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  • Question 1 - An 81-year-old man who is a resident in a nursing home reports feeling...

    Correct

    • An 81-year-old man who is a resident in a nursing home reports feeling tired and cold all the time. Blood tests are arranged which show the following:
      Investigation Result Normal value
      Thyroid-stimulating hormone (TSH) 12.8 mU/l 0.25–4.0 mU/l
      Free T4 (thyroxine) 6.8 pmol/l 12.0-22.0 pmol/l
      Free T3 (triiodothyronine) 2.6 pmol/l 3.1–6.8 pmol/l
      Which of the following is the best action to take?
      Select the SINGLE best action from the list below.

      Your Answer: Start levothyroxine 25 µg once daily

      Explanation:

      Managing Hypothyroidism in an Elderly Patient: Recommended Treatment and Monitoring

      For an elderly patient with overt hypothyroidism, immediate treatment is recommended by the National Institute for Health and Care Excellence (NICE). The recommended starting dose of levothyroxine is 25 µg once daily, with regular monitoring of response every 3-4 weeks until a stable TSH has been achieved. After that, a blood test should be performed at 4-6 months and annually thereafter. The goal of treatment is to resolve symptoms and signs of hypothyroidism, normalize TSH and T3/T4 levels, and avoid overtreatment, especially in elderly patients who are at risk of developing cardiac disease. Inappropriate treatments, such as carbimazole or radio-iodine therapy, should be avoided. It is crucial to avoid overtreatment, as it can worsen the patient’s condition and put them at risk of developing myxoedema coma, which can be life-threatening.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 2 - A 68-year-old woman presents to the emergency department with acute confusion. She arrives...

    Correct

    • A 68-year-old woman presents to the emergency department with acute confusion. She arrives unaccompanied and is unable to provide any information about her medical history. Upon examination, she appears overweight and has non-pitting edema in her eyes and legs. Additionally, she has dry skin and coarse hair. Her vital signs include a heart rate of 50 beats/min, blood pressure of 90/60 mmHg, respiratory rate of 10 breaths/min, temperature of 30°C, and oxygen saturation of 90% on air. What is the most probable diagnosis?

      Your Answer: Myxoedema coma

      Explanation:

      Understanding Myxoedema Coma

      Myxoedema coma is a serious medical condition that can lead to confusion and hypothermia. It is a medical emergency that requires immediate treatment. The treatment for myxoedema coma includes IV thyroid replacement, IV fluid, IV corticosteroids (until the possibility of coexisting adrenal insufficiency has been excluded), electrolyte imbalance correction, and sometimes rewarming.

      In simpler terms, myxoedema coma is a condition that can cause confusion and low body temperature. It is a medical emergency that requires urgent treatment. The treatment involves giving medications through an IV, correcting any imbalances in the body’s fluids and electrolytes, and sometimes warming the body.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 3 - A 55-year-old woman presents with a 4-week history of proximal muscle weakness. She...

    Incorrect

    • A 55-year-old woman presents with a 4-week history of proximal muscle weakness. She has a significant history of alcohol and smoking. Her blood tests reveal macrocytosis, abnormal liver function tests, elevated TSH (thyroid-stimulating hormone) and normal free thyroxine (fT4) levels.
      Which of the following is the most likely cause of her symptoms & blood results?

      Your Answer: Cushing’s syndrome

      Correct Answer: Alcohol excess

      Explanation:

      Differential diagnosis of a patient with alcohol excess, elevated liver function tests, macrocytosis, and compensated hypothyroidism

      Chronic excess alcohol consumption can lead to a variety of health problems, including liver disease, neurological damage, and endocrine dysfunction. In this case, the patient presents with elevated liver function tests and macrocytosis, which are consistent with alcohol excess. The thyroid function tests show compensated hypothyroidism, which can also be caused by alcohol-related liver damage. However, the proximal myopathy is not typical of hypothyroidism, which usually causes muscle weakness in a more diffuse pattern. Cushing’s syndrome, pernicious anaemia, and thyrotoxicosis are less likely diagnoses based on the absence of specific clinical features and laboratory findings. Therefore, the most likely explanation for this patient’s presentation is alcohol excess, which may require further evaluation and management to prevent further complications.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 4 - A 45-year-old woman has noticed progressive enlargement of her hands and feet over...

    Correct

    • A 45-year-old woman has noticed progressive enlargement of her hands and feet over the past two years, resulting in increasing glove and shoe size. Six months ago, a deepening of her voice was noted. Her family has observed that she snores most of the time and she reports occasional episodes of daytime sleepiness. For three months, she has had progressive blurring of vision with associated headache and dizziness. Visual acuity examination shows 20/20-2. Visual field testing shows bitemporal hemianopias.
      Which of the following is the most appropriate first line investigation to confirm a diagnosis in this woman?

      Your Answer: Insulin-like growth factor 1 (IGF-1) measurement

      Explanation:

      The measurement of insulin-like growth factor 1 (IGF-1) is now the preferred method for screening and monitoring suspected cases of acromegaly, replacing the oral glucose tolerance test (OGTT). IGF-1, also known as somatomedin C, is produced by the liver and plays a crucial role in childhood growth and has anabolic effects in adults. OGTT with growth hormone assay is no longer the first-line investigation for acromegaly diagnosis, but can be used as a second-line test to confirm the diagnosis if IGF-1 levels are elevated. The insulin tolerance test is used to assess pituitary and adrenal function, as well as insulin sensitivity, and is not useful for diagnosing acromegaly. Random growth hormone assay is also not helpful in diagnosing acromegaly due to the pulsatile nature of GH secretion. Elevated serum prolactin levels may also be present in up to 20% of GH-secreting pituitary adenomas, but this is not diagnostic.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 5 - A 21-year-old man visits his GP with complaints of increased thirst throughout the...

    Correct

    • A 21-year-old man visits his GP with complaints of increased thirst throughout the day and difficulty performing everyday tasks. He was recently treated for a UTI with ciprofloxacin. His father has a history of diabetes, but is unsure of the type. He drinks about 8 units of alcohol per week. Fasting plasma glucose is 17.1 mmol/L (3.9-5.6), ketone bodies are 0.4 mmol/L (< 0.6 mmol/L), and C-peptide level is 2.87 ng/mL (0.51-2.72). What is the most likely diagnosis based on the patient's presentation?

      Your Answer: Type 2 diabetes

      Explanation:

      Distinguishing between type 1 and type 2 diabetes can be achieved through the measurement of C-peptide levels and diabetes-specific autoantibodies.

      Diagnosis of Type 1 Diabetes Mellitus

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 6 - A 45 year-old-woman of African origin is diagnosed with type II diabetes by...

    Incorrect

    • A 45 year-old-woman of African origin is diagnosed with type II diabetes by her General Practitioner. Her haemoglobin A1c was found to be 58 mmol/mol (normal range < 48 mmol/mol) on routine bloods for her annual hypertension review. Her body mass index (BMI) is 30 kg/m2.
      Along with Metformin (an oral hypoglycaemic agent), which of the following is the most appropriate dietary recommendation for this patient?

      Your Answer: Weight loss of 10–20% (initially after diagnosis)

      Correct Answer: Low-fat dairy and oily fish

      Explanation:

      Dietary Recommendations for Type II Diabetes Management

      Managing type II diabetes requires a comprehensive approach that includes lifestyle modifications and medication. One crucial aspect of diabetes management is a healthy, balanced diet. The National Institute for Health and Care Excellence (NICE) provides guidelines on dietary recommendations for people with type II diabetes.

      Low-fat dairy and oily fish are recommended to control the intake of saturated and trans fatty acids. Oily fish contains Omega-3 fatty acids, which are cardio-protective. High-fibre foods with carbohydrates with a low glycaemic index, such as fruits, vegetables, whole grains, and pulses, are also recommended.

      Sucrose-containing foods should be limited, and care should be taken to avoid excess energy intake. NICE discourages the use of foods marketed specifically for people with type II diabetes, as they are often higher in calories.

      Weight loss is an essential aspect of diabetes management, particularly for overweight individuals. NICE recommends a weight loss target of 5-10% for overweight adults with type II diabetes. Those who achieve a weight loss of 10% or more in the first five years after diagnosis have the greatest chance of seeing their disease go into remission.

      In summary, a healthy, balanced diet that includes low-fat dairy, oily fish, high-fibre foods with low glycaemic index carbohydrates, and limited sucrose-containing foods is crucial for managing type II diabetes. Weight loss is also an essential aspect of diabetes management, particularly for overweight individuals.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 7 - A 56-year-old man undergoes a routine medical check-up for his job. He shows...

    Incorrect

    • A 56-year-old man undergoes a routine medical check-up for his job. He shows no symptoms and his clinical examination is normal. What test would confirm a diagnosis of impaired fasting glucose?

      Your Answer: Fasting glucose 7.1 mmol/L on one occasion

      Correct Answer: Fasting glucose 6.8 mmol/L on two occasions

      Explanation:

      An oral glucose tolerance test result of 8.4 mmol/L after 2 hours with a 75g glucose load suggests impaired glucose tolerance instead of impaired fasting glucose.

      Type 2 diabetes mellitus can be diagnosed through a plasma glucose or HbA1c sample. The diagnostic criteria vary depending on whether the patient is experiencing symptoms or not. If the patient is symptomatic, a fasting glucose level of 7.0 mmol/l or higher or a random glucose level of 11.1 mmol/l or higher (or after a 75g oral glucose tolerance test) indicates diabetes. If the patient is asymptomatic, the same criteria apply but must be demonstrated on two separate occasions.

      In 2011, the World Health Organization released supplementary guidance on the use of HbA1c for diagnosing diabetes. A HbA1c level of 48 mmol/mol (6.5%) or higher is diagnostic of diabetes mellitus. However, a HbA1c value of less than 48 mmol/mol (6.5%) does not exclude diabetes and may not be as sensitive as fasting samples for detecting diabetes. For patients without symptoms, the test must be repeated to confirm the diagnosis. It is important to note that increased red cell turnover can cause misleading HbA1c results.

      There are certain conditions where HbA1c cannot be used for diagnosis, such as haemoglobinopathies, haemolytic anaemia, untreated iron deficiency anaemia, suspected gestational diabetes, children, HIV, chronic kidney disease, and people taking medication that may cause hyperglycaemia (such as corticosteroids).

      Impaired fasting glucose (IFG) is defined as a fasting glucose level of 6.1 mmol/l or higher but less than 7.0 mmol/l. Impaired glucose tolerance (IGT) is defined as a fasting plasma glucose level less than 7.0 mmol/l and an OGTT 2-hour value of 7.8 mmol/l or higher but less than 11.1 mmol/l. People with IFG should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person does not have diabetes but does have IGT.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 8 - A 32-year-old woman presents to her General Practitioner with generalised fatigue and polyuria....

    Correct

    • A 32-year-old woman presents to her General Practitioner with generalised fatigue and polyuria. These symptoms started three months ago but became much more pronounced in the preceding hour.
      At the clinic, she also starts complaining of extreme thirst and mild lower back pain. She is noted to be breathing heavily, with her breath smelling of acetone.
      Which of the following is the likely diagnosis?

      Your Answer: Diabetic ketoacidosis (DKA)

      Explanation:

      The patient’s symptoms of general fatigue and polyuria suggest the possibility of type I diabetes, which can lead to diabetic ketoacidosis (DKA). DKA can occur as a complication of existing type I diabetes or as the first presentation of the disease. In rare cases, extreme stress can also cause DKA in patients with type II diabetes. DKA is caused by uncontrolled lipolysis, resulting in excess free fatty acids that are converted to ketone bodies. Common triggers include infection, missed insulin doses, and myocardial infarction.

      Anxiety attacks can cause heavy breathing and abdominal pain, but they do not explain the polyuria, polydipsia, and pear-drops-smelling breath. Symptoms of anxiety attacks include chest pain, palpitations, nausea and vomiting, sweating, insomnia, flushing, tremor, and urinary frequency.

      Acute pancreatitis should be ruled out in cases of central abdominal pain. Symptoms of acute pancreatitis include severe epigastric pain radiating to the back, vomiting, epigastric tenderness, ileus, and low-grade fever. Cullen’s sign and Grey-Turner’s sign are rare.

      Addison’s disease, the most common cause of primary hypoadrenalism in the UK, can present similarly to this case with general fatigue and abdominal pain. Other symptoms of Addison’s disease include anorexia, nausea and vomiting, weight loss, salt-craving, hyperpigmentation, vitiligo, loss of pubic hair in women, hypotension, hypoglycaemia, hyponatraemia, and hyperkalaemia.

      Hyperparathyroidism can also cause polyuria, polydipsia, and abdominal pain, but the Kussmaul respiration and pear-drops-smelling breath suggest a likely diagnosis of DKA. Symptoms of hyperparathyroidism include bone pain, osteopenia and osteoporosis, increased risk of kidney stones, constipation, nausea, vomiting and abdominal pain, and fatigue, depression, and memory impairment, all of which are symptoms of underlying hypercalcaemia.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 9 - A 65-year-old man comes in for his annual check-up for type 2 diabetes...

    Correct

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

      What would be the most appropriate next step?

      Your Answer: Add gliclazide

      Explanation:

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 10 - A 68-year-old man is admitted for an elective total knee replacement (TKR).

    His...

    Correct

    • A 68-year-old man is admitted for an elective total knee replacement (TKR).

      His past medical history includes type 2 diabetes mellitus (T2DM), which is well controlled with metformin 500mg BD and gliclazide 80 mg OD.

      The surgery is scheduled for the morning, but he is not placed on a variable rate insulin infusion (VRII).

      What adjustments should be made to his antidiabetic medication regimen on the day of surgery?

      Your Answer: Only the morning dose of gliclazide should be omitted

      Explanation:

      On the day of surgery, it is recommended to omit the morning dose of gliclazide for patients taking sulfonylureas. However, if the patient takes BD, they can have the afternoon dose. Metformin should be taken as usual on the day before and on the day of elective surgery, except for lunchtime dose if taken three times a day.

      Preparation for surgery varies depending on whether the patient is undergoing an elective or emergency procedure. For elective cases, it is important to address any medical issues beforehand through a pre-admission clinic. Blood tests, urine analysis, and other diagnostic tests may be necessary depending on the proposed procedure and patient fitness. Risk factors for deep vein thrombosis should also be assessed, and a plan for thromboprophylaxis formulated. Patients are advised to fast from non-clear liquids and food for at least 6 hours before surgery, and those with diabetes require special management to avoid potential complications. Emergency cases require stabilization and resuscitation as needed, and antibiotics may be necessary. Special preparation may also be required for certain procedures, such as vocal cord checks for thyroid surgery or bowel preparation for colorectal cases.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 11 - A 42-year-old woman visits her primary care physician complaining of sudden headaches accompanied...

    Correct

    • A 42-year-old woman visits her primary care physician complaining of sudden headaches accompanied by sweating and palpitations. During the examination, the patient appears anxious and has a pale complexion. Her blood pressure is measured at 230/190 mmHg, and a 24-hour urine collection shows elevated levels of catecholamines. What is the most probable reason for this woman's hypertension?

      Your Answer: Phaeochromocytoma

      Explanation:

      Differentiating Adrenal Gland Disorders: Phaeochromocytoma, Conn Syndrome, Cushing Syndrome, PKD, and RAS

      Adrenal gland disorders can present with similar symptoms, making it challenging to differentiate between them. However, understanding the unique features of each condition can aid in accurate diagnosis and appropriate management.

      Phaeochromocytoma is a tumour of the adrenal gland that causes paroxysmal secretion of catecholamines, resulting in hypertension, headache, sweating, and anxiety. It is associated with the 10% rule, where 10% of cases are extramedullary, malignant, familial, and bilateral.

      Conn syndrome, or primary aldosteronism, is characterised by hypertension, hypokalaemia, and metabolic alkalosis. The most common causes are aldosterone-producing adenomas and bilateral adrenal hyperplasia.

      Cushing syndrome is caused by prolonged hypercortisolism and presents with centripetal obesity, secondary hypertension, glucose intolerance, proximal myopathy, and hirsutism. Sweating, palpitations, and elevated catecholamines are not typical of hypercortisolism.

      Polycystic kidney disease (PKD) is associated with hypertension due to progressive kidney enlargement. It is a significant independent risk factor for progression to end-stage renal failure, but it does not cause elevated catecholamine levels.

      Renal artery stenosis (RAS) is a major cause of renovascular hypertension, but it is not associated with elevated catecholamines or the symptoms described. Patients with RAS may also have a history of atherosclerosis, dyslipidaemia, smoking, and hypertension resistant to multiple antihypertensive medications.

      In summary, understanding the unique features of adrenal gland disorders can aid in accurate diagnosis and appropriate management.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 12 - A 45-year-old woman with type II diabetes mellitus and a history of hypertension,...

    Correct

    • A 45-year-old woman with type II diabetes mellitus and a history of hypertension, on maximum-dose metformin, was started on gliclazide three weeks ago. Since then she has had recurrent hypoglycaemic events requiring Accident and Emergency (A&E) attendance.
      Investigation Result Normal values
      HbA1c 72 mmol/mol (8.7%) 20-42 mmol/mol (4.2-6.2%)
      Which of the following is the best action to take?
      Select the SINGLE action from the list below.

      Your Answer: Stop gliclazide and start sitagliptin

      Explanation:

      Choosing the Right Treatment for Hypoglycaemic Episodes in Type 2 Diabetes

      When metformin alone is not enough to control HbA1c in type 2 diabetes, NICE recommends adding a sulfonylurea, pioglitazone, or a DPP-4 inhibitor. However, if the patient experiences hypoglycaemic episodes, it is important to reassess the treatment plan.

      Stopping gliclazide, a sulfonylurea, is necessary as it is likely causing the hypoglycaemic episodes. Pioglitazone is contraindicated in patients with heart failure, so a DPP-4 inhibitor like sitagliptin is the appropriate next step.

      Initiating insulin is not recommended as it can be dangerous, and should only be considered after other options have failed. Reducing metformin is unlikely to prevent hypoglycaemic episodes as it does not typically cause them on its own.

      In summary, choosing the right treatment for hypoglycaemic episodes in type 2 diabetes involves careful consideration of the patient’s medical history and NICE guidelines.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 13 - A 56-year-old man with type 2 diabetes mellitus is being seen in the...

    Incorrect

    • A 56-year-old man with type 2 diabetes mellitus is being seen in the clinic. He is on a medication regimen that includes metformin, aspirin, simvastatin, and pioglitazone. What is the most probable issue that can be caused by pioglitazone?

      Your Answer: Photosensitivity

      Correct Answer: Peripheral oedema

      Explanation:

      Fluid retention may be caused by pioglitazone.

      Thiazolidinediones: A Class of Diabetes Medications

      Thiazolidinediones are a type of medication used to treat type 2 diabetes. They work by activating the PPAR-gamma receptor, which reduces insulin resistance in the body. However, one medication in this class, rosiglitazone, was withdrawn in 2010 due to concerns about its cardiovascular side effects.

      The PPAR-gamma receptor is a nuclear receptor found inside cells. It is naturally activated by free fatty acids and is involved in regulating the differentiation and function of adipocytes (fat cells).

      While thiazolidinediones can be effective in treating diabetes, they can also have adverse effects. Patients may experience weight gain, liver impairment (which requires monitoring of liver function tests), and fluid retention. Thiazolidinediones are contraindicated in patients with heart failure due to the increased risk of fluid retention, especially if the patient is also taking insulin. Recent studies have also shown an increased risk of fractures and bladder cancer in patients taking pioglitazone, another medication in this class.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 14 - A 79-year-old man with a medical history of prostate cancer, asthma, and COPD...

    Correct

    • A 79-year-old man with a medical history of prostate cancer, asthma, and COPD presents to the emergency department with complaints of abdominal pain, bone pain, and general weakness. During investigations, a shortened QT interval is noted on his ECG. What is the initial management approach for this complication in this patient?

      Your Answer: IV 0.9% N saline

      Explanation:

      Understanding the Causes of Hypercalcaemia

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 15 - A 42-year-old woman presented with complaints of constant fatigue and underwent blood tests....

    Correct

    • A 42-year-old woman presented with complaints of constant fatigue and underwent blood tests. All results were within normal limits except for her thyroid function test (TFT) which revealed:
      TSH 12.5 mU/l
      Free T4 7.5 pmol/l
      What would be the most suitable course of action?

      Your Answer: Levothyroxine

      Explanation:

      The TFTs indicate a diagnosis of hypothyroidism, which can be treated with levothyroxine. Carbimazole is not suitable for this condition as it is used to treat hyperthyroidism. To ensure proper absorption, levothyroxine should be taken 30 minutes before consuming food, caffeine, or other medications.

      Managing Hypothyroidism: Dosage, Monitoring, and Side-Effects

      Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone. The main treatment for hypothyroidism is levothyroxine, a synthetic form of thyroid hormone. When managing hypothyroidism, it is important to consider the patient’s age, cardiac history, and initial starting dose. Elderly patients and those with ischaemic heart disease should start with a lower dose of 25mcg od, while other patients can start with 50-100mcg od. After a change in dosage, thyroid function tests should be checked after 8-12 weeks to ensure the therapeutic goal of normalising the thyroid stimulating hormone (TSH) level is achieved. The target TSH range is 0.5-2.5 mU/l.

      Women with hypothyroidism who become pregnant should have their dose increased by at least 25-50 micrograms levothyroxine due to the increased demands of pregnancy. The TSH should be monitored carefully, aiming for a low-normal value. It is important to note that there is no evidence to support combination therapy with levothyroxine and liothyronine.

      While levothyroxine is generally well-tolerated, there are some potential side-effects to be aware of. Over-treatment can lead to hyperthyroidism, while long-term use can reduce bone mineral density. In patients with cardiac disease, levothyroxine can worsen angina and lead to atrial fibrillation. It is also important to be aware of drug interactions, particularly with iron and calcium carbonate, which can reduce the absorption of levothyroxine. These medications should be given at least 4 hours apart.

      In summary, managing hypothyroidism involves careful consideration of dosage, monitoring of TSH levels, and awareness of potential side-effects and drug interactions. With appropriate management, patients with hypothyroidism can achieve normal thyroid function and improve their overall health.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 16 - A 32-year-old woman with Addison's disease is seen for a follow-up appointment. She...

    Correct

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

      What advice should be given regarding her adrenal replacement therapy?

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

      Explanation:

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 17 - A 54-year-old man comes to his GP for a diabetes check-up. He has...

    Correct

    • A 54-year-old man comes to his GP for a diabetes check-up. He has a past medical history of type 2 diabetes and is currently on one diabetes medication (500mg metformin BD). He reports no adverse effects from this treatment. His most recent retinopathy screening was unremarkable. You draw blood to assess his HbA1c levels.
      What is the recommended target HbA1c for this patient?

      Your Answer: 48 mmol/mol

      Explanation:

      The recommended HbA1c goal for individuals with type 2 diabetes mellitus is 48 mmol/mol. According to NICE guidelines, this target is appropriate for patients who are managing their condition through lifestyle changes or a single antidiabetic medication. However, if a patient is prescribed a second medication or is taking a medication that increases the risk of hypoglycaemia (such as a sulphonylurea), the target may be adjusted to 53 mmol/mol. It is important to note that the HbA1c threshold for changing medications may differ from the target HbA1c level.

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 18 - A 59-year-old man with type 2 diabetes visits his GP for a check-up....

    Correct

    • A 59-year-old man with type 2 diabetes visits his GP for a check-up. He has discontinued his modified-release metformin due to experiencing nausea and diarrhoea. Lately, he has been feeling increasingly fatigued and thirsty. His blood pressure measures 150/110 mmHg and he reports no issues with his eyesight. Laboratory tests reveal an HbA1c level of 56 mmol/mol. The QRISK score is calculated and shows 23%. He is a non-smoker and non-alcoholic.

      What would be the most suitable course of action for his management?

      Your Answer: Offer dapagliflozin

      Explanation:

      Gliclazide is not the preferred initial treatment for type 2 diabetes. Due to the patient’s inability to tolerate metformin and a QRISK score of >10, there is now a higher likelihood of cardiovascular disease.

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 19 - A 27-year-old female patient complains of tremors and excessive sweating. Upon conducting thyroid...

    Correct

    • A 27-year-old female patient complains of tremors and excessive sweating. Upon conducting thyroid function tests, the results are as follows:
      TSH <0.05 mU/l
      Free T4 25 pmol/l
      What is the leading cause of this clinical presentation?

      Your Answer: Graves' disease

      Explanation:

      Thyrotoxicosis is primarily caused by Graves’ disease in the UK, while the other conditions that can lead to thyrotoxicosis are relatively rare.

      Understanding Thyrotoxicosis: Causes and Investigations

      Thyrotoxicosis is a condition characterized by an overactive thyroid gland, resulting in an excess of thyroid hormones in the body. Graves’ disease is the most common cause, accounting for 50-60% of cases. Other causes include toxic nodular goitre, subacute thyroiditis, post-partum thyroiditis, Hashimoto’s thyroiditis, amiodarone therapy, and contrast administration. The latter is rare but can occur in elderly patients with pre-existing thyroid disease. Patients with existing thyrotoxicosis should not receive iodinated contrast medium as it can result in hyperthyroidism developing over 2-12 weeks due to a large iodine load to the thyroid.

      Investigations for thyrotoxicosis include measuring TSH, which is typically low, and T4 and T3, which are elevated. Thyroid autoantibodies may also be tested. Isotope scanning may be done in some cases, but other investigations are not routinely performed. It is important to note that many causes of hypothyroidism may have an initial thyrotoxic phase, as shown in a Venn diagram. Understanding the causes and investigations of thyrotoxicosis is crucial for proper diagnosis and management of this condition.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 20 - A 65-year-old man is scheduled for elective surgery to repair an umbilical hernia....

    Correct

    • A 65-year-old man is scheduled for elective surgery to repair an umbilical hernia. He has a medical history of osteoarthritis and type two diabetes mellitus. He takes paracetamol 1 gram four times daily and metformin 500 mg once daily at breakfast. The surgery is expected to last for an hour and is scheduled for 11am. What is the appropriate management of his metformin on the day of surgery?

      Your Answer: Continue as normal

      Explanation:

      When a patient is scheduled for surgery, it can be confusing to know how to manage their medications. However, it is important for junior doctors to be knowledgeable in this area. Time-critical medications, such as those used for Parkinson’s disease, epilepsy, and diabetes, should be taken up to two hours before surgery with clear fluids. For patients taking metformin, the medication should be continued as normal if taken once or twice daily. If taken three times daily, the lunchtime dose should be skipped. This is because metformin can increase the risk of acute kidney injury if a meal is missed during surgery. If the patient’s eGFR falls below 60, metformin should be avoided for 48 hours after surgery. If the patient has poor diabetes control or a longer surgery, variable rate intravenous insulin infusion may be used. All other medications used for type two diabetes should be stopped.

      Preparation for surgery varies depending on whether the patient is undergoing an elective or emergency procedure. For elective cases, it is important to address any medical issues beforehand through a pre-admission clinic. Blood tests, urine analysis, and other diagnostic tests may be necessary depending on the proposed procedure and patient fitness. Risk factors for deep vein thrombosis should also be assessed, and a plan for thromboprophylaxis formulated. Patients are advised to fast from non-clear liquids and food for at least 6 hours before surgery, and those with diabetes require special management to avoid potential complications. Emergency cases require stabilization and resuscitation as needed, and antibiotics may be necessary. Special preparation may also be required for certain procedures, such as vocal cord checks for thyroid surgery or bowel preparation for colorectal cases.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 21 - You are performing the yearly evaluation of a 42-year-old woman with type 1...

    Correct

    • You are performing the yearly evaluation of a 42-year-old woman with type 1 diabetes mellitus. Your objective is to screen for diabetic neuropathy that may affect her feet. What is the most suitable screening test to utilize?

      Your Answer: Test sensation using a 10 g monofilament

      Explanation:

      To evaluate diabetic neuropathy in the feet, it is recommended to utilize a monofilament weighing 10 grams.

      Diabetic foot disease is a significant complication of diabetes mellitus that requires regular screening. In 2015, NICE published guidelines on diabetic foot disease. The disease is caused by two main factors: neuropathy, which results in a loss of protective sensation, and peripheral arterial disease, which increases the risk of macro and microvascular ischaemia. Symptoms of diabetic foot disease include loss of sensation, absent foot pulses, reduced ankle-brachial pressure index (ABPI), intermittent claudication, calluses, ulceration, Charcot’s arthropathy, cellulitis, osteomyelitis, and gangrene. All patients with diabetes should be screened for diabetic foot disease at least once a year. Screening for ischaemia involves palpating for both the dorsalis pedis pulse and posterial tibial artery pulse, while screening for neuropathy involves using a 10 g monofilament on various parts of the sole of the foot. NICE recommends that patients be risk-stratified into low, moderate, and high-risk categories based on factors such as deformity, previous ulceration or amputation, renal replacement therapy, neuropathy, and non-critical limb ischaemia. Patients who are moderate or high-risk should be regularly followed up by their local diabetic foot centre.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 22 - A 67-year-old woman is brought to the Emergency Department after being found near-unconscious...

    Correct

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

      Your Answer: Addisonian crisis

      Explanation:

      Differential Diagnosis: Addisonian Crisis and Other Conditions

      Addisonian Crisis: A Brief Overview

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

      Differential Diagnosis

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

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

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

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

      Conclusion

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 23 - What is the most probable adverse effect experienced by patients who are taking...

    Correct

    • What is the most probable adverse effect experienced by patients who are taking gliclazide?

      Your Answer: Weight gain

      Explanation:

      Weight gain is the most frequent side-effect observed in patients who take sulfonylureas, although they may experience all of the aforementioned side-effects.

      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 they are only effective if the pancreas is functioning properly. Sulfonylureas bind to a specific channel on the cell membrane of pancreatic beta cells, which helps to increase insulin secretion. However, there are some potential side effects associated with these drugs.

      One of the most common side effects of sulfonylureas is hypoglycaemia, which can be more likely to occur with long-acting preparations like chlorpropamide. Weight gain is another possible side effect. In rare cases, sulfonylureas can cause hyponatraemia, which is a condition where the body retains too much water and sodium levels become too low. Other rare side effects include 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:

      • Endocrinology/Metabolic Disease
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  • Question 24 - An infant is born with ambiguous genitalia, following an uneventful pregnancy and delivery....

    Correct

    • An infant is born with ambiguous genitalia, following an uneventful pregnancy and delivery. Upon further investigation, it is discovered that the child has congenital adrenal hyperplasia caused by 21-hydroxylase deficiency.
      What is a characteristic of 21-hydroxylase deficiency-related congenital adrenal hyperplasia?

      Your Answer: Adrenocortical insufficiency

      Explanation:

      Medical Conditions Associated with 21-Hydroxylase Deficiency

      21-hydroxylase deficiency is a medical condition that results in decreased cortisol synthesis and commonly reduces aldosterone synthesis. This condition can lead to adrenal insufficiency, causing salt wasting and hypoglycemia. However, it is not associated with diabetes insipidus, which is characterized by low ADH levels. Patients with 21-hydroxylase deficiency may also experience stunted growth and elevated androgens, but hypogonadism is not a feature. Treatment may involve the use of gonadotrophin-releasing hormone (GnRH).

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      • Endocrinology/Metabolic Disease
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  • Question 25 - A 28-year-old woman is referred by her General Practitioner due to irregular and...

    Correct

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

      Your Answer: Dopamine

      Explanation:

      Targeting Hormones in Prolactinoma Treatment

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 26 - A 67-year-old woman has just been prescribed gliclazide for her T2DM. What is...

    Correct

    • A 67-year-old woman has just been prescribed gliclazide for her T2DM. What is the mechanism of action of gliclazide?

      Your Answer: Stimulates insulin secretion from the b-cells of the islets of Langerhans

      Explanation:

      Different medications used to treat diabetes have varying mechanisms of action. Sulfonylureas like gliclazide stimulate insulin secretion from the pancreas, making them effective for type II diabetes but not for type I diabetes. However, they can cause hypoglycemia and should be used with caution when combined with other hypoglycemic medications. Biguanides like metformin increase glucose uptake and utilization while decreasing gluconeogenesis, making them a first-line treatment for type II diabetes. Glucosidase inhibitors like acarbose delay the digestion of starch and sucrose, but are not commonly used due to gastrointestinal side effects. DPP-4 inhibitors like sitagliptin increase insulin production and decrease hepatic glucose overproduction by inhibiting the action of DPP-4. Thiazolidinediones like pioglitazone increase insulin sensitivity in the liver, fat, and skeletal muscle, but their use is limited due to associated risks of heart failure, bladder cancer, and fractures.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 27 - A 55-year-old man visits his General Practitioner (GP) complaining of tingling in both...

    Correct

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

      Your Answer: Serum IGF1 levels

      Explanation:

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 28 - A 52-year-old man has been diagnosed with type two diabetes and prescribed medication...

    Correct

    • A 52-year-old man has been diagnosed with type two diabetes and prescribed medication by his GP. The medication functions by binding to its receptor and closing the potassium ion channels, which reduces potassium efflux from the cell and causes depolarization. This, in turn, leads to calcium ion influx and insulin release. What medication has the patient been prescribed?

      Your Answer: Gliclazide

      Explanation:

      Sulfonylureas attach to a KATP channel on the cell membrane of pancreatic beta cells that is dependent on ATP.

      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 they are only effective if the pancreas is functioning properly. Sulfonylureas bind to a specific channel on the cell membrane of pancreatic beta cells, which helps to increase insulin secretion. However, there are some potential side effects associated with these drugs.

      One of the most common side effects of sulfonylureas is hypoglycaemia, which can be more likely to occur with long-acting preparations like chlorpropamide. Weight gain is another possible side effect. In rare cases, sulfonylureas can cause hyponatraemia, which is a condition where the body retains too much water and sodium levels become too low. Other rare side effects include 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:

      • Endocrinology/Metabolic Disease
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  • Question 29 - A 55-year-old man is hospitalized for a chest infection and undergoes a standard...

    Incorrect

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

      Your Answer: Sickle-cell anaemia

      Correct Answer: Splenectomy

      Explanation:

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

      Understanding Glycosylated Haemoglobin (HbA1c) in Diabetes Mellitus

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 30 - A 63-year-old man presents to his General Practitioner with a 1-month history of...

    Correct

    • A 63-year-old man presents to his General Practitioner with a 1-month history of lethargy, extreme thirst and increased urinary frequency. Two days ago, he also started to experience a dull pain in his left flank, which seems to occasionally radiate down into his groin. He has also not opened his bowels for four days and he is usually fairly regular.
      On examination, he is found to have a blood pressure of 115/85 mmHg. The rest of the examination is unremarkable.
      Which of the following is the most likely diagnosis?

      Your Answer: Primary hyperparathyroidism

      Explanation:

      Differential Diagnosis: Polyuria, Polydipsia, Constipation, and Loin-to-Groin Pain

      Possible Causes and Clinical Features

      Primary Hyperparathyroidism: This condition can cause hypercalcemia, leading to symptoms such as bone pain, osteopenia, kidney stones, constipation, nausea, vomiting, abdominal pain, fatigue, depression, and memory impairment. In severe cases, cardiac and metabolic disturbances, delirium, or coma may occur. Diagnosis is made by measuring serum-adjusted calcium and parathyroid hormone (PTH) levels at the same time.

      Acute Pancreatitis: This condition can cause severe epigastric pain radiating to the back, vomiting, epigastric tenderness, ileus, and low-grade fever. Aetiological factors include alcohol and gallstones.

      Addison’s Disease: This condition can cause generalised fatigue, abdominal pain, anorexia, nausea, vomiting, weight loss, ‘salt craving’, hyperpigmentation, vitiligo, loss of pubic hair in women, hypotension, hypoglycaemia, hyponatraemia, and hyperkalaemia.

      Anxiety Attack: This condition can cause chest pain, palpitations, nausea, vomiting, sweating, insomnia, flushing, tremor, and urinary frequency. It typically occurs in an individual who is excessively worried about a number of different events, causing increased tension.

      Diabetic Ketoacidosis (DKA): This condition can cause polyuria, polydipsia, abdominal pain, Kussmaul respiration, and pear-drops-smelling breath.

      Differential Diagnosis of Polyuria, Polydipsia, Constipation, and Loin-to-Groin Pain

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 31 - A diabetic woman in her 50s presents with painful diabetic neuropathy in her...

    Correct

    • A diabetic woman in her 50s presents with painful diabetic neuropathy in her feet. She has no other significant medical history. What is the recommended initial treatment to alleviate her pain?

      Your Answer: Duloxetine

      Explanation:

      Diabetes can cause peripheral neuropathy, which typically results in sensory loss rather than motor loss. This often affects the lower legs first due to the length of the sensory neurons supplying this area, resulting in a glove and stocking distribution. Painful diabetic neuropathy is a common issue that can be managed with drugs such as amitriptyline, duloxetine, gabapentin, or pregabalin. If these drugs do not work, tramadol may be used as a rescue therapy, and topical capsaicin may be used for localized neuropathic pain. Pain management clinics may also be helpful for patients with resistant problems.

      Gastrointestinal autonomic neuropathy can cause gastroparesis, which can lead to erratic blood glucose control, bloating, and vomiting. This can be managed with prokinetic agents such as metoclopramide, domperidone, or erythromycin. Chronic diarrhea, which often occurs at night, is another potential complication of diabetic neuropathy. Gastroesophageal reflux disease can also occur due to decreased lower esophageal sphincter pressure.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 32 - A 42-year-old woman has a history of excessive sweating, palpitations and weight loss...

    Correct

    • A 42-year-old woman has a history of excessive sweating, palpitations and weight loss for the past six months. She now has a headache.
      On examination, her blood pressure is 230/130 mmHg, with a postural drop to 180/110 mmHg. Her pulse is bounding and 115 beats per minute and she has a tremor and looks pale. The rest of the examination is normal.
      Excess production of which of the following hormones is most likely to be the cause of this woman’s signs and symptoms?

      Your Answer: Catecholamines

      Explanation:

      Explanation of Hypertension and Possible Causes

      Hypertension, or high blood pressure, can have various underlying causes. In the case of this patient, their symptoms suggest a rare tumour called phaeochromocytoma, which secretes catecholamines and can lead to malignant hypertension. Hyperaldosteronism and excess cortisol production (Cushing’s syndrome) are other possible causes of hypertension, but they do not explain the patient’s symptoms. Abnormalities in renin, which regulates blood pressure, can also contribute to hypertension. Hyperthyroidism could explain most of the patient’s symptoms, but it is less likely to cause severe hypertension or headaches. Therefore, further investigation is needed to confirm the diagnosis and determine the appropriate treatment.

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      • Endocrinology/Metabolic Disease
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  • Question 33 - A 32-year-old woman is brought to the Emergency Department after fainting. She is...

    Correct

    • A 32-year-old woman is brought to the Emergency Department after fainting. She is now conscious and able to provide a medical history. The patient mentions having a condition, but cannot recall the name. She shows the doctor the medication she takes, which is a somatostatin analogue.
      What medical condition can be treated with somatostatin analogues?

      Your Answer: Acromegaly

      Explanation:

      Acromegaly is a condition caused by excessive secretion of growth hormone from an anterior pituitary tumor, resulting in enlarged hands, feet, and jaw, as well as other symptoms. While surgery is the preferred treatment, somatostatin analogues such as octreotide and lanreotide can be used if surgery fails. Somatostatin is an inhibitory hormone that can suppress growth hormone release. However, it can also cause side effects such as bradycardia, hypothyroidism, and hypoglycemia. Cushing’s disease, caused by excess adrenocorticotropic hormone, can be treated with pituitary gland removal, radiotherapy, or cortisol-inhibiting medications. Conn syndrome, or primary aldosteronism, is usually treated with surgery. Type I diabetes is treated with insulin, while Type II diabetes is treated with insulin and oral hypoglycemic agents. Parathyroid adenomas are also treated surgically.

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      • Endocrinology/Metabolic Disease
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  • Question 34 - A 32-year-old woman contacts the endocrinology nurse seeking advice. She has been experiencing...

    Correct

    • A 32-year-old woman contacts the endocrinology nurse seeking advice. She has been experiencing vomiting for the past 24 hours and has been unable to take her regular medications due to this. She has a medical history of Addison's disease and usually takes oral hydrocortisone and fludrocortisone. She denies any other symptoms apart from reduced oral intake and has not experienced dizziness on standing, blackouts, or diarrhea. Her temperature has been normal. She has IM hydrocortisone available at home. What is the most appropriate advice to give regarding her hydrocortisone?

      Your Answer: Advise her to take the IM hydrocortisone at home whilst vomiting

      Explanation:

      If a person with Addison’s disease experiences vomiting and is unable to take their regular oral hydrocortisone, they should be administered IM hydrocortisone until the vomiting subsides. This is crucial to prevent an Addisonian crisis. It is recommended that all patients with Addison’s disease have access to IM hydrocortisone in case of such situations. In case of systemic involvement, hospitalization for IV fluids and IV hydrocortisone may be necessary.

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

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

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      • Endocrinology/Metabolic Disease
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  • Question 35 - A 65-year-old woman comes in for a check-up with her doctor. She has...

    Correct

    • A 65-year-old woman comes in for a check-up with her doctor. She has a history of hypothyroidism and is currently taking 100mcg of levothyroxine. She reports feeling well and has no notable symptoms. Her last TFTs were normal 6 months ago.
      Free T4 18.5 pmol/l
      TSH 0.1 mu/l
      What should be done next?

      Your Answer: Decrease dose to levothyroxine 75mcg od

      Explanation:

      The latest TFTs reveal that the patient is experiencing over replacement, as evidenced by a suppressed TSH. Despite being asymptomatic, it is advisable to decrease the dosage to minimize the risk of osteoporosis and atrial fibrillation. According to the BNF, a 25mcg dose adjustment is recommended for individuals in this age bracket.

      Managing Hypothyroidism: Dosage, Monitoring, and Side-Effects

      Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone. The main treatment for hypothyroidism is levothyroxine, a synthetic form of thyroid hormone. When managing hypothyroidism, it is important to consider the patient’s age, cardiac history, and initial starting dose. Elderly patients and those with ischaemic heart disease should start with a lower dose of 25mcg od, while other patients can start with 50-100mcg od. After a change in dosage, thyroid function tests should be checked after 8-12 weeks to ensure the therapeutic goal of normalising the thyroid stimulating hormone (TSH) level is achieved. The target TSH range is 0.5-2.5 mU/l.

      Women with hypothyroidism who become pregnant should have their dose increased by at least 25-50 micrograms levothyroxine due to the increased demands of pregnancy. The TSH should be monitored carefully, aiming for a low-normal value. It is important to note that there is no evidence to support combination therapy with levothyroxine and liothyronine.

      While levothyroxine is generally well-tolerated, there are some potential side-effects to be aware of. Over-treatment can lead to hyperthyroidism, while long-term use can reduce bone mineral density. In patients with cardiac disease, levothyroxine can worsen angina and lead to atrial fibrillation. It is also important to be aware of drug interactions, particularly with iron and calcium carbonate, which can reduce the absorption of levothyroxine. These medications should be given at least 4 hours apart.

      In summary, managing hypothyroidism involves careful consideration of dosage, monitoring of TSH levels, and awareness of potential side-effects and drug interactions. With appropriate management, patients with hypothyroidism can achieve normal thyroid function and improve their overall health.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 36 - A 35-year-old woman presents with amenorrhoea and occasional breast discharge. She has never...

    Correct

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

      Your Answer: Prolactin level

      Explanation:

      Investigating Hyperprolactinaemia: Tests and Imaging

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 37 - Which of the following outcomes confirms a diagnosis of diabetes mellitus? ...

    Correct

    • Which of the following outcomes confirms a diagnosis of diabetes mellitus?

      Your Answer: Symptomatic patient with random glucose 12.0 mmol/L on one occasion

      Explanation:

      To diagnose diabetes mellitus, fasting blood glucose levels should be above 7.0 or random blood glucose levels should be above 11.1. If the patient is asymptomatic, two readings are required for confirmation.

      Type 2 diabetes mellitus can be diagnosed through a plasma glucose or HbA1c sample. The diagnostic criteria vary depending on whether the patient is experiencing symptoms or not. If the patient is symptomatic, a fasting glucose level of 7.0 mmol/l or higher or a random glucose level of 11.1 mmol/l or higher (or after a 75g oral glucose tolerance test) indicates diabetes. If the patient is asymptomatic, the same criteria apply but must be demonstrated on two separate occasions.

      In 2011, the World Health Organization released supplementary guidance on the use of HbA1c for diagnosing diabetes. A HbA1c level of 48 mmol/mol (6.5%) or higher is diagnostic of diabetes mellitus. However, a HbA1c value of less than 48 mmol/mol (6.5%) does not exclude diabetes and may not be as sensitive as fasting samples for detecting diabetes. For patients without symptoms, the test must be repeated to confirm the diagnosis. It is important to note that increased red cell turnover can cause misleading HbA1c results.

      There are certain conditions where HbA1c cannot be used for diagnosis, such as haemoglobinopathies, haemolytic anaemia, untreated iron deficiency anaemia, suspected gestational diabetes, children, HIV, chronic kidney disease, and people taking medication that may cause hyperglycaemia (such as corticosteroids).

      Impaired fasting glucose (IFG) is defined as a fasting glucose level of 6.1 mmol/l or higher but less than 7.0 mmol/l. Impaired glucose tolerance (IGT) is defined as a fasting plasma glucose level less than 7.0 mmol/l and an OGTT 2-hour value of 7.8 mmol/l or higher but less than 11.1 mmol/l. People with IFG should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person does not have diabetes but does have IGT.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 38 - A 40-year-old man comes to his General Practitioner with a painless neck lump....

    Correct

    • A 40-year-old man comes to his General Practitioner with a painless neck lump. He has a history of hyperparathyroidism in the past. During the examination, the lump is found to be irregular and fixed at his thyroid. The patient is worried about cancer, as his father died in his 50s due to a phaeochromocytoma. What type of thyroid cancer is most probable in this case?

      Your Answer: Medullary

      Explanation:

      Thyroid Cancer Types and their Association with Multiple Endocrine Neoplasia Type 2 (MEN2)

      Thyroid cancer can be classified into different types based on their histology and clinical features. Among these types, medullary thyroid cancer is associated with multiple endocrine neoplasia type 2 (MEN2), a genetic disorder that predisposes individuals to develop tumors in various endocrine glands. MEN2 has three subtypes, and medullary thyroid cancer is a hallmark feature of MEN2a and MEN2b. Other associated neoplasms include phaeochromocytoma and parathyroid tumors in MEN2a, and marfanoid habitus/mucosal neuromas in MEN2b.

      Anaplastic thyroid cancer, on the other hand, is not associated with MEN2 and has a poor prognosis. It is more common in older women and is characterized by rapid growth and aggressiveness. Follicular thyroid cancer is also not associated with MEN2 and is more prevalent in women over 50 years old. Lymphoma and papillary thyroid cancer are also not associated with MEN2, with the latter having an excellent prognosis and primarily affecting young women.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 39 - A 35-year-old woman presents to her General Practitioner with headaches. Her blood pressure...

    Correct

    • A 35-year-old woman presents to her General Practitioner with headaches. Her blood pressure is 170/96 mmHg. Routine investigations reveal the following results:
      Investigation Result Normal value
      Sodium 148 mmol/l 137–144 mmol/l
      Potassium 2.8 mmol/l 3.5–4.9 mmol/l
      Chloride 103 mmol/l 95–107 mmol/l
      The renin level is undetectable and aldosterone levels are raised. The urea and creatinine are normal.
      Which of the following is the most likely cause of her hypertension?

      Your Answer: Conn syndrome

      Explanation:

      Differentiating between causes of hypertension: A brief overview

      One possible cause of hypertension is Conn syndrome, which is characterized by primary hyperaldosteronism due to a benign adrenal adenoma that secretes aldosterone. This leads to hypokalaemia, hypertension, and elevated sodium levels. Renin levels are reduced due to negative feedback from high aldosterone levels. Treatment options include surgical excision of the adenoma or potassium-sparing diuretics.

      Acromegaly, on the other hand, is caused by excessive secretion of growth hormone, usually due to a pituitary tumor. While hypertension may be present, other clinical features such as visual field defects, abnormal increase in size of hands and feet, frontal bossing, and hyperhidrosis are expected. Abnormal electrolytes, renin, and aldosterone levels are not typically seen in acromegaly.

      Cushing syndrome is characterized by hypercortisolism and may present with central obesity, skin and muscle atrophy, osteoporosis, and gonadal dysfunction. While hypertension may also be present, low renin levels and elevated aldosterone are not expected.

      Phaeochromocytoma is a catecholamine-producing tumor that presents with episodic headaches, sweating, and tachycardia. While hypertension is also present, a low renin and elevated aldosterone are not expected.

      Finally, renal artery stenosis is caused by renal hypoperfusion, leading to a compensatory increase in renin secretion, secondary hyperaldosteronism, and hypertension. This may result in hypokalaemia and hypernatraemia, but both renin and aldosterone levels would be raised.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 40 - A 47-year-old woman comes for a check-up at the clinic. She was diagnosed...

    Correct

    • A 47-year-old woman comes for a check-up at the clinic. She was diagnosed with Hashimoto's thyroiditis three months ago and is currently on levothyroxine 75 mcg once daily. What is the most crucial blood test to evaluate her treatment progress?

      Your Answer: TSH

      Explanation:

      Managing Hypothyroidism: Dosage, Monitoring, and Side-Effects

      Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone. The main treatment for hypothyroidism is levothyroxine, a synthetic form of thyroid hormone. When managing hypothyroidism, it is important to consider the patient’s age, cardiac history, and initial starting dose. Elderly patients and those with ischaemic heart disease should start with a lower dose of 25mcg od, while other patients can start with 50-100mcg od. After a change in dosage, thyroid function tests should be checked after 8-12 weeks to ensure the therapeutic goal of normalising the thyroid stimulating hormone (TSH) level is achieved. The target TSH range is 0.5-2.5 mU/l.

      Women with hypothyroidism who become pregnant should have their dose increased by at least 25-50 micrograms levothyroxine due to the increased demands of pregnancy. The TSH should be monitored carefully, aiming for a low-normal value. It is important to note that there is no evidence to support combination therapy with levothyroxine and liothyronine.

      While levothyroxine is generally well-tolerated, there are some potential side-effects to be aware of. Over-treatment can lead to hyperthyroidism, while long-term use can reduce bone mineral density. In patients with cardiac disease, levothyroxine can worsen angina and lead to atrial fibrillation. It is also important to be aware of drug interactions, particularly with iron and calcium carbonate, which can reduce the absorption of levothyroxine. These medications should be given at least 4 hours apart.

      In summary, managing hypothyroidism involves careful consideration of dosage, monitoring of TSH levels, and awareness of potential side-effects and drug interactions. With appropriate management, patients with hypothyroidism can achieve normal thyroid function and improve their overall health.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 41 - A 70-year-old man with metastatic lung cancer visits the general practice clinic complaining...

    Correct

    • A 70-year-old man with metastatic lung cancer visits the general practice clinic complaining of lethargy and nausea. His full blood count, thyroid function test, calcium and liver function tests all come back normal. However, his urea and electrolytes reveal significant hyponatraemia, while the rest of the results are normal. He has a reduced plasma osmolality and increased urine osmolality. He is haemodynamically stable and euvolaemic.
      What is the most probable diagnosis from the options below?

      Your Answer: Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

      Explanation:

      Differentiating Causes of Abnormal Urine Osmolality: A Brief Overview

      Abnormal urine osmolality can be indicative of various underlying conditions. Here are some of the possible causes and how to differentiate them:

      Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH)
      SIADH is characterized by excessive secretion of ADH, leading to hyperosmolar urine and low plasma osmolality. It can be caused by central nervous system disorders, malignancies, and drugs. Treatment involves fluid restriction and addressing the underlying cause.

      Cranial Diabetes Insipidus
      This condition is caused by the hypothalamus not producing enough vasopressin, resulting in extreme thirst and polyuria. However, urine osmolality is reduced, not elevated.

      Nephrogenic Diabetes Insipidus
      Nephrogenic diabetes insipidus is caused by the kidneys becoming resistant to the effect of vasopressin/ADH, leading to large volumes of dilute urine with reduced osmolality. Causes include electrolyte imbalances, medications, and renal tubular acidosis.

      Addison’s Disease
      This condition is characterized by reduced production of glucocorticoids, mineralocorticoids, and adrenal androgens. Deficiency of mineralocorticoid leads to increased sodium excretion from the kidneys, resulting in hyponatremia associated with hyperkalemia. However, in this case, the patient has normal potassium levels.

      Primary Polydipsia
      This condition is caused by excessive water drinking despite no physiological stimulus, resulting in dilute polyuria. However, in this patient, the urine osmolality is concentrated, making this diagnosis unlikely. A fluid deprivation test can help confirm or rule out this condition.

      In summary, abnormal urine osmolality can be indicative of various underlying conditions, and a thorough evaluation is necessary to determine the correct diagnosis and treatment.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 42 - You are asked to assess a 76-year-old man on the surgical ward. The...

    Incorrect

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

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

      What would be the most appropriate initial treatment?

      Your Answer: 10% dextrose IV

      Correct Answer: Glucogel, orally

      Explanation:

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

      Understanding Hypoglycaemia: Causes, Symptoms, and Management

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 43 - A 21-year-old is brought unconscious to the Emergency Department. An alert ambulance attendant...

    Correct

    • A 21-year-old is brought unconscious to the Emergency Department. An alert ambulance attendant notes that the patient's breath smells like fruit punch. The patient was found holding a glass containing a clear liquid, and the ambulance attendant had noted a syringe on the patient's coffee table and a pool of vomit near the patient.
      With which of the following would this presentation be most consistent?

      Your Answer: Diabetic ketoacidosis (DKA)

      Explanation:

      Differentiating between medical conditions based on breath scent

      When a comatose patient presents with a distinct scent on their breath, it can be a helpful clue in determining the underlying medical condition. The smell of acetone is strongly indicative of diabetic ketoacidosis (DKA), which is commonly seen in patients with poorly controlled type I diabetes. In contrast, alcohol intoxication produces a scent of alcohol rather than a fruity odor. Diabetic hyperosmolar coma, typically seen in older patients with type II diabetes, does not produce a specific scent as there is no acetone production. Heroin overdose and profound hypoglycemia also do not result in a distinct breath scent. Understanding the different scents associated with various medical conditions can aid in prompt and accurate diagnosis.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 44 - An 18-year-old girl is referred to the Endocrine Clinic with primary amenorrhoea. On...

    Correct

    • An 18-year-old girl is referred to the Endocrine Clinic with primary amenorrhoea. On examination, her height and weight are normal. She has moderate hirsutism and acne, small breast buds and an enlarged clitoris. Bimanual pelvic examination is normal. A male cousin was seen in the clinic at the age of nine years with precocious puberty.
      Which is the most likely cause of her primary amenorrhoea?

      Your Answer: Congenital adrenal hyperplasia

      Explanation:

      Congenital adrenal hyperplasia is a genetic disorder that affects cortisol production, leading to an increase in adrenocorticotrophic hormone and enlargement of the adrenal glands. There are different types, with classic/severe presenting at birth with ambiguous genitalia or in an acute salt-losing crisis, and milder forms causing hyperandrogenism. The patient and her cousin are likely to have the milder form. Imperforate hymen, hyperprolactinaemia, and Sheehan syndrome are unlikely causes of the patient’s primary amenorrhoea, while Turner syndrome is ruled out due to the absence of characteristic features.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 45 - A 70-year-old man is admitted to the acute medical unit with an infective...

    Correct

    • A 70-year-old man is admitted to the acute medical unit with an infective exacerbation of chronic obstructive pulmonary disease (COPD) which has failed to improve despite a course of antibiotics and steroids. He has a medical history of type 2 diabetes and hypertension and takes aspirin, simvastatin, amlodipine, and metformin. His random blood glucose on admission is 12.3mmol/l and a HbA1c test is ordered, which shows an IFCC-HbA1c of 45 mmol/mol and HbA1c of 6.3%. What is the best course of action?

      Your Answer: Make no changes to diabetes medictions

      Explanation:

      The HbA1c is a reliable indicator of good glycaemic control and should be used to determine any necessary changes to diabetes medications. It reflects average glucose levels over a period of 2-3 months, rather than a single reading. It is possible that the recent use of steroids has temporarily worsened glycaemic control in this case.

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 46 - A 35-year-old woman has been referred by her doctor for thyrotoxicosis treatment. After...

    Correct

    • A 35-year-old woman has been referred by her doctor for thyrotoxicosis treatment. After discussing the available options, she chooses to undergo radioiodine therapy. What is the most probable side effect of this treatment?

      Your Answer: Hypothyroidism

      Explanation:

      Thyroid eye disease can be triggered by radioiodine therapy, as has been extensively recorded, but most patients will ultimately need to undergo thyroxine replacement.

      Management of Graves’ Disease

      Despite numerous attempts, there is no clear consensus on the best way to manage Graves’ disease. The available treatment options include anti-thyroid drugs (ATDs), radioiodine treatment, and surgery. In recent years, ATDs have become the most popular first-line therapy for Graves’ disease. This is particularly true for patients who have significant symptoms of thyrotoxicosis or those who are at a high risk of hyperthyroid complications, such as elderly patients or those with cardiovascular disease.

      To control symptoms, propranolol is often used to block the adrenergic effects. NICE Clinical Knowledge Summaries recommend that patients with Graves’ disease be referred to secondary care for ongoing treatment. If a patient’s symptoms are not controlled with propranolol, carbimazole should be considered in primary care.

      ATD therapy involves starting carbimazole at 40mg and gradually reducing it to maintain euthyroidism. This treatment is typically continued for 12-18 months. The major complication of carbimazole therapy is agranulocytosis. An alternative regime, known as block-and-replace, involves starting carbimazole at 40mg and adding thyroxine when the patient is euthyroid. This treatment typically lasts for 6-9 months. Patients following an ATD titration regime have been shown to suffer fewer side-effects than those on a block-and-replace regime.

      Radioiodine treatment is often used in patients who relapse following ATD therapy or are resistant to primary ATD treatment. However, it is contraindicated in pregnancy (should be avoided for 4-6 months following treatment) and in patients under the age of 16. Thyroid eye disease is a relative contraindication, as it may worsen the condition. The proportion of patients who become hypothyroid depends on the dose given, but as a rule, the majority of patients will require thyroxine supplementation after 5 years.

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      • Endocrinology/Metabolic Disease
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  • Question 47 - A 55-year-old man presents to the diabetes clinic for a follow-up appointment. He...

    Correct

    • A 55-year-old man presents to the diabetes clinic for a follow-up appointment. He was diagnosed with type 2 diabetes mellitus (T2DM) approximately 8 years ago and is currently taking gliclazide and atorvastatin. He has a history of bladder cancer, which was successfully treated 2 years ago. The patient recently tried metformin, but discontinued it due to gastrointestinal side-effects. He works as an accountant, does not smoke, and has a BMI of 31 kg/m². His annual blood work reveals the following results:
      - Sodium (Na+): 138 mmol/l
      - Potassium (K+): 4.1 mmol/l
      - Urea: 4.3 mmol/l
      - Creatinine: 104 µmol/l
      - HbA1c: 62 mmol/mol (7.8%)

      What would be the most appropriate course of action for managing this patient's diabetes?

      Your Answer: Add sitagliptin

      Explanation:

      Due to his history of bladder cancer and obesity, pioglitazone is not recommended and contraindicated. Instead, sitagliptin, a DPP-4 inhibitor, is the most suitable option. Exenatide, which typically leads to weight loss, is beneficial for obese individuals with diabetes, but it does not meet the NICE criteria for body mass index of 35 kg/m².

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 48 - Which one of the following statements regarding gestational diabetes is accurate? ...

    Correct

    • Which one of the following statements regarding gestational diabetes is accurate?

      Your Answer: Women of Afro-Caribbean origin are at an increased risk

      Explanation:

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

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      • Endocrinology/Metabolic Disease
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  • Question 49 - A 35-year-old man presents to his General Practitioner with weight loss, dry eyes...

    Correct

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

      Your Answer: Graves' disease

      Explanation:

      Differentiating Causes of Thyrotoxicosis: A Brief Overview

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 50 - A 56-year-old man is evaluated after being diagnosed with hypertension. As part of...

    Correct

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

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

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

      HbA1c 31 mmol/mol (5.0%)

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

      Your Answer: Sickle-cell anaemia

      Explanation:

      Understanding Glycosylated Haemoglobin (HbA1c) in Diabetes Mellitus

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 51 - A 35-year-old woman presents with excessive sweating and weight loss. Her partner reports...

    Correct

    • A 35-year-old woman presents with excessive sweating and weight loss. Her partner reports that she is constantly on edge and you notice a fine tremor during the consultation. A large, nontender goitre is also noted. Upon examination of her eyes, there is no evidence of exophthalmos. Her pulse rate is 96/min. The following results were obtained: Free T4 26 pmol/l, Free T3 12.2 pmol/l (3.0-7.5), and TSH < 0.05 mu/l. What is the most likely diagnosis?

      Your Answer: Graves' disease

      Explanation:

      Graves’ Disease: Common Features and Unique Signs

      Graves’ disease is the most frequent cause of thyrotoxicosis, which is commonly observed in women aged 30-50 years. The condition presents typical features of thyrotoxicosis, such as weight loss, palpitations, and heat intolerance. However, Graves’ disease also exhibits specific signs that are not present in other causes of thyrotoxicosis. These include eye signs, such as exophthalmos and ophthalmoplegia, as well as pretibial myxoedema and thyroid acropachy. The latter is a triad of digital clubbing, soft tissue swelling of the hands and feet, and periosteal new bone formation.

      Autoantibodies are also present in Graves’ disease, including TSH receptor stimulating antibodies in 90% of patients and anti-thyroid peroxidase antibodies in 75% of patients. Thyroid scintigraphy can also aid in the diagnosis of Graves’ disease, as it shows diffuse, homogenous, and increased uptake of radioactive iodine.

      Overall, Graves’ disease presents with both typical and unique features that distinguish it from other causes of thyrotoxicosis. Early diagnosis and treatment are crucial to prevent complications and improve outcomes for patients.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 52 - A 42-year-old man is worried about his chances of developing heart disease due...

    Correct

    • A 42-year-old man is worried about his chances of developing heart disease due to his family history. His father passed away from a heart attack at the age of 45. During his medical check-up, his lipid profile is as follows:

      HDL: 1.4 mmol/l
      LDL: 5.7 mmol/l
      Triglycerides: 2.3 mmol/l
      Total cholesterol: 8.2 mmol/l

      Upon clinical examination, the doctor notices tendon xanthomata around his ankles. What is the most probable diagnosis?

      Your Answer: Familial hypercholesterolaemia

      Explanation:

      Familial hypercholesterolaemia can be diagnosed when there are tendon xanthomata and elevated cholesterol levels present.

      Familial Hypercholesterolaemia: Causes, Diagnosis, and Management

      Familial hypercholesterolaemia (FH) is a genetic condition that affects approximately 1 in 500 people. It is an autosomal dominant disorder that results in high levels of LDL-cholesterol, which can lead to early cardiovascular disease if left untreated. FH is caused by mutations in the gene that encodes the LDL-receptor protein.

      To diagnose FH, NICE recommends suspecting it as a possible diagnosis in adults with a total cholesterol level greater than 7.5 mmol/l and/or a personal or family history of premature coronary heart disease. For children of affected parents, testing should be arranged by age 10 if one parent is affected and by age 5 if both parents are affected. The Simon Broome criteria are used for clinical diagnosis, which includes total cholesterol and LDL-C levels, tendon xanthoma, and family history of myocardial infarction or raised cholesterol levels.

      Management of FH involves referral to a specialist lipid clinic and the use of high-dose statins as first-line treatment. CVD risk estimation using standard tables is not appropriate for FH. First-degree relatives have a 50% chance of having the disorder and should be offered screening, including children who should be screened by age 10 if there is one affected parent. Statins should be discontinued in women 3 months before conception due to the risk of congenital defects.

      Overall, early diagnosis and management of FH are crucial in preventing cardiovascular disease and improving patient outcomes.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 53 - A 12-year-old boy is suspected of suffering from insulin-dependent diabetes. He undergoes a...

    Correct

    • A 12-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 peak of plasma glucose occurring between 1 and 2 hours that stays high

      Explanation:

      Interpreting Glucose Tolerance Test Results in Insulin-Dependent Diabetes

      Glucose tolerance tests are commonly used to diagnose and monitor diabetes. In insulin-dependent diabetes, the results of these tests can provide valuable information about the patient’s glucose metabolism. Here are some key points to consider when interpreting glucose tolerance test results in insulin-dependent diabetes:

      – A peak of plasma glucose occurring between 1 and 2 hours that stays high: In insulin-dependent diabetes, the plasma glucose remains elevated throughout the 4 hours of the test. This is in contrast to normal individuals, who typically have a sharper and earlier peak that returns to basal levels.
      – An ‘overshoot’ in the decline of plasma glucose at 3.5 hours: This phenomenon is seen in normal individuals but not in insulin-dependent diabetics.
      – A plasma glucose level of 4 mmol/l at zero time: This is unlikely in diabetic patients, who typically have high basal glucose levels.
      – A glucose concentration of 5.2 mmol/l at 4 hours: In insulin-dependent diabetes, the plasma glucose remains elevated throughout the 4 hours of the test.
      – A low haemoglobin A1c (HbA1c): If the patient has been suffering from diabetes for some time without treatment, the HbA1c would likely be elevated rather than low.

      Overall, glucose tolerance tests can provide valuable insights into the glucose metabolism of insulin-dependent diabetics. By understanding the nuances of these test results, healthcare providers can better diagnose and manage this chronic condition.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 54 - A 50-year-old woman is admitted to the Surgical Ward with severe loin-to-groin abdominal...

    Incorrect

    • A 50-year-old woman is admitted to the Surgical Ward with severe loin-to-groin abdominal pain. A computed tomography scan of the kidney, ureter and bladder (CT-KUB) reveals a right-sided renal calculus. During the morning ward round she admits that for the previous few weeks she has been having trouble with increased urinary frequency, thirst, constipation and altered mood.
      A diagnosis of primary hyperparathyroidism is suspected. Some blood tests are taken which show:
      Investigation Result Normal value
      Estimated glomerular filtration rate > 60 ml/min
      Adjusted calcium 3.0 mmol/l 2.1–2.6 mmol/l
      Phosphate 0.6 mmol/l 0.8–1.4 mmol/l
      Parathyroid hormone (PTH) 5.3 pmol/l 1.2–5.8 pmol/l
      Which of the following is the definitive management option?

      Select ONE option only.

      Your Answer: Bisphosphonates

      Correct Answer: Refer for parathyroid surgery

      Explanation:

      Referral for Parathyroid Surgery in Primary Hyperparathyroidism

      Primary hyperparathyroidism is a condition where the parathyroid glands produce too much parathyroid hormone (PTH), leading to high levels of calcium in the blood. The National Institute for Health and Care Excellence (NICE) recommends parathyroidectomy as the preferred treatment for most patients with diagnosed primary hyperparathyroidism due to its high cure rates and reduced risk of drug side effects.

      Referral for parathyroid surgery is indicated for patients with confirmed hyperparathyroidism who have symptoms of hypercalcaemia, end-organ disease, or an albumin-adjusted serum calcium level of 2.85 mmol/l or above. This patient fits all three criteria and should be referred for parathyroid surgery.

      Bisphosphonates and cinacalcet are only indicated when parathyroid surgery is not acceptable, patients are unfit for surgery, or have mild hypercalcaemia and symptoms. Laxatives and watchful waiting are not appropriate management options for hyperparathyroidism.

      In conclusion, referral for parathyroid surgery is the most appropriate management option for patients with primary hyperparathyroidism who meet the criteria for surgery.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 55 - A 36-year-old patient arrives at the emergency department experiencing confusion and vomiting. Upon...

    Correct

    • A 36-year-old patient arrives at the emergency department experiencing confusion and vomiting. Upon further inquiry, she reports six months of weight loss, fatigue, and dizziness upon standing. Blood tests reveal the following results: Na+ 126 mmol/L (135 - 145), K+ 5.6 mmol/L (3.5 - 5.0), Urea 6.8 mmol/L (2.0 - 7.0), and Creatinine 95 µmol/L (55 - 120). After stabilization, she undergoes additional testing and is prescribed a daily maintenance regimen of 20 mg hydrocortisone and 100mcg fludrocortisone. In the event of an acute illness, such as an infection, what dosage of medication should she take?

      Your Answer: 40mg hydrocortisone, 100mcg fludrocortisone

      Explanation:

      To manage this patient with Addison’s disease who is experiencing an intercurrent illness, it is recommended to increase the glucocorticoid dose by double while keeping the fludrocortisone dose the same. The patient’s symptoms, including vomiting, confusion, fatigue, weight loss, and postural hypotension, suggest adrenal insufficiency. Blood tests reveal hyponatremia and hyperkalemia due to aldosterone deficiency. Aldosterone normally regulates sodium and potassium levels in the body, and its absence leads to sodium loss and potassium elevation. The prescribed steroid replacement regimen is appropriate for intercurrent illness, as it mimics the body’s natural response by increasing glucocorticoid secretion while maintaining mineralocorticoid secretion. The patient’s hydrocortisone dose has been doubled from 20mg to 40mg, while the fludrocortisone dose remains at 100mcg.

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 56 - A 30-year-old woman presents with neck pain and swelling. She reports having symptoms...

    Correct

    • A 30-year-old woman presents with neck pain and swelling. She reports having symptoms of an upper respiratory tract infection followed by neck pain and swelling for the past 2 weeks. During examination, she appears anxious, her heart rate is 98/min, and her thyroid gland is tender and diffusely swollen.
      Her blood tests reveal the following results:
      Thyroid-stimulating hormone (TSH) 0.4 mU/L (0.5-5.5)
      Free thyroxine (T4) 42 pmol/L (9.0 - 18)
      ESR 65 mm/h (1-20)
      What is the most likely diagnosis?

      Your Answer: Subacute thyroiditis (de Quervain's thyroiditis)

      Explanation:

      Subacute (De Quervain’s) thyroiditis is the likely diagnosis for this woman who presents with hyperthyroidism and a tender goitre following an upper respiratory tract infection. This condition is characterized by high ESR and painful thyroid gland. Graves’ disease, Hashimoto’s thyroiditis, and thyroid cancer are less likely causes as they do not present with these specific symptoms.

      Subacute Thyroiditis: A Self-Limiting Condition with Four Phases

      Subacute thyroiditis, also known as De Quervain’s thyroiditis or subacute granulomatous thyroiditis, is a condition that is believed to occur after a viral infection. It is characterized by hyperthyroidism, a painful goitre, and raised ESR during the first phase, which lasts for 3-6 weeks. The second phase, which lasts for 1-3 weeks, is characterized by euthyroidism. The third phase, which can last for weeks to months, is characterized by hypothyroidism. Finally, in the fourth phase, the thyroid structure and function return to normal.

      To diagnose subacute thyroiditis, thyroid scintigraphy is used to show a globally reduced uptake of iodine-131. However, most patients do not require treatment as the condition is self-limiting. Thyroid pain may respond to aspirin or other NSAIDs, but in more severe cases, steroids may be used, particularly if hypothyroidism develops.

      It is important to note that subacute thyroiditis is just one of the many causes of thyroid dysfunction. A Venn diagram can be used to show how different causes of thyroid dysfunction may manifest. It is interesting to note that many causes of hypothyroidism may have an initial thyrotoxic phase. Proper diagnosis and management of thyroid dysfunction are crucial to ensure optimal patient outcomes.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 57 - During a geriatrics ward round, you assess a 87-year-old woman who was admitted...

    Correct

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

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

      Explanation:

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

      Understanding Sick Euthyroid Syndrome

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 58 - A 75-year-old patient presents for a follow-up appointment after undergoing private health screening....

    Correct

    • A 75-year-old patient presents for a follow-up appointment after undergoing private health screening. The patient has been advised to seek medical attention regarding her thyroid function tests (TFTs).
      TSH levels are at 9.2 mU/L and free thyroxine levels are at 14 pmol/L. Despite her age, the patient is currently in good health and shows no symptoms. What is the best course of action for managing her condition?

      Your Answer: Repeat TFTs in a few months time

      Explanation:

      According to the guidelines recommended by NICE Clinical Knowledge Summaries, this patient with subclinical hypothyroidism should be monitored at present based on both TSH and age criteria.

      Understanding Subclinical Hypothyroidism

      Subclinical hypothyroidism is a condition where the thyroid-stimulating hormone (TSH) is elevated, but the levels of T3 and T4 are normal, and there are no obvious symptoms. However, there is a risk of the condition progressing to overt hypothyroidism, especially in men, with a 2-5% chance per year. This risk is further increased if thyroid autoantibodies are present.

      Not all patients with subclinical hypothyroidism require treatment, and guidelines have been produced by NICE Clinical Knowledge Summaries (CKS) to help determine when treatment is necessary. If the TSH level is above 10mU/L and the free thyroxine level is within the normal range, levothyroxine may be offered. If the TSH level is between 5.5 – 10mU/L and the free thyroxine level is within the normal range, a 6-month trial of levothyroxine may be considered if the patient is under 65 years old and experiencing symptoms of hypothyroidism. For older patients, a ‘watch and wait’ strategy is often used, and asymptomatic patients may simply have their thyroid function monitored every 6 months.

      In summary, subclinical hypothyroidism is a condition that requires careful monitoring and consideration of treatment options based on individual patient factors.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 59 - A 35-year-old woman presents to the Emergency Department with a 2-day history of...

    Correct

    • A 35-year-old woman presents to the Emergency Department with a 2-day history of central abdominal pain, extreme thirst and polyuria. She has no past medical history but her mother and sister both have diabetes. She is noted to be breathing heavily with breath that smells of acetone. An urgent set of investigations is taken.
      Which of the following test results are most likely in this patient?
      Select the SINGLE most likely results from the list below.

      Your Answer: pH 7.21, partial pressure of pCO2 2.1 kPa, partial pressure of pO211.2 kPa, Na+ 131 mmol/l, K+ 3.1 mmol/l, HCO3 12 mmol/l, glucose 31 mmol/l, ketones 4.2 mmol/l

      Explanation:

      Interpreting Blood Test Results: Distinguishing Diabetic Ketoacidosis from Other Conditions

      Diabetic ketoacidosis (DKA) is a life-threatening condition that requires urgent treatment. It can occur as a complication of existing type I diabetes mellitus (DM) or be the first presentation of type I DM. To diagnose DKA, the Joint British Diabetes Societies have established specific criteria, including a blood glucose of more than 11 mmol/l or known DM, a venous pH of less than 7.3 and/or a serum bicarbonate of less than 15 mmol/l, and ketonaemia of more than 3 mmol/l or ketonuria 2+ on dipstick.

      When interpreting blood test results, it is important to distinguish DKA from other conditions that may present with similar symptoms. For example, a metabolic acidosis may indicate DKA, but it would also be present in other conditions. In DKA, you would expect a combination of high blood glucose, low pH and serum bicarbonate, and high ketone levels.

      Normal blood test results would rule out DKA, but hyperkalaemia may be present despite low total body potassium levels. Potassium levels may need to be monitored and adjusted during treatment. Respiratory alkalosis, indicated by low pCO2 and high pH, would suggest hyperventilation rather than DKA.

      In summary, interpreting blood test results is crucial in diagnosing and distinguishing DKA from other conditions. Understanding the specific criteria for DKA diagnosis and recognizing the patterns of abnormal results can help healthcare professionals provide timely and appropriate treatment.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 60 - Which of the following medications for treating diabetes is most likely to result...

    Incorrect

    • Which of the following medications for treating diabetes is most likely to result in cholestasis?

      Your Answer: Metformin

      Correct Answer: Gliclazide

      Explanation:

      Cholestasis can be caused by sulphonylureas.

      Understanding Drug-Induced Liver Disease

      Drug-induced liver disease is a condition that occurs when certain medications or drugs cause damage to the liver. This condition is generally divided into three categories: hepatocellular, cholestatic, or mixed. However, there is often overlap between these categories, as some drugs can cause a range of changes to the liver.

      Hepatocellular drug-induced liver disease is characterized by damage to the liver cells. Some of the drugs that tend to cause this type of damage include paracetamol, sodium valproate, phenytoin, MAOIs, halothane, anti-tuberculosis medications, statins, alcohol, amiodarone, methyldopa, and nitrofurantoin.

      Cholestatic drug-induced liver disease, on the other hand, is characterized by a reduction in bile flow from the liver. Some of the drugs that tend to cause this type of damage include the combined oral contraceptive pill, antibiotics such as flucloxacillin, co-amoxiclav, and erythromycin, anabolic steroids, testosterones, phenothiazines such as chlorpromazine and prochlorperazine, sulphonylureas, fibrates, and rare reported causes such as nifedipine. Methotrexate, methyldopa, and amiodarone can cause both hepatocellular and cholestatic damage.

      It is important to note that drug-induced liver disease can be a serious condition and can lead to liver cirrhosis if left untreated. Therefore, it is important to be aware of the potential risks associated with certain medications and to seek medical attention if any symptoms of liver damage occur.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 61 - A 28-year-old woman presents to her GP with a range of symptoms that...

    Incorrect

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

      Your Answer: Cushing's syndrome

      Correct Answer: Cushing's disease

      Explanation:

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

      Understanding the Causes of Cushing’s Syndrome

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 62 - A 35-year-old woman who is currently 33 weeks pregnant has been monitoring her...

    Correct

    • A 35-year-old woman who is currently 33 weeks pregnant has been monitoring her capillary blood glucose (CBG) at home since being diagnosed with gestational diabetes mellitus (GDM) 3 weeks ago. She has received appropriate dietary and exercise advice, as well as review by a dietitian. Additionally, she has been taking metformin and has been on the maximum dose for the past week. Fetal growth scans have been normal, with no signs of macrosomia or polyhydramnios. Today, she presents her CBG diary, which indicates a mean pre-meal CBG of 6.0 mmol/L and a mean 1-hour postprandial CBG of 8.4 mmol/L. What is the most suitable management plan?

      Your Answer: Commence insulin

      Explanation:

      If blood glucose targets are not achieved through diet and metformin in gestational diabetes, insulin should be added. Pregnant women with GDM should aim to keep their CBGs below specific levels, including fasting at 5.3mmol/L and 1 hour postprandial at 7.8 mmol/L or 2 hours postprandial at 6.4 mmol/L. If these targets are not met, insulin should be offered as an additional therapy. Gliclazide is not recommended, and the use of any sulphonylurea in GDM is an off-license indication. Gliptins are not recommended due to insufficient evidence of their safety in pregnancy. It is not appropriate to continue the same management or de-escalate treatment by stopping metformin if CBG readings are above target levels. Failure to achieve glycaemic control can result in serious risks to both mother and fetus, including pre-eclampsia, pre-term labour, stillbirth, and neonatal hypoglycaemia, even if fetal growth appears normal.

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

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      • Endocrinology/Metabolic Disease
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  • Question 63 - A 65-year-old man has scheduled an elective inguinal hernia surgery and is a...

    Correct

    • A 65-year-old man has scheduled an elective inguinal hernia surgery and is a diabetic taking metformin once daily. His blood glucose levels have been well controlled. He is wondering what he should do with his medication before the surgery.

      What advice would be appropriate for him?

      Your Answer: Continue metformin as normal the day before surgery

      Explanation:

      Preparation for surgery varies depending on whether the patient is undergoing an elective or emergency procedure. For elective cases, it is important to address any medical issues beforehand through a pre-admission clinic. Blood tests, urine analysis, and other diagnostic tests may be necessary depending on the proposed procedure and patient fitness. Risk factors for deep vein thrombosis should also be assessed, and a plan for thromboprophylaxis formulated. Patients are advised to fast from non-clear liquids and food for at least 6 hours before surgery, and those with diabetes require special management to avoid potential complications. Emergency cases require stabilization and resuscitation as needed, and antibiotics may be necessary. Special preparation may also be required for certain procedures, such as vocal cord checks for thyroid surgery or bowel preparation for colorectal cases.

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      • Endocrinology/Metabolic Disease
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  • Question 64 - A 28-year-old woman comes to the Endocrine Clinic with a history of hyperthyroidism....

    Correct

    • A 28-year-old woman comes to the Endocrine Clinic with a history of hyperthyroidism. Her blood tests confirm that she is currently experiencing thyrotoxicosis. She is hoping to conceive and wants to discuss her treatment options.
      What is the most suitable treatment for her condition in this scenario?

      Your Answer: Thyroidectomy

      Explanation:

      Treatment Options for Hyperthyroidism in Women Planning a Pregnancy

      When it comes to treating hyperthyroidism in women who are planning a pregnancy, there are several options to consider. Definitive treatment, such as thyroidectomy, is the preferred option as it eliminates the risk of thyrotoxicosis during pregnancy and the need for medication that could harm the fetus. However, following thyroidectomy, the patient will need thyroxine replacement and should wait until she is euthyroid before trying to conceive.

      Propylthiouracil and thyroxine are not recommended for use during pregnancy due to the risk of fetal goitre or hypothyroidism. Carbimazole is teratogenic and should not be started in women planning a pregnancy. Propylthiouracil can be used in low doses if there is no other suitable alternative.

      Radioactive iodine is highly effective but is contraindicated in women planning a pregnancy within six months. This option can be considered if the patient is willing to continue contraception until six months after treatment. Ultimately, the best course of action will depend on the individual patient’s needs and preferences, and should be discussed with a healthcare provider.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 65 - A 47-year-old obese man complains of fatigue and excessive thirst. What is the...

    Correct

    • A 47-year-old obese man complains of fatigue and excessive thirst. What is the lowest HbA1c level that can confirm the diagnosis of type 2 diabetes mellitus?

      Your Answer: 6.5% (48 mmol/mol)

      Explanation:

      Type 2 diabetes mellitus can be diagnosed through a plasma glucose or HbA1c sample. The diagnostic criteria vary depending on whether the patient is experiencing symptoms or not. If the patient is symptomatic, a fasting glucose level of 7.0 mmol/l or higher or a random glucose level of 11.1 mmol/l or higher (or after a 75g oral glucose tolerance test) indicates diabetes. If the patient is asymptomatic, the same criteria apply but must be demonstrated on two separate occasions.

      In 2011, the World Health Organization released supplementary guidance on the use of HbA1c for diagnosing diabetes. A HbA1c level of 48 mmol/mol (6.5%) or higher is diagnostic of diabetes mellitus. However, a HbA1c value of less than 48 mmol/mol (6.5%) does not exclude diabetes and may not be as sensitive as fasting samples for detecting diabetes. For patients without symptoms, the test must be repeated to confirm the diagnosis. It is important to note that increased red cell turnover can cause misleading HbA1c results.

      There are certain conditions where HbA1c cannot be used for diagnosis, such as haemoglobinopathies, haemolytic anaemia, untreated iron deficiency anaemia, suspected gestational diabetes, children, HIV, chronic kidney disease, and people taking medication that may cause hyperglycaemia (such as corticosteroids).

      Impaired fasting glucose (IFG) is defined as a fasting glucose level of 6.1 mmol/l or higher but less than 7.0 mmol/l. Impaired glucose tolerance (IGT) is defined as a fasting plasma glucose level less than 7.0 mmol/l and an OGTT 2-hour value of 7.8 mmol/l or higher but less than 11.1 mmol/l. People with IFG should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person does not have diabetes but does have IGT.

    • This question is part of the following fields:

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  • Question 66 - A 35-year-old woman visits her GP for a check-up of her diabetes medication....

    Incorrect

    • A 35-year-old woman visits her GP for a check-up of her diabetes medication. During the examination, the GP observes that the patient has unusually large hands and feet and prominent supraorbital ridges. After obtaining consent for a more detailed examination, the GP discovers acanthosis nigricans in the patient's neck, enlargement of her thyroid gland, and hepatomegaly. Besides diabetes, what other condition is frequently linked to acromegaly?

      Your Answer: Right ventricular hypertrophy

      Correct Answer: Atrial fibrillation

      Explanation:

      Acromegaly is a medical condition caused by hypersecretion of growth hormone, which can lead to various health problems. One of the associated conditions is diabetes mellitus, as acromegaly is often linked with insulin resistance. Another condition is acanthosis nigricans, which involves hyperpigmentation of the skin. However, there is no general pigmentation associated with acromegaly.

      Cardiovascular disease is also a common association, which can increase the risk of atrial fibrillation. Left ventricular hypertrophy is another condition that can occur with acromegaly.

      Finally, ulnar nerve entrapment is not directly associated with acromegaly, but carpal tunnel syndrome affecting the median nerve is a common association.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 67 - As a foundation doctor in the endocrine department, if you were to assess...

    Correct

    • As a foundation doctor in the endocrine department, if you were to assess a patient with hypoparathyroidism resulting in hypocalcaemia, what findings may you discover during your investigation?

      Your Answer: Chvostek's sign: percussion over the facial nerve

      Explanation:

      Hypocalcaemia: Symptoms and Signs

      Hypocalcaemia is a condition characterized by low levels of calcium in the blood. Since calcium is essential for proper muscle and nerve function, many of the symptoms and signs of hypocalcaemia are related to neuromuscular excitability. The most common features of hypocalcaemia include muscle twitching, cramping, and spasms, as well as perioral paraesthesia. In chronic cases, patients may experience depression and cataracts.

      An electrocardiogram (ECG) may show a prolonged QT interval, while Trousseau’s sign may be present when the brachial artery is occluded by inflating the blood pressure cuff and maintaining pressure above systolic. This causes wrist flexion and fingers to be drawn together, and is seen in around 95% of patients with hypocalcaemia and around 1% of normocalcaemic people. Chvostek’s sign, which is seen in around 70% of patients with hypocalcaemia and around 10% of normocalcaemic people, involves tapping over the parotid gland to cause facial muscles to twitch.

      In summary, hypocalcaemia can cause a range of symptoms and signs related to neuromuscular excitability, including muscle twitching, cramping, and spasms, as well as perioral paraesthesia, depression, and cataracts. Trousseau’s sign and Chvostek’s sign are also commonly observed in patients with hypocalcaemia.

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      • Endocrinology/Metabolic Disease
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  • Question 68 - A 35-year-old woman is brought to the Emergency Department after being found near-unconscious...

    Correct

    • A 35-year-old woman is brought to the Emergency Department after being found near-unconscious by her husband. He claims she has been increasingly depressed and tired over the last few weeks. Past medical history includes coeliac disease, for which she follows a strict gluten-free diet, and vitiligo. She is on no medical treatment. On examination, she is responsive to pain. Her pulse is 130 bpm and blood pressure is 90/60 mmHg. She is afebrile. Pigmented palmar creases are also noted. Basic blood investigations reveal:
      Investigation Result Normal value
      Hb 121 g/l 135–180 g/l
      WCC 6.1 × 109/l 4–11 × 109/l
      Platelets 233 × 109/l 150–400 × 109/l
      Na+ 129 mmol/l 135–145 mmol/l
      K+ 6.0 mmol/l 3.5–5.0 mmol/l
      Creatinine 93 μmol/l 50–120 µmol/l
      Glucose 2.7 mmol/l <11.1 mmol/l (random)
      What is the most likely diagnosis?

      Your Answer: Addisonian crisis

      Explanation:

      Medical Conditions and Differential Diagnosis

      Addisonian Crisis: A condition caused by adrenal insufficiency, often due to autoimmune disease, TB, metastases, or adrenal haemorrhage. Symptoms include vague complaints such as depression, anorexia, and GI upset, as well as tanned skin and pigmented palmar creases. Diagnosis is confirmed through a short ACTH stimulation test. Emergency treatment involves IV hydrocortisone and fluids, while long-term treatment involves oral cortisol and mineralocorticoid.

      Other Differential Diagnoses: Meningococcal septicaemia, insulin overdose, paracetamol overdose, and salicylate overdose. However, the clinical features described in the scenario are not suggestive of these conditions.

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      • Endocrinology/Metabolic Disease
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  • Question 69 - A 42-year-old woman presents to her General Practitioner with polyuria, weight loss and...

    Incorrect

    • A 42-year-old woman presents to her General Practitioner with polyuria, weight loss and tiredness for six months. Full blood count, urea and electrolytes (U&Es), liver function tests, thyroid function test and calcium are all normal. Glycosylated haemoglobin (HbA1c) is 48 mmol/mol and repeat sample is 50 mmol/mol. On examination, her body mass index is 35 kg/m2, she is normotensive and urinalysis is normal.
      Which of the following investigations should be arranged urgently?
      Select ONE investigation from the list below.

      Your Answer: Glucose tolerance test

      Correct Answer: Computed tomography (CT) abdomen

      Explanation:

      Diagnostic Tests for a Patient with Suspected Type II Diabetes Mellitus

      Computed Tomography (CT) Abdomen:
      A CT abdomen is recommended for any patient over the age of 60 with weight loss combined with a new onset of diabetes or abdominal or back pain, nausea, vomiting or change in bowel habit. This is because new-onset type II diabetes can be a presenting feature of pancreatic cancer in patients over the age of 60, especially those who have also experienced weight loss.

      Pancreatic Autoantibodies:
      Pancreatic autoantibodies include anti-glutamic acid decarboxylase, insulin autoantibodies and islet-cell antibodies, the presence of which would support a diagnosis of type I diabetes. These tests are usually carried out in secondary care for atypical presentations such as suspected type II diabetes in a child or a non-overweight person.

      Glucose Tolerance Test:
      Glucose tolerance test has a limited role in diagnosing type II diabetes now that HbA1c is an accepted diagnostic investigation. It is still used routinely to investigate pregnant women at risk of gestational diabetes.

      Short Synacthen Test:
      A short synacthen test is used to diagnose adrenal insufficiency. The history and investigation results do not suggest this as a likely diagnosis, so this test would not be indicated.

      Ultrasound of the Urinary Tract:
      Ultrasound is not indicated unless a structural problem is suspected. Although this man is experiencing polyuria, his urinalysis and PSA are both normal, which makes a urological cause for his symptoms less likely than the newly diagnosed diabetes. Diabetes can cause renal impairment, but this should be monitored with annual urine albumin : creatinine measurement and regular U&Es blood test.

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      • Endocrinology/Metabolic Disease
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  • Question 70 - A 25-year-old homeless man presents to the emergency department with altered consciousness and...

    Correct

    • A 25-year-old homeless man presents to the emergency department with altered consciousness and abdominal pain after being intoxicated a few hours prior. He has a history of alcohol and overdose admissions.

      On examination:
      A - Airway is clear.
      B - Respiratory rate is 34 breaths per minute with deep labored inspiration. Oxygen saturation is 100%.
      C - Heart rate is 124 beats per minute, blood pressure is 95/62 mmHg, and capillary refill is 4 seconds. Mucous membranes are dry.
      D - Glasgow Coma Scale score is 10.

      Lab results show a pH of 7.18 (normal range: 7.35-7.45), pCO2 of 4.3kPa (normal range: 4.5-6.0kPa), bicarbonate of 14 mmol/L (normal range: 22-28 mmol/L), glucose of 22.3mmol/L, and ketones of 4.5mmol/L.

      What is the most likely diagnosis?

      Your Answer: Diabetic ketoacidosis

      Explanation:

      Abdominal pain can be an initial symptom of DKA, which stands for diabetic ketoacidosis. In this particular case, a young man is showing signs of DKA, such as dehydration, Kussmaul respiration, and a significantly elevated capillary glucose level. DKA patients lose around 5-8 liters of fluids, which require immediate correction. The diagnostic criteria for DKA include a pH level of less than 7.3 and/or bicarbonate level of less than 15mmol/L, blood glucose level of over 11mmol/L or known diabetes mellitus, and ketonaemia level of over 3mmol/L or significant ketonuria ++ on urine dipstick. Alcoholic ketoacidosis is not the correct diagnosis as it usually presents with low or normal glucose levels and occurs due to starvation. Hyperosmolar hyperglycaemic state is also incorrect as it typically presents with marked hyperglycemia without ketoacidosis. Opioid overdose is not the correct diagnosis either as it usually presents with respiratory depression, pinpoint pupils, and a lowered GCS, while this patient has a raised respiratory rate and abnormal respirations consistent with Kussmaul respirations.

      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. However, mortality rates have decreased from 8% to under 1% in the past 20 years. DKA is caused by uncontrolled lipolysis, resulting in an excess of free fatty acids that are ultimately 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 acetone-smelling breath. Diagnostic criteria include glucose levels above 13.8 mmol/l, pH below 7.30, serum bicarbonate below 18 mmol/l, anion gap above 10, and ketonaemia.

      Management of DKA involves fluid replacement, insulin, and correction of electrolyte disturbance. Most patients with DKA are depleted around 5-8 litres, and 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. DKA resolution is defined as pH above 7.3, blood ketones below 0.6 mmol/L, and bicarbonate above 15.0mmol/L. Complications may occur from DKA itself or the treatment, such as gastric stasis, thromboembolism, arrhythmias, acute respiratory distress syndrome, acute kidney injury, and cerebral oedema. Children and young adults are particularly vulnerable to cerebral oedema following fluid resuscitation in DKA and often need 1:1 nursing to monitor neuro-observations.

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      • Endocrinology/Metabolic Disease
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  • Question 71 - A 49-year-old woman presents to her GP with tearfulness and a low mood...

    Correct

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

      Your Answer: Primary hyperparathyroidism

      Explanation:

      Differential Diagnosis for a Patient with Low Mood and Renal Stones

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

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

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

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

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

      Differential Diagnosis for a Patient with Low Mood and Renal Stones

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      • Endocrinology/Metabolic Disease
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  • Question 72 - A 45-year-old woman presents to her general practitioner with a complaint of feeling...

    Incorrect

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

      Your Answer: 9am cortisol measurement

      Correct Answer: MRI brain and pituitary

      Explanation:

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

      Understanding the Causes of Hypothyroidism

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

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

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  • Question 73 - A 25-year-old man presents to the emergency department with abdominal pain and lethargy....

    Incorrect

    • A 25-year-old man presents to the emergency department with abdominal pain and lethargy. He has areas of skin hyperpigmentation and hypopigmentation consistent with vitiligo. His blood pressure is 96/58 mmHg. Laboratory tests reveal the following results, and treatment is initiated.
      Hemoglobin: 138 g/L (Male: 135-180, Female: 115-160)
      Platelets: 210 * 109/L (150-400)
      White blood cells: 11.5 * 109/L (4.0-11.0)
      Sodium: 133 mmol/L (135-145)
      Potassium: 5.8 mmol/L (3.5-5.0)
      Urea: 6.5 mmol/L (2.0-7.0)
      Creatinine: 95 µmol/L (55-120)
      C-reactive protein: 4 mg/L (<5)
      Fasting blood sugar: 4.4 mmol/L (4-7)

      What is the most appropriate diagnostic test for the likely diagnosis?

      Your Answer: Overnight dexamethasone suppression test

      Correct Answer: Short synacthen test

      Explanation:

      The most likely diagnosis for this patient is Addison’s disease based on their clinical presentation of hypotension, hyperpigmentation, vitiligo, and electrolyte abnormalities. Immediate treatment with intravenous fluids and glucocorticoids is necessary. The best test to confirm the diagnosis is the short synacthen test, which measures cortisol levels after administering a stimulating hormone. The aldosterone renin ratio and overnight dexamethasone suppression test are not useful in this scenario. While the serum ACTH level can aid in the diagnosis, dynamic testing with suppression/stimulation is more accurate in endocrine conditions.

      Investigating Addison’s Disease: ACTH Stimulation Test and Serum Cortisol Levels

      When a patient is suspected of having Addison’s disease, the definitive investigation is an ACTH stimulation test, also known as a short Synacthen test. This involves measuring plasma cortisol levels before and 30 minutes after administering Synacthen 250ug IM. Adrenal autoantibodies, such as anti-21-hydroxylase, may also be demonstrated.

      However, if an ACTH stimulation test is not readily available, a 9 am serum cortisol level can be useful. A level of over 500 nmol/l makes Addison’s disease very unlikely, while a level of less than 100 nmol/l is definitely abnormal. A level between 100-500 nmol/l should prompt an ACTH stimulation test to be performed.

      It is important to note that around one-third of undiagnosed patients with Addison’s disease may also have associated electrolyte abnormalities, such as hyperkalaemia, hyponatraemia, hypoglycaemia, and metabolic acidosis. Therefore, it is crucial to investigate these patients thoroughly to ensure a proper diagnosis and appropriate treatment.

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  • Question 74 - A 42-year-old woman presents to her GP with complaints of ongoing fatigue and...

    Correct

    • A 42-year-old woman presents to her GP with complaints of ongoing fatigue and tiredness. She has a medical history of hypertension and eczema, and no significant family history. Upon conducting a blood test, the following results were obtained:
      - Hb: 141 g/l
      - Platelets: 222 * 109/l
      - WBC: 6.3 * 109/l
      - Neuts: 3.9 * 109/l
      - Lymphs: 1.2 * 109/l
      - Na+: 140 mmol/l
      - K+: 4.1 mmol/l
      - Urea: 4.9 mmol/l
      - Creatinine: 83 µmol/l
      - CRP: 4.1 mg/l
      - TSH: 6.2 mu/l
      - Free T4: 6 pmol/l

      What is the most likely pathology causing her symptoms?

      Your Answer: Hashimoto's thyroiditis

      Explanation:

      The most common cause of hypothyroidism is autoimmune thyroiditis, specifically Hashimoto’s thyroiditis, which is often associated with other autoimmune diseases. This is indicated by a presentation and blood test showing hypothyroidism with a raised TSH, suggesting a failure of the thyroid gland to respond to pituitary stimulation or a primary hypothyroidism. While iodine deficiency is the main cause of hypothyroidism worldwide, it is rare in the UK. Papillary thyroid cancer does not affect thyroid function, as the cancer cells do not secrete thyroxine. Although De Quervain’s can cause a primary hypothyroidism with similar symptoms, it is much less common than Hashimoto’s and therefore an incorrect answer.

      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 features of hypothyroidism, such as 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, including 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.

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  • Question 75 - An 80-year-old man comes in after a fall and reports feeling constantly cold....

    Correct

    • An 80-year-old man comes in after a fall and reports feeling constantly cold. Thyroid function tests are ordered and the results are as follows:
      Free T4 7.1 pmol/l
      TSH 14.3 mu/l
      What should be done next?

      Your Answer: Start levothyroxine 25mcg od

      Explanation:

      The patient exhibits hypothyroidism, indicated by low free T4 and elevated TSH levels. Considering her age, it is recommended to gradually introduce levothyroxine at a starting dose of 25mcg once daily.

      Managing Hypothyroidism: Dosage, Monitoring, and Side-Effects

      Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone. The main treatment for hypothyroidism is levothyroxine, a synthetic form of thyroid hormone. When managing hypothyroidism, it is important to consider the patient’s age, cardiac history, and initial starting dose. Elderly patients and those with ischaemic heart disease should start with a lower dose of 25mcg od, while other patients can start with 50-100mcg od. After a change in dosage, thyroid function tests should be checked after 8-12 weeks to ensure the therapeutic goal of normalising the thyroid stimulating hormone (TSH) level is achieved. The target TSH range is 0.5-2.5 mU/l.

      Women with hypothyroidism who become pregnant should have their dose increased by at least 25-50 micrograms levothyroxine due to the increased demands of pregnancy. The TSH should be monitored carefully, aiming for a low-normal value. It is important to note that there is no evidence to support combination therapy with levothyroxine and liothyronine.

      While levothyroxine is generally well-tolerated, there are some potential side-effects to be aware of. Over-treatment can lead to hyperthyroidism, while long-term use can reduce bone mineral density. In patients with cardiac disease, levothyroxine can worsen angina and lead to atrial fibrillation. It is also important to be aware of drug interactions, particularly with iron and calcium carbonate, which can reduce the absorption of levothyroxine. These medications should be given at least 4 hours apart.

      In summary, managing hypothyroidism involves careful consideration of dosage, monitoring of TSH levels, and awareness of potential side-effects and drug interactions. With appropriate management, patients with hypothyroidism can achieve normal thyroid function and improve their overall health.

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  • Question 76 - A 65-year-old patient visits her GP with complaints of heat intolerance, palpitations, anxiety,...

    Correct

    • A 65-year-old patient visits her GP with complaints of heat intolerance, palpitations, anxiety, and weight loss that have been progressively worsening for the past three months. She has also noticed that her eyes feel dry and appear wider than they did in photographs taken a few years ago. The patient has a medical history of hypertension and suffered a heart attack six years ago. She is currently taking ramipril, simvastatin, aspirin, clopidogrel, and atenolol. What is the most appropriate management plan for her likely diagnosis?

      Your Answer: Carbimazole

      Explanation:

      Carbimazole is the preferred initial treatment for Graves’ disease, especially in elderly patients or those with underlying cardiovascular disease and significant thyrotoxicosis, as evidenced by this patient’s symptoms and peripheral signs of Graves’ disease such as ophthalmopathy. Radioiodine treatment is not recommended as first-line therapy in these cases due to the increased risk of Graves’ ophthalmopathy. Adrenalectomy is the primary treatment for pheochromocytoma, while ketoconazole is used to manage excess cortisol production in conditions like Cushing’s. Hydrocortisone is part of the treatment plan for Addison’s Disease.

      Management of Graves’ Disease

      Despite numerous attempts, there is no clear consensus on the best way to manage Graves’ disease. The available treatment options include anti-thyroid drugs (ATDs), radioiodine treatment, and surgery. In recent years, ATDs have become the most popular first-line therapy for Graves’ disease. This is particularly true for patients who have significant symptoms of thyrotoxicosis or those who are at a high risk of hyperthyroid complications, such as elderly patients or those with cardiovascular disease.

      To control symptoms, propranolol is often used to block the adrenergic effects. NICE Clinical Knowledge Summaries recommend that patients with Graves’ disease be referred to secondary care for ongoing treatment. If a patient’s symptoms are not controlled with propranolol, carbimazole should be considered in primary care.

      ATD therapy involves starting carbimazole at 40mg and gradually reducing it to maintain euthyroidism. This treatment is typically continued for 12-18 months. The major complication of carbimazole therapy is agranulocytosis. An alternative regime, known as block-and-replace, involves starting carbimazole at 40mg and adding thyroxine when the patient is euthyroid. This treatment typically lasts for 6-9 months. Patients following an ATD titration regime have been shown to suffer fewer side-effects than those on a block-and-replace regime.

      Radioiodine treatment is often used in patients who relapse following ATD therapy or are resistant to primary ATD treatment. However, it is contraindicated in pregnancy (should be avoided for 4-6 months following treatment) and in patients under the age of 16. Thyroid eye disease is a relative contraindication, as it may worsen the condition. The proportion of patients who become hypothyroid depends on the dose given, but as a rule, the majority of patients will require thyroxine supplementation after 5 years.

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  • Question 77 - A 32-year-old woman presents to the endocrine clinic with thyroid function test results...

    Correct

    • A 32-year-old woman presents to the endocrine clinic with thyroid function test results indicating palpitations, excessive sweating, unintentional weight loss, and a notable thyroid goitre that is tender upon palpation. The test results show a TSH level of 9.4 mU/L (normal range: 0.5-5.5) and a free T4 level of 6.4 pmol/L (normal range: 9.0-18). What is the probable diagnosis?

      Your Answer: Subacute (De Quervain's) thyroiditis

      Explanation:

      Subacute Thyroiditis: A Self-Limiting Condition with Four Phases

      Subacute thyroiditis, also known as De Quervain’s thyroiditis or subacute granulomatous thyroiditis, is a condition that is believed to occur after a viral infection. It is characterized by hyperthyroidism, a painful goitre, and raised ESR during the first phase, which lasts for 3-6 weeks. The second phase, which lasts for 1-3 weeks, is characterized by euthyroidism. The third phase, which can last for weeks to months, is characterized by hypothyroidism. Finally, in the fourth phase, the thyroid structure and function return to normal.

      To diagnose subacute thyroiditis, thyroid scintigraphy is used to show a globally reduced uptake of iodine-131. However, most patients do not require treatment as the condition is self-limiting. Thyroid pain may respond to aspirin or other NSAIDs, but in more severe cases, steroids may be used, particularly if hypothyroidism develops.

      It is important to note that subacute thyroiditis is just one of the many causes of thyroid dysfunction. A Venn diagram can be used to show how different causes of thyroid dysfunction may manifest. It is interesting to note that many causes of hypothyroidism may have an initial thyrotoxic phase. Proper diagnosis and management of thyroid dysfunction are crucial to ensure optimal patient outcomes.

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  • Question 78 - A 25-year-old man with known type I diabetes mellitus presents to the Emergency...

    Correct

    • A 25-year-old man with known type I diabetes mellitus presents to the Emergency Department with abdominal pain and vomiting.
      On examination, he appears dehydrated. He is started on an insulin infusion. His blood tests are shown below:
      Investigation Result Normal value
      pH (venous) 7.23 7.35–7.45
      Partial pressure of carbon dioxide (pCO2) 2.1 kPa 4.5–6.0 kPa
      Partial pressure of oxygen (pO2) 11.2 kPa 10–14 kPa
      Sodium (Na+) 135 mmol/l 135–145 mmol/l
      Potassium (K+) 3.1 mmol/l 3.5–5.0 mmol/l
      Bicarbonate 13 mmol/l 22–28 mmol/l
      Glucose 22.4 mmol/l < 11.1 mmol/l
      Ketones 3.6 mmol/l < 0.6 mmol/l
      What should happen to his regular insulin while he is treated?
      Select the SINGLE best treatment from the list below.

      Your Answer: Continue long-acting insulin and stop short-acting insulin

      Explanation:

      Treatment of Diabetic Ketoacidosis: Continuing Long-Acting Insulin and Stopping Short-Acting Insulin

      When a patient presents with diabetic ketoacidosis (DKA), it is important to provide prompt treatment. This involves fluid replacement with isotonic saline and an intravenous insulin infusion at 0.1 unit/kg per hour. While this takes place, the patient’s normal long-acting insulin should be continued, but their short-acting insulin should be stopped to avoid hypoglycemia.

      In addition to insulin and fluid replacement, correction of electrolyte disturbance is essential. Serum potassium levels may be high on admission, but often fall quickly following treatment with insulin, resulting in hypokalemia. Potassium may need to be added to the replacement fluids, guided by the potassium levels. If the rate of potassium infusion is greater than 20 mmol/hour, cardiac monitoring is required.

      Overall, the key to successful treatment of DKA is a careful balance of insulin, fluids, and electrolyte replacement. By continuing long-acting insulin and stopping short-acting insulin, healthcare providers can help ensure the best possible outcome for their patients.

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  • Question 79 - A middle-aged patient presents with lethargy, weight loss and fainting episodes. In the...

    Correct

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

      Your Answer: Decreased cortisol; decreased aldosterone

      Explanation:

      Understanding Addison’s Disease: Hormonal Imbalances and Clinical Presentation

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

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

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

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  • Question 80 - A 21-year-old female medical student, who is an insulin-dependent diabetic, went on a...

    Correct

    • A 21-year-old female medical student, who is an insulin-dependent diabetic, went on a weekend trip to visit some friends at another university. She forgot to pack her insulin. When she returned, she went to visit her General Practitioner. Which of the following blood results would be expected?

      Your Answer: Unchanged haemoglobin A1c (HbA1c)

      Explanation:

      Insulin-dependent diabetes patients rely on insulin to regulate their blood glucose levels. Without insulin, several physiological changes occur. However, these changes do not happen immediately. Here are some effects of insulin absence in insulin-dependent diabetes patients:

      Unchanged HbA1c levels – Correct: HbA1c levels do not change significantly over two to three days without insulin. Changes in HbA1c levels are observed over weeks and months.

      Below normal fatty acid levels – Incorrect: In the absence of insulin, triglyceride hydrolysis and increased release from adipose tissue occur, giving raised fatty acid levels. Fatty acids are utilised to synthesise ketones.

      Below normal glucagon levels – Incorrect: The body responds to the absence of insulin by increasing glucagon levels. In a healthy individual, this raised glucagon would raise glucose levels in the bloodstream, providing target organs with utilisable glucose. However, in a diabetic patient, the absence of insulin means target organs are still not able to utilise this resource.

      Hypoglycaemia – Incorrect: In the absence of insulin, hyperglycaemia would be expected to develop. Ketones are generated by the body as an alternative energy source to glucose, since to utilise glucose, insulin is required.

      Undetectable ketones – Incorrect: A diabetic patient who is normally dependent on insulin is at risk of developing diabetic ketoacidosis (DKA) even with only a weekend of missed insulin doses.

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  • Question 81 - A 32-year-old man who has been recently started on insulin for type I...

    Correct

    • A 32-year-old man who has been recently started on insulin for type I diabetes presents for a check-up at his local General Practice Surgery.
      He admits to feeling a bit confused as to what he should be doing with his insulin since this was explained to him at the Diabetes Clinic while he was still in shock. He was provided with a blood glucose monitor but is unsure when he needs to use it.
      How often should the patient be checking his blood glucose?
      Select the SINGLE best option from the list below.

      Your Answer: At least four times a day, including before each meal and before bed, increase during periods of illness and before, during and after sport

      Explanation:

      The Importance of Self-Monitoring Blood Glucose in Diabetes Management

      Self-monitoring of blood glucose is a crucial aspect of diabetes management. According to the National Institute of Clinical Excellence (NICE) guidelines, blood glucose should be checked at least four times a day, including before each meal and before bed. More frequent monitoring is recommended during periods of illness and before, during, and after sport. Blood glucose targets should be 5-7 mmol/l on waking and 4-7 mmol/l before meals and at other times of the day. Additionally, glycosylated haemoglobin (HbA1c) levels should be checked every 3-6 months with a target of 48 mmol/mol (6.5%) or lower. Checking blood glucose only during illness or once a day is not recommended as it can lead to complications such as hypoglycaemia and hyperglycaemia. Regular self-monitoring of blood glucose is essential for good diabetes management.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 82 - A 54-year-old man is seen in the Cardiology clinic after experiencing a heart...

    Correct

    • A 54-year-old man is seen in the Cardiology clinic after experiencing a heart attack a year ago. He was diagnosed with hypertension and diabetes during his hospitalization. The patient reports gaining 5kg in the last 6 months and wonders if any of his medications could be causing this weight gain. Which of his prescribed drugs may be contributing to his recent weight gain?

      Your Answer: Gliclazide

      Explanation:

      Weight gain is a common side effect of sulfonylureas.

      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 they are only effective if the pancreas is functioning properly. Sulfonylureas bind to a specific channel on the cell membrane of pancreatic beta cells, which helps to increase insulin secretion. However, there are some potential side effects associated with these drugs.

      One of the most common side effects of sulfonylureas is hypoglycaemia, which can be more likely to occur with long-acting preparations like chlorpropamide. Weight gain is another possible side effect. In rare cases, sulfonylureas can cause hyponatraemia, which is a condition where the body retains too much water and sodium levels become too low. Other rare side effects include 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:

      • Endocrinology/Metabolic Disease
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  • Question 83 - A floppy four-week-old neonate presents with vomiting, weight loss and circulatory collapse. Blood...

    Incorrect

    • A floppy four-week-old neonate presents with vomiting, weight loss and circulatory collapse. Blood tests demonstrate hyponatraemia and hyperkalaemia. Further tests confirm metabolic acidosis and hypoglycaemia. The paediatrician notices that the penis was enlarged and the scrotum pigmented. The child was treated with both a glucocorticoid and a mineralocorticoid.
      What is the most likely underlying diagnosis?

      Your Answer: Addisonian crisis

      Correct Answer: Congenital adrenal hyperplasia

      Explanation:

      Endocrine Disorders: Congenital Adrenal Hyperplasia, Conn Syndrome, Addisonian Crisis, Cushing Syndrome, and Thyrotoxic Crisis

      Endocrine disorders are conditions that affect the production and regulation of hormones in the body. Here are five different endocrine disorders and their characteristics:

      Congenital Adrenal Hyperplasia (CAH) is a group of autosomal recessive conditions caused by mutations in the enzymes involved in the production of steroids and hormones from the adrenal glands. It can affect both men and women equally, and symptoms include ambiguous genitalia at birth for women and hyperpigmentation and penile enlargement for men. Treatment involves hormone replacement therapy.

      Conn Syndrome is a condition associated with primary hyperaldosteronism, which presents with hypernatraemia and hypokalaemia. It is more commonly seen in adult patients, but there are cases reported in childhood.

      Addisonian Crisis occurs due to glucocorticoid and mineralocorticoid deficiency, usually occurring in adulthood. It is a potentially fatal episode that presents with hyponatraemia, hyperkalaemia, hypoglycaemia, and hypercalcaemia. Urgent intravenous administration of glucocorticoids is necessary for management.

      Cushing Syndrome is due to cortisol excess, either exogenous or endogenous, and is usually diagnosed in adulthood. Symptoms include weight gain, hypertension, oedema, hyperglycaemia, hypokalaemia, and pigmentation of the skin in the axillae and neck.

      Thyrotoxic Crisis, also known as a thyroid storm, is a life-threatening condition associated with excessive production of thyroid hormones. It can be the first presentation of undiagnosed hyperthyroidism in neonates and children. Symptoms include tachycardia, hypertension, fever, poor feeding, weight loss, diarrhoea, nausea, vomiting, seizures, and coma. Prompt treatment is necessary to prevent acute congestive heart failure, shock, and death.

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      • Endocrinology/Metabolic Disease
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  • Question 84 - You review a 56-year-old man with a history of type II diabetes. He...

    Correct

    • You review a 56-year-old man with a history of type II diabetes. He was diagnosed one year ago and is currently managed with diet and exercise. His additional medication includes ramipril 10 mg once daily, atorvastatin 10 mg and aspirin 75 mg/day.
      On examination, his blood pressure (BP) is measured at 129/75 mmHg. His low-density lipoprotein (LDL) cholesterol is 2.1 mmol/l (normal range: < 2.6 mmol/l), while his haemoglobin A1c (HbA1c) is 62 mmol/mol (normal range: < 48 mmol/mol). and creatinine (Cr) is 110 μmol/l (normal range: 50–120 μmol/l).
      Which of the following is the most appropriate next treatment step in this case?

      Your Answer: Commence metformin

      Explanation:

      Medication Recommendations for a Patient with Diabetes and High Blood Pressure

      Based on the patient’s HbA1c level, it is recommended to start first-line treatment with metformin. If the patient experiences poor tolerance or side-effects from metformin, gliclazide may be considered as a second-line option. Pioglitazone may also be used in conjunction with metformin if HbA1c is poorly controlled on monotherapy. However, the patient’s blood pressure is adequately controlled, so an additional antihypertensive is not necessary. Lastly, the patient’s LDL cholesterol level suggests adequate control, and therefore, there is no need to increase the dosage of atorvastatin.

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      • Endocrinology/Metabolic Disease
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  • Question 85 - A 46-year-old woman who is passionate about health and fitness visits your GP...

    Correct

    • A 46-year-old woman who is passionate about health and fitness visits your GP clinic. She reports experiencing weight loss, increased thirst, and frequent urination. A urine dip test shows glucosuria, and her blood work indicates an HBA1c level of 63 mmol/mol. She mentions that her aunt passed away due to a pancreas problem. Despite receiving treatment for newly diagnosed diabetes, she still complains of weight loss. What factors should you take into account?

      Your Answer: CT scan

      Explanation:

      If a person develops new onset diabetes at the age of 56 and has a strong interest in health and fitness, it is unlikely that they have type 2 diabetes. Therefore, it may be necessary to investigate secondary causes of pancreatic insufficiency, such as pancreatic cancer. In such cases, a CT scan is the most appropriate diagnostic tool, while abdominal X-ray and ultrasound are unlikely to be helpful. Repeating the urine dip test is not likely to provide any additional information, and delaying treatment by repeating blood tests in 120 days would be inappropriate. This person should be treated promptly, as they are symptomatic with an HBA1c level of over 48mmol.

      Understanding Pancreatic Cancer: Risk Factors, Symptoms, and Management

      Pancreatic cancer is a type of cancer that is often diagnosed late due to its non-specific symptoms. Adenocarcinomas, which occur at the head of the pancreas, make up over 80% of pancreatic tumors. Risk factors for pancreatic cancer include increasing age, smoking, diabetes, chronic pancreatitis, hereditary non-polyposis colorectal carcinoma, and genetic mutations such as BRCA2 and KRAS.

      Symptoms of pancreatic cancer can include painless jaundice, pale stools, dark urine, pruritus, anorexia, weight loss, epigastric pain, loss of exocrine and endocrine function, and atypical back pain. Migratory thrombophlebitis, also known as Trousseau sign, is more common in pancreatic cancer than in other cancers.

      Diagnosis of pancreatic cancer can be made through ultrasound or high-resolution CT scanning, which may show the double duct sign – simultaneous dilatation of the common bile and pancreatic ducts. However, less than 20% of patients are suitable for surgery at diagnosis. A Whipple’s resection, or pancreaticoduodenectomy, may be performed for resectable lesions in the head of the pancreas. Adjuvant chemotherapy is usually given following surgery, and ERCP with stenting may be used for palliation.

      In summary, pancreatic cancer is a serious disease with non-specific symptoms that can be difficult to diagnose. Understanding the risk factors and symptoms can help with early detection and management.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 86 - A 43-year-old woman complains of muscle cramps and fatigue. Upon examination, her neck's...

    Incorrect

    • A 43-year-old woman complains of muscle cramps and fatigue. Upon examination, her neck's front is tender and swollen to touch. She has no medical history and does not take any regular medication. Her blood results show a TSH level of 12.3 mU/L (0.5-5.5) and a free T4 level of 4.2 pmol/L (9.0 - 18). What is the probable diagnosis?

      Your Answer: Hashimoto's thyroiditis

      Correct Answer: Subacute thyroiditis (de Quervain's)

      Explanation:

      Subacute thyroiditis can be differentiated from Hashimoto’s thyroiditis as a cause of hypothyroidism by the presence of tenderness in the thyroid gland. The symptoms are indicative of hypothyroidism, which is confirmed by elevated TSH levels and low T4 levels in the thyroid function tests. The occurrence of a painful goitre points towards subacute thyroiditis as the most probable diagnosis. Graves’ disease, on the other hand, leads to hyperthyroidism and not hypothyroidism. Although Hashimoto’s thyroiditis can also cause hypothyroidism, it is typically painless. Riedel thyroiditis can cause hypothyroidism and may be painful, but it is less likely than subacute thyroiditis.

      Understanding the Causes of Hypothyroidism

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

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

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      • Endocrinology/Metabolic Disease
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  • Question 87 - You are evaluating a 23-year-old man who has just been diagnosed with type...

    Correct

    • You are evaluating a 23-year-old man who has just been diagnosed with type 1 diabetes mellitus. He works as a software engineer and has no other medical conditions. What should be his initial target for HbA1c?

      Your Answer: 48 mmol/mol

      Explanation:

      Managing Type 1 Diabetes: NICE Guidelines

      The management of type 1 diabetes is a complex process that involves the collaboration of various healthcare professionals. It is crucial to monitor the condition regularly as it can reduce life expectancy by 13 years and lead to micro and macrovascular complications. In 2015, NICE released guidelines on the diagnosis and management of type 1 diabetes, which provide valuable information for clinicians caring for patients with this condition.

      One of the key recommendations is to monitor HbA1c levels every 3-6 months, with a target of 48 mmol/mol (6.5%) or lower for adults. However, other factors such as daily activities, comorbidities, and history of hypoglycemia should also be considered. Self-monitoring of blood glucose is also essential, with a minimum of four tests per day, including before meals and bedtime. Blood glucose targets should be between 5-7 mmol/l on waking and 4-7 mmol/l before meals at other times of the day.

      NICE recommends multiple daily injection basal-bolus insulin regimens as the preferred choice for adults with type 1 diabetes, rather than twice-daily mixed insulin regimens. Rapid-acting insulin analogues should be used before meals instead of rapid-acting soluble human or animal insulins. Metformin may also be considered if the patient’s BMI is 25 kg/m² or higher.

      In summary, managing type 1 diabetes requires a comprehensive approach that considers various factors. NICE guidelines provide a useful framework for clinicians to ensure optimal care for their patients with type 1 diabetes.

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      • Endocrinology/Metabolic Disease
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  • Question 88 - An increase in alkaline phosphatase can be attributed to any of the following...

    Incorrect

    • An increase in alkaline phosphatase can be attributed to any of the following conditions except?

      Your Answer: Paget's disease

      Correct Answer: Hypoparathyroidism

      Explanation:

      Understanding Alkaline Phosphatase and Its Causes

      Alkaline phosphatase (ALP) is an enzyme found in various tissues throughout the body, including the liver, bones, and intestines. When the levels of ALP in the blood are elevated, it can indicate a potential health issue. The causes of raised ALP can be divided into two categories based on the calcium level in the blood.

      If both ALP and calcium levels are high, it may indicate bone metastases, hyperparathyroidism, osteomalacia, or renal failure. On the other hand, if ALP is high but calcium is low, it may be due to cholestasis, hepatitis, fatty liver, neoplasia, Paget’s disease, or physiological factors such as pregnancy, growing children, or healing fractures.

      It is important to note that elevated ALP levels do not necessarily indicate a specific condition, but rather serve as a signal for further investigation.

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      • Endocrinology/Metabolic Disease
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  • Question 89 - A 50-year-old woman with suspected diabetes mellitus undergoes an oral glucose tolerance test...

    Incorrect

    • A 50-year-old woman with suspected diabetes mellitus undergoes an oral glucose tolerance test using the standard WHO protocol. The results are as follows:
      Time (hours) Blood glucose (mmol/l)
      0 5.9
      2 8.4

      What is the interpretation of these findings?

      Your Answer: Diabetes mellitus

      Correct Answer: Impaired glucose tolerance

      Explanation:

      Type 2 diabetes mellitus can be diagnosed through a plasma glucose or HbA1c sample. The diagnostic criteria vary depending on whether the patient is experiencing symptoms or not. If the patient is symptomatic, a fasting glucose level of 7.0 mmol/l or higher or a random glucose level of 11.1 mmol/l or higher (or after a 75g oral glucose tolerance test) indicates diabetes. If the patient is asymptomatic, the same criteria apply but must be demonstrated on two separate occasions.

      In 2011, the World Health Organization released supplementary guidance on the use of HbA1c for diagnosing diabetes. A HbA1c level of 48 mmol/mol (6.5%) or higher is diagnostic of diabetes mellitus. However, a HbA1c value of less than 48 mmol/mol (6.5%) does not exclude diabetes and may not be as sensitive as fasting samples for detecting diabetes. For patients without symptoms, the test must be repeated to confirm the diagnosis. It is important to note that increased red cell turnover can cause misleading HbA1c results.

      There are certain conditions where HbA1c cannot be used for diagnosis, such as haemoglobinopathies, haemolytic anaemia, untreated iron deficiency anaemia, suspected gestational diabetes, children, HIV, chronic kidney disease, and people taking medication that may cause hyperglycaemia (such as corticosteroids).

      Impaired fasting glucose (IFG) is defined as a fasting glucose level of 6.1 mmol/l or higher but less than 7.0 mmol/l. Impaired glucose tolerance (IGT) is defined as a fasting plasma glucose level less than 7.0 mmol/l and an OGTT 2-hour value of 7.8 mmol/l or higher but less than 11.1 mmol/l. People with IFG should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person does not have diabetes but does have IGT.

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  • Question 90 - As you review the blood results of a 65-year-old man who has been...

    Correct

    • As you review the blood results of a 65-year-old man who has been diagnosed with hypertension, you notice that a HbA1c level was requested as part of the routine work-up. What HbA1c range would be indicative of prediabetes?

      Your Answer: 42-47 mmol/mol (6.0-6.4%)

      Explanation:

      Understanding Prediabetes and Impaired Glucose Regulation

      Prediabetes is a term used to describe impaired glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetes mellitus. This includes individuals with impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). Diabetes UK estimates that around 1 in 7 adults in the UK have prediabetes, and many of them will eventually develop type 2 diabetes mellitus (T2DM), putting them at risk of microvascular and macrovascular complications.

      To identify patients with prediabetes, NICE recommends using a validated computer-based risk assessment tool for adults aged 40 and over, people of South Asian and Chinese descent aged 25-39, and adults with conditions that increase the risk of T2DM. Patients identified as high risk should have a blood sample taken, and a fasting plasma glucose of 6.1-6.9 mmol/l or an HbA1c level of 42-47 mmol/mol (6.0-6.4%) indicates high risk.

      Lifestyle modifications such as weight loss, increased exercise, and changes in diet are recommended for managing prediabetes. NICE also recommends metformin for adults at high risk who are still progressing towards T2DM despite lifestyle changes.

      There are two main types of impaired glucose regulation: impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). IFG is due to hepatic insulin resistance, while IGT is due to muscle insulin resistance. Patients with IGT are more likely to develop T2DM and cardiovascular disease than those with IFG.

      To rule out a diagnosis of diabetes, people with IFG should be offered an oral glucose tolerance test. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person doesn’t have diabetes but does have IGT. It is important to understand prediabetes and impaired glucose regulation to prevent the progression to T2DM and its associated complications.

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      • Endocrinology/Metabolic Disease
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  • Question 91 - A 52-year-old woman with a body mass index (BMI) of 32 was diagnosed...

    Correct

    • A 52-year-old woman with a body mass index (BMI) of 32 was diagnosed with type 2 diabetes mellitus during a routine check-up six months ago. Despite being advised about a low-energy, weight-reducing diet and exercise, she has not followed through with these recommendations and her postprandial blood glucose concentration is 13.8 mmol/l (reference range <11.1 mmol/l). What would be the drug of choice in this case?

      Your Answer: Metformin

      Explanation:

      Medications for Type 2 Diabetes

      Metformin: The Initial Drug Treatment of Choice
      For adults with type 2 diabetes, standard-release metformin is the recommended initial drug treatment. The dose should be gradually increased to avoid gastrointestinal side effects. If significant GI side effects occur, modified-release metformin can be tried. Metformin reduces hepatic gluconeogenesis and increases insulin sensitivity, leading to an increase in peripheral glucose uptake. However, caution should be exercised when using metformin in patients with renal failure, and it should be stopped if the estimated glomerular filtration rate is less than 30 ml/min per 1.73m2.

      Tolbutamide and Chlorpropamide: First-Generation Sulfonylureas
      Tolbutamide and chlorpropamide are first-generation sulfonylureas that are no longer routinely used in the treatment of type 2 diabetes due to a higher incidence of side effects compared to newer, second-generation sulfonylureas. Chlorpropamide is not available in the UK.

      Insulin: Considered for Dual Therapy
      Insulin-based treatment should be considered in type 2 diabetes patients who have not achieved optimal glycated haemoglobin control with dual therapy using metformin and another oral drug. Metformin should continue to be offered to patients without contraindications or intolerance.

      Pioglitazone: An Alternative Second-Line Agent
      Pioglitazone can be considered as an alternative second-line agent for patients with type 2 diabetes who cannot take metformin or have not tolerated it well. It can also be used in dual therapy for first intensification of treatment.

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      • Endocrinology/Metabolic Disease
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  • Question 92 - A 38-year-old woman visits her GP with complaints of weight gain and irregular...

    Correct

    • A 38-year-old woman visits her GP with complaints of weight gain and irregular menstrual cycles. She reports feeling weak and depressed. During the examination, the doctor notices multiple purplish striae on her abdomen and bruises on her lower extremities. Laboratory tests show normal thyroid hormone levels and TSH, but elevated cortisol secretion. If the patient has adrenal hyperfunction, what other symptom may also be present?

      Your Answer: Hirsutism

      Explanation:

      Effects of Cortisol on the Body: Misconceptions and Clarifications

      Cortisol, a hormone produced by the adrenal glands, plays a crucial role in regulating various bodily functions. However, there are some misconceptions about the effects of cortisol on the body. Here are some clarifications:

      Hirsutism: Elevated cortisol levels can cause a condition called Cushingoid, which may result in hirsutism in women. This is characterized by excessive hair growth in areas such as the face, chest, and back.

      Hypoglycemia: Contrary to popular belief, cortisol does not cause hypoglycemia. Instead, it increases gluconeogenesis (the production of glucose from non-carbohydrate sources) and reduces glucose uptake in peripheral tissues, resulting in hyperglycemia.

      Enhanced glucose uptake: Cortisol actually has the opposite effect on glucose uptake. It reduces the uptake of glucose into peripheral tissues and accelerates gluconeogenesis.

      Hypotension: Patients with adrenal hyperfunction (excessive cortisol production) often suffer from hypertension (high blood pressure), not hypotension (low blood pressure). This is because excessive mineralocorticoids are released, which can cause fluid retention and increase blood pressure.

      Hypocalciuria: Cortisol can lead to osteopenia and osteoporosis by increasing bone breakdown. This may result in hypercalcemia (high levels of calcium in the blood), which can cause hypercalciuria (excessive calcium in the urine), not hypocalciuria.

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      • Endocrinology/Metabolic Disease
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  • Question 93 - You assess a 75-year-old patient with a complex medical history and taking multiple...

    Correct

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

      Your Answer: Goserelin (Zoladex)

      Explanation:

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

      Understanding Gynaecomastia: Causes and Drug Triggers

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

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

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

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      • Endocrinology/Metabolic Disease
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  • Question 94 - A 55-year-old man arrives at the emergency department with complaints of abdominal pain,...

    Incorrect

    • A 55-year-old man arrives at the emergency department with complaints of abdominal pain, nausea, and vomiting. His urine and serum tests reveal elevated ketone levels, and his serum glucose level is 3 mmol/L. An ABG is conducted, and the results are as follows:
      pH 7.24
      PaO2 14.7 kPa
      PCO2 3.5 kPa
      HCO3 13 mEq/L
      What is the most probable cause of these findings?

      Your Answer: Diabetic ketoacidosis

      Correct Answer: Alcoholic ketoacidosis

      Explanation:

      If a patient is experiencing metabolic ketoacidosis with normal or low glucose levels, alcohol consumption should be considered as a possible cause. This condition is characterized by partial respiratory compensation. While diabetic ketoacidosis could also be a potential cause, a serum glucose level of 3mmol/L makes it less likely. Therefore, the patient is more likely to be suffering from alcoholic ketoacidosis. It is important to note that a hyperosmolar hyperglycemic state would present with high serum glucose levels and normal ketone levels, while a diabetic hypoglycemic episode would not typically result in elevated ketone levels or metabolic acidosis.

      Alcoholic ketoacidosis is a type of ketoacidosis that occurs in individuals who consume large amounts of alcohol regularly. This condition is not related to diabetes and is characterized by normal blood sugar levels. Alcoholics often suffer from malnutrition due to their irregular eating habits and may vomit the food they consume, leading to starvation. When the body becomes malnourished, it starts breaking down body fat, which produces ketones and leads to ketoacidosis.

      The typical symptoms of alcoholic ketoacidosis include metabolic acidosis, elevated anion gap, elevated serum ketone levels, and normal or low glucose concentration. The most effective treatment for this condition is an infusion of saline and thiamine. Thiamine is essential to prevent the development of Wernicke encephalopathy or Korsakoff psychosis. Therefore, it is crucial to provide timely and appropriate treatment to individuals suffering from alcoholic ketoacidosis to prevent further complications.

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      • Endocrinology/Metabolic Disease
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  • Question 95 - A 45-year-old woman presents to her General Practitioner with a 2-month history of...

    Incorrect

    • A 45-year-old woman presents to her General Practitioner with a 2-month history of fatigue and muscle weakness.
      During the examination, her blood pressure is found to be 160/95 mmHg. The rest of the examination is normal. The General Practitioner decides to order routine blood tests. The results are as follows:
      Investigation Result Normal value
      Sodium (Na+) 151 mmol
      Potassium (K+) 3.0 mmol
      Bicarbonate 29 mmol/l
      Urea 5.2 mmol/l
      Creatinine 70.5 µmol/l
      Random glucose 5.8 mmol/l
      What is the most appropriate first-line investigation to make a diagnosis?

      Your Answer: High-resolution computed tomography (CT) scan of the abdomen

      Correct Answer: Aldosterone/renin ratio

      Explanation:

      The patient’s symptoms of hypertension, hypokalaemia, and hypernatraemia suggest a diagnosis of hyperaldosteronism, which is characterized by increased water and sodium reabsorption in the kidneys and potassium loss due to high aldosterone levels. While muscle weakness and lethargy are common symptoms, they are only present in 40% of cases. Metabolic alkalosis is another common finding. Primary hyperaldosteronism is often caused by bilateral idiopathic adrenal hyperplasia, rather than an adrenal adenoma. To diagnose hyperaldosteronism, a plasma aldosterone/renin ratio is recommended as the first-line investigation, followed by a high-resolution CT scan of the abdomen and adrenal vein sampling to differentiate between unilateral and bilateral sources of aldosterone excess. While an overnight dexamethasone suppression test is useful for diagnosing Cushing syndrome, it is not relevant in this case. Urine dipstick and formal urinalysis would be helpful in identifying renal causes of secondary hypertension, but are not necessary in this case.

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      • Endocrinology/Metabolic Disease
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  • Question 96 - A 45-year-old man has been referred by his GP due to a history...

    Correct

    • A 45-year-old man has been referred by his GP due to a history of uncontrolled hypertension. He has come in today to undergo an aldosterone: renin ratio test. The results indicate high levels of aldosterone and low levels of renin. Additionally, a CT scan has revealed bilateral adrenal gland hyperplasia.

      What is the recommended management plan for this patient?

      Your Answer: Spironolactone

      Explanation:

      The patient is suffering from primary hyperaldosteronism, which is caused by bilateral adrenal gland hyperplasia. This condition leads to elevated aldosterone levels, resulting in increased sodium retention and negative feedback to renin release. The most common cause of primary hyperaldosteronism is bilateral adrenal hyperplasia, which can be treated with spironolactone, an aldosterone receptor antagonist, for four weeks. Adrenalectomy is only recommended for unilateral adrenal adenoma, which is not the case for this patient. Fludrocortisone and hydrocortisone are not appropriate treatments for hyperaldosteronism as they act on mineralocorticoid receptors, exacerbating the condition. Reassurance and discharge are not recommended as untreated primary hyperaldosteronism can lead to chronic elevation of blood pressure, increasing the risk of cardiovascular disease, stroke, and kidney damage.

      Understanding Primary Hyperaldosteronism

      Primary hyperaldosteronism is a medical condition that was previously believed to be caused by an adrenal adenoma, also known as Conn’s syndrome. However, recent studies have shown that bilateral idiopathic adrenal hyperplasia is the cause in up to 70% of cases. It is important to differentiate between the two as this determines the appropriate treatment. Adrenal carcinoma is an extremely rare cause of primary hyperaldosteronism.

      The common features of primary hyperaldosteronism include hypertension, hypokalaemia, and alkalosis. Hypokalaemia can cause muscle weakness, but this is seen in only 10-40% of patients. To diagnose primary hyperaldosteronism, the 2016 Endocrine Society recommends a plasma aldosterone/renin ratio as the first-line investigation. This should show high aldosterone levels alongside low renin levels due to negative feedback from sodium retention caused by aldosterone.

      If the plasma aldosterone/renin ratio is high, a high-resolution CT abdomen and adrenal vein sampling are used to differentiate between unilateral and bilateral sources of aldosterone excess. If the CT is normal, adrenal venous sampling (AVS) can be used to distinguish between unilateral adenoma and bilateral hyperplasia. The management of primary hyperaldosteronism depends on the underlying cause. Adrenal adenoma is treated with surgery, while bilateral adrenocortical hyperplasia is treated with an aldosterone antagonist such as spironolactone.

      In summary, primary hyperaldosteronism is a medical condition that can be caused by adrenal adenoma, bilateral idiopathic adrenal hyperplasia, or adrenal carcinoma. It is characterized by hypertension, hypokalaemia, and alkalosis. Diagnosis involves a plasma aldosterone/renin ratio, high-resolution CT abdomen, and adrenal vein sampling. Treatment depends on the underlying cause and may involve surgery or medication.

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  • Question 97 - A 32-year-old man is diagnosed with a phaeochromocytoma.
    The urine levels of which of...

    Correct

    • A 32-year-old man is diagnosed with a phaeochromocytoma.
      The urine levels of which of the following is most likely to be elevated in this patient?

      Your Answer: Metanephrines

      Explanation:

      Urinary Metabolites as Diagnostic Markers for Adrenal Tumors and Disorders

      The urinary excretion of certain metabolites can serve as diagnostic markers for various adrenal tumors and disorders. For instance, metanephrines, vanillylmandelic acid (VMA), and homovanillic acid (HVA) are the principal metabolic products of adrenaline and noradrenaline. Normal individuals excrete only minimal amounts of these substances in the urine. However, in phaeochromocytoma and neuroblastoma, urinary excretion of adrenaline and noradrenaline, and their metabolic products, increases intermittently.

      Similarly, increased urinary excretion of the serotonin metabolite 5-hydroxyindoleacetic acid is seen in functioning carcinoids. Free urinary cortisol levels are elevated in Cushing syndrome, which is characterized by weight gain, fatty tissue deposits, moon face, buffalo hump, striae, thin skin, and acne. Urinary dehydroepiandrosterone excretion is often increased in congenital adrenal hyperplasia, while urinary pregnanetriol excretion is often increased in congenital adrenal hyperplasia caused by 21-hydroxylase deficiency.

      It is important to note that elevated excretion of these compounds may also occur in other conditions such as coma, dehydration, extreme stress states, medication use, and ingestion of certain foods. Therefore, careful interpretation of urinary metabolite levels is necessary for accurate diagnosis of adrenal tumors and disorders.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 98 - A 57-year-old male patient with a history of type 2 diabetes mellitus and...

    Correct

    • A 57-year-old male patient with a history of type 2 diabetes mellitus and hypertension is admitted to a surgical ward for a routine cholecystectomy. He is currently taking metformin 500mg BD, gliclazide 120 mg BD, ramipril 5mg, and atorvastatin 20 mg. The nurse on the morning drug round asks the doctor if they should administer the morning dose of gliclazide, as the surgery is scheduled for 9 am. What should the doctor advise the nurse?

      Your Answer: The morning dose of gliclazide should be held but the afternoon dose can be given

      Explanation:

      On the day of surgery, sulfonylureas should be omitted, except for patients who take them twice a day. In this case, the morning dose should be withheld, and the afternoon dose given after the surgery. This is because there is a risk of hypoglycemia in the fasted state before surgery. Withholding both doses or withholding for 24 or 48 hours is incorrect. The BNF website provides a comprehensive guide for managing diabetic patients on insulin and anti-diabetic drugs during surgery, including information on when to introduce variable rate insulin infusions and withholding anti-diabetic medications.

      Preparation for surgery varies depending on whether the patient is undergoing an elective or emergency procedure. For elective cases, it is important to address any medical issues beforehand through a pre-admission clinic. Blood tests, urine analysis, and other diagnostic tests may be necessary depending on the proposed procedure and patient fitness. Risk factors for deep vein thrombosis should also be assessed, and a plan for thromboprophylaxis formulated. Patients are advised to fast from non-clear liquids and food for at least 6 hours before surgery, and those with diabetes require special management to avoid potential complications. Emergency cases require stabilization and resuscitation as needed, and antibiotics may be necessary. Special preparation may also be required for certain procedures, such as vocal cord checks for thyroid surgery or bowel preparation for colorectal cases.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 99 - A 45-year-old man presents to the Emergency Department feeling very sick. He reports...

    Correct

    • A 45-year-old man presents to the Emergency Department feeling very sick. He reports having flu-like symptoms for the past few days and is having difficulty keeping anything down. He feels weak, drowsy, and disoriented. He experiences dizziness when he stands up. Upon observation, he is found to be tachycardic and hypotensive with a fever. He reports taking only hydrocortisone 10 mg PO bidaily for Addison's disease. What is the most crucial management step in this case?

      Your Answer: Give 100 mg hydrocortisone intravenous (IV) STAT

      Explanation:

      Managing Addisonian Crisis: Treatment Options and Considerations

      Addisonian crisis is a life-threatening condition that requires prompt intervention. Patients with Addison’s disease are at risk of developing an Addisonian crisis if they forget to take their steroids or if steroids have not been increased appropriately during an accompanying illness. In such cases, the first-line treatment is to administer 100 mg hydrocortisone intravenously (IV) STAT. This should be followed by fluid resuscitation and IV glucose if hypoglycemia is present.

      It is important to note that treatment should be initiated before biochemical results are obtained. Patients with Addison’s disease should carry an IM autoinjector in case of an emergency. If an Addisonian crisis is suspected, hydrocortisone should be administered immediately, and blood tests for cortisol, ACTH, urea and electrolytes, and glucose should be carried out urgently.

      Oral hydrocortisone is not recommended in cases where the patient is vomiting. In such cases, IM hydrocortisone injection is the preferred treatment option. Additionally, glucose gel sublingually may be given for hypoglycemia, but the primary focus should be on restoring cortisol levels.

      Fludrocortisone may be of use if the cause of the Addisonian crisis is adrenal disease. However, it should be noted that hydrocortisone is the first-line treatment as it acts mainly on glucocorticoid receptors to increase blood sugar levels and counteract insulin. Fludrocortisone, on the other hand, acts mainly at mineralocorticoid receptors.

      In conclusion, managing Addisonian crisis requires prompt intervention and careful consideration of treatment options. Administering hydrocortisone, fluid resuscitation, and IV glucose if necessary should be the primary focus, with fludrocortisone being considered only if the cause is adrenal disease.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 100 - A 55-year-old woman presents to a walk-in clinic with complaints of fatigue and...

    Correct

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

      Your Answer: Lithium

      Explanation:

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

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

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

      Understanding the Causes of Hypothyroidism

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 101 - A 30-year-old man is diagnosed with Addison’s disease.
    What should be prescribed in combination...

    Correct

    • A 30-year-old man is diagnosed with Addison’s disease.
      What should be prescribed in combination with hydrocortisone to benefit him?

      Your Answer: Fludrocortisone

      Explanation:

      Treatment Options for Addison’s Disease

      Addison’s disease is a condition in which the adrenal glands do not produce enough hormones. To manage this condition, patients are typically given replacement therapy with both glucocorticoid and mineralocorticoid medications. Fludrocortisone is a common mineralocorticoid medication used in this treatment. However, dexamethasone, aspirin, and both types of contraceptive pills have no role in the treatment of Addison’s disease. It is important for patients to work closely with their healthcare provider to determine the best treatment plan for their individual needs.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 102 - A 32-year-old woman reports to her community midwife with complaints of failure to...

    Incorrect

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

      Your Answer: Decreased cortisol; decreased aldosterone

      Correct Answer: Decreased cortisol; normal aldosterone

      Explanation:

      Interpreting Cortisol and Aldosterone Levels in Sheehan’s Syndrome

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 103 - A 62-year-old woman comes to her General Practitioner for her annual medication review....

    Incorrect

    • A 62-year-old woman comes to her General Practitioner for her annual medication review. Her regular medications are levothyroxine 75 µg, lisinopril 10 mg and she has recently completed a course of ibuprofen tablets. She has been feeling tired and sluggish recently with frequent headaches. Examination reveals she has gained 2 kg since her last review, blood pressure is 142/78 mmHg, pulse is 88 bpm and she has a dry skin. Full blood count, urea and electrolytes and liver function tests are normal. Her thyroid-function test (TFT) results are: Thyroid-stimulating hormone (TSH) 6.0 mU/l (0.25–4.0 mU/l) Free T4 10.0 pmol/l (12.0–22.0 pmol/l) What is the most appropriate next step in her management?

      Your Answer: Increased dose of levothyroxine

      Correct Answer: Reduce levothyroxine dose

      Explanation:

      The patient is experiencing hyperthyroidism due to an excess of levothyroxine replacement. It is important to reduce the dose of levothyroxine and monitor the patient with regular blood tests until they become euthyroid again. Starting carbimazole or increasing the dose of levothyroxine is not recommended as it could lead to further complications. Propylthiouracil is only used in cases of thyrotoxic storm and radio-iodine therapy is not necessary in this case as the hyperthyroidism is due to over-replacement of levothyroxine.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 104 - A 70-year-old man with a history of hypothyroidism is admitted to the Emergency...

    Correct

    • A 70-year-old man with a history of hypothyroidism is admitted to the Emergency Department after experiencing chest pain. He is diagnosed with acute coronary syndrome and iron-deficiency anemia. A percutaneous coronary intervention is performed, and a coronary artery stent is inserted. Endoscopies of the upper and lower gastrointestinal tract are performed and reported as normal. Upon discharge, he is prescribed aspirin, clopidogrel, ramipril, lansoprazole, simvastatin, and ferrous sulfate in addition to his regular levothyroxine. Six weeks later, he reports feeling constantly fatigued to his GP, who orders routine blood tests. The results show a TSH level of 8.2 mu/l, which is elevated compared to the patient's previous two years of TSH levels within range. Which of the newly prescribed drugs is most likely responsible for the raised TSH?

      Your Answer: Ferrous sulphate

      Explanation:

      To avoid reduced absorption of levothyroxine, iron/calcium carbonate tablets should be administered four hours apart.

      Managing Hypothyroidism: Dosage, Monitoring, and Side-Effects

      Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormone. The main treatment for hypothyroidism is levothyroxine, a synthetic form of thyroid hormone. When managing hypothyroidism, it is important to consider the patient’s age, cardiac history, and initial starting dose. Elderly patients and those with ischaemic heart disease should start with a lower dose of 25mcg od, while other patients can start with 50-100mcg od. After a change in dosage, thyroid function tests should be checked after 8-12 weeks to ensure the therapeutic goal of normalising the thyroid stimulating hormone (TSH) level is achieved. The target TSH range is 0.5-2.5 mU/l.

      Women with hypothyroidism who become pregnant should have their dose increased by at least 25-50 micrograms levothyroxine due to the increased demands of pregnancy. The TSH should be monitored carefully, aiming for a low-normal value. It is important to note that there is no evidence to support combination therapy with levothyroxine and liothyronine.

      While levothyroxine is generally well-tolerated, there are some potential side-effects to be aware of. Over-treatment can lead to hyperthyroidism, while long-term use can reduce bone mineral density. In patients with cardiac disease, levothyroxine can worsen angina and lead to atrial fibrillation. It is also important to be aware of drug interactions, particularly with iron and calcium carbonate, which can reduce the absorption of levothyroxine. These medications should be given at least 4 hours apart.

      In summary, managing hypothyroidism involves careful consideration of dosage, monitoring of TSH levels, and awareness of potential side-effects and drug interactions. With appropriate management, patients with hypothyroidism can achieve normal thyroid function and improve their overall health.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 105 - A 46-year-old woman presents with recurring thrush and fatigue. She is concerned that...

    Correct

    • A 46-year-old woman presents with recurring thrush and fatigue. She is concerned that it may be caused by a sexually transmitted infection, but her recent sexual health screening came back negative for syphilis, HIV, Chlamydia, and Gonorrhoea. Her urine test shows ketones and glucose. A random glucose test reveals a reading of 13. What is the most suitable medication for the ongoing treatment of this condition?

      Your Answer: Metformin

      Explanation:

      The patient is displaying symptoms of type 2 diabetes, with a random blood glucose level exceeding 11.1 and experiencing related symptoms. As per protocol, the first line of treatment for type 2 diabetes is metformin, which should be prescribed to the patient. It is important to note that insulin is the primary treatment for type 1 diabetes, while gliclazide, pioglitazone, and glibenclamide are secondary medications used in the management of type 2 diabetes, but are not typically prescribed as first line treatments.

      Type 2 diabetes mellitus can be diagnosed through a plasma glucose or HbA1c sample. The diagnostic criteria vary depending on whether the patient is experiencing symptoms or not. If the patient is symptomatic, a fasting glucose level of 7.0 mmol/l or higher or a random glucose level of 11.1 mmol/l or higher (or after a 75g oral glucose tolerance test) indicates diabetes. If the patient is asymptomatic, the same criteria apply but must be demonstrated on two separate occasions.

      In 2011, the World Health Organization released supplementary guidance on the use of HbA1c for diagnosing diabetes. A HbA1c level of 48 mmol/mol (6.5%) or higher is diagnostic of diabetes mellitus. However, a HbA1c value of less than 48 mmol/mol (6.5%) does not exclude diabetes and may not be as sensitive as fasting samples for detecting diabetes. For patients without symptoms, the test must be repeated to confirm the diagnosis. It is important to note that increased red cell turnover can cause misleading HbA1c results.

      There are certain conditions where HbA1c cannot be used for diagnosis, such as haemoglobinopathies, haemolytic anaemia, untreated iron deficiency anaemia, suspected gestational diabetes, children, HIV, chronic kidney disease, and people taking medication that may cause hyperglycaemia (such as corticosteroids).

      Impaired fasting glucose (IFG) is defined as a fasting glucose level of 6.1 mmol/l or higher but less than 7.0 mmol/l. Impaired glucose tolerance (IGT) is defined as a fasting plasma glucose level less than 7.0 mmol/l and an OGTT 2-hour value of 7.8 mmol/l or higher but less than 11.1 mmol/l. People with IFG should be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person does not have diabetes but does have IGT.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 106 - A geriatric patient presents to the Emergency Department with a fast, irregular pulse,...

    Correct

    • A geriatric patient presents to the Emergency Department with a fast, irregular pulse, chest pain, weakness and palpitations. Upon arrival, investigations were carried out, including the following:
      Investigation Result Normal value
      PaO2 11.9 kPa
      pH 7.35 7.40 ± 0.05
      PaCO2 27 mmHg
      Sodium (Na+) 125 mmol
      Potassium (K+) 6.7 mmol
      HCO3− 15 mmol
      Chloride (Cl−) 107 mmol
      Normal anion gap 10–18 mmol/l
      With which of the following are the results consistent?

      Your Answer: Addisonian crisis

      Explanation:

      Causes of Metabolic Acidosis with Normal Anion Gap

      Metabolic acidosis with a normal anion gap can be caused by various medical conditions. One such condition is an Addisonian crisis, which occurs due to severe adrenal insufficiency. This results in reduced activity of aldosterone, causing sodium loss and potassium retention, leading to hyperkalaemia and metabolic acidosis with a normal anion gap.

      Burns can also cause hyperkalaemia due to rhabdomyolysis, resulting in a raised anion gap metabolic acidosis. Diabetic ketoacidosis is another condition that presents with hyperkalaemia and metabolic acidosis, but with an increased anion gap due to ketone bodies.

      Diarrhoea can cause hypokalaemia, hyponatraemia, loss of bicarbonate, and metabolic acidosis with a normal anion gap. However, excessive thiazide treatment would result in hypokalaemia and not hyperkalaemia.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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