Endo Practice Papers qs Flashcards
What hormone is released in carcinoid syndrome?
Serotonin
What is carcinoid syndrome typically caused by?
Neuroendocrine tumour in GI tract
State two symptoms of presentation of Carcinoid Syndrome
Flushing, diarrhoea, abdominal cramps, bronchospasm (wheezing, asthma), fibrosis (heart valve dysfunction, palpitations
What is the definitive treatment for carcinoid syndrome?
Resection of tumour
What is the most common cause of hyperthyroidism and hypothyroidism?
Graves’ disease and Hashimoto’s thyroiditis
List three symptoms for hyperthyroidism and hypothyroidism each.
Hyper: weight loss, Increased HR, warm moist skin
Hypo: weight gain, decreased HR, hair loss
What is the first line treatment for hypothyroidism?
Levothyroxine
What is the antibody most associated with hyperthyroidism?
TSH-receptor antibodies
Interpret data: TSH: High T4: Low
Hypothyroidism, Hashimoto’s
Interpret data: TSH: Low T4: High
Hyperthyroidism, Graves’
Interpret data: PTH: High; Calcium: Low; Phosphate: High
Secondary Hyperparathyroidism
Interpret data: PTH: High; Calcium: High; Phosphate: High
Tertiary Hyperparathyroidism
Main role of Glucose?
Required for respiration
Role of glucagon in glucose homeostasis?
Increases glucose levels when they are low by stimulating lipolysis, glycogenolysis and gluconeogenesis .
Where is glucagon released from?
From the Alpha cells in the Islets of Langerhans in the pancreas.
Role of insulin in glucose homeostasis ?
Decreases glucose levels when they are high by inhibiting lipolysis and glycogenolysis and stimulating glycogenesis.
Where is insulin produced?
From the Beta cells in the Islets of Langerhans in the pancreas.
Role of Glycogen in the body?
Main form of storage of glucose in the body.
Where is Glycogen stored in the body?
In the liver.
What process involving glycogen occurs when glucose levels are HIGH?
The liver stimulates glycogenesis (converts glucose to glycogen.
What process involving glycogen occurs when glucose levels are LOW?
The liver stimulates glycogenolysis (converts glycogen to glucose.
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
Basal-bolus Insulin
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
Gliclazide
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
Serum osmolality 330 mOsm/kg
NB: Severe hyperglycaemia (>30mmol/L)
Hypotension
Hyperosmolality (usually >320 mosmol/kg)
No/very mild ketosis
No acidosis
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
Small cell lung carcinoma
Low Dose- High Cortisol
High Dose- High Cortisol, High ACTH
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
Low renin, high aldosterone
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
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
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
Primary hyperparathyroidism
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
Propylthiouracil
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
Hypocalcaemia
Parasthesia, spasms, tetany
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
IV calcium gluconate – severe hyperkalaemia with ECG changes
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
IV 0.9% sodium chloride – rehydrate
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
Lithium
other options are causes of Cranial DI
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
Prolactinoma
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
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
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
De Quervain’s (Subacute) Thyroiditis – important is the fever like symptoms as this is preceded by a viral infection
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?
Anti TPO
Hashimoto’s hypothyroidism
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
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
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
Oral glucose tolerance test ≥11.1 mmol/L
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
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
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
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.
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
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.
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
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.
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
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.
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
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)
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
≥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
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
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
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
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.
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
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.
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
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.
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
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
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
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.
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
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’.
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
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.
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
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
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)
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.
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
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)
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)
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.
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
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.
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
High PTH, High Calcium, Low Phosphate
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
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.
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
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.
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
Increased weight
All of the above are features of Graves’ disease apart from increased weight. Weight commonly decreases in hyperthyroidism despite increased appetite.
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
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.
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
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.
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
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.
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
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.
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
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.
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
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’
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
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.
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?
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.
State 3 types of cancers that can cause SIADH.
Small cell carcinoma (remember this one, comes up) Prostate cancer
Pancreatic cancer
Lymphomas
Cancer of the thymus
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?
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
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?
Overnight dexamethasone suppression test
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?
b) Hyperkalaemia
c) Aldosterone renin ratio (ARR)
d) High ratio = primary / low ratio = secondary
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
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)
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
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.
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
A. Metformin
