Endocrinology II

Question 1

A 69-year-old lady presents to her general practitioner with a two month history of lethargy, abdominal pain, night sweats and weight loss.
On examination she is tender over the epigastrium and is noticed to have generalised lymphadenopathy. Liver function tests are normal.
She was referred to have an ultrasound of the abdomen, which revealed gross splenomegaly, together with free fluid in the abdomen and pelvis. There has been no previous history of trauma to her abdomen.
There is no history of foreign travel.
It was decided to perform a laparotomy to treat her condition which revealed an enlarged spleen with several capsular tears and rupture.

Answer 1

The symptoms and signs in this patient are clearly suggestive of non-Hodgkin’s lymphoma, which is a malignancy involving the lymph nodes. It is characterised by the spread of disease from one lymph node group to another and by the development of systemic symptoms with advanced disease.

The common clinical presentations include painless, swollen lymph nodes especially in the neck, axilla and the thigh. There may be itchiness, fever with night sweats, coughs and chest pain, weakness and unexplained loss of body weight.

If the Non-Hodgkin’s lymphoma affects the tissues in the abdomen the patient may present with abdominal pain, hepatomegaly or splenomegaly, decreased appetite, nausea and vomiting.

Question 2

A 66-year-old female is admitted with a six hour history of episodic left sided loin pain, which radiates to the groin. She is apyrexial with a blood pressure of 145/90 mmHg and is slightly tender in the right flank.

Answer 2

This case has renal colic which in this age group may be associated with hyperparathyroidism and hence hypercalcaemia and hypercalciuria.

Question 3

A 55-year-old man is routinely admitted for repair of an inguinal hernia. In his medical history he has hypertension for which he takes bendroflumethiazide. Examination reveals a blood pressure of 158/92 mmHg but is otherwise unremarkable except for his right sided indirect inguinal hernia. However, his ECG printout indicates that he has prolonged QT interval and U waves.

Answer 3

This case has treated hypertension but his ECG shows QT prolongation and U waves. These are typical of hypokalaemia. Hypokalaemia and hypertension may occur in association with Conn’s syndrome which may be exacerbated by diuretic therapy such as bendroflumethiazide.

Question 4

A 72-year-old Asian male presents with a three month history of weakness and generalised aches. His past history includes hypertension for which he takes amlodipine and he also takes Losec for gastro-oesophageal reflux. On examination he has a body mass index of 22 kg/m2 and has obvious proximal muscle weakness, some tenderness over the iliac crests but no other abnormalities.

Answer 4

This case of an elderly Asian male with weakness and generalised aches and pains associated with a proximal myopathy suggests osteomalacia - hypocalcaemia.

Question 5

A 57-year-old male with diabetes requests sildenafil for erectile dysfunction.
Which of the following are contraindicated with sildenafil?

Answer 5

Sildenafil is contraindicated if the patient is taking nitrates, or nitrate derivatives (nicorandil).

We are informed on the prescribing information that if the patient takes nitrates then they should be stopped for the period during which sildenafil is used.

Question 6

A 56-year-old female presents with a three month history of weight gain and tiredness. Examination reveals a diffuse enlargement of the thyroid with no lymphadenopathy. Her thyroid function tests reveal a T4 of 8.2 nmol/L and a TSH of 25 mU/L.

T4 10-23 nmol/L
TSH 0.5-4 mU/L
Calcium 2.2-2.5 mmol/L
PTH 3-5.5 pmol/L

Answer 6

Hashimoto’s thyroiditis
This woman has hypothyroidism and the most likely explanation is Hashimoto’s thyroiditis, an autoimmune destruction of the thyroid associated with positive thyroid microsomal autoantibodies.

Question 7

A 76-year-old female presents with a swelling in the neck and a dysphonia. Examination reveals generally enlarged hard thyroid mass. A craggy, right cervical lymph node is palpable. She has a soft voice. Thyroid function tests show a T4 of 12.8 nmol/L and a TSH of 2 mU/L.

T4 10-23 nmol/L
TSH 0.5-4 mU/L
Calcium 2.2-2.5 mmol/L
PTH 3-5.5 pmol/L

Answer 7

Anaplastic thyroid cancer
This elderly patient has features of a thyroid cancer associated with recurrent laryngeal involvement and would suggest anaplastic thyroid cancer.

Question 8

A 45-year-old male who underwent bilateral adrenalectomy for phaeochromocytoma presents with a neck swelling. Examination reveals an enlarged left lobe of the thyroid with no palpable lymphadenopathy. Thyroid function tests show a T4 of 15.2 nmol/L and a TSH of 2.2 mU/L.

T4 10-23 nmol/L
TSH 0.5-4 mU/L
Calcium 2.2-2.5 mmol/L
PTH 3-5.5 pmol/L

Answer 8

Medullary carcinoma of the thyroid
This case of a patient with bilateral phaeochromocytomas and a thyroid swelling would suggest medullary thyroid cancer associated with MEN type 2.

Question 9

A 58-year-old male presents with weight loss and palpitations. Examination reveals him to appear clinically euthyroid with an asymmetrical enlargement of the thyroid and no lymphadenopathy. His thyroid function tests show a T4 of 20.8 nmol/L and a TSH of 0.02 mU/L.

T4 10-23 nmol/L
TSH 0.5-4 mU/L
Calcium 2.2-2.5 mmol/L
PTH 3-5.5 pmol/L

Answer 9

Multinodular goitre
This patient with thyroid enlargement and subclinical hyperthyroidism (low TSH normal T4) is likely to have a toxic multinodular goitre.

Question 10

A 74-year-old male presents with a two month history of weight loss, thirst and nocturia. Examination reveals no specific abnormality. His thyroid function tests show a T4 of 13.1 nmol/L and TSH of 1.5 mU/L, with a calcium of 3.5 mmol/L and a PTH of 128 pmol/L.

T4 10-23 nmol/L
TSH 0.5-4 mU/L
Calcium 2.2-2.5 mmol/L
PTH 3-5.5 pmol/L

Answer 10

Parathyroid cancer
The elderly male with hypercalcaemia and grossly elevated PTH would suggest a parathyroid carcinoma rather than a benign parathyroid adenoma.

Question 11

A 46-year-old male who 10 years ago underwent parathyroidectomy for hyperparathyroidism, presents with recurrent duodenal ulceration despite taking proton pump inhibitor (PPI)therapy.

Answer 11

The first patient has hyperparathyroidism and features of persistent duodenal ulceration despite PPI therapy (suggesting Zollinger-Ellison [ZE] syndrome) and hence multiple endocrine neoplasia (MEN) type 1.

Pancreatic neoplasia/ZE syndrome is not a feature of MEN type 2.

Question 12

A 45-year-old male presents with a one month history of PR bleeding. On examination, he is noted to have circumoral pigmentation and freckling.

Answer 12

Case 2 has Peutz-Jeghers syndrome characterised by multiple polyps that may involve the entire gut, but are almost always present and most numerous in the small gut; in about 20-30 percent of cases they may occur in the stomach and colon.

Melanin spots, which are clinically characteristic, occur in almost all cases on the oral mucosa and lips and may occasionally be noted on the fingers, toes or on the face.

Clinical features include abdominal pain, intussusception, bleeding, etcetera.

The polyps are hamartomas.

Malignancy, in association with this syndrome, is quite rare and the subject of individual case reports. Association of this syndrome with ovarian tumours or cysts has been noted in some five percent of cases reported in females.

Inheritance occurs as an autosomal dominant trait.

Mutation can occur and may account for instances lacking a family history.

Question 13

A 65-year-old female is referred with episodic light headedness and sweats. There is no past medical history of note. On examination, she has a few rubbery skin nodules and axillary freckling which she states she has had for many years. The only other feature is a blood pressure of 198/102 mmHg. She has a past medical history of acoustic neuroma.

Answer 13

The final case has subcutaneous nodules and has episodic symptoms with hypertension suggesting a phaeochromocytoma.

This suggests a diagnosis of neurofibromatosis. An autosomal dominant condition, other features include:

neurofibrosarcomas
osteomalacia, and
acoustic neuromas

Question 14

A 62 year-old-female presents with weight loss, abdominal swelling and sweats. On examination she has a fine tremor of the outstretched hands, lid lag, but no palpable thyroid. Abdominal examination reveals a 10 cm right sided, lower abdominal mass extending above the rim of the pelvis.

Answer 14

The first patient has a pelvic mass and features of thyrotoxicosis suggesting a diagnosis of struma ovarii. This rare condition is an ovarian tumour which contains thyroid tissue and can cause thyrotoxicosis.

Question 15

A 34-year-old male presents with episodic palpitations and sweats. Eight years ago he successfully underwent parathyroidectomy for hyperparathyroidism. Examination reveals a right sided thyroid swelling, a blood pressure of 180/100 mmHg but no specific abnormality on abdominal, respiratory or cardiovascular examination.

Answer 15

The second case of a patient with previous hyperparathyroidism, features suggestive of a phaeochromocytoma with a thyroid swelling (medullary thyroid cancer) supports a diagnosis of multiple endocrine neoplasia (MEN) type 2.

This condition is associated with the RET proto-oncogene and is autosomal dominant. It differs from MEN type 1, in that the latter is characterised by pituitary, parathyroid and pancreatic neoplasia.

Question 16

A 29-year-old female presents with haematuria, weight loss and occasional night sweats. On examination, she is noted to have a right sided flank mass and fundoscopy reveals retinal haemangiomas.

Answer 16

The last case is a young woman with features suggestive of renal carcinoma and who has retinal haemangiomas.

The diagnosis is von Hippel-Lindau (vHL) disease, an autosomal dominant condition characterised by the deletion of the vHL tumour suppressor gene.

Other features include cerebellar haemangiomas, spinal cord haemangiomas and phaeochromocytoma.

Question 17

A 65-year-old female is brought to casualty by her daughter with a three hour history of drowsiness and confusion. She is a type 2 diabetic and has recently commenced treatment with Glibenclamide 10 mg daily.

Answer 17

Hypoglycaemia
This case is a typical presentation of hypoglycaemia and this was probably precipitated by her long acting sulphonylurea – Glibenclamide.

Question 18

A 60-year-old female presents with a one week history of deteriorating tiredness, polyuria and polydipsia. Two years ago she was diagnosed with metastatic breast carcinoma for which she receives Tamoxifen.

Answer 18

The case of metastatic breast cancer and polyuria/polydipsia and tiredness suggests hypercalcaemia.
Hypercalcaemia may be a consequence of direct bone erosion as with breast cancer or as a consequence of the elaboration of ectopic PTHrp by the tumour (squamous cell carcinoma of the lung) or due to elaboration of Vitamin D (Sarcoid/Lymphomas).

Question 19

A 55-year-old male is admitted with urinary retention associated with urine tract infection. He is catheterized, receives treatment with Cefuroxime and is advised to drink plenty of water. The following day he becomes increasingly drowsy and develops fits.

Answer 19

This patient has features to suggest acute hyponatraemia which may have arisen following excessive water consumption and SIADH/infection. Fits are a serious manifestation signifying hyponatraemic encephalopathy.

Question 20

Normal range sodium 134-144 mmol/l).

A 63-year-old male with a four year history of treated hypertension presents to his GP with tiredness and lethargy. On examination he appears well, is overweight and has a blood pressure of 144/90 mmHg. Routine biochemistry reveals a serum sodium of 130 mmol/l.

Answer 20

The first case of a patient with fatigue associated with hypertension and mild hyponatraemia suggests the use of diuretic therapy as a treatment of his hypertension. In particular, bendroflumethiazide, a first choice antihypertensive, often causes a mild hyponatraemia.

It is best treated by switching to an alternative antihypertensive. None of the other diagnoses would really be applicable for this patient as we are given no other suggestions.

Question 21

Normal range sodium 134-144 mmol/l).

A 22-year-old female is brought to casualty with fits after attending a ‘rave’. On examination, she has a temperature of 38.3°C, a blood pressure of 128/80 mmHg and is drowsy. She has no previous medical history. Her serum sodium is 116 mmol/l.

Answer 21

The second case of a female who is admitted with hyponatraemic encephalopathy suggests the abuse of ecstasy and excessive water consumption. This patient is at serious risk from the associated cerebral oedema and requires appropriate therapy to raise her sodium. This may include hypertonic saline.

Question 22

Normal range sodium 134-144 mmol/l).

A 33-year-old female with a past history of treated hypothyroidism presents with a two month history of weight loss and fatigue. On examination she is thin, appears pale, a pulse of 88 bpm and has a blood pressure of 100/60 mmHg. Her serum sodium concentration is 128 mmol/l.

Answer 22

The final case of a patient with hypothyroidism has hypotension, is thin and has a mild hyponatraemia which would suggest Addison’s. In particular, the autoimmunity in this patient would increase the risk of further autoimmune disorders.

The evidence would point away from a diagnosis of hypothyroidism due to under-replacement as the patient is thin and has a healthy pulse rate.

Question 23

A	72 hour fast
B	CT abdomen
C	Insulin and C-peptide concentrations
D	Insulin like growth factor 1 concentration
E	Oral glucose tolerance test
F	Overnight fasting glucose
G	Pregnancy test
H	Serum amylase
I	Short Synacthen test
J	Sulphonylurea concentrations
Which of the listed investigations is most appropriate for the following patients?
A 17-year-old female who has a seven year history of type 1 diabetes presents with a two month history of more frequent hypoglycaemic episodes, erratic home BMs and weight gain. She has been taking a steady doses of twice daily pre-mixed insulin for the last two years and her HbA1c is 7.5%. On examination she is overweight, has a blood pressure of 120/82 mmHg and a slightly swollen abdomen.

A 45-year-old female is referred with a six month history of sweats and tremor which is relieved by her eating sugary foods. She has gained approximately one stone in weight over this time.

A 33-year-old female nurse with a three year history of type 1 diabetes presents with weight loss and more frequent hypoglycaemic episodes. She takes pre-mixed insulin twice daily. She also has a five year history of hypothyroidism. Her HbA1c is currently 6.2% (NR

Answer 23

Pregnancy should be considered in any case like this with a young girl who presents with erratic control, and increasing hypoglycaemic episodes; and the weight gain is suggestive.

Question 24

A	72 hour fast
B	CT abdomen
C	Insulin and C-peptide concentrations
D	Insulin like growth factor 1 concentration
E	Oral glucose tolerance test
F	Overnight fasting glucose
G	Pregnancy test
H	Serum amylase
I	Short Synacthen test
J	Sulphonylurea concentrations

A 45-year-old female is referred with a six month history of sweats and tremor which is relieved by her eating sugary foods. She has gained approximately one stone in weight over this time.

Answer 24

72 hour fast
This case of a woman who presents with typical symptoms of hypoglycaemia and has been gaining weight should have a 72 hour fast to determine if she has spontaneous hypoglycaemia or not. Although the chances of an insulinoma are small, the 72 hour fast is the only sure fire way of determining whether this is the case.

Question 25

A	72 hour fast
B	CT abdomen
C	Insulin and C-peptide concentrations
D	Insulin like growth factor 1 concentration
E	Oral glucose tolerance test
F	Overnight fasting glucose
G	Pregnancy test
H	Serum amylase
I	Short Synacthen test
J	Sulphonylurea concentrations

A 33-year-old female nurse with a three year history of type 1 diabetes presents with weight loss and more frequent hypoglycaemic episodes. She takes pre-mixed insulin twice daily. She also has a five year history of hypothyroidism. Her HbA1c is currently 6.2% (NR

Answer 25

Short Synacthen test
This woman has increasing problems with hypoglycaemia and has exceptionally good glycaemic control. She has other features of auto-immunity, that is, hypothyroidism and is losing weight with a lowish blood pressure, all pointing to a diagnosis of hypoadrenalism/Addison’s disease. A short Synacthen test is the most appropriate method of diagnosis.

Question 26

A	De Quervain's thyroiditis
B	Factitious thyrotoxicosis
C	Graves' disease
D	Hashimoto's thyroiditis
E	Multinodular goitre
F	Pituitary adenoma
G	Pyogenic goitre
H	Riedel's thyroiditis
I	Thyroid cancer
J	Toxic adenoma
Select the most appropriate diagnosis from the given list for a 45-year-old female who presents with goitre and the following:
Normal ranges
T4	10-22
TSH	0.5-4.5
ESR	0-10

An audible thyroid bruit, temperature 37°C and investigations showing a free T4 of 40 pmol/l, TSH less than 0.02 mu/l and ESR 20 mm/hr.

A tender goitre, temperature of 38.3°C, and investigations showing a free T4 of 28.5 pmol/l, TSH less than 0.02 mU/l and ESR of 82 mm/hr.

A smooth goitre, temperature 36.6°C and investigations showing a free T4 of 25.5 pmol/l, TSH of 7 mu/l and ESR of 10 mm/hr.

Answer 26

Graves’ disease
This case has a thyroid bruit with thyrotoxicosis, the former being highly suggestive of Graves’ disease.

Other features of Graves’ include

Dermopathy - pretibial myxoedema
Eye signs.

Question 27

A	De Quervain's thyroiditis
B	Factitious thyrotoxicosis
C	Graves' disease
D	Hashimoto's thyroiditis
E	Multinodular goitre
F	Pituitary adenoma
G	Pyogenic goitre
H	Riedel's thyroiditis
I	Thyroid cancer
J	Toxic adenoma
Select the most appropriate diagnosis from the given list for a 45-year-old female who presents with goitre and the following:
Normal ranges
T4	10-22
TSH	0.5-4.5
ESR	0-10

A tender goitre, temperature of 38.3°C, and investigations showing a free T4 of 28.5 pmol/l, TSH less than 0.02 mU/l and ESR of 82 mm/hr.

Answer 27

De Quervain’s.
This case has a tender goitre, a temperature and elevated ESR. The differential is between pyogenic goitre and De Quervain’s, except that in the former disturbance of thyroid function is unusual and in this case the patient is again thyrotoxic.

Therefore the suggested diagnosis is De Quervain’s.

Question 28

A	De Quervain's thyroiditis
B	Factitious thyrotoxicosis
C	Graves' disease
D	Hashimoto's thyroiditis
E	Multinodular goitre
F	Pituitary adenoma
G	Pyogenic goitre
H	Riedel's thyroiditis
I	Thyroid cancer
J	Toxic adenoma

Select the most appropriate diagnosis from the given list for a 45-year-old female who presents with goitre and the following:

Normal ranges
T4 10-22
TSH 0.5-4.5
ESR 0-10

A smooth goitre, temperature 36.6°C and investigations showing a free T4 of 25.5 pmol/l, TSH of 7 mu/l and ESR of 10 mm/hr.

Answer 28

Pituitary adenoma
The final case has thyrotoxicosis, but this time elevated TSH which would suggest secondary hyperthyroidism due to a TSH secreting pituitary adenoma.

Question 29

A	Atrophic hypothyroidism
B	De Quervain’s thyroiditis
C	Drug induced hypothroidism
D	Graves disease
E	Hashimoto’s thyroiditis
F	Multinodular goitre
G	Pituitary adenoma
H	Pyogenic goitre
I	Riedel’s thyroiditis
J	Thyroid cancer
Which of the following diagnoses is likely to explain the presentation of a 55-year-old female who presents with tiredness and has the following:

No goitre palpable, apyrexial, slightly depressed relaxation of tendon reflexes and investigations revealing a free T4 of 8 pmol/L, free T3 of 2.2 nmol/L , TSH of 0.4 mU/L, ESR of 12 mm/hr.

Normal ranges
T4 10-22
TSH 0.5-4.5

Answer 29

Pituitary adenoma
The first case has a low T4, yet low normal TSH - this combination is highly suggestive of secondary hypothyroidism due to hypopituitarism. It is worth finding out if this patient has the bitemporal hemianopia associated optic chiasmal compression due to a pituitary tumour. It is common to have normal TSH levels in secondary hypothroidism and T3 may be normal while T4 is low. The TSH should be raised if T4 is low due to primary hypothyroidism.

Question 30

A	Atrophic hypothyroidism
B	De Quervain’s thyroiditis
C	Drug induced hypothroidism
D	Graves disease
E	Hashimoto’s thyroiditis
F	Multinodular goitre
G	Pituitary adenoma
H	Pyogenic goitre
I	Riedel’s thyroiditis
J	Thyroid cancer
Which of the following diagnoses is likely to explain the presentation of a 55-year-old female who presents with tiredness and has the following:

A smooth goitre, apyrexial, slow relaxation of tendon reflexes and investigations showing a free T4 of 5.8 nmol/L, free T3 of 2.8 nmol/L, TSH of 100 mU/L and ESR of 15 mm/hr

Normal ranges
T4 10-22
TSH 0.5-4.5

Answer 30

The second case has a smooth goitre and primary hypothyroidism - most likely to be due to Hashimoto’s thyroiditis. This condition results in autoimmune thyroiditis and is associated with the presence of thyroid microsomal autoantibodies.

Question 31

A	Atrophic hypothyroidism
B	De Quervain’s thyroiditis
C	Drug induced hypothroidism
D	Graves disease
E	Hashimoto’s thyroiditis
F	Multinodular goitre
G	Pituitary adenoma
H	Pyogenic goitre
I	Riedel’s thyroiditis
J	Thyroid cancer
Which of the following diagnoses is likely to explain the presentation of a 55-year-old female who presents with tiredness and has the following:

A past history of treated paroxysmal atrial fibrillation, no goitre, apyrexial, normal relaxation of the tendon reflexes and investigations showing a free T4 of 12.1 nmol/L, free T3 of 2.5 nmol/L and a TSH of 12.2 mU/L with ESR of 20 mm/hr.

Normal ranges
T4 10-22
TSH 0.5-4.5

Answer 31

The third case has a past history of atrial fibrillation which is highly relevant. This is treated with agents that would endeavour to restore sinus rhythm such as amiodarone. Use of amiodarone would explain these bizarre TFTs with normal T4 yet low T3 and elevated TSH. The drug interferes with the peripheral conversion of T4 to T3 and can result in both thyrotoxicosis and hypothyroidism.

Question 32

A	Addison's disease
B	Drug therapy
C	Metastatic bone disease
D	Myeloma
E	Paget's disease
F	Primary hyperparathyroidism
G	Sarcoidosis
H	Secretion of PTH related peptide
I	Thyrotoxicosis
J	Vitamin D excess
Which of the following diagnoses is likely to explain the presentation of a 54-year-old female found to have a serum calcium of 2.9 mmol/l?
Normal ranges are
Serum calcium	2.2-2.6 mmol/l
PTH	3.5-5.5 pmol/l

She presents with weight loss, cough and lethargy. She has a past history of hypertension for which she takes amlodipine and ramipril. She smokes 10 cigarettes daily and her chest x ray reveals a left hilar mass. Bone scan is normal. Her PTH concentration is 0.8 pmol/l.

Answer 32

The first case has a low parathyroid hormone (PTH), presents with weight loss, and has features suggesting lung cancer.

Squamous cell lung cancer, in particular, produces PTHrp, which is not detectable with conventional PTH assays and must be specifically requested. The absence of any metastatic deposits with bone scan argue against bony involvement.

Question 33

A	Addison's disease
B	Drug therapy
C	Metastatic bone disease
D	Myeloma
E	Paget's disease
F	Primary hyperparathyroidism
G	Sarcoidosis
H	Secretion of PTH related peptide
I	Thyrotoxicosis
J	Vitamin D excess
Which of the following diagnoses is likely to explain the presentation of a 54-year-old female found to have a serum calcium of 2.9 mmol/l?
Normal ranges are
Serum calcium	2.2-2.6 mmol/l
PTH	3.5-5.5 pmol/l

She presents with tiredness. She has a past history of hypertension for which she takes bendroflumethiazide and ramipril. She smokes 10 cigarettes daily, her chest x ray is normal and she has a PTH concentration of 20.3 pmol/l.

Answer 33

The second case has primary hyperparathyroidism with elevated Ca and PTH.

Bendroflumethiazide causes hypercalcaemia but would result in appropriate suppression of PTH if this were the case.

Question 34

A	Addison's disease
B	Drug therapy
C	Metastatic bone disease
D	Myeloma
E	Paget's disease
F	Primary hyperparathyroidism
G	Sarcoidosis
H	Secretion of PTH related peptide
I	Thyrotoxicosis
J	Vitamin D excess
Which of the following diagnoses is likely to explain the presentation of a 54-year-old female found to have a serum calcium of 2.9 mmol/l?

Normal ranges are
Serum calcium 2.2-2.6 mmol/l
PTH 3.5-5.5 pmol/l

She presents with tiredness, dyspnoea and erythematous tender nodules on the fronts of her shins. Her chest x ray reveals bilateral hilar enlargement. She smokes five cigarettes daily. Her PTH is 1 pmol/l.

Answer 34

The final case has erythema nodosum and bilateral hilar lymphadenopathy suggestive of sarcoidosis.

Hypercalcaemia associated with sarcoidosis is related to excess vitamin D synthesis by the granulomas but, as the most appropriate diagnosis is requested, one must select sarcoidosis.

Question 35

Diagnosis of hypercalcaemia
A	Addison's disease
B	Drug therapy
C	Familial benign hypocalciuric hypercalcaemia
D	Myeloma
E	Paget's disease
F	Primary hyperparathyroidism
G	Sarcoidosis
H	Secretion of PTH related peptide
I	Thyrotoxicosis
J	Vitamin D excess
Which of the diagnoses is most likely to explain the following results found in a 53-year-old female who is admitted for hip replacement due to osteoarthritis? She is otherwise well.
Normal ranges:
Calcium	2.2-2.6 mmol/L
Phosphate	0.8-1.4 mmol/L
PTH	3.5-5.5 pmol/L
ESR	0-10 mm/hr
First results:
Calcium	2.85 mmol/L
Phosphate	0.8 mmol/L
PTH	4.2 pmol/L
ESR	20 mm/hr

Answer 35

The first and second cases are most likely to have hyperparathyroidism with elevated parathyroid hormone (PTH) in one and the inappropriately normal PTH in the face of hypercalcaemia. The negative feedback would usually result in a lowering of PTH in response to a raised serum calcium (from whatever cause)

The low phosphate is typical of hypocalcaemia.

The other potential, but less likely explanation for the first case is familial benign hypocalciuric hypercalcaemia (FBHH) due to a mutation of the calcium sensing receptor (CaSR) with loss of function. It is a rare condition. No treatment is needed for this condition: parathyroidectomy should avoided. It is autosomal dominant. Homozygous cases can present with severe neonatal hypercalcaemia.

Question 36

Diagnosis of hypercalcaemia
A	Addison's disease
B	Drug therapy
C	Familial benign hypocalciuric hypercalcaemia
D	Myeloma
E	Paget's disease
F	Primary hyperparathyroidism
G	Sarcoidosis
H	Secretion of PTH related peptide
I	Thyrotoxicosis
J	Vitamin D excess
Which of the diagnoses is most likely to explain the following results found in a 53-year-old female who is admitted for hip replacement due to osteoarthritis? She is otherwise well.
Normal ranges:
Calcium	2.2-2.6 mmol/L
Phosphate	0.8-1.4 mmol/L
PTH	3.5-5.5 pmol/L
ESR	0-10 mm/hr

Second results:
Calcium	3 mmol/L
Phosphate	0.8 mmol/L
PTH	8 pmol/L
ESR	12 mm/hr

Answer 36

The first and second cases are most likely to have hyperparathyroidism with elevated parathyroid hormone (PTH) in one and the inappropriately normal PTH in the face of hypercalcaemia. The negative feedback would usually result in a lowering of PTH in response to a raised serum calcium (from whatever cause)

The low phosphate is typical of hypocalcaemia.

The other potential, but less likely explanation for the first case is familial benign hypocalciuric hypercalcaemia (FBHH) due to a mutation of the calcium sensing receptor (CaSR) with loss of function. It is a rare condition. No treatment is needed for this condition: parathyroidectomy should avoided. It is autosomal dominant. Homozygous cases can present with severe neonatal hypercalcaemia.

Question 37

Diagnosis of hypercalcaemia
A	Addison's disease
B	Drug therapy
C	Familial benign hypocalciuric hypercalcaemia
D	Myeloma
E	Paget's disease
F	Primary hyperparathyroidism
G	Sarcoidosis
H	Secretion of PTH related peptide
I	Thyrotoxicosis
J	Vitamin D excess
Which of the diagnoses is most likely to explain the following results found in a 53-year-old female who is admitted for hip replacement due to osteoarthritis? She is otherwise well.
Normal ranges:
Calcium	2.2-2.6 mmol/L
Phosphate	0.8-1.4 mmol/L
PTH	3.5-5.5 pmol/L
ESR	0-10 mm/hr

Third results:
Calcium	2.8 mmol/L
Phosphate	2 mmol/L
PTH	0.9 pmol/L
ESR	25 mm/hr

Answer 37

The final case has elevated calcium and phosphate and low PTH suggesting that something other than PTH is responsible for the hypercalcaemia. As the patient is otherwise asymptomatic, the most likely cause is vitamin D excess, often taken for arthritic complaints. The give away is the elevated phosphate, which is typical of vitamin D excess.

Question 38

A	CT abdomen
B	CT thorax
C	ERCP
D	Erect abdominal x ray
E	Iodocholesterol scintigraphy
F	MRI pituitary
G	None required
H	Plain chest x-ray
I	Selective venous sampling
J	Ultrasound abdomen
Select the most appropriate initial investigation for the following patients diagnosed with Cushing's syndrome (CS) based upon non-suppressible cortisol concentrations following low dose dexamethasone testing:
(normal range 9am ACTH - 20-55 pg/dl)

A 43-year-old female is diagnosed with Cushing’s syndrome. She appears typically cushingoid with proximal muscle weakness, is obese, hypertensive, is a smoker of 10 cigarettes per day and drinks modest amounts of alcohol. Her 9 am adrenocorticotropic hormone (ACTH) concentration is 8 pg/dl.

Answer 38

The differential diagnosis of Cushing’s syndrome revolves around distinguishing ectopic/pituitary and adrenal causes.

The first case has Cushing’s syndrome with a suppressed ACTH suggesting a non-ACTH dependent CS hence an adrenal cause. CT abdomen would be the best way of demonstrating this.

Question 39

A	CT abdomen
B	CT thorax
C	ERCP
D	Erect abdominal x ray
E	Iodocholesterol scintigraphy
F	MRI pituitary
G	None required
H	Plain chest x-ray
I	Selective venous sampling
J	Ultrasound abdomen

Select the most appropriate initial investigation for the following patients diagnosed with Cushing’s syndrome (CS) based upon non-suppressible cortisol concentrations following low dose dexamethasone testing:
(normal range 9am ACTH - 20-55 pg/dl)

A 70-year-old female is diagnosed with Cushing’s syndrome. She is thin, has a BMI of 22 kg/m2, is weak, normotensive, a smoker of 30 cigarettes daily and drinks little alcohol. Her 9 am ACTH concentration is 82 pg/dl.

Answer 39

The second case is thin, weak and has elevated ACTH. With the history of smoking an ectopic ACTH secretion should be suspected and the most appropriate initial investigation would be a chest x-ray to look for a carcinoma (This can be done during the clinic. If normal or any abnormality is found then a CT thorax would be the next investigation). These cases often present with weight loss, deranged biochemistry and pigmentation.

Question 40

A	CT abdomen
B	CT thorax
C	ERCP
D	Erect abdominal x ray
E	Iodocholesterol scintigraphy
F	MRI pituitary
G	None required
H	Plain chest x-ray
I	Selective venous sampling
J	Ultrasound abdomen
Select the most appropriate initial investigation for the following patients diagnosed with Cushing's syndrome (CS) based upon non-suppressible cortisol concentrations following low dose dexamethasone testing:
(normal range 9am ACTH - 20-55 pg/dl)

A 25-year-old female is diagnosed with Cushing’s syndrome. She looks typically cushingoid, is hypertensive, has no features of proximal muscle weakness, is a smoker of 10 cigarettes daily and drinks approximately 20 units of alcohol weekly. Her 9 am ACTH concentration is 35 pg/dl.

Answer 40

The third case has typical features of CS and the ACTH within the normal range would suggest that a pituitary cause is most probable. MRI is the best method of imaging.

However, this is a difficult question as arguably a chest x-ray would also be required. But in terms of the diagnosis this is most likely to be pituitary dependent Cushing’s disease in view of the age. Arguably MRI is justified as the most appropriate initial selection.

Question 41

Pre-operative medical treatment
A	Alpha-blockers
B	Bromocriptine
C	Hydrocortisone
D	Low molecular weight heparin
E	Metformin
F	Nifedipine
G	None required
H	Sliding scale insulin
I	Somatostatin analogues
J	Spironolactone
Select the most appropriate treatment which is used in the pre-operative management of the following conditions.

A 45-year-old female scheduled for trans-sphenoidal hypophysectomy for a non-functional pituitary tumour which has caused bitemporal hemianopia.

Answer 41

Hydrocortisone
It is essential that this woman receives hydrocortisone during and following the procedure as the risks of hypoadrenalism are high. Acute hypoadrenalism is a life threatening condition.

Question 42

Pre-operative medical treatment
A	Alpha-blockers
B	Bromocriptine
C	Hydrocortisone
D	Low molecular weight heparin
E	Metformin
F	Nifedipine
G	None required
H	Sliding scale insulin
I	Somatostatin analogues
J	Spironolactone
Select the most appropriate treatment which is used in the pre-operative management of the following conditions.
A 45-year-old female scheduled for trans-sphenoidal hypophysectomy for a non-functional pituitary tumour which has caused bitemporal hemianopia.

Answer 42

Alpha blockers
Patients with phaeochromocytomas should be pre-treated with alpha-blockers and then when adequately blocked should receive a beta-blocker. Giving a beta-blocker without adequate alpha-blockade can precipitate a hypertensive crisis.

Question 43

Pre-operative medical treatment
A	Alpha-blockers
B	Bromocriptine
C	Hydrocortisone
D	Low molecular weight heparin
E	Metformin
F	Nifedipine
G	None required
H	Sliding scale insulin
I	Somatostatin analogues
J	Spironolactone
Select the most appropriate treatment which is used in the pre-operative management of the following conditions.

A 45-year-old diet controlled female with diabetes who is to undergo nail avulsion of the great toe due to an infected toe nail.

Answer 43

None

This woman does not require any treatment other than close monitoring of BM stix after surgery.

Question 44

Pre-operative medical treatment
A	Ampicillin
B	Bromocriptine
C	Hydrocortisone
D	Insulin infusion
E	Low molecular weight heparin
F	Metformin
G	Nifedipine
H	None required
I	Somatostatin analogues
J	Spironolactone
Which of the listed agents would be required for the following procedures?

A 54-year-old diet-controlled diabetic undergoing thyroidectomy for a multinodular goitre.

Answer 44

Insulin infusion
Diet-controlled diabetics may undergo minor surgery without any intervention, but for a major procedure such as thyroidectomy, sliding scale insulin infusion is required.

Question 45

Pre-operative medical treatment
A	Ampicillin
B	Bromocriptine
C	Hydrocortisone
D	Insulin infusion
E	Low molecular weight heparin
F	Metformin
G	Nifedipine
H	None required
I	Somatostatin analogues
J	Spironolactone
Which of the listed agents would be required for the following procedures?

A 72-year-old female, with aortic stenosis due to rheumatic fever, undergoing cataract extraction.

Answer 45

None required
The final case of the 72-year-old female undergoing cataract surgery does not require any prophylaxis against endocarditis.

Question 46

Pre-operative medical treatment
A	Ampicillin
B	Bromocriptine
C	Hydrocortisone
D	Insulin infusion
E	Low molecular weight heparin
F	Metformin
G	Nifedipine
H	None required
I	Somatostatin analogues
J	Spironolactone
Which of the listed agents would be required for the following procedures?

Hepatic artery embolisation is considered in a 70-year-old female with carcinoid syndrome.

Answer 46

Somatostatin
Severe hypotension and vasodilatation may be induced by hepatic manipulation in carcinoid syndrome and should be covered with somatostatin analogues.

Question 47

Interpreatation of Calcium results
A	Addison’s disease
B	Ectopic PTH secretion
C	Hypoparathyroidism
D	Osteomalacia
E	Paget’s disease
F	Primary hyperparathyroidism
G	Pseudohypoparathyroidism
H	Sarcoidosis
I	Thyrotoxicosis
J	Vitamin D excess
Select the most appropriate diagnosis that best explains the following results.
Normal Ranges:
Calcium	2.2 - 2.6
Phosphate	0.8 - 1.2
Alkaline phosphatase	50 - 110
PTH	3 - 5.5
Calcium 2.85 mmol/l, phosphate 0.8 mmol/l, alkaline phosphatase 145 iu/l, PTH 5 pmol/l

Answer 47

The first series of results has elevated calcium (with inappropriately normal parathyroid hormone [PTH] concentration), lowish phosphate and elevated alkaline phosphatase which suggests a diagnosis of hyperparathyroidism.

Hypercalcaemia would cause a suppression of PTH concentrations so PTH within the normal range is inappropriate and suggests hyperparathyroidism when associated with hypercalcaemia.

Question 48

Interpreatation of Calcium results
A	Addison’s disease
B	Ectopic PTH secretion
C	Hypoparathyroidism
D	Osteomalacia
E	Paget’s disease
F	Primary hyperparathyroidism
G	Pseudohypoparathyroidism
H	Sarcoidosis
I	Thyrotoxicosis
J	Vitamin D excess
Select the most appropriate diagnosis that best explains the following results.
Normal Ranges:
Calcium	2.2 - 2.6
Phosphate	0.8 - 1.2
Alkaline phosphatase	50 - 110
PTH	3 - 5.5

Calcium 2.9 mmol/l, phosphate 1.5 mmol/l, alkaline phopsphatase 85 iu/l, PTH

Answer 48

The second series of results with elevated calcium, elevated phosphate and low PTH suggests vitamin D excess. This is usually a consequence of over-replacement with vitamin D.

Question 49

Interpreatation of Calcium results
A	Addison’s disease
B	Ectopic PTH secretion
C	Hypoparathyroidism
D	Osteomalacia
E	Paget’s disease
F	Primary hyperparathyroidism
G	Pseudohypoparathyroidism
H	Sarcoidosis
I	Thyrotoxicosis
J	Vitamin D excess
Select the most appropriate diagnosis that best explains the following results.
Normal Ranges:
Calcium	2.2 - 2.6
Phosphate	0.8 - 1.2
Alkaline phosphatase	50 - 110
PTH	3 - 5.5

Calcium 2.15 mmol/l, phosphate 1.2 mmol/l, alkaline phosphatase 80 iu/l, PTH 2.2 pmol/l

Answer 49

The third series with low calcium, slightly high phosphate and an inappropriately low (should be high with a low calcium if the parathyroids are working normally) PTH suggests hypoparathyroidism.

This may be autoimmune in origin and associated with other autoimmune conditions such as Addison’s, hypothyroidism and also occurs post-thyroid surgery.

Question 50

Hypercalcaemia
A	Bony metastases
B	Chronic vitamin D excess
C	Ectopic PTH related peptide secretion
D	Multiple myeloma
E	Primary hyperparathyroidism
F	Sarcoidosis

Select the most appropriate diagnosis for the following patients who present with hypercalcaemia:

Normal ranges;
Calcium	2.2-2.6 mmol/L
Phosphate	0.8-1.4 mmol/L
Alkaline phosphatase	50-100 IU/L
PTH	0.9-5.4 pmol/L

A 62-year-old female is referred by the GP with a breast lump which subsequently proves to be benign. She was otherwise entirely asymptomatic but her investigations show
Calcium	2.75 mmol/L
Phosphate	0.8 mmol/L
Alkaline phosphatase	110 IU/L
PTH	5.5 pmol/L

Answer 50

Primary hyperparathyroidism
This patient has hypercalcaemia with a lowish phosphate concentration but an inappropriately normal PTH concentration suggesting hyperparathyroidism, which is a relatively common disorder amongst elderly females. The story of the breast lump in this case is endeavouring to throw the candidate. Vitamin D excess would be expected to cause an elevated phosphate.

Question 51

Hypercalcaemia
A	Bony metastases
B	Chronic vitamin D excess
C	Ectopic PTH related peptide secretion
D	Multiple myeloma
E	Primary hyperparathyroidism
F	Sarcoidosis
Select the most appropriate diagnosis for the following patients who present with hypercalcaemia:
Normal ranges;
Calcium	2.2-2.6 mmol/L
Phosphate	0.8-1.4 mmol/L
Alkaline phosphatase	50-100 IU/L
PTH	0.9-5.4 pmol/L

A 65-year-old male smoker presents with fatigue, weight loss and polydipsia. Investigations reveal
Calcium	3.1 mmol/L
Phosphate	1 mmol/L
Alkaline phosphatase	125 IU/L
PTH

Answer 51

Ectopic PTH related peptide secretion
This 65-year-old man has features suggestive of a bronchial carcinoma, and so the differential for his hypercalcaemia with undetectable PTH would come down to either metastases or ectopic PTHrp.

The former would be expected to cause gross elevation of alkaline phosphatase and so could be excluded. PTHrp is not detected with conventional PTH assays and must be specifically requested. It is usually produced by a squamous cell carcinoma of the lung.

Question 52

Treatment of thyroid lumps
A	Excision of nodule
B	Radio-iodine
C	Radiotherapy
D	Thyroid lobectomy
E	Thyroid suppression with thyroxine
F	Total thyroidectomy
For the following clinical scenarios choose the most appropriate management.
A 40-year-old lady presents with a left-sided thyroid lump associated with lymphadenopathy of the cervical region. Fine needle aspiration reveals papillary cells.

Answer 52

Total thyroidectomy
Some endocrine surgeons have suggested that papillary carcinoma of one lobe can be dealt with by lobectomy, but generally, total thyroidectomy is typically performed. There are frequently papillary foci in the other lobe; the recurrence rate in the remaining lobe is high and the overall recurrence rate is higher if only a thyroid lobectomy has been performed. If there is lymphatic spread, a total thyroidectomy (with preservation of parathyroid tissue if possible, although again not typical) should be performed. This is then usually followed by radio-iodine and then thyroxine replacement.

Question 53

Treatment of thyroid lumps
A	Excision of nodule
B	Radio-iodine
C	Radiotherapy
D	Thyroid lobectomy
E	Thyroid suppression with thyroxine
F	Total thyroidectomy
For the following clinical scenarios choose the most appropriate management.

A 50-year-old lady presents with a right-sided thyroid nodule. Fine needle aspiration shows follicular cells.

Answer 53

Thyroid lobectomy

A thyroid lobectomy is required to allow full histological assessment of the nodule and surrounding gland.

Question 54

Causes of Gynaecomastia
A	Bronchogenic carcinoma
B	Drug-induced
C	Haemochromatosis
D	Klinefelter’s syndrome
E	Liver disease
F	Myotonic dystrophy
G	Physiological
H	Renal failure
I	Testicular tumour
J	Thyrotoxicosis
Select the most likely underlying diagnosis in the following patients who present with gynaecomastia:
A 31-year-old male presents with tender breast swelling. He is a non-smoker, drinks modest quantities of alcohol and has no past medical history of note. On examination he has modest tender gynaecomastia. He has normal secondary sexual characteristics and examination is normal other than a hydrocele of the left testis.

A 67-year-old male presents with breast soreness and impotence. He has a past history of hypertension and diabetes for which he takes metformin, bendroflumethiazide, lisinopril and spironolactone. He drinks little alcohol and is a non-smoker. On examination he has bilateral gynaecomastia, has a blood pressure of 150/90 mmHg and examination of the systems is normal except for background diabetic retinopathy. Testicular examination is normal and he has microalbuminuria on urine testing.

Answer 54

Testicular tumour

Testicular tumours such as teratoma or seminoma are both associated with gynaecomastia which may be the initial presenting complaint.

Question 55

Causes of Gynaecomastia
A	Bronchogenic carcinoma
B	Drug-induced
C	Haemochromatosis
D	Klinefelter’s syndrome
E	Liver disease
F	Myotonic dystrophy
G	Physiological
H	Renal failure
I	Testicular tumour
J	Thyrotoxicosis
Select the most likely underlying diagnosis in the following patients who present with gynaecomastia:

A 67-year-old male presents with breast soreness and impotence. He has a past history of hypertension and diabetes for which he takes metformin, bendroflumethiazide, lisinopril and spironolactone. He drinks little alcohol and is a non-smoker. On examination he has bilateral gynaecomastia, has a blood pressure of 150/90 mmHg and examination of the systems is normal except for background diabetic retinopathy. Testicular examination is normal and he has microalbuminuria on urine testing.

Answer 55

Drug-induced
Drug causes of gynaecomastia include spironolactone, digoxin and oestrogens.

Spironolactone’s actions are antiandrogenic.

Microalbuminuria is not a cause of gynaecomastia as it is one of the earliest detectable features of diabetic nephropathy.

Chronic renal failure is usually profound before gynaecomastia is noticeable.

Impotence may be due to both spironolactone and the other antihypertensives.