00
Correct
00
Incorrect
00 : 00 : 0 00
Session Time
00 : 00
Average Question Time ( Mins)
  • Question 1 - A 55-year-old woman presents to a walk-in clinic with complaints of fatigue and...

    Incorrect

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

      Your Answer: Amlodipine

      Correct Answer: Lithium

      Explanation:

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

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

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

      Understanding the Causes of Hypothyroidism

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      12.5
      Seconds
  • Question 2 - A 42-year-old man is being evaluated for possible diabetes mellitus and undergoes an...

    Incorrect

    • A 42-year-old man is being evaluated for possible diabetes mellitus and 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 8.2

      What is the interpretation of these findings?

      Your Answer: Impaired fasting glucose and impaired glucose tolerance

      Correct Answer: Normal

      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:

      • Endocrinology/Metabolic Disease
      16
      Seconds
  • Question 3 - 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
      469.3
      Seconds
  • Question 4 - A 63-year-old male visits his primary care physician for a diabetic check-up. He...

    Incorrect

    • A 63-year-old male visits his primary care physician for a diabetic check-up. He has been dealing with type-two diabetes mellitus for a while, but has not been able to control it completely. Despite making all the necessary lifestyle changes and taking metformin and gliclazide, he complains of polyuria and his Hba1c is 62 mmol/mol. He has a history of hypertension, which is managed with amlodipine, and recurrent urinary tract infections. He is hesitant to use insulin due to his fear of needles. What is the best course of action for managing his condition?

      Your Answer: Stop gliclazide and prescribe sitagliptin

      Correct Answer: Add sitagliptin

      Explanation:

      If a patient with TD2M is already taking two drugs and their HbA1c is above 58 mmol/mol, they should be offered a third drug or insulin therapy. However, insulin therapy should be avoided if possible for patients who are afraid of needles. In this case, the best option is to add sitagliptin to the patient’s current medication regimen of metformin and gliclazide. SGLT-2 inhibitors should be avoided due to the patient’s history of recurrent urinary tract infections, and pioglitazone is rarely prescribed. Exenatide is not appropriate for this patient as it is a GLP-1 mimetic and should only be added if the patient cannot tolerate triple therapy and has a BMI greater than 35. It is not recommended to stop any current medications and substitute them with sitagliptin, as the drugs should work synergistically together.

      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
      20
      Seconds
  • Question 5 - 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
      39.5
      Seconds
  • Question 6 - A 35-year-old woman presents to her GP with complaints of excessive thirst and...

    Incorrect

    • A 35-year-old woman presents to her GP with complaints of excessive thirst and frequent urination. She is currently 20 weeks pregnant and this is her first pregnancy. Her BMI is 30 kg/m². The GP decides to conduct an oral glucose tolerance test to investigate the possibility of gestational diabetes.
      What finding would confirm the suspicion of gestational diabetes in this case?

      Your Answer: 2-hour glucose level 7.2 mmol/L

      Correct Answer: Fasting glucose 5.9 mmol/L

      Explanation:

      To diagnose gestational diabetes, a fasting glucose level of >= 5.6 mmol/L or a 2-hour glucose level of >= 7.8 mmol/L can be used. A patient with a BMI of >30 kg/m² and symptoms of polydipsia and polyuria should undergo an oral glucose tolerance test during 24-28 weeks of pregnancy. In this test, the patient fasts for 8-10 hours, then drinks a glucose solution and has blood samples taken before and 2 hours after. A fasting glucose level of 5.9mmol/L or higher confirms the diagnosis of gestational diabetes.

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      10.8
      Seconds
  • Question 7 - What is the most probable adverse effect experienced by patients who are taking...

    Incorrect

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

      Your Answer: Cholestasis

      Correct 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
      4748.4
      Seconds
  • Question 8 - A 42-year-old man presents to your clinic with concerns of feeling excessively fatigued....

    Incorrect

    • A 42-year-old man presents to your clinic with concerns of feeling excessively fatigued. He is anxious that he may have developed diabetes, similar to his father. Upon conducting a blood test, his HbA1c levels are found to be 45 mmol/mol. What would be the most appropriate step to take next?

      Your Answer: Reassure and advise repeat in 6 weeks

      Correct Answer: Discuss diet and exercise

      Explanation:

      An HbA1c level ranging from 42-47 mmol/mol suggests the presence of prediabetes. Individuals with this condition should be motivated to enhance their physical activity, shed excess weight, and adopt a healthier diet by consuming more dietary fiber and reducing fat intake. Metformin may be an option for those with prediabetes, but the initial dose should be 500mg once daily. Regular HbA1c monitoring is necessary for individuals diagnosed with prediabetes as they are at a heightened risk of developing diabetes.

      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
      10.4
      Seconds
  • Question 9 - 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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      7.8
      Seconds
  • Question 10 - 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
      12.9
      Seconds
  • Question 11 - 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
      25.8
      Seconds
  • Question 12 - A 27-year-old African American woman who is 28 weeks pregnant undergoes an oral...

    Correct

    • A 27-year-old African American woman who is 28 weeks pregnant undergoes an oral glucose tolerance test (OGTT) due to her ethnicity and a history of being overweight. An ultrasound reveals that the fetus is measuring larger than expected for its gestational age. The results of the OGTT are as follows:
      Time (hours) Blood glucose (mmol/l)
      0 9.5
      2 15.0

      What would be the most suitable course of action?

      Your Answer: Start insulin

      Explanation:

      Immediate initiation of insulin is recommended due to the high blood glucose levels and presence of macrosomia. Additionally, it is advisable to consider administering aspirin as there is an elevated risk of pre-eclampsia.

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      10
      Seconds
  • Question 13 - 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.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      24
      Seconds
  • Question 14 - 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
      8.3
      Seconds
  • Question 15 - A 45-year-old woman presents to her General Practitioner with a 2-month history of...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      12.2
      Seconds
  • Question 16 - A 72-year-old man comes to the clinic complaining of fatigue, low mood, and...

    Correct

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

      Your Answer: Parathyroid hormone

      Explanation:

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

      Understanding the Causes of Hypercalcaemia

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      9.2
      Seconds
  • Question 17 - A 35-year-old man with type 1 diabetes visits his GP for a check-up...

    Incorrect

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

      Your Answer: Alcoholism

      Correct Answer: Sickle-cell anaemia

      Explanation:

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

      Understanding Glycosylated Haemoglobin (HbA1c) in Diabetes Mellitus

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      13.8
      Seconds
  • Question 18 - A 36-year-old woman visits her General Practitioner complaining of a 3 kg weight...

    Incorrect

    • A 36-year-old woman visits her General Practitioner complaining of a 3 kg weight gain, fatigue, dry hair and skin, and a small diffuse goitre. She always feels cold and has a family history of thyroid disease.

      Investigation Result Normal value
      Thyroid-stimulating hormone (TSH) 18.0 mU/l 0.25–4.0 mU/l
      Free T4 6 pmol/l 12–22 pmol/l
      Thyroid peroxidase antibody Positive at high titres

      What is the most probable diagnosis?

      Your Answer: Graves' disease

      Correct Answer: Hashimoto’s thyroiditis

      Explanation:

      The patient’s symptoms and blood test results suggest hypothyroidism, which is commonly caused by Hashimoto’s thyroiditis, an autoimmune disorder affecting the thyroid gland. Risk factors for this condition include a family history of autoimmune disease, being female, and having another autoimmune disorder. Positive thyroid antibodies and a diffuse goitre may also be present. De Quervain’s thyroiditis, on the other hand, typically presents with hyperthyroidism after a viral infection and is associated with neck pain and fever. Follicular thyroid carcinoma is characterized by a painless thyroid nodule and possible hoarseness or stridor if the recurrent laryngeal nerve is affected. Graves’ disease, the most common cause of hyperthyroidism, presents with symptoms such as sweating, anxiety, and weight loss, as well as eye signs in some cases. Multinodular goitre, which involves multiple autonomously functioning thyroid nodules, typically presents as hyperthyroidism with a multinodular goitre, but the patient in this scenario is hypothyroid.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      14.3
      Seconds
  • Question 19 - A 75-year-old man with known type 2 diabetes presents with a 1-week history...

    Incorrect

    • A 75-year-old man with known type 2 diabetes presents with a 1-week history of polydipsia, feeling generally unwell and drowsy. On examination, he looks very dehydrated and is difficult to rouse. He appears confused when he does talk to you.

      Admission bloods show:
      Na+ 149 mmol/l
      K+ 5.2 mmol/l
      Urea 22.1 mmol/l
      Creatinine 254 µmol/l
      His blood glucose is 36 mmol/L.

      What is the most important initial step in managing this patient?

      Your Answer: Start Insulin sliding scale

      Correct Answer: Rehydrate with 0.9% Saline

      Explanation:

      Complications of the hyperosmolar state, such as rhabdomyolysis, venous thromboembolism, lactic acidosis, hypertriglyceridemia, renal failure, stroke, and cerebral edema, contribute to the mortality of HONK. Identifying precipitants, such as a new diagnosis of type 2 diabetes, infection, high-dose steroids, myocardial infarction, vomiting, stroke, thromboembolism, and poor treatment compliance, is crucial.

      Supportive care and slow metabolic resolution are the mainstays of HONK management. Patients with HONK often have a fluid deficit of over 8 liters, and caution should be exercised to avoid rapid fluid replacement, which can cause cerebral edema due to rapid osmolar shifts. In this scenario, fluid resuscitation should be the top priority, followed closely by initiating a sliding scale. Some experts recommend waiting for an hour before starting insulin to prevent rapid changes and pontine myelinolysis. However, the fluid alone can lower blood sugar levels, and some argue that administering insulin immediately can cause a precipitous drop in osmolality.

      Understanding Hyperosmolar Hyperglycaemic State

      Hyperosmolar hyperglycaemic state (HHS) is a medical emergency that can be life-threatening and difficult to manage. It is characterized by severe dehydration, electrolyte deficiencies, and osmotic diuresis resulting from hyperglycaemia. HHS typically affects elderly individuals with type 2 diabetes mellitus (T2DM).

      The pathophysiology of HHS involves hyperglycaemia leading to increased serum osmolality, osmotic diuresis, and severe volume depletion. Precipitating factors include intercurrent illness, sedative drugs, and dementia. Clinical features of HHS include polyuria, polydipsia, signs of dehydration, lethargy, nausea, vomiting, altered level of consciousness, and focal neurological deficits.

      Diagnosis of HHS is based on the presence of hypovolaemia, marked hyperglycaemia, significantly raised serum osmolarity, no significant hyperketonaemia, and no significant acidosis. Management of HHS involves fluid replacement with IV 0.9% sodium chloride solution, potassium monitoring, and insulin administration only if blood glucose stops falling while giving IV fluids. Patients with HHS are at risk of thrombosis due to hyperviscosity, and venous thromboembolism prophylaxis is recommended.

      Complications of HHS include vascular complications such as myocardial infarction and stroke. It is important to recognize the clinical features of HHS and manage it promptly to prevent mortality.

      Overall, HHS is a serious medical condition that requires urgent attention and management. Understanding its pathophysiology, clinical features, and management is crucial in providing appropriate care to patients with HHS.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      12.1
      Seconds
  • Question 20 - A 68-year-old man is admitted for an elective total knee replacement (TKR).

    His...

    Incorrect

    • 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: Both doses of metformin should be omitted

      Correct 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
      18.1
      Seconds
  • Question 21 - 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
      10.2
      Seconds
  • Question 22 - 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.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      13.5
      Seconds
  • Question 23 - A 36-year-old patient arrives at the emergency department experiencing confusion and vomiting. Upon...

    Incorrect

    • 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, 200mcg fludrocortisone

      Correct 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
      10.5
      Seconds
  • Question 24 - 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
      48.5
      Seconds
  • Question 25 - A 48-year-old woman is seen in the diabetes clinic with poorly controlled type...

    Incorrect

    • A 48-year-old woman is seen in the diabetes clinic with poorly controlled type 2 diabetes mellitus (HbA1c 63 mmol/mol). She had to discontinue gliclazide due to recurrent hypoglycaemia and is currently on maximum dose metformin. Her BMI is 26 kg/m^2. What is the best course of action for further management?

      Your Answer: Refer her for insulin therapy

      Correct Answer: Add either pioglitazone, a DPP-4 inhibitor or a SGLT-2 inhibitor

      Explanation:

      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
      11.7
      Seconds
  • Question 26 - 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: Gastroenteritis

      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.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      6.3
      Seconds
  • Question 27 - You review a 56-year-old man with a history of type II diabetes. He...

    Incorrect

    • 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 pioglitazone

      Correct 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.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      12.5
      Seconds
  • Question 28 - A 20-year-old with type 1 diabetes presents to the Emergency Department feeling unwell....

    Incorrect

    • A 20-year-old with type 1 diabetes presents to the Emergency Department feeling unwell. She reports experiencing vomiting and diarrhoea for the past 2 days and has not been taking her full insulin doses due to loss of appetite. Her capillary glucose level is 37 mmol/l and urinalysis shows 4+ ketones. An arterial blood gas test is conducted, revealing the following results:
      pH 7.12
      pO2 13 kPa
      pCO2 3.5 kPa
      HCO3 13
      Na 129 mmol/l
      K 6.1 mmol/l
      What is the most appropriate initial management for this patient?

      Your Answer: IV 10 units actrapid + 50ml 50% dextrose

      Correct Answer: IV 0.9% NaCl bolus

      Explanation:

      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.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      5.8
      Seconds
  • Question 29 - 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: Thyrotoxicosis

      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
      7.1
      Seconds
  • Question 30 - 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
      5.1
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Endocrinology/Metabolic Disease (13/30) 43%
Passmed