Endo Practice Papers qs

Question 1

What hormone is released in carcinoid syndrome?

Answer 1

Serotonin

Question 2

What is carcinoid syndrome typically caused by?

Answer 2

Neuroendocrine tumour in GI tract

Question 3

State two symptoms of presentation of Carcinoid Syndrome

Answer 3

Flushing, diarrhoea, abdominal cramps, bronchospasm (wheezing, asthma), fibrosis (heart valve dysfunction, palpitations

Question 4

What is the definitive treatment for carcinoid syndrome?

Answer 4

Resection of tumour

Question 5

What is the most common cause of hyperthyroidism and hypothyroidism?

Answer 5

Graves’ disease and Hashimoto’s thyroiditis

Question 6

List three symptoms for hyperthyroidism and hypothyroidism each.

Answer 6

Hyper: weight loss, Increased HR, warm moist skin
Hypo: weight gain, decreased HR, hair loss

Question 7

What is the first line treatment for hypothyroidism?

Answer 7

Levothyroxine

Question 8

What is the antibody most associated with hyperthyroidism?

Answer 8

TSH-receptor antibodies

Question 9

Interpret data: TSH: High T4: Low

Answer 9

Hypothyroidism, Hashimoto’s

Question 10

Interpret data: TSH: Low T4: High

Answer 10

Hyperthyroidism, Graves’

Question 11

Interpret data: PTH: High; Calcium: Low; Phosphate: High

Answer 11

Secondary Hyperparathyroidism

Question 12

Interpret data: PTH: High; Calcium: High; Phosphate: High

Answer 12

Tertiary Hyperparathyroidism

Question 13

Main role of Glucose?

Answer 13

Required for respiration

Question 14

Role of glucagon in glucose homeostasis?

Answer 14

Increases glucose levels when they are low by stimulating lipolysis, glycogenolysis and gluconeogenesis .

Question 15

Where is glucagon released from?

Answer 15

From the Alpha cells in the Islets of Langerhans in the pancreas.

Question 16

Role of insulin in glucose homeostasis ?

Answer 16

Decreases glucose levels when they are high by inhibiting lipolysis and glycogenolysis and stimulating glycogenesis.

Question 17

Where is insulin produced?

Answer 17

From the Beta cells in the Islets of Langerhans in the pancreas.

Question 18

Role of Glycogen in the body?

Answer 18

Main form of storage of glucose in the body.

Question 19

Where is Glycogen stored in the body?

Answer 19

In the liver.

Question 20

What process involving glycogen occurs when glucose levels are HIGH?

Answer 20

The liver stimulates glycogenesis (converts glucose to glycogen.

Question 21

What process involving glycogen occurs when glucose levels are LOW?

Answer 21

The liver stimulates glycogenolysis (converts glycogen to glucose.

Question 22

A 17-year-old boy presents to his GP with fatigue, weight loss and polyuria. Following relevant investigations, the GP diagnoses type 1 diabetes. The patient is otherwise stable and blood ketones are not present.

Which of the following is the most appropriate next management step?
Basal-bolus Insulin
Fixed-dose Insulin
Metformin
Weight loss
Amylin analogue

Answer 22

Basal-bolus Insulin

Question 23

A 57-year-old male presents to his GP following several hypoglycaemic episodes. He has a history of type 2 diabetes and heart failure. He is currently being treated with Metformin and Gliclazide.

What is the most likely cause of his hypoglycaemic episodes?
Metformin
Gliclazide
Autonomic neuropathy
Insulin overdose
Natural progression of diabetes

Answer 23

Gliclazide

Question 24

A 75 year old male presents to the emergency department with a one day history of polyuria, polydipsia, increasing drowsiness and confusion. He has recently been started on oral antibiotics by his general practitioner for a urinary tract infection. His past medical history includes type two diabetes mellitus and hypertension. His medication history includes metformin 1g twice daily and ramipril 5mg once daily. He is apyrexial, tachycardic and hypotensive with dry mucus membranes and decreased skin turgor.

Which of the following investigation results would confirm a diagnosis of hyperosmolar hyperglycaemic state (HHS)?
Blood glucose 14 mmol/l
Urinalysis ketones +++
Serum bicarbonate 10 mmol/l
Serum osmolality 330 mOsm/kg
Arterial blood gas pH 7.21

Answer 24

Serum osmolality 330 mOsm/kg

NB: Severe hyperglycaemia (>30mmol/L)
Hypotension
Hyperosmolality (usually >320 mosmol/kg)
No/very mild ketosis
No acidosis

Question 25

A 68-year-old man presents to endocrinology clinic with a history of weight loss and increased skin pigmentation. He was found to have an elevated 24-hour urinary cortisol during a recent admission to hospital with pneumonia and was referred for further investigation. He still has a cough following treatment of his pneumonia. He has a past medical history of chronic obstructive pulmonary disease (COPD), hypertension and type 2 diabetes mellitus. Investigation results are as follows: Cortisol after low dose dexamethasone administration: 743nmol/L (137–429nmol/L) Cortisol after high dose dexamethasone administration: 724nmol/L (137–429nmol/L) Early morning serum adrenocorticotropic hormone (ACTH): 52.4pmol/L (2.2-13.3pmol/L) Which of the following is the most likely diagnosis? Cushing’s disease Small cell lung carcinoma Cortisol-secreting adrenal adenoma Iatrogenic Cushing’s syndrome

Answer 25

Small cell lung carcinoma Low Dose- High Cortisol High Dose- High Cortisol, High ACTH

Question 26

A 29-year-old gentleman, with no past medical history and is otherwise asymptomatic, has a markedly raised blood pressure incidentally diagnosed by his GP. He was referred by his GP to secondary care to investigate for secondary causes of hypertension. Noticing in the preliminary blood tests that the patient's serum sodium was raised at 149 mmol/L while his serum potassium was reduced at 3.3 mmol/L, the consultant cardiologist suspects primary hyperaldosteronism (Conn's syndrome) and sends off a renin-to-aldosterone ratio test among other investigations. Which of the following is the single most likely result of the renin-to-aldosterone ratio test? High renin, low aldosterone High renin, high aldosterone Normal renin, normal aldosterone Low renin, high aldosterone Low renin, low aldosterone

Answer 26

Low renin, high aldosterone

Question 27

A 55-year-old gentlemen has a diagnosis of small cell lung cancer. He presents to A&E complaining of nausea and vomiting and is acutely confused with an AMTS of 3/10. He is triaged, IV fluid resuscitation is initiated and bloods taken. His blood tests show that his plasma sodium is 122 mmol/L. All other blood results are normal. What is the single most likely diagnosis? Addison’s disease Hyponatremia SIADH Dehydration Diabetes Insipidus

Answer 27

SIADH Addison’s disease is known to cause hyponatraemia and hyperkalaemia due to the failure of the adrenal glands to produce glucocorticoids and mineralocorticoids Hyponatraemia is the correct abnormality, however is not the single most likely diagnosis given the presence of small cell lung cancer Dehydration would lead to hypernatremia not hyponatraemia Diabetes insipidus is caused by reduced production of ADH leading to hypernatraemia

Question 28

An 83 year old female presents with colicky abdominal pain, constipation and depressed mood. Her medical history includes hypertension and angina. Blood tests are sent which show the following: Corrected calcium 3.0 mmol/L (2.12-2.65) Phosphate 1.4 mmol/L (2.5-4.5) PTH 15.5 pmol/L (0.8-8.5) ALP 172 mmol/L (30-150) What is the most likely cause of this patient’s presentation? Tertiary hyperparathyroidism Primary hyperparathyroidism Malignancy Pseudohypoparathyroidism Pituitary Surgery Secondary hyperparathyroidism

Answer 28

Primary hyperparathyroidism

Question 29

A 36-year-old female presents to her GP with heat intolerance, sweating and palpitations. She is 10 weeks pregnant but has no other medical history. Bloods tests reveal raised free thyroxine and depressed TSH. What is the most appropriate initial step to treat this patient’s condition? Lithium Carbimazole Propylthiouracil Thyroidectomy

Answer 29

Propylthiouracil

Question 30

A 50-year-old female presents to her general practitioner with 'pins and needles' around her mouth and frequent muscle cramps. On examination, she appears well, however when taking her blood pressure reading, her wrist and fingers began to cramp and flex. What is the most likely diagnosis? Hyperkalaemia Hypocalcaemia Hypernatraemia Hypomagnesaemia

Answer 30

Hypocalcaemia Parasthesia, spasms, tetany

Question 31

You are asked to review a 71-year-old man who is being treated on the ward for community-acquired pneumonia. He has been complaining of palpitations and muscle weakness. An ECG taken on the ward that morning shows peaked T waves and a PR interval of 0.22 seconds. A K+ level of 6.4mmol/L (3.5 – 5.3 mmol/L). What is the most appropriate immediate management option? IV calcium gluconate IV fluids Intravenous (IV) calcium resonium IV insulin/dextrose infusion

Answer 31

IV calcium gluconate – severe hyperkalaemia with ECG changes

Question 32

A 62-year-old man with metastatic prostate cancer presents to the emergency department with constipation, vomiting, abdominal pain and excessive urination. His wife says that he has become increasingly confused and has complained of increased thirst. Blood tests reveal the following: What is the most appropriate initial management option? Vitamin D and calcium supplementation IV zoledronic acid Calcitonin IV 0.9% sodium chloride

Answer 32

IV 0.9% sodium chloride – rehydrate

Question 33

A 45-year-old male is seen in the endocrinology clinic for suspected diabetes insipidus. Based on the patient's history, the endocrinologist suspects a central cause of the diabetes insipidus. Which of the following is a cause of nephrogenic diabetes insipidus? Craniopharyngioma Lithium Head Trauma CNS Infections Pituitary Surgery

Answer 33

Lithium other options are causes of Cranial DI

Question 34

A 40-year-old man attends his GP because of headaches that have been going on for 3 months. It is also uncovered that he has been experiencing erectile dysfunction and he is low in mood because of this. Following referral to the Neurologists, he has an MRI scan to investigate his headache. This reveals a pituitary adenoma. What is the most likely cause for his problems? ACTH producing tumour Growth hormone producing tumour TSHoma Prolactinoma Non-secreting tumour

Answer 34

Prolactinoma

Question 35

A 55-year-old women with a thyroid carcinoma undergoes a total thyroidectomy. The post operative histology report shows a final diagnosis of medullary type thyroid cancer. Which of the tests below is most likely to be of clinical use in screening for disease recurrence? Serum CA 19-9 levels Serum thyroglobulin Serum TSH Serum Calcitonin

Answer 35

Serum Calcitonin Serum calcitonin - Medullary thyroid cancers often secrete calcitonin and monitoring the serum levels of this hormone is useful in detecting sub clinical recurrence

Question 36

A 30-year-old man presents to the acute medical unit with agitation, restlessness and palpitations. He has steadily been getting worse over the last four weeks, feeling increasingly tired and run down. He is previously well with no significant past medical or family history. On examination he is noted to have a swollen and painful neck anteriorly. He is tachycardic at 130 reg bpm. He is apyrexial. Thyroid blood tests reveal: Thyroid stimulating hormone (TSH) 1.1 (0.5-5.5mu/L) Free Thyroxine (T4) 30 (9-18pmol/L) Which of the following is the most likely diagnosis? Acute thyroiditis De Quervain’s (Subacute) Thyroiditis Autoimmune thyroiditis Thyroid cancer

Answer 36

De Quervain’s (Subacute) Thyroiditis – important is the fever like symptoms as this is preceded by a viral infection

Question 37

A 30-year-old female presents with sudden weight gain (5kg) over the last 2 months. She complains of constipation, hair loss with brittle nails. You notice the loss of hair to the lateral third of the left eyebrows. Which antibody is most likely to be associated with the condition presented above? Anti TPO Anti dsDNA TSH receptor antibodies Anti Thyroglobulin antibodies What is this condition?

Answer 37

Anti TPO Hashimoto’s hypothyroidism

Question 38

A 56-year-old diabetic female is admitted to hospital in order to have intravenous antibiotics for community acquired pneumonia. On day 4 of admission, she becomes confused and drowsy after which she has a short seizure which spontaneously resolves. Her capillary glucose is noted at 2.6mmol/L and she is unconscious. What is the most appropriate immediate management of this patient? Oral glucose tables IV glucose IV glucagon IM insulin

Answer 38

IV glucose This is the most rapid method of reversing hypoglycaemia and is indicated in this case because the patient is unconscious and has had a seizure

Question 39

A 47-year-old male presents to his GP with weight loss, polyuria and polydipsia. The GP suspects type 2 diabetes mellitus. Which one of the following describes the correct cut-off value for diagnosis of type 2 diabetes mellitus? Fasting plasma glucose >7.9mmol/L Oral glucose tolerance test ≥11.1 mmol/L HbA1c ≥ 58mmol/L Low random C-peptide Random plasma glucose >6.9mmol/L

Answer 39

Oral glucose tolerance test ≥11.1 mmol/L

Question 40

A 3-year-old boy with a history of Type 1 diabetes mellitus presents to Accident and Emergency with vomiting and lethargy. On examination, he appears dehydrated. Capillary blood gas and capillary blood ketone tests are performed, which confirm a diagnosis of moderate diabetic ketoacidosis (DKA). Which of the following treatments should be commenced first? IV insulin infusion IV sodium bicarbonate IV 0.9% sodium chloride Oral fluids and subcutaneous insulin Continuous subcutaneous insulin infusion (CSII) pump

Answer 40

IV 0.9% sodium chloride Initial management of DKA involves fluid and potassium replacement in order to correct the hypovolaemia, acidosis, ketonemia and total body hypokalaemia associated with this condition. It is important to note that fluid replacement, though vital to treatment, should be cautious as there is also an increased risk of cerebral oedema with fluid overload in DKA patients. Therefore, fluid boluses should be avoided if possible and fluid should be replaced at a slightly reduced rate

Question 41

Judy, a 34 year-old female, presents to the GP with symptoms of hypertension despite being on a current regimen of antihypertensive medications. The junior doctor orders appropriate blood tests and the results come back which suggest a diagnosis of Conn’s syndrome. She is scheduled to have an operation for an adrenalectomy. What medication is prescribed prior to her operation to stabilise her BP and K+ levels? A. Aspirin B. Furosemide C. Ramipril D. Spironolactone E. Warfarin

Answer 41

Spironolactone You can think of Conn’s syndrome as having 3 key aspects (hypertension associated with hypokalaemia, hypertension despite being on 3 or more antihypertensives, hypertension before 40 years of age). Spironolactone is a potassium sparing diuretic so it will retain the K+ ions in your body. Conn’s syndrome is hyperaldosteronism thus an increase in aldosterone will increase sodium retention. This subsequently will increase water retention causing hypertension. Simultaneously, aldosterone also causes increased potassium excretion.

Question 42

Jeremy presents to your GP for review of his recent blood test results. They show raised Renin and raised Aldosterone levels. What is the most likely diagnosis? A. Addison’s disease B. Catatonic state C. Hypertension D. Secondary hyperaldosteronism E. Pseudo pseudohypoparathyroidism

Answer 42

Secondary Hyperaldosteronism If both renin and aldosterone are raised then it is most likely that a renin secreting tumour is present. This will increase the level of renin thus feedback mechanism would lead to an increase of aldosterone. In Addison’s aldosterone levels go down. Catatonic state is a psychiatric state. Hypertension has no effect on aldosterone or renin nor does pseudo pseudohypoparathyroidism. The table below shows the levels of renin and aldosterone in primary and secondary hyperaldosteronism and the differential diagnosis.

Question 43

Which of following signs would someone with a suspected diagnosis of Cushing’s syndrome most likely present with? A. Abdominal striae B. Hypotension C. Hyperpigmentation D. Vertigo E. Weight loss centrally

Answer 43

Abdominal Striae Ptx with Cushing’s syndrome will usually present with abdominal striae, moon face, buffalo hump and weight loss in extremities. Ptx with Addison’s usually present with hyperpigmentation, central weight loss as well as hypotension.

Question 44

Loss of which of the following feedback system results in an increase of cortisol in the body? A. Hypothalamo-pituitary-adrenal axis B. Hypothalamo-adrenal-pituitary axis C. Hypothalamo-pituitary-thyroid axis D. Hypothalamo-thyroid-pituitary axis E. Hypothalamo-pituitary axis

Answer 44

Hypothalamo-pituitary-adrenal axis The hypothalamus produces Corticotrophin-releasing hormone (CRH) that acts on the pituitary gland to produce Adrenocorticotropic Hormone (ACTH) which acts on the adrenal glands to produce cortisol.

Question 45

Luke presents with symptoms of polyuria, polydipsia and dehydration. You suspect the diagnosis to be Diabetes Insipidus. What test would you perform to differentiate whether the cause is cranial or nephrogenic? A. Alcohol deprivation test B. Blood glucose C. Dexamethasone suppression test D. ECG E. Water deprivation test with desmopressin

Answer 45

Water deprivation test with desmopressin Large amounts of water is lost during DI. This is due to either a decrease in production of ADH (cranial cause) or an impaired response to ADH (nephrogenic cause). Ix= deprive ptx of water, test osmolality pre and post giving desmopressin (ADH/Vasopressin)

Question 46

James’s HbA1c levels are tested in order to determine whether he has Diabetes Mellitus or not. Which of the following values will prove diagnostic? A. ≥6.5 mmol/mol B. ≥11.1 mmol/mol C. ≥24 mmol/mol D. ≥42 mmol/mol E. ≥48 mmol/mol

Answer 46

≥48 mmol/mol The values are determined by WHO. Patient also needs to have done a glucose tolerance test in order to confirm the diagnosis. In glucose tolerance test (GTT) of a suspected diabetic patient you would expect to find that fasting glucose levels to be above 7mmol/mol and 2hr GTT levels to be more than 11mmol/mol. Full diagnostic criteria for DM is as follows: * Fasting plasma glucose >7mmol/L * HbA1c of ≥48mmol/mol * Symptoms and random plasma glucose >11mmol/L

Question 47

Which of the following is not a cause of hypercalcaemia? A. Down’s syndrome B. Familial benign hypocalciuric hypercalcaemia C. Malignancy D. Sarcoidosis E. Thyrotoxicosis

Answer 47

Down’s syndrome Down’s syndrome has no correlation with hypercalcaemia. When thinking of signs and symptoms of hypercalcaemia always remember bones, stones, groans and psychic moans. Causes of hypercalcaemia can be remembered by the mnemonic CHIMPANZEES- Calcium supplements, Hydrochlorothiazide, Iatrogenic/Immobilisation, Multiple myeloma/Medication (lithium), Parathyroid hyperplasia, Alcohol, Neoplasm, Zollinger ellison syndrome, Excessive Vit D, Excess Vit A, Sarcoidosis

Question 48

Which of the following is most likely to be present on an ECG with someone who has been hyperkalaemia? A. Narrow QRS complex B. Small T waves C. Tall T waves D. Tall P waves E. U waves

Answer 48

Tall Tented T Waves Hyperkalaemia ECG = absent P waves, prolong PR, tall T waves and wide QRS complex. Narrow QRS complex is seen in Atrial flutter and Junctional Tachycardia. U waves are seen in hypokalaemia not hyperkalaemia.

Question 49

Due to his excessive alcohol intake, Martin developed pancreatitis. Recently he started to feel thirsty and complained of having to wake up during the night to go the toilet. What is the most likely cause of his symptoms? A. Addison’s disease B. Conn’s disease C. Excessive alcohol intake D. Gilbert’s syndrome E. Pancreatogenic Diabetes

Answer 49

Pancreatogenic Diabetes Diabetes can be secondary to pancreatic pathology such as pancreatitis or removal of pancreas. Removal of pancreas would mean insulin is not produced in the body thus the blood sugar levels would increase. Remember the causes of pancreatitis and the subsequent pathology that would happen from it. Addison’s and Conn’s both present with symptoms of thirst and polyuria but in this pts history there is nothing that suggests that this might be the diagnosis. Gilbert’s is an inherited condition that affects your liver.

Question 50

Molly has come into GP complaining of diarrhoea, heart palpations and feeling quite flushed. She has also noticed a change in mood but thinks this is due to her being recently fired from her job. What is the most likely explanation for her symptoms? A. Carcinoid syndrome B. Depression C. Hypertension D. Hypothyroidism E. Pituitary tumour

Answer 50

Carcinoid syndrome Carcinoid syndrome is paraneoplastic syndrome that has a classical triad of cardiac involvement, diarrhoea and flushing. Its due to the tumour cells producing 5-HT.

Question 51

Which of the following is not a typical symptom of a patient with hyperthyroid disease? A. Diarrhoea B. Polyuria C. Increased appetite D. Irritability E. Weight loss

Answer 51

polyuria Answers A,C, D and E are symptoms of hyperthyroid disease. A good way to remember the symptoms of this is that everything in hyper speeds up, whilst in hypo everything slows down. B- polyuria is not a symptom of hyperthyroid instead it’s a symptom of Diabetes

Question 52

Mrs Andrews, a 56-year-old lady, comes into your GP surgery complaining of vision problems. She has noticed that she’s had double vision and painful sore eyes. She fells well in herself and in fact is quite happy because she’s lost quite a lot of weight in the past month without even really trying.. What is the most likely diagnosis? A. De Quervain’s thyroiditis B. Graves’ disease C. Peri-orbital cellulitis D. Thyroid Cancer E. Thyrotoxicosis

Answer 52

Grave’s disease Graves’ Disease is the most common cause of hyperthyroidism. This is an autoimmune condition in which the body produces TSH receptor stimulating antibodies. It causes the typical presentation of Graves’ ophthalmopathy, diplopia, eye pain and other hyperthyroid symptoms. De Quervain’s thyroiditis is a transient condition due to a viral infection. You get no eye involvement. In peri-orbital cellulitis the orbit would be red, painful and sore and would be systemically unwell. Thyroid cancer would not typically present with eye symptoms. Thyrotoxicosis is when you get an overproduction in thyroid hormones and get non eye related symptoms: palpitations, delirium, hyperpyrexia etc.

Question 53

A 38-year-old lady has noticed that she has become increasingly tired, put on 6kg of weight in the last month and is feeling depressed. Which of the following Thyroid Function Tests would most likely fit with this patient’s clinical picture? A. High TSH, Low T3 and Low T4 B. High TSH, High T3 and Low T4 C. Low TSH, High T3 and High T4 D. Low TSH, Low T3 and Low T4 E. Normal TSH, Normal T3 and Normal T4

Answer 53

High TSH, low T3/T4 This patient’s presentation is indicative hypothyroid disease by their fatigue, weight gain and low mood. indicated . Primary hypothyroidism results show a low T3/T4 and a high TSH (pituitary is trying to respond to negative feedback of low t3/t4 by increasing release of TSH. B is a completely made up blood result. C- low TSH, High T3/T4 indicates primary hyperthyroidism. D demonstrates a patient who has pituitary failure (Low TSH released from pituitary hence low T3/T4, this would also be a sensible answer however the patient is more likely to present with a broad spectrum of signs and symptoms caused by a lack of other pituitary hormone release not just hypothyroid symptoms).E: demonstrates a Euthyroid ‘normal’.

Question 54

Which of the following tests is the Gold Standard test for Acromegaly? A. ECG B. Oral Glucose Tolerance test C. IGF-1 test D. MRI scan of pituitary E. GH levels

Answer 54

Oral Glucose Tolerance Test Oral glucose tolerance test (B) is the gold standard test for acromegaly. IGF-1 (C) is a good indicator of GH levels but not gold standard. MRI of pituitary (D) may identify a pituitary tumour as the cause but independently would not diagnose Acromegaly- the tumour could be causing Cushing’s not acromegaly. GH levels (E) are not a reliable test as they fluctuate during the day.

Question 55

What is the most common cause of secondary hypoadrenalism? A. Autoimmune disorder B. Cessation of corticosteroid treatment C. Long term corticosteroid usage D. Pituitary Surgery E. TB

Answer 55

Long term corticosteroid usage Long term corticosteroid use is the number one cause of secondary hypoadrenalism. This condition is more common than Addison’s. Other causes include cessation of corticosteroid treatment and disorders of the pituitary (such as surgery to it). A and E are causes of Addison’s disease

Question 56

A 22-year-old male presents with dizziness and feeling generally off. He’s noticed that most of the time when he stands up he feels like he’s going to faint. He’s lost 4 kg unintentionally in the last month and has noticed that his skin has a weird tanned appearance to it despite it being winter. What is the most appropriate investigation to diagnosis this patient? A. Blood Glucose B. Blood Salts C. Low dose dexamethasone test D. Synacthen Test E. Thyroid Function Tests (TFTs)

Answer 56

Synacthen test This patient has Addison’s disease (primary hypoadrenalism) an autoimmune condition when the entire adrenal cortex is destroyed. Reduced cortisol, aldosterone and sex hormones cause a range of symptoms such as postural hypotension in this case. Hyper pigmentation is due to increased ACTH. The correct test is D this gives an infusion of ACTH.

Question 57

Which of these is not a cause of Syndrome of Inappropriate secretion of ADH (SIADH)? A. Alcohol withdrawal B. Dehydration C. Head injury D. Pneumonia E. Small cell lung cancer

Answer 57

Dehydration Dehydration is not a cause of SIADH. Alcohol withdrawal, head injury, pneumonia and small cell lung cancer are potential causes of SIADH. SIADH is a condition of inappropriate ADH release. This causes the plasma to become too dilute. It leads to water retention, excess blood volume and hyponatraemia. The patient will have a low serum Na+, high urine Na+. Management is through restricting fluid intake and use of ADH inhibitors (demeclocycline)

Question 58

What would be your immediate management for a patient with suspected Carcinoid Syndrome? A. Desmopressin B. IV salbutamol C. Oral Sando-K D. Radiotherapy E. Somatostatin Analogue (octreotide)

Answer 58

Somatostatin analogue Carcinoid Syndrome occurs as a result of a tumour of enterochromaffin cells which secrete 5-HT. They are most commonly found in the terminal ileum or appendix. Once there is hepatic involvement it’s called carcinoid syndrome. Excess secretion of substance P, insulin, serotonin, ACTH and bradykinin causes there to be a range of symptoms from hyperglycaemia to bronchoconstriction. The classical triad of carcinoid syndrome is palpitations, diarrhoea and flushing. If someone is in a crisis due to carcinoid syndrome give them a somatostatin analogue and do surgery.

Question 59

A 48-year-old lady comes to see the GP with worsening numbness in her hands and feet and changes in her breathing (more high pitched). When you measure the patient’s Blood Pressure you notice that her wrist is flexing. What is the most likely diagnosis? A. Acromegaly B. Hypocalcaemia C. Hypokalaemia D. Obstructive Sleep Apnoea E. SIADH

Answer 59

Hypocalcaemia B is the correct answer. Common symptoms of hypocalcaemia are numbness and tingling in the extremities. The case describes Trousseau’s Sign: wrist flexion following the inflation of a BP cuff. You can also get Chvostek’s Sign: tapping the facial nerve in the parotid gland causes ipsilateral facial muscle twitching. In Acromegaly obstructive sleep apnoea would be common.

Question 60

A patient presents to A&E due to increasing pain when passing urine. When you enquire more, you find out he’s had bad pain in his bones and been feeling increasingly anxious. He is found to have primary hyperparathyroidism. What would you see on his blood work? A. High PTH – Calcium High – Phosphate Low B. High PTH – Calcium Low – Phosphate High C. High PTH – Calcium High – Phosphate High D. Normal PTH – Calcium High – Phosphate Normal E. High PTH- Calcium low – Phosphate Low

Answer 60

High PTH, High Calcium, Low Phosphate

Question 61

A 38-year-old lady visits you during your morning GP clinic. You have met several times in the past but she has not attended for a number of years. She moves slowly into the room and does not make eye contact with you. She is slow to respond to your questions. During the consultation she complains of feeling increasingly tired, cold and lethargic during the day. She also discloses that her normally regular periods have become very heavy and irregular. You arrange some blood tests which show microcytic anaemia and raised thyroid stimulating hormone (TSH). What is the most appropriate first line therapy for this patient? A. Beta blocker B. Carbimazole C. Levothyroxine D. Prednisolone E. Thyroidectomy

Answer 61

Levothyroxine Levothyroxine is the first line treatment for primary hypothyroidism. This is a typical presentation of thyroid disease; a middle-aged woman with lethargy, cold intolerance, menorrhagia, depressive symptoms (poor eye contact, mental slowness). Others include dry hair & skin, bradycardia and slow relaxing reflexes. Levothyroxine synthetic thyroid hormone that is taken daily (lifetime therapy. (A) Beta-blockers (bisoprolol, propranolol etc.) reduce the rate and force of contraction of the heart via the beta-1 muscarinic receptors found in the myocardium. Beta-2 receptors are in the smooth muscle of blood vessels and airways (hence the contraindication in asthma patients as they can cause restriction of the airways). These are used for symptomatic relief in hyperthyroidism. (B) Carbimazole is a treatment for hyperthyroidism (most commonly Graves’ disease). It blocks thyroid hormone synthesis. (D) Prednisolone is a corticosteroid and is not used in hyper/hypothyroidism. (E) Thyroidectomy is a third line treatment after radioiodine ablation and carbimazole for hyperthyroidism.

Question 62

What is the thyroid function test profile found in Graves’ disease? A. Low TSH, normal T3 & T4 B. Low TSH, raised T3, low T4 C. Low TSH, raised T3 & T4 D. Raised TSH, low T3 & T4 E. Raised TSH, raised T3, low T4

Answer 62

Low TSH, raised T3 & T4 Graves’ disease is primary hyperthyroidism. The thyroid gland overproduces thyroid hormones without stimulation from the pituitary therefore elevated levels of T3&T4 causing negative feedback to the hypothalamus and pituitary inhibiting the production of TRH and TSH respectively. Raised TSH and low T3&T4 would be found in primary hypothyroidism.

Question 63

Which of the following is not a sign or symptom of Graves’ disease? A. Exophthalmos B. Increased appetite C. Increased weight D. Lid lag E. Tachycardia

Answer 63

Increased weight All of the above are features of Graves’ disease apart from increased weight. Weight commonly decreases in hyperthyroidism despite increased appetite.

Question 64

A 28-year-old woman attends your GP clinic complaining of changes to her menstrual period. On exploration of this change she discloses that her periods have been getting more irregular over the last two years and have now stopped completely, her last period being 3 months ago. She describes this coinciding with decreased libido and lack of interest in her partner. She has stopped wearing her engagement ring as it is causing discomfort and reports that she is increasingly sweaty even when not exercising. What is the initial investigation that should be organised for this woman? A. MRI Brain B. Oral glucose tolerance test C. Random blood glucose D. Serum cortisol E. TFTs

Answer 64

Oral glucose tolerance test This patient has acromegaly. She has amenorrhoea, decreased libido and acral enlargement (ring doesn’t fit) and excessive sweating. Acromegaly is caused by increased secretion of growth hormone (GH) from the pituitary gland due to a pituitary tumour or hyperplasia. The diagnostic test for acromegaly is a glucose tolerance test (A). In normal physiology glucose suppresses GH, but it remains elevated in patients with acromegaly. (A) MRI brain may show a pituitary tumour / hyperplasia but is not diagnostic of acromegaly as it does not demonstrate raised growth hormone levels. (you can get pituitary tumours that do not secrete GH i.e.. Prolactinoma) This would identify underlying pathology but is not the initial investigation. (C)Random blood glucose will be raised but is not diagnostic. (D)Serum cortisol is used in the diagnosis of adrenal abnormalities such as Cushing’s and Addison’s. (E) TFTs may be abnormal as the pituitary gland is affected but they are not implicated in acromegaly. Note that the presentation is similar to hypothyroidism however a key distinction here is the hand enlargement and excessive sweating. Sweating is a feature of hyperthyroidism not hypothyroidism so this would not fit.

Question 65

Which of the following hormones does the anterior pituitary gland not secrete? A. Corticotropin releasing hormone B. Follicular stimulating hormone C. Growth hormone D. Prolactin E. Thyroid stimulating hormone

Answer 65

Corticotropin releasing hormone (CRH) The hypothalamus secretes hormones that trigger the anterior pituitary gland to secrete hormones into the blood stream, initiating response at a desired tissue. CRH (A) is released by the hypothalamus to simulate adrenocorticotropic (ACTH) release which acts on the adrenal glands to increase production of adrenocorticoids (cortisol, aldosterone and testosterone). FSH (B) and GH (C) are secreted following stimulation by GnRH (gonadotrophin releasing hormone), prolactin (D) is secreted following stimulation by prolactin releasing hormone and TSH (E) after TRH.

Question 66

A 54-year-old man attends the GP complaining of aching pain in his both legs and back. You see in his notes he has attended frequently in the last 4 months with worsening low mood, abdominal and flank pain and increasing frequency of micturition. You see in his notes that he has chronic kidney disease stage 3 and has recently been found vitamin D deficient. What would you expect to see when doing a bloods workup? A. Low serum parathyroid hormone, hypocalcaemia and hyperphosphatemia B. Low serum parathyroid hormone, hypercalcaemia and hyperphosphatemia C. Raised serum parathyroid hormone, hypercalcaemia and hypophosphatemia D. Raised serum parathyroid hormone, hypocalcaemia and hyperphosphatemia E. Raised serum parathyroid hormone, hypercalcaemia and hyperphosphatemia

Answer 66

Raised serum PTH, hypocalcamia, hypophosphataemia\ This is secondary hyperparathyroidism. This patient has the classical symptoms ‘bones, stones, groans, moans, thrones’ bone pain, renal stones, abdo pain, polyuria and depression. However, they have compensatory hypertrophy of the parathyroid in response to CKD and low vitamin D. Secondary hyperparathyroidism has raised PTH but low calcium and phosphate on investigation. It is treated by correcting the hypocalcaemia. Primary hyperparathyroidism (parathyroid adenoma) would show raised PTH, raised Ca and low phosphate (C). This is treated by surgical removal of the adenoma Tertiary hyperparathyroidism (autonomous hyperplasia) would show raised PTH, raised Ca and raised phosphate (E) and require parathyroidectomy.

Question 67

Which of the following is not part of the immediate management for acute severe hypercalcaemia? A. Bisphosphonates B. IV fluids C. Measure serum U&E/Ca D. Parathyroidectomy E. Prednisolone

Answer 67

Parathyroidectomy Severe hypercalcaemia can present with dehydration, confusion and poses a risk of cardiac arrest and death. The immediate management is IV fluids (rehydration), bisphosphonates (inhibit osteoclasts - prevent bone resorption therefore reduce Ca in blood as bone not broken down), measurement of U&E/Ca, and prednisolone. Parathyroidectomy is not immediate management. It may make up subsequent management once the patient is stable.

Question 68

A 36-year-old patient attends A&E with high fever of 41 degrees, HR 150 and in AF. They are hypotensive, vomiting and confused. On speaking to a relative you discover that they stopped taking their regular medications 3 days ago as they forgot to take it with them on a weekend away. This included bisoprolol, atorvastatin, carbimazole and microgynon. What is the most likely diagnosis? A. Cocaine intoxication B. Conn’s syndrome C. Hyperthyroid crisis D. Meningitis E. Myxoedema coma

Answer 68

Hyperthyroid crisis This is a presentation of hyperthyroid crisis (C). The key clue is the withdrawal from carbimazole, the treatment for hyperthyroidism (Graves’ disease). Cocaine intoxication (A) presents in a very similar way, but the history is suggestive of previous hyperthyroid diagnosis. Conn’s syndrome (B) is primary hyperaldosteronism due to an adrenal adenoma. It presents with hypertension, hyperkalaemia and metabolic acidosis. Aldosterone antagonists are used to treat the patient until definitive surgery. !hyperkalaemia can cause arrhythmia and death and must be monitored and corrected. Myxoedema coma (E) is a hypothyroid emergency. It can present with hypothyroid symptoms relating to any body system but commonly affects mental state and patients are hypothermic, hypotensive and bradycardic. Immediate thyroid hormone replacement is needed.

Question 69

Which of the following clinical features do patients with Addison’s disease not commonly experience? A. Depression B. Hyperpigmentation C. Hypertension D. Vomiting E. Weight loss

Answer 69

Hypertension All of these apart from hypertension are symptoms of Addison’s disease, it causes hypotension. Addison’s: adrenal insufficiency = low levels of cortisol and aldosterone, treated with hydrocortisone and fludrocortisone replacement / treat cause). ‘tanned, tired, tearful, thin, throwing up’

Question 70

Which of the following is not a complication of long-term steroid therapy? A. Diabetes Mellitus B. Immunosuppression C. Osteoporosis D. Proximal muscle weakness E. Thickened skin

Answer 70

Thickened skin Long term steroid use causes skin thinning and easy bruising therefore (E) thickened skin is incorrect. Diabetes Mellitus (A), immunosuppression (B), osteoporosis (C) and proximal muscle weakness (D) are all potential complications of long-term steroid use.

Question 71

Ingrid, a 36-year-old woman with Crohn’s disease, went away on holiday for a few weeks, she had so much fun that in the midst of it all she forgot to take her Crohn’s long-term medication. After a week, she started feeling more tired, lost her appetite, and is dizzy upon standing. What is the most likely cause of her symptoms?

Answer 71

Secondary adrenal insufficiency due to corticosteroid withdrawal. She would’ve been on a long-term corticosteroid (e.g. prednisone) for her Crohn’s disease which leads to the suppression of the adrenal glands. With prolonged suppression, the adrenal glands atrophy, which means that they can’t produce enough corticosteroids if exogenous corticosteroids are stopped abruptly, leading to symptoms of adrenal insufficiency.

Question 72

State 3 types of cancers that can cause SIADH.

Answer 72

Small cell carcinoma (remember this one, comes up) Prostate cancer Pancreatic cancer Lymphomas Cancer of the thymus

Question 73

What ECG features would you expect to find in a patient with hyperkalaemia?

Answer 73

Hyperkalaemia-associated ECG changes: - Absent/flattened P waves - Prolonged PR interval - Tall-tented T waves - Wide QRS complex - Bradycardia Hyperkalaemia is defined as plasma potassium ≥5.5 mmol/L. One of the most common causes is renal impairment. It can be caused by many other things such as: medications, DKA, Addison’s disease, trauma and burns

Question 74

State 5 signs/ symptoms you might expect to see in a patient with hyperkalaemia?

Answer 74

Muscle weakness/ Painful cramping / Paraesthesia Neurological derangement/ irritability/ anxiety Palpitations Abdo cramping and diarrhoea Dyspnoea Hyperreflexia

Question 75

Dave, a 50 year of male presents to clinic extremely worried about some bodily changes his wife noticed. His hands have seemed to get larger as well has coarsening of his facial features. a) What is the most likely cause of this condition?

Answer 75

GH secreting pituitary adenoma

Question 76

Dave, a 50 year of male presents to clinic extremely worried about some bodily changes his wife noticed. His hands have seemed to get larger as well has coarsening of his facial features. b) On examination, you notice a loss of peripheral vision. What is this called and how is it caused?

Answer 76

Bitemporal hemianopia – pressure on the optic chiasm from a pituitary adenoma

Question 77

Dave, a 50 year of male presents to clinic extremely worried about some bodily changes his wife noticed. His hands have seemed to get larger as well has coarsening of his facial features. c) Give 3 complications of this condition?

Answer 77

Obstructive sleep apnoea; IGT/T2DM; cardiomyopathy; hypertension; IHD/stroke; colorectal cancer

Question 78

Dave, a 50 year of male presents to clinic extremely worried about some bodily changes his wife noticed. His hands have seemed to get larger as well has coarsening of his facial features. d) What is the first line investigation?

Answer 78

Serum IGF-1 raised (because GH release is pulsatile and IGF-1 levels increase with GH secretion - the majority of GH biological consequences are due to IGF-1)

Question 79

Dave, a 50 year of male presents to clinic extremely worried about some bodily changes his wife noticed. His hands have seemed to get larger as well has coarsening of his facial features. e) What is the first line treatment?

Answer 79

Transsphenoidal resection of the pituitary adenoma

Question 80

Dave, a 50 year of male presents to clinic extremely worried about some bodily changes his wife noticed. His hands have seemed to get larger as well has coarsening of his facial features. f) Give one other option of managing this condition.

Answer 80

Class, example * SST analogues: octreotide * GH antagonists: Pegvisomant * DA agonists: bromocriptine, cabergoline Stereotactic gamma knife

Question 81

A 30-year-old man presents with polyuria and polydipsia. a) Give four differential diagnoses

Answer 81

DM, DI, SIADH, primary polydipsia, hypercalcaemia

Question 82

He has severe colicky right groin pain as well. A CTKUB shows a right sided renal calculus. His blood results show: b) What is the most likely diagnosis? c) What is the most likely cause of this diagnosis? d) Give five more symptoms of this condition. e) What is the definitive treatment?

Answer 82

b) Primary hyperparathyroidism c) Solitary adenoma (80%) d) * Bones: bone pain/facture * Stones: renal/biliary stones * Groans: constipation, abdo pain, PUD, pancreatitis * Psychic moans: depression * Thrones: polyuria, polydipsia e) Total parathyroidectomy

Question 83

A 43-year-old woman is referred to the endocrine clinic with symptoms of weight gain, fatigue and headache. She was also recently diagnosed with type two diabetes. a) Give 3 differential diagnoses (3 marks)

Answer 83

Cushing’s syndrome, acromegaly, hypothyroidism Diagnosis is Cushing’s disease.

Question 84

On examination, you note truncal obesity with proximal wasting of the arms and legs. Hirsutism is present, and the skin appears thin with multiple striae and bruises. b) What is your first line investigation?

Answer 84

Overnight dexamethasone suppression test

Question 85

c) What is the most common cause of Cushing’s Syndrome?

Answer 85

Most common cause of Cushing’s syndrome is from exogenous causes e.g. glucocorticoid use (corticosteroids)

Question 86

Fatima, a 30-year-old female, presents to clinic with generalised fatigue, headaches and paraesthesia. She has been experiencing muscle cramps in her legs and has been too weak to go to her kickboxing practice. She reports being constantly thirsty and constantly urinating. a) Give 3 differential diagnoses

Answer 86

Primary hyperaldosteronism, SIADH, DM, renal artery stenosis

Question 87

On examination, her BP is 158/110. She states that her father also had high blood pressure and passed away from a stroke in his late 40s. b) What is the main feature evident on a Urea and Electrolytes (U&E) blood test? c) What is the first line investigation? d) How do you distinguish between primary and secondary hyperaldosteronism?

Answer 87

b) Hyperkalaemia c) Aldosterone renin ratio (ARR) d) High ratio = primary / low ratio = secondary

Question 88

A 55-year-old female presented to her GP with progressive abdominal pain and constipation. On further questioning, the patient stated that she is not able to walk as far as she used to be able to due to bone pain. The GP decided to take a sample of blood to test for urea & electrolytes, full blood count and thyroid function tests as well as a bone profile. The blood results showed a high PTH and high serum calcium and was subsequently diagnosed with primary hyperparathyroidism. a) What ECG changes can be seen in hypercalcaemia

Answer 88

Shortening of the QT interval

Question 89

Name two signs on clinical examination that can be seen on hypocalcaemia.

Answer 89

Chvostek’s sign - tap over the facial nerve causes spasm of the facial muscles Trousseau's sign - inflate the blood pressure cuff to 20mmHg above systolic for 5 minutes and the hand should form a claw.

Question 90

From which artery does the superior thyroid artery branch from?

Answer 90

External carotid artery Arterial supply to the thyroid gland arises from the external carotid artery and the thyrocervical trunk. The superior thyroid artery is the first branch of the external carotid artery and the inferior thyroid artery forms from the thyrocervical trunk which is the 3rd branch of the subclavian artery. The branches of the subclavian artery are as follows in order - vertebral artery. Internal thoracic artery, thyrocervical trunk, costocervical trunk.

Question 91

Briefly outline the pathophysiology of malignancy.

Answer 91

Hypercalcaemia of malignancy is caused by excessive secretion of parathyroid hormone released peptide (PTHrP)

Question 92

Give 4 functions of parathyroid hormone.

Answer 92

PTH increases bone remodelling and turnover. PTH stimulates osteoclasts to reabsorb bone mineral which liberate calcium into blood (breaks down bone). PTH increases the amount of calcium reabsorbed in the kidney which means that less is excreted in urine. PTH decreases phosphate reabsorption in the kidney. PTH decreases phosphate reabsorption in the kidney, increasing the amount excreted. PTH increases absorption of Ca2+ in the gut.

Question 93

Give 3 generalised symptoms of a pituitary adenoma.

Answer 93

Headaches Vision problems (double vision, vision loss) Nausea or vomiting Changes in behavior, including hostility, depression and anxiety Changes in the sense of smell Nasal drainage Sexual dysfunction Infertility Fatigue (extreme tiredness) Unexplained weight gain or loss Achy joints or muscle weakness Early menopause Changes in your monthly periods (women)

Question 94

Blood tests show that there is increased circulating thyroid stimulating hormone (TSH) as a result of the pituitary adenoma. What specific signs or symptoms would you see?

Answer 94

Patients may present with symptoms of hyperthyroidism including sweating, heat intolerance, shaky hands, palpitations, nervousness, increased stool frequency, weight loss, poor sleep quality, fatigue, and irregular periods. They may also present with headache, visual disturbance, an enlarged thyroid

Question 95

What is carcinoid syndrome?

Answer 95

neuroendocrine tumour secreting serotonin

Question 96

Give 3 signs or symptoms of carcinoid syndrome

Answer 96

cutaneous flushing § recurrent diarrhoea ↑ bowel motility abdominal cramps asthma-like wheezing

Question 97

What drug is commonly used to reduce thyroid hormone production?

Answer 97

Carbimazole

Question 98

Briefly outline the physiology of how this drug (Carbimazole) exerts its effects

Answer 98

Blocks thyroid peroxidase from coupling and iodinating the tyrosine residues on thyroglobulin, this leads to decreased thyroid hormone production

Question 99

Provide 4 signs and/or symptoms of a patient experiencing DKA.

Answer 99

Nausea/Vomiting Abdominal Pain Recued Conscious Levels Kussmauls Breathing Fruity Breath Polydipsia/Polyuria Hypotension Tachycardia Absence of insulin leads to unrestrained hepatic gluconeogenesis and reduced peripheral uptake of glucose. This results in the release of counterregulatory hormones such as adrenaline, noradrenaline, glucagon, and cortisol. The actions of these hormones further include blood glucose levels. High circulating levels of glucose leads to osmotic diuresis and dehydration, leading to symptoms of polydipsia/polyuria. Loss of water from the body leads to hypotension and tachycardia. The presence of ketones leads to fruity breath and Kussmauls breathing to maintain pH to a normal value.

Question 100

Phaeochromocytoma is a rare tumour of the adrenal medulla. a) Of which cells is the tumour usually composed of? b) Provide 3 symptoms someone with the tumour would experience.

Answer 100

a) Cells: Chromaffin Cells b) Symptoms: Hypertension, Tachycardia/Palpitation, Diaphoresis, Hypertensive Retinopathy, Pallor and Diabetes The tumour is able to produce massive amounts of catecholamines, Metanephrine and methoctramine. Which all cause the above symptoms.

Question 101

Phaeochromocytoma is a rare tumour of the adrenal medulla. a) Of which cells is the tumour usually composed of? b) Provide 3 symptoms someone with the tumour would experience.

Answer 101

a) Cells: Chromaffin Cells b) Symptoms: Hypertension, Tachycardia/Palpitation, Diaphoresis, Hypertensive Retinopathy, Pallor and Diabetes The tumour is able to produce massive amounts of catecholamines, Metanephrine and methoctramine. Which all cause the above symptoms.

Question 102

A 27-year-old woman presents to her GP complaining of feeling more tired than usual in the past few months and has noticed she’s lost about 5 kg over that time without trying, saying she’s not really had that much of an appetite. She also says she’s been getting “dizzy-spells” where she feels light-headed on standing up – but has never fainted from them. On examination, you notice some darkened skin in the creases of her palms, when asked about this she says she’s also noticed a scar on her knuckle has started to turn much darker. What is the most appropriate investigation to confirm your suspected diagnosis? a) A Cortisol measurement b) Abdominal ultrasound scan c) SynACTHen test d) Low-dose dexamethasone test e) Urinary free cortisol measurement

Answer 102

SynACTHen test Addison’s disease is caused by the autoimmune destruction of the adrenal cortex which results in the decrease in production of glucocorticoids (e.g. cortisol), mineralocorticoids (e.g. aldosterone) and adrenal androgens. This leads to some of the symptoms described above, such as postural hypotension (due to reduced aldosterone) and increased pigmentation in palmar creases/ newly formed scars. Other symptoms include, weight loss, fatigue, GI upset. Remember “lean, tanned, tired, tearful” when thinking about Addison’s. A short synacthen test (= ACTH stimulation test) would be done to diagnose adrenal insufficiency. - Normal adrenals: synthetic ACTH would stimulate cortisol production = cortisol levels increase - In 1 ̊ Adrenal Insufficiency (Addison’s disease): giving synthetic ACTH would NOT lead to cortisol levels rising A long synacthen test would have to be done to diagnose 2 ̊ adrenal insufficiency (usually due to long- term use of corticosteroids/ damage to pituitary glands)

Question 103

A 54 year-old patient presents with increased confusion. His family reports that over the past month he has become more irritable, and has complained about headaches and muscle cramps. He has recently been diagnosed with Small cell lung cancer. You suspect SIADH. What finding would you expect to see in SIADH? a) Hypernatremia b) Hyponatraemia c) Hypercalcaemia d) Hypocalcaemia e) Hypomagnesium

Answer 103

Hypocalcaemia ADH(=vasopressin) is an anti-diuretic hormone that causes the reabsorption of water into the blood. In SIADH, excessive ADH is inappropriately released, so too much water is reabsorbed into the blood, causing the plasma to become more dilute which leads to hyponatraemia. Hyponatraemia is a common cause of confusion. Calcium and magnesium levels would not usually be affected in SIADH.

Question 104

Billy, a 62 year-old man, is admitted to A&E with a mild exacerbation of asthma. He suffers from hypertension which is controlled with medication. On the way to hospital, paramedics gave him 5mg salbutamol and 500 μg ipratropium nebulisers. Since admission to A&E he has been given regular salbutamol 5mg nebulisers. He was then transferred to AMU where he received his antihypertension medication and given regular nebulisers. Before being discharged, you check his blood results and notice that his serum potassium is low at 2.3 mmol/L (normal range: 2.6- 5.2 mmol/L). Which drug is most likely to have caused his hypokalaemia? a) Ipratropium b) Amlodipine c) Ramipril d) Salbutamol e) Paracetamol

Answer 104

Salbutamol Regular nebulised salbutamol is commonly associated with hypokalaemia. Ipratropium shouldn’t cause any electrolyte disturbances. Amlodipine and paracetamol aren’t known to cause hypokalaemia. Ramipril can cause hyperkalaemia, not hypokalaemia.

Question 105

Lucy presents with symptoms of polyuria, polydipsia and dehydration. You suspect Diabetes insipidus. What test would you perform to differentiate between cranial or nephrogenic? a) Oral glucose tolerance test b) Dexamethasone suppression test c) CT scan d) Water deprivation test e) Random plasma glucose

Answer 105

Water deprivation test A water deprivation test using desmopressin would be used to differentiate between nephrogenic and cranial diabetes insipidus. This is because a large amount of water is lost during DI. This is either due to a decrease in production of ADH (Cranial cause) or due to an impaired response to ADH (nephrogenic cause) You would deprive the patient of water, test their osmolality pre and post giving desmopressin (desmopressin is man-made ADH)

Question 106

A 50yr old female presents to clinic with a 6-month history changes to her appearance. Her facial features have become coarse, her voice has deepened, and her joints ache more than usual. What is the first line investigation for the most likely diagnosis? a) OGTT (oral glucose tolerance test) b) Serum IGF-1 c) Pituitary MRI d) Serum GH e) Serum GHRH

Answer 106

Serum IGF-1 The presentation is that of acromegaly. * 1st IGF-1 * 2nd OGTT * 3rd Pituitary function tests (including prolactin) * 4th MRI pituitary (Also investigate for complications e.g echocardiogram for cardiomyopathies) Serum IGF1 can also be used to monitor the disease Oral glucose tolerance test (OGTT) * in normal patients, GH is suppressed to < 2 mu/L with hyperglycaemia. * in acromegaly there is no suppression of GH * may also demonstrate impaired glucose tolerance which is associated with acromegaly

Question 107

Joe, a 32-year-old male, presents to clinic after reporting that his third type of antihypertensive is not working, and his blood pressure is still through the roof. He also reports a constant headache, muscle cramps and fatigue that he is worried might be due to COVID-19. You take a thorough history and find a positive family history of early-onset hypertension. His father had passed away from a stroke at age 50. On examination, his BP is 142/110. His COVID-19 swab comes back negative. What is the first line investigation of the most likely diagnosis? a) Adrenal vein sampling b) Serum aldosterone c) Abdominal HRCT d) Aldosterone renin ratio e) Short synACTHen test

Answer 107

Aldosterone renin ratio The history and presentation describe primary hyperaldosteronism. This can be either due to Conn’s syndrome which is an adrenal adenoma (1/3), or bilateral adrenal hyperplasia (2/3). Too much aldosterone production can lead to excess potassium excretion leading to hypokalaemia and alkalosis. This can cause muscle cramps, paraesthesia, and fatigue. It can also cause excess sodium and water reabsorption leading to hypertension and excessive thirst. The kidneys are unable to concentrate urine, leading to frequent urination. Features * Hypertension (resistant to 3+ antiHT) * Hypokalaemia e.g. muscle weakness * alkalosis Investigations * first line = ARR (aldosterone renin ratio): high aldosterone levels + low renin levels (negative feedback due to sodium retention from aldosterone) * Adrenal Venous Sampling (AVS): identify the gland secreting excess hormone in primary hyperaldosteronism * HRCT abdomen + AVS is used to differentiate between unilateral (Conn's) and bilateral adrenal hyperplasia

Question 108

Karen, a 45 year old woman presents with hirsutism and central obesity and she is starting to develop purple striae on her abdomen. She is upset because she had a holiday planned and feels she can no longer wear her bikini. She has a past medical history of severe asthma which is medically controlled with the blue and brown inhaler. ACTH levels are low and there is no cortisol suppression following high dose dexamethasone suppression test. How would you initially manage this condition? a) Metyrapone b) Ketokonazole c) Bilateral adrenalectomy d) Transsphenoidal pituitary resection e) Medication review – stop the ICS

Answer 108

Medication review – stop the ICS Karen's dexamethasone suppression test showed no cortisol suppression with a low ACTH level, suggesting an ACTH independent cause of Cushing's syndrome. The most likely cause of Cushing’s syndrome is iatrogenic. She also has chronic asthma which is controlled via medication and the brown inhaler indicates an inhaled corticosteroid. Therefore, a medication review and stopping the ICS should be the first line treatment. A review would be required if there is no improvement in her symptoms.

Question 109

Joanne, a 76-year-old woman presents with polyuria and polydipsia. Blood results show: What is the most likely underlying diagnosis? a) Primary hyperparathyroidism b) Multiple myeloma c) Diabetes mellitus d) Secondary hyperparathyroidism e) Diabetes insipidus

Answer 109

Primary hyperparathyroidism High serum calcium would normally suppress PTH by negative feedback. However, with this patient's, their PTH is in the normal range. This suggests an inappropriately raised serum calcium, making the most likely diagnosis primary hyperparathyroidism, with autonomous secretion of PTH by the parathyroid gland. In secondary hyperparathyroidism, serum calcium and phosphate are usually both low/normal. PTH would be raised due to negative feedback from the low serum calcium, e.g. due to vitamin D deficiency or CKD. This can lead to tertiary hyperparathyroidism, whereby chronic hypocalcaemia causes autonomous parathyroid function, which results in high serum calcium and phosphate.

Question 110

A 35-year-old male presents with frequent and recurring episodes of dizziness when standing. On further questioning he explains that he also has frequent headaches and has noticed he is sweating a lot and experiences episodes of palpitations. On examination it was found that he has postural hypotension. He states that he has no past medical history of significance and there is also no significant family history. A urine dipstick was taken, and the patient was also referred for a CT scan. The urine sample showed high levels of plasma catecholamines and metanephrines. What is the most likely diagnosis? a) Adrenal Insufficiency b) Conns syndrome c) Hyperaldosteronism d) Wilm’s tumour e) Pheochromocytoma

Answer 110

Pheochromocytoma The patient in this case has a pheochromocytoma, a pheochromocytoma is a tumour that secretes catecholamines derived from the chromaffin cells within the adrenal medulla. Management of a pheochromocytoma is commonly a surgical resection of the tumour with alpha-blockers e/g phenoxybenzamine typically given before surgery.

Question 111

Which of the following produces and secretes corticosteroids such as cortisol? a) Anterior pituitary gland b) Zona glomerulosa c) Zona reticularis d) Zona fasciculata e) Adrenal medulla

Answer 111

Zona fasciculata The adrenal gland is divided into the cortex and medulla. The adrenal cortex is further divided into: * Zona glomerulosa - produces and secretes mineralocorticoids e/g aldosterone * Zona fasciculata - produces and secretes corticosteroids e/g cortisol * Zona reticularis - produces and secretes androgens * The adrenal medulla contains chromaffin cells which secretes catecholamines such as adrenaline

Question 112

A 30-year-old female presented to her GP after her optician had advised her to visit her GP. She had recently visited her optician as vision was becoming worse. The optician noticed redness and watering of her eyes and noticed that her eyes appeared to be ‘bulging out’ as described by her husband. The patient also stated that she is feeling increasingly tired and often feels that her heart is racing out of her chest. The GP ran some routine bloods including thyroid function tests which found raised T3. TSH receptor antibodies were also detected. Which of the following would not be a typical sign of Grave’s disease? a) Tremor b) Palpitations c) Weight gain d) Pretibial myxoedema e) Ophthalmopathy

Answer 112

Weight gain Graves’ disease is the most common cause of hyperthyroidism caused by TSH receptor antibodies. Hyperthyroidism typically leads to weight loss and not weight gain, the other signs are typical of Graves’ disease.

Question 113

A 25-year-old man is brought to A&E by ambulance complaining of abdominal pain and had been vomiting through the last few hours. Since yesterday he stated that he feels very thirsty and is going to the bathroom more frequently. On the way to the hospital, the patient had deteriorated and was losing consciousness. When the patient arrived at A&E, the doctors used an ABCDE approach to examine the patient. The following were found. A - airway was patent. B - respiratory rate was 40 breaths per minutes and noticed that his breath smelt of pears. There was also generalised abdominal tenderness without voluntary guarding. Which of the following is the most appropriate in the first line management of this patient? a) IV fluid resuscitation b) Antibiotics c) Insulin therapy d) Sepsis screen e) Glucose

Answer 113

IV fluid resuscitation This patient has presented with an episode of diabetic ketoacidosis. The first line management for this patient would be to start IV fluids before insulin therapy.

Question 114

Which of the following is not associated with hypothyroidism? a) Weight gain b) Increased sweating c) Cold intolerance d) Constipation e) Menorrhagia

Answer 114

Increased sweating Weight gain is a common side effect of hypothyroidism. As thyroid hormones decrease regulation of metabolism also decreases. Sweating is a symptom of hyperthyroidism not hypothyroidism. Cold intolerance is a consequence of lack of thyroid hormone which is normally used to convert and utilise stored energy effectively. Lack of thyroid hormones leads to decreased gut motility. This is not well understood however it is thought to be due to anovulation.

Question 115

Which of the following is the first line medicinal treatment for diabetes mellitus type II? a) Lifestyle modification b) Metformin c) Glimepiride d) Gliclazide e) Insulin

Answer 115

Metformin Lifestyle modification would be considered the first line treatment, but the question is highlighting medicinal. Metformin is usually given first line to patients with newly diagnosed diabetes. Glimepiride is an example sulfonylurea which added to treatment when metformin is not enough to keep the glucose levels under 58 mmol/L. Gliclazide is an example sulfonylurea which added to treatment when metformin is not enough to keep the glucose levels under 58 mmol/L. Insulin therapy is initiated in patients with persistently raised glucose levels even after the admiration of medicinal therapy.

Question 116

Which of the following is considered the gold standard diagnosis for phaeochromocytoma? a) Elevated plasma free Metanephrine b) 24hr Urinary Metanephrine c) MRI d) CT e) XRay

Answer 116

Elevated plasma free Metanephrine This is the gold standard as serum Metanephrine in phaeochromocytoma are continuously high. This test is also used but only when test a is not available. It is not as sensitive as test a. MRI is used in imaging the adrenal tumour. This is after the gold standard test is conducted. CT is also used in imaging the adrenal tumour however is less sensitive compared to the MRI.

Question 117

A 19-year-old woman has a previous history of type I diabetes. She has come back to the doctor as some new symptoms have developed. She describes looking more tanned than usual despite no sun exposure, anorexia, she craves salty foods (blood tests show low Na+), and is less able to control her blood sugar as she has more regular low readings. What is causing her new symptoms? a) Administering too much insulin to herself b) Primary adrenal failure (Addison’s disease) c) Diabetic ketoacidosis d) Cushing’s syndrome e) Conn’s syndrome

Answer 117

Primary adrenal failure (Addison’s disease) Addison disease (primary adrenal insufficiency) causes decreased production of adrenocortical hormones (cortisol, aldosterone and dehydroepiandrosterone). May be caused by a destructive process directly affecting the adrenal glands or a condition that interferes with hormone synthesis. Key diagnostic factors are fatigue, anorexia/weight loss, hyperpigmentation, salt craving (low sodium and high potassium). Most commonly in developed countries it is an autoimmune condition which is more common when other AI conditions are present e.g. T1DM. Secondary adrenal insufficiency interferes with pituitary function and decreased ACTH secretion. Symptoms are the same as Addison disease, normally associated with corticosteroid use or cessation or tumours. Cushing’s syndrome is an increase in cortisol caused from increased ACTH. This presents with moon face, buffalo hump, central weight gain, muscle and bone weakness and hypokalaemia. Insulin excess would cause hypoglycaemia but would cause weight gain as the glucose is being stored in cells. High insulin would also cause hypokalaemia as the glucose transporter uses K+ to take it into cells. Ketoacidosis presents with excessive thirst, frequent urination, nausea and vomiting, abdo pain, weakness and fatigue. Potassium levels are likely to be low due to excessive urination.

Question 118

A 12-week old child presents with symptoms of adrenal insufficiency. Upon further investigation, they are found to have a significantly low serum cortisol level. Which region of the adrenal gland produces the steroid hormone, cortisol? A. Zona Reticularis B. Zona Fasciculata C. Adrenal Medulla D. Zona Glomerulosa E. Adrenal Capsule

Answer 118

Zona Fasciculata

Question 119

A 17-year old Male presents to A&E with a 2 month history of unintentional weight loss, increased thirst, and polyuria. A random blood glucose is taken and reveals a level of 14 mmol/L, indicating a diagnosis of Type 1 Diabetes Mellitus. The junior doctor on-call prescribes an IM injection of fast-acting insulin. Insulin acts on cells, by stimulating which of the following? A. Increased Glycogenolysis B. Reduced fatty acid synthesis C. Increased Gluconeogenesis D. Accelerated diffusion of glucose out of the cells E. Reduced Glycogenolysis

Answer 119

Reduced Glycogenolysis

Question 120

A 66-year old Female attends her GP Practice for an annual Type-2 diabetes review. Her recent HbA1c revealed weight loss management and Metformin has failed to significantly reduce her glucose levels. In this patient, what would be the second line management of her diabetes? A. Modified-release Metformin B. Metformin and Insulin therapy C. Metformin and an SU D. Further exercise and dietary advice E. Metformin, anSU and a DPP-4i

Answer 120

Metformin and an SU

Question 121

A 39-year old known Type-1 diabetic presents to A&E after his partner noticed a sudden onset of confusion, drowsiness and vomiting. Upon examination of his throat, you notice a distinctly sweet smelling breath alerting you to the presence of daibetic ketoacidosis. Which of the following is NOT a criteria for diagnosis of DKA? A. Blood Glucose>11mmol/L B. Plasma Ketones>3mmol/L C. Blood pH<7.3 D. K+<5.5mmol/L E. Bicarbonate<15mmol/L

Answer 121

K+<5.5mmol/L

Question 122

A 26-year old female presents to her GP with a palpable thyroid lump. She is referred to an Endocrinology clinic under the 2-week wait and undergoes a fine needle biopsy. This reveals abnormal cells. What is the most common subtype of Thyroid carcinoma? A. Papillary B. MedullaryCell C. Follicular D. Anaplastic E. Lymphoma

Answer 122

Papillary

Question 123

A 35 year old lady presents to an endocrinology clinic with a history of skin ulcers, depression and central obesity with striae. The consultant orders a 24h urinary cortisol test, revealing a cortisol level of 230 micrograms per day of cortisol. They diagnose her with Cushing Syndrome. Which of the following is a corticotropin independent, endogenous cause of Cushing syndrome? A. Long term use of Prednisolone B. Pituitar yadenoma C. Ectopic production of cortisol from small cell lung cancer D. Long term use of hydrocortisone E. Adrenal adenoma

Answer 123

Adrenal adenoma Adrenal adenoma is an ENDOGENOUS, Corticotropin independent cause of Cushing Syndrome A. Exogenous B. Endogenous but corticotropin dependent C. Endogenous but corticotropin dependent D. Exogenous

Question 124

A 22 year old woman presents with a fine tremor of her hands, an increase in perspiration and sensitivity to heat, as well as unintentional weight loss. The doctor orders Thyroid function tests, and based on the results diagnoses Graves disease. What blood test results would indicate this diagnosis? A. High TSH, Low T3 and T4 B. High TSH, High T3 and T4 C. Low TSH, Low T3 and T4 D. Low TSH, High T3 and T4 E. Normal TSH, Low T3 and T4

Answer 124

D. Low TSH, High T3 and T4 In Graves disease there is TOO MUCH T3 and T4 due to the thyroid stimulating immunoglobulins (an antibody) causing the Thyroid to produce too much T3 and T4. Due to negative feedback the Pituitary glad will therefore produce LESS TSH in an attempt to stop production. Therefore in Graves, LOW TSH HIGH T3 and T4

Question 125

A 52 year old Male presents to his GP complaining of episodic headaches, heart palpitations and increased sweating. He has noticed the symptoms typically occur when stressed. A 24 hour urine fractional metanephrine and catecholamines test showed marked elevations. The doctor diagnosed Pheochromocytoma. Where in the adrenal gland are these catecholamines produced and secreted? A. Adrenal Medulla B. Zona Fasciculata of the Adrenal cortex C. Zona Reticularis of the adrenal cortex D. Zona Glomerulosa of the adrenal cortex E. The Capsule

Answer 125

A. Adrenal Medulla The adrenal Medulla at the centre of the adrenal gland is made up of chromatin cells which secrete catecholamines. B. The zona fasciculata secretes glucocorticoids and cortisol C. The zona Reticularis secretes androgens D. The zona Glomerulosa secretes aldosterone E. The Capsule encases the adrenal gland and is richly vascularised.

Question 126

A 42 year old man presents to his GP with worsening muscle cramps and weakness. He also complains of increased fatigue. Blood tests reveal high aldosterone and low renin. The doctor diagnoses Conn’s syndrome. Conn’s syndrome is what type of mineralocorticoid excess syndrome? A. Primary aldosteronism B. Acquired pseudo primary aldosteronism C. Genetic primary aldosteronism D. Hypertensive secondary aldosteronism E. Normotensive secondary aldosteronism

Answer 126

A. Primary aldosteronism Can be unilateral, bilateral of familial. Usually caused by hyperplasia or tumours B. Acquired pseudo primary aldosteronism can be caused by hypercortisolism or licorice toxicity C. Genetic pseudoprimary aldosteronism can be caused by congenital adrenal hyperplasia D. Hypertensive secondary aldosteronism can be caused by renal artery stenosis, aortic coarctation or reninoma E. Normotensive secondary aldosteronism can be caused by gitelman's syndrome or bartter's syndrome

Question 127

A 30 year old lady is suspected to have Graves disease. Her doctor orders blood tests to measure levels of TSH and T3/4, as well as the antibody usually involved in Graves disease. What class of immunoglobulin is involved in Graves disease? A. IgA B. IgD C. IgE D. IgG E. IgM

Answer 127

D. IgG The“goldstandard” test for Graves is a test for the immunoglobulin Thyrotropin receptor antibody (TRAb). Because TRAb overrides the usual regulation of the thyroid it leads to over production of the thyroid hormones. This is an IgG antibody. IgG is the most common antibody found in blood and extracellular fluid and is the most commonly involved antibody in autoimmune disease A. IgA is the immunoglobulin involved in the immune function of mucus membranes B. IgD activates B cells C. IgE is responsible for the symptoms of allergic disease E. IgM is found on B cells and is responsible for their activation

Question 128

A 47 year old woman presents to her GP with a 1 month history of increased thirst, polyuria and malaise. She also mentions that she’s been constipated and that her bones hurt when she moves around. What is your most likely diagnosis? A. Hypothyroidism B. Addison’s disease C. Type 2 diabetes mellitus D. Hypercalcaemia E. Nephrogenic diabetes insipidus

Answer 128

D. Hypercalcaemia; hypercalcaemia symptoms can be remembered using ‘bones, stones, groans and psychic moans’ A. Hypothyroidism is incorrect in this scenario as it wouldn’t explain the polyuria and polydipsia (remember, everything slows down in hypothyroidism!). B. Addison’s disease symptoms can be remembered using “leaned, tanned, tired, tearful’ (±weakness, anorexia) C.T2DM is incorrect in this scenario as typical symptoms don’t include constipation and bones hurting. The patient would more likely have polyuria, polydipsia and nocturia. E. Nephrogenic diabetes insipidus is incorrect in this scenario as, even though it fits the polyuria and polydipsia, it doesn’t explain the constipation and bones hurting

Question 129

A 31-year-old woman presents to her GP complaining of feeling more tired than usual in the past few months and has noticed she’s lost about 6 kg over that time without trying, saying she’s not really had that much of an appetite. She also says she feels light-headed whenever she stands up. On examination, you notice some darkened skin in the creases of her palms, when asked about this she says she’s also noticed a scar on her knuckle has started to turn much darker. What is the most appropriate investigation to confirm your suspected diagnosis? A. Abdo CT B. Low-dose dexamethasone test C. Aone-off cortisol measurement D. Urinary free cortisol measurement E. Synacthentest

Answer 129

E. These symptoms are indicative of Addison’s disease. a short synacthen test (= ACTH stimulation test) would be done to diagnose 1 ̊ adrenal insufficiency. In Addison’s, giving synthetic ACTH during this test would NOT lead to cortisol levels rising. A. An abdo CT is useful for certain diagnoses (e.g.to see tumours on the adrenals or to show adrenal enlargement,...) but would not be an appropriate investigation for diagnosing Addison’s B. Low-dose dexamethasone test would be used to diagnose Cushing’s syndrome C. A one off cortisol measurement would not be a very valuable investigation to make a diagnosis. Yes, cortisol levels would be reduced in Addison’s, however, cortisol has diurnal variations so one measurement is not a very specific or sensitive test for Addison’s/ D. Used to investigate Cushing’s disease

Question 130

A 68 year old man presents to A&E with heart palpitations, wheeze and is visibly flushed. He mentions he’s had ongoing diarrhoea for weeks, and has experienced significant weight loss over the last 3 months without trying. What test would be most useful to confirm your diagnosis? A. CT scan B. 5-HIAA C. MRI D. Chromagranin-A+octreoscan E. Octreoscan

Answer 130

D. elevated serum Chromagranin-A (+ octreoscan) would be the gold standard to diagnose carcinoid syndrome. A. A CT scan can be useful to help diagnose but can be unclear at times and is therefore not the gold standard B. 5- HIAA used to be the gold standard to diagnose carcinoid syndrome but has been found to be normal in some patients suffering from carcinoid syndrome so elevated serum chromagranin-A is now used C. MRI can be useful to visual the tumours, however it is not diagnostic of carcinoid syndrome E. An octreoscan by itself is not diagnostic of carcinoid syndrome, it needs to be couple with elevated chromagranin-A to make the diagnosis

Question 131

A 55 year old patient presents to A&E with chest pain, general weakness with cramps. He also reports heart palpitations. You suspect hyperkalaemia. Which of the following is most likely to be present on his ECG? A. U waves B. Delta wave C. Tall T waves D. Tall P waves E. Narrow QRS complex

Answer 131

A. U waves are deflections after the T wave that can be enlarged in hypokalaemia B. Delta waves are seen in Wolf-Parkinson-White syndrome, not hyperkalaemia C. Typical ECG findings in hyperkalaemia: absent p waves, long PR interval, wide QRS, tall-tented T waves D. P waves are absent in hyperkalaemia E. Narrow QRS is seen in atrial flutter or junctional tachycardia, not hyperkalaemia

Question 132

A 67 year-old man presents to his GP with increased confusion and his wife reports he has been complaining of headaches and muscle cramps. He has recently been diagnosed with Small cell lung cancer. You suspect SIADH. What finding would you expect to see in SIADH? A. Hyponatraemia B. Hypoglycaemia C. Hypernatraemia D. Hypocalcaemia E. Hypomagnesemia

Answer 132

A. In SIADH, excessive ADH is inappropriately released, so too much water is reabsorbed into the blood, causing the plasma to become more dilute which leads to hyponatraemia. Hyponatraemia is a common cause of confusion. B. Hypoglycemia can lead to confusion but isn’t associated with SIADH C. Incorrect, as explained above D. Calcium levels are not usually affected in SIADH E. Magnesium levels are not usually affected in SIADH

Question 133

Which is not a cause of pitting oedema? A. Pregnancy B. Grave’s disease C. Low serum albumin D. Venous insufficiency E. Congestive heart failure

Answer 133

B. Grave’s disease and other types of hyperthyroidism can cause pretibial myxoedema - a non-pitting swelling of the lower legs, usually bilateral and itchy. A. Pregnancy leads to increased cardiac demand and commonly is associated with pitting oedema C. Low serum albumin causes leakage of water into tissues, leading to pitting-oedema D. Venous insufficiency causes impaired transport of blood around the body E. Cardiac failure also leads to impaired blood transport around the body

Question 134

A 62 year old man presents to his GP with vision loss, headaches and cold intolerance. He reports losing 5 kg in the last few months without trying to. Upon examination, he has a bitemporal hemianopia and a pulse of 50bpm. A thyroid function test is ordered. Which of the following results most likely fits with this patient’s presentation? A: TSH:normal T4:low T3:low B. TSH:high T4:low T3:low C. TSH:high T4:normal T3:normal D. TSH:low T4:high T3:high E. TSH:low T4:low T3:low

Answer 134

E. This man’s symptoms are most likely due to a pituitary adenoma causing 2 ̊ hypothyroidism. You’d need to get an MRI to confirm the presence of an adenoma. The pituitary mass in this case would be compressing TSH secreting cells leading to low TSH levels. A. Incorrect B. Incorrect represents primary hypothyroidism which is more common than 2 ̊ hypothyroidism however the bitemporal hemianopia and history of headaches suggest a pituitary adenoma. C. Incorrect: this represents subclinical hypothyroidism, which wouldn’t cause such obvious symptoms (usually asymptomatic) D. Incorrect- represents primary hyperthyroidism-doesn’t fitclinical picture

Question 135

A 26 year old woman presents to you with amenorrhea. She tells you her periods have always been irregular and as far as she can remember her last one was 4 months ago. She had been previously diagnosed with depression and said this is largely due to her acne and ‘hairy face’ and inability to lose weight. Her BMI is 32 kg/m2. You perform a pregnancy test which comes back negative. What is the most likely diagnosis? A. Cushing’s disease B. Hyperprolactinaemia C. Hypothyroidism D. T2DM E. Polycystic ovary syndrome

Answer 135

E. Common PCOS clinical picture of hirsutism, acne, oligoamenorrhea (and multiple cysts in the ovaries)

Question 136

What condition results from the oversecretion of the growth hormone before adolescence? A. Gigantism B. Addison’s disease C. Cushing’s disease D. Acromegaly E. Goitre

Answer 136

A. Gigantism is due to the over-secretion of GH prior to adolescence (specifically before the fusion of the epiphyses). Most commonly due to a pituitary tumour D is incorrect - acromegaly is commonly mistaken for gigantism but acromegaly is due to the excessive secretion of GH after adolescence

Question 137

James Smith, a 20-year-old male, presents to A & E with abdominal pain. The pain started 8 hours ago. He also has polyuria and polydipsia along with the abdominal pain. He is a known Type 1 diabetic with poor adherence to his insulin regimen. You perform an ABG which shows glucose 18.2 mmol/l, pH 7.1 and potassium 3.0. Urine dipstick shows ++ for ketones. Given the most likely diagnosis, what is your immediate management for this patient? A. Isotonic saline and insulin B. Isotonic saline and insulin and bicarbonate C. Insulin D. Isotonic saline, insulin and potassium E. Isotonic saline

Answer 137

D. the most likely diagnosis here is DKA. Immediate management would involve giving isotonic saline, insulin and potassium. K+ should be started if levels are ≤5.5 within the first 24hours B. Insulin and isotonic saline are used to treat the underlying hyperglycemia however will not treat the hypokalaemi

Question 138

Which of the following hormones are not secreted by the anterior pituitary gland? A. FSH B. Prolactin C. TSH D. ADH E. LH

Answer 138

D. Hormones secreted by the anterior pituitary gland are: ● FSH ● LH ● ACTH ● TSH ● Prolactin ● GH Can be remembered by the pneumonic FLATPIG (I for ignore). ADH is synthesised by neurosecretory cells of the hypothalamus (Supraoptic nuclei) in response to dehydration. It is stored then released by the posterior pituitary gland.

Question 139

Where in the body are catecholamines such as adrenaline from? A. Zona Reticularis B. Zona Glomerulosa C. Zona Fasciculata D. Adrenal Medulla E. Adrenal cortex

Answer 139

D. The adrenal gland is subdivided into the cortex and the medulla. The cortex is then divided into 3 layers: ● Zona glomerulosa – produces mineralocorticoids e.g., aldosterone. ● Zona fasciculata – Glucocorticoids e.g., cortisol and small amounts of androgens ● Zona reticularis – Produces and secretes androgens (sex hormones) The adrenal medulla contains chromaffin cells which secrete adrenaline and noradrenaline (catecholamines) which then act on the cortex to secrete other hormones

Question 140

Which one of the following statements is true of glucagon? A. Secreted by Beta cells B. Inhibits gluconeogenesis C. Composed of 2 polypeptide chains linked together via hydrogen bonds D. Decreases glycogenolysis E. Stimulates lipolysis

Answer 140

E. Glucagon is a hormone secreted by alpha cells in the islets of Langerhans in response to reduced blood glucose concentration. It functions to reverse hypoglycaemic states by acting on the liver to convert glycogen to glucose, stimulating breakdown of fats (lipolysis) (E) and muscles and forming glucose from lactic and amino acids. Glucagon is composed of a single polypeptide chain comprising of 29 amino acid residues while Insulin is composed of 2 polypeptide chains containing 51 amino acid residues.

Question 141

Which of the following best describes the effects of PTH in response to a decrease in serum calcium? A. Directly stimulates osteoclasts to resorb bone to release calcium B. Constricts the afferent arterioles to reduce GFR and urinary calcium loss C. Activates vitamin D to increase absorption of calcium from small intestine D. Increases phosphate absorption at the distal convoluted tubule E. Increase calcium excretion at the kidneys

Answer 141

C. PTH increases the activity of 1-α-hydroxylase enzyme, which converts 25-hydroxycholecalciferol to 1,25-dihydroxycholecalciferol, the active form of vitamin D. Since osteoclasts do not have a PTH receptor, effects are mediated via osteoblasts. The remaining false answers can be eliminated via elimination since PTH functions comprise of: ● Indirect stimulation of osteoclast/direct stimulation of osteoblast to resorb bone and release calcium into blood. (Not a) ● Increasing calcium reabsorbed in the kidney so less is excreted. (Not b/e) ● Increasing calcium reabsorbed in the small intestine. (Does this via the activation of Vitamin D) (Answer is c) ● Decreasing phosphate reabsorption in kidney so more is excreted. (Not d)

Question 142

What is the difference between an endocrine gland and an exocrine gland?

Answer 142

Endocrine glands secrete substances/hormones directly into the bloodstream Exocrine glands secrete substances/hormones into a duct before they enter the bloodstream

Question 143

Acromegaly is the result of an overproduction of which pituitary hormone?

Answer 143

Growth Hormone (not GH!)

Question 144

Adrenal insufficiency can be divided into primary insufficiency and secondary insufficiency, give 2 examples of each

Answer 144

Primary: Addison’s, Surgical removal, Trauma, TB, Infarction, Invasion from tumour, ACTH resistance/blocking antibodies Secondary: Steroids, Congenital, Corticiotropin- releasing hormone deficiency, Trauma (fracture base of skull), Radiotherapy, Surgery, Neoplasm

Question 145

Describe 2 investigations appropriate for diagnosing a ptx. with Cushing’s Disease

Answer 145

24hr urine collection Blood cortisol test following dexamethasone

Question 146

Explain on a cellular level how hyperglycaemia leads to insulin secretion

Answer 146

Hyperglycaemia leads to increase glucose uptake by cells (1) Glucose metabolism leads to increased levels of ATP within cell (1) Increased ATP causes K+ channels to close (1) Causes depolarisation of cell membrane (1) Ca2+ channels open and Ca2+ enters cell (1) Increased Ca2+ in cell causes exocytosis of insulin-containing vesicles (1) Insulin released by Pancreatic Beta cells / cells in Islets of Langerhans (1)

Question 147

Give 3 blood tests with values that are diagnostic for T2 Diabetes Mellitus

Answer 147

Random plasma glucose (1) Score >11mmol/L (1) Fasting plasma glucose (1) Score > 7mmol/L (1) HbA1c (1) Score > 48 / 6.5% (1)

Question 148

Give 2 examples of microvascular and macrovascular complications of DM

Answer 148

Microvascular= Retinopathy (1) Neuropathy (1) Macrovascular= CVD (1) Cerebrovascular disease (1) Peripheral artery disease (1)

Question 149

Miranda, 35-year-old lady presents to the GP complaining of weight loss, feeling hot all the time, diarrhoea and a tremor. When you examine her pulse is 92 bpm. She has goitre, palmar erythema and bulging eyes. a) What condition do you suspect Miranda has? b) Describe the levels of TSH, T3, T4 of a patient with this condition c) Name the thyroid autoantibodies also found on Miranda’s blood test? d) What are 2 treatment options for Miranda?A.

Answer 149

a) Hyperthyroidism (1) / Grave’s Disease (2) b) TSH low (1) T3 raised (1) T4 raised (1) c) Thyroglobulin (1) and anti-thyroid peroxidase (1) antibodies d) Carbimazole (1) Beta Blockers (1) Radio Iodine therapy (1) Thyroidectomy (1)

Question 150

Give 5 signs of a patient with Hashimoto’s Thyroiditis?

Answer 150

Bradycardia (1) Reflexes relax slowly (1) Ataxia (1) Dry/thin hair + skin (1) Yawning/drowsiness/coma (1) Cold hands (1) Ascites (1) Round puffy face (1) Defeated Demeanour (1) Immobile (1) Round ‘moon’ face (1)

Question 151

What medication is used in the treatment of Hypothyroidism?

Answer 151

Synthetic Levothyroxine (2)

Question 152

Name the 2 hormones produced by the posterior pituitary gland

Answer 152

Antidiuretic Hormone / Vasopressin (1) (NOT ADH!) Oxytocin (1)

Question 153

What are the 2 main symptoms of patients with Diabetes Insipidus?

Answer 153

Polyuria (1) Polydipsia (1)

Question 154

Patient presents with palpitations, headache, episodic sweating. Blood tests reveal raised plasma catecholamines. a) What condition does this ptx have? b) Which cells produce catecholamines? c) Where are these cells found?

Answer 154

a) Phaeochromocytoma b) Chromaffin cells c) Adrenal Medulla

Question 155

What visual field defect would make you suspect a patient has a pituitary tumour?

Answer 155

Bitemporal hemianopia

Question 156

A 23 year old lady has unintentionally lost 8kg of weight over the last 8 months and is suffering from episodes of fatigue. She also complains of nausea, headaches, generalised abdominal pain and is feeling terrible overall. How would her cortisol levels react to the Synacthen test if she had secondary adrenal insufficiency? A. Short ACTH no change, long ACTH no change B. Short ACTH no change, long ACTH increase C. Short ACTH no change, long ACTH decrease D. Short ACTH increase, long ACTH decrease

Answer 156

B. Short ACTH no change, long ACTH increase Synacthen (tetracosactide) stimulates the adrenals to secrete cortisol. In primary adrenal insufficiency, the adrenal glands have been damaged and are unable to produce cortisol even with increased stimulation. In secondary adrenal insufficiency, there is a lack of ACTH from the pituitary gland so providing ‘synthetic ACTH’ helps stimulate the adrenals to release cortisol.

Question 157

A 37 year old lady has recently come back from holiday to her GP as she has noticed she is becoming much more lethargic recently. Along with this symptom she is also becoming more dizzy on standing as well as having a reduced appetite which has gotten worse in the past months. On examination the doctor notices that she has darker patches of skin around her body, being obvious in the palmar creases. The doctor asks her about this but she mentioned it is to do with her holiday. The doctor takes some blood samples which demonstrate electrolyte imbalances - Low sodium and High potassium. A deficit in which hormone in this patient's condition has caused the development of hyperpigmentation? A. Prolactin B. GH C. ADH D. ACTH

Answer 157

D. ACTH POMC - proopiomelanocortin

Question 158

Where is the most common site for carcinoid tumours to metastasise? A. Liver B. Lungs C. Brain D. Bones

Answer 158

Liver Carcinoid tumours are neuroendocrine tumours Neuroendocrine tumours most often metastasise to the liver (45-95% of patients)

Question 159

A 32 year old man presents to the GP with a general feeling of weakness along with some regular muscle cramps. He is normally fit and well. On examination the doctor notices widespread hyporeflexia and hypertension. A plasma aldosterone/renin ratio is performed and a diagnosis of primary hyperaldosteronism is made. Which electrolyte imbalances are associated with this condition? A. Hypercalcaemia, hyponatraemia B. Hyponatraemia, hypokalaemia C. Hypokalemia, hypernatraemia D. Hyperkalaemia, hypernatraemia

Answer 159

C. Hypokalemia, hypernatraemia Conn’s Syndrome causes too much production of Aldosterone. As a result, aldosterone increases reabsorption of Na+ into the bloodstream, which in turn leads to water reabsorption as water follows sodium. This causes high sodium and HTN. In order to maintain balance potassium is drawn out the blood via Na/K pumps resulting in low potassium. Symptoms of hypokalemia include muscle weakness, flaccid paralysis + hyporeflexia (decreased deep tendon reflexes). The aldosterone/ renin ratio in primary hyperaldosterone will indicate High Aldosterone but Low Renin.

Question 160

What PTH, calcium and phosphate levels would you expect to find in someone with hyperparathyroidism caused by renal disease? A. High PTH, high calcium and high phosphate B. High PTH, low calcium and high phosphate C. Low PTH, high calcium and low phosphate D. Low PTH, low calcium and low phosphate

Answer 160

B. High PTH, low calcium and high phosphate CKD causes hypocalcaemia due to lower 1-25-dihydroxycholecalciferol levels. The parathyroid works harder compensate for the lack of calcium and more PTH is produced. Phosphate levels remain raised as the kidney is not functioning properly and is unable to excrete phosphate effectively

Question 161

A 54 year old man with known DMT2 presents into the clinic complaining that his medications are not working. He is still presenting with symptoms despite compliance to medication. However, recently he has developed a loss of appetite and an upset stomach. After taking some investigations the patient is said to have lactic acidosis with severe liver failure. He is currently on triple therapy for his diabetes taking metformin + sulfonylurea + SGLT-2 inhibitor (glifazone), as well as, Ramipril for his hypertension. Which medication is most likely the cause of his new symptoms? A.Metformin B. Glifazone C. sulfonylurea D. Ramipril

Answer 161

A. Metformin

Question 162

A 48 year old lady presents to your surgery complaining of numbness and tingling in her right hand. She also appears to have large hands, rough/tanned skin and a prominent jaw and forehead. None of her clothes fit as she has also gained 10kg in the last year. Which nerve roots are associated with the condition presented above? A. C3-5 B. C4-6 C. C5/6-T1 D. C6-T2

Answer 162

C. C5/6-T1 Carpal tunnel syndrome is a complication of acromegaly Numbness, tingling, pain along median nerve distribution Can wake patient from sleep Worse at night/early morning The median nerve is compressed in carpal tunnel syndrome and its roots are C5/6-T1. It is derived from the medial and lateral cords of the brachial plexus.

Question 163

A 45 year old woman presents to her GP complaining of feeling unsteady. She has mentioned that she has become increasingly more sweaty recently despite it being the winter months. Along with this she is saying that she has begun to eat more than usual. But what's confused her most is that despite this, she is still losing weight. However, what’s been most worrying for her is that she has begun to develop what seems to be waxy discoloration to her lower legs which she describes as orange peel appearance. Which antibody is most likely to be associated with the condition presented above? A. Anti TPO B. Anti dsDNA C. TSH receptor antibodies D. Anti Thyroglobulin antibodies

Answer 163

TSH receptor antibodies Associated with Grave’s - Found in 90% Graves Ptx Graves Triad: Goitre Orbitopathy Pretibial myxoedema Anti TPO- The main antibody associated with Hashimoto’s - Found in 90% of Hashimoto’s Ptx; 75% Graves Anti dsDNA - Associated with SLE Anti Thyroglobulin antibodies - Also associated with Hashimoto’s

Question 164

A 15 year old boy with poorly controlled type 1 diabetes comes to A&E with a 2 day history of abdominal pain, vomiting and fruity smelling breath. What is the diagnostic criteria for his suspected condition? A. Ketones >= 3.3 mmol/L, glucose < 3 mmol/L and pH < 7.5 B. Ketones >= 3 mmol/L, glucose > 7 mmol/L and pH < 7.3 C. Ketones >= 3.3 mmol/L, glucose > 11 mmol/L and pH <7.5 D. Ketones >= 3 mmol/L, glucose > 11 mmol/L and pH < 7.

Answer 164

Ketones >= 3 mmol/L, glucose > 11 mmol/L and pH < 7.3

Question 165

52 year old male has noticed that his skin is becoming coarser and his shoes no longer fit. Looking over past pictures he has noticed overall enlargement in peripheral limbs. He was initially referred for surgery but is no longer fit enough to undergo the procedure as he is suffering from heart failure as a result of this condition. What is the next best management for him regarding this condition (not heart failure)? A. Radiotherapy B. Somatostatin analogue C. Growth hormone receptor antagonist D. Dopamine agonist

Answer 165

B. Somatostatin analogue Acromegaly Management 1st line - transsphenoidal surgery 2nd line - Somatostatin analogue (SSA) octreotide or lanreotide SE: pain at injection site, abdo cramps, flatulance, loose stools, ↑ gallstones, impaired glucose tolerance +/- Dopamine agonist if GH secretions persist 3rd line - GH-receptor antagonist (GHRA) pegvisomant 4th line - Radiotherapy

Question 166

An elderly gentleman is difficult to rouse and appears less responsive than usual. He is currently recovering from a chest infection in hospital and has a patent cannula for medications/fluids. Significant PMH includes type 2 diabetes and ischaemic stroke which caused him to become NBM. His blood glucose is currently 2.3 mmol/L. What is the best management for this patient? A. IM insulin B. Oral glucose gel C. IV glucose D. IV glucagon

Answer 166

IV glucose NBM so oral glucose is not an option Insulin will further lower his glucose levels which is not what we want IV glucagon - this patient does not have sufficient stores to release glucose even with glucagon stimulation

Question 167

A young gentleman presents to the GP practice complaining of sweating more than usual. Under further investigation he tells you that he has also noticed more frequent headaches and a feeling of his heart pounding his chest. He tells you that this has gotten him more anxious recently as this has never happened before. A. Blocks the alpha-adrenergic receptors leading to vasodilation B. Blocks the beta-adrenergic receptors leading to vasodilation C. Potassium channel blocker antiarrhythmic D. Releases NO causing vasodilation

Answer 167

(Pheochromocytoma) A. Blocks the alpha-adrenergic receptors leading to vasodilation --- 1st line in hypertensive crisis - phentolamine Hypertensive crisis -> BP 180/120 with accompanying symptoms B. Blocks the beta-adrenergic receptors leading to vasodilation Beta blockers. Offered in patients without hypertensive crisis as second line after alpha blockers C. Potassium channel blocker antiarrhythmic Class III antiarrhythmic drug D. Releases NO causing vasodilation 2nd line - Sodium nitroprusside

Question 168

How does first line management differ in Hyperthyroidism + Hypothyroidism?

Answer 168

Hyperthyroidism - 1st line: Propanolol + carbimazole + iodine Hypothyroidism - 1st line Levothyroxine

Question 169

What is the most common cause of hypothyroidism in the developing world?

Answer 169

Developing world -> Iodine deficiency Developed world -> Hashimoto’s Thyroiditis

Question 170

What glucose levels are seen in a non diabetic, pre-diabetic and diabetic?

Answer 170

non diabetic = HbA1c <42 A1c = less than or equal 5.6 pre-diabetic = HbA1c 42-47 A1c = 5.7 - 6.4 diabetic = HbA1c 48+ A1c = 6.5+

Question 171

Describe the management plan in a patient with newly diagnosed diabetes mellitus type 2 + what would be the follow up management if symptoms progress?

Answer 171

1. Lifestyle modifications - Diet, Exercise, Weight loss 2. Monotherapy - Metformin 3. Dual therapy - if HbA1c rises to 58mmol/mol (7.5%) 4. Triple therapy - if HbA1c rises to 58mmol/mol (7.5%) Metformin DPP4 inhibitor SU, Pioglitazone SGLT-2 inhibitor Thiazolidinedione insulin based therapy ONLY WHEN MEDS FAIL 5. Insulin or Glucagon-like peptide (GLP) analogues GLP analogues - incretin mimetics Incretins - gut peptides that work by increasing insulin release.

Question 172

What are some complications of DM?

Answer 172

Acute - DKA, HHS, hypoglycaemia Chronic Microvascular - retinopathy, nephropathy, erectile dysfunction, neuropathy (10-20 years after diagnosis in young patients) Macrovascular - atherosclerosis, ACS, stable angina, PVD, stroke Diabetic foot and ulcers

Question 173

What is the difference between Cushing’s disease and Cushing’s syndrome?

Answer 173

Cushing’s syndrome refers to the state of elevated cortisol levels Cushing’s disease is specifically caused by an ACTH secreting pituitary tumour (pituitary adenoma)

Question 174

Which investigation can be used to differentiate between the two conditions?

Answer 174

Dexamethasone suppression test Overnight Cushing’s syndrome (including disease) is confirmed when there is no suppression 48 hour Cushing’s syndrome (not including disease) = no suppression

Question 175

C. How does a patient with Cushing’s syndrome present (5 marks)?

Answer 175

central obesity striae osteoporosis buffalo hump muscle atrophy

Question 176

Which conditions would most likely cause the following TSH and T3/T4 results? TSH: Low T4: High =

Answer 176

a. TSH: Low T4: High Hyperthyroidism, thyrotoxicosis, Grave’s

Question 177

Which conditions would most likely cause the following TSH and T3/T4 results? TSH: High T4: Normal =

Answer 177

b. TSH: High T4: Normal Subclinical hypothyroidism or poor compliance with thyroxine

Question 178

Which conditions would most likely cause the following TSH and T3/T4 results? TSH: High T4: Low =

Answer 178

c. TSH: High T4: Low Primary hypothyroidism, Hashimoto’s

Question 179

Which conditions would most likely cause the following TSH and T3/T4 results? TSH: Low T4: Low =

Answer 179

d. TSH: Low T4: Low Secondary hypothyroidism

Question 180

A patient comes into the Hospital with suspected DKA. What are the first line treatments you would offer?

Answer 180

IV Fluids (0.9% Sodium Chloride) IV insulin +/- Potssium

Question 181

A patient comes into the Hospital with suspected DKA. What ecg changes are seen in a patient with hyperkalemia (list 4)?

Answer 181

Go - Absent p waves Go Long - prolonged PR Go Tall - Tall T waves Go Wide - Wide QRS ‘Sine’ Wave appearance

Question 182

A patient comes into the Hospital with suspected DKA. What arrhythmia is a consequence of untreated hyperkalaemia?

Answer 182

Ventricular Tachycardia Occurring due to cell membranes becoming partially depolarised resulting in a lower threshold potential -> Ventricles contract quicker