Passmedicine Flashcards
A 42-year-old man presents to his GP feeling generally unwell. For the past three months he has been experiencing daily frontal headaches which have not been helped by regular paracetamol. He has also noticed some unusual symptoms such as his wedding ring no longer fitting, his shoe size apparently increasing and a small amount of milky discharge from both nipples. On examination his blood pressure is 168/96 mmHg. What is the most likely diagnosis?
A. Phaeochromocytoma B.Cushing's syndrome C. Diabetes insipidus D. Macroprolactinoma E. Acromegaly
E Acromegaly
In acromegaly there is excess growth hormone secondary to a pituitary adenoma in over 95% of cases. A minority of cases are caused by ectopic GHRH or GH production by tumours e.g. pancreatic.
Features
coarse facial appearance, spade-like hands, increase in shoe size
large tongue, prognathism, interdental spaces
excessive sweating and oily skin: caused by sweat gland hypertrophy
features of pituitary tumour: hypopituitarism, headaches, bitemporal hemianopia
raised prolactin in 1/3 of cases → galactorrhoea
6% of patients have MEN-1
Complications hypertension diabetes (>10%) cardiomyopathy colorectal cancer
Which one of the following may be associated with galactorrhoea? A. Primary hypothyroidism B. Addison's disease C. Cushing's syndrome D. Grave's disease E. Bromocriptine
A. Primary hypothyroidism
A 64-year-old man presents to his GP, concerned about swelling of his chest that seems to have arisen over the past few months, around the nipples. He denies any discharge from the nipples, and otherwise feels generally well in himself. His past medical history includes hypertension, prostate cancer, recurrent nausea, osteoarthritis and depression. His regular medications include amlodipine, goserelin, metoclopramide, naproxen and sertraline.
On examination, bilateral breast tissue is visible and palpable. No discharge is present from the nipples.
Which of his medications is most likely to have caused this presentation?
A. Amlodipine B. Goserelin C. Metoclopramide D. Sertraline E. Tamoxifen
- GnRH agonists (e.g. goserelin) used in the management of prostate cancer may result in gynaecomastia
- Metoclopramide is a dopamine antagonist used in the management of nausea and vomiting. It is known to cause galactorrhoea - secretion of milk from the nipples - but not gynaecomastia. Dopamine normally inhibits prolactin, which is responsible for milk secretion, and so antagonising dopamine results in increased prolactin levels.
Each one of the following is associated with hyperkalaemia, except: A. Rhabdomyolysis B. Carbenoxolone C. Acute renal failure D. Ciclosporin E. Addison's
Causes of hyperkalaemia:
- acute kidney injury
- drugs*: potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, heparin**
- metabolic acidosis
- Addison’s disease
- rhabdomyolysis
- massive blood transfusion
A 44-year-old woman presents with a neck lump. She reports tiredness and fatigue and has put on around 3kilograms of weight recently; she reports going up 3 belt notches. Her blood results show normocytic anaemia.
On palpation of her neck, a hard, fixed, painless lump is felt.
Which one of the following complications is associated with her condition? A. Hyperthyroidism B. Retroperitoneal fibrosis C. Ascites D. Atrial fibrillation E. Photosensitivity
B. Retroperitoneal fibrosis
Riedel’s thyroiditis is associated with retroperitoneal fibrosis
Riedel thyroiditis (RT) is characterized by the replacement of normal thyroid parenchyma with dense fibrotic tissue and by the extension of this fibrosis to adjacent structures of the neck. Most patients are euthyroid, but hypothyroidism is noted in approximately 30% of cases.
Patient’s may present with a painless neck lump and symptoms of hypothyroidism such as weight gain, tiredness, fatigue and intolerance.
A 61-year-old man presents as he developed enlargement of his breast tissue. He has become very self-conscious and is worried about going on holiday in the summer. Which one of the following drugs is most likely to be responsible?
A. Amitriptyline B. Isoniazid C. Verapamil D. Methyldopa E. Spironolactone
E. Spironolactone
Which of the following statements is true regarding the pathophysiology of diabetes mellitus?
(A) Concordance between identical twins is higher in type 2 diabetes mellitus than type 1
(B) Patients with type 1 diabetes mellitus are rarely HLA-DR4 positive
(C) Type 2 diabetes mellitus is associated with HLA-DR3
(D) Haemochromatosis is an example of primary diabetes
(E) Type 1 diabetes mellitus is thought to be inherited in an autosomal dominant fashion
(A) Concordance between identical twins is higher in type 2 diabetes mellitus than type 1
Type 1 diabetes mellitus is caused by autoimmune destruction of the Beta-cells of the pancreas. Identical twins show a genetic concordance of 40%. It is associated with HLA-DR3 and DR4. It is inherited in a polygenic fashion
Type 2 diabetes mellitus is thought to be caused by a relative deficiency of insulin and the phenomenon of insulin resistance. Age, obesity and ethnicity are important aetiological factors. There is almost 100% concordance in identical twins and no HLA associations.
Haemochromatosis is an example of secondary diabetes
A diabetic man is diagnosed as having painful diabetic neuropathy in his feet. He has no other medical history of note. What is the most suitable first-line treatment to relieve his pain?
A. Duloxetine B. Sodium valproate C. Carbamazepine D. Referral to pain management clinic E. Tramadol
A. Duloxetine
First-line treatment: amitriptyline, duloxetine, gabapentin or pregabalin
if the first-line drug treatment does not work try one of the other 3 drugs
tramadol may be used as ‘rescue therapy’ for exacerbations of neuropathic pain
topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia)
pain management clinics may be useful in patients with resistant problems
How is gastrointestinal autonomic neuropathy treated?
Gastroparesis
symptoms include erratic blood glucose control, bloating and vomiting
management options include metoclopramide, domperidone or erythromycin (prokinetic agents)
Chronic diarrhoea
often occurs at night
Gastro-oesophageal reflux disease
caused by decreased lower esophageal sphincter (LES) pressure
A 3-year-old boy is investigated for lethargy. Examination is unremarkable with a blood pressure of 90/46 mmHg (normal for his age). Blood tests reveal:
Na+ 140 mmol/l K+ 2.6 mmol/l Bicarbonate 33 mmol/l Urea 4.2 mmol/l Creatinine 91 µmol/l
Which one of the following conditions is most likely to be responsible?
A. Conn's syndrome B. 11-beta hydroxylase deficiency C. Bartter's syndrome D. Liddle's syndrome E. Cushing
C. Bartter’s syndrome
Bartter’s syndrome is an inherited cause (usually autosomal recessive) of severe hypokalaemia due to defective chloride absorption at the Na+ K+ 2Cl- cotransporter in the ascending loop of Henle
Hypokalaemia with hypertension
- Cushing’s syndrome
- Conn’s syndrome (primary hyperaldosteronism)
- Liddle’s syndrome
- 11-beta hydroxylase deficiency*
Carbenoxolone, an anti-ulcer drug, and liquorice excess can potentially cause hypokalaemia associated with hypertension
Hypokalaemia without hypertension diuretics GI loss (e.g. Diarrhoea, vomiting) renal tubular acidosis (type 1 and 2**) Bartter's syndrome Gitelman syndrome
*21-hydroxylase deficiency, which accounts for 90% of congenital adrenal hyperplasia cases, is not associated with hypertension
**type 4 renal tubular acidosis is associated with hyperkalaemi
What is liddle’s syndrome
Liddle’s syndrome is a genetic disorder inherited in an autosomal dominant manner that is characterized by early, and frequently severe, high blood pressure associated with hypokalaemia, low plasma renin activity, metabolic alkalosis, and normal to low levels of aldosterone. Liddle syndrome involves abnormal kidney function, with excess reabsorption of sodium and loss of potassium from the renal tubule, and is treated with a combination of low sodium diet and potassium-sparing diuretics (e.g. amiloride).
A 23-year-old woman is diagnosed with Graves’ disease. Which one of the following statements regarding treatment is correct?
A. Block-and-replace regimes are usually of a shorter duration than carbimazole titration therapy
B. Concurrent administration of propranolol and carbimazole should be avoided
C. Patients on block-and-replace regimes have fewer side-effects than those using titration therapy
D. Carbimazole should be started at no higher than 10mg/day for patients commencing a titration regime
E. In the block-and-replace regime levothyroxine should be started at the same time as carbimazole
A. Block-and-replace regimes are usually of a shorter duration than carbimazole titration therapy
Initial treatment to control symptoms
propranolol is used to help block the adrenergic effects
NICE Clinical Knowledge Summaries recommended that patients with Graves’ disease are referred to secondary care for ongoing treatment.
NICE suggest carbimazole should be considered in primary care if patients symptoms are not controlled with propanolol
ATD therapy
carbimazole is started at 40mg and reduced gradually to maintain euthyroidism
typically continued for 12-18 months
the major complication of carbimazole therapy is agranulocytosis
an alternative regime is termed ‘block-and-replace’
carbimazole is started at 40mg
thyroxine is added when the patient is euthyroid
treatment typically lasts for 6-9 months
patients following an ATD titration regime have been shown to suffer fewer side-effects than those on a block-and-replace regime
Radioiodine treatment
often used in patients who relapse following ATD therapy or are resistant to primary ATD treatment
contraindications include pregnancy (should be avoided for 4-6 months following treatment) and age < 16 years. Thyroid eye disease is a relative contraindication, as it may worsen the condition
the proportion of patients who become hypothyroid depends on the dose given, but as a rule the majority of patient will require thyroxine supplementation after 5 years
Which one of the following is not associated with hypocalcaemia combined with a raised phosphate level? A.Chronic renal failure B. Pseudohypoparathyroidism C. Hypoparathyroidism D. Osteomalacia E. Acute rhabdomyolysis
D
Osteomalacia causes hypocalcaemia associated with a low serum phosphate, rather than a raised phosphate level.
Which one of the following features is least commonly seen in Gitelman's syndrome? A. Hypokalaemia B. Hypertension C. Metabolic alkalosis D. Hypocalciuria E. Hypomagnesaemia
B. Hypertension
Gitelman’s syndrome is due to a defect in the thiazide-sensitive Na+ Cl- transporter in the distal convoluted tubule.
Features normotension hypokalaemia hypocalciuria hypomagnesaemia metabolic alkalosis
Which one of the following processes is responsible for ketone production during diabetic ketoacidosis?
A. Glycogenolysis B. Exchange with hydrogen ions in the collecting ducts C. Gluconeogenesis D. Decreased plasma bicarbonate levels E. Lipolysis
E
The low-insulin conditions seen in diabetic ketoacidosis stimulate the process of lipolysis and the production of the ketone bodies, beta-hydroxybutyrate and acetoacetate, which can be used as metabolic fuel.
