Endocrinology Pastest PDF
Endocrinology Pastest PDF
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• Timed Test A 51-year-old man presents to A&E with altered consciousness, his blood pressure is
• Mock Exam 80/50 mmHg, his skin is pigmented and he has a past history of Hashimoto’s
thyroiditis. His family say he has been tired for several months and has been losing
• Past Papers weight and complaining of abdominal pain.
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Which of the following results is most likely to be found on investigation?
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• Media Bank Laboratory glucose level of 12.3 mmol/l
• New Multimedia Serum sodium level of 116 mmol/l
Online Extras Peaked T-waves on ECG
Library Serum potassium level of 2.4 mmol/l
Community Serum urea level of 3.2 mmol/l
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Questions Correct 10
• Timed Test A 51-year-old man presents to A&E with altered
consciousness, his blood pressure is 80/50 mmHg, his skin Questions Incorrect 3
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is pigmented and he has a past history of Hashimoto’s Questions Total 13
• Past Papers thyroiditis. His family say he has been tired for several
Questions Percentage 76 %
• Random Questions months and has been losing weight and complaining of
abdominal pain. More
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• Media Bank Which of the following results is most likely to be
found on investigation?
• New Multimedia
Online Extras Laboratory glucose level of 12.3
Library mmol/l
Community Serum sodium level of 116 mmol/l Correct answer
Help Peaked T-waves on ECG Your answer
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mmol/l
Serum urea level of 3.2 mmol/l
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My Career and Exams The clinical picture is suggestive of Addison’s disease
with hypotension, pigmentation and a prodromal period Reference: Normal Values
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with symptoms in keeping with glucocorticoid deficiency
Learning Goals in a man with a history of another autoimmune Click to open/closeHaematology
Question Filters endocrine disorder. Other disorders that can be Click to open/closeImmunoglobulins
associated are diabetes and pernicious anaemia. Click to open/closeBiochemistry
Hypoglycaemia, hyponatraemia, hyperkalaemia and an Click to open/closeDiabetes Click to
Security elevated urea are all present during a hypoadrenal crisis open/closeEndocrinology Click to
due to steroid deficiency and subsequent salt and water open/closeBlood gases Click to
Change Password loss. Although the potassium is elevated it is unusual to open/closeCSF
find peaked T-waves on the ECG in patients with
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hypoadrenalism: the complexes tend to be small, low-
volume ones.
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• Timed Test A 31-year-old man is referred to the local hypertension
clinic because of recently discovered hypertension that is Questions Incorrect 0
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labile and difficult to control. Questions Total 0
• Past Papers
Which of the following features is most likely to Questions Percentage 0%
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suggest a genetic/familial syndrome is the cause for More
• My Performance his hypertension?
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• New Multimedia Serum potassium level of 3.9 mmol/l
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Questions Correct 1
• Timed Test A 31-year-old man is referred to the local hypertension
clinic because of recently discovered hypertension that is Questions Incorrect 0
• Mock Exam
labile and difficult to control. Questions Total 1
• Past Papers
Which of the following features is most likely to Questions Percentage 100 %
• Random Questions
suggest a genetic/familial syndrome is the cause for More
• My Performance his hypertension?
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• New Multimedia Serum potassium level of 3.9 mmol/l
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Newsletters Adrenal causes of hypertension are Conn’s syndrome
My Career and Exams (primary hyperaldosteronism ), Cushing’s syndrome
(from adrenal adenoma, carcinoma or adrenal nodular Reference: Normal Values
Order History
hyperplasia) and phaeochromocytoma. Hypokalaemia is
Learning Goals a feature of Conn’s and Cushing’s syndromes. Click to open/closeHaematology
Question Filters Hyperglycaemia can be present in Cushing’s syndrome Click to open/closeImmunoglobulins
or phaeochromocytoma. Unexplained death in childbirth Click to open/closeBiochemistry
and a family history of thyroid neoplasia raise the Click to open/closeDiabetes Click to
Security possibility of multiple endocrine neoplasia type-2 open/closeEndocrinology Click to
(phaeochromocytoma, medullary thyroid tumours and open/closeBlood gases Click to
Change Password hyperparathyroidism) as the cause of his hypertension. open/closeCSF
A raised serum calcium level would also point towards
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MEN2 (multiple endocrine neoplasia – type 2) but
hypocalcaemia is not associated with adrenal causes of
hypertension.
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• Timed Test A 25-year-old woman presents to a reproductive endocrinology clinic with a history of
• Mock Exam being unable to conceive after 2 years of using no contraception. It is thought she may
have polycystic ovarian syndrome.
• Past Papers
• Random Questions Which of the following is most likely to be associated with this condition?
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A 28 day menstrual cycle
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Elevated LH/FSH ratio
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Normal free-androgen index
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Low levels of circulating insulin
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Normal BMI (body mass index)
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Questions Correct 2
• Timed Test A 25-year-old woman presents to a reproductive
endocrinology clinic with a history of being unable to Questions Incorrect 0
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conceive after 2 years of using no contraception. It is Questions Total 2
• Past Papers thought she may have polycystic ovarian syndrome.
Questions Percentage 100 %
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Which of the following is most likely to be associated More
• My Performance with this condition?
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• New Multimedia A 28 day menstrual cycle
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Polycystic ovarian syndrome is one of the commonest
Profile causes of anovulatory infertility. Patients can have a
normal menstrual cycle but are more likely to have
Newsletters oligomenorrhoea. It is associated with a number of
My Career and Exams biochemical abnormalities, including raised LH levels,
normal or elevated testosterone but with a low SHBG Reference: Normal Values
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(sex-hormone-binding globulin) resulting in a high free-
Learning Goals androgen index. Androstenedione levels can either be Click to open/closeHaematology
Question Filters normal or raised. The underlying biochemical defect in Click to open/closeImmunoglobulins
patients with PCOS is recognised to be insulin Click to open/closeBiochemistry
resistance. This causes high circulating insulin levels Click to open/closeDiabetes Click to
Security due to peripheral insulin resistance: therefore open/closeEndocrinology Click to
hyperinsulinaemia, and not low insulin levels, is open/closeBlood gases Click to
Change Password characteristic of the condition. The insulin resistance open/closeCSF
has been shown in both lean and obese patients with
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the condition.
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• Timed Test A 37-year-old woman presents to the endocrine clinic with
a history of hirsutism, acne and oligomenorrhoea. She is Questions Incorrect 0
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having difficulty losing weight and has searched the Questions Total 2
• Past Papers Internet and thinks she may have polycystic ovarian
Questions Percentage 100 %
• Random Questions syndrome. She wants to discuss the implications of this.
• My Performance More
Which of the following is the most important issue to
• Media Bank discuss with her at this stage of her life?
• New Multimedia
Exercise regimens
Online Extras Reference: Normal Values
Does she want to have children
Library
Her blood glucose level Click to
Community open/closeHaematology
Treatment for her hirsutism
Help Click to
Weight-reduction diets open/closeImmunoglobulins
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Click to
615 open/closeBiochemistry
My Account Click to open/closeDiabetes
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Click to open/closeBlood
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• Timed Test A 37-year-old woman presents to the endocrine clinic with a history of hirsutism, acne
• Mock Exam and oligomenorrhoea. She is having difficulty losing weight and has searched the
Internet and thinks she may have polycystic ovarian syndrome. She wants to discuss
• Past Papers the implications of this.
• Random Questions
Which of the following is the most important issue to discuss with her at this
• My Performance stage of her life?
• Media Bank
• New Multimedia Exercise regimens
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All the above are relevant and each should be discussed. The hirsutism and acne
Profile can be very difficult to deal with and can cause distress from a cosmetic point of
view. There are a variety of treatment options but Dianette (cyproterone acetate)
Newsletters is probably the most effective, along with cosmetic treatments like waxing,
My Career and Exams shaving, plucking or electrolysis. Her future risk of type-2 diabetes and associated
cardiovascular risk is very important and she should be advised about the need for
Order History
lifestyle treatments and the need to lose weight and exercise regularly to reduce
Learning Goals the chance of this happening. It is now recommended that all patients with PCOS
Question Filters have their fasting blood glucose level measured annually to pick up diabetes at an
earlier stage. However, the most important issue in a woman of her age is fertility,
as women with PCOS frequently require assistance with conception. Her age is
Security against her if she is going to have problems with fertility and requires help to
conceive. The commonest treatment is to induce ovulation with clomifene. She
Change Password needs to be advised that pregnancy also carries an increased risk of gestational
diabetes.
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Questions Correct 3
• Timed Test A 29-year-old woman presents to her GP with a history of
weight loss, heat intolerance, poor concentration and Questions Incorrect 0
• Mock Exam
palpitations. Questions Total 3
• Past Papers Which of the following is most likely to be associated
Questions Percentage 100 %
• Random Questions with a diagnosis of thyroiditis associated with viral
infection? More
• My Performance
• Media Bank Bilateral exophthalmos
• New Multimedia Diffuse, smooth goitre
Online Extras Reduced uptake on thyroid isotope scan Reference: Normal Values
Library Positive thyroid peroxidase antibodies
Click to
Community Pretibial myxoedema open/closeHaematology
Help Click to
616 open/closeImmunoglobulins
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Click to
open/closeBiochemistry
My Account Click to open/closeDiabetes
Click to
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Click to open/closeBlood
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Questions Correct 4
• Timed Test A 29-year-old woman presents to her GP with a history of
weight loss, heat intolerance, poor concentration and Questions Incorrect 0
• Mock Exam
palpitations. Questions Total 4
• Past Papers Which of the following is most likely to be associated
Questions Percentage 100 %
• Random Questions with a diagnosis of thyroiditis associated with viral
infection? More
• My Performance
• Media Bank Bilateral exophthalmos
• New Multimedia Diffuse, smooth goitre
Online Extras Reduced uptake on thyroid isotope Your answer
Library scan
Community Positive thyroid peroxidase antibodies
Help Pretibial myxoedema
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Graves’ disease is an autoimmune thyroid disorder and
Profile is more common in women than men. It is associated
with positive TPO (thyroid peroxidase antibodies) and
Newsletters
TSH (thyroid stimulating hormone) receptor antibodies.
My Career and Exams The goitre in Graves’ disease is normally diffusely
Order History enlarged rather than nodular. Uptake of radio-isotope is Reference: Normal Values
increased in Graves’ disease. In other conditions
Learning Goals causing thyrotoxicosis, like postpartum thyroiditis and Click to open/closeHaematology
Question Filters viral thyroiditis, the uptake is reduced. Graves’ disease Click to open/closeImmunoglobulins
is associated with a number of other features not found Click to open/closeBiochemistry
in other causes of thyrotoxicosis, eg exophthalmos, Click to open/closeDiabetes Click to
Security pretibial myxoedema and thyroid acropachy (a condition open/closeEndocrinology Click to
that affects the nails and looks like finger clubbing). The open/closeBlood gases Click to
Change Password exophthalmos can be unilateral or bilateral. open/closeCSF
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• Timed Test A 34-year-old woman is referred to the endocrine clinic
with a history of thyrotoxicosis. At her first appointment she Questions Incorrect 0
• Mock Exam
is found to have a smooth goitre, lid lag and bilateral Questions Total 4
• Past Papers exophthalmos with puffy eyelids and conjunctival injection.
Questions Percentage 100 %
• Random Questions She wants to discuss treatment of her thyroid problem as
she is keen to become pregnant. More
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• Media Bank What is the most likely treatment you would advise?
• New Multimedia
12–18 months of carbimazole alone
Online Extras Reference: Normal Values
12–18 months of propylthiouracil alone
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A combination of antithyroid drugs and thyroxine Click to
Community open/closeHaematology
Radioactive iodine (iodine-131)
Help Click to
Thyroidectomy open/closeImmunoglobulins
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617 open/closeBiochemistry
My Account Click to open/closeDiabetes
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Profile open/closeEndocrinology
Click to open/closeBlood
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Questions Correct 5
• Timed Test A 34-year-old woman is referred to the endocrine clinic
with a history of thyrotoxicosis. At her first appointment she Questions Incorrect 0
• Mock Exam
is found to have a smooth goitre, lid lag and bilateral Questions Total 5
• Past Papers exophthalmos with puffy eyelids and conjunctival injection.
Questions Percentage 100 %
• Random Questions She wants to discuss treatment of her thyroid problem as
she is keen to become pregnant. More
• My Performance
• Media Bank What is the most likely treatment you would advise?
• New Multimedia
12–18 months of carbimazole alone
Online Extras
12–18 months of propylthiouracil alone Your answer
Library
A combination of antithyroid drugs and
Community thyroxine
Help Radioactive iodine (iodine-131)
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All the above treatments are recognised treatments for
Newsletters thyrotoxicosis. Antithyroid drugs (carbimazole and
My Career and Exams propylthiouracil) can be used alone and the dose
titrated down or up to keep the patient euthyroid. Reference: Normal Values
Order History
Treatment is usually for 12–18 months. However
Learning Goals carbimazole has been associated with aplasia cutis (a Click to open/closeHaematology
Question Filters scalp defect) in babies born to mothers treated during Click to open/closeImmunoglobulins
pregnancy. The ‘block and replace’ regimen of thyroxine Click to open/closeBiochemistry
and anti-thyroid drugs is not used in pregnancy as Click to open/closeDiabetes Click to
Security thyroxine does not cross the placenta. Surgery is an open/closeEndocrinology Click to
option for people with a large goitre, or for people who open/closeBlood gases Click to
Change Password fail on other treatments but would not be first choice in open/closeCSF
a young otherwise healthy woman. Radio-iodine is a
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very effective treatment for thyrotoxicosis but is
contraindicated in women of childbearing age who are
contemplating pregnancy within 6 months.
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• Timed Test A 30-year-old man and his wife present to a reproductive
endocrinology clinic because of infertility. The man is tall Questions Incorrect 0
• Mock Exam
with bilateral gynaecomastia. Examination of the testes Questions Total 5
• Past Papers reveals bilateral, small, firm testes.
Questions Percentage 100 %
• Random Questions
Which of the following investigations is most helpful More
• My Performance in diagnosing a patient with Klinefelter’s syndrome?
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• New Multimedia CT scan of the pituitary gland
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Questions Correct 6
• Timed Test A 30-year-old man and his wife present to a reproductive
endocrinology clinic because of infertility. The man is tall Questions Incorrect 0
• Mock Exam
with bilateral gynaecomastia. Examination of the testes Questions Total 6
• Past Papers reveals bilateral, small, firm testes.
Questions Percentage 100 %
• Random Questions
Which of the following investigations is most helpful More
• My Performance in diagnosing a patient with Klinefelter’s syndrome?
• Media Bank
• New Multimedia CT scan of the pituitary gland
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Klinefelter’s syndrome is a genetic disorder with an
Profile extra X chromosome, giving a genotype XXY. It is
usually diagnosed in late pubertal or early adult life
Newsletters because of delayed sexual development or infertility. It
My Career and Exams is associated with hypogonadism giving raised
gonadotrophin levels and low testosterone levels. Reference: Normal Values
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Semen analysis would show azoospermia.
Learning Goals Gynaecomastia is often present. CT brain scan will be Click to open/closeHaematology
Question Filters normal. The other tests are appropriate for investigation Click to open/closeImmunoglobulins
of male infertility. There are other cause of infertility Click to open/closeBiochemistry
that would give high gonadotrophin and low Click to open/closeDiabetes Click to
Security testosterone levels; any primary testicular disorder open/closeEndocrinology Click to
would give this pattern, eg cryptorchidism, mumps open/closeBlood gases Click to
Change Password orchitis, haemochromatosis, myotonic dystrophy and open/closeCSF
alcohol abuse. The only test that is specific for
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Klinefelter’s syndrome is a genetic test for the XXY
genotype.
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• Timed Test A 26-year-old man is referred for gastroscopy because of several months of
• Mock Exam dyspepsia. He has routine bloods checked and is found to have a serum calcium level
of 3.2 mmol/l with a venous bicarbonate level of 33 mmol/l. Renal and liver function
• Past Papers are both normal. Chest X-ray is normal.
• Random Questions
What is the most likely cause of his hypercalcaemia?
• My Performance
• Media Bank Myeloma
• New Multimedia Metastatic malignancy
Online Extras Milk–alkali syndrome
Library Primary hyperparathyroidism
Community Sarcoidosis
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Questions Correct 7
• Timed Test A 26-year-old man is referred for gastroscopy because of
several months of dyspepsia. He has routine bloods Questions Incorrect 0
• Mock Exam
checked and is found to have a serum calcium level of 3.2 Questions Total 7
• Past Papers mmol/l with a venous bicarbonate level of 33 mmol/l. Renal
Questions Percentage 100 %
• Random Questions and liver function are both normal. Chest X-ray is normal.
• My Performance More
What is the most likely cause of his hypercalcaemia?
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• New Multimedia Myeloma
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All the above diagnoses are causes of hypercalcaemia.
Profile Symptoms of hypercalcaemia are commonly thirst,
polyuria, dyspepsia, malaise, bone pain and
Newsletters constipation. Myeloma and metastatic malignancy cause
My Career and Exams hypercalcaemia either by direct lytic lesions of bone or
by the production of PTHrP (parathyroid hormone- Reference: Normal Values
Order History
related protein). Myeloma would be extremely rare in
Learning Goals this age group. There is nothing in the history to Click to open/closeHaematology
Question Filters suggest bone pain or a diagnosis of metastatic Click to open/closeImmunoglobulins
malignancy. Primary hyperparathyroidism is most Click to open/closeBiochemistry
commonly found by chance in elderly women. It can be Click to open/closeDiabetes Click to
Security part of the multiple endocrine neoplasia syndromes and open/closeEndocrinology Click to
therefore can be seen in younger people. The normal open/closeBlood gases Click to
Change Password chest X-ray suggests that sarcoidosis is not the open/closeCSF
diagnosis in this case. The age of the patient, the
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dyspeptic symptoms and the raised bicarbonate level
suggest the most likely diagnosis is the milk–alkali
syndrome caused by the ingestion of antacids.
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• Timed Test A 17-year-old young woman is referred to the endocrine
clinic with primary amenorrhoea. She is of normal height Questions Incorrect 0
• Mock Exam
and weight. She has moderate hirsutism. A male cousin Questions Total 0
• Past Papers was seen in the clinic at the age of 8 years with precocious
Questions Percentage 0%
• Random Questions puberty.
What is the most likely cause for her primary More
• My Performance
amenorrhoea?
• Media Bank
• New Multimedia Congenital adrenal hyperplasia
Online Extras Hyperprolactinaemia Reference: Normal Values
Library Polycystic ovarian syndrome
Turner’s syndrome Click to
Community open/closeHaematology
Help Testicular feminisation syndrome Click to
open/closeImmunoglobulins
PasTest Store 621 Click to
open/closeBiochemistry
My Account Click to open/closeDiabetes
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Click to open/closeBlood
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Questions Correct 1
• Timed Test A 17-year-old young woman is referred to the endocrine
clinic with primary amenorrhoea. She is of normal height Questions Incorrect 0
• Mock Exam
and weight. She has moderate hirsutism. A male cousin Questions Total 1
• Past Papers was seen in the clinic at the age of 8 years with precocious
Questions Percentage 100 %
• Random Questions puberty.
What is the most likely cause for her primary More
• My Performance
amenorrhoea?
• Media Bank
• New Multimedia Congenital adrenal hyperplasia Your answer
Online Extras Hyperprolactinaemia
Library Polycystic ovarian syndrome
Community Turner’s syndrome
Help Testicular feminisation syndrome
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Turner’s syndrome (genotype XO) is associated with
Profile primary amenorrhoea and short stature.
Hyperprolactinaemia and PCOS are more commonly
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associated with secondary amenorrhoea. Testicular
My Career and Exams feminisation causes primary amenorrhoea and is caused
Order History by either a partial or complete androgen-receptor Reference: Normal Values
defect. Affected patients are genotypically male (XY)
Learning Goals but phenotypically female. Congenital adrenal Click to open/closeHaematology
Question Filters hyperplasia is most commonly caused by 21- Click to open/closeImmunoglobulins
hydroxylase deficiency. Severe forms present in infancy Click to open/closeBiochemistry
with salt-losing crises and females can have ambiguous Click to open/closeDiabetes Click to
Security genitalia. Milder forms cause precocious puberty in boys open/closeEndocrinology Click to
and virilism, hirsutism and primary amenorrhoea in open/closeBlood gases Click to
Change Password girls. Diagnosis is by finding raised serum 17- open/closeCSF
Sign Out hydroxyprogesterone levels that show a
hyperresponsiveness to ACTH. Treatment is with
glucocorticoids.
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Questions Correct 0
• Timed Test An 81-year-old woman is referred to the thyroid clinic with
increasing size of a pre-existing goitre. She has had long- Questions Incorrect 0
• Mock Exam
standing hypothyroidism and has been on a dose of Questions Total 0
• Past Papers
thyroxine of 100 μg daily for many years. Questions Percentage 0%
• Random Questions
• My Performance Which of the following primary thyroid cancers is she More
most likely to have?
• Media Bank
• New Multimedia Anaplastic thyroid cancer
Online Extras Follicular thyroid cancer Reference: Normal Values
Library Medullary thyroid cancer
Click to
Community Papillary thyroid cancer
open/closeHaematology
Help Thyroid lymphoma Click to
open/closeImmunoglobulins
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623 Click to
open/closeBiochemistry
My Account Click to open/closeDiabetes
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Questions Correct 1
• Timed Test An 81-year-old woman is referred to the thyroid clinic with
increasing size of a pre-existing goitre. She has had long- Questions Incorrect 0
• Mock Exam
standing hypothyroidism and has been on a dose of Questions Total 1
• Past Papers
thyroxine of 100 μg daily for many years. Questions Percentage 100 %
• Random Questions
• My Performance Which of the following primary thyroid cancers is she More
most likely to have?
• Media Bank
• New Multimedia Anaplastic thyroid cancer
Online Extras Follicular thyroid cancer
Library Medullary thyroid cancer
Community Papillary thyroid cancer
Help Thyroid lymphoma Your answer
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Primary thyroid lymphoma is strongly associated with
Profile lymphocytic thyroiditis (Hashimoto’s disease), which is
Newsletters present in 80% of cases. It is predominantly a disease
of elderly women. Up to 30% of patients have a history
My Career and Exams of goitre and may be taking thyroxine. Anaplastic
Order History thyroid cancer is commonly found in elderly patients Reference: Normal Values
and usually presents with a thyroid mass. It can occur
Learning Goals in a pre-existing goitre. It is usually rapidly progressive Click to open/closeHaematology
Question Filters and has the worst prognosis of the thyroid cancers. Click to open/closeImmunoglobulins
Medullary thyroid cancer arises from within the ‘C’ cells Click to open/closeBiochemistry
of the thyroid, cells which produce calcitonin. It is Click to open/closeDiabetes Click to
Security commonly associated with multiple endocrine neoplasia open/closeEndocrinology Click to
type-2 (MEN2) along with primary hyperparathyroidism open/closeBlood gases Click to
Change Password and phaeochromocytoma. Follicular thyroid cancer is open/closeCSF
Sign Out 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 commonly
found in the 30–50 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.
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• Timed Test A 52-year-old woman sees her GP complaining of a 4-kg
weight gain, dry hair and skin, she feels slow and always Questions Incorrect 0
• Mock Exam
has the heating up high. She has a small diffuse goitre. Her Questions Total 2
• Past Papers TSH level is 11 U/l (0.5-4.5) and free thyroxine 5 pmol/l.
Questions Percentage 100 %
• Random Questions Thyroid peroxidase antibody is positive at high titres. She
has two sisters who have had thyroid disease. More
• My Performance
What is the most likely diagnosis?
• Media Bank
• New Multimedia DeQuervain’s thyroiditis
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• Timed Test A 45-year-old man presents to his GP with headaches. His BP is 166/94 mmHg.
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• Timed Test A 45-year-old man presents to his GP with headaches. His
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142 mmol/l, potassium 2.6 mmol/l, chloride 101 mmol/l Questions Total 4
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• Timed Test A 34-year-old man presents to the diabetes clinic with a history of thirst, polyuria and
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My Account acid dehydrogenase (GAD). It is associated with HLA DR-3 or DR-4. Patients with
type-2 diabetes more commonly have a high BMI > 25, as this form of diabetes is
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levels. Finally, patients with type-2 diabetes mellitus can have + or ++ ketones in
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• Timed Test A 27-year-old woman with type-1 diabetes mellitus attends
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not be a contraindication to pregnancy and nor would
sensory neuropathy. It is important that patients with
diabetes take 5 mg folic acid daily prepregnancy (this
reduces neural tube defects) and this can be started
when the patient starts trying to conceive, although it
should ideally be taken for 3 months beforehand. The
most important thing this woman can do is to improve
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• Timed Test A 17-year-old young woman with poorly controlled diabetes mellitus presents with a
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is found to have changes in his eyes on fundoscopy. Questions Total 3
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• Timed Test A 54-year-old man, newly diagnosed with type-2 diabetes mellitus, presents to the
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Which of the following is most likely to need immediate referral to the
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exudates. Patients do not need to be referred to the ophthalmologist unless these
My Account are within 1 disc diameter of the fovea. This can be monitored annually at the
routine clinic. Cataracts appear about 10 years earlier in type-2 diabetes than in
Profile non-diabetic patients. If the vision is significantly affected the patients warrant
routine and not urgent referral to the ophthalmologist. Soft exudates suggest
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retinal ischaemia, which would require routine referral to the ophthalmologist. New
My Career and Exams vessels anywhere in the fundus are a feature of proliferative retinopathy and, as
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• Timed Test A 78-year-old man is admitted to hospital with a left
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mg, bendrofluazide 2.5 mg, atorvastatin 10 mg and Questions Total 4
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mg, bendrofluazide 2.5 mg, atorvastatin 10 mg and Questions Total 5
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Questions Percentage 40 %
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• Timed Test A 43-year-old woman presents with weight loss,
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been treated by her GP for anxiety. Examination reveals a Questions Total 5
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throughout the rest of the gland. Thyroid function tests
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• Timed Test A 43-year-old woman presents with weight loss, palpitations, diarrhoea and a
• Mock Exam cessation of periods. She has been treated by her GP for anxiety. Examination reveals
a single nodule on the left of her thyroid, about 1.5 cm in diameter. Thyroid scanning
• Past Papers with technetium shows increased uptake within the nodule with reduced activity
• Random Questions throughout the rest of the gland. Thyroid function tests showed a free thyroxine of 30
pmol/l (9–25 pmol/l), TSH < 0.05 mU/l (0.5–5).
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particularly amenable to radioactive iodine treatment. A dose of 300–500 MBq is
Newsletters usually sufficient to cure the thyrotoxicosis. Radioiodine therapy is contraindicated
My Career and Exams in children and women who are lactating or pregnant, and where the safety of
cohabitants from the effects of radioactivity can’t be guaranteed. Surgery is the
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next best option for patients in whom radioiodine is contraindicated or refused.
Learning Goals Carbimazole alone or in combination with thyroxine replacement is used in the
Question Filters medical treatment of Grave’s disease; Propanolol is a useful symptom reliever for
thyrotoxicosis.
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• Timed Test A 37-year-old woman presents to A&E after chasing thieves who were stealing her
• Mock Exam car. Her blood pressure is noted to be 185/110 mmHg on admission. She admits to
episodic headaches and feeling stressed and anxious. She is of normal appearance,
• Past Papers her serum calcium on admission is noted to be 2.95 mmol/l with normal renal
• Random Questions function, abdominal ultrasound reveals a possible adrenal mass.
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• Timed Test A 24-year-old adopted man presents with transient left-sided weakness of his arm,
• Mock Exam 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 to have a spotty skin
• Past Papers pigmentation. You notice a heart murmur, and there is suggestion of a left atrial mass
• Random Questions on echo. His prolactin is elevated at 2000 µmol/l.
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• New Multimedia Left atrial myxoma
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Questions Correct 5
• Timed Test A 24-year-old adopted man presents with transient left-
sided weakness of his arm, which resolves after a few Questions Incorrect 3
• Mock Exam
hours. His only other history of note is a reduced libido and Questions Total 8
• Past Papers inability to maintain erections. On examination he appears
Questions Percentage 62 %
• Random Questions to have a spotty skin pigmentation. You notice a heart
murmur, and there is suggestion of a left atrial mass on More
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echo. His prolactin is elevated at 2000 µmol/l.
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What is the most likely diagnosis?
• New Multimedia
Online Extras Left atrial myxoma
Library Carney complex Your answer
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This man has spotty skin pigmentation, probable
Newsletters prolactinoma and a probable left atrial myxoma. Carney
My Career and Exams complex is diagnosable with two features out of spotty
skin pigmentation, myxoma, endocrine tumours Reference: Normal Values
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(commonest being primary pigmented nodular
Learning Goals adrenocortical disease), but it is also associated with Click to open/closeHaematology
Question Filters Sertoli-cell tumours, growth hormone- or prolactin- Click to open/closeImmunoglobulins
producing pituitary adenomas, thyroid adenomas and Click to open/closeBiochemistry
ovarian cysts) and psammomatous melanotic Click to open/closeDiabetes Click to
Security schwannoma (PMS). It is also diagnosable on the open/closeEndocrinology Click to
presence of one feature and an affected first-degree open/closeBlood gases Click to
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by an inactivating mutation of protein kinase A on
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chromosome 17.
1229
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• Timed Test A 28-year-old man presents to casualty with a sudden loss
of vision in his right eye. His only past history of note is a Questions Incorrect 3
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previous cerebellar haemorrhage. On examination he has Questions Total 8
• Past Papers evidence of bilateral retinal angiomas, and a partial retinal
Questions Percentage 62 %
• Random Questions detachment in his right eye.
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• Timed Test A 28-year-old man presents to casualty with a sudden loss
of vision in his right eye. His only past history of note is a Questions Incorrect 3
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previous cerebellar haemorrhage. On examination he has Questions Total 9
• Past Papers evidence of bilateral retinal angiomas, and a partial retinal
Questions Percentage 66 %
• Random Questions detachment in his right eye.
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• New Multimedia Simple traumatic retinal detachment
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Von Hippel–Lindau disease is characterised by CNS and
Profile retinal haemangioblastomas (presenting feature in 40%
of patients), renal cysts and carcinomas (occurring
Newsletters later), phaeochromocytoma (20% of affected families,
My Career and Exams bilateral in 40% of patients) and pancreatic tumours
(50% non-functioning). The prevalence is 1 in 39,000 Reference: Normal Values
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with a mean age at presentation of 27 years. Renal
Learning Goals cysts occur later, with 70% of patients having them by Click to open/closeHaematology
Question Filters age 60 years. Ideally, genetic testing in affected Click to open/closeImmunoglobulins
families should take place around the age of 5 years. Click to open/closeBiochemistry
Affected individuals then require yearly urinalysis, Click to open/closeDiabetes Click to
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1230
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• Timed Test A 37-year-old woman presents to A&E after chasing
thieves who were stealing her car. Her blood pressure is Questions Incorrect 0
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noted to be 185/110 mmHg on admission. She admits to Questions Total 1
• Past Papers episodic headaches and feeling stressed and anxious. She is
Questions Percentage 100 %
• Random Questions of normal appearance, her serum calcium on admission is
noted to be 2.95 mmol/l with normal renal function, More
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abdominal ultrasound reveals a possible adrenal mass.
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Online Extras Phaeochromocytoma
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MEN-2 (multiple endocrine neoplasia – type 2) is
Newsletters associated with medullary thyroid carcinoma (almost
My Career and Exams always), parathyroid chief-cell hyperplasia (10–25%)
and phaeochromocytoma (20–50%). MEN-2b is also Reference: Normal Values
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associated with a marfanoid appearance, whereas MEN-
Learning Goals 2a is not. The cause is an autosomal-dominant inherited Click to open/closeHaematology
Question Filters genetic mutation on the long arm of chromosome 10.
Correct management of this patient includes appropriate
a- and β -blockade prior to surgical removal of the
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carcinoma with the iv pentagastrin test and calcitonin
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surgeon. The prognosis of MEN-2 is variable, but,
overall, the 10-year survival rate is around 65%.
1228
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• Timed Test A 32-year-old woman presents with collapse. She works in
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day. On examination in casualty she looks a little Questions Total 0
• Past Papers dehydrated. BP is 110/70 mmHg.
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The following serum electrolyte results are obtained; More
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Na + 134mmol/l
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K + 2.9mmol/l
• New Multimedia Mg ++ 0.57 mmol/l (0.75-1.05)
Online Extras HCO3 - 34mmol/l Reference: Normal Values
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• Timed Test A 32-year-old woman presents with collapse. She works in
an office environment and it has been a particularly hot Questions Incorrect 0
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day. On examination in casualty she looks a little Questions Total 1
• Past Papers dehydrated. BP is 110/70 mmHg.
Questions Percentage 100 %
• Random Questions
The following serum electrolyte results are obtained; More
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Na + 134mmol/l
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K + 2.9mmol/l
• New Multimedia Mg ++ 0.57 mmol/l (0.75-1.05)
Online Extras HCO3 - 34mmol/l
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What is the most likely diagnosis?
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Help Bartter's syndrome
PasTest Store Gitelman's syndrome Your answer
Gordon's syndrome
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Gitelman’s syndrome is due to a mutation in the
Learning Goals thiazide-sensitive Na–Cl transporter in the distal Click to open/closeHaematology
Question Filters convoluted tubule. It is associated with hypokalaemia, Click to open/closeImmunoglobulins
hypomagnesaemia (a cardinal feature) and raised Click to open/closeBiochemistry
serum bicarbonate levels. There is also hypocalciuria. Click to open/closeDiabetes Click to
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replacement with or without potassium-sparing open/closeBlood gases Click to
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excretion of magnesium (which is high in Gitelman
syndrome and normal in Bartter syndrome) and calcium
(which is high in Bartter syndrome and low in Gitelman
syndrome). Bartter’s syndrome presents earlier with
hypokalaemic 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. Liddle’s syndrome is due to a mutation in the
distal nephron sodium channel, and is associated with
hypokalaemic alkalosis and low renin and aldosterone
levels, but hypertension still occurs. Essentially,
Gordon’s syndrome is the opposite of Bartter’s
syndrome, presenting with hyperkalaemia. Conn’s
syndrome is associated with hypertension and is due to
aldosterone excess.
1231
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• Timed Test A 45-year-old woman who works in a pharmacy presents
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is 115/75 mmHg. Her bloods reveal hypokalaemia and a Questions Total 1
• Past Papers raised serum bicarbonate level. Urine collection reveals
Questions Percentage 100 %
• Random Questions hypercalciuria. Otherwise the findings are unremarkable.
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• Timed Test A 45-year-old woman who works in a pharmacy presents
with episodes of tiredness and lethargy. Her blood pressure Questions Incorrect 1
• Mock Exam
is 115/75 mmHg. Her bloods reveal hypokalaemia and a Questions Total 2
• Past Papers raised serum bicarbonate level. Urine collection reveals
Questions Percentage 50 %
• Random Questions hypercalciuria. Otherwise the findings are unremarkable.
• My Performance More
What is the likely diagnosis?
• Media Bank
• New Multimedia Bartter’s syndrome Your answer
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This picture could fit Bartter’s syndrome, although
Profile Bartter’s syndrome is rare (1 per million), has an
autosomal-recessive pattern of inheritance and
Newsletters commonly presents below the age of 5 years. Features
My Career and Exams of Bartter’s syndrome include volume depletion,
seizures, tetany and muscle weakness. This woman’s Reference: Normal Values
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occupation is the clue, which unfortunately makes
Learning Goals frusemide abuse very much more likely. Click to open/closeHaematology
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• Timed Test A 42-year-old man is referred to the hypertension clinic for advice. He is currently
• Mock Exam taking atenolol, bendrofluazide and ramipril and his blood pressure is currently
165/105 mmHg. His potassium is 3.0 mmol/l, with a serum bicarbonate concentration
• Past Papers of 28 mmol/l.
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• Media Bank Measure the aldosterone:renin ratio
• New Multimedia Wash out as many of his antihypertensive agents as is possible for a period of 2
Online Extras weeks, then review
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• Timed Test A 42-year-old man is referred to the hypertension clinic for
advice. He is currently taking atenolol, bendrofluazide and Questions Incorrect 1
• Mock Exam
ramipril and his blood pressure is currently 165/105 mmHg. Questions Total 3
• Past Papers His potassium is 3.0 mmol/l, with a serum bicarbonate
Questions Percentage 66 %
• Random Questions concentration of 28 mmol/l.
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My Career and Exams The suspicion here with hypokalaemia and metabolic
alkalosis, and resistant hypertension on three agents, is Reference: Normal Values
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that he has primary hyperaldosteronism. ACE inhibitors
Learning Goals and angiotensin II-receptor blockers, diuretics, calcium- Click to open/closeHaematology
Question Filters channel blockers, b -blockers all ideally require a Click to open/closeImmunoglobulins
washout period of 2 weeks to make the Click to open/closeBiochemistry
aldosterone:renin ratio assay meaningful. Whilst it may Click to open/closeDiabetes Click to
Security seem dangerous to wash out, a definitive diagnosis is open/closeEndocrinology Click to
impossible if you don't. Spironolactone requires a open/closeBlood gases Click to
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ratio is suggestive of primary hyperaldosteronism. The
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blood sample should be taken in the morning, standing,
and with a normalised potassium concentration (using
supplementation) if possible. Urinary potassium
excretion > 30 mmol/24 h may be another useful
adjunct in making the diagnosis. Surgery is the
treatment of choice for Conn’s adenoma and leads to
resolution of hypertension in around 70% of patients,
mitotane may be useful for controlling symptoms of
adrenal carcinoma, spironolactone is the medical
treatment of choice for adrenal hyperplasia.
1233
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• Timed Test A 42-year-old man is referred to the hypertension clinic for
advice. He is currently taking atenolol 100 mg, Questions Incorrect 1
• Mock Exam
bendrofluazide 2.5 mg and ramipril 10 mg, and his blood Questions Total 3
• Past Papers pressure is currently 165/105 mmHg. Examination is
Questions Percentage 66 %
• Random Questions otherwise unremarkable. His potassium is 3.0 mmol/l, with
a serum bicarbonate concentration of 28 mmol/l, creatinine More
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85 µmol /l, glucose tolerance is normal.
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What is the most likely underlying diagnosis?
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Online Extras Cushing’s disease Reference: Normal Values
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• Timed Test A 42-year-old man is referred to the hypertension clinic for
advice. He is currently taking atenolol 100 mg, Questions Incorrect 1
• Mock Exam
bendrofluazide 2.5 mg and ramipril 10 mg, and his blood Questions Total 4
• Past Papers pressure is currently 165/105 mmHg. Examination is
Questions Percentage 75 %
• Random Questions otherwise unremarkable. His potassium is 3.0 mmol/l, with
a serum bicarbonate concentration of 28 mmol/l, creatinine More
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85 µmol /l, glucose tolerance is normal.
• Media Bank
What is the most likely underlying diagnosis?
• New Multimedia
Online Extras Cushing’s disease
Library Primary hyperaldosteronism Your answer
Community Essential hypertension
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There is evidence of hypokalaemic metabolic alkalosis,
Newsletters probably associated with primary hyperaldosteronism.
My Career and Exams His resistant hypertension in the presence of marked
hypokalaemia supports this. Primary Reference: Normal Values
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hyperaldosteronism accounts for at least 2% and
Learning Goals perhaps up to 10% of hypertensive patients. The Click to open/closeHaematology
Question Filters aldosterone:renin ratio is likely to be raised if the Click to open/closeImmunoglobulins
patient is off antihypertensive medication, as is urinary Click to open/closeBiochemistry
potassium excretion. It is important, however, to do the Click to open/closeDiabetes Click to
Security blood testing in the morning, after a period of standing open/closeEndocrinology Click to
and wash out of this man’s antihypertensives for a open/closeBlood gases Click to
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respond to some extent to spironolactone, but surgery
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is the treatment of choice for Conn’s adenoma. Bilateral
adrenal hyperplasia, glucocorticoid-suppressible
hyperaldosteronism and adrenal carcinoma are other
causes.
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• Timed Test A 24-year-old student has been recovering at home after a
period of intensive care and general medical admission for Questions Incorrect 1
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meningococcal septicaemia. 4 days after discharge from Questions Total 4
• Past Papers hospital she visits her GP complaining of dizziness on
Questions Percentage 75 %
• Random Questions standing and profound tiredness. On examination she looks
tired and ‘washed out’ and does indeed have postural More
• My Performance
hypotension. Blood testing reveals a sodium concentration
• Media Bank of 121 mmol/l, potassium of 6.7 mmol/l and urea of 15.0
• New Multimedia mmol/l. She has mild normochromic, normocytic anaemia.
Online Extras What is the most likely underlying diagnosis? Reference: Normal Values
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Secondary adrenal insufficiency Click to
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Waterhouse–Friderichsen syndrome
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Syndrome of inappropriate ADH Click to
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• Timed Test A 24-year-old student has been recovering at home after a
period of intensive care and general medical admission for Questions Incorrect 1
• Mock Exam
meningococcal septicaemia. 4 days after discharge from Questions Total 5
• Past Papers hospital she visits her GP complaining of dizziness on
Questions Percentage 80 %
• Random Questions standing and profound tiredness. On examination she looks
tired and ‘washed out’ and does indeed have postural More
• My Performance
hypotension. Blood testing reveals a sodium concentration
• Media Bank of 121 mmol/l, potassium of 6.7 mmol/l and urea of 15.0
• New Multimedia mmol/l. She has mild normochromic, normocytic anaemia.
Profile
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My Career and Exams Waterhouse–Friderichsen syndrome is bilateral adrenal
haemorrhage occurring due to massive septicaemia, Reference: Normal Values
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often associated with severe, life-threatening
Learning Goals meningococcal disease. It may present as in this patient Click to open/closeHaematology
Question Filters with tiredness, lethargy and postural hypotension a Click to open/closeImmunoglobulins
short period after discharge from the precipitating Click to open/closeBiochemistry
illness. Classically, laboratory findings associated with Click to open/closeDiabetes Click to
Security adrenal insufficiency are hyponatraemia, hyperkalaemia, open/closeEndocrinology Click to
elevated urea, anaemia, elevated ESR, eosinophilia and open/closeBlood gases Click to
Change Password mild hypercalcaemia. The commonest cause in the open/closeCSF
western world is autoimmune disease (70%), closely
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followed by malignancy, although TB is a common
association in the developing world. Emergency
treatment of adrenal insufficiency involves fluid
replacement, iv hydrocortisone and glucose
supplementation, often even prior to determining the
underlying cause.
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• Timed Test A 38-year-old psychiatric patient who is being treated for
depression is admitted with increased confusion. His sodium Questions Incorrect 0
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is 122 mmol/l, with a plasma osmolality of 235 mOsmol/kg. Questions Total 0
• Past Papers Urine osmolality is 300mOsm/kg. There is no evidence on
Questions Percentage 0%
• Random Questions examination of cardiac, renal or hepatic failure. Random
plasma cortisol and thyroid function are normal. More
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• Media Bank Given the most likely diagnosis, which of the
following statements best fits this condition?
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Library Treatment with IV saline is likely to be necessary
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• Timed Test A 38-year-old psychiatric patient who is being treated for
depression is admitted with increased confusion. His sodium Questions Incorrect 1
• Mock Exam
is 122 mmol/l, with a plasma osmolality of 235 mOsmol/kg. Questions Total 1
• Past Papers Urine osmolality is 300mOsm/kg. There is no evidence on
Questions Percentage 0%
• Random Questions examination of cardiac, renal or hepatic failure. Random
plasma cortisol and thyroid function are normal. More
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• Media Bank Given the most likely diagnosis, which of the
following statements best fits this condition?
• New Multimedia
Online Extras Reduced renal sodium excretion is
Library likely
Community Treatment with IV saline is likely to
be necessary
Help
Renal sodium excretion is likely to Correct answer
PasTest Store be elevated
Psychiatric drugs are very unlikely
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condition
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Hypothyroidism is a possible Your answer
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Order History Reference: Normal Values
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Click to open/closeHaematology
Question Filters This is the syndrome of inappropriate antidiuretic
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hormone (SIADH) secretion. Criteria for diagnosis are
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hyponatraemia with an osmolality of less than 270
Click to open/closeDiabetes Click to
Security mOsmol/kg. Inappropriately raised urine osmolality (>
open/closeEndocrinology Click to
100 mOsmol/l). High urinary sodium of > 20 mmol/l
open/closeBlood gases Click to
Change Password (reflecting relative increased concentration due to
open/closeCSF
reduced water loss), and normal renal, adrenal and
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thyroid function. Sodium handling by the kidney is not
affected in SIADH. Psychiatric drugs, particularly
monoamine oxidase inhibitors and phenothiazines may
be possible causes. Other possible causes include
tumours, such as small-cell lung cancer, other chest
pathology, intracerebral haemorrhage or trauma, drugs
such as carbamazepine or chlorpropamide and
metabolic causes such as hypothyroidism. Treatment is
with fluid restriction or tetracycline-like compounds that
promote water excretion.
1236
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• Timed Test A 44-year-old patient with hypomania is referred for
opinion. She is noted to have a sodium concentration of Questions Incorrect 1
• Mock Exam
142 mmol/l, with a urea of 12 mmol/l and a creatinine of Questions Total 1
• Past Papers 140 µmol/l. Urine osmolality is 250 mOsmol/l. Fasting
Questions Percentage 0%
• Random Questions plasma glucose is normal. The nurses have monitored her
urine output and found it to be 4.4 litres in 24 h. More
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• Media Bank Which of the following statements best fits with her
condition?
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Online Extras Psychiatric drugs are unlikely to have played a part in Reference: Normal Values
Library her condition
Urine osmolality rising to > 375 mOsmol/l 4 h after Click to
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desmopressin in the water deprivation test is a positive
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Desmopressin in addition to her usual drugs is likely Click to
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• Timed Test A 44-year-old patient with hypomania is referred for
opinion. She is noted to have a sodium concentration of Questions Incorrect 1
• Mock Exam
142 mmol/l, with a urea of 12 mmol/l and a creatinine of Questions Total 2
• Past Papers 140 µmol/l. Urine osmolality is 250 mOsmol/l. Fasting
Questions Percentage 50 %
• Random Questions plasma glucose is normal. The nurses have monitored her
urine output and found it to be 4.4 litres in 24 h. More
• My Performance
• Media Bank Which of the following statements best fits with her
condition?
• New Multimedia
Online Extras Psychiatric drugs are unlikely to have
Library played a part in her condition
Community Urine osmolality rising to > 375 Your answer
mOsmol/l 4 h after desmopressin in the
Help water deprivation test is a positive
PasTest Store result for cranial diabetes insipidus, it is
unlikely to rise in this case
Nephrogenic diabetes insipidus usually
My Account has a dominant pattern of inheritance
Profile Desmopressin in addition to her usual
Newsletters drugs is likely to be effective
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• Timed Test A 62-year-old man presents with bony pain that has been
present for some months, particularly affecting his left Questions Incorrect 0
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femur, pelvis and lower back. Blood testing reveals a Questions Total 0
• Past Papers normal serum calcium level, but a raised alkaline
Questions Percentage 0%
• Random Questions phosphatase. X-rays of the femur and pelvis reveal mixed
lytic and sclerotic change, with accentuated trabecular More
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markings. Chest X-ray is normal.
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What is the likely diagnosis?
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Online Extras Secondary carcinoma Reference: Normal Values
Library Multiple myeloma
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• Timed Test A 62-year-old man presents with bony pain that has been
present for some months, particularly affecting his left Questions Incorrect 0
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femur, pelvis and lower back. Blood testing reveals a Questions Total 1
• Past Papers normal serum calcium level, but a raised alkaline
Questions Percentage 100 %
• Random Questions phosphatase. X-rays of the femur and pelvis reveal mixed
lytic and sclerotic change, with accentuated trabecular More
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markings. Chest X-ray is normal.
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What is the likely diagnosis?
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Online Extras Secondary carcinoma
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Paget’s disease is thought to be present in 2% of the
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There are said to be three phases associated with the
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there are mixed lytic and sclerotic changes, progressing Click to open/closeBiochemistry
later to primarily sclerotic change with increasing bony Click to open/closeDiabetes Click to
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turnover, maintain the alkaline phosphatase level within open/closeBlood gases Click to
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long-term complications. The mainstay of treatment for
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this has been use of the bisphosphonates. These are
now often given as intermittent iv courses a few weeks
apart. Long-term complications include deafness (in up
to 50% of patients with skull-base Paget’s disease),
and vary rarely osteogenic sarcoma.
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• Timed Test A 32-year-old woman presents with amenorrhoea for 6
months. A pregnancy test is negative. Over the past few Questions Incorrect 0
• Mock Exam
months she has occasionally been leaking milk, and Questions Total 1
• Past Papers presents now as this has occurred more and more during
Questions Percentage 100 %
• Random Questions stimulation and intercourse and she is becoming distressed
by it. Thyroid function testing is normal. She is on no More
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medication. Her serum prolactin level is 2400 mU/l and a
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Library She is likely to have a macroprolactinoma
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• Timed Test A 32-year-old woman presents with amenorrhoea for 6
months. A pregnancy test is negative. Over the past few Questions Incorrect 0
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months she has occasionally been leaking milk, and Questions Total 2
• Past Papers presents now as this has occurred more and more during
Questions Percentage 100 %
• Random Questions stimulation and intercourse and she is becoming distressed
by it. Thyroid function testing is normal. She is on no More
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medication. Her serum prolactin level is 2400 mU/l and a
• Media Bank CT scan of the pituitary is unremarkable.
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Which of the following best fits her condition?
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macroprolactinoma
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She should be observed for 12 months
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Surgery is the best option here
A visual field defect is likely
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My Career and Exams She most likely has a microprolactinoma, which would
appear as a hypodense area on MRI scanning. Serum Reference: Normal Values
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prolactin is often in the range 1500 mU/l to 3000 mU/l
Learning Goals in patients with microadenomas; levels are usually Click to open/closeHaematology
Question Filters above 3000 mU/l in those with macroadenomas. Click to open/closeImmunoglobulins
Although surgery in conjunction with dopamine-agonist Click to open/closeBiochemistry
therapy is the treatment of choice for patients with Click to open/closeDiabetes Click to
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not usually preferable to normalisation of prolactin
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levels with dopamine agonists, if this observational
approach is taken then adequate sex-hormone
replacement should be undertaken. Of course,
normalisation of prolactin may restore fertility, and the
patient should be warned of this possibility.
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• Timed Test A 55-year-old woman presents with her husband to the endocrine clinic. She has
• Mock Exam distressing symptoms of sweating, and her husband noticed increased prominence of
her jaw when he was archiving photos from recent years. Last year she was diagnosed
• Past Papers with type-2 diabetes. Other past history of note is that she has recently been
• Random Questions operated on for carpal tunnel syndrome.
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• New Multimedia Random growth-hormone level is likely to be < 1 mU/l
Library Growth-hormone levels are likely to remain above 2 mU/l after a 75-g glucose
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• Timed Test A 55-year-old woman presents with her husband to the
endocrine clinic. She has distressing symptoms of sweating, Questions Incorrect 0
• Mock Exam
and her husband noticed increased prominence of her jaw Questions Total 3
• Past Papers when he was archiving photos from recent years. Last year
Questions Percentage 100 %
• Random Questions she was diagnosed with type-2 diabetes. Other past history
of note is that she has recently been operated on for carpal More
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tunnel syndrome.
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Which of the following most likely to fit with her
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condition?
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Library Random growth-hormone level is likely
to be < 1 mU/l
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IGF-1 levels are likely to be normal
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Growth-hormone levels are likely to Your answer
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glucose load
My Account 1-25-OH vitamin D level is invariably
normal
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Click to open/closeHaematology
Question Filters The diagnosis here is acromegaly. A random growth- Click to open/closeImmunoglobulins
hormone level of < 1 mU/l excludes the diagnosis, Click to open/closeBiochemistry
growth-hormone levels usually remain above 2 mU/l Click to open/closeDiabetes Click to
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levels of 1,25-OH vitamin D in some patients. IGF-1 is open/closeBlood gases Click to
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Sweating is present in more than 80% of cases,
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hypertension in 40%, impaired glucose tolerance in
40% and frank type-2 diabetes in 20%. Coarse facial
features including prognathism are often noticed by
patients on comparing old photographs, enlargement of
the hands and feet and soft tissue swelling are also
common features. Growth hormone-secreting pituitary
tumours are usually identified on MRI scanning and
trans-sphenoidal resection is the treatment of choice.
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• Timed Test A 32-year-old woman presents with extreme lethargy a
couple of weeks after the birth of her third child by Questions Incorrect 0
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emergency caesarean section. The reason for the caesarean Questions Total 3
• Past Papers section was severe blood loss and hypotension. She
Questions Percentage 100 %
• Random Questions complained to the health visitor of increasing problems
some 7 days earlier, but was told that this was to be More
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expected after the birth of her child. On admission via
• Media Bank casualty she was noted to have a sodium concentration of
• New Multimedia 127 mmol/l, a potassium concentration of 5.0 mmol/l and a
urea of 12 mmol/l.
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• Timed Test A 32-year-old woman presents with extreme lethargy a
couple of weeks after the birth of her third child by Questions Incorrect 0
• Mock Exam
emergency caesarean section. The reason for the caesarean Questions Total 4
• Past Papers section was severe blood loss and hypotension. She
Questions Percentage 100 %
• Random Questions complained to the health visitor of increasing problems
some 7 days earlier, but was told that this was to be More
• My Performance
expected after the birth of her child. On admission via
• Media Bank casualty she was noted to have a sodium concentration of
• New Multimedia 127 mmol/l, a potassium concentration of 5.0 mmol/l and a
urea of 12 mmol/l.
Online Extras
Library What is the likely diagnosis?
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• Timed Test A 25-year-old overweight woman presents with hirsutism and oligomenorrhoea. She
• Mock Exam has been unable to conceive for 18 months. The adrenals appear normal on
ultrasound scanning, but an ovarian ultrasound scan reveals numerous small cysts in
• Past Papers both ovaries.
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Which of the following is likely to fit best with her diagnosis?
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• Media Bank The LH/FSH ratio is likely to be normal
• New Multimedia Sex hormone-binding globulin is low in 50% of sufferers with this condition
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• Timed Test A 25-year-old overweight woman presents with hirsutism
and oligomenorrhoea. She has been unable to conceive for Questions Incorrect 0
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18 months. The adrenals appear normal on ultrasound Questions Total 5
• Past Papers scanning, but an ovarian ultrasound scan reveals numerous
Questions Percentage 100 %
• Random Questions small cysts in both ovaries.
• My Performance More
Which of the following is likely to fit best with her
• Media Bank diagnosis?
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The LH/FSH ratio is likely to be normal
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Sex hormone-binding globulin is low in Your answer
Library 50% of sufferers with this condition
Community Testosterone levels are usually normal
Help Fertility is usually unaffected by this
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DHEAS is usually normal or low
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Newsletters This is polycystic ovarian syndrome (PCOS). The
My Career and Exams prevalence of PCOS is estimated to range from 8 to
22% of women. Oligo/amenorrhoea is present in 70%, Reference: Normal Values
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hirsutism in 60%, obesity in 35% and infertility in 30%.
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Question Filters Sex hormone-binding globulin is low in 50% of Click to open/closeImmunoglobulins
sufferers. due primarily to hyperinsulinaemia. Click to open/closeBiochemistry
Testosterone and DHEAS (dehydroepiandrosterone) Click to open/closeDiabetes Click to
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PCOS may have impaired glucose tolerance, and up to open/closeBlood gases Click to
Change Password 10% frank type-2 diabetes mellitus. The insulin- open/closeCSF
resistant state is also associated with dyslipidaemia.
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Management is usually with weight loss and lifestyle
advice. Metformin is a useful treatment for insulin
resistance and may help restore fertility, although
clomifene may also be required for ovulation induction.
Local creams and electrolysis may have a useful role to
play if the primary complaint is one of hirsutism.
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• Timed Test A 38-year-old woman presents to the clinic with difficult to
treat hypertension. She is on two agents and currently has Questions Incorrect 0
• Mock Exam
a BP of 155/95 mmHg. She has noted that her face has Questions Total 5
• Past Papers become more rounded over the years and she is having
Questions Percentage 100 %
• Random Questions increasing trouble with both acne and hirsutism. Fasting
blood glucose testing has revealed impaired glucose More
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tolerance. There has also been increasing trouble with
• Media Bank abdominal obesity and she has noticed some purple
• New Multimedia stretchmarks appearing around her abdomen.
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• Timed Test A 38-year-old woman presents to the clinic with difficult to
treat hypertension. She is on two agents and currently has Questions Incorrect 0
• Mock Exam
a BP of 155/95 mmHg. She has noted that her face has Questions Total 6
• Past Papers become more rounded over the years and she is having
Questions Percentage 100 %
• Random Questions increasing trouble with both acne and hirsutism. Fasting
blood glucose testing has revealed impaired glucose More
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tolerance. There has also been increasing trouble with
• Media Bank abdominal obesity and she has noticed some purple
• New Multimedia stretchmarks appearing around her abdomen.
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My Career and Exams Cushing’s syndrome is associated with a round,
plethoric, facial appearance and weight gain – in Reference: Normal Values
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particular truncal obesity, buffalo hump and
Learning Goals supraclavicular fat pads, skin fragility, proximal muscle Click to open/closeHaematology
Question Filters weakness, mood disturbance, menstrual disturbance Click to open/closeImmunoglobulins
and reduced libido. Hypertension is present in more Click to open/closeBiochemistry
than 50% of patients, impaired glucose tolerance in Click to open/closeDiabetes Click to
Security 30%. Osteopenia and osteoporosis, and premature open/closeEndocrinology Click to
vascular disease are an inevitable consequence in open/closeBlood gases Click to
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approximately 2 per million and the disease is
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commoner in women. The disease results from
hypercortisolaemia and the cause in 68% of cases is a
pituitary adenoma producing ACTH. Ectopic ACTH
production is the cause in 12%, adrenal adenoma in
10% and adrenal carcinoma in 8%. Diagnosis is made
on the results of the 24-h urinary free-cortisol assay.
Differentiation as to the cause is carried out with the
dexamethasone-suppression test and selective venous
sampling in cases when a discrete tumour cannot be
identified on contrast-CT scanning.
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• Timed Test A 24-year-old woman presents with 13 months of
amenorrhoea. For the past few months she has been Questions Incorrect 0
• Mock Exam
experiencing hot flushes, night sweats, mood changes and Questions Total 6
• Past Papers pain on intercourse. FSH has been > 40 mIU/l on two
Questions Percentage 100 %
• Random Questions separate occasions, and her serum estradiol level is low.
TSH is normal. Fasting blood glucose is normal. Pregnancy More
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test is negative.
• Media Bank What is the most likely diagnosis?
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Premature ovarian failure
Online Extras Reference: Normal Values
Polycystic ovarian syndrome (PCOS)
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Androgen-secreting adrenal tumour Click to
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Pituitary failure
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• Timed Test A 24-year-old woman presents with 13 months of
amenorrhoea. For the past few months she has been Questions Incorrect 0
• Mock Exam
experiencing hot flushes, night sweats, mood changes and Questions Total 1
• Past Papers pain on intercourse. FSH has been > 40 mIU/l on two
Questions Percentage 100 %
• Random Questions separate occasions, and her serum estradiol level is low.
TSH is normal. Fasting blood glucose is normal. Pregnancy More
• My Performance
test is negative.
• Media Bank What is the most likely diagnosis?
• New Multimedia
Premature ovarian failure Your answer
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Polycystic ovarian syndrome (PCOS)
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Androgen-secreting adrenal tumour
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• Timed Test A 44-year-old woman has attended A&E on a number of
occasions this year because of renal tract stones. She has Questions Incorrect 0
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also suffered depression during the past year or two. She is Questions Total 1
• Past Papers found to have a serum calcium of 3.10 mmol/l (2.4–2.6),
Questions Percentage 100 %
• Random Questions creatinine of 138 µmol/l and albumin of 40 g/l.
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What is her most likely underlying diagnosis?
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• New Multimedia Hyperparathyroidism
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• Timed Test A 44-year-old woman has attended A&E on a number of occasions this year because
• Mock Exam of renal tract stones. She has also suffered depression during the past year or two.
She is found to have a serum calcium of 3.10 mmol/l (2.4–2.6), creatinine of 138
• Past Papers µmol/l and albumin of 40 g/l.
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What is her most likely underlying diagnosis?
• My Performance
• Media Bank Hyperparathyroidism Your answer
• New Multimedia Familial hypercalcaemic hypocalciuria
Online Extras Multiple endocrine neoplasia
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• Timed Test A 40-year-old man presents with a serum calcium
concentration of 3.05 mmol/l, and urinary calcium Questions Incorrect 0
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excretion of 12 mg/24 h (100-250 mg/24hr). There is no Questions Total 2
• Past Papers history of renal stones, pancreatitis, depression or any prior
Questions Percentage 100 %
• Random Questions illness. He was referred by a particularly zealous GP and
underwent parathyroidectomy. More
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• Media Bank Which of the following is true of the disease which
underlies this man's case history?
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Online Extras He has hyperparathyroidism that is likely to have Reference: Normal Values
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Urinary calcium excretion is increased Click to
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• Timed Test A 40-year-old man presents with a serum calcium
concentration of 3.05 mmol/l, and urinary calcium Questions Incorrect 0
• Mock Exam
excretion of 12 mg/24 h (100-250 mg/24hr). There is no Questions Total 3
• Past Papers history of renal stones, pancreatitis, depression or any prior
Questions Percentage 100 %
• Random Questions illness. He was referred by a particularly zealous GP and
underwent parathyroidectomy. More
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• Media Bank Which of the following is true of the disease which
underlies this man's case history?
• New Multimedia
Online Extras He has hyperparathyroidism that is
Library likely to have been cured by the surgery
Community Urinary calcium excretion is increased
Help Inheritance is autosomal dominant Your answer
PasTest Store Acute pancreatitis is commonly
associated with the condition
The body has an increased ability to
My Account sense raised calcium levels
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This is not hyperparathyroidism. This is familial Reference: Normal Values
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hypocalciuric hypercalcaemia. It has an autosomal-
Learning Goals dominant pattern of inheritance with virtually complete Click to open/closeHaematology
Question Filters penetrance. The heterozygotic state is commonly Click to open/closeImmunoglobulins
asymptomatic, but homozygotes present with severe Click to open/closeBiochemistry
hypercalcaemia soon after birth and require Click to open/closeDiabetes Click to
Security parathyroidectomy. Occasionally a subgroup of adult open/closeEndocrinology Click to
heterozygotes does present with recurrent pancreatitis open/closeBlood gases Click to
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causes a reduced ability for the calcium sensor to detect
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hypercalcaemia, so the body tolerates levels of serum
calcium that would usually be said to be outside the
normal range.
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• Timed Test A 51-year-old woman presents to her GP with polyuria,
tiredness and a finger prick glucose level of 13.0 mmol/l. Questions Incorrect 0
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According to the ADA criteria what should happen Questions Total 3
• Past Papers next?
Questions Percentage 100 %
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• My Performance She should be reassured that the result is normal More
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fasting blood test the following day to confirm the
• New Multimedia diagnosis
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Library should undergo a 2-h glucose tolerance test
A 2-h glucose tolerance test plasma glucose level of Click to
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10.5 mmol/l would confirm diabetes mellitus
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• Timed Test A 51-year-old woman presents to her GP with polyuria, tiredness and a finger prick
• Mock Exam glucose level of 13.0 mmol/l. According to the ADA criteria what should happen
next?
• Past Papers
• Random Questions She should be reassured that the result is normal
• My Performance She may have diabetes mellitus and requires a fasting blood test Your answer
• Media Bank the following day to confirm the diagnosis
• New Multimedia She probably has impaired glucose tolerance and should undergo
a 2-h glucose tolerance test
Online Extras
A 2-h glucose tolerance test plasma glucose level of 10.5 mmol/l
Library would confirm diabetes mellitus
Community A fasting plasma glucose of 7.2 mmol/l the following day would
Help suggest impaired fasting glucose
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The American Diabetes Association (ADA) criteria were developed in 1997, with a
Profile suggestion that a glucose tolerance test should be avoided, if possible, to make
diagnosis simpler and quicker. Three methods of classification of diabetes mellitus
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were developed: symptoms and a random plasma glucose of greater than or equal
My Career and Exams to 11.1 mmol/l; fasting plasma glucose of greater than or equal to 7.0 mmol/l;
Order History and 75-g oral glucose tolerance test 2-h glucose of greater than or equal to 11.1
mmol/l. These diagnostic criteria still stand the test of time today. Ideally a
Learning Goals random raised fasting plasma glucose should be confirmed with a fasting sample.
Question Filters ‘Impaired fasting glucose’ (analogous to ‘impaired glucose tolerance’), is defined as
a plasma glucose level of greater than or equal to 5.6 mmol/l and less than 7.0
mmol/l.
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• Timed Test A 26-year-old woman has been recently diagnosed with
type-1 diabetes. She has read a great deal about the Questions Incorrect 0
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prognosis of renal disease in type-1 diabetes and has a Questions Total 4
• Past Papers number of questions to ask.
Questions Percentage 100 %
• Random Questions Which of the following statements best describes the
renal disease in patients with type-1 diabetes? More
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• Media Bank Microalbuminuria usually occurs within 2 years of the
• New Multimedia diagnosis of type-1 diabetes
Online Extras Peak incidence of frank albuminuria is 17 years after Reference: Normal Values
the diagnosis of type-1 diabetes
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After the serum creatinine level reaches 200 µmol/l, Click to
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• Timed Test A 26-year-old woman has been recently diagnosed with
type-1 diabetes. She has read a great deal about the Questions Incorrect 1
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prognosis of renal disease in type-1 diabetes and has a Questions Total 5
• Past Papers number of questions to ask.
Questions Percentage 80 %
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renal disease in patients with type-1 diabetes? More
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• Media Bank Microalbuminuria usually occurs
• New Multimedia within 2 years of the diagnosis of
type-1 diabetes
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Peak incidence of frank albuminuria Correct answer
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reaches 200 µmol/l, a fall in GFR of
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0.5 ml/min per month might be
expected
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occurs within 5 years of the onset of
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In type-1 diabetes microalbuminuria usually occurs 5– Click to open/closeDiabetes Click to
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once the serum creatinine level has reached around 200
µmol/l.Traditionally, end-stage renal failure is said to
occur some 7–10 years after a diagnosis of albuminuria,
but it is hoped that improved management of
hyperglycaemia and hypertension may stretch this
period a little. Unfortunately, nephropathy carries a 20–
100 times higher mortality than that for age- and sex-
matched controls: 40% of deaths of patients with
nephropathy is due to cardiovascular disease.
1410
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• Timed Test A 70-year-old man is brought unconscious to the emergency department, his blood
• Mock Exam sugar level is 70 mmol/l. There is no evidence of ketoacidosis. His chest X-ray reveals
evidence of left-sided consolidation.
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• Random Questions What is the most likely diagnosis?
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Simple pneumonia
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A complication of type-1 diabetes
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A complication of type-2 diabetes
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• Timed Test A 70-year-old man is brought unconscious to the
emergency department, his blood sugar level is 70 mmol/l. Questions Incorrect 1
• Mock Exam
There is no evidence of ketoacidosis. His chest X-ray Questions Total 6
• Past Papers reveals evidence of left-sided consolidation.
Questions Percentage 83 %
• Random Questions
What is the most likely diagnosis? More
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• Media Bank Simple pneumonia
• New Multimedia A complication of type-1 diabetes
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• Timed Test A 65-year-old obese woman who has had type-2 diabetes for 4 years presents to the
• Mock Exam clinic for her annual review. Her current medication is metformin 2 g/day. You decide
to add in gliclazide 80 mg po bd because of poor control as her Hb A 1c is 8.5%.
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• Random Questions Which of the following best describes sulphonylureas?
• My Performance
In the UKPDS study they demonstrated no effects on microvascular outcome
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In the UKPDS study they demonstrated no effect on macrovascular outcome
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In the UKPDS study they demonstrated positive effects on macrovascular
Online Extras outcome
Library Mild hypoglycaemia in response to sulphonylurea therapy is rare
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• Timed Test A 65-year-old obese woman who has had type-2 diabetes for 4 years presents to the
• Mock Exam clinic for her annual review. Her current medication is metformin 2 g/day. You decide
to add in gliclazide 80 mg po bd because of poor control as her Hb A 1c is 8.5%.
• Past Papers
• Random Questions Which of the following best describes sulphonylureas?
• My Performance
In the UKPDS study they demonstrated no effects on
• Media Bank microvascular outcome
• New Multimedia In the UKPDS study they demonstrated no effect on Correct answer
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Library In the UKPDS study they demonstrated positive effects on Your answer
macrovascular outcome
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Mild hypoglycaemia in response to sulphonylurea therapy is
Help rare
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Newsletters Although sulphonylurea therapy was proven by the UKPDS study to have
microvascular benefits, no benefit on macrovascular outcome (cardiovascular
My Career and Exams disease) was demonstrated: this was, of course, in contrast to metformin.
Order History Sulphonylureas work by stimulating insulin release from pancreatic beta cells and
are associated with mild hypoglycaemia in up to 16% of users, although
Learning Goals hypoglycaemia may be less frequent when short-acting compounds are used.
Question Filters Certain groups of people (the elderly and those with renal impairment) may be at
a higher risk of hypoglycaemia. Sulphonylureas have no effect on insulin
resistance.
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• Timed Test A 56-year-old, highly insulin resistant, type-2 diabetes
sufferer has been taking 200 units total daily dose of sc Questions Incorrect 2
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insulin per day. His weight is increasing and his control Questions Total 7
• Past Papers worsening, with an Hb A 1C of 9.1%. You add in pioglitazone
Questions Percentage 71 %
• Random Questions 30 mg to his insulin. Some 4 weeks later he presents to
• My Performance the emergency department in heart failure. More
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• New Multimedia pioglitazone therapy?
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Library directly toxic effect on the myocardium
Click to
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sensitising effects than metformin Click to
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taking glitazones due to fluid retention
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• Timed Test A 56-year-old, highly insulin resistant, type-2 diabetes
sufferer has been taking 200 units total daily dose of sc Questions Incorrect 2
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insulin per day. His weight is increasing and his control Questions Total 8
• Past Papers worsening, with an Hb A 1C of 9.1%. You add in pioglitazone
Questions Percentage 75 %
• Random Questions 30 mg to his insulin. Some 4 weeks later he presents to
• My Performance the emergency department in heart failure. More
• Media Bank Which of the following statements best describes
• New Multimedia pioglitazone therapy?
Online Extras Pioglitazone causes heart failure by
Library exerting a directly toxic effect on the
myocardium
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Pioglitazone has no more peripheral
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insulin-sensitising effects than
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Troglitazone and pioglitazone have
My Account similar profiles of hepatotoxicity
Heart failure may be precipitated in Your answer
Profile some patients taking glitazones due to
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the PPAR- α receptor Reference: Normal Values
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There is currently one glitazone (insulin sensitisers) Click to open/closeDiabetes Click to
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at the site of the PPAR- γ receptor, promoting the open/closeBlood gases Click to
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transcription of genes predominantly linked to fatty acid
Sign Out metabolism. Fibrates, and some newer dual agonists
currently in development, have activity at the PPAR- α
receptor site. Fluid retention may be precipitated by
these drugs, which may (in less than 1% of users)
precipitate heart failure. Experimental evidence has
demonstrated that these drugs actually improve
myocardial blood flow and glucose utilisation. Metformin
acts primarily by affecting hepatic insulin resistance,
whereas pioglitazone acts by improving insulin
sensitivity and peripheral glucose uptake in skeletal
muscle and fat. Troglitazone has been withdrawn due to
liver side-effects.
1413
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• Timed Test A 17-year-old young woman presents to the emergency department with a blood
• Mock Exam glucose of 29 mmol/l. She is known to have type-1 diabetes. Her pH is 7.12 with a
serum bicarbonate of 11 mmol/l. There is ketonuria.
• Past Papers
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in DKA?
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• Media Bank Myocardial infarction may be the precipitating factor in up to 5% of cases of
• New Multimedia DKA
Online Extras Infection may be the precipitating cause in 60% of cases of DKA
Library The patient is not previously known to have diabetes in 30% of DKA cases
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• Timed Test A 17-year-old young woman presents to the emergency
department with a blood glucose of 29 mmol/l. She is Questions Incorrect 3
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known to have type-1 diabetes. Her pH is 7.12 with a Questions Total 9
• Past Papers serum bicarbonate of 11 mmol/l. There is ketonuria.
Questions Percentage 66 %
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Which of the following statements best fits the More
• My Performance predisposing factors involved in DKA?
• Media Bank
• New Multimedia Myocardial infarction may be the
precipitating factor in up to 5% of
Online Extras cases of DKA
Library Infection may be the precipitating Your answer
Community cause in 60% of cases of DKA
Help The patient is not previously known
to have diabetes in 30% of DKA
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Non-compliance with treatment is Correct answer
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Inappropriate alterations to insulin
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are the cause in 20% of DKA cases
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Click to open/closeHaematology
Question Filters (DKA) is infection (30–40%). This is closely followed by
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non-compliance with treatment (25%), alterations to
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insulin dose (13%), newly diagnosed diabetes (10–
Click to open/closeDiabetes Click to
Security 20%) and myocardial infarction (< 1%). The condition
open/closeEndocrinology Click to
is characterised by hyperglycaemia, acidosis and
open/closeBlood gases Click to
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EURODIAB study reporting hospitalisation over the
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period of a year. DKA is caused by insulin deficiency and
counter-regulatory hormone excess. The mortality rate
is 2–5%, but up to 50% in more elderly patients.
1414
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• Timed Test A 36-year-old woman who is 28 weeks pregnant attends
the midwife clinic for a pregnancy check. She is noted to Questions Incorrect 3
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have glycosuria and has a BMI of 30 You understand her Questions Total 9
• Past Papers mother has Type-2 diabetes.
Questions Percentage 66 %
• Random Questions What is her correct management plan?
• My Performance More
Observe and follow up in 4 weeks time with repeat
• Media Bank urine glucose testing
• New Multimedia Carry out a fasting blood glucose; if it is less than 7.0
Online Extras mmol/l then repeat the sample in 4 weeks’ time Reference: Normal Values
Library Carry out a fasting blood glucose; if it is over 5.5
mmol/l then proceed to administer a 75-g oral glucose Click to
Community tolerance test open/closeHaematology
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mmol/l then proceed to administer a 75-g oral glucose open/closeImmunoglobulins
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tolerance test Click to
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Proceed directly to administer an oral glucose Click to open/closeDiabetes
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• Timed Test A 36-year-old woman who is 28 weeks pregnant attends
the midwife clinic for a pregnancy check. She is noted to Questions Incorrect 3
• Mock Exam
have glycosuria and has a BMI of 30 You understand her Questions Total 10
• Past Papers mother has Type-2 diabetes.
Questions Percentage 70 %
• Random Questions What is her correct management plan?
• My Performance More
Observe and follow up in 4 weeks time
• Media Bank with repeat urine glucose testing
• New Multimedia Carry out a fasting blood glucose; if it
Online Extras is less than 7.0 mmol/l then repeat the
sample in 4 weeks’ time
Library
Carry out a fasting blood glucose; if it Your answer
Community is over 5.5 mmol/l then proceed to
Help administer a 75-g oral glucose tolerance
test
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Carry out a fasting blood glucose; it is
over 7.0 mmol/l then proceed to
My Account administer a 75-g oral glucose tolerance
test
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Proceed directly to administer an oral
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Click to open/closeHaematology
Question Filters A glucose tolerance test is required if the patient’s Click to open/closeImmunoglobulins
fasting blood glucose level is over 5.5 mmol/l. Diabetes Click to open/closeBiochemistry
is defined as a fasting level of > 7.0 mmol/l or > 11.0 Click to open/closeDiabetes Click to
Security mmol/l 2 h after a glucose tolerance test. Gestational open/closeEndocrinology Click to
impaired glucose tolerance (IGT) is defined as a fasting open/closeBlood gases Click to
Change Password blood glucose level of 6.0–7.8 mmol/l and/or a 2-h level open/closeCSF
Sign Out of 9–11 mmol/l. Although initial treatment for
gestational diabetes is with dietary advice, insulin is
also required in 10–30% of cases. Insulin should be
considered for those with fasting levels above 6.0
mmol/l after dietary intervention, or postprandial sugar
levels above 8.0 mmol/l. Untreated gestational diabetes
is said to carry a perinatal mortality rate of 4.4–6.4%,
compared to 0.5–1.5% in a similarly matched
normoglycaemic population: hence, good glycaemic
control is essential for this reason.
1415
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• Timed Test A 28-year-old mature student nurse is admitted from the
emergency department, where she is on placement, having Questions Incorrect 0
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suffered a collapse. Her blood sugar was noted to be 1.5 Questions Total 1
• Past Papers mmol/l and she responded to 50 ml of 50% iv dextrose.
Questions Percentage 100 %
• Random Questions After a second collapse, her insulin level was raised without
a similar rise in c-peptide, her glucose level was 1.9 More
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mmol/l.
• Media Bank What is the most appropriate next investigation?
• New Multimedia
A 3-day fast in an attempt to precipitate a further
Online Extras attack Reference: Normal Values
Library Audit of insulin stocks that she has had access to
Click to
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• Timed Test A 28-year-old mature student nurse is admitted from the
emergency department, where she is on placement, having Questions Incorrect 0
• Mock Exam
suffered a collapse. Her blood sugar was noted to be 1.5 Questions Total 2
• Past Papers mmol/l and she responded to 50 ml of 50% iv dextrose.
Questions Percentage 100 %
• Random Questions After a second collapse, her insulin level was raised without
a similar rise in c-peptide, her glucose level was 1.9 More
• My Performance
mmol/l.
• Media Bank What is the most appropriate next investigation?
• New Multimedia
A 3-day fast in an attempt to
Online Extras precipitate a further attack
Library Audit of insulin stocks that she has had Your answer
Community access to
Help Alcohol history
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Discharge the patient
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The clue is the fact that her insulin level was raised
My Career and Exams without a corresponding rise in c-peptide. This
Order History essentially rules out insulinoma, and suggests that the Reference: Normal Values
patient is either injecting excess insulin herself or is
Learning Goals taking sulphonylureas. In fact, on further questioning Click to open/closeHaematology
Question Filters her aunt has type-2 diabetes, she has been struggling Click to open/closeImmunoglobulins
with her studies and taking sulphonylureas to Click to open/closeBiochemistry
precipitate the attacks as a ‘cry for help’. Standard Click to open/closeDiabetes Click to
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blood glucose (not test strips) measurement, liver open/closeBlood gases Click to
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testing, insulin and c-peptide levels taken during an
attack as well as a chest X-ray to exclude occult
malignancy.
1416
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• Timed Test A 68-year-old man attends his GP on the insistence of his
wife because his left forefoot has become increasingly Questions Incorrect 0
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unstable and abnormally shaped with bony swelling. He has Questions Total 2
• Past Papers a long history of diabetes mellitus and his control has been
Questions Percentage 100 %
• Random Questions erratic, with Hb A 1c in the range of 9–10%.
• My Performance More
Which of the following pieces of information best fits
• Media Bank the pathology or management of Charcot’s foot?
• New Multimedia
Tight glucose control is unlikely to be of benefit in
Online Extras this condition Reference: Normal Values
Library Reduction of oedema is unimportant with respect to Click to
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this condition
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The pathology of this condition is thought to be due Click to
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the joint and osteoclast activity Click to open/closeBlood
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• Timed Test A 68-year-old man attends his GP on the insistence of his
wife because his left forefoot has become increasingly Questions Incorrect 0
• Mock Exam
unstable and abnormally shaped with bony swelling. He has Questions Total 3
• Past Papers a long history of diabetes mellitus and his control has been
Questions Percentage 100 %
• Random Questions erratic, with Hb A 1c in the range of 9–10%.
• My Performance More
Which of the following pieces of information best fits
• Media Bank the pathology or management of Charcot’s foot?
• New Multimedia
Tight glucose control is unlikely to be
Online Extras of benefit in this condition
Library Reduction of oedema is unimportant
Community with respect to preventing deterioration
Help Orthotic shoes are unnecessary in the
management of this condition
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Plain radiography is always abnormal,
even early in this condition
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The pathology of this condition is Your answer
Profile thought to be due to sympathetic
dysfunction, excessive blood flow to the
Newsletters joint and osteoclast activity
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Click to open/closeHaematology
Question Filters This man has a Charcot left foot. This is a rare condition Click to open/closeImmunoglobulins
now, with the average general hospital clinic seeing a Click to open/closeBiochemistry
maximum of 10 Charcot’s patients. Chronic untreated Click to open/closeDiabetes Click to
Security Charcot’s foot results in either ‘rocker-bottom’ foot due open/closeEndocrinology Click to
to downward displacement and subluxation of the open/closeBlood gases Click to
Change Password tarsus, or medial convexity due to talonavicular joint open/closeCSF
Sign Out displacement or dislocation of the tarsometatarsal
joints. Management involves tight glycaemic control,
reduction of oedema and orthotic and chiropody
involvement. Intravenous bisphosphonate treatment
may be of benefit in some patients. Although plain
radiographs may be normal in the early stages of the
disease, they later show joint destruction, osteolysis,
joint reorganisation and subluxation.
1417
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• Timed Test A 56-year-old patient on gliclazide for his type-2 diabetes
presents with an acute, central, crushing chest pain. He is Questions Incorrect 0
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diagnosed with myocardial infarction. Questions Total 3
• Past Papers
Which of the following best fits the outcome or Questions Percentage 100 %
• Random Questions
management of myocardial infarction associated with More
• My Performance type-2 diabetes?
• Media Bank
• New Multimedia The mortality rate from myocardial infarction in
patients with type-2 diabetes is the same as that for
Online Extras non-diabetics Reference: Normal Values
Library Intravenous insulin followed by sc insulin after MI
reduces mortality by 11% at 3.5 years compared to Click to
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controls
Help Click to
Use of ACE inhibition after MI improves the 6-week open/closeImmunoglobulins
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• Timed Test A 56-year-old patient on gliclazide for his type-2 diabetes
presents with an acute, central, crushing chest pain. He is Questions Incorrect 0
• Mock Exam
diagnosed with myocardial infarction. Questions Total 4
• Past Papers
Which of the following best fits the outcome or Questions Percentage 100 %
• Random Questions
management of myocardial infarction associated with More
• My Performance type-2 diabetes?
• Media Bank
• New Multimedia The mortality rate from myocardial
infarction in patients with type-2
Online Extras diabetes is the same as that for non-
Library diabetics
Community Intravenous insulin followed by sc
insulin after MI reduces mortality by
Help 11% at 3.5 years compared to controls
PasTest Store Use of ACE inhibition after MI improves
the 6-week mortality rate by 50%
My Account Statins should always be started unless Your answer
they are contra-indicated
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Blood pressure target should be
Newsletters 150/80 mmHg
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Click to open/closeHaematology
Question Filters Diabetics may be up to twice as likely to die from
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myocardial infarction as non-diabetics, and are more
Click to open/closeBiochemistry
likely to suffer an MI in the first place. The DIGAMI
Click to open/closeDiabetes Click to
Security study used iv insulin for 24 h followed by sc insulin for
open/closeEndocrinology Click to
patients who had suffered an MI. Risk reductions
open/closeBlood gases Click to
Change Password equalled 7.5% at 1 year and 11% at 3.5 years
open/closeCSF
compared to controls. There is now significant doubt
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about this result as the study was repeated in the
DIGAMI-2 study. This showed no advantage in terms of
cardiac outcomes for patients treated for a prolonged
period with insulin. Use of ACE inhibitors (GISSI-3
Diabetic Subgroup Study) is associated with a 30%
relative-risk reduction in the 6-week mortality rate
(8.7% vs 12.4%). Blood pressure reduction should be
aggressively targeted, aiming for 130/80 mmHg, and all
patients with diabetes who are over 40 years of age
should be started on statin treatment unless there is a
contraindication, (Joint British Societies Guidelines).
1418
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• Timed Test A 51-year-old patient on metformin and gliclazide for his
type-2 diabetes presents for review. He has a BMI of 31 Questions Incorrect 0
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and his blood pressure is 158/92 mmHg. Questions Total 4
• Past Papers
When considering hypertension in type-2 diabetes, Questions Percentage 100 %
• Random Questions
which of the following statements best fits the More
• My Performance condition?
• Media Bank
• New Multimedia Development of hypertension is strongly linked to a
genetically inherited variant of red cell sodium–lithium
Online Extras counter-transport activity Reference: Normal Values
Library Good hypertensive control has a weaker effect on
macrovascular outcomes than good tight glucose Click to
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control
Help Click to
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• Timed Test A 51-year-old patient on metformin and gliclazide for his
Questions Incorrect 1
• Mock Exam type-2 diabetes presents for review. He has a BMI of 31
and his blood pressure is 158/92 mmHg. Questions Total 5
• Past Papers
Questions Percentage 80 %
• Random Questions When considering hypertension in type-2 diabetes,
which of the following statements best fits the More
• My Performance condition?
• Media Bank
• New Multimedia Development of hypertension is Your answer
strongly linked to a genetically
Online Extras inherited variant of red cell sodium–
Library lithium counter-transport activity
Community Good hypertensive control has a
weaker effect on macrovascular
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Hypertension in type-2 diabetes is Correct answer
primarily associated with
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• Timed Test A 52-year-old man is sent by his GP for an urgent review.
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type-2 diabetes. For the past week or so he has had Questions Total 0
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type-2 diabetes. For the past week or so he has had Questions Total 1
• Past Papers feelings of severe aching pain and paraesthesias in his
Questions Percentage 0%
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and has begun losing weight. There is also proximal muscle More
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Recovery from this condition usually Your answer
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The condition is much more
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sensory proximal neuropathy said to cause severe pain, Click to open/closeDiabetes Click to
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pathology
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Estimates say that 20% of men with diabetes
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Questions Percentage 50 %
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Which of the following statements is most strongly More
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to physical pathology
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Estimates say that 20% of men with
Library diabetes mellitus of more than 6 years’
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Penile pain is a common association
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Libido is rarely affected, which makes the condition all Reference: Normal Values
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autonomic neuropathies such as postural hypotension Click to open/closeBiochemistry
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• Timed Test A 54-year-old woman presents to the diabetes clinic for
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Questions Percentage 50 %
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few months and has mild anaemia. Ultrasound scan of her
• Media Bank liver reveals a suggestion of a number of small metastases
• New Multimedia within the liver.
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years and has now progressed from sulphonylurea Questions Total 3
• Past Papers treatment to insulin therapy. A past history of gallstones is
Questions Percentage 66 %
• Random Questions noted and she failed to tolerate metformin due to chronic
diarrhoea. She has been slowly losing weight over the past More
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few months and has mild anaemia. Ultrasound scan of her
• Media Bank liver reveals a suggestion of a number of small metastases
• New Multimedia within the liver.
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GP is thinking about insulin therapy. A normochromic, Questions Total 3
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Questions Percentage 66 %
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rash in her groin, which extends to her lower limbs, More
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GP is thinking about insulin therapy. A normochromic, Questions Total 4
• Past Papers normocytic anaemia is noted. On examination she has
Questions Percentage 75 %
• Random Questions angular stomatitis and a well-demarcated erythematous
rash in her groin, which extends to her lower limbs, More
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buttocks and perineum.
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What is the next step in her management?
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Measure plasma somatostatin levels
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My Career and Exams glucagonoma, 90% of which are associated with the
characteristic skin rash – necrolytic migratory Reference: Normal Values
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erythema. The annual incidence of glucagonoma is
Learning Goals estimated at 1 in 20 million. Over 70% of glucagonomas Click to open/closeHaematology
Question Filters are malignant, but, because of their indolent Click to open/closeImmunoglobulins
presentation, the diagnosis is often overlooked for many Click to open/closeBiochemistry
years. Due to insulin antagonism over 90% are Click to open/closeDiabetes Click to
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many years prior to presentation. Octreotide improves
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the skin rash but may have a detrimental effect on
glucose control; combination chemotherapy with
streptazocin and 5-fluoruracil (5-FU) gives good
palliative results, as does hepatic embolisation.
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• Timed Test A 52-year-old woman is referred for opinion, she has been
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weight, her GP is thinking about insulin therapy. A Questions Total 4
• Past Papers normochromic, normocytic anaemia is noted. On
Questions Percentage 75 %
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demarcated erythematous rash in her groin, extending to More
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her lower limbs, buttocks and perineum.
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Online Extras Poorly controlled type-2 diabetes Reference: Normal Values
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• Timed Test A 52-year-old woman is referred for opinion, she has been diagnosed with type-2
• Mock Exam diabetes mellitus and is losing weight, her GP is thinking about insulin therapy. A
normochromic, normocytic anaemia is noted. On examination she has angular
• Past Papers stomatitis and a well-demarcated erythematous rash in her groin, extending to her
• Random Questions lower limbs, buttocks and perineum.
• My Performance What is the underlying diagnosis?
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• New Multimedia Poorly controlled type-2 diabetes
Library Somatostatinoma
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The skin rash, necrolytic migratory erythema, glucose intolerance, a
Profile normochromic, normocytic anaemia, weight loss and angular stomatitis are all
highly suggestive of glucagonoma. The annual incidence of glucagonoma is
Newsletters estimated at 1/20 million. Over 70% of glucagonomas are malignant, but because
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Due to insulin antagonism over 90% are associated with impaired glucose
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tolerance, and eventually weight loss due to protein catabolism. Surgical cure rate
Learning Goals is as low as 5%, as metastases occur many years prior to presentation. Octreotide
Question Filters improves the skin rash but may have a detrimental effect on glucose control;
combination chemotherapy with streptazocin and 5-fluoruracil (5-FU) gives good
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• Timed Test A 36-year-old man is referred after his first myocardial
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of 9.5 mmol/l, with normal triglycerides. You note the Questions Total 5
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• Timed Test A 36-year-old man is referred after his first myocardial
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of 9.5 mmol/l, with normal triglycerides. You note the Questions Total 6
• Past Papers presence of corneal arcus and tendon xanthomas.
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Which of the following genetic factors is not likely to More
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Familial hypercholesterolaemia is associated with an
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affinity, low-density lipoprotein (LDL) receptors by up to Reference: Normal Values
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50%. Over 300 mutations have been described so far
Learning Goals and they may be a combination of any of options B–E. Click to open/closeHaematology
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(CHD) and have a standardised mortality ratio of up to Click to open/closeBiochemistry
nine times that of age- and sex-matched controls. Click to open/closeDiabetes Click to
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• Timed Test A 31-year-old man presents with acute pancreatitis. This is
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follow him up in clinic, and find he has a markedly elevated Questions Total 1
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Questions Percentage 100 %
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Which of the following statements best fits his
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Usually improved by thiazide diuretics
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Usually improved by glucocorticoids
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Usually improved by alcohol Click to
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• Timed Test A 31-year-old man presents with acute pancreatitis. This is
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follow him up in clinic, and find he has a markedly elevated Questions Total 2
• Past Papers triglyceride fraction and hypercholesterolaemia, but with
Questions Percentage 100 %
• Random Questions HDL and LDL cholesterol within the normal range.
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Which of the following statements best fits his
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Usually improved by thiazide diuretics
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Usually improved by glucocorticoids
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Usually improved by alcohol
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Has an autosomal-recessive mode of
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This is familial hypertriglyceridaemia, an autosomal-
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• Past Papers overweight and has sleep apnoea. On examination you
Questions Percentage 100 %
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some evidence of hair loss. More
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Screening of family members for
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factor clinic. Her total cholesterol is 9.0 mmol/l. She is Questions Total 3
• Past Papers overweight and has sleep apnoea. On examination you
Questions Percentage 100 %
• Random Questions notice her skin is particularly dry and there appears to be
some evidence of hair loss. More
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• Media Bank What is the next step in her management?
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Screening of family members for
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The suspicion with the history of dry skin, hair loss,
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is said to occur in 4% of patients with dyslipidaemias,
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Question Filters a raised TSH level, but with a free T 4 still within the Click to open/closeImmunoglobulins
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• Timed Test You review a 67-year-old man in the lipid clinic. He is
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drugs should be used with caution? Questions Total 3
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Questions Percentage 100 %
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Online Extras Antifungals Reference: Normal Values
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• Timed Test You review a 67-year-old man in the lipid clinic. He is
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drugs should be used with caution? Questions Total 4
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Questions Percentage 75 %
• Random Questions Warfarin
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with atorvastatin and simvastatin. Antacid and
antifungal agents are known to interact with
My Account atorvastatin. Erythromycin has known interactions with
simvastatin, fluvastatin, atorvastatin and pravastatin.
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and should be used with caution in patients on fibrate
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therapy as the risk of rhabdomyolysis may be increased.
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• Timed Test The presence of galactorrhoea is MOST suggestive of
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Questions Total 4
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Turner’s syndrome Questions Percentage 75 %
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Polycystic ovary disease
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Hypothyroidism
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Sheehan’s syndrome
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• Timed Test The presence of galactorrhoea is MOST suggestive of
which one of the following conditions? Questions Incorrect 1
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Questions Total 5
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Turner’s syndrome Questions Percentage 80 %
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Polycystic ovary disease
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Hypothyroidism Your answer
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Galactorrhoea is nonpuerperial expression of milk.
Help Hyperprolactinaemia causes galactorrhoea and
PasTest Store amenorrhoea, which may result from a prolactin
secreting pituitary tumour or hyperplasia.
Hypothyroidism is a cause of raised prolactin levels. In
My Account acromegaly one-third of patients have mild elevation of
prolactin levels resulting in galactorrhoea, amenorrhoea
Profile and decreased libido. Similar elevation of prolactin
Newsletters levels occurs in a small percentage of patients with
primary hypothyroidism. Sheehan’s syndrome is a
My Career and Exams primary hypopituitarism due to ischaemic necrosis of
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it is characterised by failure of postpartum lactation and
Learning Goals failure to resume normal cyclic menstruation. Turner’s Click to open/closeHaematology
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• Timed Test Which one of the following proteins is most likely to
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chylomicrons? Questions Total 5
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Questions Correct 5
• Timed Test Which one of the following proteins is most likely to
be associated with very high levels of plasma Questions Incorrect 1
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chylomicrons? Questions Total 6
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Questions Percentage 83 %
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• My Performance Apoprotein CII Your answer More
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PasTest Store Dietary triglycerides in cholesterol are packaged by
gastrointestinal epithelial cells into large lipoprotein
particles called chylomicrons. After secretion into the
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circulation, chylomicrons bind to the enzyme lipoprotein
Profile lipase, which is located on endothelial surfaces. This
enzyme is activated by a protein contained in the
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chylomicron, apoprotein CII, liberating free fatty acids
My Career and Exams and monoglycerides, which then pass through the
Order History endothelial cells and enter adipocyte or muscle cells. Reference: Normal Values
Therefore, complete inactivation of either lipoprotein
Learning Goals lipase or apoprotein CII as a result of the inheritance of Click to open/closeHaematology
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accumulation of chylomicrons (type I lipoprotein Click to open/closeBiochemistry
elevation) owing to failure of conversion to the Click to open/closeDiabetes Click to
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resulting from triglyceride deposition. Treatment should
consist of a low-fat diet that may be supplemented by
medium-chain triglycerides, which are not incorporated
into chylomicrons. The absence of functional apoprotein
CII, with consequent failure to activate lipoprotein
lipase, presents with a similar phenotype, although the
affected patients are typically detected at a somewhat
later age than are patients with familial lipoprotein
lipase deficiency.
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• Timed Test A 65-year-old woman known to have chronic low back pain
notices severe sharp pain in the left groin after a minor fall Questions Incorrect 1
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and is unable to walk. Left neck of femur fracture is Questions Total 6
• Past Papers identified on radiological examination. Routine laboratory
Questions Percentage 83 %
• Random Questions evaluation discloses a serum calcium concentration of 1.9
mmol/l, a serum phosphorus concentration of 0.68 mmol/l More
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and increased serum alkaline phosphatase activity. The
• Media Bank serum parathyroid hormone level was subsequently found
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Questions Correct 6
• Timed Test A 65-year-old woman known to have chronic low back pain
notices severe sharp pain in the left groin after a minor fall Questions Incorrect 1
• Mock Exam
and is unable to walk. Left neck of femur fracture is Questions Total 7
• Past Papers identified on radiological examination. Routine laboratory
Questions Percentage 85 %
• Random Questions evaluation discloses a serum calcium concentration of 1.9
mmol/l, a serum phosphorus concentration of 0.68 mmol/l More
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and increased serum alkaline phosphatase activity. The
• Media Bank serum parathyroid hormone level was subsequently found
• New Multimedia to be elevated. The most likely diagnosis is?
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The combination of hypocalcaemia and
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hypophosphataemia points to the diagnosis of
My Career and Exams osteomalacia and vitamin D deficiency. Dietary
Order History deficiency and malabsorption are common causes of Reference: Normal Values
vitamin D deficiency. Primary hyperparathyroidism and
Learning Goals hypervitaminosis D are associated with hypercalcaemia Click to open/closeHaematology
Question Filters rather than hypocalcaemia. Paget’s disease is Click to open/closeImmunoglobulins
associated with increased risk of fracture and increased Click to open/closeBiochemistry
serum alkaline phosphatase activity, but the serum Click to open/closeDiabetes Click to
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• Timed Test In glucagonoma the MOST likely associated skin
lesion is? Questions Incorrect 1
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Questions Total 7
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Erythema chronicum migrans Questions Percentage 85 %
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Acanthosis nigricans
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Necrolytic migratory erythema
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• Timed Test In glucagonoma the MOST likely associated skin
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Questions Total 8
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Erythema chronicum migrans Questions Percentage 87 %
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Acanthosis nigricans
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Necrolytic migratory erythema Your answer
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Help Glucagonoma syndrome (diabetes mellitus, weight loss
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rash (necrolytic migratory erythema) in 75% of cases.
The lesion starts as an indurated erythema at the
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cover the surface of the skin which then crust and heal
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days with lesions developing in one area while others
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are resolving.
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• Timed Test A 23-year-old woman presents to her GP after the birth of
her second child. She complains of extreme tiredness and a Questions Incorrect 1
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persistent hoarse voice that she is having problems shaking Questions Total 8
• Past Papers off. Despite breast-feeding her child she is failing to lose
Questions Percentage 87 %
• Random Questions her pregnancy weight. Thyroid autoantibodies are negative.
Her TSH is 12 mU/l, with a free T 4 of 5 pmol/l. There is no More
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thyroid tenderness on examination. Her GP notes that her
• Media Bank pulse is only 52 beats per minute.
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What diagnosis fits best with this clinical picture?
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• Timed Test A 23-year-old woman presents to her GP after the birth of
her second child. She complains of extreme tiredness and a Questions Incorrect 1
• Mock Exam
persistent hoarse voice that she is having problems shaking Questions Total 9
• Past Papers off. Despite breast-feeding her child she is failing to lose
Questions Percentage 88 %
• Random Questions her pregnancy weight. Thyroid autoantibodies are negative.
Her TSH is 12 mU/l, with a free T 4 of 5 pmol/l. There is no More
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thyroid tenderness on examination. Her GP notes that her
• Media Bank pulse is only 52 beats per minute.
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What diagnosis fits best with this clinical picture?
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This woman is hypothyroid after the birth of her second
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Order History has no signs of autoimmune disease, which might Reference: Normal Values
suggest atrophic hypothyroidism were they present (eg
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• Timed Test A 57-year-old woman presents with a feeling of shortness
of breath and choking on lying down. Some 4 months Questions Incorrect 1
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earlier she had been diagnosed with atrial fibrillation and Questions Total 9
• Past Papers was started on aspirin and digoxin by her GP. On
Questions Percentage 88 %
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confirmed retrosternal extension, which was presumed to More
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be contributing to her shortness of breath. Her TSH level
• Media Bank was less than 0.05 mU/l. Thyroid autoantibodies were
• New Multimedia negative.
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• Timed Test A 57-year-old woman presents with a feeling of shortness
of breath and choking on lying down. Some 4 months Questions Incorrect 1
• Mock Exam
earlier she had been diagnosed with atrial fibrillation and Questions Total 10
• Past Papers was started on aspirin and digoxin by her GP. On
Questions Percentage 90 %
• Random Questions examination her GP could feel a goitre. Plain radiography
confirmed retrosternal extension, which was presumed to More
• My Performance
be contributing to her shortness of breath. Her TSH level
• Media Bank was less than 0.05 mU/l. Thyroid autoantibodies were
• New Multimedia negative.
Online Extras What diagnosis best fits with this clinical picture?
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Hashimoto’s thyroiditis
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My Career and Exams Toxic multinodular goitre usually occurs in women over
55 years of age and is more common than Grave’s Reference: Normal Values
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disease in the elderly. Her atrial fibrillation may well be
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• Timed Test A 62-year-old man presents for review some 3 months
after first being diagnosed with type-2 diabetes. His BMI is Questions Incorrect 1
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30. Despite having lost about 7 kg in weight, his morning Questions Total 10
• Past Papers blood sugars are still around 9 mmol/l; an Hb A 1C check
Questions Percentage 90 %
• Random Questions was 8.9%. He is hypertensive and taking ramipril, his
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• Timed Test A 62-year-old man presents for review some 3 months
after first being diagnosed with type-2 diabetes. His BMI is Questions Incorrect 1
• Mock Exam
30. Despite having lost about 7 kg in weight, his morning Questions Total 11
• Past Papers blood sugars are still around 9 mmol/l; an Hb A 1C check
Questions Percentage 90 %
• Random Questions was 8.9%. He is hypertensive and taking ramipril, his
• My Performance triglycerides are raised and his HDL cholesterol is low. More
• Media Bank Which therapy for his diabetes would be the best
• New Multimedia initial choice for his hyperglycaemia?
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the metabolic syndrome, is metformin. This drug
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should be introduced at a dose of 500 mg per day,
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was not found in the sulphonylurea or insulin group).
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Metformin is a partial insulin sensitiser that works to
reduce hepatic glucose output and also has some
anti-inflammatory action, showing positive effects on
plasminogen-activator inhibitor-1 (PAI-1) in
particular. PAI-1 is associated with an increased
tendency to blood clotting and may be associated with
an increased vascular risk in sufferers of the
metabolic syndrome.
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• Timed Test A 57-year-old man, with a BMI of 30 and a history of
hypertension, dyslipidaemia and type-2 diabetes presents Questions Incorrect 1
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for review. He has tolerated 2 g/day of metformin well, but Questions Total 11
• Past Papers 2 years after the initial diagnosis of diabetes his blood
Questions Percentage 90 %
• Random Questions sugars are still too high in the morning on occasions, and a
recent HB A 1c was 7.5%. His job entails occasional shift More
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work, during which he is unable to eat for long periods.
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to his metformin treatment?
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• Timed Test A 57-year-old man, with a BMI of 30 and a history of
hypertension, dyslipidaemia and type-2 diabetes presents Questions Incorrect 2
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for review. He has tolerated 2 g/day of metformin well, but Questions Total 12
• Past Papers 2 years after the initial diagnosis of diabetes his blood
Questions Percentage 83 %
• Random Questions sugars are still too high in the morning on occasions, and a
recent HB A 1c was 7.5%. His job entails occasional shift More
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work, during which he is unable to eat for long periods.
• Media Bank
• New Multimedia Which would be the most appropriate add-in therapy
to his metformin treatment?
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The choice is between the addition of sulphonylurea
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therapy, insulin or a glitazone. Sulphonylurea therapy
Order History or insulin may not be appropriate due to his shift Reference: Normal Values
Learning Goals work and risk of hypoglycaemia. In addition, he has
features of the insulin resistance (metabolic) Click to open/closeHaematology
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addition. Click to open/closeBiochemistry
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skeletal muscle and fat. Pioglitazone binds to the open/closeBlood gases Click to
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proliferator-activated receptor), which promotes the
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transcription of a number of enzymes concerned with
glucose and lipid metabolism. Clinical trials indicate
that by targeting insulin resistance they appear to
have positive effects on other features of the
metabolic syndrome such as blood pressure and HDL
cholesterol.
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• Timed Test A 56-year-old man with type-2 diabetes presents with
background diabetic retinopathy. His HB A 1c has been Questions Incorrect 2
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consistently above 9% for the past 5 years. Questions Total 12
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Questions Percentage 83 %
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• Timed Test A 56-year-old man with type-2 diabetes presents with
background diabetic retinopathy. His HB A 1c has been Questions Incorrect 2
• Mock Exam
consistently above 9% for the past 5 years. Questions Total 13
• Past Papers
Questions Percentage 84 %
• Random Questions Which of the following factors would most worsen
• My Performance prognosis for his retinopathy? More
• Media Bank Rapid improvement in blood glucose Your answer
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• Timed Test A 45-year-old man is to undergo trans-sphenoidal surgery
for resection of a growth hormone-secreting pituitary Questions Incorrect 2
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adenoma. He asks about the prospect of a cure and you Questions Total 13
• Past Papers explain that he will require biochemical monitoring over the
Questions Percentage 84 %
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Blood glucose
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• Timed Test A 42-year-old man presents to his GP complaining of
decreased libido. He has also noticed having to shave less Questions Incorrect 2
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frequently. On the few occasions he has tried to have sex Questions Total 13
• Past Papers he has failed to maintain his erection to penetration. His
Questions Percentage 84 %
• Random Questions visual field testing is normal and he has no medication
history. Serum prolactin levels are 890 mg/l, growh More
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hormone and thyroid function levels are normal.
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What diagnosis fits best with this clinical picture?
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Online Extras Microprolactinoma Reference: Normal Values
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• Timed Test A 42-year-old man presents to his GP complaining of
decreased libido. He has also noticed having to shave less Questions Incorrect 3
• Mock Exam
frequently. On the few occasions he has tried to have sex Questions Total 14
• Past Papers he has failed to maintain his erection to penetration. His
Questions Percentage 78 %
• Random Questions visual field testing is normal and he has no medication
history. Serum prolactin levels are 890 mg/l, growh More
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hormone and thyroid function levels are normal.
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What diagnosis fits best with this clinical picture?
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Men with prolactinoma tend to present substantially
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unlikely given his normal visual fields. Prolactinoma is Reference: Normal Values
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usually attempted first with a dopamine agonist, such Click to open/closeBiochemistry
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• Timed Test A 19-year-old student is brought to A&E by his flatmates.
He had been playing squash that afternoon, and while Questions Incorrect 3
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resting (after having had a pasta meal), complained of Questions Total 14
• Past Papers generalised weakness. He was unable to stand and had to
Questions Percentage 78 %
• Random Questions be carried in by his friends. His potassium level was noted
to be 2.6 mmol/l. Urine screen for diabetic and laxative More
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abuse was normal. Apparently, he has had similar attacks
• Media Bank since his early teenage years. Symptoms were aborted by
• New Multimedia potassium chloride.
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• Timed Test A 19-year-old student is brought to A&E by his flatmates.
He had been playing squash that afternoon, and while Questions Incorrect 3
• Mock Exam
resting (after having had a pasta meal), complained of Questions Total 15
• Past Papers generalised weakness. He was unable to stand and had to
Questions Percentage 80 %
• Random Questions be carried in by his friends. His potassium level was noted
to be 2.6 mmol/l. Urine screen for diabetic and laxative More
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abuse was normal. Apparently, he has had similar attacks
• Media Bank since his early teenage years. Symptoms were aborted by
• New Multimedia potassium chloride.
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• Timed Test A 23-year-old woman with type-1 diabetes presents with
an unusual lesion on her shin. It began as a patch of Questions Incorrect 3
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spreading erythema, but now looks yellow and has begun Questions Total 15
• Past Papers to ulcerate.
Questions Percentage 80 %
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What diagnosis best fits this lesion? More
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• Media Bank Acanthosis nigricans
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• Timed Test A 23-year-old woman with type-1 diabetes presents with
an unusual lesion on her shin. It began as a patch of Questions Incorrect 3
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spreading erythema, but now looks yellow and has begun Questions Total 16
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What diagnosis best fits this lesion? More
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• Timed Test A 71-year-old man with established sarcoidosis presents for
review. He suffers from a degree of pulmonary fibrosis due Questions Incorrect 3
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to previous pulmonary infiltration and has been taking Questions Total 16
• Past Papers corticosteroids intermittently. You are asked for a
Questions Percentage 81 %
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mmol/l. His renal function is normal and parathyroid More
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hormone is just below the lower end of the normal range.
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What is the most likely cause of his hypercalcaemia?
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Online Extras Hyperparathyroidism Reference: Normal Values
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• Timed Test A 71-year-old man with established sarcoidosis presents for
review. He suffers from a degree of pulmonary fibrosis due Questions Incorrect 3
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to previous pulmonary infiltration and has been taking Questions Total 17
• Past Papers corticosteroids intermittently. You are asked for a
Questions Percentage 82 %
• Random Questions consultation as his serum calcium concentration is 3.1
mmol/l. His renal function is normal and parathyroid More
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hormone is just below the lower end of the normal range.
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What is the most likely cause of his hypercalcaemia?
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Online Extras Hyperparathyroidism
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In this case, parathyroid hormone is virtually in the
Newsletters normal range and his renal function is normal, so there
My Career and Exams is nothing to suggest a diagnosis of the milk–alkali
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established cases of sarcoid, and may eventually lead to
Learning Goals nephrocalcinosis. The cause is increased 1 a- Click to open/closeHaematology
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• Timed Test You are asked to review a 54-year-old psychiatric patient
by his GP. This patient has been diagnosed with impaired Questions Incorrect 3
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glucose tolerance. He also has a history of hypertension, Questions Total 17
• Past Papers for which he takes ramipril.
Questions Percentage 82 %
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known as a cause of impaired glucose tolerance? More
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• Media Bank Thiazolidinediones
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• Timed Test You are asked to review a 54-year-old psychiatric patient
by his GP. This patient has been diagnosed with impaired Questions Incorrect 3
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glucose tolerance. He also has a history of hypertension, Questions Total 18
• Past Papers for which he takes ramipril.
Questions Percentage 83 %
• Random Questions Which of the following drug classes is most well
known as a cause of impaired glucose tolerance? More
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• Media Bank Thiazolidinediones
• New Multimedia ACE inhibitors
Online Extras Atypical antipsychotics Your answer
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• Timed Test You are asked by a GP to review a 16-year-old girl who
presents with primary amenorrhoea. She appears on Questions Incorrect 3
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examination to have minimal body hair but normal breast Questions Total 18
• Past Papers development. Examination also reveals a blind-ended
Questions Percentage 83 %
• Random Questions vagina. Biochemistry reveals increased LH, normal FSH,
raised estradiol and raised testosterone levels. More
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• Media Bank Which diagnosis fits best with this history and
examination?
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Online Extras Polycystic ovarian syndrome Reference: Normal Values
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• Timed Test You are asked by a GP to review a 16-year-old girl who
presents with primary amenorrhoea. She appears on Questions Incorrect 3
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examination to have minimal body hair but normal breast Questions Total 19
• Past Papers development. Examination also reveals a blind-ended
Questions Percentage 84 %
• Random Questions vagina. Biochemistry reveals increased LH, normal FSH,
raised estradiol and raised testosterone levels. More
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• Media Bank Which diagnosis fits best with this history and
examination?
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Online Extras Polycystic ovarian syndrome
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in which androgen receptors are defective. This girl,
My Career and Exams although having the external phenotype of a female,
Order History will have the XY karyotype. These individuals are, of Reference: Normal Values
course, infertile. Patients with testicular feminisation
Learning Goals do possess testes, and orchidectomy is advised since Click to open/closeHaematology
Question Filters there is a high risk of testicular malignancy. Click to open/closeImmunoglobulins
Girls with Turner’s syndrome usually have the typical Click to open/closeBiochemistry
Turner’s phenotype of short stature and webbed neck. Click to open/closeDiabetes Click to
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• Timed Test A 27-year-old man presents via his GP for review. He
Questions Incorrect 3
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small phallus. He also has difficulty becoming aroused. On Questions Total 19
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• Random Questions a general paucity of body hair, his penis is small and he has
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and examination?
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• Timed Test A 27-year-old man presents via his GP for review. He
wants to start a relationship but is concerned about his Questions Incorrect 3
• Mock Exam
small phallus. He also has difficulty becoming aroused. On Questions Total 20
• Past Papers examination he is slim and there is gynaecomastia. There is
Questions Percentage 85 %
• Random Questions a general paucity of body hair, his penis is small and he has
small testes. Which diagnosis fits best with this history More
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and examination?
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• New Multimedia Testicular feminisation
Online Extras Klinefelter’s syndrome Your answer
Library Congenital adrenal hyperplasia
Community True hermaphroditism
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This man is likely to have karyotype XXY and has the
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features of Klinefelter’s syndrome. Individuals with
Newsletters testicular feminisation are phenotypic females.
My Career and Exams Karyotypic females with congenital adrenal
hyperplasia may have clitoromegaly and labial fusion,
Order History as well as ambiguous external genitalia that may Reference: Normal Values
Learning Goals appear male; they do not, however, have testes.
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Question Filters True hermaphrodites are vanishingly rare and may be Click to open/closeImmunoglobulins
XX/XY or mosaic in karyotype; they possess both Click to open/closeBiochemistry
testes and ovaries and usually have male or Click to open/closeDiabetes Click to
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• Timed Test A 54-year-old man presents to the diabetes clinic for
review. He has had type-1 diabetes for 30 years. Recently Questions Incorrect 3
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he has suffered a number of falls, which he describes as Questions Total 20
• Past Papers attacks where he feels ‘faint’ and loses his footing. He has
Questions Percentage 85 %
• Random Questions suffered from impotence for a number of years and takes
antireflux medication. On examination he has a postural More
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drop of 35 mmHg in his blood pressure. Which diagnosis
• Media Bank fits best with this history and examination?
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Diabetic autonomic neuropathy
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Transient ischaemic attacks
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Arrhythmia Click to
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• Timed Test A 54-year-old man presents to the diabetes clinic for
review. He has had type-1 diabetes for 30 years. Recently Questions Incorrect 3
• Mock Exam
he has suffered a number of falls, which he describes as Questions Total 21
• Past Papers attacks where he feels ‘faint’ and loses his footing. He has
Questions Percentage 85 %
• Random Questions suffered from impotence for a number of years and takes
antireflux medication. On examination he has a postural More
• My Performance
drop of 35 mmHg in his blood pressure. Which diagnosis
• Media Bank fits best with this history and examination?
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Diabetic autonomic neuropathy Your answer
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Transient ischaemic attacks
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• Timed Test A 42-year-old woman presents with difficult-to-treat
hypertension. She is taking ramipril, atenolol and Questions Incorrect 3
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bendrofluazide yet her blood pressure as measured in the Questions Total 21
• Past Papers clinic is still 150/100 mmHg. Her serum potassium
Questions Percentage 85 %
• Random Questions concentration as measured in clinic was 2.9 mmol/l. She
has been weaned off her antihypertensives for a period of More
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4–6 weeks; at this time her renin level was noted to be
• Media Bank suppressed and her aldosterone level was above normal.
• New Multimedia Abdominal ultrasound suggests enlargement of the right
adrenal.
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• Timed Test A 42-year-old woman presents with difficult-to-treat
hypertension. She is taking ramipril, atenolol and Questions Incorrect 3
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bendrofluazide yet her blood pressure as measured in the Questions Total 22
• Past Papers clinic is still 150/100 mmHg. Her serum potassium
Questions Percentage 86 %
• Random Questions concentration as measured in clinic was 2.9 mmol/l. She
has been weaned off her antihypertensives for a period of More
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4–6 weeks; at this time her renin level was noted to be
• Media Bank suppressed and her aldosterone level was above normal.
• New Multimedia Abdominal ultrasound suggests enlargement of the right
adrenal.
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Library Which of the following diagnoses is most likely to fit
with this clinical picture?
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Order History Reference: Normal Values
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80% were said to be related to an adenoma, but the Click to open/closeBiochemistry
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Sign Out Primary hyperaldosteronism is estimated to be
responsible for 1–2% of cases of hypertension and is
generally asymptomatic. Rarely, there may be muscle
cramps associated with hypokalaemia.
To estimate renin and aldosterone levels accurately it
may be necessary to wean the patient off
antihypertensive drugs for a period of a few weeks,
since most classes of antihypertensives have effects
on the renin–angiotensin axis. CT or MRI scanning
may be used to confirm the adenoma.
After removal of the adenoma, blood pressure is
normal in 70% of patients at 1 year. At 5 years’
postsurgery, 50% of patients remain normotensive.
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• Timed Test An 18-year-old girl is referred by her GP who is concerned
that she may have an underlying endocrine problem. The Questions Incorrect 3
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girl had been taken to the GP by her mother. She is a good Questions Total 22
• Past Papers student and has just won a place at university. She weighs
Questions Percentage 86 %
• Random Questions only 38 kg (6 stone) and is 1.78 m (5ft 10 inches) tall. She
is emaciated, her skin is dry and she has excessive growth More
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of lanugo hair. She has been amenorrhoeic for 9 months.
• Media Bank Her cortisol level is elevated, her free T 4 is normal. She has
• New Multimedia an anaemia and associated reduced white cell and platelet
count. Which of the following diagnoses is most likely
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• Timed Test An 18-year-old girl is referred by her GP who is concerned
that she may have an underlying endocrine problem. The Questions Incorrect 3
• Mock Exam
girl had been taken to the GP by her mother. She is a good Questions Total 23
• Past Papers student and has just won a place at university. She weighs
Questions Percentage 86 %
• Random Questions only 38 kg (6 stone) and is 1.78 m (5ft 10 inches) tall. She
is emaciated, her skin is dry and she has excessive growth More
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of lanugo hair. She has been amenorrhoeic for 9 months.
• Media Bank Her cortisol level is elevated, her free T 4 is normal. She has
• New Multimedia an anaemia and associated reduced white cell and platelet
count. Which of the following diagnoses is most likely
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to fit with this clinical picture?
Library
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Anorexia nervosa has a female to male
Order History preponderance of 9:1. It is estimated that around Reference: Normal Values
Learning Goals 0.5–1% of American women between 15 and 30
years of age have anorexia, and the numbers are Click to open/closeHaematology
Question Filters likely to be similar in the UK. The aetiology of Click to open/closeImmunoglobulins
anorexia is unknown, but it is likely to be an Click to open/closeBiochemistry
interaction between environmental and genetic Click to open/closeDiabetes Click to
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as high as 50% in anorexic females. Despite an open/closeBlood gases Click to
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association with depressive and other psychiatric
Sign Out illness, demographic studies show no impairment of
cognitive level nor educational achievement in the
group of patients with anorexia nervosa as compared
to the general population.
Indeed such patients may fit the profile of being "high
achievers", which is what is being hinted at in this
question.
Typical laboratory tests include decreased FSH, LH,
oestrogens and 17-OH steroids. Free T 4 and TSH
levels are usually normal. Anaemia with decreased
white and platelet cell count may also occur. There
may be metabolic alkalosis, hypocalcaemia,
hypokalaemia and hypomagnesaemia.
Treatment may involve complex psychotherapy for a
number of years, and referral to a specialist in the
field is recommended.
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• Timed Test A 60-year-old woman is sent by A&E for endocrine review.
During the past 18 months she has suffered two Colle’s Questions Incorrect 3
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fractures and a fractured neck of her left femur. Results of Questions Total 23
• Past Papers thyroid function testing, serum protein electrophoresis and
Questions Percentage 86 %
• Random Questions serum parathyroid hormone estimation are all normal. Bone
densitometry of the lumbar spine and femoral neck on the More
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non-replaced side reveal a bone density within the
• Media Bank osteoporotic range. Which of the following
• New Multimedia interventions would be most appropriate for her?
Online Extras Observe and repeat the densitometry in 12 months Reference: Normal Values
Library Initiate bisphosphonate therapy
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• Timed Test A 60-year-old woman is sent by A&E for endocrine review.
During the past 18 months she has suffered two Colle’s Questions Incorrect 3
• Mock Exam
fractures and a fractured neck of her left femur. Results of Questions Total 24
• Past Papers thyroid function testing, serum protein electrophoresis and
Questions Percentage 87 %
• Random Questions serum parathyroid hormone estimation are all normal. Bone
densitometry of the lumbar spine and femoral neck on the More
• My Performance
non-replaced side reveal a bone density within the
• Media Bank osteoporotic range. Which of the following
• New Multimedia interventions would be most appropriate for her?
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This woman has idiopathic osteoporosis, with normal
My Career and Exams thyroid function and parathyroid hormone assay ruling
Order History out hyperthyroidism and hyperparathyroidism. Her Reference: Normal Values
osteoporosis is clearly of clinical significance in that she
Learning Goals has suffered two fractures of the distal radius and a Click to open/closeHaematology
Question Filters fractured neck of a femur during the past 19 months. Click to open/closeImmunoglobulins
Hormone replacement therapy (HRT) would not be Click to open/closeBiochemistry
advised in this age group due to the increased Click to open/closeDiabetes Click to
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• Timed Test A 58-year-old woman is taking alendronate for
osteoporosis. She visits the clinic and is keen to discuss the Questions Incorrect 3
• Mock Exam
mechanism of action of this class of drugs as she has been Questions Total 24
• Past Papers studying them on the Internet. Which of the following
Questions Percentage 87 %
• Random Questions options best describes the mode of action of the
bisphosphonate class of agents? More
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• Media Bank Inhibits osteoblast activity
• New Multimedia Stimulates osteoblast activity
Online Extras Stimulates osteoclast activity Reference: Normal Values
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• Timed Test A 58-year-old woman is taking alendronate for
osteoporosis. She visits the clinic and is keen to discuss the Questions Incorrect 3
• Mock Exam
mechanism of action of this class of drugs as she has been Questions Total 25
• Past Papers studying them on the Internet. Which of the following
Questions Percentage 88 %
• Random Questions options best describes the mode of action of the
bisphosphonate class of agents? More
• My Performance
• Media Bank Inhibits osteoblast activity
• New Multimedia Stimulates osteoblast activity
Online Extras Stimulates osteoclast activity
Library Inhibits osteoclast activity Your answer
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The primary mode of action of the bisphosphonates is
Profile inhibition of osteoclast activity. With the results from
large-scale HRT studies suggesting an increased risk of
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carcinoma or cardiovascular disease, they have become
My Career and Exams the first-choice therapy for osteoporosis. They may be
Order History given orally, although some clinicians prefer intermittent Reference: Normal Values
intravenous use. This class of drugs may be associated
Learning Goals with an increased risk of oesophageal ulceration. When Click to open/closeHaematology
Question Filters the class was developed there was initial concern over Click to open/closeImmunoglobulins
prolonged inhibition of bone turnover over a number of Click to open/closeBiochemistry
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• Timed Test A 61-year-old farmer who has long-standing type-1
diabetes is brought to the clinic by his wife. He has been Questions Incorrect 3
• Mock Exam
limping for a while and his wife noticed that his ankle was Questions Total 25
• Past Papers rather abnormally shaped after he stepped out of the
Questions Percentage 88 %
• Random Questions shower. Examination of his right ankle reveals a painless
joint that is warm and swollen. There is crepitus and what More
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appears to be palpable bone debris. X-ray reveals gross
• Media Bank joint destruction and apparent dislocation. His CRP and
• New Multimedia white count are normal, the joint aspiration fluid shows no
microbes and historical review of HB A 1c reveals that it has
Online Extras Reference: Normal Values
rarely been below 9%. What is the most likely
Library diagnosis in this case?
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Charcot’s ankle
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• Timed Test A 61-year-old farmer who has long-standing type-1
diabetes is brought to the clinic by his wife. He has been Questions Incorrect 3
• Mock Exam
limping for a while and his wife noticed that his ankle was Questions Total 26
• Past Papers rather abnormally shaped after he stepped out of the
Questions Percentage 88 %
• Random Questions shower. Examination of his right ankle reveals a painless
joint that is warm and swollen. There is crepitus and what More
• My Performance
appears to be palpable bone debris. X-ray reveals gross
• Media Bank joint destruction and apparent dislocation. His CRP and
• New Multimedia white count are normal, the joint aspiration fluid shows no
microbes and historical review of HB A 1c reveals that it has
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Order History Charcot’s joint is said to occur in 1 in every 750 Reference: Normal Values
patients with diabetes mellitus, although this is
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Question Filters neuropathy. However, a Charcot’s joint does not just Click to open/closeImmunoglobulins
occur in those with diabetes but may occur in 20–40% Click to open/closeBiochemistry
of patients with syringomyelia and 5–10% of those with Click to open/closeDiabetes Click to
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bisphosphonates may slow the pace of joint destruction.
1928
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• Timed Test A 32-year-old merchant banker presents for endocrine
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previous medical history is unremarkable. She gives a Questions Total 26
• Past Papers history of increasing fatigue, being sometimes unable to
Questions Percentage 88 %
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few steps without feeling exhausted. She has lost a little More
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awakes unrefreshed. Full blood count, viscosity, urea and
Online Extras electrolytes, liver function testing, thyroid function testing Reference: Normal Values
Library and a Synacthen test arranged by her GP have all been
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• Timed Test A 32-year-old merchant banker presents for endocrine
review. Apart from a past history of reflux symptoms, her Questions Incorrect 3
• Mock Exam
previous medical history is unremarkable. She gives a Questions Total 27
• Past Papers history of increasing fatigue, being sometimes unable to
Questions Percentage 88 %
• Random Questions leave her bedroom; she says that she is only able to walk a
few steps without feeling exhausted. She has lost a little More
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weight and gone on long-term sick leave from her job. She
• Media Bank feels unable to concentrate, has headaches, intermittent
• New Multimedia sore throats and feels that when she is able to sleep, she
awakes unrefreshed. Full blood count, viscosity, urea and
Online Extras electrolytes, liver function testing, thyroid function testing
Library and a Synacthen test arranged by her GP have all been
normal. On examination in the clinic there are no abnormal
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physical findings in this normal weight, normal height
Help young woman. What diagnosis fits best with this
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The prevalence of chronic fatigue syndrome is estimated Click to open/closeBiochemistry
at 1–3 per 1000 individuals. The predominant age at Click to open/closeDiabetes Click to
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there is a slight female preponderance. Sufferers often open/closeBlood gases Click to
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be responsible. Conventional investigation and physical
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Epstein–Barr virus infection being that trigger, but
concrete proof has not yet been demonstrated.
Education, counselling and goal setting have proved
useful in stimulating recovery, and trials have
demonstrated improvements with amitriptyline use, but
many patients take years to return to normal life.
1929
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• Timed Test A 62-year-old man presents with evidence of
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warfarin therapy for persistent atrial fibrillation. In addition, Questions Total 27
• Past Papers he takes another tablet for heartburn. Results of tests for
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Warfarin therapy
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Digoxin therapy
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• Timed Test A 62-year-old man presents with evidence of
gynaecomastia. He has been taking long-term digitalis and Questions Incorrect 3
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warfarin therapy for persistent atrial fibrillation. In addition, Questions Total 28
• Past Papers he takes another tablet for heartburn. Results of tests for
Questions Percentage 89 %
• Random Questions androgens, HCG, liver function and thyroid function are all
normal. More
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• Media Bank What is the most likely cause of his gynaecomastia?
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Warfarin therapy
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• Timed Test A 21-year-old university student presents for review. She is
distressed by the fact that she is overweight and is having Questions Incorrect 3
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to shave or pluck excessive facial hair. She also notices Questions Total 28
• Past Papers that she appears to have more generalised body hair than
Questions Percentage 89 %
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that she can sometimes miss a couple of menses, but More
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pregnancy testing is consistently negative. Her mother
• Media Bank apparently had similar problems in her youth, took a while
• New Multimedia to conceive and now has type-2 diabetes. Testosterone is
just outside the upper limit of normal range, her LH:FSH
Online Extras ratio is increased and prolactin is normal. Which Reference: Normal Values
Library diagnosis fits best with this woman’s clinical picture?
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Polycystic ovarian syndrome (PCOS)
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• Timed Test A 21-year-old university student presents for review. She is
distressed by the fact that she is overweight and is having Questions Incorrect 3
• Mock Exam
to shave or pluck excessive facial hair. She also notices Questions Total 29
• Past Papers that she appears to have more generalised body hair than
Questions Percentage 89 %
• Random Questions other women. On further questioning you elicit a history
that she can sometimes miss a couple of menses, but More
• My Performance
pregnancy testing is consistently negative. Her mother
• Media Bank apparently had similar problems in her youth, took a while
• New Multimedia to conceive and now has type-2 diabetes. Testosterone is
just outside the upper limit of normal range, her LH:FSH
Online Extras ratio is increased and prolactin is normal. Which
Library diagnosis fits best with this woman’s clinical picture?
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Polycystic ovarian syndrome (PCOS) Your answer
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Order History PCOS is said to occur in 3% of adult women. Symptoms Reference: Normal Values
usually begin around the time of menarche and the
Learning Goals diagnosis is often made in adolescence. Obesity is Click to open/closeHaematology
Question Filters present in around 40% of sufferers and there is an Click to open/closeImmunoglobulins
increased association with type-2 diabetes due to Click to open/closeBiochemistry
insulin resistance. Biochemical abnormalities Click to open/closeDiabetes Click to
Security characteristically include a mildly raised testosterone open/closeEndocrinology Click to
level and an increased LH:FSH ratio. Treatment includes open/closeBlood gases Click to
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Sign Out with wedge ovarian resection may reduce androgen
secretion and symptoms. Many women just require
reassurance and effective local treatment for hirsutism.
Those who wish to conceive do so with increased
frequency after a trial of metformin therapy, clomifene,
or in some cases gonadotrophins.
2216
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• Timed Test A 21-year-old woman presents for review. She is concerned
on this occasion because she has not had a period for 5 Questions Incorrect 3
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months. She is 1.76 m in height and weighs only 43.7 kg Questions Total 29
• Past Papers (7 stone). A pregnancy test is negative and thyroid function
Questions Percentage 89 %
• Random Questions testing is normal. Which diagnosis fits best with this
woman’s clinical picture? More
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• Media Bank Gonadotrophin deficiency
• New Multimedia Weight-related amenorrhoea
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Library Primary ovarian failure
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• Timed Test A 21-year-old woman presents for review. She is concerned
on this occasion because she has not had a period for 5 Questions Incorrect 3
• Mock Exam
months. She is 1.76 m in height and weighs only 43.7 kg Questions Total 30
• Past Papers (7 stone). A pregnancy test is negative and thyroid function
Questions Percentage 90 %
• Random Questions testing is normal. Which diagnosis fits best with this
woman’s clinical picture? More
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• Media Bank Gonadotrophin deficiency
• New Multimedia Weight-related amenorrhoea Your answer
Online Extras Hyperprolactinaemia
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• Timed Test A 75-year-old woman is admitted in an unconscious state.
Her daughter found her on the floor. On examination in Questions Incorrect 3
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casualty she is found to have a core temperature of 33 °C Questions Total 30
• Past Papers and also to be in left ventricular failure. Her blood glucose
Questions Percentage 90 %
• Random Questions level is 5.7 mmol/l, random cortisol is elevated. By chance
you also catch the twice weekly run of thyroid function More
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testing and her free T 4 is 4.4 pmol/l. A CT scan of her brain
• Media Bank reveals no focal lesion and a cursory assessment reveals no
• New Multimedia gross focal neurology. Which diagnosis fits best with
this woman’s clinical picture?
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• Timed Test A 75-year-old woman is admitted in an unconscious state.
Her daughter found her on the floor. On examination in Questions Incorrect 3
• Mock Exam
casualty she is found to have a core temperature of 33 °C Questions Total 31
• Past Papers and also to be in left ventricular failure. Her blood glucose
Questions Percentage 90 %
• Random Questions level is 5.7 mmol/l, random cortisol is elevated. By chance
you also catch the twice weekly run of thyroid function More
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testing and her free T 4 is 4.4 pmol/l. A CT scan of her brain
• Media Bank reveals no focal lesion and a cursory assessment reveals no
• New Multimedia gross focal neurology. Which diagnosis fits best with
this woman’s clinical picture?
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Library Hypoglycaemia
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This woman has a greatly reduced free T 4
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concentration, is hypothermic, unconscious and has
Order History evidence of associated heart failure. Mortality Reference: Normal Values
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50%, but with modern intensive care management, Click to open/closeHaematology
Question Filters survival has improved. T 3 is usually given via a Click to open/closeImmunoglobulins
nasogastric (NG) tube or iv injection at the rate of 2.5– Click to open/closeBiochemistry
Click to open/closeDiabetes Click to
Security 5 μ g every 8 h, with conversion to T 4 after the patient
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regains consciousness. There is a risk of precipitating open/closeBlood gases Click to
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Sign Out period. Other supportive measures include oxygen
therapy, hydrocortisone iv therapy and glucose infusion,
but none of these have been effectively proven in a
randomised, controlled trial setting.
2219
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• Timed Test A 62-year-old woman undergoes subtotal thyroidectomy
for goitre. Some 12-h postsurgery she calls the duty doctor Questions Incorrect 3
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and is found to be suffering from pins and needles in her Questions Total 31
• Past Papers hands and carpopedal spasm. An urgent corrected calcium
Questions Percentage 90 %
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term prognosis?
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• New Multimedia She is likely to have permanent hypoparathyroidism
due to surgery
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Her hypocalcaemia is likely to be transient due to
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• Timed Test A 62-year-old woman undergoes subtotal thyroidectomy
for goitre. Some 12-h postsurgery she calls the duty doctor Questions Incorrect 3
• Mock Exam
and is found to be suffering from pins and needles in her Questions Total 32
• Past Papers hands and carpopedal spasm. An urgent corrected calcium
Questions Percentage 90 %
• Random Questions level is found to be 2.1 mmol/l. What is the most likely
cause of her hypocalcaemia and what is the long- More
• My Performance
term prognosis?
• Media Bank
• New Multimedia She is likely to have permanent
hypoparathyroidism due to surgery
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Her hypocalcaemia is likely to be Your answer
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hormone concentration after thyroid
gland removal and she will recover
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a fall in calcitonin after thyroidectomy
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Her hypocalcaemia is probably due to
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vitamin D
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Up to 10% of patients who undergo subtotal Click to open/closeDiabetes Click to
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Thankfully, it becomes permanent hypoparathyroidism open/closeBlood gases Click to
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Sign Out calcium chloride infusion (slowly) under ECG monitoring,
which should lead to the rapid resolution of symptoms.
Expert thyroid surgeons have now minimised the risk of
permanent hypoparathyroidism.
2220
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• Timed Test You review a 32-year-old woman with relapsed Grave’s
disease. TSH is less than 0.05 mU/l, with a free T 4 of 32.5 Questions Incorrect 3
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pmol/l. She has severe bilateral thyroid eye disease with Questions Total 32
• Past Papers
marked orbital oedema and proptosis. You are considering Questions Percentage 90 %
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• My Performance the following statements best fits the management of More
her thyroid eye disease?
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eye disease
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Orbital irradiation is commonly used to treat thyroid
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eye disease Click to
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Corrective eye muscle surgery should now be
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• Timed Test You review a 32-year-old woman with relapsed Grave’s
disease. TSH is less than 0.05 mU/l, with a free T 4 of 32.5 Questions Incorrect 3
• Mock Exam
pmol/l. She has severe bilateral thyroid eye disease with Questions Total 33
• Past Papers
marked orbital oedema and proptosis. You are considering Questions Percentage 90 %
• Random Questions radiotherapy as she has failed drug treatment. Which of
• My Performance the following statements best fits the management of More
her thyroid eye disease?
• Media Bank
• New Multimedia Systemic steroids are of no value in
managing the eye disease
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Orbital irradiation is commonly used to
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treat thyroid eye disease
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Corrective eye muscle surgery should
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Exacerbation of eye disease is more common after
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radioiodine treatment (15% vs 3% on drug therapy Click to open/closeHaematology
Question Filters alone). Only 5–10% of these worsening cases threaten Click to open/closeImmunoglobulins
sight, but discomfort and deteriorating cosmetic Click to open/closeBiochemistry
appearance may cause much patient anxiety. Systemic Click to open/closeDiabetes Click to
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(NSAIDs) may ease the discomfort and decrease open/closeBlood gases Click to
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Corrective eye muscle surgery should be delayed until
thyroid eye disease has been stable for at least 6
months, but may be of value in improving diplopia.
2221
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• Timed Test A 34-year-old woman with a long history of type-1
diabetes, microalbuminuria and diabetic eye disease Questions Incorrect 3
• Mock Exam
presents for review. She has been amenorrhoeic for 12 Questions Total 33
• Past Papers months and recent pregnancy tests have been negative.
Questions Percentage 90 %
• Random Questions She has a healthy 1-year-old child but suffered a
postpartum haemorrhage just after his birth. Over the past More
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few months she has also been increasingly tired and has
• Media Bank noticed thinning of her pubic and axillary hair. On
• New Multimedia examination she is slim and pale, with small breasts and
thin or largely absent pubic and axillary hair. ACTH, FSH,
Online Extras LH are all low, with TSH just below the normal range. MRI Reference: Normal Values
Library of the pituitary gland reveals an empty sella. What
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• Timed Test A 34-year-old woman with a long history of type-1
diabetes, microalbuminuria and diabetic eye disease Questions Incorrect 3
• Mock Exam
presents for review. She has been amenorrhoeic for 12 Questions Total 34
• Past Papers months and recent pregnancy tests have been negative.
Questions Percentage 91 %
• Random Questions She has a healthy 1-year-old child but suffered a
postpartum haemorrhage just after his birth. Over the past More
• My Performance
few months she has also been increasingly tired and has
• Media Bank noticed thinning of her pubic and axillary hair. On
• New Multimedia examination she is slim and pale, with small breasts and
thin or largely absent pubic and axillary hair. ACTH, FSH,
Online Extras LH are all low, with TSH just below the normal range. MRI
Library of the pituitary gland reveals an empty sella. What
diagnosis fits best with this clinical picture?
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Help Prolactinoma
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Polyglandular syndrome
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Sheehan’s syndrome is well known to occur in women
Learning Goals due to postpartum haemorrhage and hypovolaemic Click to open/closeHaematology
Question Filters shock, but the risk of it occurring is increased in women Click to open/closeImmunoglobulins
with type-1 diabetes who have microvascular disease, Click to open/closeBiochemistry
and in patients with sickle-cell anaemia. It is said to Click to open/closeDiabetes Click to
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includes immediate steroid therapy with later full open/closeBlood gases Click to
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Sign Out dependent hormones (eg thyroxine) as required.
Further conception may be difficult and require pulsed
gonadotrophin therapy to restart ovulation. Diabetes
insipidus is not usually associated with the syndrome.
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• Timed Test A 23-year-old woman is admitted to the Casualty department from her office, for the
• Mock Exam third time in the space of 2 months, after having suffered a syncopal attack. On
questioning she admits to feeling very tired over the past few months and being dizzy
• Past Papers on a number of occasions. On examination she looked slim and tanned, her blood
• Random Questions pressure was 110/70 mmHg lying, but dropped to 85/65 mmHg on standing. ACTH is
markedly raised, free thyroxine is below the lower limit of normal and cortisol is low.
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Which diagnosis fits best with the clinical picture?
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• Timed Test A 23-year-old woman is admitted to the Casualty
department from her office, for the third time in the space Questions Incorrect 3
• Mock Exam
of 2 months, after having suffered a syncopal attack. On Questions Total 35
• Past Papers questioning she admits to feeling very tired over the past
Questions Percentage 91 %
• Random Questions few months and being dizzy on a number of occasions. On
examination she looked slim and tanned, her blood More
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pressure was 110/70 mmHg lying, but dropped to 85/65
• Media Bank mmHg on standing. ACTH is markedly raised, free thyroxine
• New Multimedia is below the lower limit of normal and cortisol is low.
Which diagnosis fits best with the clinical picture?
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Library Hypothyroidism
Community Primary hypoadrenalism Your answer
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pigmentation due to her high ACTH and a low cortisol,
My Career and Exams making primary hypoadrenalism the most likely
Order History diagnosis. Free thyroxine may also be low at time of Reference: Normal Values
diagnosis, but thyroid hormone replacement should not
Learning Goals be started as this may worsen the adrenal crisis. Click to open/closeHaematology
Question Filters Instead, steroid replacement therapy should be started, Click to open/closeImmunoglobulins
accompanied by fluid replacement, and thyroid function Click to open/closeBiochemistry
reassessed at a later stage. Autoimmune destruction of Click to open/closeDiabetes Click to
Security the adrenal glands is responsible for 80% of cases. open/closeEndocrinology Click to
Tuberculosis accounts for a further 15% of cases. There open/closeBlood gases Click to
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Sign Out prevalence of around 5 per 100,000.
2223
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• Timed Test A 54-year-old publican is referred by his GP for endocrine
assessment. He is obese with a BMI of 32 and has Questions Incorrect 3
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hypertension, which is poorly controlled on atenolol, Questions Total 35
• Past Papers ramipril and bendrofluazide. A recent fasting blood glucose
Questions Percentage 91 %
• Random Questions test has revealed type-2 diabetes. On examination he looks
cushingoid with a blood pressure of 150/95 mmHg. You More
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order a 24-h urinary free cortisol estimation, which turns
• Media Bank out to be just above the normal range. An overnight
• New Multimedia dexamethasone suppression test is also unremarkable.
Which diagnosis fits best with this clinical picture?
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Questions Correct 33
• Timed Test A 54-year-old publican is referred by his GP for endocrine
assessment. He is obese with a BMI of 32 and has Questions Incorrect 3
• Mock Exam
hypertension, which is poorly controlled on atenolol, Questions Total 36
• Past Papers ramipril and bendrofluazide. A recent fasting blood glucose
Questions Percentage 91 %
• Random Questions test has revealed type-2 diabetes. On examination he looks
cushingoid with a blood pressure of 150/95 mmHg. You More
• My Performance
order a 24-h urinary free cortisol estimation, which turns
• Media Bank out to be just above the normal range. An overnight
• New Multimedia dexamethasone suppression test is also unremarkable.
Which diagnosis fits best with this clinical picture?
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Library Cushing’s disease
Community Pseudo-Cushing’s Your answer
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Primary aldosteronism
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excess may acquire a cushingoid appearance. In this
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case, this man’s occupation as a publican suggests
Order History that he may have easy access to alcohol. His two Reference: Normal Values
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dexamethasone suppression test and 24-h urinary Click to open/closeHaematology
Question Filters free cortisol – are normal, which effectively rules out Click to open/closeImmunoglobulins
option A. His type-2 diabetes is likely to be related to Click to open/closeBiochemistry
obesity and his sedentary lifestyle, although diabetes Click to open/closeDiabetes Click to
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induced chronic pancreatitis. open/closeBlood gases Click to
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weight loss, and strict control of his alcohol intake.
Metformin would be the ideal treatment for his
diabetes, although this would be contraindicated in
the presence of continued alcohol excess.
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Questions Correct 33
• Timed Test You are asked to review a 36-year-old man who has
suffered a myocardial infarction. He is a non-smoker with Questions Incorrect 3
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no past history of note and is not diabetic. On admission Questions Total 36
• Past Papers his total cholesterol was 10.2 mmol/l, with triglycerides just
Questions Percentage 91 %
• Random Questions above the normal range, normal HDL and markedly raised
LDL cholesterol. His father died of a myocardial infarction at More
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the age of 43. What is the most likely cause of his
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Heterozygous familial hypercholesterolaemia
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• Timed Test You are asked to review a 36-year-old man who has
suffered a myocardial infarction. He is a non-smoker with Questions Incorrect 3
• Mock Exam
no past history of note and is not diabetic. On admission Questions Total 37
• Past Papers his total cholesterol was 10.2 mmol/l, with triglycerides just
Questions Percentage 91 %
• Random Questions above the normal range, normal HDL and markedly raised
LDL cholesterol. His father died of a myocardial infarction at More
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the age of 43. What is the most likely cause of his
• Media Bank raised cholesterol?
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Heterozygous familial Your answer
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Heterozygous familial hypercholesterolaemia is an
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autosomal-dominant monogenic disorder present in 1 in
My Career and Exams 500 of the population; the prevalence is increased in
Order History French-Canadians, Finns and South Africans. Reference: Normal Values
Homozygous FH occurs in 1 in 10 6 patients and is
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associated with early cardiovascular death in childhood. Click to open/closeHaematology
Question Filters Clinical features may include tendon xanthomas and Click to open/closeImmunoglobulins
xanthelasma. There is a genetic abnormality of the liver Click to open/closeBiochemistry
LDL receptor. It is said that 50% of men with this Click to open/closeDiabetes Click to
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Questions Correct 34
• Timed Test A 28-year-old man presents with acute pancreatitis. He
admits to occasionally drinking wine, but not to excess, and Questions Incorrect 3
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there have been no symptoms to suggest gall-bladder Questions Total 37
• Past Papers disease. He suffered a left retinal vein thrombosis 2 years
Questions Percentage 91 %
• Random Questions ago. Triglyceride concentration was estimated at 10
mmol/l, with normal HDL and LDL levels. What is the More
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most likely cause of his clinical presentation?
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• New Multimedia Secondary hyperlipidaemia
Online Extras Familial hypercholesterolaemia Reference: Normal Values
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Questions Correct 35
• Timed Test A 28-year-old man presents with acute pancreatitis. He
admits to occasionally drinking wine, but not to excess, and Questions Incorrect 3
• Mock Exam
there have been no symptoms to suggest gall-bladder Questions Total 38
• Past Papers disease. He suffered a left retinal vein thrombosis 2 years
Questions Percentage 92 %
• Random Questions ago. Triglyceride concentration was estimated at 10
mmol/l, with normal HDL and LDL levels. What is the More
• My Performance
most likely cause of his clinical presentation?
• Media Bank
• New Multimedia Secondary hyperlipidaemia
Online Extras Familial hypercholesterolaemia
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Questions Correct 35
• Timed Test A 24-year-old man with learning difficulties presents for
review. He complains of a sudden deterioration of vision in Questions Incorrect 3
• Mock Exam
his left eye. His past history of note includes a deep vein Questions Total 38
• Past Papers thrombosis. On examination he appears tall and slim and
Questions Percentage 92 %
• Random Questions almost marfanoid in appearance. He has a markedly
elevated urinary homocysteine. Which enzyme defect is More
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most likely to be responsible for this clinical picture?
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• New Multimedia Methylene tetrahydrofolate reductase
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Questions Correct 35
• Timed Test A 24-year-old man with learning difficulties presents for
review. He complains of a sudden deterioration of vision in Questions Incorrect 4
• Mock Exam
his left eye. His past history of note includes a deep vein Questions Total 39
• Past Papers thrombosis. On examination he appears tall and slim and
Questions Percentage 89 %
• Random Questions almost marfanoid in appearance. He has a markedly
elevated urinary homocysteine. Which enzyme defect is More
• My Performance
most likely to be responsible for this clinical picture?
• Media Bank
• New Multimedia Methylene tetrahydrofolate
reductase
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Histidase
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Homogentisic acid oxidase Your answer
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This is the presentation of type-1 homocystinuria,
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where a defect in cystathionine synthetase is
My Career and Exams responsible. Patients present with mild to moderate
Order History mental handicap, a marfan-like syndrome and Reference: Normal Values
thrombotic episodes. The sudden visual deterioration
Learning Goals may be due to a thrombotic episode or to the lens Click to open/closeHaematology
Question Filters dislocation associated with this condition. Click to open/closeImmunoglobulins
Homocystinuria may also associated with defects in Click to open/closeBiochemistry
methylene tetrahydrofolate reductase (type-2 disease), Click to open/closeDiabetes Click to
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• Timed Test A 54-year-old man with long-standing type-2 diabetes
presents for review. He has a history of hypertension, a 20 Questions Incorrect 4
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cigarettes per day smoking habit; recent Hb A 1c results Questions Total 39
• Past Papers
have averaged 8.9%. He wore deck shoes without socks on Questions Percentage 89 %
• Random Questions a recent holiday in Spain, and his wife noticed a large ulcer
• My Performance over the big toe on his left foot. On examination there is More
obvious loss of sensation, probing of the depth of the ulcer
• Media Bank elicits no pain. His foot appears warm with a bounding
• New Multimedia dorsalis pedis pulse, and there is some toe clawing. What
is the likely cause of his ulcer?
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Questions Correct 36
• Timed Test A 54-year-old man with long-standing type-2 diabetes
presents for review. He has a history of hypertension, a 20 Questions Incorrect 4
• Mock Exam
cigarettes per day smoking habit; recent Hb A 1c results Questions Total 40
• Past Papers
have averaged 8.9%. He wore deck shoes without socks on Questions Percentage 90 %
• Random Questions a recent holiday in Spain, and his wife noticed a large ulcer
• My Performance over the big toe on his left foot. On examination there is More
obvious loss of sensation, probing of the depth of the ulcer
• Media Bank elicits no pain. His foot appears warm with a bounding
• New Multimedia dorsalis pedis pulse, and there is some toe clawing. What
is the likely cause of his ulcer?
Online Extras
Library Simple trauma with no underlying
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Questions Correct 0
• Timed Test A 69-year-old woman presented via her GP with episodes
of facial flushing and diarrhoea. An ultrasound scan Questions Incorrect 0
• Mock Exam
revealed multiple hepatic lesions, and a 24-h urine Questions Total 0
• Past Papers collection revealed an elevated 5-HIAA. Unfortunately she
Questions Percentage 0%
• Random Questions did not consent to follow-up and next presented 2 years
later. Her son noticed a gradual deterioration in her More
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condition so that she appeared unable to cope at home.
• Media Bank There was apathy, depression and the onset of mild
• New Multimedia confusion. The diarrhoea is still present at review, and now
she appears to have photosensitive dermatitis, glossitis and
Online Extras angular stomatitis. What diagnosis fits best with her Reference: Normal Values
Library clinical picture?
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Pellagra
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• Timed Test A 69-year-old woman presented via her GP with episodes
of facial flushing and diarrhoea. An ultrasound scan Questions Incorrect 0
• Mock Exam
revealed multiple hepatic lesions, and a 24-h urine Questions Total 1
• Past Papers collection revealed an elevated 5-HIAA. Unfortunately she
Questions Percentage 100 %
• Random Questions did not consent to follow-up and next presented 2 years
later. Her son noticed a gradual deterioration in her More
• My Performance
condition so that she appeared unable to cope at home.
• Media Bank There was apathy, depression and the onset of mild
• New Multimedia confusion. The diarrhoea is still present at review, and now
she appears to have photosensitive dermatitis, glossitis and
Online Extras angular stomatitis. What diagnosis fits best with her
Library clinical picture?
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Pellagra Your answer
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In the presence of hepatic metastases, diarrhoea,
Order History facial flushing and a raised urinary 5-HIAA (5- Reference: Normal Values
Learning Goals hydroxyindoleacetic acid), it is highly likely that this
woman has the carcinoid syndrome. Unfortunately Click to open/closeHaematology
Question Filters during the 2 years that she has been lost to follow- Click to open/closeImmunoglobulins
up, it appears that she has developed pellagra. Click to open/closeBiochemistry
Click to open/closeDiabetes Click to
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manufactured via an enzymatic pathway that involves open/closeBlood gases Click to
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produce 5-hydroxytryptamine. As the carcinoid
tumour mass increases, more and more of the
available tryptophan is consumed, and less is
available for niacin production. Eventually patients
may become niacin deficient, suffering the triad of
dermatitis, diarrhoea and dementia, the features of
pellagra.
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• Timed Test A 45-year-old woman is referred to the endocrine clinic by
her GP for review. She has a body mass index of 35, Questions Incorrect 0
• Mock Exam
hypertension and impaired glucose tolerance. By the time Questions Total 1
• Past Papers she visits you in clinic she has succeeded in losing 3 kg in
Questions Percentage 100 %
• Random Questions weight. You decide to give her a trial of orlistat and
behavioural therapy. Which of the following best More
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describes the mode of action of orlistat?
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• New Multimedia Orlistat is a centrally acting appetite suppressant
Online Extras Orlistat is a pancreatic and gastric lipase inhibitor Reference: Normal Values
Library Orlistat reduces hepatic glucose production
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• Timed Test A 45-year-old woman is referred to the endocrine clinic by
her GP for review. She has a body mass index of 35, Questions Incorrect 0
• Mock Exam
hypertension and impaired glucose tolerance. By the time Questions Total 2
• Past Papers she visits you in clinic she has succeeded in losing 3 kg in
Questions Percentage 100 %
• Random Questions weight. You decide to give her a trial of orlistat and
behavioural therapy. Which of the following best More
• My Performance
describes the mode of action of orlistat?
• Media Bank
• New Multimedia Orlistat is a centrally acting appetite
suppressant
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Orlistat is a pancreatic and gastric Your answer
Library lipase inhibitor
Community Orlistat reduces hepatic glucose
Help production
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Orlistat is a b 3 -agonist
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Newsletters Orlistat, a pancreatic lipase inhibitor, blocks the
breakdown and hence absorption of dietary fat. In
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essence, this means that ingested fat continues its
Order History passage through the gut. If patients taking orlistat do Reference: Normal Values
Learning Goals not maintain a low-fat diet then they may suffer
distressing oily diarrhoea. This is why it is essential to Click to open/closeHaematology
Question Filters combine orlistat therapy with an effective patient Click to open/closeImmunoglobulins
support programme. Sibutramine is a centrally acting Click to open/closeBiochemistry
drug that acts on serotoninergic and noradrenergic Click to open/closeDiabetes Click to
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• Timed Test A 42-year-old man with long-standing HIV infection
presents for review. He has been taking antiretroviral Questions Incorrect 0
• Mock Exam
therapy for 5 years and has been relatively free of Questions Total 2
• Past Papers associated disease. You notice on examination that he
Questions Percentage 100 %
• Random Questions appears to have lost subcutaneous fat on his arms, legs
and face, and has increased deposition of fat around his More
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abdomen. His lipids are also abnormal, with a raised
• Media Bank triglyceride level and low HDL cholesterol. What is the
• New Multimedia most likely cause of this clinical picture?
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• Timed Test A 42-year-old man with long-standing HIV infection
presents for review. He has been taking antiretroviral Questions Incorrect 0
• Mock Exam
therapy for 5 years and has been relatively free of Questions Total 3
• Past Papers associated disease. You notice on examination that he
Questions Percentage 100 %
• Random Questions appears to have lost subcutaneous fat on his arms, legs
and face, and has increased deposition of fat around his More
• My Performance
abdomen. His lipids are also abnormal, with a raised
• Media Bank triglyceride level and low HDL cholesterol. What is the
• New Multimedia most likely cause of this clinical picture?
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As the survival of HIV-positive patients improves, more
My Career and Exams complications of antiretroviral therapy (ARVs) are
Order History becoming apparent. These include a lipodystrophy-type Reference: Normal Values
syndrome characterised by the loss of peripheral and
Learning Goals facial subcutaneous fat, but increased abdominal and Click to open/closeHaematology
Question Filters visceral fat deposition. There is also an increase in the Click to open/closeImmunoglobulins
size of the dorsocervical fat pad ‘buffalo-hump’. This fat Click to open/closeBiochemistry
redistribution is associated with a picture of Click to open/closeDiabetes Click to
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proved equivocal.
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• Timed Test You are asked by the psychiatrists to review a 42-year-old
woman who has long-standing bipolar disorder for which Questions Incorrect 0
• Mock Exam
she takes lithium. During a recent inpatient stay she Questions Total 3
• Past Papers appeared to be drinking vast amounts of water and getting
Questions Percentage 100 %
• Random Questions up many times in the night to urinate. Urea and electrolyte
testing reveals elevated sodium and urea concentrations, More
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suggesting possible mild dehydration. Water deprivation
• Media Bank testing reveals a progressively rising serum osmolality to
• New Multimedia above 300 mOsm/kg, without increased urine osmolality.
Blood glucose is normal. What is the most likely cause
Online Extras of this clinical picture? Reference: Normal Values
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• Timed Test You are asked by the psychiatrists to review a 42-year-old
woman who has long-standing bipolar disorder for which Questions Incorrect 0
• Mock Exam
she takes lithium. During a recent inpatient stay she Questions Total 4
• Past Papers appeared to be drinking vast amounts of water and getting
Questions Percentage 100 %
• Random Questions up many times in the night to urinate. Urea and electrolyte
testing reveals elevated sodium and urea concentrations, More
• My Performance
suggesting possible mild dehydration. Water deprivation
• Media Bank testing reveals a progressively rising serum osmolality to
• New Multimedia above 300 mOsm/kg, without increased urine osmolality.
Blood glucose is normal. What is the most likely cause
Online Extras of this clinical picture?
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Cranial diabetes insipidus
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Order History This woman has nephrogenic diabetes insipidus (DI) Reference: Normal Values
secondary to chronic lithium therapy. There is usually
Learning Goals some recovery after withdrawing lithium therapy but Click to open/closeHaematology
Question Filters many patients suffer some degree of permanent Click to open/closeImmunoglobulins
nephrogenic DI. Lithium therapy should only be Click to open/closeBiochemistry
discontinued with psychiatric advice, but at least now Click to open/closeDiabetes Click to
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• Timed Test A 35-year-old woman is referred by her GP because of
Questions Incorrect 0
• Mock Exam recurrent headaches. These tend to come on at times of
stress or exercise and appear almost ‘in a flash’. She also Questions Total 4
• Past Papers complains of intermittent palpitations and problems with Questions Percentage 100 %
• Random Questions sweating. He has tried her on a course of antidepressants,
which only seemed to make her symptoms worse. Her 24-h More
• My Performance
urinary catecholamines are markedly raised. An MRI scan
• Media Bank reveals a mass in the right adrenal medulla. Her blood
• New Multimedia pressure in clinic is 145/95 mmHg.
What is the best management plan?
Online Extras Reference: Normal Values
Library Urgent β-blockade
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• Timed Test A 35-year-old woman is referred by her GP because of recurrent headaches. These
• Mock Exam tend to come on at times of stress or exercise and appear almost ‘in a flash’. She also
complains of intermittent palpitations and problems with sweating. He has tried her on
• Past Papers a course of antidepressants, which only seemed to make her symptoms worse. Her
• Random Questions 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.
• My Performance
What is the best management plan?
• Media Bank
• New Multimedia Urgent β-blockade
Online Extras Urgent surgery
Library Urgent a-blockade, then β-blockade if required, and surgery Your answer
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Help β-Blockade followed by urgent surgery
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Profile This woman has a phaeochromocytoma of the right adrenal medulla. The
commonest presenting features are headache (80%), palpitations (70%),
Newsletters hyperhydrosis (60%) and hypertension (sustained in 55% and paroxysmal in 45%
My Career and Exams of patients). Drugs that inhibit catecholamine reuptake, such as tricyclic
antidepressants and cocaine, can exacerbate or unmask the symptoms of this
Order History condition. MRI or MIBG (metaiodobenzyl guanidine) scanning are the definitive
Learning Goals 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
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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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• Timed Test A 25-year-old woman presents with a lump on the left-hand side of her neck in the
• Mock Exam thyroid region. Thyroid function is normal, and uptake scanning reveals it to be a cold
nodule. Fine-needle aspiration biopsy reveals architecture suspicious of follicular
• Past Papers carcinoma of the thyroid, this is confirmed on thyroid lobectomy.
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Which of the following is the most appropriate management plan?
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• Media Bank Oral thyroxine therapy
• New Multimedia No further surgery
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• Timed Test A 25-year-old woman presents with a lump on the left-
hand side of her neck in the thyroid region. Thyroid Questions Incorrect 0
• Mock Exam
function is normal, and uptake scanning reveals it to be a Questions Total 6
• Past Papers cold nodule. Fine-needle aspiration biopsy reveals
Questions Percentage 100 %
• Random Questions architecture suspicious of follicular carcinoma of the thyroid,
this is confirmed on thyroid lobectomy. More
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• Media Bank Which of the following is the most appropriate
management plan?
• New Multimedia
Online Extras Oral thyroxine therapy
Library No further surgery
Community Total thyroidectomy
Help Total thyroidectomy, radioiodine Your answer
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therapy
Radioiodine therapy
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My Career and Exams The definitive management for follicular carcinoma of
the thyroid without metastases is total thyroidectomy, Reference: Normal Values
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followed by radioiodine therapy, with thyroxine
Learning Goals replacement to a TSH-suppressive dose. If metastases Click to open/closeHaematology
Question Filters are present they usually respond to radioiodine therapy, Click to open/closeImmunoglobulins
and this is added. Metastases are subject to Click to open/closeBiochemistry
haematological spread, with bone being the commonest Click to open/closeDiabetes Click to
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80% for follicular carcinoma. This is much higher than open/closeBlood gases Click to
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occurs in the elderly and only carries a 5-year survival
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rate of 5%.
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• Timed Test A 58-year-old woman presents with fever, marked anxiety
and agitation, palpitations, marked muscle weakness and Questions Incorrect 0
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diarrhoea. On examination she has a goitre, and is in fast Questions Total 6
• Past Papers atrial fibrillation with a ventricular rate of 135 beats per
Questions Percentage 100 %
• Random Questions minute. Urine testing reveals evidence of protein, white
cells and red blood cells. Thyroid function testing reveals a More
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TSH of < 0.05 mU/l. Which of the following diagnoses
• Media Bank best fits this clinical picture?
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Urinary tract infection
Online Extras Reference: Normal Values
Paroxysmal atrial fibrillation
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Hypothyroidism Click to
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• Timed Test A 58-year-old woman presents with fever, marked anxiety
and agitation, palpitations, marked muscle weakness and Questions Incorrect 0
• Mock Exam
diarrhoea. On examination she has a goitre, and is in fast Questions Total 7
• Past Papers atrial fibrillation with a ventricular rate of 135 beats per
Questions Percentage 100 %
• Random Questions minute. Urine testing reveals evidence of protein, white
cells and red blood cells. Thyroid function testing reveals a More
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TSH of < 0.05 mU/l. Which of the following diagnoses
• Media Bank best fits this clinical picture?
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Urinary tract infection
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Paroxysmal atrial fibrillation
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Thyroid storm Your answer
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Thyroid storm is an unusual presentation of
Profile thyrotoxicosis, precipitated by acute stress in a
Newsletters previously undiagnosed patient. Causes include
infection (as in this case), myocardial infarction or
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diabetic ketoacidosis. Inadequate adherence to
Order History therapy in an already diagnosed patient may also be Reference: Normal Values
Learning Goals responsible. Symptoms include fever, anxiety and
agitation, sweating, marked proximal muscle Click to open/closeHaematology
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heart failure, particularly in the elderly. Click to open/closeBiochemistry
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conjunction with carbimazole therapy may bring a
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• Timed Test A 54-year-old thyrotoxic man has been treated with
radioiodine. What is the best advice for the patient Questions Incorrect 0
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during the post-radioiodine period? Questions Total 7
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Questions Percentage 100 %
• Random Questions Antithyroid drugs should never be taken after
• My Performance radioiodine treatment More
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the age of 11 years for about 2 weeks after treatment
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There is no need to monitor his TSH level
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He will never need further doses of radioiodine
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• Timed Test A 54-year-old thyrotoxic man has been treated with
radioiodine. What is the best advice for the patient Questions Incorrect 0
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during the post-radioiodine period? Questions Total 8
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Questions Percentage 100 %
• Random Questions Antithyroid drugs should never be
• My Performance taken after radioiodine treatment More
• Media Bank He should not have close contact with Your answer
children under the age of 11 years for
• New Multimedia about 2 weeks after treatment
Online Extras There is no need to monitor his TSH
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radioiodine
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He may have close contact with
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• Timed Test A 61-year-old patient with a history of recent
thyrotoxicosis underwent major surgery a week ago. He Questions Incorrect 0
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now presents with altered mental status, tachycardia, high- Questions Total 8
• Past Papers grade fever, vomiting and cardiac failure. A diagnosis of
Questions Percentage 100 %
• Random Questions thyroid storm (crisis) is made. What is the most
important next step in management? More
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• Media Bank Transfer the patient to ITU
• New Multimedia Avoid chlorpromazine in the treatment of agitation
Online Extras Avoid carbimazole treatment Reference: Normal Values
Library Potassium iodide should be given immediately before
propylthiouracil Click to
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• Timed Test A 61-year-old patient with a history of recent
thyrotoxicosis underwent major surgery a week ago. He Questions Incorrect 0
• Mock Exam
now presents with altered mental status, tachycardia, high- Questions Total 9
• Past Papers grade fever, vomiting and cardiac failure. A diagnosis of
Questions Percentage 100 %
• Random Questions thyroid storm (crisis) is made. What is the most
important next step in management? More
• My Performance
• Media Bank Transfer the patient to ITU Your answer
• New Multimedia Avoid chlorpromazine in the treatment
Online Extras of agitation
Library Avoid carbimazole treatment
Community Potassium iodide should be given
immediately before propylthiouracil
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Peritoneal dialysis should be started
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• Timed Test A 25-year-old woman develops hyperthyroidism 6 weeks
after delivery. On examination she has painless, firm Questions Incorrect 0
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enlargement of the thyroid gland. Questions Total 9
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Which of the following statements is most correct Questions Percentage 100 %
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with regards to the probable diagnosis? More
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• Media Bank The condition is more likely in those in whom thyroid
• New Multimedia peroxidase (TPO) antibodies were positive prior to
delivery
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When followed up, most patients have lifelong
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• Timed Test A 25-year-old woman develops hyperthyroidism 6 weeks
after delivery. On examination she has painless, firm Questions Incorrect 0
• Mock Exam
enlargement of the thyroid gland. Questions Total 10
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Which of the following statements is most correct Questions Percentage 100 %
• Random Questions
with regards to the probable diagnosis? More
• My Performance
• Media Bank The condition is more likely in those in Your answer
• New Multimedia whom thyroid peroxidase (TPO)
antibodies were positive prior to delivery
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When followed up, most patients have
Library lifelong hypothyroidism
Community It is less common in patients with a
Help history of Type-1 diabetes
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degree of thyroid dysfunction post
partum
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of the thyroid gland
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Postpartum thyroiditis is thyroid dysfunction occurring
Learning Goals within the first 6 months’ postpartum. Prevalence Click to open/closeHaematology
Question Filters ranges from 5 to 7%. It develops in 30–52% of women Click to open/closeImmunoglobulins
who have positive TPO antibodies. Most patients have a Click to open/closeBiochemistry
complete remission but some may progress to Click to open/closeDiabetes Click to
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• Timed Test A 27-year-old woman on bromocriptine for
microprolactinoma becomes pregnant. What is the most Questions Incorrect 0
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appropriate management advice? Questions Total 10
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Questions Percentage 100 %
• Random Questions Continue bromocriptine at the same dose
• My Performance Visual field testing to be done every fortnight More
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• New Multimedia congenital abnormalities
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• Timed Test A 27-year-old woman on bromocriptine for
microprolactinoma becomes pregnant. What is the most Questions Incorrect 1
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appropriate management advice? Questions Total 11
• Past Papers
Questions Percentage 90 %
• Random Questions Continue bromocriptine at the same Your answer
• My Performance dose More
• Media Bank Visual field testing to be done every
fortnight
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Continuing bromocriptine would
Online Extras significantly increase congenital
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pregnancy is confirmed
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Needs cerebral magnetic resonance
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pregnancy
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Whilst bromocriptine is an effective treatment for
My Career and Exams microprolactinoma in terms of suppression of prolactin
Order History secretion, it may interfere with the natural rise in Reference: Normal Values
prolactin seen in pregnancy. Bromocriptine should
Learning Goals therefore be stopped as soon as pregnancy is Click to open/closeHaematology
Question Filters confirmed. Visual field testing and MRI are indicated Click to open/closeImmunoglobulins
only in the occasional patient who becomes Click to open/closeBiochemistry
symptomatic. Data on children whose mothers received Click to open/closeDiabetes Click to
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• Timed Test A 41-year-old heavy smoker presents with a serum sodium
level of 112 mmol/l. A diagnosis of SIADH is confirmed. Questions Incorrect 1
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What is the most appropriate initial management of Questions Total 11
• Past Papers his fluid balance?
Questions Percentage 90 %
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• Media Bank Fluid restriction
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• Timed Test A 41-year-old heavy smoker presents with a serum sodium
level of 112 mmol/l. A diagnosis of SIADH is confirmed. Questions Incorrect 2
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What is the most appropriate initial management of Questions Total 12
• Past Papers his fluid balance?
Questions Percentage 83 %
• Random Questions
• My Performance Immediate normal saline infusion More
• Media Bank Fluid restriction Correct answer
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PasTest Store In patients with the syndrome of inappropriate ADH
(SIADH) secretion, it is important to restrict fluids to
500–1000 ml/24 hours. The underlying cause must also
My Account be detected and treated. If the problem is not
temporary and long-term fluid restriction is likely to be
Profile difficult, then demeclocycline may be effective by
Newsletters inducing partial nephrogenic diabetes insipidus. In an
emergency, saline infusion may be required; however,
My Career and Exams great care is required as rapid overcorrection of
Order History hyponatraemia may cause central pontine myelinolysis. Reference: Normal Values
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• Timed Test You are called to the psychiatric unit to see an 18-year-old
woman with anorexia nervosa. What would you expect Questions Incorrect 2
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to see in the results of her biochemical Questions Total 12
• Past Papers investigations?
Questions Percentage 83 %
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• My Performance Raised LH, FSH More
• Media Bank Elevated circulating cortisol
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• Timed Test You are called to the psychiatric unit to see an 18-year-old
woman with anorexia nervosa. What would you expect Questions Incorrect 2
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to see in the results of her biochemical Questions Total 13
• Past Papers investigations?
Questions Percentage 84 %
• Random Questions
• My Performance Raised LH, FSH More
• Media Bank Elevated circulating cortisol Your answer
Community
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PasTest Store The typical patient with anorexia nervosa is a woman
aged < 25 years with weight loss, amenorrhea and
behavioural changes. There is a long-term risk of severe
My Account osteoporosis. Endocrine abnormalities include GnRH
deficiency, low LH and FSH, low oestrogen in women,
Profile raised circulating cortisol, low to normal thyroxine,
Newsletters reduced T 3 , normal TSH and increased resting GH
levels.
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• Timed Test A 72-year-old woman recently diagnosed as having
hyperparathyroidism has a serum calcium concentration of Questions Incorrect 2
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3.2 mmol/l. What is the most appropriate treatment? Questions Total 13
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Questions Percentage 84 %
• Random Questions Surgery
• My Performance Long-term observation with regular blood tests More
• Media Bank Long-term bisphosphonates
• New Multimedia Hormone replacement therapy
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• Timed Test A 72-year-old woman recently diagnosed as having
hyperparathyroidism has a serum calcium concentration of Questions Incorrect 2
• Mock Exam
3.2 mmol/l. What is the most appropriate treatment? Questions Total 14
• Past Papers
Questions Percentage 85 %
• Random Questions Surgery Your answer
• My Performance Long-term observation with regular More
• Media Bank blood tests
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• Timed Test What is the commonest cause of death in patients
with von Hippel–Lindau disease? Questions Incorrect 2
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Questions Total 14
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Cerebellar haemangioblastoma Questions Percentage 85 %
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Renal carcinoma
• My Performance More
Retinal tumours
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Myocardial infarction
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Phaeochromocytoma
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• Timed Test What is the commonest cause of death in patients
with von Hippel–Lindau disease? Questions Incorrect 3
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Questions Total 15
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Cerebellar haemangioblastoma Questions Percentage 80 %
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Renal carcinoma Correct answer
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Retinal tumours
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Myocardial infarction Your answer
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VHL disease is an autosomal-dominant condition, with
Help the VHL gene being located on chromosome 3.
PasTest Store Estimated prevalence is 1/39,000. Retinal angiomatosis
is the initial presentation in 40% patients. Cerebellar
haemangioblastoma is a common initial presentation.
My Account Renal carcinoma is the commonest cause of death, with
phaeochromocytoma occurring in 40% of patients with
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• Timed Test A 30-year-old man arrives in A&E in an unconscious state.
His initial blood glucose reading by monitor is 2.1 mmol/l. Questions Incorrect 3
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What is the most important immediate management Questions Total 15
• Past Papers of this patient?
Questions Percentage 80 %
• Random Questions
• My Performance Oral glucose More
• Media Bank Mannitol
• New Multimedia 50% glucose into a large vein after first taking a
blood sample
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10 mg glucagon im
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• Timed Test A 30-year-old man arrives in A&E in an unconscious state.
His initial blood glucose reading by monitor is 2.1 mmol/l. Questions Incorrect 3
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What is the most important immediate management Questions Total 16
• Past Papers of this patient?
Questions Percentage 81 %
• Random Questions
• My Performance Oral glucose More
• Media Bank Mannitol
• New Multimedia 50% glucose into a large vein after Your answer
first taking a blood sample
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10 mg glucagon im
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Check his serum ethanol concentration
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Hypoglycaemia is defined as a plasma glucose
concentration < 2.5 mmol/l and associated with
My Account symptoms of neuroglycopenia. Large-bore venous
access should be achieved and blood samples for serum
Profile glucose, liver function, ethanol, cortisol, insulin, C-
Newsletters peptide, proinsulin and sulphonylurea levels should be
sent for testing. If the patient’s Glasgow Coma Score
My Career and Exams (GCS) is < 13, then 25–50 ml 50% glucose should be
Order History given intravenously. Glucagon (1 mg im) may be Reference: Normal Values
administered if no intravenous access can be obtained.
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• Timed Test A 28-year-old man presents with erectile dysfunction.
What is the commonest cause in this age group? Questions Incorrect 3
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Questions Total 16
• Past Papers
Alcohol Questions Percentage 81 %
• Random Questions
b-Blockers
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Diabetes mellitus
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Psychological factors
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Testicular tumour
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• Timed Test A 28-year-old man presents with erectile dysfunction.
What is the commonest cause in this age group? Questions Incorrect 3
• Mock Exam
Questions Total 17
• Past Papers
Alcohol Questions Percentage 82 %
• Random Questions
b-Blockers
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Diabetes mellitus
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Psychological factors Your answer
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Testicular tumour
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Help Erectile dysfunction is present in approximately 10% of
PasTest Store 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
My Account include serum testosterone, prolactin, fasting glucose,
LH and FSH, thyroid function tests, liver and renal
Profile function, lipids and ferritin.
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• Timed Test Which of the following is the most likely long-term
consequence of the menopause? Questions Incorrect 3
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Questions Total 17
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Decreased thrombotic tendency Questions Percentage 82 %
• Random Questions
Less likelihood of developing ischaemic heart disease
• My Performance (IHD) More
• Media Bank Increased possibility of developing Alzheimer’s
• New Multimedia dementia
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• Timed Test Which of the following is the most likely long-term
consequence of the menopause? Questions Incorrect 3
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Questions Total 18
• Past Papers
Decreased thrombotic tendency Questions Percentage 83 %
• Random Questions
Less likelihood of developing ischaemic
• My Performance heart disease (IHD) More
• Media Bank Increased possibility of developing Your answer
• New Multimedia Alzheimer’s dementia
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PasTest Store During the perimenopausal period there is an
accelerated loss of BMD, rendering postmenopausal
women more susceptible to osteoporotic fractures. They
My Account are also more likely to develop IHD, decreased insulin
sensitivity and increased thrombotic tendency. Women
Profile are 2–3 times more likely to develop Alzheimer’s
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diagnosis of carcinoid syndrome is suspected. Which of Questions Total 22
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patients with carcinoid syndrome. Alkaline phosphatase
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Which of the following is the best management step? More
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in the shortest time. Both propylthiouracil and
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pregnancy. Surgery is rarely performed during
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121 mmol/l, K 3.9 mmol/l, urea 2.4 mmol/l, creatinine 64
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become increasingly confused. On examination he was Questions Total 4
• Past Papers drowsy, had a BP of 142/75 mmHg and was clinically
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pneumonia. Blood biochemistry investigations revealed Na More
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121 mmol/l, K 3.9 mmol/l, urea 2.4 mmol/l, creatinine 64
• Media Bank µmol/l and glucose 4.2 mmol/l. Plasma osmolarity was 261
• New Multimedia mOsmol/kg, and thyroid function testing was normal. Urine
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panic attacks over the past few years. She currently takes Questions Total 5
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normal renal function and calcium concentration, an ECG More
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showed mild LVH. Unfortunately during the operation, as
• Media Bank the surgeon attempts to mobilise her uterus, her blood
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• Timed Test A marfanoid-looking, 21-year-old man is referred by his GP for review. He has been
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is still 7.8%. You elect to add in a peroxisome proliferator- Questions Total 6
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• Timed Test A 45-year-old man presents for review at the type-2
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is still 7.8%. You elect to add in a peroxisome proliferator- Questions Total 7
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PPAR- γ agonists act by binding to the PPAR-gamma
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the upregulation of a number of enzymes concerned
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possible action in improving insulin sensitivity.
Currently, there is one PPAR- γ agonist on the market,
pioglitazone.
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last 3 years. She underwent a total hysterectomy at the Questions Total 7
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• Timed Test A 52-year-old woman is referred by the A&E department
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last 3 years. She underwent a total hysterectomy at the Questions Total 8
• Past Papers age of 38 for carcinoma. Bone densitometry confirms
Questions Percentage 87 %
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are normal. Which of the following is the most likely More
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Grave’s disease
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tachycardias and panic attacks. There is no significant past Questions Total 9
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• Timed Test A 17-year-old student presents with intermittent weakness
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tests and found her to have a potassium level of 2.8 Questions Total 10
• Past Papers mmol/l and a bicarbonate of 32 mmol/l. She is
Questions Percentage 80 %
• Random Questions normotensive. You arrange a renin and aldosterone level,
and both are elevated. Urinary calcium excretion is More
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elevated. Urinary diuretic screen is negative.
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mutation, whilst most patients present in childhood,
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Hyperplasia of the juxtaglomerular apparatus is seen on
renal biopsy. Gitelman’s syndrome is due to a different
mutation, and produces a clinical picture similar to that
seen with chronic thiazide administration. Liddle’s
syndrome is characterised by potassium wasting and
hypertension.
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metabolic abnormalities and he is concerned about the Questions Total 10
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metabolic abnormalities and he is concerned about the Questions Total 11
• Past Papers possibility of Conn’s syndrome. The blood picture is one of
Questions Percentage 81 %
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aldosterone levels. What diagnosis fits with this clinical More
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picture?
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retention and volume expansion. Addison’s disease is,
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hyperaldosteronism and is associated with
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tamoxifen for breast cancer prophylaxis. Which of the Questions Total 11
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tamoxifen for breast cancer prophylaxis. Which of the Questions Total 12
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It is a progesterone-receptor agonist
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anterior neck. Thyroid ultrasound reveals infiltration, and Questions Total 0
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anterior neck. Thyroid ultrasound reveals infiltration, and Questions Total 1
• Past Papers biopsy does reveal dense infiltration of the gland. Free T 4 is
Questions Percentage 100 %
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• My Performance hypothyroidism. Thyroid autoantibodies are negative. More
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unidentified. Treatment is with thyroxine replacement.
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development of secondary sexual characteristics. There is a
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Her mother is concerned that she has short stature and is Questions Total 2
• Past Papers still to commence her periods. On examination she is
Questions Percentage 100 %
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have excess skin around her neck, and has poor More
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development of secondary sexual characteristics. There is a
• Media Bank murmur suggestive of aortic stenosis. Chromosome analysis
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this clinical picture?
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Library Noonan’s syndrome
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acutely unwell. He is shocked, drowsy and confused. Blood Questions Total 3
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blood glucose was 8.7 mmol/l. More
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Intravenous insulin therapy
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• Timed Test A 54-year-old type-2 diabetic man presents for review.
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associated with autoimmune thyroid disease or type-
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disease. Her daughter has been researching autoimmune Questions Total 5
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Questions Percentage 80 %
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of the following HLA subtypes is most strongly More
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associated with autoimmune thyroid disease or type-
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hypothyroidism and Cushing’s disease, is negative. She Questions Total 5
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hypothyroidism and Cushing’s disease, is negative. She Questions Total 6
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Alopecia, thrombocytopenia, anaemia and dermatitis
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2410
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Questions Percentage 66 %
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abnormal chest X-ray revealing a right hilar mass. There is Questions Total 7
• Past Papers a history of 40 years of cigarette smoking. He is noted to
Questions Percentage 71 %
• Random Questions have a markedly raised corrected calcium level of 3.25
mmol/l. Apart from a mildly raised urea level due to More
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dehydration, his other renal function testing is normal. He
• Media Bank also has a normochromic normocytic anaemia with a
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• Timed Test A 19-year-old student nurse was admitted after her third
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sugar of 0.9 mmol/l on finger -prick testing and responded Questions Total 7
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Questions Percentage 71 %
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markedly raised insulin level, but her C-peptide levels were More
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Insulinoma
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Glucagonoma
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• Timed Test A 19-year-old student nurse was admitted after her third
collapse in recent months. She was noted to have a blood Questions Incorrect 2
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sugar of 0.9 mmol/l on finger -prick testing and responded Questions Total 8
• Past Papers well to intravenous glucose therapy. Venous blood taken at
Questions Percentage 75 %
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markedly raised insulin level, but her C-peptide levels were More
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normal. What diagnosis fits best with this clinical
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Insulinoma
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Glucagonoma
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• Timed Test A 35-year-old woman visits you in the paediatric diabetes
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He has a 100% future risk of developing type-1
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• Timed Test A 35-year-old woman visits you in the paediatric diabetes
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type-1 diabetes. He has an identical twin brother and she is Questions Total 9
• Past Papers concerned about his risk of developing diabetes. What
Questions Percentage 77 %
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He has a 100% future risk of
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GAD antibodies in the unaffected child
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IA-2 antibodies in the unaffected child
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50% or greater. Maturity-onset diabetes of the young
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• Timed Test You are reviewing a 45-year-old man who has type-2
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and has not tolerated metformin therapy due to Questions Total 9
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Questions Percentage 77 %
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appropriate therapy choice. Which of the following best More
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describes the mode of action of nateglinide?
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• Timed Test You are reviewing a 45-year-old man who has type-2
Questions Incorrect 2
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and has not tolerated metformin therapy due to Questions Total 10
• Past Papers gastrointestinal side-effects. You decide that the Questions Percentage 80 %
• Random Questions postprandial glucose regulator nateglinide is the most
appropriate therapy choice. Which of the following best More
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describes the mode of action of nateglinide?
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output
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It acts by reducing peripheral insulin
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coincide with meals. Nateglinide is more expensive than Click to open/closeHaematology
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sulphonylureas but offers advantages for shift workers
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result in “less strain” on the β-cell.
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• Timed Test A 74-year-old man is admitted to A&E in an acute
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mmol/l and because he has heavily nicotine-stained Questions Total 10
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• Timed Test A 74-year-old man is admitted to A&E in an acute
confusional state. His serum sodium concentration is 105 Questions Incorrect 3
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mmol/l and because he has heavily nicotine-stained Questions Total 11
• Past Papers fingers, SIAD is suspected.
Questions Percentage 72 %
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Which of the following biochemical findings best More
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Random urine osmolality of 380 Correct answer
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A diagnosis of SIAD (syndrome of inappropriate
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satisfies one criterion. Urea concentration is low: this
is likely to be because of water overload.
Patients with SIAD are usually in sodium balance and
sodium excretion is appropriate for intake. A very low
urine sodium would suggest that hyponatraemia was
due to sodium depletion.
2573
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• Timed Test Following a head injury, a 24-year-old patient develops
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diabetes insipidus. He undergoes a water deprivation test. Questions Total 11
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A rise in plasma osmolality to 302 mmol/kg during
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720 mmol/kg following the administration of
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• Timed Test Following a head injury, a 24-year-old patient develops
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diabetes insipidus. He undergoes a water deprivation test. Questions Total 12
• Past Papers Which one of the following responses would most
Questions Percentage 75 %
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A rise in plasma osmolality to 302
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urine osmolality of 720 mmol/kg
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DI. A low plasma osmolality at the end of the
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cranial DI can be transient following head injury.
2574
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• Timed Test A 49-year-old woman presents complaining of fatigue and
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prolactinoma 3 years ago, and it is suspected that she Questions Total 12
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Questions Percentage 75 %
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Medullar carcinoma of thyroid
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Parathyroid hyperplasia
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• Timed Test A 49-year-old woman presents complaining of fatigue and
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prolactinoma 3 years ago, and it is suspected that she Questions Total 13
• Past Papers might now have MEN-1. Which of the following
Questions Percentage 76 %
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Medullar carcinoma of thyroid
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Parathyroid hyperplasia is seen in the vast majority of
patients with multiple endocrine neoplasia type 1 (MEN-
My Account 1), and the hypercalcaemia that they cause is the most
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My Career and Exams gastrinomas) are present in about 40% of cases.
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a half are prolactinomas. Medullary-cell carcinomas of
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• Timed Test A 51-year-old man presents with weight loss and is found
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telangiectasia. Urinary 5-HIAA levels are found to be Questions Total 13
• Past Papers elevated. Given the diagnosis of carcinoid syndrome,
Questions Percentage 76 %
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• Timed Test A 51-year-old man presents with weight loss and is found
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telangiectasia. Urinary 5-HIAA levels are found to be Questions Total 14
• Past Papers elevated. Given the diagnosis of carcinoid syndrome,
Questions Percentage 78 %
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• Timed Test A 73-year-old woman presents with weight loss and is
found to have a serum calcium concentration of 3.22 Questions Incorrect 3
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mmol/l. A skeletal survey is normal. Non-metastatic Questions Total 14
• Past Papers hypercalcaemia is suspected. Endoscopy reveals a gastric
Questions Percentage 78 %
• Random Questions carcinoma.
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Secretion of which of the following substances by the
• Media Bank tumour is most likely to be responsible?
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Calcitonin
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Calcitriol (1,25-dihydroxycholecalciferol)
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• Timed Test A 73-year-old woman presents with weight loss and is
found to have a serum calcium concentration of 3.22 Questions Incorrect 3
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mmol/l. A skeletal survey is normal. Non-metastatic Questions Total 15
• Past Papers hypercalcaemia is suspected. Endoscopy reveals a gastric
Questions Percentage 80 %
• Random Questions carcinoma.
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Secretion of which of the following substances by the
• Media Bank tumour is most likely to be responsible?
• New Multimedia
Calcitonin
Online Extras
Calcitriol (1,25-
Library dihydroxycholecalciferol)
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• Timed Test A 55-year-old man is found incidentally to have
hypercalcaemia during a routine health screen. Questions Incorrect 3
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Which one of the following biochemical findings Questions Total 15
• Past Papers would be most suggestive of this being caused by
Questions Percentage 80 %
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cause of hypercalcaemia? More
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• Timed Test A 55-year-old man is found incidentally to have
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Which one of the following biochemical findings Questions Total 16
• Past Papers would be most suggestive of this being caused by
Questions Percentage 81 %
• Random Questions primary hyperparathyroidism rather than any other
cause of hypercalcaemia? More
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• Media Bank Elevated 24-h urinary calcium
• New Multimedia excretion
Online Extras Elevated serum alkaline phosphatase
activity
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Low serum concentration of calcitriol
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My Career and Exams they are not always so. PTH secretion should be
Order History suppressed by hypercalcaemia from any other cause, so Reference: Normal Values
that a PTH value in the normal range is consistent with
Learning Goals the diagnosis. Urinary calcium excretion is increased in Click to open/closeHaematology
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hypocalciuric hypercalcaemia), including Click to open/closeBiochemistry
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and calcitriol concentrations to be increased (PTH
stimulates the formation of this hormone).
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• Timed Test A 57-year-old woman is brought to A&E after sustaining a
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that there is erosion of the anterior clinoid processes of the Questions Total 16
• Past Papers pituitary fossa, suggesting a pituitary tumour. Which of
Questions Percentage 81 %
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secreted in excess? More
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• Timed Test A 57-year-old woman is brought to A&E after sustaining a
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that there is erosion of the anterior clinoid processes of the Questions Total 17
• Past Papers pituitary fossa, suggesting a pituitary tumour. Which of
Questions Percentage 82 %
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secreted in excess? More
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• Media Bank Adrenocorticotrophin (ACTH)
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• Timed Test A 42-year-old patient complains of severe fatigue following
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hormone replacement. Which of the following is a well- Questions Total 17
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• Timed Test A 42-year-old patient complains of severe fatigue following
surgery for a pituitary tumour and is put on growth Questions Incorrect 3
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hormone replacement. Which of the following is a well- Questions Total 18
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• Timed Test A 37-year-old man with a diagnosis of hypogonadotrophic hypogonadism is being
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• Timed Test A 37-year-old man with a diagnosis of hypogonadotrophic
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does not desire fertility at present. Which would be the Questions Total 19
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• Timed Test A 44-year-old man is surprised to find that he cannot
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• Timed Test A 44-year-old man is surprised to find that he cannot
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years ago. He goes to buy a new pair and is told that his Questions Total 20
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• Timed Test MR imaging indicates a microadenoma in a 36-year-old
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have excessive growth hormone secretion. Which of the Questions Total 20
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• Timed Test MR imaging indicates a microadenoma in a 36-year-old
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have excessive growth hormone secretion. Which of the Questions Total 21
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• Timed Test A 49-year-old woman is investigated to determine the
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hypercortisolaemia by a high 24-hour urinary cortisol Questions Total 21
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• Timed Test A 49-year-old woman is investigated to determine the
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hypercortisolaemia by a high 24-hour urinary cortisol Questions Total 22
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• Timed Test A 50-year-old woman with hypertension that has been
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hypercortisolaemia. Which one of the following clinical Questions Total 23
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• Timed Test An 18-year-old woman complains of a 2-month history of
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of dizziness and is found to have postural hypotension. Questions Total 23
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• Timed Test An 18-year-old woman complains of a 2-month history of
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of dizziness and is found to have postural hypotension. Questions Total 24
• Past Papers Which of the following investigations is required to
Questions Percentage 79 %
• Random Questions best demonstrate that these features are the result
of adrenal failure? More
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• Media Bank Measurement of early morning and
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• Timed Test A 17-year-old young woman is admitted to A&E having
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give a coherent history, but is found to have a card in her Questions Total 24
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• Timed Test A 17-year-old young woman is admitted to A&E having
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give a coherent history, but is found to have a card in her Questions Total 25
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Questions Percentage 76 %
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Finger prick glucose testing reveals a BM of 3.4 mmol/l.
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• Timed Test A 24-year-old man is found to have hypertension during an
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months, this is demonstrated to fluctuate considerably in Questions Total 25
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Questions Percentage 76 %
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• Timed Test A 24-year-old man is found to have hypertension during an
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months, this is demonstrated to fluctuate considerably in Questions Total 26
• Past Papers severity and proves difficult to control. Which of the
Questions Percentage 76 %
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that a phaeochromocytoma is causing his More
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• Timed Test A 39-year-old man with untreated hypertension has a
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Plasma cortisol concentration was also measured at both
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• Timed Test A 39-year-old man with untreated hypertension has a
plasma potassium concentration of 2.8 mmol/l. When Questions Incorrect 7
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measured at 0900 h with the patient supine, his plasma Questions Total 27
• Past Papers aldosterone concentration is elevated and renin activity is
Questions Percentage 74 %
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the plasma aldosterone concentration increases by 20%. More
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Plasma cortisol concentration was also measured at both
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• Timed Test A 52-year-old woman with primary hypothyroidism is being
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Which (if any) would be the most appropriate next
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being titrated against the results of biochemical thyroid Questions Total 1
• Past Papers function tests. Two weeks after the last increase in dose,
Questions Percentage 0%
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pmol/l (normal 9–26); TSH 14 mU/l (normal 0.2–5.0). More
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Which (if any) would be the most appropriate next
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A decrease in the dose of thyroxine
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Irregular medication could explain these results but
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Triiodothyronine is usually only used in very severe
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• Timed Test A 20-year-old woman presents with anxiety and weight
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and various investigations are performed. Which of the Questions Total 0
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High serum triiodothyronine (T3 ) concentration but
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High titre of thyroid peroxidase autoantibodies
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• Timed Test A 20-year-old woman presents with anxiety and weight
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and various investigations are performed. Which of the Questions Total 1
• Past Papers following findings would most suggest that she has
Questions Percentage 100 %
• Random Questions Graves’ disease?
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High ESR
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High serum triiodothyronine (T3 )
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• Timed Test A 35-year-old woman had a febrile infection associated
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• Timed Test A 35-year-old woman had a febrile infection associated with a painful swelling in her
• Mock Exam neck a week ago. Her thyroid function tests show evidence of thyrotoxicosis and her
ESR is raised. What is the most likely diagnosis?
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• New Multimedia De Quervain’s thyroiditis Your answer
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PasTest Store Subacute (or de Quervain’s) thyroiditis is due to thyroid infection by any of a
number of viruses, especially paramyxoviruses (mumps), coxsackieviruses,
influenza viruses, adenoviruses and echoviruses.
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The most prominent symptom is pain in the thyroid, often radiating to the ears.
Profile A small, tender goitre can be palpated that is usually diffuse, but there can be
asymmetrical involvement. Systemic upset with fever is variable but sometimes
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My Career and Exams be recalled. There is a granulomatous thyroid inflammation with follicular
destruction, and the release of thyroid hormones often results in a transient
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thyrotoxicosis, lasting for 1–4 weeks. Continuing thyroid destruction then leads
Learning Goals to a phase of hypothyroidism once stored hormone is depleted. This lasts 4–12
Question Filters weeks before euthyroidism is restored, but relapses occur in 10–20% of cases.
Sometimes only one phase of thyroid disturbance is seen.
Confirmation of the clinical diagnosis is made by finding an elevated erythrocyte
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Thyroid function requires continuous monitoring as the disease evolves. Mild
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the pain. The dose is tapered over 6–8 weeks, depending largely on symptoms.
Propranolol may be useful for thyrotoxic symptoms, and temporary thyroxine
replacement is sometimes needed during the hypothyroid phase.
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• Timed Test A 60-year-old woman presented complaining of a 6.3 kg (1
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weeks. The following laboratory results are obtained: Questions Total 2
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• Timed Test A 60-year-old woman presented complaining of a 6.3 kg (1
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for 5 months, although no gynaecological abnormality has Questions Total 3
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Her height is 168 cm. On examination her BP is 90/60 More
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• Mock Exam complaining of amenorrhoea for 5 months, although no gynaecological abnormality
has been found. She feels well and is very active but her weight has decreased from
• Past Papers 61 kg to 43 kg in the last 6 months. Her height is 168 cm. On examination her BP is
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Patients with anorexia nervosa actively maintain an unduly low body weight. For
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Profile mass index below 17.5. Amenorrhoea (in postmenarchal women who are not
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palpitations associated with a low blood glucose level. The Questions Total 4
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peptide of < 0.2 nmol/l (reference 0.2–1.4 nmol/l). What
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palpitations associated with a low blood glucose level. The Questions Total 5
• Past Papers family history reveals a brother with type-1 diabetes. A
Questions Percentage 100 %
• Random Questions blood test shows the following results: glucose 1.1 mmol/l,
insulin > 500 pmol/l (reference 15–100 pmol/l) and C- More
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peptide of < 0.2 nmol/l (reference 0.2–1.4 nmol/l). What
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• Timed Test A 55-year-old obese patient with hypercholesterolaemia
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therapeutic step in his management?
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• Timed Test A 55-year-old obese patient with hypercholesterolaemia
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diabetes and hypertension has been on a low cholesterol Questions Total 6
• Past Papers diet for the last 6 months. His latest LDL level is 4.8
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The latest European guidelines suggest that LDL
Profile cholesterol should be < 4.5 mmol/l rather than < 5
mmol/l in secondary prevention, while evidence from
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primary prevention suggests that similar targets should
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Ultrasound
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PasTest Store Ultrasound is useful in determining thyroid size
accurately. Thyroidal uptake of radioisotopes (especially
technetium-99m) is indicated if destructive thyroiditis is
My Account suspected as a cause of goitre. Otherwise, the major
role for imaging is to ensure there is no tracheal
Profile compression or intrathoracic/retrosternal component in
a patient with suggestive symptoms, and a CT scan is
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then the preferred investigation.
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Wilson’s disease may present in childhood, adolescence
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the disease presents with juvenile hepatic disease or
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After an overnight fast, the subject drinks 75 g of
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raised 2-hour value (the ‘lag’ curve).
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diabetes is well controlled and he is normotensive. What Questions Total 12
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• Timed Test A patient with longstanding type-2 diabetes was found to
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diabetes is well controlled and he is normotensive. What Questions Total 13
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In patients with type-1 diabetes with a mean entry
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My Account of one European and one American study (total n =
225) showed an adjusted risk reduction of 63% (95%
Profile CI, 16–84%; p = 0.017) for the development of clinical
nephropathy comparing the ACE inhibitor captopril 100
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wheezing. There have also been episodes of profuse watery Questions Total 1
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wheezing. There have also been episodes of profuse watery Questions Total 2
• Past Papers diarrhoea. Given the suspected diagnosis, what would
Questions Percentage 100 %
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Dexamethasone suppression test
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Urinary catecholamine collection
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The biologically active metabolite characteristically
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bronchoconstriction. It is metabolised to 5-
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medication. On examination her BMI is 28, BP 170/100 Questions Total 2
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medication. On examination her BMI is 28, BP 170/100 Questions Total 3
• Past Papers mmHg, she has a round red face and a slight atrophy of
Questions Percentage 100 %
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normal. What is the next step in obtaining the More
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diagnosis?
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concomitant condition would be a contraindication Questions Total 4
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Lactic acidosis is best known in diabetic patients as a
rare, but often fatal, complication of the biguanide
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gluconeogenesis. The risk is much increased in patients
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Ectopic ACTH syndrome, which accounts for about 15–
20% of patients with Cushing's syndrome, occurs two to
My Account three times more frequently in male patients. Small-cell
lung carcinoma accounts for about 50–75% of all cases
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• Timed Test An overweight patient with type-2 diet-controlled diabetes
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appropriate diet and increased exercise his blood glucose is Questions Total 6
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Pioglitazone
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Metformin is used as a first-line treatment of type-2
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• Timed Test A 20-year-old patient presents with large-volume watery diarrhoea which has
• Mock Exam gradually increased over the last 2 weeks. He has no other complaints and there has
been no recent travel abroad. On examination he looks dehydrated. His blood results
• Past Papers show a hypokalaemic acidosis. Which of the following is the most likely cause for
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• Timed Test A 20-year-old patient presents with large-volume watery
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weeks. He has no other complaints and there has been no Questions Total 7
• Past Papers recent travel abroad. On examination he looks dehydrated.
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VIPomas arise in the pancreas in 90% of cases. The
Profile remaining tumours are mainly gangliomas or
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chain or adrenal medulla, and these tumours are
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Order History tumours are benign, but 50% of pancreatic VIPomas Reference: Normal Values
have metastasised at the time of diagnosis, usually to
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excrete more than 3 litres daily, with volumes of over
20 litres having been described. It is often
intermittent at first, but in severe crises the volume
loss coupled with the vasodilatory effects of VIP and
the associated hypokalaemia may precipitate
cardiovascular collapse. Hypokalaemia results from
loss in stools and activation of the renin–angiotensin
system, and may be profound. The loss of bicarbonate
in the stool leads to acidosis, which may mask the
true potassium deficit.
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• Timed Test A patient has been diagnosed with hyperparathyroidism.
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being due to a prolactinoma. Endocrine tumours in Questions Total 7
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• Timed Test A patient has been diagnosed with hyperparathyroidism.
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being due to a prolactinoma. Endocrine tumours in Questions Total 8
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Multiple endocrine neoplasia-1 (MEN-1) is characterised
by the association of parathyroid hyperplasia, pancreatic
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autosomal-dominant mode of inheritance. The
Profile prevalence of the condition has been estimated at about
1 in 10,000. The affected gene has been termed ‘menin’
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and is found on the 11q13 region of the long arm of
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• Timed Test A 46-year-old magazine columnist is referred by her
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lethargy. There has been no weight loss. The GP found her Questions Total 8
• Past Papers serum sodium to be 128 mmol/l (137–144) and 130 mmol/l
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glucose concentrations), and ordered a chest X-ray. This More
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was reported as showing a small area of increased
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lethargy. There has been no weight loss. The GP found her Questions Total 1
• Past Papers serum sodium to be 128 mmol/l (137–144) and 130 mmol/l
Questions Percentage 100 %
• Random Questions on two occasions (with a normal creatinine and normal
glucose concentrations), and ordered a chest X-ray. This More
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was reported as showing a small area of increased
• Media Bank radiodensity in the right lung apex. Paired plasma and urine
• New Multimedia osmolalities are 255 mosmol/kg (285–295) and 148
mosmol/kg (50–1200) respectively. Which is the most
Online Extras likely diagnosis?
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A tumour of the posterior pituitary
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sodium is measured by flame photometry (since the
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A tumour of the posterior pituitary is exceedingly rare.
Hypothalamic tumours can either cause ADH excess or
diabetes insipidus with the features mentioned above.
The diagnosis that is most compatible with the
biochemical results is hysterical polydipsia. This is
associated with low plasma and urine osmolalities due
to a very large throughput of water. The chest x-ray
changes are an incidental finding.
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normochromic, normocytic anaemia (haemoglobin (Hb) 9.9
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• Timed Test A 28-year-old single machinist, who describes herself as
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(59 to 50 kg), tiredness and amenorrhoea over the past Questions Total 1
• Past Papers year. Examination reveals: pallor, pulse 96/min regular
Questions Percentage 100 %
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standing, tendon reflexes slightly slow relaxing. There is a More
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normochromic, normocytic anaemia (haemoglobin (Hb) 9.9
• Media Bank g/dl). Urea and electrolytes, liver function tests, plasma
• New Multimedia glucose and serum calcium are normal. Which of the
following is the most likely diagnosis?
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Library Microprolactinoma
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Hypopituitarism produces pallor (due to loss of the
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normochromic, normocytic anaemia which responds to
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amenorrhoea due to loss of gonadotrophins. Most Click to open/closeDiabetes Click to
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Sign Out in hypothyroidism, weight gain, menorrhagia and
macrocytic anaemia are more common (unless
menorrhagia is very severe, in which case an iron-
deficient microcytic picture might be seen). The
presence of slow reacting reflexes and amenorrhoea,
and menorrhagia and a macrocytic anaemia are more
common. The presence of slow relaxing reflexes and
amenorrhoea (rather than oligomenorrhea) is
uncommon in thyrotoxicosis. It is unusual for anorexia
nervosia patients to present concerned about their
health. Others often initiate the call for help. There are
too few features of anorexia, and too many
hypopituitary features to make anorexia the most likely
diagnosis.
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palpitations and excess sweating. The GP suspects Questions Total 1
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• My Performance undetectable thyroid-stimulating hormone (TSH). On More
examination she has a normal sized thyroid gland with a
• Media Bank suggestion of bulkiness on the right hand side. A
• New Multimedia technetium uptake scan reveals a single ‘hot’ nodule in the
right lobe of the thyroid with suppression of activity
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elsewhere. Which of the following clinical features
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palpitations and excess sweating. The GP suspects Questions Total 2
• Past Papers thyrotoxicosis and confirms this by finding a free tetra-
Questions Percentage 100 %
• Random Questions iodothyronine (T4 ) of 58 pmol/l (10–22) with an
• My Performance undetectable thyroid-stimulating hormone (TSH). On More
examination she has a normal sized thyroid gland with a
• Media Bank suggestion of bulkiness on the right hand side. A
• New Multimedia technetium uptake scan reveals a single ‘hot’ nodule in the
right lobe of the thyroid with suppression of activity
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elsewhere. Which of the following clinical features
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Presence of thyroid-stimulating
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Lid retraction and lag are signs of sympathetic
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overactivity, and occur in any thyrotoxic state Click to open/closeHaematology
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The other symptoms are features of thyroid eye disease Click to open/closeBiochemistry
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fasting triglyceride concentration is 4.0 mmol/l. Which of Questions Percentage 100 %
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• Timed Test An apparently healthy, 20-year-old man has blood taken
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insurance. His body mass index (BMI) is 22 kg/m2 . The Questions Total 3
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fasting triglyceride concentration is 4.0 mmol/l. Which of Questions Percentage 66 %
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• Timed Test An 82-year-old Caucasian woman has short history of bone
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concentration 2.14 mmol/l, phosphate 0.70 mmol/l, Questions Total 3
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• Timed Test An 82-year-old Caucasian woman has short history of bone
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concentration 2.14 mmol/l, phosphate 0.70 mmol/l, Questions Total 4
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Questions Percentage 75 %
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• Timed Test Which ONE of the following findings in an elderly
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carcinoma suggests a diagnosis of Paget’s disease Questions Total 4
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Questions Percentage 75 %
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upper limit of normal
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Serum prostate-specific antigen (PSA) 8 ng/l
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carcinoma suggests a diagnosis of Paget’s disease Questions Total 5
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Questions Percentage 60 %
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Community (PSA) 8 ng/l
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• Timed Test A 45-year-old man presents with episodes of tremor,
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wakes in the morning. What would be the most useful Questions Total 5
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Questions Percentage 60 %
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An insulin hypoglycaemia test (insulin stress test)
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Measurement of serum 3-hydroxybutyrate
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wakes in the morning. What would be the most useful Questions Total 6
• Past Papers investigation(s) to establish a diagnosis of an
Questions Percentage 66 %
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Online Extras Measurement of glycated haemoglobin
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hydroxybutyrate
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blood glucose, and serum insulin and C-
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In health, serum insulin concentration falls to low values
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Order History hypoglycaemia and hyperinsulinaemia suggests that Reference: Normal Values
insulin is causing the hypoglycaemia. Measurement of
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hypothalamo-pituitary function. Measurement of
glycated haemoglobin is used to monitor glycaemic
control in diabetes but is of no value in the diagnosis of
hypoglycaemia. Hyperinsulinism suppresses lipolysis,
therefore the induced hypoglycaemia is not associated
with a ketosis, as is usual. Measurement of 3-
hydroxybutyrate can be helpful to exclude
hyperinsulinism but is not diagnostic.
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• Timed Test A patient with type-1 diabetes mellitus has a deficiency of
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Questions Total 6
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Questions Total 7
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A cells of the islets of Langerhans Questions Percentage 71 %
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Help Insulin is synthesised and stored by the B cells of the
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volume of the islets. Glucagon is synthesised and stored
in the A cells (10–20% of the islets). Somatostatin is
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islets).
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progression risk? Questions Total 7
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• Timed Test A patient with impaired glucose tolerance has an increased
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progression risk? Questions Total 8
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Questions Percentage 75 %
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PasTest Store Impaired glucose tolerance (IGT) is defined by the
World Health Organization (WHO) criteria as being
present in individuals with a fasting plasma glucose of
My Account less than 7.0 mmol/l, and a plasma glucose of between
7.8 and 11.1 mmol/l when measured two hours after an
Profile oral 75 g glucose load. The risk of progression to frank
diabetes is 20–30% within five years. Half of patients
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with IGT will have normal glucose tolerance on later
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• Timed Test A 52-year-old business man undergoes a routine medical
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His blood tests, performed on a fasting venous sample, Questions Total 8
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Questions Percentage 75 %
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His blood tests, performed on a fasting venous sample, Questions Total 9
• Past Papers show amongst other results a serum glucose concentration
Questions Percentage 77 %
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• Timed Test You undertake a 12-month attachment to the renal unit of
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session in their diabetic nephropathy clinic. Which is the Questions Total 9
• Past Papers most appropriate oral hypoglycaemic drug in patients
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Chlorpropamide
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• Timed Test You undertake a 12-month attachment to the renal unit of
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session in their diabetic nephropathy clinic. Which is the Questions Total 10
• Past Papers most appropriate oral hypoglycaemic drug in patients
Questions Percentage 70 %
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Chlorpropamide
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Glibenclamide Your answer
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Chlorpropamide has a long duration of action and is
My Account excreted largely unchanged by the kidneys.
Glibenclamide has a long biological duration of action
Profile (active metabolites) and is largely excreted by the
kidneys. Both should be avoided in renal failure and in
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the elderly to avoid accumulation and subsequent
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Order History hepatic metabolism and has a short duration of action. Reference: Normal Values
It is useful in renal failure. Metformin is largely excreted
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• Timed Test An obese patient with type-2 diabetes mellitus that is not
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medication. Which would be the most appropriate Questions Total 10
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• Timed Test An obese patient with type-2 diabetes mellitus that is not
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medication. Which would be the most appropriate Questions Total 11
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Questions Percentage 72 %
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Metformin is preferable to sulphonylureas in treating
obese non-insulin diabetes mellitus (NIDDM) patients
My Account since it promotes weight loss and sulphonylureas tend
to cause weight gain. Metformin accumulates in the
Profile intestinal mucosa after ingestion and frequently causes
gastrointestinal side-effects. These tend to reduce in
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severity with continued treatment. Glimepiride is a
My Career and Exams sulphonylurea which is renally excreted and thus is
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• Timed Test A patient with longstanding type-2 diabetes is found to
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diabetes is well controlled on metformin and he is Questions Total 11
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Questions Percentage 72 %
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• Timed Test A patient with longstanding type-2 diabetes is found to
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diabetes is well controlled on metformin and he is Questions Total 12
• Past Papers normotensive. What is the most appropriate additional
Questions Percentage 75 %
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In patients with type-1 diabetes with a mean entry
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of one European and one American study showed an
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clinical nephropathy comparing the Angiotensin-
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converting enzyme (ACE) inhibitor captopril 100 mg/day
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Order History patients with type-2 diabetes have reported a similar Reference: Normal Values
reduction in the rate of development of clinical
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• Timed Test A 34-year-old accountant is referred to you with a history
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methodical man and appears always to have striven to Questions Total 0
• Past Papers maintain reasonable metabolic control of his condition,
Questions Percentage 0%
• Random Questions while managing a normal lifestyle.
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What is the most likely finding on examination and
• Media Bank routine testing?
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• Timed Test A 34-year-old accountant is referred to you with a history
of diabetes mellitus since the age of sixteen years. He is a Questions Incorrect 1
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methodical man and appears always to have striven to Questions Total 1
• Past Papers maintain reasonable metabolic control of his condition,
Questions Percentage 0%
• Random Questions while managing a normal lifestyle.
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• Media Bank routine testing?
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testing
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Newsletters The risk of developing retinopathy progressively
My Career and Exams increases with increasing duration of diabetes.
Standardised methods of assessing retinopathy, Reference: Normal Values
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including retinal photography, have revealed that 97%
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are ever going to occur will have occurred by 20 years
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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.
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• Timed Test A patient presents with diabetic ketoacidosis. They have a
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respiratory rate of 32, you commence oxygen therapy. Questions Total 1
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• Timed Test A patient presents with diabetic ketoacidosis. They have a
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respiratory rate of 32, you commence oxygen therapy. Questions Total 2
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Patients with ketoacidosis tend to die of circulatory
My Account problems due to hypovolaemia, and to electrolyte
disturbances, rather than due to insulin deficiency per
Profile se. Early fluid and electrolyte replacement takes
precedence over insulin treatment. All patients with
Newsletters ketoacidosis are depleted of potassium. Insulin will push
My Career and Exams potassium into cells with a risk of hypokalaemia, even in
oliguric patients. Potassium should be given with fluid Reference: Normal Values
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from the beginning and only withdrawn later if oliguria
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Questions Percentage 75 %
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ovulating normally. Which of the following hormone Questions Total 5
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In a normal menstrual cycle, there is a gradual increase
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examination pubic hair growth is minimal. Facial hair Questions Total 8
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Questions Percentage 62 %
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Which of the following hormones is most likely to be More
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sexual intercourse. Her periods have been regular to date, Questions Total 8
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• Timed Test A 25-year-old woman has been prescribed emergency
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sexual intercourse. Her periods have been regular to date, Questions Total 9
• Past Papers and her last period was 2 weeks ago. What is the most
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effects is most likely to occur with this dose of Questions Percentage 0%
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most likely to be effective in treating this condition? Questions Total 1
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• Timed Test An infant with hypoglycaemia is administered glucagon.
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• Timed Test A 47-year-old woman is undergoing investigations for
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her follicle-stimulating hormone level to be 40 IU/l (> 30 in Questions Total 2
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her follicle-stimulating hormone level to be 40 IU/l (> 30 in Questions Total 3
• Past Papers postmenopausal women). What would be the best
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techniques for estimating skeletal mass or bone mineral
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sweating and palpitations, confusion, fits and occasional Questions Total 3
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sweating and palpitations, confusion, fits and occasional Questions Total 4
• Past Papers abnormal behaviour. On examination his pulse is 92 bpm
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catecholamine level is normal and blood glucose is 1.9 More
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Decreased activity of suprachiasmatic nuclei
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acetyltransferase + acetyl-CoA converts serotonin to N-acetyl serotonin, which is
then catalysed by hydroxyindole-o-methyltransferase to melatonin.
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Exposure to darkness causes activation of the hypothalamus by the
Profile retinohypothalamic nerves. This results in increased noradrenaline secretion by the
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Noradrenaline acts via β-adrenergic receptors in the pineal gland to increase the
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Fine-tuning of salt and water balance is achieved in the
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• Timed Test A 35-year-old woman has been prescribed a sulphonylurea
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• Timed Test A 40-year-old man is suffering from type-2 diabetes mellitus and hypertension.
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• Timed Test A 39-year-old man with Grave’s disease is being
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within 1 year of surgery. This percentage increases with
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postoperative bleeding may cause tracheal compression.
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decreased sense of smell. On examination, his testes are Questions Total 5
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Kallmann’s syndrome is due to isolated gonadotrophin-
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• Timed Test A 12-year-old girl presents with short stature, webbed
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required. Growth hormone may be useful for a limited
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• Timed Test A 15-year-old girl presents with primary amenorrhoea. She
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commonly associated with shedding of the Questions Total 0
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Involution of the corpus luteum results in a decrease in
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hormonal support causes endometrial shedding. LH,
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• Timed Test A 30-year-old man presents complaining of headaches and visual field defects. On
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mild hypotension and hyponatraemia. Blood tests reveal a testosterone level of 8
• Past Papers nmol/l (9–35). An MRI scan shows a 12-mm pituitary tumour.
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Prolactinomas cause hyperprolactinaemia. Large tumours (macroprolactinomas)
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result in growth hormone excess and acromegaly, while basophil adenomas cause
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• Timed Test A 50-year-old diabetic man presents with malaise and loss
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• Mock Exam there is evidence of hepatomegaly. Blood tests show Hb 14.1 g/dl (13–18), fasting
glucose 8 mmol/l (3–6), serum iron 45 µmol/l (14–29) and serum ferritin 250,000
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• Timed Test A 13-year-old boy is brought to your clinic with a complaint
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patient which of the following features is most likely Questions Total 3
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patient which of the following features is most likely Questions Total 4
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The first clinical sign of the onset of puberty in boys is
My Account an increase in testicular volume (> 5 ml). This is
followed by growth of external genitalia, deepening of
Profile the voice and pubic and axillary hair growth.
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• Timed Test A 49-year-old overweight police constable presents with
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• Timed Test A 49-year-old overweight police constable presents with
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history of osteoporosis or fracture. She does not smoke and Questions Total 5
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field examination reveals bitemporal hemianopia. His blood Questions Total 6
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• Timed Test A 27-year-old man is found to have oligospermia. Blood
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• Timed Test A 27-year-old man is found to have oligospermia. Blood
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• Timed Test A 16-year-old girl presents with primary amenorrhoea.
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• Timed Test A 16-year-old girl presents with primary amenorrhoea.
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Secondary sex characteristics appear well developed. On Questions Total 9
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• Timed Test A 25-year-old woman presents with recurrent episodes of
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died of a tumour in her neck. On examination a nodule is Questions Total 10
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most important investigation the surgeon must More
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undertake prior to surgery?
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• Timed Test A 33-year-old woman presents with polydipsia and
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accident 6 months ago. Her blood pressure is 120/80 Questions Total 10
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• Timed Test A 33-year-old woman presents with polydipsia and
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accident 6 months ago. Her blood pressure is 120/80 Questions Total 11
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Plasma osmolality is 268 mOsmol/l (278–305) and urine
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• Timed Test A 22-year-old man presents with tremor, sweating,
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• Timed Test A 40-year-old woman who has been prescribed
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• Timed Test A 40-year-old woman who has been prescribed
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• Timed Test A 35-year-old man presents with weight loss, irritability,
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his pulse is 110 bpm, BP 150/100 mmHg. Lid lag is Questions Total 13
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• Timed Test A 25-year-old man is admitted to the A&E having
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is prescribed. What is the main mechanism of action of Questions Total 14
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• Timed Test A 25-year-old man is admitted to the A&E having
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is prescribed. What is the main mechanism of action of Questions Total 15
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• Timed Test A 50-year-old man presents with a history of panic attacks,
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examination his pulse rate is 120 bpm, BP 190/110 mmHg. Questions Total 15
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• Timed Test A 50-year-old man presents with a history of panic attacks,
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examination his pulse rate is 120 bpm, BP 190/110 mmHg. Questions Total 16
• Past Papers A blood test shows high levels of noradrenaline. Which of
Questions Percentage 62 %
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• Timed Test A 20-year-old woman with a history of migraine is
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contraceptive mechanism of action of this drug? Questions Total 16
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• Timed Test A 20-year-old woman with a history of migraine is
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• Timed Test An 11-month old boy weighing 7 kg has polyuria, polydipsia
and delayed motor milestones. Blood tests: creatinine 80 Questions Incorrect 7
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µmol/l (60–110), urea 6.0 mmol/l (2.5–7.5), potassium 5.0 Questions Total 17
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• Timed Test An 11-month old boy weighing 7 kg has polyuria, polydipsia
and delayed motor milestones. Blood tests: creatinine 80 Questions Incorrect 8
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µmol/l (60–110), urea 6.0 mmol/l (2.5–7.5), potassium 5.0 Questions Total 18
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In diabetes insipidus, there is excessive loss of water in
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• Timed Test A 15-year-old boy is being treated with ADH for diabetes
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6), sodium 148 mmol/l (137–144), potassium 4.5 mmol/l Questions Total 18
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• Timed Test A 15-year-old boy is being treated with ADH for diabetes
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6), sodium 148 mmol/l (137–144), potassium 4.5 mmol/l Questions Total 19
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• Timed Test A 70-year-old diabetic man being treated with amiloride for
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Blood tests: sodium 152 mmol/l (137–144), potassium 5.0 Questions Total 19
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• Timed Test A 70-year-old diabetic man being treated with amiloride for
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Blood tests: sodium 152 mmol/l (137–144), potassium 5.0 Questions Total 20
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• Random Questions bicarbonate 30 mmol/l (20–28), glucose 50 mmol/l (3–6)
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• Timed Test A 40-year-old woman is brought to A&E in a semi-
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• Timed Test A 40-year-old woman is brought to A&E in a semi-
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thirsty all the time over the past couple of weeks. Blood Questions Total 21
• Past Papers tests: potassium 5.0 mmol/l (3.5–4.9), sodium 140 mmol/l
Questions Percentage 57 %
• Random Questions (137–144), bicarbonate 7 mmol/l (20–28) and pH 7.1
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• Timed Test A 25-year-old woman is being investigated for suspected
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features. What will be the most characteristic finding Questions Total 22
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• Timed Test Which of the following investigations is most likely to
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Increase in basal body temperature
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• Timed Test Which of the following investigations is most likely to
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temperature and secretory changes in the endometrium
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• Timed Test A 14-year-old girl is seen at the endocrine clinic because
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not yet started. In reviewing her history, which of the Questions Total 23
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• Timed Test A 14-year-old girl is seen at the endocrine clinic because
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not yet started. In reviewing her history, which of the Questions Total 24
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Breast-bud enlargement is the first sign of puberty in
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• Timed Test A 55-year-old chronic smoker presents with polyuria,
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known to be suffering from squamous-cell carcinoma of the Questions Total 0
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• Timed Test A 55-year-old chronic smoker presents with polyuria,
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known to be suffering from squamous-cell carcinoma of the Questions Total 1
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• Timed Test An 8-day-old baby presents with vomiting, poor feeding
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bpm, BP 50/30 mmHg and respiratory rate 72 breaths/min. Questions Total 1
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• Timed Test An 8-day-old baby presents with vomiting, poor feeding
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bpm, BP 50/30 mmHg and respiratory rate 72 breaths/min. Questions Total 2
• Past Papers Blood tests: Hb 15 g/dl (13–18), sodium 120 mmol/l (137–
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• Random Questions 144), potassium 6.0 mmol/l (3.5–4.9), chloride 80 mmol/l
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(2.5–7.5) and creatinine 80 µmol/l (60–110).
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Online Extras Congenital adrenal hyperplasia Correct answer
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unlikely. Acute tubular necrosis is ruled out, as urea and
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• Timed Test A 10-month-old boy weighing 5 kg has polyuria, polydipsia
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µmol/l (60–110), urea 6.5 mmol/l (2.5–7.5), potassium 3.0 Questions Total 2
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• Timed Test A 10-month-old boy weighing 5 kg has polyuria, polydipsia
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µmol/l (60–110), urea 6.5 mmol/l (2.5–7.5), potassium 3.0 Questions Total 3
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Questions Percentage 66 %
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• Timed Test What is the optimum time for the administration of
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adrenalectomy for Cushing’s disease? Questions Total 3
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• Timed Test A previously fit 30-year-old man presents with a two
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Investigations show (normal range in brackets): Questions Total 4
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Mean cell volume (MCV) 88 fL (80–96)
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White cell count 6.0 ´ 109/l (4–11)
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Investigations show (normal range in brackets): Questions Total 1
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• Timed Test A 16-year-old woman with Addison’s disease is intolerant
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of 20 mg in the morning and 5 mg in the evening. Which Questions Total 1
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• Timed Test A 16-year-old woman with Addison’s disease is intolerant
of her hydrocortisone treatment, which she takes at a dose Questions Incorrect 0
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of 20 mg in the morning and 5 mg in the evening. Which Questions Total 2
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Questions Percentage 100 %
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hydrocortisone? More
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• Timed Test A 40-year-old woman who has been prescribed thyroid
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(TFTs). On examination she appeared clinically euthyroid Questions Total 0
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Thyroid-stimulating hormone (TSH) 3.2 mU/l (0. 35– More
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Total tetra-iodothyronine (T4 ) 20 nmol/l (55–144)
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• Timed Test A 40-year-old woman who has been prescribed thyroid replacement therapy has
• Mock Exam routine thyroid function tests (TFTs). On examination she appeared clinically euthyroid
with no abnormal findings. Her TFTs revealed:
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• Random Questions Thyroid-stimulating hormone (TSH) 3.2 mU/l (0. 35–5.0)
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Free T 4 2.6 pmol/l (9–24)
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Online Extras Total tri-iodothyronine (T3 ) 2.5 nmol/l (0. 9–2).
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She has tertiary hypothyroidism
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She has sick euthyroid syndrome
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Thyroid-stimulating hormone (TSH) measurements are used as the standard
Learning Goals method to monitor thyroid hormone replacement. She is clinically euthyroid and
Question Filters her TSH is within the normal range. Tri-iodothyronine (T3 ) and tetra-iodothyronine
(T4 ) exist in a state of dynamic equilibrium, so although her free T 4 is low, her T 3
is within the normal range. Many patients who have adequate thyroid hormone
Security replacement do still complain of symptoms of tiredness, lethargy, and mental
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• Timed Test A woman with history of bipolar affective disorder on lithium presented with infertility.
• Mock Exam BMI= 35. Investigation: TSH 13, free T4 4.8, prolactin 800, US pelvis - polycystic
ovaries.
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• Timed Test A woman with history of bipolar affective disorder on lithium presented with infertility.
• Mock Exam BMI= 35. Investigation: TSH 13, free T4 4.8, prolactin 800, US pelvis - polycystic
ovaries.
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Dopamine agonist
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Thyroxine
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Stop lithium after consultation with psychiatrist Your answer
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The answer is stop lithium after consultation with psychiatrist. Long-term
My Account treatment with lithium may produce frank hypothyroidism, as in this case. The
raised prolactin is likely to be related to a combination of lithium therapy and
Profile hypothyroidism. Subfertility in this case may be related to a combination of
hypothyroidism and polycystic ovarian syndrome. The best management in this
Newsletters case would be to discontinue lithium therapy and replace it with another agent
My Career and Exams (after consulting the patient’s psychiatrist). Carbamazepine, sodium valproate and
lamotrigine may all be alternative agents for mood stabilisation. The other serious
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side-effect of long-term lithium use that must be considered is nephrogenic
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• Timed Test An elderly woman came with weight loss of 6 kg over 6
months. Investigation showed low free T3, low free T4 and Questions Incorrect 0
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low TSH. What is the diagnosis? Questions Total 2
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Questions Percentage 100 %
• Random Questions Hypothyroidism
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• Timed Test An elderly woman came with weight loss of 6 kg over 6
months. Investigation showed low free T3, low free T4 and Questions Incorrect 1
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low TSH. What is the diagnosis? Questions Total 3
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Questions Percentage 66 %
• Random Questions Hypothyroidism
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• New Multimedia Primary hypothyroidism
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strong suspicion that this patient has suffered anterior
pituitary failure. Isolated secondary hypothyroidism
My Account would not usually be associated with weight loss. The
weight loss of 6 kg over 6 months raises the possibility
Profile of anterior pituitary failure. Thyroid function testing
confirms secondary hypothyroidism, and this patient
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should also be screened for Addison’s disease. If 9 am
My Career and Exams cortisol and ACTH are low, this would point towards a
Order History diagnosis of pituitary failure. The investigation of choice Reference: Normal Values
to elucidate the cause is MRI of the pituitary fossa to
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• Timed Test A 23-year-old woman presented with painful oral ulcers.
Her mother had history of thyroidectomy. Which of the Questions Incorrect 1
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following would suggest polyglandular syndrome Questions Total 3
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• Timed Test A 23-year-old woman presented with painful oral ulcers. Her mother had history of
• Mock Exam thyroidectomy. Which of the following would suggest polyglandular syndrome
type 1?
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• Random Questions Celiac disease Your answer
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PasTest Store The answer is hypocalcaemia. Polyglandular syndrome type 1 is an autosomal
recessive condition associated with hypoparathyroidism in around 90%,
mucocutaneous candidiasis, adrenal insufficiency in around 60%, primary gonadal
My Account failure, primary hypothyroidism, and rarely hypopituitarism or diabetes insipidus.
There may be associated malabsorption, pernicious anaemia, chronic active
Profile hepatitis or vitiligo. Polyglandular syndrome type 2 may be autosomal-recessive,
autosomal-dominant or polygenic. Adrenal insufficiency occurs in all patients, and
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there may be associated hypothyroidism, type-1 diabetes, gonadal failure, and
My Career and Exams rarely diabetes insipidus. Associated conditions include vitiligo, myasthenia gravis,
Order History alopecia, immune thrombocytopaenic purpura or pernicious anaemia.
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• Timed Test An obese lady has come for poor diabetic control, despite
being on gliclazide 160 mg bd. Biochemistry: mildly raised Questions Incorrect 2
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urea, Cr 160, ALT, GGT normal. HbA1c 9.4. Questions Total 4
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Which of the following would you start next? Questions Percentage 50 %
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Acarbose
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Guar gum
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Repaglinide
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Metformin
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• Timed Test An obese lady has come for poor diabetic control, despite
being on gliclazide 160 mg bd. Biochemistry: mildly raised Questions Incorrect 2
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urea, Cr 160, ALT, GGT normal. HbA1c 9.4. Questions Total 5
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Which of the following would you start next? Questions Percentage 60 %
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Guar gum
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Repaglinide
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Metformin
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The answer is pioglitazone. Her raised creatinine
My Account precludes her from metformin therapy. She is also
obese, which would suggest some insulin resistance. As
Profile such, the best choice for additional therapy would be
pioglitazone. Pioglitazone is a PPAR - γ agonist that acts
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to improve glucose uptake into muscle and fat by
My Career and Exams reducing peripheral insulin resistance. It may be used at
Order History doses of 4 or 8 mg. Initial and then periodic monitoring Reference: Normal Values
of liver function tests is recommended. Data suggest
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• Timed Test A 32-year-old patient is being investigated for polydipsia. There was no recent loss of
• Mock Exam weight. Investigation: Na, K, Ca, glucose, urea, Cr normal; serum osmolality 290
(normal), urine osmolality 200 (normal). What is the most likely diagnosis?
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• Random Questions Nephrogenic diabetes insipidus
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• Timed Test A 32-year-old patient is being investigated for polydipsia.
There was no recent loss of weight. Investigation: Na, K, Questions Incorrect 2
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Ca, glucose, urea, Cr normal; serum osmolality 290 Questions Total 6
• Past Papers (normal), urine osmolality 200 (normal). What is the
Questions Percentage 66 %
• Random Questions most likely diagnosis?
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Psychogenic polydipsia Your answer
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Syndrome of inappropriate antidiuretic
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• Timed Test You review a 28-year-old girl who has been referred with amenorrhoea. She is noted
• Mock Exam on routine screening to have a raised prolactin level. She has read about her condition
on the Internet and has some questions about prolactin physiology.
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continuous inhibition?
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• Timed Test You review a 28-year-old girl who has been referred with
amenorrhoea. She is noted on routine screening to have a Questions Incorrect 2
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raised prolactin level. She has read about her condition on Questions Total 7
• Past Papers the Internet and has some questions about prolactin
Questions Percentage 71 %
• Random Questions physiology.
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Thinking of hormones in general, which of the
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Prolactin Your answer
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• Timed Test <font ">An obese patient presented with increased
abdominal striae, and 12-midnight cortisol was elevated. Questions Incorrect 2
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He has hypertension with a BP of 155/82 mmHg, type 2 Questions Total 7
• Past Papers diabetes and has recently suffered a left Colle's fracture.
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Which of the following would best confirm the More
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• Timed Test <font ">An obese patient presented with increased abdominal striae, and 12-midnight
• Mock Exam cortisol was elevated. He has hypertension with a BP of 155/82 mmHg, type 2
diabetes and has recently suffered a left Colle's fracture.
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• Random Questions Which of the following would best confirm the diagnosis of Cushing's
disease?
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• Media Bank <font ">Low-dose dexamethasone suppression test
• New Multimedia <font ">Synacthen® test
Online Extras <font ">24-hour urinary cortisol collection
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• Timed Test A 42-year-old woman is diagnosed with
phaeochromocytoma. Screening with pentagastrin testing Questions Incorrect 3
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suggests that she has medullary thyroid carcinoma, and Questions Total 8
• Past Papers you plan a thyroidectomy.
Questions Percentage 62 %
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What anti-hypertensive medication should be started More
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Phenoxybenzamine
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Atenolol
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• Timed Test A 42-year-old woman is diagnosed with
phaeochromocytoma. Screening with pentagastrin testing Questions Incorrect 3
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suggests that she has medullary thyroid carcinoma, and Questions Total 9
• Past Papers you plan a thyroidectomy.
Questions Percentage 66 %
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What anti-hypertensive medication should be started More
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Phenoxybenzamine Your answer
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• Timed Test A 51-year-old white man was recently diagnosed with a solitary 2.7- cm papillary
• Mock Exam cancer of the thyroid with no invasion of the capsule, no lymphadenopathy and no
distant metastases. He denies a history of head and neck irradiation, hoarseness,
• Past Papers pain, dysphagia or haemoptysis. His physical exam is otherwise normal, with no lab
• Random Questions abnormailities. Which of the following measures is most appropriate for his
management?
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• Media Bank Partial thyroidectomy followed by radioactive iodine (RAI) treatment
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• Timed Test A 51-year-old white man was recently diagnosed with a
solitary 2.7- cm papillary cancer of the thyroid with no Questions Incorrect 3
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invasion of the capsule, no lymphadenopathy and no distant Questions Total 10
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Questions Percentage 70 %
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His physical exam is otherwise normal, with no lab More
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abnormailities. Which of the following measures is
• Media Bank most appropriate for his management?
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Thyroid cancer remains a significant medical problem in
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which accounts for approximately 70% of all thyroid
cancers. It is two to three times more common in
females and peaks in the third and fourth decades of
life. Papillary cancer is usually non-encapsulated and
sometimes multi-focal and tends to spread by the
lymphatic route.
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• Timed Test You saw a 71-year-old white woman, a nursing home resident who was brought in by
• Mock Exam her daughter for a complete physical examination. Her complaints include a poor
appetite, weight loss, cramps and weakness. She was diagnosed with Crohn's disease
• Past Papers 10 years ago but is not taking any medications. Five months ago she had a
• Random Questions mammogram and flexible sigmoidoscopy, both of which were normal. Because her
exam was normal, she was given a 1-month return appointment and sent for blood
• My Performance
work. At the end of the day, your lab calls to report a panic value of calcium of 1.4
• Media Bank mmol/l (normal range, 2.2-2.6 mmol/l) with an inorganic phosphate of 0.58 mmol/l
• New Multimedia (normal range, 0.8-1.5 mmol/l). She has a creatinine of 80 μmol/l (normal range, 60-
Online Extras 110 μmol/l), albumin is 35 g/l (normal range, 37-49 g/l) and alkaline phosphatase is
250 U/l (normal range, 42-98 U/l).
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Community Which of the following diagnoses is most compatible with these lab data?
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• Timed Test You saw a 71-year-old white woman, a nursing home
resident who was brought in by her daughter for a Questions Incorrect 4
• Mock Exam
complete physical examination. Her complaints include a Questions Total 11
• Past Papers poor appetite, weight loss, cramps and weakness. She was
Questions Percentage 63 %
• Random Questions diagnosed with Crohn's disease 10 years ago but is not
taking any medications. Five months ago she had a More
• My Performance
mammogram and flexible sigmoidoscopy, both of which
• Media Bank were normal. Because her exam was normal, she was given
• New Multimedia a 1-month return appointment and sent for blood work. At
the end of the day, your lab calls to report a panic value of
Online Extras calcium of 1.4 mmol/l (normal range, 2.2-2.6 mmol/l) with
Library an inorganic phosphate of 0.58 mmol/l (normal range, 0.8-
1.5 mmol/l). She has a creatinine of 80 μmol/l (normal
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range, 60-110 μmol/l), albumin is 35 g/l (normal range,
Help 37-49 g/l) and alkaline phosphatase is 250 U/l (normal
PasTest Store range, 42-98 U/l).
Profile Hypoparathyroidism
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My Career and Exams Vitamin D deficiency Correct answer
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Sign Out the serum phosphate, creatinine and calcium. In
hypoparathyroidism, there is reduced mobilisation of
calcium from bone, reduced renal reabsorption of
calcium (along with decreased phosphaturia) and
reduced formation of 1,25-hydroxyvitamin D, resulting
in reduced intestinal absorption of calcium.
Consequently, the hypocalcemia is accompanied by
hyperphosphatemia. Hypoparathyroidism can be
congenital or acquired; the latter is accounted for by
transient or permanent disorders. Hypomagnesemia
causes deficient secretion of parathyroid hormone (PTH)
and consequent functional hypoparathyroidism. In
vitamin D deficiency, decreased intestinal absorption of
calcium leads to secondary hyperparathyroidism, which
increases renal tubular loss of phosphate. Vitamin D
deficiency can result from inadequate dietary intake,
lack of sun exposure and malabsorption in this case due
to the long-standing Crohn’s disease. Renal failure
impairs hydroxylation of 25-hydroxyvitamin D, which
results in the malabsorption of calcium. The body
compensates by increased secretion of PTH, leading to
increased mobilisation of calcium from bone. Renal
failure is characterized by an abnormal serum
creatinine, whereas renal dysfunction is not the critical
pathogenetic feature of the other forms of
hypocalcemia.
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• Timed Test A 38-year-old black woman draws your attention to a
swelling in her neck, which she noticed 2 days ago. She Questions Incorrect 4
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denies palpitations, diaphoresis and weight loss. There is no Questions Total 11
• Past Papers pain, hoarseness or dysphagia. Her medical history is
Questions Percentage 63 %
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atenolol 50 mg once daily. On exam, blood pressure is More
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150/80 mm Hg; pulse is 70. There is a 2 x 1-cm non-
• Media Bank tender nodule on the right lobe of the thyroid. No
• New Multimedia lymphadenopathy is detected. The remainder of the exam
is unremarkable. Electrolytes, urea, creatinine, liver
Online Extras function tests, calcium, phosphate and FBC are normal. Reference: Normal Values
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• Timed Test A 38-year-old black woman draws your attention to a swelling in her neck, which she
• Mock Exam 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.
• Past Papers Medications include only atenolol 50 mg once daily. On exam, blood pressure is
• Random Questions 150/80 mm Hg; pulse is 70. There is a 2 x 1-cm non-tender nodule on the right lobe
of the thyroid. No lymphadenopathy is detected. The remainder of the exam is
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unremarkable. Electrolytes, urea, creatinine, liver function tests, calcium, phosphate
• Media Bank and FBC are normal.
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What would you do next?
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Library Arrange a thyroid ultrasound scan Your answer
Community Elicit a family history of thyroid cancer
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Newsletters The clinically apparent (>1 cm) thyroid nodule is a common clinical finding; up to
My Career and Exams 5% of the 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
Order History
a solitary thyroid nodule is low (4%); cold nodules carry a higher risk than hot
Learning Goals nodules (20% vs 1%). Evaluation of a solitary nodule should be aimed at detecting
Question Filters 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
Security differentiated thyroid cancer or medullary cancer of the thyroid (which can be a
component of multiple endocrine neoplasia (MEN) type IIA or IIB). Fine-needle
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characterized cytologically as benign, malignant, suspicious for malignancy or
indeterminate.
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• Timed Test A 60-year-old white man comes to see you for chronic
back pain, which worsened 1 week ago. He has been Questions Incorrect 5
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wheelchair bound for 6 months because of severe Questions Total 12
• Past Papers osteoporosis with multiple lumbosacral spine fractures. He
Questions Percentage 58 %
• Random Questions has severe asthma, which has required large doses of
glucocorticoids for many years. The patient reports More
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progressive loss of height and kyphosis over the past year.
• Media Bank Other medications include salbutamol and ipratropium
• New Multimedia inhalers and long-acting theophylline 300 mg twice a day.
Significant physical findings include bilateral cataracts,
Online Extras multiple ecchymoses and a prolonged expiratory phase with Reference: Normal Values
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first choice in this patient? Click to
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• Timed Test A 60-year-old white man comes to see you for chronic back pain, which worsened 1
• Mock Exam week ago. He has been wheelchair bound for 6 months because of severe
osteoporosis with multiple lumbosacral spine fractures. He has severe asthma, which
• Past Papers has required large doses of glucocorticoids for many years. The patient reports
• Random Questions progressive loss of height and kyphosis over the past year. Other medications include
salbutamol and ipratropium inhalers and long-acting theophylline 300 mg twice a day.
• My Performance
Significant physical findings include bilateral cataracts, multiple ecchymoses and a
• Media Bank prolonged expiratory phase with bilateral wheezes. Which of the following
• New Multimedia treatments is first choice in this patient?
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This patient has significant osteoporosis, almost certainly related to chronic use of
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glucocorticoid therapy for his asthma. First-line therapy in this case would be
My Career and Exams bisphosphonates, which improve bone mass in the lumbar spine and the hip. Older
Order History preparations are associated with significant gastrointestinal (GI) side-effects
(predominantly oesophagitis and ulceration), so that newer treatments that may
Learning Goals be dosed weekly over significant advantages in terms of side-effect reduction.
Question Filters Calcium and vitamin D supplementation would be a viable alternative in patients
not tolerating bisphosphonates. Testosterone supplementation is only of use in
patients with low testosterone levels, where it does improve bone mass.
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• Timed Test A 60-year-old white man comes to see you for chronic back pain, which worsened 1
• Mock Exam week ago. He has been wheelchair bound for 6 months because of severe
osteoporosis with multiple lumbosacral spine fractures. He has severe asthma, which
• Past Papers has required large doses of glucocorticoids for many years. The patient reports
• Random Questions progressive loss of height and kyphosis over the past year. Other medications include
salbutamol and ipratropium inhalers and long-acting theophylline 300 mg twice a day.
• My Performance
Significant physical findings include bilateral cataracts, multiple ecchymoses and a
• Media Bank prolonged expiratory phase with bilateral wheezes. Which of the following
• New Multimedia mechanisms underlies his osteoporosis?
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• Timed Test A 60-year-old white man comes to see you for chronic back pain, which worsened 1
• Mock Exam week ago. He has been wheelchair bound for 6 months because of severe
osteoporosis with multiple lumbosacral spine fractures. He has severe asthma, which
• Past Papers has required large doses of glucocorticoids for many years. The patient reports
• Random Questions progressive loss of height and kyphosis over the past year. Other medications include
salbutamol and ipratropium inhalers and long-acting theophylline 300 mg twice a day.
• My Performance
Significant physical findings include bilateral cataracts, multiple ecchymoses and a
• Media Bank prolonged expiratory phase with bilateral wheezes. Which of the following
• New Multimedia mechanisms underlies his osteoporosis?
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Glucocorticoids are used in the treatment of chronic inflammatory diseases of the
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lungs, connective tissue and intestines as well as in transplantation because of
My Career and Exams their antiinflammatory effect. When long-term treatment is required, several
Order History complications (eg, cataracts, truncal obesity, skin-thinning, hyperglycemia) may be
seen. A particularly disabling complication is bone loss, which can lead to fracture;
Learning Goals it can occur with or without the other complications of chronic steroid treatment.
Question Filters The incidence of steroid-induced osteoporosis is unknown, but it appears to be
related to the duration of treatment, half-life of the steroid and its dose. Risk
factors associated with increased bone loss include age, body mass index and
Security duration of use. Steroid-induced osteoporosis proceeds rapidly in the first 6
months of steroid use and slows thereafter. Trabecular bone and the cortical rim of
Change Password the vertebral body are most susceptible to the effects of steroids. Steroids induce
Sign Out bone loss by several mechanisms. First, they inhibit calcium absorption in the
gastrointestinal (GI) tract while enhancing calcium loss in the kidneys. These
effects induce secondary hyperparathyroidism, which leads to increased bone
resorption. Second, they lower sex hormone levels through an effect on the
gonadotropin levels and a direct effect at the gonadal level, as well as by
decreasing adrenal sex steroid synthesis by inhibiting ACTH release. Third, they
have a direct inhibitory effect on osteoblast proliferation, activity and half-life,
leading to decreased bone formation. Fourth, they induce proximal muscle
weakness.
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• Timed Test A 35-year-old woman comes to see you for a complete
physical exam. She has experienced cold intolerance, Questions Incorrect 5
• Mock Exam
weakness and constipation for 3 months. Her menses are Questions Total 14
• Past Papers regular but scanty. Her history is significant for
Questions Percentage 64 %
• Random Questions hypertension and peptic ulcer disease and her family
history includes hypertension and diabetes. The patient is More
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married but has never been pregnant and takes cimetidine
• Media Bank 400 mg at bedtime, sustained-release nifedipine 60 mg
• New Multimedia daily and docusate sodium 100 mg three times a day. Her
pulse is 58 beats/minute with a blood pressure of 135/90
Online Extras mm Hg. Her skin is dry and scaly and she has hung-up Reference: Normal Values
Library reflexes. The rest of her exam is normal and the following
labs are obtained serum chemistries are normal except for Click to
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a creatine kinase of 300 U/l (normal range, 26-140 U/l);
Help CBC is normal, free thyroxine (T4) is 6.4 pmol/l (normal Click to
range, 10-22 pmol/l) and thyroid stimulating hormone open/closeImmunoglobulins
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(TSH) is 1.5 mIU (normal range, 0.3-5.0 mIU). Which of Click to
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gases Click to
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Learning Goals Antithyroid antibodies
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• Timed Test A 35-year-old woman comes to see you for a complete
physical exam. She has experienced cold intolerance, Questions Incorrect 0
• Mock Exam
weakness and constipation for 3 months. Her menses are Questions Total 1
• Past Papers regular but scanty. Her history is significant for
Questions Percentage 100 %
• Random Questions hypertension and peptic ulcer disease and her family
history includes hypertension and diabetes. The patient is More
• My Performance
married but has never been pregnant and takes cimetidine
• Media Bank 400 mg at bedtime, sustained-release nifedipine 60 mg
• New Multimedia daily and docusate sodium 100 mg three times a day. Her
pulse is 58 beats/minute with a blood pressure of 135/90
Online Extras mm Hg. Her skin is dry and scaly and she has hung-up
Library reflexes. The rest of her exam is normal and the following
labs are obtained serum chemistries are normal except for
Community
a creatine kinase of 300 U/l (normal range, 26-140 U/l);
Help CBC is normal, free thyroxine (T4) is 6.4 pmol/l (normal
PasTest Store range, 10-22 pmol/l) and thyroid stimulating hormone
(TSH) is 1.5 mIU (normal range, 0.3-5.0 mIU). Which of
the following is most likely to confirm the underlying
My Account cause?
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• Timed Test A 38-year-old woman comes to you for renewal of her
medications. She has had hypertension since her last Questions Incorrect 0
• Mock Exam
pregnancy at age 30 and has been maintained on clonidine Questions Total 1
• Past Papers 0.2 mg twice a day. She gets headaches, dyspnea on
Questions Percentage 100 %
• Random Questions exertion; swelling of her feet and orthopnea but denies
chest pain. Her father is also being treated for More
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hypertension. She is married and does not smoke. She is
• Media Bank five feet seven inches tall and weighs 15 stones. Her blood
• New Multimedia pressure is 180/110 mm Hg; pulse is 92 beats/minute. The
rest of her exam is remarkable for hypertensive
Online Extras retinopathy, bibasilar rales and 1+ pitting edema Reference: Normal Values
Library bilaterally. Initial labs were normal except for serum
potassium of 3.0 mEq/l (normal range, 3.5-5.0 mEq/l) and Click to
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serum bicarbonate of 33 mEq/l (normal range, 22-28
Help mEq/l). You correct hypokalemia and obtain a random Click to
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ng/dl) with a plasma renin activity of 0.5 ng/ml/h (normal Click to
range, 1.6-7.4 ng/ml/h) while the patient is on a normal open/closeBiochemistry
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Question Filters Adrenal CT, adrenal vein sampling and 18-
hydroxycorticosterone testing
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Questions Correct 2
• Timed Test A 38-year-old woman comes to you for renewal of her
medications. She has had hypertension since her last Questions Incorrect 0
• Mock Exam
pregnancy at age 30 and has been maintained on clonidine Questions Total 2
• Past Papers 0.2 mg twice a day. She gets headaches, dyspnea on
Questions Percentage 100 %
• Random Questions exertion; swelling of her feet and orthopnea but denies
chest pain. Her father is also being treated for More
• My Performance
hypertension. She is married and does not smoke. She is
• Media Bank five feet seven inches tall and weighs 15 stones. Her blood
• New Multimedia pressure is 180/110 mm Hg; pulse is 92 beats/minute. The
rest of her exam is remarkable for hypertensive
Online Extras retinopathy, bibasilar rales and 1+ pitting edema
Library bilaterally. Initial labs were normal except for serum
potassium of 3.0 mEq/l (normal range, 3.5-5.0 mEq/l) and
Community
serum bicarbonate of 33 mEq/l (normal range, 22-28
Help mEq/l). You correct hypokalemia and obtain a random
PasTest Store serum aldosterone level of 25 ng/dl (normal range, 5-30
ng/dl) with a plasma renin activity of 0.5 ng/ml/h (normal
range, 1.6-7.4 ng/ml/h) while the patient is on a normal
My Account diet.
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Questions Correct 0
• Timed Test A 27-year-old woman was admitted 2 days ago through
the emergency room for seizures. She has a history of Questions Incorrect 0
• Mock Exam
moderate alcohol use. Two weeks ago she received Questions Total 0
• Past Papers benzathine penicillin for secondary syphilis. She is
Questions Percentage 0%
• Random Questions complaining of muscle cramps, weakness and headache.
She received 1 g of phenytoin on the day of admission and More
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is now taking 100 mg three times a day. She is also taking
• Media Bank paracetamol, multi-vitamins and tapering doses of
• New Multimedia chlordiazepoxide. There is a history of seizures in her
family. She is 152 cm tall and weighs 55kg. Her blood
Online Extras pressure is 130/80 mm Hg; pulse is 90 beats/minute. The Reference: Normal Values
Library rest of the physical exam is normal except for a round face,
a short neck, short fourth and fifth metacarpals and Click to
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bilateral cataracts. Abnormal labs include calcium of 1.5
Help mmol/l (normal range, 2.2-2.6 mmol/l), phosphorus of 1.7 Click to
mmol/l (normal range, 0.8-1.4 mmol/l) and an intact open/closeImmunoglobulins
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parathyroid hormone (PTH) of 200 pg/ml (normal range, Click to
15-65). open/closeBiochemistry
My Account Click to open/closeDiabetes
Which of the following is most likely? Click to
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Hypothyroidism Click to open/closeBlood
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Pseudohypoparathyroidism
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Hypoparathyroidism
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Pseudo-pseudohypoparathyroidism
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Hyperparathyroidism
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• Timed Test You review a 52-year-old woman in the thyroid clinic. She has a thyroid mass.
• Mock Exam Unfortunately this turns out to be a thyroid lymphoma.
• Past Papers Which of the following is the best choice therapy in this case?
• Random Questions
Suppressive treatment with thyroid hormone
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Radioiodine treatment
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Chemotherapy and external beam radiotherapy
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External beam radiotherapy
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Palliative measures
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• Timed Test You review a 52-year-old woman in the thyroid clinic. She has a thyroid mass.
• Mock Exam Unfortunately this turns out to be a thyroid lymphoma.
• Past Papers Which of the following is the best choice therapy in this case?
• Random Questions
Suppressive treatment with thyroid hormone
• My Performance
Radioiodine treatment
• Media Bank
Chemotherapy and external beam radiotherapy Your answer
• New Multimedia
External beam radiotherapy
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Palliative measures
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Iodine 131 is a radioactive isotope of iodine (RAI) that is selectively concentrated
in the thyroid tissue and metabolized by the same pathways as naturally occurring
My Account iodine. This, together with its long half-life (8 days), allows it to deliver high doses
of radiation to the thyroid gland ( β-radiation) sufficient to destroy thyroid follicular
Profile cells. So, 131I is used in the treatment of Graves' disease, toxic multi-nodular
Newsletters 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
My Career and Exams those used in the treatment of thyroid cancer (in which it is used in conjunction
Order History with surgery). RAI has no place in the treatment of thyroid lymphoma because
lymphoma cells do not concentrate iodine. Like all lymphomas, chemotherapy is
Learning Goals extremely useful here. 3-6 courses of combination chemotherapy are usually
Question Filters administered, and trials of additional rituximab look promising, this is usually
combined with external beam radiotherapy.
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Questions Correct 2
• Timed Test You review a 54-year-old patient with
hyperparathyroidism. Which of the following Questions Incorrect 0
• Mock Exam
statements is true regarding parathyroid hormone Questions Total 2
• Past Papers (PTH)?
Questions Percentage 100 %
• Random Questions
• My Performance Secretion is inhibited by hypocalcemia More
• Media Bank Secretion is stimulated by hypercalcemia
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• Timed Test You review a 54-year-old patient with
hyperparathyroidism. Which of the following Questions Incorrect 0
• Mock Exam
statements is true regarding parathyroid hormone Questions Total 3
• Past Papers (PTH)?
Questions Percentage 100 %
• Random Questions
• My Performance Secretion is inhibited by hypocalcemia More
• Media Bank Secretion is stimulated by
hypercalcemia
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The effect of magnesium on secretion
Online Extras is the same as that of calcium
Library Secretion is stimulated by low 1,25- Your answer
Community hydroxyvitamin D and inhibited by high
levels of 1,25-hydroxyvitamin D
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Hyperparathyroidism invariably causes
PasTest Store hypophosphataemia
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PTH, an 84-amino-acid peptide synthesized and
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secreted by the parathyroid gland, is a potent regulator
My Career and Exams of the serum calcium level. Hypocalcemia stimulates the
Order History secretion of PTH acutely (with increased PTH synthesis Reference: Normal Values
and parathyroid cell hypertrophy and hyperplasia after
Learning Goals chronic hypocalcemia), whereas hypercalcemia leads to Click to open/closeHaematology
Question Filters decreased secretion of PTH. Hypomagnesemia inhibits Click to open/closeImmunoglobulins
PTH secretion. Elevated 1,25-dihydroxyvitamin D Click to open/closeBiochemistry
affects PTH synthesis and secretion by directly inhibiting Click to open/closeDiabetes Click to
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Sign Out prevalence of 1 in 1000, but increases in the fifth
decade and is commoner in women, where the
prevalence may be as high as 3% in the post
menopausal period.
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• Timed Test A 40-year-old female complains of feeling tired all the time. The following laboratory
• Mock Exam results have been obtained:
• Past Papers Cholesterol 6.8 mmol/l
• Random Questions High-density lipoprotein (HDL) 0.9 mmol/l
Thyroglobulin (TG) 2.2 mmol/l
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Free thyroxine (T4) 10 pmol/l
• Media Bank Thyroid-stimulating hormone (TSH) 22.5 mu/l
• New Multimedia
What is the most appropriate treatment?
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Library Atorvastatin
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• Timed Test A 40-year-old female complains of feeling tired all the time. The following laboratory
• Mock Exam results have been obtained:
• Past Papers Cholesterol 6.8 mmol/l
• Random Questions High-density lipoprotein (HDL) 0.9 mmol/l
Thyroglobulin (TG) 2.2 mmol/l
• My Performance
Free thyroxine (T4) 10 pmol/l
• Media Bank Thyroid-stimulating hormone (TSH) 22.5 mu/l
• New Multimedia
What is the most appropriate treatment?
Online Extras
Library Atorvastatin
Community Ezetimibe
Help Gemfibrozil
PasTest Store Omega 3 fish oil
Thyroid hormone replacement Your answer
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Newsletters In hypothyroidism, serum low-density lipoprotein (LDL) cholesterol and, less
My Career and Exams frequently, serum triglycerides are raised. Levels of high-density lipoprotein (HDL)
tend to be increased. There is decreased receptor-mediated LDL catabolism, and
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lipoprotein lipase activity may be decreased. Hypothyroidism should always be
Learning Goals considered in the diagnosis of hyperlipidaemia, and it is particularly important to
Question Filters exclude it when marked hyperlipidaemia occurs in women and in diabetic patients.
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• Timed Test A diabetic heavy goods vehicle (HGV) driver has been
changed from oral medication to insulin. What is the Questions Incorrect 0
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consequence for his driving licence? Questions Total 0
• Past Papers
Questions Percentage 0%
• Random Questions Keep the licence
• My Performance Suspension for 3 months More
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• Timed Test A diabetic heavy goods vehicle (HGV) driver has been
changed from oral medication to insulin. What is the Questions Incorrect 0
• Mock Exam
consequence for his driving licence? Questions Total 1
• Past Papers
Questions Percentage 100 %
• Random Questions Keep the licence
• My Performance Suspension for 3 months More
• Media Bank Suspension for 6 month
• New Multimedia Suspension for 1 year
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PasTest Store Drivers with insulin-treated diabetes may NOT obtain a
licence for categories C, C+E, D, D1 and D+E UNLESS
they held a heavy goods vehicle/public service vehicle
My Account (HGV/PSV) licence valid on 1 April 1991 and the traffic
commissioner in whose area they lived, or who issued
Profile the licence, had knowledge of the insulin treatment
before 1 January 1991. Drivers with insulin-treated
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diabetes applying for C1, C1+E entitlement (vehicles
My Career and Exams between 3.5 and 7.5 tonnes with a trailer up to a
Order History combined weight of 8.25 tonnes, or 12 tonnes if a Reference: Normal Values
separate test has been passed previously), will need
Learning Goals specialist assessment and must meet strict criteria for Click to open/closeHaematology
Question Filters diabetic control, and meet the other higher medical Click to open/closeImmunoglobulins
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• Timed Test A 56-year-old diabetic male had an anterior myocardial
infarction 5 years ago. He is receiving aspirin 150 mg once Questions Incorrect 0
• Mock Exam
daily and twice daily insulin. Baseline screen revealed a Questions Total 1
• Past Papers body mass index (BMI) of 34, blood pressure 150/90
Questions Percentage 100 %
• Random Questions mmHg , haemoglobin A1c (HbA1c) 6.9 %, serum
cholesterol 3.6 mmol/l (normal < 5.1 mmol/l). More
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• Media Bank Which of the following measures would delay
deterioration in renal function?
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Online Extras Orlistat Reference: Normal Values
Library Increase to ×4 daily insulin
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• Timed Test A 56-year-old diabetic male had an anterior myocardial
infarction 5 years ago. He is receiving aspirin 150 mg once Questions Incorrect 0
• Mock Exam
daily and twice daily insulin. Baseline screen revealed a Questions Total 2
• Past Papers body mass index (BMI) of 34, blood pressure 150/90
Questions Percentage 100 %
• Random Questions mmHg , haemoglobin A1c (HbA1c) 6.9 %, serum
cholesterol 3.6 mmol/l (normal < 5.1 mmol/l). More
• My Performance
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function tests on the hospital computer reveal thyroid- Questions Total 7
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• Timed Test A 32-year-old lawyer presents with non-specific symptoms
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private MRI scan of her pituitary. Blood testing by her Questions Total 1
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growth hormone is persistently elevated. Questions Total 2
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• Timed Test A 32-year-old man presents with unilateral gynaecomastia.
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ago. On examination he has, sparse body hair in the axilla Questions Total 3
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• Timed Test A 42-year-old woman is referred to the clinic with very difficult to manage
• Mock Exam hypertension. She is currently taking indapamide, ramipril, amlodipine and doxasosin,
yet her blood pressure is still 155/95 mmHg. On examination she has a BMI of 25.
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Hb 14.0g/dl
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Whilst CT/ MRI abdomen is useful in differentiating the underlying cause of primary
Sign Out hyperaldosteronism (bilateral adrenal hyperplasia vs adenoma, aldosterone:renin
ratio is still needed to make the primary diagnosis. Anti-hypertensives can affect
interpretation of the result and ideally the test should be done following a period
off medication, although the test may still be of use if only some of the anti-
hypertensive medications can be discontinued. Iodocholesterol scanning is very
expensive and not a first line investigation. There is no indication of Cushing’s, so
a morning cortisol is not likely to be useful in this case.
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• Timed Test A 38-year-old woman presents to her GP complaining of
palpitations, sweating and weight loss of around 4kg over Questions Incorrect 0
• Mock Exam
the past 6 months. She has a history of thyroid disease in Questions Total 4
• Past Papers the family. On examination she has a blood pressure of
Questions Percentage 100 %
• Random Questions 145/85 mmHg and a pulse of 92/minute.
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Bloods;
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• New Multimedia TSH <0.05 mU/l
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PLT 223 x10 9 /l
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You suspect that she has thyrotoxicosis. Click to open/closeBlood
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action/effects of excess thyroxine?
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Learning Goals Improved insulin sensitivity
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Leads to increased bone mass
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• Timed Test A 38-year-old woman presents to her GP complaining of
palpitations, sweating and weight loss of around 4kg over Questions Incorrect 1
• Mock Exam
the past 6 months. She has a history of thyroid disease in Questions Total 5
• Past Papers the family. On examination she has a blood pressure of
Questions Percentage 80 %
• Random Questions 145/85 mmHg and a pulse of 92/minute.
• My Performance More
Bloods;
• Media Bank
• New Multimedia TSH <0.05 mU/l
Online Extras Hb 13.4 g/dl
Library WCC 5.6 x10 9 /l
Community
PLT 223 x10 9 /l
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PasTest Store Na + 140 mmol/l
K+ 4.0 mmol/l
My Account Creatinine 100 μmol/l
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You suspect that she has thyrotoxicosis.
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My Career and Exams Which of the following fits best with the
action/effects of excess thyroxine?
Order History Reference: Normal Values
Learning Goals Improved insulin sensitivity Correct answer
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Question Filters Decreases myocardial oxygen Click to open/closeImmunoglobulins
demand Click to open/closeBiochemistry
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• Timed Test A 21-year-old Medical Student presents with recurrent
collapses. These have occurred on a number of occasions in Questions Incorrect 1
• Mock Exam
association with stressful periods on the wards. Most Questions Total 5
• Past Papers recently she has been attached to the Emergency
Questions Percentage 80 %
• Random Questions department and has suffered two collapses during cardiac
arrests of patients on the unit. Her father has a history of More
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Type 1 diabetes. You are on call with her overnight and she
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Bloods;
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Insulinoma Click to
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gases Click to
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• Timed Test A 21-year-old Medical Student presents with recurrent collapses. These have occurred
• Mock Exam on a number of occasions in association with stressful periods on the wards. Most
recently she has been attached to the Emergency department and has suffered two
• Past Papers collapses during cardiac arrests of patients on the unit. Her father has a history of
• Random Questions Type 1 diabetes. You are on call with her overnight and she collapses again, you
collect a blood sample.
• My Performance
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Glucose 1.6 mmol/l
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Library Insulin 1261 pmol/l
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Which of the following is the most likely diagnosis?
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Insulinoma
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Illicit use of insulin Your answer
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Question Filters Whilst insulinoma would be a possibility in a patient with this medical history, the
marked elevation in insulin levels in the presence of a normal c-peptide suggests
that illicit use of insulin is the most likely diagnosis. Illicit use of sulphonylureas is
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commoner in relatives of patients with Type 2 diabetes. Collapse due
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Questions Correct 5
• Timed Test A 45-year-old man presents to the clinic complaining of a
lump in the neck which becomes particularly more Questions Incorrect 1
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prominent when she swallows. On examination there is a Questions Total 6
• Past Papers thyroid nodule at the base of the neck. Leukocyte screening
Questions Percentage 83 %
• Random Questions of two other family members who suffered thyroid
carcinoma has revealed the ret proto-oncogene. More
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• Timed Test A 45-year-old man presents to the clinic complaining of a lump in the neck which
• Mock Exam becomes particularly more prominent when she swallows. On examination there is a
thyroid nodule at the base of the neck. Leukocyte screening of two other family
• Past Papers members who suffered thyroid carcinoma has revealed the ret proto-oncogene.
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Which type of thyroid carcinoma is linked to the ret-proto-oncogene?
• My Performance
• Media Bank Papillary thyroid carcinoma
• New Multimedia Anaplastic thyroid carcinoma
Online Extras Follicular thyroid carcinoma
Library Medullary thyroid carcinoma Your answer
Community Thyroid lymphoma
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My Account The ret proto-oncogene encodes for a receptor tyrosine kinase. In medullary
thyroid carcinoma the mutation is associated with hyperfunction. Ret is associated
Profile with familial cases of medullary thyroid carcinoma and the MEN-2 syndrome.
Formerly the condition was screened for with the pentagastrin suppression test,
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although a DNA probe for ret is now readily available and patients can be screened
My Career and Exams via a leukocyte sample.
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• Timed Test A 62-year-old man is brought to the Emergency
department with a grand-mal seizure. You are aware from Questions Incorrect 1
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his notes that he has undergone chemotherapy for small Questions Total 7
• Past Papers cell carcinoma of the bronchus a few months earlier. His
Questions Percentage 85 %
• Random Questions wife tells you that he was drowsy and not himself for a day
or two before the seizure. More
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• Media Bank On examination he is very drowsy but you can wake him
• New Multimedia up with stimulation. He is very thin with evidence of muscle
and fat loss consistent with his carcinoma. Neurological
Online Extras examination reveals no focal signs. Reference: Normal Values
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Bloods on admission; Click to
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Urea 3.5 mmol/l Click to
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Hb 11.1 g/dl Click to open/closeBlood
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You suspect SIADH and fluid restrict him. Despite no
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documented his sodium deteriorates to 119 mmol/l the
following day. His drowsiness has increased.
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Questions Correct 7
• Timed Test A 62-year-old man is brought to the Emergency
department with a grand-mal seizure. You are aware from Questions Incorrect 1
• Mock Exam
his notes that he has undergone chemotherapy for small Questions Total 8
• Past Papers cell carcinoma of the bronchus a few months earlier. His
Questions Percentage 87 %
• Random Questions wife tells you that he was drowsy and not himself for a day
or two before the seizure. More
• My Performance
• Media Bank On examination he is very drowsy but you can wake him
• New Multimedia up with stimulation. He is very thin with evidence of muscle
and fat loss consistent with his carcinoma. Neurological
Online Extras examination reveals no focal signs.
Library
Bloods on admission;
Community
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Na + 123 mmol/l
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K+ 4.0 mmol/l
Creatinine 100 µmol/l
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Urea 3.5 mmol/l
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Hb 11.1 g/dl
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My Career and Exams WCC 4.5 x10 9 /l
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• Timed Test A 45-year-old builder is admitted to the Emergency room
after falling of his ladder. Past history of note includes Questions Incorrect 1
• Mock Exam
hypertension which is managed with ramipril 10mg daily. Questions Total 8
• Past Papers The Emergency scan reveals a 4cm right sided adrenal
Questions Percentage 87 %
• Random Questions mass. His blood pressure in the Emergency room is 145/90
mmHg. More
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• Media Bank Blood results;
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Hb 12.1 g/dl
Online Extras Reference: Normal Values
Library WCC 6.2 x10 9 /l
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Help Click to
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K+ 3.6 mmol/l Click to
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the underlying diagnosis? Click to open/closeBlood
Newsletters gases Click to
My Career and Exams 24hr Urinary catecholamines open/closeCSF
Order History Plasma renin/aldosterone
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Questions Correct 7
• Timed Test A 45-year-old builder is admitted to the Emergency room
after falling of his ladder. Past history of note includes Questions Incorrect 2
• Mock Exam
hypertension which is managed with ramipril 10mg daily. Questions Total 9
• Past Papers The Emergency scan reveals a 4cm right sided adrenal
Questions Percentage 77 %
• Random Questions mass. His blood pressure in the Emergency room is 145/90
mmHg. More
• My Performance
• Media Bank Blood results;
• New Multimedia
Hb 12.1 g/dl
Online Extras
Library WCC 6.2 x10 9 /l
Community PLT 232 x10 9 /l
Help
Na + 138 mmol/l
PasTest Store
K+ 3.6 mmol/l
Creatinine 100 μmol/l
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• Timed Test You review a 59-year-old man with Type 2 diabetes. He is
managed with metformin 1g BD and also has a history of Questions Incorrect 2
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hypertension for which he is treated with ramipril 10mg. Questions Total 9
• Past Papers
Questions Percentage 77 %
• Random Questions Investigations;
• My Performance More
Hb 13.0 g/dl
• Media Bank
• New Multimedia WCC 5.1 x10 9 /l
Online Extras PLT 205 x10 9 /l Reference: Normal Values
Library
Na + 139 mmol/l Click to
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K+ 4.9 mmol/l
Help Click to
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Glucose 8.1 mmol/l Click to
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HbA1c 8.4% Click to open/closeDiabetes
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receptor (PPAR)gamma agonist. Click to open/closeBlood
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DNA transcription
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Fatty acid metabolism
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DNA replication
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• Timed Test You review a 59-year-old man with Type 2 diabetes. He is managed with metformin
• Mock Exam 1g BD and also has a history of hypertension for which he is treated with ramipril
10mg.
• Past Papers
• Random Questions Investigations;
• My Performance
Hb 13.0 g/dl
• Media Bank
• New Multimedia WCC 5.1 x10 9 /l
Online Extras PLT 205 x10 9 /l
Library
Na + 139 mmol/l
Community
K+ 4.9 mmol/l
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Creatinine 120 μmol/l
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Glucose 8.1 mmol/l
HbA1c 8.4%
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• Timed Test You review a 16-year-old girl with Type 1 diabetes. She is
currently managed with 18U of 30/70 mixed insulin BD. Her Questions Incorrect 0
• Mock Exam
parents tell you that she does not eat properly, and they Questions Total 0
• Past Papers occasionally hear her dreaming in the night and go in to
Questions Percentage 0%
• Random Questions find her suffering a hypoglycaemic attack.
• My Performance More
Investigations;
• Media Bank
• New Multimedia Hb 13.9 g/dl
Online Extras WCC 5.4 x10 9 /l Reference: Normal Values
Library
PLT 234 x10 9 /l Click to
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Help Na + 140 mmol/l Click to
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You decide to make a change to an insulin glargine/ Click to open/closeBlood
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Which of the following best represents the main
Order History advantage of insulin glargine?
Learning Goals
Reduced post-prandial hypoglycaemia
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Ability to miss a meal
Reduced nocturnal hypoglycaemia
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Increased ability to undertake exercise more easily
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• Timed Test You review a 16-year-old girl with Type 1 diabetes. She is currently managed with
• Mock Exam 18U of 30/70 mixed insulin BD. Her parents tell you that she does not eat properly,
and they occasionally hear her dreaming in the night and go in to find her suffering a
• Past Papers hypoglycaemic attack.
• Random Questions
Investigations;
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• Media Bank Hb 13.9 g/dl
• New Multimedia
WCC 5.4 x10 9 /l
Online Extras
Library PLT 234 x10 9 /l
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• Timed Test A 19-year-old woman is admitted to the Emergency room
after a collapse. She is found to be hypoglycaemic. You Questions Incorrect 0
• Mock Exam
understand from colleagues who accompanied her in the Questions Total 1
• Past Papers ambulance that she collapsed at work, and this has
Questions Percentage 100 %
• Random Questions happened at least 3 times in the past 2 months. There is no
past medical history of note apart from the fact that her More
• My Performance
father is obese and was diagnosed with Type 2 diabetes
• Media Bank some 7 years ago.
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Bloods;
Online Extras Reference: Normal Values
Library Hb 13.9 g/dl
Click to
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WCC 5.6 x10 9 /l open/closeHaematology
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PLT 231 x10 9 /l open/closeImmunoglobulins
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Glucose 2.4 mmol/l Click to open/closeBlood
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Order History C-Peptide 0.1 U/l
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Which of the following is the most likely diagnosis?
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Sulphonylurea abuse
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• Timed Test A 19-year-old woman is admitted to the Emergency room
after a collapse. She is found to be hypoglycaemic. You Questions Incorrect 1
• Mock Exam
understand from colleagues who accompanied her in the Questions Total 2
• Past Papers ambulance that she collapsed at work, and this has
Questions Percentage 50 %
• Random Questions happened at least 3 times in the past 2 months. There is no
past medical history of note apart from the fact that her More
• My Performance
father is obese and was diagnosed with Type 2 diabetes
• Media Bank some 7 years ago.
• New Multimedia
Bloods;
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Library Hb 13.9 g/dl
Community
WCC 5.6 x10 9 /l
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PLT 231 x10 9 /l
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Na + 139 mmol/l
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• Timed Test A 20-year-old student presents to the diabetes clinic for
review. She is a keen rower who suffers from Type 1 Questions Incorrect 1
• Mock Exam
diabetes and has suffered two severe hypoglycaemic Questions Total 2
• Past Papers attacks after rowing training. Her current insulin regime is
Questions Percentage 50 %
• Random Questions BD 30/70 mixed insulin.
• My Performance More
Investigations;
• Media Bank
• New Multimedia Hb 13.1 g/dl
Online Extras WCC 4.3 x10 9 /l Reference: Normal Values
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PLT 295 x10 9 /l Click to
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Help Na + 140 mmol/l Click to
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My Account HbA1c 9.1% Click to open/closeDiabetes
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You plan to make a change to a basal bolus insulin regime Click to open/closeBlood
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short acting insulin for her?
Order History
Learning Goals Insulin glargine
Question Filters Insulin lispro
Insulin detemir
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Novomix 50/50
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Questions Correct 2
• Timed Test A 20-year-old student presents to the diabetes clinic for
review. She is a keen rower who suffers from Type 1 Questions Incorrect 1
• Mock Exam
diabetes and has suffered two severe hypoglycaemic Questions Total 3
• Past Papers attacks after rowing training. Her current insulin regime is
Questions Percentage 66 %
• Random Questions BD 30/70 mixed insulin.
• My Performance More
Investigations;
• Media Bank
• New Multimedia Hb 13.1 g/dl
Online Extras WCC 4.3 x10 9 /l
Library
PLT 295 x10 9 /l
Community
Help Na + 140 mmol/l
Profile
You plan to make a change to a basal bolus insulin regime
Newsletters
My Career and Exams Which of the following would be the most appropriate
short acting insulin for her?
Order History Reference: Normal Values
Learning Goals Insulin glargine
Click to open/closeHaematology
Question Filters Insulin lispro Your answer Click to open/closeImmunoglobulins
Insulin detemir Click to open/closeBiochemistry
Click to open/closeDiabetes Click to
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• Timed Test A 39-year-old woman with Hashimoto’s thyroiditis presents
to the clinic for review. Her Hashimoto’s is managed with Questions Incorrect 1
• Mock Exam
thyroxine 125μg/day replacement. She presents to the Questions Total 3
• Past Papers clinic complaining of bilateral loin pain.
Questions Percentage 66 %
• Random Questions
Investigations; More
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• Media Bank Hb 12.1 g/dl
• New Multimedia
WCC 5.4 x10 9 /l
Online Extras Reference: Normal Values
Library PLT 294 x10 9 /l
Click to
Community Na + 139 mmol/l open/closeHaematology
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Creatinine 140 μmol/l Click to
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HCO3 - 15 mmol/l Click to open/closeDiabetes
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KUB Evidence of nephrocalcinosis Click to
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Renal tubular acidosis Type 4
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Medullary sponge kidney
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Renal tubular acidosis Type 2
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Renal tubular acidosis Type 1
Chronic interstitial nephritis
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• Timed Test A 39-year-old woman with Hashimoto’s thyroiditis presents
to the clinic for review. Her Hashimoto’s is managed with Questions Incorrect 1
• Mock Exam
thyroxine 125μg/day replacement. She presents to the Questions Total 4
• Past Papers clinic complaining of bilateral loin pain.
Questions Percentage 75 %
• Random Questions
Investigations; More
• My Performance
• Media Bank Hb 12.1 g/dl
• New Multimedia
WCC 5.4 x10 9 /l
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Library PLT 294 x10 9 /l
HCO3 - 15 mmol/l
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KUB Evidence of nephrocalcinosis
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Renal tubular acidosis Type 4
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Medullary sponge kidney
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Renal tubular acidosis Type 2 Click to open/closeHaematology
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Renal tubular acidosis Type 1 (hypokalaemic distal renal
tubular acidosis) may occur in association with a
number of autoimmune conditions including SLE,
vasulitis and autoimmune hypothyroidism. Other causes
include drugs such as amphotericin B and lithium,
inherited conditions such as Marfan’s and conditions
such as chronic pyelonephritis and obstructive uropathy.
Treatment includes oral supplementation with potassium
and bicarbonate.
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• Timed Test A 42-year-old woman presents with a mass in her neck
and symptoms of choking/ shortness of breath when she Questions Incorrect 1
• Mock Exam
lies down. Past history of note includes a family history of Questions Total 4
• Past Papers goitre, for which her mother and grandmother both
Questions Percentage 75 %
• Random Questions endured partial thyroid resection.
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You examine her and suspect that she has a multinodular
• Media Bank goitre.
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Investigations;
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Library Hb 14.1 g/dl
Click to
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TSH 0.9 U/l Click to open/closeBlood
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You suspect that she may have retrosternal thyroid
Order History extension
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Which of the following would be the investigation of
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retrosternal involvement?
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Questions Correct 3
• Timed Test A 42-year-old woman presents with a mass in her neck
and symptoms of choking/ shortness of breath when she Questions Incorrect 2
• Mock Exam
lies down. Past history of note includes a family history of Questions Total 5
• Past Papers goitre, for which her mother and grandmother both
Questions Percentage 60 %
• Random Questions endured partial thyroid resection.
• My Performance More
You examine her and suspect that she has a multinodular
• Media Bank goitre.
• New Multimedia
Investigations;
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Library Hb 14.1 g/dl
Community
WCC 5.4 x10 9 /l
Help
PLT 235 x10 9 /l
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Na + 140 mmol/l
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• Timed Test A 54-year-old man presents with a new diagnosis of Type
2 diabetes. He is also concerned that his fingers seem a Questions Incorrect 2
• Mock Exam
little swollen and he is unable to wear his wedding ring Questions Total 5
• Past Papers anymore. He attends with some pictures from his youth,
Questions Percentage 60 %
• Random Questions which appear to show that his jaw has acquired increasing
prominence over the past few years. On examination his BP More
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is 152/90 mmHg.
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• Timed Test A 54-year-old man presents with a new diagnosis of Type
2 diabetes. He is also concerned that his fingers seem a Questions Incorrect 2
• Mock Exam
little swollen and he is unable to wear his wedding ring Questions Total 6
• Past Papers anymore. He attends with some pictures from his youth,
Questions Percentage 66 %
• Random Questions which appear to show that his jaw has acquired increasing
prominence over the past few years. On examination his BP More
• My Performance
is 152/90 mmHg.
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Hb 14.0 g/dl
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Help PLT 302 x10 9 /l
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Creatinine 110 μmol/l
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My Career and Exams Which of the following would be the most appropriate
initial screening test for the likely underlying
Order History condition? Reference: Normal Values
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GNRH concentration Click to open/closeHaematology
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Oral glucose tolerance test with growth Click to open/closeBiochemistry
hormone measurement Click to open/closeDiabetes Click to
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measurement
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• Timed Test A 48-year-old psychiatric nurse with Type 2 diabetes
presents to the clinic for review. He was diagnosed with Questions Incorrect 2
• Mock Exam
Type 2 diabetes following a myocardial infarction 3 years Questions Total 6
• Past Papers ago. Current medication includes metformin 1g bd, ramipril
Questions Percentage 66 %
• Random Questions 10mg, simvastatin 40mg and aspirin 75mg. He aslo takes
bendroflumethiazide started by his GP for mild bilateral More
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ankle swelling. On examination his BMI is 33 and he has
• Media Bank gained 7kg since his last appointment 6 months earlier. His
• New Multimedia BP is 135/80 mmHg.
Pioglitazone
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Sitagliptin
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Questions Correct 4
• Timed Test A 48-year-old psychiatric nurse with Type 2 diabetes
presents to the clinic for review. He was diagnosed with Questions Incorrect 3
• Mock Exam
Type 2 diabetes following a myocardial infarction 3 years Questions Total 7
• Past Papers ago. Current medication includes metformin 1g bd, ramipril
Questions Percentage 57 %
• Random Questions 10mg, simvastatin 40mg and aspirin 75mg. He aslo takes
bendroflumethiazide started by his GP for mild bilateral More
• My Performance
ankle swelling. On examination his BMI is 33 and he has
• Media Bank gained 7kg since his last appointment 6 months earlier. His
• New Multimedia BP is 135/80 mmHg.
Na + 140 mmol/l
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K+ 5.4 mmol/l
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Creatinine 120 µmol/l
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HBA1c 8.5%
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C-peptide elevated Reference: Normal Values
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Learning Goals Which of the following represents the most Click to open/closeHaematology
Question Filters appropriate additional medication for him? Click to open/closeImmunoglobulins
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Pioglitazone Click to open/closeDiabetes Click to
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open/closeBlood gases Click to
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Sitagliptin Correct answer
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• Timed Test A 19-year-old man presents to his GP complaining of tiredness, polyuria, thirst and
• Mock Exam recurrent thrush infections. He has a history of Type 2 diabetes in the family. On
examination he looks slim, with a BMI of 22.
• Past Papers
• Random Questions Investigations;
• My Performance
Hb 12.9 g/dl
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Creatinine 120 µmol/l
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Fasting glucose 8.5 mmol/l
Islet cell, GAD, insulin antibody negative
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HDL 1.8 mmol/l (>1.5)
Profile
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Type 1 diabetes
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Type 2 diabetes
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(Maturity Onset Diabetes of the Young) MODY 3
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MODY 5
(Latent Autoimmune Diabetes of Adulthood) LADA
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Questions Correct 5
• Timed Test A 19-year-old man presents to his GP complaining of
tiredness, polyuria, thirst and recurrent thrush infections. Questions Incorrect 3
• Mock Exam
He has a history of Type 2 diabetes in the family. On Questions Total 8
• Past Papers examination he looks slim, with a BMI of 22.
Questions Percentage 62 %
• Random Questions
Investigations; More
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• Media Bank Hb 12.9 g/dl
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WCC 5.4 x10 9 /l
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Questions Correct 5
• Timed Test You see a poorly controlled 58-year-old type 2 diabetes
patient who is fasting for Ramadan. He has background Questions Incorrect 3
• Mock Exam
diabetic retinopathy, and currently takes metformin 500mg Questions Total 8
• Past Papers TDS as well as ramipril 10mg and aspirin 75mg.
Questions Percentage 62 %
• Random Questions
Investigations More
• My Performance
• Media Bank Hb 12.1 g/dl
• New Multimedia
WCC 5.0 x10 9 /l
Online Extras Reference: Normal Values
Library PLT 212 x10 9 /l
Click to
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• Timed Test You see a poorly controlled 58-year-old type 2 diabetes patient who is fasting for
• Mock Exam Ramadan. He has background diabetic retinopathy, and currently takes metformin
500mg TDS as well as ramipril 10mg and aspirin 75mg.
• Past Papers
• Random Questions Investigations
• My Performance
Hb 12.1 g/dl
• Media Bank
• New Multimedia WCC 5.0 x10 9 /l
Online Extras PLT 212 x10 9 /l
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Na + 139 mmol/l
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HbA1c 7.4%
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What advice would you give him regarding his medication while fasting?
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Stop metformin
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Give short acting insulin for the evening meal
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Switch to glicazide BD
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Give metformin 500mg before dawn, 1000mg in evening Correct answer
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Do not fast for health reasons Your answer
Question Filters
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Change Password Metformin is not associated with hypoglycaemia when used as monotherapy. It
Sign Out reduces hepatic glucose output and has its predominant effects on fasting plasma
glucose. Even so, it would seem sensible to divide the dose with the larger portion
taken in the evening after the fast is broken. Giving short acting insulin or
switching to insulin is likely to increase the risk of hypoglycaemia. Whilst diabetes
patients are exempted from the need to fast, if this patient wishes to do so in this
case it would seem unfair to prevent him fasting, as metformin should not
preclude it altogether.
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• Timed Test A 19-year-old female gymnast presents with complaints of headache and fatigue. She
• Mock Exam has had no significant previous medical history, but has been amenorrhoeic for the
past 4 months. On examination her BP is 110/70 mmHg and pulse is 55/min. Her BMI
• Past Papers is 16.
• Random Questions
Investigations
• My Performance
• Media Bank Hb 11.5 g/dl
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WCC 5.2 x10 9 /l
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My Account The GP requests you to assess her hormone levels. Which of the following
hormone panel do you expect to be most elevated?
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Order History LH
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• Timed Test A 19-year-old female gymnast presents with complaints of headache and fatigue. She
• Mock Exam has had no significant previous medical history, but has been amenorrhoeic for the
past 4 months. On examination her BP is 110/70 mmHg and pulse is 55/min. Her BMI
• Past Papers is 16.
• Random Questions
Investigations
• My Performance
• Media Bank Hb 11.5 g/dl
• New Multimedia
WCC 5.2 x10 9 /l
Online Extras
Library PLT 156 x10 9 /l
My Account The GP requests you to assess her hormone levels. Which of the following
hormone panel do you expect to be most elevated?
Profile
Newsletters Cortisol Your answer
Order History LH
Security
Change Password This woman’s low BMI and amenorrhoea, raises the possibility that she is weight
Sign Out restricting, particularly given her profession as a gymnast. Resting growth
hormone levels are likely to be slightly elevated, LH levels will be low, and
prolactin levels are normal in this case. T3 and T4 are often low normal, with a
normal TSH. Cortisol levels are most elevated, and they often fail to suppress with
dexamethasone. Weight gain leads to a restoration of the normal menstrual cycle.
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• Timed Test A lady presents with amenorrhoea and galactorrhoea. She has normal visual fields.
• Mock Exam You are concerned that she may have a prolactinoma.
Investigations
• Past Papers
• Random Questions Hb 12.5 g/dl
• My Performance
WCC 4.9 x10 9 /l
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PLT 199 x10 9 /l
• New Multimedia
Online Extras Na + 140 mmol/l
Library K+ 4.9 mmol/l
Community Creatinine 90 μmol/l
Help Prolactin 1150 mU/l
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MRI 7 mm pituitary microadenoma
Profile ADH
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Questions Correct 7
• Timed Test A lady presents with amenorrhoea and galactorrhoea. She
has normal visual fields. You are concerned that she may Questions Incorrect 4
• Mock Exam
have a prolactinoma. Questions Total 11
• Past Papers Investigations
Questions Percentage 63 %
• Random Questions
• My Performance Hb 12.5 g/dl More
• Media Bank 9
WCC 4.9 x10 /l
• New Multimedia
PLT 199 x10 9 /l
Online Extras
Na + 140 mmol/l
Library FusionCharts needs Adobe Flash Player
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here, it
Help Creatinine 90 μmol/l
PasTest Store Prolactin 1150 mU/l
MRI 7 mm pituitary microadenoma
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Which of the following hormones would you expect to
Profile be low?
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ADH
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Cortisol
Order History
GH
Learning Goals
Thyroxine
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LH Your answer
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Sign Out You would not expect ADH levels to be affected by a
prolactinoma, and production of ACTH, TSH and growth
hormone should not be affected by a
microprolactinoma, as it is usually macroadenomas that
cause pressure effects, suppressing production of other
hormones. Hyperprolactinaemia suppresses release of
gonadotrophin releasing hormone, which leads to
reduced production of LH and FSH. There may also be a
direct effect of prolactin itself on the ovary to disrupt LH
and FSH signalling.
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• Timed Test A patient with poorly controlled Type 2 diabetes comes to the clinic for review. He has
• Mock Exam a history of hypertension for which he takes ramipril 10mg daily, and amlodipine
10mg. Current diabetes medication is metformin 1g BD and gliclazide 160mg BD. On
• Past Papers examination his BP is 145/85 mmHg. His vision is 6/6 bilaterally on clinical
• Random Questions examination.
• My Performance
Investigations
• Media Bank
• New Multimedia Hb 12.0 g/dl
Online Extras WCC 5.0 x10 9 /l
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PLT 231 x10 9 /l
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Help Na + 139 mmol/l
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Questions Correct 8
• Timed Test A patient with poorly controlled Type 2 diabetes comes to
the clinic for review. He has a history of hypertension for Questions Incorrect 4
• Mock Exam
which he takes ramipril 10mg daily, and amlodipine 10mg. Questions Total 12
• Past Papers Current diabetes medication is metformin 1g BD and
Questions Percentage 66 %
• Random Questions gliclazide 160mg BD. On examination his BP is 145/85
mmHg. His vision is 6/6 bilaterally on clinical examination. More
• My Performance
• Media Bank Investigations
• New Multimedia
Hb 12.0 g/dl
Online Extras
Library WCC 5.0 x10 9 /l FusionCharts needs Adobe Flash Player
Community to run. If you're unable to see the chart
PLT 231 x10 9 /l
here, it means that your browser does
Help not seem to have the Flash Player
Na + 139 mmol/l
PasTest Store Installed. You can downloaded it here
K+ 4.5 mmol/l for free.
20735
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Questions Correct 8
• Timed Test A 60-year-old man with a history of Type 2 diabetes and
left ventricular hypertrophy presents to the clinic. He is Questions Incorrect 4
• Mock Exam
currently taking metformin and pioglitazone for his glucose Questions Total 12
• Past Papers control. He is hypertensive with a BP of 160/95 mmHg, but
Questions Percentage 66 %
• Random Questions his GP reports he has suffered various side effects of anti-
hypertensives including a dry, irritating cough, swollen More
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ankles, gum hypertrophy, lethargy and urinary frequency.
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Questions Correct 8
• Timed Test A 60-year-old man with a history of Type 2 diabetes and
left ventricular hypertrophy presents to the clinic. He is Questions Incorrect 5
• Mock Exam
currently taking metformin and pioglitazone for his glucose Questions Total 13
• Past Papers control. He is hypertensive with a BP of 160/95 mmHg, but
Questions Percentage 61 %
• Random Questions his GP reports he has suffered various side effects of anti-
hypertensives including a dry, irritating cough, swollen More
• My Performance
ankles, gum hypertrophy, lethargy and urinary frequency.
• Media Bank
• New Multimedia Investigations;
Online Extras
Hb 12.9 g/dl
Library
WCC 5.4 x10 9 /l
Community
Help PLT 199 x10 9 /l
PasTest Store Na + 141 mmol/l
K+ 5.0 mmol/l
My Account
Creatinine 132 μmol/l
Profile
HbA1c 8.2%
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My Career and Exams Which of the following would be the most appropriate
therapy choice for him? Reference: Normal Values
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Learning Goals Indapamide Click to open/closeHaematology
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• Timed Test A 56-year-old man with a history of Type 2 diabetes comes to the clinic complaining
• Mock Exam of increased shortness of breath and bilateral ankle swelling. An echocardiogram
arranged by the GP reveals that he has an ejection fraction of 35%. His diabetes is
• Past Papers relatively well controlled, with a recent HbA1c measured at 7.2%. He takes ramipril
• Random Questions and furosemide currently for control of his hypertension and heart failure.
• My Performance
Investigations;
• Media Bank
• New Multimedia Hb 12.3 g/dl
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PLT 190 x10 9 /l
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Help Na + 141 mmol/l
Profile CXR LVH, increased basal shadowing consistent with mild LVF
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Which of the following glucose control strategies would be most suitable in
My Career and Exams this patient with respect to avoiding fluid overload?
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Pioglitazone
Learning Goals
Basal insulin
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Chlorpropamide
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Questions Correct 9
• Timed Test A 56-year-old man with a history of Type 2 diabetes comes
to the clinic complaining of increased shortness of breath Questions Incorrect 5
• Mock Exam
and bilateral ankle swelling. An echocardiogram arranged Questions Total 14
• Past Papers by the GP reveals that he has an ejection fraction of 35%.
Questions Percentage 64 %
• Random Questions His diabetes is relatively well controlled, with a recent
HbA1c measured at 7.2%. He takes ramipril and More
• My Performance
furosemide currently for control of his hypertension and
• Media Bank heart failure.
• New Multimedia
Investigations;
Online Extras
Library Hb 12.3 g/dl
Community
WCC 5.0 x10 9 /l
Help
PLT 190 x10 9 /l
PasTest Store
Na + 141 mmol/l
20957
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Questions Correct 9
• Timed Test A 61-year-old man with Type 2 diabetes comes to the clinic
with a foot ulcer on the plantar surface of his left foot. He Questions Incorrect 5
• Mock Exam
has had Type 2 diabetes for the past 8 years and is Questions Total 14
• Past Papers currently managed with metformin and sulphonylurea. On
Questions Percentage 64 %
• Random Questions examination his BP is 160/92 mmHg, his pulse 75/min and
regular. He is obese with a BMI of 32. He has loss of More
• My Performance
vibration sense on his big toes and insensitivity to the 10g
• Media Bank monofilament on the soles of both feet. He has loss of the
• New Multimedia arches on both sides.
20958
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Questions Correct 10
• Timed Test A 61-year-old man with Type 2 diabetes comes to the clinic
with a foot ulcer on the plantar surface of his left foot. He Questions Incorrect 5
• Mock Exam
has had Type 2 diabetes for the past 8 years and is Questions Total 15
• Past Papers currently managed with metformin and sulphonylurea. On
Questions Percentage 66 %
• Random Questions examination his BP is 160/92 mmHg, his pulse 75/min and
regular. He is obese with a BMI of 32. He has loss of More
• My Performance
vibration sense on his big toes and insensitivity to the 10g
• Media Bank monofilament on the soles of both feet. He has loss of the
• New Multimedia arches on both sides.
Na + 141 mmol/l
My Account
K+ 4.9 mmol/l
Profile
Creatinine 110 μmol/l
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My Career and Exams HbA1c 7.8%
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Questions Correct 10
• Timed Test A 42-year-old man who works as a security guard and
suffers from morbid obesity (BMI 34) attends the clinic Questions Incorrect 5
• Mock Exam
because his GP has documented fasting blood glucose of Questions Total 15
• Past Papers 8.2 mmol/l, and he has symptoms of frequent nocturia and
Questions Percentage 66 %
• Random Questions lethargy. He has a history of hypertension which is
managed with ramipril 10mg daily but is currently taking no More
• My Performance
other medication.
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Questions Correct 11
• Timed Test A 42-year-old man who works as a security guard and
suffers from morbid obesity (BMI 34) attends the clinic Questions Incorrect 5
• Mock Exam
because his GP has documented fasting blood glucose of Questions Total 16
• Past Papers 8.2 mmol/l, and he has symptoms of frequent nocturia and
Questions Percentage 68 %
• Random Questions lethargy. He has a history of hypertension which is
managed with ramipril 10mg daily but is currently taking no More
• My Performance
other medication.
• Media Bank
• New Multimedia Investigations;
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Hb 12.1 g/dl
Library
WCC 6.9 x10 9 /l
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Help PLT 309 x10 9 /l
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K+ 4.4 mmol/l
My Account
Creatinine 110 µmol/l
Profile
Newsletters Which of the following would be the most appropriate
initial medication for him?
My Career and Exams
Order History Pioglitazone Reference: Normal Values
Learning Goals Sitagliptin
Click to open/closeHaematology
Question Filters Gliclazide Click to open/closeImmunoglobulins
Basal bolus insulin Click to open/closeBiochemistry
Click to open/closeDiabetes Click to
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Questions Correct 11
• Timed Test You are drawing up guidelines for the management of oral
blood glucose lowering agents in patients post myocardial Questions Incorrect 5
• Mock Exam
infarction. Questions Total 16
• Past Papers
Looking at a synthesis of the available evidence, Questions Percentage 68 %
• Random Questions
which of the following pieces of advice would you More
• My Performance give?
• Media Bank
• New Multimedia Pioglitazone should be started in patients post
myocardial infarction
Online Extras Reference: Normal Values
Metformin should be stopped in all patients post
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patients who have an unstable circulation post infarct Click to
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Insulin should be given IV for the first 48hrs Click to open/closeDiabetes
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Questions Correct 11
• Timed Test You are drawing up guidelines for the management of oral
blood glucose lowering agents in patients post myocardial Questions Incorrect 6
• Mock Exam
infarction. Questions Total 17
• Past Papers
Looking at a synthesis of the available evidence, Questions Percentage 64 %
• Random Questions
which of the following pieces of advice would you More
• My Performance give?
• Media Bank
• New Multimedia Pioglitazone should be started in
patients post myocardial infarction
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Metformin should be stopped in all Your answer
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Help permanent insulin therapy
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patients in those patients who have
an unstable circulation post infarct
My Account Insulin should be given IV for the
first 48hrs
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Order History Reference: Normal Values
Glitazones are generally not used in patients at risk of
Learning Goals fluid retention due to the risk of heart failure, which Click to open/closeHaematology
Question Filters includes some of those patients who have suffered a Click to open/closeImmunoglobulins
myocardial infarction. The DIGAMI-2 study was Click to open/closeBiochemistry
generally disappointing with respect to demonstrating Click to open/closeDiabetes Click to
Security any benefits of insulin therapy, and for this reason open/closeEndocrinology Click to
permanent insulin therapy is no longer recommended open/closeBlood gases Click to
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Metformin was originally ruled out in all patients who
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suffered an MI, but is continued by many clinicians now
unless there is evidence of significant circulatory
impairment or raised creatinine.
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Questions Correct 11
• Timed Test A 45-year-old man presents to the clinic after being
referred by his GP. He complains of recurrent episodes of Questions Incorrect 6
• Mock Exam
sweating and light headedness which are relieved by eating Questions Total 17
• Past Papers snacks. Tiredness and poor concentration have affected his
Questions Percentage 64 %
• Random Questions ability to work and he has gained 12kg in weight over the
past 3 months. On examination he has a BMI of 31, his BP More
• My Performance
is 145/89 mmHg, pulse 75/min regular. He is obese but
• Media Bank there are no other clinical findings of note.
• New Multimedia
Investigations;
Online Extras Reference: Normal Values
Library Hb 13.9 g/dl
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WCC 5.8 x10 9 /l open/closeHaematology
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Na + 141 mmol/l open/closeBiochemistry
My Account K+ 4.9 mmol/l Click to open/closeDiabetes
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Which of the following is the most appropriate next
Order History
investigation?
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Question Filters TSH
Barium swallow
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Questions Correct 12
• Timed Test A 45-year-old man presents to the clinic after being
referred by his GP. He complains of recurrent episodes of Questions Incorrect 6
• Mock Exam
sweating and light headedness which are relieved by eating Questions Total 18
• Past Papers snacks. Tiredness and poor concentration have affected his
Questions Percentage 66 %
• Random Questions ability to work and he has gained 12kg in weight over the
past 3 months. On examination he has a BMI of 31, his BP More
• My Performance
is 145/89 mmHg, pulse 75/min regular. He is obese but
• Media Bank there are no other clinical findings of note.
• New Multimedia
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• Timed Test A 35-year-old man comes to the clinic complaining of tiredness, lethargy and an
• Mock Exam increasingly hoarse voice. He also tells you that he has been losing his hair over the
past few months and has noticed fullness in his neck; he has gained 7kg in the past 3
• Past Papers months. On examination he has a puffy face and periorbital oedema and there is a
• Random Questions firm, rubbery goitre. His pulse is 48/min and regular, his BP 142/73 mmHg.
• My Performance
Investigations;
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• New Multimedia Hb 11.4 g/dl
Online Extras WCC 5.4 x10 9 /l
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PLT 183 x10 9 /l
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De Quervain’s thyroiditis
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Questions Correct 13
• Timed Test A 35-year-old man comes to the clinic complaining of
tiredness, lethargy and an increasingly hoarse voice. He Questions Incorrect 6
• Mock Exam
also tells you that he has been losing his hair over the past Questions Total 19
• Past Papers few months and has noticed fullness in his neck; he has
Questions Percentage 68 %
• Random Questions gained 7kg in the past 3 months. On examination he has a
puffy face and periorbital oedema and there is a firm, More
• My Performance
rubbery goitre. His pulse is 48/min and regular, his BP
• Media Bank 142/73 mmHg.
• New Multimedia
Investigations;
Online Extras
Library Hb 11.4 g/dl
Community
WCC 5.4 x10 9 /l
Help
PLT 183 x10 9 /l
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Na + 141 mmol/l
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• Timed Test A 27-year-old pharmacist is admitted to the Emergency
room with a panic attack. On further questioning it Questions Incorrect 6
• Mock Exam
transpires that she has been suffering from palpitations and Questions Total 19
• Past Papers has lost weight over the past 6 months. Her periods
Questions Percentage 68 %
• Random Questions stopped 3 months ago. On examination her BP is 145/90
mmHg, pulse is 92/min at rest. Her BMI is 20; the More
• My Performance
remainder of her clinical examination is unremarkable.
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Questions Correct 14
• Timed Test A 27-year-old pharmacist is admitted to the Emergency
room with a panic attack. On further questioning it Questions Incorrect 6
• Mock Exam
transpires that she has been suffering from palpitations and Questions Total 20
• Past Papers has lost weight over the past 6 months. Her periods
Questions Percentage 70 %
• Random Questions stopped 3 months ago. On examination her BP is 145/90
mmHg, pulse is 92/min at rest. Her BMI is 20; the More
• My Performance
remainder of her clinical examination is unremarkable.
• Media Bank
• New Multimedia Investigations;
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• Timed Test A 19-year-old girl with a history of Type 1 diabetes
presents with confusion, hyperventilation and dehydration. Questions Incorrect 6
• Mock Exam
On examination she is hyperventilating, smells of pear Questions Total 20
• Past Papers drops and has a BP of 95/50 mmHg with a pulse of
Questions Percentage 70 %
• Random Questions 105/min. Arterial blood gas measurement reveals a pH of
7.2. You suspect that she has diabetic ketoacidosis (DKA). More
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• Media Bank What is the primary cause of ketoacidosis in Type 1
diabetes?
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Library Lipolysis
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Questions Correct 15
• Timed Test A 19-year-old girl with a history of Type 1 diabetes
presents with confusion, hyperventilation and dehydration. Questions Incorrect 6
• Mock Exam
On examination she is hyperventilating, smells of pear Questions Total 21
• Past Papers drops and has a BP of 95/50 mmHg with a pulse of
Questions Percentage 71 %
• Random Questions 105/min. Arterial blood gas measurement reveals a pH of
7.2. You suspect that she has diabetic ketoacidosis (DKA). More
• My Performance
• Media Bank What is the primary cause of ketoacidosis in Type 1
diabetes?
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Online Extras Lipogenesis
Library Lipolysis Your answer
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• Timed Test A 32-year-old woman presents to the clinic with tiredness.
She has 3 children and a full time job and is finding it very Questions Incorrect 6
• Mock Exam
difficult to hold everything together. There is no significant Questions Total 21
• Past Papers past medical history. On examination her BP is 145/80
Questions Percentage 71 %
• Random Questions mmHg, her BMI is 28.
• My Performance More
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• Timed Test A 32-year-old woman presents to the clinic with tiredness.
She has 3 children and a full time job and is finding it very Questions Incorrect 7
• Mock Exam
difficult to hold everything together. There is no significant Questions Total 22
• Past Papers past medical history. On examination her BP is 145/80
Questions Percentage 68 %
• Random Questions mmHg, her BMI is 28.
• My Performance More
Investigations;
• Media Bank
• New Multimedia Hb 12.4 g/dl
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• Timed Test A 23-year-old South African woman who has recently
started the oral contraceptive pill comes to the dermatology Questions Incorrect 7
• Mock Exam
clinic. She is concerned as the skin on her hands and Questions Total 22
• Past Papers forearms has become increasingly fragile with a bullous
Questions Percentage 68 %
• Random Questions rash. In addition she has increased pigmentation and some
hair growth on her face. More
• My Performance
• Media Bank Investigations;
• New Multimedia
Hb 12.2 g/dl
Online Extras Reference: Normal Values
Library WCC 8.1 x10 9 /l
Click to
Community PLT 284 x10 9 /l
open/closeHaematology
Help Na + 141 mmol/l Click to
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K+ 4.9 mmol/l Click to
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Creatinine 110 µmol/l Click to open/closeDiabetes
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ANA positive Click to
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Which of the following is the most likely diagnosis? Click to open/closeBlood
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Polycystic ovarian syndrome
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Erythema multiforme
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Hereditary coproporphyria
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Questions Correct 16
• Timed Test A 23-year-old South African woman who has recently
started the oral contraceptive pill comes to the dermatology Questions Incorrect 7
• Mock Exam
clinic. She is concerned as the skin on her hands and Questions Total 23
• Past Papers forearms has become increasingly fragile with a bullous
Questions Percentage 69 %
• Random Questions rash. In addition she has increased pigmentation and some
hair growth on her face. More
• My Performance
• Media Bank Investigations;
• New Multimedia
Hb 12.2 g/dl
Online Extras
Library WCC 8.1 x10 9 /l
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• Timed Test A 31-year-old woman who is 22 weeks pregnant is referred
to the diabetes clinic with glycosuria. It is her first Questions Incorrect 7
• Mock Exam
pregnancy. On examination her BP is 139/80 mmHg, her Questions Total 23
• Past Papers BMI is 32. She has no other past medical history of note.
Questions Percentage 69 %
• Random Questions
Investigations; More
• My Performance
• Media Bank Hb 11.9 g/dl
• New Multimedia
WCC 5.9 x10 9 /l
Online Extras Reference: Normal Values
PLT 178 x10 9 /l
Library
Na + 140 mmol/l Click to
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She monitors her post-prandial glucoses and you decide Click to
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her. She is not keen on insulin therapy. Click to open/closeBlood
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Persuade her to accept BD mixed insulin
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Persuade her that a basal bolus regime is the best
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thing for her
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Questions Correct 17
• Timed Test A 31-year-old woman who is 22 weeks pregnant is referred
to the diabetes clinic with glycosuria. It is her first Questions Incorrect 7
• Mock Exam
pregnancy. On examination her BP is 139/80 mmHg, her Questions Total 24
• Past Papers BMI is 32. She has no other past medical history of note.
Questions Percentage 70 %
• Random Questions
Investigations; More
• My Performance
• Media Bank Hb 11.9 g/dl
• New Multimedia
WCC 5.9 x10 9 /l
Online Extras
PLT 178 x10 9 /l
Library
Community Na + 140 mmol/l
Help K+ 4.9 mmol/l
PasTest Store Creatinine 95 µmol/l
Fasting glucose 9.2 mmol/l
My Account
She monitors her post-prandial glucoses and you decide
Profile that dietary intervention alone is unlikely to be sufficient for
Newsletters her. She is not keen on insulin therapy.
My Career and Exams How would you plan to manage her sugars initially?
Order History Reference: Normal Values
Persuade her to accept BD mixed
Learning Goals
insulin Click to open/closeHaematology
Question Filters Click to open/closeImmunoglobulins
Persuade her that a basal bolus regime
is the best thing for her Click to open/closeBiochemistry
Click to open/closeDiabetes Click to
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• Timed Test A 34-year-old obese woman with a history of polycystic
ovarian syndrome (PCOS) comes to the clinic with Questions Incorrect 7
• Mock Exam
tiredness, thirst and polyuria. She complains that she is Questions Total 24
• Past Papers unable to get pregnant, and that she has been trying for a
Questions Percentage 70 %
• Random Questions baby with her partner for the past 3 years. On examination
her BMI is 31, her BP is 155/90 mmHg. She also has acne More
• My Performance
and a pattern of hirsutism consistent with PCOS.
• Media Bank
Investigations;
• New Multimedia
Online Extras Hb 13.4 g/dl Reference: Normal Values
Library
WCC 5.6 x10 9 /l Click to
Community open/closeHaematology
PLT 230 x10 9 /l
Help Click to
Na + 139 mmol/l open/closeImmunoglobulins
PasTest Store
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My Account Click to open/closeDiabetes
Creatinine 110 µmol/l Click to
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Which of the following is the most appropriate
My Career and Exams therapy with respect to both her fertility and Type 2 open/closeCSF
Order History diabetes?
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Dietary advice
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Metformin monotherapy
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Questions Correct 18
• Timed Test A 34-year-old obese woman with a history of polycystic
ovarian syndrome (PCOS) comes to the clinic with Questions Incorrect 7
• Mock Exam
tiredness, thirst and polyuria. She complains that she is Questions Total 25
• Past Papers unable to get pregnant, and that she has been trying for a
Questions Percentage 72 %
• Random Questions baby with her partner for the past 3 years. On examination
her BMI is 31, her BP is 155/90 mmHg. She also has acne More
• My Performance
and a pattern of hirsutism consistent with PCOS.
• Media Bank
Investigations;
• New Multimedia
Online Extras Hb 13.4 g/dl
Library
WCC 5.6 x10 9 /l
Community
PLT 230 x10 9 /l
Help
PasTest Store Na + 139 mmol/l
K+ 4.9 mmol/l
My Account Creatinine 110 µmol/l
Profile Fasting glucose 9.1 mmol/l
Newsletters
Which of the following is the most appropriate
My Career and Exams therapy with respect to both her fertility and Type 2
Order History diabetes? Reference: Normal Values
Learning Goals
Dietary advice Click to open/closeHaematology
Question Filters Click to open/closeImmunoglobulins
Metformin monotherapy Your answer
Click to open/closeBiochemistry
Pioglitazone monotherapy Click to open/closeDiabetes Click to
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• Timed Test An 18-year-old girl is referred to the clinic because of
secondary amenorrhoea. She had two periods at the age of Questions Incorrect 7
• Mock Exam
14 and had been taking the combined oral contraceptive Questions Total 25
• Past Papers pill since the age of 16 but stopped it 6 months ago,
Questions Percentage 72 %
• Random Questions because as she wasn’t having any periods she didn’t see
any need to continue it. Her mother’s periods apparently More
• My Performance
stopped at the age of 26. On examination her height is 152
• Media Bank cm and her BMI is 18. She admits to training for long
• New Multimedia distance running when you question her about her weight.
Other physical examination is unremarkable. She has a
Online Extras normal pattern of secondary sexual hair. Reference: Normal Values
Library
Investigations; Click to
Community open/closeHaematology
Help Hb 12.9 g/dl Click to
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PasTest Store WCC 8.0 x10 9 /l Click to
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PLT 172 x10 9 /l
My Account Click to open/closeDiabetes
Na + 139 mmol/l Click to
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K+ 4.3 mmol/l Click to open/closeBlood
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Order History TSH 2.3 U/l (<0.5-4.5)
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Questions Correct 19
• Timed Test An 18-year-old girl is referred to the clinic because of
secondary amenorrhoea. She had two periods at the age of Questions Incorrect 7
• Mock Exam
14 and had been taking the combined oral contraceptive Questions Total 26
• Past Papers pill since the age of 16 but stopped it 6 months ago,
Questions Percentage 73 %
• Random Questions because as she wasn’t having any periods she didn’t see
any need to continue it. Her mother’s periods apparently More
• My Performance
stopped at the age of 26. On examination her height is 152
• Media Bank cm and her BMI is 18. She admits to training for long
• New Multimedia distance running when you question her about her weight.
Other physical examination is unremarkable. She has a
Online Extras normal pattern of secondary sexual hair.
Library
Investigations;
Community
Help Hb 12.9 g/dl
PasTest Store WCC 8.0 x10 9 /l
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• Timed Test A 25-year-old woman goes to her GP complaining of
tiredness and thirst. She tells you that she has no Questions Incorrect 7
• Mock Exam
significant history of previous medical problems, apart from Questions Total 26
• Past Papers two episodes with a kidney stone. In terms of family
Questions Percentage 73 %
• Random Questions history, her father had two of his parathyroid glands
removed for high calcium levels and recurrent pancreatitis More
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when he was in his thirties but this didn’t seem to cure the
• Media Bank problem. On examination she looks well. Her BP is 118/72
• New Multimedia mmHg, pulse 75/min, her BMI is 22.
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Questions Correct 20
• Timed Test A 25-year-old woman goes to her GP complaining of
tiredness and thirst. She tells you that she has no Questions Incorrect 7
• Mock Exam
significant history of previous medical problems, apart from Questions Total 27
• Past Papers two episodes with a kidney stone. In terms of family
Questions Percentage 74 %
• Random Questions history, her father had two of his parathyroid glands
removed for high calcium levels and recurrent pancreatitis More
• My Performance
when he was in his thirties but this didn’t seem to cure the
• Media Bank problem. On examination she looks well. Her BP is 118/72
• New Multimedia mmHg, pulse 75/min, her BMI is 22.
Na + 141 mmol/l
My Account
K+ 4.5 mmol/l
Profile
Creatinine 105 µmol/l
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Ca ++ 2.83 mmol/l
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PTH 9 (normal<10) Reference: Normal Values
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Alkaline phosphatase 82 U/l
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Click to open/closeHaematology
Question Filters Urine calcium excretion decreased
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Familial hypercalcaemic hypocalcicuria Your answer
Osteomalacia
http://pmj.bmj.com/content/63/744/835.full.pdf
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• Timed Test A 26-year-old woman presents to the clinic with nausea,
thirst and dehydration. She explains that she has an uncle Questions Incorrect 7
• Mock Exam
with a previous parathyroid gland excision and a cousin Questions Total 27
• Past Papers who has recently been diagnosed with an insulinoma. On
Questions Percentage 74 %
• Random Questions examination her BP is 135/72 mmHg, pulse is 70/min and
regular, her BMI is 20. Cardiovascular, respiratory and More
• My Performance
abdominal examinations are unremarkable.
• Media Bank
Investigations;
• New Multimedia
Online Extras Hb 12.6 g/dl Reference: Normal Values
Library
WCC 5.4 x10 9 /l Click to
Community open/closeHaematology
PLT 299 x10 9 /l
Help Click to
Na + 139 mmol/l open/closeImmunoglobulins
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My Account Click to open/closeDiabetes
Creatinine 121 µmol/l Click to
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Click to open/closeBlood
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Learning Goals Which of the following is the most likely cause of her
raised calcium?
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• Timed Test A 26-year-old woman presents to the clinic with nausea,
thirst and dehydration. She explains that she has an uncle Questions Incorrect 8
• Mock Exam
with a previous parathyroid gland excision and a cousin Questions Total 28
• Past Papers who has recently been diagnosed with an insulinoma. On
Questions Percentage 71 %
• Random Questions examination her BP is 135/72 mmHg, pulse is 70/min and
regular, her BMI is 20. Cardiovascular, respiratory and More
• My Performance
abdominal examinations are unremarkable.
• Media Bank
Investigations;
• New Multimedia
Online Extras Hb 12.6 g/dl
Library
WCC 5.4 x10 9 /l
Community
PLT 299 x10 9 /l
Help
PasTest Store Na + 139 mmol/l
K+ 4.4 mmol/l
My Account Creatinine 121 µmol/l
Profile Albumin 37 g/l
Newsletters Ca ++ 2.95 mmol/l
My Career and Exams PTH 18 (normal<10)
Order History Reference: Normal Values
Learning Goals Which of the following is the most likely cause of her
raised calcium? Click to open/closeHaematology
Question Filters Click to open/closeImmunoglobulins
MEN 2a Your answer Click to open/closeBiochemistry
Click to open/closeDiabetes Click to
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• Timed Test A 34-year-old man presents with tiredness and postural
hypotension. He works nights in a factory and suffers from Questions Incorrect 8
• Mock Exam
both asthma for which he takes inhaled fluticasone, and Questions Total 28
• Past Papers allergic rhinitis for which he takes an over the counter nasal
Questions Percentage 71 %
• Random Questions spray. On examination he has a BP of 130/80 mmHg,
which drops to 95/60 mmHg on standing. His pulse also More
• My Performance
increases from 65/min to 92/min. Otherwise physical
• Media Bank examination is unremarkable.
• New Multimedia
Investigations;
Online Extras Reference: Normal Values
Library Hb 12.9 g/dl
Click to
Community WCC 7.8 x10 9 /l open/closeHaematology
Help Click to
PLT 210 x10 9 /l
open/closeImmunoglobulins
PasTest Store
Na + 132 mmol/l Click to
open/closeBiochemistry
My Account K+ 5.3 mmol/l Click to open/closeDiabetes
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Creatinine 129 µmol/l open/closeEndocrinology
Profile
9am cortisol: 200 nmol/l (200-700) Click to open/closeBlood
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Which of the following is the most likely diagnosis?
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Question Filters ACTH deficiency
Primary adrenal failure
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Questions Correct 21
• Timed Test A 34-year-old man presents with tiredness and postural
hypotension. He works nights in a factory and suffers from Questions Incorrect 8
• Mock Exam
both asthma for which he takes inhaled fluticasone, and Questions Total 29
• Past Papers allergic rhinitis for which he takes an over the counter nasal
Questions Percentage 72 %
• Random Questions spray. On examination he has a BP of 130/80 mmHg,
which drops to 95/60 mmHg on standing. His pulse also More
• My Performance
increases from 65/min to 92/min. Otherwise physical
• Media Bank examination is unremarkable.
• New Multimedia
Investigations;
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Library Hb 12.9 g/dl
Community WCC 7.8 x10 9 /l
Help
PLT 210 x10 9 /l
PasTest Store
Na + 132 mmol/l
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Questions Correct 21
• Timed Test An 18-year-old man comes to the endocrine clinic. He
complains that his weight has increased very significantly Questions Incorrect 8
• Mock Exam
over the last 6 months. He works hard as a computer Questions Total 29
• Past Papers operator and has a sedentary job, but tells you that he at
Questions Percentage 72 %
• Random Questions least tries to get out for a walk most lunchtimes. On
examination his BP is 142/84 mmHg, his pulse 75/min and More
• My Performance
regular. His BMI is 28 and he has abdominal striae.
• Media Bank
Investigations;
• New Multimedia
Online Extras Hb 12.8 g/dl Reference: Normal Values
Library
WCC 6.1 x10 9 /l Click to
Community open/closeHaematology
PLT 217 x10 9 /l
Help Click to
Na + 141 mmol/l open/closeImmunoglobulins
PasTest Store
Click to
K+ 3.4 mmol/l open/closeBiochemistry
My Account Click to open/closeDiabetes
Creatinine 110 µmol/l Click to
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Given the suspected diagnosis, which of the following Click to open/closeBlood
Newsletters is the most appropriate next investigation? gases Click to
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Aldosterone levels
Order History
ACTH levels
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Short synacthen test
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24hr urinary free cortisol
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Questions Correct 22
• Timed Test An 18-year-old man comes to the endocrine clinic. He
complains that his weight has increased very significantly Questions Incorrect 8
• Mock Exam
over the last 6 months. He works hard as a computer Questions Total 30
• Past Papers operator and has a sedentary job, but tells you that he at
Questions Percentage 73 %
• Random Questions least tries to get out for a walk most lunchtimes. On
examination his BP is 142/84 mmHg, his pulse 75/min and More
• My Performance
regular. His BMI is 28 and he has abdominal striae.
• Media Bank
Investigations;
• New Multimedia
Online Extras Hb 12.8 g/dl
Library
WCC 6.1 x10 9 /l
Community
PLT 217 x10 9 /l
Help
PasTest Store Na + 141 mmol/l
K+ 3.4 mmol/l
My Account Creatinine 110 µmol/l
Profile
Given the suspected diagnosis, which of the following
Newsletters is the most appropriate next investigation?
My Career and Exams
Aldosterone levels Reference: Normal Values
Order History
ACTH levels
Learning Goals
Click to open/closeHaematology
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• Timed Test A 19-year-old woman presents with nausea, vomiting and dehydration. She has been
• Mock Exam unwell for some weeks and passed out whilst shopping and was brought to hospital by
ambulance. The only other past history of note is that her periods stopped a few
• Past Papers months earlier. On examination her BP is 110/80 mmHg lying, and drops to 90/60
• Random Questions mmHg on standing; her pulse is 90/min and regular. Her BMI is 19 and her skin looks
quite tanned. Other examination is unremarkable.
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Hb 11.0 g/dl
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Library WCC 8.3 x10 9 /l
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Questions Correct 22
• Timed Test A 19-year-old woman presents with nausea, vomiting and
dehydration. She has been unwell for some weeks and Questions Incorrect 9
• Mock Exam
passed out whilst shopping and was brought to hospital by Questions Total 31
• Past Papers ambulance. The only other past history of note is that her
Questions Percentage 70 %
• Random Questions periods stopped a few months earlier. On examination her
BP is 110/80 mmHg lying, and drops to 90/60 mmHg on More
• My Performance
standing; her pulse is 90/min and regular. Her BMI is 19
• Media Bank and her skin looks quite tanned. Other examination is
• New Multimedia unremarkable.
Na + 131 mmol/l
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Creatinine 130 µmol/l
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My Career and Exams She is diagnosed with Addison’s disease.
Order History Reference: Normal Values
Change in which hormone is likely to be responsible
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Aldosterone
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Questions Correct 22
• Timed Test A 41-year-old woman presents to the clinic because she is
concerned about recent weight gain. In total she has put on Questions Incorrect 9
• Mock Exam
around 5kg over the past 4 months. She is also feeling Questions Total 31
• Past Papers rather tired and has asked to reduce her hours at work
Questions Percentage 70 %
• Random Questions because of this. There is no history of medication use apart
from the progesterone-only pill. On examination her BMI is More
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28, her BP is 155/90 mmHg, pulse 72/min regular. Her
• Media Bank heart sounds are normal, chest is clear and abdominal
• New Multimedia examination is unremarkable. There is a slight, smooth
goitre on examination of the neck.
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Free T3 3.0 pmol/l (5-10)
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Hashimoto’s thyroiditis
Grave’s disease
Viral thyroiditis
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Weight gain due to lifestyle changes
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Questions Correct 23
• Timed Test A 41-year-old woman presents to the clinic because she is
concerned about recent weight gain. In total she has put on Questions Incorrect 9
• Mock Exam
around 5kg over the past 4 months. She is also feeling Questions Total 32
• Past Papers rather tired and has asked to reduce her hours at work
Questions Percentage 71 %
• Random Questions because of this. There is no history of medication use apart
from the progesterone-only pill. On examination her BMI is More
• My Performance
28, her BP is 155/90 mmHg, pulse 72/min regular. Her
• Media Bank heart sounds are normal, chest is clear and abdominal
• New Multimedia examination is unremarkable. There is a slight, smooth
goitre on examination of the neck.
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Library Investigations;
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• Timed Test A 72-year-old woman is admitted to the Emergency room
with confusion. She is known to have both hypothyroidism Questions Incorrect 9
• Mock Exam
and hypertension and takes ramipril and 150mcg daily of Questions Total 32
• Past Papers thyroid hormone replacement. Her thyroxine dose was
Questions Percentage 71 %
• Random Questions increased a few weeks earlier because her T4 was still
slightly below the normal range. On examination her BP is More
• My Performance
142/82 mmHg. Her pulse is 74/min and regular, her BMI is
• Media Bank 29. There are no abnormal heart sounds and her chest is
• New Multimedia clear. Abdominal examination reveals obesity but nil else of
note.
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Order History Free T4 6.7 pmol/l (10-22)
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Question Filters Which of the following is the most likely diagnosis?
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Questions Correct 24
• Timed Test A 72-year-old woman is admitted to the Emergency room
with confusion. She is known to have both hypothyroidism Questions Incorrect 9
• Mock Exam
and hypertension and takes ramipril and 150mcg daily of Questions Total 33
• Past Papers thyroid hormone replacement. Her thyroxine dose was
Questions Percentage 72 %
• Random Questions increased a few weeks earlier because her T4 was still
slightly below the normal range. On examination her BP is More
• My Performance
142/82 mmHg. Her pulse is 74/min and regular, her BMI is
• Media Bank 29. There are no abnormal heart sounds and her chest is
• New Multimedia clear. Abdominal examination reveals obesity but nil else of
note.
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Library Investigations;
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• Timed Test A 32-year-old woman attends the GP complaining of
anxiety and tiredness. She has no other past medical Questions Incorrect 9
• Mock Exam
history of note. On examination she has a diffusely Questions Total 33
• Past Papers enlarged smooth non-tender goitre. Her BP is 142/85
Questions Percentage 72 %
• Random Questions mmHg and her pulse is 90/min.
• My Performance More
Investigations;
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• Timed Test A 32-year-old woman attends the GP complaining of
anxiety and tiredness. She has no other past medical Questions Incorrect 10
• Mock Exam
history of note. On examination she has a diffusely Questions Total 34
• Past Papers enlarged smooth non-tender goitre. Her BP is 142/85
Questions Percentage 70 %
• Random Questions mmHg and her pulse is 90/min.
• My Performance More
Investigations;
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• New Multimedia Hb 12.4 g/dl
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• Timed Test A 34-year-old man presents to the Emergency room. His
wife says that he complained of sudden onset severe Questions Incorrect 10
• Mock Exam
headache, nausea and vomiting and double vision and then Questions Total 34
• Past Papers passed out on the hall floor. He works as a lawyer and has
Questions Percentage 70 %
• Random Questions no significant past medical history of note, but has recently
been undergoing a trial of sildenafil for erectile dysfunction. More
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On examination he looks pale, his BP is 105/70 mmHg, his
• Media Bank pulse is 98/min. Heart sounds are normal, his chest is
• New Multimedia clear, and abdominal examination is unremarkable. He
begins to wake up more as you are examining him and is
Online Extras orientated, able to speak and obey commands. He Reference: Normal Values
Library complains of severe retro-orbital headache. He has a
bitemporal superior quadrantinopia on visual field testing. Click to
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You give him some IV cyclizine, as he continues to vomit.
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Subarachnoid haemorrhage
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Migraine
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Non-functioning pituitary adenoma
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• Timed Test A 34-year-old man presents to the Emergency room. His
wife says that he complained of sudden onset severe Questions Incorrect 10
• Mock Exam
headache, nausea and vomiting and double vision and then Questions Total 35
• Past Papers passed out on the hall floor. He works as a lawyer and has
Questions Percentage 71 %
• Random Questions no significant past medical history of note, but has recently
been undergoing a trial of sildenafil for erectile dysfunction. More
• My Performance
On examination he looks pale, his BP is 105/70 mmHg, his
• Media Bank pulse is 98/min. Heart sounds are normal, his chest is
• New Multimedia clear, and abdominal examination is unremarkable. He
begins to wake up more as you are examining him and is
Online Extras orientated, able to speak and obey commands. He
Library complains of severe retro-orbital headache. He has a
bitemporal superior quadrantinopia on visual field testing.
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You give him some IV cyclizine, as he continues to vomit.
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Investigations;
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Hb 12.4 g/dl
My Account WCC 5.4 x10 9 /l
Profile PLT 203 x10 9 /l
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Na + 132 mmol/l
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Order History K+ 5.4 mmol/l Reference: Normal Values
Learning Goals Creatinine 119 µmol/l
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Non-functioning pituitary adenoma
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• Timed Test A 16-year-old Jewish girl comes to the GP complaining of
primary amenorrhoea. On examination she looks a little Questions Incorrect 10
• Mock Exam
hirsute, and has evidence of facial acne. She is within her Questions Total 35
• Past Papers predicted adult height and has normal breast and external
Questions Percentage 71 %
• Random Questions genitalia development, although there is excess hair over
her lower abdomen and around her nipple area. More
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• Media Bank Investigations;
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Hb 13.1 g/dl
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Library WCC 8.6 x10 9 /l
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bilateral ovaries and uterus Click to
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Which of the following is the most likely diagnosis?
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Question Filters Polycystic ovarian syndrome
Classical congenital adrenal hyperplasia
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• Timed Test A 16-year-old Jewish girl comes to the GP complaining of
primary amenorrhoea. On examination she looks a little Questions Incorrect 11
• Mock Exam
hirsute, and has evidence of facial acne. She is within her Questions Total 36
• Past Papers predicted adult height and has normal breast and external
Questions Percentage 69 %
• Random Questions genitalia development, although there is excess hair over
her lower abdomen and around her nipple area. More
• My Performance
• Media Bank Investigations;
• New Multimedia
Hb 13.1 g/dl
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Library WCC 8.6 x10 9 /l
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