raise glucose levels in the blood.

      SGLT2 inhibitors, such as dapagliflozin, function by reducing the reabsorption of glucose in the kidneys.

      Diabetes mellitus is a condition that has seen the development of several drugs in recent years. One hormone that has been the focus of much research is glucagon-like peptide-1 (GLP-1), which is released by the small intestine in response to an oral glucose load. In type 2 diabetes mellitus (T2DM), insulin resistance and insufficient B-cell compensation occur, and the incretin effect, which is largely mediated by GLP-1, is decreased. GLP-1 mimetics, such as exenatide and liraglutide, increase insulin secretion and inhibit glucagon secretion, resulting in weight loss, unlike other medications. They are sometimes used in combination with insulin in T2DM to minimize weight gain. Dipeptidyl peptidase-4 (DPP-4) inhibitors, such as vildagliptin and sitagliptin, increase levels of incretins by decreasing their peripheral breakdown, are taken orally, and do not cause weight gain. Nausea and vomiting are the major adverse effects of GLP-1 mimetics, and the Medicines and Healthcare products Regulatory Agency has issued specific warnings on the use of exenatide, reporting that it has been linked to severe pancreatitis in some patients. NICE guidelines suggest that a DPP-4 inhibitor might be preferable to a thiazolidinedione if further weight gain would cause significant problems, a thiazolidinedione is contraindicated, or the person has had a poor response to a thiazolidinedione.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 9 - A 30-year-old woman complains of menstrual irregularity and galactorrhoea for the past year....

    Incorrect

    • 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: Tumour of the hypothalamus

      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.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 10 - A 56-year-old woman visits her primary care physician with concerns about recent weight...

    Correct

    • A 56-year-old woman visits her primary care physician with concerns about recent weight gain. She reports maintaining her usual diet and exercise routine, but has noticed her face appearing rounder and the development of purplish stretch marks on her abdomen. During the exam, her heart rate is 89 beats per minute, respiratory rate is 16 breaths per minute, and blood pressure is 157/84 mmHg. Her waist circumference measures 41 inches and her body mass index is 28 kg/m2. What is one effect of the primary hormone involved in this patient's condition?

      Your Answer: Upregulation of alpha-1-adrenoceptors on arterioles

      Explanation:

      The patient is exhibiting symptoms consistent with a state of elevated cortisol levels, known as Cushing syndrome. These symptoms include recent weight gain, a round face (moon face), abdominal striae, high blood pressure, and truncal obesity. Cushing syndrome can have various causes, including the use of glucocorticoids or an ectopic ACTH secretion.

      Elevated cortisol levels can lead to an increase in blood glucose levels, putting individuals at risk for hyperglycemia and diabetes. Cortisol can also suppress the immune system, inhibiting the production of prostaglandins, leukotrienes, and interleukin-2, and decreasing the adhesion of white blood cells. Additionally, cortisol can up-regulate alpha-1-adrenoceptors on arterioles, resulting in high blood pressure. High cortisol levels can also decrease osteoblast activity, leading to weakened bones, and reduce fibroblast activity and collagen synthesis, resulting in delayed wound healing. The abdominal striae seen in patients with high cortisol levels are typically due to decreased collagen synthesis.

      Causes of Cushing’s Syndrome

      Cushing’s syndrome is a condition that can be caused by both endogenous and exogenous factors. However, it is important to note that exogenous causes, such as the use of glucocorticoid therapy, are more common than endogenous ones. The condition can be classified into two categories: ACTH dependent and ACTH independent causes.

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

      In some cases, a condition called Pseudo-Cushing’s can mimic Cushing’s syndrome. This is often caused by alcohol excess or severe depression and can cause false positive results in dexamethasone suppression tests or 24-hour urinary free cortisol tests. To differentiate between Cushing’s syndrome and Pseudo-Cushing’s, an insulin stress test may be used.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 11 - A 33-year-old man arrives at the emergency department with symptoms of increased thirst...

    Correct

    • A 33-year-old man arrives at the emergency department with symptoms of increased thirst and frequent urination. He had suffered a head injury a few days ago and had previously been discharged after investigations. Upon examination, he appears dehydrated and is admitted to a medical ward. The urine osmolality test results show a low level of 250 mosmol/kg after water deprivation and a high level of 655 mosmol/kg after desmopressin administration. Based on this information, where is the deficient substance typically active?

      Your Answer: Collecting duct

      Explanation:

      The site of action for antidiuretic hormone (ADH) is the collecting ducts in the kidneys. A diagnosis of cranial diabetes insipidus, which can occur after head trauma, is confirmed by low urine osmolalities. In this condition, there is a deficiency of ADH, which is synthesized in the hypothalamus but acts on the collecting ducts to promote water reabsorption. Therefore, the hypothalamus is not the site of action for ADH, despite being where it is synthesized. The Loop of Henle and proximal convoluted tubule are also not the primary sites of action for ADH. ADH is released from the posterior pituitary gland, but its action occurs in the collecting ducts.

      Understanding Antidiuretic Hormone (ADH)

      Antidiuretic hormone (ADH) is a hormone that is produced in the supraoptic nuclei of the hypothalamus and released by the posterior pituitary gland. Its primary function is to conserve body water by promoting water reabsorption in the collecting ducts of the kidneys through the insertion of aquaporin-2 channels.

      ADH secretion is regulated by various factors. An increase in extracellular fluid osmolality, a decrease in volume or pressure, and the presence of angiotensin II can all increase ADH secretion. Conversely, a decrease in extracellular fluid osmolality, an increase in volume, a decrease in temperature, or the absence of ADH can decrease its secretion.

      Diabetes insipidus (DI) is a condition that occurs when there is either a deficiency of ADH (cranial DI) or an insensitivity to ADH (nephrogenic DI). Cranial DI can be treated with desmopressin, which is an analog of ADH.

      Overall, understanding the role of ADH in regulating water balance in the body is crucial for maintaining proper hydration and preventing conditions like DI.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 12 - A 4-month-old boy is being evaluated for possible hypospadias. In boys with this...

    Incorrect

    • A 4-month-old boy is being evaluated for possible hypospadias. In boys with this condition, where is the urethral opening most commonly found?

      Your Answer: On the proximal ventral surface of the penis

      Correct Answer: On the distal ventral surface of the penis

      Explanation:

      The anomaly is typically situated on the underside and frequently towards the end. Urethral openings found closer to the body are a known occurrence. Surgical removal of the foreskin may hinder the process of repairing the defect.

      Understanding Hypospadias: A Congenital Abnormality of the Penis

      Hypospadias is a congenital abnormality of the penis that affects approximately 3 out of 1,000 male infants. It is usually identified during the newborn baby check, but if missed, parents may notice an abnormal urine stream. This condition is characterized by a ventral urethral meatus, a hooded prepuce, and chordee in more severe forms. In some cases, the urethral meatus may open more proximally in the more severe variants, but 75% of the openings are distally located.

      There appears to be a significant genetic element to hypospadias, with further male children having a risk of around 5-15%. While it most commonly occurs as an isolated disorder, associated conditions include cryptorchidism (present in 10%) and inguinal hernia.

      Once hypospadias has been identified, infants should be referred to specialist services. Corrective surgery is typically performed when the child is around 12 months of age. It is essential that the child is not circumcised prior to the surgery as the foreskin may be used in the corrective procedure. In boys with very distal disease, no treatment may be needed.

      Overall, understanding hypospadias is important for parents and healthcare providers to ensure proper management and treatment for affected infants.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 13 - A 25-year-old woman presents to the endocrinology clinic with a diagnosis of Grave's...

    Correct

    • A 25-year-old woman presents to the endocrinology clinic with a diagnosis of Grave's disease. The diagnosis was made based on her elevated levels of thyroid hormones T3 and T4, as well as symptoms of heat intolerance, weight loss, and tremors. Typically, where are the receptors for thyroid hormones found?

      Your Answer: Nucleus

      Explanation:

      Thyroid hormones can enter cells through diffusion or carriers. Once inside, they bind to intracellular DNA-binding proteins called thyroid hormone receptors located in the nucleus. This binding forms a complex that attaches to the thyroid hormone responsive element on DNA. The outcome of this process is an increase in mRNA production, protein synthesis, Na/K ATPase, mitochondrial function leading to higher oxygen consumption, and adrenoceptors.

      Thyroid disorders are commonly encountered in clinical practice, with hypothyroidism and thyrotoxicosis being the most prevalent. Women are ten times more likely to develop these conditions than men. The thyroid gland is a bi-lobed structure located in the anterior neck and is part of a hypothalamus-pituitary-end organ system that regulates the production of thyroxine and triiodothyronine hormones. These hormones help regulate energy sources, protein synthesis, and the body’s sensitivity to other hormones. Hypothyroidism can be primary or secondary, while thyrotoxicosis is mostly primary. Autoimmunity is the leading cause of thyroid problems in the developed world.

      Thyroid disorders can present in various ways, with symptoms often being the opposite depending on whether the thyroid gland is under or overactive. For example, hypothyroidism may result in weight gain, while thyrotoxicosis leads to weight loss. Thyroid function tests are the primary investigation for diagnosing thyroid disorders. These tests primarily look at serum TSH and T4 levels, with T3 being measured in specific cases. TSH levels are more sensitive than T4 levels for monitoring patients with existing thyroid problems.

      Treatment for thyroid disorders depends on the cause. Patients with hypothyroidism are given levothyroxine to replace the underlying deficiency. Patients with thyrotoxicosis may be treated with propranolol to control symptoms such as tremors, carbimazole to reduce thyroid hormone production, or radioiodine treatment.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 14 - A 25-year-old woman visits the endocrinology department for weight management issues. She has...

    Incorrect

    • A 25-year-old woman visits the endocrinology department for weight management issues. She has been struggling with her weight since she was a child and currently has a BMI of 46 kg/m². Despite eating large portions at meals, she never feels full and snacks between meals. Her parents and two older siblings are all at a healthy weight. Genetic testing reveals a de novo mutation in the satiety signalling pathway. Which hormone's decreased synthesis may be responsible for her condition?

      Your Answer: Ghrelin

      Correct Answer: Leptin

      Explanation:

      Leptin is the hormone that lowers appetite, while ghrelin is the hormone that increases appetite. Leptin is produced by adipose tissue and plays a crucial role in regulating feelings of fullness and satiety. Mutations that affect leptin signaling can lead to severe childhood-onset obesity. On the other hand, ghrelin is known as the hunger hormone and stimulates appetite. However, decreased ghrelin synthesis does not cause obesity. Insulin is an anabolic hormone that promotes glucose uptake and lipogenesis, while obestatin’s role in satiety is still controversial.

      The Physiology of Obesity: Leptin and Ghrelin

      Leptin is a hormone produced by adipose tissue that plays a crucial role in regulating body weight. It acts on the hypothalamus, specifically on the satiety centers, to decrease appetite and induce feelings of fullness. In cases of obesity, where there is an excess of adipose tissue, leptin levels are high. Leptin also stimulates the release of melanocyte-stimulating hormone (MSH) and corticotrophin-releasing hormone (CRH), which further contribute to the regulation of appetite. On the other hand, low levels of leptin stimulate the release of neuropeptide Y (NPY), which increases appetite.

      Ghrelin, on the other hand, is a hormone that stimulates hunger. It is mainly produced by the P/D1 cells lining the fundus of the stomach and epsilon cells of the pancreas. Ghrelin levels increase before meals, signaling the body to prepare for food intake, and decrease after meals, indicating that the body has received enough nutrients.

      In summary, the balance between leptin and ghrelin plays a crucial role in regulating appetite and body weight. In cases of obesity, there is an imbalance in this system, with high levels of leptin and potentially disrupted ghrelin signaling, leading to increased appetite and weight gain.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 15 - A 50-year-old man comes to the clinic complaining of gynaecomastia. He is currently...

    Correct

    • A 50-year-old man comes to the clinic complaining of gynaecomastia. He is currently undergoing treatment for heart failure and gastro-oesophageal reflux. Which medication that he is taking is the most probable cause of his gynaecomastia?

      Your Answer: Spironolactone

      Explanation:

      Medications Associated with Gynaecomastia

      Gynaecomastia, the enlargement of male breast tissue, can be caused by various medications. Spironolactone, ciclosporin, cimetidine, and omeprazole are some of the drugs that have been associated with this condition. Ramipril has also been linked to gynaecomastia, but it is a rare occurrence.

      Aside from these medications, other drugs that can cause gynaecomastia include digoxin, LHRH analogues, cimetidine, and finasteride. It is important to note that not all individuals who take these medications will develop gynaecomastia, and the risk may vary depending on the dosage and duration of treatment.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 16 - A 58-year-old man with chronic pancreatitis of many years develops pancreatic insufficiency. What...

    Incorrect

    • A 58-year-old man with chronic pancreatitis of many years develops pancreatic insufficiency. What substance will be absorbed normally?

      Your Answer: Vitamin B12

      Correct Answer: Folic acid

      Explanation:

      The digestion of fat necessitates the presence of pancreatic lipase, while the absorption of protein and B12 is aided by proteases. Folate digestion, on the other hand, does not rely on the pancreas.

      Pancreatic Secretions and their Regulation

      Pancreatic secretions are composed of enzymes and aqueous substances, with a pH of 8 and a volume of 1000-1500ml per day. The acinar cells secrete enzymes such as trypsinogen, procarboxylase, amylase, and elastase, while the ductal and centroacinar cells secrete sodium, bicarbonate, water, potassium, and chloride. The regulation of pancreatic secretions is mainly stimulated by CCK and ACh, which are released in response to digested material in the small bowel. Secretin, released by the S cells of the duodenum, also stimulates ductal cells and increases bicarbonate secretion.

      Trypsinogen is converted to active trypsin in the duodenum via enterokinase, and trypsin then activates the other inactive enzymes. The cephalic and gastric phases have less of an impact on regulating pancreatic secretions. Understanding the composition and regulation of pancreatic secretions is important in the diagnosis and treatment of pancreatic disorders.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 17 - Sarah is a 15-year-old female who presented to the clinic with concerns about...

    Incorrect

    • Sarah is a 15-year-old female who presented to the clinic with concerns about her development. She has not grown as expected and remains shorter than most of the girls in her class. She also notes that she has not started her period yet, which is affecting her confidence.

      On examination, she is 150cm tall and has no breast development. Pubic hair is sparse and axillary hair is absent. The uterus and ovaries are not palpable. A cleft palate is noted on examination of the mouth. When cranial nerve I was examined, she was unable to detect the smell of the odours sampled.

      Blood tests show low levels of estrogen, follicular stimulating hormone (FSH) and luteinizing hormone (LH). Liver function tests were normal. Blood glucose reading was 5.6mmol/L. Iron studies were unremarkable.

      What is the likely cause for her symptoms?

      Your Answer: Klinefelter syndrome

      Correct Answer: Kallmann syndrome

      Explanation:

      The patient’s symptoms of delayed puberty and underdeveloped secondary sexual characteristics, along with a cleft palate and anosmia, suggest Kallmann syndrome. This condition is characterized by hypogonadotropic hypogonadism, as evidenced by low-normal levels of LH and FSH, as well as low testosterone levels. Kallmann syndrome is an X-linked inherited disorder caused by the failure of gonadotrophin-releasing hormone-producing neurons to migrate properly during fetal development.

      While Klinefelter syndrome can also cause delayed puberty and small testes, it is associated with hypergonadotropic hypogonadism, which is characterized by elevated levels of FSH and LH but low testosterone levels. Anosmia is not typically a symptom of Klinefelter syndrome.

      Hemochromatosis, a condition in which iron accumulates in the body, can also cause hypogonadotropic hypogonadism by affecting the hypothalamus. However, this is unlikely in this case as the patient’s iron studies were normal and anosmia is not a common symptom of hemochromatosis.

      Kallmann’s syndrome is a condition that can cause delayed puberty due to hypogonadotropic hypogonadism. It is often inherited as an X-linked recessive trait and is believed to be caused by a failure of GnRH-secreting neurons to migrate to the hypothalamus. One of the key indicators of Kallmann’s syndrome is anosmia, or a lack of smell, in boys with delayed puberty. Other features may include hypogonadism, cryptorchidism, low sex hormone levels, and normal or above-average height. Some patients may also have cleft lip/palate and visual/hearing defects.

      Management of Kallmann’s syndrome typically involves testosterone supplementation. Gonadotrophin supplementation may also be used to stimulate sperm production if fertility is desired later in life. It is important for individuals with Kallmann’s syndrome to receive appropriate medical care and monitoring to manage their symptoms and ensure optimal health outcomes.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 18 - A 54-year-old man with a history of type II diabetes mellitus presents for...

    Correct

    • A 54-year-old man with a history of type II diabetes mellitus presents for a routine check-up. He reports no symptoms of increased urination or thirst. Laboratory results reveal an HbA1c level of 67 mmol/mol and a random plasma glucose level of 15.6 mg/l. The patient is currently taking metformin, and his physician decides to add gliclazide to his medication regimen. What is the mechanism of action of gliclazide?

      Your Answer: Stimulates sulphonylurea-1 receptors

      Explanation:

      The primary mode of action of gliclazide, which belongs to the sulphonylurea class, is to activate the sulphonylurea-1 receptors present on pancreatic cells, thereby promoting insulin secretion. The remaining choices pertain to alternative medications for diabetes.

      Common Medications for Type 2 Diabetes

      Type 2 diabetes is a chronic condition that affects millions of people worldwide. Fortunately, there are several medications available to help manage the disease. Some of the most commonly prescribed drugs include sulphonylureas, metformin, alpha-glucosidase inhibitors (such as acarbose), glitazones, and insulin.

      Sulphonylureas are a type of medication that stimulates the pancreas to produce more insulin. This helps to lower blood sugar levels and improve glucose control. Metformin, on the other hand, works by reducing the amount of glucose produced by the liver and improving insulin sensitivity. Alpha-glucosidase inhibitors, like acarbose, slow down the digestion of carbohydrates in the small intestine, which helps to prevent spikes in blood sugar levels after meals.

      Glitazones, also known as thiazolidinediones, improve insulin sensitivity and reduce insulin resistance. They work by activating a specific receptor in the body that helps to regulate glucose metabolism. Finally, insulin is a hormone that is naturally produced by the pancreas and helps to regulate blood sugar levels. In some cases, people with type 2 diabetes may need to take insulin injections to help manage their condition.

      Overall, these medications can be very effective in helping people with type 2 diabetes to manage their blood sugar levels and prevent complications. However, it’s important to work closely with a healthcare provider to determine the best treatment plan for each individual.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 19 - As a medical student observing a health visitor in community care, I noticed...

    Incorrect

    • As a medical student observing a health visitor in community care, I noticed that she was measuring the height and weight of all the children. I was curious about what drives growth during the early childhood stage (from birth to 3 years old). Can you explain this to me?

      Your Answer: Growth hormone and thyroid function

      Correct Answer: Nutrition and insulin

      Explanation:

      Understanding Growth and Factors Affecting It

      Growth is a significant difference between children and adults, and it occurs in three stages: infancy, childhood, and puberty. Several factors affect fetal growth, including environmental, placental, hormonal, and genetic factors. Maternal nutrition and uterine capacity are the most crucial environmental factors that affect fetal growth.

      In infancy, nutrition and insulin are the primary drivers of growth. High fetal insulin levels result from poorly controlled diabetes in the mother, leading to hypoglycemia and macrosomia in the baby. Growth hormone is not a significant factor in infancy, as babies have low amounts of receptors. Hypopituitarism and thyroid have no effect on growth in infancy.

      In childhood, growth is driven by growth hormone and thyroxine, while in puberty, growth is driven by growth hormone and sex steroids. Genetic factors are the most important determinant of final adult height.

      It is essential to monitor growth in children regularly. Infants aged 0-1 years should have at least five weight recordings, while children aged 1-2 years should have at least three weight recordings. Children older than two years should have annual weight recordings. Children below the 2nd centile for height should be reviewed by their GP, while those below the 0.4th centile for height should be reviewed by a paediatrician.

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      • Endocrine System
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  • Question 20 - A 62-year-old male with type 2 diabetes is urgently referred by his GP...

    Incorrect

    • A 62-year-old male with type 2 diabetes is urgently referred by his GP due to poor glycaemic control for the past three days, with home blood glucose readings around 25 mmol/L. He is currently being treated with metformin and lisinopril. Yesterday, his GP checked his U+E and found that his serum sodium was 138 mmol/L (137-144), serum potassium was 5.8 mmol/L (3.5-4.9), serum urea was 20 mmol/L (2.5-7.5), and serum creatinine was 350 µmol/L (60-110). On examination, he has a temperature of 39°C, a pulse of 108 bpm, a blood pressure of 96/60 mmHg, a respiratory rate of 32/min, and oxygen saturations of 99% on air. His cardiovascular, respiratory, and abdominal examination are otherwise normal. Further investigations reveal a plasma glucose level of 17 mmol/L (3.0-6.0) and urine analysis showing blood ++ and protein ++, but ketones are negative. What is the likely diagnosis?

      Your Answer: Hyperosmolar non-ketotic state

      Correct Answer: Sepsis

      Explanation:

      The causes of septic shock are important to understand in order to provide appropriate treatment and improve patient outcomes. Septic shock can cause fever, hypotension, and renal failure, as well as tachypnea due to metabolic acidosis. However, it is crucial to rule out other conditions such as hyperosmolar hyperglycemic state or diabetic ketoacidosis, which have different symptoms and diagnostic criteria.

      While metformin can contribute to acidosis, it is unlikely to be the primary cause in this case. Diabetic patients may be prone to renal tubular acidosis, but this is not likely to be the cause of an acute presentation. Instead, a type IV renal tubular acidosis, characterized by hyporeninaemic hypoaldosteronism, may be a more likely association.

      Overall, it is crucial to carefully evaluate patients with septic shock and consider all possible causes of their symptoms. By ruling out other conditions and identifying the underlying cause of the acidosis, healthcare providers can provide targeted treatment and improve patient outcomes. Further research and education on septic shock and its causes can also help to improve diagnosis and treatment in the future.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 21 - A 25-year-old male patient presents to the endocrine clinic with delayed-onset puberty. His...

    Incorrect

    • A 25-year-old male patient presents to the endocrine clinic with delayed-onset puberty. His history revealed a cleft palate as a child which had been repaired successfully. On direct questioning, he revealed he had anosmia but was told this was due to a minor head injury aged 5. On examination, he was 1.80 metres tall, had sparse pubic hair and small volume testes (Tanner staging grade 1).

      Blood results revealed:

      FSH 2 IU/L (1-7)
      LH 2 IU/L (1-8)
      Testosterone 240 ng/dL (280-1100)

      What is the most likely cause of this patient's condition?

      Your Answer:

      Correct Answer: Kallmann syndrome

      Explanation:

      The minor head injury is unlikely to be the cause of the patient’s anosmia. However, the combination of anosmia and cleft palate, along with the blood test results indicating hypogonadotropic hypogonadism, suggests that the patient may have Kallmann’s syndrome, which is an X-linked inherited disorder. Constitutional developmental delay is less likely due to the patient’s age and abnormal blood test results.

      Empty sella syndrome is a condition where the sella turcica, the area of the brain where the pituitary gland is located, is empty and filled with cerebrospinal fluid. Although this condition can be asymptomatic, it can also present with symptoms of hypopituitarism. However, since the patient also has anosmia and cleft palate, empty sella syndrome is less likely.

      Klinefelter’s syndrome is characterized by tall stature, gynecomastia, and small penis/testes. Blood tests would reveal elevated gonadotropins and low testosterone levels. However, since the patient’s FSH and LH levels are low, Klinefelter’s syndrome can be ruled out.

      Kallmann’s syndrome is a condition that can cause delayed puberty due to hypogonadotropic hypogonadism. It is often inherited as an X-linked recessive trait and is believed to be caused by a failure of GnRH-secreting neurons to migrate to the hypothalamus. One of the key indicators of Kallmann’s syndrome is anosmia, or a lack of smell, in boys with delayed puberty. Other features may include hypogonadism, cryptorchidism, low sex hormone levels, and normal or above-average height. Some patients may also have cleft lip/palate and visual/hearing defects.

      Management of Kallmann’s syndrome typically involves testosterone supplementation. Gonadotrophin supplementation may also be used to stimulate sperm production if fertility is desired later in life. It is important for individuals with Kallmann’s syndrome to receive appropriate medical care and monitoring to manage their symptoms and ensure optimal health outcomes.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 22 - A 60-year-old woman complains of persistent diarrhoea, wheezing, and flushing. During the physical...

    Incorrect

    • A 60-year-old woman complains of persistent diarrhoea, wheezing, and flushing. During the physical examination, an irregular pulsatile hepatomegaly and a pansystolic murmur that is most pronounced during inspiration are detected. What diagnostic test could provide insight into the probable underlying condition?

      Your Answer:

      Correct Answer: Urinary 5-HIAA (5-hydroxyindole acetic acid)

      Explanation:

      Carcinoid Syndrome and its Diagnosis

      Carcinoid syndrome is characterized by the presence of vasoactive amines such as serotonin in the bloodstream, leading to various clinical features. The primary carcinoid tumor is usually found in the small intestine or appendix, but it may not cause significant symptoms as the liver detoxifies the blood of these amines. However, systemic effects occur when malignant cells spread to other organs, such as the lungs, which are not part of the portal circulation. One of the complications of carcinoid syndrome is damage to the right heart valves, which can cause tricuspid regurgitation, as evidenced by a pulsatile liver and pansystolic murmur.

      To diagnose carcinoid syndrome, the 5-HIAA test is usually performed, which measures the breakdown product of serotonin in a 24-hour urine collection. If the test is positive, imaging and histology are necessary to confirm malignancy.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 23 - A 57-year-old man comes to the diabetes clinic for a check-up. He has...

    Incorrect

    • A 57-year-old man comes to the diabetes clinic for a check-up. He has a medical history of type 2 diabetes, which is currently managed with metformin and sitagliptin, and hypertension, for which he takes ramipril. His recent blood tests show an increase in HbA1c from 51mmol/L to 59mmol/L. He has not experienced any hypoglycaemic events and reports good adherence to his medication and blood glucose monitoring. He expresses interest in trying an additional antidiabetic medication and is prescribed tolbutamide after receiving counselling on hypoglycaemic awareness.

      What is the mechanism of action of tolbutamide?

      Your Answer:

      Correct Answer: Binds to and shuts pancreatic beta cell ATP-dependent K+ channels, causing membrane depolarisation and increased insulin exocytosis

      Explanation:

      Sulfonylureas are a type of medication used to treat type 2 diabetes mellitus. They work by increasing the amount of insulin produced by the pancreas, but only if the beta cells in the pancreas are functioning properly. Sulfonylureas bind to a specific channel on the cell membrane of pancreatic beta cells, known as the ATP-dependent K+ channel (KATP).

      While sulfonylureas can be effective in managing diabetes, they can also cause some adverse effects. The most common side effect is hypoglycemia, which is more likely to occur with long-acting preparations like chlorpropamide. Another common side effect is weight gain. However, there are also rarer side effects that can occur, such as hyponatremia (low sodium levels) due to inappropriate ADH secretion, bone marrow suppression, hepatotoxicity (liver damage), and peripheral neuropathy.

      It is important to note that sulfonylureas should not be used during pregnancy or while breastfeeding.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 24 - Cortisol is mainly synthesized by which of the following? ...

    Incorrect

    • Cortisol is mainly synthesized by which of the following?

      Your Answer:

      Correct Answer: Zona fasciculata of the adrenal

      Explanation:

      The adrenal gland’s zona fasciculata produces cortisol, with a relative glucocorticoid activity of 1. Prednisolone has a relative glucocorticoid activity of 4, while dexamethasone has a relative glucocorticoid activity of 25.

      Cortisol: Functions and Regulation

      Cortisol is a hormone produced in the zona fasciculata of the adrenal cortex. It plays a crucial role in various bodily functions and is essential for life. Cortisol increases blood pressure by up-regulating alpha-1 receptors on arterioles, allowing for a normal response to angiotensin II and catecholamines. However, it inhibits bone formation by decreasing osteoblasts, type 1 collagen, and absorption of calcium from the gut, while increasing osteoclastic activity. Cortisol also increases insulin resistance and metabolism by increasing gluconeogenesis, lipolysis, and proteolysis. It inhibits inflammatory and immune responses, but maintains the function of skeletal and cardiac muscle.

      The regulation of cortisol secretion is controlled by the hypothalamic-pituitary-adrenal (HPA) axis. The pituitary gland secretes adrenocorticotropic hormone (ACTH), which stimulates the adrenal cortex to produce cortisol. The hypothalamus releases corticotrophin-releasing hormone (CRH), which stimulates the pituitary gland to release ACTH. Stress can also increase cortisol secretion.

      Excess cortisol in the body can lead to Cushing’s syndrome, which can cause a range of symptoms such as weight gain, muscle weakness, and high blood pressure. Understanding the functions and regulation of cortisol is important for maintaining overall health and preventing hormonal imbalances.

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      • Endocrine System
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  • Question 25 - A 55-year-old man presents to your clinic with numbness and paraesthesia in his...

    Incorrect

    • A 55-year-old man presents to your clinic with numbness and paraesthesia in his right thumb and index finger. His hands seem enlarged and you observe significant gaps between his teeth. Which hormone is expected to be elevated?

      Your Answer:

      Correct Answer: Growth hormone

      Explanation:

      Excessive growth hormone can cause prognathism, spade-like hands, and tall stature. Patients may experience discomfort due to ill-fitting hats or shoes, as well as joint pain, headaches, and visual issues. It is important to note that gigantism occurs when there is an excess of growth hormone secretion before growth plate fusion, while acromegaly occurs when there is an excess of secretion after growth plate fusion.

      Understanding Growth Hormone and Its Functions

      Growth hormone (GH) is a hormone produced by the somatotroph cells in the anterior pituitary gland. It plays a crucial role in postnatal growth and development, as well as in regulating protein, lipid, and carbohydrate metabolism. GH acts on a transmembrane receptor for growth factor, leading to receptor dimerization and direct or indirect effects on tissues via insulin-like growth factor 1 (IGF-1), which is primarily secreted by the liver.

      GH secretion is regulated by various factors, including growth hormone releasing hormone (GHRH), fasting, exercise, and sleep. Conversely, glucose and somatostatin can decrease GH secretion. Disorders associated with GH include acromegaly, which results from excess GH, and GH deficiency, which can lead to short stature.

      In summary, GH is a vital hormone that plays a significant role in growth and metabolism. Understanding its functions and regulation can help in the diagnosis and treatment of GH-related disorders.

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      • Endocrine System
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  • Question 26 - As a third year medical student working in a GP surgery, you come...

    Incorrect

    • As a third year medical student working in a GP surgery, you come across a worried 54-year-old male patient who is experiencing chest discomfort. He has recently begun taking a new tablet for his high blood pressure and suspects it may be the cause of his symptoms. During your examination, you notice bilateral non-tender glandular swellings around the areolae. There are no signs of lymphadenopathy in the axillary region, and testicular examination is normal. Which medication is most likely responsible for this clinical presentation?

      Your Answer:

      Correct Answer: Spironolactone

      Explanation:

      Spironolactone-Induced Gynaecomastia

      Spironolactone is a type of diuretic that helps to increase urine production by blocking aldosterone receptors in the kidneys. However, it also has anti-androgenic properties that can lead to the development of gynaecomastia, a condition where men develop breast tissue. This is because spironolactone inhibits the production of testosterone and increases the level of free oestrogen in the blood, causing the proliferation of glandular tissue in the mammary glands.

      While gynaecomastia is not commonly associated with other medications, they all have their own side effects. Aspirin, for example, can cause gastrointestinal ulceration by inhibiting COX enzymes and prostaglandin synthesis. Thiazide diuretics work by blocking the sodium chloride co-transporter in the distal convoluted tubule, which can lead to a decrease in blood volume. Loop diuretics, on the other hand, can cause severe hyponatraemia but do not affect testosterone production. Statins, which are used to lower cholesterol levels, can cause rhabdomyolysis, a serious condition where muscle tissue breaks down and releases harmful substances into the bloodstream.

      In summary, while spironolactone can be an effective diuretic, it is important to be aware of its potential side effects, including gynaecomastia. Patients should always consult with their healthcare provider before starting any new medication and report any unusual symptoms or side effects.

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      • Endocrine System
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  • Question 27 - A 32-year-old female patient visits your clinic complaining of fatigue and unexplained weight...

    Incorrect

    • A 32-year-old female patient visits your clinic complaining of fatigue and unexplained weight gain. She mentions feeling extremely sensitive to cold temperatures. You suspect hypothyroidism and decide to conduct a test on her serum levels of thyroid stimulating hormone (TSH) and free thyroxine (T4). Which of the following hormones is not secreted from the anterior pituitary gland, where TSH is released?

      Your Answer:

      Correct Answer: antidiuretic hormone

      Explanation:

      The hormone ADH (also known as vasopressin) is secreted by the posterior pituitary gland and acts in the collecting ducts of the kidneys to increase water reabsorption. Unlike ADH, all of the other hormone options presented are released from the anterior pituitary. ACTH is a component of the hypothalamic-pituitary-axis and increases the production and release of cortisol from the adrenal gland. GH (also called somatotropin) is an anabolic hormone that stimulates growth in childhood and has metabolic effects on protein, glucose, and lipids. FSH is a gonadotropin that promotes the maturation of germ cells.

      Thyroid disorders are commonly encountered in clinical practice, with hypothyroidism and thyrotoxicosis being the most prevalent. Women are ten times more likely to develop these conditions than men. The thyroid gland is a bi-lobed structure located in the anterior neck and is part of a hypothalamus-pituitary-end organ system that regulates the production of thyroxine and triiodothyronine hormones. These hormones help regulate energy sources, protein synthesis, and the body’s sensitivity to other hormones. Hypothyroidism can be primary or secondary, while thyrotoxicosis is mostly primary. Autoimmunity is the leading cause of thyroid problems in the developed world.

      Thyroid disorders can present in various ways, with symptoms often being the opposite depending on whether the thyroid gland is under or overactive. For example, hypothyroidism may result in weight gain, while thyrotoxicosis leads to weight loss. Thyroid function tests are the primary investigation for diagnosing thyroid disorders. These tests primarily look at serum TSH and T4 levels, with T3 being measured in specific cases. TSH levels are more sensitive than T4 levels for monitoring patients with existing thyroid problems.

      Treatment for thyroid disorders depends on the cause. Patients with hypothyroidism are given levothyroxine to replace the underlying deficiency. Patients with thyrotoxicosis may be treated with propranolol to control symptoms such as tremors, carbimazole to reduce thyroid hormone production, or radioiodine treatment.

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      • Endocrine System
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  • Question 28 - A 65-year-old man with a medical history of obesity, hypertension, type 2 diabetes...

    Incorrect

    • A 65-year-old man with a medical history of obesity, hypertension, type 2 diabetes mellitus, and ischaemic heart disease is hospitalized for SARS-CoV-2 infection. He is started on oxygen therapy and a 10-day course of oral dexamethasone. What is the most crucial monitoring strategy following the initiation of this medication?

      Your Answer:

      Correct Answer: Four times daily capillary blood glucose

      Explanation:

      Regular monitoring of capillary blood glucose is recommended when using corticosteroids as they can worsen diabetic control due to their anti-insulin effects. Dexamethasone, a corticosteroid with a high glucocorticoid effect, carries a high risk of hyperglycaemia in patients with or without diabetes. Monitoring blood sugars is essential for patients with diabetes who are started on glucocorticoids. Monitoring cardiac function, daily amylase levels, daily lying and standing blood pressure, and daily urea and electrolytes are not routinely recommended while on corticosteroids. However, these tests may be necessary if suggestive symptoms develop.

      Corticosteroids are commonly prescribed medications that can be taken orally or intravenously, or applied topically. They mimic the effects of natural steroids in the body and can be used to replace or supplement them. However, the use of corticosteroids is limited by their numerous side effects, which are more common with prolonged and systemic use. These side effects can affect various systems in the body, including the endocrine, musculoskeletal, gastrointestinal, ophthalmic, and psychiatric systems. Some of the most common side effects include impaired glucose regulation, weight gain, osteoporosis, and increased susceptibility to infections. Patients on long-term corticosteroids should have their doses adjusted during intercurrent illness, and the medication should not be abruptly withdrawn to avoid an Addisonian crisis. Gradual withdrawal is recommended for patients who have received high doses or prolonged treatment.

    • This question is part of the following fields:

      • Endocrine System
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  • Question 29 - A 58-year-old woman arrives at the emergency department complaining of persistent nausea and...

    Incorrect

    • A 58-year-old woman arrives at the emergency department complaining of persistent nausea and vomiting for the past 4 days. Despite taking cyclizine and metoclopramide, she has not experienced any relief. The patient is currently under palliative care for lung cancer with cerebral metastases.

      Upon consultation with the palliative care team, it is decided to administer a steroid with potent glucocorticoid activity and minimal mineralocorticoid activity.

      What medication is the patient expected to receive?

      Your Answer:

      Correct Answer: Dexamethasone

      Explanation:

      Dexamethasone is the most suitable example of a steroid that has very high glucocorticoid activity and minimal mineralocorticoid activity among the given options.

      Corticosteroids are commonly prescribed medications that can be taken orally or intravenously, or applied topically. They mimic the effects of natural steroids in the body and can be used to replace or supplement them. However, the use of corticosteroids is limited by their numerous side effects, which are more common with prolonged and systemic use. These side effects can affect various systems in the body, including the endocrine, musculoskeletal, gastrointestinal, ophthalmic, and psychiatric systems. Some of the most common side effects include impaired glucose regulation, weight gain, osteoporosis, and increased susceptibility to infections. Patients on long-term corticosteroids should have their doses adjusted during intercurrent illness, and the medication should not be abruptly withdrawn to avoid an Addisonian crisis. Gradual withdrawal is recommended for patients who have received high doses or prolonged treatment.

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      • Endocrine System
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  • Question 30 - A 20-year-old woman arrives at the emergency department complaining of abdominal pain, nausea,...

    Incorrect

    • A 20-year-old woman arrives at the emergency department complaining of abdominal pain, nausea, and vomiting. She reports having a cough and fever for the past few days. Upon examination, she has dry mucous membranes and her breath has a fruity odor. Her vital signs are as follows: blood pressure 95/55 mmHg, heart rate 120/min, respiratory rate 29/min, temperature 37.8ºC (100ºF), and oxygen saturation 98% on room air. Laboratory results show:

      - Sodium (Na+): 124 mmol/L (135 - 145)
      - Potassium (K+): 5.5 mmol/L (3.5 - 5.0)
      - Bicarbonate: 13 mmol/L (22 - 29)
      - Serum glucose: 30 mmol/L (4 - 7.8)
      - pH: 7.15 (7.35 - 7.45)
      - Serum ketones: 3.5 mmol/L (0 - 0.6)

      What is the most likely cause of the increased ketones in this patient?

      Your Answer:

      Correct Answer: Lipolysis

      Explanation:

      DKA is a condition that arises due to uncontrolled lipolysis, leading to an excess of free fatty acids that are converted to ketone bodies. This life-threatening complication of diabetes is characterized by elevated levels of blood glucose, ketones, and acidosis, with symptoms such as nausea, vomiting, abdominal pain, dehydration, and fruity breath odor. DKA is commonly observed in type 1 diabetes mellitus and can be triggered by non-compliance with treatment or an infection. Insulin deficiency and increased levels of counterregulatory hormones cause lipolysis in adipose tissue, leading to the release of free fatty acids that undergo hepatic oxidation to form ketone bodies. In DKA, increased gluconeogenesis and glycogenolysis occur due to insulin deficiency and counterregulatory hormones, leading to the synthesis of glucose from non-carbohydrate precursors and breakdown of glycogen, respectively. Glycolysis is not involved in DKA as it does not lead to the breakdown of fatty acids.

      Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus, accounting for around 6% of cases. It can also occur in rare cases of extreme stress in patients with type 2 diabetes mellitus. DKA is caused by uncontrolled lipolysis, resulting in an excess of free fatty acids that are converted to ketone bodies. The most common precipitating factors of DKA are infection, missed insulin doses, and myocardial infarction. Symptoms include abdominal pain, polyuria, polydipsia, dehydration, Kussmaul respiration, and breath that smells like acetone. Diagnostic criteria include glucose levels above 11 mmol/l or known diabetes mellitus, pH below 7.3, bicarbonate below 15 mmol/l, and ketones above 3 mmol/l or urine ketones ++ on dipstick.

      Management of DKA involves fluid replacement, insulin, and correction of electrolyte disturbance. Fluid replacement is necessary as most patients with DKA are deplete around 5-8 litres. Isotonic saline is used initially, even if the patient is severely acidotic. Insulin is administered through an intravenous infusion, and correction of electrolyte disturbance is necessary. Long-acting insulin should be continued, while short-acting insulin should be stopped. Complications may occur from DKA itself or the treatment, such as gastric stasis, thromboembolism, arrhythmias, acute respiratory distress syndrome, acute kidney injury, and cerebral edema. Children and young adults are particularly vulnerable to cerebral edema following fluid resuscitation in DKA and often need 1:1 nursing to monitor neuro-observations, headache, irritability, visual disturbance, focal neurology, etc.

    • This question is part of the following fields:

      • Endocrine System
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