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  • Question 1 - A 32-year-old female presents to her GP with complaints of weight gain, hair...

    Correct

    • A 32-year-old female presents to her GP with complaints of weight gain, hair thinning, fatigue, and dry skin. What is the most probable reason for her symptoms?

      Your Answer: Hypothyroidism

      Explanation:

      Differential Diagnosis of Endocrine Disorders: Symptoms and Treatment Options

      Hypothyroidism, adrenal insufficiency, Cushing syndrome, primary hypoparathyroidism, and secondary hypoparathyroidism are all endocrine disorders that can present with various symptoms. Hypothyroidism may cause cerebellar ataxia, myxoedema, and congestive cardiac failure, and is treated with replacement of thyroid hormone. Adrenal insufficiency may cause tiredness, weakness, and postural hypotension, among other symptoms. Cushing syndrome may present with central obesity, skin and muscle atrophy, and osteoporosis. Primary hypoparathyroidism may cause hypocalcaemia symptoms, while secondary hypoparathyroidism may also present with hypocalcaemia symptoms. Treatment options vary depending on the specific disorder.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      964.1
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  • Question 2 - A 42-year-old man is worried about his chances of developing heart disease due...

    Correct

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

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

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

      Your Answer: Familial hypercholesterolaemia

      Explanation:

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

      Familial Hypercholesterolaemia: Causes, Diagnosis, and Management

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      336.3
      Seconds
  • Question 3 - A 65-year-old man with a history of myocardial infarction, congestive heart failure, and...

    Incorrect

    • A 65-year-old man with a history of myocardial infarction, congestive heart failure, and chronic obstructive pulmonary disease presents for a diabetes check-up at his GP's office. He was recently diagnosed with type 2 diabetes mellitus, and despite attempting lifestyle changes, his HbA1c remains at 56 mmol/mol. The GP decides to initiate drug therapy.
      Which of the following medications would be inappropriate for this patient?

      Your Answer: Gliclizide

      Correct Answer: Pioglitazone

      Explanation:

      Patients with heart failure should not take pioglitazone due to its potential to cause fluid retention.

      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
      12
      Seconds
  • Question 4 - A 67-year-old woman is brought to the Emergency Department after being found near-unconscious...

    Incorrect

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

      Your Answer: Salicylate overdose

      Correct Answer: Addisonian crisis

      Explanation:

      Differential Diagnosis: Addisonian Crisis and Other Conditions

      Addisonian Crisis: A Brief Overview

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

      Differential Diagnosis

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

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

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

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

      Conclusion

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      158.7
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  • Question 5 - Which one of the following statements regarding gestational diabetes is accurate? ...

    Incorrect

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

      Your Answer: The majority of women are managed with insulin

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

      Explanation:

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      4.3
      Seconds
  • Question 6 - A 42-year-old woman presents to her GP with complaints of ongoing fatigue and...

    Incorrect

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

      What is the most likely pathology causing her symptoms?

      Your Answer: Hypopituitarism

      Correct Answer: Hashimoto's thyroiditis

      Explanation:

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

      Understanding Hashimoto’s Thyroiditis

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      22.6
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  • Question 7 - You receive a letter from an endocrinology consultant following a referral that you...

    Incorrect

    • You receive a letter from an endocrinology consultant following a referral that you made for a 25 year old gentleman who has been newly diagnosed with hyperthyroidism. The consultant requests that you start the patient on carbimazole 15mg daily with a repeat thyroid function test (TFT) in 4 weeks. What is the most crucial advice to give the patient?

      Your Answer: Must have monthly liver function tests (LFT)

      Correct Answer: Attend for urgent medical review if develops any symptoms of infection e.g. sore throat or fever

      Explanation:

      Understanding Carbimazole and Its Mechanism of Action

      Carbimazole is a medication used to manage thyrotoxicosis, a condition characterized by an overactive thyroid gland. It is typically administered in high doses for six weeks until the patient becomes euthyroid, or has a normal thyroid function. The drug works by blocking thyroid peroxidase, an enzyme responsible for coupling and iodinating the tyrosine residues on thyroglobulin, which ultimately reduces thyroid hormone production.

      In contrast to propylthiouracil, another medication used to treat thyrotoxicosis, carbimazole only has a central mechanism of action. Propylthiouracil, on the other hand, also has a peripheral action by inhibiting 5′-deiodinase, an enzyme that reduces peripheral conversion of T4 to T3.

      While carbimazole can be effective in managing thyrotoxicosis, it is not without its adverse effects. One of the most serious side effects is agranulocytosis, a condition characterized by a severe reduction in white blood cells. Additionally, carbimazole can cross the placenta, but may be used in low doses during pregnancy.

      Overall, carbimazole is a medication that can be effective in managing thyrotoxicosis, but it is important to be aware of its mechanism of action and potential adverse effects. Patients should always consult with their healthcare provider before starting any new medication.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      4.3
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  • Question 8 - A 35-year-old woman presents with amenorrhoea and occasional breast discharge. She has never...

    Incorrect

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

      Your Answer: Thyroid function tests

      Correct Answer: Prolactin level

      Explanation:

      Investigating Hyperprolactinaemia: Tests and Imaging

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      2.9
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  • Question 9 - A 65-year-old man comes in for his annual check-up for type 2 diabetes...

    Correct

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

      What would be the most appropriate next step?

      Your Answer: Add gliclazide

      Explanation:

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      13.3
      Seconds
  • Question 10 - A 54-year-old man is seen in the Cardiology clinic after experiencing a heart...

    Correct

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

      Your Answer: Gliclazide

      Explanation:

      Weight gain is a common side effect of sulfonylureas.

      Sulfonylureas are a type of medication used to treat type 2 diabetes mellitus. They work by increasing the amount of insulin produced by the pancreas, but they are only effective if the pancreas is functioning properly. Sulfonylureas bind to a specific channel on the cell membrane of pancreatic beta cells, which helps to increase insulin secretion. However, there are some potential side effects associated with these drugs.

      One of the most common side effects of sulfonylureas is hypoglycaemia, which can be more likely to occur with long-acting preparations like chlorpropamide. Weight gain is another possible side effect. In rare cases, sulfonylureas can cause hyponatraemia, which is a condition where the body retains too much water and sodium levels become too low. Other rare side effects include bone marrow suppression, hepatotoxicity (liver damage), and peripheral neuropathy. It is important to note that sulfonylureas should not be used during pregnancy or while breastfeeding.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      110.9
      Seconds
  • Question 11 - A 32-year-old man visits his doctor because he has been experiencing sweaty palms...

    Incorrect

    • A 32-year-old man visits his doctor because he has been experiencing sweaty palms and his colleagues have noticed a change in his facial appearance. He also reports difficulty driving due to difficulty seeing the sides of his visual fields.

      What is the most probable diagnosis?

      Your Answer: Hyperthyroidism

      Correct Answer: Acromegaly

      Explanation:

      Endocrine Disorders and Their Clinical Presentations

      Acromegaly, Cushing’s syndrome, hyperprolactinaemia, hyperthyroidism, and multiple sclerosis are all endocrine disorders that can present with various clinical features. Acromegaly is caused by excess growth hormone secretion and can lead to enlarged hands, coarse facial features, and bitemporal hemianopia. Cushing’s syndrome may present with central obesity, muscle atrophy, and osteoporosis, but visual dysfunction is not typical. Hyperprolactinaemia can cause amenorrhoea or oligomenorrhoea, infertility, and galactorrhoea, but this presentation more closely fits with acromegaly. Hyperthyroidism may present with weight loss, tremor, and heat intolerance, but bitemporal hemianopia is not typical. Multiple sclerosis is a chronic inflammatory demyelination of the central nervous system and can present with various symptoms, but this patient’s presentation does not fit with features of multiple sclerosis.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      8
      Seconds
  • Question 12 - A 56-year-old man has just been diagnosed with type 2 diabetes after a...

    Incorrect

    • A 56-year-old man has just been diagnosed with type 2 diabetes after a routine blood test. He has a history of myocardial infarction and chronic left ventricular systolic dysfunction. The patient is started on metformin and titrated to the maximum tolerated dose. The following are the results of his blood tests:
      - Na+ 138 mmol/L (135 - 145)
      - K+ 3.9 mmol/L (3.5 - 5.0)
      - Urea 4.0 mmol/L (2.0 - 7.0)
      - Creatinine 75 µmol/L (55 - 120)
      - eGFR >90 mL/min (>90)
      - Hba1c 62 mmol/mol (7.8%) (20-41)

      What is the most appropriate medication to initiate for this patient?

      Your Answer: Gliclazide

      Correct Answer: Empagliflozin

      Explanation:

      For this patient with type 2 diabetes mellitus (T2DM) and cardiac comorbidity, the most appropriate medication would be an SGLT-2 inhibitor. This is especially true for patients with established cardiovascular disease (CVD) or those under 40 with one or more cardiovascular risk factors. Studies have shown that SGLT-2 inhibitors have a cardioprotective effect, with the greatest benefit seen in those with CVD. Additionally, these medications have been associated with reduced hospital admissions and mortality in patients with heart failure.

      Gliclazide is not the best option for this patient as there is no evidence that it would have a beneficial effect on their cardiac comorbidity, unlike SGLT-2 inhibitors. While gliclazide is effective at lowering HbA1c, it can cause weight gain. In some cases, gliclazide may be used as rescue therapy for patients with T2DM who have very poor glycemic control and are symptomatic, but this is not the case for this patient.

      Insulin is not necessary at this stage, as there are many other medications available to optimize glycemic control before insulin should be considered. In some cases, insulin may be used as short-term rescue therapy for patients with T2DM who have very poor glycemic control and are symptomatic, but this is not the case for this patient.

      Pioglitazone is not a suitable option for this patient, as it is contraindicated in patients with heart failure due to its potential to worsen fluid retention and edema. Additionally, pioglitazone is associated with an increased risk of fractures. However, pioglitazone does have benefits such as safety in renal impairment and a low risk of hypoglycemia.

      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
      9.2
      Seconds
  • Question 13 - A 32-year-old woman reports to her community midwife with complaints of failure to...

    Incorrect

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

      Your Answer: Increased cortisol; increased aldosterone

      Correct Answer: Decreased cortisol; normal aldosterone

      Explanation:

      Interpreting Cortisol and Aldosterone Levels in Sheehan’s Syndrome

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      3
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  • Question 14 - As the on-call FY2 covering the wards, you are asked to assess a...

    Correct

    • As the on-call FY2 covering the wards, you are asked to assess a 55-year-old woman who was admitted yesterday with community-acquired left basal pneumonia. Over the past 12 hours, she has deteriorated significantly with a temperature of 40.5ºC, blood pressure 160/95 mmHg, and heart rate of 130 bpm. On examination, she appears jaundiced, agitated, and confused. Her medical history includes hayfever and Graves' disease, but she has been generally healthy otherwise. What is the most important initial treatment to start for this patient, given the likely diagnosis?

      Your Answer: IV propranolol

      Explanation:

      Thyroid storm is a medical emergency that can occur in patients with hyperthyroidism, such as those with Graves’ disease. It is characterized by symptoms such as high fever, rapid heartbeat, jaundice, and altered mental status. In such cases, IV beta-blockers, such as propranolol, are the first-line treatment to inhibit the peripheral adrenergic effects of excess thyroid hormone. However, propranolol should not be used in patients with asthma or reversible COPD, and caution should be exercised in patients with heart failure. Lugol’s solution can also be used to inhibit the release of stored thyroid hormone, but it is usually delayed until after antithyroid therapy has been initiated. Therapeutic plasma exchange may be considered for patients who do not respond to medical therapy. In this case, the patient’s jaundice is likely due to her hyperthyroid crisis, and there is no evidence of biliary disease or cholecystitis. Therefore, IV co-amoxiclav, which is the first-line antibiotic for community-acquired pneumonia, would be appropriate for this patient. If propranolol is contraindicated, a cardiac-specific beta-blocker or calcium-channel blocker may be used instead. However, in this patient, IV propranolol should be used as the first-line treatment.

      Understanding Thyroid Storm

      Thyroid storm is a rare but serious complication of thyrotoxicosis, which is characterized by an overactive thyroid gland. It is usually seen in patients who already have thyrotoxicosis and is not typically the first symptom. It is important to note that an excess of thyroxine caused by medication does not usually lead to thyroid storm.

      There are several events that can trigger thyroid storm, including surgery, trauma, infection, and exposure to iodine, such as through CT contrast media. The clinical features of thyroid storm include fever, tachycardia, confusion, nausea, vomiting, hypertension, heart failure, and abnormal liver function tests.

      The management of thyroid storm involves treating the underlying cause and providing symptomatic relief. This may include medications such as beta-blockers, anti-thyroid drugs, Lugol’s iodine, and dexamethasone. Paracetamol may also be used to manage fever.

      In summary, thyroid storm is a serious complication of thyrotoxicosis that requires prompt medical attention. Understanding the triggers and clinical features of thyroid storm can help with early diagnosis and effective management.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 15 - A 47-year-old woman comes for a check-up at the clinic. She was diagnosed...

    Correct

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

      Your Answer: TSH

      Explanation:

      Managing Hypothyroidism: Dosage, Monitoring, and Side-Effects

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      9.7
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  • Question 16 - A 62-year-old man presents to the clinic with a history of ischaemic heart...

    Correct

    • A 62-year-old man presents to the clinic with a history of ischaemic heart disease and a recent diagnosis of type 2 diabetes mellitus. His HbA1c at the time of diagnosis was 7.6% (60 mmol/mol) and he was started on metformin, which was titrated up to a dose of 1g bd. His most recent blood work shows a HbA1c of 6.8% (51 mmol/mol). He has recently retired from the IT industry and has a BMI of 28 kg/m². He is currently taking atorvastatin 80 mg, aspirin 75mg, bisoprolol 2.5 mg, and ramipril 5mg. What would be the most appropriate next step?

      Your Answer: Add empagliflozin

      Explanation:

      In addition to metformin, an SGLT-2 inhibitor (such as empagliflozin) should be prescribed for this patient who has a history of cardiovascular disease.

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
      9.3
      Seconds
  • Question 17 - A 75-year-old woman presents to the breast clinic with a painless lump in...

    Incorrect

    • A 75-year-old woman presents to the breast clinic with a painless lump in her left breast. After undergoing triple assessment, she is diagnosed with oestrogen receptor-positive breast cancer and her oncologist prescribes anastrozole as treatment. What potential risks may this medication pose for her?

      Your Answer: Venous thromboembolism

      Correct Answer: Osteoporosis

      Explanation:

      Anastrozole, an aromatase inhibitor, may lead to the development of osteoporosis. This medication is commonly used to treat oestrogen receptor-positive breast cancer in postmenopausal women by reducing the production of peripheral oestrogen. However, patients taking this medication are at an increased risk of developing osteoporosis. On the other hand, selective oestrogen receptor modulators (SERM) like tamoxifen may cause amenorrhoea, endometrial cancer, vaginal bleeding, and venous thromboembolism. Tamoxifen is typically used to treat oestrogen receptor-positive breast cancer in pre-menopausal women.

      Anti-oestrogen drugs are used in the management of oestrogen receptor-positive breast cancer. Selective oEstrogen Receptor Modulators (SERM) such as Tamoxifen act as an oestrogen receptor antagonist and partial agonist. However, Tamoxifen can cause adverse effects such as menstrual disturbance, hot flushes, venous thromboembolism, and endometrial cancer. On the other hand, aromatase inhibitors like Anastrozole and Letrozole reduce peripheral oestrogen synthesis, which is important in postmenopausal women. Anastrozole is used for ER +ve breast cancer in this group. However, aromatase inhibitors can cause adverse effects such as osteoporosis, hot flushes, arthralgia, myalgia, and insomnia. NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 18 - A 30-year-old man is diagnosed with Addison’s disease.
    What should be prescribed in combination...

    Incorrect

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

      Your Answer: Dexamethasone

      Correct Answer: Fludrocortisone

      Explanation:

      Treatment Options for Addison’s Disease

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 19 - A 67-year-old male with a history of multiple myeloma presents with confusion. Blood...

    Incorrect

    • A 67-year-old male with a history of multiple myeloma presents with confusion. Blood tests are taken and the following results are obtained:

      Adjusted calcium 3.1 mmol/l

      What would be the best initial approach to manage this situation?

      Your Answer: Oral alendronate + prednisolone

      Correct Answer: Admit for IV normal saline

      Explanation:

      The primary treatment for hypercalcaemia is IV fluid therapy.

      Managing Hypercalcaemia

      Hypercalcaemia is a condition where there is an excess of calcium in the blood. The initial management of hypercalcaemia involves rehydration with normal saline, typically 3-4 litres per day. This helps to flush out the excess calcium from the body. Once rehydration is achieved, bisphosphonates may be used to further lower the calcium levels. These drugs take 2-3 days to work, with maximal effect being seen at 7 days.

      Calcitonin is another option for managing hypercalcaemia. It works quicker than bisphosphonates but is less commonly used due to its short duration of action. Steroids may be used in sarcoidosis, a condition that can cause hypercalcaemia.

      Loop diuretics such as furosemide may also be used in hypercalcaemia, particularly in patients who cannot tolerate aggressive fluid rehydration. However, they should be used with caution as they may worsen electrolyte derangement and volume depletion.

      In summary, the management of hypercalcaemia involves rehydration with normal saline followed by the use of bisphosphonates or other medications depending on the underlying cause of the condition. It is important to monitor electrolyte levels and adjust treatment accordingly to prevent complications.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 20 - A 38-year-old woman visits her GP with complaints of weight gain and irregular...

    Correct

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

      Your Answer: Hirsutism

      Explanation:

      Effects of Cortisol on the Body: Misconceptions and Clarifications

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

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 21 - An increase in alkaline phosphatase can be attributed to any of the following...

    Incorrect

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

      Your Answer: Healing bone fractures

      Correct Answer: Hypoparathyroidism

      Explanation:

      Understanding Alkaline Phosphatase and Its Causes

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 22 - A 55-year-old man presents to the diabetes clinic for a follow-up appointment. He...

    Incorrect

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

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

      Your Answer: Add pioglitazone

      Correct Answer: Add sitagliptin

      Explanation:

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 23 - A 55-year-old man is hospitalized for a chest infection and undergoes a standard...

    Correct

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

      Your Answer: Splenectomy

      Explanation:

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

      Understanding Glycosylated Haemoglobin (HbA1c) in Diabetes Mellitus

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 24 - A 45-year-old woman with type II diabetes mellitus and a history of hypertension,...

    Incorrect

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

      Your Answer: Stop metformin and start sitagliptin

      Correct Answer: Stop gliclazide and start sitagliptin

      Explanation:

      Choosing the Right Treatment for Hypoglycaemic Episodes in Type 2 Diabetes

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 25 - A 65-year-old man is scheduled for elective surgery to repair an umbilical hernia....

    Correct

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

      Your Answer: Continue as normal

      Explanation:

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 26 - A 63-year-old man presents to his General Practitioner with a 1-month history of...

    Correct

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

      Your Answer: Primary hyperparathyroidism

      Explanation:

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

      Possible Causes and Clinical Features

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

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

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

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 27 - A 75-year-old patient presents for a follow-up appointment after undergoing private health screening....

    Incorrect

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

      Your Answer: Start levothyroxine + carbimazole ('block and replace')

      Correct Answer: Repeat TFTs in a few months time

      Explanation:

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

      Understanding Subclinical Hypothyroidism

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 28 - A 56-year-old man is evaluated after being diagnosed with hypertension. As part of...

    Correct

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

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

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

      HbA1c 31 mmol/mol (5.0%)

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

      Your Answer: Sickle-cell anaemia

      Explanation:

      Understanding Glycosylated Haemoglobin (HbA1c) in Diabetes Mellitus

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

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

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 29 - A 42 year old undergoes a thyroidectomy and is informed about the potential...

    Incorrect

    • A 42 year old undergoes a thyroidectomy and is informed about the potential impact on her parathyroid glands. What is a possible sign of parathyroid damage after the surgery?

      Your Answer: Dry, thick skin, coarse hair and brittle nails

      Correct Answer: Tingling around the hands, feet or mouth, and unusual muscle movements

      Explanation:

      Symptoms and Complications of Thyroidectomy

      Thyroidectomy is a common surgical procedure that involves the removal of the thyroid gland. However, it can lead to various complications, including hypoparathyroidism and hyperparathyroidism. Here are some symptoms to watch out for:

      Acute hypocalcaemia, characterized by tingling around the hands, feet, or mouth, and unusual muscle movements, is a common complication of hypoparathyroidism post-thyroidectomy. Intravenous calcium may be necessary to correct the hypocalcaemia.

      Headache, sweating, and tachycardia are classic symptoms of phaeochromocytoma, which can occur in patients at risk of hypoparathyroidism post-thyroidectomy.

      Dry, thick skin, coarse hair, and brittle nails are signs of hypothyroidism, not hypoparathyroidism.

      Feeling thirsty and passing a lot of urine are signs of hypercalcaemia, which may be caused by hyperparathyroidism. Hypoparathyroidism post-thyroidectomy is a common complication that can lead to hypercalcaemia.

      Hyperactivity and mood swings are more indicative of hyperthyroidism, but patients at risk of hypoparathyroidism post-thyroidectomy should still be monitored for these symptoms.

      In summary, patients who undergo thyroidectomy should be aware of the potential complications and symptoms that may arise. Regular monitoring and prompt medical attention can help manage these issues effectively.

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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  • Question 30 - An infant is born with ambiguous genitalia, following an uneventful pregnancy and delivery....

    Correct

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

      Your Answer: Adrenocortical insufficiency

      Explanation:

      Medical Conditions Associated with 21-Hydroxylase Deficiency

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

    • This question is part of the following fields:

      • Endocrinology/Metabolic Disease
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