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Question 1
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A 55-year-old man presents to the ED complaining of extreme fatigue. He has a history of Graves disease. On examination, his blood pressure is 103/58 mmHg, pulse 64/min and temperature 36.3ºC.
The following results are obtained:
Na+ 135 mmol/l
K+ 5.4 mmol/l
Urea 5.2 mmol/l
Creatinine 42 umol/l
TSH 3.5 mu/l
Free thyroxine (T4) 12 pmol/l
You arrange for a random cortisol test, however, whilst awaiting the result he becomes unresponsive. In addition to giving intravenous steroids and fluid, what test is urgent to check first given the likely diagnosis?Your Answer: Glucose
Explanation:The patient is most likely to have Addison’s disease as he has a history of autoimmune disease, hyperkalaemia and hypotension.
It is important to keep an Addisonian crisis on the differential in cases of shock, especially since adrenal crisis can be the patient’s first presentation of adrenal insufficiency.
Patients with Addison’s disease are prone to developing hypoglycaemia due to loss of the glucogenic effect of glucocorticoids. Given the sudden deterioration, a glucose level must be checked. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 2
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A 58-year-old woman has multiple non-healing leg ulcers. She reports feeling unwell for several months. Examination findings include a normal blood pressure, pulse 90 bpm, pale conjunctivae and poor dentition associated with bleeding gums. What is the most likely underlying diagnosis?
Your Answer: Vitamin C deficiency
Explanation:Severe vitamin C deficiency results in scurvy, a disorder characterized by hemorrhagic manifestations and abnormal osteoid and dentin formation.
Vitamin C plays a role in collagen, carnitine, hormone, and amino acid formation. It is essential for bone and blood vessel health and wound healing and facilitates recovery from burns. Vitamin C is also an antioxidant, supports immune function, and facilitates the absorption of iron (see table Sources, Functions, and Effects of Vitamins).
Dietary sources of vitamin C include citrus fruits, tomatoes, potatoes, broccoli, strawberries, and sweet peppers. (See also Overview of Vitamins.) -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 3
Correct
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A 40-year-old woman presents with weight loss, palpitations, diarrhoea and cessation of periods. She has been treated by her GP for anxiety. Examination reveals a single nodule on the left of her thyroid, about 1.5 cm in diameter.
Thyroid scan shows increased uptake within the nodule with reduced activity throughout the rest of the gland.
Thyroid function tests showed a free thyroxine of 30 pmol/l (9-25 pmol/l), TSH < 0.05 mU/l (0.5-5).
Based on these findings, what would be the definitive treatment?Your Answer: Radioactive iodine therapy
Explanation:Patients who have autonomously functioning nodules should be treated definitely with radioactive iodine or surgery.
Na131 I treatment – In the United States and Europe, radioactive iodine is considered the treatment of choice for Toxic Nodular Goitre. Except for pregnancy, there are no absolute contraindications to radioiodine therapy. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 4
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A 19-year-old previously well male presented with abdominal pain and a reduced level of consciousness. On examination he was drowsy, tachypnoeic and dehydrated with dry mucous membranes. His random blood sugar was 17 mmol/l. Which of the following is the most appropriate next step?
Your Answer: ABG
Explanation:The most probable diagnosis is diabetic ketoacidosis. ABG is mandatory to look for acidosis and correct pH accordingly.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 5
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Following a head injury, a 22-year-old patient develops polyuria and polydipsia. He is suspected to have cranial diabetes insipidus so he undergoes a water deprivation test.
Which one of the following responses would most indicate a positive (abnormal) result?Your Answer: Failure to concentrate the urine during water deprivation, but achievement of urine osmolality of 720 mmol/kg following the administration of desmopressin
Explanation:The water deprivation test (i.e., the Miller-Moses test), is a semiquantitative test to ensure adequate dehydration and maximal stimulation of ADH for diagnosis. It is typically performed in patients with more chronic forms of Diabetes Insipidus (DI). The extent of deprivation is usually limited by the patient’s thirst or by any significant drop in blood pressure or related clinical manifestation of dehydration.
In healthy individuals, water deprivation leads to a urinary osmolality that is 2-4 times greater than plasma osmolality. Additionally, in normal, healthy subjects, administration of ADH produces an increase of less than 9% in urinary osmolality. The time required to achieve maximal urinary concentration ranges from 4-18 hours.
In central and nephrogenic DI, urinary osmolality will be less than 300 mOsm/kg after water deprivation. After the administration of ADH, the osmolality will rise to more than 750 mOsm/kg in central DI but will not rise at all in nephrogenic DI. In primary polydipsia, urinary osmolality will be above 750 mOsm/kg after water deprivation.
A urinary osmolality that is 300-750 mOsm/kg after water deprivation and remains below 750 mOsm/kg after administration of ADH may be seen in partial central DI, partial nephrogenic DI, and primary polydipsia. -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 6
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: Anaplastic carcinoma of thyroid
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 7
Incorrect
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A 50-year-old heavy drinker is brought to the A&E in a drowsy state. He is responding to questions however on examination he has nystagmus and hyper-reflexia. His MCV is 103fL.What is the most likely cause for his cognitive impairment?
Your Answer: B6 deficiency
Correct Answer: B1 Deficiency
Explanation:Thiamine deficiency is very common with alcoholism. It manifests by Wernicke-Korsakoff encephalopathy. The patient is usually agitated, with an abnormal gait and amnesia.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 8
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A 40-year-old man comes to the endocrine clinic after his second episode of acute pancreatitis.
On examination, he has a BP of 125/70 mmHg, his pulse is regular 70 bpm and his BMI is 23. There is evidence of eruptive xanthomas on examination of his skin.
It was noted that his fasting triglycerides level is 8.5 mmol/l (0.7-2.1) at his follow up appointment although his LDL level is not particularly raised.
Which of the following is the most appropriate therapy for him?Your Answer: Fenofibrate
Explanation:Three classes of medications are appropriate for the management of major triglyceride elevations: fibric acid derivatives, niacin, and omega-3 fatty acids.
Fibrate is used as a first-line agent for reduction of triglycerides in patients at risk for triglyceride-induced pancreatitis.
High-dose niacin (vitamin B-3) (1500 or more mg/d) decreases triglyceride levels by at least 40% and can raise HDL cholesterol levels by 40% or more. Niacin also reliably and significantly lowers LDL cholesterol levels, which the other major triglyceride-lowering medications do not.
Omega-3 fatty acids are attractive because of their low risk of major adverse effects or interaction with other medications. At high doses (>4 g/d), triglycerides are reduced.
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This question is part of the following fields:
- Endocrine System & Metabolism
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Question 9
Correct
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All of the following are true regarding the management of thyroid diseases during pregnancy, except?
Your Answer: Block-and-replace is preferable in pregnancy compared to antithyroid drug titration
Explanation: -
This question is part of the following fields:
- Endocrine System & Metabolism
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Question 10
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A 66-year-old woman comes to you with a tender lump near the anal opening and a fever. She has history of T1DM for the last 20 years. What treatment should she get?
Your Answer: I&D + antibiotics
Explanation:Surgical incision and drainage is the most common treatment for anal abscesses. About 50% of patients with an anal abscess will develop a complication called a fistula. Diabetes is a risk factor for an anal abscess.
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This question is part of the following fields:
- Endocrine System & Metabolism
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SESSION STATS - PERFORMANCE PER SPECIALTY
