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Endocrinology

201. A 21-year-old university student presents for review. She is distressed by thefact that she is overweight and is having to shave or pluck excessive facial hair.She also notices that she appears to have more generalised body hair than otherwomen. On further questioning you elicit a history that she can sometimes miss acouple of menses, but pregnancy testing is consistently negative. Her motherapparently had similar problems in her youth, took a while to conceive and nowhas type-2 diabetes. Testosterone is just outside the upper limit of normalrange, her LH:FSH ratio is increased and prolactin is normal. Which diagnosis fitsbest with this womans clinical picture?

Polycystic ovarian syndrome (PCOS)

Your answer

Hyperprolactinaemia

Androgen-secreting tumour

Cushings disease

Type-2 diabetes

PCOS is said to occur in 3% of adult women. Symptoms usually begin around thetime of menarche and the diagnosis is often made in adolescence. Obesity ispresent in around 40% of sufferers and there is an increased association withtype-2 diabetes due to insulin resistance. Biochemical abnormalitiescharacteristically include a mildly raised testosterone level and an increasedLH:FSH ratio. Treatment includes weight loss or metformin therapy. Surgicalintervention with wedge ovarian resection may reduce androgen secretion andsymptoms. Many women just require reassurance and effective local treatment

for hirsutism. Those who wish to conceive do so with increased frequency after atrial of metformin therapy, clomifene, or in some cases gonadotrophins.

202. A 52-year-old woman is referred by the A&E department after attending with a

Colles fracture, the second in the last 3 years. She underwent a total hysterectomy at the

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age of 38 for carcinoma. Bone densitometry confirms osteoporosis. The calcium and

parathyroid hormone assays are normal. Which of the following is the most likely

concerning her underlying pathophysiology?

She has suffered predominantly cortical bone loss

She has probably suffered an equal mix of cortical and trabecular boneloss

She has probably suffered predominantly trabecular bone loss Your answer

Underlying hyperparathyroidism will have contributed

Underlying hypoparathyroidism will have contributed

Hypo-oestrogenisation, as in this case, is usually characterised by predominantly trabecular

bone loss. Involutional bone loss of old age is characterised by a mixed picture oftrabecular and cortical bone loss. In the presence of normal calcium and parathyroid

hormone levels, parathyroid disease is somewhat unlikely. Hormone replacement therapy

was formerly the mainstay of treatment, but this has fallen out of favour due to increased

thromboembolic disease and the risk of breast carcinoma. Bisphosphonates are now thefavoured treatment modality in this group of patients.

203. A 19-year-old student is brought to A&E by his flatmates. He had beenplaying squash that afternoon, and while resting (after having had a pasta meal),complained of generalised weakness. He was unable to stand and had to becarried in by his friends. His potassium level was noted to be 2.6 mmol/l. Urinescreen for diabetic and laxative abuse was normal. Apparently, he has had

similar attacks since his early teenage years. Symptoms were aborted bypotassium chloride. What type of mutation best fits the underlying pathology ofthis autosomal-dominant condition involving intermittent paralysis?

Mutation of a muscle voltage-gated sodium channel

Mutation in a muscle voltage-gated potassium channel

Mutation in a renal potassium channel

Mutation in a renal sodium channel

Mutation in a muscle voltage-gated calcium channel Your answer

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Hypokalaemic periodic paralysis is related to a muscle calcium-channel mutation(CAClN1A3). It is an autosomal-dominant condition; attacks usually begin in theteenage years and may remit after around 35 years of age. Potassium is normally

below 3 mmol/l during an attack and symptoms resolve with the administrationof potassium chloride. Attacks appear to be precipitated either by a highcarbohydrate meal or by a period of rest after extreme exercise. Loss of functionof muscles concerning speech, bulbar or generalised weakness may occur andattacks can last for several hours.

204. You undertake a 12-month attachment to the renal unit of a large district generalhospital, and have a weekly clinic session in their diabetic nephropathy clinic. Which is the

most appropriate oral hypoglycaemic drug in patients with impaired renal function?

Chlorpropamide

Glibenclamide

Glimepiride

Metformin

Tolbutamide Your answer

Chlorpropamide has a long duration of action and is excreted largely unchanged by thekidneys. Glibenclamide has a long biological duration of action (active metabolites) and is

largely excreted by the kidneys. Both should be avoided in renal failure and in the elderly

to avoid accumulation and subsequent hypoglycaemia. Tolbutamide is largely eliminatedby hepatic metabolism and has a short duration of action. It is useful in renal failure.

Metformin is largely excreted by the kidneys and thus accumulates as they fail.

Glimepiride is a sulphonylurea which is renally excreted and thus is contraindicated inrenal impairment.

205. An 81-year-old woman is referred to the thyroid clinic with increasing size of a pre-

existing goitre. She has had long-standing hypothyroidism and has been on a dose of

thyroxine of 100 g daily for many years. Which of the following primary thyroid cancersis she most likely to have?

Anaplastic thyroid cancer

Follicular thyroid cancer

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Medullary thyroid cancer

Papillary thyroid cancer

Thyroid lymphoma Your answer

Primary thyroid lymphoma is strongly associated with lymphocytic thyroiditis

(Hashimotos disease), which is present in 80% of cases. It is predominantly a disease ofelderly women. Up to 30% of patients have a history of goitre and may be taking thyroxine.

Anaplastic thyroid cancer is commonly found in elderly patients and usually presents witha thyroid mass. It can occur in a pre-existing goitre. It is usually rapidly progressive and

has the worst prognosis of the thyroid cancers. Medullary thyroid cancer arises from within

the C cells of the thyroid, cells which produce calcitonin. It is commonly associated withmultiple endocrine neoplasia type-2 (MEN2) along with primary hyperparathyroidism and

phaeochromocytoma. Follicular thyroid cancer is typically found in middle-aged to older

individuals and usually presents as a solitary asymptomatic thyroid nodule. Eventually 20%

of patients will develop distant metastases. Papillary thyroid cancer is most commonlyfound in the 3050 age group but can occur at any age. It most commonly metastasises to

the local lymph nodes within the neck. Prognosis is better than the other thyroid cancers.

206. A 32-year-old woman presents with collapse. She works in an officeenvironment and it has been a particularly hot day. On examination in casualtyshe looks a little dehydrated, her bloods reveal low serum potassium andmagnesium levels and an elevated serum bicarbonate. What is the most likelydiagnosis?

Bartters syndrome

Gitelmans syndrome

Your answer

Gordons syndrome

Conns syndrome

Liddles syndrome

Gitelmans syndrome is due to a mutation in the thiazide-sensitive NaCltransporter in the distal convoluted tubule. It is associated with hypokalaemia,

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hypomagnesaemia and raised serum bicarbonate levels. There is alsohypocalciuria. Treatment is with potassium and magnesium replacement with orwithout potassium-sparing diuretics. Bartters syndrome presents earlier withhypokalaemic alkalosis and hypercalciuria, due to a mutation in the bumetanide-sensitive Na+K+-2Cl- transporter. Treatment is with potassium replacement, non-

steroidal anti-inflammatories and sometimes ACE inhibitors. Liddles syndrome isdue to a mutation in the distal nephron sodium channel, and is associated withhypokalaemic alkalosis and low renin and aldosterone levels, but hypertensionstill occurs. Essentially, Gordons syndrome is the opposite of Bartterssyndrome, presenting with hyperkalaemia. Conns syndrome is associated withhypertension and is due to aldosterone excess.

207. A 54-year-old publican is referred by his GP for endocrine assessment. He is

obese with a BMI of 32 and has hypertension, which is poorly controlled onatenolol, ramipril and bendrofluazide. A recent fasting blood glucose test hasrevealed type-2 diabetes. On examination he looks cushingoid and is obese witha blood pressure of 150/95 mmHg. You order a 24-h urinary free cortisolestimation, which turns out to be well within the normal range. An overnightdexamethasone suppression test is also unremarkable. Which diagnosis fits bestwith this clinical picture?

Cushings disease

Pseudo-Cushings

Your answer

Simple obesity

Essential hypertension

Primary aldosteronism

Obese patients who consume alcohol to chronic excess may acquire acushingoid appearance. In this case, this mans occupation as a publicansuggests that he may have easy access to alcohol. His two screening tests forCushings disease the dexamethasone suppression test and 24-h urinary freecortisol are normal, which effectively rules out option A. His type-2 diabetesis likely to be related to obesity and his sedentary lifestyle, although diabetes

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mellitus could, of course, also be due to alcohol-induced chronic pancreatitis.

Management involves lifestyle measures to promote weight loss, and strictcontrol of his alcohol intake. Metformin would be the ideal treatment for hisdiabetes, although this would be contraindicated in the presence of continuedalcohol excess.

208. A patient presents with truncal obesity, insulin resistance and dyslipidaemia. Whatadditional clinical feature might you expect to be present?

Asthma

Renal failureHypertension Your answer

Cancer

Ophthalmoplegia

Metabolic syndrome X is the term given to the co-occurrence of insulin resistance and

glucose intolerance (ranging from mild to overt type-2 diabetes), with truncal obesity,

dyslipidaemia (raised triglycerides and a high LDL:HDL ratio) and hypertension.

209. A 17-year-old young woman presents to the emergency department with ablood glucose of 29 mmol/l. She is known to have type-1 diabetes. Her pH is 7.12with a serum bicarbonate of 11 mmol/l. There is ketonuria. Which of thefollowing statements best fits the predisposing factors involved in DKA?

Myocardial infarction may be the precipitating factor in up to 5%of cases of DKA

Infection may be the precipitating cause in 60% of cases of DKA

The patient is not previously known to have diabetes in 30% ofDKA cases

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Non-compliance with treatment is the cause in 25% of DKA cases

Youranswer

Inappropriate alterations to insulin are the cause in 20% of DKAcases

The commonest precipitant of diabetic ketoacidosis (DKA) is infection (3040%).This is closely followed by non-compliance with treatment (25%), alterations toinsulin dose (13%), newly diagnosed diabetes (1020%) and myocardial infarction(< 1%). The condition is characterised by hyperglycaemia, acidosis and ketonuria.DKA is common, with 9.1% of patients in the EURODIAB study reportinghospitalisation over the period of a year. DKA is caused by insulin deficiency andcounter-regulatory hormone excess. The mortality rate is 25%, but up to 50% inmore elderly patients.

210. A 45-year-old man presents for review at the type-2 diabetes clinic. He is on maximal

metformin and his Hb A1c is still 7.8%. You elect to add in a peroxisome proliferator-activated receptor (PPAR)-gamma agonist, pioglitazone. Which of the following best

describes the mode of action of PPAR- agonists?

They act at the PPAR- receptor site, promoting binding as a heterodimerwith the retinoid X-receptor to DNA

Youranswer

They bind to a promoter region of DNA as a heterodimer with the retinoidA-receptor

They act by reducing peripheral insulin sensitivity

They act by stimulating insulin output

They act via receptors at the cell surface

PPAR-agonists act by binding to the PPAR-gamma receptor, which binds to a promoterregion of DNA in tandem with the retinoid X-receptor. This then leads to the upregulation

of a number of enzymes concerned with lipid metabolism, bringing about a fall in free fattyacids. The fall in free fatty acids promotes a reduction in hepatic insulin resistance, a rise in

adiponectin and improved peripheral insulin sensitivity. Retinoid X-receptors are also now

under investigation for their possible action in improving insulin sensitivity. Currently,there are two PPAR- agonists on the market, rosiglitazone and pioglitazone, both withpromising data for long-term glycaemic control in type-2 diabetes.

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211. A 25-year-old woman presents with recurrent episodes of headaches and sweating.

Her mother had renal calculi and died of a tumour in her neck. On examination a nodule is

felt in the patients neck in the region of the thyroid gland. A surgeon advises completethyroidectomy. What is the most important investigation the surgeon must undertake prior

to surgery?

Serum thyroxine

Serum calcium

24-h urine test for 5-hydroxyindoleacetic acid

Plasma catecholamine Your answer

Serum calcitonin

This patient probably has medullary carcinoma of the thyroid, which is usually associatedwith phaeochromocytoma and hyperparathyroidism as part of the MEN-2a syndrome.

Here, the serum thyroxine level is unchanged, while A 24-h urine test for 5

hydroxyindoleacetic acid is performed for the diagnosis of carcinoid syndrome. Serum

calcium levels will be raised, but this is not an essential investigation prior to surgery.Phaeochromocytoma must be excluded before surgery. If present, the effect of

catecholamines must be blocked prior to surgery.

212. A patient has been referred by her GP because she has been complaining of frequent

episodes of sweating and palpitations associated with a low blood glucose level. The family

history reveals a brother with type-1 diabetes. A blood test shows the following results:glucose 1.1 mmol/l, insulin > 500 pmol/l (reference 15100 pmol/l) and C-peptide of < 0.2

nmol/l (reference 0.21.4 nmol/l). What is the most likely diagnosis?

Type-1 diabetes mellitus

Insulinoma

Pancreatic carcinoma

Factitious insulin-induced hypoglycaemia Your answer

Maturity-onset diabetes of the young (MODY)

Factitious insulin-induced hypoglycaemia is as common in previously healthy subjects as

in insulin-dependent diabetics and is due to the deliberate, but concealed, injection of

insulin. The history suggests insulinoma, but this is eliminated by the laboratory results thatreveal high plasma insulin and low C-peptide (and proinsulin) concentrations during

hypoglycaemia. In longstanding factitious hypoglycaemia, and in insulin-treated diabetics,insulin antibodies may be present in the plasma. Although once considered a strong pointer

to factitious hypoglycaemia, the presence of insulin antibodies should nowadays suggest

autoimmune insulin syndrome.

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213. A 24-year-old man with learning difficulties presents for review. He complains of a

sudden deterioration of vision in his left eye. His past history of note includes a deep veinthrombosis. On examination he appears tall and slim and almost marfanoid in appearance.

He has a markedly elevated urinary homocysteine. Which enzyme defect is most likely tobe responsible for this clinical picture?

Methylene tetrahydrofolate reductase

Histidase

Homogentisic acid oxidase

Branch-chain ketoacid dehydrogenase

Cystathionine synthetase Your answer

This is the presentation of type-1 homocystinuria, where a defect in cystathioninesynthetase is responsible. Patients present with mild to moderate mental handicap, a

marfan-like syndrome and thrombotic episodes. The sudden visual deterioration may bedue to a thrombotic episode or to the lens dislocation associated with this condition.Homocystinuria may also associated with defects in methylene tetrahydrofolate reductase

(type-2 disease), but survivors often have more severe mental retardation and rarely survive

the neonatal period.

214. A 24-year-old adopted man presents with transient left-sided weakness ofhis arm, which resolves after a few hours. His only other history of note is a

reduced libido and inability to maintain erections. On examination he appears tohave a spotty skin pigmentation. You notice a heart murmur, and there is

suggestion of a left atrial mass on echo. His prolactin is elevated at 2000mol/l.What is the most likely diagnosis?

Left atrial myxoma

Carney complex

Your answer

Prolactinoma

Protein C deficiency

Somatisation disorder

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This man has spotty skin pigmentation, probable prolactinoma and a probable

left atrial myxoma. Carney complex is diagnosable with two features out ofspotty skin pigmentation, myxoma, endocrine tumours (commonest beingprimary pigmented nodular adrenocortical disease), but it is also associated withSertoli-cell tumours, growth hormone- or prolactin-producing pituitaryadenomas, thyroid adenomas and ovarian cysts) and psammomatous melanoticschwannoma (PMS). It is also diagnosable on the presence of one feature and anaffected first-degree relative. It is an autosomal-dominant condition caused byan inactivating mutation of protein kinase A on chromosome 17.

215. A 30-year-old schoolteacher is on an oral contraceptive pill containing 20 gof ethinylestradiol. She asks about its possible side-effects. Which of thefollowing side-effects is most likely to occur with this dose of oestrogen?

Deep vein thrombosis

Nausea and vomiting

Increased pregnancy rate

Breakthrough bleeding

Your answer

Migraine

Breakthrough bleeding is most commonly associated with low-dose oral

contraceptive pills, especially those containing 20 g ethinylestradiol. Nauseaand vomiting are less with this dose. Migraine may occur in susceptible womenirrespective of the dosage. There is no appreciable increase in clotting risk orpregnancy rate with these pills.

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216. A 45-year-old woman is referred to the endocrine clinic by her GP for review. She hasa body mass index of 35, hypertension and impaired glucose tolerance. By the time she

visits you in clinic she has succeeded in losing 3 kg in weight. You decide to give her atrial of orlistat and behavioural therapy. Which of the following best describes the mode of

action of orlistat?

Orlistat is a centrally acting appetite suppressant

Orlistat is a pancreatic and gastric lipase inhibitor Your answer

Orlistat reduces hepatic glucose production

Orlistat reduces insulin resistance

Orlistat is a 3-agonist

Orlistat, a pancreatic lipase inhibitor, blocks the breakdown and hence absorption of dietary

fat. In essence, this means that ingested fat continues its passage through the gut. If patients

taking orlistat do not maintain a low-fat diet then they may suffer distressing oilydiarrhoea. This is why it is essential to combine orlistat therapy with an effective patient

support programme. Sibutramine is a centrally acting drug that acts on serotoninergic andnoradrenergic pathways to encourage earlier satiety and the ingestion of smaller meal

portions.

217. A patient with type-1 diabetes mellitus has a deficiency of insulin. Which cells secrete

insulin?

A cells of the islets of Langerhans

B cells of the pancreatic islets Your answer

Hepatocytes

Fat cells

Melanocytes

Insulin is synthesised and stored by the B cells of the pancreatic islets. The B cells make up

6070% of the volume of the islets. Glucagon is synthesised and stored in the A cells (10

20% of the islets). Somatostatin is synthesised and stored in the D cells (510% of theislets).

218. What is the commonest cause of death in patients with von HippelLindau disease?

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Cerebellar haemangioblastoma

Renal carcinoma Your answer

Retinal tumours

Myocardial infarction

Phaeochromocytoma

VHL disease is an autosomal-dominant condition, with the VHL gene being located onchromosome 3. Estimated prevalence is 1/39,000. Retinal angiomatosis is the initialpresentation in 40% patients. Cerebellar haemangioblastoma is a common initial

presentation. Renal carcinoma is the commonest cause of death, with phaeochromocytoma

occurring in 40% of patients with VHL.

219. A 33-year-old woman presents with polydipsia and polyuria. Her symptoms started

soon after a road traffic accident 6 months ago. Her blood pressure is 120/80 mmHg. Thedaily urinary output is 68 litres. Blood tests: sodium 130 mmol/l (137144), potassium 3.5

mmol/l (3.54.9), urea 6 mmol/l (2.57.5) and glucose 4 mmol/l (36). Plasma osmolalityis 268 mOsmol/l (278305) and urine osmolality is 45 mOsmol/l (3501000). What is themost likely diagnosis?

Cranial diabetes insipidus

Diuretic phase of acute renal failure

Nephrogenic diabetes insipidus

Psychogenic polydipsia Your answer

Syndrome of inappropriate antidiuretic hormone secretion

In psychogenic polydipsia, there is excessive water intake and hence serum sodium, plasmaosmolality and urine osmolality will be decreased. In diabetes insipidus, whether cranial or

nephrogenic, there will be an increase in plasma osmolality and serum sodium levels aswater is lost from the body. In the diuretic phase of acute renal failure, the serum sodium

level will be increased. The syndrome of inappropriate secretion of ADH (SIADH) leads to

retention of water and hyponatraemia. Plasma osmolality will be decreased as well.However, urine osmolality will be raised and may be even higher than plasma osmolality.

220. A 16-year-old girl presents with primary amenorrhoea. General physical examinationreveals no abnormality. Secondary sex characteristics appear well developed. Onkaryotyping, she is found to have XY genotype. What is the most probable cause for her

condition?

Lack of testosterone formation

Decreased 5-reductase

Increased aromatase synthesis

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Lack of dihydrotestosterone receptors Your answer

Total absence of testes

This girl has testicular feminisation, wherein testosterone is being produced in adequate

amounts by the testes located in the abdomen. The majority of cases occur due to a lack of

androgen receptors to dihydrotestosterone (DHT). DHT is formed from testosterone by 5-reductase and is responsible for the development of male secondary sex characteristics. Inthe absence of androgen receptors, the cells are more receptive to estradiol, which is also

produced from testosterone by the enzyme aromatase. Thus, although the genotype is XY,

these girls will have well-developed feminine secondary sex characteristics. Primary

amenorrhoea is often the only symptom that brings these girls to medical attention.

221. A 42-year-old woman presents to the Emergency Clinic with palpitations and

shortness of breath. Recent thyroid function tests on the hospital computer reveal thyroid-

stimulating hormone (TSH) of

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Erectile dysfunction is present in approximately 10% of all men and >50% of men over the

age of 70 years. Common causes are psychological factors (20%), drugs (25%) and

endocrine causes. Baseline investigations include serum testosterone, prolactin, fastingglucose, LH and FSH, thyroid function tests, liver and renal function, lipids and ferritin.

223. A 26-year-old woman attends her GP complaining of feeling tired all the time for thelast few months. She has had no period for 6 months and has been feeling dizzy first thing

in the morning. Which of the following clinical signs would the GP be most likely to find if

the diagnosis was thought to be Addisons disease?

Buccal pigmentation Your answer

Diminished body hair

Pallor

Postural hypotensionOptic atrophy

Hypoadrenalism has many causes including Addisons disease, granulomatous disorders,TB, tumour (particularly lung) or related to infection (meningococcal septicaemia).

Secondary hypoadrenalism is caused by hypopituitarism or hypothalamic disorders. Pallor

is present in hypopituitarism due to normochromic, normocytic anaemia and a lack ofmelanocyte-stimulating hormone (MSH; cleaved from the precursor of ACTH). Buccal

pigmentation is also associated with glucocorticoid deficiency, most commonly from

Addisons disease. ACTH is elevated in Addisons disease and results in higher levels ofMSH, which causes the skin and buccal pigmentation found in this condition. Lack of body

hair and amenorrhoea are features of hypogonadism in hypopituitarism. Posturalhypotension is related to glucocorticoid deficiency regardless of cuase.

224. An 8-day-old baby presents with vomiting, poor feeding and loose stools. On

examination, his heart rate is 190 bpm, BP 50/30 mmHg and respiratory rate 72

breaths/min. Blood tests: Hb 15 g/dl (1318), sodium 120 mmol/l (137144), potassium6.0 mmol/l (3.54.9), chloride 80 mmol/l (95107), bicarbonate 15 mmol/l (21-28), urea

7.0 mmol/l (2.57.5) and creatinine 80 mol/l (60110). What is the most likely

diagnosis?

Congenital adrenal hyperplasia Your answer

Acute tubular necrosis

Congenital hypertrophic pyloric stenosis

Galactosaemia

Lactose intolerance

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The features and findings are highly suggestive of congenital adrenal hyperplasia. Absence

of jaundice and hepatomegaly make the diagnosis of galactosaemia unlikely. Acute tubular

necrosis is ruled out, as urea and creatinine levels are normal. In congenital hypertrophicpyloric stenosis, hypokalaemia is the presenting feature and constipation (not loose stools)

is the chief complaint. Lactose intolerance would again present with diarrhoea or vomiting,

thus hypokalaemia would be the characteristic finding.

225. A 25-year-old woman presents with a lump on the left-hand side of her neck in the

thyroid region. Thyroid function is normal, and uptake scanning reveals it to be a coldnodule. Fine-needle aspiration biopsy reveals architecture suspicious of follicular

carcinoma of the thyroid. Which of the following is the most appropriate management

plan?

Resection of the thyroid noduleSub-total thyroidectomy

Total thyroidectomy

Total thyroidectomy with oral thyroxine therapy Your answer

Radioiodine therapy

The definitive management for follicular carcinoma of the thyroid without metastases istotal thyroidectomy with thyroxine to a TSH-suppressive dose. If metastases are present

they usually respond to radioiodine therapy, and this is added. Metastases are subject to

haematological spread, with bone being the commonest metastatic site. The 5-year survivalrate approaches 80% for follicular carcinoma. This is much higher than for anaplastic

carcinoma of the thyroid, which usually occurs in the elderly and only carries a 5-yearsurvival rate of 5%.

226. A 27-year-old woman presenting with polyuria is found to have diabetes insipidus.Which part of the nephron is most affected in this condition?

Proximal tubule

Cortical and medullary collecting tubules Your answer

Distal convoluted tubule

Thin ascending limb of Henle

Glomerular efferent arterioles

Fine-tuning of salt and water balance is achieved in the distal and collecting tubules under

the influence of aldosterone and antidiuretic hormone (ADH). ADH, however, plays acentral role in urinary concentration by increasing the water permeability of the normally

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impermeable cortical and medullary collecting tubules. In the absence of ADH, little water

is reabsorbed in the collecting tubules and dilute urine is excreted.

227. A 25-year-old woman is being investigated for suspected MEN-2a syndrome. She is

also noted to have marfanoid features. What will be the most characteristic finding in a

blood test in this patient?

Elevated serum calcium

Elevated metanephrines Your answer

Elevated thyroxine

Elevated parathyroid hormone

Elevated glucagon

MEN-2a syndrome with a marfanoid phenotype is associated with phaeochromocytomaand medullary carcinoma of the thyroid. Hyperparathyroidism occurs in 2A, but is said not

to occur in MEN-2B. Thyroxine remains normal. Glucagon excess is seen in MEN-1

syndrome.

228. You are asked to urgently review a 58-year-old woman who presents with a slowly

enlarging hard mass in the anterior neck. Thyroid ultrasound reveals infiltration, and biopsydoes reveal dense infiltration of the gland. Free T4 is low and her TSH is markedly raised,

consistent with hypothyroidism. Thyroid autoantibodies are negative. Which of thefollowing is the most likely diagnosis given this clinical picture?

Riedels thyroiditis Your answer

Thyroid carcinoma

Hashimotos thyroiditis

Graves disease

Toxic multinodular goitre

By the nature of its presentation, Riedels thyroiditis is often confused with thyroid

carcinoma. It is characterised by marked fibrous infiltration of the thyroid gland, the

aetiology of this being as yet unidentified. Treatment is with thyroxine replacement.Hashimotos thyroiditis is autoimmune in aetiology and is characterised by lymphocytic

infiltration and the presence of antimicrosomal antibodies. Graves disease is associated

with thyroid-stimulating autoantibodies and hyperthyroidism.Thyroid ultrasound reveals

infiltration but no discrete mass is identified, and biopsy does reveal dense infiltration ofthe gland.

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229. A 38-year-old black woman draws your attention to a swelling in her neck, which she

noticed 2 days ago. She denies palpitations, diaphoresis and weight loss. There is no pain,hoarseness or dysphagia. Her medical history is notable only for hypertension. Medications

include only atenolol 50 mg once daily. On exam, blood pressure is 150/80 mm Hg; pulseis 70. There is a 2 1-cm non-tender nodule on the right lobe of the thyroid. No

lymphadenopathy is detected. The remainder of the exam is unremarkable. Electrolytes,blood urea nitrogen (BUN), creatinine, liver function tests, calcium, phosphorus and CBC

are normal. What would you do next?

Arrange a thyroid ultrasound scan

Elicit a family history of thyroid cancer

Obtain thyroid function tests

Perform fine-needle aspiration

All of the above Your answer

The clinically apparent (>1 cm) thyroid nodule is a common clinical finding; up to 5% ofthe population is affected. It is more common in women than in men and a majority (85%)

are hypofunctional or cold nodules. The likelihood of malignancy in a solitary thyroid

nodule is low (4%); cold nodules carry a higher risk than hot nodules (20% vs 1%).Evaluation of a solitary nodule should be aimed at detecting potentially malignant lesions

so that as many cancers are removed with as few operations as possible. A history of head

and neck irradiation raises the likelihood that a thyroid nodule is malignant, as does the

presence of a family history of differentiated thyroid cancer or medullary cancer of thethyroid (which can be a component of multiple endocrine neoplasia (MEN) type IIA or

IIB). Fine-needle aspiration of the thyroid gland is a cost-effective procedure with a high

sensitivity and specificity for malignancy. Fine-needle aspiration allows the nodule to becharacterized cytologically as benign, malignant, suspicious for malignancy or

indeterminate.

230. A 35-year-old woman, with a strong family history of breast cancer, visits you

because she is keen to start on tamoxifen for breast cancer prophylaxis. Which of thefollowing statements best describes the mode of action of tamoxifen?

It is a progesterone-receptor agonist

It is a progesterone-receptor antagonist

It is an oestrogen-receptor agonist

It is an oestrogen-receptor antagonist

It is a mixed oestrogen-receptor antagonist and partial agonist Your answer

The use of tamoxifen after breast cancer is associated with a 25% risk reduction in metastatic

disease, and is also associated with a reduction in the risk of primary breast cancer in high-risk women. It is a mixed antagonist and partial agonist at the oestrogen receptor. Its partial

agonist action is probably reflected in the increased risk of endometrial carcinoma associated

with chronic tamoxifen use. Tamoxifen has been considered the treatment of choice,

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although positive evidence for other hormone modulators is accumulating.

Additional modern selective oestrogen-receptor modifiers now exist, one example being

raloxifene which is currently used for the treatment of osteoporosis.

231. A 70-year-old man is brought unconscious to the emergency department, hisblood sugar level is 70 mmol/l. There is no evidence of ketoacidosis. His chest X-ray reveals evidence of left-sided consolidation. What is the most likelydiagnosis?

Simple pneumonia

A complication of type-1 diabetes

A complication of type-2 diabetes

Your answer

Stroke

Glucagonoma

He is most likely to be suffering from hyperosmolar non-ketotic coma, which isassociated with type-2 diabetes and with coexistent infection. The commonpresentation is often with blood glucose levels of over 50 mmol/l, a markedlyraised serum osmolality and a decreased conscious level, without ketosis.Management is with iv insulin and isotonic saline infusion, although the bloodglucose level often drops quickly after insulin is initiated. Hyperosmolar comamay be the initial presentation of diabetes mellitus, and two-thirds of suffererspresent with type-2 diabetes mellitus for the first time. Mortality is high,particularly in elderly sufferers. Glucagonoma is vanishingly rare, with an annual

incidence of 1/20 million in the UK.

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232. Exposure to darkness is found to increase melatonin secretion. What is the most

common mechanism by which this is achieved?

Decreased activity of suprachiasmatic nuclei

Increased serotonin N-acetyltransferase Your answer

Decreased hydroxyindole-o-methyltransferase activityBlockade of noradrenaline release from sympathetic nerve terminals

Increased intracellular cAMP in the hypothalamus

Melatonin is synthesised and secreted by the pineal gland from serotonin: N-acetyltransferase + acetyl-CoA converts serotonin to N-acetyl serotonin, which is then

catalysed by hydroxyindole-o-methyltransferase to melatonin.

Exposure to darkness causes activation of the hypothalamus by the retinohypothalamic

nerves. This results in increased noradrenaline secretion by the postganglionic sympathetic

nerves (nervi conarii) innervating the pineal gland. Noradrenaline acts via -adrenergicreceptors in the pineal gland to increase the intracellular levels of cAMP, this then causesan increase in N-acetyltransferase activity.

233. A 35-year-old woman is referred by her GP because of recurrent headaches. These

tend to come on at times of stress or exercise and appear almost in a flash. She alsocomplains of intermittent palpitations and problems with sweating. He has tried her on a

course of antidepressants, which only seemed to make her symptoms worse. Her 24-h

urinary catecholamines are markedly raised. An MRI scan reveals a mass in the right

adrenal medulla. Her blood pressure in clinic is 145/95 mmHg. What is the bestmanagement plan?

Urgent -blockade

Urgent surgery

Urgent a-blockade, then -blockade if required, and surgery Your answer

Observation

-Blockade followed by urgent surgery

This woman has a phaeochromocytoma of the right adrenal medulla. The commonest

presenting features are headache (80%), palpitations (70%), hyperhydrosis (60%) andhypertension (sustained in 55% and paroxysmal in 45% of patients). MRI or MIBG

(metaiodobenzyl guanidine) scanning are the definitive methods of localisation.

Management involves a-blockade prior to surgery to avoid a hypertensive crisis. The 5-year survival rate is 95% for patients with benign phaeochromocytoma, but this falls to

40% in those with malignant disease. Phaeochromocytomas are three times more likely to

be malignant in women.

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234. A 42-year-old patient complains of severe fatigue following surgery for a pituitary

tumour and is put on growth hormone replacement. Which of the following is a well-recognised effect of this treatment?

Decrease in serum lipoprotein(a) concentration

Increase in fasting serum triglyceride concentration

Increase in fat mass

Increase in lean body mass Your answer

Increase in serum total cholesterol concentration

Growth hormone replacement in adults with deficiency of the hormone has numerous

effects, including an increase in vitality and overall quality of life. Lean body mass tends to

increase but body fat decreases, often to a greater extent. Serum total- and LDL-cholesterol

concentrations and triglycerides tend to decrease but lipoprotein(a) concentration mayincrease.

235. A 55-year-old man is found incidentally to have hypercalcaemia during a routine

health screen. Which one of the following biochemical findings would be most suggestiveof this being caused by primary hyperparathyroidism rather than any other cause of

hypercalcaemia?

Elevated 24-h urinary calcium excretion

Elevated serum alkaline phosphatase activity

Low serum concentration of calcitriol (1,25-dihydroxycholecalciferol)

Normal serum phosphate concentration

Serum PTH concentration within the normal range Your answer

Although parathyroid hormone (PTH) concentrations are often increased in patients withhyperparathyroidism, they are not always so. PTH secretion should be suppressed by

hypercalcaemia from any other cause, so that a PTH value in the normal range is consistent

with the diagnosis. Urinary calcium excretion is increased in many causes of

hypercalcaemia (except familial hypocalciuric hypercalcaemia), includinghyperparathyroidism. Serum alkaline phosphatase activity can also be elevated with

hypercalcaemia, regardless of the cause (with the exception of myeloma). Serum phosphate

concentrations tend to be reduced in hyperparathyroidism (PTH is phosphaturic) and

calcitriol concentrations to be increased (PTH stimulates the formation of this hormone).

236. A 34-year-old woman presents with 4-month history of anorexia and weight loss,

excess pigmentation and dizziness on standing. Initial investigations reveal hyponatraemia

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and hyperkalaemia. Which of the following tests will be most useful to confirm the

diagnosis?

ESR

Thyroid function tests

Serum ureaShort Synacthen test Your answer

Serum calcium

Hyponatraemia is present in 90% and hyperkalemia in 65% of patients with primaryadrenal insufficiency. Although increased urea, increased ESR and raised TSH levels and

mild hypercalcaemia are seen in Addisons disease, these are not particularly useful in

confirming the diagnosis. However, failure to respond following a short Synacthen testsuggests adrenal failure.

237. An obese, 45-year-old woman is brought to A&E in a semi-comatose condition. Blood

tests: potassium 5.0 mmol/l (3.54.9), sodium 140 mmol/l (137144), bicarbonate 7mmol/l (2028) and pH 7.1 (7.367.44). Which of the following blood sugar levels is mostlikely to be found in this case?

11 mmol/l

2.5 mmol/l

20 mmol/l

> 30 mmol/l Your answer

5.5 mmol/l

This patient has severe diabetic ketoacidosis. Plasma glucose is often elevated to 30 mmol/lor higher. In non-ketotic hyperosmolar coma, bicarbonate levels are high (> 30 mmol/l),

which differentiates it from diabetic ketoacidosis. The blood pH will also be in the normalrange.

238. A 34-year-old accountant is referred to you with a history of diabetes mellitus sincethe age of nine years. He is a methodical man and appears always to have striven to

maintain reasonable metabolic control of his condition, while managing a normal lifestyle.

What is the most likely finding on examination and routine testing?

A raised albumin to creatinine ratio in the urine (microalbuminuria)

Absent ankle jerks

Anti-thyroid antibodies

Background retinopathy Your answer

Macroproteinuria dipstick urine testing

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The risk of developing retinopathy progressively increases with increasing duration of

diabetes. Standardised methods of assessing retinopathy, including retinal photography,

have revealed that 97% of insulin-dependent diabetics have some evidence of retinopathy(ie background changes at the least) 15 years after diagnosis. Half have proliferative

changes 20 years after diagnosis.

Diabetic nephropathy affects 2530% of people with insulin dependent diabetes and most

of the cases that are ever going to occur will have occurred by 20 years of diabetes in thisgroup of patients. These patients will have macroproteinuria. Insulin dependent diabetes is

an autoimmune disease, and there is an increased prevalence of other autoimmune diseases

despite this, only a minority have positive anti-thyroid antibodies.

239. A 56-year-old man with type-2 diabetes presents with background diabetic

retinopathy. His HB A1c has been consistently above 9% for the past 5 years. Which of the

following factors may impact most negatively on the prognosis for his retinopathy?

Rapid improvement in blood glucose levels Your answerTotal cholesterol 5.2 mmol/l

Long-term improvements in blood glucose control

Triglyceride levels of 2.1 mmol/l

Stopping smoking

Rapid improvement in blood glucose levels may be associated with worsening of diabeticeye disease. Both the Diabetes Control and Complications Trial (DCCT) in type-1 diabetes

and the UKPDS (United Kingdom Prospective Diabetes Study) in type-2 diabetes have

demonstrated the long-term benefits of reducing blood sugar levels in controlling futuremicrovascular complications. All diabetic patients should be offered yearly eye screening,

preferably with a digital retinal camera. Rapidly deteriorating visual acuity, hard exudates

encroaching on the macula, preproliferative changes or new-vessel formation are all reasonsfor early referral to an ophthalmologist.

Diabetic retinopathy has been known for many years to be the leading cause of blindness in

the UK in people of working age, but progression to blindness is now slowing and tailing off

due to improved ophthalmic care. Smoking has no effect on the prognosis of retinopathy.

240. A 52-year-old man is sent by his GP for an urgent review. He has been

maintained on metformin and gliclazide for his type-2 diabetes. For the pastweek or so he has had feelings of severe aching pain and paraesthesias in hisupper legs. He has felt off his food during the past week and has begun losingweight. There is also proximal muscle weakness. Which of the following best fitsdiabetic amyotrophy?

75% of patients recover fully from this condition

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Transference to insulin therapy is the mainstay of treatment

Your answer

Recovery from this condition usually takes over 1 year

The condition is much more common in type-1 diabetes

Weight loss is unlikely to be related to the diagnosis

Diabetic amyotrophy is said to occur most commonly in men in their fifties withtype-2 diabetes treated with oral hypoglycaemic agents. It is a mixed motor and

sensory proximal neuropathy said to cause severe pain, which is responsible foranorexia and weight loss. Some 50% of patients recover fully from this condition,usually within 34 months. The mainstay of treatment is supportive care andtransference to insulin therapy.

241. A patient who has had a subtotal thyroidectomy for hyperthyroidism is on thyroxinereplacement. She has a normal thyroid-stimulating hormone (TSH), normal tri-

iodothyronine (T3) and low free thyroxine (T4) levels. What is the most likely reason for

those results?

Hypothalamic pituitary causes

Poor compliance with thyroxine supplements

The patients results are as expected no change in treatment is

requiredYour answer

She has sick euthyroid syndrome

Malabsorption

Once on a full replacement dose, thyroid-stimulating hormone (TSH) levels should be

checked at intervals of 13 years, depending on their stability. Fluctuating or elevated TSH

levels in a previously stable patient, or thyroxine requirements in excess of 200 g/day,usually indicate compliance problems. It is important to rule out malabsorption or

abnormal thyroxine kinetics caused by drugs: cholestyramine, ferrous sulphate, lovastatin,

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aluminium hydroxide, rifampicin, amiodarone, carbamazepine, and phenytoin all alter the

absorption or clearance of thyroxine.

242. You review a 52-year-old woman in the thyroid clinic. She has a thyroid mass.

Unfortunately this turns out to be a thyroid lymphoma.

Which of the following is the best choice therapy in this case?

Suppressive treatment with thyroid hormone

Radioiodine treatment

Chemotherapy

External beam radiotherapy Your answer

Palliative measures

Iodine 131 is a radioactive isotope of iodine (RAI) that is selectively concentrated in thethyroid tissue and metabolized by the same pathways as naturally occurring iodine. This,

together with its long half-life (8 days), allows it to deliver high doses of radiation to the

thyroid gland (-radiation) sufficient to destroy thyroid follicular cells. So, 131I is used inthe treatment of Graves' disease, toxic multi-nodular goiter and differentiated thyroid

cancer. The doses of RAI used in the treatment of Graves' disease and toxic multi-nodular

goiter are relatively low compared with those used in the treatment of thyroid cancer (inwhich it is used in conjunction with surgery). RAI has no place in the treatment of thyroid

lymphoma because lymphoma cells do not concentrate iodine. External beam radiotherapy

is used in the treatment of thyroid lymphoma, but not all tumours are responsive and

treatment may only be effective for a short time.

243. A 52-year-old woman, diagnosed with type-2 diabetes mellitus and losingweight, is referred for an opinion; her GP is thinking about insulin therapy. Anormochromic, normocytic anaemia is noted. On examination she has angularstomatitis and a well-demarcated erythematous rash in her groin, which extendsto her lower limbs, buttocks and perineum. What is the next step in hermanagement?

Refer to nursing colleagues for conversion to insulin

Try high-dose sulphonylurea therapy

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(PTH) are diagnostic of pseudohypoparathyroidism (Type IA). This is an autosomal-

dominant disorder resulting from a G protein (Gs) defect, which leads to parathyroid

hormone (PTH) resistance. Hypothyroidism and ovarian failure are also seen because Gproteins are also involved in TSH and gonadotropin receptor signaling, respectively.

Mental retardation is seen in 70% of cases.

245. A 49-year-old woman presents complaining of fatigue and weight loss. She wassuccessfully treated medically for a prolactinoma 3 years ago, and it is suspected that she

might now have MEN-1. Which of the following tumours is she most likely to have?

Medullar carcinoma of thyroid

Parathyroid adenoma Your answer

Pancreatic islet-cell tumourPituitary adenoma

Phaeochromocytoma

Parathyroid tumours are present in 95% of patients with multiple endocrine neoplasia type1 (MEN-1), and the hypercalcaemia that they cause is the most common presenting feature

of the condition. Hypercalcaemia may be discovered incidentally or because it is

symptomatic, but the symptoms are often non-specific. Islet-cell tumours (most frequentlygastrinomas) are present in about 40% of cases. Pituitary tumours occur in about 30% of

patients: over a half are prolactinomas. Medullary-cell carcinomas of the thyroid and

phaeochromocytomas occur in MEN-2 but not in MEN-1.

246. A 52-year-old woman with primary hypothyroidism is being treated with thyroxine

replacement, the dose of which is being titrated against the results of biochemical thyroid

function tests. Two weeks after the last increase in dose, the results of thyroid function testsare: free thyroxine 28 pmol/l (normal 926); TSH 14 mU/l (normal 0.25.0). Which (if

any) would be the most appropriate next step in the management of this patient?

A decrease in the dose of thyroxine

A further increase in the dose of thyroxine

No change in dose at this time Your answer

Question patients compliance with medication

Replace thyroxine with triiodothyronine

It is too soon after the last change in dose for a new steady state to have been achieved: it isusual to wait for a month before reviewing the response. When thyroxine replacement is

started, the TSH concentration often falls to normal more slowly than free thyroxine

increases. Free thyroxine concentrations in clinically euthyroid patients on thyroxine

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replacement are often high normal or even slightly elevated, reflecting the lack of production

of triiodothyronine (T3) by the thyroid: peripheral metabolism of thyroxine is the only source

of T3. Irregular medication could explain these results but should not be considered untilsufficient time has elapsed for the data reliably to reflect the effects of replacement.

Triiodothyronine is usually only used in very severe hypothyroidism, when a rapid response

to treatment is required.

247. A patient with Addison's disease presents with an acute onset of diarrhoea and

vomiting. He currently takes fludrocortisone and hydrocortisone. What is the most

appropriate management?

Intravenous (iv) cyclizine

iv Ondansetroniv Fluids and iv hydrocortisone Your answer

Increase fludrocortisone

iv Antibiotics

Patients receiving glucocorticoid replacement therapy should be advised to double the dose

in the event of intercurrent febrile illness, accident, or mental stress such as an important

examination. If the patient is vomiting and cannot take by mouth, parenteral hydrocortisonemust be given urgently, as indicated above. For minor surgery, 50100 mg of

hydrocortisone hemisuccinate is given with the premedication. For major procedures this is

then followed by the same regimen as for acute adrenal insufficiency.

248. A 32-year-old woman presents with extreme lethargy a couple of weeks after the birth

of her third child by emergency caesarean section. She complained to the health visitor of

increasing problems some 7 days earlier, but was told that this was to be expected after thebirth of her child. On admission via casualty she was noted to have a sodium concentration

of 127 mmol/l, a potassium concentration of 6.8 mmol/l and a urea of 12 mmol/l. What is

the likely diagnosis?

Sheehans syndrome Your answerHypothyroidism

Primary adrenal failure

Postnatal depression

Dehydration

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She has suffered a period of hypotension and blood loss associated with her emergency

caesarean section. This has resulted in pituitary infarction, and she presents now with

symptoms of hypoadrenalism. She, of course, requires fluid rehydration and emergencysteroid replacement with iv hydrocortisone. She will also have pituitary-dependent

hypothyroidism and require thyroxine replacement. Restoration of fertility is more difficult,

pulsed delivery of pituitary sex-axis hormones is usually required. Postnatal depression andsimple dehydration are somewhat unlikely with this set of blood results.

249. A 36-year-old woman who is 28 weeks pregnant attends the midwife clinicfor a pregnancy check. She is noted to have glycosuria. What is her correctmanagement plan?

Observe and follow up in 4 weeks time with repeat urine glucosetesting

Carry out a fasting blood glucose; if it is less than 7.0 mmol/l thenrepeat the sample in 4 weeks time

Carry out a fasting blood glucose; if it is over 6.0 mmol/l thenproceed to administer a 75-g oral glucose tolerance test

Your

answer

Carry out a fasting blood glucose; it is over 7.0 mmol/l then

proceed to administer a 75-g oral glucose tolerance test

Proceed directly to administer an oral glucose tolerance test

A glucose tolerance test is required if the patients fasting blood glucose level is over 6.0

mmol/l. Diabetes is defined as a fasting level of > 7.0 mmol/l or > 11.0 mmol/l 2 h after a

glucose tolerance test. Gestational impaired glucose tolerance (IGT) is defined as a fasting

blood glucose level of 6.07.8 mmol/l and/or a 2-h level of 911 mmol/l. Although initialtreatment for gestational diabetes is with dietary advice, insulin is also required in 1030%

of cases. Insulin should be considered for those with fasting levels above 6.0 mmol/l afterdietary intervention, or postprandial sugar levels above 8.0 mmol/l. Untreated gestationaldiabetes is said to carry a perinatal mortality rate of 4.46.4%, compared to 0.51.5% in a

similarly matched normoglycaemic population: hence, good glycaemic control is essential

for this reason.

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250. A 68-year-old man attends his GP on the insistence of his wife because hisleft forefoot has become increasingly unstable and abnormally shaped with bonyswelling. He has a long history of diabetes mellitus and his control has beenerratic, with Hb A1c in the range of 910%. Which of the following pieces ofinformation best fits the pathology or management of Charcots foot?

Tight glucose control is unlikely to be of benefit in this condition

Reduction of oedema is unimportant with respect to preventingdeterioration

Orthotic shoes are unnecessary in the management of thiscondition

Plain radiography is always abnormal, even early in this condition

The pathology of this condition is thought to be due to sympatheticdysfunction, excessive blood flow to the joint and osteoclastactivity

Your

answer

This man has a Charcot left foot. This is a rare condition now, with the averagegeneral hospital clinic seeing a maximum of 10 Charcots patients. Chronic

untreated Charcots foot results in either rocker-bottom foot due to downwarddisplacement and subluxation of the tarsus, or medial convexity due totalonavicular joint displacement or dislocation of the tarsometatarsal joints.Management involves tight glycaemic control, reduction of oedema and orthoticand chiropody involvement. Intravenous bisphosphonate treatment may be ofbenefit in some patients. Although plain radiographs may be normal in the earlystages of the disease, they later show joint destruction, osteolysis, jointreorganisation and subluxation.