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Question 1
Incorrect
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A 17-year-old Jewish girl presents with primary amenorrhoea. On examination, she looks a little hirsute and has evidence of facial acne. She is within her predicted adult height and has normal breast and external genitalia development, however, there is excess hair over her lower abdomen and around her nipple area.
Investigations were as follows:
Hb 13.1 g/dl
WCC 8.6 x109/l
PLT 201 x109/l
Na+ 139 mmol/l
K+ 4.5 mmol/l
Creatinine 110 µmol/l
17-OH progesterone 1.4 times the upper limit of normal
Pelvic ultrasound: bilateral ovaries and uterus visualised.
Which of the following is the most likely diagnosis?Your Answer: Polycystic ovarian syndrome
Correct Answer: Non-classical congenital adrenal hyperplasia
Explanation:Mild deficiencies of 21-hydroxylase or 3-beta-hydroxysteroid dehydrogenase activity may present in adolescence or adulthood with oligomenorrhea, hirsutism, and/or infertility. This is termed nonclassical adrenal hyperplasia.
Late-onset or nonclassical congenital adrenal hyperplasia (NCAH) due to 21-hydroxylase deficiency is one of the most common autosomal recessive disorders. Reported prevalence ranges from 1 in 30 to 1 in 1000. Affected individuals typically present due to signs and symptoms of androgen excess.
Treatment needs to be directed toward the symptoms. Goals of treatment include normal linear growth velocity, a normal rate of skeletal maturation, ‘on-time’ puberty, regular menstrual cycles, prevention of or limited progression of hirsutism and acne, and fertility. Treatment needs to be individualized and should not be initiated merely to decrease abnormally elevated hormone concentrations.
Normal Ultrasound rules out Turner’s syndrome. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 2
Correct
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An 18-year-old woman in her 30th week of pregnancy is brought to the hospital in altered sensorium. She is taking slow, shallow breaths and her breath has a fruity smell. An arterial blood gas (ABG) shows the presence of ketones. What is the most probable diagnosis?
Your Answer: Diabetic Ketoacidosis (DKA)
Explanation:This a case of gestational diabetes presenting with DKA. It is a serious case that requires immediate intervention. Pregnant diabetics tend to develop DKA on a lower serum glucose level than non-pregnant diabetics. The shortness of breath is a trial to wash the excess CO2 to compensate for the metabolic acidosis seen in the ABG. The fruity smell is acetone excreted through the lungs. The main treatment of this case is proper fluid management and insulin infusion.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 3
Incorrect
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A 25-year-old obese woman is diagnosed with polycystic ovarian syndrome (PCOS). Which of the following findings is most consistently seen in PCOS?
Your Answer: Raised LH:FSH ratio
Correct Answer: Ovarian cysts on ultrasound
Explanation: -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 4
Correct
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An 8-year-old boy was admitted following a MVA. His BMI is 28 kb/m2 and he's been found to have glycosuria, which resolved after his recovery. Which investigation is necessary to perform as part of the follow-up?
Your Answer: Fasting blood glucose concentration
Explanation:The boy has an increased BMI which implies he is overweight. Possible trauma to his pancreas might have led to a diabetes-like condition, induced by damage to the beta cells. Fasting blood glucose should be measured as a follow-up strategy to see if the damage is reversible or irreversible and to conclude if the glycosuria is related to his metabolic profile or to his accident.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 5
Incorrect
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A 39-year-old female had surgery for the removal of thyroid carcinoma. One week later, she presented in the OPD with complaints of numbness, tingling, involuntary spasm of the upper extremities, paraesthesia and respiratory stridor. Which of the following is the most likely cause?
Your Answer: External laryngeal nerve injury
Correct Answer: Hypocalcaemia
Explanation:Hypocalcaemia presents with such symptoms. It probably happened due to accidental removal of a parathyroid gland during the thyroid surgery. Hypocalcaemia causes laryngospasm which produces stridor.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 6
Correct
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A 20-year-old woman presents for review. She is concerned due to absence of menstruation for 5 months.
She is 1.76 m in height and weighs only 43.7 kg (7 stone).
A pregnancy test is negative and thyroid function testing is normal.
Which of the following is the diagnosis of this case?Your Answer: Weight-related amenorrhoea
Explanation: -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 7
Incorrect
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A 77-year-old woman is admitted in an unconscious state. On examination in casualty, her temperature is 33 °C and she was in left ventricular failure.
Her blood glucose level is 5.7 mmol/l and random cortisol is elevated. Free T4 is 4.4 pmol/l.
A CT scan of her brain reveals no focal lesion and a cursory assessment reveals no gross focal neurology.
Which diagnosis fits best with this woman's clinical picture?Your Answer: Hypoglycaemia
Correct Answer: Profound hypothyroidism
Explanation:Elderly patients with severe hypothyroidism often present with variable symptoms that may be masked or potentiated by co-morbid conditions. Characteristic symptoms may include fatigue, weight gain, cold intolerance, hoarseness, constipation, and myalgias. Neurologic symptoms may include ataxia, depression, and mental status changes ranging from mild confusion to overt dementia.
Clinical findings that may raise suspicion of thyroid hormone deficiency include hypothermia, bradycardia, goitrous enlargement of the thyroid, cool dry skin, myxoedema, delayed relaxation of deep tendon reflexes, a pericardial or abdominal effusion, hyponatremia, and hypercholesterolemia.The patient has a greatly reduced free T4 concentration, is hypothermic, unconscious and has evidence of associated heart failure. All of those support the diagnosis of profound hypothyroidism.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 8
Correct
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A 60-year-old man with a history of recent thyrotoxicosis underwent major surgery a week ago. He now presents with altered mental status, tachycardia, high-grade fever, vomiting and cardiac failure. A diagnosis of thyroid storm (crisis) is made.
What is the most important next step in management?Your Answer: Transfer the patient to ITU
Explanation:Thyroid storm, also referred to as thyrotoxic crisis, is an acute, life-threatening, hypermetabolic state induced by excessive release of thyroid hormones (THs) in individuals with thyrotoxicosis.
Patients with thyroid storm should be treated in an ICU setting for close monitoring of vital signs and for access to invasive monitoring and inotropic support, if necessary.
– Supportive measures
If needed, immediately provide supplemental oxygen, ventilatory support, and intravenous fluids. Dextrose solutions are the preferred intravenous fluids to cope with continuously high metabolic demand.
– Correct electrolyte abnormalities.
– Treat cardiac arrhythmia, if necessary.
– Aggressively control hyperthermia by applying ice packs and cooling blankets and by administering acetaminophen (15 mg/kg orally or rectally every 4 hours).
– Antiadrenergic drugs.
– Thionamides: Correct the hyperthyroid state. Administer antithyroid medications to block further synthesis of thyroid hormones (THs).
High-dose propylthiouracil (PTU) or methimazole may be used for treatment of thyroid storm.
– Administer glucocorticoids to decrease peripheral conversion of T4 to T3. This may also be useful in preventing relative adrenal insufficiency due to hyperthyroidism and improving vasomotor symptoms.
– Bile acid sequestrants prevent reabsorption of free THs in the gut (released from conjugated TH metabolites secreted into bile through the enterohepatic circulation).
– Treat the underlying condition. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 9
Correct
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A 36-year-old lady presented with increased bowel motions, palpitations, heat intolerance and loss of weight. She is also tachycardiac. The investigation of choice in this case would be?
Your Answer: Thyroid function test
Explanation:Hyperthyroidism is characterised by heat intolerance, loss of weight, increased sweating, increased bowel frequency and tachycardia. On GPE, there might be proptosis of eyes and tremors in the hands.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 10
Incorrect
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A 35-year-old female admitted with heat intolerance, neck pain, palpitations and recent onset weight loss despite increased appetite. Which of the following is most likely to be associated with diagnosis of thyroiditis associated with viral infection?
Your Answer: Positive thyroid peroxidase antibodies
Correct Answer: Reduced uptake on thyroid isotope scan
Explanation:Subacute thyroiditis (De Quervain’s thyroiditis) is a self-limiting thyroid condition presenting with three clinical courses of hyperthyroidism, hypothyroidism, and return to normal thyroid function. In subacute thyroiditis serum thyroglobulin (TG) levels are elevated. ESR is usually greater than 50 mm/h, often exceeding 100 mm/h. Radio-iodine uptake is low or nil. Antithyroperoxidase antibodies are associated with autoimmune thyroiditis
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 11
Correct
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A 55-year-old man known with Addison's disease presented with complaints of recurrent attacks of postural hypotension. What kind of electrolyte imbalance would be seen in his biochemical profile investigations?
Your Answer: Low Na+, High K+
Explanation:Patients suffering from Addison’s disease have low aldosterone. Aldosterone increases Na+ absorption and excretion of K+. So in these patients there would be decreased Na+ and increased K+ levels.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 12
Correct
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A 60-year-old patient diagnosed with Type-2 diabetes mellitus is not responding to dietary modifications and weight reduction. He needs to be started on an oral hypoglycemic agent. Which among the following statements regarding oral hypoglycaemic agents is true?
Your Answer: Acarbose inhibits ?-glucosidase
Explanation: -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 13
Incorrect
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A 25-year-old male presents at the OPD complaining of excessive tiredness and frequent headaches. On examination, his blood pressure was 205/100 mmHg. Blood tests reveal a decreased serum potassium and renin level and elevated aldosterone level. Which condition is this patient most likely suffering from?
Your Answer:
Correct Answer: Primary hyperaldosteronism (Conn's disease)
Explanation:Conn’s disease is a condition in which excessive amounts of aldosterone are secreted from the adrenal glands. Because aldosterone increases the reabsorption of sodium, it leads to a very high blood pressure.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 14
Incorrect
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A 20-year-old student nurse was admitted after her third collapse in recent months. She was noted to have a blood sugar of 0.9 mmol/l on finger-prick testing and responded well to intravenous glucose therapy.
Venous blood taken at the same showed a markedly raised insulin level, but her C-peptide levels were normal.
What diagnosis fits best with this clinical picture?Your Answer:
Correct Answer: Self-administration of a short-acting insulin
Explanation:The patient has hyperinsulinemia and hypoglycaemia, but her C-peptide levels are normal. This is strongly suggestive of the fact that she is self-administering insulin.
In Insulinoma, common diagnostic criteria include:
– blood glucose level < 50 mg/dl with hypoglycaemic symptoms,
– relief of symptoms after eating
– absence of sulfonylurea on plasma assays.
The classic diagnostic criteria include the demonstration of the following during a supervised fast:
Increased plasma insulin level
Increased C peptide level
Increased proinsulin level
However, the patient has normal C-peptide levels.
In type-1 diabetes mellitus, insulin and C-peptide levels are low. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 15
Incorrect
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In which of the following is there Growth hormone deficiency (GHD)?
Your Answer:
Correct Answer: Sheehan's syndrome
Explanation:The main cause of growth hormone (GH) deficiency is a pituitary tumour or the consequences of treatment of the tumour including surgery and/or radiation therapy.
Sheehan’s syndrome (SS) is postpartum hypopituitarism caused by necrosis of the pituitary gland. It is usually the result of severe hypotension or shock caused by massive haemorrhage during or after delivery. Patients with SS have varying degrees of anterior pituitary hormone deficiency.Laron syndrome is Insulin-like growth factor I (IGF-I) deficiency due to GH resistance or insensitivity due to genetic disorders of the GH receptor causing GH receptor deficiency.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 16
Incorrect
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A 35-year-old female had an oral glucose tolerance test. Her oral glucose test after 2 hrs was 10mml/l. What is the result of her test?
Your Answer:
Correct Answer: Impaired glucose tolerance
Explanation:Impaired glucose tolerance is a pre-diabetic state of hyperglycaemia that is associated with insulin resistance and increased risk of cardiovascular pathology. To diagnose impaired glucose tolerance, the OGTT value after 2 hrs should be 140-199mg/dl (7.7 – 11.0 mmol/l). Impaired fasting glucose is diagnosed as fasting blood sugar between 100 mg/dl to 125 mg/dl.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 17
Incorrect
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A 27-year-old woman presents with a history of weight loss and palpitations. Examination reveals unilateral proptosis. She also admits that despite having a healthy appetite she has difficulty putting on weight. What is the most probable diagnosis?
Your Answer:
Correct Answer: Thyroid-associated ophthalmopathy
Explanation:The patient’s age and symptoms suggest Grave’s disease with thyroid-associated ophthalmopathy. In Grave’s disease, weight loss is noticed regardless of normal eating habits of the patient. Palpitations are also typical and may be confused with a panic attack. Proptosis is usually bilateral, but unilateral is also possible.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 18
Incorrect
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A 60-year-old female who was on dexamethasone underwent abdominal surgery. Her blood sugar levels remained around 18 mmol/l during and after the surgery. Which of the following is the most suitable method to control her blood sugar level?
Your Answer:
Correct Answer: Insulin
Explanation:She has steroid induced hyperglycaemia. She needs satisfactory glycaemic control to avoid post surgical infections. As she is in a stressful event following a major surgery, insulin is the best method to manage her hyperglycaemia.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 19
Incorrect
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Which of the following is most consistent with achondroplasia?
Your Answer:
Correct Answer: May be diagnosed radiologically at birth
Explanation:Achondroplasia is the most common type of short-limb disproportionate dwarfism. A single gene mapped to the short arm of chromosome 4 (band 4p16.3) is responsible for achondroplasia and is transmitted as an autosomal dominant trait. All people with achondroplasia have a short stature.
Characteristic features of achondroplasia include an average-size trunk, short arms and legs with particularly short upper arms and thighs, limited range of motion at the elbows, and an enlarged head (macrocephaly) with a prominent forehead. Fingers are typically short and the ring finger and middle finger may diverge, giving the hand a three-pronged (trident) appearance. People with achondroplasia are generally of normal intelligence.
Examination of the infant after birth shows increased front-to-back head size. There may be signs of hydrocephalus. It may be diagnosed radiographically at birth, or becomes obvious within the first year with disparity between a large skull, normal trunk length and short limbs. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 20
Incorrect
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A 43-year-old woman is concerned about osteoporosis as she as a strong family history of it. She is one year postmenopausal and aware of hot flushes at night.
Which one of the following therapies would be most appropriate?Your Answer:
Correct Answer: Cyclical oestrogen and progestogen
Explanation:As the patient has early menopause, hormone replacement therapy (HT) is considered to be the first line of choice for prevention of bone loss and fracture in the early postmenopausal period for 5 years.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 21
Incorrect
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A 70-year-old man presents to the emergency department acutely unwell. He is shocked, drowsy and confused.
He is known to be type-2 diabetic maintained on metformin.
Blood tests reveal a metabolic acidosis with an anion gap of 24 mmol/l. Ketones are not significantly elevated and random blood glucose was 8.7 mmol/l.
What is the mainstay of treatment for this condition?Your Answer:
Correct Answer: Rehydration
Explanation:Lactic acidosis is occasionally responsible for metabolic acidosis in diabetics. It may occur in the presence of normal blood levels of the ketone bodies, and such cases are often described as having non-ketotic diabetic acidosis.
It is most commonly associated with tissue hypoperfusion and states of acute circulatory failure.
Appropriate measures include treatment of shock, restoration of circulating fluid volume, improved cardiac function, identification of sepsis source, early antimicrobial intervention, and resection of any potential ischemic regions. Reassessment of lactate levels for clearance assists ongoing medical management. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 22
Incorrect
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A 42-year-old male with long history of diabetes is complaining of a red-hot tender lump near his anus. What is the most possible diagnosis?
Your Answer:
Correct Answer: Abscess
Explanation:A diabetic patient is a patient with depressed immunity. It is not uncommon to develop abscesses. Diabetic patients have a defected cellular innate immunity. On the other hand, bacteria become much more virulent in a high glucose environment in the interstitium.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 23
Incorrect
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A 30-year-old lawyer presents with non-specific symptoms of tiredness.
Blood tests reveal normal thyroid function, cortisol, growth hormone and gonadotropins. Pituitary MRI reveals a 0.8cm microadenoma.
Which of the following represents the most appropriate course of action?Your Answer:
Correct Answer: Observation and reassurance
Explanation:The patient has a non-functioning pituitary tumour as her hormone profile is normal.
Non-functioning pituitary tumours are relatively common. A large number of these tumours are incidentally found pituitary microadenomas (<1 cm) and are usually of no clinical importance. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 24
Incorrect
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A 17-year-old boy was brought to clinic, as his parents were concerned regarding possible delayed puberty. He was otherwise well, played sports regularly and his academic performance was good. His height was 1.7m and weight was 70 kg. On examination, he had a small penis and testes, absent pubic hair, but no other abnormalities. Investigations revealed: Serum testosterone 4 nmol/L (9-35) Plasma follicle stimulating hormone (FSH) 1 U/L (1-7) Plasma luteinising hormone (LH) 1 U/L (1-10) Plasma prolactin 300 mU/L (<450) Plasma TSH 2 mU/L (0.5-5) Which one of the following is the most likely cause?
Your Answer:
Correct Answer: Kallman's syndrome
Explanation:Klinefelter’s syndrome: The low follicle-stimulating hormone (FSH) and luteinising hormone (LH), together with the low testosterone, suggests a hypogonadotropic hypogonadism. We know that there is no mental retardation, and we are told that physical examination is normal and sense of smell would usually not be tested. Consequently a diagnosis of Kallman’s is suggested. We are not told of a family history of growth delay, thus this is unlikely to be constitutional delay. The thyroid-stimulating hormone (TSH) is normal, making hypothyroidism unlikely and this together with the normal prolactin make hypopituitarism most unlikely.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 25
Incorrect
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A 45-year-old obese patient arrives at the clinic for a regular health check up. His labs are as follows: Fasting blood sugar: 6 mmol/l, Oral glucose tolerance test (OGTT): 10 mmol/L. What is the most likely diagnosis?
Your Answer:
Correct Answer: Impaired glucose tolerance
Explanation:Impaired glucose tolerance means that blood glucose is raised beyond normal levels, but not high enough to warrant a diabetes diagnosis. With impaired glucose tolerance you face a much greater risk of developing diabetes and cardiovascular disease. Impaired glucose tolerance is defined as 2-hour glucose levels of 140 to 199 mg per dL (7.8 to 11.0 mmol) on the 75-g oral glucose tolerance test, and impaired fasting glucose is defined as glucose levels of 100 to 125 mg per dL (5.6 to 6.9 mmol per L) in fasting patients.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 26
Incorrect
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Which of the following is correct regarding post-menopausal hormone replacement therapy (HRT) according to randomised clinical studies ?
Your Answer:
Correct Answer: Increases plasma triglycerides
Explanation:Oestrogen therapy reduces plasma levels of LDL cholesterol and increases levels of HDL cholesterol. It can improve endothelial vascular function, however, it also has adverse physiological effects, including increasing the plasma levels of triglycerides (small dense LDL particles). Therefore, although HRT may have direct beneficial effects on cardiovascular outcomes, these effects may be reduced or balanced by the adverse physiological effects.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 27
Incorrect
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Raloxifene is used in the treatment of osteoporosis, which of the following best describes it?
Your Answer:
Correct Answer: A selective oestrogen receptor modulator
Explanation:Raloxifene is a selective oestrogen-receptor modulator (SERM) that has been approved for use in the prevention and treatment of osteoporosis in postmenopausal women.
A SERM interacts with oestrogen receptors, functioning as an agonist in some tissues and an antagonist in other tissues. Because of their unique pharmacologic properties, these agents can achieve the desired effects of oestrogen without the possible stimulatory effects on the breasts or uterus. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 28
Incorrect
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A 64-year-old male patient was admitted for dysphagia, emesis and weight loss. He has a firm lump in his left supraclavicular fossa. What is the most probable diagnosis?
Your Answer:
Correct Answer: Gastric carcinoma
Explanation:The history is suggestive of gastric carcinoma with dysphagia, vomiting, weight loss and lymphatic metastasis to the supraclavicular node, known as Virchow’s node.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 29
Incorrect
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A 30-year-old woman is referred to endocrinology with thyrotoxicosis. Following a discussion of management options, she chooses to have radioiodine therapy. Which one of the following is the most likely adverse effect?
Your Answer:
Correct Answer: Hypothyroidism
Explanation:Approximately one third of patients treated with radioiodine therapy develop transient hypothyroidism. Unless a patient is highly symptomatic, thyroxine replacement may be withheld if hypothyroidism occurs within the first 2 months of therapy. If it persists for longer than 2 months, permanent hypothyroidism is likely and replacement with T4 should be initiated.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 30
Incorrect
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A 33-year-old woman presents to the clinic with chronic fatigue. She has 3 children and a full-time job and is finding it very difficult to hold everything together. There is no significant past medical history.
On examination, her BP is 145/80 mmHg and her BMI is 28.
Investigations show:
Hb 12.5 g/dl
WCC 6.7 x109/l
PLT 204 x109/l
Na+ 141 mmol/l
K+ 4.9 mmol/l
Creatinine 120 μmol/l
Total cholesterol 5.0 mmol/l
TSH 7.8 U/l
Free T4 10.0 pmol/l (10-22)
Free T3 4.9 pmol/l (5-10)
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Subclinical hypothyroidism
Explanation:Elevated TSH (usually 4.5-10.0 mIU/L) with normal free T4 is considered mild or subclinical hypothyroidism.
Hypothyroidism commonly manifests as a slowing in physical and mental activity but may be asymptomatic. Symptoms and signs are often subtle and neither sensitive nor specific.
The following are symptoms of hypothyroidism:
– Fatigue, loss of energy, lethargy
– Weight gain
– Decreased appetite
– Cold intolerance
– Dry skin
– Hair loss
– Sleepiness
– Muscle pain, joint pain, weakness in the extremities
– Depression
– Emotional lability, mental impairment
– Forgetfulness, impaired memory, inability to concentrate
– Constipation
– Menstrual disturbances, impaired fertility
– Decreased perspiration
– Paraesthesia and nerve entrapment syndromes
– Blurred vision
– Decreased hearing
– Fullness in the throat, hoarseness
Physical signs of hypothyroidism include the following:
– Weight gain
– Slowed speech and movements
– Dry skin
– Jaundice
– Pallor
– Coarse, brittle, straw-like hair
– Loss of scalp hair, axillary hair, pubic hair, or a combination
– Dull facial expression
– Coarse facial features
– Periorbital puffiness
– Macroglossia
– Goitre (simple or nodular)
– Hoarseness
– Decreased systolic blood pressure and increased diastolic blood pressure
– Bradycardia
– Pericardial effusion
– Abdominal distention, ascites (uncommon)
– Hypothermia (only in severe hypothyroid states)
– Nonpitting oedema (myxoedema)
– Pitting oedema of lower extremities
– Hyporeflexia with delayed relaxation, ataxia, or both. -
This question is part of the following fields:
- Endocrine System & Metabolism
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SESSION STATS - PERFORMANCE PER SPECIALTY
