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Question 1
Correct
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A 57-year-old woman presents to the physician with a recurring blistering rash on her hands. The rash has also affected her legs, inguinal creases, and the corners of her mouth at different times. She was diagnosed with type 2 diabetes mellitus three months ago and has occasional loose stools. The patient denies experiencing palpitations, abdominal pain, or vomiting, but reports having occasional watery stools.
During the physical examination, the physician observes coalescing erythematous plaques with crusting and scaling at the borders and central areas of brownish induration over the lower abdomen and in the perioral skin.
What is the most likely diagnosis for this patient?Your Answer: Glucagonoma
Explanation:The patient is likely suffering from a glucagonoma, a rare tumor that originates from the alpha cells of the pancreas. This condition causes the excessive secretion of glucagon, resulting in hyperglycemia or diabetes mellitus. One of the characteristic symptoms of glucagonoma is necrolytic migratory erythema, a painful and itchy rash that appears on the face, groin, and limbs.
Gastrinoma, on the other hand, does not cause a blistering rash or diabetes mellitus. However, it is often associated with abdominal pain, diarrhea, and ulceration.
Somatostatinoma typically presents with abdominal pain, constipation, hyperglycemia, and steatorrhea, which are not present in this patient.
VIPoma is unlikely as it usually causes intractable diarrhea, hypokalemia, and achlorhydria.
Although zinc deficiency can cause skin lesions that resemble necrolytic migratory erythema, the patient’s recent diabetes mellitus diagnosis and lack of other symptoms make glucagonoma the more likely diagnosis.
Glucagonoma: A Rare Pancreatic Tumor
Glucagonoma is a rare type of pancreatic tumor that usually originates from the alpha cells of the pancreas. These tumors are typically small and malignant, and they can cause a range of symptoms, including diabetes mellitus, venous thrombo-embolism, and a distinctive red, blistering rash known as necrolytic migratory erythema. To diagnose glucagonoma, doctors typically look for a serum level of glucagon that is higher than 1000pg/ml, and they may also use CT scanning to visualize the tumor. Treatment options for glucagonoma include surgical resection and octreotide, a medication that can help to control the symptoms of the disease. Overall, glucagonoma is a rare but serious condition that requires prompt diagnosis and treatment to manage its symptoms and prevent complications.
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This question is part of the following fields:
- Endocrine System
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Question 2
Correct
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A 29-year-old male attends a pre-operative assessment clinic for thyroidectomy due to failed treatment with carbimazole and radio-iodine for Grave's disease. What is the potential complication that he is at a high risk of developing during this procedure?
Your Answer: Recurrent laryngeal nerve palsy
Explanation:The risk of complications during thyroidectomy is relatively low, but there are still potential risks to be aware of. One of the most common complications is damage to the recurrent laryngeal nerve, which can result in vocal cord paralysis and hoarseness. However, the vagal nerve and phrenic nerve are rarely damaged during the procedure as they are not in close proximity to the operating site. Trauma to the esophagus is also uncommon. If the parathyroid glands are inadvertently removed during the procedure, it can result in hypoparathyroidism rather than hyperparathyroidism.
Thyroid disorders are commonly encountered in clinical practice, with hypothyroidism and thyrotoxicosis being the most prevalent. Women are ten times more likely to develop these conditions than men. The thyroid gland is a bi-lobed structure located in the anterior neck and is part of a hypothalamus-pituitary-end organ system that regulates the production of thyroxine and triiodothyronine hormones. These hormones help regulate energy sources, protein synthesis, and the body’s sensitivity to other hormones. Hypothyroidism can be primary or secondary, while thyrotoxicosis is mostly primary. Autoimmunity is the leading cause of thyroid problems in the developed world.
Thyroid disorders can present in various ways, with symptoms often being the opposite depending on whether the thyroid gland is under or overactive. For example, hypothyroidism may result in weight gain, while thyrotoxicosis leads to weight loss. Thyroid function tests are the primary investigation for diagnosing thyroid disorders. These tests primarily look at serum TSH and T4 levels, with T3 being measured in specific cases. TSH levels are more sensitive than T4 levels for monitoring patients with existing thyroid problems.
Treatment for thyroid disorders depends on the cause. Patients with hypothyroidism are given levothyroxine to replace the underlying deficiency. Patients with thyrotoxicosis may be treated with propranolol to control symptoms such as tremors, carbimazole to reduce thyroid hormone production, or radioiodine treatment.
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This question is part of the following fields:
- Endocrine System
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Question 3
Incorrect
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A 72-year-old woman presents to the emergency department with right hip pain following a fall at home. She is unable to bear weight and her right leg appears externally rotated and shorter. Her medical history includes osteoarthritis in her knee, type 2 diabetes mellitus, and hypertension. She is currently being tapered off prednisolone for polymyalgia rheumatica which was diagnosed 2 years ago. Which medication in her regimen may have contributed to her increased risk?
Your Answer: Ibuprofen gel
Correct Answer: Prednisolone
Explanation:Patients who take systemic corticosteroids over a long period of time are at a higher risk of developing osteoporosis and experiencing fractures. In this case, the patient’s hip fracture may have been caused by her pre-existing osteoporosis.
Corticosteroids are commonly prescribed medications that can be taken orally or intravenously, or applied topically. They mimic the effects of natural steroids in the body and can be used to replace or supplement them. However, the use of corticosteroids is limited by their numerous side effects, which are more common with prolonged and systemic use. These side effects can affect various systems in the body, including the endocrine, musculoskeletal, gastrointestinal, ophthalmic, and psychiatric systems. Some of the most common side effects include impaired glucose regulation, weight gain, osteoporosis, and increased susceptibility to infections. Patients on long-term corticosteroids should have their doses adjusted during intercurrent illness, and the medication should not be abruptly withdrawn to avoid an Addisonian crisis. Gradual withdrawal is recommended for patients who have received high doses or prolonged treatment.
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This question is part of the following fields:
- Endocrine System
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Question 4
Incorrect
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A 35-year-old woman is referred to the endocrine clinic due to missed periods and lactation. She has also gained weight and experiences vaginal dryness. The endocrinologist decides to measure her prolactin levels. What hormone is responsible for suppressing the release of prolactin from the pituitary gland?
Your Answer: Gonadotropin releasing hormone
Correct Answer: Dopamine
Explanation:Dopamine consistently prevents the release of prolactin.
Understanding Prolactin and Its Functions
Prolactin is a hormone that is produced by the anterior pituitary gland. Its primary function is to stimulate breast development and milk production in females. During pregnancy, prolactin levels increase to support the growth and development of the mammary glands. It also plays a role in reducing the pulsatility of gonadotropin-releasing hormone (GnRH) at the hypothalamic level, which can block the action of luteinizing hormone (LH) on the ovaries or testes.
The secretion of prolactin is regulated by dopamine, which constantly inhibits its release. However, certain factors can increase or decrease prolactin secretion. For example, prolactin levels increase during pregnancy, in response to estrogen, and during breastfeeding. Additionally, stress, sleep, and certain drugs like metoclopramide and antipsychotics can also increase prolactin secretion. On the other hand, dopamine and dopaminergic agonists can decrease prolactin secretion.
Overall, understanding the functions and regulation of prolactin is important for reproductive health and lactation.
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This question is part of the following fields:
- Endocrine System
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Question 5
Incorrect
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A 23-year-old woman is experiencing renal colic and is being evaluated for possible MEN IIa. What is the most common parathyroid gland abnormality associated with this condition?
Your Answer: Adenoma
Correct Answer: Hyperplasia
Explanation:Medullary thyroid cancer, hypercalcaemia, and phaeochromocytoma are associated with multiple endocrine neoplasia type IIa. The most frequent occurrence in this condition is medullary thyroid cancer, while hyperplasia is the most common lesion in the parathyroid glands. In contrast, parathyroid adenoma is the most common lesion in MEN I.
Understanding Multiple Endocrine Neoplasia
Multiple endocrine neoplasia (MEN) is an autosomal dominant disorder that affects the endocrine system. There are three main types of MEN, each with its own set of associated features. MEN type I is characterized by the 3 P’s: parathyroid hyperplasia leading to hyperparathyroidism, pituitary tumors, and pancreatic tumors such as insulinomas and gastrinomas. MEN type IIa is associated with the 2 P’s: parathyroid hyperplasia leading to hyperparathyroidism and phaeochromocytoma, as well as medullary thyroid cancer. MEN type IIb is characterized by phaeochromocytoma, medullary thyroid cancer, and a marfanoid body habitus.
The most common presentation of MEN is hypercalcaemia, which is often seen in MEN type I due to parathyroid hyperplasia. MEN type IIa and IIb are both associated with medullary thyroid cancer, which is caused by mutations in the RET oncogene. MEN type I is caused by mutations in the MEN1 gene. Understanding the different types of MEN and their associated features is important for early diagnosis and management of this rare but potentially serious condition.
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This question is part of the following fields:
- Endocrine System
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Question 6
Incorrect
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A 35-year-old man, with a history of type 1 diabetes, was discovered disoriented on the road. He was taken to the ER and diagnosed with hypoglycemia. As IV access was not feasible, IM glucagon was administered. What accurately explains the medication's mechanism of action?
Your Answer: Increases secretion of desmopressin
Correct Answer: Increases secretion of somatostatin
Explanation:Somatostatin, a hormone that inhibits the secretion of insulin and glucagon, is produced in the pancreas. Glucagon can increase the secretion of somatostatin through a feedback mechanism, while insulin can decrease it. Somatostatin also plays a role in controlling the emptying of the stomach and bowel.
Glucagon is a treatment option for hypoglycemia, along with IV dextrose if the patient is confused and IV access is available.
Cortisol is produced in the adrenal gland’s zona fasciculate and is triggered by ACTH, which is released from the anterior pituitary gland. Glucagon can stimulate ACTH-induced cortisol release.
Desmopressin is an analogue of vasopressin and is used to replace vasopressin/ADH in the treatment of central diabetes insipidus, where there is a lack of ADH due to decreased or non-existent secretion or production by the hypothalamus or posterior pituitary.
Prolactin, produced in the anterior pituitary, is responsible for milk production in the breasts.
Somatostatin: The Inhibitor Hormone
Somatostatin, also known as growth hormone inhibiting hormone (GHIH), is a hormone produced by delta cells found in the pancreas, pylorus, and duodenum. Its main function is to inhibit the secretion of growth hormone, insulin, and glucagon. It also decreases acid and pepsin secretion, as well as pancreatic enzyme secretion. Additionally, somatostatin inhibits the trophic effects of gastrin and stimulates gastric mucous production.
Somatostatin analogs are commonly used in the management of acromegaly, a condition characterized by excessive growth hormone secretion. These analogs work by inhibiting growth hormone secretion, thereby reducing the symptoms associated with acromegaly.
The secretion of somatostatin is regulated by various factors. Its secretion increases in response to fat, bile salts, and glucose in the intestinal lumen, as well as glucagon. On the other hand, insulin decreases the secretion of somatostatin.
In summary, somatostatin plays a crucial role in regulating the secretion of various hormones and enzymes in the body. Its inhibitory effects on growth hormone, insulin, and glucagon make it an important hormone in the management of certain medical conditions.
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This question is part of the following fields:
- Endocrine System
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Question 7
Correct
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A 20-year-old man comes to the emergency department complaining of abdominal pain, vomiting, polyuria, polydipsia, and confusion that have been present for the past 12 hours. During the examination, he shows mild generalized abdominal tenderness without guarding. His breathing is observed to be deep and rapid.
The patient has a medical history of type 1 diabetes, but he confesses to being non-compliant with his insulin regimen.
What is the probable pathophysiology behind his symptoms?Your Answer: Uncontrolled lipolysis which results in an excess of free fatty acids
Explanation:The cause of DKA is uncontrolled lipolysis, leading to an excess of free fatty acids that are converted to ketone bodies. This results in high levels of ketones in the urine. Hypoglycemia activates the sympathetic nervous system. Lactic acidosis is similar to DKA but lacks the presence of ketones in urine. Appendicitis can cause abdominal pain, vomiting, and urinary symptoms, but the presence of ketones in urine suggests DKA. Urinary tract infections are rare in men under 50 and typically occur with abnormal anatomy or catheterization.
Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus, accounting for around 6% of cases. It can also occur in rare cases of extreme stress in patients with type 2 diabetes mellitus. DKA is caused by uncontrolled lipolysis, resulting in an excess of free fatty acids that are converted to ketone bodies. The most common precipitating factors of DKA are infection, missed insulin doses, and myocardial infarction. Symptoms include abdominal pain, polyuria, polydipsia, dehydration, Kussmaul respiration, and breath that smells like acetone. Diagnostic criteria include glucose levels above 11 mmol/l or known diabetes mellitus, pH below 7.3, bicarbonate below 15 mmol/l, and ketones above 3 mmol/l or urine ketones ++ on dipstick.
Management of DKA involves fluid replacement, insulin, and correction of electrolyte disturbance. Fluid replacement is necessary as most patients with DKA are deplete around 5-8 litres. Isotonic saline is used initially, even if the patient is severely acidotic. Insulin is administered through an intravenous infusion, and correction of electrolyte disturbance is necessary. Long-acting insulin should be continued, while short-acting insulin should be stopped. Complications may occur from DKA itself or the treatment, such as gastric stasis, thromboembolism, arrhythmias, acute respiratory distress syndrome, acute kidney injury, and cerebral edema. Children and young adults are particularly vulnerable to cerebral edema following fluid resuscitation in DKA and often need 1:1 nursing to monitor neuro-observations, headache, irritability, visual disturbance, focal neurology, etc.
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This question is part of the following fields:
- Endocrine System
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Question 8
Incorrect
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Which of the following most accurately explains how glucocorticoids work?
Your Answer: Binding of cell wall receptors and intracellular tyrosine kinase activation
Correct Answer: Binding of intracellular receptors that migrate to the nucleus to then affect gene transcription
Explanation:The effects of glucocorticoids are mediated by intracellular receptors that bind to them and are subsequently transported to the nucleus, where they modulate gene transcription.
Corticosteroids are commonly prescribed medications that can be taken orally or intravenously, or applied topically. They mimic the effects of natural steroids in the body and can be used to replace or supplement them. However, the use of corticosteroids is limited by their numerous side effects, which are more common with prolonged and systemic use. These side effects can affect various systems in the body, including the endocrine, musculoskeletal, gastrointestinal, ophthalmic, and psychiatric systems. Some of the most common side effects include impaired glucose regulation, weight gain, osteoporosis, and increased susceptibility to infections. Patients on long-term corticosteroids should have their doses adjusted during intercurrent illness, and the medication should not be abruptly withdrawn to avoid an Addisonian crisis. Gradual withdrawal is recommended for patients who have received high doses or prolonged treatment.
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This question is part of the following fields:
- Endocrine System
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Question 9
Incorrect
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A 65-year-old woman with type 2 diabetes mellitus is being evaluated by her diabetic nurse. Despite taking metformin for the past 6 months, her glycaemic control remains poor. To improve management, the decision is made to add sitagliptin (a dipeptidyl-peptidase 4 (DPP-4) inhibitor) to her current metformin regimen.
What is the mechanism of action of the newly prescribed medication?Your Answer: Increases cell sensitivity to insulin
Correct Answer: Increased levels of glucagon-like peptide 1 (GLP-1)
Explanation:DPP-4 inhibitors, like sitagliptin, work by inhibiting the breakdown of incretins such as GLP-1 and GIP. This leads to higher levels of insulin being released, as incretins increase insulin release. These inhibitors are often weight-neutral, but can occasionally cause weight loss.
The answer Increases cell sensitivity to insulin is incorrect, as this is the mechanism of action of metformin, not DPP-4 inhibitors. Metformin increases cell sensitivity to insulin, but the exact mechanism is not fully understood.
Similarly, Inhibition of sodium-glucose co-transporter (SGLT2) is incorrect, as this is the mechanism of action of SGLT2 inhibitors, not DPP-4 inhibitors. SGLT2 inhibitors prevent glucose absorption in the kidneys, leading to higher levels of glucose in the urine and an increased risk of urinary tract infections.
Lastly, Increases adipogenesis is incorrect, as this is the mechanism of action of thiazolidinediones, not DPP-4 inhibitors. Thiazolidinediones stimulate adipogenesis, causing cells to become more dependent on glucose for energy.
Diabetes mellitus is a condition that has seen the development of several drugs in recent years. One hormone that has been the focus of much research is glucagon-like peptide-1 (GLP-1), which is released by the small intestine in response to an oral glucose load. In type 2 diabetes mellitus (T2DM), insulin resistance and insufficient B-cell compensation occur, and the incretin effect, which is largely mediated by GLP-1, is decreased. GLP-1 mimetics, such as exenatide and liraglutide, increase insulin secretion and inhibit glucagon secretion, resulting in weight loss, unlike other medications. They are sometimes used in combination with insulin in T2DM to minimize weight gain. Dipeptidyl peptidase-4 (DPP-4) inhibitors, such as vildagliptin and sitagliptin, increase levels of incretins by decreasing their peripheral breakdown, are taken orally, and do not cause weight gain. Nausea and vomiting are the major adverse effects of GLP-1 mimetics, and the Medicines and Healthcare products Regulatory Agency has issued specific warnings on the use of exenatide, reporting that it has been linked to severe pancreatitis in some patients. NICE guidelines suggest that a DPP-4 inhibitor might be preferable to a thiazolidinedione if further weight gain would cause significant problems, a thiazolidinedione is contraindicated, or the person has had a poor response to a thiazolidinedione.
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This question is part of the following fields:
- Endocrine System
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Question 10
Correct
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A 54-year-old man with a history of type II diabetes mellitus presents for a routine check-up. He reports no symptoms of increased urination or thirst. Laboratory results reveal an HbA1c level of 67 mmol/mol and a random plasma glucose level of 15.6 mg/l. The patient is currently taking metformin, and his physician decides to add gliclazide to his medication regimen. What is the mechanism of action of gliclazide?
Your Answer: Stimulates sulphonylurea-1 receptors
Explanation:The primary mode of action of gliclazide, which belongs to the sulphonylurea class, is to activate the sulphonylurea-1 receptors present on pancreatic cells, thereby promoting insulin secretion. The remaining choices pertain to alternative medications for diabetes.
Common Medications for Type 2 Diabetes
Type 2 diabetes is a chronic condition that affects millions of people worldwide. Fortunately, there are several medications available to help manage the disease. Some of the most commonly prescribed drugs include sulphonylureas, metformin, alpha-glucosidase inhibitors (such as acarbose), glitazones, and insulin.
Sulphonylureas are a type of medication that stimulates the pancreas to produce more insulin. This helps to lower blood sugar levels and improve glucose control. Metformin, on the other hand, works by reducing the amount of glucose produced by the liver and improving insulin sensitivity. Alpha-glucosidase inhibitors, like acarbose, slow down the digestion of carbohydrates in the small intestine, which helps to prevent spikes in blood sugar levels after meals.
Glitazones, also known as thiazolidinediones, improve insulin sensitivity and reduce insulin resistance. They work by activating a specific receptor in the body that helps to regulate glucose metabolism. Finally, insulin is a hormone that is naturally produced by the pancreas and helps to regulate blood sugar levels. In some cases, people with type 2 diabetes may need to take insulin injections to help manage their condition.
Overall, these medications can be very effective in helping people with type 2 diabetes to manage their blood sugar levels and prevent complications. However, it’s important to work closely with a healthcare provider to determine the best treatment plan for each individual.
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This question is part of the following fields:
- Endocrine System
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Question 11
Incorrect
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A 70-year-old man with chronic back pain and renal failure presents with the following blood test results:
Reference range
Ca2+ 2.10 2.15-2.55 mmol/l
Parathyroid hormone 9.8 1-6.5 pmol/l
Phosphate 0.75 0.6-1.25 mmol/l
What is the probable diagnosis?Your Answer: Pseudohypoparathyroidism
Correct Answer: Secondary hyperparathyroidism
Explanation:Secondary hyperparathyroidism is characterized by elevated levels of PTH, while calcium levels are either normal or low. This condition occurs due to the parathyroid glands’ hyperplasia in response to chronic hypocalcemia or hyperphosphatemia, which is a natural physiological reaction. The body releases calcium from the kidneys, gastrointestinal system, and bones.
Parathyroid Glands and Disorders of Calcium Metabolism
The parathyroid glands play a crucial role in regulating calcium levels in the body. Hyperparathyroidism is a disorder that occurs when these glands produce too much parathyroid hormone (PTH), leading to abnormal calcium metabolism. Primary hyperparathyroidism is the most common form and is usually caused by a solitary adenoma. Secondary hyperparathyroidism occurs as a result of low calcium levels, often in the setting of chronic renal failure. Tertiary hyperparathyroidism is a rare condition that occurs when hyperplasia of the parathyroid glands persists after correction of underlying renal disorder.
Diagnosis of hyperparathyroidism is based on hormone profiles and clinical features. Treatment options vary depending on the type and severity of the disorder. Surgery is usually indicated for primary hyperparathyroidism if certain criteria are met, such as elevated serum calcium levels, hypercalciuria, and nephrolithiasis. Secondary hyperparathyroidism is typically managed with medical therapy, while surgery may be necessary for persistent symptoms such as bone pain and soft tissue calcifications. Tertiary hyperparathyroidism may resolve on its own within a year after transplant, but surgery may be required if an autonomously functioning parathyroid gland is present. It is important to consider differential diagnoses, such as benign familial hypocalciuric hypercalcaemia, which is a rare but relatively benign condition.
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This question is part of the following fields:
- Endocrine System
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Question 12
Incorrect
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A 25-year-old woman presents for her first-trimester review at the antenatal clinic. She reports feeling well with no specific concerns. Due to complications in her previous pregnancy, she undergoes several screening blood tests, including thyroid function testing. The results reveal a TSH level of 4.2 mIU/L (normal range: 0.4-4.0), thyroxine (T4) level of 220 nmol/L (normal range: 64-155), and free thyroxine (fT4) level of 15 pmol/L (normal range: 12.0-21.9). Despite having no symptoms of thyrotoxicosis and a normal physical examination, what thyroid-associated protein primarily causes these findings to occur?
Your Answer: Thyroglobulin
Correct Answer: Thyroid binding globulin
Explanation:During pregnancy, thyroid function can be affected, leading to a range of conditions. However, in the case of a patient with a nodular goitre, antithyroid antibodies are not a likely cause. Thyroglobulin levels may increase slightly in the final trimester, but this is not the primary issue. Similarly, while TSH levels may be raised in pregnancy, this is a secondary effect caused by an increase in TBG.
During pregnancy, there is an increase in the levels of thyroxine-binding globulin (TBG), which causes an increase in the levels of total thyroxine. However, this does not affect the free thyroxine level. If left untreated, thyrotoxicosis can increase the risk of fetal loss, maternal heart failure, and premature labor. Graves’ disease is the most common cause of thyrotoxicosis during pregnancy, but transient gestational hyperthyroidism can also occur due to the activation of the TSH receptor by HCG. Propylthiouracil has traditionally been the antithyroid drug of choice, but it is associated with an increased risk of severe hepatic injury. Therefore, NICE Clinical Knowledge Summaries recommend using propylthiouracil in the first trimester and switching to carbimazole in the second trimester. Maternal free thyroxine levels should be kept in the upper third of the normal reference range to avoid fetal hypothyroidism. Thyrotropin receptor stimulating antibodies should be checked at 30-36 weeks gestation to determine the risk of neonatal thyroid problems. Block-and-replace regimes should not be used in pregnancy, and radioiodine therapy is contraindicated.
On the other hand, thyroxine is safe during pregnancy, and serum thyroid-stimulating hormone should be measured in each trimester and 6-8 weeks postpartum. Women require an increased dose of thyroxine during pregnancy, up to 50% as early as 4-6 weeks of pregnancy. Breastfeeding is safe while on thyroxine. It is important to manage thyroid problems during pregnancy to ensure the health of both the mother and the baby.
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This question is part of the following fields:
- Endocrine System
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Question 13
Correct
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A 23-year-old male patient visits his GP complaining of breast tissue enlargement that has been progressively worsening for the past 3 months. He also reports the presence of a new lump on his left testicle. Upon thorough examination and taking a detailed medical history, the GP suspects that the patient may be suffering from testicular cancer.
What is the probable diagnosis?Your Answer: HCG secreting seminoma
Explanation:Gynaecomastia can be caused by testicular conditions such as seminoma that secrete hCG.
Understanding Gynaecomastia: Causes and Drug Triggers
Gynaecomastia is a condition characterized by the abnormal growth of breast tissue in males, often caused by an increased ratio of oestrogen to androgen. It is important to distinguish the causes of gynaecomastia from those of galactorrhoea, which is caused by the actions of prolactin on breast tissue.
Physiological changes during puberty can lead to gynaecomastia, but it can also be caused by syndromes with androgen deficiency such as Kallmann and Klinefelter’s, testicular failure due to mumps, liver disease, testicular cancer, and hyperthyroidism. Additionally, haemodialysis and ectopic tumour secretion can also trigger gynaecomastia.
Drug-induced gynaecomastia is also a common cause, with spironolactone being the most frequent trigger. Other drugs that can cause gynaecomastia include cimetidine, digoxin, cannabis, finasteride, GnRH agonists like goserelin and buserelin, oestrogens, and anabolic steroids. However, it is important to note that very rare drug causes of gynaecomastia include tricyclics, isoniazid, calcium channel blockers, heroin, busulfan, and methyldopa.
In summary, understanding the causes and drug triggers of gynaecomastia is crucial in diagnosing and treating this condition.
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This question is part of the following fields:
- Endocrine System
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Question 14
Correct
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A 15-year-old male arrives at the emergency department with intense abdominal pain and a decreased Glasgow coma score (GCS). Over the past few weeks, he has been experiencing excessive urination, abnormal thirst, and weight loss. Laboratory results reveal:
Ketones 4.2 mmol/L (<0.6 mmol/L)
Glucose 20 mmol/L
pH 7.25
What is the probable cause of the acidosis and hyperketonemia in this case?Your Answer: Uncontrolled lipolysis
Explanation:The likely cause of the patient’s condition is diabetic ketoacidosis, which is a result of uncontrolled lipolysis. This process leads to an excess of free fatty acids that are eventually converted into ketone bodies. It is important to note that proteolysis, the breakdown of proteins into smaller polypeptides, does not yield ketone bodies and is not the cause of this condition. While glycogenolysis and gluconeogenesis are increased due to the lack of insulin and rise of glucagon, they do not result in acidosis or elevated levels of ketone bodies. It is ketogenesis, not ketolysis, that leads to the increased levels of ketone bodies.
Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus, accounting for around 6% of cases. It can also occur in rare cases of extreme stress in patients with type 2 diabetes mellitus. DKA is caused by uncontrolled lipolysis, resulting in an excess of free fatty acids that are converted to ketone bodies. The most common precipitating factors of DKA are infection, missed insulin doses, and myocardial infarction. Symptoms include abdominal pain, polyuria, polydipsia, dehydration, Kussmaul respiration, and breath that smells like acetone. Diagnostic criteria include glucose levels above 11 mmol/l or known diabetes mellitus, pH below 7.3, bicarbonate below 15 mmol/l, and ketones above 3 mmol/l or urine ketones ++ on dipstick.
Management of DKA involves fluid replacement, insulin, and correction of electrolyte disturbance. Fluid replacement is necessary as most patients with DKA are deplete around 5-8 litres. Isotonic saline is used initially, even if the patient is severely acidotic. Insulin is administered through an intravenous infusion, and correction of electrolyte disturbance is necessary. Long-acting insulin should be continued, while short-acting insulin should be stopped. Complications may occur from DKA itself or the treatment, such as gastric stasis, thromboembolism, arrhythmias, acute respiratory distress syndrome, acute kidney injury, and cerebral edema. Children and young adults are particularly vulnerable to cerebral edema following fluid resuscitation in DKA and often need 1:1 nursing to monitor neuro-observations, headache, irritability, visual disturbance, focal neurology, etc.
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This question is part of the following fields:
- Endocrine System
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Question 15
Incorrect
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A 32-year-old man has been admitted to the emergency department with severe hypocalcaemia that has not responded to calcium replacement therapy. What other serum electrolytes should be checked urgently?
Your Answer: Potassium
Correct Answer: Magnesium
Explanation:If a person has hypomagnesaemia, it can lead to hypocalcaemia and make it difficult to treat. Therefore, when dealing with hypocalcaemia, it is important to keep an eye on the levels of calcium, phosphate, and magnesium. The phosphate levels can provide insight into potential causes, as low calcium levels combined with high phosphate levels may indicate hypoparathyroidism.
The Importance of Magnesium and Calcium in the Body
Magnesium and calcium are essential minerals in the body. Magnesium plays a crucial role in the secretion and action of parathyroid hormone (PTH) on target tissues. However, a deficiency in magnesium can cause hypocalcaemia and make patients unresponsive to calcium and vitamin D supplementation.
The body contains 1000 mmol of magnesium, with half stored in bones and the rest in muscle, soft tissues, and extracellular fluid. Unlike calcium, there is no specific hormonal control of magnesium. Hormones such as PTH and aldosterone affect the renal handling of magnesium.
Magnesium and calcium also interact at a cellular level. A decrease in magnesium levels can affect the permeability of cellular membranes to calcium, leading to hyperexcitability. Therefore, it is essential to maintain adequate levels of both magnesium and calcium in the body for optimal health.
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This question is part of the following fields:
- Endocrine System
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Question 16
Correct
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A 65-year-old man presents with abdominal tenderness, steatorrhoea, and jaundice. Upon investigation, a somatostatinoma of the pancreas is discovered. What is the probable cell type from which this neoplasm originated?
Your Answer: Delta-cells
Explanation:Somatostatin is secreted by the delta cells located in the pancreas. These cells are also present in the stomach, duodenum, and jejunum. In the pancreas, somatostatin plays a role in inhibiting the release of exocrine enzymes, glucagon, and insulin. In rare cases of large somatostatinomas, patients may experience mild diabetes mellitus.
The answer choices of alpha-cells, beta-cells, and S-cells are incorrect as they secrete glucagon, insulin, and secretin, respectively.
Somatostatin: The Inhibitor Hormone
Somatostatin, also known as growth hormone inhibiting hormone (GHIH), is a hormone produced by delta cells found in the pancreas, pylorus, and duodenum. Its main function is to inhibit the secretion of growth hormone, insulin, and glucagon. It also decreases acid and pepsin secretion, as well as pancreatic enzyme secretion. Additionally, somatostatin inhibits the trophic effects of gastrin and stimulates gastric mucous production.
Somatostatin analogs are commonly used in the management of acromegaly, a condition characterized by excessive growth hormone secretion. These analogs work by inhibiting growth hormone secretion, thereby reducing the symptoms associated with acromegaly.
The secretion of somatostatin is regulated by various factors. Its secretion increases in response to fat, bile salts, and glucose in the intestinal lumen, as well as glucagon. On the other hand, insulin decreases the secretion of somatostatin.
In summary, somatostatin plays a crucial role in regulating the secretion of various hormones and enzymes in the body. Its inhibitory effects on growth hormone, insulin, and glucagon make it an important hormone in the management of certain medical conditions.
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This question is part of the following fields:
- Endocrine System
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Question 17
Correct
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A 33-year-old man arrives at the emergency department with symptoms of increased thirst and frequent urination. He had suffered a head injury a few days ago and had previously been discharged after investigations. Upon examination, he appears dehydrated and is admitted to a medical ward. The urine osmolality test results show a low level of 250 mosmol/kg after water deprivation and a high level of 655 mosmol/kg after desmopressin administration. Based on this information, where is the deficient substance typically active?
Your Answer: Collecting duct
Explanation:The site of action for antidiuretic hormone (ADH) is the collecting ducts in the kidneys. A diagnosis of cranial diabetes insipidus, which can occur after head trauma, is confirmed by low urine osmolalities. In this condition, there is a deficiency of ADH, which is synthesized in the hypothalamus but acts on the collecting ducts to promote water reabsorption. Therefore, the hypothalamus is not the site of action for ADH, despite being where it is synthesized. The Loop of Henle and proximal convoluted tubule are also not the primary sites of action for ADH. ADH is released from the posterior pituitary gland, but its action occurs in the collecting ducts.
Understanding Antidiuretic Hormone (ADH)
Antidiuretic hormone (ADH) is a hormone that is produced in the supraoptic nuclei of the hypothalamus and released by the posterior pituitary gland. Its primary function is to conserve body water by promoting water reabsorption in the collecting ducts of the kidneys through the insertion of aquaporin-2 channels.
ADH secretion is regulated by various factors. An increase in extracellular fluid osmolality, a decrease in volume or pressure, and the presence of angiotensin II can all increase ADH secretion. Conversely, a decrease in extracellular fluid osmolality, an increase in volume, a decrease in temperature, or the absence of ADH can decrease its secretion.
Diabetes insipidus (DI) is a condition that occurs when there is either a deficiency of ADH (cranial DI) or an insensitivity to ADH (nephrogenic DI). Cranial DI can be treated with desmopressin, which is an analog of ADH.
Overall, understanding the role of ADH in regulating water balance in the body is crucial for maintaining proper hydration and preventing conditions like DI.
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This question is part of the following fields:
- Endocrine System
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Question 18
Correct
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A 68-year-old man with a long history of poorly controlled type-2 diabetes is prescribed a new medication that increases urinary glucose excretion. The doctor informs him that it belongs to the SGLT-2 inhibitor drug class.
Which of the following medications is classified as an SGLT-2 inhibitor?Your Answer: Dapagliflozin
Explanation:SGLT2 inhibitors are known as gliflozins.
Sulfonylurea refers to tolbutamide.
GLP-1 receptor agonist is exenatide.
DPP-4 inhibitor is linagliptin.
Understanding SGLT-2 Inhibitors
SGLT-2 inhibitors are medications that work by blocking the reabsorption of glucose in the kidneys, leading to increased excretion of glucose in the urine. This mechanism of action helps to lower blood sugar levels in patients with type 2 diabetes mellitus. Examples of SGLT-2 inhibitors include canagliflozin, dapagliflozin, and empagliflozin.
However, it is important to note that SGLT-2 inhibitors can also have adverse effects. Patients taking these medications may be at increased risk for urinary and genital infections due to the increased glucose in the urine. Fournier’s gangrene, a rare but serious bacterial infection of the genital area, has also been reported. Additionally, there is a risk of normoglycemic ketoacidosis, a condition where the body produces high levels of ketones even when blood sugar levels are normal. Finally, patients taking SGLT-2 inhibitors may be at increased risk for lower-limb amputations, so it is important to closely monitor the feet.
Despite these potential risks, SGLT-2 inhibitors can also have benefits. Patients taking these medications often experience weight loss, which can be beneficial for those with type 2 diabetes mellitus. Overall, it is important for patients to discuss the potential risks and benefits of SGLT-2 inhibitors with their healthcare provider before starting treatment.
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This question is part of the following fields:
- Endocrine System
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Question 19
Correct
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A 38-year-old woman presents with symptoms of irritability and changes in bowel habits. During examination, a smooth enlargement of the thyroid gland is noted. Thyroid function tests are ordered and the results are as follows:
TSH 0.1 mug/l
Free T4 35 pmol/l
What is the most likely underlying diagnosis?Your Answer: Graves disease
Explanation:When TSH receptor antibodies are present, they stimulate the thyroid to produce T4. This results in a decrease in TSH levels due to negative feedback on the pituitary. However, in cases where hyperthyroidism is caused by pregnancy, the TSH levels are usually elevated.
Understanding Thyroid Disease and its Management
Thyroid disease can present with various manifestations, which can be classified based on the presence or absence of clinical signs of thyroid dysfunction and the presence of a mass. To assess thyroid disease, a thorough history and examination, including ultrasound, are necessary. If a nodule is identified, it should be sampled through an image-guided fine needle aspiration. Radionucleotide scanning is not very useful.
Thyroid tumors can be papillary, follicular, anaplastic, medullary, or lymphoma. Multinodular goitre is a common reason for presentation, and if the patient is asymptomatic and euthyroid, they can be reassured. However, if they have compressive symptoms, surgery is required, and total thyroidectomy is the best option. Patients with endocrine dysfunction are initially managed by physicians, and surgery may be offered alongside radioiodine for those with Graves disease that fails with medical management or in patients who prefer not to be irradiated. Patients with hypothyroidism do not generally get offered a thyroidectomy.
Complications following surgery include anatomical damage to the recurrent laryngeal nerve, bleeding, and damage to the parathyroid glands resulting in hypocalcaemia. For further information, the Association of Clinical Biochemistry guidelines for thyroid function tests and the British Association of Endocrine Surgeons website can be consulted.
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This question is part of the following fields:
- Endocrine System
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Question 20
Incorrect
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As a medical student on a gastrointestinal ward, you come across a patient suffering from long-standing reflux. During the ward round, you notice that the patient, who is in his late 40s, is being treated with metoclopramide, a pro-kinetic drug that blocks the action of dopamine and speeds up gastrointestinal motility. However, the patient is now experiencing gynaecomastia and erectile dysfunction. Which hormone is most likely being overproduced in this patient, leading to his current symptoms?
Your Answer: Luteinizing hormone
Correct Answer: Prolactin
Explanation:Understanding Prolactin and Galactorrhoea
Prolactin is a hormone produced by the anterior pituitary gland, and its release is regulated by various physiological factors. Dopamine is the primary inhibitor of prolactin release, and dopamine agonists like bromocriptine can be used to manage galactorrhoea. It is crucial to distinguish between the causes of galactorrhoea and gynaecomastia, which are both related to the actions of prolactin on breast tissue.
Excess prolactin can lead to different symptoms in men and women. Men may experience impotence, loss of libido, and galactorrhoea, while women may have amenorrhoea and galactorrhoea. Several factors can cause raised prolactin levels, including prolactinoma, pregnancy, oestrogens, stress, exercise, sleep, acromegaly, polycystic ovarian syndrome, and primary hypothyroidism.
Certain drugs can also increase prolactin levels, such as metoclopramide, domperidone, phenothiazines, and haloperidol. Although rare, some SSRIs and opioids may also cause raised prolactin levels.
In summary, understanding prolactin and its effects on the body is crucial in diagnosing and managing conditions like galactorrhoea. Identifying the underlying causes of raised prolactin levels is essential in providing appropriate treatment and care.
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This question is part of the following fields:
- Endocrine System
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Question 21
Incorrect
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A 28-year-old female patient presents to her GP with concerns about the appearance of lumps in her lower abdomen. She has been diagnosed with type 1 diabetes and has been using insulin for more than a decade. The lumps have developed in the areas where she administers her insulin injections.
What is the probable cause of the lumps?Your Answer: Glucose deposits
Correct Answer: Lipodystrophy
Explanation:Small subcutaneous lumps at injection sites, known as lipodystrophy, can be caused by insulin.
The type and location of the lump suggest that lipodystrophy is the most probable cause.
Deposits of insulin and glucose are not responsible for the formation of these lumps.
While a lipoma could also cause similar lumps, it is less likely than lipodystrophy, which is a known complication of insulin injections, especially at the injection site. These lumps can occur in multiple locations.
Insulin therapy can have side-effects that patients should be aware of. One of the most common side-effects is hypoglycaemia, which can cause sweating, anxiety, blurred vision, confusion, and aggression. Patients should be taught to recognize these symptoms and take 10-20g of a short-acting carbohydrate, such as a glass of Lucozade or non-diet drink, three or more glucose tablets, or glucose gel. It is also important for every person treated with insulin to have a glucagon kit for emergencies where the patient is not able to orally ingest a short-acting carbohydrate. Patients who have frequent hypoglycaemic episodes may develop reduced awareness, and beta-blockers can further reduce hypoglycaemic awareness.
Another potential side-effect of insulin therapy is lipodystrophy, which typically presents as atrophy or lumps of subcutaneous fat. This can be prevented by rotating the injection site, as using the same site repeatedly can cause erratic insulin absorption. It is important for patients to be aware of these potential side-effects and to discuss any concerns with their healthcare provider. By monitoring their blood sugar levels and following their treatment plan, patients can manage the risks associated with insulin therapy and maintain good health.
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This question is part of the following fields:
- Endocrine System
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Question 22
Incorrect
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A 60-year-old male presents with increasing fatigue.
Three months ago, he was diagnosed with bronchial carcinoma and has undergone chemotherapy. Upon admission, his electrolyte levels were measured as follows:
- Sodium: 118 mmol/L (137-144)
- Potassium: 3.5 mmol/L (3.5-4.9)
- Urea: 3.2 mmol/L (2.5-7.5)
- Creatinine: 65 ”mol/L (60-110)
What would be the most appropriate initial investigation for this patient?Your Answer: Thyroid function tests
Correct Answer: Urine osmolality and sodium concentration
Explanation:Hyponatraemia in Bronchial Carcinoma Patients
Hyponatraemia is a common condition in patients with bronchial carcinoma. It is characterized by a marked decrease in sodium levels, which appears to be dilutional based on other test results that fall within the lower end of the normal range. The most likely cause of this condition is the syndrome of inappropriate ADH secretion (SIADH), which occurs when the tumour produces ADH in an ectopic manner. However, the diagnosis of SIADH is one of exclusion, and other possibilities such as hypoadrenalism due to metastatic disease to the adrenals should also be considered.
To determine the cause of hyponatraemia, initial tests such as urine sodium and osmolality are recommended. These tests can help rule out other possible causes and confirm the diagnosis of SIADH. Treatment for this condition typically involves fluid restriction. It is important to note that measuring ADH concentrations is not a reliable diagnostic tool as it is not widely available and does not provide any useful information.
In summary, hyponatraemia is a common condition in bronchial carcinoma patients, and SIADH is the most likely cause. Initial tests such as urine sodium and osmolality can help confirm the diagnosis, and treatment involves fluid restriction.
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This question is part of the following fields:
- Endocrine System
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Question 23
Incorrect
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A 15-year-old male arrives at the emergency department with complaints of abdominal pain, nausea, and shortness of breath. He has a history of insulin-dependent diabetes and is diagnosed with diabetic ketoacidosis after undergoing tests. During treatment, which electrolyte should you be particularly cautious of, as it may become depleted in the body despite appearing normal in plasma concentrations?
Your Answer: Bicarbonate
Correct Answer: Potassium
Explanation:Insulin normally helps to move potassium into cells, but in a state of ketoacidosis, there is a lack of insulin to perform this function. As a result, potassium leaks out of cells. Additionally, high levels of glucose in the blood lead to glycosuria in the urine, causing potassium loss through the kidneys.
Even though patients in a ketoacidotic state may have normal levels of potassium in their blood, their overall potassium levels in the body are often depleted. When insulin is administered to these patients, it can cause a dangerous drop in potassium levels as the minimal amount of potassium left in the body is driven into cells.
Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus, accounting for around 6% of cases. It can also occur in rare cases of extreme stress in patients with type 2 diabetes mellitus. DKA is caused by uncontrolled lipolysis, resulting in an excess of free fatty acids that are converted to ketone bodies. The most common precipitating factors of DKA are infection, missed insulin doses, and myocardial infarction. Symptoms include abdominal pain, polyuria, polydipsia, dehydration, Kussmaul respiration, and breath that smells like acetone. Diagnostic criteria include glucose levels above 11 mmol/l or known diabetes mellitus, pH below 7.3, bicarbonate below 15 mmol/l, and ketones above 3 mmol/l or urine ketones ++ on dipstick.
Management of DKA involves fluid replacement, insulin, and correction of electrolyte disturbance. Fluid replacement is necessary as most patients with DKA are deplete around 5-8 litres. Isotonic saline is used initially, even if the patient is severely acidotic. Insulin is administered through an intravenous infusion, and correction of electrolyte disturbance is necessary. Long-acting insulin should be continued, while short-acting insulin should be stopped. Complications may occur from DKA itself or the treatment, such as gastric stasis, thromboembolism, arrhythmias, acute respiratory distress syndrome, acute kidney injury, and cerebral edema. Children and young adults are particularly vulnerable to cerebral edema following fluid resuscitation in DKA and often need 1:1 nursing to monitor neuro-observations, headache, irritability, visual disturbance, focal neurology, etc.
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This question is part of the following fields:
- Endocrine System
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Question 24
Incorrect
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A 49-year-old man visits the clinic with complaints of muscle cramps and constipation that have been present for a week. He appears to be in good health otherwise. Upon conducting a serum potassium test, you discover that his levels are below the normal range. Your next step is to determine the underlying cause of his hypokalaemia. Which of the following medical conditions is commonly linked to low potassium levels?
Your Answer: Rhabdomyolysis
Correct Answer: Cushing's syndrome
Explanation:Cushing’s syndrome is the correct answer as it causes excess cortisol which can exhibit mineralocorticoid activity and lead to hypokalaemia. The kidneys play a major role in maintaining potassium balance, but other factors such as insulin, catecholamines, and aldosterone also influence potassium levels. The other options listed (congenital adrenal hypoplasia, Addison’s, rhabdomyolysis, metabolic acidosis) all cause hyperkalaemia. Addison’s disease and adrenal hypoplasia result in mineralocorticoid deficiency, leading to hyperkalaemia. Acidosis and rhabdomyolysis also cause hyperkalaemia. Symptoms of hypokalaemia include fatigue, muscle weakness, myalgia, muscle cramps, constipation, hyporeflexia, and rarely paralysis.
Causes of Cushing’s Syndrome
Cushing’s syndrome is a condition that can be caused by both endogenous and exogenous factors. However, it is important to note that exogenous causes, such as the use of glucocorticoid therapy, are more common than endogenous ones. The condition can be classified into two categories: ACTH dependent and ACTH independent causes.
ACTH dependent causes of Cushing’s syndrome include Cushing’s disease, which is caused by a pituitary tumor secreting ACTH and producing adrenal hyperplasia. Ectopic ACTH production, which is caused by small cell lung cancer, is another ACTH dependent cause. On the other hand, ACTH independent causes include iatrogenic factors such as steroid use, adrenal adenoma, adrenal carcinoma, Carney complex, and micronodular adrenal dysplasia.
In some cases, a condition called Pseudo-Cushing’s can mimic Cushing’s syndrome. This is often caused by alcohol excess or severe depression and can cause false positive results in dexamethasone suppression tests or 24-hour urinary free cortisol tests. To differentiate between Cushing’s syndrome and Pseudo-Cushing’s, an insulin stress test may be used.
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This question is part of the following fields:
- Endocrine System
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Question 25
Incorrect
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A 65-year-old man presents to the Emergency Department with confusion, drowsiness, and nausea accompanied by vomiting. His daughter reports that he has been feeling fatigued and unwell with a persistent cough, and he has been smoking 20 cigarettes per day for 45 years. The patient is unable to provide a complete medical history due to his confusion, but he mentions that he sometimes coughs up blood and his urine has been darker than usual. On examination, he appears to be short of breath but euvolaemic. Blood tests reveal low serum sodium, high urinary sodium, low plasma osmolality, and high urinary osmolality. Renal and thyroid function tests are normal. A chest x-ray shows a lung carcinoma, leading you to suspect that this presentation may be caused by a syndrome of inappropriate antidiuretic hormone secretion.
What is the underlying mechanism responsible for the hyponatraemia?Your Answer:
Correct Answer: Insertion of aquaporin-2 channels
Explanation:The insertion of aquaporin-2 channels is promoted by antidiuretic hormone, which facilitates water reabsorption. However, in the case of syndrome of inappropriate antidiuretic hormone secretion (SiADH), which is caused by small cell lung cancer, the normal negative feedback loop fails, resulting in the continuous production of ADH even when serum osmolality returns to normal. This leads to euvolemic hyponatremia, where the body retains water but continues to lose sodium, resulting in concentrated urine. The underlying mechanism of this condition is the persistent increase in the number of aquaporin-2 channels, which promotes water reabsorption, rather than any effect on sodium transport mechanisms.
Understanding Antidiuretic Hormone (ADH)
Antidiuretic hormone (ADH) is a hormone that is produced in the supraoptic nuclei of the hypothalamus and released by the posterior pituitary gland. Its primary function is to conserve body water by promoting water reabsorption in the collecting ducts of the kidneys through the insertion of aquaporin-2 channels.
ADH secretion is regulated by various factors. An increase in extracellular fluid osmolality, a decrease in volume or pressure, and the presence of angiotensin II can all increase ADH secretion. Conversely, a decrease in extracellular fluid osmolality, an increase in volume, a decrease in temperature, or the absence of ADH can decrease its secretion.
Diabetes insipidus (DI) is a condition that occurs when there is either a deficiency of ADH (cranial DI) or an insensitivity to ADH (nephrogenic DI). Cranial DI can be treated with desmopressin, which is an analog of ADH.
Overall, understanding the role of ADH in regulating water balance in the body is crucial for maintaining proper hydration and preventing conditions like DI.
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This question is part of the following fields:
- Endocrine System
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Question 26
Incorrect
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A 36-year-old woman visits her GP complaining of frequent urination. She has been waking up several times at night to urinate for the past two weeks and has been feeling more thirsty than usual. Her temperature is 37.3ÂșC. She has a history of bipolar disorder and is currently on lithium medication.
What could be the possible cause of her polyuria?Your Answer:
Correct Answer: Lithium reducing ADH-dependent water reabsorption in the collecting duct
Explanation:The site of action for antidiuretic hormone (ADH) is the collecting ducts. Lithium treatment for bipolar disorder can lead to diabetes insipidus, which is characterized by increased thirst (polydipsia) and increased urination (polyuria). Lithium use can cause nephrogenic diabetes insipidus, where the kidneys are unable to respond adequately to ADH. Normally, ADH induces the expression of aquaporin 2 channels in the collecting duct, which stimulates water reabsorption.
Central diabetes insipidus occurs when there is damage to the posterior pituitary gland, resulting in insufficient production and release of ADH. However, lithium use causes nephrogenic diabetes insipidus instead of central diabetes insipidus.
Although insulin resistance and hyperglycemia can also cause polyuria and polydipsia, as seen in diabetic ketoacidosis, the use of lithium suggests that the patient’s symptoms are due to diabetes insipidus rather than diabetes mellitus.
Lithium inhibits the expression of aquaporin channels in the renal collecting duct, rather than the distal convoluted tubule, which causes diabetes insipidus.
While a urinary tract infection can also present with polyuria and nocturia, the presence of lithium in the patient’s drug history and the fact that the patient also has polydipsia suggest nephrogenic diabetes insipidus. Diabetes insipidus causes increased thirst due to the excessive volume of urine produced, leading to water loss from the body. In addition, a urinary tract infection would likely cause dysuria (burning or stinging when passing urine) and lower abdominal pain.
Understanding Antidiuretic Hormone (ADH)
Antidiuretic hormone (ADH) is a hormone that is produced in the supraoptic nuclei of the hypothalamus and released by the posterior pituitary gland. Its primary function is to conserve body water by promoting water reabsorption in the collecting ducts of the kidneys through the insertion of aquaporin-2 channels.
ADH secretion is regulated by various factors. An increase in extracellular fluid osmolality, a decrease in volume or pressure, and the presence of angiotensin II can all increase ADH secretion. Conversely, a decrease in extracellular fluid osmolality, an increase in volume, a decrease in temperature, or the absence of ADH can decrease its secretion.
Diabetes insipidus (DI) is a condition that occurs when there is either a deficiency of ADH (cranial DI) or an insensitivity to ADH (nephrogenic DI). Cranial DI can be treated with desmopressin, which is an analog of ADH.
Overall, understanding the role of ADH in regulating water balance in the body is crucial for maintaining proper hydration and preventing conditions like DI.
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This question is part of the following fields:
- Endocrine System
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Question 27
Incorrect
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The acute phase response to injury in elderly patients does not involve which of the following?
Your Answer:
Correct Answer: Increased transferrin
Explanation:The acute phase response is characterized by various physiological changes, such as the production of acute phase proteins, decreased levels of transport proteins like albumin and transferrin, hepatic retention of cations, fever, an increase in neutrophil count, elevated muscle proteolysis, and alterations in vascular permeability.
Surgery triggers a stress response that causes hormonal and metabolic changes in the body. This response is characterized by substrate mobilization, muscle protein loss, sodium and water retention, suppression of anabolic hormone secretion, activation of the sympathetic nervous system, and immunological and haematological changes. The hypothalamic-pituitary axis and the sympathetic nervous systems are activated, and the normal feedback mechanisms of control of hormone secretion fail. The stress response is associated with increased growth hormone, cortisol, renin, adrenocorticotrophic hormone (ACTH), aldosterone, prolactin, antidiuretic hormone, and glucagon, while insulin, testosterone, oestrogen, thyroid stimulating hormone, luteinizing hormone, and follicle stimulating hormone are decreased or remain unchanged. The metabolic effects of cortisol are enhanced, including skeletal muscle protein breakdown, stimulation of lipolysis, anti-insulin effect, mineralocorticoid effects, and anti-inflammatory effects. The stress response also affects carbohydrate, protein, lipid, salt and water metabolism, and cytokine release. Modifying the response can be achieved through opioids, spinal anaesthesia, nutrition, growth hormone, anabolic steroids, and normothermia.
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This question is part of the following fields:
- Endocrine System
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Question 28
Incorrect
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A 63-year-old male presents with a sudden onset of double vision that has been ongoing for eight hours. He has a medical history of hypertension, which is managed with amlodipine and atenolol, and type 2 diabetes that is controlled through diet. Upon examination, the patient displays watering of the right eye, a slight droop of the eyelid, and displacement of the eye to the right. The left eye appears to have a full range of movements, and the pupil size is the same as on the left. What is the probable cause of his symptoms?
Your Answer:
Correct Answer: Diabetes
Explanation:Causes of Painless Partial Third Nerve Palsy
A painless partial third nerve palsy with pupil sparing is most likely caused by diabetes mononeuropathy. This condition is thought to be due to a microangiopathy that leads to the occlusion of the vasa nervorum. On the other hand, an aneurysm of the posterior communicating artery is associated with a painful third nerve palsy, and pupillary dilatation is typical. Cerebral infarction, on the other hand, does not usually cause pain. Hypertension, which is a common condition, would normally cause signs of CVA or TIA. Lastly, cerebral vasculitis can cause symptoms of CVA/TIA, but they usually cause more global neurological symptoms.
In summary, a painless partial third nerve palsy with pupil sparing is most likely caused by diabetes mononeuropathy. Other conditions such as aneurysm of the posterior communicating artery, cerebral infarction, hypertension, and cerebral vasculitis can also cause similar symptoms, but they have different characteristics and causes. It is important to identify the underlying cause of the condition to provide appropriate treatment and management.
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This question is part of the following fields:
- Endocrine System
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Question 29
Incorrect
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Which one of the following does not trigger insulin secretion?
Your Answer:
Correct Answer: Atenolol
Explanation:The release of insulin is prevented by beta blockers.
Factors that trigger insulin release include glucose, amino acids, vagal cholinergic stimulation, secretin/gastrin/CCK, fatty acids, and beta adrenergic drugs.
Insulin is a hormone produced by the pancreas that plays a crucial role in regulating the metabolism of carbohydrates and fats in the body. It works by causing cells in the liver, muscles, and fat tissue to absorb glucose from the bloodstream, which is then stored as glycogen in the liver and muscles or as triglycerides in fat cells. The human insulin protein is made up of 51 amino acids and is a dimer of an A-chain and a B-chain linked together by disulfide bonds. Pro-insulin is first formed in the rough endoplasmic reticulum of pancreatic beta cells and then cleaved to form insulin and C-peptide. Insulin is stored in secretory granules and released in response to high levels of glucose in the blood. In addition to its role in glucose metabolism, insulin also inhibits lipolysis, reduces muscle protein loss, and increases cellular uptake of potassium through stimulation of the Na+/K+ ATPase pump.
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This question is part of the following fields:
- Endocrine System
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Question 30
Incorrect
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A 28-year-old woman comes to her outpatient appointment after being diagnosed with Grave's disease. This condition is known for having three distinct signs, in addition to thyroid eye disease. What are the other signs?
Your Answer:
Correct Answer: Thyroid acropachy & pretibial myxoedema
Explanation:Grave’s disease is commonly linked to several other conditions, including thyroid eye disease, thyroid acropachy, and pretibial myxoedema.
This autoimmune disease, known as Grave’s thyroiditis, is caused by antibodies that target the thyroid stimulating hormone (TSH) receptor, leading to prolonged stimulation.
One of the most noticeable symptoms of Grave’s disease is exophthalmos, which occurs when TSH receptor antibodies bind to receptors at the back of the eye, causing inflammation and an increase in glycosaminoglycans. This results in swelling of the eye muscles and connective tissue.
Pretibial myxoedema is a skin condition that often develops in individuals with Grave’s disease. It is characterized by localized lesions on the skin in front of the tibia, which are caused by an increase in glycosaminoglycans in the pretibial dermis.
Thyroid acropachy is another condition associated with Grave’s disease, which involves swelling of soft tissues, clubbing of the fingers, and periosteal reactions in the extremities.
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 displays 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.
Graves’ disease is characterized by the presence of autoantibodies, including TSH receptor stimulating antibodies in 90% of patients and anti-thyroid peroxidase antibodies in 75% of patients. Thyroid scintigraphy reveals a diffuse, homogenous, and increased uptake of radioactive iodine. These features help distinguish Graves’ disease from other causes of thyrotoxicosis and aid in its diagnosis.
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This question is part of the following fields:
- Endocrine System
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